Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery.

BACKGROUND: The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery. METHODS: The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used. RESULTS: Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality. CONCLUSIONS: A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer: Analysis of Feasibility and Safety from a Single Western Center.

BACKGROUND: Colectomies performed according to complete mesocolic excision (CME) principles have demonstrated an improvement in the quality of surgical specimen and a potential improvement of long-term results. Laparoscopic CME right hemicolectomy is considered a demanding procedure and adopted in few centers from the West. The main purpose of this paper is to present a video showing our technique for laparoscopic CME right hemicolectomy and to analyze our short-term results to prove its safety. METHODS: Data from 38 patients operated on at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between September 2014 and February 2017, were included in the study. RESULTS: In the present series, 37% of patients were ≥75 years old, 32% of patients were ASA class 3, 46% of patients had ≥2 comorbidities, 30% of patients had BMI >28 and 17% of patients had ≥2 previous abdominal surgeries. Despite these unfavorable clinic characteristics, no mortality was observed, Clavien-Dindo ≥3 complications occurred in 13.1% and redo surgery in 5.3%. Good quality specimens were obtained with a mean (SD) length of 34.5±7.5 cm, a proximal margin of 16.8±9.2 cm and a distal margin of 14.3±6.4 cm. The mean (SD) number of harvested lymph nodes was 24.3 (8.3). CONCLUSIONS: When implemented in a Western center, laparoscopic CME right hemicolectomy is feasible and safe and allows obtaining good quality specimens.

Management of nodal disease from colon cancer in the laparoscopic era.

PURPOSE: In colon cancer (CC), nodal involvement is the main prognostic factor following potentially curative (R0) resection. The purpose of this study was to examine data from the literature to provide an up-to-date analysis of the management of nodal disease with special reference to laparoscopic treatment. METHODS: MEDLINE and EMBASE databases were searched for potentially eligible studies published in English up to July 15, 2014. RESULTS: In CC, nodal involvement is a frequent event and represents the main risk of cancer recurrence. Node negative patients recur in 10-30 % of cases most likely due to underdiagnosed or undertreated nodal disease. Extended colonic resections (complete mesocolic excision with central vascular ligation; D3 lymphadenectomy) provides a survival benefit and better local control. Sentinel lymph node mapping in addition to standard surgical resection represents an option for improving staging of clinical node negative patients. Both extended resection and sentinel lymph node mapping are feasible in a laparoscopic setting. CONCLUSIONS: Both extended colonic resection and sentinel lymph node mapping should play a role in the laparoscopic treatment of CC with the purpose of improving control and staging of nodal disease.

The Dagradi-Serio-Iacono operation central pancreatectomy.

Central pancreatectomy (CP) is a segmental pancreatic resection indicated to remove benign or low-grade malignant tumors of the isthmus and proximal part of the body of the pancreas. The main advantage of this operation compared with major resections is that it permits to spare normal pancreatic parenchyma; moreover, spleen and upper digestive and biliary tracts are saved. The description of the complete operation was reported for the first time by Dagradi and Serio in 1984 and subsequently spread worldwide by Iacono and Serio. In our opinion, it should be called the Dagradi-Serio-Iacono operation, by the names of the surgeons who first performed it (Dagradi and Serio), and by the names of the surgeons responsible for reporting it worldwide with precise indications (Iacono and Serio). Operation requires a midline or a bilateral subcostal incision; the lesser sac is entered through dissection of the transverse colon from the omentum or by transecting the gastrocolic ligament. The pancreatic segment harboring the lesion is then mobilized and its posterior surface carefully dissected from the splenic vein and artery. Subsequently, the pancreatic portion harboring the tumor is isolated at its superior margin from the splenic artery after the pancreas is transacted. The extent of the resection of the central segment is limited on the right by the gastroduodenal artery and on the left by the need to leave at least 5 cm of normal pancreatic remnant. The resected pancreatic specimen is sent to the pathologist for confirmation of diagnosis and to check if the resection margins are adequate. Hemostasis of the two raw surfaces is achieved with interrupted 5 or 4/0 nonabsorbable stitches. When it is not stapled, the Wirsung's duct of the cephalic stump is sutured selectively with a figure-of-eight nonabsorbable stitch. An end-to-end invaginated pancreaticojejunostomy is carried out with a single layer of interrupted stitches. The operation is concluded with the construction of an end-to-side jejuno-jejunostomy about 50 cm distal to the pancreatic anastomosis. Other techniques for reconstruction of the distal stump using jejunum or stomach have been described. One or two soft drains are brought out on the right side. The fluid collected from this drain is checked for amylase level on postoperative days 3, 5, and 7; if the level is low or absent, the drain is removed. Central pancreatectomy is a safe technique for benign or low malignant tumors of the pancreatic neck that allows curing the tumor with evident functional results without increasing the risk for the patient. We can say that CP has a clear role like pancreaticoduodenectomy and distal pancreatectomy and we think that a pancreatic surgeon has to include this procedure in his/her technical skills. In order to obtain excellent results, correct indications and experience in pancreatic surgery are recommended.

[What is new in fasting guidelines of surgical patients? Review of the literature]. / Cosa c'è di nuovo nelle linee-guida del digiuno nel paziente chirurgico? Revisione della letteratura.

The concept of perioperative starvation requires an update on a more balanced physiological bias. The old British dictum "nil by mouth from midnight" is a thing of the past. We need to administer food and fluids as early as possible both before both before and after surgery and to avoid or reduce hospital infections. Resumption of bowel movements is very rapid, and the patients are fed and experience no thirst and thus have better compliance during their hospital stay. Moreover, the social cost is reduced. A short review of the rules of various Associations of Anaesthetists both in Europe and the US shows that today the starvation time is reduced, and re-feeding after surgery is implemented early. For clear fluids a 2-h period before surgery without ingestion of clear fluids is enough, whilst in most countries a 6-h period of starvation for solid foods is the rule, but if proper distinctions are made between the various nutrients given to the patients, this time could be reduced to 2-3 hours.