Erector Spinae Plane (ESP) Block for Postoperative Pain Management after Open Oncologic Abdominal Surgery.

Patients undergoing abdominal oncologic surgical procedures require particular surgical and anesthesiologic considerations. Traditional pain management, such as opiate treatment, continuous epidural analgesia, and non-opioid drugs, may have serious side effects in this patient population. We evaluated erector spinae plane (ESP) blocks for postoperative pain management following elective oncologic abdominal surgeries. In this single-center, prospective, and randomized study, we recruited 100 patients who underwent elective oncological abdominal surgery between December 2020 and January 2022 at Soroka University Medical Center in Beer Sheva, Israel. We compared postoperative pain levels in patients who were treated with a preincisional ESP block in addition to traditional pain management with intravenous opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen, compared to patients who were only given traditional pain management (control). Patients who were treated with a preincisional ESP block demonstrated significantly lower Visual Analog Scale scores at 60 minutes and 4, 8, and 12 hours following the surgery, compared to the control group (p < 0.001). Accordingly, patients in the ESP group required less morphine from 60 minutes to 12 hours after surgery, but they required increased non-opioid postoperative analgesia management at 4, 8, and 12 hours after surgery (p from 0.002 to <0.001) compared to the control group. In this study, we found ESP blocks to be a safe, technically simple, and effective treatment for postoperative pain management after elective oncologic abdominal procedures.

Clinical characteristics of SARS-CoV-2 vaccine-related acute appendicitis.

BACKGROUND: In a large nationwide mass vaccination setting, the SARS-CoV-2 vaccine was recently linked to myocarditis, lymphadenopathy, herpes zoster infection and appendicitis. We aimed to examine the characteristics and management of SARS-CoV-2 vaccine-related acute appendicitis. METHODS: We performed a retrospective cohort study in a large tertiary medical centre in Israel. All patients presenting with acute appendicitis within 21 days of receiving their SARS-CoV-2 vaccination (PCVAA group) were compared with patients who presented with acute appendicitis not related to the vaccination (N-PCVAA group). RESULTS: We reviewed the records of 421 patients with acute appendicitis from December 2020 to September 2021; 38 (9%) patients presented with acute appendicitis within 21 days of receiving their SARS-CoV-2 vaccination. Patients in the PCVAA group were older than those in the N-PCVAA group (mean 41 ± 19 yr v. 33 ± 15 yr, respectively, p = 0.008), with male predominance. More patients were managed nonsurgically during the pandemic than before the pandemic (24% v. 18%, p = 0.03). CONCLUSION: With the exception of older age, the clinical characteristics of patients presenting with acute appendicitis within 21 days of receiving the SARS-CoV-2 vaccination did not differ from those of patients who presented with acute appendicitis not related to the vaccination. This finding suggests that vaccine-related acute appendicitis is similar to "classic" acute appendicitis.

The Role of Early Sequential Biopsies in Delayed Renal Graft Function of Transplanted Kidney Is Reduced in Modern Immunosuppression Era.

BACKGROUND: Delayed graft function (DGF) immediately after kidney transplantation is considered a risk factor for acute rejection. According to clinical guidelines, a weekly allograft biopsy should be performed until DGF resolves. Based on clinical evidence, the first biopsy is considered appropriate. However, the recommendation for further biopsies is based on sparse evidence from era of earlier immunosuppression protocols, and the benefit of the second and further biopsies remains uncertain. The aim of this study was to reevaluate this policy. METHODS: The database of a transplant medical center was retrospectively reviewed for all patients who underwent kidney transplantation in 2011-2020. Those with DGF who performed two or more graft biopsies within the first 60 days after transplantation were identified. Clinical data were collected from the medical files. The rates of diagnosis of acute rejection at the second and subsequent biopsies were analyzed relative to the previous ones. RESULTS: Kidney transplantation was performed in 1,722 patients during the study period, of whom 225 (13.07%) underwent a total of 351 graft biopsies within 60 days after transplantation, mostly due to DGF. A second biopsy was performed in 32 patients (14.2%), and a third biopsy in 8, at weekly intervals. In 2 patients (6.25%), the diagnosis changed from the first biopsy (acute tubular necrosis or toxic damage) to acute rejection in the second biopsy. In both, the rejection was borderline. Third and fourth biopsies did not add information to the previous diagnosis. CONCLUSIONS: The common practice of performing sequential biopsies during a postoperative course of DGF seems to be of low benefit and should be considered on a case-by-case basis.

An Unusual Presentation of HCC in a Patient with No Underlying Liver Disease: A Case Study.

Pedunculated hepatocellular carcinoma (P-HCC) is a rare subtype of HCC. P-HCC may occur in patients without underlying liver cirrhosis and can be present with negative serum tumor markers. With a growing worldwide incidence of nonalcoholic fatty liver disease, non-cirrhotic HCC will likely become more prevalent. We report a patient presenting to the hospital with nonspecific symptoms of weight loss, abdominal discomfort, and early satiety. Abdomen palpation found a large firm mass in the right middle abdomen. Computed tomography imaging showed a large right abdominal mass without evidence of liver attachment. The patient underwent a diagnostic laparotomy where a single 17 cm exophytic mass originating from the left liver lobe was found and resected. Clear margins were attained, and pathology demonstrated HCC. Early diagnosis of HCC is critical to achieving curative treatment, and physicians should keep P-HCC in mind when presented with a similar patient.

The Clinical Significance of Fluctuations in the Minute-to-minute Urine Flow Rate and in its Minute-to-minute Variability During Septic Events in Critically Ill Patients.

BACKGROUND: Septic events complicated by hemodynamic instability can lead to decreased organ perfusion, multiple organ failure, and even death. Acute renal failure is a common complication of sepsis, affecting up to 50-70 % of cases, and it is routinely diagnosed by close monitoring of urine output. We postulated that analysis of the minute-to-minute changes in the urine flow rate (UFR) and also of the changes in its minute-to-minute variability might lead to earlier diagnosis of renal failure. We accordingly analyzed the clinical significance of these two parameters in a group of critically ill patients suffering from new septic events. METHODS: The study was retrospective and observational. Demographic and clinical data were extracted from the hospital records of 50 critically ill patients who were admitted to a general intensive care unit (ICU) and developed a new septic event characterized by fever with leukocytosis or leukopenia. On admission to the ICU, a Foley catheter was inserted into the urinary bladder of each patient. The catheter was then connected to an electronic urinometer - a collecting and measurement system that employs an optical drop detector to measure urine flow. Urine flow rate variability (UFRV) was defined as the change in UFR from minute to minute. RESULTS: Both the minute-to-minute UFR and the minute-to-minute UFRV decreased significantly immediately after each new septic episode, and they remained low until fluid resuscitation was begun (p < 0.001 for both parameters). Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFR and the decrease in the systemic mean arterial pressure (MAP) (R = 0.03, p = 0.003) and between the decrease in UFRV and the decrease in the MAP (R = 0.03, p = 0.004). Additionally, both the UFR and the UFRV demonstrated good responses to fluid administration prior to improvement in the MAP. CONCLUSION: We consider that minute-to-minute changes in UFR and UFRV could potentially serve as early and sensitive signals of clinical deterioration during new septic events in critically ill patients. We also suggest that these parameters might be able to identify the optimal endpoint for the administration of fluid resuscitative measures in such patients.

Examining the safety of colon anastomosis on a rat model of ischemia-reperfusion injury.

INTRODUCTION: Intestinal ischemia and reperfusion can impair anastomotic strength. The purpose of this study was to evaluate the safety of delayed colon anastomosis following remote ischemia-reperfusion (IR) injury. METHODS: Rats divided into two groups underwent bilateral groin incisions, however only the study group had femoral artery clamping to inflict IR injury. Twenty-four hours following this insult, the animals underwent laparotomy, incision of the transverse colon and reanastomosis. End points included anastomotic leakage, strength and histopathological features. RESULTS: Anastomotic leak among IR animals (22.2%) was not statistically different in comparison to the controls [10.5% (p = 0.40)]. Anastomotic mean burst pressures showed no statistically significant difference [150.6 ± 15.57 mmHg in the control group vs. 159.9 ± 9.88 mmHg in the IR group (p = 0.64)]. The acute inflammatory process in the IR group was similar to controls (p = 0.26), as was the chronic repair process (p = 0.88). There was no significant difference between the inflammation:repair ratios amongst the two groups (p = 0.67). CONCLUSION: Primary colon repair is safe when performed 24 hours following systemic IR injury.