Pain distraction during awake low anterior resection and Cuddle Delivery initiative for inpatient: frugal procedural options to support surgery in the COVID-19 era.

OBJECTIVE: Since minimally invasive surgery and general anesthesia are both aerosol-generating procedures, their use became controversial during the outbreak of coronavirus disease 2019 (COVID-19). Moreover, social distancing resulted in serious psychological consequences for inpatients. This case report investigates pain distraction during awake laparotomy, as well as new possibilities for emotional postoperative support to inpatients. PATIENTS AND METHODS: A 72-year-old man affected by middle rectal adenocarcinoma underwent lower anterior resection plus total mesorectal excision under combined spinal-epidural anesthesia. A 3D mobile theatre (3DMT) was intraoperatively used for pain distraction. A postoperative "Cuddle delivery" service was instituted: video-messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional correlations were investigated through a clinical interview by the psychologist of our Hospital. RESULTS: Intraoperative, as well as postoperative pain, resulted well-controlled: visual analogue scale (VAS) ≤3. Conversion to general anesthesia and postoperative intensive support/monitoring were unnecessary. The "Cuddle delivery" initiative positively fed our patient's mood and attitude, strengthening his bond to life. CONCLUSIONS: During pandemic, awake laparotomy under loco-regional anesthesia may be a crucial option in delivering acute care surgery to selected patients when intensive care beds are unavailable. Our procedure introduces potential ways to optimize this approach.

Awake laparotomy: is locoregional anesthesia a functional option for major abdominal surgeries in the COVID-19 era?

OBJECTIVE: Over the ongoing pandemic of coronavirus disease 2019 (COVID-19), the demand for critical care beds among medical services has rapidly exceeded its supply. Elective surgery has comprehensively been drastically limited and allocating intensive care beds to emergency cases or to high risk scheduled elective cases has become an even more difficult task. Here we present our experience which could help to handle undelayable surgical procedures during this emergency. PATIENTS AND METHODS: In 2019, eight patients (4 men, 4 women) with a mean age of 88 years, needing emergency abdominal surgery underwent awake open surgery at our Department of Surgery. All of them were identified as fragile patients at preoperative evaluation by the anesthesiologist. In all cases, locoregional anesthesia (spinal, epidural or combined spinal-epidural anesthesia) was performed. Intraoperative and postoperative pain has been monitored and regularly assessed. RESULTS: None of the patients was intubated. Mean operative time was 80 minutes (minimum 30 minutes, maximum 130 minutes). Intraoperative and postoperative pain were both well controlled. None of them required postoperative intensive care support. No perioperative complications were observed. CONCLUSIONS: Based on our preliminary case series, awake open surgery has resulted feasible and safe. This approach has allowed to perform undelayable major abdominal surgeries on fragile patients when intensive care beds were not available. Surely, it represents a helpful alternative in the COVID-19 era. A streamlining of workflows would fast-track both fragile patients management, as well as healthcare workers' tasks and activity.

A subset of genetic susceptibility variants for colorectal cancer also has prognostic value.

We investigated the possible influence of 86 single-nucleotide polymorphisms (SNPs), known to associate with the risk of colorectal cancer (CRC), on overall survival and time to recurrence (TTR) in 733 Italian CRC patients followed up for up to 84 months after surgery. In the Cox multivariate analysis, adjusted for gender, age, pathological stage and adjuvant chemotherapy (yes/no), the risk of death significantly increased by rare allele count (P<0.05) for rs1801133 (MTHFR), rs4939827 (SMAD7), rs2306283 (SLCO1B1) and rs12898159 (BMP4), whereas for rs736775 (GPX3) the opposite was observed. Two additional SNPs associated with TTR, namely rs16892766 (downstream of EIF3H) and rs10749971 (COLCA2). Our findings show that some genetic variants previously found to associate with CRC risk are also associated with survival after treatment. The identification of alleles defining subgroups of patients with worse clinical outcome may have application in developing pharmacogenetic strategies aimed at personalizing CRC treatment.

The impact of EUS to predict lymph node metastasis in patients with rectal cancer: a difficult challenge.

OBJECTIVE: Current trends in the management of rectal cancer, identify accurate local assessment of positive lymph nodes (LN), as the strongest predictor for stratifying patients who would benefit from preoperative therapy. We a present retrospective analysis of a prospective data collection, to determine the clinical concordance between the suspicious LN at the pre-operative EUS (uN) and a post-operative EUS detection (pN). PATIENTS AND METHODS: From March 2009 to March 2011, 31 patients with suspicious LNs at EUS (uN positive) were enrolled. The surgeon performed pre-operative EUS and directly in the operating room, an ex vivo EUS of the specimen. The immediate mesorectal LN sampling by the surgeon was delivered to the pathologist. Endosonographic staging was compared to postoperative pathological staging. RESULTS: Preoperative EUS identified 67 suspicious LN. The LN medium size was 6.8 mm. We repeated the EUS after surgery. The pathologist found 41 positive LN. The definitive LN medium size was 6.3 mm. Eleven LN presented the same size between ultrasound and pathological examination, 11 LN a smaller size and 41 a bigger size, the remnants 4 were not discovered. EUS LN staging presented 83.9% in overstaging and 3.2% in understaging. Although endo ultrasonography (EUS) is a very effective method for assessing LN metastasis, this is still a difficult challenge. Inaccurate assessment of LNs can conceivably lead to either under-staging or over-staging. The present study indicates that the clinical concordance between the suspected metastatic LN at the pre-operative EUS (uN) and a post-operative (ex-vivo) ultrasound LN detection, is moderate. CONCLUSIONS: We should re-consider all this strategy: we need to switch from morphological information to biological behavior.

Anastomotic leakage following colorectal resection for cancer: how to define, manage and treat it.

AIM: Aim of the study was to report the experience of a single center in the surgical treatment of anastomotic leak after colorectal resection for cancer, focusing on its incidence, diagnosis and management, with particular attention to surgical options. METHODS: Demograhic and clinical data from 1284 consecutive patients operated on for colorectal cancer during a period of 11 years, were prospectively collected and inserted into an electronic database. For the purpose of the study, only patients in whom an anastomosis was performed were considered. Therefore, 128 patients (9.9%) were excluded and 1156 represent the study population. All complications occurring after surgery were systematically recorded. The incidence of colorectal anastomotic leak (CAL), its management and outcome was analyzed. RESULTS: An ileo-colic anastomosis was performed in 426 cases (36.8%), ileo-rectal in 29 (2.5%), colo-colic in 409 (35.4), colo-rectal with partial mesorectal excision in 211 (18.3%) and lower colorectal or coloanal anastomosis with total mesorectal excision and temporary loop ileostomy in 81 (7%). Colorectal anastomotic leak occurred in 78/1156 patients (6.7%), accounting for 19% of overall complications. Thirty-six out of 78 patients (46.2%) were successfully treated conservatively, whereas 42 (53.8%) underwent re-operation. Nine out of 78 patients (11.5%) with CAL died owing to an uncontrolled sepsis. All had undergone previous re-intervention, with a post-operative mortality rate of 21.4% (9 out of 42). CONCLUSION: Mortality rate in patients undergoing re-operation for colorectal anastomotic leakeage is still high, and accounts for up to 40% of the deaths after colorectal resection for cancer. In the light of these data, strategic clinical decisions are mandatory to optimize the selection of patients who need an early and fast surgical approach. What does this paper add to the literature? Systematic and prospective data recording is an essential tool to assess the quality of healthcare and to plan quality improvement programs. Every effort should be done to reach an early diagnosis of CAL, possibly in a pre-clinical phase in which non clinical methods could be used to predict it.

Pelvic lymphedema in rectal cancer: a magnetic resonance feasibility study: a preliminary report.

BACKGROUND: Functional pelvic disorders in patients undergoing conservative surgical approach for rectal cancer are considered a major public health issue and represent one third of cost of colorectal cancer. We investigated the hypothesis that lymphadenectomy, involves the pelvic floor results in a localized hides or silent pelvic lymphedema characterized by symptoms without signs. PATIENTS AND METHODS: We examined 13 colo-rectal cancer patients: five intra-peritoneal adenocarcinoma: 1 sigmoid and 4 upper third rectal cancer (1 male and 3 female) and 9 extra-peritoneal adenocarcinoma: 3 middle and 5 lower third rectal cancer (4 male and 5 female) using 1.5-T magnetic resonance, one week before and twelve months after discharged from hospital. RESULTS: Lymphedema was discovered on post-operative magnetic resonance imaging of all 9 patients with extra-pertitoneal cancer, whereas preoperative magnetic resonance imaging as well as a post-operative examination of 4 intra-peritoneal adenocarcinoma, revealed no evidence of lymphedema. Unlike the common clinical skin signs that typify all other sites of lymphedema, pelvic lymphedema is hides or silent, with no skin changes or any single symptom manifested. Magnetic resonance imaging showed that pelvic illness alone is accompanied by lymphedema related exclusively to venous congestion, and accumulation of liquid in adipose tissue or lipedema. CONCLUSIONS: Alteration of the pelvic lymphatic network during pelvic surgery can lead to lymphedema and, pelvic floor disease. Patients should be routinely examined for the possibility of developing this post-surgical syndrome and further studies are needed to establish diagnosis and to evaluate treatment preferences.

Delayed and occult splenic rupture: a diagnostic puzzle.

Splenic rupture is a common complaint encountered in emergency surgery. Trauma is the most common cause of splenic rupture, while non-traumatic or occult splenic rupture (OSR) is a rare condition. The differential diagnosis weighs on treatment that ranges between close monitoring, splenorrhaphy, splenic conservation and splenectomy. We report a case of an 63-year-old man presenting with acute atraumatic left upper quadrant pain. Preliminary diagnosis was subsequently determined to be a hematoma secondary to OSR. More accurate detailed history revealed a previous trauma, which occurred more than one year before and mimicked an OSR. Delayed and occult splenic rupture are as different diagnosis as different treatment. Even in emergency surgery, the key for a target therapeutic strategy should consider an accurate diagnostic time.

Small bowel occlusion due to giant perineal hernia: abdominal approach with plastic perineal reconstruction.

A perineal hernia is defined as a protrusion of peritoneal or extraperitoneal content through a pelvic floor defect. A 64-year-old woman with a bowel occlusions due to a giant postoperative perineal hernia was admitted to our hospital. We describe abdominal approach with plastic perineal reconstruction.

[Elective laparoscopic cholecystectomy: the limit of a dream become true]. / La colecistectomia videolaparoscopica elettiva: i limiti di un sogno ormai realtà.

Laparoscopic technique in elective cholecystectomy is the last step in an evolutive time to minimize the abdominal access. From 1st January 2004 to 31th December 2006 we analyzed 5515 cholecystectomy procedures: 4877 laparoscopic cholecystectomy, 635 open cholecystectomy. Complications and supplementary diagnosis have been identified in SDO Lombardia's country database. Morbidity occurred in 82 patients (12.9%) with open technique and 109 patients (2.23%) with laparoscopic technique; mortality occurred in 11 patients (1.73%) with open technique and 1 patient (0.02%) with laparoscopic technique. Mean hospital stay are 14.40 days with open technique and 4.75 with laparoscopic technique. Morbidity in open technique is 6 fold more than laparoscopia technique. The difference between the two technique is present in literature and it's the result of non invasive technique compared with the incision of the laparoscopia technique. This is the critical point in the difference of hospital stay between the two technique all to the good of laparoscopy. The high mortality ratio is due to the selective criteria in laparoscopic technique. First remark is the high quality of our hospital care, compared with hospital teaching in the word. In this hospital the laparoscopic cholecystectomy is the gold standard in cholelitiasis treatment. The second remark is the limit of the open technique in severe cholelitiasis with evidence in high ratio of hospital stay, morbidity and mortality.

A novel Cx32 mutation causes X-linked Charcot-Marie-Tooth disease with brainstem involvement and brain magnetic resonance spectroscopy abnormalities.

The objective of this study was to study genetic and phenotypic features of a family with X-linked Charcot-Marie-Tooth consisting of a healthy father, affected mother, two affected sons and one healthy one. A detailed electrophysiological and neuroimaging study, along with sequencing of the Cx32 gene, was performed in all family members. A novel Cx32 123 G>C mutation, determining an aminoacid variation (Glu41Asp), was found in the mother and the affected sons. An alteration in brainstem evoked potentials was found in the mother and one affected son. The affected son, who underwent magnetic resonance imaging, showed symmetrical hyperintensities in paratrigonal white matter, not found in his heterozygous mother, while both subjects exhibited alterations in brain metabolite ratios derived from localised proton-magnetic resonance spectroscopy. These data extend previous findings about central nervous system involvement in Cx32 mutated subjects and further support a functional role of the protein expression in oligodendrocytes.

Fístulas postlaringectomía: variables que favorecen su desarrollo / Posttlaringectomy fistula: factors that favour its development

Antecedentes: A pesar del gran número de autores que se refieren a esta complicación, no hay aún hoy acuerdo sobre causas. Objetivo: Reconocer los factores que favorecen su desarrollo. Lugar de aplicación: Hospital público de atención terciaria de pacientes oncológicos. Diseño: Prospectivo no randomizado. Población: 100 enfermos, 93 por ciento masculinos, edad media 59,13 años, 98 por ciento portadores de carcinoma epidermoide sometidos a laringectomía total. Método: Análisis uni y multivariado de 21 variables potencialmente favorecedoras de fístulas postoperatorias. Resultados: Ninguna de las vriables resultó estadísticamente significativa. La radioterapia previa se comportó como el factor de mayor probabilidad del evento. La incidencia de fístulas alcanzó el 55 por ciento de los operados. Su momento de aparición tuvo una media de 9 días. El 76,3 por ciento cerró espontáneamente. Las peores consecuencias del evento resultaron la prolongación en el uso 3,6 veces mayor a la media de la sonda de alimentación, la necesidad de nuevos tiempos quirúrgicos en 13 pacientes y la rehabilitación 2 meses después que el resto. Conclusiones: La dimensión de la muestra resultó insuficiente para desarrollar el modelo predictivo del fenómeno (AU)

Fístulas postlaringectomía: variables que favorecen su desarrollo / Posttlaringectomy fistula: factors that favour its development

Antecedentes: A pesar del gran número de autores que se refieren a esta complicación, no hay aún hoy acuerdo sobre causas. Objetivo: Reconocer los factores que favorecen su desarrollo. Lugar de aplicación: Hospital público de atención terciaria de pacientes oncológicos. Diseño: Prospectivo no randomizado. Población: 100 enfermos, 93 por ciento masculinos, edad media 59,13 años, 98 por ciento portadores de carcinoma epidermoide sometidos a laringectomía total. Método: Análisis uni y multivariado de 21 variables potencialmente favorecedoras de fístulas postoperatorias. Resultados: Ninguna de las vriables resultó estadísticamente significativa. La radioterapia previa se comportó como el factor de mayor probabilidad del evento. La incidencia de fístulas alcanzó el 55 por ciento de los operados. Su momento de aparición tuvo una media de 9 días. El 76,3 por ciento cerró espontáneamente. Las peores consecuencias del evento resultaron la prolongación en el uso 3,6 veces mayor a la media de la sonda de alimentación, la necesidad de nuevos tiempos quirúrgicos en 13 pacientes y la rehabilitación 2 meses después que el resto. Conclusiones: La dimensión de la muestra resultó insuficiente para desarrollar el modelo predictivo del fenómeno

Total laryngectomy: pre- and intrasurgical variables of infection risk.

Postoperative infection has influence on costs, quality of life, and outcome of the disease. It is suspected that post-total laryngectomy infections have increased in frequency and seriousness, because of the failure of the preservation protocol or the previous radiotherapy, making rescue surgery necessary. The objective of this study was to develop a predictive model of infection based on the pre- and intrasurgical variables considered risky. One hundred fifty five patients with E III-IV laryngeal cancer, with 24.8:1 male to female ratio (mean age, 58 years) who underwent total laryngectomy were evaluated for uni- and multivariate analysis of age, sex, histological grade, primary or recurrent disease, tobacco, alcohol, diabetes, tuberculosis/chronic emphysema, red and white cell counts, erythrosedimentation rate (ESR), albumin, chemotherapy, neck radiotherapy and/or previous surgery, confinement days, type and time of surgery, which were factors in the infection event. A predictive model of infection was developed and included albuminemia (<3.5 g%), >1 liter of alcohol daily, and exclusive surgery of the primary. The sensitivity was 90.5% and the specificity 68%. The variance reached 29.6%. The causes of infection were multiple, having analyzed only 30% of them. However, the resulting model was classified correctly in 83.2% of cases. A careful preoperative assessment, an adjusted planning of the surgery, an appropriate use of antibiotics, and a meticulous operative technique are needed to prevent infection.