Laparoscopic management of a left hepatic vein injury during one -step laparoscopic Roux-en-Y gastric bypass after adjustable gastric banding removal: A case report.

INTRODUCTION AND IMPORTANCE: The occurrence of a left hepatic vein injury during laparoscopic removal of an adjustable gastric band is exceptional and should be known by any surgeon approaching the hiatal region. We report here the laparoscopic control of such a wound. CASE PRESENTATION: A 39-year-old morbidly obese woman (body mass index 47.7 kg/m2) presented the failure in weight loss following a laparoscopic adjustable gastric banding. It was decided to perform a one-step laparoscopic Roux-en-Y gastric bypass. Laparoscopic exploration showed post-surgical tissular retraction and adhesions. After the lap-band™ removal the left hepatic vein was accidentally bluntly injured while freeing adhesions between left hepatic lobe and the stomach. After a direct hemorrhagic control, intraoperative diagnosis of left hepatic vein injury was confirmed. A laparoscopic repair was performed by two running sutures using absorbable monofilament 4/0. Then, a Roux-en-Y gastric bypass was performed without any other complications. Operative time was 119 min; intraoperative blood loss was estimated as 200 cm3. No blood transfusion was necessary. The total hospital stay was 48 h. The excess weight lost after 10 years was 87,9%. CLINICAL DISCUSSION: Adjustable gastric band can modify anatomic landmarks, leading to a wrong dissection path, with possibility of left hepatic vein injury. CONCLUSION: The left hepatic vein injury can occur during revisional surgery for laparoscopic adjustable gastric banding failure. Its laparoscopic management can be done safely, in trained hands without increasing morbidity.

Extension of Collagen Deposition in COVID-19 Post Mortem Lung Samples and Computed Tomography Analysis Findings.

Lung fibrosis has specific computed tomography (CT) findings and represents a common finding in advanced COVID-19 pneumonia whose reversibility has been poorly investigated. The aim of this study was to quantify the extension of collagen deposition and aeration in postmortem cryobiopsies of critically ill COVID-19 patients and to describe the correlations with qualitative and quantitative analyses of lung CT. Postmortem transbronchial cryobiopsy samples were obtained, formalin fixed, paraffin embedded and stained with Sirius red to quantify collagen deposition, defining fibrotic samples as those with collagen deposition above 10%. Lung CT images were analyzed qualitatively with a radiographic score and quantitatively with computer-based analysis at the lobe level. Thirty samples from 10 patients with COVID-19 pneumonia deceased during invasive mechanical ventilation were included in this study. The median [interquartile range] percent collagen extension was 6.8% (4.6-16.2%). In fibrotic compared to nonfibrotic samples, the qualitative score was higher (260 (250-290) vs. 190 (120-270), p = 0.036) while the gas fraction was lower (0.46 (0.32-0.47) vs. 0.59 (0.37-0.68), p = 0.047). A radiographic score above 230 had 100% sensitivity (95% confidence interval, CI: 66.4% to 100%) and 66.7% specificity (95% CI: 41.0% to 92.3%) to detect fibrotic samples, while a gas fraction below 0.57 had 100% sensitivity (95% CI: 66.4% to 100%) and 57.1% specificity (95% CI: 26.3% to 88.0%). In COVID-19 pneumonia, qualitative and quantitative analyses of lung CT images have high sensitivity but moderate to low specificity to detect histopathological fibrosis. Pseudofibrotic CT findings do not always correspond to increased collagen deposition.

Interleukin-32 Contributes to Human Nonalcoholic Fatty Liver Disease and Insulin Resistance.

Nonalcoholic fatty liver disease (NAFLD) is a metabolic disorder due to increased accumulation of fat in the liver and in many cases to enhanced inflammation. Although the contribution of inflammation in the pathogenesis of NAFLD is well established, the cytokines that are involved and how they influence liver transformation are still poorly characterized. In addition, with other modifiers, inflammation influences NAFLD progression to liver cirrhosis and hepatocellular carcinoma, demonstrating the need to find new molecular targets with potential future therapeutic applications. We investigated gene signatures in 38 liver biopsies from patients with NAFLD and obesity who had received bariatric surgery and compared these to 10 control patients who had received a cholecystectomy, using DNA microarray technology. A subset of differentially expressed genes was then validated on a larger cohort of 103 patients who had received bariatric surgery for obesity; data were thoroughly analyzed in terms of correlations with NAFLD pathophysiological parameters. Finally, the impact of a specific cytokine, interleukin-32 (IL32), was addressed on primary human hepatocytes (PHHs). Transcript analysis revealed an up-regulation of proinflammatory cytokines IL32, chemokine (C-X-C motif) ligand 9 (CXCL9), and CXCL10 and of ubiquitin D (UBD), whereas down-regulation of insulin-like growth factor-binding protein 2 (IGFBP2) and hypoxanthine phosphoribosyltransferase 1 (HPRT1) was reported in patients with NAFLD. Moreover, IL32, which is the major deregulated gene, correlated with body mass index (BMI), waist circumference, NAFLD activity score (NAS), aminotransferases (alanine aminotransferase [ALAT] and aspartate aminotransferase [ASAT]), and homeostasis model assessment of insulin resistance (HOMA-IR) index in patients. Consistent with an instrumental role in the pathophysiology of NAFLD, treatment of control human hepatocytes with recombinant IL32 leads to insulin resistance, a hallmark metabolic deregulation in NAFLD hepatocytes. Conclusion: IL32 has a critical role in the pathogenesis of NAFLD and could be considered as a therapeutic target in patients.

Respiratory mechanics during general anaesthesia.

Intraoperative mechanical ventilation is mandatory during many surgical procedures. Knowledge in this field has been widely derived from the experience in the treatment of patients with acute respiratory distress syndrome in the intensive care unit. However, also in surgical patients without lung injury, mechanical ventilation settings affect the clinical outcome, and in particular the occurrence of postoperative pulmonary complications (PPCs). A deep understanding of respiratory physiology is mandatory for the clinician, in order to tailor ventilation settings based on the specific characteristics of each patient. In this paper we will discuss the basis of lung physiology applied to the mechanical ventilation in the operating room. The role of compliance, tidal volume, positive end-expiratory pressure (PEEP), plateau pressure, driving pressure, stress index, mechanical power and other ventilator-derived parameters will be discussed. The above-mentioned physiological parameters are easy to measure and can guide the clinician to assess and titrate mechanical ventilation parameters, but the clinical impact of guiding mechanical ventilation based on these parameters has yet to be determined.

Lung imaging: how to get better look inside the lung.

In the last years, imaging has played a key role in the diagnosis and monitoring and critical illness, including acute respiratory distress syndrome (ARDS). Chest X-ray (CXR) and computed tomography (CT) are the conventional techniques most performed in the critically ill patients, the latter being the gold standard to assess lung aeration in ARDS patients. In addition, two bedside techniques are now gaining popularity alongside the conventional ones: lung ultrasound (LUS) and electrical impedance tomography (EIT). These techniques do not involve the use of ionizing radiations, are non-invasive and relatively easy to use, and are under extensive investigation as a complement, and for some application a substitution of conventional techniques. At last, positron emission tomography (PET) and magnetic resonance imaging (MRI) can provide functional information on the lung and respiratory function, and are increasingly used in research to improve the understanding of the pathophysiological mechanisms underlying ARDS. The purpose of this review is to give an up-to-date overview of the conventional and emerging imaging techniques available the diagnosis and management of patients with ARDS.

Intraoperative mechanical ventilation: state of the art.

Mechanical ventilation is a cornerstone of the intraoperative management of the surgical patient and is still mandatory in several surgical procedures. In the last decades, research focused on preventing postoperative pulmonary complications (PPCs), both improving risk stratification through the use of predictive scores and protecting the lung adopting so-called protective ventilation strategies. The aim of this review was to give an up-to-date overview of the currently suggested intraoperative ventilation strategies, along with their pathophysiologic rationale, with a focus on challenging conditions, such as obesity, one-lung ventilation and cardiopulmonary bypass. While anesthesia and mechanical ventilation are becoming increasingly safe practices, the contribution to surgical mortality attributable to postoperative lung injury is not negligible: for these reasons, the prevention of PPCs, including the use of protective mechanical ventilation is mandatory. Mechanical ventilation should be optimized providing an adequate respiratory support while minimizing unwanted negative effects. Due to the high number of surgical procedures performed daily, the impact on patients' health and healthcare costs can be relevant, even when new strategies result in an apparently small improvement of outcome. A protective intraoperative ventilation should include a low tidal volume of 6-8 mL/kg of predicted body weight, plateau pressures ideally below 16 cmH2O, the lowest possible driving pressure, moderate-low PEEP levels except in obese patients, laparoscopy and long surgical procedures that might benefit of a slightly higher PEEP. The work of the anesthesiologist should start with a careful preoperative visit to assess the risk, and a close postoperative monitoring.

Effects of ventilator settings, nebulizer and exhalation port position on albuterol delivery during non-invasive ventilation: an in-vitro study.

BACKGROUND: Few studies have investigated the factors affecting aerosol delivery during non-invasive ventilation (NIV). Our aim was to investigate, using a bench-top model, the effect of different ventilator settings and positions of the exhalation port and nebulizer on the amount of albuterol delivered to a lung simulator. METHODS: A lung model simulating spontaneous breathing was connected to a single-limb NIV ventilator, set in bi-level positive airway pressure (BIPAP) with inspiratory/expiratory pressures of 10/5, 15/10, 15/5, and 20/10 cmH2O, or continuous positive airway pressure (CPAP) of 5 and 10 cmH2O. Three delivery circuits were tested: a vented mask with the nebulizer directly connected to the mask, and an unvented mask with a leak port placed before and after the nebulizer. Albuterol was collected on a filter placed after the mask and then the delivered amount was measured with infrared spectrophotometry. RESULTS: Albuterol delivery during NIV varied between 6.7 ± 0.4% to 37.0 ± 4.3% of the nominal dose. The amount delivered in CPAP and BIPAP modes was similar (22.1 ± 10.1 vs. 24.0 ± 10.0%, p = 0.070). CPAP level did not affect delivery (p = 0.056); in BIPAP with 15/5 cmH2O pressure the delivery was higher compared to 10/5 cmH2O (p = 0.033) and 20/10 cmH2O (p = 0.014). Leak port position had a major effect on delivery in both CPAP and BIPAP, the best performances were obtained with the unvented mask, and the nebulizer placed between the leak port and the mask (p < 0.001). CONCLUSIONS: In this model, albuterol delivery was marginally affected by ventilatory settings in NIV, while position of the leak port had a major effect. Nebulizers should be placed between an unvented mask and the leak port in order to maximize aerosol delivery.

Postoperative complications of patients undergoing cardiac surgery.

PURPOSE OF REVIEW: Cardiac surgery is at high risk for the development of postoperative complications involving cardiovascular and respiratory system, as well as kidneys and central nervous system. The aim of this review is to provide an overview on the most recent findings concerning the type and incidence of different complications after cardiac surgery and to summarize the current recommendations. RECENT FINDINGS: Despite an improvement of surgical and anaesthesia techniques that resulted in a significant decrease in mortality, postoperative complications play a major role in affecting morbidity, mortality, length of hospital stay and patients' quality of life. The most recent evidence suggests that fluid and inotropes administration should be targeted to maintain a cardiac index above 3 l/min/m throughout the perioperative period. Volatile anaesthesia and mechanical ventilation with low tidal volumes, low driving pressure and moderate-low positive end-expiratory pressure should be preferred. Preoperative steroids could reduce postoperative atrial fibrillation, whereas no drug has shown to effectively prevent kidney injury. SUMMARY: Cardiac surgery is still at high risk for postoperative complications. The optimal type of anaesthesia, protective mechanical ventilation during and after surgery as well as haemodynamic management with vasoactive and inotropic drugs is still to be determined.

Barbed unidirectional V-Loc 180 suture in laparoscopic Roux-en-Y gastric bypass: a study comparing unidirectional barbed monofilament and multifilament absorbable suture.

BACKGROUND: This study aimed primarily to evaluate the safety of digestive running suture (in gastrojejunal and antecolic jejunojejunal anastomosis closure) using unidirectional absorbable barbed suture (V-Loc 180) in laparoscopic Roux-en-Y gastric bypass (LRYGB) and secondarily to assess the efficacy of V-Loc 180 in reducing operative time. METHODS: A prospective cohort study of 315 consecutive patients who underwent LRYGB was performed between October 2009 and October 2012 using an identical procedure technique. For the first 76 patients, a multifilament absorbable suture was used to assess the gastrojejunal anastomosis and the antecolic jejunal suture. For the following 239 patients, a unidirectional barbed monofilament suture was used. Data including operative time, time required for gastric pouch creation, time spent in both anastomoses constructions, conversion rate, and complications were prospectively recorded. RESULTS: The postoperative complications did not differ significantly between the two groups. Early complications were observed for 1 patient (1.3%) in the multifilament group and for 14 patients (5.8%) in the barbed procedure group (p > 0.05). Late complications were observed for 1 patient (1.3%) in the multifilament group and for 5 patients (2%) in the barbed procedure group (p > 0.05). A shortened operative time was achieved in the barbed suture group. The mean operative time was 74.3 ± 15.3 min in the Vicryl group versus 62.7 ± 15.5 min in the V-Loc group (p < 0.05). The mean operative time required to fashion the gastrojejunal anastomosis was 21.3 ± 6.3 min in the Vicryl group versus 17.4 ± 5.1 min in the V-Loc group (p < 0.05). The mean operative time required to fashion the jejunojejunal anastomosis was 21.4 ± 4.9 min in the Vicryl group versus 15.2 ± 5.5 min in the V-Loc group (p < 0.05). CONCLUSIONS: The authors' experience has demonstrated that the use of interlocked V-Loc suture during LRYGB anastomosis appears to be safe and efficient. The findings show a shortened total operative time in terms of single gastrojejunal or jejunojejunal anastomosis time. No statistically significant differences in early or late postoperative complications were observed between the V-Loc and multifilament absorbable suture patients.

Prospective evaluation of peritoneal fluid contamination following transabdominal vs. transanal specimen extraction in laparoscopic left-sided colorectal resections.

BACKGROUND: Natural orifice specimen extraction (NOSE) in colorectal surgery prevents the need for an enlarged port site or minilaparotomy to extract the surgical specimen. The downside of this technique may be an increased risk of bacterial contamination of the peritoneal cavity from the external milieu. The aim of this study was to prospectively analyze the peritoneal bacterial contamination in NOSE and non-NOSE laparoscopic colorectal procedures. METHODS: Consecutive patients operated for sigmoid diverticulitis with laparoscopic approach and transanal extraction of the specimen from January to December 2010 at our university hospital were enrolled. Patients who underwent a laparoscopic sigmoidectomy in the same study period with conventional specimen extraction were used as reference. Peritoneal fluid samples were collected under sterile conditions at the end of the procedure and sent for gram stain as well as anaerobic, aerobic, and fungal cultures. RESULTS: Twenty-nine patients underwent laparoscopic sigmoidectomy for diverticulitis with transanal NOSE, while 9 patients underwent laparoscopic sigmoidectomy with conventional specimen extraction during the same period. The two groups were successfully matched 1:2 (17 NOSE and 9 non-NOSE) according age, sex, ASA, and Charlson comorbidity score. The contamination rate of peritoneal fluid was 100% vs. 88.9% in NOSE and non-NOSE procedures, respectively (P = 0.23). Overall and major complications rates were 27.6% vs. 11.10% (P = 0.41) and 5.08% vs. 11.1% (P = 1) in NOSE vs. non-NOSE procedures, respectively. In the NOSE group there was a statistically significant lower consumption of oral paracetamol (P = 0.007) and of oral tramadol (P = 0.02). CONCLUSIONS: Although a higher peritoneal contamination was found in the NOSE procedures, there were no significant differences in clinical outcomes relative to standard approach. Avoiding a minilaparotomy to extract the specimen resulted in a significantly lower postoperative analgesic requirement in the NOSE group.

Mentored trainees obtain comparable operative results to experts in complex laparoscopic colorectal surgery.

PURPOSE: The aim of this study is to evaluate the impact of an expert monitoring on the quality and results of laparoscopic reversal of Hartmann's procedure (LRHP) performed by trainee surgeons by comparing their results to the expert's outcomes. METHODS: Forty-two LRHP were performed between 2000 and 2008 following a step-by-step, standardised, full laparoscopic procedure. Patients operated upon by a senior surgeon were compared to patients operated upon by trainee surgeons while being mentored by the senior surgeon. Operative time, conversion, complications and post-operative outcome were measured. RESULTS: Each group included 21 patients. All patients underwent LRHP successfully. Two procedures were converted. No significant difference was observed between the expert and the trainees: operative time, 132 min (SD ± 50) vs. 131 min (SD ± 47) and complications (2-14%), 4 vs. 2. Three complications required re-operation, and three other were treated medically, including one dilatation of an anastomosis. Post-operative outcomes were comparable (oral intake, 3 vs. 2 days; post-operative hospital stay, 6 vs. 7.5 days); no mortality occurred. CONCLUSIONS: Standardisation simplifies this difficult laparoscopic procedure and offers the same outcome whether it is performed by an expert or by mentored trainees. The complications were comparable to those occurring at experienced centres (anastomotic leak or stricture, ureteral injury, re-operation). The expert mentoring does not prevent all complications but can solve intra-operative technical problems, thus improving the trainee's confidence. Mentoring should be promoted as it can be performed locally or remotely using modern interactive technology.

Laparo-endoscopic single-site (LESS) with transanal natural orifice specimen extraction (NOSE) sigmoidectomy: a new step before pure colorectal natural orifices transluminal endoscopic surgery (NOTES®).

INTRODUCTION: We present the first human case of laparo-endoscopic single-site sigmoidectomy with transanal natural orifice specimen extraction. DISCUSSION: This technical achievement is a new step toward pure colorectal Natural Orifices Transluminal Endoscopic Surgery. It is the product of a gradual development with critical steps being conceived and standardised in years of experimental and clinical procedures.

Fully laparoscopic colorectal anastomosis involving percutaneous endoluminal colonic anvil control (PECAC).

INTRODUCTION: A novel technique for secure placement of the anvil for mechanical stapled anastomosis in the proximal colon without exteriorization of the bowel is described. METHODS: After standard laparoscopic segmental colonic mobilization, a needle-cannula from a percutaneous endoscopic gastrostomy kit is passed under direct endoscopic vision transparietally into the colon at the site intended for anvil placement. A wire passed through the cannula into the colon is then withdrawn endoscopically per ano. The stapler anvil is fixed to the wire and pulled back along the intestine before being positioned by traction through the needle puncture site. After distal specimen transection, a standard stapled anastomosis is performed. RESULTS: The technique is illustrated in 2 patients undergoing laparoscopic sigmoidectomy by either a single port or a multiport procedure with transanal specimen extraction. CONCLUSION: By positioning the anvil without colon exteriorization, this technique enables pure intraperitoneal colonic anastomoses that may advance natural orifice operating.