Management of critically ill surgical patients Case reports.

The acute abdomen (AA) still remains a challenging situation for surgeons. New pathological conditions have been imposed to our attention in this field in recent years. The definition of abdominal compartmental syndrome (ACS) in surgical practice and the introduction of new biological matrices, with the concepts of tension-free (TS) repair of incisional hernias, prompted us to set up new therapeutic strategies for the treatment of patients with AA. Thus we reviewed the cases of AA that we observed in recent years in which we performed a laparostomy in order to prevent or to treat an ACS. They are all cases of acute abdomen (AA), but from different origin, including chronic diseases, as in the course of inflammatory bowel disease (IBD), and acute pancreatitis. In all the cases, the open abdominal cavity was covered with a polyethylene sheet. The edges of the wound were sutured to the plastic sheet, and a traction exerted by a device that causes a negative pressure was added. This method was adopted in several cases without randomization, and resulted in excellent patient's outcomes. KEY WORDS: Abdominal compartmental syndrome, Acute abdomen, Laparostomy.

[Artificial nutrition in severe acute pancreatitis: an evolving concept]. / La nutrizione artificiale nella pancreatite acuta grave. Un concetto in evoluzione.

We reviewed our series of consecutive cases of severe pancreatitis observed from 2002 to 2004, in order to verify how our actual therapeutic strategy improved prognosis. Seventeen patients with diagnosis of severe pancreatitis (SP) were admitted. On presumption of SP we inserted a naso-jejunal self-propelling feeding tube (SPT) in all but one patients, and an early enteral nutrition ( EEN ) was started. Severity of pancreatitis has been scored by APACHE II (> 8), IMRIE (> or = 3), and Balthazar Computed Tomography findings (> 30% necrosis). We always used a polymeric diet added with glutamine and fibres at initial rate of 20-30 ml/h until achievement of a full regimen of EEN, based on Harris-Benedict formula but no more than 30 kcal/kg/day. Only one patient has been submitted to surgical removal of infected necrosis. A patient died (5.8%) by dis-metabolic and septic state. From our experience we can state EEN is safe and useful to determine a favourable outcome on this dismal pathology, preserving the patient from infection, without significative alterations of nutritional index.

[Acute abdomen in antiphospholipid antibodies syndrome (PAPS)]. / Addome acuto nella sindrome da anticorpi antifosfolipidi (PAPS).

Intestinal ischemia in antiphospholipid antibody syndrome (PAPS) could be due to arterial thrombosis from hypercoagulability. A male patient, 45 years old, was admitted to the hospital with symptoms of acute abdomen and after laparotomy he developed sepsis, right kidney infarction, jejunal ischemia, aortic thrombosis, wide necrosis of both gluteus muscles, left subclavian vein thrombosis. Our therapeutic and diagnostic strategy was delineated after demonstration of antiphospholipid antibodies. The patient was treated with total parenteral nutrition in the presence of 5 enteric fistulas with very high outflow, arterial stent insertion and daily changes of medicated dressings. Outcome was excellent with small residual deficit in walking. Continuous nutritional status monitoring and very high nitrogen supply allowed excellent healing of huge wounds and closure of enteral fistulas.

[Perioperative enteral nutrition]. / Nutrizione enterale perioperatoria.

Enteral nutrition, as demonstrated by the many published papers, is not only safer and cheaper than parenteral supply of nutrients, but modulates an exaggerated cytokine response related to surgical trauma that leads to an increase in intestinal permeability, bacterial translocation and infection. The aim of enteral nutrition is to reduce the impact of cytokines on surgical patients and the related infectious complications. Via the enteral route the nutrients can reach the bowel lumen where enterocytes draw upon their fuel, preserving the barrier effect and modulating the cytokine response. Parenteral supply does not achieve this target since the blood supply of nutrients is not as important as the luminal supply. It is only via the enteral supply route that we can preserve the barrier effect. Since the cytokine response sets in immediately after a trauma such as surgery, we implement uninterrupted enteral nutrition, which means before, during and after surgery, plus parenteral support till the full calorie intake is achieved. In a hepatic resection study, we have demonstrated that enteral nutrition modulates the interleukin-6 immunological response and shortens both the period to bowel movement resumption and the duration of hospital stay. Aggressive enteral nutrition has also been implemented in severe pancreatitis, allowing control of the disease without the onset of septic complications. The most important target is not to achieve full calorie intake rapidly, but to supply the enteric mucosa continuously with useful immuno-nutrients, such as glutamine and fibres, to preserve the barrier effect, the mucus layer, and immunological status of the mucosa. In this way we have obtained significant results in the surgical treatment of these patients, reducing the infection rate and hospital stay. New prospects may be,possible in the fight against surgical infections by adding probiotics to enteral nutrition in order to improve the microenvironment of the colon.

Using the angio-seal to achieve hemostasis in prosthetic endovascular surgery: report of three cases.

At least 10% of patients who undergo bilateral aortofemoral bypass are at risk of needing a reoperation for late prosthetic thrombosis because of reduced outflow as the disease progresses. To prevent occlusion of the prostheses, we performed endovascular surgery with transprosthetic access for distal stenosis. We report our experience of using the Angio-Seal with transprosthetic access after angioplasty in three patients who had undergone bilateral aortofemoral bypass. Hemostasis was achieved in all three patients. There were no complications, such as hemorrhage, hematoma, or prosthetic infection, and all three patients were discharged within 24 h. At the 12-, 15-, and 24-month follow-up, none of the patients had any sign of recurrent claudication. Using the Angio-Seal in bilateral aortofemoral bypass provided the means of treating distal stenosis by endovascular surgery with transprosthetic access. This method is both rapid and safe, and may broaden the indications for the endovascular treatment of distal arteriopathies in patients with vascular prostheses.

Surgical treatment for liver metastases from colorectal carcinoma: results of 228 patients.

BACKGROUND/AIMS: Liver metastases are a very common event. Multiple choices of therapies can be used. The aim of this paper is to analyze results and methods of a single institution series of 228 consecutive patients with colorectal liver metastases. METHODOLOGY: 228 consecutive patients underwent hepatic resection for colorectal liver metastases. From different periods intraoperative ultrasound, intraoperative histological examination, locoregional intra-arterial chemotherapy, and radiofrequency thermal ablation were introduced. RESULTS: Operative mortality was 0.9%. Mean follow-up was 29.5 months. Overall survival was 16% and 9% at 5 and 10 years. 5-year survival was 23% and 6% for patients with single and multiple metastases respectively. For patients with extrahepatic metastatic single lesion 5-year survival was 15%. From the start of intraoperative ultrasound use, 5-year survival was 9% and 27% for patients with multiple and single metastases. Five-year survival for re-resected patients was 13%. Overall survival at 1 and 3 years was 90% and 58% in patients treated with HAI and systemic chemotherapy (disease-free 70% and 47%) and 94% and 12% in patients treated with systemic chemotherapy alone after radical resection (disease-free 53% and 0%). CONCLUSIONS: Aggressive approach, re-resections, intraoperative ultrasound staging, intra-arterial chemotherapy and radiofrequency thermal ablation are justified in multimodal therapeutic strategy of colorectal metastases and seem to improve patients' survival.

A case of rapid intrahepatic dissemination of hepatocellular carcinoma after radiofrequency thermal ablation.

BACKGROUND: Radiofrequency ablation (RFA) is a novel technique for the treatment of liver malignancies that is becoming increasingly more popular because of its feasibility, effectivity, repeatability, and safety. However, an increased number of complications after RFA has been reported in literature. The aim of this paper is to discuss the possible role of RFA in rapid intrahepatic spreading of hepatocellular carcinoma (HCC). PATIENTS AND METHODS: We treated a 66-year-old woman who had a 3.5-cm HCC with two courses of percutaneous RFA using a modified needle with seven hooks. The effectiveness of the treatment was assessed 1 month later by enhanced computed tomography. RESULTS: Two courses of treatment were needed owing to the nodule position (close to the inferior vena cava). Computed tomography scan performed 1 month after the second RFA showed an intrahepatic arteriovenous fistula. Angiography performed after 1 month showed a rapid intrahepatic spreading of HCC. CONCLUSIONS: Radiofrequency ablation can create an arteriovenous fistula that can facilitate migration of tumoral cells from the nodule to the hepatic portal system and rapid intrahepatic dissemination of HCC.

[Current trends of artificial enteral nutrition in acute pancreatitis]. / Attuali indirizzi di nutrizione artificiale enterale nella pancreatite acuta.

During recent years, there has been considerable debate as to the nutritional supply that needs to be established for a patient with acute pancreatitis. The main problem is still infection of the pancreatic necrosis, which has a decisive bearing on the indication for surgery and is the main cause of mortality. Infection stems from bacterial translocation from the patient's gut. Enteral nutrition with its known potential for reducing this type of infection constitutes an attempt to prevent it by preserving the enteric mucosal barrier. Today, the concept of pancreatic rest is no longer considered mandatory in the guidelines of many Surgical and Nutritional Societies, whilst enteral nutrition is the gold standard for acute pancreatitis. Assuring an integrated parenteral and enteral supply before reaching the full regimen of enteral nutrition is the most reliable policy during the early days of the disease. Moreover, outcomes being equal, enteral nutrition is cheaper than parenteral nutrition, as has been extensively demonstrated in many clinical trials in severe acute pancreatitis.

[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.

[Influence of enteral nutrition on cytokine response in resective liver surgery]. / Influenza della nutrizione enterale sulla risposta citochinica in chirurgia resettiva epatica.

Postoperative infectious complications are nowadays a major problem in liver surgery. Better surgical outcomes with a consequent reduction in treatment and hospitalisation costs are a primary objective. The aim of this prospective, randomised study was to evaluate the cytokine response during and after portal clamping in patients undergoing liver resection and continuously fed with enteral nutrition as compared to patients receiving parenteral nutritional support. Forty patients with liver tumours were divided into two groups of 20 on the basis of the presence or absence of chronic liver disease. Furthermore, the latter group of 20 were randomised to two subgroups A and B of 10 patients on the basis of the different perioperative nutrition modalities. Group A patients were fed by so-called uninterrupted enteral nutrition, which means without interruption from the day before surgery with a nutritional solution delivered via a nasojejunal tube. The patients in group B were submitted to hepatic resection with parenteral nutritional support. Liver resection had to consist in resection of at least 30% of the parenchyma in non-cirrhotic patients or in segmental resection in cirrhotic ones. Ten milliliter blood samples were harvested before operation, and 10, 30 and 60 min after declamping and at 24 h. Interleukin 6 and a-tumour necrosis factor values were detected in blood samples. The values of C reactive protein and of prealbumin were recorded at 72 h postoperatively. We also evaluated postoperative complications, resumption of bowel movements, oral intake of nourishment, and patient discharge. Values in blood samples in the two groups showed a statistically significant difference in interleukin 6 values only after 24 h (10 min: group A 121 +/- 25.3, group B 156 +/- 31.4; after 24 h: group A 31.5 +/- 12, group B 105.1 +/- 24.1), while the a-tumour necrosis factor assay showed no significant difference between the two groups. However, there was an appreciably longer hospital stay (group A 10.9 +/- 3.1 days (range: 7-21 days), group B 13.2 +/- 2.7 days (range: 8-19 days) (P < 0.02) and a quicker resumption of bowel movements in group A. The data available show that uninterrupted enteral nutrition produces a modulation of the cytokine response following portal clamping. A lower cytokine activation cascade reduces the impact of the action of cytokines on the hepatic parenchyma with consequent enhancement of the hepatic Kupffer cell component. These factors thus substantially reduce the length of the patient's hospital stay and consequently the cost of medical care.