Risks of COVID-19 transmission in blood and serum during surgery A prospective cross-sectional study from a single dedicated COVID-19 center.

The present pandemic caused by the SARS COV-2 coronavirus is still ongoing, although it is registered a slowdown in the spread for new cases. The main environmental route of transmission of SARS-CoV-2 is through droplets and fomites or surfaces, but there is a potential risk of virus spread also in smaller aerosols during various medical procedures causing airborne transmission. To date, no information is available on the risk of contagion from the peritoneal fluid with which surgeons can come into contact during the abdominal surgery on COVID-19 patients. We have investigated the presence of SARS-CoV-2 RNA in the peritoneal cavity of patients affected by COVID-19, intraoperatively and postoperatively. KEY WORDS: Covid-19, Laparotomy, Surgery.

Risk for lower intestinal perforations in patients with rheumatoid arthritis treated with tocilizumab in comparison to treatment with other biologic or conventional synthetic DMARDs.

OBJECTIVE: To investigate the risk of developing lower intestinal perforations (LIPs) in patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ). METHODS: In 13 310 patients with RA observed in the German biologics register Rheumatoid Arthritis: Observation of Biologic Therapy, 141 serious gastrointestinal events possibly associated with perforations were reported until 31 October 2015. All events were validated independently by two physicians, blinded for treatment exposure. RESULTS: 37 LIPs (32 in the colon/sigma) were observed in 53 972 patient years (PYs). Only two patients had a history of diverticulitis (one in TCZ). Age, current/cumulative glucocorticoids and non-steroidal anti-inflammatory drugs were significantly associated with the risk of LIP. The crude incidence rate of LIP was significantly increased in TCZ (2.7/1000 PYs) as compared with all other treatments (0.2-0.6/1000 PYs). The adjusted HR (ref: conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs)) in TCZ was 4.48 (95% CI 2.0 to 10.0), in tumour necrosis factor-α inhibitor (TNFi) 1.04 (0.5 to 2.3) and in other biologic DMARDs 0.33 (0.1 to 1.4). 4/11 patients treated with TCZ presented without typical symptoms of LIP (acute abdomen, severe pain). Only one patient had highly elevated C reactive protein (CRP). One quarter of patients died within 30 days after LIP (9/37), 5/11 under TCZ, 2/13 under TNFi and 2/11 under csDMARD treatment. CONCLUSIONS: The incidence rates of LIP under TCZ found in this real world study are in line with those seen in randomised controlled trials of TCZ and higher than in all other DMARD treatments. To ensure safe use of TCZ in daily practice, physicians and patients should be aware that, under TCZ, LIP may occur with mild symptoms only and without CRP elevation.

Patients with endometriosis of the rectosigmoid have a higher percentage of natural killer cells in peripheral blood.

STUDY OBJECTIVE: To estimate the concentration of natural killer (NK) cells in the peripheral blood in patients with and without endometriosis. DESIGN: Case-control study (Canadian Task Force classification II-2). SETTING: Tertiary referral hospital. PATIENTS: One hundred fifty-five patients who had undergone videolaparoscopy were divided into 2 groups: those with endometriosis (n = 100) and those without endometriosis (n = 55). INTERVENTIONS: The percentage of NK cells relative to peripheral lymphocytes was quantified at flow cytometry in 155 patients who had undergone laparoscopy. In addition to verifying the presence of endometriosis, stage of disease and the sites affected were also evaluated. MEASUREMENTS AND MAIN RESULTS: The mean (SD) percentage of NK cells was higher (15.3% [9.8%]) in patients with endometriosis than in the group without the disease (10.6% [5.8%]) (p < .001). The percentage of NK cells was highest (19.8 [10.3%]) in patients with advanced stages of endometriosis and in those in whom the rectosigmoid colon was affected. In a statistical model of probability, the association of this marker (NK cells ≥11%) with the presence of symptoms such as pain and intestinal bleeding during menstruation and the absence of previous pregnancy yielded a 78% likelihood of the rectosigmoid colon being affected. CONCLUSION: Compared with patients without endometriosis, those with endometriosis demonstrate a higher concentration of peripheral NK cells. The percentage of NK cells is greater, primarily in patients with advanced stages of endometriosis involving the rectosigmoid colon. Therefore, it may serve as a diagnostic marker for this type of severe endometriosis, in particular if considered in conjunction with the symptoms.

A clinical and radiological comparison of sigmoid diverticulitis episodes 1 and 2.

AIM: After an initial uncomplicated attack, sigmoid diverticulitis may recur, but the morphological characteristics of recurrent diverticulitis have not been investigated. We compared the clinical and radiological severity, the respective location and clinical outcome of the first two episodes of sigmoid diverticulitis. METHOD: We reviewed the charts of 60 patients [median age 61 (range 31-90) years] who were admitted initially for a first episode of uncomplicated left colonic diverticulitis, and who were eventually readmitted for a second episode, both being documented by abdominal computed tomography (CT) scan. RESULTS: The median delay between the two episodes was 19 (3-97) months. Six (10%) patients developed a second complicated episode of diverticulitis [Hinchey II (n = 2), CT-guided percutaneous drainage; Hinchey III (n = 3), emergency Hartmann's operation; colovesical fistula (n = 1), elective sigmoid resection]. Fifty-four (90%) patients were admitted for a second episode of uncomplicated diverticulitis. In this group, the duration of hospital stay [11 (4-22) vs 10 (1-39) days, P = 0.28], serum levels of C-reactive protein [131 (31-350) vs 112 (22-333) mm, P = 0.62] and CT scan-based severity score [3 (1-6) vs 3 (0-7) points, P = 0.07] were similar between the two episodes. In 19 out of 54 (35%) patients with simple recurrent diverticulitis, although disease severity was similar, the disease topography differed and recurrence involved another segment of the left colon. CONCLUSION: The majority of patients who develop recurrence do so in a similar mode and location. However, 10% develop complicated diverticulitis and in 35% of patients recurrent diverticulitis occurs at a different location.

Does a 48-hour rule predict outcomes in patients with acute sigmoid diverticulitis?

INTRODUCTION: Sigmoid diverticulitis is an infection that resolves with conservative management in 70-85% of patients. Some patients require prolonged hospitalization or surgery during their admission. It has been taught that one should expect clinical improvement within 48 h. In this study, we examined whether basic clinical parameters (the maximum temperature and leukocyte count) of patients would predict improvement and discharge as expected, or prolonged hospitalization. MATERIALS AND METHODS: Data was acquired from 198 patients admitted with acute sigmoid diverticulitis as confirmed by computed tomography (CT) scanning and physical exam. One hundred sixty-five patients recovered without surgery with an average hospital stay of 4 days: 120 were discharged within 4 days, whereas 45 patients required longer stays. Nineteen patients underwent surgery early during their admission (within 48 h). Fourteen patients did not improve over time and required surgery later during their hospital stay. The daily maximum temperature and leukocyte count of patients with prolonged stays was compared to the patients who were discharged within 4 days using analysis of variance analysis. RESULTS: The average maximum temperature and leukocyte count on admission were not statistically different between the groups; therefore, maximum temperature and leukocyte count on admission alone are not predictive. After the first 24 h, however, one could see a statistically significant difference in maximum temperature (p=0.004). The leukocyte count responded significantly by hospital day 2 (p=0.003). Both trends were significant through hospital day 4. DISCUSSION: Patients with a noticeable drop in leukocyte count and maximum temperature over the first 48 h of medical management were predictably discharged early on oral antibiotics. Patients failing to improve at 48 h required prolonged stays or surgery. CONCLUSION: By observing early trends in leukocyte count and maximum temperature of patients with diverticulitis, one can predict whether they will recover quickly as expected or if they will likely require prolonged IV antibiotics and/or surgery.

[Perioperative management of a patient with an acquired von Willebrand syndrome]. / Gestion périopératoire d'un patient porteur d'un syndrome de von Willebrand acquis.

We report the case of a man suffering from a monoclonal gammapathy with an acquired von Willebrand disease in a perioperative context. This pathology is rare, but is important to diagnose because of the possible haemorrhagic complications encountered. We describe the main therapeutic options available today to prevent bleeding during major surgery.

Diverticulitis causing a high serum level of carbohydrate antigen 19-9: report of a case.

We report herein a rare case of diverticulitis causing a high serum level of carbohydrate antigen (CA) 19-9. A 52-year-old man was admitted to our hospital with lower abdominal pain. Laboratory data showed evidence of inflammation and a high serum level of CA 19-9 (370 U/ml). Computed tomography demonstrated thickening of the wall of the sigmoid colon. He was diagnosed as having diverticulitis of the sigmoid colon and was treated with antibiotics. Although his symptoms improved, the presence of a malignancy such as colorectal cancer could not be completely ruled out because of the persistently high serum level of CA 19-9. A laparotomy was performed and the sigmoid colon was found to be adherent to the bladder. Under a diagnosis of diverticulitis, a sigmoidectomy was performed. Pathological examination revealed diverticulitis of the sigmoid colon, but there was no evidence of malignancy in the resected specimen. The serum CA 19-9 level decreased to normal postoperatively and immunohistochemical staining revealed CA 19-9 antigen in the cytoplasm of the diverticular epithelium. Therefore, a possible explanation for the high level of this tumor marker was diverticulitis of the sigmoid colon.

[Use of plasmapheresis in a 62-year-old patient with severe infection]. / Einsatz einer Plasmapherese bei einem 62jährigen Patienten mit schwerer Sepsis.

INTRODUCTION: The elimination of cytotoxic substances from blood as part of sepsis treatment has been controversely discussed so far. The following case report demonstrates the advantages and disadvantages of this therapy strategy. CASE REPORT: A 62-year-old male patient developed a paralytic ileus with wound dissection 3 days after elective sigma resection. A few hours after surgical revision he went into severe sepsis. A controlled ventilation was necessary as well as the use of catecholamines to maintain sufficient mean arterial pressure. Body temperature stayed between 39 and 40 degrees C (rectal). The patient's extremities and body showed severe marmorations due to the pathologic vasal alteration. A laparotomy one day after the operation revealed a massive generalized edema of the bowels without any evidence of insufficient anastomosis. The fulminant septic process could not be stopped with conservative treatment including continuous veno-venous hemofiltration. Under further deterioration of the pulmonary function (signs of beginning ARDS) and the generalized capillary leak syndrome we started plasmapheresis 2 days after operation in order to eliminate high-molecular cytokines. The plasmapheresis was done twice the following 2 days. Under this treatment the septic process was stopped. The pulmonary function and the circulation improved. The disturbed peripheral perfusion normalized. A laparotomy confirmed a significant decrease of the intestine wall edema. Unfortunately we could not repeat plasmapheresis. On the following days the patient worsened again and died 20 days later due to multiorgan failure. DISCUSSION: The temporary improvement during plasmapheresis suggests that the patient might have profited from plasmapheresis-related optimized oxygen delivery, controlled diuresis and decrease of oxygen consumption. In addition we hypothesized that elimination of high-molecular cytokines and toxines contributed to the improvement under plasmapheresis. Using plasmapheresis one has to consider the high costs, risk of infection, and the unexplained mode of action to the mediatory process. Therefore we cannot recommend this treatment in general. Further controlled studies should investigate the therapeutic benefits of plasmapheresis in patients with severe sepsis.

[Toxemia syndrome in patients with acute intestinal obstruction]. / Sindrom intoksikatsii u bol'nykh ostroi kishechnoi neprokhodi- most'iu.

The results of examination and treatment of 216 patients with acute intestinal obstruction of benign genesis are discussed. The values of blood plasma toxicity and the values of hemostasis determined before and after the operation were compared. Intoxication of patients was found to increase in the postoperative period. Its increase was appraised according to the duration of the disease. The causes of mortality were analysed and the risk factors of intoxication increase in the postoperative period were revealed. The authors suggest a classification of the phases of intoxication in patients with acute intestinal obstruction on the basis of the degree of intoxication and the condition of homeostasis.