VATS in complicated COVID-19 patients: case series.

Common complications of coronavirus disease 2019 (COVID-19) related ARDS and ventilation are barotrauma-induced pneumothorax, pneumatocele and/or empyema. We analysed indications and results of video-assisted thoracoscopic surgery (VATS) in complicated COVID-19 patients. This is a retrospective single-institution study analysing a case series of patients treated by VATS for secondary spontaneous pneumothorax (SSP), pneumatocele and empyema complicating COVID-19, not responding to drainage in Lodi Maggiore Hospital between February 2020 and May 2021. Out of 2076 patients hospitalized in Lodi Maggiore Hospital with COVID-19, nine Males (0,43%; mean age 58,1-33-81) were treated by VATS for complications of pneumonia (6 SSP and 3 empyema; 1 case complicated by haemothorax). 7 patients (77%) had CPAP before surgery for 21.3 days mean (4-38). Mean Operative time was 80.9 min (38-154). Conversion rate was 0%. 3 (33%) patients were admitted to ICU before VATS. Treatments were: bullectomy in six patients (66%), drainage of the pleural space in all patients, pleural decortication and fluid aspiration in five cases (55%). two patients (22%) needed surgery interruption and bilateral ventilation to restore adequate oxygenation. Mortality was 1/9 (11%) due to respiratory failure for persistent pneumonia. In one patient (11%) redo surgery was performed for bleeding. Mean postop Length of Stay (LOS) was 37.9 days (10-77). Our report shows that VATS can be considered an extreme, but effective treatment for COVID-19 patients with SSP, pneumatocele or empyema, for patients who can tolerate general anaesthesia. Attention must be paid to the aerosol-generation of infected droplets.

[Multimodal approach to rectal carcinoma with hepatic metastasis]. / Approccio multimodale al carcinoma del retto con metastasi epatica.

BACKGROUND: The role of surgery in the treatment of rectal cancer has been demonstrated worldwide. Moreover, curative liver resection of colorectal liver metastases is the only treatment offering a chance of long-term survival. Unfortunately, the liver resection can be performed in only 10% of the patients. AIM: In order to extend the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer, we describe, in the video, a multimodal approach to rectal cancer with liver metastasis in the right lobe. Patient and methods. A 51 years old woman was admitted to our Department for adenocarcinoma of the distal rectum and a resectable solitary synchronous liver metastasis located across the right and the middle hepatic vein. Unfortunately, the future remnant liver was too small, risking severe post-operative liver failure. For this reason, a portal vein embolization or occlusion has been proposed. First of all, the patient has been submitted to laparoscopic low anterior resection with simultaneous right portal vein ligature. Two months later, after a CT estimation of liver volume in vivo, she was submitted to right hepatectomy (open surgery). RESULTS: Both postoperative courses were uneventful. CONCLUSIONS: As a preparation for large hepatic resection for liver rectal metastasis the laparoscopic ligature of the right portal vein performed simultaneously to the laparoscopic low anterior resection is feasible and safe.

[Minimally invasive esophagectomy for adenocarcinoma of the lower esophagus and the gastroesophageal junction]. / Esofagectomia mininvasiva per adenocarcinoma siewert i della giunzione gastroesofagea.

BACKGROUND: Adenocarcinoma of lower esophagus and GEJ shows worldwide an increasing incidence. The optimal approach to resection is still controversial. One of the major disadvantages of radical esophagectomy with extensive lymphadenectomy with open technique is its high rate of morbidity and mortality. Recent advances in minimally invasive surgical technology have allowed surgeons to apply laparoscopy and thoracoscopy to perform esophagectomy. PATIENT AND METHODS: In the video we report the case of a 79 years old man with Siewert I adenocarcinoma of GEJ, who was submitted to a 3-stage minimally invasive esophagectomy by laparoscopy, right thoracoscopy and cervicotomy. Preoperative endoscopic ultrasound and CT scan showed a marked thickening of the wall of the distal esophagus, with extension proximal to the mediastinal pleura and the anterior surface of the aorta, but still showing features of resectability. Four ports were used for the abdominal approach. A complete mobilization of the stomach preserving the right gastroepiploic arcade was achieved. The patient was then turned to the left lateral decubitus position proned to 30 degrees. Three ports were needed for right thoracoscopy. Mobilization of the thoracic esophagus was carried out from the diaphragm to the thoracic inlet. After extraction of the specimen through a small abdominal incision, the stomach was pulled up to the neck and esophagogastric anastomosis with the Orringer technique was constructed through a left cervicotomy. Pathology showed pT3 pN1 G3 adenocarcinoma. CONCLUSIONS: The minimally invasive approach to adenocarcinoma of the lower esophagus, in center with expertise in minimally invasive surgical technique, is feasible and safe.

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study.

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.

Laparoscopic treatment of epiphrenic diverticula.

BACKGROUND AND PURPOSE: Epiphrenic diverticula are a rare disease probably caused by long-standing impairment of esophageal motor activity. Symptomatic disease, which may worsen clinically during follow-up even to severe symptoms, is usually considered an indication for surgical treatment. Surgery for epiphrenic diverticula consists of diverticulectomy, which traditionally is performed through a left thoracotomy; a myotomy and partial fundoplication are generally included in order to treat the underlying motor disorder and to prevent or correct reflux. The same principles of surgical treatment can be achieved through the laparoscopic transhiatal approach. The aim of this paper is to describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap to treat epiphrenic diverticula of the esophagus. PATIENTS AND METHODS: From January 1994 through May 2001, 11 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. RESULTS: In all patients, the operation was completed through the minimally invasive access. The postoperative course was complicated in one patient (9%), who had a leak from the staple line, which was repaired through a thoracotomy. At follow-up, this patient had persistence of a small pouch at the diverticuletomy site. However, he was asymptomatic. All other patients were free of symptoms and without recurrence. CONCLUSION: Laparoscopy offers good access to the distal esophagus and the inferior mediastinum. Removal of the diverticulum, treatment of the motor disorder, and prevention of postoperative reflux can all be obtained through this approach. The immediate postoperative and long-term results are satisfactory.

Coupled plasma filtration-adsorption in a rabbit model of endotoxic shock.

OBJECTIVE: To test the hypothesis that nonselective adsorption by a hydrophobic resin of cytokines and other proinflammatory mediators could improve 72-hr survival in a rabbit model of endotoxic shock. DESIGN: Prospective, randomized, controlled animal trial. SETTING: Animal care facility at a research institution. SUBJECTS: A total of 109 New Zealand white male rabbits. INTERVENTIONS: Anesthetized rabbits were cannulated with indwelling femoral arterial and venous lines. Septic shock was induced by a single intravenous injection of Escherichia coli lipopolysaccharide. The dose was experimentally assessed in 40 rabbits receiving 1.0, 0.5, 0.1, and 0.05 mg/kg body weight to determine LD80 at 72 hrs. Extracorporeal circulation consisted of plasma filtration coupled with passage of the plasma filtrate through a hydrophobic sorbent and reinfusion into the venous line. The extracorporeal treatment lasted for 3 hrs. Rabbits injected with endotoxin (0.05 mg/kg) were submitted to plasma filtration with (19 rabbits) or without (20 rabbits) sorbent adsorption. As controls, rabbits injected with vehicle alone were treated with plasma filtration (ten rabbits) or without (ten rabbits) sorbent adsorption. Ten rabbits were monitored under anesthesia to determine basal survival. MEASUREMENTS AND MAIN RESULTS: Plasma concentrations of endotoxin, bioactive tumor necrosis factor, resin-adsorbed platelet-activating factor, mean arterial pressure, base excess, and white cell count were assessed and a global severity score was established. At 72 hrs, cumulative survival was significantly (p = .0041) improved in septic rabbits treated with coupled plasma filtration-adsorption. Circulating tumor necrosis factor bioactivity remained similar in control and treated rabbits. Biologically significant amounts of platelet activating factor were eluted from the sorbent during the entire treatment time. The severity score inversely correlated with survival (p < .001). CONCLUSIONS: Coupled plasma filtration-adsorption improved survival in a rabbit model of endotoxic shock. Coupled plasma filtration-adsorption may be an extracorporeal treatment capable of removing structurally different inflammatory mediators associated with sepsis.

Artificial nutrition after major abdominal surgery: impact of route of administration and composition of the diet.

OBJECTIVE: To evaluate the impact of the route of administration of artificial nutrition and the composition of the diet on outcome. DESIGN: Prospective, randomized, clinical trial. SETTING: Department of surgery, university hospital. PATIENTS: One hundred sixty-six consecutive patients undergoing curative surgery for gastric or pancreatic cancer. INTERVENTIONS: At operation, the patients were randomized into three groups to receive: a) a standard enteral formula (control group; n = 55); b) the same enteral formula enriched with arginine, RNA, and omega-3 fatty acids (enriched group; n = 55); and c) total parenteral nutrition (TPN group; n = 56). The three regimens were isocaloric and isonitrogenous. Enteral nutrition was started within 12 hrs following surgery. The infusion rate was progressively increased to reach the nutritional goal (25 kcal/kg/day) on postoperative day 4. MEASUREMENTS AND MAIN RESULTS: Tolerance of enteral feeding, rate and severity of postoperative complications, and length of hospital stay were recorded. Early enteral infusion was well tolerated. Side effects were recorded in 22.7% of the patients, but only 6.3% did not reach the nutritional goal. The enriched group had a lower severity of infection than the parenteral group (4.0 vs. 8.6; p < .05). In subgroups of malnourished (n = 78) and homologous transfused patients (n = 42), the administration of the enriched formula significantly reduced both severity of infection and length of stay compared with the parenteral group (p < .05). Moreover, in transfused patients, the rate of septic complications was 20.0% in the enriched group, 38.4% in the control group, and 42.8% in the TPN group. CONCLUSIONS: Early enteral feeding is a suitable alternative to TPN after major abdominal surgery. The use of the enriched diet appears to be more beneficial in malnourished and transfused patients.

Effect of route of delivery and formulation of postoperative nutritional support in patients undergoing major operations for malignant neoplasms.

OBJECTIVE: To study the effect of the route of delivery and formulation of postoperative nutritional support on host defense, protein metabolism, infectious complications, and outcome. DESIGN: Prospective, randomized, clinical trial. SETTING: Department of Surgery at a university hospital. PATIENTS: Two hundred sixty candidates for pancreaticoduodenectomy or gastrectomy for cancer. INTERVENTIONS: Patients were randomly allocated into 3 groups during surgery. Starting 6 hours after operation, the first group received a standard enteral formula (standard group; n = 87); the second, the same enteral formula enriched with arginine, omega-3 fatty acids, and RNA (immunonutrition group; n = 87); and the third, total parenteral nutrition (parenteral group; n = 86). The 3 regimens were isocaloric and isonitrogenous. The nutritional goal was 105 kJ/kg per day. MAIN OUTCOME MEASURES: Immune response by phagocytosis ability of polymorphonuclear cells, interleukin (IL)-2 receptor levels, and delayed hypersensitivity response; protein synthesis by IL-6 and prealbumin; tolerance of enteral feeding; incidence of postoperative complications; and length of hospital stay. RESULTS: The immunonutrition group had a significantly better recovery of the immune parameters on postoperative day 8 compared with the other groups. Linear regression analysis showed an inverse correlation between IL-6 and preambulin levels (r = 0.766) only in the immunonutrition group. Only 11 patients (6.3%) in both enteral groups did not reach the nutritional goal. Postoperative infection rate was 14.9% (13/87) in the immunonutrition group, 22.9% (20/87) in the standard group, and 27.9% (24/86) in the parenteral group (P = .06). Mean +/- SD length of hospital stay was 16.1 +/- 6.2, 19.2 +/- 7.9, and 21.6 +/- 8.9 days in the immunonutrition, standard, and parenteral groups, respectively (P = .01 vs standard group; P = .004 vs parenteral group). CONCLUSIONS: Early postoperative enteral feeding is a valid alternative to parenteral feeding in patients undergoing major surgery. Immunonutrition enhances the host response, induces a switch from acute-phase to constitutive proteins, and improves outcome.