The Video-Consulting Emergency protocol: a proposition from the World Society of Emergency Surgery members for the initial management of non-traumatic acute abdomen.

BACKGROUND: Our aim is to propose the Video-Consulting Emergency (VCE) protocol as a tool to improve the decision-making process between an on-site emergency physician and a remote acute care surgeon using a smartphone, the FaceTime application, and the Acute Abdominal Decision Making (AADM®) model proposed by World Society of Emergency Surgeons members. METHODS: The VCE protocol involves the emergency physician and the on-call emergency surgeon. Both must be provided with a smartphone for 24-hour VC with FaceTime application. The AADM® model is a simple, systematic, diagnostic methodology developed by WSES to guide and support physicians throughout the management of acute abdominal pain in the emergency department (ED). FaceTime videoconsulting and the AADM® model con simply systematize the clinical reasoning of the emergency physician when evaluating acute non-traumatic abdomen. RESULTS: The VCE protocol in ED could be fundamental for an effective first surgical screening and it is an interesting clinical tool with the potential to improve clinical evaluation of patients admitted for acute abdomen. CONCLUSIONS: The videoconsulting application could decrease healthcare costs related to unnecessary exams, admissions, surgeries or transfers.

Cholecystectomy in Emilia-Romagna region (Italy): A retrospective cohort study based on a large administrative database.

BACKGROUND: The aim of this study was to ascertain the variability and to identify a trend for the outcome of cholecystectomy surgery when used to treat cholelithiasis and acute cholecystitis. METHODS: This was a large retrospective cohort study following patients up to 11 years post surgery, based on administrative data collected from 2002 to 2012 in the Emilia-Romagna Region (Northern Italy) and comparing the effectiveness and efficiency of surgical activity (laparoscopic (LC) and open cholecystectomy (OC)). Analyses included patient characteristics, length of hospital stay, type of admission and mortality risk. Outcomes considered were death from all causes (during the index hospital admission or thereafter), hospital readmissions with cholecystitis or cholelithiasis as principal diagnosis and time to surgery. RESULTS: A total of 84,628 cholecystomies were performed from 2002 to 2012 out of 123,061 admissions with primary diagnostic category of cholecystitis or cholelitiasis. Laparoscopic procedure was used in 69,842 patients. Over time there was a rising linear statistically significant trend in the use of LC. Mortality rate at 1 year of OC treated patients showed a statistically significant difference compared to LC treated patients (using a cohorts match with propensity score). Only a small number of patients with acute cholecystitis was operated according guidelines within 72 hours. CONCLUSIONS: The analysis of aggregate administrative data is a powerful tool to support regional health management, improve the quality of medical care, and assess the appropriateness of therapeutic or diagnostic approaches. It is important to stress a short hospital stay for laparoscopic cholecystectomy patients (50% less than open surgery): this shorter hospital stay leads to a significant economic advantage. Moreover, mortality is significantly higher in open surgery for acute cholecystitis. Interestingly, the same finding was confirmed after 30 days and 1 year, probably due to comorbidities that are more evident in open surgery. KEY WORDS: Cholecystitis, Cholelithiasis, Delivery of health care, Disease management, Surgical.

Preoperative localization of parathyroid adenoma in video-assisted era: is cervical ultrasound or 99mTc Sesta MIBI scintigraphy better?

BACKGROUND: Endocrine surgeon localizes solitary adenoma (SA) in preoperative time by cervical ultrasound (c-US) and/or 99mTc Sesta MIBI scintigraphy (MIBI-S), but in clinical practice they often show discordant results. The aim of our study is to verify if c-US and MIBI-S have different sensitivity in preoperative localization of SA, depending on its localization, in planning minimally invasive video-assisted parathyroidectomy (MIVAP). METHODS: This is a retrospective analysis of data (demographics data, preoperative localization of SA by US and MIBI-S, presence of associated thyroid disease, preoperative calcemia, preoperative serum PTH, surgical time, intraoperative PTH values, day 1 postoperative calcemia, definitive histological report) about patients consecutively submitted to MIVAP because of SA between January 2011 and January 2014 in the department of endocrine and general surgery of the University Hospital of Parma (Italy). The data, expressed as percentages (%) and means (±SD), were analyzed with SPSS Statistics 22.0 program. RESULTS: The c-US detected 56.25% of the superior SA (9/16 patients) and it failed to identify 7 superior adenomas (43.75%); MIBI-S identified 6/16 superior SA (37.5%) and failed in the identification of 10 superior adenomas (62.5%). For inferior SA, c-US was positive in 39/45 patients (86.66%) and falsely negative in 6/45 patients (13.33%); MIBI-S correctly showed 31/45 inferior adenomas (68.88%) and it was falsely negative in 14/45 patients (31.11%). MIBI-S showed decreased sensitivity in the identification of superior SA (P=0.0383). C-US had a high sensitivity in the identification of the inferior SA (P=0.0280). CONCLUSIONS: C-US and MIBI-S are the best diagnostic tools for preoperative localization of SA, but both have decreased sensitivity in the presence of a concomitant thyroid diseases. In our experience c-US showed high sensitivity in the identification of inferior SA and MIBI-S showed a decreased sensitivity in the identification of superior SA. Discordant results in the identification of SA did not contraindicate MIVAP. Intraoperative parathormone dosage is fundamental to guide the endocrine surgeon and to verify the completeness of surgical resection.

Complicated colorectal cancer in nonagenarian patients: is it better not to perform anastomosis in emergency?

BACKGROUND: Colorectal cancer (CRC) is predominantly a disease of elderly people. Cancer in nonagenarian patients presents an ethical dilemma for surgeons and oncologists, and management of this group of patients in emergency for complicated CRC is debated. Presently described is retrospective study reporting experience of 6 departments of emergency surgery with management of nonagenarian patients sent to emergency surgery for CRC complications. METHODS: Data concerning patients aged over 90 years hospitalized from January 2011 to June 2015 in 6 departments of emergency surgery for complicated CRC were retrospectively analyzed. Data were collected in a dedicated database. Statistical analysis was conducted using IBM software SPSS 22 (IBM Corp., Armonk, NY, USA); statistical significance was set at p=0.05. RESULTS: In the period of study, 19 patients aged over 90 underwent surgery in emergency department for complicated CRC. Of the total, 52.63% were female, with sex ratio F:M of 1.11:1. Mean age was 92.52 years (range: 90-97 years; SD 1.49). Preoperative assessment of surgical risk was made using American Society of Anesthesiologists (ASA) score. There was no statistically significant difference in terms of in-hospital mortality between patients with ASA score ≤ 3 and patients with an ASA score >3. Primary anastomosis was performed in 6 of 19 patients (31.57%), all of whom had right-side colon cancer. Diverting stoma was created for 12 of 19 patients (63.15%). There was a statistically significant difference in incidence of postoperative complications between patients with right-side colon cancer and patients with left-side colon cancer (p=0.0498). Mean length of hospital stay was 12.78 days (range: 2-31 days; SD 6.31). In-hospital mortality rate was 21.05% (n=4). At follow up, overall survival was 47.36% (n=9). CONCLUSION: Elective surgery is the best way to manage CRC in all patients affected. Emergency surgery for CRC complications in patients over 90 is feasible with careful preoperative selection and evaluation of the patient. One-stage surgery is the best choice, in selected patients. Two- and three-stage surgery is indicated in case of peritonitis, for frail patients, for hemodynamically unstable patients. If there is high risk of anastomotic leakage, decompressive stoma is suggested as bridge to elective surgery, and in advanced neoplastic disease, as palliative procedure. In emergency setting, diverting stoma is a good surgical option in nonagenarian patients to decrease surgical risk, morbidity, and mortality; however, clinical randomized controlled trials are necessary to confirm this.

What is changing in the surgical treatment of gastrointestinal stromal tumors after multidisciplinary approach? A comprehensive literature's review.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) represent the most common mesenchymal neoplasms of the gastrointestinal tract. Surgery is the only curative treatment for GIST. The aim of our review was to highlight the changes in the surgical treatment of GIST after the introduction of TKI therapy in a multimodality management (neo-adiuvant or adiuvant setting). EVIDENCE ACQUISITION: We carried out a review of the recent literature about surgical treatment of GIST according to its anatomical location and size according to PRISMA STATEMENT to systematic review. We searched the Cochrane Library, MEDLINE, and EMBASE, limited to the final search date [31/12/2015], limited to English language publications. We used the search terms "GIST" in combination with the terms "surgery" or "multidisciplinary approach" or "TKI therapy" or "neo-adiuvant - adiuvant treatment". EVIDENCE SYNTHESIS: The optimal surgical technique to achieve the best results in terms of Overall Survival, Relapse Free Survival and Disease Free Survival is oncological resection with disease free margins. Proper preoperative staging is essential to decide the surgical approach. Data reported in literature showed that laparoscopic approach to GIST obtains the same oncological results as conventional surgery. CONCLUSIONS: The medical oncologist, radiologist and surgeon must collaborate to determine the appropriateness of primary surgery, with curative intent, after neoadiuvant therapy or as palliative treatment. Laparoscopy is feasible and safe for small GIST, but there is no international consensus for large GIST yet. The introduction of imatinib as neoadjuvant therapy with the goal of reducing tumor size, minimizes surgical morbidity and, in some cases, makes operable the inoperable cases. In addition, the use of imatinib in the adjuvant setting, to eradicate micrometastases and to prevent recurrence, has shown promising results in reducing relapse rates.

Fibroproliferative response to urothelial failure obliterates the ureter lumen in a mouse model of prenatal congenital obstructive nephropathy.

Congenital obstructive nephropathy (CON) is the most prevalent cause of pediatric chronic kidney disease and end-stage renal disease. The ureteropelvic junction (UPJ) region, where the renal pelvis transitions to the ureter, is the most commonly obstructed site in CON. The underlying causes of congenital UPJ obstructions remain poorly understood, especially when they occur in utero, in part due to the lack of genetic animal models. We previously showed that conditional inactivation of Sec10, a central subunit of the exocyst complex, in the epithelial cells of the ureter and renal collecting system resulted in late gestational bilateral UPJ obstructions with neonatal anuria and death. In this study, we show that without Sec10, the urothelial progenitor cells that line the ureter fail to differentiate into superficial cells, which are responsible for producing uroplakin plaques on the luminal surface. These Sec10-knockout urothelial cells undergo cell death by E17.5 and the urothelial barrier becomes leaky to luminal fluid. Also at E17.5, we measured increased expression of TGFß1 and genes associated with myofibroblast activation, with evidence of stromal remodeling. Our findings support the model that a defective urothelial barrier allows urine to induce a fibrotic wound healing mechanism, which may contribute to human prenatal UPJ obstructions.

The exocyst gene Sec10 regulates renal epithelial monolayer homeostasis and apoptotic sensitivity.

The highly conserved exocyst protein complex regulates polarized exocytosis of subsets of secretory vesicles. A previous study reported that shRNA knockdown of an exocyst central subunit, Sec10 (Sec10-KD) in Madin-Darby canine kidney (MDCK) cells disrupted primary cilia assembly and 3D cyst formation. We used three-dimensional collagen cultures of MDCK cells to further investigate the mechanisms by which Sec10 and the exocyst regulate epithelial polarity, morphogenesis, and homeostasis. Sec10-KD cysts initially demonstrated undisturbed lumen formation although later displayed significantly fewer and shorter primary cilia than controls. Later in cystogenesis, control cells maintained normal homeostasis, while Sec10-KD cysts displayed numerous apoptotic cells extruded basally into the collagen matrix. Sec10-KD MDCK cells were also more sensitive to apoptotic triggers than controls. These phenotypes were reversed by restoring Sec10 expression with shRNA-resistant human Sec10. Apico-basal polarity appeared normal in Sec10-KD cysts, whereas mitotic spindle angles differed significantly from controls, suggesting a planar cell polarity defect. In addition, analysis of renal tubules in a newly generated kidney-specific Sec10-knockout mouse model revealed significant defects in primary cilia assembly and in the targeted renal tubules; abnormal epithelial cell extrusion was also observed, supporting our in vitro results. We hypothesize that, in Sec10-KD cells, the disrupted exocyst activity results in increased apoptotic sensitivity through defective primary cilia signaling and that, in combination with an increased basal cell extrusion rate, it affects epithelial barrier integrity and homeostasis.

Urothelial Defects from Targeted Inactivation of Exocyst Sec10 in Mice Cause Ureteropelvic Junction Obstructions.

Most cases of congenital obstructive nephropathy are the result of ureteropelvic junction obstructions, and despite their high prevalence, we have a poor understanding of their etiology and scarcity of genetic models. The eight-protein exocyst complex regulates polarized exocytosis of intracellular vesicles in a large variety of cell types. Here we report generation of a conditional knockout mouse for Sec10, a central component of the exocyst, which is the first conditional allele for any exocyst gene. Inactivation of Sec10 in ureteric bud-derived cells using Ksp1.3-Cre mice resulted in severe bilateral hydronephrosis and complete anuria in newborns, with death occurring 6-14 hours after birth. Sec10 FL/FL;Ksp-Cre embryos developed ureteropelvic junction obstructions between E17.5 and E18.5 as a result of degeneration of the urothelium and subsequent overgrowth by surrounding mesenchymal cells. The urothelial cell layer that lines the urinary tract must maintain a hydrophobic luminal barrier again urine while remaining highly stretchable. This barrier is largely established by production of uroplakin proteins that are transported to the apical surface to establish large plaques. By E16.5, Sec10 FL/FL;Ksp-Cre ureter and pelvic urothelium showed decreased uroplakin-3 protein at the luminal surface, and complete absence of uroplakin-3 by E17.5. Affected urothelium at the UPJ showed irregular barriers that exposed the smooth muscle layer to urine, suggesting this may trigger the surrounding mesenchymal cells to overgrow the lumen. Findings from this novel mouse model show Sec10 is critical for the development of the urothelium in ureters, and provides experimental evidence that failure of this urothelial barrier may contribute to human congenital urinary tract obstructions.

Hyperthermic intraperitoneal chemotherapy with cisplatin and paclitaxel in advanced ovarian cancer: a multicenter prospective observational study.

OBJECTIVE: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been recently reported with favorable oncological outcomes as treatment of advanced epithelial ovarian cancer (EOC). The aim of this study was to demonstrate the feasibility of CRS+HIPEC with cisplatin and paclitaxel for the treatment of advanced EOC. METHODS: This is a prospective observational study of 54 patients, from April 2007 to October 2013, with primary or recurrent peritoneal carcinomatosis due to EOC. The mean age was 54.51±9.34. Thirty patients (59%) had primary EOC, and 24 patients (41%) had recurrent disease. RESULTS: Mean peritoneal cancer index was 10.11 (range, 0 to 28), complete cytoreduction (CC0) was achieved for 47 patients (87%), CC1 for seven patients (13%). Patients with suboptimal cytoreduction (CC2 and CC3) were not included in the study. The mean stay in intensive care unit was 4.73±5.51 days and the mean hospitalization time was 24.0±10.03 days. We did not observe any intraoperative death. Seven patients (13%) required additional operations. Three patients (5.6%) died within 30 days from the procedure. Severe complications were seen in 19 patients (35.2%). During the follow-up period, disease recurred in 33 patients (61.1%); the median disease-free survival time was 12.46 months and the median overall survival time was 32.91 months. CONCLUSION: CRS+HIPEC with cisplatin and paclitaxel for advanced EOC is feasible with acceptable morbidity and mortality. Additional follow-up and further studies are needed to determine the effects of HIPEC on long term survival.