Pharmacokinetics of concomitant cisplatin and paclitaxel administered by hyperthermic intraperitoneal chemotherapy to patients with peritoneal carcinomatosis from epithelial ovarian cancer.

BACKGROUND: Hyperthermic intraperitoneal chemotherapy (HIPEC) is advised as a treatment option for epithelial ovarian cancer (EOC) with peritoneal carcinomatosis. This study was designed to define the pharmacokinetics of cisplatin (CDDP) and paclitaxel (PTX) administered together during HIPEC. METHODS: Thirteen women with EOC underwent cytoreductive surgery (CRS) and HIPEC, with CDDP and PTX. Blood, peritoneal perfusate and tissue samples were harvested to determine drug exposure by high-performance liquid chromatography and matrix-assisted laser desorption ionization imaging mass spectrometry (IMS). RESULTS: The mean maximum concentrations of CDDP and PTX in perfusate were, respectively, 24.8±10.4 µg ml(-1) and 69.8±14.3 µg ml(-1); in plasma were 1.87±0.4 µg ml(-1) and 0.055±0.009 µg ml(-1). The mean concentrations of CDDP and PTX in peritoneum at the end of HIPEC were 23.3±8.0 µg g(-1) and 30.1±18.3 µg(-1)g(-1), respectively. The penetration of PTX into the peritoneal wall, determined by IMS, was about 0.5 mm. Grade 3-4 surgical complications were recorded in four patients, five patients presented grade 3 and two patients presented grade 4 hematological complications. CONCLUSIONS: HIPEC with CDDP and PTX after CRS is feasible with acceptable morbidity and has a favorable pharmacokinetic profile: high drug concentrations are achieved in peritoneal tissue with low systemic exposure. Larger studies are needed to demonstrate its efficacy in patients with microscopic postsurgical residual tumours in the peritoneal cavity.

The Italian Register of Biological Prostheses.

BACKGROUND: A wide variety of meshes are available for surgical treatment of abdominal wall defects. These meshes are constructed with different materials with different biological properties. METHODS: A prospective database was instituted (January 2009-December 2010) to register biological prostheses (BPs) implanted in Italy. RESULTS: A total of 193 cases were registered. The mean age of the patients was 53.1 years (SD ±7.4). The ratio of males to females was 1.3 to 1. The mean body mass index was 28.2 (SD ±4.1). The breakdown of American Society of Anesthesiologists (ASA) scores was as follows: ASA I, 35.7%; ASA II, 27.5%; ASA III, 31.6%, and ASA IV, 5.2%. For ventral-incisional hernias, the mean duration of surgery was 101.1 min (SD ±25.3), while for inguinal-femoral hernias it was 49.2 min (SD ±19.1). The rate of urgent procedures was 36.7%. The surgical field was clean in 57.4% of cases, clean-contaminated in 21.3%, contaminated in 12.3% and dirty in 9%. Techniques used for inguinal-femoral hernias were as follows: Lichtenstein in 66.7%, plug and mesh in 3.8%, transabdominal-preperitoneal in 25.7% and intraperitoneal onlay mesh in 3.8%. The following prostheses were used: swine intestinal submucosa in 54.9%, porcine dermal collagen in 39.9% and bovine pericardium in 5.2%. In 45.1% of cases the prostheses were cross-linked. Techniques used for ventral-incisional hernias were as follows: onlay in 3.6%, inlay in 5.5%, sublay in 62.7% and underlay via laparoscopy in 28.2%. The mean overlap was 4.1 cm (SD ±1.2). No intestinal anastomosis was necessary in 65.3% of cases; however, small/large bowel resection and anastomoses were necessary in 22.3 and 12.4% of cases, respectively. Intraoperative blood transfusion was necessary in 10.4% of procedures. The skin was completely closed in 84% of procedures. At the 1-month follow-up, there were no complications in 54.4% of cases. Among the cases with complications, 10 patients (5.8%) experienced recurrence, and the postoperative readmission rate was 12.9%. The average visual analog scale (VAS) score for pain was 2.9 (SD ±1.2) at rest. At the 1-year follow-up, there were no complications in 96.4% of cases. Two patients experienced recurrence, and the postoperative readmission rate was 3.6%. The average VAS score for pain was 1.8 (SD ±0.8) at rest. CONCLUSIONS: This register shows that BPs are highly versatile and can be used in either open or laparoscopic surgery in all kinds of patients and in contaminated surgical fields. However, due to the very good outcomes of synthetic meshes and the high costs of BPs, the latter should only be used in selected cases.

PROPHYlactic Implantation of BIOlogic Mesh in peritonitis (PROPHYBIOM): a prospective multicentric randomized controlled trial.

BACKGROUND: Patients undergoing emergency surgery for peritonitis are at increased risk of abdominal wall-related complications. In patients with peritonitis, the risk of incisional hernia (IH) is extremely elevated. The evaluation of quality of life of patients with incisional hernia showed lower mean scores on physical components of health-related quality of life and body image. Furthermore, the arise of a post-operative abdominal wall complication (i.e., wound dehiscence, evisceration and IH) greatly increases morbidity and mortality rates and prolongs the hospitalization. METHODS: The present study aims to evaluate the efficacy of the use of a swine dermal collagen prosthesis implanted preperitoneally as a prophylactic procedure in urgency/emergency setting against abdominal wall complications in patients operated with contaminated/infected field in peritonitis. The sample size was defined in 90 patients divided in two arms (prosthesis positioning versus normal wall abdominal closure). The follow-up will be performed at 3, 6, and 12 months after surgery. The percentage of incisional hernias, wound infections, and adverse events will be investigated by physical examination and ultrasound. DISCUSSION: The objective is to evaluate the possibility to reduce the incisional hernia rate in patients undergoing urgent/emergent laparotomy in contaminated/infected field with peritonitis by using swine dermal collagen prosthesis preperitoneal positioning as a prophylactic procedure. TRIAL REGISTRATION: ClinicalTrials.gov NCT04681326. Registered (retrospectively after first patient recruited) on 23 December 2020.

Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery.

BACKGROUND: : This study evaluated the incidence of postoperative delirium (POD) in elderly patients undergoing general surgery, the risk factors associated with POD, and its impact on hospital stay and mortality. METHODS: : Patients aged over 65 years who had emergency or elective operations were eligible for this case-control study. Risk factors significantly associated with POD using univariable analysis were entered into multivariable analysis, to establish those independently associated with POD. RESULTS: : A total of 351 patients (357 admissions) were enrolled in the study. The incidence of POD was 13.2 per cent (17.9 per cent for emergency operations). Independent variables associated with POD were: age above 75 years, co-morbidity, preoperative cognitive impairment, psychopathological symptoms and abnormal glycaemic control. Median length of hospital stay was 21 (range 1-75) days for patients with POD versus 8 (range 1-79) days for control patients (P < 0.001). The hospital mortality rate was 19 and 8.4 per cent respectively (P = 0.021). CONCLUSION: : The incidence of POD is high in elderly patients for both emergency and elective surgery, leading to an increase in hospital stay and perioperative mortality. To minimize POD, associated risk factors of co-morbidity, cognitive impairment, psychopathology and abnormal glycaemic control must be identified and treated.

Emergency repair of complicated abdominal wall hernias: WSES guidelines.

PURPOSE: In July 2013, the World Society of Emergency Surgery (WSES) held the first Consensus Conference on emergency repair of abdominal wall hernias in adult patients with the intention of producing evidence-based guidelines to assist surgeons in the management of complicated abdominal wall hernias. Guidelines were updated in 2017 in keeping with varying clinical practice: benefits resulting from the increased use of biological prosthesis in the emergency setting were highlighted, as previously published in the World Journal of Emergency Surgery. This executive summary is intended to consolidate knowledge on the emergency management of complicated hernias by providing the broad readership with a practical and concise version of the original guidelines. METHODS: This executive manuscript summarizes the WSES guidelines reporting on the emergency management of complicated abdominal wall hernias; statements are highlighted focusing the readers' attention on the main concepts presented in the original guidelines. CONCLUSIONS: Emergency repair of complicated abdominal hernias remains one of the most common and challenging surgical emergencies worldwide. WSES aims to provide an essential version of the evidence-based guidelines focusing on the timing of intervention, laparoscopic approach, surgical repair following the Centers for Disease Control and Prevention (CDC) wound classification, antimicrobial prophylaxis and anesthesia in the emergency setting.

Emergency surgery during the COVID-19 pandemic: what you need to know for practice.

INTRODUCTION: Several articles have been published about the reorganisation of surgical activity during the COVID-19 pandemic but few, if any, have focused on the impact that this has had on emergency and trauma surgery. Our aim was to review the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic. METHODS: A systematic review was conducted of the most relevant English language articles on COVID-19 and surgery published between 15 December 2019 and 30 March 2020. FINDINGS: Access to the operating theatre is almost exclusively restricted to emergencies and oncological procedures. The use of laparoscopy in COVID-19 positive patients should be cautiously considered. The main risk lies in the presence of the virus in the pneumoperitoneum: the aerosol released in the operating theatre could contaminate both staff and the environment. CONCLUSIONS: During the COVID-19 pandemic, all efforts should be deployed in order to evaluate the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. If surgery is deemed necessary, the emergency surgeon must minimise the risk of exposure to the virus by involving a minimal number of healthcare staff and shortening the occupation of the operating theatre. In case of a lack of security measures to enable safe laparoscopy, open surgery should be considered.

Effect of early antibiotic prophylaxis with ertapenem and meropenem in experimental acute pancreatitis in rats.

BACKGROUND: The clinical course in acute necrotizing pancreatitis is mainly influenced by bacterial infection of pancreatic and peripancreatic necrosis. The effect of two antibiotic treatments for early prophylaxis was studied in the taurocholate model of necrotizing pancreatitis in the rat. METHODS: Sixty male Sprague-Dawley rats were divided into three pancreatitis groups (15 animals each) and a sham-operated group (15 animals, control group). Pancreatitis was induced by intraductal infusion of 3% taurocholate under sterile conditions. Animals were placed on one of two different antibiotic regimens (15 mg/kg ertapenem or 20 mg/kg meropenem, one shot) after the induction of pancreatitis or received no antibiotics (control). All animals were sacrificed after 24 h to study pancreatic and extrapancreatic infection. RESULTS: Early antibiotic prophylaxis with either erapenam or meropenem significantly decreased pancreatic infection from 12/15 (control group) to 4/15 (ertapenem antibiotic group) and 3/15 (meropenem antibiotic group) (P < 0.05). CONCLUSIONS: In our animal model of necrotizing pancreatitis, early antibiotic prophylaxis with ertapenem and meropenem reduced bacterial infection of the pancreas. The efficacy of early antibiotic prophylaxis with ertapenem in the clinical setting should be subject to further research.

Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years of experience.

PURPOSE: The aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma. MATERIALS AND METHODS: We studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O). RESULTS: In the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively. CONCLUSIONS: Our study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.

Trauma patients centralization for the mechanism of trauma: old questions without answers.

INTRODUCTION: Centralization of trauma patients has become the standard of care. Unfortunately, overtriage can overcome the capability of Trauma Centres. This study aims to analyse the association of different mechanisms of injury with severe or major trauma defined as Injury Severity Score (ISS) greater than 15 and an estimation of overtriage upon our Trauma Centre. METHODS: A retrospective review of our prospective database was undertaken from March 2014 to August 2016. Univariate and multivariable logistic regression models were used to estimate the association between covariates (gender, age, and mechanisms of injury) and the risk of major trauma. RESULTS: The trauma team (TT) treated 1575 patients: among the 1359 (86%) were triaged only because of dynamics or mechanism of trauma. Overtriage according to an ISS < 15, was 74.6% on all trauma team activation (TTA) and 83.2% among the TTA prompted by the mechanism of injury. Patients aged 56-70 years had an 87% higher risk of having a major trauma than younger patients (OR 1.87, 95% CI 1.29-2.71) while for patients aged more than 71 years OR was 3.45, 95% CI 2.31-5.15. Car head-on collision (OR 2.50, 95% CI 1.27-4.92), intentional falls (OR 5.61, 95% CI 2.43-12.97), motorbike crash (OR 1.67, 95% CI 1.06-2.65) and pedestrian impact (OR 2.68, 95% CI 1.51-4.74) were significantly associated with a higher risk of major trauma in a multivariate analysis. CONCLUSIONS: Significant association with major trauma was demonstrated in the multivariate analysis of different mechanisms of trauma in patients triaged only for dynamics. A revision of our field triage protocol with a prospective validation is needed to improve overtriage that is above the suggested limits.

Open conversion for laparoscopically difficult cholecystectomy is still a valid solution with unsolved aspects.

The difficult laparoscopic cholecystectomy remains a surgical challenge for surgeons who must decide between laparoscopic continuation and open conversion. The balance between the lack of open surgery training of young surgeons and the risk of maintaining the laparoscopic approach in difficult laparoscopic cholecystectomy is still an unresolved problem. Furthermore, the time that must be spent in an attempt to complete laparoscopic surgery before conversion is still controversial. The authors in this letter discuss about these and other questions that still require an answer.

Gastrointestinal perforations following kidney transplantation.

This study reports major gastrointestinal (GI) complications among a group of 1611 patients following kidney transplantation. The immunosuppressive regimen changed somewhat during the course of the study but included azathioprine, prednisolone, antilymphocyte globulin, cyclosporine, tacrolimus, mycophenolate mofetil, and sirolimus. Perforations occurred in the colon (n=21), small bowel (n=15), duodenum (n=6), and stomach (n=4). Nearly 50% of the complications occurred while patients were being given high-dose immunosuppression to manage either the early postoperative period or acute rejection episodes. Of the 46 patients affected, 11 (24%) died as a direct result of the GI complication. This high mortality appeared to be related to the effects of the immunosuppression and the associated response to sepsis. Reduction of these complications may be achieved by improved surgical management, preventive measures, prompt diagnosis, and a reduced immunosuppressive protocol.

Acute cellular rejection monitoring after intestinal transplant: utility of serologic markers and zoom videoendoscopy as support of conventional biopsy and clinical findings.

Acute cellular rejection (ACR) episodes in intestinal transplant recipients are diagnosed by histologic and clinical findings. We have applied zoom video endoscopy and the use of serologic markers granzyme B (GrB) and perforin (PrF) to monitor rejection together with conventional tools. Seven hundred eighty-two blood samples (obtained at the time of the biopsy) collected from 34 recipients for GrB/PrF upregulation were positive among 64.9% of ACRs during a 3-year follow-up. Considering only the first year results posttransplantation, it reached 73.1% of rejection events. Zoom videoendoscopy was used by our group in 29 recipients of isolated intestine (n = 24) or multivisceral transplantations (n = 5) to enable observation of villi and crypt areas. From more than 270 procedures, 84% of the zoom findings agreed with the histologic results, namely, a specificity of 95%. In fact, during ongoing ACR, villi were altered in 80% of cases. Both procedures were helpful to support conventional histologic findings and clinical symptoms of ACR in intestinal transplant recipients.

The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry.

PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes. METHODS: REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported. RESULTS: Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion. CONCLUSIONS: This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.

Hernia repair with porcine small-intestinal submucosa.

PURPOSE: Although at present nonabsorbable meshes are the preferred material for tension-free hernioplasty, some problems with their use have yet to be addressed (i.e., chronic pain and infections). In order to address these disadvantages, a collagen-based material, the porcine small-intestinal submucosa mesh (Surgisis Inguinal Hernia Matrix, Cook Surgical, Bloomington, IN, USA), has recently been developed for hernia repair. METHODS: With the aim of investigating the clinical safety and effectiveness of Surgisis IHM inguinal hernia repair, we report our experience of 45 consecutive hernioplasties with a medium-term follow-up. The surgical technique for the use of this material in hernioplasty is described in detail. RESULTS: Although some local (i.e., seromas) and general (i.e., hyperpyrexia), complications appeared in the immediate postoperative period (all of them disappeared spontaneously), no rejection or infection was observed after operations. At the 2-year follow-up, a low degree of pain and discomfort and no recurrences were observed. CONCLUSIONS: We conclude that the Surgisis IHM hernioplasty is feasible with promising results and, from a clinical perspective, seems safe and effective.

Use of porcine dermal collagen graft (Permacol) for hernia repair in contaminated fields.

BACKGROUND: Complicated hernias often involve contaminating surgical procedures in which the use of polypropylene meshes can be hazardous. Prostheses made of porcine dermal collagen (PDC) have recently been proposed as a means to offset the disadvantages of polypropylene meshes and have since been used in humans for hernia repairs. The aim of our study was to evaluate the safety and efficacy of incisional hernia repair using PDC as a mesh in complicated cases involving contamination. METHODS: A prospective study of hernia repair of complicated incisional hernias with contamination using PDC grafts was carried out at the Department of General, Emergency and Transplant Surgery of St Orsola-Malpighi University Hospital. RESULTS: From January 2004 up to the writing of this article, seven patients were treated for complicated incisional hernias with a PDC prosthesis. In six out of seven patients a bowel resection was carried out. There were not surgical complications. Morbidity was 14.2%. No recurrences and wound infections were observed. CONCLUSIONS: Incisional hernioplasty using PDC grafts is a potentially safe and efficient approach in complicated cases with contamination.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Experimental evaluation of Surgisis as scaffold for neointestine regeneration in a rat model.

The aim of the study was to evaluate the use of Surgisis (Cook Biotech Inc.), a porcine derived extracellular matrix already used in tissue engineering, as a scaffold for neointestinal regeneration in a rat model. A 3-cm length of tubular Surgisis graft was interposed with bilateral anastomoses in the middle of an isolated ileal loop of Sprague Dawley rats with an ileostomy. The grafts were harvested and analyzed using histology and immunohistochemistry at 24 weeks after operation. Macroscopic examination revealed neither stenosis nor adhesions in the area surrounding the neointestine. The regenerated small bowel showed a mean shrinkage of 30.7% (range 20%-40%). Histologic and immunohistochemical evaluation showed a well-developed three layers of mucosa and smooth muscle and serosa in the regenerated bowel wall that were similar to those of the normal bowel with evident neovascularization. Also, the regeneration of smooth muscle fibers and innervation were evident. The preliminary results of this study showed that Surgisis allowed rapid regeneration of mucosa and smooth muscle and therefore may be a promising material for the creation of a neointestine.