Damage control surgery for abdominal emergencies.

BACKGROUND: Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery. METHODS: A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed. RESULTS: Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis. CONCLUSION: Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients.

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.

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

Subcutaneous forearm transplantation of autologous parathyroid tissue in patients with renal hyperparathyroidism.

BACKGROUND: Parathyroidectomy is required in up to 5% of patients with chronic renal failure. Intramuscular transplantation of autologous parathyroid tissue in the forearm has been the traditional method of transplantation at the time of total parathyroidectomy. The removal of an intramuscular transplantation can be technically difficult should graft-dependent hyperparathyroidism (GRH) occur. This problem resulted in our initiating a study of subcutaneous transplantation with total parathyroidectomy in patients with renal failure. METHODS: Twenty-six patients who were receiving dialysis therapy underwent total parathyroidectomy and subcutaneous transplantation. Parathyroid tissue was diced into 1- to 2-mm pieces, and 6 pieces were grafted into 6 subcutaneous pockets of the forearm. Intact parathyroid hormone was measured within 48 hours of operation and in the bilateral antecubital veins 1 to 24 months after the operation to assess completeness of resection and graft function, respectively. RESULTS: No major surgical complications occurred. Symptoms improved in 24 patients (85%). Graft failure rate was 4.3%. No GRH was observed. Follow-up was 4 to 55 months (mean, 27 months). CONCLUSIONS: This study indicates that the subcutaneous transplantation function is comparable to intramuscular transplantation and suggests a decreased incidence of GRH. Subcutaneous transplantation is technically easier than intramuscular transplantation and has the additional advantage of easy removal should GRH occur.

Endoscopic parathyroidectomy: report of an initial experience.

BACKGROUND: Preoperative localization of parathyroid lesions and intraoperative quick parathyroid hormone (PTH) assay have been proposed to minimize the extent of operation in primary hyperparathyroidism. To this purpose, endoscopic procedures have been introduced recently. METHODS: During a period of 13 months, 39 of 65 consecutive patients with primary hyperparathyroidism were selected for endoscopic parathyroidectomy on the basis of the following criteria: preoperative echographic diagnosis of a single adenoma, absence of nodular goiter, and no prior neck operations. Unilateral neck exploration and excision of the adenoma was performed through a gasless procedure combined with intraoperative PTH measurements. Mean follow-up after the operation was 7 months (range 1 to 13 months). RESULTS: Thirty-nine parathyroid adenomas were removed; the mean diameter was 21 mm (range 5 to 30 mm). The mean operative time was 65 minutes (range 30 to 180 minutes). In all cases PTH concentration decreased significantly. Patients who underwent endoscopic parathyroidectomy had less postoperative pain compared with patients who underwent conventional hemithyroidectomy. At follow-up, serum calcium and PTH levels were normal in all cases. CONCLUSIONS: Endoscopic parathyroidectomy proved to be a feasible surgical procedure that can be performed in an acceptable operative time with an excellent cosmetic result. The gasless approach avoided any emphysema.

Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study.

BACKGROUND: Several studies demonstrated the feasibility of minimally invasive parathyroidectomy as a treatment for primary hyperparathyroidism. We compared its results with those of traditional surgery in a prospective randomized study. METHODS: From March to November 1998, 38 patients eligible for video-assisted parathyroidectomy (VAP) were referred to us. They were randomly divided into 2 groups: patients of group A underwent a conventional cervicotomy with bilateral exploration and frozen section of the removed adenoma; patients of group B underwent VAP with intraoperative measurement of parathyroid hormone. Operative time, postoperative pain, fever and hypocalcemia, cosmetic result, and costs were compared. Two cases of VAP were performed with locoregional anesthesia. RESULTS: Groups A (18 patients) and B (20 patients) were statistically balanced. Operative time was significantly shorter in group B (57 vs 70 minutes). Cosmetic result was significantly better in group B, which also experienced less postoperative pain (P < .05). No cases of persistent primary hyperparathyroidism were present in either group, but recurrent laryngeal nerve palsy occurred in 1 patient in group B. CONCLUSIONS: Compared with conventional surgery, VAP is associated with a shorter operative time, a better cosmetic result, and a less painful postoperative course.

Renin-angiotensin-aldosterone system in primary hyperparathyroidism before and after surgery.

Twenty consecutive unselected patients with proven primary hyperparathyroidism (PH), 26 essential hypertensive (EH) patients, and 13 normotensives were studied. Blood pressure (BP) and, under constant salt intake, plasma renin activity (PRA), parathyroid hormone (PTH), urinary and plasma sodium, potassium, aldosterone (ALD), creatinine, total calcium, and phosphate were measured. Patients with PH were also studied 1 and 6 months after successful surgery. In patients with PH, systolic and diastolic BP was significantly lower (P < .001) than in EH patients and higher (P < .005) than in controls. Eight patients with PH (40%) had BP levels greater than 140/90 mm Hg. PTH and plasma and urinary calcium in patients with PH were significantly (P < .01) higher than in controls, while PRA, ALD, phosphate, potassium, and sodium were superimposable in the three groups. PTH in patients with PH was weakly correlated with PRA (positively) and with plasma potassium (negatively) and was not associated with ALD, calcium, sodium, and BP levels. Surgery was followed by a significant reduction (P < .01) in PTH, calcium, and urinary phosphate and an increase (P < .02) in plasma phosphate, potassium, and sodium, whereas PRA, ALD, urinary potassium and sodium, and BP showed no change. In hypertensive patients with PH, PTH, PRA, and plasma and urinary ALD, calcium, and sodium did not differ from the values in normotensive PH patients, and variations in these humoral parameters after surgery were comparable in the two groups. In conclusion, our results show that hypertension is frequently associated with PH. However, the present data raise doubts about the assumption of a renin-mediated causal relationship between hyperparathyroidism and high BP. Indeed, as a unique finding in favor of the hypothesis of a stimulating role of PTH in renin secretion, we observed only a weak relation between PTH and PRA. Thus, unknown and/or unassessed factors related to parathyroid disease cannot be ruled out to explain the hypertension observed in some patients with PH.

Surgical aspects of thyroid nodules previously treated by ethanol injection.

Some concern has been expressed about surgical operations in thyroid nodules previously treated by ethanol injection: the reasons are mainly represented both by the possibility of more surgical risks due to the adhesions caused by ethanol and the difficulty of interpreting the histological pattern when a cancer is suspected. During the last 8 years 219 patients underwent ethanol injection: among these 6 were subsequently submitted to surgical operation. Total thyroidectomy was performed in 5 cases and isthmusectomy in one case: No vocal cord palsy was registered in these patients.. They were all normocalcemic after surgery. Histology showed no significant fibrosis in the ethanol treated nodules but only macrofollicles and this did not affect the histological examination in presence of suspected malignancies.

Endoscopic surgery in Senegal. Benefits, costs and limits.

BACKGROUND: Evaluating the introduction of endoscopic surgery in Senegal may be useful for assessing the role of this technology in developing countries. METHODS: The endoscopic surgery performed at the Hospital Principal and the Hospital Le Dantec, Dakar, from January 1995 to December 2000 was evaluated retrospectively. Operative time, postoperative stay, patients, and hospital costs were compared in samples of 100 patients treated endoscopically and 80 patients treated with open techniques. RESULTS: Altogether, 826 endoscopic procedures were performed (11.6% of elective surgical activity). Of these, thoracoscopic (34%) and laparoscopic (14%) vagotomy, cholecystectomy (21%), fundoplication (12%), and diagnostic laparoscopy (11%) were selected for comparisons. Operative time proved to be reduced by endoscopic surgery except for laparoscopic fundoplication (+40 min). After endoscopic surgery, postoperative hospitalization was 3.7 days shorter, and patient fees were consequently reduced. In 6 years, 87% of the hospital investment (36,000 Euro) was recovered. CONCLUSIONS: Developing countries can benefit from endoscopic surgery. First-world countries might supply staff training.

Endoscopic parathyroidectomy by a gasless approach.

Endoscopic approach for the treatment of primary hyperparathyroidism is one of the new fields of interest for minimally invasive surgery. The removal of the parathyroid gland can be achieved either by a gas or gasless technique. Massive carbon dioxide (CO2) diffusion and absorption has been reported to occur during the gas procedure. Endoscopic techniques that do not rely on CO2 insufflation have still to be set. We have developed a new procedure that was offered to 20 selected patients with a localized parathyroid adenoma. A 3-minute CO2 insufflation (12 mm Hg) through a conventional trocar inserted under the strap muscles is used just to anatomically dissect the virtual thyrotracheal groove. Actually, the working space is maintained by means of skin retractors so as to allow needlescopic instruments to perform a parathyroid adenomectomy with the gasless procedure. In all cases the parathyroid adenoma was removed through a 1.5-cm skin incision. Quick parathyroid hormone assays always confirmed the removal of all pathologic glands and permitted unilateral cervical exploration. Mean operative time was 71.7 +/- 35.5 minutes. No complication was registered. At follow-up, all patients were normocalcemic. This new endoscopic approach to the neck seems to be safe, effective, and cosmetically satisfactory.

Traditional versus laparoscopic surgery in the treatment of pheochromocytoma: a preliminary study.

Laparoscopic removal of adrenal masses has been successfully accomplished by many authors, but some doubts still remain about the surgical treatment of pheochromocytomas by the laparoscopic approach. The outcome of 6 patients who had laparoscopic removal of pheochromocytoma, 1 of which bilateral, was compared with that of 20 patients with pheochromocytoma who underwent open surgery. The following parameters were evaluated: frequency of hypertensive crises, time required for surgery, total volume of infused fluids, severity of postoperative pain, hospital stay, wound suppuration, or occurrence of incisional hernia, persistence or recurrence of hypertension. Laparoscopic patients had shorter hospitalizations, less postoperative fever, less fluid infusion, and absence of scar complications. There was no evident difference in the frequency of intraoperative hypertensive crises between patients who were treated by laparoscopic versus those treated by open procedure. The laparoscopic approach seems to be as safe as the open approach. However, it causes less postoperative distress, better cosmetic results, and permits a faster recovery.

Adrenal masses in non-small cell lung carcinoma patients: is there any role for laparoscopic procedures?

Surgical treatment of adrenal metastases from non-small cell lung carcinoma (NSCLC) is a current and controversial issue. We analyze our experience with the laparoscopic treatment of NSCLC solitary adrenal metastases. In the last 4 years, six patients underwent laparoscopic adrenalectomy for suspected solitary NSCLC metastasis. A metastasis was removed in four patients and a cortical adenoma in two. Laparoscopy with intraoperative ultrasonography was demonstrated to be an excellent procedure for the diagnostic and therapeutic management of the patient affected by a solitary adrenal metastasis from NSCLC. Longer follow-up and a larger series are necessary to enable definitive conclusions to be drawn about the impact on survival of laparoscopic adrenalectomy for NSCLC metastasis.

[Laparoscopic adrenalectomy. A retrospective comparison with traditional methods]. / Surrenectomia laparoscopica. Un confronto retrospettivo con le metodiche tradizionali.

BACKGROUND: After 3 years from the introduction of laparoscopic adrenalectomy in an endocrine surgery unit the results are retrospectively compared with those achieved by traditional techniques with the aim of comparing the respective advantages. METHODS: During this period 68 laparoscopic adrenalectomies have been performed. The main pre-, intra- e postoperative parameters of the adrenalectomies for benign neoplasm have been examined. Mean follow-up was 51 months (65.3 for open adrenalectomy and 18.8 for laparoscopic). RESULTS: Statistical studies were homogeneous between the two groups. The laparoscopic adrenalectomy--with the same effectiveness--thanks to less peritoneum and parietal stress, is followed by fewer postoperative complications, faster resumption of biological functions, earlier return to work and better cosmetic results. CONCLUSIONS: On the basis of our personal experience laparoscopic adrenalectomy is to be considered the treatment of choice in the majority of adrenal benign neoplasms.

[Postoperative organotherapy for multinodular goiter]. / La opoterapia post chirurgica nei pazienti operati per struma multinodulare.

Post-operative therapy with L-Tiroxine can have a suppressive or substitutional aim. After a total thyroidectomy the patients need a substitutional therapy, while after subtotal thyroidectomy the aim of the therapy is to suppress the TSH secretion. In the second case we want either to avoid the recurrence, either to give the hormones that residual gland cannot produce. The drug of choice is L-Tiroxine for both suppressive o substitutional therapy: There is a difference in dosage, that must be greater in first case. While there are some doubts in the literature on the success of the suppressive therapy, we believe that there is enough evidence of his utility.

[Total colectomy with ileorectal anastomosis (IRA): our experience in 57 patients]. / La colectomia totale con ileo-retto-anastomosi (IRA): nostra osservazione su 57 pazienti.

Total colectomy with IRA in ulcerative colitis, Crohn's disease, familial polyposis and multicentric colonic cancer is still debated. In this paper the Authors present their experience with a retrospective review of 57 patients, treated in the Surgical Department of Pisa's University from 1978 to 1990. Through the results obtained, it is concluded that total colectomy with IRA is a valid procedure in the treatment of multiple polyposis, but must be associated with a long and careful follow up using fulguration for local recurrence. The usefulness of this treatment in multicentric colonic cancer is confirmed. However, the use of IRA in ulcerative colitis is debatable. This series shows the failure of colectomy with IRA in patients with Crohn's disease, due to the high incidence of local recurrences requiring reoperation.

Seatbelt: a double-edged sword.

Intra-abdominal vascular injury due to blunt trauma is unusual in children. Due to its rarity, detailed reports dealing with its management are scarce in paediatric literature. Diagnosis of these injuries is challenging, and a high degree of awareness is necessary for rapid identification and treatment of these injuries. We report the case of a child with seatbelt sign and mesenteric vein injury due to blunt trauma to the abdomen during a motor vehicle accident where the seatbelt was incorrectly placed. She also sustained cervical vertebral injury. The pattern of injuries in children in these situations may differ from that found in adults. While seatbelts have undoubtedly saved many lives, awareness about correct placement of these restraints is extremely necessary.

The treatment of traumatic shock: recent advances and unresolved questions.

Uncontrolled bleeding remains a leading cause of potentially preventable death after trauma. Timely, adequate resuscitation in traumatic shock is an essential, lifesaving aspect of polytrauma care. Whilst basic principles in the treatment of traumatic shock remain the same-achieving hemorrhage control and replacing lost volume, the way this is achieved has changed significantly in the last five years. The abandonment of blood pressure driven uncontrolled fluid resuscitation, the introduction of the concept of hemostatic resuscitation, and the increasing use of massive transfusion protocols have all contributed to an improvement in timely access to various blood products. The increase in knowledge regarding the pathophysiology of trauma, the availability of adjuncts, and the array of resuscitation monitoring options available have all contributed to a potentially improved approach to resuscitation. The purpose of this report is to review the most important advances in traumatic shock therapy in the last five years.

Minimally invasive video-assisted surgery of the thyroid: a preliminary report.

BACKGROUND: Endoscopic thyroidectomy has not yet met the favor of most endocrine surgeons. We evaluated the technical feasibility of a video-assisted approach to thyroid surgery. PATIENTS AND METHODS: The study group comprised 22 females and 5 males, all with a single thyroid nodule. The nodule was "hot" in 4 patients, microfollicular in 17 and with Hürthle cell cytology in 6. A 15-mm skin incision was made above the sternal notch. The midline was opened and a 12-mm trocar inserted into the thyro-tracheal groove. It was inflated with CO2 for 3 min. The trocar was then removed and the procedure performed using external retractors and needlescopic instruments. The upper pedicle was dissected. Identification of recurrent nerve and parathyroid glands was facilitated by endoscopic magnification. The upper gland portion was then retracted out of the operative cavity; inferior veins were ligated and the lobe entirely extracted and dissected. Frozen section was obtained for "cold" nodules. RESULTS: Video-assisted hemithyroidectomy was accomplished in 24 patients; 1 underwent video-assisted total thyroidectomy (positive frozen section). Cervicotomy was required once to achieve hemostasis and once to perform total thyroidectomy (positive frozen section). Mean operative time was 82 min (range 60-120 min). No complications were registered. The cosmetic result was excellent. CONCLUSIONS: Video-assisted thyroid surgery is feasible and may improve cosmetic outcome; total thyroidectomy can be accomplished through the same access point.