ICG-Enhanced Compression Anatomical Segment 7 Segmentectomy in Laparoscopic and Robotic Approach.

BACKGROUND: Minimally invasive anatomical resection (AR) for posterosuperior lesions is technically challenging.1,2 The Glissonean approach or puncture technique is generally selected.3,4 The tumor-feeding portal pedicle compression AR (C-AR) is an established procedure in open surgery.5 This technique has benefited from the association with indocyanine green (ICG) fluorescence, used to enhance the anatomical area to be resected.6 Recently, C-AR via the minimal access approach has been reported.7 Herein, we report the first cases of laparoscopic and robotic segment 7 (S7) segmentectomy using the ICG-enhanced compression technique. PATIENTS AND METHODS: Two cases of CHILD-class A hepatocellular carcinoma (HCC) in segment 7 with a liver stiffness less than 7 kPa treated by laparoscopic and robotic anatomical S7 segmentectomies were reported. Using the intraoperative ultrasound (IOUS), the tumor-bearing portal pedicle and the level targeted for compression were identified. The right hemiliver was adequately mobilized to allow handling of the organ during dissection. Using the grasper and the probe itself, the S7 Glissonean pedicle was transparenchymally compressed under real-time IOUS control. To further enhance the visibility of the discolored S7, ICG was administered intravenously, obtaining the compressed area to be resected as a non-stained one. Dissection was performed under intermittent Pringle maneuver up to exposing the right hepatic vein, dividing the Glissonean pedicle to segment 7 and then completing the resection. RESULTS: Pathologic findings demonstrated a 4.9 cm and 7.3 cm HCC with a R0-resection margin (> 1 cm in both). Postoperative complications were nil. The patients were discharged 6 days after surgery. CONCLUSIONS: This preliminary experience shows that the C-AR is a feasible and reliable technique in laparoscopic and robotic approach for posterosuperior lesions. Further studies are needed to investigate its applicability and standardization.

Clinical Frailty Score is a good predictor of postoperative mortality in patients undergoing open abdomen surgery: a multicenter retrospective cohort study.

BACKGROUND: Open Abdomen (OA) is gaining popularity in damage control surgery (DCS) but there is not an absolute prognostic score to identify patients that may benefit from it. Our study investigates the correlation between the clinical frailty scale score (CFSS) and postoperative morbidity and mortality in patients undergoing OA. METHODS: Patients ≥65 yo undergoing OA in two referral centres between 2015 and 2020 were included and stratified according to CFSS in non-frail (NF), frail (F) and highly-frail (HF). The primary endpoint was 30-day mortality. Secondary endpoints were postoperative morbidity and 1- year survival. RESULTS: One hundred and thirty-six patients were included: 35 NF (25.7%), 56 F (41.2%), 45 HF (33.1%). Average age 76.8. The 73.5% of cases were non-traumatic diseases with no difference in preoperative characteristics. 95 (71.4%) had one complication, 26 NF (74.3%), 34 F (63.2%), 35 HF (77.8%) (P=0.301) and 59.4% had a complication with a CD≥3, 57.1% NF, 56.6% F and 64.4 HF. The 30-day mortality was 32.4%, higher in HF (46.7%) and F (30.4%) compared to NF (17.1%, P=0.018). The Overall 1-year survival was 41% (SE ±4) with statistically significant difference between HF vs. NF and HF vs. F (P=0.009 and P=0.029, respectively). In the univariate analysis, the only significant prognostic factor impacting mortality was CFSS, with HF having an HR of 1.948 (95% CI 1.097-3.460, P=0.023). CONCLUSIONS: When OA is a surgical option, frail patients should not be precluded, while HF should be carefully evaluated. The CFSS might be a good prognostic score for patients that may safely benefit from OA.

Prevalence of anxiety and depression risk during the prepartum period in the different groups of women and responses from the Italian National Health Service.

BACKGROUND: Specific screening for anxiety and depression in pregnant women is important to identify those at risk and to provide timely intervention. The aims of the study were: 1) to compare the risk of anxiety and depression in four groups of pregnant women belonging to four types of healthcare centers distinguished by the level of risk: at low-risk; at high-risk for an obstetric reason; at high-risk for fetal anomalies; at high-risk for psychiatric conditions and 2) to identify the response that the National Health Service offers to women positively screened for anxiety and depression. METHODS: A cross-sectional study was conducted on 2801 pregnant women, cared for by National Health Service, divided into four groups: 1) low-risk pregnancy (N.=1970); 2) high-risk pregnancy for an obstetric reason (N.=218); 3) high-risk for fetal anomalies (N.=505); and 4) high-risk for psychiatric conditions (N.=108). Participants were screened using the Edinburgh Postnatal Depression Scale, the General Anxiety Disorder, and sociodemographic, anamnestic, and clinic questionnaires. RESULTS: 28.9% of participants obtained an EPDS Score ≥9 and 17.1% a GAD-7 Score ≥8. The group at high-risk for fetal anomalies presented the highest prevalence of anxiety (29.3%) and depression (49.1%) while the group at low risk presented the lowest prevalence of anxiety (13%) and depression (24.6%). The groups at risk for obstetric reasons presented an intermediate prevalence. Psychiatric conditions constituted a higher risk for anxiety than depression. Counselling is recommended for about 70% of women at risk for anxiety and depression. Moreover, about 15% of women positive for screening were initiated into psychotherapy and about 1.5% into pharmacotherapy. 15% of women positive for screening were referred to other specialists. CONCLUSIONS: This study underlined the relevance of a prompt response by the National Health Service to mental health needs, especially in the risk conditions related to obstetric and/or fetal anomalies and psychopathology.

From Pregnancy to Lactation: When the Pathway is Complicated by Cancer.

BACKGROUND: Women with a cancer history report high distress during pregnancy and infant feeding. Despite the clear advantages of breastfeeding, little is known about factors influencing infant feeding behavior in women with cancer history. RESEARCH AIM: This three-time point longitudinal study aimed to explore the centrality of pregnancy and infant feeding experiences in 17 pregnant women with a cancer history (cases) compared to 17 pregnant women without cancer history (controls). METHODS: During pregnancy, participants filled out the Centrality of Events Scale and an ad hoc questionnaire about specific emotions, concerns, and expectations about infant feeding (T1), and their childbirth and infant feeding experiences during hospitalization (T2), and at 3-months postpartum (T3). RESULTS: Results at T1 demonstrated that participants with a history of cancer reported a higher perception of negative judgment and moral choice about breastfeeding than participants without a history of cancer. At T2 they reported a more positive childbirth experience than controls. From T2 to T3 participants with a history of cancer breastfed at a higher percentage than controls, and at T3 they reported higher levels of emotional and physical pleasure about the infant feeding experiences. CONCLUSIONS: Women with cancer history may experience a higher emotional and physical pleasure with infant feeding. Despite initial difficulties, a greater prevalence of breastfeeding was present for women with a history of cancer. Although this is a small sample, this research suggests that support and promotion of breastfeeding might be very effective after a serious medical diagnosis.

Do prenatal depressive symptoms developed by hospitalized women with high-risk pregnancy persist to post-partum?

This study aims to explore the level of depressive symptoms during pregnancy and after childbirth comparing women hospitalized due to high-risk pregnancy (clinical group) and women with low-risk pregnancy (control group). Seventy pregnant women (26 clinical group and 44 control group) filled in the Edinburgh Postnatal Depression Scale both during pregnancy and three months after childbirth. Results showed that the clinical group reported significant higher levels of prenatal depression than the control group, while no differences were found on postnatal depression. Data highlighted that hospitalization could represents a significant stressor that can exacerbate depression in women with high-risk pregnancy.

Prenatal Mental Representations in Italian First-Time Mothers Before and During the COVID-19 Pandemic: A Study with Interviews on Maternal Representations During Pregnancy.

INTRODUCTION: Psychosocial risks increase the levels of not-integrated/ambivalent and restricted/disengaged representations during pregnancy, but no study has specifically analysed the impact of the COVID-19 pandemic on maternal representation styles. OBJECTIVES: (1) to compare maternal representation styles in primiparous women who became pregnant before and during the COVID-19 pandemic and (2) to analyse the content of representation styles during the COVID-19 pandemic. METHODS: A total of 37 Italian pregnant women were recruited from 2019 to 2021. The sample was divided into two groups: the pre-COVID-19 group (22 women, mean age = 33.14 years; SD = 3.78) and the COVID-19 group (15 women, mean age = 35.9 years; SD = 4.6). Interviews on maternal representations during pregnancy were administered and analysed for style and content. RESULTS: Women during the COVID-19 pandemic reported more restricted/disengaged and less integrated/balanced representation styles than women pre-COVID-19. Content analysis showed that the COVID-19 pandemic led women to focus more on concrete aspects of pregnancy in lieu of emotional aspects, thus leading them to develop more restricted/disengaged representation styles. CONCLUSIONS FOR PRACTICE: In future pandemics pregnant women should be supported in focusing their attention to emotions, sensations and fantasies about themselves as mothers and their children.

Endosonography-Guided Versus Percutaneous Gallbladder Drainage Versus Cholecystectomy in Fragile Patients with Acute Cholecystitis-A High-Volume Center Study.

Background and Objectives: Acute cholecystitis is a frequent cause of admission to the emergency department, especially in old and frail patients. Percutaneous drainage (PT-GBD) and endosonographic guided drainage (EUS-GBD) could be an alternative option for relieving symptoms or act as a definitive treatment instead of a laparoscopic or open cholecystectomy (LC, OC). The aim of the present study was to compare different treatment groups. Materials and Methods: This is a five-year monocentric retrospective study including patients ≥65 years old who underwent an urgent operative procedure. A descriptive analysis was conducted comparing all treatment groups. A propensity score was estimated based on the ACS score, incorporated into a predictive model, and tested by recursive partitioning analysis. Results: 163 patients were included: 106 underwent a cholecystectomy (81 laparoscopic (LC) and 25 Open (OC)), 33 a PT-GBD and 21 EUS-GBD. The sample was categorized into three prognostic groups according to the adverse event occurrence rate. All patients treated with EUS-GBD or LC resulted in the low risk group, and the adverse event rate (AE) was 10/96 (10.4%). The AE was 4/28 (14.2%) and 21/36 (58.3%) in the middle- and high-risk groups respectively (p < 0.001). These groups included all the patients who underwent an OC or a PT-GBD. The PT-GBD group had a lower clinical success rate (55.5%) and higher RR (16,6%) when compared with other groups. Conclusions: Surgery still represents the gold standard for AC treatment. Nevertheless, EUS-GBD is a good alternative to PT-GBD in terms of clinical success, RR and AEs in all kinds of patients.

The impact of Covid-19 restrictions on depressive symptoms in low-risk and high-risk pregnant women: a cross-sectional study before and during pandemic.

BACKGROUND: The COVID-19 social restrictions have increased the risk for depression compared to the previous period in Italian women with Low-Risk Pregnancy (LRP). lLess is known about the impact of COVID-19 restrictions on High-Risk Pregnancy (HRP). This study aimed: 1) to explore levels of depression in women who become pregnant before and during COVID-19 pandemic, distinguishing between LRP and HRP; 2) to analyze the impact of COVID-19 restrictions on pregnancy experience in LRP and HRP. METHODS: A before-during COVID-19 pandemic cross-sectional study was carried out on 155 pregnant women (Mean age = 34.18), between 23 and 32 weeks of gestation. 77 women were recruited before COVID-19 pandemic (51.9% LRP; 48.1% HRP) and 78 women were recruited during COVID-19 pandemic (51.3% LRP; 48.7% HRP). HRP group was enrolled during hospitalization for high-risk pregnancy. Participants filled out Edinburgh Postnatal Depression Scale. Moreover, only COVID-19 group answered an open-ended question about the impact of restriction on pregnancy experience. RESULTS: HRP women reported higher levels of depressive symptoms than LRP. No difference emerged for COVID (before/during) but an interaction effect between COVID-19 and obstetric condition was found. The qualitative results showed the impact of restrictions on emotions and concerns. CONCLUSION: Respect to the previous period, LRP women during COVID-19 presented an increased risk for depressive symptoms than HRP. The HRP women during COVID-19 seemed to use hospitalization as a resource to find a social support network with other pregnant women and to be reassured on the clinical ongoing of pregnancy.

Pregnancy after miscarriage in primiparae and multiparae: implications for women's psychological well-being.

Introduction: Miscarriage is a stressful life event with negative consequences that can last into the subsequent gestation, increasing women's risk for psychological symptoms. Less clear in literature is whether having a living child may buffer the psychological impact of miscarriage on subsequent pregnancies.Objective: explore levels of depression, anxiety and fear of delivery in women with and without a previous miscarriage, taking into consideration the presence of a living child.Method: 208 women (M = 34.68) were recruited during the third trimester of gestation. The sample was composed of 159 women without a previous miscarriage (72.3% primiparae and 27.7% multiparae) and 49 women with a history of miscarriage (53.1% primiparae and 46.9% multiparae). Participants filled out a battery of questionnaires aimed at assessing anxiety, depression, and fear of delivery.Results: Primiparae reported higher levels of fear of childbirth than multiparae. Moreover, women without a history of previous perinatal loss showed lower levels of depression and fear of childbirth than women with a previous perinatal loss.Conclusions: Data highlight the importance of developing specific support groups, for primiparae, due to their great emotional vulnerability, and for women with past miscarriage, to help them cope in adaptive ways with a new pregnancy.

Psychological factors and maternal-fetal attachment in relation to epidural choice.

INTRODUCTION: A woman's first childbirth is an event of great importance to her life, involving her transition to parenthood. Many studies have analyzed the roles of depression, anxiety and fear of childbirth linked to childbirth expectations and the consequent choice of an epidural to avoid pain. Few studies have investigated the predictor role of maternal-fetal attachment on the choice of epidural. OBJECTIVE: Explore, in a sample of low-risk pregnant nulliparous women, differences regarding the preference, or not, of epidural for vaginal childbirth. DESIGN AND SETTING: 87 nulliparous women, aged 24 to 44 years of age, were recruited in the maternity ward of a public hospital of the metropolitan area of Tuscany (Italy) during the 3rd trimester of gestation. Participants were asked to complete the Pregnancy Related Anxiety Questionnaire-R, Wijma Delivery Expectancy Questionnaire, Centrality of Events Scale, and Prenatal Attachment Inventory. FINDINGS: Multivariate analyses of variance showed that women who chose delivery without epidural reported lower levels of fear of childbirth and anxiety, and higher levels of centrality of pregnancy and prenatal attachment to unborn child, than women who chose epidural. KEY CONCLUSIONS: Our data highlight the importance that medical staff focus on the maternal bond, to help future mothers have the best possible childbirth experience.