The Role of DAMPS in Burns and Hemorrhagic Shock Immune Response: Pathophysiology and Clinical Issues. Review.

Severe or major burns induce a pathophysiological, immune, and inflammatory response that can persist for a long time and affect morbidity and mortality. Severe burns are followed by a "hypermetabolic response", an inflammatory process that can be extensive and become uncontrolled, leading to a generalized catabolic state and delayed healing. Catabolism causes the upregulation of inflammatory cells and innate immune markers in various organs, which may lead to multiorgan failure and death. Burns activate immune cells and cytokine production regulated by damage-associated molecular patterns (DAMPs). Trauma has similar injury-related immune responses, whereby DAMPs are massively released in musculoskeletal injuries and elicit widespread systemic inflammation. Hemorrhagic shock is the main cause of death in trauma. It is hypovolemic, and the consequence of volume loss and the speed of blood loss manifest immediately after injury. In burns, the shock becomes evident within the first 24 h and is hypovolemic-distributive due to the severely compromised regulation of tissue perfusion and oxygen delivery caused by capillary leakage, whereby fluids shift from the intravascular to the interstitial space. In this review, we compare the pathophysiological responses to burns and trauma including their associated clinical patterns.

Laparoscopic adrenalectomy for giant adrenal tumours: Technical considerations and surgical outcome.

BACKGROUND: Giant adrenal tumours are tumours with size ≥6 cm. These are rare cancer associated with malignancy in 25% of cases. PATIENTS AND METHODS: A retrospective review was conducted on the medical records of patients admitted to our high-volume centre of Careggi University Hospital with a giant adrenal tumour and submitted to adrenalectomy between January 2008 and December 2018. The group of patients who underwent to laparoscopic adrenalectomy was compared with a group of patients that was submitted to open adrenalectomy. RESULTS: In the past 10 years, we performed about 245 adrenalectomies for benign and malignant adrenal tumours. Fifty (20.4%) of these were giant tumours. The medium size was 9.9 cm (7-22 cm). The mean age was 57 years (21-81 years). Thirty-four (68%) of these cancers were laparoscopically removed and 16 (32%) with an open approach. The surgical outcomes in these patients were optimal if compared to the group of patients submitted to open approach in terms of good pain control, hospital stay, mean operative time and bloodless. No difference was observed about post-operative complications in the two groups. The follow-up after 30 months for malignant tumours did not show local recurrences. CONCLUSION: Our results pinpoint the advantages of performing a laparoscopic adrenalectomy for giant adrenal tumours. The tumour size is only a predictive parameter of possible malignancy, and the laparoscopic approach is a safe and feasible method in terms of surgical and oncological, only if performed by expert surgeons and in high-volume centres.

Laparoscopic assisted balloon enteroscopy to detect obscure gastrointestinal bleeding sources missed by capsule endoscopy.

Jejunoileal neuroendocrine tumours (NETs) are frequently multifocal and represent a consistent source of obscure gastrointestinal bleeding (OGIB). We report the real-life case of a female presenting to our attention for severe episodes of haematochezia caused by multiple localisation of jejunoileal NETs. A discrepancy between pre-operative total body contrast-enhancement computed tomography scan and capsule endoscopy (CE) emerged, in terms of numbers of lesions, so that, as completeness, an intraoperative balloon-assisted enteroscopy (BAE) was carried out, leading to the detection of the multiple lesions missed during CE. In case of obscure gastrointestinal bleeding sources missed by capsule endoscopy, laparoscopic-assisted balloon enteroscopy plays an essential role, allowing both to assess a precise diagnosis and to resect the intestinal bleeding tract.

Bedside diagnostic laparoscopy for critically ill patients in the Intensive Care Unit: Retrospective study and review of literature.

BACKGROUND: Bedside diagnostic laparoscopy could be helpful in extremely critically ill patients. The aim of this retrospective study is to evaluate the safety and diagnostic accuracy of bedside diagnostic laparoscopy in the identification of intra-abdominal pathology in critically ill patients and to compare its accuracy and outcomes with the ones of laparotomy. PATIENTS AND METHODS: A retrospective review was conducted on the medical records of patients admitted to the Intensive Care Unit (ICU) of Careggi University Hospital and submitted to bedside diagnostic laparoscopy between January 2006 and May 2017. This group of patients was compared with a group of patients that were admitted to the ICU and submitted directly to explorative laparotomy for suspected intra-abdominal pathologies. RESULTS: One hundred and twenty-nine patients (M/F = 81/48, mean age = 71.64 years) underwent bedside diagnostic laparoscopy in ICU. 154 patients instead were submitted directly to explorative laparotomy in operatory room (mean age 75.70 years, M/F = 94/60). Among the 129 patients submitted to bedside laparoscopy, 53.49% were positive for intra-abdominal pathologies whereas 46.51% were negative, while among the 154 patients submitted directly to laparotomy, 76.62% were positive for intra-abdominal pathologies whereas 23.38% were negative. In 55.03% of all patients submitted to bedside laparoscopy, a non-therapeutic laparotomy was avoided, while the 33.76% of patients submitted directly to laparotomy had a non-therapeutic laparotomy that could be avoidable. CONCLUSIONS: Our results pinpoint the advantages of performing bedside diagnostic laparoscopy in the ICU setting, which can be considered an option every time there is the suspicion of an intra-abdominal pathology.

Results of surgical treatment for jejunal Crohn's disease: choice between resection, strictureplasty, and combined treatment.

PURPOSE: The jejunum is a relatively uncommon localization of Crohn's disease (CD) compared to the terminal ileum or the large bowel. The type of surgery and the short and long-term results after surgery have not been extensively investigated. A review of patients who underwent surgery for jejunal CD in our center was examined. METHODS: Between 1986 and 2011, 110 patients underwent surgery for jejunal CD. Thirty patients (27.3 %) were surgically treated with resection, 29 patients (26.4 %) with one or more strictureplasties, and 51 patients (46.3 %) with both a resection and one or more strictureplasties. RESULTS: There was no statistical difference in terms of short-term postoperative complications between patients operated with three different options (p = 0.72). Patients were followed up for a period ranging from 2 to 18 years (mean 11 years). During this period, 42 patients had no CD recurrence, 11 patients had medical recurrences only, while 57 patients had surgical recurrences, too. There was no statistical difference in terms of medical and surgical recurrence between the three types of surgical procedures employed (p = 0.24) and between smokers and non-smokers. The recurrent CD was prevalently treated with strictureplasty. CONCLUSIONS: The most frequently employed surgery for the treatment of jejunal CD is a combined type of treatment, i.e., resection of the most affected tract and strictureplasty of the residual strictures. This approach does not imply an increased risk of postoperative complications and recurrence and can reduce the risk of the short bowel syndrome.

A long-term evaluation of the quality of life after laparoscopic Nissen-Rossetti anti-reflux surgery.

BACKGROUND: The quality of life (QoL) has been suggested to be the most relevant parameter to assess and monitor the long-term outcome in patients who underwent surgery for gastroesophageal reflux disease (GERD). PATIENTS AND METHODS: A retrospective evaluation was conducted on patients who underwent Laparoscopic Nissen-Rossetti Fundoplication for GERD between January 1998 and December 2010. To evaluate the long-term results a telephone interview was made using the VISICK score and the GERD-health-related QoL (HRQL) questionnaire at 1, 3, 5 years and at the end of the study. If the questionnaires resulted unsatisfactory, a complete diagnostic revaluation was performed. RESULTS: A total of 168 patients underwent laparoscopic surgery for GERD. When evaluated at the end of the study, the number of unsatisfied patients according to the VISICK score was significantly higher than the one obtained with the GERD-HRQL questionnaire. CONCLUSIONS: Many data suggest a possible recurrence of the symptoms after surgery in a long follow-up period. Our data seem to demonstrate a slight but significant trend in symptoms relapse after surgery. Considering the non-specific and specific nature of the two scores, VISICK and GERD HRQL, our result showed a significantly more relevant trend of symptoms relapse only for the non-specific ones. Such QoL scores seem to be important in selecting patients who need to be instrumentally examined. Consequently, our work proves that only a few patients out of the total number of followed up patients, are to be recalled to undergo instrumental examination.

Fluorescence-guided laparoscopic lymph node biopsy for lymphoma: the FLABILY study.

To date, no reports have indicated laparoscopic lymph node biopsies using Indocyanine green (ICG) in cases of lymphoproliferative disease. Preliminary data of patients undergoing fluorescence-guided laparoscopic lymph node biopsy (FGLLB) using ICG was retrospectively analysed from the multicentre registry FLABILY study. Between June 2022 and February 2024, 50 patients underwent FGLLB. The surgical biopsy aimed to re-stage lymphoproliferative disease for 25 patients and to establish a diagnosis in 25 patients. The median duration of the procedure was 65 ± 26.5 min. All the procedures were performed laparoscopically. One surgical conversion occurred due to bleeding. Median length of hospitalization was 1 ± 1.7 days. Two unrelated complications occurred in the immediate postoperative course. ICG was administrated preoperatively by means of an inguinal, perilesional, or intravenous injection according to the anatomical sites of the biopsy. Fluorescence was obtained in 43/50 (86%) of patients. A significant difference was highlighted in the appearance of fluorescence in sub-mesocolic lymph nodes compared to supra-mesocolic and mesenteric lymph nodes (41/49 (83.6%) vs. 13/22 (59%), p = 0,012). In 98% of cases, FGLLB provided the information necessary for the correct diagnosis. Fluorescence with ICG offers a simple and safe method for detecting pathological lymph nodes. FGLLB in suspected intra-abdominal lymphoma can largely benefit from this new opportunity which, to date, has not yet been tested. Further studies with a larger case series are needed to confirm its efficacy.

The role of bed-side laparoscopy in the management of acute mesenteric ischemia of recent onset in post-cardiac surgery patients admitted to ICU.

PURPOSE: Acute mesenteric ischemia with non-occlusive mechanism (NOMI) is a possible complication after cardiac surgery in patients admitted to Intensive Care Unit (ICU). Since the diagnosis is often difficult with CT-scan, some authors have evaluated the role of bed-side diagnostic laparoscopy (DL). We aimed to contribute to this topic with a personal series. METHODS: We retrospectively evaluated patients admitted to ICU after cardiac surgery since 2009 up to 2019, successively operated on for a suspected NOMI of recent onset with non-conclusive CT. They were divided into laparoscopic (Ls) and laparotomic (Lt) group, depending on whether or not they had a DL. They were compared for the CT false-positive (FP) and true-positive (TP) rate and the surgical outcome. RESULTS: Seventy-three patients were enrolled. Lt included 30 patients (41%), Ls 43 (59%). The overall FP were 38 (52%), with a higher incidence in Ls. There was no difference in the mortality rate. The morbidity rate was higher in Lt, and especially in Lt-FP. The TP were 35 (47.9%). The mean operating time (OT) in the Lt-TP group was similar to the sum of the mean OT of the laparotomies plus that of the laparoscopies in the Ls-TP group. Conversely, when considering only laparotomic procedures, the Lt-TP had higher mean OT, such as an increased blood loss CONCLUSIONS: Post-cardiosurgical patients admitted to ICU have a relatively high rate of NOMI, in which CT-scan is often initially non-conclusive. Our data and those from the literature seem to show that in such cases bed-side DL may be an advantageous and safe procedure to avoid needless laparotomy and enables a more tailored open surgery.

Post-laparoscopic mesh in post-menopausal umbilical hernia repair: a case series.

We evaluated the efficacy and safety of the use of a composite PTFE/polypropylene patch, Ventralex (Davol Inc., C.R. Bard, Inc., RI, USA), to repair, concurrent with laparoscopy, umbilical hernia in 51 postmenopausal women. After laparoscopy, patients were submitted to the hernia repair by a patch intraperitoneally placed behind the hernia. Primary outcomes included complication rates, while hernia recurrence was the secondary outcome. Patient age range was 58 ± 4.3 years, the size of patches was small in 17.6% of women, medium in 68.7% and large in 13.7%. Seventy-six percent of patients had an ASA I-II score, the mean operating time for hernia repair was 7 ± 2 minutes with 15 cc of related blood loss, with 1.8 days of hospital stay. The visual analogue scale was 0-3 for 62.7%, 4-6 for 27.5% and 7-10 for 9.8% of women. All laparoscopic and umbilical hernia repair terminated without any further intra or postoperative complications, with 36 months of follow-up; none of the patients showed recurrences. Combining laparoscopy and intraperitoneal mesh repair appears to be indicated for umbilical hernia treatment in post-menopausal patients undergoing laparoscopy, resulting in a safe and easy procedure, with short hospital stay and fast dismissal, with no major morbidity or recurrence.

Emergency surgery in the time of Coronavirus: the pandemic effect.

BACKGROUND: The COVID-19 epidemic became a challenge for Emergency Departments (ED) and a remarkable reduction in surgical emergencies has been widely noticed. The aim of the present study was to evaluate the impact of the pandemic period in the need of surgical emergencies. METHODS: Between January 1, and May 31, 2020 all the consecutive general surgery emergencies performed by the Unit Hospital Emergency Surgery of the Careggi University (Florence, Italy) were prospectively recorded and compared to the same period of 2019. Demographic and clinical data were recorded and analyzed. RESULTS: The number of surgical procedures decreased only in the month of March 2020 (compared to 2019), while in April the total numer of emergency surgical procedures was similar. Only appendectomy, complicated hernia repair and colonic resection were significantly reduced (40%, 48% and 33% respectively). The number of small intestine excision, cholecystectomy and lysis of peritoneal adhesions remained stable throughout the entire period. No statistically significant differences were found considering age, sex, Emergency Surgery Score, mortality, ICU postoperative admission and time between admission and surgery, even when analyzed with multivariate analysis for every single surgical procedure, suggesting a comparable disease severity and comorbility patterns. Mortality in COVID patients was 25%, compared to 7% of no-covid patients. CONCLUSIONS: The COVID-19 pandemic has caused major changes in daily clinical practice, especially in areas such as Emergency. This has led to a temporary reduction and changes in the flow of patients to the emergency room, with implications also for emergency surgical activities.

Open abdomen management for massive intestinal infarction due to acute splanchnic venous thrombosis in a patient with protein S deficiency. A case report.

INTRODUCTION: Acute mesenteric ischemia (AMI) refers to the sudden onset of intestinal hypoperfusion that can also result from splanchnic venous occlusion. The portomesenteric venous system (PMVS) is an unusual site of thrombosis in patients with protein S deficiency and its obstruction is a rare cause of AMI. Aim of this report is to illustrate a successful strategy in a case of massive small bowel infarction managed with an open abdomen (OA) approach. CASE PRESENTATION: A 64 year-old woman presented to the emergency department with acute abdominal pain, rectal bleeding, diarrhea and vomiting. Contrast-enhanced computed tomography (CECT) showed small bowel ischemia and the complete occlusion of all the PMVS branches. Surgery was performed with an OA approach and anticoagulation was immediately begun. Further workup revealed isolated protein S deficiency and history of atrophic gastritis. Thromboprophylaxis with warfarin was started on discharge and no recurrence of thrombotic events was recorded during the one-year follow-up. DISCUSSION: PMVS thrombosis related to protein S deficiency is a rare condition that can rapidly lead to an acute abdomen. CECT is the gold standard, because it detects splanchnic thrombosis and its possible complications, like bowel ischemia. In case of surgery, a planned second-look operation is the best strategy to assess bowel viability and possible ischemic progression. CONCLUSIONS: OA management plays a fundamental role in case of resection for bowel ischemia. Patients with thrombosis at an uncommon site should be further investigated for prothrombotic states.

Obstructive left side colon cancer: time for a tailored operative approach?

BACKGROUND: Colorectal cancer (CRC) obstruction is frequent but doubts remain on the best treatment. The aim of this study is to analyze the different operative approach used for CRC treatment and evaluate the outcomes for the different cases. METHODS: Patients were collected from January 2014 to December 2019 and divided in four groups: two "P" groups, namely the Hartmann's procedure (PH) group and the primary anastomosis (PA) group, and two "S" groups, namely the deviating stoma (SD) group and the self-expanding metallic stent (SS) group. The main endpoints were the quality of life and the oncologic safety. RESULTS: One hundred and eight patients were enrolled. The mean follow-up time was 39 months. The stomas were performed less frequently in SS but lasted more in that group. Only 45% underwent reversal surgery. Cumulative operating time was greater in S versus P groups. The rate of major complications was similar. PA had greater overall survival and disease-free survival rates than PH. CONCLUSIONS: The various options of treatment should have different indications: primary anastomosis in stable patients, Hartmann in critical cases, SEMS for palliative intent and stoma when neo-adjuvant therapy is needed.

Chevrel technique for ventral incisional hernia. Is it still an effective procedure?

BACKGROUND: Incisional hernia still represents the most frequent late complication of abdominal surgery. After a direct repair, in literature is reported a recurrence rate ranging from 31 to 49%, meanwhile after a prosthetic repair such values were much lower, with a recurrence rate up to 10%. The sites of prosthetic placement in the abdominal wall are premusculo-aponeurotic (onlay, or Chevrel technique), retromuscular-prefascial and preperitoneal (Rives technique, Stoppa technique), whereas intraperitoneal insertion can be done with open or laparoscopic surgery. The aim of this study was to evaluate the immediate and late postoperative results in patients treated with a Chevrel technique for ventral incisional hernia. METHODS: A retrospective review was conducted on the medical records of patients undergoing ventral hernia repair between January 2008 and December 2018 at the Emergency Surgery Unit of the Careggi University Hospital in Florence. RESULTS: Between January 2008 and December 2018 at the Emergency Surgery Unit of the Careggi University Hospital in Florence, 461 patients (245 male, 216 female) with a mean age of 61,52 years were submitted to ventral incisional hernia repair with a Chevrel technique. The mean operatory time was 95.29 min (±50.48) and in 72 patients (15.61%) human fibrin glue was vaporized under the mesh using a spray device. Mean postoperative hospital stay was 5 days and all drain tubes were removed after 7.1 days as mean (±4.3). No intraoperative mortality nor postoperative mortality was reported. In our experience the Chevrel technique for ventral incisional hernia show a recurrence rate (3.2%). Parietal complications observed were seroma in 7.1% of patients, hematoma in 4.7%, localized skin necrosis in 5.2%, surgical site infection in 6.7%, data comparable with the results reported in the other studies. CONCLUSIONS: Most of the objections to the Chevrel procedure focus on the parietal complications and risk of infection. Chevrel procedure cannot be considered an obsolete intervention, in our series, results were very satisfactory in both immediate and late follow-up; moreover this technique is safe and easy to perform.

Laparosacopic management with combination of fatty meal and methylen-blu for chylous leak after a left para-aortic paraganglioma excision.

We report a case of chylous leak recognized post-operatively after abdominal surgery for left para-aortic paraganglioma in a young female with a history of open botallo's duct. Conservative measures failed to control the leak and the patient is not eligible for sclerotisation. Laparoscopic exploration with intralipidand methylen blue injection through an orogastric tube revealed the leaking area near the superior mesenteric vein behind the Traitz, and this was ligated with non-asorbable suture and placement of acrylic glue. The patient was discharged the 7th post-operative day after removal of the drainage which appeared to supply <100 cc of serum material. Outpatient control was successful and the patient is actually in good conditions.

Urgent cholecystectomy in patient with left-sided gallbladder Case report and review of the literature.

INTRODUCTION: Sinistroposition of the gallbladder, or true left-sided gallbladder (LSG) without situs viscerum inversus, is a rare congenital anatomical variant where the gallbladder is located to the left of round/falciform ligament. It can be associated with anomalies of the biliary tree, portal system and hepatic vascularization. The surgical management of a LSG could be challenging even for an experienced operator, being usually an incidental intraoperative finding. CASE REPORT: A 72 years old woman was admitted to our emergency department because of acute cholecystitis. There were no pre-operative indications of sinistroposition of the gallbladder and its aberrant position was discovered during the explorative laparoscopy; because of the unusual anatomy and chronic flogosis, the laparoscopic approach was converted to open surgery. The patient underwent a successful intervention and was discharged after 4 days without complications. Her family history revealed a daughter with biliary atresia. DISCUSSION: LSG could remain undetected at preoperative imaging, but today, with advances in diagnostic imaging, the report of this condition has increased. Several hypothesis suggest the presence of an underlying embriologic mechanism for LSG and its associated anomalies, but its etiology is still unknown. The association with the daughter's biliary atresia makes reasonable a possible genetic correlation with this condition. CONCLUSIONS: In case of LSG, laparoscopic cholecystectomy could be feasible and safe, but with an increased risk of injury to the major biliary structures, mostly in case of severe and chronic inflammation of the gallbladder. Surgeons have to know this variant because of its associated hepatic anomalies. KEY WORDS: Cholecystectomy, Emergency Surgery, Left-Sided-Gallbladder.

Comparing outcomes after treatment of rectal cancer over a long-lasting follow-up between patients who were offered surgery alone and surgery with neoadjuvant therapy.

BACKGROUND: To assess outcomes of patients operated on for rectal cancer (RC) by analysing the trends of disease free survival curves (DFSc) after a very long-term follow-up. METHODS: All patients treated with curative intent for RC from 1986 to 2005 were retrospectively analyzed. Other than demographics, disease characteristics and treatment-related factors were considered. The DFSc were compared between patients who had neoadjuvant therapy (NAT) and those who had surgery alone. RESULTS: Median age of 319 patients included in the study was 66.3 years (range 23-89) and 140 (57.6%) of them were males. Moreover, NAT was given in 24 (11.8%) patients, and adjuvant therapy in 40 (19.7%) patients. Median follow-up was of 150 months (60-240). In patients who had NAT the mean age was higher (P=0.05), RC were located lower (P=0.009) and higher positive lymph-nodes were found (P=0.003), whereas the number of both local (P=0.4) and distant recurrences (P=0.7) was not significantly lower, compared to the other group. Comparing trends of DFSc a more progressive decrease was shown in patients treated with surgery alone. Even if the differences of DSFc between groups at the end of follow-up were not significant (95% CI: 0.609-2.963, P=0.46), patients who had NAT displayed better survival up to 180 months. CONCLUSIONS: Overall, these results showed comparable outcomes between both groups over such a long lasting follow-up. This time frame might be used more extensively for increasing our knowledge of RC biological behaviour as well.