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BACKGROUND: This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses. METHODS: This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed. RESULTS: Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23). CONCLUSIONS: Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.
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Antibacterianos , Drenaje , Tomografía Computarizada por Rayos X , Insuficiencia del Tratamiento , Humanos , Masculino , Femenino , Estudios de Casos y Controles , Persona de Mediana Edad , Drenaje/métodos , Factores de Riesgo , Anciano , Antibacterianos/uso terapéutico , Diverticulitis del Colon/terapia , Diverticulitis del Colon/diagnóstico por imagen , Diverticulitis del Colon/cirugía , Absceso Abdominal/terapia , Absceso Abdominal/etiología , Absceso Abdominal/diagnóstico por imagen , Absceso Abdominal/cirugía , Enfermedad Aguda , Adulto , Absceso/terapia , Absceso/diagnóstico por imagen , Absceso/cirugía , Tratamiento Conservador/métodosRESUMEN
AIM: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. METHOD: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. RESULTS: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). CONCLUSION: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.
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Neoplasias del Recto , Recto , Humanos , Recto/cirugía , Recto/patología , Ileostomía/efectos adversos , Neoplasias del Recto/patología , Fuga Anastomótica/etiología , Anastomosis Quirúrgica/efectos adversos , Estudios RetrospectivosRESUMEN
BACKGROUND: The identification of metastatic lymph nodes is one of the most important prognostic factors in gastrointestinal (GI) cancers. Near-infrared fluorescence (NIRF) imaging has been successfully used in GI tumors to detect the lymphatic pathway and the sentinel lymph node (SLN), facilitating fluorescence image-guided surgery (FIGS) with the purpose to achieve a correct nodal staging. The aim of this study was to analyze the current results of NIRF SLN navigation and lymphography through data collected in the EURO-FIGS registry. METHODS: Prospectively collected data regarding patients and ICG-guided lymphadenectomies were analyzed. Additional analyses were performed to identify predictors of metastatic SLN and determinants of fluorescence positivity and nodal metastases outside the boundaries of standard lymphadenectomies. RESULTS: Overall, 188 patients were included by 18 surgeons from 10 different centers. Colorectal cancer was the most reported pathology (77.7%), followed by gastric (19.1%) and esophageal tumors (3.2%). ICG was injected with higher doses (p < 0.001) via extraparietal side (63.3%), and with higher volumes (p < 0.001) via endoluminal side (36.7%). Overall, NIRF SLN navigation was positive in 75.5% of all cases and 95.5% of positive SLNs were retrieved, with a metastatic rate of 14.7%. NIRF identification of lymph nodes outside standard lymphatic stations occurred in 52.1% of all cases, 43.8% of which were positive for metastatic involvement. Positive NIRF SLN identification was an independent predictor of metastasis outside standard lymphatic stations (OR = 4.392, p = 0.029), while BMI independently predicted metastasis in retrieved SLNs (OR = 1.187, p = 0.013). Lower doses of ICG were protective against NIRF identification outside standard of care lymphadenectomy (OR = 0.596, p = 0.006), while higher volumes of ICG were predictive of metastatic involvement outside standard of care lymphadenectomy (OR = 1.597, p = 0.001). CONCLUSIONS: SLN mapping helps identifying potentially metastatic lymph nodes outside the boundaries of standard lymphadenectomies. The EURO-FIGS registry is a valuable tool to share and analyze European surgeons' practices.
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Ficus , Neoplasias Gastrointestinales , Linfadenopatía , Ganglio Linfático Centinela , Cirugía Asistida por Computador , Humanos , Ganglio Linfático Centinela/patología , Biopsia del Ganglio Linfático Centinela/métodos , Linfografía , Metástasis Linfática/diagnóstico por imagen , Metástasis Linfática/patología , Verde de Indocianina , Ganglios Linfáticos/patología , Escisión del Ganglio Linfático/métodos , Neoplasias Gastrointestinales/patología , Linfadenopatía/patología , Sistema de RegistrosRESUMEN
BACKGROUND: Liver transplantation (LT) is a well-established procedure for hepatocellular carcinoma (HCC) within the Milan criteria. Yttrium-90 microspheres radioembolization (Y90-RE) has shown to be an effective and safe treatment of primary liver tumors. We retrospectively evaluate the efficacy of the Y90-RE in patients with HCC prior to LT. METHODS: From January 2002 to December 2015, 365 patients were transplanted at the San Camillo Hospital Center. One hundred forty-three patients were transplanted for HCC, and in 22 cases the patients were treated with Y90-RE before LT. RESULTS: Three patients were treated with Y90-RE within the Milan criteria, and 19 patients were out of criteria before Y90-RE. Four patients had an increasing MELD score between Y90-RE and LT. On the other hand, alpha-fetoprotein decreases after Y90-RE treatment in all cases. No patient death was observed in Y90-RE procedure or at LT. In 78.9 % of cases, a successful downstaging was observed, and in 100 % of cases bridging was achieved. From Y90-RE treatment overall survival was 43.9 months. From LT, overall mean survival was 30.2 months with a free survival of 29.6 months. The overall survival after LT analysis between the patients treated with Y90-RE and patients without was not significant (p = 0.113). Free survival analysis was not significant (p = 0.897) between the two populations. CONCLUSIONS: We successfully performed LT in patients after Y90-RE treatment both as bridging and downstaging for HCC and obtained a similar overall and free survival of LT for HCC within Milan criteria. Y90-RE becomes a real option to provide curative therapy for patients who traditionally are not considered eligible for surgery.
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Embolización Terapéutica/métodos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/terapia , Radiofármacos/uso terapéutico , Radioisótopos de Itrio/uso terapéutico , Adulto , Anciano , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/terapia , Femenino , Humanos , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios , Estudios RetrospectivosRESUMEN
BACKGROUND: Uterine leiomyomas represent the gynecological neoplasm with the highest prevalence worldwide. This apparently benign pathological entity may permeate into the venous system causing the so-called intravenous leiomyomatosis of the uterus (IVL). IVL may seldom extend to large caliber veins and reach the right cardiac chambers or pulmonary arteries and cause signs of right sided congestive heart failure and sudden death. Due to its low incidence, however, IVL with intracardiac extension is often misdiagnosed resulting in deferred treatment. No consensus has been obtained regarding the standard surgical approach to be used for this rare condition. We describe the case of a massive pelvic recurrence of uterine leiomyomatosis with intracardiac extension and provide a review of the literature, analyzing management and surgical outcomes. CASE PRESENTATION: We present the case of a 46-year-old premenopausal woman presenting with lower-extremity edema, recurrent syncopes and a history of subtotal hysterectomy for multiple uterine fibroids. She was diagnosed with pelvic recurrence of uterine leiomyomatosis and IVL with cardiac involvement. A two-stage surgical excision of the intracardiac-intracaval mass and pelvic leiomyomatosis was performed. The patient had an uneventful recovery and no evidence of recurrence was observed on follow-up. CONCLUSIONS: By virtue of the rarity of the present pathology, awareness is widely scarce and diagnosis is often delayed. Early recognition is difficult due to initial aspecific and subtle clinical manifestations. Nevertheless, suspicion should be held high in premenopausal women with known history of uterine leiomyomata, presenting with cardiovascular symptoms and evidence of a free-floating mass within the right cardiac chambers. In-depth imaging is crucial for defining its anatomical origin and relations. Prompt surgical treatment with radical excision of pelvic and intravenous leiomyomatosis guarantees favorable outcomes and excellent prognosis with low rates of recurrence, whereas delayed diagnosis and treatment exposes to increased risk of congestive heart failure and sudden death.
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Neoplasias Cardíacas/patología , Leiomiomatosis/patología , Neoplasias Uterinas/patología , Femenino , Humanos , Histerectomía , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Pelvis/patología , Arteria Pulmonar , Neoplasias Uterinas/cirugía , Vena Cava InferiorRESUMEN
BACKGROUND: Hepatocellular carcinoma (HCC) tends to have a particular invasiveness toward the portal vein (PV) branches and hepatic veins. This situation can hamper major surgical resection with a risk of postoperative liver failure due to the small future liver remnant (FLR) in cirrhotic livers. These patients are then usually directed to palliative treatments with poor results. The associating liver partition and PV ligation (PVL) in staged hepatectomy (ALPPS) strategy is one of the main surgical innovations in recent years in the field of liver surgical oncology. The ALPPS approach could allow surgical resection in patients with HCC and associated major vascular invasion. METHODS: Among 1,143 liver resection performed in our center, the ALPPS approach was employed in order to induce rapid hypertrophy of the left FLR in patients with HCC and associated major vascular invasion. This strategy consists of combining the in situ splitting of the liver along the main portal scissura or on the right side of the falciform ligament and PVL in a strategy of staged hepatectomy. RESULTS: In our experience the ALPPS approach allowed us to achieve a sufficient FLR in two cases of HCC with major vascular invasion, in which the classic two-stage strategy could not be applied. In both cases the patients could undergo major hepatectomies without mortality. CONCLUSIONS: This novel strategy could expand the number of patients undergoing major liver resections that were previously considered non-resectable because of the risk of liver decompensation for an insufficient FLR.
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Carcinoma Hepatocelular/irrigación sanguínea , Carcinoma Hepatocelular/cirugía , Hepatectomía/métodos , Neoplasias Hepáticas/irrigación sanguínea , Neoplasias Hepáticas/cirugía , Vena Porta/cirugía , Adulto , Anciano , Carcinoma Hepatocelular/patología , Estudios de Seguimiento , Humanos , Ligadura/métodos , Neoplasias Hepáticas/patología , Masculino , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Medición de Riesgo , Muestreo , Factores de Tiempo , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
We present a video case of a 51-year-old man admitted to our surgical and liver transplantation unit for hepatocellular cancer (HCC). Patient has a HCV cirrhosis with portal hypertension and esophageal varices F1. Child Pugh score was B7 and model of end staged liver disease (MELD) was 11. Body mass index (BMI) was 26.7 and ASA score was 2. No previous abdominal surgery. According with our multidisciplinary group we suggest a laparoscopic left lobectomy for the patient. Pringle manoeuvre was not performed. Operation time was 193 min and blood loss estimation was 100 cc. No transfusion was required. Post-operative course was uneventful, grade I of Clavien-Dindo Classification. Patient was discharged in day 8. In our experience laparoscopic resection in cirrhotic liver should be performed in selected patients and in an experienced team.
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Purpose: Sigmoidectomy is performed in most cases for benign pathologies and mainly in cases of diverticulitis. Few studies in the literature report oncological results after sigmoidectomy for adenocarcinoma. The aim of this study was to report the long-term oncological outcomes after elective laparoscopic sigmoidectomy (LS) for adenocarcinoma. Methods: This study is a retrospective analysis of prospectively collected data. From January 2003 to February 2021, 173 patients underwent elective LS for adenocarcinoma. Twenty-four patients with a diagnosis of preoperative distant metastases were excluded (13.9%). Results: Seven postoperative complications were observed (7.1%). Of these, 2 (2%) anastomotic leakages were treated surgically by the Hartmann procedure (Clavien-Dindo grade III-b). The mean number of harvested lymph nodes with the specimen was 14.2 ± 7.1. At a median follow-up of 115 months (interquartile range 133.8), 2 (2%) and 9 patients (9.2%) had developed recurrence and metastases, respectively. During follow-up, 6 patients (6.1%) with metastases died due to disease progression and 6 other patients (6.1%) died due to causes other than cancer related. At the 5- and 10-year follow-ups, the overall survival rates were 90.5% ± 3.4% and 83.8% ± 4.5%, respectively, while the disease-free survival rates were 87.1% ± 4.1% and 83.5% ± 4.7%, respectively. Conclusion: LS is a safe and feasible technique both in terms of the number of harvested lymph nodes and oncological results. The possibility of sparing the colon without mobilizing the splenic flexure and dividing the left colic artery could reduce intra- and postoperative complications. Further studies with larger samples of patients are required to confirm these data.
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Adenocarcinoma , Laparoscopía , Humanos , Estudios Retrospectivos , Laparoscopía/métodos , Colon/cirugía , Complicaciones Posoperatorias/cirugía , Adenocarcinoma/cirugía , Resultado del Tratamiento , Colectomía/métodosRESUMEN
Several objective severity measurement questionnaires of the fecal incontinence (FI), are available to describe type, frequency and degree of FI, and their impact on quality of life, aiming to establish baseline scores measure response to treatment over time and allow comparison among patients treated using different strategies. Presently, despite their widespread use in clinical practice, none of these questionnaire have been validated in the Italian language. The aim is to test the translated Italian version of the Vaizey and Wexner and Fecal Incontinence Severity Index (FISI) questionnaires assessing their reliability and validity among Italian-speaking patients. Two researchers proficient in spoken English and Italian translated both questionnaires in the Italian language. They independently translated the two questionnaires from English and then they met to produce a single version of the two questionnaires, to solve any possible discrepancy. A forward-backward translation was then obtained by a professional bilingual translator, so as to define the final version of the questionnaires. The questionnaires were independently administered twice to 100 Italian-speaking patients by two different and independent raters. Cronbach's α of the first and second Vaizey and Wexner questionnaire was 0.755 and 0.727, respectively. While Cronbach's α of the first and second FISI questionnaire was 0.810 and 0.806, respectively. Spearman correlation and inter-rater reliability were 0.937 and 0.913 for Vaizey and Wexner questionnaire, respectively, and 0.915 and 0.871 for FISI questionnaire, respectively. Italian version of the Vaizey and Wexner and FISI questionnaires proved good consistency, reliability, reproducibility, showing good psychometric properties.
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Incontinencia Fecal , Calidad de Vida , Humanos , Reproducibilidad de los Resultados , Estudios Prospectivos , Incontinencia Fecal/diagnóstico , Índice de Severidad de la Enfermedad , Lenguaje , Encuestas y Cuestionarios , ItaliaRESUMEN
During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020-February 2021) and during the control period (March 2019-February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.
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COVID-19 , Estomía , Colostomía/métodos , Humanos , Estomía/métodos , Pandemias , Calidad de VidaRESUMEN
INTRODUCTION: The recent COrona Virus Disease 2019 (COVID-19) pandemic caused a massive disruption of surgical activity and after a year from its first outbreak surgeons still struggle to keep their regular activity coexisting with the virus exhausting requests of healthcare resources. The aim of this paper is to offer a comprehensive overview of the most important recommendations by the International Guidelines about general surgery, and possibly to invite building common shared guidelines to preserve the potential to provide surgical assistance despite the pandemic. EVIDENCE ACQUISITION: This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. PubMed, Embase, Cochrane and Web of Science databases were searched. EVIDENCE SYNTHESIS: The searches revealed a total of 18579 articles published up to the end of February 2021. Five articles published between March and May 2020, were included in the present study: Guidelines from The European Society of Trauma and Emergency Surgery (ESTES), The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and The European Association for Endoscopic Surgeons (EAES), The Endoscopic and Laparoscopic Surgeons of Asia (ELSA), The European Hernia Society (EHS) and The International Organization for the Study of Inflammatory Bowel Disease (IOS-IBD). CONCLUSIONS: In the likely scenario that the SARS-CoV-2 pandemic will become an endemic chronic problem, we should not be forced to choose between COVID-19 or surgery in the future and find a way to make both coexisting.
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COVID-19 , Laparoscopía , Cirujanos , COVID-19/epidemiología , Humanos , Pandemias , SARS-CoV-2RESUMEN
Background and Objectives: To compare the outcomes of extracorporeal hand-sewn side-to-side isoperistaltic ileocolic anastomosis (EHSIA) versus intracorporeal mechanic side-to-side isoperistaltic ileocolic anastomosis (IMSIA) during laparoscopic right hemicolectomy for adenocarcinoma. Methods: This is a retrospective propensity score-matched analysis of prospectively collected data. Fifty-four patients who underwent surgery with EHSIA (intervention group) were paired with 54 patients who underwent surgery with IMSIA (control group) based on patients' demographics and type of surgery (standard right hemicolectomy or extended right hemicolectomy). Results: Fifty-four patients were included for each group. Statistically significant differences between groups were not observed in patients' demographics and type of surgery. Conversion occurred in three patients of the intervention group due to intra-abdominal adhesions for previous surgery (5.6%) (p = 0.079). Median operative time was statistically significant shorter in the control group in comparison to the intervention group (85 and 117.5 minutes, respectively, p ≤ 0.0001). In both groups one anastomotic leakage was observed (1.9%) (Clavien-Dindo grade III-a). In the control group one patient (1.9%) underwent reintervention for acute postoperative anemia (Clavien-Dindo grade III-b). Median number of harvested lymph-nodes was 17 and 12 (p ≤ 0.0001), in the intervention and the control group, respectively. Median hospital stay was statistically significant lower in the control group in comparison to the intervention group (5 and 6.5 days, respectively, p ≤ 0.013). Conclusion: IMSIA showed lower operative time and hospital stay in comparison to EHSIA. Further randomized studies are required to draw definitive conclusions about the best anastomotic technique during laparoscopic right hemicolectomy.
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Laparoscopía , Anastomosis Quirúrgica/métodos , Colectomía/métodos , Humanos , Laparoscopía/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.
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COVID-19 , Colecistitis Aguda , Colecistitis , Sepsis , Masculino , Humanos , Persona de Mediana Edad , Femenino , Pandemias , SARS-CoV-2 , COVID-19/epidemiología , Colecistitis/epidemiología , Colecistitis/cirugía , Colecistitis Aguda/epidemiología , Colecistitis Aguda/cirugía , Complicaciones Posoperatorias/epidemiologíaRESUMEN
BACKGROUND: In the surgical scenario, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion worldwide entails on the one hand the need to continue to perform surgery at least in case of emergency or oncologic surgery, in patients with or without COronaVIrus Disease 2019 (COVID-19); and on the other hand, to avoid the pandemic diffusion both between patients and medical and nursing team. The aim of this study was to report our surgical management protocol during the COVID-19 pandemic in an Italian non-referral center. METHODS: Data retrieved during the outbreak for the COVID-19 pandemic, from March 8 to May 4, 2020 (study period) were analyzed and compared to data obtained during the same period in 2019 (control period). RESULTS: During the study period, 41 surgical procedures (24 electives, 17 emergency surgical procedures) underwent surgery in comparison to 99 procedures in the control period. Stratifying the procedures in elective and emergency surgery, and based on the indication for surgery, the only statistically significant difference was observed in the elective surgery regarding the abdominal wall surgery (0 vs. 13 procedures, P=0.0339). Statistically significant differences were not observed regarding the colorectal and the breast oncologic surgery. All stuff members were COVID-19 free. CONCLUSIONS: The present protocol proved to be safe and useful to prevent SARS-CoV-2 infection before and after surgery for both patients and stuff. The pandemic was responsible for the reduction in number of procedures performed, anyway for the oncologic surgery a statistically significant volume reduction in comparison to 2019 was not observed.
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COVID-19/epidemiología , Pandemias , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Pared Abdominal/cirugía , COVID-19/prevención & control , Prueba de COVID-19 , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Humanos , Italia/epidemiología , Neoplasias/cirugía , Quirófanos , Estudios RetrospectivosRESUMEN
The surgical strategy for adenocarcinoma of the esophagogastric junction is still controversial. The aim of this study was to evaluate surgical results of the abdominal-transhiatal approach for 100 consecutively operated type II and III cardia adenocarcinoma, to clarify clinicopathological differences between these tumors, and to define prognostic factors. A prospectively maintained database identified 100 consecutively operated patients with Siewert type II and III cardia adenocarcinoma. Survival was analyzed by the Kaplan-Meier method. Differences between subgroups and prognostic factors were evaluated by the log rank test and Cox regression. Concerning clinicopathological characteristics, only the incidence of T1-2 stage was significantly higher in Siewert II type (P = .006). A complete (R0) resection was obtained in 74 patients (74%). Overall postoperative mortality and morbidity rates were 6% and 28%, respectively. Overall actuarial 5-year survival rate in resected patients was 27.4% (median 27 months), with 20.6% for type II and 34 for type III cancers (P = .07). Considering R0 resections, overall actuarial 5-year survival rate was 33.9% (median 33 months), with 26.7% for type II and 40.5 for type III cancer (P = .06). Pathologic T and N stage and R status were independent prognostic factors by multivariate analysis, and Siewert type showed a trend toward significance. The abdominal-transhiatal approach is a safe surgical approach, allowing complete tumor resection and adequate lymphadenectomy in these patients. True carcinoma of the cardia may be a distinct clinical entity with a more aggressive natural history than subcardial gastric carcinoma.
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Adenocarcinoma/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo , Unión Esofagogástrica/cirugía , Neoplasias Gástricas/cirugía , Adenocarcinoma/patología , Adulto , Anciano , Anciano de 80 o más Años , Cardias/patología , Cardias/cirugía , Unión Esofagogástrica/patología , Femenino , Humanos , Ganglios Linfáticos/patología , Ganglios Linfáticos/cirugía , Metástasis Linfática , Masculino , Persona de Mediana Edad , Invasividad Neoplásica , Estadificación de Neoplasias , Pronóstico , Estudios Prospectivos , Neoplasias Gástricas/patología , Tasa de Supervivencia , Resultado del TratamientoAsunto(s)
Braquiterapia/métodos , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/terapia , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/terapia , Trasplante de Hígado , Carcinoma Hepatocelular/radioterapia , Humanos , Neoplasias Hepáticas/radioterapia , Trasplante de Hígado/métodos , Trasplante de Hígado/normas , Resultado del Tratamiento , Carga TumoralRESUMEN
In patients with biliary papillomatosis, complete resection of the biliary tree (that is, liver transplant along with duodenocephalo-pancreatectomy) is considered the only potential curative treatment, given its diffuse pattern and likelihood of malignant transformation. Nevertheless, such a combined surgical approach can increase patient morbidity and mortality and should be considered only when the distal part of the common bile duct is involved. Here, we avoided duodenocephalo-pancreatectomy in a patient with distal common bile duct free from disease; this approach did not negatively influence survival and appeared to be safer during liver transplant.
Asunto(s)
Neoplasias de los Conductos Biliares/cirugía , Transformación Celular Neoplásica/patología , Trasplante de Hígado , Papiloma/cirugía , Adulto , Neoplasias de los Conductos Biliares/diagnóstico por imagen , Neoplasias de los Conductos Biliares/patología , Humanos , Masculino , Papiloma/diagnóstico por imagen , Papiloma/patología , Factores de Tiempo , Resultado del TratamientoRESUMEN
The incidence of hepatocellular carcinoma (HCC) spontaneous tumor rupture varies between 3% and 26%. For resectable HCC ruptures, emergency hepatectomy or staged hepatectomy after transcatheter arterial embolization (TAE) are life-saving procedures, and efficient therapeutic methods. We report a multimodal therapy including TAE, associating liver partition and portal vein ligation (ALPPS) and immunoglobuline infusion for a huge bleeding HCC with portal vein tumor thrombosis (PVTT) in hepatitis B virus (HBV) cirrhosis. ALPPS first step began with an abdominal toilette due to the massive hemoperitoneum and a portal vein incision at the bifurcation of the right and left portal veins was performed. A freely floating left part of the thrombus was extracted from the left portal vein in order to restore the left portal vein. The right portal vein with complete thrombosis was closed. Liver partition was then performed. The second step was performed without complications. A HCC Edmondson grade 4 (pT3b) and a cirrhotic liver parenchyma were described. Postoperative ascites decompensation was treated and patient was discharged in postoperative day 21. The reported triple strategy allowed us to prolong patient live. A multimodal therapy including TAE, ALPPS and immunoglobuline is a good option for a life treatment in case of huge bleeding hepatocellular carcinoma with PVTT in HBV cirrhosis.
RESUMEN
At pancreatic ductal adenocarcinoma is an aggressive malignancy with a high recurrence rate. Due to its high potentials of local invasion and distant metastasis, surgical resection is the only means for possible long-term survival. Surgical treatment comprises a distal pancreatectomy with or without splenectomy. Surgery has been conventionally contraindicated for patients with cirrhosis and portal vein hepato-biliary hypertension. Splenorenal shunt was first described by Warren and colleagues, to prevent death from bleeding esophageal varices in a patient with a patent portal vein hypertension. A 55-year-old Caucasian woman presented with an incidental pancreatic tumor. In our case, the shunt was necessary to complete the corrective oncological surgery for pancreatic ductal adenocarcinoma. The main difficulty was the presence of portal hypertension due to liver cirrhosis Child A; moreover, preservation of the spleen was mandatory in this patient. We successfully performed a distal pancreatectomy without splenectomy through the help of splenorenal shunt to preserve venous circulation.