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

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

Emergency repair of complicated abdominal wall hernias: WSES guidelines.

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

Ultrasound and thyroiditis in patient candidates for thyroidectomy.

AIM: Thyroiditis is often associated with nodules based on the Bethesda classification system, and the presence of thyroiditis can make thyroid surgery difficult using both conventional techniques and minimally invasive videoassisted approaches (MIVAT). METHODS: We analyzed 326 patients who underwent total thyroidectomy in 2012. We collected all data in dedicated database. The patients were divided in 4 groups: group 1 no affected by thyroiditis, group 2 affected by thyroiditis, group 3 only histological diagnosis of thyroiditis, group 4all patients affected by thyroiditis. RESULTS: Group 1 included 201 cases, group 2 included 64 patients, group 3 included 61 patients. No statistically significant difference between group 2 and 3 about Ultrasound (US) examination. Statistically significant difference in incidence of "THYR 3-4" between group 1 and group 4. No differences in MIVAT vs. Conventional group. CONCLUSION: US examination of the thyroid is essential for the diagnostic study of the gland also in the selection of a surgical approach. Thyroiditis is a relative contraindication to MIVAT but the experience of the endocrine surgeon is the most important factor to reduce intra and postoperative complications together a correct collaboration in multidisciplinart endocrinological team.

Schwannoma mimicking a neoplastic thyroid nodule.

Schwannoma is a rare benign tumor of nerve fibers that originates from neuronal sheath cells; it is frequently located extramedullary and about 25-45 % of this type of neoplastic lesion is localized in the head and in the neck. Primary schwannoma of the thyroid gland is very uncommon. We report the case of a 50-year-old female patient affected by schwannoma of the thyroid gland underwent total thyroidectomy for nodule of the left lobe suspicious for neoplasm, without complications.

Right colon laparoscopic resection with three-trocar access and associated gynecological procedures in patients with colorectal cancer and ovarian metastases.

BACKGROUND: Right laparoscopic colectomy was introduced to colorectal surgery later than the left colon procedure. Three-trocar laparoscopy has already been used successfully in the treatment of gynecological cancers. In the present study, we aimed to analyze the feasibility of performing an associated gynecological procedure following abdominal laparoscopic exploration and to evaluate the suitability of laparoscopic right colectomy for treating elderly patients. METHODS: We conducted a review of prospectively collected data on 100 consecutive patients who were treated with right laparoscopic colectomy using three trocars from January 2005 to April 2010. We recorded the patients' age (<70 or > 70 years), ASA status, body mass index (BMI), pain on postoperative days 1 and 2 (POD 1, 2), nodes retrieved, laparotomic conversion, mean operative time, time to intestinal recovery, and length of postoperative stay. RESULTS: All subjects were treated for cancer. Conversion to the laparotomic procedure was performed in 13/100, with no difference in terms of age. Operative time was longer for laparotomic conversion (p <0.05), with a longer postoperative stay. Elderly patients had higher ASA scores (p < 0.005); age did not influence the conversion rate or BMI status. Pain on POD 1 and 2 differed between the laparotomic and laparoscopic groups (p <0.0001). Associated procedures were performed in five subjects (3 oophorectomy and 2 cholecystectomy). CONCLUSIONS: Laparoscopy using the three-trocar technique is a safe procedure for treating colon cancer, including in elderly patients, and enables associated gynecological laparoscopic procedures to be performed.

Use of oxidized and regenerated cellulose in thyroid surgery: a prospective analysis as cause of postoperative hypocalcemia on 485 patients consecutively treated.

AIM: The intraoperative hemorrage determines an higher risk of parathyroid glands lesions, and laryngeal nerve injuries. We have examined if the use of oxidized and regenerated cellulose could be a cause of postoperative hypocalcemia because of the compression on the parathyroid glands or for tissue adhesions METHODS: From June 2009 to December 2010 we have examined 485 patients consecutively treated with total thyroidectomy. The cases examined were divided in two groups on the use of ionized cellulose (group A and B). 24 hours after surgical procedure, all patients were submitted to serum calcium evaluation. The data were analyzed with χ2 test and t-student test; P<0.05 was statistically significant. RESULTS: We have selected 372 cases out of 485 examined. We have registered after 10 hours from surgical procedure a case of hemorrhage with reintervention in group B (no use of cellulose). The cost of ionized cellulose is € 46; we have used this device in 212 cases on 372 patients undergone to total thyroidectomy, with a cost of € 9 752. The mean value of the serum calcium was statistically different between pre- and postoperative evaluation in all cases (P<0.0001) divided both on gender and on the use of hemostatic devices. CONCLUSION: In our experience, there isn't a statistically significant difference on incidence of postoperative hypocalcemia, related to use of ionized and regenerated cellulose on mean surgical time in all patients either treated with traditional surgery or with video-assisted procedure.

Extracoronary atherosclerosis and genetic variants of apolipoprotein AI-CIII cluster in myocardial infarction survivors from southern Italy.

The relationships between some genetic markers, as evaluated by DNA analysis, and ultrasound evidence of extracoronary athero-sclerosis, as detected by ultrasound methods, were evaluated in 39 myocardial infarction survivors of middle age and in 40 healthy controls of comparable age. Coronary heart disease (CHD) patients showed higher levels of triglycerides (P = 0.01) and greater number of exsmokers (P = 0.004). Carotid stenoses (> 15%) were detected in ten CHD patients and in two controls; iliac stenoses (> 15%) or abnormal ankle/arm ratio (< 0.97) were found in ten CHD patients and in one control; the scores of vascular disease severity in the myocardial infarction survivors were higher (Mann-Whitney test) than in controls (P < 0.01). Molecular genetic analysis of SstI restriction fragment length polymorphism (RFLP) of the apolipoprotein (apo) AI-CIII cluster and of the apo B gene demonstrated a higher frequency of the S2 allele (SstI RFLP) in coronary patients than in controls (P = 0.04) and no significant differences in the frequencies of XbaI RFLP of the apo B gene between patients and controls. The relative risk of myocardial infarction associated with an abnormal vascular score (> 8) or with the presence of the rare allele S2 (SstI apo AI-CIII polymorphism) was estimated by odds ratios. The lower 95% limits of odds ratios were above 1 (indicating significant increase in the relative risk of myocardial infarction) both in the case of vascular score and that of SstI RFLP. These associations were independent of one another and of triglyceride levels. SstI RFLP association with CHD disappeared after adjustment for smoking habits.(ABSTRACT TRUNCATED AT 250 WORDS)

Arachidonic acid metabolites and chloride secretion in rabbit distal colonic mucosa.

The relationships between arachidonic acid (AA) metabolism and chloride secretion were investigated in mucosal preparations of rabbit distal colon. Tissues displayed a significant cyclooxygenase activity already in nonstimulated conditions and incubation with exogenous AA and calcium ionophore A23187 produced a predominant prostaglandin F2 alpha (PGF2 alpha) profile [PGF2 alpha greater than PGE2 greater than thromboxane B2 (TxB2) greater than 6-keto-PGF1 alpha] as assessed by HPLC of tissue homogenates, whereas 5-hydroxy-6,8,11,14-eicosatetraenoic acid (5-HETE) was not detected in AA- or A23187-stimulated tissues. Radioimmunological assays showed that PGE2 synthesis was time dependent, plateaued at 10 min, and proceeded at rates 15-20 times over TxB2 and 6-keto-PGF1 alpha. Among the PGs produced by colonic mucosa, only PGE2 and, to a lower extent, PGF2 alpha were found to stimulate chloride secretion and cAMP synthesis. Pretreatment with 10 microM 5,8,11,14-eicosatetraynoic acid, a cyclo- and lipoxygenase inhibitor, prevented AA-induced chloride secretion and PG and cAMP synthesis with the same strength as the cyclooxygenase inhibitor indomethacin. No effects were found after preincubation with nordihydroguaiaretic acid, a lipoxygenase blocker with moderate cyclooxygenase inhibitory properties, and caffeic acid, a lipoxygenase inhibitor. 5-HETE (5 microM) had no effect on short-circuit currents (Isc) and chloride transport, but it significantly reduced the increase in Isc, chloride secretion, and PGE2 synthesis elicited by AA or A23187. Platelet-activating factor, reported to stimulate rabbit colon Isc through an indomethacin-sensitive pathway, was not detected at concentrations as low as 10(-10) M.

Extracoronary atherosclerosis in familial hypercholesterolemia.

Sixty-two patients (31 males, 31 females) with familial hypercholesterolemia (FH) underwent a vascular examination by Doppler ultrasound. The ankle/arm systolic pressure index was determined, and serum lipoproteins were analyzed. Eight of 124 legs examined (6.5%) showed an ankle/arm pressure index less than 0.95, suggesting flow reducing stenosis. Common carotid, internal carotid, and iliac arteries were evaluated by echo Doppler examination with spectral analysis. Forty-five of the 372 arteries examined (12.1%) had detectable abnormalities at echo Doppler examination. Iliac and internal carotid artery lesions were significantly (P less than 0.01) more frequent among FH patients than in a control group (30 men, 20 women) comparable for sex and age. The mean age of the patients with heterozygous FH and detectable arterial lesions was 45.3 years and that of those without lesions 30.7 years (P less than 0.05). When 14 patients with heterozygous FH and arterial lesions were compared to another 14 without lesions and matched for age and gender, it was found that patients with lesions had on average lower concentrations of HDL-cholesterol, and that 10 of 14 cases were actual smokers.

Carotid atherosclerosis in familial hypercholesterolemia.

Common and internal carotids have been studied by noninvasive method (echo-Doppler) in 30 normotensive patients with familial hypercholesterolemia (FH). Vascular lesions were detected in 14 patients (46%), who presented one or more lesions of different degree (between 1-15% and 16-49%). In one case, only one carotid had stenosis greater than 50%. Severity and number of stenosis were related to age and levels of hypercholesterolemia. FH patients with carotid lesions showed a significantly higher LDL-cholesterol (p less than 0.01) and plasma apolipoprotein B (p less than 0.001) concentrations and a significantly lower HDL-cholesterol (p less than 0.05) and plasma apolipoprotein A (p less than 0.001) levels as compared to those with normal echo-Doppler findings. These data indicate that investigation of arterial districts other than coronaries are useful in quantitative evaluation of atherosclerotic involvement.

Premature development of iliac artery stenosis in asymptomatic type II hyperlipoproteinemia.

There is conflicting evidence on the relationship between increased low density lipoprotein (LDL) concentration in Type II hyperlipoproteinemia and premature development of peripheral atherosclerosis of the lower limbs. We evaluated the early signs of iliac artery involvement in patients with asymptomatic Type II hyperlipoproteinemia. Of these, 23 were Type IIA, 12 were Type IIB. Thirty-five consecutive patients, ages 40 to 60 years, with asymptomatic Type II hyperlipoproteinemia (LDL cholesterol greater than or equal to 3.80 mmol/liter, 147 mg/dl) and 54 normocholesterolemic controls (plasma cholesterol less than 5.70 mmol/liter, 220.6 mg/dl) from a random sample of clinically healthy, 50-year-old men had a noninvasive examination to detect common and external iliac artery stenosis. Both Type II patients and the controls were examined by the echo-Doppler technique (Duplex Scanner III-ATL Mark V) with spectral analysis of the Doppler signals. This method is sensitive not only to severe stenosis or occlusion but also to non-flow-reducing stenosis (less than 50% narrowing of the lumen diameter) and to minor wall irregularities (1%-15% stenosis). In Type II patients, 19 of 70 limbs (27%) were abnormal as compared to 6 of 108 limbs (6%) in the controls (p less than 0.001). The premature development of an obliterating disease of the iliac arteries was demonstrated in persons asymptomatic for Type II hyperlipoproteinemia.

Effect of oral mesoglycan on plasma lipoprotein concentration and on lipoprotein lipase activity in primary hyperlipoproteinemia.

Mesoglycan extracted from calf aorta was orally administered (96 mg/day) to 15 patients with primary hyperlipoproteinemia: 4 type IIA, 4 type IIB, 6 type IV and one type V. In the seven hypertriglyceridemic patients the drug after two months of treatment reduced total and VLDL-triglyceride from 701 mg/dl to 423 mg/dl (p less than 0.025) and from 562 mg/dl to 377 mg/dl (p less than 0.025) respectively and increased lipoprotein lipase activity from 19.7 mumol/l/min to 27.8 mumol/l/min (p less than 0.05). No change was observed in the group with type IIA-IIB hyperlipoproteinemia.