Pain distraction during awake low anterior resection and Cuddle Delivery initiative for inpatient: frugal procedural options to support surgery in the COVID-19 era.

OBJECTIVE: Since minimally invasive surgery and general anesthesia are both aerosol-generating procedures, their use became controversial during the outbreak of coronavirus disease 2019 (COVID-19). Moreover, social distancing resulted in serious psychological consequences for inpatients. This case report investigates pain distraction during awake laparotomy, as well as new possibilities for emotional postoperative support to inpatients. PATIENTS AND METHODS: A 72-year-old man affected by middle rectal adenocarcinoma underwent lower anterior resection plus total mesorectal excision under combined spinal-epidural anesthesia. A 3D mobile theatre (3DMT) was intraoperatively used for pain distraction. A postoperative "Cuddle delivery" service was instituted: video-messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional correlations were investigated through a clinical interview by the psychologist of our Hospital. RESULTS: Intraoperative, as well as postoperative pain, resulted well-controlled: visual analogue scale (VAS) ≤3. Conversion to general anesthesia and postoperative intensive support/monitoring were unnecessary. The "Cuddle delivery" initiative positively fed our patient's mood and attitude, strengthening his bond to life. CONCLUSIONS: During pandemic, awake laparotomy under loco-regional anesthesia may be a crucial option in delivering acute care surgery to selected patients when intensive care beds are unavailable. Our procedure introduces potential ways to optimize this approach.

Anastomotic leakage following colorectal resection for cancer: how to define, manage and treat it.

AIM: Aim of the study was to report the experience of a single center in the surgical treatment of anastomotic leak after colorectal resection for cancer, focusing on its incidence, diagnosis and management, with particular attention to surgical options. METHODS: Demograhic and clinical data from 1284 consecutive patients operated on for colorectal cancer during a period of 11 years, were prospectively collected and inserted into an electronic database. For the purpose of the study, only patients in whom an anastomosis was performed were considered. Therefore, 128 patients (9.9%) were excluded and 1156 represent the study population. All complications occurring after surgery were systematically recorded. The incidence of colorectal anastomotic leak (CAL), its management and outcome was analyzed. RESULTS: An ileo-colic anastomosis was performed in 426 cases (36.8%), ileo-rectal in 29 (2.5%), colo-colic in 409 (35.4), colo-rectal with partial mesorectal excision in 211 (18.3%) and lower colorectal or coloanal anastomosis with total mesorectal excision and temporary loop ileostomy in 81 (7%). Colorectal anastomotic leak occurred in 78/1156 patients (6.7%), accounting for 19% of overall complications. Thirty-six out of 78 patients (46.2%) were successfully treated conservatively, whereas 42 (53.8%) underwent re-operation. Nine out of 78 patients (11.5%) with CAL died owing to an uncontrolled sepsis. All had undergone previous re-intervention, with a post-operative mortality rate of 21.4% (9 out of 42). CONCLUSION: Mortality rate in patients undergoing re-operation for colorectal anastomotic leakeage is still high, and accounts for up to 40% of the deaths after colorectal resection for cancer. In the light of these data, strategic clinical decisions are mandatory to optimize the selection of patients who need an early and fast surgical approach. What does this paper add to the literature? Systematic and prospective data recording is an essential tool to assess the quality of healthcare and to plan quality improvement programs. Every effort should be done to reach an early diagnosis of CAL, possibly in a pre-clinical phase in which non clinical methods could be used to predict it.

Impact of hypertension on vascular remodeling in patients with psoriatic arthritis.

We studied the impact of hypertension along with traditional and new cardiovascular risk factors on the structural and functional properties of arteries in psoriatic arthritis (PsA) patients. We examined 42 PsA subjects (aged 51±9 years) stratified according to hypertensive status (19 normotensive, PsA-NT and 23 hypertensives, PsA-HT). Thirty-eight normotensive subjects (C-NT) and 23 hypertensives (C-HT) comparable by age and sex served as controls. Mean carotid intima-media thickness (mean-IMT) and mean of the maximum IMT (M-Max) were evaluated by ultrasound in carotid artery segment bilaterally. Post-occlusion flow-mediated dilation (FMD) of the brachial artery was evaluated by ultrasonography. These parameters were correlated with risk factors, markers of inflammation and disease activity. Values of mean-IMT were higher in both groups of PsA patients compared with C-NT (0.68 mm in PsA-NT and 0.75 mm in PsA-HT versus 0.61 mm in C-NT). PsA-HT displayed higher M-Max (0.95 mm) versus both C-HT (0.71 mm) and PsA-NT (0.79 mm). FMD was impaired in PsA subjects compared with C-NT (5.7% in PsA-NT and 6.0% PsA-HT versus 9.3% in C-NT), whereas there was no difference among PsA-HT, PsA-NT, and C-HT groups. Values of carotid IMT were directly related to tumor necrosis factor (TNF)-α, osteoprotegerin (OPG), blood pressure and lipid profile levels. FMD showed an inverse relationship with TNF-α and blood pressure, but no correlation with lipids. In conclusion, PsA per se implies a pro-atherogenic remodeling, which is enhanced by the hypertensive status. TNF-α and OPG may have an independent role in the development of such vascular damage.

Pelvic lymphedema in rectal cancer: a magnetic resonance feasibility study: a preliminary report.

BACKGROUND: Functional pelvic disorders in patients undergoing conservative surgical approach for rectal cancer are considered a major public health issue and represent one third of cost of colorectal cancer. We investigated the hypothesis that lymphadenectomy, involves the pelvic floor results in a localized hides or silent pelvic lymphedema characterized by symptoms without signs. PATIENTS AND METHODS: We examined 13 colo-rectal cancer patients: five intra-peritoneal adenocarcinoma: 1 sigmoid and 4 upper third rectal cancer (1 male and 3 female) and 9 extra-peritoneal adenocarcinoma: 3 middle and 5 lower third rectal cancer (4 male and 5 female) using 1.5-T magnetic resonance, one week before and twelve months after discharged from hospital. RESULTS: Lymphedema was discovered on post-operative magnetic resonance imaging of all 9 patients with extra-pertitoneal cancer, whereas preoperative magnetic resonance imaging as well as a post-operative examination of 4 intra-peritoneal adenocarcinoma, revealed no evidence of lymphedema. Unlike the common clinical skin signs that typify all other sites of lymphedema, pelvic lymphedema is hides or silent, with no skin changes or any single symptom manifested. Magnetic resonance imaging showed that pelvic illness alone is accompanied by lymphedema related exclusively to venous congestion, and accumulation of liquid in adipose tissue or lipedema. CONCLUSIONS: Alteration of the pelvic lymphatic network during pelvic surgery can lead to lymphedema and, pelvic floor disease. Patients should be routinely examined for the possibility of developing this post-surgical syndrome and further studies are needed to establish diagnosis and to evaluate treatment preferences.

[Anastomotic fistulas after colorectal resection for carcinoma: incidence and treatment in our recent experience]. / Le fistole anastomotiche dopo resezioni coliche e rettali per neoplasia. Incidenza e trattamento nella nostra esperienza recente.

AIM: The incidence of anastomotic fistula after colorectal surgery did not significantly change in the literature during the last years, despite the advances in the treatment with the use of surgical staplers. Taking into account this and other considerations, the authors present their recent experience in the surgical treatment of colorectal carcinoma, referring in particular to anastomotic fistula, related postoperative mortality and results of consequent reoperations. METHODS: From January 1, 2002 to December 31, 2005, 448 patients affected with colorectal cancer were operated on at the Surgical Department of Valduce Hospital in Como, and in 373 cases an anastomosis was performed, subdivided as follows: 144 ileocolic (38.6%), 10 ileorectal (2.7%), 219 colocolic or colorectal (58.7%). RESULTS: Twenty-five out of 373 anastomotic leaks developed (6.7%). In 9 cases (36%), the fistulas spontaneously closed with conservative treatment, while in 16 (64%) reoperation was necessary. With reference to the anatomical site, the leak occurred in 9 out of 144 patients submitted to right hemicolectomy (6.3%), in 14 out of 219 patients after left hemicolectomy or anterior resection of the rectum (6.4%) and in 2 out of 10 patients (20%) after total colectomy. The following is a detailed report of the therapeutic choices adopted by the authors. Four out of 16 reoperated patients (25%) died postoperatively from infective complications related to the fistula, while the total postoperative mortality was 2.2% (10/448). Therefore, anastomotic dehiscence was responsible for 40% of all postoperative deaths. CONCLUSIONS: Among all the different operative choices, the authors give their preference to the direct suture of the fistula and loop ileostomy, which they consider the best available choice. The subsequent operation of ileostomy closure is easier for the surgeon to perform and for the patient to withstand than colostomy closure, particularly after Hartmann's operation.

[Angiosarcoma of the breast after conservative surgery and radiotherapy for early breast carcinoma. Description of a case]. / L'angiosarcoma della mammella dopo chirurgia conservativa e radioterapia per carcinoma mammario precoce. Descrizione di un caso clinico.

The occurrence of an angiosarcoma of the residual breast after conservative surgery and adjuvant radiotherapy for early mammary carcinoma is a very rare event. In western countries only 57 cases have been published in the literature (5 in Italy) since the first described case in 1987. Radiotherapy seems to be the most important etiological factor in the development of the neoplasm. Diagnosis is often delayed, owing to the "benign" aspect of the lesion. The only effective treatment is residual mastectomy, because chemotherapy is ineffective. The prognosis is often dismal, because of the aggressive behaviour of the lesion in most cases. The case of a patient with a multicentric secondary angiosarcoma of the breast recently operated on is described.

[Laparoscopic cholecystectomy. Our clinical experience from 1994 to 1996]. / La colecistectomia laparoscopica. La nostra esperienza clinica dal 1994 al 1996.

BACKGROUND AND AIM: Videolaparocholecystectomy is now regarded as the gold standard of treatment for lithiasis of the gallbladder. METHODS: The authors report a retrospective of 258 consecutive videolaparocholecystectomies performed by the Surgical Division of Valduce Hospital in Como between 1994 and 1996. The authors describe the indications for VLC, techniques for the induction of pneumoperitoneum and the realisation of VLC and the percentage and caused of conversion. RESULTS: During this period a steady reduction was noted in the number of laparotomic cholecystectomies and a parallel increase in cholecystectomies performed using a laparoscopic technique (69.2 vs. 30.8% in 1994; 76.4 vs. 23.2% in 1995; 91.1 vs. 8.9% in 1996). A gradual extension of the indications for laparoscopic surgery can be seen leading to the application of this technique in patients suffering from acute cholecystic infection, hydros or empyema of the gallbladder. Conversion were required in 25 cases in this series (9.7%). During the last year analysed there were a total of 9 conversions (7.9%) even though the percentage of acute cholecystitis accounted for 38.9% of all cases of cholecystectomy. CONCLUSIONS: In line with the experience of other centres, the authors, currently propose VLC as the treatment of choice for lithiasic pathologies of the cholecyst.