A research agenda to explore the emergency operations center.

OBJECTIVE: The emergency operations center (EOC) is an essential component of modern emergency management. Traditionally understood as a place where officials communicate with the public, support coordination, manage operations, craft policy, gather information, and host visitors; there has been little recent research on their structure, operations, or work procedures. EOCs may in fact be, as we argue here, places where emergency managers come to find workarounds, delegate tasks, and find new sources of expertise in order to make sense, make meaning, and make decisions. However, despite their status as a symbol of emergency management and recipients of large amounts of funding, there has been relatively little scientific research into the EOC. With this paper, we synthesize the existing research and propose a variety of research questions to accelerate the process of inquiry into the EOC. DESIGN: Informed by an extensive literature review, this article presents a comprehensive look at the existing state of knowledge surrounding EOCs. INTERVENTIONS: Research questions to support investigation of the EOC are suggested. CONCLUSIONS: The EOC is an underexplored setting ripe for development and discovery by researchers and emergency managers seeking to influence the field of emergency management.

The Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) A retrospective review of 379 patients undergoing laparoscopic splenectomy.

In December 2000, the Italian Registry of Laparoscopic Surgery of the Spleen (IRLSS) was formally launched under the auspices of the Italian Society for Endoscopic Surgery and New Technologies (SICE). The aim of this multicentre study was to analyse various aspects of the treatment that are still under discussion, such as the extension of the laparoscopic indications in cases of malignancy, independently of the associated splenomegaly, patient selection and operative techniques. A retrospective review of 379 patients undergoing laparoscopic splenectomy for haematological diseases from February 1, 1993, to September 15, 2005, was conducted. Data were collected from the 18 italian centres participating in the IRLSS. The mean length of surgery was 140 minutes (range: 25-420). Conversion was necessary in 25 cases (6.6%), and at least one accessory spleen was found in 30 patients (8%). The mean spleen weight was 1200 g (range: 85-4500). Perioperative death occurred in two cases (0.5%). There were no complications in 312 patients (82.3%), with a mean hospital stay of 5.5 days (range: 2-30). Morbidity occurred in 67 patients (17.8%), mainly consisting in transient fever (n = 22), pleural effusions (n = 16), and actual or suspected haemorrhage (n = 14), requiring re-intervention in 7 patients. This first study carried out on the IRLSS data shows that laparoscopic splenectomy may constitute the gold standard for haematological diseases with a normal-sized spleen. The low morbidity and mortality rates suggest that laparoscopic splenectomy can be successfully proposed also for splenomegaly in haematological malignancies.

Management of patients with gastrointestinal stromal tumors: experience from an Italian hospital.

Gastrointestinal stromal tumors are malignancies originating from stromal/mesenchymal tissues, most commonly in the stomach and small intestine, although they can be located everywhere in the gastrointestinal tract. Diagnosis is based on histological and immunohistochemical examination, and these rare tumors are characterized by c-kit (CD117) staining. Complete removal of the tumor is often curative in localized gastrointestinal stromal tumors and is always recommended. Clinically, their behavior is difficult to predict, and mitotic count and tumor size seem to be the most effective prognostic factors. We performed a retrospective analysis of clinical presentation and course, surgical management and pathological features of patients with gastrointestinal stromal tumors treated in our institution from 1995 to 2003. Twenty-two patients were enrolled in the study, and all of them underwent surgery. There were two perioperative deaths, and global morbidity was about 13%. Nineteen patients were followed (mean, 31 months): 4 patients had disease progression/recurrence and died, and one patient experienced a local recurrence and was reoperated with a curative intent; 14 patients were disease free. Our experience shows that histological and immunohistochemical examinations are fundamental for a definitive diagnosis and to assess the risk of aggressive behavior. Moreover, our results confirm that in stromal tumors complete surgical resection remains the mainstay of treatment in localized gastrointestinal stromal tumors, although the recurrence rate is relatively high. It is conceivable that treatment and prognosis of metastatic and non-resectable gastrointestinal stromal tumors, as well as the adjuvant treatment of high-risk, radically excised gastrointestinal stromal tumors will be strongly impacted by the c-kit target therapy.

[Laparoscopic management of small-bowel obstruction]. / La laparoscopia nell'occlusione intestinale del tenue.

Laparoscopy is not generally accepted as an effective, advantageous alternative to formal laparotomy for abdominal emergencies. Its use in patients with previous surgery and intestinal obstruction is often debatable. A retrospective study was performed to analyse the results of the laparoscopic approach for acute small-bowel obstruction in terms of efficacy and safety. From January 2000 to December 2003, 44 non-consecutive patients underwent laparoscopic surgery for radiologically documented small-bowel obstruction. Thirty-nine (89%) had undergone previous abdominal operations (mean number of laparotomies: 2; range 1-5). Twelve were men and 32 women (mean age: 57 years; range 13-91). We retrospectively reviewed the patient data, analysing operative time, need for accessory incision or conversion, length of hospital stay, and intraoperative and postoperative morbidity and mortality. The aetiology was established in 40 patients (91%), and the procedures were completed laparoscopically in 28/44. Mean operative time was 58 min (range 25-160). Six patients required an accessory target incision and 10 patients were converted to formal laparotomy. The reasons for conversion were extent of adhesions (n = 3), problems with laparoscopic view (n = 2), gangrenous bowel (n = 2), locally advanced colon cancer (n = 1), haemoperitoneum (n = 1), and diffuse peritonitis (n = 1). The mean hospital stay was 6 days (range 2-28). Postoperative mortality and morbidity were 2% and 16%, respectively. In conclusion, this study suggest that laparoscopy should be considered early in the clinical course of patients presenting with acute small-bowel obstruction. In most patients definitive treatment is possible, effective and safe, thus justifying the early laparoscopic approach.

Successful laparoscopic treatment of ileocecal-appendicular endometriosis.

Intestinal endometriosis is an uncommon clinical entity that is rarely seen by general surgeons. It traditionally requires laparoscopy for diagnosis and an open laparotomy procedure for the treatment. Herein, we report a rare case of colonic endometriosis involving the ileocecal region and left adnexal region. The management was totally laparoscopic: an ileocecal resection of the lesions was successfully performed. Endometriosis was not suspected preoperatively; however, it became a differential diagnosis during the operation and then confirmed by the histopathologic examination. We discuss the investigation process, surgical management, and prognosis related to ectopic endometriosis.

[Operative laparoscopy in the management of perforated peptic ulcer]. / La laparoscopia operativa nella gestione delle ulcere peptiche perforate.

The aim of this retrospective study was to assess the feasibility, safety and efficacy of the laparoscopic approach in the management of perforated peptic ulcers. From January 1997 to December 2002, all patients referred to our community hospital for abdominal surgical emergencies were routinely managed by laparoscopic surgery. A review was carried out on 39 consecutive patients suffering from perforated peptic ulcers with or without generalised peritonitis. The study population comprised 24 male and 15 female patients, aged 30 to 94 years (mean age: 62 +/- 18). Laparoscopic repair was attempted in all patients. Laparoscopy afforded the correct diagnosis in all cases. Laparoscopic peritoneal washout (irrigation and suction of the entire abdominal cavity) with simple suture of the perforation proved successful in 34 patients. An additional omental patching was performed in 15 of these cases. Conversion to conventional open surgery was necessary in 5 patients. The morbidity and mortality rates were 13% and 10%, respectively. The mean operative time was 77 minutes (range: 40-120) and the mean hospital stay 9 days (range: 3-22). Laparoscopic repair of perforated ulcers is technically feasible but requires sound experience in laparoscopic abdominal emergencies. This study shows that the mini-invasive procedure is safe and effective, offering a valid alternative to traditional laparotomy.

Prognostic evaluation of stage B colon cancer patients is improved by an adequate lymphadenectomy: results of a secondary analysis of a large scale adjuvant trial.

OBJECTIVE: To determine if the extent of lymphadenectomy (number of recovered lymph nodes) was associated with long-term outcome in patients operated on for stage B and C colon cancer. SUMMARY BACKGROUND DATA: Lymphatic spreading is the main prognostic indicator in colon cancer patients, although the optimal extent of lymphadenectomy and its prognostic impact are still unknown. METHODS: In 3,648 patients (median follow-up 3.6 years) enrolled in two consecutive INTACC multicentric trials on adjuvant therapy for colon cancer, we studied the association of the number of recovered nodes with overall survival and relapse free survival by means of univariate and Cox regression analysis. RESULTS: The worst overall survival was related to ages > 65 (risk ratio [RR] = 1.30), higher grading (RR = 1.96). Better overall survival was related to female gender (RR = 0.80) and to higher number of recovered nodes (8-12 nodes, RR = 0.46, 13-17 nodes, RR = 0.76, nodes > or = 18, RR = 0.79). The same pattern was observed for relapse free survival. Longer overall and relapse free survival were related to a higher number of recovered nodes with P =.034 and P =.003 respectively (stratified analysis for absence or presence of positive nodes). Stage B patients with fewer than 7 nodes in the specimen had both shorter overall survival (P =.0000) and relapse free survival (P =.0016) than the other B patients. Outcome of stage C patients was not related to the number of recovered nodes (P =.28 and 0.12 respectively). The interaction test between stage of disease and number of recovered nodes was statistically significant (P =.017). CONCLUSIONS: Stage B patients with a small number of examined nodes may be understaged. Thus, these patients might be considered for adjuvant therapy because of their poorer life expectancy than other stage B patients. For stage C patients, the number of recovered nodes does not seem to affect long-term outcome.