Metachronous peritoneal metastases in patients with pT4b colon cancer: An international multicenter analysis of intraperitoneal versus retroperitoneal tumor invasion.

BACKGROUND: It was hypothesized that colon cancer with only retroperitoneal invasion is associated with a low risk of peritoneal dissemination. This study aimed to compare the risk of metachronous peritoneal metastases (mPM) between intraperitoneal and retroperitoneal invasion. METHODS: In this international, multicenter cohort study, patients with pT4bN0-2M0 colon cancer who underwent curative surgery were categorized as having intraperitoneal invasion (e.g. bladder, small bowel, stomach, omentum, liver, abdominal wall) or retroperitoneal invasion only (e.g. ureter, pancreas, psoas muscle, Gerota's fascia). Primary outcome was 5-year mPM cumulative rate, assessed by Kaplan-Meier analysis. RESULTS: Out of 907 patients with pT4N0-2M0 colon cancer, 198 had a documented pT4b category, comprising 170 patients with intraperitoneal invasion only, 12 with combined intra- and retroperitoneal invasion, and 16 patients with retroperitoneal invasion only. At baseline, only R1 resection rate significantly differed: 4/16 for retroperitoneal invasion only versus 8/172 for intra- +/- retroperitoneal invasion (p = 0.010). Overall, 22 patients developed mPM during a median follow-up of 45 months. Two patients with only retroperitoneal invasion developed mPM, both following R1 resection. The overall 5-year mPM cumulative rate was 13% for any intraperitoneal invasion and 14% for retroperitoneal invasion only (Log Rank, p = 0.878), which was 13% and 0%, respectively, in patients who had an R0 resection (Log Rank, p = 0.235). CONCLUSION: This study suggests that pT4b colon cancer patients with only retroperitoneal invasion who undergo an R0 resection have a negligible risk of mPM, but this is difficult to prove because of its rarity. This observation might have implications regarding individualized follow-up.

Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages.

BACKGROUND: There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally. METHODS: A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. RESULTS: Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance. CONCLUSION: Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

Mesenteric closure with polymer-ligating clips after right colectomy with complete mesocolic excision for cancer and mesentery-based ileocolic resection for Crohn's disease.

Mesenteric closure following right colectomy remains controversial and, following the advent of laparoscopic surgery, many surgeons do not routinely close the mesentery after colorectal resection. Nevertheless, especially after the introduction of operations such as right colectomy with complete mesocolic excision and ileocolic resections with extensive mesentery removal for Crohn's disease, the wide mesenteric defect resulting from the dissections can certainly expose the patients to complications such as internal hernias or volvuli. In general, mesenteric closure requires intracorporeal suturing. We describe a simple technique for the closure of the mesentery after surgical resection using polymer-ligating clips. This novel technique seems to minimize the time, effort and risk inherent to the procedure, even after large mesenteric excisions.

Volume-outcome relationship in rectal cancer surgery.

INTRODUCTION: Hospital centralization effect is reported to lower complications and mortality for high risk and complex surgery operations, including colorectal surgery. However, no linear relation between volume and outcome has been demonstrated. Aim of the study was to evaluate the increased surgical volume effect on early outcomes of patient undergoing laparoscopic restorative anterior rectal resection (ARR). METHODS: A retrospective analysis of all consecutive patients undergoing ARR with primary anastomosis between November 2016 and December 2020 after centralization of rectal cancer cases in an academic Centre. Short-term outcomes are compared to those of patients operated in the same unit during the previous 10 years before service centralization. The primary outcome was estimated anastomotic leak rate. Mean operative time, need of conversion, postoperative use of blood transfusion, radicality, in-hospital stay, number and type of complications, readmission and reoperation rate, mortality and 1-year and stoma persistence rates were evaluated as secondary outcomes. RESULTS: 86 patients were operated in the study period and outcomes compared to those of 101 patients operated during the previous ten years. Difference in volume of surgery was significant between the two periods (p 0.019) and the estimated leak rate was significantly lower in the higher volume unit (p 0.047). Mean operative time, need of conversion, postoperative use of blood transfusion and in-hospital stay (p < 0.05) were also significantly reduced in Group A. CONCLUSION: This study suggests that the shift toward higher volume in rectal cancer surgery is associated to decreased anastomotic leak rate. Potentiation of lower volume surgical units may yield optimal perioperative outcomes.

Central vascular ligation and mesentery based abdominal surgery.

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Pathophysiology of Crohn's disease inflammation and recurrence.

Chron's Disease is a chronic inflammatory intestinal disease, first described at the beginning of the last century. The disease is characterized by the alternation of periods of flares and remissions influenced by a complex pathogenesis in which inflammation plays a key role. Crohn's disease evolution is mediated by a complex alteration of the inflammatory response which is characterized by alterations of the innate immunity of the intestinal mucosa barrier together with a remodeling of the extracellular matrix through the expression of metalloproteins and increased adhesion molecules expression, such as MAcCAM-1. This reshaped microenvironment enhances leucocytes migration in the sites of inflammation, promoting a TH1 response, through the production of cytokines such as IL-12 and TNF-α. IL-12 itself and IL-23 have been targeted for the medical treatment of CD. Giving the limited success of medical therapies, the treatment of the disease is invariably surgical. This review will highlight the role of inflammation in CD and describe the surgical approaches for the prevention of the almost inevitable recurrence.

The Role of Active Inflammation and Surgical Therapy in Crohn's Disease Recurrence.

An altered balance between effector and regulatory factors is supposed to sustain the tissue-damaging immune response in inflammatory bowel disease (IBD). Several studies demonstrate that severe active inflammation is a strong predictor for surgical complications and recurrence. Indeed, bowel resection in Crohn's disease (CD) patients has a high surgical recurrence rate. In this review, we examined the IBD inflammatory pathways, the current surgical treatments, and the almost inevitable recurrence. The question that might arise is if the cure of intestinal CD is to be found in the surgical approach. A selective search of two databases (PubMed and the Cochrane Library) has been carried out without considering a specific time horizon as inclusion criteria. The scope of this literature review was investigating on the role of inflammation in the management of CD. The following key words have been used to develop the query string: (i) inflammation; (ii) Crohn's disease; (iii) surgery; and (iv) postsurgical recurrence.

The Role of Inflammation in Crohn's Disease Recurrence after Surgical Treatment.

INTRODUCTION: Postoperative recurrence after surgery for Crohn's disease (CD) is virtually inevitable, and its mechanism is poorly known. AIM: To review the numerous factors involved in CD postoperative recurrence (POR) pathogenesis, focusing on single immune system components as well as the immune system as a whole and highlighting the clinical significance in terms of preventive strategies and future perspectives. METHODS: A systematic literature search on CD POR, followed by a review of the main findings. RESULTS: The immune system plays a pivotal role in CD POR, with many different factors involved. Memory T-lymphocytes retained in mesenteric lymph nodes seem to represent the main driving force. New pathophysiology-based preventive strategies in the medical and surgical fields may help reduce POR rates. In particular, surgical strategies have already been developed and are currently under investigation. CONCLUSIONS: POR is a complex phenomenon, whose driving mechanisms are gradually being unraveled. New preventive strategies addressing these mechanisms seem promising.

Histotype influences emergency presentation and prognosis in colon cancer surgery.

AIM: To investigate whether differences in histotype in colon cancer correlate with clinical presentation and if they might influence oncological outcomes and survival. METHODS: Data regarding colon cancer patients operated both electively or in emergency between 2009 and 2014 were retrospectively collected from a prospectively maintained database and analyzed for the purpose of this study. Rectal cancer was excluded from this analysis. Statistical univariate and multivariate analyses were performed to investigate possible significant variables influencing clinical presentation, as well as oncological outcomes and survival. RESULTS: Data from 219 patients undergoing colorectal resection for cancer of the colon only were retrieved. One hundred seventy-four patients had an elective procedure and forty-five had an emergency colectomy. Emergency presentation was more likely to occur in mucinous (p < 0.05) and signet ring cell (p < 0.01) tumors. No definitive differences in 5-year overall (44.7% vs. 60.6%, p = 0.078) and disease-free (51.2% vs. 64.4%, p = 0.09) survival were found between the two groups as a whole, but the T3 emergency patients showed worse prognosis than the elective (p < 0.03). Lymph node invasion, laparoscopy, histology, and blood transfusions were independent variables found to influence survival. Distribution assessed for pTNM stage showed T3 cancers were more common in emergency (p < 0.01). CONCLUSIONS AND DISCUSSION: Mucinous and signet ring cell tumors are related to emergency presentation, pT3 stage, poorest outcomes, and survival. Disease-free survival in patients who had emergency surgery for T3 colon cancer seems related to the histotype.

Avaliação da eficácia do fipronil em Rhipicephalus (Boophilus) microplus em tratamentos consecutivos / Evaluating the effectiveness of fipronil in Rhipicephalus (Boophilus) microplus in consecutive treatments

A realização deste trabalho teve como objetivo avaliar a eficácia do fipronil em Rhipicephalus (Boophilus) microplus, durante e após 14 tratamentos, no período de dezembro de 2006 a abril de 2009. O experimento foi realizado em uma propriedade rural do município de Lages, SC, utilizando-se 20 bovinos mestiços charolês mantidos em campo nativo, naturalmente infestados com R. (B.) microplus. A cada 14 dias, foram realizadas contagens das fêmeas de carrapato, maior ou igual a 4,5mm. Os animais foram tratados com fipronil 1mg/kg via pour on, quando a média do número de carrapatos foi igual ou superior a 40 fêmeas. Ao final do experimento, para análise da eficácia do fipronil 1%, foi realizado o teste de estábulo, utilizando 10 animais infestados com larvas provenientes de teleóginas coletadas de bovinos da propriedade. Os animais foram randomizados, de acordo com a produção inicial de teleóginas, estabelecendo-se dois grupos: controle (n=5) e tratado (n=5). A redução da média do número de fêmeas de R. (B.) microplus nas contagens após tratamentos foi de 100% nos três primeiros, com um leve declínio até o sexto tratamento. No sétimo tratamento a redução foi de 91,3%. Ao final do experimento a eficácia do fipronil 1%, avaliada pelo teste de estábulo, na redução do número de teleóginas, foi de 79,3%. A porcentagem média de inibição de reprodução calculada foi de 22,47%. Concluiu-se que, após seis tratamentos com fipronil, média de um a cada 2,7 meses, o princípio ativo deve ser substituído e que, após 14 tratamentos, o R. (B.) microplus adquiriu resistência parcial a esse carrapaticida.

This study aimed to evaluate the effectiveness of fipronil in Rhipicephalus (Boophilus) microplus during and after 14 treatments from December 2006 to April 2009. The experiment was performed on a rural property in the city of Lages/SC, using 20 crossbred Charolais cattle maintained on open pasture naturally infected with R. (B.) microplus. Every 14 days, tick counts of the females greater than or equal to 4.5mm were conducted. When tick counts averaged 40 females or more the animals were treated with applications of a 1% applied to the dorsal formulation of fipronil 1mg/kg. At the end of the experiment, barn testing was performed on 10 animals infested with larvae of the Engorging females collected from the cattle on the property, for analysis of the effectiveness of 1% fipronil. The animals were randomized according to the initial production of Engorging females, establishing five animals in the control group and five in the treated group. The reduction in the average number of females of R. (B.) microplus was 100% during the first three treatments, with a slight decline up to the sixth treatment. On the seventh treatment the reduction was 91.3%. At the end of the experiment the effectiveness of 1% fipronil for reducing the number of ticks was 79.3%, assessed by the barn testing. The average percentage of inhibition of reproduction was calculated at 22.47%. It was concluded that after six treatments with fipronil, with an average of one treatment every 2.7 months, there must be a change in the active ingredient and that after 14 treatments R. (B.) microplus acquired partial resistance to this acaricide.

Antibodies against rickettsiae from spotted fever groups in horses from two mesoregions in the state of Santa Catarina, Brazil / Anticorpos contra rickettsias do grupo da febre maculosa em equinos de duas mesorregiões de Santa Catarina, Brasil

Bacteria of the Rickettsia genus are agents of Brazilian Spotted Fever (BSF), a zoonotic disease which is difficult to diagnose, evolves quickly and can result in death. Antibodies against Rickettsia spp. in horses were studied, by means of Indirect Immunofluorescence Assay (IFAT ≥64), in 150 blood samples taken from animals in two Santa Catarina mesoregions (Planalto Serrano and Vale do Itajaí). The overall occurrence of Rickettsia spp. antibodies in horses was 18.66%, with cross-reactivity occurring in all positive samples for at least two of the species tested. Separately, according to the species, 25 (16.66%) samples were positive for R. rickettsii, 15 (10%) for R. parkeri, 22 (14.66%) for R. amblyommii, 23 (15.33%) for R. rhipicephali, 16 (10.66%) for R. bellii and 19 (12.66%) for R. felis. Only two animals resulted in a conclusive serodiagnosis, one for R. bellii and the other for R. rickettsii, at maximum dilutions of 1:4096 and 1:512, respectively. The occurrence of antibodies against Rickettsia spp. in horses from two mesoregions in the state of Santa Catarina indicates the movement of BSF agents in these sentinel animals and confirms the importance of studying spotted fever in the state of Santa Catarina.

Bactérias do gênero Rickettsia são agentes da Febre Maculosa Brasileira (FMB), uma doença zoonótica, de difícil diagnóstico, rápida evolução e que pode levar o indivíduo à morte. Anticorpos contra Rickettsia spp. em equinos foram pesquisados, por meio da Reação de Imunofluorescência Indireta (RIFI≥64), em 150 amostras de sangue colhidas de animais em duas mesorregiões de Santa Catarina (Planalto Serrano e Vale do Itajaí). A ocorrência de anticorpos contra Rickettsia spp. observada em equinos de duas mesorregiões de Santa Catarina foi de 18,66%, ocorrendo reações cruzadas em todas as amostras positivas para, no mínimo, duas das espécies testadas. Isoladamente, de acordo com as espécies, 25 (16,66%) amostras foram positivas para R. rickettsii, 15 (10%) para R. parkeri, 22 (14,66%) para R. amblyommii, 23 (15,33%) para R. rhipicephali, 16 (10,66%) para R. bellii e 19 (12,66%) para R. felis. Somente dois animais resultaram em um sorodiagnóstico conclusivo, um para Rickettsia bellii e outro para R. rickettsii, nas diluições máximas de 1:4096 e 1:512, respectivamente. A ocorrência de anticorpos contra Rickettsia spp. em equinos de duas mesorregiões de Santa Catarina indica a circulação de agentes da FMB nestes animais sentinela e ratificam a importância do estudo da febre maculosa no estado de Santa Catarina.

Anticorpos contra neospora caninum e fatores de risco em cães de Lages e Balneário Camboriú, SC / Neospora caninum antibodies and risk factors in dogs from Lages and Balneário Camboriú, SC

Identificaram-se os fatores de risco e a ocorrência de anticorpos contra Neospora caninum em cães das cidades de Lages e Balneário Camboriú, SC. Amostras de soro de 400 cães domiciliados (200 de cada município) foram processadas para a detecção de anticorpos contra N. caninum pela técnica de imunofluorescência indireta. Informações acerca dos fatores de risco foram obtidas por meio de questionário. Dos 400 cães, 49 (12,3 por cento) apresentaram anticorpos contra N. caninum. Em Lages, 26 (13 por cento) foram positivos para N. caninume; em Balneário Camboriú, 23 (11,5 por cento). Não foram observadas diferenças estatísticas entre as ocorrências de anticorpos contra N. caninum (P= 0,647) nas duas cidades. Das variáveis analisadas, somente idade apresentou associação (P=0.020, odds ratio= 2.557, IC 95 por cento, 1.16-5.64) com a freqüência de cães reagentes ao N. caninum. Dentre os animais positivos, 41 (83,7 por cento) eram adultos, indicando ocorrência de infecção pós-natal do agente.

Ocorrência de Amblyomma aureolatum (Pallas, 1772) e A. ovale (Kock, 1844) (Acari: Ixodidae) parasitando Alouatta clamitans Cabrera, 1940 (Primates: Atelidae) na região norte do estado de Santa Catarina / Ocurrence of Amblyomma aureolatum (Pallas, 1772) and A. ovale (Kock, 1844) (Acari: Ixodidae) parasitizing Alouatta clamitans Cabrera, 1940 (Primates: Atelidae) in the north of Santa Catarina state, Brazil

The authors confirm the presence of one female and two males of Amblyomma aureolatum and five females and one male of A. ovale parasitizing southern brown howler monkeys in the municipalities of Indaial, Blumenau, Garuva, and Jaraguá do Sul, Santa Catarina State, Brazil.

Training resident anesthesiologists in adult challenging intubation comparing Truview EVO2 and Macintosh laryngoscope: a preliminary study.

AIM: Teaching airway management continues to be of high importance to the anesthesiologist, since the care of each individual patient depends on the expertise, training and knowledge of the anesthetist with different airway devices, techniques and algorithms. The aim of our study was to compare intubation performed by resident anesthesiologists in training, under senior supervision, using Truview EVO2 (Group 1) or Macintosh blade (Group 2) in a group of adult patients undergoing elective surgery. METHODS: This was a pilot prospective study. Thirty patients who were scheduled for surgery under general anesthesia were randomized into two groups. In Group 1, intubation was performed by using the Truview EVO2, and in Group 2 intubation was performed by using the Macintosh blade. Mallampati score, thyromental distance and neck mobility were recorded for each patient. The exclusion criteria included a Mallampati score =or<2 and a Patil distance >6 cm. The time of intubation and any occurrence of complications were recorded. RESULTS: Intubation was always successful on the first attempt in Group 1, while it failed for 46.7% of patients in Group 2 (P=0.006). The time of intubation was not different between the two groups. No complications were recorded for Group 1 (Truview), while seven were reported in Group 2 (Macintosh) (P=0.003). CONCLUSIONS: The resident managed to intubate all patients on the first attempt with the Truview, which led to a lower incidence of complications. Despite the exiguity of the population in the study, Truview EVO2 and other videolaryngoscopes can be considered to be useful tools in training resident anesthesiologists in elective intubation.

Platypnea-orthodeoxia syndrome in interatrial right to left shunt postpneumonectomy.

Platypnea-orthodeoxia is a syndrome characterized by dyspnea and hypoxemia on adoption of an upright posture (i.e., orthodeoxia), and by the absence or reduction of symptoms and of hypoxemia in a supine position. We describe the case of a 64-year-old patient who had developed an acute respiratory insufficiency due to right-to-left shunt in a patent foramen ovale one month after right intrapericardiac pneumonectomy. The patient was initially treated unsuccessfully with bronchodilators, corticosteroids and oxygen therapy. He was then admitted to the ICU due to severe refractory hypoxemia. Diagnosis of platypnea-orthodeoxia syndrome was demonstrated by O2 saturation and arterial blood gas analysis in the supine and upright positions. The presence of a right-to-left interatrial shunt through a patent foramen ovale was documented by transesophageal echocardiography 24 h after admission to intensive care. The next day, the patient underwent a percutaneous occlusion procedure with an Amplatzer device after consultation with surgeons and cardiologists. The patient was dismissed from the ICU after 24 hours of monitoring, and successfully discharged to home after one week.

[Continuous infusion of enoximone in the treatment of acute myocardial ischemia with low output syndrome]. / Enoximone in infusione continua nel trattamento dell' ischemia miocardica acuta con sindrome da bassa gittata.

OBJECTIVE: To evaluate efficacy and tolerability of enoximone, a phosphodiesterase inhibitor, in the treatment of cardiogenic shock. DESIGN: A prospective non randomized, non comparative study. SETTING: A general intensive care unit of a university hospital. PATIENTS: Six patients with cardiogenic shock (cardiac index < 2.5 l/min/m2, PWP > 15 mmHg) unsuccessfully treated with catecholamines. INTERVENTIONS: Enoximone was administered (0.5-1 mg/kg)by iv bolus according to clinical response (CI > or = 2.5 l/min/m2), then was continued by iv infusion (5-16 micrograms/kg/min). Dopamine infusion at low doses (3 micrograms/kg/min) was maintained during the study. In all patients a pulmonary artery catheter was inserted before the study began. MEASUREMENTS AND MAIN RESULTS: Direct and measured (using standard formula) haemodynamic parameters were registered. Basal data (before treatment) were compared with values after 30 minutes (bolus) and 8 hours (maintenance). CI (+57%) and O2 delivery (+74.7%) were significantly increased after 30 minutes and 8 hours, O2 extraction ratio normalized whereas heart rate and systemic blood pressure were unchanged. CONCLUSIONS: Enoximone proved to be safe and effective in the treatment of cardiogenic shock. Its pharmacological effects combines inotropic and vasodilatant action without any change of heart rate thus avoiding an increase of O2 consumption in the jeopardized myocardium. Further studies will define better its routine use in critically ill patients with acute heart failure.

Continuous veno-venous hemofiltration in critically ill patients with multiple organ failure.

18 critically ill patients, with multiple organ failure (MOF) (from shock either septic, n = 15, or cardiogenic, n = 3), oliguria and increase in BUN and creatinine were treated with pump driven, high flux continuous veno-venous hemofiltration (CVVH). Replacement fluids were administered in predilution mode. All patients were under respiratory support and vasoactive drugs, and received early nutritional support (N input: 0.2-0.3 g/kg/day). Mean duration of treatment was 9.2 days and mean ultrafiltrate production was 21.4 l/day; treatment resulted in a significant reduction of both urea nitrogen and creatinine blood levels (-20 and -40% of initial values respectively) in spite of a very severe catabolism. The total amount of urea nitrogen removed through CVVH ranged from 15 to 73 g/day (mean 33.5), the median value of urea nitrogen clearance was 12.8 ml/min with a median ultrafiltration coefficient of 0.8. The mean duration of hemofilters was 69 hours (38-108); the efficacy of filters remained stable throughout the entire lifespan and changes were made in case of sudden decrease of ultrafiltration (< ml/min). No major complication was observed in over than 4000 hours of treatment. Pump driven, high flux CVVH proved effective in the control of water electrolyte balance and metabolic homeostasis in a group of critically ill, hemodynamically unstable, catabolic patients with MOF and acute renal failure. In no case we had to add intermittent hemodialysis or to use hemodiafiltration. The constant extracorporeal blood flow and the stable efficacy of hemofilters allowed an easy control of the overall effectiveness of this technique.