Relaparoscopy for management of postoperative complications following colorectal surgery: ten years experience in a single center.

BACKGROUND: Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant disease. On the basis of this growing experience, there is now an expanded role for laparoscopic approach to postoperative complications after primary colorectal resection. However, there is little literature specific to this topic. We report a ten-year experience with laparoscopic treatment of early complications following laparoscopic colorectal surgery. METHODS: From January 2003 to December 2012, a total of 1,292 patients underwent elective laparoscopic colorectal surgery in our department. One hundred and two (7.9%) patients required reoperation for a postoperative complication. Laparoscopy has been also adopted as the preferred procedure for management of postoperative complications. A retrospective review of 84 patients who had relaparoscopy (RL) for postoperative complications, including peritonitis, ureteral injury, bowel obstruction, and bleeding, was performed. RESULTS: Reoperation was carried out laparoscopically in 79 (94.0%) patients. Five (6.0%) conversions were necessary because of massive colonic ischemia, generalized fecal peritonitis, and lack of working space. The most common finding at RL was anastomotic leakage (57.1%) that was managed by peritoneal lavage and ileostomy in 91.7% of cases. Six percent of patients had negative RL. Overall morbidity rate was 25.0%. Five patients required additional surgery: four (5.1%) after RL and one after a converted procedure. There were five (6.0%) deaths from septic shock, myocardial infarction, and pulmonary embolism. CONCLUSIONS: Laparoscopy is a safe and effective tool for management of complications following laparoscopic colorectal surgery. In this setting, RL represents the first step of re-exploration and treatment, with no delay to conversion to open procedure even in skilled laparoscopic hands.

Management of Rheumatoid Arthritis in Primary Care: A Scoping Review.

Rheumatoid arthritis (RA) can lead to severe joint impairment and chronic disability. Primary care (PC), provided by general practitioners (GPs), is the first level of contact for the population with the healthcare system. The aim of this scoping review was to analyze the approach to RA in the PC setting. PubMed, Scopus, and Web of Science were searched using the MESH terms "rheumatoid arthritis" and "primary care" from 2013 to 2023. The search strategy followed the PRISMA-ScR guidelines. The 61 articles selected were analyzed qualitatively in a table and discussed in two sections, namely criticisms and strategies for the management of RA in PC. The main critical issues in the management of RA in PC are the following: difficulty and delay in diagnosis, in accessing rheumatological care, and in using DMARDs by GPs; ineffective communication between GPs and specialists; poor patient education; lack of cardiovascular prevention; and increase in healthcare costs. To overcome these criticisms, several management strategies have been identified, namely early diagnosis of RA, quick access to rheumatology care, effective communication between GPs and specialists, active patient involvement, screening for risk factors and comorbidities, clinical audit, interdisciplinary patient management, digital health, and cost analysis. PC appears to be the ideal healthcare setting to reduce the morbidity and mortality of chronic disease, including RA, if a widespread change in GPs' approach to the disease and patients is mandatory.

Laparoscopic pancreaticoduodenectomy: experience of 22 cases.

BACKGROUND: Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center. METHODS: From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed. RESULTS: Mean operative time was 392 (range, 327-570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12-35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14-20). CONCLUSIONS: The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.

Laparoscopic pancreas-preserving subtotal duodenectomy for gastrointestinal stromal tumor.

Gastrointestinal stromal tumors (GISTs) of the duodenum are rare neoplasms. The optimal surgical procedure is debated and several options ranging from limited resections to pancreaticoduodenectomy have been reported. The laparoscopic approach has been validated for gastric GISTs, but it does not yet represent a standard technique for tumors of the duodenum. We report the case of a localized duodenal GIST that was successfully treated by totally laparoscopic pancreas-preserving subtotal duodenectomy. This procedure may represent a feasible and effective treatment option for localized GISTs of the duodenum. Large series with long-term follow-up are needed.

Laparoscopic splenectomy: experience of a single center in a series of 300 cases.

BACKGROUND: Laparoscopic splenectomy (LS) has gradually become the technique of choice for surgical removal of the spleen. The aim of this study was to evaluate the efficacy of LS in a large cohort of patients from a single center. METHODS: From March 1992 to June 2010, 300 patients underwent LS at our hospital for predominantly hematologic disorders. The first 92 cases were performed using an anterior approach, whereas in the remaining 208 cases a lateral approach with a four-trocar technique was used. Patient demographics, diagnosis, and outcomes were reviewed. RESULTS: Spleen volume was similar between the anterior (350 ml) and the lateral (370 ml) approaches. The lateral approach was associated with shorter operative time (60 vs. 80 min), less blood loss (30 vs. 110 ml), and no conversion (0 vs. 2.2 %) compared to the anterior approach. Reoperations were required in three patients (1.0 %) because of bleeding, subphrenic abscess, and intestinal ischemia. Postoperative complications were significantly fewer for the lateral (4.8 %) than for the anterior (31.5 %) approach and the hospital stay was shorter (3.1 vs. 5.2 days) and there was less postoperative pain. Splenectomy for hematologic malignancies resulted in a higher morbidity rate, more postoperative pain, and longer hospital stay. Overall mortality rate was 0.3 %. No late complications were observed during the 1-5-year follow-up. CONCLUSIONS: LS using the lateral approach with the placement of four trocars can be considered the procedure of choice for both benign and malignant diseases affecting the spleen. Extensive experience and technical standardization help to avoid surgical pitfalls, providing an adequate control of hemostasis, the excision of accessory spleens (AS), and the avoidance of parenchymal rupture.

Early outcomes of colon laparoscopic resection in the elderly patients compared with the younger.

BACKGROUND: The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 75 years old (OP) compared with the outcomes of a younger populations (YP). METHODS: Forty elderly patients undergoing laparoscopic colectomy for colorectal cancer between 2007-2011 were studied, the patients are divided for gender, age, year of surgery, site of cancer, and comorbidity on admission and compared with 40 younger patients. RESULTS AND DISCUSSION: Mean (standard deviation) age was 81.3 in OP and 68.3 YP Conversion rate was the same between the two groups. There was no difference in operative mean time . The overall mortality rate was 0% percent. The surgical morbidity rate was the same but there was an increased in cardiologic e bronchopneumonia complications in older population. Patients treated with laparoscopic approach had a faster recovery of bowel function and a significant reduction of the mean length of hospital stay not age related. Laparoscopy allowed a better preservation of postoperative independence status. CONCLUSIONS: Laparoscopic colectomy for cancer in elderly patients is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

Studying the effects of an advanced driver-assistance system to improve safety of cyclists overtaking.

Among all crashes involving cyclists, a motorist approaching from behind a cyclist on a shared lane is particularly dangerous and likely to result in serious injuries and fatalities. Previous research has highlighted that inadequate lateral distance and high vehicle speed are among the main contributing factors of crashes involving cars overtaking cyclists. A new advanced driver assistance system (ADAS) which supports drivers as they overtake cyclists was designed to avoid or, at least, mitigate crashes. In human-machine interface (HMI) design, the information was presented via multiple modalities with a multistage warning system. A combination of lateral clearance (LC) and time-to-danger (TTD) parameters was used as ADAS activation criterion. Experimentation was carried out using the medium-fidelity driving simulator at the Transportation Research Institute (IMOB) of Hasselt University in Belgium. Forty-eight drivers drove the two-lane rural experimental route two times, in baseline condition and with the ADAS activated, testing three overtaking events. Statistical tests showed that the proposed in-vehicle driving assistance system had a significant effect in increasing 1) the length of the passing phase, 2) the LC in the overtaking passing phase, and 3) the TTD along the overtaking maneuver. No effect of the ADAS system on vehicle speed was observed. Overall, the designed system is effective in improving car-cyclist overtaking behaviour in terms of both safety and cyclists' mobility.

Safety Index for evaluation of urban roundabouts.

Recently, there is a growing interest in road safety assessments based on the examination of the characteristics of the road aimed at identifying the presence of risk factors. This approach, named road assessment program or network wide road safety assessment, is required by the EU Directive 2019/1936 on road infrastructure safety management. Reliable procedures for assessing the inherent safety of all the elements of the road network are required to conduct roadway safety assessments. To provide a contribution toward the development of procedures for network wide road safety assessment, this paper develops and validates a Safety Index (SI) for evaluating urban roundabouts. The SI is assessed both at the roundabout level as well as at the roundabout approach level. This procedure detects the safety issues that are the largest contributors to crash risk in order to identify the safety measures that provide the greatest crash reduction at roundabouts. The SI is formulated by combining two components: the exposure of road users to road hazards (Exposure) and the risk factors which increase the probability of involvement in crashes (Risk Index). The procedure considers 33 detailed safety issues and 5 general safety issues to compute the Risk Index. Criteria for identifying and ranking the safety issues are defined. The SI procedure was validated in a sample of 50 urban roundabouts located in Rome, Italy. The sample consisted of 12 single-lane roundabouts and 38 two-lane roundabouts, with a total number of approaches equal to 179. In these roundabouts, the SI scores and the EB crash estimates were compared with reference both to the whole roundabouts as well as to the single roundabout approaches. The correlation between the SI scores and EB estimates was highly significant both at the roundabout level (R2 = 0.85, t = 16.49, p-value < 0.001) as well as at the approach level (R2 = 0.56, t = 14.88, p-value < 0.001). The results from Spearman's rank-correlation analysis provided further validation for the SI indicating that rankings from the SI and the EB estimates agree at the 99.9 % confidence level both at the roundabout level (ρs = 0.80) as well as at the approach level (ρs = 0.70).

Crash modification functions for pavement surface condition and geometric design indicators.

The combined contribution to highway safety of pavement surface and geometric design indicators is not well investigated due to the complexity of data collection and high time variability of pavement surface conditions. Introduction of high efficiency equipment for comprehensive road surveys is mitigating this issue, expanding possibilities of data integration. In this framework, the present study developed crash modification functions (CMFs) of pavement surface and geometric design indicators for different crash types (total, run-off-the-road, and others), pavement conditions (dry and wet), and lighting conditions (daytime and nighttime) based on data from two-lane rural highways in Italy. Geometric and pavement data were surveyed with the Automatic Road Analyzer and the Grip Tester. Pavement surface condition data were corrected to the crash time by pavement performance deterioration models based on traffic load to account for the variation in pavement conditions over time. Crash, traffic and weather data were retrieved from national and local databases. This study used safety performance functions (SPFs), fitted with generalized linear modelling techniques and a negative binomial distribution error structure, for developing CMFs. The SPFs were used to quantify the effect of a specific variable on crash occurrence and CMFs were then derived from the model coefficients. CMFs were developed for the following parameters: Grip Number, International Roughness Index, curvature change ratio, coefficient of variation of the curvature, maximum superelevation deficiency, and minimum lane width. According to the study results, an increase in friction, as measured by the Grip Number, is associated with a reduction in crash frequency while an increase in roughness, as measured by the International Roughness Index, is associated with an increase in crash frequency. Thus, both pavement maintenance treatments aimed at increasing friction as well as treatments aimed at reducing irregularities have a positive safety effect, especially when wet, run-off-the-road or nighttime crashes are overrepresented. Study results allow to effectively integrate pavement management systems and safety management systems. When developing paving schedules, transportation agencies often base their decisions on asset management condition targets but do not explicitly account for the role of pavement conditions in highway safety. Availability of CMFs for both pavement surface parameters as well as geometric design parameters is crucial to improve pavement and geometric characteristics considering their safety effects.

Longitudinal control behaviour: Analysis and modelling based on experimental surveys in Italy and the UK.

This paper analyses driving behaviour in car-following conditions, based on extensive individual vehicle data collected during experimental field surveys carried out in Italy and the UK. The aim is to contribute to identify simple evidence to be exploited in the ongoing process of driving assistance and automation which, in turn, would reduce rear-end crashes. In particular, identification of differences and similarities in observed car-following behaviours for different samples of drivers could justify common tuning, at a European or worldwide level, of a technological solution aimed at active safety, or, in the event of differences, could suggest the most critical aspects to be taken into account for localisation or customisation of driving assistance solutions. Without intending to be exhaustive, this paper moves one step in this direction. Indeed, driving behaviour and human errors are considered to be among the main crash contributory factors, and a promising approach for safety improvement is the progressive introduction of increasing levels of driving automation in next-generation vehicles, according to the active/preventive safety approach. However, the more advanced the system, the more complex will be the integration in the vehicle, and the interaction with the driver may sometimes become unproductive, or risky, should the driver be removed from the driving control loop. Thus, implementation of these systems will require the interaction of human driving logics with automation logics and then an enhanced ability in modelling drivers' behaviour. This will allow both higher active-safety levels and higher user acceptance to be achieved, thus ensuring that the driver is always in the control loop, even if his/her role is limited to supervising the automatic logic. Currently, the driving mode most targeted by driving assistance systems is longitudinal driving. This is required in various driving conditions, among which car-following assumes key importance because of the huge number of rear-end crashes. The increased availability of lower-cost information and communication technologies (ICTs) has enhanced the possibility of collecting copious and reliable car-following individual vehicle data. In this work, data collected from three different experiments, two carried out in Italy and one in the UK, are analysed and compared. The experiments involved 146 drivers (105 Italian drivers and 41 UK drivers). Data were collected by two instrumented vehicles. Our analysis focused on inter-vehicular spacing in equilibrium car-following conditions. We observed that (i) the adopted equilibrium spacing can be fitted using lognormal distributions, (ii) the adopted equilibrium spacing increases with speed, and (iii) the dispersion between drivers increases with speed. In addition, according to different headway thresholds (up to 1 second) a significant number of potentially dangerous behaviours is observed. Three different car-following paradigms are also applied to each of the experiments, and modelling parameters are calibrated and compared to obtain indirect confirmation about the observed similarities and differences in driving behaviour.

Simulator evaluation of drivers' speed, deceleration and lateral position at rural intersections in relation to different perceptual cues.

Aim of the study was to investigate, by means of a driving simulator experiment, drivers' behaviour in terms of speed, deceleration, and lateral position on major approaches of rural intersections in relation to different perceptual cues. In the experiment, ten different design conditions with and without speed-reducing treatments along the approach to the intersection were tested. Twenty-three drivers drove a test route two times and data from the second drive were used for comparison. The order of the ten design conditions was counterbalanced for all the drivers to minimize the presentation order effect. Three different data analysis techniques were used: (a) cluster analysis of speed and lateral position data, (b) statistical tests of speed and lateral position data, and (c) categorical analysis of deceleration behaviour patterns. The most effective treatments were the dragon teeth markings (based on the principle of optical road narrowing), the colored intersection area (based on the principle of intersection highlighting), and the raised median island (based on the principle of physical road narrowing). These measures, in comparison to the base intersection, produced: (1) a significant speed reduction starting from 250 m before the intersection in the range between 13 and 23 km/h, (2) a significant change in the deceleration behaviour with a reduction in the proportion of drivers which did not decelerate, and (3) a shift away from the intersection of the deceleration beginning. Given the significant effects on drivers' behaviour, the dragon teeth markings, the colored intersection area, and the raised median island are strongly recommended for real world implementation.

Traffic calming along rural highways crossing small urban communities: driving simulator experiment.

The paper investigated drivers' speed behaviour in a section of a rural highway crossing a small urban community in the existing scenario without any traffic calming device and in two different design scenarios with traffic calming in the urban community. Two gateways and four integrative traffic calming devices along the route within the urban area were tested. The gateways were aimed at slowing down the vehicles entering in the built-up area, while the traffic calming devices were aimed at complementing the gateway effect inside the built-up area. Two design options were tested: first option (alt1) is a combination of low cost measures, whereas the second option (alt2) is more expensive as includes a chicane and requires land acquisition. Drivers' behaviour was investigated by means of a driving simulator experiment. The VERA dynamic-driving simulator operating at the TEST Road Safety Laboratory located in Naples (Italy) was used. Simulation results were validated by the comparison of speed behaviour in the real world and in the driving simulator, in the scenario without traffic calming. Analysis of the driving simulator experiment results was performed using two different approaches: (a) explorative description of data by cluster analysis; (b) inferential procedures about population using statistical tests. Cluster analysis was carried out in order to test if the drivers' speed behaviour in the different design alternatives was substantially different. Statistical tests were performed in order to verify if speeds in specific sections were significantly different. Cluster analysis looked at speed profiles, whereas statistical tests looked at speed data in specific points. The obtained results showed a different behaviour of drivers approaching the urban community in the existing scenario and in the design scenarios. In the south direction, mean speed reduction ranging between 16 and 17 km/h, with 5% level of significance, was observed. In the north direction, mean speed reduction equal to 11 km/h, with 10% level of significance, was observed. Differences between the two design alternatives were not statistically significant. Along the urban community, a statistically significant mean speed reduction ranging between 9 and 15 km/h was observed in the south direction. In the north direction, speed reduction was not statistically significant. Overall, combined results of cluster analysis and statistical tests showed that the treatments were more effective in the direction with higher speeds in the base scenario.