Haemostasis in Thyroid Surgery: Collagen-Fibrinogen-Thrombin Patch versus Cellulose Gauze—Our Experience

Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, “near total,” or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery

Inhibition of PDE4D prevents migration of HCC cells through modulation of IGF2/H19 cluster

Cyclic nucleotide phosphodiesterases (PDEs) play major roles in several different signalling pathways and thus control key cellular events, including cell proliferation, differentiation, and survival. Among PDEs, PDE4 is abundantly expressed in liver and appears deregulated in many tumours. The PDE4 family is encoded by four genes, namely PDE4A, PDE4B, PDE4C and PDE4D. Our previous studies showed that PDE4D is a major regulator of cAMP expression in hepatocarcinoma (HCC) cells and tissues. Its silencing or inhibition reduced cell proliferation and increased apoptosis of HCC cell lines by interfering with the expression of key cell cycle effectors. In addition, PDE4D silencing, or inhibition, affected the expression of several cancer-related genes, with a significant down regulation of the pro-oncogenic insulin growth factor 2 (IGF2), an imprinted gene whose transcription is regulated in a cluster with the region encoding for the H19 long non-coding RNA deeply involved in HCC proliferation, migration and invasion. Specific objectives of this research were to investigate the possible correlation between PDE4D overexpression, epithelial-mesenchymal transition (EMT) and uncontrolled cell migration, as well as to verify whether pharmacological inhibition of PDE4D can reverse EMT by acting on the IGF2/H19 cluster. The correlation between PDE4D and IGF2 expression patterns were confirmed by the CancerLivER database. Low tumorigenic (HepG2) and highly tumorigenic (Hep3B and Huh7) cell lines were used as HCC in vitro models. PDE4D activity was selectively inhibited using Gebr-7b. Western blotting experiments were performed to analyze the expression of proteins involved in epithelial-mesenchymal transition and cell migration, while qRT-PCR was employed to analyse the expression of IGF2 and H19 mRNA. Finally, Real-Time cell migration was evaluated using the IncuCyte video microscopy system in cell treated and nontreated with Gebr 7b. Selective pharmacological inhibition of PDE4D, using Gebr-7b, induced an upregulation of the epithelial marker E-cadherin and a down-regulation of the mesenchymal markers Twist and Snail. Gebr-7b treatment also significantly reduced HCC cell migration and induced upregulation of H19 gene expression, thus reducing the expression of IGF2 protein. We hypothesize that an aberrant up-regulation of PDE4D might impact the transcription of the IGF2/H19 cluster by disrupting its epigenetic regulation, potentially involving various already identified H19lnc regulators such as cAMP, PKA, and paxillin. Therefore, targeting the PDE4D/IGF2/H19 cluster with pharmacological selective inhibitors of PDE4D (e.g. Gebr-7b) may prevent metastatic dissemination and increase the efficacy of current HCC treatments while reducing toxicity. However, since the upstream signals governing the regulation of the IGF2/H19 cluster are only partially understood during hepatocarcinogenesis, further exploration is warranted to corroborate our hypothesis

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Management Cholestasis Due to Choledocal Lithiasis

Background: The management of common bile duct stones still remains an area of controversy. Over the years, numerous authors have proposed various solutions: based on the time of cholecystectomy treatment can be preoperatively or intra and post-operative (in singlestage and two-stage). Methods: We have selected and compared several studies that make a compare between one-stage management [Laparoscopic Cholecystectomy (LC) Plus Laparoscopic Common Bile Duct Exploration (LCBDE) or Intra-Operative ERCP) and two-stage management [laparoscopic cholecystectomy preceded or followed by Endoscopic Retrograde Cholangio Pancreatography (ERCP)] in secondary choledocholithiasis, adding our personal experience in two stage management of CBDS. Results: In accordance with relevant randomized trials, we can say that the clinical outcome after one-stage laparoscopic/endoscopic management of bile duct stones is no different to the outcome after two-stage management. Conclusion: Our evaluations indicate that the best treatment of choice for any patient with CBDS must be based on locally available expertise, experience of the multidisciplinary team and standardization of the technique (endoscopic, laparoscopic and surgical), as determined by success rates, rates of morbidity and mortality, costs, and patient preference

Laparoscopic Treatment of Hepatic Cysts: A 10-Years Single Institution Experience

Aims: This study presents our experience in the laparoscopic management of simple hepatic cysts (SHCs) and the polycystic liver disease (PCLD). Study Design: Retrospective institutional study. Place and Duration: Department of Medical and surgical Science, University of Foggia, Foggia, from January 2004 to December 2014. Methodology: Laparoscopic deroofing was performed in 20 consecutive patients. There were 15 cases with SHCs and only 5 cases with PCLD (Gigot’s type I). In SHCs group, cyst was single in 10 cases and multiple in 5. Cysts were located in both hepatic lobes in 4 cases. The two groups were homogeneous for age, sex and ASA score. Preoperative investigations include routine laboratory tests, ultrasonography and the use of computed tomography in order to make diagnosis ad to rule out parasitic and neoplastic liver cysts. CT scan was performed in all cases to assess the characteristics, dimensions, and exact position of the lesion. Surgery was planned for all patients because of evident and persistent symptomatology, characterized of the presence from no less of 6 months of typical symptoms such as nausea, vomiting and epigastric pain. In our series, 6 cases of cholelithiasis were associated. Results: The analyzed outcome variables included surgical procedure, operative time, blood loss, length of hospital stay, complications, and medium follow-up period. All the patients underwent laparoscopic deroofing of the larger cysts and puncturing of the smaller cysts. There were no conversions. The mean operative time was estimated twice in the group PCLD than SHCs (110 min vs 60 min). The histological examinations revealed the typical pattern of the simple liver cysts in any case, without evidence of malignancy. No significant blood loss was found. The total morbidity recorded was 25% (5/20), 2 cases in the group of SHCs (13,3%) and 3 cases in the PCLD one (60%) and was characterized of 2 cases of ascites through trocar insertion sites after removal of drainage tube and 3 case of pleural effusion. There were no significant group differences in term of length of hospital stay. The follow-up period (a mean of 22 months) confirmed that all the patients remained free of symptoms and relapse of the disease. Conclusion: The technical feasibility and the good short- and medium-term results made the laparoscopic approach the procedure of choice for the management of symptomatic liver cysts

Haemostasis in Thyroid Surgery: Collagen-Fibrinogen-Thrombin Patch versus Cellulose Gauze—Our Experience

Purpose. Postoperative hemorrhage is fortunately uncommon but potentially life-threatening complication of thyroid surgery that increases the postoperative morbidity and the hospital stay. In this study we compare the efficacy of collagen patch coated with human fibrinogen and human thrombin (CFTP) (group C) and oxidized regenerated cellulose gauze (group B) versus traditional hemostatic procedures (group A) in thyroid surgery. Methods. From January 2011 to December 2013, 226 were eligible for our prospective, nonrandomized, comparative study. Patients requiring a video-assisted thyroidectomy without drain, “near total,” or hemithyroidectomy were excluded. Other exclusion criteria were a diagnosis of malignancy, substernal goiter, disorders of hemostasis or coagulation, and Graves or hyperfunctioning thyroid diseases. Outcomes included duration of operation, drainage volume, and postoperative complications. Results. Our results show a significant reduction in drainage volume in group C in comparison with the other two groups. In group C there was no bleeding but the limited numbers do not make this result significant. There were no differences in terms of other complications, except for the incidence of seroma in group B. Conclusion. The use of CFTP reduces the drainage volume, potentially the bleeding complications, and the hospital stay. These findings confirm the efficacy of CFTP, encouraging its use in thyroid surgery

A Rare Case of Functioning Adrenocortical Oncocytoma Presenting as Cushing Syndrome

Functioningadrenocorticaloncocytomaisveryrareneoplasm.Itisusuallynonfunctionalandbenignandincidentallydetected. Generally,thesetumorsoriginateinthekidneys,thyroid,parathyroid,andsalivaryorpituitaryglands;theyhavealsobeenreported inothersitesincludingchoroidplexus,respiratorytract,andlarynx.Histologically,theyarecharacterizedbycellswitheosinophilic granularcytoplasmandnumerouspackedmitochondria.Wereportedacaseofa44-year-oldfemalewhopresentedwithCushing syndrome for hypersecretion of cortisol due to adrenocortical oncocytoma. Magnetic resonance of abdomen revealed a right adrenalmass.Laparoscopicadrenalectomywasperformedandthetumorwaspathologicallyconfirmedasbenignadrenocortical oncocytoma.Aftersurgicaltreatment,Cushing’ssyndrome resolved