Laparoscopic para-aortic lymphadenectomy for metastatic colon cancer in a patient with left-sided inferior vena cava: a case report

Transposition of inferior vena cava, or, left-sided inferior vena cava (LS-IVC) is a rare clinical entity, in which the inferior vena cava ascends along the left side of the abdominal aorta. Literature contains mainly clinical case reports. Although it is usually not associated with clinical symptomatology, this anomaly should be detected during preoperative planning to avoid iatrogenic injuries intraoperatively. We present a case of left-sided inferior vena cava encountered during laparoscopic lymphadenectomy in a 45-year-old man with previous laparoscopic hemicolectomy due to colon adenocarcinoma. Preoperative CT abdomen revealed the left-sided location of infrarenal IVC and laparoscopic trans-peritoneal aortic lymphadenectomy was decided. Intraoperatively, transposition of inferior vena cava was confirmed in accordance with the CT findings. Resection of lymph node block was conducted with no complications and with minimal blood loss. The postoperative course was uneventful, and the patient was discharged from the hospital the day following surgery. In conclusion, transposition of the inferior vena cava, although rare, constitutes an anatomical variant that should be identified preoperatively to decrease intraoperative risks. Several anatomical variants have been associated with left-sided inferior vena cava

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

COVID-19 infection is a significant risk factor for death in patients presenting with acute cholecystitis: a secondary analysis of the ChoCO-W cohort study

Background: During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy.” Methods: The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality. Results: The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection (p < 0.001), postoperative complications (p < 0.001), and type (open/laparoscopic) of surgical intervention (p = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%). Conclusions: COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Comparative study of fluorescent cholangiography with indocyanine green in relation to classical during laparoscopic cholecystectomy

Introduction: Laparoscopic cholecystectomy is the treatment of choice for treating symptomatic and complicated cholelithiasis, and it is currently the most frequently performed operation in general surgery. The two most feared intraoperative complications that can occur during laparoscopic cholecystectomy are the retention of stones in the biliary tree and iatrogenic injuries to the biliary ducts. Specifically, for the latter, intraoperative cholangiography has been developed for decades, during which the cystic duct is catheterized and possible injuries to the extrahepatic bile ducts can be checked. In recent years, Indocyanine Green (ICG), a disulfide heptamethine indocyanine that is metabolized in the liver and excreted in the bile, has become particularly widespread. ICG is most commonly administered intravenously, and the available literature advocates for its safety and effectiveness in imaging the anatomy and preventing injuries to the biliary tree. Little study has been conducted in the literature examining the direct administration of ICG into the gallbladder instead of the systemic circulation. Materials and Methods: In this prospective study, a total of 240 patients participated, randomized into three groups of 80 individuals. In the first group (A), classical cholangiography was performed. In group (B), intravenous fluorescent cholangiography with Indocyanine Green was performed, administered at a dose of 0.3 mg/mL/Kg 6 (six) hours before the start of the surgical operation. Finally, in the third group (C), intraoperative cholangiography was carried out with the direct administration of Indocyanine Green at a dose of 0.03 mg/ml/Kg into the gallbladder. For each patient, the time required to perform the operation as well as the intraoperative complications related or not to cholangiography (bleeding, bile leakage, and biliary injury) were recorded. Parameters of toxicity of the methods were evaluated with an assessment of liver tests, coagulation mechanism, renal function, inflammation markers, and inflammatory response indicators (TNFa, Il6). Within the framework of the preoperative check and postoperative monitoring through blood draws, the collection and recording of the laboratory values of the aforementioned parameters were conducted. Results: No adverse effects from the intravenous administration of ICG or from its direct injection into the gallbladder were detected. Cholangiography time was significantly longer in group A, when compared to groups B and C. Conclusions: Fluorescent cholangiography was found to be superior to classic cholangiography, regarding the recognition of intra- and extrahepatic biliary tree and surgeon’s satisfaction.Εισαγωγή: Η λαπαροσκοπική χολοκυστεκτομή αποτελεί την μέθοδο εκλογής για την αντιμετώπιση της συμπτωματικής και της επιπλεγμένης χολολιθίασης, ενώ σήμερα είναι η συχνότερα εκτελούμενη επέμβαση στη γενική χειρουργική. Οι δύο πιο επίφοβες διεγχειρητικές επιπλοκές που μπορεί να παρουσιαστούν κατά τη λαπαροσκοπική χολοκυστεκτομή είναι οι παραμονή λίθων στο χοληφόρο δέντρο και οι ιατρογενείς κακώσεις των χοληφόρων. Ειδικότερα για την τελευταία έχει αναπτυχθεί εδώ και δεκαετίες η διεγχειρητική χολαγγειογραφία, κατά την οποία καθετηριάζεται ο κυστικός πόρος και δύναται να ελεγχθούν πιθανές κακώσεις στα εξωηπατικά χοληφόρα. Τα τελευταία χρόνια έχει διαδοθεί ιδιαίτερα το πράσινο της ινδοκυανίνης (ICG), μια δισουλφιδική επταμεθυλινική ινδοκυανίνη που μεταβολίζεται στο ήπαρ και εκκρίνεται στη χολή. Το ICG χορηγείται συνηθέστερα ενδοφλεβίως, και η διαθέσιμη βιβλιογραφία συνηγορεί υπέρ της ασφάλειάς του και υπέρ της αποτελεσματικότητάς του στην απεικόνιση της ανατομίας της και στην πρόληψη κακώσεων στο χοληφόρο δέντρο. Ελάχιστη μελέτη έχει πραγματοποιηθεί βιβλιογραφικά που να εξετάζει την απευθείας χορήγηση ICG εντός της χοληδόχου κύστης αντί εντός της συστηματικής κυκλοφορίας. Υλικά και Μέθοδοι: Στην παρούσα προοπτική μελέτη συμμετείχαν συνολικά 240 ασθενείς, τυχαιοποιημένοι σε τρεις ομάδες των 80 ατόμων. Στην πρώτη ομάδα (Α) έγινε κλασική χολαγγειογραφία. Στην ομάδα (Β) έγινε ενδοφλέβια φθορίζουσα χολαγγειογραφία με πράσινο της ινδοκυανίνης που χορηγήθηκε σε δόση 0,3 mg/mL/Kg 6(έξι) ώρες πριν από την έναρξη της χειρουργικής επέμβασης. Τέλος, στην τρίτη ομάδα (Γ) πραγματοποιήθηκε διεγχειρητική χολαγγειογραφία με απευθείας χορήγηση πράσινου της ινδοκυανίνης σε δόση 0,03 mg/ml/Kg στη χοληδόχο κύστη. Για κάθε ασθενή καταγράφηκε ο χρόνος που απαιτείται για την πραγματοποίηση της επέμβασης καθώς και οι διεγχειρητικές επιπλοκές που σχετίζονται ή όχι με τη χολαγγειογραφία (αιμορραγία, χολόρροια και κάκωση χοληφόρων). Αξιολογήθηκαν παράμετροι τοξικότητας των μεθόδων με αξιολόγηση ηπατικών δοκιμασιών, πηκτικού μηχανισμού, νεφρικής λειτουργίας, δεικτών φλεγμονής και δεικτών φλεγμονώδους αντίδρασης (TNFa, Il6). Στα πλαίσια του προεγχειρητικού ελέγχου και της μετεγχειρητικής παρακολούθησης μέσω των αιμοληψιών έγινε η συλλογή και καταγραφή των εργαστηριακών τιμών των αναφερόμενων παραμέτρων. Αποτελέσματα: Δεν ανιχνεύθηκαν ανεπιθύμητες ενέργειες από τη χορήγηση του ICG ενδοφλεβίως ούτε από την απευθείας έγχυση αυτού εντός της χοληδόχου κύστης. Η διάρκεια χολαγγειογραφίας ήταν σημαντικά μεγαλύτερη στην ομάδα Α, σε σύγκριση με τις ομάδες Β και Γ. Συμπεράσματα: H φθορίζουσα κλασικής χολαγγειογραφίας εμφανίζει σημαντική υπεροχή σε σύγκριση με την κλασική χολαγγειογραφία, όσον αφορά την οπτικοποίηση του ενδο και εξωηπατικού χοληφόρου δένδρου, καθώς και την ευκολία διενέργειας της χολαγγειογραφίας από τον χειρουργό

Use of isolated Roux loop for pancreaticojejunostomy reconstruction after pancreaticoduodenectomy

AIM: To evaluate the efficacy of the isolated Roux loop technique in decreasing the frequency of pancreaticojejunal anastomosis failure

Laparoscopic para-aortic lymphadenectomy for metastatic colon cancer in a patient with left-sided inferior vena cava: a case report

Transposition of inferior vena cava, or, left-sided inferior vena cava (LS-IVC) is a rare clinical entity, in which the inferior vena cava ascends along the left side of the abdominal aorta. Literature contains mainly clinical case reports. Although it is usually not associated with clinical symptomatology, this anomaly should be detected during preoperative planning to avoid iatrogenic injuries intraoperatively. We present a case of left-sided inferior vena cava encountered during laparoscopic lymphadenectomy in a 45-year-old man with previous laparoscopic hemicolectomy due to colon adenocarcinoma. Preoperative CT abdomen revealed the left-sided location of infrarenal IVC and laparoscopic trans-peritoneal aortic lymphadenectomy was decided. Intraoperatively, transposition of inferior vena cava was confirmed in accordance with the CT findings. Resection of lymph node block was conducted with no complications and with minimal blood loss. The postoperative course was uneventful, and the patient was discharged from the hospital the day following surgery. In conclusion, transposition of the inferior vena cava, although rare, constitutes an anatomical variant that should be identified preoperatively to decrease intraoperative risks. Several anatomical variants have been associated with left-sided inferior vena cava

Biliary Anatomy Visualization and Surgeon Satisfaction Using Standard Cholangiography versus Indocyanine Green Fluorescent Cholangiography during Elective Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration