Emergency surgery for recurrent intraabdominal cancer

Recurrent abdominal cancer can manifest in many ways but there are certain situations that are a great challenge to clinicians. Emergency presentation is one such situation. Surgeons are faced with a therapeutic dilemma that on the one hand most of these patients have a limited life expectancy, and on the other surgical procedures are unavoidable. We reviewed our experience of recurrent abdominal cancers presenting with acute abdominal symptoms requiring emergency

Shared decision-making in trauma and emergency surgery settings. A literature review

Emergency teams are made up of professionals of different specialities, including emergency physicians, surgeons, anesthesiologists, and nurses. Such units are characterized by the need to face unexpected situations with little time to make clinical decisions. In trauma and emergency settings, clinicians must act in a coordinated way, ensuring, at the same time, proper knowledge transfer and sharing to reach the best possible result for the patient. While such dynamics must be explicit and clear within the team, involving the patient in the decision-making process may require additional tools and procedures. Indeed, the time to engage with the patient and the family to understand the patient’s wishes and treatment preferences may be limited or absent at all. While the so-called shared decision-making (SDM) stands as one of the pillars of the modern patient-centric healthcare scenario, knowledge translation and transfer dynamics may appear particularly challenging in emergency settings. Starting from an investigation of the recent literature on SDM, the paper presents a literature review of the barriers, facilitators, and knowledge translation dynamics of SDM in trauma and emergency surgery. Results assess the importance, tools, and dynamics of SDM processes

The added value of operator’s judgement in thyroid nodule ultrasound classification arising from histologically based comparison of different risk stratification systems.

Objective: Several ultrasound classifications for thyroid nodules were proposed but their accuracy is still debated, since mainly estimated on cytology and not on histology. The aim of this study was to test the diagnostic accuracy and the inter-classification agreement of AACE/ACE-AME, American Thyroid Association (ATA), British Thyroid Association (BTA), and Modena Ultrasound Thyroid Classification (MUT) that stratifies malignancy risk considering also the clinician subjective impression. Methods: A prospective study collecting thyroid nodule features at ultrasound and histological diagnosis was conducted. Ultrasound features were collected following a preformed checklist in candidates for surgery because of indeterminate, suspicious, or malignant cytology. All the nodules, besides the cytologically suspicious one, were blinded analyzed. MUT score was applied prospectively, and the others retrospectively. Sensitivity, specificity, diagnostic cut-off value, and accuracy of each classification were calculated. The overall agreement between classifications was tested by Bland-Altman, and agreement between single nodule analysis by different classifications by Weighted Cohen's Kappa. Results: In classifying a total of 457 nodules, MUT has the highest accuracy (AUC 0.808) and specificity (89%), followed by ATA and BTA, and finally by AACE/ACE-AME. ATA, BTA, and MUT are highly interchangeable. Considering agreement between single nodule analyses, ATA and BTA had the best (κ = 0.723); AACE/ACE-AME showed slight agreement with BTA (κ = 0.177) and MUT (κ = 0.183), and fair agreement with ATA (κ = 0.282); MUT had fair agreement with both ATA (κ = 0.291) and BTA (κ = 0.271). Conclusion: Classifications have an acceptable overall diagnostic accuracy, improved using a less rigid system that takes into consideration operator subjective impression

Improving splenic conservation rate after trauma by applying a protocol for non-operative management and follow-up: A propensity-score analysis

Background: There are shared guidelines about Non-Operative Management (NOM) of splenic injuries, but some unanswered questions remain. The aim of the present study is to establish the usefulness of a standardized protocol for management and follow-up of NOM patients with splenic injuries. Methods: Multicenter retrospective observational study including patients with major blunt trauma (ISS.15) with splenic injuries managed between January 1st 2014 and December 31st 2016 in two Italian I level Trauma Centers: one with a standardized management and follow-up protocol for NOM (Bufalini Hospital, Cesena, BH), and the other without it (ASST Papa Giovanni XXIII Hospital, Bergamo, PG23H). Comparison between patients' outcomes were performed and a propensity score model was calculated. Results: 47 patients managed in BH and 49 patients in PG23H were included. In BH, a higher proportion of patients was treated with NOM (72.3 % vs. 53.1 %, p ¼ 0.051). There was no difference in complication rate and mortality in patients treated with NOM in the two hospitals. A borderline significant trend to a higher NOM failure rate in PG23H was found (BH 0.0 % vs. PG23H 11.3 %, p ¼ 0.076). The total splenic conservation rate was significantly higher in BH (BH 72.3 % vs. PG23H 46.9 %, p ¼ 0.011). After the Propensity Score based matching, 72 patients were included and the total splenic conservation rate was significantly higher in BH (BH: 77.8 % vs. PG23H: 50.9 %, p ¼ 0.014). Conclusions: The application of a protocol for in-hospital management and follow-up for NOM of patients with splenic injury could decrease the NOM failure rate and improve splenic conservation rate

Diagnostic and Therapeutic Pathway in Diffuse Malignant Peritoneal Mesothelioma

Diffuse malignant peritoneal mesothelioma (DMPM) is a rare form of mesothelioma that carries a very poor prognosis. The 5-year overall survival is about 20% (±5.9). Survival is optimal for patients suitable for cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), with a median OS ranging from 34 to 92 months. However, selecting patients for surgery remains a complex task and requires a careful preoperative workup, rational analysis of prognostic profiles, and risk prediction models. Systemic chemotherapy could be offered: (1) in the adjuvant setting for high-risk patients; (2) for patients not eligible for CRS; and (3) for those with recurrent disease. It mainly includes the combination of Platin compound with Pemetrexed or immunotherapy. The biology of DMPM is still largely unknown. However, progress has been made on some fronts, such as telomere maintenance mechanisms, deregulation of apoptosis, tyrosine kinase pathways, and mutation of BRCA1-associated protein 1 (BAP1). Future perspectives should include translational research to improve our understanding of the disease biology to identify druggable targets. We should also clear the role of immune checkpoint inhibitors and investigate new locoregional technologies, such as pressurized intraperitoneal aerosol chemotherapy (PIPAC) or normothermic intraperitoneal chemotherapy (NIPEC)

Cytoreductive Surgery (CRS) and HIPEC for Advanced Ovarian Cancer with Peritoneal Metastases: Italian PSM Oncoteam Evidence and Study Purposes

Ovarian cancer is the eighth most common neoplasm in women with a high mortality rate mainly due to a marked propensity for peritoneal spread directly at diagnosis, as well as tumor recurrence after radical surgical treatment. Treatments for peritoneal metastases have to be designed from a patient’s perspective and focus on meaningful measures of benefit. Hyperthermic intraperitoneal chemotherapy (HIPEC), a strategy combining maximal cytoreductive surgery with regional chemotherapy, has been proposed to treat advanced ovarian cancer. Preliminary results to date have shown promising results, with improved survival outcomes and tumor regression. As knowledge about the disease process increases, practice guidelines will continue to evolve. In this review, we have reported a broad overview of advanced ovarian cancer management, and an update of the current evidence. The future perspectives of the Italian Society of Surgical Oncology (SICO) are discussed conclusively

Peritoneal carcinomatosis

Several gastrointestinal and gynecological malignancies have the potential to disseminate and grow in the peritoneal cavity. The occurrence of peritoneal carcinomatosis (PC) has been shown to significantly decrease overall survival in patients with liver and/or extraperitoneal metastases from gastrointestinal cancer. During the last three decades, the understanding of the biology and pathways of dissemination of tumors with intraperitoneal spread, and the understanding of the protective function of the peritoneal barrier against tumoral seeding, has prompted the concept that PC is a loco-regional disease: in absence of other systemic metastases, multimodal approaches combining aggressive cytoreductive surgery, intraperitoneal hyperthermic chemotherapy and systemic chemotherapy have been proposed and are actually considered promising methods to improve loco-regional control of the disease, and ultimately to increase survival. The aim of this review article is to present the evidence on treatment of PC in different tumors, in order to provide patients with a proper surgical and multidisciplinary treatment focused on optimal control of their locoregional disease. (C) 2013 Baishideng Publishing Group Co., Limited. All rights reserved

T.E.A. Study: three-day ertapenem versus three-day Ampicillin-Sulbactam.

Background: Intra-abdominal infections are one of the most common infections encountered by a general surgeon. However, despite this prevalence, standardized guidelines outlining the proper use of antibiotic therapy are poorly defined due to a lack of clinical trials investigating the ideal duration of antibiotic treatment. The aim of this study is to compare the efficacy and safety of a three-day treatment regimen of Ampicillin-Sulbactam to that of a three-day regimen of Ertapenem in patients with localized peritonitis ranging from mild to moderate severity. Methods: This study is a prospective, multi-center, randomized investigation performed in the Department of General, Emergency, and Transplant Surgery of St. Orsola-Malpighi University Hospital in Bologna, Italy. Discrete data were analyzed using the Chi-squared and Fisher exact tests. Differences between the two study groups were considered statistically significant for p-values less than 0.05. Results: 71 patients were treated with Ertapenem and 71 patients were treated with Ampicillin-Sulbactam. The two groups were comparable in terms of age and gender as well as the site of abdominal infection. Post-operative infection was identified in 12 patients: 10 with wound infections and 2 with intra-abdominal infections. In the Ertapenem group, 69 of the 71 patients (97%) were treated successfully, while the therapy failed in 2 cases (3%). Therapy failures were more frequent in the Unasyn group, amounting to 10 of 71 cases (p = 0.03). Conclusion: According to these preliminary findings, the authors conclude that a three-day Ertapenem treatment regimen is the most effective antibiotic therapy for patients with localized intra-abdominal infections ranging from mild to moderate severity