La sindrome compartimentale addominale ed il ruolo della re-laparotomia decompressiva

Premessa. La Sindrome Compartimentale Addominale (ACS) è una complicanza la cui insorgenza è sempre più riconosciuta sia nei pazienti medici che in quelli chirurgici. La World Society of the Abdominal Compartment Syndrome definisce Ipertensione Intra-Addominale (IAH) la presenza di una Pressione Intra-Addominale (IAP) ≥ 12mmHg e definisce la ACS una condizione caratterizzata da una IAP ≥ 20mmHg (con o senza una pressione di perfusione addominale < 60 mmHg) associata alla disfunzione o al danneggiamento di uno o più organi non presenti precedentemente. La IAH contribuisce alla disfunzione d'organo nei pazienti con trauma addominale e sepsi e porta alla formazione di ACS. Obiettivo. In questo studio si è cercato di valutare la reale incidenza della sindrome compartimentale addominale nei pazienti sottoposti a laparotomie d’urgenza e si è valutato il ruolo della re-laparotomia decompressiva. Pazienti e metodi. Lo studio include 10 pazienti, 4 uomini e 6 donne con un'età media di 68 anni (range, 38-86), sottoposti a laparotomia dal gennaio 2007 al settembre 2008. In accordo alle indicazioni dettate dalla WSACS (World Society of the Abdominal Compartment Syndrome) abbiamo misurato la IAP in maniera indiretta attraverso l'uso di un catetere vescicale di Foley. Risultati. Dei 10 pazienti , in 8 la pressione intraaddominale rientrava nei valori compresi tra 8 mmHg e 20 mmHg e, non essendo stati riscontrati sintomi clinici significativi correlati all’aumento della IAP, non è stato necessario eseguire una re-laparotomia decompressiva. Nei 2 pazienti in cui la pressione intra-addominale era superiore ai 20 mmHg la sintomatologia era caratterizzata da tensione della parete addominale, instabilità emodinamica, oligo/anuria, modificazioni respiratorie e squilibrio acido-base per cui sono sati sottoposti a re-laparotomia decompressiva d’urgenza. Conclusioni. In base alla nostra esperienza ed ai risultati della letteratura riteniamo indispensabile il monitoraggio della pressione intraaddominale nei pazienti sottoposti a re-laparotomia addominale. Nelle re-laparotomie decompressive eseguite d’urgenza la sutura solo cutanea ha permesso una rapida chiusura dell’addome in pazienti instabili ed a rischio

Il linfonodo sentinella nei tumori del colon

Introduzione. I tumori maligni possono dare metastasi seguendo il sistema linfatico in modo sequenziale. In ogni catena linfatica al primo linfonodo che drena la regione dove si è sviluppato il tumore viene dato il nome di “linfonodo sentinella’’ (LS). Obiettivo dello studio. L’obiettivo principale del presente studio è la determinazione del valore predittivo della metodica del linfonodo sentinella nella stadiazione del cancro colico non metastatico. Pazienti e metodi. Abbiamo effettuato uno studio prospettico arruolando pazienti con adenocarcinoma del colon che soddisfacessero i seguenti criteri: - età minima di 18 anni; - stadiazione con colonoscopia, Rx torace, ecografia o TC addome completo per selezionare pazienti con adenocarcinoma del colon T2-T3 senza metastasi linfonodali ed epatiche; - rischio anestesiologico ASA 1-3; - consenso informato. A seguito della resezione colica con linfadenectomia è stata eseguita un’iniezione sottomucosa di colorante vitale (patent blue) che ha permesso di identificare il linfonodo sentinella. I linfonodi sono stati sottoposti ad esame istologico con ematossilina-eosina e successivamente con tecnica immunoistochimica. Risultati. Dal gennaio a dicembre 2008, 26 pazienti sono stati arruolati in questo studio prospettico. Di questi sono stati considerati elegibili per il nostro studio solamente 14 pazienti. L’esame con ematossilina - eosina dei linfonodi ha evidenziato: a) in 4 casi su 14 (28,57%) erano presenti metastasi sui linfonodi contenuti nel mesocolon, b) in 10 casi su 14 (71,42%) erano assenti metastasi sui linfonodi contenuti nel mesocolon. Nei casi in cui non erano presenti metastasi, all’esame con ematossilina-eosina, nei linfonodi del mesocolon è stato eseguito l’esame istologico dei linfonodi sentinella con tecnica immunoistochimica; in 2 casi è stata evidenziata la presenza di micrometastasi. In un caso sono state identificate linee aberranti di drenaggio mesenterico (skip metastasis); il linfonodo sentinella (negativo all’esame con ematossilina eosina) è stato studiato con tecnica immunoistochimica che non ha evidenziato la presenza di micrometastasi. Conclusioni. È possibile affermare che l’esame del linfonodo sentinella è fattibile con la metodica ex vivo. Nel 20% dei casi da noi studiati a livello dei LS sono presenti micrometastasi non evidenziate al classico esame con ematossilina-eosina. Lo studio dei linfonodi sentinella con sezioni multiseriate e tecniche immunoistochimiche consente un miglioramento della stadiazione patologica

Robotic pancreaticoduodenectomy in a case of duodenal gastrointestinal stromal tumor

BACKGROUND: Laparoscopic pancreaticoduodenectomy is rarely performed, and it has not been particularly successful due to its technical complexity. The objective of this study is to highlight how robotic surgery could improve a minimally invasive approach and to expose the usefulness of robotic surgery even in complex surgical procedures. CASE PRESENTATION: The surgical technique employed in our center to perform a pancreaticoduodenectomy, which was by means of the da Vinci™ robotic system in order to remove a duodenal gastrointestinal stromal tumor, is reported. CONCLUSIONS: Robotic technology has improved significantly over the traditional laparoscopic approach, representing an evolution of minimally invasive techniques, allowing procedures to be safely performed that are still considered to be scarcely feasible or reproducibl

Robotic distal pancreatectomy with or without preservation of spleen: a technical note

BACKGROUND: Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy. METHODS: In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy. RESULTS: In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years). CONCLUSIONS: RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially