Diversity and ethics in trauma and acute care surgery teams: results from an international survey

Background Investigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject. Methods The article employs an international questionnaire promoted by the World Society of Emergency Surgery. Results Through the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. Conclusions Our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures. Level of evidence Trauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception

Dosaggio intraoperatorio dell’ormone paratiroideo in chirurgia tiroidea: esperienza preliminare su 36 casi

Attraverso la revisione della nostra esperienza preliminare su 36 casi consecutivi di chirurgia tiroidea, abbiamo valutato se la determinazione intraoperatoria rapida del paratormone intatto (iPTH) sia un efficace fattore predittivo del rischio di ipocalcemia a confronto con il criterio comunemente usato, ovvero la concentrazione sierica di calcio in prima giornata post-operatoria, al fine di individuare i pazienti a rischio di ipocalcemia sintomatica e selezionare quelli candidati ad una dimissione precoce. Allo stesso tempo abbiamo cercato di stabilire se la concentrazione intraoperatoria di iPTH possa fornire indicazioni oggettive sulla necessità di un autotrapianto di paratiroide durante tiroidectomia, sopperendo pertanto alla inadeguatezza della sola valutazione macroscopica della vitalità del tessuto paratiroideo. English version Through the analysis of our preliminary experience on 36 consecutive cases of thyroid surgery, we assessed the feasibility of the rapid intraoperative assay of the intact parathyroid hormone (iPTH) as predictive risk factor of hypocalcemia versus seric calcium level on the first post-operative day to select the patients eligible to an early discharge. Furthemore, we managed to determine if iPTH level during thyroid surgery could point out the cases in which parathyroid autotransplantantion is necessary, as the macroscopic evaluation of the parathyroid gland's viability is inadequate

Minimally invasive video-assisted thyroidectomy: Ascending the learning curve

Minimally invasive video-assisted thyroidectomy (MIVAT) is a technically demanding procedure and requires a surgical team skilled in both endocrine and endoscopic surgery. The aim of this report is to point out some aspects of the learning curve of the video-assisted thyroid surgery, through the analysis of our preliminary series of procedures

Il ruolo attuale della esplorazione bilaterale del collo nel trattamento dell’iperparatiroidismo primario

La chirurgia è l'unico trattamento realmente curativo per l'iperparatiroidismo primario (pHPT). Per tutti i pazienti con pHPT biochimicamente documentato c?è indicazione all'intervento, poiché anche coloro apparentemente asintomatici hanno dei disturbi lievi e progressivi che beneficiano del trattamento chirurgico. Da quando Felix Mandl nel 1925 realizzò con successo la prima esplorazione bilaterale del collo (BNE) per l?identificazione di tutte e quattro le paratiroidi, essa è rimasta per anni il tempo obbligato nella chirurgia del pHPT. Poiché più dell?80% dei casi di pHPT è dovuto ad un adenoma paratiroideo singolo, a partire dagli anni Novanta molti si sono interrogati sulla utilità della BNE e hanno proposto, in alternativa, approcci diretti unilaterali, definiti come paratiroidectomie mini-invasive (MIP). In questo lavoro si intende pertanto chiarire quale sia attualmente il ruolo della chirurgia tradizionale (BNE) nel trattamento dell'iperparatiroidismo primitivo

La stenosi cicatriziale benigna dell’anastomosi colorettale: considerazioni su due casi di nostra osservazione

Nel corso del trattamento chirurgico di due pazienti affetti da ste - nosi benigna dell’anastomosi colorettale, gli Autori hanno osservato la concomitanza di tenaci aderenze del tratto anastomotico al sacro. Tale evenienza, secondo gli Autori, potrebbe costituire una delle cause di fal - limento e di maggior rischio di perforazione in corso di trattamento mediante le diverse terapie endoscopiche che, nel loro insieme, sono pur sempre da considerarsi il gold standard nella terapia delle stenosi ana - stomotiche benigne. Alla luce di tali osservazioni, gli Autori sviluppano il razionale della loro ipotesi fisiopatologica, anche in funzione della ricerca di una procedura diagnostica capace di mettere in evidenza la presenza di una tenace aderenza con strutture solide nel corso della valutazione preope - ratoria. Se ulteriori studi orientati in questo senso portassero ad un risultato soddisfacente, ciò costituirebbe un ulteriore complemento per la scelta dell’approccio terapeutico più idoneo della stenosi benigna post-anastomotica

Laparoscopic right colectomy: Miles away or just around the corner?

Background: Despite the drive toward centralization of surgery in high-volume centers, the majority of colectomies are still performed by low- or medium-volume surgeons. Materials and Methods: A modification of the technique of laparoscopic right colectomy (LRC) originally described by Young-Fadok and Nelson was developed. The key points of that technique were maintained, but a different port-site layout and a counterclockwise approach were adopted, to warrant better trocar triangulation, to reduce the need of right colon manipulation and to avoid dissection along false planes. This modified technique was applied in 82 patients by 16 surgeons with no previous experience in LRC. Results: Average operative time was 125 ± 35 min. Conversion occurred in 10 cases (12.2%). Grade III postoperative complications occurred in 3 patients (3.6%). No postoperative mortality was observed. Average number of lymph nodes retrieved was 19 ± 6. Average length of stay was 7 ± 4 days. Conclusion: Providing low-volume surgeons with simplified and easy-to-learn surgical techniques could improve outcomes and lead to an increased use of laparoscopy

Laparoscopic HIPEC: A bridge between open and closed-techniques

Hyperthermic intraperitoneal chemotherapy (HIPEC) is currently delivered after cytoreductive surgery in patients with several kinds of peritoneal surface malignancies. Different methods for delivering HIPEC have been proposed all of them being variations between two modalities: the open technique and the closed technique. The open technique assures optimal distribution of heat and cytotoxic solution, with the disadvantage of heat loss and leakage of cytotoxic drugs. The closed technique prevents heat loss and drug spillage, increases drug penetration, but does not warrant homogeneous distribution of the perfusion fluid. A novel procedure that combines the advantages of the two techniques by means of laparoscopy is herein presented