Spectacular Retroperitoneal Impalement

A 47-year-old woman presented with a history of an accidental fall against a glass door at home, causing a 15 cm-wide wound on the right gluteal region and hematuria. General health was good: blood pressure115/70 mmHg with a heart rate of 100 beats/min; red cell count 4.460 x103/100 mL; hemoglobin concentration 10 g/100 ml; and hematocrit 31% . Computed tomography of the thorax and abdomen (Figure) showed the presence of a foreign body penetrating the right gluteal region and extending along the retroperitoneum. The object had passed across the entire longitudinal diameter of the right kidney. A concomitant retroperitoneal hematoma in the right perirenal space and pelvis was present. At emergency laparotomy a 25cm piece of glass was extracted from the gluteal wound after right nefrectomy and suture of a 2 cm laceration of the suprarenal inferior vena cava. The postoperative course was uneventful. Impalement injuries are rare and may occur either as a result of fall or collision of the human body against an immobile object or by means of a mobile object penetrating a stationary subject. They often pose particular challenges in surgical management. Mortality for penetrating abdominal vena cava injury is 36%-66%. Admission hypotension, suprarenal vena cava injuries and association with other visceral and/or other major vascular injuries are predictive of mortality

Sympathetic Control of Circulation in Hypertension and Congestive Heart Failure

Adrenergic overactivity is a common hallmark of both essential hypertension and congestive heart failure. Indirect and direct measures of sympathetic function have clearly shown that sympathetic activation characterizes essential hypertension. This adrenergic overactivity appears to be related to the severity of the hypertensive state, being detectable in its early stages and showing a progressive increase with the severity of the disease. Essential hypertension is also associated with an impaired baroreflex control of vagal activity, whereas baroreceptor modulation of sympathetic nerve traffic remains unaltered, although undergoing a resetting phenomenon. In contrast, secondary hypertension is not associated with an increased adrenergic activity, thus suggesting that an enhancement in efferent sympathetic outflow is a peculiar feature of essential hypertension. Congestive heart failure is a condition also characterized by sympathetic activation, whose degree is proportional to the clinical severity of the disease. This is paralleled by an impairment in arterial baroreceptor modulation of both vagal and sympathetic activity, thus suggesting that the adrenergic overactivity in congestive heart failure is triggered by a reduced afferent restraint on the vasomotor centre. Chronic angiotensin-converting enzyme inhibition reduces the degree of both sympathetic activation and baroreflex dysfunction occurring in heart failure patients, a finding which documents that the neurohumoral abnormalities can be at least partially reversed by pharmacologic treatment

A possible cause of misdiagnosis in tumors of the axilla: schwannoma of the brachial plexus

The Authors report a rare case of a 57 years old man affected by a left radial nerve schwannoma that occurred as an asymptomatic lesion of the axilla. At clinical examination the lump was undistinguishable from the most common axillary lymphadenopathy. A lymphoadenopathy was erroneously diagnosed with ultrasonography (US). This mistake was due to the low specificity of the instrumental methodology and to the rarity of an asymptomatic schwannoma of the infraclavicular brachial plexus. The neoplasia was excised without using the microscope. In the early post-operative follow up, a “falling” attitude of the wirst, the hand and the fingers appeared, peculiar for a lesion of the radial nerve. Furthermore a hypoaesthesia of the skin of first finger and of the first interosseus space was associated. The sensitive and motor electromyography showed a radial nerve suffering. The “stupor” of the nerve trunk was treated with steroid therapy for 7 days and the patient underwent to some series of neuro-rehabilitative physical therapy for 12 weeks. The postoperative total body CT, showed that the lesion was unique: therefore it was possible to exclude the diagnosis of neurofibromatosis. After 28 months electromyography and axillary US were performed showing the complete resolution of the motor and sensitive deficit and the absence of local recurrence

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

Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids

PURPOSE: This study was designed to assess the long-term results of stapled hemorrhoidopexy in 291 patients with Grade III and Grade IV hemorrhoids after a minimum follow-up of five years. METHODS: Records of patients submitted to stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids between January 1999 and December 2002 were retrospectively analyzed. Long-term outcome was evaluated with a standardized questionnaire and an office visit, including anorectal examination and rigid proctoscopy. RESULTS: A total of 291 patients with Grade III (57.4 percent) and Grade IV (42.6 percent) hemorrhoids were evaluated. Intraoperative (20.3 percent) and postoperative (4.8 percent) bleeding was the most frequent complication. The questionnaire was submitted to all patients at a median follow-up of 73 (range 60-93) months. There were no symptoms related to hemorrhoids in 65.3 percent of patients, moderate symptoms in 25.4 percent of patients, and severe symptoms in 9.3 percent of patients. Fifty-three (18.2 percent) patients had recurrence. Reoperation was necessary in 21 (7.2 percent) patients (4 in Grade III hemorrhoids and 17 in Grade IV hemorrhoids; P < 0.001), with no recurrent symptoms and/or prolapse. Patient satisfaction for operation was 89.7 percent. CONCLUSIONS: Stapled hemorrhoidopexy is a safe and effective treatment for Grade III and Grade IV hemorrhoids. Recurrence requiring reoperation was higher in Grade IV hemorrhoids than in Grade III hemorrhoids

Laparoscopic correction of enterocele associated to stapled transanal rectal resection for obstructed defecation syndrome

Background and aims: We report our experience of concomitant laparoscopic treatment for enterocele and stapled transanal rectal resection (STARR) for rectocele and/or rectal prolapse in patients with complex obstructed defecation syndrome (ODS). Patients and methods: From June 2005 to June 2007, we submitted 20 patients with ODS due to rectal prolapse and/or rectocele, combined with stable enterocele, to STARR and laparoscopic correction of the enterocele. Preoperative assessment included symptom evaluation with standardized questionnaires, clinical examination, colonoscopy, proctoscopy, anal sphincter ultrasonography, video-defecography with synchronous opacification of the ileal loops in all patients and colpography in female patients, and anorectal manometry. Follow-up was performed in the first, third, sixth, 12th, and 24th month after surgery. Results: Eighteen (90%) patients were submitted to both procedures, simultaneously. One patient, previously submitted to STARR, underwent laparoscopic treatment of the enterocele. Postoperative complications occurred in two (10%) patients: one case of postoperative rectal bleeding and one case of retropneumoperitoneum. Median (range) preoperative and postoperative Altomare's obstructed defecation score was ten (6-14) and two (0-14), respectively (p<0.001). Median (range) preoperative and postoperative quality of life score was 79 (39-109) and 109 (50-126), respectively (p<0.001). No symptom related to ODS was detected at 6-month follow-up (19 patients) and at 24-month follow-up (19 patients). Conclusion: The combination of STARR and laparoscopy provides a safe and effective method to treat ODS caused by rectal internal prolapse and/or rectocele combined with enterocele. © 2009 Springer-Verlag

Transient effects of carotid baroreflex stimulation via the neck chamber device on central venous pressure

Abstract We examined in 11 young subjects (age 29.7±3.6 years, mean±SEM) whether carotid baroreceptor stimulation via the neck chamber device may affect central venous pressure (CVP), thus potentially involving other reflexogenic areas in the examined responses. Application of progressively greater neck chamber subatmospheric pressures caused a progressive lengthening in RR interval, which reached a peak at the maximal value of negative neck chamber pressure applied. This was accompanied by significant and progressively greater reduction in CVP values when the data were calculated considering the early changes occurring within the first 2 seconds of the stimulus. There was a weak correlation between the early changes in CVP and the RR interval responses when all stimuli were pooled together (r = 0.32, P < .05). The results of the present study suggest that the neck chamber technique employed to assess carotid baroreceptor‐heart rate sensitivity can transiently affect via the CVP reduction cardiopulmonary receptors activity, which may participate at the integrated reflex responses