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

A Rare Case of Functioning Adrenocortical Oncocytoma Presenting as Cushing Syndrome

Functioningadrenocorticaloncocytomaisveryrareneoplasm.Itisusuallynonfunctionalandbenignandincidentallydetected. Generally,thesetumorsoriginateinthekidneys,thyroid,parathyroid,andsalivaryorpituitaryglands;theyhavealsobeenreported inothersitesincludingchoroidplexus,respiratorytract,andlarynx.Histologically,theyarecharacterizedbycellswitheosinophilic granularcytoplasmandnumerouspackedmitochondria.Wereportedacaseofa44-year-oldfemalewhopresentedwithCushing syndrome for hypersecretion of cortisol due to adrenocortical oncocytoma. Magnetic resonance of abdomen revealed a right adrenalmass.Laparoscopicadrenalectomywasperformedandthetumorwaspathologicallyconfirmedasbenignadrenocortical oncocytoma.Aftersurgicaltreatment,Cushing’ssyndrome resolved

Surgical management of non-parasitic hepatic cysts. A single center experience and a review of the literature

AIM: We present our experience in the laparoscopic management of the hepatic cysts (SHCs) and the polycystic liver disease (PCLD), and a literature review. MATERIAL AND METHODS: Between 2005 and 2018, laparoscopic deroofing was performed in 28 consecutive patients. There were 19 cases with SHCs and only 9 cases with PCLD (Gigot’s type I). CT scan was performed in all cases to assess the characteristics, dimensions, and exact position of the lesion. Surgery was planned for all patients because of evident and persistent symptomatology, RESULTS: We have analyzed operative time, surgical procedure, blood loss, hospital stay, complications, and medium follow- up period. All the patients underwent laparoscopic deroofing of the larger cysts and puncturing of the smaller cysts. The total morbidity recorded was 25% (7/28), 3 cases in the group of SHCs (16 %) and 4 cases in the PCLD one (44%) and was characterized of 3 cases of ascites through trocar insertion sites after removal of drainage tube and 4 case of pleural effusion. DISCUSSION: There were no significant group differences in term of length of hospital stay. The follow-up period (a mean of 24 months) confirmed that all the patients remained free of symptoms and relapse of the disease. Conclusion: The technical feasibility and the good short- and medium-term results made the laparoscopic approach the procedure of choice for the management of symptomatic liver cysts

Robotic voluminous paraesophageal hernia repair: a case report and review of the literature

BACKGROUND: The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative, but surgical treatment is recommended for refractory sliding esophageal hernia, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. Robotic surgery overcomes laparoscopic pitfalls by providing steady-state three-dimensional visualization, augmented dexterity with endo-wrist movements, and superior ergonomics for the surgeon. CASE PRESENTATION: To investigate robotic paraesophageal hernia repair, a literature search was conducted using PubMed with the following key words: mini invasive surgery, robotic surgery, hiatal hernia, and Nissen fundoplication. We present the case of a 44-year-old Italian woman with a 20-year history of gastroesophageal reflux disease refractory to medical treatment, who underwent robotic Nissen fundoplication. In our center, we use the da Vinci® Xi™ Surgical System, which is an advanced tool for minimally invasive surgery. CONCLUSIONS: Various reports published in the literature suggested that the robot-assisted approach was effective and was associated with very low postoperative morbidity and was accompanied by satisfactory symptomatic and anatomical radiological outcomes during a follow-up period. The robotic approach to paraesophageal repair is safe and effective with low complication rates. With increased experience, the operative time, length of stay, and complications decrease without compromising surgical principles

A recurrent epidermoid cyst of the spleen: report of a case and literature review

Background: Splenic cysts are rare disease. Epidermoid cysts of the spleen belong to the primary nonparasitic splenic cysts group. They are an unusual event in surgical practice. Usually, epidermoid cysts occur in children and young female. Most often, they are asymptomatic, but they may present with abdominal discomfort. Case presentation: We are reporting a rare case of a 23-year-old female came to our attention with history of intermittent pain and previously undergone two times to laparoscopic decapsulation of the cyst in others institutions. During hospitalization, serum and intracystic levels of tumor marker CA19-9 increased. Enhanced CT of the abdomen showed recurrent large cyst in the upper pole of the spleen with satellite nodules. Laparotomic total splenectomy was performed. Histopathological and immunoreactive examinations were executed, and they revealed stratified squamous epithelium on the inner surface of cystic wall, which was positive for EMA, CEA, and CA19-9. The diagnosis of epidermoid cyst was confirmed. Conclusions: Recently, the surgical approach is changing towards conservative treatments in order to save the spleen in young patients for immunological reasons. Sometimes, this target is not achievable. In such circumstances, like recurrent large cyst, anomalous anatomical relationship to the surrounding tissues, total splenectomy is safe and necessary

Robotic Cholecystectomy: Preliminary Experience and Future Perspectives.

Background: The main advantages of robotics in general surgery may be for advanced minimally invasive procedures. Unlike other specialties, formal fellowship training opportunities for robotic general surgery are few. As a result, most surgeons currently develop robotic skills in practice and robotic cholecystectomy represents the operation of choice for general surgeons to acquire clinical da Vinci experience. Methods: Before performing advanced robotic procedures, 2 surgeons completed the Intuitive Surgical da Vinci-Xi training course and agreed to work together on all procedures. We performed a retrospective review of our pilot series of robotic cholecystectomies and compared them with contemporaneous laparoscopic controls. The primary outcome was safety, and the Secondary outcome was learning curve. Results: There were 10 procedures in the robotic arm and 15 in the laparoscopic Arm. One complication (port-site hernia) occurred in the laparoscopic arm, and only one robotic patient (surgical wound infection) experienced a complication. The mean time required to perform robotic cholecystectomy was significantly longer than laparoscopic surgery (70 v. 40 min, p < 0.001) due to the docking of da Vinci system. The mean time to clear the operating room was significantly longer for robotic procedures (20 v. 11 min, p = 0.015). Regarding learning curve, the mean operative time needed for the first 3 robotic procedures was longer than for the last 3 (80 v. 66 min, p<0,05). Conclusion: Our experience can suggest that robotic cholecystectomy is one means by which general surgeons may gain confidence in performing advanced robotic procedures and it confirms the reliability of this training course