Metabolic Syndrome (MetS), Systemic Inflammatory Response Syndrome (SIRS), and Frailty: Is There any Room for Good Outcome in the Elderly Undergoing Emergency Surgery?

Background: Patients with MetS or SIRS experience higher rates of mortality and morbidity, across both cardiac and noncardiac surgery. Frailty assessment has acquired increasing importance in recent years as it predisposes elderly patients to a worse outcome. The aim of our study was to investigate the influence of MetS, SIRS, and with or without frailty on elderly patients undergoing emergency surgical procedures. Methods: We analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. The occurrence of MetS was identified using modified definition criteria used by the NCEP-ATP III Expert Panel: obesity, hypertension, diabetes, or if medication for high triglycerides or for low HDL cholesterol was taken. Systemic inflammatory response syndrome (SIRS) was evaluated according to the original consensus study (Sepsis-1). The frailty profile was investigated by the 5-modified Frailty Index (5-mFI) and the Emergency Surgery Frailty Index (EmSFI). Postoperative complications have been reported and categorized according to the Clavien–Dindo (C–D) classification system. Morbidity and mortality have been mainly considered as the 30-day standard period definition. Results: Of the 2,318 patients included in this study, 1,010 (43.6%) fulfilled the criteria for MetS (MetsG group). Both 5-Items score and EmsFI showed greater fragility in patients with MetS. All patients with MetS showed more frequently a CACI index greater than 6. The occurrence of SIRS was higher in MetSG. LOS was longer in patients with MetS (MetSG 11.4 ± 12 days vs. n-MetSG 10.5 ± 10.2 days, p = 0.046). MetSG has a significantly higher rate of morbidity (353 (35.%) vs. 385 (29.4%), p = 0.005). The mortality rate in patients with MetS (98/1010, 10%) was similar to that in patients without it (129/1308, 10%). Considering patients with MetS who developed SIRS and those who had frailty or both, the occurrence of these conditions was associated with a higher rate of morbidity and mortality. Conclusion: Impact of MetS and SIRS on elderly surgical patient outcomes has yet to be fully elucidated. The present study showed a 43.6% incidence of MetS in the elderly population. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role

Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach

BackgroundPerforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure.MethodsA retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared.ResultsA total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 +/- 37.2 vs LapA 88.47 +/- 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 +/- 12 vs LapA 10.3 +/- 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2.ConclusionsBased on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay

Emergency hernia repair in the elderly. multivariate analysis of morbidity and mortality from an Italian registry

Purpose The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed. Methods This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson's comorbidity index, P-POSSUM and CR-POSSUM were assessed. Results 259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson's comorbidity index >= 6, altered mental status, and need for laparotomy were associated with major complications and mortality Conclusion Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson's comorbidity index could be adopted to select patients for elective operation

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure

E-commerce ethics and its impact on buyer repurchase intentions and loyalty: an empirical study of small and medium Egyptian businesses

The theoretical understanding of e-commerce has received much attention over the years; however, relatively little focus has been directed towards e-commerce ethics, especially the SMEs B2B e-commerce aspect. Therefore, the purpose of this paper is to develop and empirically test a framework that explains the impact of SMEs B2B e-commerce ethics on buyer repurchase intentions and loyalty. Using SEM to analyse the data collected from a sample of SME e-commerce firms in Egypt, the results indicate that buyers’ perceptions of supplier ethics construct is composed of six dimensions (security, non-deception, fulfilment/reliability, service recovery, shared value, and communication) and strongly predictive of online buyer repurchase intentions and loyalty. Furthermore, our results also show that reliability/fulfilment and non-deception are the most effective relationship-building dimensions. In addition, relationship quality has a positive effect on buyer repurchase intentions and loyalty. The results offer important implications for B2B e-commerce and are likely to stimulate further research in the area of relationship marketing

Laparoscopic resection of splenic flexure colon cancer - a video vignette

Splenic flexure colon cancer is relatively rare. It accounts for 2%–5% of all colorectal cancers [1], and for this reason there is still no consensus about its surgical management. The controversy is mainly focused on the extent of the resection, about the surgical approach to be adopted and on the type of anastomosis to be performed. Different approaches have been proposed in the literature, varying from a right extended colectomy to a left super-extended resection, with or without splenectomy and distal pancreatectomy. We believe these are not necessary routinely except in cases of widespread lymph node metastasis and visceral involvement. The aim of this didactic video (Video S1) is to show how we perform totally laparoscopic resection of splenic flexure colon cancer, focusing on the key vascular steps but most of all on the lymph node dissection and feasibility of intracorporeal anastomosis. The wide variability of the surgical approach also arises from the fact that patients with tumours in this location have been excluded from randomized controlled trials because of the difficulty in deciding the appropriate operative procedure, as well as technical dif- ficulties with laparoscopic lymph node dissection. The lymphatic drainage at this site is variable, and the exact site of lymphatic dissection is uncertain. In their recent study, Watanabe and colleagues [2] proposed a lymph flow pattern evaluation in splenic flexure colon cancer using real-time indocyanine green fluorescence imaging. They concluded that in the case of the distal third of the transverse colon cancer a lymph node dissection of the left branch of the middle colic artery and the root of the inferior mesenteric vein should be performed; in the case of the first part of the descending colon cancer, one should perform lymph node dissection along the left colic artery and the root of the inferior mesenteric vein. Finally, in splenic flexure cancer, the lymph flow can run in various directions necessitating ligation of both the middle colic artery and left colic artery, at least in cases without widespread lymph node metastasis. It should be noted that, regardless of the type of technique and technology used, compliance with the correct oncological parameters is mandatory, and therefore there is need for clearance of tumour resection margins of 3–5 cm, isolation of the neoplasm using a ‘no-touch isolation technique’ and an adequate lymphadenectomy of at least 17 lymph nodes [3]. In conclusion, we believe lymph node dissection may be required depending on each individual case; however, it is quite difficult to determine this during surgery. An accurate preoperative study using real-time indocyanine green fluorescence imaging could be the future for a commonly accepted technique

Accidental injury of the Latissimus Dorsi flap pedicle during axillae dissection: types and reconstruction algorithm

The intra-operative latissimus dorsi (LD) pedicle damage during axillary lymph-node dissection by the general surgeon is a rare complication leading to flap failure and poor outcomes. The authors present their experience on this topic and develop a classification of the thoracodorsal (TD) pedicle injuries and reconstruction algorithm. Pedicle damage of LD occurred in five cases, three of which were experienced during immediate breast reconstruction and two observed in patients who underwent prior surgery. In two cases the thoracodorsal vein (TDV) was damaged in its proximal segment, thus end-to-end anastomosis was performed between distal stump of TDV and circumflex scapular vein (CSV). In one case the TDV required simple microsurgical repair while in other two cases the severe damage of vein and artery required more complex surgical strategies in attempt to salvage the flap. Four cases completely survived with one case of rippling phenomenon. One case had partial flap necrosis that required subtotal muscle resection. Based on these cases, the authors have developed a reconstruction algorithm in attempt to repair LD pedicle damage while preserving breast reconstruction. Taking into account its anatomical conformation, TD pedicle injuries are classified in four different types and available options are suggested for all of them according to the anatomical site and to the mechanism and timing of injury.The intra-operative latissimus dorsi (LD) pedicle damage during axillary lymph-node dissection by the general surgeon is a rare complication leading to flap failure and poor outcomes. The authors present their experience on this topic and develop a classification of the thoracodorsal (TD) pedicle injuries and reconstruction algorithm. Pedicle damage of LD occurred in five cases, three of which were experienced during immediate breast reconstruction and two observed in patients who underwent prior surgery. In two cases the thoracodorsal vein (TDV) was damaged in its proximal segment, thus end-to-end anastomosis was performed between distal stump of TDV and circumflex scapular vein (CSV). In one case the TDV required simple microsurgical repair while in other two cases the severe damage of vein and artery required more complex surgical strategies in attempt to salvage the flap. Four cases completely survived with one case of rippling phenomenon. One case had partial flap necrosis that r

Total Laparoscopic Pancreaticoduodenectomy with Venous Reconstruction for Pancreatic Head Cancer with Involvement of the Superior Mesenteric Vein-Portal Vein Confluence

Background: Laparoscopic pancreaticoduodenectomy with venous reconstruction is not commonly performed due to its technical challenges. In this video, we focus on the technical aspects for how to perform this procedure safely. Methods: In a 69-year-old female with jaundice and diarrhea, a computed tomography scan showed a mass in the head of the pancreas, with a 180-degree involvement of the superior mesenteric vein. Endoscopic retrograde cholangiopancreatography with stenting was performed together with endoscopic ultrasound and fine-needle aspiration. Biopsy showed well-differentiated adenocarcinoma. The patient underwent six cycles of neoadjuvant chemotherapy, with reduction of the vein involvement to 90 degrees. The mass invaded the right lateral aspect of the superior mesenteric vein–portal vein confluence. As a result, this portion of the vein was removed en bloc with the specimen. The vascular defect was repaired using two running sutures. Once the choledocojejunostomy and intussuscepted pancreatico-gastric anastomosis were completed, the specimen was removed via a small subxiphoid incision. Results: Operative time was 6 h and 30 min, blood loss was 50 mL, and hospital stay was 12 days. Histopathological examination was ypT3 N1 (1 of 18 lymph nodes was positive). All margins were negative. Conclusion: Laparoscopic pancreaticoduodenectomy with vascular reconstruction can be performed safely in selected cases of pancreatic head cancer with vein involvement. Advanced laparoscopic skills are necessary to complete such procedures safely