Damage Control Surgery nel trauma addominale: esperienza e risultati in dieci anni di attività

Introduzione: nel corso degli ultimi vent’anni si è assistito ad un significativo aumento del numero di pazienti con lesioni traumatiche estremamente gravi che giungono, ancora in vita, all’osservazione in ambito ospedaliero. E’ frequente riscontrare in questi pazienti una combinazione di alterazioni omeostatiche quali un grave stato di acidosi, ipotermia e coagulopatia (“triade killer”) che sono in grado di portare al fallimento l’intervento chirurgico stesso. Il termine “Damage Control” sta ad indicare una strategia chirurgica relativamente recente, articolata in più fasi, sviluppatasi con l’obiettivo di ridurre gli elevati tassi di mortalità riscontrati nei pazienti con traumi severi effettuando manovre chirurgiche minime, nell’ottica di ridurre il tempo operatorio del primo intervento, lasciando lo spazio alle manovre rianimatorie in Unità di Terapia Intensiva. Scopo dello studio: scopo del nostro studio è stato quello di analizzare i risultati ottenuti dalla nostra Unità Operativa di Chirurgia D’Urgenza in 10 anni di attività con l’applicazione del Damage Control Surgery nel grave trauma addominale. Materiali e metodi: nel periodo compreso tra il febbraio 2003 ed il febbraio 2013, sono giunti alla nostra osservazione, presso la U.O. Chirurgia Generale e d’Urgenza, circa 1190 pazienti traumatizzati dei quali in 558 casi è stato necessario un intervento chirurgico per il trattamento delle lesioni riportate. Di questi 558 pazienti sottoposti a chirurgia in 34 pazienti (6 %) le lesioni riportate erano talmente gravi, determinanti la comparsa di coagulopatia, acidosi e ipotermia ovvero della triade killer, da richiedere un trattamento di Damage Control Surgery. 24 erano maschi e 10 erano femmine con età media di 49,78 anni. L’Injury Severity Score è risultato di 30,12. In tutti i casi si è trattato di politraumi con prevalenza di trauma addominale in 11 casi (32,2 %), addominale e cranico in 7 casi (20,6 %), addominale e toracico in 5 pazienti (14,7 %), addominale e scheletrico in 6 casi (17,6 %), addominale, cranico e toracico in 1 paziente (2,9 %), addominale, toracico, cranico e scheletrico in 3 pazienti (8,8 %) e cranico e scheletrico in 1 caso (2,9 %). La Damage Control Surgery è stata effettuata in 27 casi (79,4 %) per il controllo dell’emorragia; nei restanti casi in 3 pazienti (8,8 %) per la comparsa di una sindrome compartimentale, in 1 caso (2,9 %) per la prevenzione della sindrome compartimentale, in 1 caso (2,9 %) per la presenza di peritonite stercoracea da perforazione intestinale e in 2 casi (5,8 %) per l’instaurarsi di una pancreatite necrotico emorragica post-traumatica. Risultati: il tasso di mortalità è stato del 67,6 % (23 pazienti). La durata media di degenza per i pazienti dimessi è stata di 25 gironi. Per quanto concerne la morbilità essa ha presentano un tasso complessivo del 38,5 %. Abbiamo peraltro riscontrato un’ incidenza di laparoceli a distanza dalla chiusura definitiva della parete addominale pari al 27 % . Conclusioni: dai dati riportati nei principali studi in letteratura emerge come un intervento chirurgico secondo il principio della Demage Control Surgery, con risultati minimi ma utili e soprattutto rapidi, lasciando precocemente lo spazio alle manovre rianimatorie in Unità di Terapia Intensiva per la prevenzione ed il trattamento della “triade Killer”, rappresenti l’approccio migliore dimostrandone l’indubbia utilità nel ridurre il tasso di mortalità post-operatoria. È certamente importante in un prossimo futuro uniformare le indicazioni per un appropriato utilizzo della DCS facendola così entrare nella pratica comune dei chirurghi che si occupano di urgenze traumatiche non come scelta “drammatica” ma come programma terapeutico articolato tra rianimatore e chirurg

Laparoscopic bariatric surgery is safe during phase 2-3 of COVID-19 pandemic in Italy: A multicenter, prospective, observational study

Background: Sars-Cov-2 epidemic in Italy caused one of the greatest 2020 European outbreaks, with suspension of elective bariatric/metabolic surgery (BMS). From May 2020 a significant decline of the epidemic has been observed (phase 2); National Health Service protocols permitted elective BMS' resumption. A new, more severe COVID-19 surge, the "second wave", started on October 2020 (phase 3).Aim: The primary end point was to analyze the outcomes of any Sars-Cov-2 infection and related morbidity/mortality within 30 POD after laparoscopic BMS during phase 2-3; secondary end points were readmission and reoperation rates.Methods: Study design prospective, multicenter, observational.Setting: Eight Italian high-volume bariatric centers. All patients undergoing BMS from July 2020 through January 2021 were enrolled according to the following criteria: no Sars-Cov-2 infection; primary procedures; no concomitant procedure; age > 18 < 60 years; compensated comorbidities; informed consent including COVID-19 addendum; adherence to specific admission, in-hospital and follow-up protocols. Data were collected in a prospective database. Patients undergone BMS during July-December 2019 were considered a control group.Results: 1258 patients were enrolled and compared with 1451 operated on in 2019, with no differences for demographics, complications, readmission, and reintervention rates. Eight patients (0.6%) tested positive for Sars-Cov-2 infection after discharge, as well as and 15 healthcare professionals, with no related complications or mortality.Conclusions: Introduction of strict COVID-19 protocols concerning the protection of patients and health-care professionals guaranteed a safe resumption of elective BMS in Italy. The safety profile was, also, maintained during the second wave of outbreak, thus allowing access to a cure for the obese population. (C) 2021 Elsevier B.V. All rights reserved

Targeting SIRT1 Rescues Age- and Obesity-Induced Microvascular Dysfunction in Ex Vivo Human Vessels

ackground: Experimental evidence suggests a key role of SIRT1 (silent information regulator 1) in age- and metabolic-related vascular dysfunction. Whether these effects hold true in the human microvasculature is unknown. We aimed to investigate the SIRT1 role in very early stages of age- and obesity-related microvascular dysfunction in humans. Methods: Ninety-five subjects undergoing elective laparoscopic surgery were recruited and stratified based on their body mass index status (above or below 30 kg/m2) and age (above or below 40 years) in 4 groups: Young Nonobese, Young Obese, Old Nonobese, and Old Obese. We measured small resistance arteries' endothelial function by pressurized micromyography before and after incubation with a SIRT1 agonist (SRT1720) and a mitochondria reactive oxygen species (mtROS) scavenger (MitoTEMPO). We assessed vascular levels of mtROS and nitric oxide availability by confocal microscopy and vascular gene expression of SIRT1 and mitochondrial proteins by qPCR. Chromatin immunoprecipitation assay was employed to investigate SIRT1-dependent epigenetic regulation of mitochondrial proteins. Results: Compared with Young Nonobese, obese and older patients showed lower vascular expression of SIRT1 and antioxidant proteins (FOXO3 [forkhead box protein O3] and SOD2) and higher expression of pro-oxidant and aging mitochondria proteins p66Shc and Arginase II. Old Obese, Young Obese and Old Nonobese groups endothelial dysfunction was rescued by SRT1720. The restoration was comparable to the one obtained with mitoTEMPO. These effects were explained by SIRT1-dependent chromatin changes leading to reduced p66Shc expression and upregulation of proteins involved in mitochondria respiratory chain. Conclusions: SIRT1 is a novel central modulator of the earliest microvascular damage induced by age and obesity. Through a complex epigenetic control mainly involving p66Shc and Arginase II, it influences mtROS levels, NO availability, and the expression of proteins of the mitochondria respiratory chain. Therapeutic modulation of SIRT1 restores obesity- and age-related endothelial dysfunction. Early targeting of SIRT1 might represent a crucial strategy to prevent age- and obesity-related microvascular dysfunction. Keywords: aging; endothelial cells; microcirculation; mitochondria; obesity; sirtuin

Is elastography actually useful in the presurgical selection of thyroid nodules with indeterminate cytology?

BACKGROUND: Although fine-needle aspiration cytology remains the mainstay of the preoperative workup of thyroid nodules, those with follicular proliferation still represent a diagnostic challenge. Real-time elastography (RTE) estimates the stiffness/elasticity of lesions and is regarded as a promising technique for the presurgical selection of thyroid nodules (including those with indeterminate cytology). AIM:Our aim was to verify the potential role of RTE in the presurgical diagnosis of cancer in a large cohort of consecutive patients with follicular thyroid nodules. PATIENTS AND METHODS: One hundred two patients were submitted to conventional ultrasonography and RTE evaluation before being operated on for thyroid nodule with indeterminate cytology (54% single nodules). Tissue stiffness on RTE was scored from 1 (greatest elasticity) to 4 (no elasticity). RESULTS: At conventional ultrasonography examination, the nodules (median diameter 2.2 cm) were solid (cystic areas < 10%); microcalcifications were detected in 56% of them and a hypoechoic pattern in 64%. Elasticity was high in eight cases only (score 1-2) although low in 94 (score 3-4). Cancer was diagnosed in 36 nodules (35%), being associated with microcalcifications (P < 0.0001) and inversely related to nodule diameter (P < 0.01). Malignancy was detected in 50% of the nodules with RTE score 1-2 and in 34% of those with score 3-4. Therefore, either the positive (34%) or the negative predictive value (50%) was clinically negligible. CONCLUSIONS: The current study does not confirm the recently reported usefulness of RTE in presurgical selection of nodules with indeterminate cytology and suggest the need for quantitative analytical assessment of nodule stiffness to improve RTE efficacy