Acute appendicitis in overweight patients: the role of preoperative imaging.

BACKGROUND: The diagnosis of acute appendicitis in overweight patients is challenging due to the limited value of the clinical examination. The benefits of ultrasonography and abdominal CT have been studied in the general population, but there is limited data regarding their use in overweight and obese patients with suspected appendicitis. This study analyzes the role of preoperative radiological modalities in overweight patients with suspected appendicitis. METHODS: Retrospective analysis of a prospectively acquired database including 705 patients operated for suspected acute appendicitis. Patients were divided into two groups according to their BMI (BMI ≥25 kg/m(2) (n = 242) and BMI <25 kg/m(2) (n = 463)). The use of preoperative radiological modalities, laboratory findings and outcome parameters were analyzed. RESULTS: Ultrasonography was the preferred radiological assessment in our cohort (68 % in BMI <25 kg/m and 52.4 % in BMI ≥25 kg/m(2)). However, it was non-conclusive in 42 % of overweight as compared to 6 % in patients with a BMI < 25 (p < 0.0001). This difference was particularly obvious between female patients (8 % of non-conclusive US for BMI <25 kg/m(2) vs 52 % for BMI ≥25 kg/m(2), p < 0.0001). Significantly more CT scans were performed in overweight patients (37 % vs. 20 %; p <0.0001). The accuracy of CT did not differ according to BMI (85 % vs. 88 %; p = 0.76). Preoperative radiological imaging did not significantly delay surgery. Laparoscopy was the preferred approach for both groups (98.2 % vs 98.7 %, P = 0.86) with an overall conversion rate of 4 %. The overall rate of negative appendectomy was 10 %. CONCLUSIONS: The role of ultrasonography in patients with BMI ≥25 kg/m(2) with suspected acute appendicitis is questionable due to its high rate of non-conclusive findings. Therefore, abdominal CT scans should be preferred to investigate suspected appendicitis in overweight patient if clinical findings are not conclusive

Surgical site infections after pancreatic surgery in the era of enhanced recovery protocols.

Few data exist on risk factors (RF) for surgical site infections (SSI) among patients treated in an enhanced recovery after surgery (ERAS) pathway. This study aimed to assess RF for SSI after pancreas surgery in a non-ERAS group and an ERAS cohort.An exploratory retrospective analysis of all pancreas surgeries prospectively collected (01/2000-12/2015) was performed. RF for SSI were calculated using uni- and multivariable binary logistic regressions in non-ERAS and ERAS patients.Pancreas surgery was performed in 549 patients. Among them, 144 presented a SSI (26%). In the non-ERAS group (n = 377), SSI incidence was 27% (99/377), and RF for SSI were male gender and preoperative biliary stenting. Since 2012, 172 consecutive patients were managed within an ERAS pathway. Forty-five patients (26%) had SSI. On multivariable analysis no RF for SSI in the ERAS cohort was found. In the ERAS group, patients with a pathway compliance ≤70% had higher occurrence of SSI (30/45 = 67% vs. 7/127 = 6%, p < 0.001) and patients with and without SSI had similar median overall compliances (77%, IQR 71-80 vs. 80%, IQR 73-83, p = 0.097).In the non-ERAS cohort, male gender and preoperative biliary stenting were RF for SSI, whereas in the ERAS group no RF for SSI was found. In an ERAS pathway, having an overall compliance >70% might diminish the SSI rate

Impact of Variations in the Nursing Care Supply-Demand Ratio on Postoperative Outcomes and Costs.

Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio. Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need (estimated PRN) and the actual care they received (real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics. The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes (P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group (P = 0.633). A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run

Spontaneous non-traumatic splenic artery aneurysm rupture: a case report and review of the literature.

The current case report is about spontaneous non-traumatic rupture of a splenic artery aneurysm (SAA) in a 53-year-old woman with no particular medical history. An emergent laparotomy with splenectomy was required, unfortunately without success as the patient died. SAA is the most common visceral artery aneurysm. Most of SAA remain asymptomatic and are discovered incidentally on imaging. The overall risk of rupture increases with the size of SAA, especially when above 2 cm. Initial presentation of SAA has been associated with acute rupture and hemodynamic instability leading to substantial perioperative morbidity and mortality

Local control and short-term outcomes after video-assisted thoracoscopic surgery segmentectomy versus lobectomy for pT1c pN0 non-small-cell lung cancer.

The aim of this study was to compare short-term outcomes and local control in pT1c pN0 non-small-cell lung cancer that were intentionally treated by video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy. Multicentre retrospective study of consecutive patients undergoing VATS lobectomy (VL) or VATS segmentectomy (VS) for pT1c pN0 non-small-cell lung cancer from January 2014 to October 2021. Patients' characteristics, postoperative outcomes and survival were compared. In total, 162 patients underwent VL (n = 81) or VS (n = 81). Except for age [median (interquartile range) 68 (60-73) vs 71 (65-76) years; P = 0.034] and past medical history of cancer (32% vs 48%; P = 0.038), there was no difference between VL and VS in terms of demographics and comorbidities. Overall 30-day postoperative morbidity was similar in both groups (34% vs 30%; P = 0.5). The median time for chest tube removal [3 (1-5) vs 2 (1-3) days; P = 0.002] and median postoperative length of stay [6 (4-9) vs 5 (3-7) days; P = 0.039] were in favour of the VS group. Significantly larger tumour size (mean ± standard deviation 25.1 ± 3.1 vs 23.6 ± 3.1 mm; P = 0.001) and an increased number of lymph nodes removal [median (interquartile range) 14 (9-23) vs 10 (6-15); P < 0.001] were found in the VL group. During the follow-up [median (interquartile range) 31 (14-48) months], no statistical difference was found for local and distant recurrence in VL groups (12.3%) and VS group (6.1%) (P = 0.183). Overall survival (80% vs 80%) was comparable between both groups (P = 0.166). Despite a short follow-up, our preliminary data shows that local control is comparable for VL and VS

Uniportal ligamentum-based approach to posterolateral segments 9 and 10.

Uniportal VATS posterolateral segmentectomy (S9 and S10) can be an option for treatment of early-stage lung cancer or in cases of central metastases. Lower lobe segmentectomy is challenging because the pyramidal shape of the basilar segments makes the identification of the intersegmental plane difficult, and the segmental arterial and venous supply is highly variable. Although identifying the segmental arterial branches is easier with a fissure-based technique, the ligamentum-based approach has emerged as a valid and safe alternative in cases of fused fissure. This video tutorial illustrates the technical aspects of the uniportal VATS ligamentum-based S9+10 segmentectomy of the right lower lobe

Recurrent complex incisional hernia repair by enhanced-view totally extraperitoneal (eTEP) technique.

Treatment of large recurrent abdominal wall hernias remains a surgical challenge. The enhanced-view totally extraperitoneal (eTEP) approach is an emerging technique used to treat hernias with minimally invasive procedure. This article illustrates a step-by-step eTEP approach, used in a complex recurrent hernia repair. A 56-years-old male had a previous epigastric hernia repair with an intraperitoneal onlay mesh (IPOM) technique in 2018. Six months later, he presented a recurrent epigastric protrusion and a new painful ombilical hernia, objectified on the CT-scan. Four suprapubic trocars were used to dissect the preperitoneal space below the arcuate line and the retromuscular spaces on both sides. On the mid-line, posterior fascia was divided and both hernia sacs were fully dissected. Both anterior and posterior sheats were closed with self-locking non-absorbable threads before placing a Polypropylene self-gripping mesh. The follow-up was uneventful, and the patient was discharged on day 2. This case report illustrates that eTEP technique can be used safely and effectively to treat complex recurrent ventral hernias even with a mesh already in place. The potential advantages of the eTEP procedure are multiple, such as improving mobility and esthetic results, reducing pain and shorting hospital length of stay

Performance of prolonged air leak scoring systems in patients undergoing video-assisted thoracoscopic surgery segmentectomy.

We assessed the accuracy of 3 validated lobectomy scoring systems to predict prolonged air leak (PAL) in patients undergoing video-assisted thoracoscopic surgery (VATS) segmentectomy. We reviewed all consecutive patients who had a VATS segmentectomy between January 2016 and October 2020. We determined PALs on postoperative day 5. These findings were correlated with the calculated Brunelli (gender, age, body mass index [BMI], forced expiratory volume in 1 s < 80 and pleural adhesion), Epithor (gender, location, dyspnoea score, BMI, type of resection and pleural adhesion) and European Society of Thoracic Surgeons (ESTS) (gender, BMI and forced expiratory volume in 1 s) scores of each patient. A total of 453 patients (mean age: 66.5 years, female/male sex ratio: 226/227) underwent a VATS segmentectomy for malignant (n = 400) and non-malignant (n = 53) disease. Postoperative cardiopulmonary complications and in-hospital mortality rates were 19.6% and 0.4%, respectively. Median chest tube drainage duration and hospital stay were 2 (interquartile range: 1-4) and 4 (interquartile range: 3-7) days, respectively. On day 5, the prevalence of PAL was 14.1%. The ESTS, Brunelli and Epithor scores for the treated population were, respectively, class A (6.8%), class B (3.2%), class C (10.8%) and class D (28.2%); very low and low (0%), moderate (5%), high (6.3%) and very high (21%); and class A (7%), class B (13.2%), class C (24%) and class D (27.8%). All scores correlated with PAL (p ≤ 0.001). The areas under the receiver operating characteristic (ROC) curve were 0.686, 0.680 and 0.644, respectively. All 3 scoring systems were correlated with PAL > 5 days following the VATS segmentectomies. ESTS scores seem easier to introduce in clinical practice, but validation by a multicentre cohort is mandatory

Immune cell infiltration in colonic cancer: correlation between biopsy and surgical specimens.

Infiltration of CD3+ and CD8+ T cells in tumour biopsies of patients with colonic cancer correlated positively with CD3+ and CD8+ T cell infiltration in matched tumour surgical specimens. This opens new perspectives in the potential of tumour biopsies for prognosis and treatment decisions

Neutrophils suppress tumor-infiltrating T cells in colon cancer via matrix metalloproteinase-mediated activation of TGFβ.

High T-cell infiltration in colorectal cancer (CRC) correlates with a favorable disease outcome and immunotherapy response. This, however, is only observed in a small subset of CRC patients. A better understanding of the factors influencing tumor T-cell responses in CRC could inspire novel therapeutic approaches to achieve broader immunotherapy responsiveness. Here, we investigated T cell-suppressive properties of different myeloid cell types in an inducible colon tumor mouse model. The most potent inhibitors of T-cell activity were tumor-infiltrating neutrophils. Gene expression analysis and combined in vitro and in vivo tests indicated that T-cell suppression is mediated by neutrophil-secreted metalloproteinase activation of latent TGFβ. CRC patient neutrophils similarly suppressed T cells via TGFβ in vitro, and public gene expression datasets suggested that T-cell activity is lowest in CRCs with combined neutrophil infiltration and TGFβ activation. Thus, the interaction of neutrophils with a TGFβ-rich tumor microenvironment may represent a conserved immunosuppressive mechanism in CRC