Hollow viscus injuries. Predictors of outcome and role of diagnostic delay

INTRODUCTION: Hollow viscus injuries (HVIs) are uncommon but potentially catastrophic conditions with high mortality and morbidity rates. The aim of this study was to analyze our 16-year experience with patients undergoing surgery for blunt or penetrating bowel trauma to identify prognostic factors with particular attention to the influence of diagnostic delay on outcome. METHODS: From our multicenter trauma registry, we selected 169 consecutive patients with an HVI, enrolled from 2000 to 2016. Preoperative, intraoperative, and postoperative data were analyzed to assess determinants of mortality, morbidity, and length of stay by univariate and multivariate analysis models. RESULTS: Overall mortality and morbidity rates were 15.9% and 36.1%, respectively. The mean length of hospital stay was 23±7 days. Morbidity was independently related to an increase of white blood cells (P=0.01), and to delay of treatment >6 hours (P=0.033), while Injury Severity Score (ISS) (P=0.01), presence of shock (P=0.01), and a low diastolic arterial pressure registered at emergency room admission (P=0.02) significantly affected postoperative mortality. CONCLUSION: There is evidence that patients with clinical signs of shock, low diastolic pressure at admission, and high ISS are at increased risk of postoperative mortality. Leukocytosis and delayed treatment (>6 hours) were independent predictors of postoperative morbidity. More effort should be made to increase the preoperative detection rate of HVI and reduce the delay of treatment

Needlestick injuries, glove perforation and round-tipped blunt needles

We read with great interest the article by Battersby et al. [1] about the impairment of surgical knot quality due to double gloving. The practice to wearing two pairs of gloves during surgical procedures to reduce the risks of exposure to patient’s blood and transmission of infectious organisms has been recommended worldwide, by several healthcare authorities, also on the basis of a Cochrane review showing the absence of compromised dexterity as a result of double gloving [2]. The study performed by Battersby and Colleagues clearly shows that double gloving reduces the quality of surgical knots by 24%, no matter the suture type used. A wider reduction of knot quality (50%) was noted with 4.0 sutures. These results question the safety of surgical knots tied wearing double gloves and, as a consequence, push surgeons to consider other precautions to reduce bloody contamination during surgery ..

Pharyngolaryngo-Esophagectomy with Laparoscopic Gastric Pull-Up: A Reappraisal for the Pharyngoesophageal Junction Cancer

Surgical treatment of advanced hypopharyngeal tumors is still a surgical challenge. We report a case of a hypopharyngeal tumor treated with a pharyngolaryngo-esophagectomy (PLE) and laparoscopic gastric tubulization and interposition. A 56-year-old man presented with a relapsing hypopharynx carcinoma, after primary chemoradiation therapy. Preoperative workup showed a stage IV cancer with esophageal invasion and multiple cervical lymph node metastases. Surgical treatment consisted of a cervical phase, with larynx, pharynx, and esophagus dissection, radical lymph node dissection, homolateral hemithyroidectomy and definitive tracheostomy, and an abdominal phase with a 4-trocar laparoscopy. The gastrocolic ligament was opened, and short gastric and left gastric vessels were divided preserving an accessory left hepatic artery. Gastric tailoring was carried out with 45-mm linear staplers. The hiatus was opened and the esophagus dissected free with Ultracision (Ethicon Endo-Surgery, Cincinnati, OH) to the tracheal bifurcation. The upper esophagus was bluntly mobilized by finger and sponge stick dissection. The gastric tube was pulled up, and the anastomosis between the stomach and the tongue base was performed with a 2-layer interrupted hand-sewn technique. Total operative time was 390 min (abdominal time 180 min). Estimated blood loss was 400 cc. The number of dissected cervical lymph nodes was 32. Oral feeding was started after 10 days, and the patient was discharged after 14 days. Stage of disease was pT4N1M0 G3 R0. Laparoscopic surgery allows a minimally invasive gastric tailoring and tubulization and transhiatal esophageal dissection and represents a valuable alternative for intestinal reconstruction after PLE

Laparoscopic Left Nephrectomy with "En Bloc" Distal Splenopancreatectomy

Background: Multiorgan resection for cancer is considered a demanding laparoscopic procedure. We report a laparoscopic radical nephrectomy and distal splenopancreatectomy for a locally advanced kidney tumor. Methods: A 67-year-old woman presented with left flank pain and hematuria. CT scan showed a left kidney upper pole large mass with direct extension to spleen and pancreatic tail, but not metastases. With the patient on the right flank, three 10-mm trocars were placed forming an isosceles triangle in the left subcostal arch. Entering the lesser sac, splenic vessels were separately divided between clips. The pancreatic tail was dissected free and divided with Ultracision. The left renal vein was dissected free, and the aorta was exposed to perform the lymphadenectomy. Superior mesenteric artery and left renal vein and artery were isolated, and renal vessels were separately divided with a vascular stapler. The left kidney was mobilized. The specimen was inserted in a bag and retrieved transvaginally through a posterior colpotomy. Results: Total operation time was 210 minutes. Estimated blood loss was 250 mL. The patient was discharged after 7 days. Final stage of disease was pT4N0M0 G2 R0 renal cell carcinoma. The patient came back 6 years later presenting a ductal adenocarcinoma of pancreatic head. At the second look laparoscopy, very few adhesions were found in right upper quadrant, and the posterior colpotomy scar was very small. The patient died 1 year after Whipple operation. Conclusions: Oncologic rules of an "en bloc" resection can be respected also with a laparoscopic approach. © 2011 Society of Surgical Oncology

Transoral Extraction of a Laparoscopically Resected Large Gastric GIST

Although natural orifice specimen extraction is now widely performed, there have been no reports of transoral extraction following laparoscopic gastric resection. This report describes the first transoral specimen extraction in a patient with a gastrointestinal stromal tumor (GIST) of the lesser curvature of the stomach. The clinical data of a patient with a large gastric GIST were reviewed. Totally laparoscopic resection of the gastric lesser curvature was performed using four trocars. The specimen, put in a retrieval bag, was withdrawn via the transgastric and esophageal route. Reconstruction of the stomach was performed using the intracorporeal technique. The procedure was successfully accomplished without intraoperative and postoperative complications. In conclusion, transoral specimen extraction after laparoscopic gastric resection is a safe and feasible operative procedure for selected patients with a large benign gastric tumor

Laparoscopy can be Very Effective in Reducing Mortality Rate for Caustic Ingestion in Suicide Attempt

[No abstract available