Minimal-Access Splenectomy: a Viable Alternative to Laparoscopic Splenectomy in Massive Splenomegaly

BACKGROUND: Laparoscopic splenectomy of normal-sized spleens or in moderate splenomegaly is performed with increasing frequency. By using a modification of the open laparotomy, minimal-access splenectomy is an attractive alternative in severe splenomegaly. METHODS: Between September 2002 and October 2003, 9 patients (mean age, 58.8 years; range, 41 to 72) with severe splenomegaly (mean length, 27.9 cm; range, 23 to 32) underwent minimal-access splenectomy. Indications for splenectomy were non-Hodgkin's lymphoma in 5 cases and idiopathic myelofibrosis in 4. RESULTS: Minimal-access splenectomy was successfully completed in all patients. Mean operative time was 124 minutes (range, 75 to 165). Postoperative complications occurred in 2 cases; one perioperative death occurred in a patient with idiopathic myelofibrosis as a consequence of a secondary blast crisis. Median postoperative hospital stay was 9.1 days (range, 6 to 15). CONCLUSIONS: Minimal-access splenectomy seems to be a viable alternative to laparoscopic splenectomy in cases of severe splenomegaly. It combines the advantages of hand assistance like shorter operative times and increased safety of the procedure to the classical benefits of minimally invasive surgery

Splenic Doppler Resistive Index Variation Mirrors Cardiac Responsiveness and Systemic Hemodynamics upon Fluid Challenge Resuscitation in Postoperative Mechanically Ventilated Patients

Objective. To test if splenic Doppler resistive index (SDRI) allows noninvasive monitoring of changes in stroke volume and regional splanchnic perfusion in response to fluid challenge. Design and Setting. Prospective observational study in cardiac intensive care unit. Patients. Fifty-three patients requiring mechanical ventilation and fluid challenge for hemodynamic optimization after cardiac surgery. Interventions. SDRI values were obtained before and after volume loading with 500 mL of normal saline over 20 min and compared with changes in systemic hemodynamics, determined invasively by pulmonary artery catheter, and arterial lactate concentration as expression of splanchnic perfusion. Changes in stroke volume >10% were considered representative of fluid responsiveness. Results. A <4% SDRI reduction excluded fluid responsiveness, with 100% sensitivity and 100% negative predictive value. A >9% SDRI reduction was a marker of fluid responsiveness with 100% specificity and 100% positive predictive value. A >4% SDRI reduction was always associated with an improvement of splanchnic perfusion mirrored by an increase in lactate clearance and a reduction in systemic vascular resistance, regardless of fluid responsiveness. Conclusions. This study shows that SDRI variations after fluid administration is an effective noninvasive tool to monitor systemic hemodynamics and splanchnic perfusion upon volume administration, irrespective of fluid responsiveness in mechanically ventilated patients after cardiac surgery

Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: a systematic review and meta-analysis

Purpose: Although invasive intracranial devices (IIDs) are the gold standard for intracranial pressure (ICP) measurement, ultrasonography of the optic nerve sheath diameter (ONSD) has been suggested as a potential non-invasive ICP estimator. We performed a meta-analysis to evaluate the diagnostic accuracy of sonographic ONSD measurement for assessment of intracranial hypertension (IH) in adult patients. Methods: We searched on electronic databases (MEDLINE/PubMed\uae, Scopus\uae, Web of Science\uae, ScienceDirect\uae, Cochrane Library\uae) until 31 May 2018 for comparative studies that evaluated the efficacy of sonographic ONSD vs. ICP measurement with IID. Data were extracted independently by two authors. We used the QUADAS-2 tool for assessing the risk of bias (RB) of each study. A diagnostic meta-analysis following the bivariate approach and random-effects model was performed. Results: Seven prospective studies (320 patients) were evaluated for IH detection (assumed with ICP > 20 mmHg or > 25 cmH2O). The accuracy of included studies ranged from 0.811 (95% CI 0.678\u20120.847) to 0.954 (95% CI 0.853\u20120.983). Three studies were at high RB. No significant heterogeneity was found for the diagnostic odds ratio (DOR), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), with I2< 50% for each parameter. The pooled DOR, PLR and NLR were 67.5 (95% CI 29\u2012135), 5.35 (95% CI 3.76\u20127.53) and 0.088 (95% CI 0.046\u20120.152), respectively. The area under the hierarchical summary receiver-operating characteristic curve (AUHSROC) was 0.938. In the subset of five studies (275 patients) with IH defined for ICP > 20 mmHg, the pooled DOR, PLR and NLR were 68.10 (95% CI 26.8\u2012144), 5.18 (95% CI 3.59\u20127.37) and 0.087 (95% CI 0.041\u20120.158), respectively, while the AUHSROC was 0.932. Conclusions: Although the wide 95% CI in our pooled DOR suggests caution, ultrasonographic ONSD may be a potentially useful approach for assessing IH when IIDs are not indicated or available (CRD42018089137, PROSPERO)

Ultrasound- versus landmark-guided subclavian vein catheterization: a prospective observational study from a tertiary referral hospital

This was a single-center, observational, prospective study designed to compare the effectiveness of a real-time, ultrasound- with landmark-guided technique for subclavian vein cannulation. Two groups of 74 consecutive patients each underwent subclavian vein catheterization. One group included patients from intensive care unit, studied by using an ultrasound-guided technique. The other group included patients from surgery or emergency units, studied by using a landmark technique. The primary outcome for comparison between techniques was the success rate of catheterization. Secondary outcomes were the number of attempts, cannulation failure, and mechanical complications. Although there was no difference in total success rate between ultrasound-guided and landmark groups (71 vs. 68, p\u2009=\u20090.464), the ultrasound-guided technique was more frequently successful at first attempt (64 vs. 30, p\u2009<\u20090.001) and required less attempts (1 to 2 vs. 1 to 6, p\u2009<\u20090.001) than landmark technique. Moreover, the ultrasound-guided technique was associated with less complications (2 vs. 13, p\u2009<\u20090.001), interruptions of mechanical ventilation (1 vs. 57, p\u2009<\u20090.001), and post-procedure chest X-ray (43 vs. 62, p\u2009=\u20090.001). In comparison with landmark-guided technique, the use of an ultrasound-guided technique for subclavian catheterization offers advantages in terms of reduced number of attempts and complications

Treatment of primary epiglottis collapse in OSA in adults with glossoepiglottopexy: a 5-year experience

Objective. To review our 5-year experience with a modified version of glossoepiglottopexy for treatment of obstructive sleep apnoea syndrome (OSA) in two hospitals.Methods. A retrospective analysis was carried out on a cohort of adult patients affected by OSA suffering from primary collapse of the epiglottis who underwent a modified glossoepiglottopexy. All patients underwent drug-induced sleep endoscopy, polysomnographic and swallowing evaluation, and assessment with the Epworth Sleepiness Scale (ESS).Results. Forty-nine patients were retrospectively evaluated. Both the apnoea-hypopnoea index (AHI) (median AHI(post)-AHI(pre) = -22.4 events/h; p < 0.001) and oxygen desaturation index (ODI) showed a significant postoperative decrease (median ODIpost-ODIpre = -18 events/h; p < 0.001), as did hypoxaemia index (median T-90% post - T-90% pre = 5%; p < 0.001). The ESS questionnaire revealed a significant decrease in postoperative scores (median ESSpost-ESSpre =- 9; p < 0.001). None of the patients developed postoperative dysphagia.Conclusions. Our 5-year experience demonstrates that modified glossoepiglottopexy is a safe and reliable surgical technique for treatment of primary epiglottic collapse in OSA patients

A model to prioritize access to elective surgery on the basis of clinical urgency and waiting time

<p>Abstract</p> <p>Background</p> <p>Prioritization of waiting lists for elective surgery represents a major issue in public systems in view of the fact that patients often suffer from consequences of long waiting times. In addition, administrative and standardized data on waiting lists are generally lacking in Italy, where no detailed national reports are available. This is true although since 2002 the National Government has defined implicit Urgency-Related Groups (URGs) associated with Maximum Time Before Treatment (MTBT), similar to the Australian classification. The aim of this paper is to propose a model to manage waiting lists and prioritize admissions to elective surgery.</p> <p>Methods</p> <p>In 2001, the Italian Ministry of Health funded the Surgical Waiting List Info System (SWALIS) project, with the aim of experimenting solutions for managing elective surgery waiting lists. The project was split into two phases. In the first project phase, ten surgical units in the largest hospital of the Liguria Region were involved in the design of a pre-admission process model. The model was embedded in a Web based software, adopting Italian URGs with minor modifications. The SWALIS pre-admission process was based on the following steps: 1) urgency assessment into URGs; 2) correspondent assignment of a pre-set MTBT; 3) real time prioritization of every referral on the list, according to urgency and waiting time. In the second project phase a prospective descriptive study was performed, when a single general surgery unit was selected as the deployment and test bed, managing all registrations from March 2004 to March 2007 (1809 ordinary and 597 day cases). From August 2005, once the SWALIS model had been modified, waiting lists were monitored and analyzed, measuring the impact of the model by a set of performance indexes (average waiting time, length of the waiting list) and Appropriate Performance Index (API).</p> <p>Results</p> <p>The SWALIS pre-admission model was used for all registrations in the test period, fully covering the case mix of the patients referred to surgery. The software produced real time data and advanced parameters, providing patients and users useful tools to manage waiting lists and to schedule hospital admissions with ease and efficiency. The model protected patients from horizontal and vertical inequities, while positive changes in API were observed in the latest period, meaning that more patients were treated within their MTBT.</p> <p>Conclusion</p> <p>The SWALIS model achieves the purpose of providing useful data to monitor waiting lists appropriately. It allows homogeneous and standardized prioritization, enhancing transparency, efficiency and equity. Due to its applicability, it might represent a pragmatic approach towards surgical waiting lists, useful in both clinical practice and strategic resource management.</p

Appropriate statistical descriptions for evaluating the predictive role of epithelial-to-mesenchymal transition in patients with pancreatic cancer.

I read with interest the recent article by Yamada et al. entitled \u2018\u2018Epithelial-to-mesenchymal transition predicts prognosis of pancreatic cancer.\u2019\u2019 Although the authors reported that epithelial-to-mesenchymal transition is predictive for both survival and response to adjuvant therapy in patients with pancreatic cancer, in the article there are several statistical inaccuracies that could limit the impact of these findings

Research papers: Journals should drive data reproducibility

restricted1noLettera pubblicata in Nature 2016; 535(7612): 355 [Scopus: 2-s2.0-84979710703; WOS: 000380344200020; PMID: 27443731; URL: http://www.nature.com/nature/journal/v535/n7612/full/535355b.html]. Il prodotto è stato registrato in IRIS come "Articolo su rivista" ai sensi dell'art. 4 del D.M. 602/2016.Peer-reviewed journals — as well as researchers and their funders — must take responsibility for improving the reproducibility of published results (see Nature 533, 452–454; 2016). I suggest that journals should be required to sign a global statement indicating that, to the best of their knowledge, the data that they publish are reproducible. This statement would be collaboratively formulated by the editors-in-chief in accordance with recommendations from the International Committee of Medical Journal Editors and guidelines proposed by the US National Institutes of Health, Nature and Science (see Nature 515, 7; 2014 and go.nature.com/29bxphv). Journals would then publish only papers that are accompanied online by full experimental protocols, raw data and source code, as in the Protocol Exchange repository (www.nature.com/protocolexchange). For manuscripts containing statistical analyses, journals should peer review only those papers that use statistics environments based on source code, enforcing the ban on 'point-and-click' statistical software (see go.nature.com/29pdpcl).restrictedSantori, GregorioSantori, Gregori