Correlation between preoperative CT scan and lung metastases according to surgical approach in patients with colorectal cancer

IntroductionThe number of lung metastases (M1) of colorectal carcinoma (CRC) in relation to the findings of computed tomography (CT) is the object of study.MethodsProspective and multicenter study of the Spanish Group for Surgery of CRC lung metastases (GECMP-CCR). The role of CT in the detection of pulmonary M1 is evaluated in 522 patients who underwent a pulmonary metastasectomy for CRC. We define M1/CT as the ratio between metastatic nodules and those found on preoperative CT. Disease-specific survival (DSS), disease-free survival (DFS), and surgical approach were analyzed using the Kaplan–Meier method.Results93 patients were performed by video-assisted surgery (VATS) and 429 by thoracotomy. In 90%, the M1/CT ratio was ≤1, with no differences between VATS and thoracotomy (94.1% vs 89.7%, p = 0.874). In the remaining 10% there were more M1s than those predicted by CT (M1/CT > 1), with no differences between approaches (8.6% vs 10%, p = 0.874). 51 patients with M1/CT > 1, showed a lower median DSS (35.4 months vs 55.8; p = 0.002) and DFS (14.2 months vs 29.3; p = 0.025) compared to 470 with M1/CT ≤ 1. No differences were observed in DSS and DFS according to VATS or thoracotomy.ConclusionsOur study shows equivalent oncological results in the resection of M1 of CRC using VATS or thoracotomy approach. The group of patients with an M1/CT ratio >1 have a worse DSS and DFS, which may mean a more advanced disease than predicted preoperatively.     

Impact of visceral fat on laparoscopy-assisted distal gastrectomy

BackgroundObesity is known to be a preoperative risk factor for gastric cancer surgery. However, the influence of obesity on laparoscopy-assisted distal gastrectomy (LADG) remains controversial. In the present study, we evaluated several obesity parameters and investigated the influence of obesity on the surgical outcomes of LADG for gastric cancer.Materials and methodsBetween January 2010 and July 2011, 84 patients who underwent LADG for gastric cancer were enrolled. Visceral fat area (VFA) and subcutaneous fat area (SFA) were measured in cross-sectional CT scan using SlimVision^® software. Patients were classified into two groups by the degree of BMI or VFA. Surgery time and blood loss were compared between each two groups. Predictive factors for perioperative complications were assessed by univariate and multivariate analyses.ResultsThere were no significant differences in surgery time or blood loss between patients with high and low BMIs. In contrast, high VFA patients had significantly longer surgery times (p = 0.0047) and higher estimated blood loss (p = 0.0034) than low VFA patients. By univariate and multivariate analyses, only a high VFA significantly predicted perioperative complications (p = 0.0162, p = 0.0288).ConclusionsWe suggest that VFA is more accurate than BMI in predicting surgery time, blood loss, and perioperative complications associated with LADG for gastric cancer. The visceral fat area could be efficiently assessed before laparoscopic surgery for gastric cancer in obese patients.     

Treatment of shoulder calcifications of the cuff: A controlled study

ObjectivesAbout 1 in 10 patients with shoulder calcifications complains of chronic pain. Removal techniques have been developed. We carried out the first randomized study to validate bursoscopy (BS) and (needling fragmentation irrigation) (NFI) versus a control group (CT).Methods102 shoulders (96 patients) with calcifications >5 mm whose medical treatment had failed (>4 months) were first injected using a corticosteroid; 49 shoulders improved by more than 70%. The other 53 shoulders were randomized in 3 groups: NFI (n = 16), BS (n = 20), and CT (n = 17). All patients were reviewed at T 1–4–12–24 months.ResultsAfter 4 months, we observed respectively in groups NFI – BS – CT: 62%, 65% and 29% patients showing global improvements >70% (NFI vs CT: p = 0.03; BS vs CT: p = 0.02); ?37%, ?29% and ?11% pain VAS variation (ns), +16%, +12% and ?15% Constant score variation (NFI vs CT: p = 0.03; BS vs CT: p = 0.02), and ?58%, ?77% and +4% area calcification variation (NFI vs CT: p = 0.005; BS vs CT: p = 0.0002; BS vs NFI: p = 0.01). After 24 months, results were maintained in NFI and BS groups, and in the CT group only 6/17 patients were still improved. There were no significant differences between NFI and BS groups. Three partial tears of the cuff were found using MRI in failures, (1 in each group).ConclusionNFI and BS are now validated removal techniques of shoulder calcifications when there is chronic pain and other medical treatments have failed. Results were maintained after 24 months, and were similar between NFI and BS. However NFI could be preferred because of its simplicity and low cost.     

The effect of aortic stenosis on elderly hip fracture outcomes: A case control study

IntroductionAortic stenosis (AS) is an established predictor of perioperative complications following both cardiac and non-cardiac surgery. The purpose of this study was to evaluate the risk of mortality and perioperative complications among surgically treated hip fractures in elderly patients with moderate or severe AS compared to those without AS (negative controls).Materials and methodsA retrospective case-controlled review (1:2) of elderly (≥65 years) surgically treated hip fractures from 2011 to 2015 with moderate/severe AS (according to American Heart Association criteria) was conducted. Postoperative complication rates, 30 days and 1 year mortality were reviewed.ResultsModerate/severe AS was identified in 65 hip fracture cases and compared to 129 negative controls. AS cases were significantly older with higher rates of coronary artery disease and atrial fibrillation (p < 0.05). Rates of any 30-day perioperative complication (74% vs. 37%, p < 0.001) and severe non-cardiac 30-day perioperative complication (52% vs. 26%, p = 0.002) were significantly higher among AS cases compared to controls. Kaplan Meier estimates of 30-day mortality (14.7% vs. 4.2%, p < 0.001) and 1-year mortality (46.8% vs. 14.1%, p < 0.001) were significantly higher in AS cases compared to controls. Multivariate analysis of severe 30-day postoperative complications identified moderate/severe AS (OR 4.02, p = 0.001), pulmonary disease (OR 7.36, p = 0.002) and renal disease (OR 3.27, p = 0.04) as independent predictors. Moderate/severe AS (OR 3.38, p = 0.03), atrial fibrillation (OR 3.73, p = 0.03) and renal disease (OR 4.44, p = 0.02) were independent predictors of 30-day mortality. Moderate/severe AS (OR 5.79, p < 0.001) and renal disease (OR 3.39, p = 0.02) were independent predictors of 1-year mortality.ConclusionAortic stenosis is associated with a significantly increased risk of perioperative complications, 30-day mortality and 1-year mortality in elderly patients undergoing surgical treatment of hip fractures.     

Location of atypical femoral fracture can be determined by tensile stress distribution influenced by femoral bowing and neck-shaft angle: a CT-based nonlinear finite element analysis model for the assessment of femoral shaft loading stress

IntroductionLoading stress due to individual variations in femoral morphology is thought to be strongly associated with the pathogenesis of atypical femoral fracture (AFF). In Japan, studies on AFF regarding pathogenesis in the mid-shaft are well-documented and a key factor in the injury is thought to be femoral shaft bowing deformity. Thus, we developed a CT-based finite element analysis (CT/FEA) model to assess distribution of loading stress in the femoral shaft.Patients and MethodsA multicenter prospective study was performed at 12 hospitals in Japan from August 2015 to February 2017. We assembled three study groups—the mid-shaft AFF group (n = 12), the subtrochanteric AFF group (n = 10), and the control group (n = 11)—and analyzed femoral morphology and loading stress in the femoral shaft by nonlinear CT/FEA.ResultsFemoral bowing in the mid-shaft AFF group was significantly greater (lateral bowing, p < 0.0001; anterior bowing, p < 0.01). Femoral neck-shaft angle in the subtrochanteric AFF group was significantly smaller (p < 0.001). On CT/FEA, both the mid-shaft and subtrochanteric AFF group showed maximum tensile stress located adjacent to the fracture site. Quantitatively, there was a correlation between femoral bowing and the ratio of tensile stress, which was calculated between the mid-shaft and subtrochanteric region (lateral bowing, r = 0.6373, p < 0.0001; anterior bowing, r = −0.5825, p < 0.001).ConclusionsCT/FEA demonstrated that tensile stress by loading stress can cause AFF. The location of AFF injury could be determined by individual stress distribution influenced by femoral bowing and neck-shaft angle.     

Closed incision negative pressure therapy decreases complications after periprosthetic fracture surgery around the hip and knee

IntroductionPeriprosthetic fractures (PPFXs) are becoming increasingly common following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients sustaining PPFXs face considerable perioperative morbidity, with relatively increased rates of surgical site infection. We sought to evaluate the efficacy of closed-incision negative-pressure wound therapy (ciNPT) in decreasing perioperative wound complications following lower extremity periprosthetic fracture surgery.MethodsWe performed a retrospective review of 69 consecutive patients who underwent surgery to address lower extremity periprosthetic fractures around hip or knee implants performed over a 6.5-year period. The population was divided into two groups based on the surgical dressing used at the conclusion of the procedure: (1) a sterile, antimicrobial hydrofiber dressing, or (2) ciNPT. There were no baseline demographic differences between the two groups. Rates of wound complications, surgical site infection, and reoperation related to the surgical site were compared between groups. Continuous variables were analyzed using a student’s t-test, and categorical variables using either chi-square or fisher’s exact test.ResultsPatients treated with ciNPT developed fewer wound complications (4% vs. 35%; p = 0.002), fewer deep infections (0% vs. 25%; p = 0.004), and underwent fewer reoperations related to the surgical site (4% vs. 25%; p = 0.021) compared to patients treated with standard of care.ConclusionsOur findings suggest that ciNPT may reduce wound complications, SSIs, and reoperations in patients undergoing lower extremity periprosthetic fracture surgery. This is the first study to investigate ciNPT as a treatment for periprosthetic fracture surgery, and has the potential to change the postoperative management of these patients.     

A comparative study of laparoscopic and robotic assisted radical prostatectomy performed by a single surgeon

ObjectiveTo present the transition from laparoscopic radical prostatectomy (LRP) to robotic-assisted laparoscopic radical prostatectomy (RALP) over 10 years in a medium volume center by a single surgeon.Materials and methodsWe retrospectively reviewed 140 prostate cancer patients who underwent LRP (100 patients) or RALP (40 patients) between May 2005 and May 2015. Preoperative parameters included age, body mass index, and serum prostate specific antigen. Operative course parameters included operative time, estimated blood loss, intraoperative blood transfusion, conversion to open surgery, hospitalization days, duration of Foley catheterization, and complications. Pathological stage, surgical margin status, biochemical recurrence (BCR) rate, and continence rate at 12 months after surgery were reviewed and compared between the LRP and RALP groups.ResultThe operative outcomes revealed significantly less blood loss (143 mL vs. 306 mL, p < 0.001), shorter hospital stay (6.9 days vs. 8.7 days, p = 0.006), and shorter duration of Foley catheterization (9.3 days vs. 11.3 days, p < 0.001) in patients who underwent RALP. Major perioperative complications occurred in four LRP patients (4%), and none were observed in RALP patients. LRP and RALP had similar positive surgical margin rates (p = 0.285) and BCR rates (p = 0.88). RALP resulted in better continence recovery than LRP (55% vs. 82.5%, p = 0.003).ConclusionPatients who underwent RALP had better perioperative and functional outcomes. Oncologic outcomes were similar compared to patients who underwent LRP.     

Computed tomography features of acinar cell carcinoma of the pancreas

PurposeTo report the computed tomography (CT) features of pancreatic acinar cell carcinoma (ACC) and identify CT features that may help discriminate between pancreatic ACC and pancreatic ductal adenocarcinoma (PDA).Materials and methodsThe CT examinations of 20 patients (13 men, 7 women; mean age, 66.5 ± 10.7 [SD] years; range: 51–88 years) with 20 histopathologically proven pancreatic ACC were reviewed. CT images were analyzed qualitatively and quantitatively and compared to those obtained in 20 patients with PDA. Comparisons were performed using univariate analysis with a conditional logistic regression model.ResultsPancreatic ACC presented as an enhancing (20/20; 100%), oval (15/20; 75%), well-delineated (14/20; 70%) and purely solid (13/20; 65%) pancreatic mass with a mean diameter of 52.6 ± 28.0 (SD) mm (range: 24–120 mm) in association with visible lymph nodes (14/20; 70%). At univariate analysis, well-defined margins (Odds ratio [OR], 7.00; P = 0.005), nondilated bile ducts (OR, 9.00; P = 0.007), visible lymph nodes (OR, 4.33; P = 0.028) and adjacent organ involvement (OR, 5.67; P = 0.02) were the most discriminating CT features to differentiate pancreatic ACC from PDA. When present, lymph nodes were larger in patients with pancreatic ACC (14 ± 4.8 [SD]; range: 7–25 mm) than in those with PDA (8.8 ± 4.1 [SD]; range: 5–15 mm) (P = 0.039).ConclusionOn CT, pancreatic ACC presents as an enhancing, predominantly oval and purely solid pancreatic mass that most frequently present with no bile duct dilatation, no visible lymph nodes, no adjacent organ involvement and larger visible lymph nodes compared to PDA.     

A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis

ObjectiveCT scans with a flat Inferior Vena Cava (IVC) suggest hypovolemia, and the presence of shock bowel implies hypoperfusion. The purpose of this study is to correlate injury severity, resuscitation needs, and clinical outcomes with CT indices of hypovolemia and hypoperfusion.DesignRetrospective cohort study.SettingLevel II trauma centre in Central California.PatientsAdult patients imaged with abdominal and pelvic CT scans, from January 2010–January 2011.InterventionsNone.Measurements and main resultsCirculatory derangements on CT scans were defined as an IVC (AP) diameter measurement of <9 mm, flat IVC (FIVC), hypovolemia. The presence of small intestine hypoperfusion was shock bowel (SB). The absence of these findings was a normal CT scan (NCT). Comparisons of acid-base status, fluids, morbidity and mortality were made based on CT findings. Subgroups were: FIVC (n = 20), FIVC + SB (n = 19), SB (n = 4) only versus normal CT scans, NCT (n = 47).ResultsOverall ISS was 19 (SD) 14. The lowest ISS was in NCT 14 (SD) 10 and there was an incremental increase in ISS based on circulatory derangements, p = 0.001. ICU admission was lowest in NCT and highest in the presence of hyovolemia and hypoperfusion, p = 0.03.Similarly ED crystalloid requirements and the activation of a massive transfusion protocol (MTP), was lowest in NCT group and gradually increased significantly as hypovolemia and hypoperfusion was demonstrated on CT scans. Additional parameters such as metabolic acidosis, nosocomial infections and mortality were associated with acute CT findings of circulatory failure.ConclusionsHypovolemia and hypoperfusion, markers of abnormal circulation, were demonstrated on CT scans for trauma evaluation. The presence of these findings alone or in combination showed strong correlation with high injury severity, and the need for aggressive resuscitation.     

Outcome of patients in laparoscopic training courses compared to standard patients

Background & aimCurrent Laparoscopic simulators have limited usefulness and patients have been used for training since the dawn of surgery. NUGITS (Northumbrian Upper Gastro Intestinal Team of Surgeons) Laparoscopic Skills courses utilise hands-on experience with simulators moving to live operating on volunteer patients. It is vital to know that the volunteer patient is not disadvantaged by greater surgical risk.MethodsThis was a case-controlled prospective comparison of patients undergoing both Laparoscopic Cholecystectomy (LC) [n = 51] and Laparoscopic Inguinal Hernia (LIH) [n = 62] during NUGITS training courses. They are compared with a matched (age, sex and ASA grade) control group LC (n = 51) and LIH (n = 62) operated on by consultants. The outcome measures were surgical peri-and post-operative complications, post-operative hospital stay, readmission and early recurrence of inguinal hernia (<6 months).ResultsIn the LC cohort, there was no significant difference in the length of hospital stay (p = 0.07) or readmission (p = 0.16) in both the groups. The mean operating time was higher in the trainee compared to the control group (p = 0.001). There was no difference in the post-operative morbidity or mortality in either group. In LIH cohort, the mean operating time was higher in the trainee compared with the control group. There was no significant difference in post-operative complications (p > 0.05) and early post-operative recurrence of hernia (p > 0.05).ConclusionThe post-operative outcomes of patients undergoing laparoscopic surgery during laparoscopic training courses are similar to consultant-operated patients. Thus, it is acceptable and safe to encourage patients to volunteer for laparoscopic training courses.     

The effects of a resistive warming mattress during caesarean section: a randomised,controlled trial

BackgroundThe adverse effects of inadvertent perioperative hypothermia in the surgical population are well established. The aim of this study was to investigate whether a resistive warming mattress would reduce the incidence of inadvertent perioperative hypothermia in patients undergoing elective caesarean section.MethodsA total of 116 pregnant women booked for elective caesarean section were randomised to either intraoperative warming with a mattress or control. The primary outcome was the incidence of inadvertent perioperative hypothermia, defined as a temperature <36.0°C on admission to the recovery room. Shivering in the perioperative period, severity of shivering and the need for treatment, total blood loss, fall in haemoglobin, incidence of blood transfusion, immediate health of baby, and length of hospital stay were also recorded.ResultsThe incidence of inadvertent perioperative hypothermia in the mattress-warmed group was significantly lower than in the control group (5.2% vs. 19.0%, P = 0.043); mean temperatures differed between the two groups, 36.5°C and 36.3°C, respectively (P = 0.046). There was also a significantly lower mean (± SD) haemoglobin change in the mattress-warmed group at −1.1 ± 0.9 g/dL versus −1.6 ± 0.9 g/dL in the control group (P = 0.007). There was no difference in shivering (P = 0.798).ConclusionsA resistive warming mattress reduced the incidence of inadvertent perioperative hypothermia and attenuated the fall in haemoglobin. The use of resistive mattress warming should be considered during caesarean section.     

Efeito do bloqueio paravertebral torácico na redução de seroma em cirurgia de mama – estudo randomizado controlado

BackgroundIncreasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.ObjectiveWith this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.MethodsForty ASA I–II female patients aged 18–65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient‐controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24^th hour postoperatively.Results and conclusionsMean seroma formation at postoperative 24^th hour was 112.5 ± 53.3 mL in the control group and 74.5 ± 47.4 mL in the TPVB group (p = 0.022). NRS scores were similar between two groups (p = 0.367) at postoperative 24^th hour but mean morphine consumption at postoperative 24^th hour was 5.6 ± 4 mg in the TPBV group, and 16.6 ± 6.9 mg in the control group (p < 0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.     

Spanish Video-Assisted Thoracic Surgery Group: Method,Auditing, and Initial Results From a National Prospective Cohort of Patients Receiving Anatomical Lung Resections

IntroductionOur study sought to know the current implementation of video-assisted thoracoscopic surgery (VATS) for anatomical lung resections in Spain. We present our initial results and describe the auditing systems developed by the Spanish VATS Group (GEVATS).MethodsWe conducted a prospective multicentre cohort study that included patients receiving anatomical lung resections between 12/20/2016 and 03/20/2018. The main quality controls consisted of determining the recruitment rate of each centre and the accuracy of the perioperative data collected based on six key variables. The implications of a low recruitment rate were analysed for “90-day mortality” and “Grade IIIb-V complications”.ResultsThe series was composed of 3533 cases (1917 VATS; 54.3%) across 33 departments. The centres’ median recruitment rate was 99% (25–75th:76–100%), with an overall recruitment rate of 83% and a data accuracy of 98%. We were unable to demonstrate a significant association between the recruitment rate and the risk of morbidity/mortality, but a trend was found in the unadjusted analysis for those centres with recruitment rates lower than 80% (centres with 95–100% rates as reference): grade IIIb-V OR = 0.61 (p = 0.081), 90-day mortality OR = 0.46 (p = 0.051).ConclusionsMore than half of the anatomical lung resections in Spain are performed via VATS. According to our results, the centre's recruitment rate and its potential implications due to selection bias, should deserve further attention by the main voluntary multicentre studies of our speciality. The high representativeness as well as the reliability of the GEVATS data constitute a fundamental point of departure for this nationwide cohort.     

Has the COVID-19 pandemic changed the clinical picture and tumour stage at the time of presentation of patients with colorectal cancer? A retrospective cohort study

IntroductionTreatment of patients with Coronavirus Disease 2019 (COVID-19) has affected the management of patients with colorectal cancer (CRC). The aim of this study was to compare the diagnosis delay, symptoms, and stage of patients with CRC during the pandemic with a control cohort.Material and methodsPatients referred to the CRC multidisciplinary team between September 2019 and January 2020 (cohort 1, control group) were compared with those who presented between September 2020 and March 2021 (cohort 2, pandemic group).Results389 patients were included, 169 in cohort 1 and 220 in cohort 2. No differences were observed in the main characteristics of the patients. CRC screening and anaemia were the most common causes leading to the diagnosis of the tumour in cohort 1 and 2, respectively (p < 0.001). Diagnostic and therapeutic delay was longer in cohort 2 [6.4 (95% CI 5.8–6.9) vs. 4.8 (95% CI 4.3–5.3) months, p < 0.001]. More patients required non-elective treatment in the pandemic cohort (15.5% vs. 9.5%, p = 0.080). The tumour stage was more advanced in patients in cohort 2 [positive nodes in 52.3% vs. 36.7% (p = 0.002), and metastatic disease in 23.6% vs. 16.6% (p = 0.087)].ConclusionCRC patients in the pandemic cohort had a longer diagnostic and therapeutic delay and less patients were diagnosed because of CRC screening. In addition, patients with CRC during the pandemic needed non-elective treatment more frequently than patients in the control cohort, and their tumour stage tended to be more advanced.     

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis

IntroductionOutcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections.MethodsRetrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients’ age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann–Whitney U test for continuous variables.ResultsA total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p = 0.369), major complications (RATS: 9% vs VATS: 9.2%; p = 0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p = 1; pneumonia RATS:0%, VATS:4.6%, p = 0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p = 0.718) and reoperation (RATS: 3%, VATS: 1.5%, p = 1) were comparable between both groups. The median length of stay was 3 days in both groups (p = 0.101).ConclusionsA RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.     

Efeito do bloqueio do gânglio estrelado direito guiado por ultrassom na fibrilação atrial perioperatória em pacientes submetidos a lobectomia pulmonar: estudo controlado randomizado

ObjectiveTo observe the effects of preoperative right stellate ganglion block on perioperative atrial fibrillation in patients undergoing lung lobectomy.MethodsTwo hundred patients who underwent a scheduled lobectomy were randomly divided into the S and C groups. The S group was injected with 4 mL of 0.2% ropivacaine under ultrasound guidance, and the C group did not receive stellate ganglion block. The patients underwent continuous ECG monitoring, and the incidences of atrial fibrillation and other types of arrhythmias were recorded from the start of surgery to 24 hours after surgery.ResultsThe respective incidences of atrial fibrillation in the S group and the C group were 3% and 10% (p = 0.045); other atrial arrhythmias were 20% and 38% (p = 0.005); and ventricular arrhythmia were 28% and 39% (p = 0.09).ConclusionsThe results of the study indicated that preoperative right stellate ganglion block can effectively reduce the incidence of intraoperative and postoperative atrial fibrillation.     

Utilidad de la quimioterapia neoadyuvante en el carcinoma vesical músculo invasivo no metastásico

ObjectiveWe analyzed the profile of patients who were candidates for neoadjuvant chemotherapy (NACT) in stage pT2-4aN0M0, the tolerability and adherence of our cisplatin-based protocol and oncological outcomes.Material and methodsRetrospective observational cohort study including patients diagnosed with muscle-invasive bladder carcinoma treated with NACT. Clinical, histopathological, therapeutic and evolutionary characteristics of the patients were analyzed. The use of NACT was evaluated by the complete response in the surgical specimen (pT0). This and other pathological factors were related to overall survival and progression-free survival.ResultsWe included 90 patients with muscle-invasive bladder carcinoma (clinical stage T2a-T4aN0M0) who received a cisplatin-based NACT regimen between January 2011 and December 2018, prior to radical surgery. Forty percent of patients presented an adverse reaction, with a compliance with the NACT regimen of 92.2%. There were no deaths related to systemic treatment and no adverse reaction to treatment made radical cystectomy impracticable. After performing radical cystectomy, the presence of complete response (pT0) was observed in 20 patients (21%), lower stage in the surgical specimen (<pT2) in 36 patients (40%), positive surgical margins in 7 patients (8%), lymph node involvement (N1) in 16 patients (17.8%). A shorter time to progression was observed in the group of patients who did not achieve a complete pathological response (53 months vs. 83.1 in pT0 patients, P = 0.012), in patients with lymph node involvement compared to pN0 (65.4 vs. 28, 2 months, P = 0.014) and in those with positive surgical margins compared to those with tumor-free margins (63.5 vs. 8.5 months, P = 0.021).ConclusionThe adequate selection of patients with muscle-invasive bladder carcinoma has shown a good tolerance to NACT, with a high compliance rate prior to RC. The improvement in the complete response rate implies a greater survival in this group of patients, with lymph node involvement and positive surgical margins being important prognostic factors.     

Retroperitoneal packing or angioembolization for haemorrhage control of pelvic fractures—Quasi-randomized clinical trial of 56 haemodynamically unstable patients with Injury Severity Score ≥33

AimsBoth retroperitoneal pelvic packing and primary angioembolization are widely used to control haemorrhage related to pelvic fractures. It is still unknown which protocol is the safest. The primary aim of this study is to compare survival and complications of pelvic packing and angioembolization in massive haemorrhage related to pelvic fractures.MethodsPatients with haemodynamically unstable pelvic fractures were quasi-randomized to either pelvic packing (PACK) or angiography (ANGIO) using the time of admission as separator. Physiological markers of haemorrhage, time to intervention, procedure/surgical time, transfusion requirements, complications and early mortality were recorded and analyzed.Results29 patients were randomized to PACK and 27 patients to ANGIO. The Injury Severity Score (ISS) in the ANGIO group was lower than in the PACK group (43 ± 7 vs 48 ± 6) (p < 0.01). The median time from admission to angiography for the ANGIO group was 102 min (range 76–214), and longer than 77 min (range 43–125) from admission to surgery for the PACK group (p < 0.01). The procedure time for the ANGIO group was 84 min (range 62–105); while the surgical time was 60 min (range 41–92) for the PACK group (p < 0.001). The ANGIO group received 6.4 units packed red blood cells (range 4–10) in the first 24 h after angiography. The PACK group required 5.2 units (range 3–10) in the first 24 h after leaving the operating theatre (p = 0.124). 9 patients in the ANGIO group underwent pelvic packing for persistent bleeding. 6 patients in the PACK group required pelvic angiography after pelvic packing for ongoing hypotension following packing (p = 0.353). 5 patients in the ANGIO group died (2 from exsanguination), while 4 in the PACK group died (none from exsanguination) (p = 0.449). Complications occurred without differences in both groups.ConclusionsCompared with angioembolization, pelvic packing has shorter time to intervention and surgical time. Thus pelvic packing is the more rapid treatment of severe pelvic trauma than pelvic angioembolization. It is suitable for patients with haemodynamic instability at centers where the interventional radiology staff is not in-house at all times.RegistrationClinicalTrials.gov (NCT02535624) and ISRCTN registry (ISRCTN91713422).     

CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma

BackgroundThe diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high.Patients and methodsBlunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR ≥ 1. CT findings, DPL and surgery results, and global outcome were analyzed.ResultsThirty-seven were included in the study (27 males, median age of 30 years (range, 17–69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p = 0.02) and small bowel wall abnormalities (p = 0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59–100]) and 43% (CI 95% [25–63]). The sensitivity remained 100% (CI 95% [59–100]) when the ratio was ≥4 (n = 10 patients), and the specificity reached 90% (CI 95% [73–98]).ConclusionDPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR ≥ 1. Indications for exploratory laparotomy could be restricted to patients with a CCR ≥ 4 to improve the specificity of diagnosis management.     

Case series of sphenoid wing meningioma - What is a maximal safe resection?

BackgroundSphenoid wing meningiomas are a challenging surgical disease with relatively high perioperative morbidity. Most studies to date have focused on resection strategies as it relates to disease recurrence. Few have examined the optimal strategy as it relates to overall patient survival. We retrospectively reviewed our case series and evaluated extent of resection and perioperative stroke as it relates to all cause and disease-specific survival.Patients/MethodsNinety-four patients were included in the study. Demographics, clinical features, operative features and clinical course, and time to mortality evaluation were collected. Extent of resection (EOR) was defined as gross total (GTR, 100%), near total (NTR, ≥ 95%), and subtotal (STR, < 95%).ResultsThe overall mean EOR was 94.5% with 70.2% of cases achieving GTR, 12.8% achieved NTR, and 17% achieved STR. Postoperative stroke only occurred with GTR or NTR (p = 0.041). Age alone was significant on Cox regression analysis for all cause mortality (p = 0.042, HR 1.054 [95% CI 1.002 – 1.109]). Postoperative stroke was associated with worse disease-specific mortality (p = 0.046, HR 23.337 [95% CI 1.052 – 517.782) with no impact from extent of resection (p = 0.258).ConclusionsAlthough maximizing resection and minimizing recurrence is ideal, GTR or NTR confer a significantly higher stroke risk. Most patients do not die from their meningioma, as all cause mortality was associated only with age. However, perioperative stroke conferred decreased survival throughout follow up. This series demonstrates that an overly aggressive surgical philosophy negatively impacted disease specific survival.