Mininvasive abdominal aortic surgery. Early recovery and reduced hospitalization after multidisciplinary approach

AIM: Clinical experience in gastrointestinal surgery demonstrated that a multimodal approach can improve the outcome and reduce the length of hospital stay. In this paper we investigate the impact of a multimodal clinical program, based on mininvasive surgery, epidural anesthesia and early feeding and mobilization, on postoperative morbidity and hospitalization after abdominal aortic surgery. METHODS: A 2-armed study was designed. All patients undergoing abdominal aortic surgery between May 2000 and April 2001 were enrolled in a multidisciplinary clinical program including thoracic epidural anesthesia and analgesia, left sub-costal minilaparotomy without evisceration, encouragement to feed and mobilize soon after surgery (Multidisciplinary group: n=82). For comparison purposes, a retrospective analysis was conducted using the data of all patients operated on between January and December 1997, receiving standard anesthesia care and a standard surgical and nursing program (Standard group: n=64). RESULTS: In the Multidisciplinary group we observed significantly better pain relief (p<0.01), earlier restoration of ambulation (p<0.01), earlier feeding (p<0.01) and passage of stools (p<0.01). The incidence of complications was significantly lower in the Multidisciplinary group: pulmonary (0% vs 14.1%), cardiac (2.4% vs 9.4% ) and gastrointestinal (0% vs 10.9%). None of the patients in the Multidisciplinary group required admission to Intensive Care. Median postoperative hospitalization was 3 days in the Multidisciplinary group compared to 9 days in the Standard group (p<0.01). CONCLUSION: These results suggest that a multidisciplinary intervention with review of the traditional surgical care program would enhance recovery, decrease morbidity and hospitalization after abdominal aortic surgery.     

L-arginine effects on myocardial stress in cardiac surgery: preliminary results.

BACKGROUND: L-arginine in addition to cardioplegia stimulates the release of nitric oxide and increases coronary blood flow, decreasing platelet activation and leukocyte adhesion. The aim of our study was to determine the feasibility and the efficacy of the addition of L-arginine to antegrade and retrograde blood cardioplegia in reducing myocardial damage and stress. METHODS: Twenty-eight consecutive patients who underwent coronary artery bypass grafting were randomized to receive 7.5 g of L-arginine in 500 ml of cardioplegic solution. To assess safety of use of L-arginine, hemodynamic evaluation was performed before sternum opening, at sternum closure, and 1 hour after arrival in the intensive care unit to measure cardiac index, systemic and pulmonary vascular resistances, and pulmonary capillary wedge pressure. Moreover, transesophageal echocardiography was performed to assess myocardial contractility. To determine the effects on myocardial stress, blood samples were taken from the retrograde coronary sinus catheter for lactate, interleukin (IL)-2 receptor, IL-6 and tumor necrosis factor (TNF)-alpha levels. Serum samples (preoperatively, 2, 18 and 42 hours after aortic cross-clamping removal) were also analyzed to measure creatine phosphokinase, creatine kinase-MB mass, cardiac troponin T, platelets, and leukocytes. RESULTS: We found statistical differences for IL-2 receptor, IL-6, TNF-alpha, platelets and leukocytes, in favor of the treated group, and decreasing trends in creatine kinase-MB mass and troponin T levels. CONCLUSIONS: The present study shows the positive effects of the addition of L-arginine to cardioplegia. Reduced IL-2 receptor, IL-6 and TNF-alpha indicate a decrease in myocardial stress. Safety of Larginine is related to lower values of systemic vascular resistances and pulmonary capillary wedge pressure observed in group A postoperatively that could improve the patient's outcome in terms of a reduced need for inotropic support. Moreover, the decrease in platelet and leukocyte count in the treated group might express a reduced no-reflow phenomenon and a better reperfusion, limiting endothelial injury from oxygen radical production.     

Intermittent clamping of the hepatic pedicle in simultaneous ultrasonography-guided liver resection and colorectal resection with intestinal anastomosis: is it safe?

Purpose

In patients with colorectal cancer (CRC) and synchronous colorectal liver metastases (CRLM) potentially candidates to combined liver (LR) and colorectal resection (CRR), the extent of LR and the need of hepatic pedicle clamping (HPC) in selected cases are considered risk factors for the outcome of the intestinal anastomosis. This study aimed to determine whether intermittent HPC is predictive of anastomotic leakage (AL) and has an adverse effect on the clinical outcome in patients undergoing combined restorative CRR and LR.

Methods

One hundred six LR have been performed for CRLM in our unit from July 2005. Patients who received CRR with anastomosis and simultaneous intraoperative ultrasonography (IOUS)-guided LR/ablation for resectable CRLM were included in this study. CRR was performed first. Intermittent HPC was decided at the discretion of the liver surgeon. The perioperative outcome was evaluated according to occurrence of AL and overall postoperative morbidity and mortality.

Results

Thirty-eight patients underwent simultaneous IOUS-guided LR/ablation and CRR with intestinal anastomosis; 19 underwent intermittent HPC (group ICHPY) while 19 did not (group ICHPN); the mean?±?SD (range) duration of clamping in group ICHPY was 58.6?±?32.2 (10.0–125.0)?min. Postoperative results were similar between groups. One asymptomatic AL occurred in group ICHPY (5.2 %). Major postoperative complications were none in group ICHPY and one (5.2 %) in group ICHPN, respectively. One patient in group ICHPY died postoperatively (5.2 %).

Conclusions

This study suggests that intermittent HPC during LR is not predictive of AL and has no adverse effect on the overall clinical outcome in patients undergoing combined restorative colorectal surgery and hepatectomy for advanced CRC.     

Emergency endovascular treatment of acute symptomatic or ruptured abdominal aortic aneurysm: a single-center experience

The purpose of this study is to report our early experience with endovascular treatment of patients with symptomatic non-ruptured (sAAA) or ruptured (rAAA) abdominal aortic aneurysms. Between September 2005 and September 2008, all patients with a diagnosis of sAAA or rAAA were evaluated for endovascular suitability. We did not consider hemodynamic instability to be a contraindication for endovascular aneurysm repair (EVAR). Patients whose aneurysm anatomy was not suitable for EVAR received open repair (OR). A total of 46 patients with sAAA or rAAA underwent emergency EVAR: in particular, 18/46 patients were treated for sAAA and 28/46 for rAAA. Successful stent-graft deployment was achieved in 44 patients (96%); we had two open surgical conversions. The 30-day mortality rate was 19.5%. Nine patients died during the first 30 postoperative days: four patients died within 24 hours because of severe hypovolemic shock, two died of respiratory failure, one died as a result of bowel ischemia and two because of myocardial infarction after hospital discharge. Complete follow-up data were available for 35 patients (median 185 days; range 30-730 days). In conclusion, endovascular treatment is feasible and the early experience is promising. The capability of offering EVAR and OR for sAAA and rAAA according to our experience suggests that EVAR and OR should be regarded as complementary techniques to improve outcome of patients with acute AAA.     

Laparoscopic Division of a Portosystemic Shunt for Recurrent Life-Threatening Rectal Variceal Bleeding: Report of a Case

In patients with severe portal hypertension related to liver cirrhosis, recanalization of umbilical veins may lead to both development and rupture of massive anorectal varices. In this setting, while transjugular intrahepatic portosystemic shunt (TIPS) is considered as the treatment of choice, the management of these patients remains unclear in case of contraindications to TIPS. Laparoscopic division of massive portosystemic shunts has been reported to yield beneficial effects in patients with isolated hepatic encephalopathy but has never been attempted in a context of life-threatening lower gastrointestinal bleeding. In the present case report, we both describe the operative technique of laparoscopic division of recanalized umbilical veins to treat recurrent massive haemorrhage following rupture of giant rectal varices in a 68-year-old Child C cirrhotic patient contraindicated to TIPS and report the postoperative course of the patient.     

Antigen-specific oligoclonal IgG in AIDS-related cytomegalovirus and toxoplasma encephalitis

Objective — We retrospectively studied serum and cerebrospinal fluid (CSF) specimens from AIDS patients with either Cytomegalovirus (2 cases) or Toxoplasma gondii (5 cases) encephalitis. The samples, which had previously proved to be negative for total IgG oligoclonal bands (OCBs), were investigated for antigen-specific OCBs directed to the disease-related opportunistic agent. Material & methods — Paired serum and CSF samples from the given AIDS patients were considered. We undertook affinity immunoblotting of either virus- or protozoan-specific IgG onto antigen-coated nitrocellulose paper after protein separation by agarose isoelectric focusing (IEF). Results — Antigen-specific OCBs to the disease-related opportunistic agent were detected in serum and in CSF samples from all the patients. Conclusions — During overt AIDS, routine IEF methods may fail to detect OCBs, probably because nonspecific polyclonal hypergammaglobulinemia, which is typical of this disease, reduces their visibility. Our IEF/immunoblotting profiles are characterized by identical serum and CSF bands. The detection of antigen-specific OCBs may support the diagnosis of some opportunistic infections of the central nervous system in AIDS.