The surgeon's approach to preoperative evaluation of esophageal cancer: recent developments

Esophageal resection for cancer is still associated with high morbidity and mortality. Postoperative complications may be either patient- or surgeon-related. Patient-related factors include age, malnutrition, immunodepression and associated diseases. Surgeon-related factors are surgical experience, hospital volume and multidisciplinary approach. In the last 20 years major improvements and new technologies have been proposed and applied in esophageal surgery: its evolution depended on a thorough knowledge of surgical anatomy and technique, as well as on important developments in pre- and postoperative care. Preoperative evaluation is defined as the process of clinical assessment that precedes the induction of anesthesia. The principle is to gain information about the patient that could lead to modify his/her management, and improve outcome.     

Bilateral ureteral compression by multiple abdominal desmoid tumors in Gardner syndrome: case report and literature review

A 28-year-old man with Gardner syndrome was admitted to our Department because of multiple abdominal masses. Abdominal computed tomography revealed severe hydronephrosis of both kidneys due to ureteral compression against the pelvic bones exerted by multiple solid abdominal masses. The patient developed oligoanuria. Right percutaneous nephrostomy tube placement was followed by restoration of diuresis and progressive recovery of renal function of the left side. The patient then underwent median laparotomy and removal of five large desmoid tumors originating from the abdominal wall. Bilateral ureteral obstruction due to abdominal desmoid tumors can be a rare urologic complication of Gardner syndrome.     

Robotic‐Assisted Laparoscopic Donor Nephrectomy with Transvaginal Extraction of the Kidney

Transvaginal recovery of the kidney has recently been reported, in a donor who had previously undergone a hysterectomy, as a less‐invasive approach to perform laparoscopic live‐donor nephrectomy. Also, robotic‐assisted laparoscopic kidney donation was suggested to enhance the surgeon's skills during renal dissection and to facilitate, in a different setting, the closure of the vaginal wall after a colpotomy. We report here the technique used for the first case of robotic‐assisted laparoscopic live‐donor nephrectomy with transvaginal extraction of the graft in a patient with the uterus in place. The procedure was carried out by a multidisciplinary team, including a gynecologist. Total operative time was 215 min with a robotic time of 95 min. Warm ischemia time was 3 min and 15 s. The kidney was pre‐entrapped in a bag and extracted transvaginally. There was no intra‐ or postoperative complication. No infection was seen in the donor or in the recipient. The donor did not require postoperative analgesia and was discharged from the hospital 24 h after surgery. Our initial experience with the combination of robotic surgery and transvaginal extraction of the donated kidney appears to open a new opportunity to further minimize the trauma to selected donors.     

Differential diagnosis of hematoma, pulsating hematoma and pseudoaneurysm of the femoral artery using color Doppler

Color Doppler and Duplex Doppler US were employed on 4 patients with clinically suspected pseudoaneurysms as a complication of femoral artery puncture after cardiac catheterization. Pseudoaneurysms were identified with Color Doppler US and their typical appearance was confirmed. The grey-scale findings did not allow an adequate differentiation between hematoma and pulsed hematoma without fibrous encapsulation: only Color Doppler US easily detected the track between damaged artery and blood collection and allowed a sample to be obtained for pulsed Doppler examination. Color Doppler US allowed an accurate and non-invasive diagnosis of groin masses after femoral artery catheterization.     

Early Versus Delayed Source Control in Open Abdomen Management for Severe Intra-abdominal Infections: A Retrospective Analysis on 111 Cases

Background

Time to source control plays a determinant prognostic role in patients having severe intra-abdominal infections (IAIs). Open abdomen (OA) management became an effective treatment option for peritonitis. Aim of this study was to analyze the correlation between time to source control and outcome in patients presenting with abdominal sepsis and treated by OA.

Methods

We retrospectively analyzed 111 patients affected by abdominal sepsis and treated with OA from May 2007 to May 2015. Patients were classified according to time interval from first patient evaluation to source control. The end points were intra-hospital mortality and primary fascial closure rate.

Results

The in-hospital mortality rate was 21.6% (24/111), and the primary fascial closure rate was 90.9% (101/111). A time to source control ≥6 h resulted significantly associated with a poor prognosis and a lower fascial closure rate (mortality 27.0 vs 9.0%, p = 0.04; primary fascial closure 86 vs 100%, p = 0.02). We observed a direct increase in mortality (and a reduction in closure rate) for each 6-h delay in surgery to source control.

Conclusion

Early source control using OA management significantly improves outcome of patients with severe IAIs. This damage control approach well fits to the treatment of time-related conditions, particularly in case of critically ill patients.

     

Time interval in diagnosis and treatment of papillary thyroid cancer: a descriptive, retrospective study

Background

Studies have investigated delays in the diagnosis of neoplasms to identify delays to treatment on the part of patients and primary care practitioners. The aim of the current study was to evaluate the time interval (TI) required for the diagnosis of symptomatic papillary thyroid carcinoma (PTC).

Methods

The study included 97 patients with PTC. Other histologic types and incidental microcarcinomas were excluded. The primary outcome variable was the TI between the occurrence of a sign/symptom and thyroidectomy. TI was composed of: patient's TI (PTI), diagnostic TI (DTI), and therapeutic TI (TTI).

Results

The TI between the occurrence of a sign/symptom and thyroidectomy averaged 3 months. PTI ranged from 25-85 days, DTI from 12-40 days, and TTI from 7-30 days. PTI was higher (P < .05) than DTI and TTI.

Conclusion

PTI is the most important factor affecting TI. Implementation of information may increase patient's alertness and reduce misinterpretation of signs/symptoms. Collaboration between specialists is fundamental to further reduce DTI and TTI.     

Unique vascular tumor primary arising in the liver and exhibiting histopathological features consistent with so‐called polymorphous hemangioendothelioma

Reported herein is an unusual vascular tumor primary arising in the liver and exhibiting unique histopathological features. A 47‐year‐old woman underwent left hepatectomy because of a large hepatic mass. On histology the tumor had a composite pattern, consisting of angiomatous, retiform and solid areas, formed by oval to cuboidal to spindle cells, that expressed only endothelial markers (CD31 and factor VIII‐related antigen). These findings led to the diagnosis of a low‐grade vascular neoplasm with morphological features consistent with so‐called polymorphous hemangioendothelioma. The tumor was completely resected. At 24 month follow up the patient was alive, without evidence of disease. Polymorphous hemangioendothelioma is a rare vascular neoplasm, with borderline malignant potential, which usually occurs in lymph nodes and, rarely, at extranodal sites. Its classification as an entity has been questioned recently. The unusual morphological features of the present case, which do not fit neatly with any other recognized hemangioendothelioma subtype, indicate that the family of vascular tumors is broader than currently accepted. In addition the present case widens the spectrum of primary vascular tumors arising in the liver.     

The influence of alexithymia on persistent symptoms of dyspepsia after laparoscopic cholecystectomy

OBJECTIVE: The aim of this study was to evaluate whether preoperative alexithymia might play a role in the persistence of gastrointestinal symptoms after laparoscopic cholecystectomy. METHODS: A sample of 52 consecutive patients with gallstone disease and symptoms of dyspepsia were assessed with validated scales for alexithymia (20-item Toronto Alexithymia Scale), and psychological (90-item Symptom Checklist) and gastrointestinal (GI) (Gastrointestinal Symptom Rating Scale) symptoms before surgery. GI symptoms were evaluated also one year after surgery. Change from preoperative to postoperative GI symptoms and level of GI symptoms after surgery were used to form groups of improved (n = 31) and unimproved (n = 21) patients. RESULTS: Unimproved patients had significantly higher preoperative alexithymia, psychological distress, and gastrointestinal symptom scores than patients who had improved. Regression analyses showed that alexithymia predicted the persistence of gastrointestinal symptoms more strongly than did psychological distress, even after controlling for preoperative gastrointestinal symptoms. CONCLUSION: Alexithymia played a substantial and predictive role in the persistence of GI symptoms in gallstone patients after surgery. Treatment planning and outcome of gallstone disease might be improved by preoperative assessment of alexithymia.     

An innovative percutaneous technique for the removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE) in the management of malignant billiary occlusions

PURPOSE: The purpose of this study was to assess the feasibility and clinical impact of the percutaneous removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE). MATERIALS AND METHODS: Over a period of 24 months, we observed eight patients (age 54-82 years; mean 65) with dysfunctioning PBE. After transhepatic cholangiography and bile duct catheterisation, the endoprostheses were grasped with a gooseneck snare and pushed into the duodenum using a long introducer sheath. Subsequently, we implanted six metallic stents in middle and distal occlusions and four plastic endoprostheses in two patients with proximal occlusion. Clinical and ultrasound followup was performed 1, 3 and 6 months after the procedure and then yearly. RESULTS: The procedure was technically successful in all patients. No major complication occurred. All patients were discharged without biliary drainage catheters. During the follow-up period (mean: 7.1 months), four patients died and two occlusions of metallic stents were treated by implanting a further metallic stent. CONCLUSIONS: Percutaneous removal of a dysfunctioning PBE is feasible and allows better quality of life owing to the absence of biliary drainage. Patency of metallic stents is higher than that of PBE. Larger studies are clearly required to validate this approach.