Comparison of modified rapid deployment hemostat dressing with standard haemostat as part of standardized perihepatic packing for major liver trauma in a level 1 trauma center

Introduction

Uncontrolled hemorrhage is a major cause of mortality in surgery and trauma. Damage control surgery (DCS) is essential in the management of these cases. The use of topical hemostatic agents has increased over the last two decades with the evolution of DCS and trauma-induced coagulopathy. The aim of this study was to compare the performance of standard perihepatic packing with the addition of either a MRDH (modified rapid deployment hemostat) or a non-MRDH hemostatic dressing.

Methods

This was a retrospective, comparative analysis of prospectively collected data held in the registry of a level I trauma center in Bologna, Italy, between 2005 and 2019. 33 patients with grade IV/V liver injuries who underwent a standardized perihepatic packing with hemostatic dressings were enrolled in the study. The study group included 21 patients treated with standard packing plus MRDH. The control group included 12 patients treated with standard packing plus a combination of fibrillar absorbable hemostat and human fibrin sealant.

Results

The two groups were homogeneous in terms of age and American Association for the Surgery of Trauma (AAST) grade although the MRDH one seemed to have more severe injury: hemodynamic instability was present in 95% of MRDH patients vs. 83% in the control group. Also, Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 41 vs 35.5 and 47 vs 39.1, respectively. The incidence of re-bleeding requiring repacking at the second-look laparotomy was 4.7% in MRDH patients vs. 16.7% in non-MRDH patients ( p = .5, OR = 4). The overall complication rate was of 23% after the introduction of MRDH vs. 81% in the control group.

Conclusion

Despite the potential effectiveness of MRDH, this study does not seem to confirm a significant superiority of this hemostat over the standard.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

What is the treatment of tracheal lesions associated with traditional thyroidectomy? Case report and systematic review

Aim

The aim of this study is to review the literature focusing on various treatments based on time of tracheal injury and on different surgeons' personal experience.

Methods

We retrospectively reviewed all cases of total thyroidectomy performed at the University Surgical Department of Ospedali Riuniti of Foggia from 2006 to 2017. Only a single case of tracheal lesion due to traditional total thyroidectomy was found. An extensive search of the relevant literature was carried out using MEDLINE (PubMed). We included articles that reported article type, patient number, sex, age, reasons for surgery, time of tracheal perforation intraoperatively or delayed rupture, symptoms, diagnosis, type of surgical procedure, pathological report and follow-up.

Results

A total of 156 published studies were screened from the sources listed. Of these, 15 studies were included in the present study. We introduced our case in the analysis. A total of 16 patients were totally analysed. There were seven males (43.7%) and seven females (43.7%), and for two patients, gender was not available. The mean patient age was 41.6 years.

Conclusions

The literature review showed very few cases treated differently. However, it would be good to standardise treatments. Tracheal perforation, if encountered, needs to be managed appropriately in centres of expertise with a high volume of thyroidectomies.

One stage surgery for synchronous liver metastasis from a neuroendocrine tumor of the colon. A case report

INTRODUCTION

Neuroendocrine tumors (NETs) are a heterogeneous group of tumors. NET of colon represent less than 1% of colonic tumors. Synchronous liver metastases, present in 75-80%, are considered significant adverse prognostic indicators. Liver is the second commonest site for metastasis in patients with colorectal neuroendocrine tumors. Available treatment options include surgical resection, chemotherapy, biotherapy. Surgery is the gold standard for curative therapy and it is strictly related to the localization, the grade of tumor, and the stage of disease.

CASE REPORT

We present a 64-year-old man with clinical carcinoid syndrome. Colonoscopy revealed ileocecal valve vegetating mass with negative biopsy. CT scans of thorax and abdomen showed a voluminous lesion (10 cm of diameter) of right liver. CEA, CA 19.9 and aFP were all normal. Only urinary 5HIAASerum 5-hydroxyindoleactic acid and blood Chromogranin A were positive. Surgical strategy was to treat the primary tumor and the liver synchronous metastasis in one stage surgery.

DISCUSSION

Management of NETs liver metastases is challenging and requires aggressive therapy. Currently, there are many therapeutic options for metastatic NETs. Although complete surgical resection remains the optimal therapy and aggressive surgical resection increases the 5-year survival of NETs with solitary liver metastasis to 100%. In this case, clinical status with doubt of carcinoid syndrome was essential for diagnosis and for subsequent surgical strategy with one stage surgery.

CONCLUSION

Resection of the primary tumor, liver metastases, and local mesenteric lymph node metastases is thought to strictly promote long-term survival and quality of life. Typically, a multidisciplinary approach is a cornerstone for decision making while dealing with this aggressive disease.

KEY WORDS

Carcinoid syndrome, Liver surgery, NETs, Neuroendocrine tumor, One stage surgery, Synchronous liver metastasis.

Triple peptide vaccination as consolidation treatment in women affected by ovarian and breast cancer: Clinical and immunological data of a phase I/II clinical trial

Vaccination with priming and expansion of tumour reacting T cells is an important therapeutic option to be used in combination with novel checkpoint inhibitors to increase the specificity of the T cell infiltrate and the efficacy of the treatment. In this phase I/II study, 14 high-risk disease-free ovarian (OC) and breast cancer (BC) patients after completion of standard therapies were vaccinated with MUC1, ErbB2 and carcinoembryonic antigen (CEA) HLA-A2+-restricted peptides and Montanide. Patients were subjected to 6 doses of vaccine every two weeks and a recall dose after 3 months. ECOG grade 2 toxicity was observed at the injection site. Eight out of 14 patients showed specific CD8+ T cells to at least one antigen. None of 4 patients vaccinated for compassionate use showed a CD8 activation. An OC patient who suffered from a lymph nodal recurrence, showed specific anti-ErbB2 CD8+ T cells in the bulky aortic lymph nodes suggesting homing of the activated T cells. Results confirm that peptide vaccination strategy is feasible, safe and well tolerated. In particular OC patients appear to show a higher response rate compared to BC patients. Vaccination generates a long-lasting immune response, which is strongly enhanced by recall administrations. The clinical outcome of patients enrolled in the trial appears favourable, having registered no deceased patients with a minimum follow-up of 8 years. These promising data, in line with the results of similar studies, the high compliance of patients observed and the favourable toxicity profile, support future trials of peptide vaccination in clinically disease-free patients who have completed standard treatments.

Use of an intrauterine inflated catheter balloon in massive post-partum hemorrhage: a series of 52 cases

AIM

Massive post-partum hemorrhage (PPH) is an important cause of maternal death that occurs as a complication of delivery. We report a large case series to evaluate the efficacy of uterine balloon tamponade to treat PPH avoiding hysterectomy.

MATERIAL AND METHODS

This prospective study was conducted in two Italian hospitals (from December 2002 to July 2012). Fifty-two patients with PPH not responsive to uterotonics were treated by Rusch balloon. A follow-up was conducted among the study population to assess the subsequent fertility.

RESULTS

The most frequent cause of PPH was atony (59.6%), followed by placenta previa (21.2%), placenta accreta (9.6%), and placenta previa and accreta (9.6%). The balloon success rate to control hemorrhage was 75%. From the sample of 52 patients, 13 patients needed additional procedures. In three failure cases, other conservative techniques were used and the overall effectiveness of them was 80.7%. The follow-up group consisted of 31 women. Of these women, 24 women (77.4%) had no further pregnancies, but only one due to sterility. Four of seven patients with subsequent pregnancies made it to term without complications.

CONCLUSIONS

The Rusch balloon is effective in controlling non-traumatic PPH in 75% of cases. It is simple to use, readily available and cheap. If necessary, this technique does not exclude other procedures. We suggest that this balloon should be included routinely in the PPH protocol.

Targeted drug delivery via folate receptors in recurrent ovarian cancer: a review

Ovarian cancer is the most common cause of gynecological cancer-related mortality, with the majority of women presenting with advanced disease; although chemotherapeutic advances have improved progression-free survival, conventional treatments offer limited results in terms of long-term responses and survival. Research has recently focused on targeted therapies, which represent a new, promising therapeutic approach, aimed to maximize tumor kill and minimize toxicity. Besides antiangiogenetic agents and poly (ADP-ribose) polymerase inhibitors, the folate, with its membrane-bound receptor, is currently one of the most investigated alternatives. In particular, folate receptor (FR) has been shown to be frequently overexpressed on the surface of almost all epithelial ovarian cancers, making this receptor an excellent tumor-associated antigen. There are two basic strategies to targeting FRs with therapeutic intent: the first is based on anti-FR antibody (ie, farletuzumab) and the second is based on folate–chemotherapy conjugates (ie, vintafolide/etarfolatide). Both strategies have been investigated in Phase III clinical trials. The aim of this review is to analyze the research regarding the activity of these promising anti-FR agents in patients affected by ovarian cancer, including anti-FR antibodies and folate–chemotherapy conjugates.

Nonabsorbable suture granuloma mimicking ovarian cancer recurrence at combined positron emission tomography/computed tomography evaluation: a case report

Introduction

This is the first case of suture granuloma mimicking isolated ovarian cancer relapse. Only six analogous cases have been previously reported in other malignancies.

Case presentation

We report the case of a 44-year-old Caucasian woman with partially platinum-sensitive ovarian cancer in which radiological features, including computed tomography and combined ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography, were strongly suggestive of isolated cancer relapse in her right subdiaphragmatic region. Laparoscopic examination resulted negative, but was not completely suitable due to widespread adhesive syndrome. The laparotomy for secondary cytoreductive surgery and biopsy of the suspected area showed inflammatory granuloma caused by nonabsorbable propylene suture, without evidence of neoplastic cells. Moreover, unexpected peritoneal carcinosis was found.

Conclusions

This evidence suggests that clinical details about previous surgical procedures are necessary for adequate interpretation. Although much progress has been made in imaging techniques, especially in the promising field of combined ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography, these procedures should be still thoroughly investigated in order to promptly rule out tumor recurrence and avoid unnecessary surgery.

Urinary desmosine excretion in acute exacerbations of COPD: a preliminary report

Desmosine (DES) is an elastin-derived, cross-link amino acid, which is not metabolized; hence, its urinary levels reflect elastin breakdown. We hypothesized that elastin degradation should increase as a result of increased lung inflammation during an acute exacerbation of COPD and should decrease after recovery. To test this hypothesis we measured DES in three urine samples from nine COPD subjects during the first 5 days of an acute exacerbation and at 2 months after recovery. We also measured forced expiratory volume in 1 sec (FEV1) to monitor the effects ofthe exacerbation on ventilatory function. The mean (SD) FEV1 was 45 (15)% predicted during the exacerbation and 57.8 (16)% predicted 2 months later (P=0.00001). The mean (SD) DES excretion was 25.3 (9) microg g(-1) creatinine at day 1;23.5 (9) at day 3 and 24 (9) at day 5 of the exacerbation. The mean (SD) urinary DES excretion 60 days after discharge was 20.9 (7) microg g(-1) creatinine (P=0.049) in comparison with the mean of the three acute-phase values. The size of the increase in desmosine excretion during exacerbation is small, 3.2 microg g(-1) creatinine or 16% of the recovery desmosine value. We conclude that there is a small but statistically significant increase in lung elastin breakdown in the body during an acute exacerbation of COPD.