Emergency surgery during the COVID-19 pandemic: what you need to know for practice

INTRODUCTION

Several articles have been published about the reorganisation of surgical activity during the COVID-19 pandemic but few, if any, have focused on the impact that this has had on emergency and trauma surgery. Our aim was to review the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic.

METHODS

A systematic review was conducted of the most relevant English language articles on COVID-19 and surgery published between 15 December 2019 and 30 March 2020.

FINDINGS

Access to the operating theatre is almost exclusively restricted to emergencies and oncological procedures. The use of laparoscopy in COVID-19 positive patients should be cautiously considered. The main risk lies in the presence of the virus in the pneumoperitoneum: the aerosol released in the operating theatre could contaminate both staff and the environment.

CONCLUSIONS

During the COVID-19 pandemic, all efforts should be deployed in order to evaluate the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. If surgery is deemed necessary, the emergency surgeon must minimise the risk of exposure to the virus by involving a minimal number of healthcare staff and shortening the occupation of the operating theatre. In case of a lack of security measures to enable safe laparoscopy, open surgery should be considered.

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Ultrasound and thyroiditis in patient candidates for thyroidectomy

AIM

Thyroiditis is often associated with nodules based on the Bethesda classification system, and the presence of thyroiditis can make thyroid surgery difficult using both conventional techniques and minimally invasive videoassisted approaches (MIVAT).

METHODS

We analyzed 326 patients who underwent total thyroidectomy in 2012. We collected all data in dedicated database. The patients were divided in 4 groups: group 1 no affected by thyroiditis, group 2 affected by thyroiditis, group 3 only histological diagnosis of thyroiditis, group 4all patients affected by thyroiditis.

RESULTS

Group 1 included 201 cases, group 2 included 64 patients, group 3 included 61 patients. No statistically significant difference between group 2 and 3 about Ultrasound (US) examination. Statistically significant difference in incidence of "THYR 3-4" between group 1 and group 4. No differences in MIVAT vs. Conventional group.

CONCLUSION

US examination of the thyroid is essential for the diagnostic study of the gland also in the selection of a surgical approach. Thyroiditis is a relative contraindication to MIVAT but the experience of the endocrine surgeon is the most important factor to reduce intra and postoperative complications together a correct collaboration in multidisciplinart endocrinological team.

Schwannoma mimicking a neoplastic thyroid nodule

Schwannoma is a rare benign tumor of nerve fibers that originates from neuronal sheath cells; it is frequently located extramedullary and about 25-45 % of this type of neoplastic lesion is localized in the head and in the neck. Primary schwannoma of the thyroid gland is very uncommon. We report the case of a 50-year-old female patient affected by schwannoma of the thyroid gland underwent total thyroidectomy for nodule of the left lobe suspicious for neoplasm, without complications.

Use of oxidized and regenerated cellulose in thyroid surgery: a prospective analysis as cause of postoperative hypocalcemia on 485 patients consecutively treated

AIM

The intraoperative hemorrage determines an higher risk of parathyroid glands lesions, and laryngeal nerve injuries. We have examined if the use of oxidized and regenerated cellulose could be a cause of postoperative hypocalcemia because of the compression on the parathyroid glands or for tissue adhesions

METHODS

From June 2009 to December 2010 we have examined 485 patients consecutively treated with total thyroidectomy. The cases examined were divided in two groups on the use of ionized cellulose (group A and B). 24 hours after surgical procedure, all patients were submitted to serum calcium evaluation. The data were analyzed with χ2 test and t-student test; P<0.05 was statistically significant.

RESULTS

We have selected 372 cases out of 485 examined. We have registered after 10 hours from surgical procedure a case of hemorrhage with reintervention in group B (no use of cellulose). The cost of ionized cellulose is € 46; we have used this device in 212 cases on 372 patients undergone to total thyroidectomy, with a cost of € 9 752. The mean value of the serum calcium was statistically different between pre- and postoperative evaluation in all cases (P<0.0001) divided both on gender and on the use of hemostatic devices.

CONCLUSION

In our experience, there isn't a statistically significant difference on incidence of postoperative hypocalcemia, related to use of ionized and regenerated cellulose on mean surgical time in all patients either treated with traditional surgery or with video-assisted procedure.

Right colon laparoscopic resection with three-trocar access and associated gynecological procedures in patients with colorectal cancer and ovarian metastases

BACKGROUND

Right laparoscopic colectomy was introduced to colorectal surgery later than the left colon procedure. Three-trocar laparoscopy has already been used successfully in the treatment of gynecological cancers. In the present study, we aimed to analyze the feasibility of performing an associated gynecological procedure following abdominal laparoscopic exploration and to evaluate the suitability of laparoscopic right colectomy for treating elderly patients.

METHODS

We conducted a review of prospectively collected data on 100 consecutive patients who were treated with right laparoscopic colectomy using three trocars from January 2005 to April 2010. We recorded the patients' age (<70 or > 70 years), ASA status, body mass index (BMI), pain on postoperative days 1 and 2 (POD 1, 2), nodes retrieved, laparotomic conversion, mean operative time, time to intestinal recovery, and length of postoperative stay.

RESULTS

All subjects were treated for cancer. Conversion to the laparotomic procedure was performed in 13/100, with no difference in terms of age. Operative time was longer for laparotomic conversion (p <0.05), with a longer postoperative stay. Elderly patients had higher ASA scores (p < 0.005); age did not influence the conversion rate or BMI status. Pain on POD 1 and 2 differed between the laparotomic and laparoscopic groups (p <0.0001). Associated procedures were performed in five subjects (3 oophorectomy and 2 cholecystectomy).

CONCLUSIONS

Laparoscopy using the three-trocar technique is a safe procedure for treating colon cancer, including in elderly patients, and enables associated gynecological laparoscopic procedures to be performed.

Extracoronary atherosclerosis and genetic variants of apolipoprotein AI-CIII cluster in myocardial infarction survivors from southern Italy

The relationships between some genetic markers, as evaluated by DNA analysis, and ultrasound evidence of extracoronary athero-sclerosis, as detected by ultrasound methods, were evaluated in 39 myocardial infarction survivors of middle age and in 40 healthy controls of comparable age. Coronary heart disease (CHD) patients showed higher levels of triglycerides (P = 0.01) and greater number of exsmokers (P = 0.004). Carotid stenoses (> 15%) were detected in ten CHD patients and in two controls; iliac stenoses (> 15%) or abnormal ankle/arm ratio (< 0.97) were found in ten CHD patients and in one control; the scores of vascular disease severity in the myocardial infarction survivors were higher (Mann-Whitney test) than in controls (P < 0.01). Molecular genetic analysis of SstI restriction fragment length polymorphism (RFLP) of the apolipoprotein (apo) AI-CIII cluster and of the apo B gene demonstrated a higher frequency of the S2 allele (SstI RFLP) in coronary patients than in controls (P = 0.04) and no significant differences in the frequencies of XbaI RFLP of the apo B gene between patients and controls. The relative risk of myocardial infarction associated with an abnormal vascular score (> 8) or with the presence of the rare allele S2 (SstI apo AI-CIII polymorphism) was estimated by odds ratios. The lower 95% limits of odds ratios were above 1 (indicating significant increase in the relative risk of myocardial infarction) both in the case of vascular score and that of SstI RFLP. These associations were independent of one another and of triglyceride levels. SstI RFLP association with CHD disappeared after adjustment for smoking habits.(ABSTRACT TRUNCATED AT 250 WORDS)

Early signs of carotid and iliac atherosclerosis in patients with severe hyperlipoproteinemia

Hyperlipidemia is a major risk factor for atherosclerosis. Early signs of cardiovascular disease can be detected also in asymptomatic patients with hyperlipidemia. Forty-four patients with serum cholesterol greater than 300 mg/dl (7.8 mmol/l) and/or serum triglycerides greater than 500 mg/dl (5.6 mmol/l) and 35 healthy controls had their carotid and iliac arteries examined by echo-Doppler with spectral analysis. Systolic ankle pressure was also measured. A vascular score was calculated: a 0 score was assigned to normal findings and a 1 score for each artery with abnormality at echo-Doppler or Winsor index less than 0.97. The XbaI Restriction Fragment Length Polymorphism of Apo B gene was investigated in all hyperlipidemic patients. Arterial lesions, especially those of internal carotid and iliac arteries, were more frequent (p less than 0.01) in patients with high serum lipids, compared to controls. Patients with lesions were older and had higher serum triglyceride concentrations compared to those without lesions. When divided according to serum triglycerides, patients with concentrations exceeding 200 mg/dl had higher vascular score (p less than 0.02) compared to those with serum triglycerides less than 200 mg/dl. No difference in restriction fragment length polymorphism (XbaI) of Apo B gene was demonstrated in patients with arterial lesions compared to those without lesions. Non-invasive echo-Doppler examination gives useful information on the arterial involvement of hyperlipidemic patients and its use should therefore be implemented, especially when high triglyceride concentrations are present.

Mechanism of arachidonic acid transport across rabbit distal colonic mucosa

The initial rate of [1-14C]arachidonic acid (AA) entry in the serosal side of rabbit distal colonic mucosa mounted in Ussing-type chambers is linear and independent of intracellular metabolism. When the maximal AA uptake was plotted as a function of medium AA concentration in ranges between 50 and 500 nM, saturation of the AA uptake with increasing concentrations was observed. The time course of the uptake of oleic acid and palmitic acid was similar to that observed with AA, and their separate addition to incubation medium strongly reduced the AA uptake. The influx of arachidonate was largely inhibited by ouabain and by incubation with mucosal sodium-free solution and amiloride, while it was increased when colonic mucosa was exposed to luminal amphotericin B. However, voltage-clamp studies showed that the AA entry rate appeared to be linearly related (r = 0.99) to transepithelial potential difference (PD) and suggested that the sodium dependence of AA translocation is an indirect effect of the changes in transepithelial PD induced by sodium transport shifts. These features provide evidence that there is a common entry pathway for AA and other long-chain free fatty acids mediated by a mechanism of facilitated diffusion driven by transmembrane PD.

Arachidonic acid metabolites and chloride secretion in rabbit distal colonic mucosa

The relationships between arachidonic acid (AA) metabolism and chloride secretion were investigated in mucosal preparations of rabbit distal colon. Tissues displayed a significant cyclooxygenase activity already in nonstimulated conditions and incubation with exogenous AA and calcium ionophore A23187 produced a predominant prostaglandin F2 alpha (PGF2 alpha) profile [PGF2 alpha greater than PGE2 greater than thromboxane B2 (TxB2) greater than 6-keto-PGF1 alpha] as assessed by HPLC of tissue homogenates, whereas 5-hydroxy-6,8,11,14-eicosatetraenoic acid (5-HETE) was not detected in AA- or A23187-stimulated tissues. Radioimmunological assays showed that PGE2 synthesis was time dependent, plateaued at 10 min, and proceeded at rates 15-20 times over TxB2 and 6-keto-PGF1 alpha. Among the PGs produced by colonic mucosa, only PGE2 and, to a lower extent, PGF2 alpha were found to stimulate chloride secretion and cAMP synthesis. Pretreatment with 10 microM 5,8,11,14-eicosatetraynoic acid, a cyclo- and lipoxygenase inhibitor, prevented AA-induced chloride secretion and PG and cAMP synthesis with the same strength as the cyclooxygenase inhibitor indomethacin. No effects were found after preincubation with nordihydroguaiaretic acid, a lipoxygenase blocker with moderate cyclooxygenase inhibitory properties, and caffeic acid, a lipoxygenase inhibitor. 5-HETE (5 microM) had no effect on short-circuit currents (Isc) and chloride transport, but it significantly reduced the increase in Isc, chloride secretion, and PGE2 synthesis elicited by AA or A23187. Platelet-activating factor, reported to stimulate rabbit colon Isc through an indomethacin-sensitive pathway, was not detected at concentrations as low as 10(-10) M.

Diabetes mellitus and localizations of obliterating arterial disease of the lower limbs

Thirty patients with intermittent claudication (IC) and treated diabetes mellitus and 30 age- and gender-matched nondiabetic claudicants underwent a vascular examination by noninvasive ultrasound methods (continuous-wave Doppler, duplex scanner). The ankle/arm systolic pressure index did not differ in the two groups. Diabetic patients with IC had more (p less than .001) non-flow-reducing stenoses (lumen reduction less than 50%) and fewer (p less than .002) flow-reducing obstructions (lumen reduction greater than 50%) of the iliac arteries than nondiabetics had. These data are consistent with a preferentially distal (below the inguinal ligament) localization of arterial stenoses in diabetic patients, whereas iliac artery diseases are relatively more severe in nondiabetics.

[Proposed scoring system for the early diagnosis of infection in neonates]

Infections are currently often responsible for neonatal morbidity and mortality. The present study examines the possibility of reducing this incidence by the early diagnosis of infections. With this in mind the early clinical signs of infection were examined as well as the results of certain quickly and easily performed blood and blood chemical tests which were scored from 0 to 2. The results showed that newborns with scores less than 5 should be considered free of sepsis, those scoring 5-7 should arouse suspicion of sepsis, while sepsis should be considered definitely present in those scoring greater than 7. This scoring system presented 100% sensitivity, 88.2% specificity as well as 100% positive and an 88.2% negative predictive value. The system is therefore considered reliable as well as easy to use.

Adrenergic blocking agents and lipoprotein lipase activity

Lipoprotein lipase activity, total serum cholesterol and triglycerides, HDL cholesterol were determined before and after two weeks of treatment with a low dose of an alpha 1-blocking agent (prazosin) or of a beta-adrenergic-blocking drug (metoprolol). Lipoprotein lipase activity was almost doubled after prazosin (p less than 0.02) and practically unchanged after metoprolol, at a time and at a drug dosage when only minor changes in blood pressure and serum lipids were detectable. HDL cholesterol was slightly but significantly increased after prazosin (p less than 0.05). Heart rate was increased after prazosin (p less than 0.05) and decreased after metoprolol (p less than 0.01).

Extracoronary atherosclerosis in familial hypercholesterolemia

Sixty-two patients (31 males, 31 females) with familial hypercholesterolemia (FH) underwent a vascular examination by Doppler ultrasound. The ankle/arm systolic pressure index was determined, and serum lipoproteins were analyzed. Eight of 124 legs examined (6.5%) showed an ankle/arm pressure index less than 0.95, suggesting flow reducing stenosis. Common carotid, internal carotid, and iliac arteries were evaluated by echo Doppler examination with spectral analysis. Forty-five of the 372 arteries examined (12.1%) had detectable abnormalities at echo Doppler examination. Iliac and internal carotid artery lesions were significantly (P less than 0.01) more frequent among FH patients than in a control group (30 men, 20 women) comparable for sex and age. The mean age of the patients with heterozygous FH and detectable arterial lesions was 45.3 years and that of those without lesions 30.7 years (P less than 0.05). When 14 patients with heterozygous FH and arterial lesions were compared to another 14 without lesions and matched for age and gender, it was found that patients with lesions had on average lower concentrations of HDL-cholesterol, and that 10 of 14 cases were actual smokers.

A case of association between type I hyperlipoproteinemia and systemic lupus erythematosus (SLE). Effects of steroid treatment

The case of a girl aged 19 yr with hypertriglyceridemia and systemic lupus erythematosus (SLE) is described. The girl had been admitted to a Lipid Outpatient Clinic in 1981 and diagnosed as having a Type I hyperlipidemia pattern. In November 1984 the patient acutely developed a SLE syndrome. Steroid treatment led to a dramatic fall of serum triglycerides from a starting value of 2100 mg/dl to 95 mg/dl. The role of steroids in completely correcting genetically deficient Lipoprotein Lipase Activity (LLA) is discussed.

Effects of alpha-adrenergic and beta-adrenergic receptor blockade on lipid metabolism

The role of lipoprotein lipase in the pathophysiology of lipid changes during alpha-receptor or beta-receptor blockade was evaluated in this clinical trial. Thirty hypertensive patients were given 2 mg of prazosin twice daily or 100 mg of metoprolol twice daily for 10 weeks, according to an open, randomized protocol. Both drugs were effective in reducing arterial blood pressure (from 153 +/- 16/102 +/- 6 mm Hg to 146 +/- 12/92 +/- 8 mm Hg with prazosin and from 158 +/- 17/103 +/- 8 to 144 +/- 14/94 +/- 10 mm Hg with metoprolol). Prazosin significantly reduced total plasma cholesterol from 202 +/- 39 to 188 +/- 36 mg/dl and increased high-density lipoprotein cholesterol from 36 +/- 8 to 40.5 +/- 11 mg/dl. Prazosin did not affect plasma triglycerides levels, whereas patients taking metoprolol had a slight rise in these levels, from 122 +/- 42 to 142 +/- 57 mg/dl, along with a decrease in high-density lipoprotein cholesterol from 37 +/- 10 to 31 +/- 8 mg/dl. The concentration of apoprotein B did not change significantly with either treatment. Lipoprotein lipase activity increased in the prazosin group from 28.4 +/- 16 to 37.7 +/- 14 mumol/liter per minute (p less than 0.01), but did not change significantly (29.9 +/- 12 versus 32.8 +/- 8 mumol/liter per minute) in patients treated with the beta blocker. These data, which confirm previous reports of serum lipid changes during antihypertensive therapy, suggest that alpha1 blockers may interfere with lipoprotein lipase, possibly by reducing its catecholamine-mediated inactivation.

Carotid atherosclerosis in familial hypercholesterolemia

Common and internal carotids have been studied by noninvasive method (echo-Doppler) in 30 normotensive patients with familial hypercholesterolemia (FH). Vascular lesions were detected in 14 patients (46%), who presented one or more lesions of different degree (between 1-15% and 16-49%). In one case, only one carotid had stenosis greater than 50%. Severity and number of stenosis were related to age and levels of hypercholesterolemia. FH patients with carotid lesions showed a significantly higher LDL-cholesterol (p less than 0.01) and plasma apolipoprotein B (p less than 0.001) concentrations and a significantly lower HDL-cholesterol (p less than 0.05) and plasma apolipoprotein A (p less than 0.001) levels as compared to those with normal echo-Doppler findings. These data indicate that investigation of arterial districts other than coronaries are useful in quantitative evaluation of atherosclerotic involvement.

Premature development of iliac artery stenosis in asymptomatic type II hyperlipoproteinemia

There is conflicting evidence on the relationship between increased low density lipoprotein (LDL) concentration in Type II hyperlipoproteinemia and premature development of peripheral atherosclerosis of the lower limbs. We evaluated the early signs of iliac artery involvement in patients with asymptomatic Type II hyperlipoproteinemia. Of these, 23 were Type IIA, 12 were Type IIB. Thirty-five consecutive patients, ages 40 to 60 years, with asymptomatic Type II hyperlipoproteinemia (LDL cholesterol greater than or equal to 3.80 mmol/liter, 147 mg/dl) and 54 normocholesterolemic controls (plasma cholesterol less than 5.70 mmol/liter, 220.6 mg/dl) from a random sample of clinically healthy, 50-year-old men had a noninvasive examination to detect common and external iliac artery stenosis. Both Type II patients and the controls were examined by the echo-Doppler technique (Duplex Scanner III-ATL Mark V) with spectral analysis of the Doppler signals. This method is sensitive not only to severe stenosis or occlusion but also to non-flow-reducing stenosis (less than 50% narrowing of the lumen diameter) and to minor wall irregularities (1%-15% stenosis). In Type II patients, 19 of 70 limbs (27%) were abnormal as compared to 6 of 108 limbs (6%) in the controls (p less than 0.001). The premature development of an obliterating disease of the iliac arteries was demonstrated in persons asymptomatic for Type II hyperlipoproteinemia.

Effect of oral mesoglycan on plasma lipoprotein concentration and on lipoprotein lipase activity in primary hyperlipoproteinemia

Mesoglycan extracted from calf aorta was orally administered (96 mg/day) to 15 patients with primary hyperlipoproteinemia: 4 type IIA, 4 type IIB, 6 type IV and one type V. In the seven hypertriglyceridemic patients the drug after two months of treatment reduced total and VLDL-triglyceride from 701 mg/dl to 423 mg/dl (p less than 0.025) and from 562 mg/dl to 377 mg/dl (p less than 0.025) respectively and increased lipoprotein lipase activity from 19.7 mumol/l/min to 27.8 mumol/l/min (p less than 0.05). No change was observed in the group with type IIA-IIB hyperlipoproteinemia.

Acquired dermatitis due to zinc deficiency in a premature infant

A case of dermatitis with lesions reminiscent of enteropathic acrodermatitis of the premature of low gestational age is presented. The condition responded dramatically to oral zinc sulphate therapy.