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Bergamini C, Alemanno G, Giordano A, Pantalone D, Fontani G, Di Bella AM, Iacopini V, Prosperi P, Martellucci J. The role of bed-side laparoscopy in the management of acute mesenteric ischemia of recent onset in post-cardiac surgery patients admitted to ICU. Eur J Trauma Emerg Surg 2020; 48:87-96. [PMID: 32951071 DOI: 10.1007/s00068-020-01500-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Acute mesenteric ischemia with non-occlusive mechanism (NOMI) is a possible complication after cardiac surgery in patients admitted to Intensive Care Unit (ICU). Since the diagnosis is often difficult with CT-scan, some authors have evaluated the role of bed-side diagnostic laparoscopy (DL). We aimed to contribute to this topic with a personal series. METHODS We retrospectively evaluated patients admitted to ICU after cardiac surgery since 2009 up to 2019, successively operated on for a suspected NOMI of recent onset with non-conclusive CT. They were divided into laparoscopic (Ls) and laparotomic (Lt) group, depending on whether or not they had a DL. They were compared for the CT false-positive (FP) and true-positive (TP) rate and the surgical outcome. RESULTS Seventy-three patients were enrolled. Lt included 30 patients (41%), Ls 43 (59%). The overall FP were 38 (52%), with a higher incidence in Ls. There was no difference in the mortality rate. The morbidity rate was higher in Lt, and especially in Lt-FP. The TP were 35 (47.9%). The mean operating time (OT) in the Lt-TP group was similar to the sum of the mean OT of the laparotomies plus that of the laparoscopies in the Ls-TP group. Conversely, when considering only laparotomic procedures, the Lt-TP had higher mean OT, such as an increased blood loss CONCLUSIONS: Post-cardiosurgical patients admitted to ICU have a relatively high rate of NOMI, in which CT-scan is often initially non-conclusive. Our data and those from the literature seem to show that in such cases bed-side DL may be an advantageous and safe procedure to avoid needless laparotomy and enables a more tailored open surgery.
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Affiliation(s)
- Carlo Bergamini
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy.
| | - Giovanni Alemanno
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Alessio Giordano
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Desiré Pantalone
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Giovanni Fontani
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Anna Maria Di Bella
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Veronica Iacopini
- Medical School, Department of Surgery, University of Florence, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Paolo Prosperi
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
| | - Jacopo Martellucci
- Department of Emergency Surgery, University Hospital of Careggi, Largo Brambilla n° 3, 50134, Florence, Italy
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Alemanno G, Prosperi P, Di Bella A, Socci F, Batacchi S, Peris A, Pieri M, Olivo G, Quilghini P, Fontanari P, Stefàno P, Giordano A, Iacopini V, Bergamini C, Valeri A. Bedside diagnostic laparoscopy for critically ill patients in the Intensive Care Unit: Retrospective study and review of literature. J Minim Access Surg 2019; 15:56-62. [PMID: 29483381 PMCID: PMC6293667 DOI: 10.4103/jmas.jmas_232_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Bedside diagnostic laparoscopy could be helpful in extremely critically ill patients. The aim of this retrospective study is to evaluate the safety and diagnostic accuracy of bedside diagnostic laparoscopy in the identification of intra-abdominal pathology in critically ill patients and to compare its accuracy and outcomes with the ones of laparotomy. Patients and Methods: A retrospective review was conducted on the medical records of patients admitted to the Intensive Care Unit (ICU) of Careggi University Hospital and submitted to bedside diagnostic laparoscopy between January 2006 and May 2017. This group of patients was compared with a group of patients that were admitted to the ICU and submitted directly to explorative laparotomy for suspected intra-abdominal pathologies. Results: One hundred and twenty-nine patients (M/F = 81/48, mean age = 71.64 years) underwent bedside diagnostic laparoscopy in ICU. 154 patients instead were submitted directly to explorative laparotomy in operatory room (mean age 75.70 years, M/F = 94/60). Among the 129 patients submitted to bedside laparoscopy, 53.49% were positive for intra-abdominal pathologies whereas 46.51% were negative, while among the 154 patients submitted directly to laparotomy, 76.62% were positive for intra-abdominal pathologies whereas 23.38% were negative. In 55.03% of all patients submitted to bedside laparoscopy, a non-therapeutic laparotomy was avoided, while the 33.76% of patients submitted directly to laparotomy had a non-therapeutic laparotomy that could be avoidable. Conclusions: Our results pinpoint the advantages of performing bedside diagnostic laparoscopy in the ICU setting, which can be considered an option every time there is the suspicion of an intra-abdominal pathology.
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Affiliation(s)
- Giovanni Alemanno
- General, Emergency and Minimally Invasive Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Paolo Prosperi
- General, Emergency and Minimally Invasive Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Annamaria Di Bella
- General, Emergency and Minimally Invasive Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Filippo Socci
- Department of Emergency, Intensive Care Unit and Regional ECMO Referral Centre, Careggi University Hospital, Florence, Italy
| | - Stefano Batacchi
- Department of Emergency, Intensive Care Unit and Regional ECMO Referral Centre, Careggi University Hospital, Florence, Italy
| | - Adriano Peris
- Department of Emergency, Intensive Care Unit and Regional ECMO Referral Centre, Careggi University Hospital, Florence, Italy
| | - Matteo Pieri
- Department of Heart and Vessels, Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Giuseppe Olivo
- Department of Heart and Vessels, Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Pietro Quilghini
- Department of Heart and Vessels, Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Paolo Fontanari
- Department of Heart and Vessels, Cardiac Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Pierluigi Stefàno
- Cardiac Surgery Unit, Department of Heart and Vessels, Careggi University Hospital, Florence, Italy
| | - Alessio Giordano
- General, Emergency and Minimally Invasive Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Veronica Iacopini
- General, Emergency and Minimally Invasive Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Carlo Bergamini
- General, Emergency and Minimally Invasive Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Andrea Valeri
- General, Emergency and Minimally Invasive Surgery Unit, Careggi University Hospital, Florence, Italy
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Zemlyak A, Heniford BT, Sing RF. Diagnostic Laparoscopy in the Intensive Care Unit. J Intensive Care Med 2013; 30:297-302. [PMID: 23761270 DOI: 10.1177/0885066613492102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 02/05/2013] [Indexed: 11/15/2022]
Abstract
Primary and acquired abdominal pathology accounts for a significant proportion of sepsis and SIRS in the ICU population. Abdominal processes often present a difficult diagnostic dilemma in the truly critically ill patient who, due to hemodynamic instability or severe acute respiratory distress syndrome (ARDS) requiring high-level ventilatory support, is at significant risk during transport to radiology department. Furthermore, the accuracy of radiologic studies in the ICU setting is often limited. Laparoscopy provides a "minimally invasive" definitive modality to diagnose intra-abdominal problems. It may quickly provide the necessary information to define further management. In selective circumstances, it may actually allow appropriate intervention. However, the overall mortality of patients who undergo diagnostic laparoscopy in the ICU is high regardless of diagnostic findingsduring this procedure. Although not a technically difficult procedure, diagnostic laparoscopy does require a certain skill level, especially when limited time and unfavorable patient physiology are taken into account. The use of diagnostic laparoscopy should be limited to patients in whom a therapeutic intervention is feasible.
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Affiliation(s)
- Alla Zemlyak
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Ronald F Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Karasakalides A, Triantafillidou S, Anthimidis G, Ganas E, Mihalopoulou E, Lagonidis D, Nakos G. The use of bedside diagnostic laparoscopy in the intensive care unit. J Laparoendosc Adv Surg Tech A 2009; 19:333-8. [PMID: 19397393 DOI: 10.1089/lap.2008.0279] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The clinical evaluation of the abdomen in intensive care (ICU) patients who are intubated can be very complex. Many bedside diagnostic tests are available to assist the clinician, including ultrasound, peritoneal lavage, and plain X-rays. However, in the ICU setting, these tests can be unreliable. An abdominal computed tomography (CT) scan is more reliable, but it requires transportation to the Radiology Department, which can be risky. In this paper, we present our experience with bedside laparoscopy in the general ICU population. METHODS Between April 2004 and November 2007, 35 adult patients (19 male, 16 female), with a mean age of 69 years (range, 39-83), underwent bedside diagnostic laparoscopy (DL) in the ICU. Hemodynamic and ventilatory parameters as well as the time required for the DL and CT scan procedure were compared. In addition, the ASA, APACHE II, and SOFA scores were documented. RESULTS Laparoscopic findings were negative for intra-abdominal disease in 57.1% (n = 20) patients. The remaining patients (42.9%; n = 15) had positive laparoscopic findings for intra-abdominal disease. The overall mortality rate in our group of patients was 60%. The time required for DL was less (21.8 +/- 7.6 minutes) than the time required for a CT scan (38.2 +/- 6.2 minutes; P < 0.05). Three patients went on to have a therapeutic procedure in the ICU. CONCLUSION The evaluation of the critically ill patient for intra-abdominal pathology with DL is a practical solution and needs to be used more frequently in this setting. In this paper, we present our experience with diagnostic laparoscopy in the ICU and found it to be safe and, in certain cases, may have a potential role as a bedside therapeutic tool. Although a number of reports with small series of patients have addressed the benefits and feasibility of DL, it is still being underutilized in the ICU. A more aggressive attempt should be made to incorporate DL as a routine procedure in the ICU.
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Peris A, Matano S, Manca G, Zagli G, Bonizzoli M, Cianchi G, Pasquini A, Batacchi S, Di Filippo A, Anichini V, Nicoletti P, Benemei S, Geppetti P. Bedside diagnostic laparoscopy to diagnose intraabdominal pathology in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R25. [PMID: 19243621 PMCID: PMC2688143 DOI: 10.1186/cc7730] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Revised: 01/20/2009] [Accepted: 02/25/2009] [Indexed: 11/10/2022]
Abstract
Introduction Delayed diagnosis of intraabdominal pathology in the intensive care unit (ICU) increases rates of morbidity and mortality. Intraabdominal pathologies are usually identified through presenting symptoms, clinical signs, and laboratory and radiological results; however, these could also delay diagnosis because of inconclusive laboratory tests or imaging results, or the inability to safely transfer a patient to the radiology room. In the current study we evaluated the safety and accuracy of bedside diagnostic laparoscopy to confirm the presence of intraabdominal pathology in an ICU setting. Methods This retrospective study, carried out between January 2006 and June 2008, evaluated the diagnostic accuracy of bedside diagnostic laparoscopy performed on patients with a suspicion of ongoing intraabdominal pathology. Clinical indications for bedside diagnostic laparoscopy were: ultrasonography (US) images of gallbladder distension or wall thickening of more than 3 to 4 mm, with or without pericholecystic fluid; elevation of laboratory tests (bilirubin, transaminases, myoglobin, lactate dehydrogenase, creatine phosphokinase, gamma-glutamyltransferase); high level of lactate/metabolic acidosis; CT images inconclusive for intraabdominal pathology; or inability to perform a CT scan. Patients did not undergo bedside diagnostic laparoscopy if they presented clear indications for open surgery, coagulopathy, abdominal wall infection or high intraabdominal pressure. Results Thirty-two patients underwent bedside diagnostic laparoscopy (Visiport Plus, Autosuture, US), 14 of whom had been admitted to the ICU for major trauma, 12 for sepsis of unknown origin and 6 for complications after cardiac surgery. The procedure was performed on an average of eight days after ICU admission (95% confidence interval = 5 to 15 days) and mean procedure duration was 40 minutes. None of the procedures resulted in complications. Bedside diagnostic laparoscopy was diagnostic for intraabdominal pathology in 15 patients, who subsequently underwent surgery, except in two cases of diffuse gut hypoperfusion. Diagnosis of cholecystitis was obtained in seven cases: two were treated with laparotomic cholecystectomy and five with percutaneous gallbladder drainage positioning. Conclusions Bedside diagnostic laparoscopy represents a safe and accurate technique for diagnosing intraabdominal pathology in an ICU setting and should be taken into consideration when patient transfer to radiology or the operating room is considered unsafe, or when routine radiological examinations are not conclusive enough to reach a definite diagnosis.
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Affiliation(s)
- Adriano Peris
- Intensive Care Unit of Emergency Department, Careggi Teaching Hospital and University of Florence, Florence, Italy.
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