The Influence of Intravenous Lidocaine Infusion on Postoperative Outcome and Neutrophil-to-Lymphocyte Ratio in Colorectal Cancer Patients. A Pilot Study

BACKGROUND AND AIMS

In the last years increasing scientific evidence drew attention on the potential effects of anesthetic drugs on postoperative outcome in cancer patients. Local anesthetics, especially lidocaine, have been intensively studied in relation with postoperative outcome in colorectal cancer patients. Our study objectives were to investigate the effects of perioperative intravenous lidocaine infusion on neutrophil-to-lymphocyte ratio and short-term postoperative outcome. Additionally, we also looked at 1 year outcome after intended radical colorectal cancer surgery.

METHODS

150 patients scheduled for colorectal cancer surgery were randomized to receive sevoflurane anaesthesia with or without 48 hours lidocaine infusion.

RESULTS

73 patients were included in the group A (sevoflurane) and 77 in the group B (sevoflurane with lidocaine). Lidocaine infusion did not modify neutrophil-to-lymphocyte ratio at 24 hours after surgery (p=0.58). Patients receiving intravenous lidocaine had significantly lower morphine consumption (p=0.04), faster mobilization time (p=0.001) and fewer days spent in the hospital (p=0.04). Moreover, at 1 year follow- up, patients in group B had a significant decreased rate of recurrences (p=0.03). There was no significant difference in 1 year survival (p=0.22).

CONCLUSIONS

In our study, intravenous lidocaine infusion hastened the postoperative recovery of patients in terms of mobilization, hospital discharge and opioid consumption and reduced 1 year recurrence rate. Further studies on larger groups of patients are needed.

Multiple Pancreatic Metastasis of Clear Renal Cell Carcinoma Associated with Neuroendocrine Tumor

Introduction: Metastatic tumors of the pancreas are uncommon, but renal cell carcinoma is one of the few known cancers that can metastasize to the pancreas. Few cases have been reported as being metachronous multicentric metastases to the pancreas, but none associated with a pancreatic neuroendocrine tumor and reported in literature, to our knowledge. Case presentation: We describe a case of 66-year-old woman who was diagnosed with multicentric pancreatic metastases from clear renal cell carcinoma associated with concomitant pancreatic neuroendocrine tumor, after 14 years from the initial diagnosis of kidney cancer. For this patient, the symptoms were unspecific for neoplastic disease, she had multiple pancreatic metastases which is an uncommon finding, but even rarer was the association of metastases with neuroendocrine tumor in the pancreas. Because of the good outcome and survival, surgical resection is recommended for solitary and multiple pancreatic metastases, as well as for pancreatic neuroendocrine tumors. Conclusion: Differential diagnosis for multiple pancreatic tumors is undisputedly important, even though it would not have changed anything in our patient's preoperatively course. Patients with renal cell carcinoma must follow long-term surveillance with regular examination and imaging investigation so that any possible metastases can be detected early and treated properly.

Laparoscopic Pancreatoduodenectomy in Elderly Patients: A Systematic Review and Meta-Analysis

Background and Aims: Recent single-center retrospective studies have focused on laparoscopic pancreatoduodenectomy (LPD) in elderly patients, and compared the outcomes between the laparoscopic and open approaches. Our study aimed to determine the outcomes of LPD in the elderly patients, by performing a systematic review and a meta-analysis of relevant studies. Methods: A comprehensive literature review was conducted utilizing the Embase, Medline, PubMed, Scopus and Cochrane databases to identify all studies that compared laparoscopic vs. open approach for pancreatoduodenectomy (PD). Results: Five retrospective studies were included in the final analysis. Overall, 90-day mortality rates were significantly decreased after LPD in elderly patients compared with open approaches (RR = 0.56; 95%CI: 0.32−0.96; p = 0.037, I2 = 0%). The laparoscopic approach had similar mortality rate at 30-day, readmission rate in hospital, Clavien−Dindo complications, pancreatic fistula grade B/C, complete resection rate, reoperation for complications and blood loss as the open approach. Additionally, comparing with younger patients (<70 years old), no significant differences were seen in elderly cohort patients regarding mortality rate at 90 days, readmission rate to hospital, and complication rate. Conclusions: Based on our meta-analysis, we identify that LPD in elderly is a safe procedure, with significantly lower 90-day mortality rates when compared with the open approach. Our results should be considered with caution, considering the retrospective analyses of the included studies; larger prospective studies are required.

Postoperative Analgesia after Laparoscopic Cholecystectomy - Prospective, Randomized, Double Blind, Control Trial

In this prospective, randomized, double blind control trial we aim to investigate which of the most used analgesic techniques after laparoscopic cholecystectomy is the most efficient. Methods: This study included 81 patients that were randomly distributed into 3 groups using a computer-generated random number which was enclosed in a sealed envelope: group A (control) received classic multimodal iv opioid analgesia, group B received Tap block in oblique subcostal approach (OSTAP) and group C received local anesthetic infiltration of the trocar insertion sites (LAI). The primary outcome of this trial was to evaluate the efficacy of each analgetic technique by measuring VAS pain scores. Secondary outcome included intraoperative opioid requirement and the opioid consumption in the first 24h postoperatively. Intraoperative parameters and outcome data were recorded by an anesthesiologist who was blinded to the study groups. Results: We analyzed a total of 75 patients. For the primary outcome variable, VAS pain scores at rest were significantly reduced in OSTAP group at each time point assessed in the first 24 hours after surgery compared with LAI group and IV opioid analgesia group (p 0.001). Intraoperative fentanyl consumption and 24h pethidine consumption were also significantly reduced in TAP block group compared with LAI group and IV opioid analgesia group (p 0.001). Conclusions: Our study showed that OSTAP block is a more efficient analgesia technique compared with IV opioid analgesia and with local anesthetic infiltration of trocar sites after laparoscopic cholecystectomy surgery. This trial was registered at www.clinicaltrials.gov (NCT02707250).

Abdominal Sepsis - Current Definitions and Practice

Abdominal sepsis remains the second most common source of sepsis, a life-threatening condition that became a global health priority in the medical field research. Open abdomen is part of the damage control surgery, a life-saving strategy in a well-selected group of surgical patients with severe abdominal sepsis and intra-abdominal hypertension. Definitions and recommendations in the management of abdominal sepsis and open abdomen have gradually evolved, as a reflection of the progress of both the comprehension of physiopathological mechanisms involved in sepsis and the technology of different temporary abdominal closure systems. The aim of this paper is to make an up-to-date literature narrative review of the definitions and current practice guidelines in abdominal sepsis, with illustration of clinical experience in the management of open abdomen wounds. In the past decades, progress has been made in the management of abdominal sepsis, with greatly ameliorated survival rates. Rapid diagnosis, extensive comprehension of the physiopathological mechanisms of sepsis, adapted fluid resuscitation, antimicrobial therapy and damage-control surgery, orchestrated by a multy-disciplinary team, play an equally important role in the prognosis of a patient.

Rare Causes of Gastrointestinal Bleeding: Focus on Pancreatic Pathology and Visceral Artery Aneurysms

Beside the common situations of upper gastrointestinal bleeding (GIB) managed by endoscopy, there are clinical situations when the endoscopic approach is limited by the amount of blood, the hemodynamic instability, the intermittent nature of bleeding and a proper diagnosis and treatment requires radiological interventional methods and even surgery. The pancreatic pathology is rarely considered as a possible cause for patients that presents in emergencies with GIB. The rupture of visceral artery aneurysms (VAAs), without underlying pancreatic pathology, should also be regarded in the differential diagnosis of GIB. Even the natural history of VAAs is not well understood, there is a potential risk of bleeding in the gastrointestinal tract, peritoneal cavity and retroperitoneal space, that can result in death. In this paper, we aim to review the rare causes of GIB focusing on pancreatic pathology and VAAs, unrevealed by the underlying pathology and presenting in the emergency department with bleeding symptoms and signs.

Association of Moral Distress with Anxiety, Depression, and an Intention to Leave among Nurses Working in Intensive Care Units during the COVID-19 Pandemic

BACKGROUND

Wide geographical variations in depression and anxiety rates related to the ethical climate have been reported during the COVID-19 pandemic in intensive care units (ICUs). The objective was to investigate whether moral distress is associated and has predictive values for depression, anxiety, and intention to resign.

METHODS

79 consenting ICU nurses completed MMD-HP and PHQ-4 scales in this cross-sectional study between October 2020-February 2021, after ethical approval. The association between MMD-HP and PHQ-4, and the predictive value of MMD-HP for anxiety, depression, and an intention to leave were analyzed (linear regression and receiver operating characteristics curve analysis).

RESULTS

From MMD-HP items, system related factors had highest scores (Kruskal-Wallis test, p < 0.0001). MMD-HP and PHQ-4 were weakly correlated (r = 0.41 [0.21-0.58]). MMD-HP and its system-related factors discriminate between nurses with and without depression or anxiety, while system-related factors differentiate those intending to resign (p < 0.05). The MMD-HP score had 50 [37.54-62.46] sensitivity with 80.95 [60-92.33] specificity to predict the intention to leave, and 76.12 [64.67-84.73] sensitivity with 58.33 [31.95-80.67] specificity to detect anxiety or depression symptoms.

CONCLUSIONS

During the COVID-19 pandemic, system-associated factors seem to be the most important root factors inducing moral distress. Moral distress is associated with negative psychological outcomes.

Role of radio-ablative technique for optimizing the survival of patients with locally advanced pancreatic adenocarcinoma (Review)

Pancreatic ductal adenocarcinoma (PDAC) is one of the most common and frequently diagnosed malignant tumor of the pancreas with few treatment options and poor life expectancy. Despite the advances in the surgical field, 40% of the patients are diagnosed with locally advanced disease which is not suitable for surgery. Radio-frequency ablation (RFA) has been described as a new ‘weapon’ in the multimodal treatment of PDAC, representing a cytoreductive procedure which must be completed with radiotherapy or chemo-radiotherapy. A systematic research was carried out utilizing the PubMed database in regards to this subject, to evaluate the role of RFA in PDAC management. Abstracts, letters-to-the-editor and non-English language manuscripts were excluded. The literature showed that RFA can be used in open and laparoscopic surgery but it is also feasible for endoscopic ultrasound (EUS-guided RFA) or percutaneous approach. Even though we found optimistic and encouraging reports on overall survival (OS), randomized studies are still required to corroborate these findings. Our review research underline that surgical resection remains the only radical treatment option, RFA being a safe and feasible technique reserved for unresectable, non-metastatic pancreatic tumors. Its combination with oncological treatment can improve the OS of these patients.

Desmoid tumor of the mesentery. Case report of a rare non-metastatic neoplasm

Desmoid tumors (DT) are rare non-metastatic neoplasms that occur through myofibroblast proliferation in musculoaponeurotic or fascial structures of the body, being commonly diagnosed in young women during pregnancy or in the post-partum period. We present the case of a 38-year-old woman, who recently gave birth, manifesting non-specific abdominal symptoms. Computed tomography indicated the presence of a solitary tumor arising from the intestinal wall or from the mesentery. Surgery confirmed the diagnosis, revealing a tumor that was localized at the level of the jejunal mesentery, having about 7 cm in diameter, in tight contact with the duodenum and the mesenteric vessels. “En bloc” resection of the tumor was performed, together with the involved enteral loops followed by end-to-end anastomosis of the jejunum. Histopathological examination of the surgical specimen sustained the diagnosis of desmoid tumor.

Nucleobases thin films deposited on nanostructured transparent conductive electrodes for optoelectronic applications

Environmentally-friendly bio-organic materials have become the centre of recent developments in organic electronics, while a suitable interfacial modification is a prerequisite for future applications. In the context of researches on low cost and biodegradable resource for optoelectronics applications, the influence of a 2D nanostructured transparent conductive electrode on the morphological, structural, optical and electrical properties of nucleobases (adenine, guanine, cytosine, thymine and uracil) thin films obtained by thermal evaporation was analysed. The 2D array of nanostructures has been developed in a polymeric layer on glass substrate using a high throughput and low cost technique, UV-Nanoimprint Lithography. The indium tin oxide electrode was grown on both nanostructured and flat substrate and the properties of the heterostructures built on these two types of electrodes were analysed by comparison. We report that the organic-electrode interface modification by nano-patterning affects both the optical (transmission and emission) properties by multiple reflections on the walls of nanostructures and the electrical properties by the effect on the organic/electrode contact area and charge carrier pathway through electrodes. These results encourage the potential application of the nucleobases thin films deposited on nanostructured conductive electrode in green optoelectronic devices.

Nanomedicine and contrast enhanced imaging. Applications in cancer diagnosis and therapy

OBJECTIVE

Nanotechnology and its applications in medicine made us live a new era of healthcare, particularly in oncology. The objective of this paper is to review the contribution of nanotechnology in clinical use of contrast agents for gastrointestinal cancer diagnosis and follow-up and to offer an overview of the impact of nanotechnology in the management of cancer.

MATERIALS AND METHODS

In this regard, we reviewed the main areas of expertise where nanotechnology has contributed to the improvement of diagnostic methods (CE-US, CE-CT, MRI), along with the therapeutic applications that nanoparticles can have. Last but not least, the article highlights the potential that theragnostic molecules can have in the diagnosis and treatment of neoplasia, including those in an advanced stage.

RESULTS AND CONCLUSIONS

Nanomedicine has the ability to improve the specificity and sensitivity of cancer diagnosis, together with the enhancing of the systemic cytostatic effect by developing nano bioconjugates that have a wider effect, higher tumor selectivity and thus, lower systemic toxicity.

KEY WORDS

Ablative treatment, Cancer, Contrast enhanced imaging, Drug delivery, Nanomedicine.

Laparoscopic Central Pancreatectomy with Pancreato-Gastric Anastomosis for Pancreatic Cystadenoma

We present the case of a 42-year-old woman diagnosed with a cystic pancreatic lesion, suggestive of a serous cystadenoma of 27/13 mm. The diagnosis was established by the examination of abdominal CT and eco-endoscopy. The patient was referred to the surgery department for treatment. The benign etiology suggested by imaging and the desire to preserve the spleen along with as much of the pancreatic parenchyma, indicated a laparoscopic central pancreatectomy with a anastomosis between the distal pancreatic stump and the stomach. The authors reviewed the national and international publications related to the indications of this minimally invasive surgery.

Laparoscopic Contrast-Enhanced Ultrasonography for Real Time Monitoring of Laparoscopic Radiofrequency Ablation for Hepatocellular Carcinoma: an Observational Pilot Study

BACKGROUND AND AIMS

Laparoscopic radio-frequency ablation (L-RFA) for hepatocellular carcinoma (HCC) is used for unresectable tumors, with difficult location, unfitted for a percutaneous ablation technique. L-RFA has a high incidence of local recurrence. Even if intraoperative-ultrasound is standardized for staging and RFA probe guidance, the role of laparoscopic contrast-enhanced ultrasound (L-CEUS) for the real time monitoring of L-RFA efficacy has not been previously reported. We evaluated in a pilot observational study the efficacy of L-CEUS to assess the necrotic post-ablative area in difficult to treat HCC.

METHODS

Eight consecutive patients diagnosed with HCC (peripherally located) on liver cirrhosis were referred for L-RFA between May 2016 and December 2018. For L-RFA a SturBurst XL (AngioDinamics®) internally cooled electrode was used, being placed under ultrasound guidance. L-CEUS was used to assess the necrotic post-ablative area. The median follow up period was 18 months.

RESULTS

L-CEUS real time monitoring of the L-RFA efficacy indicated residual neoplastic tissue in 4 cases (50%). The procedure was repeated by reinserting the needle in the suspected areas indicated by L-CEUS. Complete tumor ablation was achieved in all treated patients. After a median follow-up of 18 months no recurrence of HCC was observed in 7 patients (87.5%).

CONCLUSIONS

L-CEUS was a reliable procedure for the immediate assessment of L-RFA efficacy; half of the ablated HCC nodules required a second ablation session. This approach might decrease the local recurrences, but its role must be further investigated in larger cohorts.

Acute Intermittent Porphyria - an Unexpected Association in a Patient with Newly Diagnosed Crohn's Disease

The association of Crohn's disease (CD) with acute intermittent porphyria (AIP), both without a family or personal pathological history, is a very rare clinical possibility. We present the case of a 23-year-old male diagnosed on the same admission with ileal CD and with an AIP crisis. The diagnosis was challenging as the symptoms overlapped. Crohn's disease was complicated with intestinal occlusion and sepsis; the inflammatory, metabolic and septic changes represented the trigger factor for the first AIP seizure. The neurological symptoms were the key element for AIP diagnosis. The presence of atypical extra-intestinal manifestations in CD patients should raise also the possibility of AIP.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis: Our Initial Experience

Introduction: Peritoneal carcinomatosis represents an advanced stage of tumor dissemination of abdominal cancers in general and colorectal cancer in particular. The only therapeutic methods currently available for the treatment of this pathology are systemic chemotherapy (palliative character) and cytoreductive surgery (CR) with intraperitoneal chemotherapy. After evaluation of evidence-based medical literature and current guide lines we can state that CR + HIPEC procedure is considered to be the treatment of choice in case of patients with peritoneal carcinomatosis of colorectal, ovarian and mucinous appendicular origin. Material and method: In the present study we prospectively analyzed the immediate postoperative results obtained in the first 50 patients that were treated by our team for peritoneal carcinomatosis of different origin. We described the protocol of selection, the patients characteristics that were included in our CR+HIPEC program and analyzed the complications and death rate. Results: From January 2015 till Dec 2018 we evaluated 98 patients with peritoneal carcinomatosis. From them, 51 received radical CR+HIPEC treatment, 33 were not suitable for surgery because of the exclusion criteria's and 15 had only exploratory laparotomies. In regard with the histopathological diagnosis, 30 patients had ovarian cancer and 19 had colorectal cancer or peritoneal pseudomixoma of appendicular origin. There was no 30 days postoperative mortality. The incidence of significant postoperative complications was 15%. Conclusions: Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is a complex technique accompanied by an acceptable rate of complications and postoperative deaths, the results being optimized by a standardized perioperative management and patient selection. The initial results obtained by our team emphasize the feasibility of this procedure, with immediate good results, as a result of a standardization protocol of patient selection and perioperative care.

Cytoreduction with Hyperthermic Intraperitoneal Chemotherapy and Renal Insufficiency Related to Diabetes Mellitus: An Anesthetic Challenge

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) improves the prognosis in selected patients with peritoneal surface malignancies but it is an extensive procedure predisposing to major complications. Among them renal toxicity was reported. Severe renal insufficiency is considered a contraindication for this complex procedure. We present a patient with diabetic nephropathy with renal insufficiency KDOQI 3 and peritoneal metastasis from sigmoid adenocarcinoma with a good clinical outcome after CRS with HIPEC, highlighting the anesthetic precautions considered for this particular clinical case.

Radiofrequency ablation of locally advanced pancreatic tumors. The surgical approach

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Hyperthermic intraperitoneal chemotherapy (HIPEC). Mechanisms of action and the role of HIPEC in the treatment of peritoneal carcinomatosis

Peritoneal carcinomatosis represents the advanced, final stage of peritoneal malignancy, although it is often not accompanied by systemic neoplasia. The development of the pharmaceutical industry in combination with advanced surgery techniques has helped to improve the outcome of these patients, considered for a long time without radical resources. Tumoral cytoreduction followed by hypertermic intraperitoneal chemotherapy (HIPEC) is the treatment of choice for these patients, of course, this beeing done in a multimodal treatment, carefully chosen, following a multidisciplinary consensus. In this article we reviewed the main aspects of HIPEC procedure, describing the main chemotherapeutic agents used, highlighting the role that they play in this oncological treatment. Finally, we have pinpointed the main research lines in this field, which although have a well-established role in recent guidelines, have a great potential for development, with a maximum impact on the prognosis of patients with peritoneal metastases. KEY WORDS: Cytoreductive surgery, Hyperthermia, Intraperitoneal chemotherapy, Pharmacology, Peritoneal metastasis.

Short-term outcome and survival after multiorgan resection for locally advanced colo-rectal cancer. Identification of risk factors

INTRODUCTION

Although multi-organ resections (MOR) are recommended by international guidelines for advanced colorectal cancer, the literature shows that the morbidity and mortality that accompanies these complex interventions limits the number of patients receiving this treatment. The purpose of our study was to analyse the immediate and remote results obtained after MOR and to identify potential factors that might influence the outcome.

MATERIAL AND METHOD

Our study is a retrospective cohort which included patients surgically treated in our service for locally advanced colorectal cancer. We excluded patients with hepatic metastatic tumors and those who needed pelvic exenteration. Between 2006 and 2010, in our service, have been treated with MOR 146 patients, 107 being included in our study. We analysed morbidity, mortality and survival after MOR and the factors that could have influenced the postoperative course.

RESULTS

Identified risk factors that negatively influenced the postoperative outcome were: diabetes, personal neoplastic pathologies, associated cardiovascular disease, history of major surgeries, intraoperative blood loss, number of resected organs. Survival was negatively influenced by positive resection margins, the presence of lymph node metastases and the presence of complications in the postoperative period.

CONCLUSIONS

The data of this study support the indication for routine MOR for patients diagnosed with locally advanced colorectal cancer with the condition that R0 resection margins are achieved. All mentioned above underline the importance of the experience that the surgical team has in this type of surgeries, in order to achieve optimum results. This experience must concern the preoperative management, surgical technique and postoperative care.

KEY WORDS

Colo-rectal cancer, Multi-organ resections, Risk factors.

Clinical Experiences with the FRONT Formula for Pre-Operative Airway Assessment and Documentation: a Multi-Centre Study

OBJECTIVE

The prediction of difficult airway is one of the most important challenges before general anaesthesia. This study aimed to assess the clinical usefulness of the FRONT score, a recently developed scoring system to predict and document airway difficulties.

METHODS

This multi-centre, inter-observer, prospective and double-blinded study included 976 patients from two university centres. The pre-operative evaluation of the patients was performed by a pre-operative team of anaesthesiologists (team A) who evaluated and scored the expected difficulty of airway management. An intra-operative team of evaluators (team B) working independently of team A, performed the actual instrumentation of the airway and scored the actual findings. Both teams used the FRONT scoring system and worked independently of each other to ensure blinded assessments. The statistical analysis of the pre- and intra-operative FRONT scores was performed in an off-line blinded manner.

RESULTS

Our results show a fair and promising association between pre-operative composite FRONT score and that observed at the induction phase (Spearman=0.43). Among the score components, the best correlation was observed for the F and R components (kappa=0.44 and 0.36, respectively), and the worse correlation was observed for the O and T components (kappa=0.25 and 0.24, respectively).

CONCLUSION

The FRONT formula for the prediction and documentation of the airway status is a simple and effective method for assessing and defining airway management difficulties. Further prospective studies are required to assess the sensitivity and specificity of the system.

Recent achievements in colorectal cancer diagnostic and therapy by the use of nanoparticles

Colorectal cancer is a major public health issue, being the third most common cancer in men and the second in women. It is one of the leading causes of cancer deaths. Nanomedicine is an emerging field of interest, many of its aspects being linked to cancer research. Chemotherapy has a well-established role in colorectal cancer management, unfortunately being limited by inability to have a selective distribution, by multidrug resistance and adverse effects. Researches carried out in recent years about nanotechnologies aimed, among others, to resolve the issues mentioned above. Targeted and localized delivery of the chemotherapeutic drugs, using nanoparticles, with selective destruction of cancerous cells would minimize the toxicity on healthy tissues. Also, the use of nanomaterials as contrast agent could improve sensitivity and specificity of diagnosis. The purpose of this review is to highlight the recent achievements of cancer research by use of nanomaterials, in the idea of finding the ideal composite, capable to simultaneous diagnostic and treat cancer.