Pain distraction during awake low anterior resection and Cuddle Delivery initiative for inpatient: frugal procedural options to support surgery in the COVID-19 era

OBJECTIVE

Since minimally invasive surgery and general anesthesia are both aerosol-generating procedures, their use became controversial during the outbreak of coronavirus disease 2019 (COVID-19). Moreover, social distancing resulted in serious psychological consequences for inpatients. This case report investigates pain distraction during awake laparotomy, as well as new possibilities for emotional postoperative support to inpatients.

PATIENTS AND METHODS

A 72-year-old man affected by middle rectal adenocarcinoma underwent lower anterior resection plus total mesorectal excision under combined spinal-epidural anesthesia. A 3D mobile theatre (3DMT) was intraoperatively used for pain distraction. A postoperative "Cuddle delivery" service was instituted: video-messages from relatives and close friends were delivered daily to the patient through the 3DMT. Emotional correlations were investigated through a clinical interview by the psychologist of our Hospital.

RESULTS

Intraoperative, as well as postoperative pain, resulted well-controlled: visual analogue scale (VAS) ≤3. Conversion to general anesthesia and postoperative intensive support/monitoring were unnecessary. The "Cuddle delivery" initiative positively fed our patient's mood and attitude, strengthening his bond to life.

CONCLUSIONS

During pandemic, awake laparotomy under loco-regional anesthesia may be a crucial option in delivering acute care surgery to selected patients when intensive care beds are unavailable. Our procedure introduces potential ways to optimize this approach.

[Stereotaxic breast microhistology]

Mammography is currently the most reliable imaging technique to detect clinically occult breast cancer. Stereotaxic-guided aspiration biopsy during mammography allows lesion nature to be diagnosed in many cases. Our experience with 72 microhistologic breast samplings with fine-needle aspiration cytology is reported; 50% of inadequate cytologic samplings were avoided. Adequate cytologic samples were obtained in 88.9% of cases, while microhistologic samples were adequate in 94.4% of cases. Inadequate samples were 11.1% and 5.6%, respectively. Microhistologic biopsies yielded fewer questionable results than fine-needle aspiration cytology, which helped reduce the number of unnecessary biopsies. This method, which is reliable and well tolerated by the patients, can be considered as a valuable alternative procedure to fine-needle aspiration cytology.

[Plain radiographic examination and abdominal echography in intestinal occlusion syndrome. Preliminary note]

Plain film of the abdomen is widely used in the diagnostic evaluation of intestinal occlusion. Even though this technique can yield a panoramic and high-resolution view of gas-filled intestinal loops, several factors, such as type and duration of occlusion, neurovascular status of the intestine and general patient condition, may reduce the diagnostic specificity of the plain film relative to the organic or functional nature of the occlusion. From 1987 to 1989, fifty-four patients with intestinal occlusion were studied combining plain abdominal film with abdominal ultrasound (US). This was done in order to evaluate whether the additional information obtained from US could be of value in better determining the nature of the ileus. US evaluation was guided by the information already obtained from plain film which better demonstrates gas-filled loops. The results show that in all 27 cases of dynamic ileus (intestinal ischemia, acute appendicitis, acute cholecystitis, acute pancreatitis or blunt abdominal trauma) US demonstrates: intestinal loops slightly increased in caliber, with liquid content, or loops containing rare hyperechoic particles, intestinal wall thickening and no peristalsis. In 27 cases of acute, chronic or complicated mechanical ileus (adhesions, internal hernia, intestinal neoplasm, peritoneal seedings) US shows: 1) in acute occlusion: hyperperistaltic intestinal loops containing inhomogeneous liquid; 2) in chronic occlusion: liquid content with a solid echogenic component; 3) in complicated occlusion: liquid stasis, frequent increase in wall thickness, moderate peritoneal effusion and inefficient peristalsis. In conclusion, based on the obtained data, the authors feel that the combination of plain abdominal film and abdominal US can be useful in the work-up of patient with intestinal occlusion. The information provided by US allows a better definition of the nature of the ileus.