Updates in surgery
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Local anesthesia in laparoscopic operations is gaining increasing consensus. To standardize analgesia, a prospective case-control study was created over a 1-year period, in collaboration with the anesthesiology service in our community hospital. Starting from February 2016, we prospectively enrolled adult patients (more than 16 years old) undergoing laparoscopic appendectomy or cholecystectomy, either in emergency or elective setting. ⋯ In the comparison between patients undergoing TAP block or TSA with the control arm, a significance difference in reported pain was recorded in every scheduled time (p < 0.05 at 0, 6, 12, 18, 24, and 48 h from awakening). Both local anesthesia groups share a benefit in terms of primary outcome. The use of pre-incisional TSA for all the patients undergoing laparoscopic cholecystectomy and appendectomy could become a routine practice to reduce post-operative pain both in the elective and emergency setting.
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Gastric cancer in patients is often associated with bleeding; when it occurs, especially in the presence of an anemia, a transfusion is necessary to avoid further deterioration of the patient's clinical state. The aim of this study was to evaluate the relationship between the administration of peri-operative transfusions due to the anemia or the clinical status and the post-operative clinical outcomes. 188 patients diagnosed with of gastric cancer were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. ⋯ The clinical data most frequently associated with blood transfusion is the appearance of a post-operative infection (OR 2.26, 95% CI 0.87-5.79, P = 0.061). If the administration time of transfusion is considered, the clinical outcomes are different: preoperative transfusions showed a higher incidence of infections (OR 2.26, 95% CI 0.87-5.79, P = 0.061) and acute renal failure (OR 2.82, 95% CI 0.70-10.78, P = 0.078); patients who received intra or post-operative transfusions showed a prolonged hospitalization (OR 8.66, 95% CI 1.73-83.00, P = 0.002). The administration of blood products in the perioperative period is correlated in a statistically significant manner to the incidence of infections, acute renal failure and prolonged hospitalization; therefore, transfusions should be avoided unless clinically necessary and in particular intraoperative transfusions should be avoided because the immunomodulation effect linked to surgical stress may be enhanced hence worsening the prognosis.
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Previous studies have had conflicting results when comparing risk of mortality in patients with gunshot wounds (GSWs) treated at Level-I and II trauma centers. However, the populations studied were restricted geographically. We hypothesized that patients presenting after a GSW to the torso at Level-I centers would have a shorter time to surgical intervention (exploratory laparotomy or thoracotomy) and a lower risk of mortality, compared to Level-IIs in a national database. ⋯ After adjusting for covariates, only patients undergoing thoracotomy (OR = 0.66, CI = 0.47-0.95, p = 0.02) or those undergoing non-operative management (NOM) (OR = 0.85, CI = 0.74-0.98, p = 0.03) at a Level-I center had lower risk for death, compared to Level-II. Patients with torso GSWs managed with thoracotomy or NOM at a Level-I center have a lower risk of mortality, compared to a Level-II. Future prospective studies examining variations in practice, resources available and surgeon experience to account for these differences are warranted.
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Randomized Controlled Trial
Never put equipoise in appendix! Final results of ASAA (antibiotics vs. surgery for uncomplicated acute appendicitis in adults) randomized controlled trial.
Acute appendicitis is the most common surgical emergency; however, its etiology and diagnosis are still discussed with a considerable proportion of wrong diagnosis resulting in appendectomies for non inflamed appendix. Moreover, the biologic function of the appendix is still unclear. For uncomplicated acute appendicitis the conservative treatment with antibiotics has been proposed with interesting results. ⋯ Due to the poor patients' accrual the study had no enough statistical power to demonstrate the non-inferiority of conservative treatment and results were inconclusive. Due to the poor patient's accrual rate the study failed to demonstrate the non-inferiority of conservative treatment in uncomplicated acute appendicitis. On the other hand the study demonstrates the difficulty in performing randomized trials in emergency surgery and focus on the ethical aspects.
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Meta Analysis
Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis.
In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. ⋯ No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.