Updates in surgery
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Preoperative fasting aims to increase patient safety by reducing the risk of adverse events during general anaesthesia. However, prolonged fasting may be associated with dehydration, hypoglycaemia and electrolyte imbalance as well as patient discomfort. We aimed to examine compliance with the current best practice guidelines in a large surgical unit and to identify areas for improvement. ⋯ The use of universal fasting instructions and patient choice are factors that unnecessarily prolong preoperative fasting, which however appears to be multifactorial. Service improvement by abbreviation of the observed fasting periods will rely on targeted staff education and effective clinical communication by provision of written information for both elective and emergency surgical patients. The routine use of preoperative nutritional supplements may need to be re-examined when further evidence is available.
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Corona mortis (CMOR) is an anastomotic branch between the external iliac or inferior epigastric vessels and the obturator artery or vein, or any vascular connection between the obturator and the external iliac systems in general with high anatomic variability. The aim of this study was to evaluate the type of anastomosis, if arterial, venous or both and the other subtypes of CMOR. Twenty-five laparoscopic procedures of bilateral pelvic lymphadenectomy for gynecological oncologic procedures (50 half pelvises) were performed. ⋯ In the cases of both arterial and venous anastomosis, one venous and one arterial vessel in 5/6 (83 %) were detected, and one type of anastomosis with one arterial and two venous vessels. Our data suggest that venous CMOR is usually present in higher frequency than the arterial one, followed by the combined type with arterial and venous connections. The isolated venous anastomosis resulted the frequent subtype.
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The limit to surgical treatment of patients with hepatic tumors is represented by the proportion of residual hepatic parenchyma at the end of surgery (FLR, future liver remnant) that provides an estimation of the risk of postoperative liver failure. Recently, a new two-stage technique has been developed with the acronym (ALPPS) associating liver partitioning and portal vein ligation for staged hepatectomy with the aim of obtaining a more rapid and effective increase in FLR, even though indications are not clear yet. Between January and December 2012, eight patients were candidates to ALPPS at the Hepatobiliary Surgery Unit of San Raffaele Hospital, Milan. ⋯ In Series 2 postoperative course was uneventful in all the patients, and in particular no patient showed disease progression between the two procedures or signs of postoperative liver failure. ALPPS approach was initially considered suitable for patients affected by Klatskin tumors who require, despite a small tumor volume, extended hepatectomies associated with surgery of the biliary tract: the analysis of this first series of patients has led to a re-evaluation of the indication to this strategy, as a consequence of encountered criticisms. Actually only a subset of patients affected by colorectal liver metastases are candidates to ALPPS.
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Randomized Controlled Trial Comparative Study
Ultrasound-guided transversus abdominis plane block for retroperitoneal varicocele repair. Could it be an anesthesia method?
To assess the efficacy of transversus abdominis plane (TAP) block as anesthesia method for retroperitoneal varicocele repair and to evaluate its postoperative analgesic effectiveness. Thirty-three consecutive male patients undergoing retroperitoneal varicocele repair (Palomo technique) were enrolled in this study. Patients were randomly allocated to undergo ultrasound-guided TAP block anesthesia (case group), or conventional spinal anesthesia (control group). ⋯ Moreover, the need of rescue analgesia resulted significantly higher in the control group (p = 0.03). This is the first study showing that TAP block could be employed as an effective and feasible anesthesia method for the retroperitoneal varicocelectomy. Moreover, our results demonstrate that this method is more effective than spinal anesthesia in the pain control after varicocele repair.