Alessandro Bacuzzi

Protective Mechanical Ventilation during General Anesthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function

Background:The impact of intraoperative ventilation on postoperative pulmonary complications is not defined. The authors aimed at determining the effectiveness of protective mechanical ventilation during open abdominal surgery on a modified Clinical Pulmonary Infection Score as primary outcome and postoperative pulmonary function. Methods:Prospective randomized, open-label, clinical trial performed in 56 patients scheduled to undergo elective open abdominal surgery lasting more than 2 h. Patients were assigned by envelopes to mechanical ventilation with tidal volume of 9 ml/kg ideal body weight and zero-positive end-expiratory pressure (standard ventilation strategy) or tidal volumes of 7 ml/kg ideal body weight, 10 cm H2O positive end-expiratory pressure, and recruitment maneuvers (protective ventilation strategy). Modified Clinical Pulmonary Infection Score, gas exchange, and pulmonary functional tests were measured preoperatively, as well as at days 1, 3, and 5 after surgery. Results:Patients ventilated protectively showed better pulmonary functional tests up to day 5, fewer alterations on chest x-ray up to day 3 and higher arterial oxygenation in air at days 1, 3, and 5 (mmHg; mean ± SD): 77.1 ± 13.0 versus 64.9 ± 11.3 (P = 0.0006), 80.5 ± 10.1 versus 69.7 ± 9.3 (P = 0.0002), and 82.1 ± 10.7 versus 78.5 ± 21.7 (P = 0.44) respectively. The modified Clinical Pulmonary Infection Score was lower in the protective ventilation strategy at days 1 and 3. The percentage of patients in hospital at day 28 after surgery was not different between groups (7 vs. 15% respectively, P = 0.42). Conclusion:A protective ventilation strategy during abdominal surgery lasting more than 2 h improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay.

Treatment of failed back surgery syndrome.

Objectives. To evaluate the long‐term results of different therapies for failed back surgery syndrome (FBSS).

What is the learning curve for intraoperative neuromonitoring in thyroid surgery

BACKGROUND The study describes the initial experience and learning curve of intraoperative neuromonitoring (IONM) during thyroidectomy. We describe the prevalence and patterns of IONM technical problems. METHODS Prospective series of 152 consecutive thyroid operations (304 nerves at risk) were analyzed. Standard technique consists of monitoring vagal and RLNs before, during and after resection. Personal gain of experience was defined by the preceding number of thyroid operations. To establish the number of thyroidectomies required before achieving an effective and safe IONM technique, all of the procedures were divided into three chronological groups of about 50 cases (groups 1, 2, and 3). RESULTS Patients (90%) had successful IONM with initial endotracheal tube position. Fifteen patients (10%) needed further tube adjustment. Out of 15 patients 14 (93%) were due to non-optimal contact of endotracheal surface electrodes to vocal cords. Tube malrotation was the main reason for initial failure (53%). The success rates of prompt IONM technique were 80% in group 1, 92% in group 2, and 98% in group 3 (p<0.05). Mean operating time was low in group 3 (p<0.03). Vagus and RLNs were localized and monitored in all the cases (100%). The incidence of temporary RLN injury was 2.6%. No permanent complications occurred. Negative EMG response indicated an altered function of RLN and stage thyroidectomies were scheduled. Transient RLN palsies were seen without changes during the entire study period. CONCLUSIONS This is the first series of thyroidectomies with standardized IONM technique performed in Italy. Neuromonitoring was effective in providing identification and function of laryngeal nerves. IONM successful rates were affected considerably by the extent of surgical and anaesthesiological experiences, starting with relatively low rates in the beginner group and then increasing. We assessed the learning curve: improved operative variables and safe technique were seen in about 50 patients.

Visualization versus Neuromonitoring of Recurrent Laryngeal Nerves during Thyroidectomy: What About the Costs?

BackgroundThe objective of the present study was to evaluate costs for thyroidectomy performed with the aid of intraoperative neural monitoring (IONM), which has gained widespread acceptance during thyroid surgery as an adjunct to the gold standard of visual nerve identification.MethodsThrough a micro-costing approach, the thyroidectomy patient-care process (with and without IONM) was analyzed by considering direct costs (staff time, consumables, equipment, drugs, operating room, and general expenses). Unit costs were collected from hospital accounting and standard tariff lists. To assess the impact of the IONM technology on hospital management, three macro-scenarios were considered: (1) traditional thyroidectomy; (2) thyroidectomy with IONM in a high-volume setting (5 procedures per week); and (3) thyroidectomy with IONM in a low-volume setting (1 procedure per week). Energy-based devices (EBD) for hemostasis and dissection in thyroidectomy were also evaluated, as well as the reimbursement made by the Italian Healthcare System on the basis of diagnosis related groups (DRGs), about €2,600.ResultsComparison between costs and the DRG fee shows an underfunding of total hospitalization costs for all thyroidectomies, regardless of IONM use (scenario 1: €3,471). The main cost drivers are consumables and technologies (25%), operating room (16%), and staff (14%). Hospitalization costs for a thyroidectomy with IONM range from €3,713 to €3,770 (scenarios 2 and 3), 5–7% higher than those for traditional thyroidectomy. Major economic differences emerge when an EBD is used (€3,969).ConclusionsThe regional DRG tariff for thyroid surgery is barely sufficient to cover conventional surgery costs. Intraoperative neural monitoring accounts for 5–7% of the hospitalization costs for a thyroidectomy.

Predictive factors for endoleaks after thoracic aortic aneurysm endograft repair

BACKGROUND Our prospective investigation aimed to determine and analyze the incidence and the determinants of endoleaks after thoracic stent graft. METHODS Sixty-one patients affected by thoracic aortic aneurysms were treated between January 2000 and March 2008. The study cohort contained 54 men, with a mean age of 63.6 +/- 17.9 years. The follow-up imaging protocol included chest radiographs and triple-phase computed tomographic angiography performed at 1, 4, and 12 postoperative months and annually thereafter. RESULTS Median follow-up was 32.4 months (range: 1-96 months). Endoleaks were detected in 9 (14.7%) patients, of which 7 were type 1. Five endoleaks were detected at 30 postoperative days, and the other 4 developed with a mean delay of 12 months. Endovascular or hybrid interventions were used to treat the endoleaks. Secondary technical success rate was 100%. Multivariate analysis demonstrated that the diameter of the aneurysmal aorta (odds ratio 1.75, 95% confidence interval 1.07-2.86) and the coverage of the left subclavian artery (odds ratio 12.05, 95% confidence interval 1.28-113.30) were independently associated with endoleak development. The percentages of patients in whom reinterventions were unnecessary were 94.6% +/- 3.0%, 88.3% +/- 4.5%, and 85.4% +/- 5.2%, at 1, 2, and 5 years, respectively. The actuarial survival estimates at 1, 2, and 5 years were 85.2% +/- 4.6%, 78.1% +/- 5.4%, and 70.6% +/- 6.4%, respectively. CONCLUSIONS The diameter of the aneurysmal aorta and the position of the landing zone are independent predictors of endoleak occurrence after thoracic stent-graft procedures. A careful follow-up program should be considered in patients in whom these indices are unfavorable, because most of the endoleaks may be successfully and promptly treated by additional endovascular procedures.

Microwave ablation of liver metastases to overcome the limitations of radiofrequency ablation

PurposeThe purpose of our study was to evaluate technical success, effectiveness and safety of microwave ablation (MWA) in patients with unresectable liver metastases, where radiofrequency ablation (RFA) presents some limits.Materials and methodsTwenty-five patients (17 men, 8 women) with 31 liver metastases >3 cm or located near vessels (>3 mm) were treated in a total of 29 sessions. Tumours were subdivided as follows: colorectal metastases (n=21) and no colorectal metastases (n=10). All procedures were performed percutaneously under ultrasound (US) guidance. Follow-up was performed with computed tomography (CT) scan at 1, 3, 6 and 12 months after treatment; mean follow-up period was 12.04 (range, 3–36) months. Technical success, mean disease-free survival, effectiveness and safety were evaluated.ResultsTechnical success was obtained in all cases. Mean disease-free survival was of 20.5 months. Local recurrence was recorded in 12.9% of metastases treated (4/31). No major complications were recorded. The rate of minor complications was 44.8% (13/29 sessions). Mortality at 30 days was 0%.ConclusionsPercutaneous MWA of liver metastases >3 cm or located near vessels (>3 mm) can be considered a valid and safe option, probably preferable to RFA. Further studies are required to confirm these encouraging initial results.RiassuntoObiettivoLo scopo del nostro studio è stato quello di valutare il successo tecnico, l’efficacia e la sicurezza della ablazione con microonde (MWA) di metastasi epatiche inoperabili, nei casi in cui la radiofrequenza (RFA) presenta alcuni limiti.Materiali e metodiVenticinque pazienti (17 uomini, 8 donne), con un’età media di 65,9 anni (range 49-83), sono stati sottoposti ad ablazione percutanea con microonde (MWA) eco-guidata di 31 metastasi epatiche con un diametro medio maggiore di 3 cm e/o situate in prossimità di grossi vasi (diametro>3 mm). I tumori erano così suddivisi: metastasi da carcinoma del colon-retto (n=21) e metastasi da carcinoma non del colon-retto (n=10). In totale sono state eseguite 29 sessioni di ablazione. Il followup è stato eseguito con la tomografia computerizzata (TC) a 1, 3, 6 e 12 mesi dopo il trattamento; il periodo medio di follow-up è di 12,04 mesi (range 3–36 mesi). Sono stati valutati il successo tecnico, la sopravvivenza libera da malattia, l’efficacia e la sicurezza.RisultatiIl successo tecnico della procedura è stato del 100%. L’efficacia clinica è stata ottenuta nell’87,1% dei casi: in 4 delle 31 lesioni trattate si è avuta una recidiva locale. Non sono state registrate complicanze maggiori. La percentuale delle complicanze minori è stata del 44,8% (13/29 procedure). La mortalità a 30 giorni è stata dello 0%. La sopravvivenza media libera da malattia è stata di 20,5 mesi.ConclusioniLa MWA percutanea di metastasi epatiche con diametro maggiore di 3 cm e/o localizzate in siti critici, in vicinanza di vasi di grosse dimensioni e/o di organi cavi, può essere considerata una opzione valida e sicura, probabilmente preferibile alla RFA, in questi casi. Ovviamente sono necessari ulteriori studi per confermare questi incoraggianti risultati iniziali.

Mobile Thrombus of the Thoracic Aorta: Management and Treatment Review

Detection of mobile thrombus of the thoracic aorta has become increasingly higher after any embolic event. Although the indication for treatment remains controversial, there is a growing interest about the ethiopathogenesis of this rare entity, and to define proper diagnostic and therapeutic approaches. The purpose of this article was to review the current management strategies and follow-up results of this rare pathology.

Implementation of systematic neuromonitoring training for thyroid surgery

Neural monitoring is increasingly applied to thyroid surgery and yet few surgeons have received formal training in intraoperative neuromonitoring (IONM). Standardized application of neural monitoring is an expected outcome of formal training programs in IONM. This study was designed to document a systematic training course that focuses on standardized state-of-art IONM knowledge. Seventeen 1-day courses were organized by the Department of Surgical Sciences, University of Insubria Medical School (Varese-Como, Italy), between 2009–2010. The course included didactic and practical training sessions. Some specific steps and checklist identified for courses included: knowledge of IONM technology and troubleshooting algorithms; IONM anesthetic perspectives, standards of IONM equipment set up and technique. A total of 75 trainees completed a questionnaire after completion of the respective courses. Questions probed demographic data, operative IONM experience and evaluation of course content. Data gathered showed that 97% of participants had no prior experience with the standardized approach of IONM technique (i.e. stimulation of the vagal nerve). The most useful parts of the course were judged to be (a) algorithms for perioperative IONM problem solving (30%), (b) live surgery with hands-on training (25%), (c) standardization of IONM technique (25%), and (d) IONM equipment set-up (20%). Poor reimbursement for hospital thyroid procedures is the main reason of limitation of IONM technology. The course offered participants novel knowledge and training and gave participants a systematic and standard approach to IONM technique.

Radiofrequency ablation of a pancreatic metastasis from renal cell carcinoma: case report

Introduction There is little reported experience of radiofrequency ablation (RFA) of pancreatic tumors. The pancreas is surrounded by structures such as the stomach, duodenum, and colon and concerns regarding the risks of thermal injury to these structures have limited the use of RFA for nonresectable pancreatic tumors. Case Report This brief report describes the application of this technique for the treatment of a metastasis from renal cell carcinoma localized at the body-tail portion of the pancreas in a 77-year-old man and the outcome of the procedure at 1-year follow-up. Conclusions In our experience, RFA is feasible also for metastatic lesion at the pancreas and it was safely carried out in this case. Long-term follow-up and larger series are necessary to assess the spectrum of complications and the true oncologic efficacy.

Predictive factors for cerebrovascular accidents after thoracic endovascular aortic repair

BACKGROUND Cerebrovascular accidents are devastating and worrisome complications after thoracic endovascular aortic repair. The aim of this study was to determine cerebrovascular accident predictors after thoracic endovascular aortic repair. METHODS Between January 2001 and June 2008, 76 patients treated with thoracic endovascular aortic repair were prospectively enrolled. The study cohort included 61 men; mean age was 65.4 +/- 16.8 years. All patients underwent a specific neurologic assessment on an hourly basis postoperatively to detect neurologic deficits. Cerebrovascular accidents were diagnosed on the basis of physical examination, tomography scan or magnetic resonance imaging, or autopsy. RESULTS Cerebrovascular accidents occurred in 8 (10.5%) patients, including 4 transient ischemic attack and 4 major strokes. Four cases were observed within the first 24-hours. Multivariable analysis revealed that anatomic incompleteness of the Willis circle (odds ratio [OR] 17.19, 95% confidence interval [CI] 2.10 to 140.66), as well as the presence of coronary artery disease (OR 6.86, 95 CI% 1.18 to 40.05), were independently associated with postoperative cerebrovascular accident development. Overall hospital mortality was 9.2%, with no significant difference for patients hit by cerebrovascular accidents (25.0% vs 7.3%, p = 0.102). CONCLUSIONS Preexisting coronary artery disease, reflecting a severe diseased aorta and anomalies of Willis circle are independent cerebrovascular accident predictors after thoracic endovascular aortic repair procedures. A careful evaluation of the arch vessels and cerebral vascularization should be mandatory for patients suitable for thoracic endovascular aortic repair.