Federico Perez Quirante

The FAST D protocol: a simple method to rule out traumatic vascular injuries of the lower extremities

BackgroundThe aim of this study is to assess the accuracy of a Fast Doppler protocol for the examination of an injured lower limb, namely 2-Point Fast Doppler (2PFD), in order to rapidly triage arterial lesions after penetrating trauma.MethodsThe presence of flow and the aspects of the Doppler waveform of the dorsalis pedis artery (DPA) and posterior tibial artery (PTA) of the injured lower limb (2PFD) were evaluated immediately before the execution of a standardized Color Duplex Doppler (SD) evaluation in 149 limbs of 140 patients with gunshot penetrating injuries. We considered 2PFD normal exams as the ones with triphasic patterns in both the DPA and PTA, and 2PFD pathologic exams as the ones with absent, biphasic, or monophasic flow patterns in the DPA and/or PTA. 2PFD data were then analyzed to assess accuracy variables, using SD results as matching test reference. According to the trauma center standard protocols, SD positive cases underwent also angiography and surgical exploration, whose findings were used to further match the 2PFD specificity.ResultsThe 2PFD protocol showed a sensitivity of 100%, and a specificity of 100% compared with the SD, in the diagnostic workup of arterial injuries of the lower limbs after penetrating trauma. Furthermore, all the pathologic cases that resulted in all true positives (TP), compared with SD, were confirmed as TP also when matched with the angiography evaluation results.ConclusionsThe 2PFD protocol can rapidly identify arterial flow and differentiate between normal and pathologic spectral Doppler analyses in distal arteries. The presence of the normal triphasic flows in DPA and PTA is as sensitive as the standardized Color Doppler Duplex assessment of the entire limb in ruling out arterial lesions in lower-limb penetrating trauma. The absence of flow or the presence of a biphasic or monophasic pathologic flow in DPA and PTA is pathologic and should be always followed by further investigation. 2PFD is faster and easier to perform compared with the SD approach. It could become a new first-line screening technique, both in pre-hospital and hospital critical scenarios, particularly in contexts where advanced diagnostic performance is limited by time concerns or scarce resources.

Laparoscopic treatment of gastroparesis: a single center experience

BACKGROUND Gastroparesis (GP) is a chronic disorder of gastric motility with delayed gastric emptying. Gastric electrical stimulator (GES) implantation and Roux-en-Y gastric bypass (RYGB) are surgical options for medically refractory GP. OBJECTIVE Evaluate operational outcomes and symptom improvement of patients with diabetic (DM) and idiopathic (IP) GP. SETTING University Hospital, United States. METHODS A retrospective chart review was performed of all patients who underwent surgical treatment of GP from February 2003 to December 2014. Subgroup analysis was performed based on etiology of GP (DM versus IP) and procedure received (GES versus RYGB). Postoperative outcomes and postoperative symptom improvements were compared between groups. RESULTS Of 93 patients, 47 (50.5%) had IP and 46 (49.5%) had DM. The majority underwent GES implantation (83.8%, n = 78), and 15 patients (16%) underwent RYGB. There were significant differences in hospital stay (2 versus 3 days) and reoperation rate (30% versus 7%) between IP and DM. Operation time, complication rate, and 30-day readmission rate were similar in both groups. DM patients significantly improved GP-related complaints compared with preoperatively. IP patients also improved nausea and vomiting and had no change in abdominal pain between pre- and postoperative period. GES showed significant improvement of nausea, vomiting, and abdominal pain. RYGB showed improvement of nausea, but not vomiting or abdominal pain. CONCLUSIONS Surgery is a feasible intervention for GP for both DM and IP patients; however, based on the data presented in this manuscript and the current literature, the use of gastric bypass as an effective treatment modality for patients with intractable GP remains highly controversial. Care must be taken for IP patients in the postoperative period due to high incidence of reoperation. Although both procedures offer some degree of symptomatic improvement, GES seems to provide improvement of more GP symptoms. However, there is no significant difference in the need for postoperative medications regardless of the procedure used.

Robotic-Assisted Transanal Microscopic Surgery

This chapter will review the operative technique and advanced approach to perform a robotic transanal minimally invasive surgery (R-TAMIS) and a robotic transanal total mesorectal excision (R-TME). We will briefly describe indications and preoperative study, topics covered in the management of rectal cancer, and we will focus the chapter to outline the surgical technique and landmarks of R-TAMIS and R-TME.

Proctectomy: Total Robotic Approach

This chapter will review the operative technique and advanced approaches to a total robotic low anterior resection (LAR) and abdominoperineal resection (APR). The hybrid approach has been described in detail in the previous chapter. Specifically, this chapter will address the technique of single or dual docking for the mobilization of splenic flexure during rectal and left colonic surgery. We will also describe the end-to-end anastomosis utilizing the double purse-string technique described by Prasad et al. and the transabdominal transanal (TATA) robotic-assisted, coloanal pull-through for sphincter-sparing ultralow rectal cancers.

The case of the missing appendix: a case report of appendiceal intussusception at the site of colonic mullerianosis.

Abstract Right lower quadrant pain is a symptom with an exceptionally broad differential diagnosis. Intussusception of the appendix is a very uncommon condition with many manifestations. Additionally, the pathologic finding of ectopic presence of a mixture of at least two mullerian-derived tissue components is rare. This report presents the case of a 49-year-old woman who presented twice with acute right lower abdominal pain. Diagnosis of appendiceal inversion was made surgically. Pathologic examination of the specimen identified extensive endometriosis, endosalpingiosis and endocervicosis of the colon wall. Appendiceal intussusception and colonic mullerianosis, present together, are discussed, and recommendations for the diagnosis and treatment of appendiceal intussusception are discussed.