OBJECTIVES Our goal was to assess the results and the costs of the quasilobar minimalist (QLM) ... more   OBJECTIVES Our goal was to assess the results and the costs of the quasilobar minimalist (QLM) thoracoscopic lung volume reduction (LVR) surgical method developed to minimize the trauma from the operation and the anaesthesia and to maximize the effect of the lobar volume reduction. METHODS Forty patients with severe emphysema underwent QLM-LVR that entailed adoption of sole intercostal block analgesia and lobar plication through a single thoracoscopic incision. Results were compared after propensity matching with 2 control groups undergoing non-awake resectional LVR with double-lumen tracheal intubation or awake non-resectional LVR by plication with thoracic epidural anaesthesia. As a result, we had 3 matched groups of 30 patients each. RESULTS Baseline forced expiratory volume in 1 s, residual volume, the 6-min walking test and the modified Medical Research Council dyspnoea index were 0.77 ± 0.18, 4.97 ± 0.6, 328 ± 65 and 3.3 ± 0.7, respectively, with no intergroup difference aft...
Happy hypoxemia is an unspecified definition that is used in COVID-19 patients to define hypoxemi... more Happy hypoxemia is an unspecified definition that is used in COVID-19 patients to define hypoxemia without dyspnoea. Dyspnoea is a very complex symptom, and although hypoxemia can cause breathlessness, dyspnoea is not related to hypoxemia, but is more closely related to inspiratory drive and mechanical alterations. The lack of dyspnoea in the early stages of the disease is likely related to the absence of increased inspiratory drive due to compensatory mechanisms of hypoxemia, while in the advanced stages there is no evidence of a lack of dyspnoea in COVID-19 patients.
Interactive CardioVascular and Thoracic Surgery, Oct 1, 2017
; (2) >80% GGO ratio on high-resolution computed tomography (HR-CT); (3) negative 18F-fluorodeoxy... more ; (2) >80% GGO ratio on high-resolution computed tomography (HR-CT); (3) negative 18F-fluorodeoxyglucose accumulation in the tumour on positron emission tomography (PET)-CT; (4) patients with expected intentional cure with wedge resection (segmentectomy was tolerated in the tumour location); (5) Noguchi type A/B diagnosed via frozen section; and (6) no cancer cells on intraoperative stump cytology. Between November 2006 and April 2012, a total of 73 patients with suspected lung cancer were prospectively enrolled from 16 institutions. The overall survival and recurrence-free survival were analysed. Results: Fifty-three patients were eligible for this study by the intraoperative evaluations. The mean age was 61.7±10.8 years (range 26-79 years). The mean tumour size was 14±3.4 mm (8-9 mm, n = 4; 10-14 mm, n = 26; 15-20 mm, n = 23) and the mean GGO ratio was 95.9±7.2% (80-89%, n = 12; 90-99%, n = 2; 100%, n = 39). Thirty-nine and 14 patients underwent wedge resections and segmentectomies, respectively. Five open thoracotomies and 48 thoracoscopic surgeries were performed. Forty-seven patients were diagnosed with Noguchi type A/B (88.7%) and 6 patients had Noguchi type C (11.3%). All patients were staged as pT1aN0M0-IA. No completion lobectomies were performed. One patient died due to another malignant disease. The 5-year overall survival and recurrence-free survival rates were 98.1% and 100%, respectively, during a mean follow-up period of 64.8±17.6 months (range 22-107 months).
This paper presents the analysis of the autonomic nervous system (ANS) control and cardiac barore... more This paper presents the analysis of the autonomic nervous system (ANS) control and cardiac baroreflex sensitivity in patients undergoing general anesthesia for major surgery, with the goal of evaluating the effects of anesthesia bolus induction with propofol on autonomic control of heart rate (HR) and arterial blood pressure (ABP). The decrease in baroreflex gain observed through two different methods in the LF band suggests that baroreflex responses could be impaired by propofol during anesthesia.
Aim: Knee osteoarthritis is a degenerative disease complicated by pain and functional limitation.... more Aim: Knee osteoarthritis is a degenerative disease complicated by pain and functional limitation. Newer pain-relieving interventions include pulsed radiofrequency (PRF), but studies on its efficacy have limitations including lack of control group and retrospective design that prevent sound conclusions. Materials & methods: We conducted a blind prospective randomized sham-controlled crossover pilot trial according to the CONSORT guidelines, to evaluate the efficacy of ultrasound-guided saphenous nerve PRF in gonarthritis pain. Results: Sixteen patients completed the study. Pain and function significantly improved after real PRF (numerical rating scale mean difference = 3.31), which was superior to sham PRF over time for pain (3 months) and function (6 months). Conclusion: PRF of the saphenous nerve is an alternative to relieve pain in gonarthritis. Our results provide data to support a sample size calculation for future trials. Clinical trial registration: NCT04454710
Background/Aim: Knowledge of Coronavirus 19 (COVID19) pathogenetic mechanisms is necessary to pro... more Background/Aim: Knowledge of Coronavirus 19 (COVID19) pathogenetic mechanisms is necessary to provide new treatment strategies. This study aims to assess how oncological disease impacts on the clinical course of COVID-19 patients. Patients and Methods: From 1 st March to 30 th April 2020, 96 COVID-19 patients were classified according to clinical outcome as severe (n=67) and moderate (n=29). Demographic data, medical history, admission lymphocytes, procalcitonin (PCT), c-reactive-protein (CRP), D-dimer, and Interleukin-6 (IL-6) were collected. Results: A statistically significant association was found between hypertension (p=0.007) and three or more comorbidities with severe outcomes (p=0.034). No statistical differences were found between the severe and moderate groups with regards to the rate of patients with past oncological history. However, no patient allocated in the moderate group had received oncological treatment within 12 months. Higher values of CRP, IL-6, D-Dimer and lower values of lymphocytes were reported in the severe group (p=0.0007, p=0.00386, p=0.041, and p=0.007, respectively). Using binary logistic regression, higher values of CRP (OR=8.861; p=0.012) and PCT were associated with a higher risk of severe outcome (OR=21.075; p=0.008). Within the oncological population, D-Dimer and IL-6 did not confirm their prognostic significance as in the general population (p>0.05). Conclusion: Specific prognostic factors for oncological patients should be designed for COVID-19 clinical practice. The Coronavirus-19 (COVID-19) pandemic represents a global challenge due to the rapid spread and poor prognosis, with a fatality rate of 6.2% and more than 5 million people infected worldwide (1). COVID-19 has strongly impacted all medical science fields and several physicians are currently reorganizing their clinical practice in order to provide the best treatment and reduce the risk of cross contamination (2-4). Based on the most recent flu pandemic, the Center for Infectious Disease Research and Policy (CIDRAP) calculated that this outbreak will likely last up to 24 months (1). In 307 This article is freely accessible online.
Introduction COVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospit... more Introduction COVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospitals and beds in intensive care unit, oncological and breast cancer (BC) resources are temporarily shifted to COVID-19 patients. In addition, risk of cross-infections should be considered in these frail patients. To accomplish more surgical procedures and to reduce the length of hospital stay (LOS), fast track awake BC surgery should be implemented. The aim of the study is to estimate the effects of surgical shift in our facility during the early COVID-19 outbreak. Materials and methods From 30th January 2020 to 30th of March 2020, 86 consecutive patients were retrospectively enrolled and divided into pre-COVID-19-BC and COVID-19-BC. Clinical parameters and anamnestic data were collected and analyzed. Surgical procedures, relative complications and type of anaesthesia were reported. The effect on surgical time (ST), operative room time (ORT) and length of stay (LOS) were described and exa...
Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection o... more Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection of severely damaged emphysematous tissue carried out by thoracoscopic or open surgical approaches, under general anesthesia with single-lung ventilation, has resulted in significant and longlasting clinical and functional benefit. Unfortunately, the morbidity rates reported by simultaneous bilateral resectional LVRS has led to raise criticism regarding its cost-effectiveness and has stimulated in recent years the development of less invasive bronchoscopic and surgical non-resectional methods of treatment that are preferentially performed in a staged unilateral fashion. We had previously proposed an innovative LVRS modality, which did not entail any resection of lung tissue and was electively carried out according to a staged unilateral strategy by a multiport thoracoscopic access, through thoracic epidural anesthesia in conscious, spontaneously ventilating patients (awake LVRS). The awake LVRS resulted in significant clinical benefit paralleling that achieved by the resectional method with lower morbidity rates and shorter hospital stay. Moreover, the awake LVRS proved also suitable to be employed in stringently selected patients to perform redo procedures following previous successful bilateral LVRS. More recently, in order to minimize the global surgery-and anesthesia-related traumas, we have modified our original non-resectional method by adopting a single thoracoscopic access as well as an anesthesia protocol entailing use of a simple intercostal block with target control sedation, to realize an ultra-minimally invasive or minimalist LVRS. Hence, a deeper investigation of the pros and cons of staged unilateral LVRS strategies as well as of the novel surgical non-resectional and redo LVRS is warranted in order to verify, the optimal strategies of treatment, which will prove to reduce the typical LVRS-related morbidity while assuring the most durable benefit in patients with advanced emphysema.
Background: Surgical stress and anesthesia affect the patient's immune system. Analysis of the ly... more Background: Surgical stress and anesthesia affect the patient's immune system. Analysis of the lymphocyte response after breast-conserving surgery was conducted to investigate the differences between effects after general and local anesthesia. Materials and Methods: Fifty-six patients with breast cancer were enrolled for BCS through local or general anesthesia. Total leukocytes, total lymphocytes, lymphocyte-subsets including CD3 + , CD19 + , CD4 + , CD8 + , CD16 + CD56 + and CD4 + /CD8 + ratio was examined at baseline and on postoperative days 1, 2 and 3. Results: Baseline data showed no statistical difference between the two groups. Within-group ANOVA test showed significant differences for total leukocyte count (p<0.001), total lymphocyte count (p=0.009) and proportion of natural-killer cells (p=0.01) in the control group. Between-group analysis showed lower median values of total lymphocytes in the awake surgery group on postoperative days 1, 2 and 3 (p=0.001, p=0.02 and p=0.01, respectively) when compared to the control group. Patients who underwent surgery under general anesthesia had higher total lymphocyte counts on postoperative day 2 (p=0.04). Conclusion: In this randomized study, breast-conserving surgery plus local anesthesia had a lower impact on postoperative lymphocyte response when compared to the same procedure performed under general anesthesia. Lymphocytes are fundamental types of white blood cells. Cells of the lymphatic system play a crucial role in the immune system due to their regulatory function through regulatory cytokines and due to cytotoxic activity against tumors and infections (1, 2). As underlined in the literature, surgical stress and general anesthesia may reduce the numbers of circulating lymphocytes (1-6). It is a widely held view that impairment of immune function can predispose to infectious complications such as surgical site infections (SSI) (5-8). Moreover, reduced cytotoxic activity of peripheralblood lymphocytes can increase the probability of tumor progression and metastasis (4, 5, 9-13). According to several studies, use of a minimally invasive approach in thoracic surgery (1, 14, 15) and abdominal surgery (16-18) demonstrated that immune function may be better preserved. However, there is lack of high-level evidence about the protective role of minimally invasive techniques in early lymphocyte response and it is conceivable that, regardless of the surgical approach, any 1879 This article is freely accessible online.
Archives of Medical Science - Civilization Diseases, 2019
Introduction: Surgery and anaesthesia may affect the outcomes of cancer. The aim of the study was... more Introduction: Surgery and anaesthesia may affect the outcomes of cancer. The aim of the study was to evaluate the effect of propofol or sevoflurane on cancer biomarkers such as interleukins, adhesion molecules, and EGFR. Material and methods: Eighty patients scheduled for colorectal cancer surgery were randomised to either propofol or sevoflurane anaesthesia. Blood samples for interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α (TNF-α), interferon α (IFN-α), soluble intracellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), sE-selectin, and sEGFR measurements were obtained before induction of anaesthesia, at the end of surgery, and 72 h postoperatively. Results: Complete samples were obtained from 71 patients. Demographic data and anaesthesia/surgery-related data were similar between the two groups. There were significant differences produced by sevoflurane vs. propofol on the sE-selectin (median (IQR) 57.1 (59.2) vs. 42.7 (22.9) ng/ml, p = 0.011) and sEGFR (median (IQR) 49905.7 (22673.5) vs. 25.657.2 (13842.1) ng/ml, p < 0.001) concentrations postoperatively, while sEGFR plasma levels also showed a significant difference during surgery (median (IQR) 32964.5 (14402.5) vs. 25567.0 (13315.4) ng/ml, p = 0.04). IL-10 levels were significantly higher in the propofol group postoperatively (median (IQR) 13.7 (18.5) vs. 14.9 (66.6) pg/ml, p = 0.05). Conclusions: Given the role of EGFR and adhesion molecules on tumour progression and the generation of metastases, the inhibitory effect of propofol observed in this study might prove useful in the future. Further studies in larger populations investigating the effect of anaesthetic agents on these biomarkers are warranted.
Thymoma represents a relatively rare slowly growing tumor of the thymic gland. Complete thymomect... more Thymoma represents a relatively rare slowly growing tumor of the thymic gland. Complete thymomectomy along with all thymic and peri-thymic tissue is recommended to reduce risks of recurrence and proved to be beneficial for patients with associated myasthenia gravis (MG). Various surgical approaches have been advocated for thymomectomy and in recent years, use of video-assisted thoracoscopic surgery (VATS) has become more and more popular. Moreover, combining minimally invasive approaches together will have an excellent impact on the very early post-operative outcome. We report on a patient with MG who underwent a minimalist uniportal three dimensional thoracoscopic extended thymomectomy under non intubated, spontaneous ventilation anaesthesia protocol.
The aim of this study was to identify potential variables influencing the clinical presentation o... more The aim of this study was to identify potential variables influencing the clinical presentation of breakthrough cancer pain (BTP). Cancer patients with a diagnosis of BTP were enrolled. Demographic and clinical characteristics, as well as background pain and BTP characteristics were collected. Multivariate analyses were conducted to assess the correlation between BTP characteristics and the variables examined. Data of 4016 patients were analysed. Average daily number of BTP episodes was 2.4, mean intensity was 7.5, and a mean duration was 43.3 min. A short onset BTP was observed in 68.9% of patients. In 30.5% of patients BTP was predictable. There were 86.0% of participants who reported a marked interference of BTP with their daily activities. Furthermore, 86.8% of patients were receiving opioids for the management of BTP. The average time to meaningful pain relief was 16.5 min and 70.9% of patients were satisfied with their BTP medications. Age, head and neck cancer, Karnofsky, bac...
Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of ... more Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of which patient might be at risk for such events may help guide peri- and postoperative care. We show how archiving and mining of intraoperative hemodynamic data in orthotopic liver transplantation (OLT) can aid in the prediction of postoperative 180-day mortality and acute renal failure (ARF), improving upon predictions that rely on preoperative information only. From 101 patient records, we extracted 15 preoperative features from clinical records and 41 features from intraoperative hemodynamic signals. We used logistic regression with leave-one-out cross-validation to predict outcomes, and incorporated methods to limit potential model instabilities from feature multicollinearity. Using only preoperative features, mortality prediction achieved an area under the receiver operating characteristic curve (AUC) of 0.53 (95% CI: 0.44-0.78). By using intraoperative features, performance improved...
The increasing number of opioid users among chronic pain patients, and opioid abusers among the g... more The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioidtolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and patients under maintenance programs with methadone, buprenorphine, or naltrexone.
The Journal of Thoracic and Cardiovascular Surgery, 2017
Surgical maneuvering and tumor dissection through a single thoracoscopic access. Central Message ... more Surgical maneuvering and tumor dissection through a single thoracoscopic access. Central Message A novel minimalist thoracoscopic resection method of thymomas associated with myasthenia gravis, which is performed through a single surgical access and under spontaneous ventilation, is reported.
Journal of Translational Medicine and Research, 2016
Background: There has been a relative lack of research on the effect of applying enhanced recover... more Background: There has been a relative lack of research on the effect of applying enhanced recovery principles in the context of morbid obesity surgery and monitoring outcome. Objectives: To determine the feasibility of applying enhanced recovery after surgery (ERAS) principles application on a bariatric population and review the effect on outcome in this population. Methods: We analyzed data prospectively collected on a cohort of 111 patients undergoing laparoscopic bariatric surgery between March 2013 and December 2014. All patients were enrolled in an ERAS protocol and were assessed for fitness for early discharge. We focused our attention on earlycomplications (within 30 days) and any late complications. Results: All 111 patients who underwent bariatric surgery were suitable for early discharge between 24-72 hours. Short term complications (within 30 days postoperatively) were acceptable. Mortality rate was 0%, reoperation rate was 0% and hospital readmission rate was 2%. Concerning the short term complications in the 63 patients who underwent LAGB the commonest was the raised temperature. Hospital readmission rate, reoperation rate and mortality were all 0%. Conclusion: Application of ERAS protocol on bariatric surgery is feasible with an acceptable number of minor complications. Further studies are required to improve outcome further.
Introduction: An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multice... more Introduction: An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] is evaluating the characteristics of breakthrough cancer pain (BTP) in different clinical settings. Preliminary data from the first 1500 cancer patients with BTP enrolled in this study are presented here. Methods: Thirty-two clinical centers are involved in the survey. A diagnosis of BTP was performed by a standard algorithm. Epidemiological data, Karnofsky index, stage of disease, presence and sites of metastases, ongoing oncologic treatment, and
2015 37th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC), 2015
Liver transplantation remains the only curative treatment option for a variety of end-stage liver... more Liver transplantation remains the only curative treatment option for a variety of end-stage liver diseases. Prediction of major adverse events following surgery has traditionally focused on static predictors that are known prior to surgery. The effects of intraoperative management can now be explored due to the archiving of high-resolution monitoring data. We extracted intraoperative hemodynamic trend data of 55 patients undergoing orthotopic liver transplantation (OLT) and computed 12 features from the systolic arterial blood pressure (ABP), cardiac index, central venous pressure (CVP), and stroke volume variation (SVV) signals. Using a logistic regression classifier with a leave-one-out cross-validation procedure, we selected subsets of these features to predict mortality up to 180 days after surgery. Best performance was achieved with a combination of 3 features - median absolute deviation (MAD) of ABP, median CVP, and time spent with SVV &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;; 10% - reaching an area under the receiver-operating characteristic (or c-statistic) of 0.808. Odds ratios (OR) computed from the coefficients of the multivariate logistic regression model constructed from these features showed that greater time spent with SVV &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;; 10% (OR = 0.981 min(-1), p = 0.001) and greater MAD of systolic ABP (OR = 0.696 mmHg(-1), p = 0.026) were significantly associated with survival. Adding preoperative measures such as age and serum concentrations of albumin, bilirubin, and creatinine failed to improve performance of the prediction model. These results show that the course of intraoperative hemodynamics can predict 180-day mortality after OLT.
: The Authors report the causal discovery of isolated persistent left superior vena cava (IPLSVC)... more : The Authors report the causal discovery of isolated persistent left superior vena cava (IPLSVC) during a central venous incannulation with a Groshong's catheter, in a patient undergoing bone marrow transplant. After a short introduction about the IPLSVC ontogenesis, they stress the need for fluoroscopy during the central venous incannulation. The Authors conclude that the possibility of angiocardiography has been very helpful, in this case, for diagnosis and prognosis.
  OBJECTIVES Our goal was to assess the results and the costs of the quasilobar minimalist (QLM) ... more   OBJECTIVES Our goal was to assess the results and the costs of the quasilobar minimalist (QLM) thoracoscopic lung volume reduction (LVR) surgical method developed to minimize the trauma from the operation and the anaesthesia and to maximize the effect of the lobar volume reduction. METHODS Forty patients with severe emphysema underwent QLM-LVR that entailed adoption of sole intercostal block analgesia and lobar plication through a single thoracoscopic incision. Results were compared after propensity matching with 2 control groups undergoing non-awake resectional LVR with double-lumen tracheal intubation or awake non-resectional LVR by plication with thoracic epidural anaesthesia. As a result, we had 3 matched groups of 30 patients each. RESULTS Baseline forced expiratory volume in 1 s, residual volume, the 6-min walking test and the modified Medical Research Council dyspnoea index were 0.77 ± 0.18, 4.97 ± 0.6, 328 ± 65 and 3.3 ± 0.7, respectively, with no intergroup difference aft...
Happy hypoxemia is an unspecified definition that is used in COVID-19 patients to define hypoxemi... more Happy hypoxemia is an unspecified definition that is used in COVID-19 patients to define hypoxemia without dyspnoea. Dyspnoea is a very complex symptom, and although hypoxemia can cause breathlessness, dyspnoea is not related to hypoxemia, but is more closely related to inspiratory drive and mechanical alterations. The lack of dyspnoea in the early stages of the disease is likely related to the absence of increased inspiratory drive due to compensatory mechanisms of hypoxemia, while in the advanced stages there is no evidence of a lack of dyspnoea in COVID-19 patients.
Interactive CardioVascular and Thoracic Surgery, Oct 1, 2017
; (2) >80% GGO ratio on high-resolution computed tomography (HR-CT); (3) negative 18F-fluorodeoxy... more ; (2) >80% GGO ratio on high-resolution computed tomography (HR-CT); (3) negative 18F-fluorodeoxyglucose accumulation in the tumour on positron emission tomography (PET)-CT; (4) patients with expected intentional cure with wedge resection (segmentectomy was tolerated in the tumour location); (5) Noguchi type A/B diagnosed via frozen section; and (6) no cancer cells on intraoperative stump cytology. Between November 2006 and April 2012, a total of 73 patients with suspected lung cancer were prospectively enrolled from 16 institutions. The overall survival and recurrence-free survival were analysed. Results: Fifty-three patients were eligible for this study by the intraoperative evaluations. The mean age was 61.7±10.8 years (range 26-79 years). The mean tumour size was 14±3.4 mm (8-9 mm, n = 4; 10-14 mm, n = 26; 15-20 mm, n = 23) and the mean GGO ratio was 95.9±7.2% (80-89%, n = 12; 90-99%, n = 2; 100%, n = 39). Thirty-nine and 14 patients underwent wedge resections and segmentectomies, respectively. Five open thoracotomies and 48 thoracoscopic surgeries were performed. Forty-seven patients were diagnosed with Noguchi type A/B (88.7%) and 6 patients had Noguchi type C (11.3%). All patients were staged as pT1aN0M0-IA. No completion lobectomies were performed. One patient died due to another malignant disease. The 5-year overall survival and recurrence-free survival rates were 98.1% and 100%, respectively, during a mean follow-up period of 64.8±17.6 months (range 22-107 months).
This paper presents the analysis of the autonomic nervous system (ANS) control and cardiac barore... more This paper presents the analysis of the autonomic nervous system (ANS) control and cardiac baroreflex sensitivity in patients undergoing general anesthesia for major surgery, with the goal of evaluating the effects of anesthesia bolus induction with propofol on autonomic control of heart rate (HR) and arterial blood pressure (ABP). The decrease in baroreflex gain observed through two different methods in the LF band suggests that baroreflex responses could be impaired by propofol during anesthesia.
Aim: Knee osteoarthritis is a degenerative disease complicated by pain and functional limitation.... more Aim: Knee osteoarthritis is a degenerative disease complicated by pain and functional limitation. Newer pain-relieving interventions include pulsed radiofrequency (PRF), but studies on its efficacy have limitations including lack of control group and retrospective design that prevent sound conclusions. Materials & methods: We conducted a blind prospective randomized sham-controlled crossover pilot trial according to the CONSORT guidelines, to evaluate the efficacy of ultrasound-guided saphenous nerve PRF in gonarthritis pain. Results: Sixteen patients completed the study. Pain and function significantly improved after real PRF (numerical rating scale mean difference = 3.31), which was superior to sham PRF over time for pain (3 months) and function (6 months). Conclusion: PRF of the saphenous nerve is an alternative to relieve pain in gonarthritis. Our results provide data to support a sample size calculation for future trials. Clinical trial registration: NCT04454710
Background/Aim: Knowledge of Coronavirus 19 (COVID19) pathogenetic mechanisms is necessary to pro... more Background/Aim: Knowledge of Coronavirus 19 (COVID19) pathogenetic mechanisms is necessary to provide new treatment strategies. This study aims to assess how oncological disease impacts on the clinical course of COVID-19 patients. Patients and Methods: From 1 st March to 30 th April 2020, 96 COVID-19 patients were classified according to clinical outcome as severe (n=67) and moderate (n=29). Demographic data, medical history, admission lymphocytes, procalcitonin (PCT), c-reactive-protein (CRP), D-dimer, and Interleukin-6 (IL-6) were collected. Results: A statistically significant association was found between hypertension (p=0.007) and three or more comorbidities with severe outcomes (p=0.034). No statistical differences were found between the severe and moderate groups with regards to the rate of patients with past oncological history. However, no patient allocated in the moderate group had received oncological treatment within 12 months. Higher values of CRP, IL-6, D-Dimer and lower values of lymphocytes were reported in the severe group (p=0.0007, p=0.00386, p=0.041, and p=0.007, respectively). Using binary logistic regression, higher values of CRP (OR=8.861; p=0.012) and PCT were associated with a higher risk of severe outcome (OR=21.075; p=0.008). Within the oncological population, D-Dimer and IL-6 did not confirm their prognostic significance as in the general population (p>0.05). Conclusion: Specific prognostic factors for oncological patients should be designed for COVID-19 clinical practice. The Coronavirus-19 (COVID-19) pandemic represents a global challenge due to the rapid spread and poor prognosis, with a fatality rate of 6.2% and more than 5 million people infected worldwide (1). COVID-19 has strongly impacted all medical science fields and several physicians are currently reorganizing their clinical practice in order to provide the best treatment and reduce the risk of cross contamination (2-4). Based on the most recent flu pandemic, the Center for Infectious Disease Research and Policy (CIDRAP) calculated that this outbreak will likely last up to 24 months (1). In 307 This article is freely accessible online.
Introduction COVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospit... more Introduction COVID-19 is a declared worldwide pandemic. In our country, due to shortage of hospitals and beds in intensive care unit, oncological and breast cancer (BC) resources are temporarily shifted to COVID-19 patients. In addition, risk of cross-infections should be considered in these frail patients. To accomplish more surgical procedures and to reduce the length of hospital stay (LOS), fast track awake BC surgery should be implemented. The aim of the study is to estimate the effects of surgical shift in our facility during the early COVID-19 outbreak. Materials and methods From 30th January 2020 to 30th of March 2020, 86 consecutive patients were retrospectively enrolled and divided into pre-COVID-19-BC and COVID-19-BC. Clinical parameters and anamnestic data were collected and analyzed. Surgical procedures, relative complications and type of anaesthesia were reported. The effect on surgical time (ST), operative room time (ORT) and length of stay (LOS) were described and exa...
Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection o... more Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection of severely damaged emphysematous tissue carried out by thoracoscopic or open surgical approaches, under general anesthesia with single-lung ventilation, has resulted in significant and longlasting clinical and functional benefit. Unfortunately, the morbidity rates reported by simultaneous bilateral resectional LVRS has led to raise criticism regarding its cost-effectiveness and has stimulated in recent years the development of less invasive bronchoscopic and surgical non-resectional methods of treatment that are preferentially performed in a staged unilateral fashion. We had previously proposed an innovative LVRS modality, which did not entail any resection of lung tissue and was electively carried out according to a staged unilateral strategy by a multiport thoracoscopic access, through thoracic epidural anesthesia in conscious, spontaneously ventilating patients (awake LVRS). The awake LVRS resulted in significant clinical benefit paralleling that achieved by the resectional method with lower morbidity rates and shorter hospital stay. Moreover, the awake LVRS proved also suitable to be employed in stringently selected patients to perform redo procedures following previous successful bilateral LVRS. More recently, in order to minimize the global surgery-and anesthesia-related traumas, we have modified our original non-resectional method by adopting a single thoracoscopic access as well as an anesthesia protocol entailing use of a simple intercostal block with target control sedation, to realize an ultra-minimally invasive or minimalist LVRS. Hence, a deeper investigation of the pros and cons of staged unilateral LVRS strategies as well as of the novel surgical non-resectional and redo LVRS is warranted in order to verify, the optimal strategies of treatment, which will prove to reduce the typical LVRS-related morbidity while assuring the most durable benefit in patients with advanced emphysema.
Background: Surgical stress and anesthesia affect the patient's immune system. Analysis of the ly... more Background: Surgical stress and anesthesia affect the patient's immune system. Analysis of the lymphocyte response after breast-conserving surgery was conducted to investigate the differences between effects after general and local anesthesia. Materials and Methods: Fifty-six patients with breast cancer were enrolled for BCS through local or general anesthesia. Total leukocytes, total lymphocytes, lymphocyte-subsets including CD3 + , CD19 + , CD4 + , CD8 + , CD16 + CD56 + and CD4 + /CD8 + ratio was examined at baseline and on postoperative days 1, 2 and 3. Results: Baseline data showed no statistical difference between the two groups. Within-group ANOVA test showed significant differences for total leukocyte count (p<0.001), total lymphocyte count (p=0.009) and proportion of natural-killer cells (p=0.01) in the control group. Between-group analysis showed lower median values of total lymphocytes in the awake surgery group on postoperative days 1, 2 and 3 (p=0.001, p=0.02 and p=0.01, respectively) when compared to the control group. Patients who underwent surgery under general anesthesia had higher total lymphocyte counts on postoperative day 2 (p=0.04). Conclusion: In this randomized study, breast-conserving surgery plus local anesthesia had a lower impact on postoperative lymphocyte response when compared to the same procedure performed under general anesthesia. Lymphocytes are fundamental types of white blood cells. Cells of the lymphatic system play a crucial role in the immune system due to their regulatory function through regulatory cytokines and due to cytotoxic activity against tumors and infections (1, 2). As underlined in the literature, surgical stress and general anesthesia may reduce the numbers of circulating lymphocytes (1-6). It is a widely held view that impairment of immune function can predispose to infectious complications such as surgical site infections (SSI) (5-8). Moreover, reduced cytotoxic activity of peripheralblood lymphocytes can increase the probability of tumor progression and metastasis (4, 5, 9-13). According to several studies, use of a minimally invasive approach in thoracic surgery (1, 14, 15) and abdominal surgery (16-18) demonstrated that immune function may be better preserved. However, there is lack of high-level evidence about the protective role of minimally invasive techniques in early lymphocyte response and it is conceivable that, regardless of the surgical approach, any 1879 This article is freely accessible online.
Archives of Medical Science - Civilization Diseases, 2019
Introduction: Surgery and anaesthesia may affect the outcomes of cancer. The aim of the study was... more Introduction: Surgery and anaesthesia may affect the outcomes of cancer. The aim of the study was to evaluate the effect of propofol or sevoflurane on cancer biomarkers such as interleukins, adhesion molecules, and EGFR. Material and methods: Eighty patients scheduled for colorectal cancer surgery were randomised to either propofol or sevoflurane anaesthesia. Blood samples for interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α (TNF-α), interferon α (IFN-α), soluble intracellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), sE-selectin, and sEGFR measurements were obtained before induction of anaesthesia, at the end of surgery, and 72 h postoperatively. Results: Complete samples were obtained from 71 patients. Demographic data and anaesthesia/surgery-related data were similar between the two groups. There were significant differences produced by sevoflurane vs. propofol on the sE-selectin (median (IQR) 57.1 (59.2) vs. 42.7 (22.9) ng/ml, p = 0.011) and sEGFR (median (IQR) 49905.7 (22673.5) vs. 25.657.2 (13842.1) ng/ml, p < 0.001) concentrations postoperatively, while sEGFR plasma levels also showed a significant difference during surgery (median (IQR) 32964.5 (14402.5) vs. 25567.0 (13315.4) ng/ml, p = 0.04). IL-10 levels were significantly higher in the propofol group postoperatively (median (IQR) 13.7 (18.5) vs. 14.9 (66.6) pg/ml, p = 0.05). Conclusions: Given the role of EGFR and adhesion molecules on tumour progression and the generation of metastases, the inhibitory effect of propofol observed in this study might prove useful in the future. Further studies in larger populations investigating the effect of anaesthetic agents on these biomarkers are warranted.
Thymoma represents a relatively rare slowly growing tumor of the thymic gland. Complete thymomect... more Thymoma represents a relatively rare slowly growing tumor of the thymic gland. Complete thymomectomy along with all thymic and peri-thymic tissue is recommended to reduce risks of recurrence and proved to be beneficial for patients with associated myasthenia gravis (MG). Various surgical approaches have been advocated for thymomectomy and in recent years, use of video-assisted thoracoscopic surgery (VATS) has become more and more popular. Moreover, combining minimally invasive approaches together will have an excellent impact on the very early post-operative outcome. We report on a patient with MG who underwent a minimalist uniportal three dimensional thoracoscopic extended thymomectomy under non intubated, spontaneous ventilation anaesthesia protocol.
The aim of this study was to identify potential variables influencing the clinical presentation o... more The aim of this study was to identify potential variables influencing the clinical presentation of breakthrough cancer pain (BTP). Cancer patients with a diagnosis of BTP were enrolled. Demographic and clinical characteristics, as well as background pain and BTP characteristics were collected. Multivariate analyses were conducted to assess the correlation between BTP characteristics and the variables examined. Data of 4016 patients were analysed. Average daily number of BTP episodes was 2.4, mean intensity was 7.5, and a mean duration was 43.3 min. A short onset BTP was observed in 68.9% of patients. In 30.5% of patients BTP was predictable. There were 86.0% of participants who reported a marked interference of BTP with their daily activities. Furthermore, 86.8% of patients were receiving opioids for the management of BTP. The average time to meaningful pain relief was 16.5 min and 70.9% of patients were satisfied with their BTP medications. Age, head and neck cancer, Karnofsky, bac...
Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of ... more Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of which patient might be at risk for such events may help guide peri- and postoperative care. We show how archiving and mining of intraoperative hemodynamic data in orthotopic liver transplantation (OLT) can aid in the prediction of postoperative 180-day mortality and acute renal failure (ARF), improving upon predictions that rely on preoperative information only. From 101 patient records, we extracted 15 preoperative features from clinical records and 41 features from intraoperative hemodynamic signals. We used logistic regression with leave-one-out cross-validation to predict outcomes, and incorporated methods to limit potential model instabilities from feature multicollinearity. Using only preoperative features, mortality prediction achieved an area under the receiver operating characteristic curve (AUC) of 0.53 (95% CI: 0.44-0.78). By using intraoperative features, performance improved...
The increasing number of opioid users among chronic pain patients, and opioid abusers among the g... more The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioidtolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and patients under maintenance programs with methadone, buprenorphine, or naltrexone.
The Journal of Thoracic and Cardiovascular Surgery, 2017
Surgical maneuvering and tumor dissection through a single thoracoscopic access. Central Message ... more Surgical maneuvering and tumor dissection through a single thoracoscopic access. Central Message A novel minimalist thoracoscopic resection method of thymomas associated with myasthenia gravis, which is performed through a single surgical access and under spontaneous ventilation, is reported.
Journal of Translational Medicine and Research, 2016
Background: There has been a relative lack of research on the effect of applying enhanced recover... more Background: There has been a relative lack of research on the effect of applying enhanced recovery principles in the context of morbid obesity surgery and monitoring outcome. Objectives: To determine the feasibility of applying enhanced recovery after surgery (ERAS) principles application on a bariatric population and review the effect on outcome in this population. Methods: We analyzed data prospectively collected on a cohort of 111 patients undergoing laparoscopic bariatric surgery between March 2013 and December 2014. All patients were enrolled in an ERAS protocol and were assessed for fitness for early discharge. We focused our attention on earlycomplications (within 30 days) and any late complications. Results: All 111 patients who underwent bariatric surgery were suitable for early discharge between 24-72 hours. Short term complications (within 30 days postoperatively) were acceptable. Mortality rate was 0%, reoperation rate was 0% and hospital readmission rate was 2%. Concerning the short term complications in the 63 patients who underwent LAGB the commonest was the raised temperature. Hospital readmission rate, reoperation rate and mortality were all 0%. Conclusion: Application of ERAS protocol on bariatric surgery is feasible with an acceptable number of minor complications. Further studies are required to improve outcome further.
Introduction: An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multice... more Introduction: An ongoing national multicenter survey [Italian Oncologic Pain multiSetting Multicentric Survey (IOPS-MS)] is evaluating the characteristics of breakthrough cancer pain (BTP) in different clinical settings. Preliminary data from the first 1500 cancer patients with BTP enrolled in this study are presented here. Methods: Thirty-two clinical centers are involved in the survey. A diagnosis of BTP was performed by a standard algorithm. Epidemiological data, Karnofsky index, stage of disease, presence and sites of metastases, ongoing oncologic treatment, and
2015 37th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC), 2015
Liver transplantation remains the only curative treatment option for a variety of end-stage liver... more Liver transplantation remains the only curative treatment option for a variety of end-stage liver diseases. Prediction of major adverse events following surgery has traditionally focused on static predictors that are known prior to surgery. The effects of intraoperative management can now be explored due to the archiving of high-resolution monitoring data. We extracted intraoperative hemodynamic trend data of 55 patients undergoing orthotopic liver transplantation (OLT) and computed 12 features from the systolic arterial blood pressure (ABP), cardiac index, central venous pressure (CVP), and stroke volume variation (SVV) signals. Using a logistic regression classifier with a leave-one-out cross-validation procedure, we selected subsets of these features to predict mortality up to 180 days after surgery. Best performance was achieved with a combination of 3 features - median absolute deviation (MAD) of ABP, median CVP, and time spent with SVV &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;; 10% - reaching an area under the receiver-operating characteristic (or c-statistic) of 0.808. Odds ratios (OR) computed from the coefficients of the multivariate logistic regression model constructed from these features showed that greater time spent with SVV &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;; 10% (OR = 0.981 min(-1), p = 0.001) and greater MAD of systolic ABP (OR = 0.696 mmHg(-1), p = 0.026) were significantly associated with survival. Adding preoperative measures such as age and serum concentrations of albumin, bilirubin, and creatinine failed to improve performance of the prediction model. These results show that the course of intraoperative hemodynamics can predict 180-day mortality after OLT.
: The Authors report the causal discovery of isolated persistent left superior vena cava (IPLSVC)... more : The Authors report the causal discovery of isolated persistent left superior vena cava (IPLSVC) during a central venous incannulation with a Groshong's catheter, in a patient undergoing bone marrow transplant. After a short introduction about the IPLSVC ontogenesis, they stress the need for fluoroscopy during the central venous incannulation. The Authors conclude that the possibility of angiocardiography has been very helpful, in this case, for diagnosis and prognosis.
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