Malignant ascites is relatively common in patients with certain types of end-stage cancer. Traditional treatments based on fluid and salt restriction and diuretic therapy often are not able to contain neoplastic ascites. These patients consequently undergo repeated abdominal paracentesis, with further plasma protein loss and risk of injury to abdominal viscera. The aim of this study was to evaluate our experience with Denver peritoneovenous shunt and the outcome of patients with malignant ascites and suggest some modifications to improve device patency. From February 1997 to December 1999, 44 Denver peritoneovenous shunts were placed in 42 patients, 17 women and 25 men, aged between 38 and 77 years (mean, 62.3), affected with malignant ascites due to advanced abdominal cancer. At the time of admission, 72% of patients had pain, 88% dysphagia, 66% nausea and/or vomiting, and 83% dyspnea. Eleven patients underwent local anesthesia with lidocaine and 33 general anesthesia with rapidly metabolized drugs. In 27 cases we used the peritoneal-internal jugular right vein surgical approach and in 3 cases the peritoneal-femoral vein surgical access, joining the saphena vein to the cross. In 10 cases, a radiological positioning of the Denver peritoneovenous shunt was effected by a trans-subclavian access. Relief of ascites symptoms was obtained in 87.5% of cases, with reduction of dyspnea, an increased appetite and improved ambulation. Denver peritoneovenous shunt is a good device to relieve malignant ascites, thereby reducing the risk of complications and the number of hospital admissions due to repeated paracentesis and consequently improving the quality of life. A careful patient selection, an accurate follow-up and some device modifications could improve the shunt performance, allowing a wider application of the Denver peritoneovenous shunt.
Background Diastasis recti is a pathology that affects not only the abdominal wall but also the stability of lumbopelvic muscles, consequently altering urinary and digestive functionality. Preaponeurotic endoscopic repair (REPA) is an endoscopic alternative to tummy tuck for the treatment of diastasis. In this study, the outcomes of REPA application by a single surgeon are presented. Methods A total of 172 patients underwent REPA for the treatment of diastasis recti between August 2017 and December 2019. One hundred twenty-four patients were followed for at least one year. Sixty-three patients responded to a survey on satisfaction and quality of life 12 months after surgery. Results Three (2.4%) recurrences occurred, of which two occurred in the same patient. The main postoperative complications observed were 12 (9.7%) seromas, 3 (2.4%) haematomas, a single wound infection, 3 (2.4%) cases of skin fold formation, and a case of trophic skin lesion that required negative pressure therapy. Quality of life after surgery, as reported by 63 patients who responded to the survey, was satisfactory. Conclusions REPA is a safe and effective technique for diastasis recti treatment, representing a valid alternative to abdominoplasty. Since there is no need to access the peritoneal cavity and the mesh is onlay, there are no risks of bowel damage or adhesions between the intestine and prosthesis.
Background: Postoperative analgesia in SCOLA (subcutaneous onlay laparoscopic approach) surgery is traditionally based on intravenous opioids. The aim of this retrospective observational study was to evaluate the efficacy of bilateral subcostal transversus abdominis plane (SCTAP) block on postoperative pain relief in the first 48 postoperative hours following SCOLA.Materials and Methods: From August 2017 to December 2019, 163 patients were eligible for the analysis. Postoperative analgesia was managed either with an intravenous tramadol continuous infusion (opioid group) or a multimodal opioid-sparing strategy based on bilateral SCTAP block (SCTAP group), according to the anesthesiologist's postoperative plan. After data collection, 103 patients were assigned post hoc to the SCTAP group and 60 patients to the opioid group. The primary outcome was the evaluation of postoperative pain, considering both the Numeric Rating Scale score and the percentage of patients with uncontrolled pain at 6, 12, 24, or 48 hours. Secondary outcomes were differences in the administration of ketorolac rescue analgesia and incidence of mild adverse effects.Results: There were no significant differences in median Numeric Rating Scale at 6, 12, 24, and 48 hours and ketorolac rescue dose consumption in both groups. Five patients (4.85% of a total of 103 patients) referred postoperative nausea and vomiting in the SCTAP group versus 10 patients (16.67% of a total of 60 patients) in the opioid group (P = 0.02). Conclusion:Analgesia with SCTAP block seems to represent a feasible and efficient strategy for pain management in patients undergoing SCOLA surgery, allowing good quality analgesia, low opioids requirements, and reduced incidence of postoperative nausea and vomiting.
INTRODUZIONELe lesioni cutanee croniche (LCC) sono caratterizzate da una mancata guarigione entro 6 settimane dall'insorgenza e rappresentano la manifestazione di plurime patologie sottostanti, determinando complesse esigenze assistenziali.1 Esse sono una problematica largamente diffusa, ma difficilmente quantificabile per la difficoltà nel disporre di dati epidemiologici aggiornati 2 sia perché l'eziopatogenesi è varia, sia perché spesso vi sono più cause concomitanti, dovute perlopiù all'aumento dell'età media della popolazione che contribuisce all'incremento di patologie che favoriscono l'insorgenza di LCC. 3Esse impattano sulla mortalità, sul mantenimento dell'autonomia delle persone e sulla loro qualità di vita, causando un incremento dei costi dei servizi che erogano assistenza sanitaria in tutti i contesti di cura, 4 e per tale motivo l'approccio più efficace per fornire risposte appropriate risulta essere la creazione di percorsi assistenziali costruiti con la collaborazione dei diversi professionisti coinvolti in ambito vulnologico.5 La gestione delle LCC da parte di gruppi multiprofessionali è infatti sostenuta dalla letteratura che raccomanda un approccio collaborativo e interdisciplinare. 6 In altri termini, un team sanitario che si occupa di assistenza a persone affette da LCC dovrebbe essere formato da professionisti appartenenti a diversi profili che affrontano questa complessa problematica ponendo al centro del processo la persona, attorno alla quale ruota un gruppo non solo multidisciplinare, composto da diverse figure professionali che trattano problemi specifici dell'assistito secondo la specializzazione, ma anche interdisciplinare, che unisce le conoscenze delle diverse discipline per creare un'assistenza coordinata realizzando un piano RIASSUNTOLe lesioni cutanee croniche (LCC) sono una problematica diffusa che impatta fortemente sulla vita delle persone colpite, ma se vengono gestite da gruppi multiprofessionali dedicati alla vulnologia l'assistenza viene ottimizzata e gli esiti clinici migliorano. Nell'ASL TO4, azienda sanitaria piemontese, è stato formalizzato con delibera del Direttore Generale un gruppo di esperti vulnologi denominato Rete Aziendale per il trattamento delle lesioni cutanee croniche il cui principale obiettivo è uniformare i percorsi diagnostici-assistenziali nell'Asl TO4 su prevenzione e cura delle LCC. Nel 2016 l'attività svolta dal gruppo negli ospedali e nei distretti attraverso le consulenze vulnologiche da un lato e con le prestazioni erogate negli ambulatori dall'altro ha preso in carico 504 pazienti; nello stesso periodo il team ha ideato e gestito 4 corsi di formazione su prevenzione e cura delle lesioni da decubito rivolto a dipendenti e Medici di Medicina Generale operanti sul territorio dell'ASL TO4.
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