Abstract Introduction In breast surgery, an autologous flap combined with implant may reduce the risk or repair the soft-tissue defects in several cases. Traditionally, the preferred flap is the myocutaneous latissimus dorsi (LD) flap. In the perforator flap era, the evolution of LD flap is the thoracodorsal artery perforator (TDAP) flap. The aim of this study is the comparison between LD flap and TDAP flap with implants in terms of early complications and shoulder function. Methods We performed a retrospective cohort study in accordance with the STROBE guidelines. Between January 1 2015 and January 1 2020, 27 women underwent a unilateral total breast reconstruction with LD or TDAP flap combined with an implant at our institution. 15 women were operated with LD flap and 12 with TDAP flap. The most frequent indications for intervention were results of mastectomy and radiation-induced contracture. We evaluated several data in terms of clinical and demographical characteristics, operative and perioperative factors, and follow-up variables. We assessed shoulder function through the Disability of the Arm, Shoulder and Hand Questionnaire (DASH). Results The rate of complications was significantly lower in the TDAP group compared with the LD group (16.7% vs 60.0%, p = 0.047. Table 3). Although the small sample size limited further detailed statistical analyses, we particularly noticed no cases of donor site seroma in the TDAP group, as compared with four in the LD group. Patients in the TDAP group had an ∼11-point lower mean DASH score compared with the LD group (9.8 vs 20.5). This difference was statistically significant (p = 0.049). Conclusions TDAP flap seems to be a reliable technique for soft-tissue coverage in total breast reconstruction with implants. In comparison with the traditional LD flap, it could be a more favorable option in terms of less complications and better quality of life.

Objective: Pediatric oncology patients are more likely to develop venous thromboembolic events related to central venous catheter (CVC). Study aim was to determine the incidence of catheter related thrombosis (CRT) in a cohort of pediatric oncology patients using vascular ultrasound (US). Methods: Consecutive children of a single cancer referral center, requiring medium to long term CVC implantation, were screened for CRT, using serial ultrasound exams. Measurements and main results: US examinations were taken 15, 30 and 90 days after CVC implantation. A total of 113 catheters were studied in 103 patients (median age 10.5 years old). Ultrasound screening was completed in 80.5% patients. Apart from three subjects, US investigations were well tolerated. Patients were followed for a median of 87 days. No symptomatic CRT was recorded throughout. Three cases of asymptomatic thrombosis were identified with early US screening; incidence of CRT events for 1000 catheter-days was 0.11. The presence of previous catheter-related infection and an history of one or more previous CVC placement were identified as risk factors. Conclusions: In our pediatric patients the incidence of CRT is low. Ultrasound monitoring is well tolerated and allows detecting asymptomatic CRT. Patients with previous CVC infection or insertion seem to have a higher risk of CRT (p =0.003 and p = 0.043 respectively). Keywords: Central venous catheters, Venous thrombosis, Vascular ultrasound, Vascular catheter infections, Children

Retroperitoneal soft tissue sarcomas (RPSs) are mesenchymal neoplasms. The prevalence of protein energetic malnutrition (PEM) and its impact in RPS patients who were candidates for surgery is unknown. A prospective feasibility study enrolled 35 patients with primary RPS who were candidates for extended multivisceral resection. PEM was screened at enrollment. Preoperative high protein β-hydroxy-β-methyl butyrate oral nutritional support (ONS) was provided according to the degree of PEM. After surgery, nutritional support followed standard practice, targeting at least 1 g/kg/day protein and 20 kcal/kg/day caloric intake within the third postoperative day (POD). PEM was re-evaluated before surgery on POD 10, and at 4 and 12 months after surgery. Primary outcomes were the patient’s compliance to preoperative ONS and the physician’s compliance to postoperative nutritional targets. PEM was documented in 46% of patients at baseline; ONS met a 91% adherence (overall well tolerated). After ONS, PEM reduced to 38% (p = 0.45). The postoperative caloric target was reached on day 4.1 (standard error ± 2.7), with a protocol adherence rate of 52%. On POD 10, 91% of patients experienced PEM, the worsening of which was greater after resection of four or more organs (p = 0.06). At 4 and 12 months after surgery, almost all patients had fully recovered. A significant correlation between PEM at surgery and postoperative complications was found (p = 0.04). Relevant PEM prevalence in RPS is documented for the first time. PEM correlates with greater morbidity. In this setting, preoperative ONS was feasible and well-tolerated. Disease-related factors for PEM and the ideal perioperative caloric target in the context of extended multivisceral resection need to be further investigated. Nutritional support should be included in enhanced recovery after surgery programs for RPS. ClinicalTrials.gov identifier: NCT03877588.

BACKGROUND. Axicabtagene ciloleucel and tisagenlecleucel have been approved by FDA and EMA for the treatment of relapsed/refractory diffuse large B-cell and mediastinal Lymphoma (NHL) patients (pts). Selection of pts who can benefit the most from these novel treatments with a low risk of life-threatening toxicities is currently a matter of discussion and outside clinical trials the selection of pts is up to clinicians of the CAR T-cell team in several countries. However, based on the results and follow up of clinical trials and the US reports about real life treatment with CAR T-cells, it is emerging that an expert clinical assessment and application of some inclusion criteria could optimize the success of therapy and minimize the severity of adverse events. AIMS.We are conducting a single center prospective observational trial to evaluate the accessibility and feasibility of CAR T-cells treatment among the population of NHL pts potentially eligible to this therapy. METHODS. Since September 2018 we have prospectively registered all pts referred at our center for CART-cells eligibility evaluation either for the enrollment in clinical trials or in the contest of the expanded access program (EAP) open for enrollment since February 2019 at our Institution. We have recorded clinical data including disease characteristics, comorbidities, history and present disease status at imaging. Patients were evaluated and screened for inclusion/exclusion criteria of the CAR T-cells program available at that moment and planned for treatment. RESULTS. Fifty-four pts with relapsed or refractory NHL potentially eligible to treatment according to EMA were recorded in 10 months. Median age was 48 yrs (range, 20 - 70). Thirty-nine pts were affected by DLBCL and 15 by PMBCL, all pts were refractory or relapsed to at least two chemotherapy regimens, median number of previous therapy was 3. Overall, among the 54 pts referred to our center only 7 pts (13%) have been enrolled in CAR T-cells programs (4 pts treated, 2 pts are waiting for infusion, one is in screening for a protocol) whereas other 11 (20%) have been considered eligible for CART-cells treatment but are still waiting for availability of treatment-slots. On the contrary 36 pts were considered not eligible. Seventeen pts (31%) were excluded after the first CAR T cell team visit because of rapidly progressive disease, or ECOG >1 or lymphoma mass larger than 20 cm and 7 pts (13%) were excluded for comorbidities. Nine pts requiring a treatment in a short time period were shifted to other strategies (conventional or experimental) and 3 pts were lost at follow-up. Overall 18 pts in 10 months (33%) have been considered eligible but only 7 out of 18 have been treated, remaining pts are waiting for the treatment. One third of pts have been excluded and cardiopathy, uncontrolled progressive disease and poor performance status represent the major causes for not being eligible to treatment. More criteria such as high ferritin levels, total tumor volume and active infections will delineate even better the patient population really receiving the infusion. CONCLUSIONS. Among all pts with relapsed and refractory NHL referred at our Center only 33% presented clinical and disease characteristics suitable for CAR T-cells treatment. Moreover, the majority of eligible pts are at the risk of becoming ineligible because of poor disease control. The time needed to plan the apheresis and the 4-5 weeks period to obtain CAR T-cells is a major obstacle to a larger applicability of this strategy, therefore exclusion of pts with large tumor mass and with rapid progressive disease is indicated. Probably, CAR T-cells treatment needs to be planned earlier in the disease course to optimize the outcome. In Italy the feasibility over the last 10 months of CAR T-cells treatment has been largely unsatisfactory and primarily limited by the lack of commercial products. Our observational study is ongoing. Disclosures Corradini: Novartis: Honoraria, Other: Travel Costs; Janssen: Honoraria, Other: Travel Costs; KiowaKirin: Honoraria; Celgene: Honoraria, Other: Travel Costs; Amgen: Honoraria; AbbVie: Consultancy, Honoraria, Other: Travel Costs; Sanofi: Honoraria; Servier: Honoraria; Takeda: Honoraria, Other: Travel Costs; Gilead: Honoraria, Other: Travel Costs; Daiichi Sankyo: Honoraria; Jazz Pharmaceutics: Honoraria; Kite: Honoraria; Roche: Honoraria; BMS: Other: Travel Costs.

Introduction. The aim of the present investigation was to retrospectively evaluate the utilization of Swan-Ganz catheter during orthotopic liver transplantation as opposed to FloTrac/Vigileo in selected cases, comparing a number of clinical outcomes across postoperative hospitalization. Materials and methods. Before 2015 all recipients received pulmonary artery catheter (Swan-Ganz group, n = 109). After 2015 Swan-Ganz was used only if coronary artery disease or high-grade portal hypertension or Child-Pugh C were present; the remaining recipients were assigned to FloTrac/Vigileo monitoring (Mini group, n =100). A number of clinical outcomes were considered. Results. Donor's Risk Index was similar between groups (median value 1.7, P = .27). Anthropometric characteristics of the recipients were similar in the 2 groups. There were no significant differences in the proportion of patients with Child-Pugh C (P = .873), coronary artery disease (P = .18), and grade of portal hypertension (P = .733). The Model for End-Stage Liver Disease score was slightly higher in the Mini group: (9 [7-11] vs 9 [8-12], Swan-Ganz vs Mini, respectively, P < .035). Swan-Ganz utilization decreased over time (92% vs 26%, Swan-Ganz vs Mini, P < .001). Upon admission to the intensive care unit, patients of the Mini group presented a higher SAPS II score with similar values of Sequential Organ Failure Assessment score. Days on mechanical ventilation were similar between groups. The incidence of graft failure was similar between groups (2% vs 5%, Swan-Ganz and Mini group respectively, P = .376). Recipients' hospital length of stay was similar (13 days [11-19] vs 14 [11-20], P < .083). Conclusions. Our data suggest that the intraoperative utilization of FloTrac/Vigileo for oncologic patients with low grade end stage liver disease is reasonably safe.

Introduction: Endobronchial ultrasound (EBUS) is an endoscopic diagnostic procedure combining flexible fibrobronchoscopy with ultrasound techniques; it allows transbronchial needle aspiration biopsy for the diagnosis and staging of mediastinal masses. We present our preliminary experience with the use of the i-gel O2 supraglottic airway device for management of EBUS procedures. Methods: An observational study on 39 patients who underwent EBUS under general anesthesia was performed. Airways were managed with i-gel O2 by anesthesiologists unfamiliar with it. Data collected included patient characteristics, i-gel O2 positioning, mechanical ventilation, procedure, and complications occurring during and after the EBUS. Results: The i-gel airway was successfully positioned during the first attempt in 34/39 cases (87.2%). No failed positioning was recorded. The EBUS scope easily passed through the i-gel in all patients and in 14 (35.6%) cases it was also inserted through the esophagus allowing the examination or fine needle aspiration of paraesophageal lymph nodes. In one case, during the EBUS procedure, the i-gel was dislocated but easily put in place again. During EBUS, air leakages were significant in 2 cases (5.1%) and minimal in 14 cases (35.9%). A brief self-solved laryngospasm and a bronchospasm during bronchoscopy were recorded. After recovery, no patients had dysphagia; mild odynophagia and pharyngodinia were referred by 2 (5.1%) and 12 (30.1%) patients, respectively. Conclusions: The i-gel O2 airway is easy to position and manage even for anesthesiologists unfamiliar with it. This supraglottic airway device is suitable for a complete endosonographic evaluation of the mediastinum.

RPS are mesenchymal non-epithelial neoplasms. Prevalence of PEM in patients with RPS is unknown. A prospective feasibility study enrolled 35 patients affected by primary RPS candidate to surgery. Patients were screened for PEM (according to SINPE Guidelines 2002). Preoperative high protein-beta-hydroxy-beta-methyl butyrate oral nutritional support (ONS) was provided according to PEM degree (Figure1). After surgery, nutritional support followed standard practice targeting 20-25 Kcal/Kg/die within 3rd postoperative day (pod). PEM was re-evaluated before surgery, at 10th pod, at 4 and 12 months. Primary outcome was patient's compliance to preoperative ONS. PEM was documented in 46% patients; although only 8.6% had been clinically undernourished. ONS had a 91% adherence, overall well tolerated. After ONS, PEM lowered to 38% (P=.45). Postoperative caloric target was reached on day 4.1 (SE±2.7), with 51% of protocol adherence. In 34% patients a naso-jejunal tube was positioned; Delayed gastric emptying (DGE) occurred in 38% patients. On 10th pod the majority of patients experienced serious PEM, and worsening was greater after resection of ≥4 organs (P=.06). At 4 and 12 months, almost all fully recovered (Figure 2). Relevant PEM prevalence in RPS, at risk to be clinically underestimated, is documented for the first time. In this setting, preoperative ONS was feasible and safe, and partially recovered PEM. Disease-related factors for PEM and ideal perioperative caloric target need to be further investigated. A wider use of jejunal access should be evaluated, considered the incidence of DGE. Nutritional support should be included in ERAS programs for RPS.

INTRODUCTION:Thoracic surgery can have serious side effects. Accurate preoperative evaluation to assess which patients with anatomically resectable disease are suitable candidates for surgery is mandatory.CASE DESCRIPTION:A 58-year-old man, scheduled for left pneumonectomy for lung cancer, passed all the preoperative examinations suggested by guidelines and underwent the surgery. Three days after pneumonectomy, he experienced hemorrhagic shock and subsequent acute respiratory distress syndrome. Fifteen days after left pneumonectomy, he experienced exertional acute right heart failure (ARHF). We administered sildenafil and he improved, clinically and echocardiographically. During the following 2 years of follow-up, he was asymptomatic at rest but under exercise test, he developed pulmonary hypertension with echocardiographic signs of right ventricular impairment.CONCLUSIONS:In patients scheduled for major lung resections, preoperative stress echocardiography may give an adjunctive value to cardiopulmonary exercise test, quantifying the exercise-induced reduction in right ventricle ejection fraction and identifying asymptomatic patients at risk for postoperative ARHF.

Background: Pediatric oncology patients are more likely to develop venous thromboembolic events CVC–related, but the incidence of CVC-related thrombosis (CRT) is still under debate. First objective of this perspective monocentric study is to investigate the incidence of symptomatic and asymptomatic CRT using Doppler Ultrasound and evaluate the possible risk factors linked to this pathology. Methods: This study was performed on all paediatric patients with cancer, aged< 18, requiring CVC implantation for chemotherapy infusion, from October 2015 to December 2016 in Istituto Nazionale Tumori of Milan. All patients underwent US examination at 15, 30 and 90 days after implantation. Results: A total of 114 medium - long term CVC were inserted into 104 patients (median age; range: 9.5; 0.4-17 years). Patients have been followed up for an average of 269 (range: 11-503) days. Incidence of asymptomatic CRT was 0.11 (0.03-0.33) events for 1000 catheter-days. Only three cases of thrombosis were identified with Doppler Ultrasound screening. In no patient symptomatic DVT occurred. The only common risk factor in these cases was the presence of a previous catheter-related infection (p value= 0.0018). Conclusion: Despite the high risk of CRT associated with the considered sample, the incidence of symptomatic and asymptomatic thrombosis in our patients is very low, especially when compared to other studies. Following these results, the role of US surveillance for the prevention of CRT could be revaluated, perhaps limiting it to patients with previous CVC-related complications. Possible limitations of this study are the limited number of patients and the limited follow up.

Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy The authors have disclosed that they do not have any potential conflicts of interest.

To the Editor: Metabolic alkalosis (MA) is the commonest form of acid-base disorder seen in critically ill patients, including children (1). It is itself associated with important physiologic derangements (impairment of hypoxic pulmonary vasoconstriction, alterations in oxyhemoglobin dissociation, reduced cardiac output, cardiac dysrhythmias, and alteration in cerebral perfusion) and increased mortality (2). A knowledge of the causative factors and treatment options is important. MA in critically ill pediatric patients is usually hypochloremic and is associated with high-dose diuretic therapy and important losses of gastric secretions (1). Restoring the physiologic pH in timely manner should reverse the alkalosis-induced effects; the removal of the underlying cause is the best therapy, but it is not always possible and so we have to take different ways. Acetazolamide promotes renal excretion of bicarbonate along with strong cations by inhibition of carbonic anhydrase (CA) IV in the proximal tubules. In a recent issue of Pediatric Critical Care Medicine, Lopez et al (3) retrospectively evaluated the effectiveness of acetazolamide therapy (5–10 mg/kg/d every 12 hr) for MA in PICU patients. They concluded that acetazolamide decreases serum bicarbonate in PICU patients and that acetazolamide increases urine output in cardiac postoperative patients. In pathophysiologic terms, this work confirms that in critically ill children, acetazolamide, increasing bicarbonate excretion in the urine, leads to pH normalization and that it enhances urine output in patients treated with loop diuretics. From these data, we can conclude that acetazolamide is useful to normalize pH and to augment urine output. But a question arises: are these the goals we want to reach when we start acetazolamide? Usually, these are not the primary targets: slow weaning is the real clinical problem associated with MA. MA produce compensatory hypercapnia by hypoventilation; restoring a normal pH or even more inducing a mild metabolic acidosis should cause stimulation of chemoreceptors, which in turn induces an increase in minute ventilation and potentially can help weaning (4). Acetazolamide may be a possible solution because it augments renal excretion of bicarbonate and also because acetazolamide acts on CA II, which plays a role in regulating gas exchange in the lung and in the erythrocyte, and might modulate the activity of slowly adapting pulmonary stretch receptors, which seem to play a role in the control of respiratory rate and tidal volume (5). In recent years, acetazolamide was proposed as an adjunctive treatment for ventilatory failure due to chronic obstructive pulmonary disease, with mixed results (1, 4). Patients with chronic respiratory disease are often chronically hypercapnic and have a compensatory increase in serum bicarbonate; acute administration of acetazolamide may alter bicarbonate level but may have no effect on respiratory drive. Lopez et al (3) noted a decrease in Pco 2 in children who did not have underlying respiratory disease, unfortunately no data on minute ventilation, weaning variables were collected. Thus, we can speculate that acetazolamide may have a role in reducing hypoventilation in patients without respiratory disease. At the moment, we can say with certainty that acetazolamide is well tolerated and has few side effects. This must be the starting point for testing the efficacy of acetazolamide in this group of critically ill children and to develop and test drugs modulating specific CA isoenzymes. The authors have disclosed that they do not have any potential conflicts of interest.

794 www.anesthesia-analgesia.org anesthesia & anaLgesia supported by aggressive and effective treatment of hypotension in all patients throughout the trial. We are grateful to Kappen et al for identifying an error in our article. We specified that our pilot cohort accrued from July to December 2012; that is, in the middle of the actual trial. Of course the sample size was estimated from data obtained before the trial started, specifically between July and December 2011. More importantly, the pilot incidence was based on 3 minutes of hypotension with either direct or oscillometric measurements, whereas alerts in the actual trial were triggered after only a single oscillometric measurement, thus explaining the higher incidence in the trial. In summary, decision alerts should be formally evaluated just like other diagnostic systems and therapeutic interventions. We present an initial example of a rigorous evaluation that is nonetheless technically simple and inexpensive. The results were clear: an alert for severe hypotension was ineffective because clinicians recognized hypotension on their own and effectively intervened. There is nothing in this result that implies that intraoperative hemodynamic management is simple or solved; it is not and remains an active area of investigation. But it is clear from our results that decision support is more likely to prove beneficial in more complicated clinical situations.

Here we present a case of a 49-year-old man affected by Pseudomyxoma peritonei who experienced extended venous thromboembolism (VTE) 15 days after cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Despite the large sizes of thrombi, the involvement of superior vena cava, right atrium and pulmonary artery, patient was asymptomatic and hemodynamically stable. He had just been subjected to a radical surgery so that we decided to avoid thromboembolectomy on cardio-pulmonary-bypass and to start anticoagulation (continuous intravenous infusion of unfractioned heparin to maintain the APTT in a range of 46-90 seconds). We monitored sonographically the intracardiac portion of the thrombus: we noticed change in shape and a progressive dimensionality reduction. These findings were confirmed by CT scan, which, on the 14th day of anticoagulant therapy, showed only small residues of the known thrombus. We switched anticoagulant therapy to low-molecular-weight heparins (LMWH) and the patient was moved to his surgical ward.

Objective: To evaluate the effects of prophylactic perioperative corticosteroid administration, compared with placebo, on postoperative mortality and clinical outcomes (renal dysfunction, duration of mechanical ventilation, and ICU length of stay) in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass.Data Sources: MEDLINE and Cochrane Library were screened through August 2013 for randomized controlled trials in which perioperative steroid treatment was adopted.Study Selection: Included were randomized controlled trials conducted on pediatric population that reported clinical outcomes about mortality and morbidity.Data Extraction: Eighty citations (PubMed, 48 citations; Cochrane, 32 citations) were identified, of which 14 articles were analyzed in depth and six articles fulfilled eligibility criteria and reported mortality data (232 patients), two studies reported ICU length of stay and mechanical ventilation duration (60 patients), and two studies reported renal dysfunction (49 patients).Data Synthesis: A nonsignificant trend of reduced mortality was observed in steroid-treated patients (11 [4.7%] vs 4 [1.7%] patients; odds ratio, 0.41; 95% CI, 0.14-1.15; p = 0.089). Steroids had no effects on mechanical ventilation time (117.4 +/- 95.9 hr vs 137.3 +/- 102.4 hr; p = 0.43) and ICU length of stay (9.6 +/- 4.6 d vs 9.9 +/- 5.9 d; p = 0.8). Perioperative steroid administration reduced the prevalence of renal dysfunction (13 [54.2%] vs 2 [8%] patients; odds ratio, 0.07; 95% CI, 0.01-0.38; p = 0.002).Conclusion: Despite a demonstrated attenuation of cardiopulmonary bypass-induced inflammatory response by steroid administration, a systematic review of randomized controlled trials performed so far reveals that steroid administration has potential clinical advantages (lower mortality and significant reduction of renal function deterioration). A larger prospective randomized study is needed to verify clearly the effects of steroid prophylaxis in pediatric patients.

The rate of margins involvement and the associated recurrence risk in basal cell carcinomas (BCCs) varies widely in published works (7%-25% and 26%-67%, respectively). This study investigated the risk factors associated with incomplete excision and their relevance in surgical management when positive margins occur in 3957 BCCs excised in 2358 patients. This study performed a multivariate analysis on the database collected from all patients operated for BCCs in the Plastic Surgery Department between 1 January 1992 and 1 September 2007. All data collected (3957 excisions; 2358 individuals) were divided into complete and incomplete excisions groups and analyzed according to 14 variables. The overall rate of incomplete excisions was 14%. Mean age (68), size of the lesion (< 0.5 cm), BCC subtype (nodular with sclerosant aspects, sclerosant and basosquamous), location (face), infiltration depth (hypodermis and deep tissues), recurrent BCC and re-excised BCC were significantly associated with a higher rate of incomplete excision. The recurrence rate for incompletely excised tumours was 26.8%, while only 5.9% for completely excised tumours. Most of the risk factors associated to incomplete excision can be identified before surgery (by simple anamnesis and clinical examination) and successfully overcome by appropriate surgical margins. The high recurrence rate after incomplete excision and the low patient compliance towards follow-up should lead the surgeon to early re-excise residual cancer.