A meta-analysis and trial sequential analysis comparing nonoperative versus operative management for uncomplicated appendicitis: a focus on randomized controlled trials

Background: The aim of this study is to provide a meta-analysis of randomized controlled trials (RCT) comparing conservative and surgical treatment in a population of adults with uncomplicated acute appendicitis. Methods: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL. We have exclusively incorporated randomized controlled trials (RCTs). Studies involving participants with complicated appendicitis or children were excluded. The variables considered are as follows: treatment complications, complication-free treatment success at index admission and at 1 year follow-up, length of hospital stay (LOS), quality of life (QoL) and costs. Results: Eight RCTs involving 3213 participants (1615 antibiotics/1598 appendectomy) were included. There was no significant difference between the two treatments in terms of complication rates (RR = 0.66; 95% CI 0.61-1.04, P = 0.07, I2 = 69%). Antibiotics had a reduced treatment efficacy compared with appendectomy (RR = 0.80; 95% CI 0.71 to 0.90, p < 0.00001, I2 = 87%) and at 1 year was successful in 540 out of 837 (64.6%, RR = 0.69, 95% confidence interval 0.61 to 0.77, p < 0.00001, I2 = 81%) participants. There was no difference in LOS (mean difference - 0.58 days 95% confidence interval - 1.59 to 0.43, p = 0.26, I2 = 99%). The trial sequential analysis has revealed that, concerning the three primary outcomes, it is improbable that forthcoming RCTs will significantly alter the existing body of evidence. Conclusions: As further large-scale trials have been conducted, antibiotic therapy proved to be safe, less expensive, but also less effective than surgical treatment. In order to ensure well-informed decisions, further research is needed to explore patient preferences and quality of life outcomes

A systematic review of the Da Vinci® Single-Port system (DVSP) in the context of colorectal surgery

Purpose: The purpose of this study is to review the application of the da Vinci® Single-Port system (DVSP) in colorectal surgery, with a view to assessing its safety and feasibility, and investigating its clinical and oncological outcomes. Methods: A comprehensive search of the scientific literature was conducted across three major databases (PubMed, Web of Science, and Cochrane) up to November 2024. The study was registered in PROSPERO (CRD42024612762) and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies pertained to the utilisation of DVSP in the domain of colorectal surgery. Results: Eleven articles were included in the final analysis. No randomized controlled trials were identified. A total of 396 patients (199 men, 197 women) underwent robotic colorectal surgery using the DVSP. Surgical resections were indicated for benign pathology in 56 patients, colon carcinoma in 194 cases, and rectal carcinoma in 146 cases. The median incision length for Uniport placement was 4 cm. The median docking time was 5.96 min (IQR, 9.33 min), and the median console time was 105 min (IQR, 62.51 min). The mean operative time was 186.3 min (IQR, 77.65 min). Intraoperative complications were rare, with only two cases reported (0.47%). Postoperative complications occurred in 12.47% of patients, with ileus being the most common. No patients were readmitted for complications within 30 days. Short-term oncological outcomes seemed promising, with a median of 24.59 lymph nodes retrieved. There were no reported deaths within 30 days. The median follow up time was 11.4 months (IQR, 11.76 months). Conclusion: This study shows that the use of DVSP in colorectal surgery is both feasible and safe. Short-term clinical and oncological outcomes seem promising. However, longer follow-up data and larger patient cohorts are needed to fully assess the long-term efficacy of this novel technique. Prospero registry: Registration number CRD42024612762

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Global disparities in surgeons’ workloads, academic engagement and rest periods: the on-calL shIft fOr geNEral SurgeonS (LIONESS) study

: The workload of general surgeons is multifaceted, encompassing not only surgical procedures but also a myriad of other responsibilities. From April to May 2023, we conducted a CHERRIES-compliant internet-based survey analyzing clinical practice, academic engagement, and post-on-call rest. The questionnaire featured six sections with 35 questions. Statistical analysis used Chi-square tests, ANOVA, and logistic regression (SPSS® v. 28). The survey received a total of 1.046 responses (65.4%). Over 78.0% of responders came from Europe, 65.1% came from a general surgery unit; 92.8% of European and 87.5% of North American respondents were involved in research, compared to 71.7% in Africa. Europe led in publishing research studies (6.6 ± 8.6 yearly). Teaching involvement was high in North America (100%) and Africa (91.7%). Surgeons reported an average of 6.7 ± 4.9 on-call shifts per month, with European and North American surgeons experiencing 6.5 ± 4.9 and 7.8 ± 4.1 on-calls monthly, respectively. African surgeons had the highest on-call frequency (8.7 ± 6.1). Post-on-call, only 35.1% of respondents received a day off. Europeans were most likely (40%) to have a day off, while African surgeons were least likely (6.7%). On the adjusted multivariable analysis HDI (Human Development Index) (aOR 1.993) hospital capacity > 400 beds (aOR 2.423), working in a specialty surgery unit (aOR 2.087), and making the on-call in-house (aOR 5.446), significantly predicted the likelihood of having a day off after an on-call shift. Our study revealed critical insights into the disparities in workload, access to research, and professional opportunities for surgeons across different continents, underscored by the HDI

Standardization and learning curve in laparoscopic hernia repair: experience of a high-volume center

Abstract Purpose Groin hernias are a common condition that can be treated with various surgical techniques, including open surgery and laparoscopic approaches. Laparoscopic surgery has several advantages but its use is limited due to the complexity of the posterior inguinal region and the need for advanced laparoscopic skills. This paper presents a standardized and systematic approach to trans-abdominal pre-peritoneal (TAPP) groin hernioplasty, which is useful for training young surgeons. Methods The paper provides a detailed, step-by-step description of the TAPP based on evidence from literature, anatomical knowledge, and the authors’ experience spanning over 30 years. The sample includes 487 hernia repair procedures, with 319 surgeries performed by experienced surgeons and 168 surgeries performed by young surgeons in training. The authors performed a descriptive analysis of their data to provide an overview of the volume of laparoscopic hernioplasty performed. Results The analysis of the data shows a low complication rate of 0.41% (2/487) and a low recurrence rate of 0.41% (2/487). The median duration of the surgery was 55 min, while the median operation time for surgeons in training was 93 min, specifically 83 min for unilateral hernia and 115 min for bilateral hernia. Conclusions The TAPP procedure appears, to date, comparable to the open inguinal approach in terms of recurrence, postoperative pain and speed of postoperative recovery. In this paper, the authors challenge the belief that TAPP is not suitable for surgeons in training. They advocate for a training pathway that involves gradually building surgical skills and expertise. This approach requires approximately 100 procedures to achieve proficiency

Yersinia Enterocolitica intestinal infection with ileum perforation: report of a clinical oservation

Abstract Yersinia enterocolitica infection is responsible in human beings for ileocolitis appearing with abdominal pain, diarrhoea and fever. This kind of disease usually heals spontaneously with no remarkable complication. Intestinal perforation is a rare complication of the disease. To date only eleven cases of surgical complications arising from abscess and intestinal perforation due to Yersinia enterocolitica have been reported in literature. In our clinical case the patient, who had previously undergone appendicectomy, required urgent surgery for pelvi-peritonitis due to intestinal perforation on necrotic-ulcerative ileitis with adenomesenteritis from Yersinia enterocolitica. The surgical treatment combined with intestinal resection and targeted antibiotic therapy have proved to be effective

Current Management of Acute Severe Ulcerative Colitis: New Insights on the Surgical Approaches

Acute severe ulcerative colitis (ASUC) is a life-threatening medical emergency with considerable morbidity. Despite recent advances in medical IBD therapy, colectomy rates for ASUC remain high. A scoping review of published articles on ASUC was performed. We collected data, such as general information of the disease, diagnosis and initial assessment, and available medical and surgical treatments focusing on technical aspects of surgical approaches. The most relevant articles were considered in this scoping review. The management of ASUC is challenging; currently, personalized treatment for it is unavailable. Sequential medical therapy should be administrated, preferably in high-volume IBD centers with close patient monitoring and indication for surgery in those cases with persistent symptoms despite medical treatment, complications, and clinical worsening. A total colectomy with end ileostomy is typically performed in the acute setting. Managing rectal stump is challenging, and all individual and technical aspects should be considered. Conversely, when performing elective colectomy for ASUC, a staged surgical procedure is usually preferred, thus optimizing the patients’ status preoperatively and minimizing postoperative complications. The minimally invasive approach should be selected whenever technically feasible. Robotic versus laparoscopic ileal pouch–anal anastomosis (IPAA) has shown similar outcomes in terms of safety and postoperative morbidity. The transanal approach to ileal pouch–anal anastomosis (Ta-IPAA) is a recent technique for creating an ileal pouch–anal anastomosis via a transanal route. Early experiences suggest comparable short- and medium-term functional results of the transanal technique to those of traditional approaches. However, there is a need for additional comparative outcomes data and a better understanding of the ideal training and implementation pathways for this procedure. This manuscript predominantly explores the surgical treatment of ASUC. Additionally, it provides an overview of currently available medical treatment options that the surgeon should reasonably consider in a multidisciplinary setting

Non-operative management of uncomplicated appendicitis in children, why not? A meta-analysis of randomized controlled trials

Abstract Background This study aims to provide a meta-analysis of randomized controlled trials (RCTs) comparing non-operative management (NOM) and operative management (OM) in a pediatric population with uncomplicated acute appendicitis. Methods A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. A comprehensive search was conducted in MEDLINE, Embase, and CENTRAL from inception to June 2024. Only randomized controlled trials (RCTs) were included, excluding studies involving adult patients and/or participants with complicated appendicitis. The variables considered were treatment complications, treatment efficacy during index admission and one-year follow-up, length of hospital stay (LOS), quality of life, and presence of appendicoliths. Results Three RCTs involving 269 participants (134 antibiotics/135 appendectomy) were included. There was no statistically significant difference between the two treatments in terms of complication risk (combined RD = − 0.03; 95% CI − 0.11; 0.06, p = 0.54), even including complications related to NOM failure. The risk of complication-free treatment success rate in the antibiotic group is lower than in the surgery group (combined RD = − 0.05; 95% CI − 0.13; − 0.04; p = 0.29). In patients without appendicolith, the combined risk difference of treatment success between NOM and OM was not statistically significant − 0.01 (IC − 0.17; 0.16; p value: 0.93). There is no statistical difference in terms of efficacy at 1 year, between NOM and OM (combined RD = − 0.06; 95% CI − 0.21; 0.09), p = 0.44). The LOS in the NOM group is significantly longer than in the OM group (difference of median = − 19.90 h; 95% CI − 29.27; − 10.53, p < .0001). Conclusions This systematic review and meta-analysis provide evidence that NOM is safe and feasible for children with uncomplicated appendicitis and, in the group of patients without appendicolith, it is associated with a similar success rate to OM. However, more high-quality studies with adequate power and construction are still needed

Chronic Groin Pain After Hernia Surgery: What Are We Missing?

Background: Chronic postoperative inguinal pain [CPIP] is a prevalent and often debilitating complication following inguinal hernia repair. With the widespread adoption of mesh-based techniques, recurrence rates have significantly declined, shifting clinical focus toward postoperative pain management. Methods: This narrative review synthesizes international literature on CPIP incidence, surgical technique, geographic variation, and the distinction between neuropathic and nociceptive pain. Studies were selected based on relevance, sample size, and inclusion of pain subclassification. Results: CPIP incidence varies markedly across studies (6&ndash;64.3%), influenced by follow-up duration, surgical approach, and regional healthcare practices. The risk of CPIP varies significantly, depending on the surgical technique employed, with open repairs generally associated with higher rates than laparoscopic approaches. Neuropathic pain predominates in specific cohorts, particularly following open repairs with limited nerve preservation. Few studies differentiate pain types, revealing a critical gap in diagnostic precision. Conclusions: CPIP is a multifactorial and under-recognized problem in clinical practice. The adoption of standardized diagnostic tools and long-term follow-up protocols is essential to improve pain classification and management. A structured diagnostic algorithm may assist clinicians in distinguishing pain types and tailoring treatment strategies to individual patient profiles