Isolating the Role of Bone Lacunar Morphology on Static and Fatigue Fracture Progression through Numerical Simulations

Currently, the onset of bone damage and the interaction of cracks with the surrounding micro-architecture are still black boxes. With the motivation to address this issue, our research targets isolating lacunar morphological and densitometric effects on crack advancement under both static and cyclic loading conditions by implementing static extended finite element models (XFEM) and fatigue analyses. The effect of lacunar pathological alterations on damage initiation and progression is evaluated; the results indicate that high lacunar density considerably reduces the mechanical strength of the specimens, resulting as the most influencing parameter among the studied ones. Lacunar size has a lower effect on mechanical strength, reducing it by 2%. Additionally, specific lacunar alignments play a key role in deviating the crack path, eventually slowing its progression. This could shed some light on evaluating the effects of lacunar alterations on fracture evolution in the presence of pathologies

Colorectal Cancer Stage at Diagnosis Before vs During the COVID-19 Pandemic in Italy

IMPORTANCE Delays in screening programs and the reluctance of patients to seek medical attention because of the outbreak of SARS-CoV-2 could be associated with the risk of more advanced colorectal cancers at diagnosis. OBJECTIVE To evaluate whether the SARS-CoV-2 pandemic was associated with more advanced oncologic stage and change in clinical presentation for patients with colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included all 17 938 adult patients who underwent surgery for colorectal cancer from March 1, 2020, to December 31, 2021 (pandemic period), and from January 1, 2018, to February 29, 2020 (prepandemic period), in 81 participating centers in Italy, including tertiary centers and community hospitals. Follow-up was 30 days from surgery. EXPOSURES Any type of surgical procedure for colorectal cancer, including explorative surgery, palliative procedures, and atypical or segmental resections. MAIN OUTCOMES AND MEASURES The primary outcome was advanced stage of colorectal cancer at diagnosis. Secondary outcomes were distant metastasis, T4 stage, aggressive biology (defined as cancer with at least 1 of the following characteristics: signet ring cells, mucinous tumor, budding, lymphovascular invasion, perineural invasion, and lymphangitis), stenotic lesion, emergency surgery, and palliative surgery. The independent association between the pandemic period and the outcomes was assessed using multivariate random-effects logistic regression, with hospital as the cluster variable. RESULTS A total of 17 938 patients (10 007 men [55.8%]; mean [SD] age, 70.6 [12.2] years) underwent surgery for colorectal cancer: 7796 (43.5%) during the pandemic period and 10 142 (56.5%) during the prepandemic period. Logistic regression indicated that the pandemic period was significantly associated with an increased rate of advanced-stage colorectal cancer (odds ratio [OR], 1.07; 95%CI, 1.01-1.13; P = .03), aggressive biology (OR, 1.32; 95%CI, 1.15-1.53; P < .001), and stenotic lesions (OR, 1.15; 95%CI, 1.01-1.31; P = .03). CONCLUSIONS AND RELEVANCE This cohort study suggests a significant association between the SARS-CoV-2 pandemic and the risk of a more advanced oncologic stage at diagnosis among patients undergoing surgery for colorectal cancer and might indicate a potential reduction of survival for these patients

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

JChain: A new way to look inside the firm

JChain takes advantage of the blockchain mechanism to measure all activities into the firm. The idea is that to create a large database where all activities are masured and recorded by means of a Eurocoin-based-payment system

Small bowel obstruction due to metastasis of cutaneous melanoma: 7-years after primary diagnosis.

Aim of study: Metastatic involvement of the small bowel by melanoma is rare. The average time from the excision of the primary cutaneous melanoma to the occurrence of intestinal metastases tends to be between 3 and 5 years; one case of recurrence after 15 years is described. The most common kind of lesion is polypoid: this can cause intussusception and intestinal occlusion. We report a case of intestinal occlusion by an ileal metastasis of a melanoma occurred 7 years earlier. Materials and Methods: Case Report: The patient was a 57-year-old female who was admitted to our hospital for persistent abdominal pain and sub-occlusion. The patient's past medical history included cutaneous malignant melanoma 7 years before and lobular breast adenocarcinoma 10 years before. During the previous three months, she had intermittent abdominal pain and a weight loss of about 7 kg. Abdominal-US, EGDS and colonoscopy were all negative for pathologic findings. During the hospital stay, a CT enterography revealed lower intestinal intussusception, and enlarged lymph nodes both in the abdominal cavity and in the retroperitoneum. Intraoperatively we found an ileal invagination due to a polypoid mass of the ileal tract. Segmental ileal resection was performed; wide mesenteric lymph node dissection was not possible because of large and extended retroperitoneal lymphadenopathies. Histological examination showed epithelioid and spindle tumor cells with obvious cytoplasmic melanin deposition. Immunohistochemical staining revealed that tumor cells were positive for S-100, HMB-45 and vimentin, confirming the diagnosis of melanoma. Main results and conclusions: Appearance of GI metastases is reported up to 15 years after the inital diagnosis of melanoma. Reported clinical signs and symptoms generally include chronic abdominal pain, occult or gross bleeding and, as in this case, weight loss. Aspecificity of symptoms may impede early diagnosis and treatment of the disease. As in this case, where curative surgery is impossible because of the extent of disease, metastatic tumor resection or GI tract bypass surgery is recommended to relieve symptoms or avoid future complications. Early diagnosis of metastases requires adequate imaging (CT) and prolonged follow up

FACTORS PREDICTING MORBIDITY AND MORTALITY AFTER SURGERY FOR COMPLICATED ACUTE DIVERTICULITIS: A SINGLE CENTER EXPERIENCE

Introduzione Complicated acute diverticulitis (CAD) occurs in approximately 10 to 25 percent of patients affected by diverticular disease and a surgical treatment is often necessary. Postoperative morbidity and mortality are still high, up to 40% of cases in patients with generalized peritonitis. The purpose of this study is to identify predictive prognostc factor for postoperative morbidity and mortality in patients requiring surgical intervention for CAD. Pazienti e metodi From September 2011 to May 2015 170 patients underwent surgical intervention for diverticular disease in our unit. Of these, 119 patients required urgent surgery for complicated acute diverticulitis (CAD). Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative morbidity and mortality. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati There were 56 males and 63 females with mean age of 68 \ub1 15 years. 100 patients (84.0%) were at first hospital admission for diverticular disease and in 16 cases (13.4%) the disease was localized at right colon or ceacum. A stomy was required in 84 patients (70.6%) and postoperative morbidity rate was 52,9% according Clavien\u2013Dindo Classification. Anyway only 10.9% of patients were affected by grade III or IV complication with a mortality rate of 16.8%. At multivariate analysis the presence of a postoperative medical complication was the only predictive factor for mortality (OR 10.3; 95%CI 2.1-51.3 p=0.004) while the presence of COPD and purulent or fecal peritonitis were not statistically significant (OR 3.3; 95%CI 0.9-12.2 p=0.073 and OR 3.1 95%CI 0.8-11.6 p=0.099 respectively). For postoperative morbidity the logistic regression showed that patients 6575 years and with ASA score > 2 were independently associated with postoperative morbidity (OR 2.8; 95%CI 1.1-7.2 p=0.028 and OR 5.3 95%CI 2.0-13.9 p=0.001 respectively). The same factors were independent prognostic factor associated with medical complication with OR 3.0; 95%CI 1.1-7.8 p=0.028 and OR 6.5 95%CI 2.0-21.3 p=0.002 respectively. Multivariate analysis of factor predicting surgical morbidity showed that age 6575 was the only predictive factor for postoperative surgical morbidity (OR 3.1; 95%CI 1.1-8.8 P=0.027). Conclusioni In our experience the majority of patients who require surgery for CAD are at the first episode of acute diverticulitis. Medical complication after surgery for CAD is the only factor associated with mortality while surgical complications do not seem to have the same weight. Age 6575 years and ASA score >2 are independent predictive factors for postoperative medical complications while only age seems to have a significant effect on surgical morbidity

SHORT TERM RESULTS OF ELECTIVE COLON RESECTIONS FOR UNCOMPLICATED DIVERTICULAR DISEASE

Introduzione Indications for elective surgery in diverticular disease are sill debated and recent findings suggest a conservative approach since most patients present complicated diverticulitis as the first manifestation of diverticular disease. In our study we analyze the result in term of postoperative morbidity and mortality in patiets who underwent elective surgery for diverticular disease. Pazienti e metodi From September 2011 to May 2015 we perfomerd 170 surgical interventions for diverticular disease in our unit. Of these, 51 resection were performed in elective setting. Pre-, intra- and postoperative findings were collected in a prospective database. Multivariate analysis with logistic regression was performed to find out independent predictive factors for postoperative events. Statistical analysis was made with SPSS v.13.0 and significance was considered with p value < 0.05. Risultati Male:Female ratio was 1:1 with mean age of 59\uf0b114 years. 44 patients was younger than 75 years. 54.9% of patients had one or more comorbidities and 12 patients (23.5%) had ASA score >2. Most patients had only one previous hospital admission (28 patients, 54.9&) while 9 patients reported two or more admissions. 2 patient underwent surgery for the development of colo-vescical or colovaginal fistula and 2 patient for paracolic or pelvic abscess refractory to medical therapy. In 70.6% (36 patients) of cases a laparoscopic approach was performed with a conversion rate of 16.7%. No postoperative in-hospital mortality was recorded. Postoperative complication rate was 31.4% (16 patients) according Clavien-Dindo Classification. Anyway 14 patients had grade I or II complication with mild clinical impairment. Multivariate analysis did not find any independent predictive factor for overall and surgical complications. On the other hand presence of diabetes mellitus (DM) and ASA score > 2 was associated with increased risk of medical complication (OR 16.7; 95%CI 1.1-259.9 P=0.044 and OR 8.5; 95%CI 1.1-62.6 P=0.036 respectively). A T-test was performed to compare mean of postoperative stay within the two variables. Patients with ASA score > 2 were found to have longer postoperative stay respect to those with ASA score 1-2 (13,5 vs 8,4 P=0.008). No significant difference was found in patients with or without DM (9.0 vs 9.6 P=0.818). Conclusioni In our experience, elective surgery for diverticular disease can be performed safely and often with mini-invasive approach, with accetable rate of significant postoperative event. Anyway we need powerful studies providing strong evidence to identify patients who could really take advantage of elective surgical intervention

Laparoscopic appendectomy: Which factors are predictors of conversion? A high-volume prospective cohort study

Appendicitis represents one of the most frequent condition requiring surgery. In Italy almost 0.2% of the population will be affected by acute appendicitis every year. Laparoscopic appendectomy (LA) has gained acceptance over the past years and despite several meta-analyses, randomized studies and retrospective studies have been conducted, the indications and results are still conflicting especially in cases of complicated appendicitis. The aim of our study is to evaluate which factors are related to conversion to open appendectomy (OA) during laparoscopic appendectomy (LA). Matherials and methods: From September 2011 to May 2013, appendectomy for acute appendicitis was performed on 434 patients in our Surgical Unit at S. Orsola-Malpighi Hospital, Bologna, Italy. Of these, 369 patients (85%) underwent LA. The clinical, demographic, surgical and pathological data of these patients were included in a prospective database. To note, only laparoscopic appendectomies were considered to be included in the analysis. The following factors were analyzed in order to identify which were associated with the conversion: age, sex, body mass index (BMI), previous abdominal surgery, comorbidities, clinical and laboratory parameters including Alvarado score, PCR, intraoperative findings such as anatomy and degree of inflammation. During our study period, laparoscopic appendectomies were performed by different surgeons both residents and attending surgeons. The decision to convert the intervention in an open procedure was taken by the individual surgeon. Regarding the postoperative period, were considered the time of hospitalization and related costs, time of oral intake of liquid and solid, time of passage of stool, readmissions and reoperations. Results: At univariate analysis, the factors significantly related to the conversion were the presence of comorbidities (p < 0.001) and, among these, the presence of arterial hypertension (p = 0.006) or other cardiovascular diseases (p = 0.031) and the history of previous abdominal surgery (p = 0.023). Patients with higher mean age (33.9 ± 15.4 vs. 46.0 ± 19.3, p = 0.001) and higher body mass index (BMI) (23.5 ± 4.3 vs 25.8 ± 4.9 kg/m², p = 0.006) had a higher risk of conversion.Multivariate analysis finally showed that factors significantly related to the conversion were the presence of comorbidities (p = 0.029), the presence of an appendiceal perforation (p = 0.003), a retrocecal appendix (p = 0.004), the presence of appendicular abscess (p = 0.023) and the presence of diffuse peritonitis (p = 0.008). Conclusion: The majority of patients with acute appendicitis can be successfully managed with laparoscopy. We found that the only preoperative independent factor related to conversion during laparoscopic appendectomy is the presence of comorbidities. Nevertheless surgeons should take into account that presence of peri-appendicular abscess and diffuse peritonitis are both independently related not only to higher rate of conversion but also to higher risk of postoperative complication