Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

Simultaneous Minimally Invasive Treatment of Colorectal Neoplasm with Synchronous Liver Metastasis

Purpose. To analyse perioperative and oncological outcomes of minimally invasive simultaneous resection of primary colorectal neoplasm with synchronous liver metastases. Methods. A Medline revision of the current published literature on laparoscopic and robotic-assisted combined colectomy with hepatectomy for synchronous liver metastatic colorectal neoplasm was performed until February 2015. The specific search terms were “liver metastases”, “hepatic metastases”, “colorectal”, “colon”, “rectal”, “minimally invasive”, “laparoscopy”, “robotic-assisted”, “robotic colorectal and liver resection”, “synchronous”, and “simultaneous”. Results. 20 clinical reports including 150 patients who underwent minimally invasive one-stage procedure were retrospectively analysed. No randomized trials were found. The approach was laparoscopic in 139 patients (92.7%) and robotic in 11 cases (7.3%). The rectum was the most resected site of primary neoplasm (52.7%) and combined liver procedure was in 89% of cases a minor liver resection. One patient (0.7%) required conversion to open surgery. The overall morbidity and mortality rate were 18% and 1.3%, respectively. The most common complication was colorectal anastomotic leakage. Data concerning oncologic outcomes were too heterogeneous in order to gather definitive results. Conclusion. Although no prospective randomized trials are available, one-stage minimally invasive approach seems to show advantages over conventional surgery in terms of postoperative short-term course. On the contrary, more studies are required to define the oncologic values of the minimally invasive combined treatment

Assessing the learning curve for totally laparoscopic major-complex liver resections: A single hepatobiliary surgeon experience

Background: Encouraging results have been reported in terms of feasibility, safety, and oncologic, outcomes even for major (Z3 segments) or complex for location-specific (right posterior segments) laparoscopic liver resections. Despite this, technically challenging issues and advanced laparoscopic skills required to perform it have limited its use in few highly specialized centers. The aim of this study was to assess the learning curve for major-complex totally laparoscopic liver resections (TLLR) performed by a single HPB surgeon. Materials and Methods: From October 2008 to February 2012, a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in 2 groups according to time of operation: group A (12 cases early series) and group B (12 cases late series); perioperative outcomes were retrospectively analyzed and compared. Results: Comparing the 2 groups, a statistically significant improvement was found in terms of operative time (P=0.017), blood loss (P=0.004), number of cases requiring a Pringle maneuver (P=0.006), and blood transfusion (P=0.001) from case number ten onward. Conclusions: This study shows that a minimum of 10 cases are required to obtain a significant improvement in perioperative outcome for surgeons with specific training on hepatobiliary surgery and advanced laparoscopic surgical procedures. More studies are required to clarify the minimum standard of training to perform safely this kind of advanced laparoscopic liver surgery on a large scale.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Seismic data of Mt. Etna: the contribution of in situ data to MED-SUV Project

In the context of main objectives of the MED-SUV Project’s “Work Package 3”, one goal of the sub-task 3.2.4 is to provide already available in situ seismic data concerning Mt. Etna volcano. In particular, this sub-task envisages sharing data detected during the period 2005-2011. Three kinds of seismic data have been selected for sharing with MED-SUV users: i) raw continuous signals from broadband digital stations; ii) an earthquake catalogue, concerning local shocks hypocentres calculated by expert personnel at Osservatorio Etneo (INGV-OE) by means of off-line analysis of digital seismograms; iii) the RMS amplitude value of the continuous seismic signal. Regarding the first data type, starting from the original SUDS format seismic records (each 1-min long), stored as compressed files in the INGV-OE repository, we produced files, each 1-h long, in standard SAC format. Several working phases were performed to achieve the objective: copying data from the original repository to a temporary storage, decompressing data files, extracting the records of selected seismic stations, converting data from SUDS to SAC format, and finally moving the obtained SAC files in the MED-SUV repository. Overall, about 3.5E6 SUDS files were processed, obtaining about 2E6 SAC files, that overall amount to about 2.6 TB. If needed, raw continuous signals for sharing can also be provided in standard miniSEED format. The earthquake catalogue reports parametric information (e.g. latitude, longitude, depth, magnitude) on the hypocentres of ca. 800 earthquakes. This catalogue refers to shocks with magnitude greater than or equal to 2.0 and error threshold not greater than particular values (e.g. horizontal and vertical hypocentral errors less than or equal to 2.0 km, RMS travel-time residual less than or equal to 0.35s, etc.). These data are provided in ASCII format. Finally, RMS amplitude values of the continuous seismic signal have been calculated by an automatic tool, processing the on-line seismic signal received from remote stations. Amplitude data are calculated over 10s long time windows, in frequency bands, 1 Hz wide, between 0.5 and 15 Hz, as well as in the unfiltered continuous signal. Data format is ASCII. Appropriate metadata (such as technical specifications, geographical coordinates of sites, etc.) have also been defined for the three data types, enabling users to perform analysis and characterization of data. All data and metadata are shared with subscriber users in the MED-SUV Project portal.PublishedRome (Italy)4IT. Banche dat

Current status of liver surgery for non-colorectal non-neuroendocrine liver metastases: the NON.LI.MET. Italian Society for Endoscopic Surgery and New Technologies (SICE) and Association of Italian Surgeons in Europe (ACIE) collaborative international survey

Despite the increasing trend in liver resections for non-colorectal non-neuroendocrine liver metastases (NCNNLM), the role of surgery for these liver malignancies is still debated. Registries are an essential, reliable tool for assessing epidemiology, diagnosis, and therapeutic approach in a single hub, especially when data are dispersive and inconclusive, as in our case. The dissemination of this preliminary survey would allow us to understand if the creation of an International Registry is a viable option, while still offering a snapshot on this issue, investigating clinical practices worldwide. The steering committee designed an online questionnaire with Google Forms, which consisted of 37 questions, and was open from October 5th, 2022, to November 30th, 2022. It was disseminated using social media and mailing lists of the Italian Society of Endoscopic Surgery and New Technologies (SICE), the Association of Italian Surgeons in Europe (ACIE), and the Spanish Chapter of the American College of Surgeons (ACS). Overall, 141 surgeons (approximately 18% of the total invitations sent) from 27 countries on four continents participated in the survey. Most respondents worked in general surgery units (62%), performing less than 50 liver resections/year (57%). A multidisciplinary discussion was currently performed to validate surgical indications for NCNNLM in 96% of respondents. The most commonly adopted selection criteria were liver resectability, RECIST criteria, and absence of extrahepatic disease. Primary tumors were generally of gastrointestinal (42%), breast (31%), and pancreaticobiliary origin (13%). The most common interventions were parenchymal-sparing resections (51% of respondents) of metachronous metastases with an open approach. Major post-operative complications (Clavien-Dindo > 2) occurred in up to 20% of the procedures, according to 44% of respondents. A subset analysis of data from high-volume centers (> 100 cases/year) showed lower post-operative complications and better survival. The present survey shows that NCNNLM patients are frequently treated by surgeons in low-volume hospitals for liver surgery. Selection criteria are usually based on common sense. Liver resections are performed mainly with an open approach, possibly carrying a high burden of major post-operative complications. International guidelines and a specific consensus on this field are desirable, as well as strategies for collaboration between high-volume and low-volume centers. The present study can guide the elaboration of a multi-institutional document on the optimal pathway in the management of patients with NCNNLM

NIR ICG-Enhanced Fluorescence: A Quantitative Evaluation of Bowel Microperfusion and Its Relation to Central Perfusion in Colorectal Surgery

Background: To date, no standardized protocols nor a quantitative assessment of the near-infrared fluorescence angiography with indocyanine green (NIR-ICG) are available. The aim of this study was to evaluate the timing of fluorescence as a reproducible parameter and its efficacy in predicting anastomotic leakage (AL) in colorectal surgery. Methods: A consecutive cohort of 108 patients undergoing minimally invasive elective procedures for colorectal cancer was prospectively enrolled. The difference between macro and microperfusion (ΔT) was obtained by calculating the timing of fluorescence at the level of iliac artery division and colonic wall, respectively. Results: Subjects with a ΔT ≥ 15.5± 0.5 s had a higher tendency to develop an AL (p p < 0.01); a cut-off threshold of 832 was identified (sensitivity 0.86, specificity 0.77). Perfusion parameters were also associated with a faster bowel motility resumption and a reduced length of hospital stay. Conclusions: The analysis of the timing of fluorescence provides a quantitative, easy evaluation of tissue perfusion. A ΔT/HR interaction ≥832 may be used as a real-time parameter to guide surgical decision making in colorectal surgery

Superior mesenteric artery syndrome: Clinical, endoscopic, and radiological findings

Background. The superior mesenteric artery (SMA) syndrome is a rare entity presenting with upper gastrointestinal tract obstruction and weight loss. Studies to determine the optimal methods of diagnosis and treatment are required. Aims and Methods. This study aims at analyzing the clinical presentation, diagnosis, and management of SMA syndrome. Ten cases of SMA syndrome out of 2074 esophagogastroduodenoscopies were suspected. A contrast-enhanced computed tomography (CECT) scan was performed to confirm the diagnosis. After, a gastroenterologist and a nutritionist personalized the therapy. Furthermore, we compared the demographical, clinical, endoscopic, and radiological parameters of these cases with a control group consisting of 10 cases out of 2380 EGDS of initially suspected (but not radiologically confirmed) SMA over a follow-up 2-year period (2015-2016). Results. The prevalence of SMA syndrome was 0.005%. Median age and body mass index were 23.5 years and 21.5 kg/m2, respectively. Symptoms developed between 6 and 24 months. Median aortomesenteric angle and aorta-SMA distance were 22 and 6 mm, respectively. All patients improved on conservative treatment. In our series, a marked (&gt;5 kg) weight loss (p=0.006) and a long-standing presentation (more than six months in 80% of patients) (p=0.002) are significantly related to a diagnosis of confirmed SMA syndrome at CECT after an endoscopic suspicion. A "resembling postprandial distress syndrome dyspepsia" presentation may be helpful to the endoscopist in suspecting a latent SMA syndrome (p=0.02). The narrowing of both the aortomesenteric angle (p=0.001) and the aortomesenteric distance (p&lt;0.001) was significantly associated with the diagnosis of SMA after an endoscopic suspicion; however, the narrowing of the aortomesenteric distance seemed to be more accurate, rather than the narrowing of the aortomesenteric angle. Conclusion. SMA syndrome represents a diagnostic and therapeutic challenge. Our results show the following findings: the importance of the endoscopic suspicion of SMA syndrome; the preponderance of a long-standing and chronic onset; a female preponderance; the importance of the nutritional counseling for the treatment; no need of surgical intervention; and better diagnostic accuracy of the narrowing of the aorta-SMA distance. Larger prospective studies are needed to clarify the best diagnosis and management of the SMA syndrome

Perioperative outcomes of laparoscopic and robot-assisted major hepatectomies: an Italian multi-institutional comparative study

Background: Laparoscopic major hepatectomy (LMH), although safely feasible in experienced hands and in selected patients, is a formidable challenge because of the technical demands of controlling hemorrhage, sealing bile ducts, avoiding gas embolism, and maintaining oncologic surgical principles. The enhanced surgical dexterity offered by robotic assistance could improve feasibility and/or safety of minimally invasive major hepatectomy. The aim of this study was to compare perioperative outcomes of LMH and robotic-assisted major hepatectomy (RMH).SCOPUS: ar.jinfo:eu-repo/semantics/publishe

The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy.Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group.Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 (P = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P &lt; .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P &lt; .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P = .01). Major postoperative complications were similar in both years (11% versus 11%, P = .9).Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period