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Background Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons’ knowledge and perception of using AI-based tools in clinical decision-making processes. Methods An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society’s website and Twitter profile. Results 650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust. Discussion The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI.

The rapid identification of patients at risk for massive blood transfusion is of paramount importance as uncontrolled exsanguination may lead to death within 2 to 6 h. The aim of this study was to analyze a cohort of severe trauma patients to identify risk factors associated with massive transfusion requirements and hypocalcemia. All major trauma (ISS > 16) presented directly from the scene to the Niguarda hospital between 1 January 2015 and 31 December 2021 were analyzed. A total of 798 patients were eligible out of 1586 screened. Demographic data showed no significant difference between hypocalcemic (HC) and normocalcemic (NC) patients except for the presence of crush trauma, alcohol intake (27% vs. 15%, p < 0.01), and injury severity score (odds ratio 1.03, p = 0.03). ISS was higher in the HC group and was an independent, even if weak, predictor of hypocalcemia (odds ratio 1.03, p = 0.03). Prehospital data showed a lower mean systolic arterial pressure (SAP) and a higher heart rate (HR) in the HC group (105 vs. 127, p < 0.01; 100 vs. 92, p < 0.001, respectively), resulting in a higher shock index (SI) (1.1 vs. 0.8, p < 0.001). Only retrospective studies such as ours are available, and while hypocalcemia seems to be an independent predictor of mortality and massive transfusion, there is not enough evidence to support causation. Therefore, randomized prospective studies are suggested.

Thoracic trauma occurs in 20–25% of all trauma patients worldwide and represents the third cause of trauma-related mortality. Retained hemothorax (RH) is defined as a residual hematic pleural effusion larger than 500 mL after 72 h of treatment with a thoracic tube. The aim of this study is to investigate risk factors for the development of RH in thoracic trauma and predictors of surgery. A retrospective, observational, monocentric study was conducted in a Trauma Hub Hospital in Milan, recording thoracic trauma from January 2011 to December 2020. Pre-hospital peripheric oxygen saturation (SpO2) was significantly lower in the RH group (94% vs. 97%, p = 0.018). Multivariable logistic regression analysis identified, as independent predictors of RH, sternum fracture (OR 7.96, 95% CI 1.16–54.79; p = 0.035), pre-admission desaturation (OR 0.96; 95% CI 0.77–0.96; p = 0.009) and the number of thoracic tube maintenance days (OR 1.22; 95% CI 1.09–1.37; p = 0.0005). The number of tubes placed and the 1° rib fracture were both significantly associated with the necessity of surgical treatment of RH (2 vs. 1, p = 0.004; 40% vs. 0%; p = 0.001). The risk of developing an RH in thoracic trauma should not be underestimated. Variables related to RH must be taken into account in order to schedule a proper follow-up after trauma.

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the Covid-19 pandemic (C-19), different trends for Pediatric Trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of C-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SA).Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyzes. Results: 684 PT were accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (pConclusions: NTC is the adult level I referral trauma center for the Milan urban area, with pediatric commitment. During C-19, every traumatic emergency was centralized to NCT. In 2020 we observed an increasing trend of SA and VRT among PTs. The psychological impact of the C-19 restriction could explain this evidence. The long-term effects of C-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SA and VRT should be implemented, especially during socio-demographic storms like the last pandemic.

Purpose: To identify preoperative predictive factors for technically challenging laparoscopic appendectomy (LA) and the need for external help to laparoscopically complete the procedure. Methods: We analysed data from a two-year data lock on the Resident-1 multicentre registry. The operator classified each procedure following a five-grade Likert scale to define technical difficulty. We performed univariate analysis comparing Grade 1–3 versus 4–5 procedures and then built a logistic regression model to identify independent predictors of Grade 4–5 procedures defined as needing external help to complete a LA. Results: 561 patients were recruited from 2019 to 2021, and 485 patients were included in the final analysis due to missing data. A BMI > 30 kg/m2, preoperative CT scan, and the AIR score were independent preoperative predictors of complex LA with the need for external help to be completed. Patients undergoing such procedures were more affected by CA, had longer operative times, and had the worst postoperative outcomes. Conclusion: The preoperative identification of technically demanding LA could be helpful in optimising the preoperative planning, maximise surgeons’ preparedness, and include expert surgeons in the procedure earlier. Creating a scoring system for the technical difficulty of LA is desirable.

Background: Tissue regeneration is a complex process that allows wounds to heal. Many options are currently available to help human skin repair and to reduce the recurrence of hernias. The aim of this study is to analyze the best decellularization protocol for allogenic human dermal tissues. Methods: Dermal flaps from donors were used and compared with a control group. Each flap was subjected to seven different decellularization protocols and washed with a sequence of five solutions. The samples were then subjected to four control tests (such as Nile Red), and long-term contacts were analyzed to assess whether the decellularized dermis samples could support the growth of human fibroblasts. Results: All the samples had an average residual viability of 60%. Except for one sample, the decellularization treatments were able to reduce cell viability significantly. The Nile Red test showed a significant reduction in phospholipid content (mean 90%, p-value < 0.05) in all treatments. The cell growth increased in a linear manner. As described in the literature, sodium-dodecyl-sulfate (SDS) caused an interference between the test and the detergent. Conclusions: This paper shows the first step to finding the best decellularization protocol for allografting human dermal tissues. Further biocompatibility tests and DNA quantification are necessary.

Background: During the COVID-19 pandemic, the centralization of patients allowed trauma and transplants referral centers to continue their routine activity, ensuring the best access to health care. This study aims to analyze how the centralization of trauma is linked with liver allocation in Northern Italy. Methods: Cluster analysis was performed to generate patient phenotype according to trauma-related variables. Comparison between clusters was performed to evaluate differences in damage control strategy procedures (DCS) performed and the 30-day graft dysfunction. Results: During the pandemic period, the centralization of major trauma has deeply impaired the liver procurement and allocation between the transplant centers in the metropolitan area of Milan (Niguarda: 22 liver procurement; other transplant centers: 2 organ procurement). Two clusters were identified the in Niguarda’s series: cluster 1 is represented by 17 (27.4%) trauma donors, of which 13 (76.5%) were treated with DCS procedures, and 4 (23.5%) did not; cluster 2 is represented by 45 trauma donors (72.6%), of which 22 (48.8%) underwent DCS procedures. A significant difference was found in the number of DCS procedures performed between clusters (3.18 ± 2.255 vs. 1.11 ± 1.05, p = 0.0001). Comparative analysis did not significantly differ in the number of transplanted livers (cluster1/cluster2 94.1%/95.6% p = 0.84) and the 30-day graft dysfunction rate (cluster1/cluster2 0.0%/4.8% p = 0.34). Conclusions: The high level of care guaranteed by first-level trauma centers could reduce the loss of organs suitable for donation, maintaining the good outcomes of transplanted ones, even in case of multiple organ injuries. The pandemic period underlined that the centralization of major trauma impairs the liver allocation between transplant centers.

Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL.Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL.561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL.This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process.

Background: Bicycle-related trauma has increased during the last decades, mainly thanks to the antipollution environmental policies and the diffusion of bike-sharing companies. This study investigates the outcome of bicycle-related trauma in our level one trauma center over a period of eight years.Methods: Data of 446 consecutive bicycle-related trauma admitted to our trauma center from 2011 to 2019 were selected and retrospectively analysed. The sample was divided into 3 age groups: ≤ 17 years, 18–54 years, and ≥ 55 years. Mortality rates were obtained for the overall population and patients with Injury Severity Score (ISS) ≥ 25. Month and seasonal patients’ distribution was described to provide an epidemiological overview of bike-related trauma over the years.Results: Patients ³ 55 years showed a lower pre-hospital and in-hospital GCS (p≤ 0.001), higher levels of lactates (p< 0.019) and higher ISS (p≤ 0.001), probability of death (p≤ 0.001), and overall mortality (p≤ 0.001). The head and chest Abbreviated Injury Scale (AIS) ≥3 injuries were predictors of mortality, especially in patients over 55 years (pConclusions: Age over 55 years old, head and chest injuries, and an ISS > 25 were independent predictors of mortality. Multiple factors probably contributed to mortality rates in these patients.

Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.

The results of the Global Burden of Disease (GBD) study showed that, in 2019, 8% of deaths worldwide were trauma related [...]

Purpose: Complex enteric fistulas (CEF) represent general surgeons’ nightmare. This paper aims to explore the impact on failure-to-rescue (FTR) rate of a standardised and integrated surgical and critical care step-up approach. Methods: This was a retrospective observational cohort study. Patients treated for CEF from 2009 to 2019 at Niguarda Hospital were included. Each patient was approached following a three-step approach: study phase, sepsis control and strategy definition phase, and surgical rescue phase. Results: Sixteen patients were treated for CEF. Seven fistulas were classified as complex entero-cutaneous (ECF) and nine as entero-atmospheric fistula (EAF). Median number of surgical procedures for fistula control before definitive surgical attempt was 11 (IQR 2–33.5). The median time from culprit surgery and the first access at Niguarda Hospital to definitive surgical attempt were 279 days (IQR 231–409) and 120 days (IQR 34–231), respectively. Median ICU LOS was 71 days (IQR 28–101), and effective hospital LOS was 117 days, (IQR 69.5–188.8). Three patients (18.75%) experienced spontaneous fistula closure after conversion to simple ECF, whereas 13 (81.25%) underwent definitive surgery for fistula takedown. Surgical rescue was possible in nine patients. Nine patients underwent multiple postoperative revision for surgical complications. Four patients failed to be rescued. Conclusion: An integrated step-up rescue strategy is crucial to standardise the approach to CEF and go beyond the basic surgical rescue procedure. The definition of FTR is dependent from the examined population. CEF patients are a unique cluster of emergency general surgery patients who may need a tailored definition of FTR considering the burden of postoperative events influencing their outcome.

Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the COVID-19 pandemic (COVID-19), different trends for pediatric trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of COVID-19, focusing on trauma mechanisms, violence-related trauma (VRT) and intentionality, especially suicide attempts (SAs). Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analyses. Results: There were 684 cases of PT accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019 and 144 in 2020 (p < 0.001), 66.2% male, mean age 9.88 (±5.17). We observed a higher number of traffic-related, fall-related injuries and an increasing trend for VRT and SAs, peaking in 2020. We report an increasing trend over time for head trauma (p = 0.002). The Injury Severity Score did not significantly change. During COVID-19 we recorded a higher number of self-presenting patients with low priority codes. Conclusions: NTC is the adult level I referral trauma center for the Milan urban area with pediatric commitment. During COVID-19, every traumatic emergency was centralized to NCT. In 2020, we observed an increasing trend in SAs and VRT among PT patients. The psychological impact of the COVID-19 restriction could explain this evidence. The long-term effects of COVID-19 on the mental health of the pediatric population should not be underestimated. Focused interventions on psychological support and prevention of SAs and VRT should be implemented, especially during socio-demographic storms such as the last pandemic.

Breast cancer surgery is going to be a relevant specialty involved in the multidisciplinary disease management, finalized to guarantee high performances on mortality reduction together with a quality of life improvement. The intellectual architecture of this field is characterized by its inclination to respect, sharing, empathy and scientific knowledge that can make it a high model of medical culture. In this context, oncoplastic breast conserving surgery is identified by special aesthetic sensitivities, as well as creativity and innovation. Knowing how to reshape the gland and fill the gaps, planning the targeted exeresis design, while anticipating the final outcome, respecting symmetries and ensuring first of all oncological safety, are the new skills that are required to the breast surgeon. Several tecniques could provide a refined surgical treatment but always challenging according to anatomical findings and patient expectations, as a systematic process of self-critical reflection, with the purpose to optimize criteria for improving therapeutic results.

Highlights • Autoimmune Metaplastic Atrophic Gastritis and Pernicious Anemia increase the risk of cancer. • Multifocality is a condition described in 0.8–22% of Early Gastric Cancer. • Subtotal gastrectomy can be safely performed when endoscopic treatment is not feasible. • Multidisciplinary approach is very important to reduce the under-treatment risk., Introduction Pernicious anemia (PA) caused by vitamin B12 deficiency is associated with Autoimmune Metaplastic Atrophic Gastritis (AMAG). Patients with AMAG have threefold risk of the development of gastric cancer. Presentation of case We describe a case of a 66 year old man with a history of PA and atrophic antral-corpus gastritis. After endoscopic and chromoendoscopic evaluation the patient was treated with subtotal gastrectomy plus D2 lymphadenectomy. The tumor was diagnosed as Stage Ia; pT1a pN0 pM0 G2 with multiple foci of high grade dysplasia and intramucosal adenocarcinoma. Discussion Multifocal Early Gastric Cancer can be a problem for minimally invasive treatment such as endoscopic excision. Surgical management where it is not possible Endoscopic Mucosal Resection or Submucosal Resection (EMR/ESD) should include D1 or more type of lymphadenectomy because of the risk of nodes metastases. The chromoendoscopic evaluation may be helpful in the preoperative work-up and during the follow-up period. Conclusion Multidisciplinary approach is very important to reduce the under-treatment risk in multifocal early gastric cancer. Further studies will be needed to evaluate the safety of Subtotal vs Total Gastrectomy in this kind of disease.

Funding Information: The authors are grateful to the Birmingham Surgical Trials Consortium at the University of Birmingham for the use of their servers for secure online data collection. Disclosure: The authors declare no conflict of interest.

Fournier’s gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects.

Background Leiomyosarcomas (LMS) of the inferior vena cava (IVC) originate in the retrohepatic (RHVC) portion in 15% of cases.1 Due to complex anatomy and need to preserve venous outflow from the infra-diaphragmatic viscera, the operation may require total vascular exclusion, veno-venous bypass and hypothermic liver resections.2,3 In this video, virtual planning of the operation allowed a parenchyma-sparing radical resection in a patient with limited liver reserve. Methods A 12-cm LMS of RHVC invading the entire segment 1 (i.e., Spiegel’s lobe, paracaval portion, and caudate process) was diagnosed in a man with metabolic steato-hepatitis (BMI: 34). He had no response to previous chemotherapy. Major hepatectomy was excluded considering the high risk of postoperative liver failure. 3D-reconstruction of regional anatomy allowed planning of a parenchymal-sparing, en bloc resection of tumor, RHVC, and caudate lobe while avoiding hilar and suprahepatic venous clamping. Results The operation strategy relied on the en bloc separation of caudate lobe, RHVC, and tumor from the hepatic veins confluence and the posterior segments after complete mobilization of the liver. Vessel loop-assisted hanging maneuver, encircling tumor, and RHVC with superimposed 3D-reconstructions guided the parenchymal transection, while preserving the middle hepatic vein outflow. RHVC was replaced with prosthetic material. Conclusions Complex resection of primary tumor of the IVC en bloc with caudate lobe and RHVC can be attempted in chronic liver diseases at-risk of postoperative failure. Preservations of transhepatic flow and liver function depends on tumor size and preservation of noninvaded hepatic-veins confluence. Preoperative virtual 3D reconstruction is crucial in surgical planning.

Gastric cancer (GC) is the third most common cancer-related cause of death worldwide. In locally advanced tumors, neoadjuvant chemotherapy has recently been introduced in most international Western guidelines. For metastatic and unresectable disease, there is still debate regarding correct management and the role of surgery. The standard approach for stage IV GC is palliative chemotherapy. Over the last decade, an increasing number of M1 patients who responded to palliative regimens of induction chemotherapy have been subsequently undergone surgery with curative intent. The objective of the present review is to analyze the literature regarding this approach, known as "conversion surgery", which has become one of the most commonly adopted therapeutic options. It is defined as a treatment aiming at an R0 resection after chemotherapy in initially unresectable tumors. The 13 retrospective studies analyzed, with a total of 411 patients treated with conversion therapy, clearly show that even if standardization of unresectable and metastatic criteria, post-chemotherapy resectability evaluation and timing of surgery has not yet been established, an R0 surgery after induction chemotherapy with partial or complete response seems to offer superior survival results than chemotherapy alone. Additional larger sample-size randomized control trials are needed to identify subgroups of well-stratified patients who could benefit from this multimodal approach.

AIM Acute post-operative pain following modified radical mastectomy (MRM) in patients with breast cancer is challenging for anesthesiologists. This study aimed to prospectively compare the quality outcome of interfascial plane blocks performed with ultrasound guidance, and evaluate the consequences of sharing tasks with the breast surgeon. PATIENTS AND METHODS The study involved 255 patients scheduled for unilateral MRM, who were divided into two groups: Pecs group: General anesthesia plus ultrasound-guided modified pectoral nerves blocks type I and II, including serratus and parasternal infiltration according to surgical requirements; and Control group: general anesthesia only. Quality was evaluated based on perioperative opioid consumption, reported pain intensity, rescue analgesic requirement, side-effects and length of hospital stay. Moreover, a breast surgeon with expertise in ultrasound-guided breast biopsy was trained to perform the blocks. The patient benefits from regional anesthesia delivered by a non-anesthesiologist were assessed. RESULTS Significant reductions were noted in all of the following: Intraoperative opioid consumption (p

Evaluate Alvarado Score's (AS) accuracy related with C-reactive protein (CRP). Evaluate the accuracy rate of ultrasonography (US).We analyzed data on 290 patients admitted to Emergency Department (ED) of Sant'Andrea Hospital (Rome - Italy) presenting abdominal pain in lower quadrants between Jan2009-Apr2015. AS, laboratory tests, images and report from CT-scan and US were collected. Histological examination is considered as Gold Standard. We calculated Specificity(Sp), Sensitivity(Se), Accuracy(Ac), positive predictive value(PPV), and negative predictive value(NPV). We use Exact Fisher Test (EFT) for samples less than 50 units, and Chi square test (χ2). CRP were assessed as possible laboratory marker to be added to AS.Two hundred and forty patients (82%) were enrolled following the inclusion criteria. The variations obtained from the AS with C-reactive protein show no difference. CT-scan vs US results show a higher Sp for US despite CT (p= 0.0509 χ2=3.803. Se and NPV are higher in CT compared to the US (Se: p=0.000315 χ2= 12.88 NVP: p=0.015. We evaluated Ac of US and CT within the individual groups (low(L), Intermediate(I), High(H): L; 37 patients show no statistically significant difference (EFT=1; p0.05). I: show superiority of CT-scan in Se and NPV (FE:0.0162 p0.05; FE:0.0432 p0.05). Regarding H only Se show an acceptable p-value (p0.0021).Alvarado score (AS) can be used as the first diagnostic approach in the diagnosis of acute appendicitis (AA). Ultrasound must be considered the first level instrumental examination; necessary and sufficient in low risk patients (0-3 pt) to exclude, with a high reliability rate, the diagnosis of acute appendicitis.Acute Appendicitis, Alvarado Score, CT scan, Ultrasound, Peritonitis.Lo scopo dello studio è stato quello di valutare l’accuratezza dell’Alvarado Score (AS) in relazione alla proteina C-reattiva (CRP) per l’appendicite acuta ed il livello di precisazione diagnostica ottenibile con l’ecografia (US). Sono stati analizzati i dati di 290 pazienti ricoverati presso il Dipartimento di Emergenza dell’Ospedale Sant’Andrea di Roma, che presentavano dolore addominale nei quadranti inferiori tra gennaio 2009 e aprile 2015. Sono stati raccolti i punti dell’AS, gli esami di laboratorio, immagini e referti di TC ed ecografia, considerando come “gold standard” l’esame istologico. Abbiamo calcolato Specificità (Sp), Sensibilità (Se), Precisione (Ac), valore predittivo positivo (PPV) e valore predittivo negativo (NPV). Abbiamo usato Exact Fisher Test per campioni inferiori a 50 unità, ed il Chi square test (χ2). La PC Reattiva è stata valutata come possibile marker in aggiunta ai AS. Sono stati arruolati nello studio 240 pazienti (82%) in rispetto dei criteri di inclusione. L’aggiunta della PCR agli AS non ha dimostrano differenze. Il confronto tra TC e US ha mostrato una maggiore specificità degli ultrasuoni rispetto alla tomografia computerizzata (p= 0.0509 χ2=3.803. Sensibilità e valore predittivo negativo sono risultati più alti nella CT rispetto agli US (Se: p=0.000315 χ2= 12.88 NVP: p=0.015). Abbiamo valutato la accuratezza di US e CT all’interno dei singoli gruppi (basso (L), intermedio (I), alto (H): nel L 37 pazienti non hanno mostrato differenze statisticamente significative (EFT = 1; p0,05). Negli I hanno presentato la superiorità della CT in termini di sensibilità e valore predittivo negativo (FE: 0,0162 p0,05; FE: 0,0432 p0,05). Nel gruppo H solo la sensibilità ha mostrato un valore p accettabile (p0,0021). In conclusione il punteggio Alvarado (AS) può essere usato come primo approccio diagnostico nella diagnosi di appendicite acuta (AA) L’ecografia deve essere considerato l’esame strumentale di primo livello, necessario e sufficiente in pazienti a basso rischio (0-3 pt) per escludere, con un alto tasso di affidabilità, la diagnosi di appendicite acuta.

The prognosis of patients with metastatic gastric cancer remains dismal, with palliative treatment as standard of care. However, encouraging results have been reported for surgical resection of liver only metastatic gastric cancer in carefully selected patients. A systematic review of articles published from 2000 onwards was conducted according to PRISMA guidelines. Twenty-nine studies were included in qualitative and quantitative analysis. Meta-analysis of proportions pointed out 29.1 % 5ySR (I 2 = 39 %). The pooled weighted median of MSTs was 31.1 months. T stage > 2, metastasis greatest dimension ≥ 5 cm, the presence of multiple metastases and bilobar disease resulted among the strongest predictors of mortality. Funnel plots, Egger's tests, and P-curve analyses failed to show significant publication bias. Based on strict selection criteria and robust statistical analyses, our results show that, in very carefully selected patients without extrahepatic disease, surgical resection with curative intent may significantly improve overall survival.

e23555 Background: Desmoplastic small round cell tumor (DSRCT) is an ultra rare sarcoma predominantly involving the abdomino-pelvic peritoneum and mostly occurring in male children and young adults. It is marked by the EWSR1-WT1 fusion gene. Prognosis is poor with reported 5-year overall of < 20%. Methods: Data of patients with primary intra-abdominal DSRCT, who had surgery at our institution between 2000 and 2020, were analyzed. Information regarding disease presentation, cytoreductive surgery (CRS) with or without hypertermic intraperitoneal chemotherapy (HIPEC) and perioperative treatments were reported. Kaplan-Meier survival analysis was performed for both the whole cohort (A) and separately for peritoneal (B) vs peritoneal + lymphnode involvement (C) at disease presentation. Also, patients who underwent CRS alone vs CRS + HIPEC were compared. Results: 43 patients (pts) were identified, only 18 (42%) underwent surgical resection with curative intent in addition to perioperative chemotherapy (CT) ± radiotherapy (RT). 6 pts had also synchronous abdominal nodal metastases and one resectable liver metastases. Median tumor size was 19cm (12-20). 9 pts received pre and postoperative chemotherapy (CT), 7 pts preoperative CT, 2 pts postoperative CT. Postoperative abdominal RT was administered in 3 pts. Partial response (PR) to preoperative CT was observed in more than 50% of pts. Complete cytoreduction was achieved in 14 pts (78%). HIPEC was performed in 5 patients (28%). Overall, 8 pts died (44%), 1 patient after developing liver and lung metastases while 7 had peritoneal and intra-abdominal lymphnode recurrence. Of 10 patients alive, 7 had a recurrence. Of them, 5 are alive with disease (1 presenting extra-abdominal recurrence, 3 lymph node involvement and 1 liver metastases) at 75, 38, 33, 15 and 31 months, respectively, from diagnosis. 2 are alive without disease (after having a further surgery for local recurrence) at 35 and 36 months, respectively, from diagnosis. 3 patients are alive without disease at 12, 64, and 213 months from diagnosis. As a result, 5-year OS was 39.6%, 35.6% and 40% for group A, B and C, respectively. Median survival time was 39.2, 39.2 and 57.7 months for group A, B and C, respectively. 5-year OS was 35.2% and 50% for CRS and CRS + HIPEC group respectively. Conclusions: Despite an intense multimodal approach, DSRCT prognosis remains poor. CRS may improve oncologic outcomes. Our data confirmed significant tumor shrinkage after administration of preoperative CT which may be helpful to achieve macroscopically complete resections. The value of HIPEC and radiation therapy is more controversial and needs to be further investigated in a larger series. Interestingly, the presence of synchronous nodal metastases was not a negative survival prognosticator showing comparable outcome to peritoneal disease.

Background Laparoscopic appendectomy has progressively gained acceptance as the standard of care for acute appendicitis. Focusing on the incidence of postoperative intra-abdominal abscess after a laparoscopic appendectomy, discordant data have been reported ranging from 1.5 to 20%. Besides, evidence advocating advantages from peritoneal irrigation over suction only are lacking. Most studies are burdened by a high level of heterogeneity regarding the severity of the appendicitis and modalities of peritoneal irrigation. One of the main drawbacks is the lack of an accepted classification for different degrees of appendicitis and peritoneal contamination. The aim of the study is to introduce a classification to clarify the relationship between grade of appendicitis, contamination, and postoperative incidence of IAA considering the surgeon’s attitude toward irrigation or suction alone. Preoperative, intra-operative, and postoperative predictive factors for infectious complication will also be assessed. This study is meant to be the first Italian multicenter resident-based observational study. Methods Patients suffering from acute appendicitis will be enrolled during a 1-year period, according to inclusion and exclusion criteria. Participants will fill an online form reporting all clinical and intra-operative data of each patient undergoing a laparoscopic appendectomy. General surgery residents will be responsible for data collection. Our proposal of classification is based on the histological grade of appendicitis and intra-operative degree of peritoneal contamination. For each grade, a progressively increasing score is assigned. Discussion The observational nature of this study is mandatory to examine surgeons’ attitude toward peritoneal contamination during laparoscopic appendectomy for appendicitis. Identification of different severity grades of acute appendicitis and their relationship with the development of postoperative abscesses is necessary. The resulting classification and score, even considering peritoneal lavage or suction alone, will define risk classes of peri-appendiceal contamination each one related to a specific incidence rate of postoperative IAA. Nowadays, maximum effort should be made to reach the best procedural standardization and surgical decision-making should be supported by solid evidence, especially in an emergency surgery setting.

Despite the high burden of respiratory disease, no spirometry reference values for African children are available.Investigate whether the Global Lung Initiative (GLI-2012) reference values for spirometry are appropriate for children in sub-Saharan Africa and assess the impact of malnutrition on lung function.Anthropometry and spirometry were obtained in children aged 6 to 12 years from urban and semiurban schools in three African countries. Spirometry z-scores were derived using the GLI-2012 prediction equations for African Americans. Thinness (body mass index z-score -2) was a surrogate for malnutrition. Spirometry outcomes were compared with those of African American children from the third National Health and Nutrition Survey.Spirometry data were analyzed from 1,082 schoolchildren (51% boys) aged 6.0 to 12.8 years in Angola (n = 306), Democratic Republic of the Congo (n = 377), and Madagascar (n = 399). GLI-2012 provided a good fit with mean (SD) z-scores of -0.11 (0.83) for FEVThe results of this study support the use of GLI-2012 reference values for schoolchildren in sub-Saharan Africa. Malnutrition affects body growth, leading to a proportionately smaller FEV

Binary asymmetric nanocrystals (BNCs), composed of a photoactive TiO2 nanorod joined with a superparamagnetic γ-Fe2O3 spherical domain, were embedded in polyethylene glycol modified phospholipid micelle and successfully bioconjugated to a suitably designed peptide containing an RGD motif. BNCs represent a relevant multifunctional nanomaterial, owing to the coexistence of two distinct domains in one particle, characterized by high photoactivity and magnetic properties, that is particularly suited for use as a phototherapy and hyperthermia agent as well as a magnetic probe in biological imaging. We selected the RGD motif in order to target integrin expressed on activated endothelial cells and several types of cancer cells. The prepared RGD-peptide/BNC conjugates, comprehensively monitored by using complementary optical and structural techniques, demonstrated a high stability and uniform dispersibility in biological media. The cytotoxicity of the RGD-peptide/BNC conjugates was studied in vitro. The cellular uptake of RGD-peptide conjugates in the cells, assessed by means of two distinct approaches, namely confocal microscopy analysis and emission spectroscopy determination in cell lysates, displayed selectivity of the RGD-peptide-BNC conjugate for the αvβ3 integrin. These RGD-peptide-BNC conjugates have a high potential for theranostic treatment of cancer.

A simple fabrication approach for achieving nanoparticle patterns based on a room temperature chemically driven strategy is reported. Suitably engineered colloidal luminescent nanocrystals (NCs) (4 and 6 nm in diameter), namely organic capped and silica-coated negatively charged CdSe@ZnS NCs, have been selectively assembled onto defined domains in a binary hydrophobic/hydrophilic chemical pattern, purposely fabricated by combining microcontact printing and wet chemistry procedures. The goal of the work has been to investigate the experimental parameters governing the assembly process at molecular level, in order to elucidate factors regulating interactions at the interfaces. For this purpose, specific sets of conditions, namely substrate patterns and NCs with distinct surface functionalization, have been prepared and tested using different NC dispersing solvents. The NC assembly has been demonstrated driven by non-covalent forces, namely Van der Waals or electrostatic interactions occurring at the NC/substrate interface. The overall study has provided a comprehensive understanding of the role of solvent and molecular chemistry at interfaces in NC assembling. The obtained results can be valuable to set up reliable procedures for developing reproducible patterning protocols potentially useful for the fabrication of NC-based devices.