Lucia Romano

Giovanni Domenico Tebala, Fanny Massimi, Francesca Duro, Ahmed Abdelsamad, Stefano Avenia, Gian Luca Baiocchi, Andrea Barberis, Chafik Bouzid, Antoine Castel, Graziano Ceccarelli, Andrea Celotti, Nicola Cillara, Nicola Cinardi, Roberto Cirocchi, Maria Conticchio, Giuseppe Currò, Antonella Delvecchio, Raffaele Vincenzo De Rosa, Jacopo Desiderio, Antonio Di Cintio, Fabio Francesco Di Mola, Domenico Di Nardo, Alessia Fassari, Alessandro Gemini, Carlos Augusto Gomes, Gian Luca Grazi, Giuseppe Margani, Alessandro Mazzotta, Luca Morelli, Andrea Muratore, Fabrice Muscari, Edoardo Maria Muttillo, Alberto Patriti, Gaetano Piccolo, Luca Properzi, Alessandro Puzziello, Lucia Romano, Edoardo Rosso, Sara Saeidi, Andrea Sagnotta, Edoardo Saladino, Marcello Giuseppe Spampinato, Laurent Sulpice, Nádia Tenreiro, Paolo Ubiali, Riccardo Memeo, DoS-RAP Collaborative. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.26-007

Background: Organ transplant recipients are at a significantly higher risk of developing skin cancer compared to the general population, particularly cutaneous squamous cell carcinoma. Approximately 3–8% of these carcinomas are located on the scalp. Scalp reconstruction is particularly challenging, especially for large excisions, due to the thickness of the scalp, the inelastic aponeurosis of the galea, and the integrity of the hair-bearing scalp. Additionally, in organ transplant recipients, the presence of numerous comorbidities and the increased risk of infection due to immunosuppressive therapy make management more complex. Based on our experience and the existing literature, we aim to describe possible reconstruction methods and discuss the combined management of medical and immunosuppressive therapy. Method: We present our experience with seven kidney transplant patients who underwent excision of cutaneous squamous cell carcinoma with a diameter larger than 3 cm. The crane technique involves three key steps. First, the tumor is excised with wide margins of disease-free tissue. Next, a pericranial flap is rotated and positioned to cover the exposed cranial bone. Finally, a bilayer dermal substitute is applied to create a microenvironment that supports skin graft implantation. Results: The crane technique was used for six patients. In one case, an O-Z rotation flap was used. All patients modified their immunosuppressive therapy, with those receiving antiproliferative therapy switching everolimus after surgery. Conclusions: When combined with a post-operative modification of the immunosuppressive regimen, the crane technique could be considered a feasible, safe, and effective approach to managing large cSCC of the scalp in fragile patients.

Clinical risk prediction models are ubiquitous in many surgical domains. The traditional approach to develop these models involves the use of regression analysis. Machine learning algorithms are gaining in popularity as an alternative approach for prediction and classification problems. They can detect non-linear relationships between independent and dependent variables and incorporate many of them. In our work, we aimed to investigate the potential role of machine learning versus classical logistic regression for the preoperative risk assessment in proctological surgery. We used clinical data from a nationwide audit: the database consisted of 1510 patients affected by Goligher’s grade III hemorrhoidal disease who underwent elective surgery. We collected anthropometric, clinical, and surgical data and we considered ten predictors to evaluate model-predictive performance. The clinical outcome was the complication rate evaluated at 30-day follow-up. Logistic regression and three machine learning techniques (Decision Tree, Support Vector Machine, Extreme Gradient Boosting) were compared in terms of area under the curve, balanced accuracy, sensitivity, and specificity. In our setting, machine learning and logistic regression models reached an equivalent predictive performance. Regarding the relative importance of the input features, all models agreed in identifying the most important factor. Combining and comparing statistical analysis and machine learning approaches in clinical field should be a common ambition, focused on improving and expanding interdisciplinary cooperation.

Purpose: Femoral hernia accounts for 22% of groin hernia operations in women and for 1.1% in men. Numerous surgical approaches have been reported but there is no consensus. Many of the recurrence rates are reported in old literature, while recent reports are scarce. The aim of the present study was to review rates of recurrences in patients who underwent open repair of a primary femoral hernia. Methods: We conducted a systematic search in the electronic literature, using the search terms “femoral hernia” and “recurrence”. We included studies published from 2002 that had as primary or secondary endpoint to evaluate the recurrence after surgery. Risk of bias was assessed by the Cochrane risk of bias tool for RCT and by the Newcastle-Ottawa Scale for cohort studies. Results: Fifteen eligible articles were included in our systematic review. A total of 1087 procedures were performed according to the defined criteria. The metanalytic evaluation highlighted a higher probability of recurrence for non-mesh than mesh repairs (6.5% vs 1.9%; RR 0.924, 95% CI: 0.857 - 0.996). In patients treated in emergency settings the rate of recurrences was 3.7%; in patients who received elective repairs it was 0.71%. Six studies reported that most of recurrences occurred within the first post-operative year. Conclusion: We found that crude recurrence rate after open repair of a primary femoral hernia is about 4%. This rate is higher in case of non-mesh techniques and in emergency surgery. Our results support the recommendation that femoral hernias should be repaired with mesh techniques.

Background: It is common practice to classify waste from the operating theater as “clinical”. The development of sustainable policies could have a significant impact. In the first phase, our study aims to measure general surgery waste and to assess the potential financial and carbon savings of appropriate recycling. Based on this information, we will plan for a second phase in which educational interventions will be put in place to promote waste segregation in surgical environments.Methods: We conducted a preliminary cognitive audit of the most common general surgery procedures to examine the types and quantity of waste produced. We calculated the economic and environmental impacts of disposing of waste treated as clinical or general, and we measured how much of it could actually be recycled. Then, we attempted a projection of the savings we could expect if recycling policies were implemented.Results: We found that more than 30% of total waste was actually recyclable. Considering a projection based on annual procedures performed in our hospital, we estimated that for each kind of surgical procedure, we could expect a reduction of the carbon footprint by approximately 6%, and an average 3% reduction in costs every year, only by improving waste segregation in the general surgery operating rooms.Conclusion: There could be a great potential for reducing environmental and economic footprint of the operating rooms by promoting waste recycling protocols. Surgeons are in a unique position to implement for these protocols. Interventions should be codesigned with theater staff to create a “green culture”.

BACKGROUND: Over the past few decades, several surgical approaches have been proposed to treat hemorrhoids. OBJECTIVE: This multicenter study aimed to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease. DESIGN: Multicenter retrospective study. SETTINGS: Any center belonging to the Italian Society of Colorectal Surgery in which at least 30 surgical procedures per year for hemorrhoidal disease were performed was able to join the study. PATIENTS: Clinical data from patients with Goligher’s grade III hemorrhoidal disease who underwent excisional hemorrhoidectomy or hemorrhoidal artery ligation were retrospectively analyzed after a 24-month follow-up period. MAIN OUTCOME MEASURES: The primary aims were to evaluate the adoption of 2 different surgical techniques and to compare them in terms of symptoms, postoperative adverse events, and recurrences at a 24-month follow-up. RESULTS: Data from 1681 patients were analyzed. The results of both groups were comparable in terms of postoperative clinical score by multiple regression analysis and matched case–control analysis. Patients who underwent excisional hemorrhoidectomy had a significantly higher risk of postoperative complication (adjusted OR = 1.58; p = 0.006). A secondary analysis highlighted that excisional hemorrhoidectomy performed with new devices and hemorrhoidal artery ligation reported a significantly lower risk for complications than excisional hemorrhoidectomy performed with traditional monopolar diathermy. At the 24-month follow-up assessment, recurrence was significantly higher in the hemorrhoidal artery ligation group (adjusted OR = 0.50; p = 0.001). A secondary analysis did not show a higher risk of recurrences based on the type of device. LIMITATIONS: The retrospective design and the self-reported nature of data from different centers. CONCLUSIONS: Hemorrhoidal artery ligation is an effective option for grade III hemorrhoidal disease; however, it is burdened by a high risk of recurrences. Excisional hemorrhoidectomy performed with newer devices is competitive in terms of postoperative complications. HEMORROIDECTOMÍA POR ESCISIÓN VERSUS DESARTERIALIZACIÓN CON MUCOPEXIA PARA EL TRATAMIENTO DE LA ENFERMEDAD HEMORROIDAL DE GRADO 3: EL ESTUDIO MULTICÉNTRICO EMODART3 ANTECEDENTES: En las últimas décadas se han propuesto varios abordajes quirúrgicos para el tratamiento de las hemorroides. OBJETIVO: Este estudio multicéntrico tiene como objetivo comparar la ligadura de la arteria hemorroidal transanal y la hemorroidectomía por escisión convencional para la enfermedad hemorroidal de grado III. DISEÑO: Estudio retrospectivo multicéntrico. ÁMBITO: Cualquier centro perteneciente a la Sociedad Italiana de Cirugía Colorrectal en el que se realizaron al menos 30 procedimientos quirúrgicos por año para la enfermedad hemorroidal pudo participar en el estudio. PACIENTES: Los datos clínicos de pacientes con enfermedad hemorroidal de grado III de Goligher que se sometieron a hemorroidectomía por escisión o ligadura de arterias hemorroidales se analizaron retrospectivamente después de un período de seguimiento de 24 meses. PRINCIPALES MEDIDAS DE RESULTADO: Los objetivos primarios fueron evaluar la adopción de dos técnicas quirúrgicas diferentes y compararlas en términos de síntomas, eventos adversos posoperatorios y recurrencias a los 24 meses de seguimiento. RESULTADOS: Se analizaron datos de 1681 pacientes. Los 2 grupos resultaron ser comparables en términos de puntuación clínica posoperatoria mediante análisis de regresión múltiple y análisis de casos y controles emparejados. Los pacientes sometidos a hemorroidectomía excisional tuvieron un riesgo significativamente mayor de complicaciones posoperatorias (odds ratio ajustado = 1,58; p = 0,006). Un análisis secundario destacó que la hemorroidectomía por escisión realizada con nuevos dispositivos y la ligadura de la arteria hemorroidal informaron un riesgo significativamente menor de complicaciones que la hemorroidectomía por escisión realizada con diatermia monopolar tradicional. En la evaluación de seguimiento de 24 meses, la recurrencia fue significativamente mayor en el grupo de ligadura de la arteria hemorroidal (razón de probabilidad ajustada = 0,50; p = 0,001). Un análisis secundario no mostró un mayor riesgo de recurrencias según el tipo de dispositivo. LIMITACIONES: El diseño retrospectivo y el carácter autoinformado de los datos de diferentes centros. CONCLUSIÓN: HAL es una opción efectiva para la enfermedad hemorroidal grado III; sin embargo, se ve afectado por un alto riesgo de recurrencias. La hemorroidectomía por escisión realizada con dispositivos más nuevos es competitiva en términos de complicaciones posoperatorias. (Traducción—Dr Yolanda Colorado)

Purpose Various risk factors have been associated with the development of incisional hernia (IH). Some recent papers underlined that visceral fat could be a reliable indicator. Another risk factor which is of increasing clinical interest is sarcopenia. Recent studies have identified it as an independent predictor of poor postoperative outcomes following abdominal surgery. We aimed to investigate the role of visceral fat and skeletal muscle as emerging risk factors for IH after urgent laparotomy. Methods Patients aged 18 years or older who underwent urgent median laparotomy and with continuous direct suturing of the laparotomy were included. They were categorized into two groups: those with a median IH and those without IH at 12-month follow-up. Demographic data were prospectively collected while CT scans were retrospectively reviewed. The data were compared among two groups. Results From January 2018 to May 2021, 364 patients underwent urgent surgery in our Department, of whom 222 were aged >18 years old and underwent median laparotomy. Forty-four patients had diagnosis of median IH, while 41 patients without IH were identified as the control group. Statistically significant differences emerged for BMI and for the area of visceral fat. The association with the presence/absence of sarcopenia was not significant. Conclusion Even when surgery is performed in urgent settings, it could be important to identify patients at risk, especially as CT scans are generally available for all patients with urgent abdominal disease.