Mauro Santarelli

Background: Chronological age remains deeply embedded in perioperative risk assessment because it is readily available and intuitively associated with adverse outcomes. In clinical practice, however, patients of similar age frequently experience markedly different postoperative trajectories, suggesting that physiological reserve may more accurately reflect vulnerability to surgical stress than years lived alone. We therefore investigated whether age-based stratification inadequately captures perioperative vulnerability when compared with functional phenotyping based on frailty status and baseline handgrip strength (HGS). Methods: We conducted a prospective multicenter observational cohort study including 223 adults undergoing elective abdominal surgery between January 2023 and June 2025. Chronological age was evaluated both continuously and using a conventional threshold ( 10 days, was used as a pragmatic clinical benchmark. Cross-classification analyses, logistic regression, and receiver operating characteristic (ROC) curve analyses were performed to compare the discriminatory performance of chronological age, frailty phenotype, and HGS. Results: Substantial discordance was observed between chronological age and frailty phenotype. Among patients younger than 70 years, 7.7% met criteria for frailty, whereas 58.0% of patients aged ≥70 years were classified as fit or pre-frail. Prolonged hospitalization occurred in 48 patients (21.5%) and varied markedly according to frailty status within each age group. Frail patients younger than 70 years demonstrated higher rates of prolonged LOS than fit older patients (40.0% vs. 10.5%). Chronological age demonstrated limited discrimination for prolonged hospitalization (AUC 0.579), while the ≥70-year threshold showed poor discriminatory performance (AUC 0.541). Frailty phenotype demonstrated improved discrimination (AUC 0.679), whereas the combined multivariable model integrating age, frailty, HGS, sex, and oncologic indication achieved good discriminatory performance (AUC 0.810). In multivariable analyses, frailty remained independently associated with prolonged LOS, whereas chronological age did not. Conclusions: Chronological age alone demonstrated limited discriminatory performance for perioperative risk stratification. Functional phenotyping based primarily on frailty status, complemented by objective functional measures such as HGS, may better capture physiological reserve and support more individualized, function-centered perioperative assessment in abdominal surgery.

Background: Chronological age remains deeply embedded in perioperative risk assessment because it is readily available and intuitively linked to adverse outcomes. In clinical practice, however, patients of similar age frequently experience markedly different postoperative trajectories. This observation may suggest that physiological reserve, rather than years lived, more accurately reflects vulnerability to surgical stress. We therefore examined whether age-based stratification misclassifies perioperative risk when compared with functional phenotyping using frailty status and baseline handgrip strength. Methods: We conducted a prospective, multicenter observational cohort study including 223 adults undergoing elective abdominal surgery between January 2023 and June 2025. Chronological age was evaluated both continuously and using a conventional threshold (<70 vs ≥70 years). Physiological reserve was characterized using a phenotype-based frailty model (fit, pre-frail, frail) and baseline handgrip strength measured at hospital admission. Prolonged hospitalization, defined a priori as a length of stay exceeding 10 days, was used as an external benchmark to examine classification performance. Analyses were primarily descriptive and classificatory, focusing on discordance, overlap, and risk re-ranking across age and functional strata rather than outcome prediction. Results: Substantial discordance was observed between chronological age and frailty phenotype. Among patients younger than 70 years, 7.7% met criteria for frailty, whereas 58.0% of patients aged 70 years or older were classified as fit or pre-frail. Prolonged hospitalization occurred in 48 patients (21.5%) and varied markedly by frailty status within each age group. Frail individuals consistently exhibited the highest hospitalization burden regardless of age, while fit and pre-frail older patients often demonstrated outcomes comparable to, or better than, younger fit patients. Baseline handgrip strength showed wide dispersion and extensive overlap between age groups, indicating substantial inter-individual variability in physiological reserve that chronological age alone did not capture. Conclusions: Chronological age appears to provide limited discriminatory resolution for perioperative risk stratification. Functional phenotyping using frailty status and baseline handgrip strength may better reflect underlying physiological reserve and support more individualized, function-centered perioperative decision-making.

Clinical responses to acute physiological stress differ widely among patients of similar age and comorbidity. Frailty and muscle strength commonly indicate physiological reserve, yet the role of sex remains incompletely understood. This study aimed to assess the unadjusted association between sex and major morbidity and determine whether sex independently is independently associated with major postoperative morbidity. In this prospective multicenter cohort, 223 adults undergoing elective abdominal surgery (2023–2025) had frailty and preoperative handgrip strength assessed. Major postoperative morbidity (Clavien–Dindo grade ≥ III) was analyzed using multivariable logistic regression including chronological age, oncologic indication, frailty status, admission handgrip strength, and sex. Secondary analyses examined length of stay. Major postoperative complications occurred in 6.3% of patients and were more frequent among men than women (10.3% vs. 2.0%, p = 0.032). In multivariable analysis (n = 216 complete cases), female sex was independently associated with lower odds of major complications compared with male sex (OR 0.12, 95% CI 0.02–0.72; p = 0.020). Chronological age (OR 1.02 per year, 95% CI 0.97–1.07; p = 0.533), frailty status (p = 0.557), admission handgrip strength (p = 0.723), and oncologic indication (p = 0.116) were not independently associated with major morbidity. In secondary analyses, oncologic indication (p < 0.001) and frailty status (p = 0.001) were independently associated with prolonged length of stay, whereas chronological age was not (p = 0.972). These findings suggest sex-specific postoperative vulnerability persists beyond age and physiological reserve, supporting inclusion of sex in perioperative risk stratification.

Background: Chronological age inadequately captures biological vulnerability among surgical patients. Frailty and muscle strength reflect physiological reserve, yet their combined contribution to postoperative length of stay (LOS) remains insufficiently explored. Methods: We conducted a prospective multicenter observational cohort study including 223 adults undergoing elective abdominal surgery. Frailty was assessed using the Fried phenotype, and admission handgrip strength (HGS) was measured with a calibrated dynamometer. Prolonged LOS was defined as >10 days (75th percentile) and also analyzed continuously using ln(LOS + 1). Multivariable logistic and linear regression models adjusted for age, sex, frailty status, and surgical indication. Patients were additionally stratified into four physiological reserve phenotypes combining frailty and HGS. Results: LOS ranged from 0 to 68 days; a total of 48 patients (21.6%) experienced prolonged hospitalization. In multivariable logistic regression, frailty (adjusted OR 3.12, 95% CI 1.72–5.67) and oncologic surgery (adjusted OR 7.63, 95% CI 3.12–18.65) were independently associated with prolonged LOS, whereas chronological age was not. Female sex was associated with lower odds of prolonged LOS (adjusted OR 0.39, 95% CI 0.18–0.87). Similar associations were observed when LOS was analyzed continuously. Physiological reserve phenotyping revealed graded LOS distributions: Fit–Strong patients had the shortest stays (mean 5.5 ± 4.3 days), while Frail–Weak patients experienced the longest and most variable hospitalization. Conclusions: Postoperative LOS clusters according to multidimensional physiological reserve rather than chronological age. Integrating frailty and muscle strength identifies clinically meaningful phenotypes that may improve perioperative risk stratification beyond age-based approaches and inform personalized perioperative planning, resource allocation, and patient-centered decision-making across heterogeneous surgical populations in worldwide settings.

In hemodynamically stable adults sustaining a splenic trauma, non-operative management (NOM) represents the standard approach even in high-severity injuries. However, knowledge, structural, and logistic limitations still reduce its wider diffusion. This study aims to identify such issues to promote the safe and effective management of these injuries. A survey was developed using the SurveyMonkey^® software and spread nationally in Italy. The survey was structured into: (1) Knowledge of classification systems; (2) Availability to refer patients; (3) Patients monitoring and follow-up; (4) Center-related. The survey was filled in by 327 surgeons, with a completeness rate of 63%. Three responders out of four are used to manage trauma patients. Despite most responders knowing the existing classifications, their use is still limited in daily practice. If a patient needs to be centralized, the concern about possible clinical deterioration represent the main obstacle to achieving a NOM. The lack of protocols does not allow standardization of patient surveillance according to the degree of injury. The imaging follow-up is not standardized as well, varying between computed tomography, ultrasound, and contrast-enhanced ultrasound. The classification systems need to be spread to all the trauma-dedicated physicians, to speak a common language. A more rational centralization of patients should be promoted, ideally through agreements between peripheral and reference centers, both at regional and local level. Standardized protocols need to be shared nationally, as well as the clinical and imaging follow-up criteria should be adapted to the local features.

To date, the exact pathophysiology of haemorrhoids is poorly understood. The different philosophies on haemorrhoids aetiology may lead to different approaches of treatment. A pathogenic theory involving a correlation between altered anal canal microflora, local inflammation, and muscular dyssynergia is proposed through an extensive review of the literature. Since the middle of the twentieth century, three main theories exist: (1) the varicose vein theory, (2) the vascular hyperplasia theory, and (3) the concept of a sliding anal lining. These phenomena determine changes in the connective tissue (linked to inflammation), including loss of organization, muscular hypertrophy, fragmentation of the anal subepithelial muscle and the elastin component, and vascular changes, including abnormal venous dilatation and vascular thrombosis. Recent studies have reported a possible involvement of gut microbiota in gut motility alteration. Furthermore, dysbiosis seems to represent the leading cause of bowel mucosa inflammation in any intestinal district. The alteration of the gut microbioma in the anorectal district could be responsible for haemorrhoids and other anorectal disorders. A deeper knowledge of the gut microbiota in anorectal disorders lays the basis for unveiling the roles of these various gut microbiota components in anorectal disorder pathogenesis and being conductive to instructing future therapeutics. The therapeutic strategy of antibiotics, prebiotics, probiotics, and fecal microbiota transplantation will benefit the effective application of precision microbiome manipulation in anorectal disorders.

Background: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. Methods: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. Results: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. Conclusions: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands. Graphical

Laparoscopic splenectomy in the case of massive or supermassive splenomegaly has been associated with higher conversion rates and morbidity. The purpose of our study is to evaluate the feasibility and safety of laparoscopic splenectomy for massive spleens and to identify if there are limits beyond which the laparoscopic approach is not recommended in massive and supermassive spleens. This is a retrospective study of 93 consecutive laparoscopic splenectomies in adult patients performed by a single surgeon, from January 2008 to December 2017. The data collected included the patient’s age, sex, ASA, spleen weight, volume and dimension, type of disease, hospital stay, surgical technique, operative time. Median splenic weight was 400 g (range 65–3800 g) and median volume was 1365 cc (range 600–3800). Median operative time was 120 min and the overall conversion rate was 5.4%. Globally, 52 patients (55.9%) had a normal-weight spleen, 25 (26.9%) had massive and 16 (17.2%) had supermassive splenomegaly. In splenomegaly group (n = 41), patient’s age, percentage of malignant diagnosis, spleen weight, anteroposterior (AP), medio-lateral (ML) and craniocaudal (CC) diameter, surgical time and conversion rate were significantly higher compared to normal-weight spleen patients. None of the normal-weight spleen patients underwent open conversion, while 5 patients among 41 splenomegalic cases underwent laparotomic conversion (12.2%). Comparing massive and super-massive patients, the latter showed longer operative time and hospital length of stay, and higher conversion rate. We identified as significant cut-off limits for higher conversion risk a spleen weight ≥ 1300 g and a spleen CC diameter ≥ 22 cm. In our experience laparoscopy was the gold standard in the case of spleen weight and diameter equal to or less than 1300 g and 22 cm, but it was safe and feasible also in the case of larger spleens, taking into account the greater risk of conversion.