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Major surgical societies advised using non-operative management of appendicitis and suggested against laparoscopy during the COVID-19 pandemic. The hypothesis is that a significant reduction in the number of emergent appendectomies was observed during the pandemic, restricted to complex cases. The study aimed to analyse emergent surgical appendectomies during pandemic on a national basis and compare it to the same period of the previous year. This is a multicentre, retrospective, observational study investigating the outcomes of patients undergoing emergent appendectomy in March–April 2019 vs March–April 2020. The primary outcome was the number of appendectomies performed, classified according to the American Association for the Surgery of Trauma (AAST) score. Secondary outcomes were the type of surgical technique employed (laparoscopic vs open) and the complication rates. One thousand five hundred forty one patients with acute appendicitis underwent surgery during the two study periods. 1337 (86.8%) patients met the inclusion criteria: 546 (40.8%) patients underwent surgery for acute appendicitis in 2020 and 791 (59.2%) in 2019. According to AAST, patients with complicated appendicitis operated in 2019 were 30.3% vs 39.9% in 2020 (p = 0.001). We observed an increase in the number of post-operative complications in 2020 (15.9%) compared to 2019 (9.6%) (p 24 h after admission (+ 58%), open surgery (+ 112%) and conversion to open surgery (+ 166%). In Italian hospitals, in March and April 2020, the number of appendectomies has drastically dropped. During the first pandemic wave, patients undergoing surgery were more frequently affected by more severe appendicitis than the previous year's timeframe and experienced a higher number of complications. Trial registration number and date: Research Registry ID 5789, May 7th, 2020

The administration of justice in Italy includes first, second and third instance. The first and second instances are represented by the Court of First Instance and the Court of Appeal: these are judgment of Romamerit. The court of last appeal for both the civil and the criminal jurisdiction is the Court of Cassation, the Italian Supreme Court. It is a court of legitimacy that should provide for a consistent and uniform interpretation of the law and that only on points of law, not on factual evidence. The Court of Cassation can confirm the sentence of second instance, can dismiss it without referral, can deciding and closing the trial definitively, or dismiss it referring the case to the judge of merit that must decide according to the principles set out in the legitimacy. The aim of this study is to analyze the Supreme Cassation Court's judgments on the legal proceedings about retained sponges in abdomen.

Carlo Boselli,1 Claudio Renzi,2 Alessandro Gemini,1 Elisa Castellani,1 Stefano Trastulli,2 Jacopo Desiderio,2 Alessia Corsi,2 Francesco Barberini,1 Roberto Cirocchi,2 Alberto Santoro,3 Amilcare Parisi,4 Adriano Redler,3 Giuseppe Noya1 1Department of General and Oncologic Surgery, University of Perugia, Perugia, 2Department of General Surgery, University of Perugia, St Maria Hospital, Terni, 3Department of Surgical Sciences, Sapienza University of Rome, Rome, 4Department of Digestive Surgery, St Maria Hospital, Terni, Italy Purpose: In asymptomatic patients with Stage IV colorectal cancer, the debate continues over the efficacy of primary resection compared to chemotherapy alone. The aim of this study was to define the optimal management for asymptomatic patients with colorectal cancer and unresectable liver metastases. Patients and methods: Patients receiving elective surgery (n = 17) were compared to patients receiving chemotherapy only (n = 31). Data concerning patients' demographics, location of primary tumor, comorbidities, performance status, Child–Pugh score, extension of liver metastases, size of primary, and other secondary locations were collected. Results: Thirty-day mortality after chemotherapy was lower than that after surgical resection (19.3% versus 29.4%; not significant). In patients with >75% hepatic involvement, mortality at 1 month was higher after receiving surgical treatment than after chemotherapy alone (50% versus 25%). In patients with

Despite centuries of anatomical studies, controversies and contradictions still exist in the literature regarding the definition, anatomical terminology and the limits of the abdominal wall. We conducted a systematic research of books published from 1901 until December 2012 in Google Books. After the index screening, 16 remaining books were further assessed for eligibility. We decided to exclude journals. The aim of the study was to focus on surface landmarks and borders of the abdominal cavity. After this revision of the literature, we propose that the surface landmarks of the abdominal wall should be standardized. © 2014 Termedia and Banach.

Nipple sparing mastectomy (NSM) is the current surgical alternative to conventional techniques, when mastectomy is required. This less invasive procedure safeguards the integrity of the nipple areola complex (NAC), whose removal is recognized as a factor that exacerbates the patient's feeling of mutilation, however ensuring oncological radicality for women with breast cancer.From January 2003 to January 2011, 77 patients underwent Nipple Sparing Mastectomy (NSM). Patients were carefully selected according to specific criteria. When requested, postoperative radiotherapy on the residual glandular tissue was performed within 6 months of surgery. Patients were on close clinical and instrumental follow-up every 4 months for 2 years and every 6 months for the remaining 3 years.Of the 77 patients who underwent NSM, 10 suffering from bilateral cancer were subjected to bilateral procedure, for a total of 87 performed procedures. Furthermore, in the same group, 13 NSMs were carried out for preventive purposes. The average diameter of resected tumors was 13.5 mm, with a range of 2 to 25 mm. During the follow-up (range 23-115 months, mean 50.33 months) 2 locoregional recurrences in the NAC were observed, identified through instrumental check, and surgically treated by NAC removal after 33 and 37 months respectively.According to the litterature data and confirmed by our experience, we consider NSM as an oncologically safe technique that, in the respect of inclusion criteria may be performed in any patient with indication to mastectomy. A careful selection of patients by a multidisciplinary team according to strict criteria is the key in determining feasibility as well as oncological safety and should lead the general acceptance and widespread use of such surgical technique.

Appendiceal mucocele is a rare disease (0.3% of all appendectomy) and is characterized by the accumulation of mucoid material in the appendiceal lumen. Etiopathogenesis can be inflammatory or neoplastic. Four entities can be distinguished on the basis of histopathologic epithelial characteristics: simple appendiceal mucocele (AM), mucocele with epithelial hyperplasia, cystadenoma and cystadenocarcinoma; the last two subgroups represent neoplastic forms. Dissemination of neoplastic cells and mucoid material in abdominal cavity, caused by appendiceal perforation, clinically results in pseudomyxoma peritonei which is the dramatic evolution in 10-15% of cases. Clinically it can remain either asymptomatic for long time or it can manifest with abdominal pain that can be associated with the presence of a palpable mass. The most common clinical manifestation is pain in the right iliac fossa. Preoperative diagnosis is rare, while it is more frequently intraoperative. Therapy is fundamentally surgical: appendectomy is curative for simple AM, for AM with epithelial hyperplasia and for cystadenoma with intact appendiceal base; cecum resection is indicated for cystadenoma with larger base of implantation; right hemicolectomy has been the elective treatment in case of cystadenocarcinoma for several years although Gonzalez-Moreno and Sugarbaker have recently demonstrated its validity as definitive treatment only if it is performed in order to obtain complete cytoreduction, if there is lymph node involvement, or if histopathological examination indicates non-mucinous type. We report the case of a 60-year-old woman that presented with cystic neoformation in the right iliac fossa, that was preoperatively considered deriving from the ovary. We intraoperatively found the presence of appendiceal mucocele that histological examination defined as mucinous cystadenoma.

To evaluate the convenience in terms of recurrence and fecal incontinence rates of fibrin glue versus surgical treatment in the management of fistula-in-ano.Randomized controlled trials (RCTs) and non-randomized studies (CCTs) comparing conventional surgical treatment versus fibrin glue treatment in patients with perianal fistulae were identified using a predefined search strategy. The post treatment anal incontinence rate and the fistula recurrence rates between the two operations were compared by using the methods provided by the Cochrane Handbook for Systematic Reviews of Interventions. The lack of homogeneity of results between the different studies did not allow to analyze other secondary outcomes. Patients with cryptoglandular and Crohn's anal fistula were enrolled in the analysis. The employed fibrin glue came from commercial kits: Beriplast (Aventis Behring, Sussex, United Kingdom) and Tisseal or Tissucol (Baxter, Inc, Mississauga, Ontario). Surgical conventional treatment consisted of fistulotomy, placement of a cutting or loose latex seton and advancement mucosal flap closure. All patients were followed up at 6 and 12 weeks, the longest follow up was 6 months.Two RCTs (106 patients) and 1 non randomized studies (232 patients) were identified. The recurrence rate is higher, although still not statistically significant, in those patients who underwent fibrin glue injection (44/81) versus conventional surgical treatment (108/230), (OR: 0.44; 95 %CI: 0.12-1.68; P = 0.23). Furthermore in the analysis of the subgroup of RCTs alone there were not significant differences with the previous results of RCTs with CCT analysis (OR: 0.33; 95 %CI: 0.03-3.66; P = 0.37). In the same way the analysis of the subgroup of RCTs with complex anal fistulae were not statistically significant and similar to the previous results regarding all type of fistulas (OR: 0.86; 95 %CI: 0.01-72.36; P = 0.95). The analysis of post-operative anal incontinence showed no difference between the group who underwent fibrin glue injection (9/230) and the conventional surgical treatment group (10/81), (OR: 1.00; 95 %CI: 0.43-2.34; P = 1.00). A very low heterogeneity in the analysis was detected (Chi-square = 0.04 - P = 0%).Our statistical analysis does not show any significant statistical difference between fibrin glue treatment versus conventional surgical treatment for all perianal fistulae in terms of recurrence (P = 0.23) and anal incontinence (P = 1.00).

the Abdominal Compartment Syndrome (ACS) is an increasingly recognized complication of both medical and surgical patients. The World Society of the Abdominal Compartmental Syndrome defined Intra Abdominal Hypertension (IAH) as a mean Intra Abdominal Pressure (IAP) ≥ 12 mm Hg and the ACS as IAP ≥ 20 mmHg (with or without an abdominal perfusion pressure60 mm Hg) that is associated with dysfunction or failure of one or more organ systems that was not previously present. The IAH contributes to organ failure in patients with abdominal trauma and sepsis and leads to the development of ACS.This study aims to investigate the clinical significance of IAH, the prevalence of ACS and the importance to the effects to the abdominal decompressive re-laparotomy. Patients and methods. The study included 10 patients, 4 men and 6 women with an average age of 68 years (range, 38-86) operated and and treated with xifo-pubic laparotomy between January 2007 and December 2008. According to gold-standard methods, we measured the IAP by indirect measurement using the transvescical route via Foley bladder catheter.among 10 patients with laparotomy, 8 patients (80%) developed IAH20 mm Hg but they have not reported significant organ dysfunction , while 2 patients (20%) developed an IAH20 mm Hg associated whit organ dysfunction. For this reason, the last 2 patients were undergoing to the decompressive re-laparotomy with temporary closure.in according to our experience and the results of the literature, we believe essential monitoring abdominal pressure in patients with abdominal laparotomy. The abdominal decompressive re-laparotomy is a useful procedure to reduce symptoms and improve the health of the patient.

Considering that laparoscopic procedure is associated with increased resistance to lower-limb venous return and subsequent stasis, with possible implications in terms of thromboembolic complications, the aim of our study was to investigate prospectively the coagulative-fibrinolytic profile, in laparoscopic and open cholecystectomy, in patients randomly alloted to receive or not preoperative heparin.We prospectively analyzed 36 patients (20 laparoscopic and 16 open) and we randomly divided the patients in two groups: Group-A (28 patients--16 laparoscopic and 12 open) didn't take any preoperative thromboprophylaxis, Group-B (8 patients--4 laparoscopic and 4 open) took preoperative subcutaneous heparin. We took blood venous samples before surgery, at time 0 and + 30 min., at the end and 1 and 24 hours postoperatively. The following parameters were assessed: prothrombin time, partial thromboplastin time, fibrinogen and D-dimer. We statistically analyzed the differences by ANOVA test.In Group A, fibrinogen and D-dimer were significantly higher (p0.0001 and p = 0.0266) in open group as compared with laparoscopic one and we observed significant time-depending changes of fibrinogen's concentration (p = 0.0168). In Group B we obtained a higher fibrinogen's value in laparoscopic group than in conventional one, with a significant difference (p = 0.0283); also, the sampling-time affected the result in a very significant meaning (p = 0.0041). Comparing fibrinogen levels between Groups A and B, we observed lower values in heparin-treated group than in the other one (p0.0001), while in laparoscopic surgery there was not a significant difference between two groups of treatment.Our preliminary data suggest that, perioperatively (besides a smaller laparoscopic acute-phase response) the coagulative-fibrinolytic changes are lower in laparoscopic cholecystectomy than in open one and heparin treatment significantly reduces these changes in open surgery but doesn't seem to affect laparoscopic group. Our results seem to show another possible advantage of the laparoscopic surgical procedures over the traditional ones.

Monoclonal antibodies (MAbs) reacting with the human T cell receptor (TCR) V beta or V alpha region have been shown to be almost as specific as a private idiotypic MAb in identifying T cell clones. When available, V beta-specific MAbs offer the ease of immunofluorescence analysis to identify and quantitate expanded malignant or nonmalignant T cell populations without requiring polymerase chain reaction (PCR) technology to evaluate expression of V beta gene families. The V beta expression of peripheral blood lymphocytes from twenty-three consecutive patients with Sézary syndrome has been analyzed by reverse transcriptase (RT)-PCR. Ten patients had malignant T cell clones that expressed a TCR V beta corresponding to a commercially available anti-V beta antibody. Immunofluorescence staining with anti-V beta MAbs showed a direct correlation with RT-PCR results in seven of ten patients. No false positive reactivity was noted on immunofluorescence staining with any MAb. Cells from three patients, however, did not react with the corresponding anti-V beta MAb. These three cases expressed a TCR V beta from gene families containing a single member, ie, V beta 14, V beta 18, and V beta 20, yet MAbs reported to be specific for these regions failed to react with the T cell clone from these patients. Sequencing of the PCR product in these cases confirmed the RT-PCR results. Cells from two patients expressed a TCR using V beta 5.1-D beta 1.1 genes with different J-C segments. One patient's cells reacted with an anti-V beta 5.1 MAb (LC4) whereas the other patient's cells bound one-tenth the amount of this same MAb. These results indicate that currently available anti-TCR V region MAbs may not react consistently with T cell clones expressing the corresponding V region or may react with a low affinity making detection difficult. Differences in the J-C junction or in CDR3 may influence the binding of these MAbs. Until the false negative rate is reduced and the fine specificity and affinity of these MAbs is better characterized, both PCR and MAb studies will be required to reliably identify and quantitate clonal T cell populations.

The aim of our study was to evaluate feasibility, reliability and cost-benefit balance of sentinel node (SN) biopsies conducted under local anaesthesia (LA) in patients affected by stage I-B or II cutaneous melanoma.A retrospective analysis was carried out in 153 patients, evaluating the number of harvested lymph nodes, perioperative and postoperative complications, operating time and operating room costs, comparing interventions under LA and general anaesthesia (GA). Operations were carried out under LA in 112 cases (73%) and under GA in the remaining 41(27%).The mean number of removed SN was overall higher in the GA group but was not significantly different under LA with respect to the subgroups of axillary biopsies. No difference was noted in the number of complications. Operating time was significantly shorter under LA, with significantly lower costs.LA for groin and axillary SN biopsies can be a reliable and effective alternative to GA in melanoma patients, with shorter operating time, lower costs and without the side-effects and risks associated with GA.

AIM The purpose of this meta-analysis and systematic review is to compare minimally invasive necrosectomy (MIN) versus open necrosectomy (ON) surgery for infected necrosis of acute pancreatitis. METHODS One randomized controlled trial and 3 clinical controlled trials were selected, with a total of 336 patients (215 patients who underwent MIN and 121 patients underwent ON) included after searching in the following databases: Medline, Embase, Cochrane Central Register of Controlled Trials, BioMed Central, Science Citation Index (from inception to August 2011), Greynet, SIGLE (System for Information on Grey Literature in Europe), National Technological Information Service, British Library Integrated catalogue, and the Current Controlled Trials. Statistical analysis is performed using the odds ratio (OR) and weighted mean difference with 95% confidence interval (CI). RESULTS After the analysis of the data amenable to polling, significant advantages were found in favor of the MIN in terms of: incidence of multiple organ failure (OR, 0.16; 95% CI, 0.06-0.39) (P < 0.0001), incisional hernias (OR, 0.23; 95% CI, 0.06-0.90) (P = 0.03), new-onset diabetes (OR, 0.32; 95% CI, 0.12-0.88) (P = 0.03), and for the use of pancreatic enzymes (OR, 0.005; 95% CI, 0.04-0.57) (P = 0.005). No differences were found in terms of mortality rate (OR, 0.43; 95% CI, 0.18-1.05) (P = 0.06), multiple systemic complications (OR, 0.34; 95% CI, 0.01-8.60) (P = 0.51), surgical reintervention for further necrosectomy (OR, 0.16; 95% CI, 0.00-3.07) (P = 0.19), intra-abdominal bleeding (OR, 0.79; 95% CI, 0.41-1.50) (P = 0.46), enterocutaneous fistula or perforation of visceral organs (OR, 0.52; 95% CI, 0.27-1.00) (P = 0.05), pancreatic fistula (OR, 0.66; 95% CI, 0.30-1.46) (P = 0.30), and surgical reintervention for postoperative complications (OR, 0.50; 95% CI, 0.23-1.08) (P = 0.08). CONCLUSIONS The lack of comparative studies and high heterogeneity of the data present in the literature did not permit to draw a definitive conclusion on this topic. The results of the present meta-analysis might be helpful to design future high-powered randomized studies that compare MIN with ON for acute necrotizing pancreatitis.

Background We conducted an observational multicentric clinical study on a cohort of patients undergoing thyroidectomy for thyroid carcinoma. The aim of this study was to evaluate the benefits of the use of ultrasonic dissector (UAS) vs. the use of a conventional technique (vessel clamp and tie) in patients undergoing thyroid surgery for cancer. Methods From June 2009 to May 2010 we evaluated 321 consecutive patients electively admitted to undergo total thyroidectomy for thyroid carcinoma. The first 201 patients (89 males, 112 females) presenting to our Department underwent thyroidectomy with the use of UAS while the following 120 patients (54 males, 66 females) underwent thyroidectomy performed with a conventional technique (CT): vessel clamp and tie. Results The operative time (mean: 75 min in UAS vs. 113 min in CT, range: 54 to 120 min in UAS vs. 68 to 173 min in CT) was much shorter in the group of thyroidectomies performed with UAS. The incidence of transient laryngeal nerve palsy (UAS 3/201 patients (1.49%); CT 1/120 patients (0.83%)) was higher in the group of UAS; the incidence of permanent laryngeal nerve palsy was similar in the two groups (UAS 2/201 patients (0.99%) vs. CT 2/120 patients (1.66%)). The incidence of transient hypocalcaemia (UAS 17/201 patients (8.4%) vs. CT 9/120 patients (7.5%)) was higher in the UAS group; no relevant differences were reported in the incidence of permanent hypocalcaemia in the two groups (UAS 5/201 patients (2.48%) vs. 2/120 patients (1.66%)). Also the average postoperative length of stay was similar in two groups (2 days). Conclusion The only significant advantage proved by this study is represented by the cost-effectiveness (reduction of the usage of operating room) for patients treated with UAS, secondary to the significant reduction of the operative time. The analysis failed to show any advantages in terms of postoperative transient complications in the group of patients treated with ultrasonic dissector: transient laryngeal nerve palsy (1.49% in UAS vs. 0.83% in CT) and transient hypocalcaemia (8.4% in UAS vs. 7.5%in CT). No significant differences in the incidence of permanent laryngeal nerve palsy (0.8% in UAS vs. 1.04% in CT) and permanent hypocalcaemia (2.6% in UAS vs. 2.04% in CT) were demonstrated. The level of surgeons’ expertise is a central factor, which can influence the complications rate; the use of UAS can only help surgical action but cannot replace the experience of the operator.

Post-operatory wound infections are a very uncommon finding after thyroidectomy. For these reasons international guidelines do not routinely recommend systemic antibiotic prophylaxis. The benefits of this antibiotic prophylaxis is not supported by clinical evidence in the literature. We have conducted a multicentric randomized double-blind trial on 500 patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The 500 patients enrolled in the study (mean age 47 years) were randomized in two subgroups of 250 patients. 250 patients were treated with standard antibiotic prophylaxis with sulbactam/ampicillin 1 fl (3 gr.) 30 min before surgery. No antibiotic prophylaxis was instituted in the remainder 250 patients. Our RCT showed that prophylactic antibiotic treatment is not beneficial in patients younger than eighty years old, with no concomitant metabolic, infective and hematologic disease, with no cardiac valvulopathies, not under steroidal or immunosuppressive treatment, and not severely obese. Our study should be regarded only as a preliminary RCT, and should be followed by a study in which a larger number of patients should be enrolled so that statistically significant data can be obtained.