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Introduction: Management of pancreatic incidentalomas(PI) is challenging due to high risk of malignancy and limitations in prediction of their histology and biological behavior. IPAS is one of such lesions and is often misdiagnosed as a PNET. Aim(s): Case: A 65-year-old male presented with PI of 1.6, 1.3 cm suspected for IPAS on CT but finally misdiagnosed as a nonfunctioning PNET. Post-surgical histopathology identified lesions as IPAS. Materials and methods: Literature review. Results: Thirty-two cases of IPAS were described: 15 were correctly diagnosed as IPAS by Tc-99m, FNA stain for CD-8 or contrast enhanced sonography; 17 underwent surgery of IPAS misdiagnosed as PNETs. Pancreatic lesion were 1) mostly solitary; 2) solid on imaging; 3) well-defined; 4) located predominantly at pancreatic tail (97%); 5) not exceeding 3 cm; mean size 1.6±0.5cm (range 1-3); 6) detected in adults (mean age 54±16 yrs; range 22-81); 7) F/M ratio 16/16. In those referred for surgery, imaging studies didn't differentiate between IPAS and PNET. FNA (5/32 cases), all were false positive for PNET. Distal pancreatectomy and splenectomy were carried out in 60%, distal pancreatecomy in 40%. Conclusion: IPAS should be considered before surgery in PI, even when imaging or FNA are suggestive of PNET. Characteristic archiform splenic enhancement pattern on dynamic CT, imunohistichemical stain for CD-8, nuclear scan as Tc-99m, or contrast-enhanced sonography can be used for better preoperative evaluation. This may provide the definitive diagnosis of IPAS and thus avoid unnecessary major surgery. [ABSTRACT FROM AUTHOR]

Abstract Background Compromised physiological reserve, comorbidities, and the natural history of pancreatic cancer may deny pancreatic resection from elderly patients. We evaluated outcomes of elderly patients amenable to pancreatic surgery. Methods The medical records of all patients who underwent pancreatic resection at our institution (1995-2007) were retrospectively reviewed. Patient, tumor, and outcomes characteristics in elderly patients aged ≥ 70 years were compared to a younger cohort ( Results Of 460 patients who had surgery for pancreatic neoplasm, 166 (36%) aged ≥ 70y. Compared to patients < 70y (n = 294), elderly patients had more associated comorbidities; 72% vs. 43% (p = 0.01) and a higher rate of malignant pathologies; 73% vs. 59% (p = 0.002). Operative time and blood products consumption were comparable; however, elderly patients had more post-operative complications (41% vs. 29%; p = 0.01), longer hospital stay (26.2 vs. 19.7 days; p < 0.0001), and a higher incidence of peri-operative mortality (5.4% vs. 1.4%; p = 0.01). Multivariable analysis identified age ≥ 70y as an independent predictor of shorter disease-specific survival (DSS) among patients who had surgery for pancreatic adenocarcinoma (n = 224). Median DSS for patients aged ≥ 70y vs. < 70y were 15 months (SE: 1.6) vs. 20 months (SE: 3.4), respectively (p = 0.05). One, two, and 5-Y DSS rates for the cohort of elderly patients were 58%, 36% and 23%, respectively. Conclusions Properly selected elderly patients can undergo pancreatic resection with acceptable post-operative morbidity and mortality rates. Long term survival is achievable even in the presence of adenocarcinoma and therefore surgery should be seriously considered in these patients.

The intestinal epithelium is a polarized monolayer of cells, with an apical side facing the lumen and a basal side facing the blood stream. In mice, both proteins and mRNAs have been shown to exhibit global basal-apical polarization; however, polarization in the human intestine has not been systematically explored. Here, we employed laser-capture microdissection to isolate apical and basal epithelial segments from intestinal tissues of 8 individuals and performed RNA sequencing and mass-spectrometry proteomics. We find a substantial polarization of mRNA molecules that largely overlaps polarization patterns observed in mice. This mRNA polarization remains consistent across different zones of the intestinal villi and is generally correlated with the polarization of proteins. Our protein analysis exposes streamlined intracellular nutrient transport and processing and reveals that mitochondria and ribosomes are less polarized in humans compared to mice. Our study provides a resource for understanding human intestinal epithelial biology., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Novoselsky et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Liver regeneration following resection is a complex process relying on coordinated pathways and cell types in the remnant organ. Myeloid-Derived Suppressor Cells (MDSCs) have a role in liver regeneration-related angiogenesis but other roles they may play in this process remain to be elucidated. In this study, we sought to examine the effect of G-MDSCs on hepatocytes proliferation and immune modulation during liver regeneration. Global gene expression profiling of regenerating hepatocytes in mice with CD11b + Ly6G + MDSCs (G-MDSCs) depletion revealed disrupted transcriptional progression from day one to day two after major liver resection. Key genes and pathways related to hepatocyte proliferation and immune response were differentially expressed upon MDSC depletion. Hepatocytes cellularity increased when co-cultured with G-MDSCs, or treated with amphiregulin, which G-MDSCs upregulate during regeneration. Cytometry by time-of-flight (CyTOF) analysis of the intra-liver immune milieu upon MDSC depletion during regeneration demonstrated increased natural killer cell proportions, alongside changes in other immune cell populations. Taken together, these results provide evidence that MDSCs contribute to early liver regeneration by promoting hepatocyte proliferation and modulating the intra-liver immune response, and illuminate the multifaceted role of MDSCs in liver regeneration., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Kidney involvement in systemic sclerosis (SSc) is common with altered kidney function present in approximately half of the patients [1]. Scleroderma renal crisis (SRC), the most severe kidney manifestation, occurs in about 20% of patients with this autoimmune disorder [1]. SRC mainly affects patients with the diffuse cutaneous systemic sclerosis (dcSSc) subtype of the disease, and particularly in those who are seropositive to anti RNA polymerase III antibodies [2]. In recent years, the prevalence of SRC has decreased following the initiation of medication therapy with angiotensin-converting-enzyme inhibitors (ACE-i). Previously, SRC mortality rates were as high as 78%. Contemporary studies in the post-ACE-i era suggest lower rates, with mortality rate ranging from 30% to 36% [3]. Nevertheless, progression to end-stage renal disease (ESRD) is evident and may require renal replacement therapies (RRTs). While renal transplant rates in SSc have increased, they constitute a small proportion of SSc-SRC patients (3-8%) and SSc-ESRD patients (4-17%).

The mouse small intestine shows profound variability in gene expression along the crypt-villus axis 1,2 . Whether similar spatial heterogeneity exists in the adult human gut remains unclear. Here we use spatial transcriptomics, spatial proteomics and single-molecule fluorescence in situ hybridization to reconstruct a comprehensive spatial expression atlas of the adult human proximal small intestine. We describe zonated expression and cell type representation for epithelial, mesenchymal and immune cell types. We find that migrating enterocytes switch from lipid droplet assembly and iron uptake at the villus bottom to chylomicron biosynthesis and iron release at the tip. Villus tip cells are pro-immunogenic, recruiting γδ T cells and macrophages to the tip, in contrast to their immunosuppressive roles in mouse. We also show that the human small intestine contains abundant serrated and branched villi that are enriched at the tops of circular folds. Our study presents a detailed resource for understanding the biology of the adult human small intestine., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Incisional hernias (IH) are a significant postoperative complication with profound implications for patient morbidity and healthcare costs. The relationship between IH and perioperative factors in pancreatic surgery, with particular attention to preoperative biliary stents and pancreatic fistulas requires further exploration., Methods: This retrospective observational study examined adult patients who underwent open pancreatic surgeries via midline incision at a high-volume tertiary hepatopancreatobiliary center from January 2008 to December 2021. The study focused on IH incidence and associated risk factors, with particular attention to preoperative biliary stents and pancreatic fistulas., Results: In a cohort of 620 individuals undergoing pancreatic surgery, 351 had open surgery with at least one-year follow-up. Within a median follow-up of 794 days (IQR 1694-537), the overall incidence of IH was 17.38%. The highest frequency of IH was observed among patients who had a Pancreaticoduodenectomy (PD). Significant predictors for the development of IH within the entire study population in a multivariable analysis included perioperative biliary stenting (OR 2.05; 95% CI 1.06-3.96; p = 0.03), increased age at diagnosis (OR 2.05; 95% CI 1.06-3.96; p = 0.01), and BMI (OR 1.08; 95% CI 1.01-1.15; p = 0.01). In the subset of patients who underwent Pancreaticoduodenectomy (PD), although the presence of biliary stents was associated with a heightened occurrence of SSIs, it did not demonstrate a direct correlation with an increased incidence of incisional hernias (IH). The development of pancreatic fistulas did not show a significant correlation with IH in either the Distal Pancreatectomy with Splenectomy (DPS) or the PD patient groups., Conclusions: The study underscores a notable association between biliary stent placement and increased IH risk after PD, mediated by elevated SSI incidence. Pancreatic fistulas were not directly correlated with IH in the studied cohorts. Further research is necessary to validate these findings and guide clinical practice., (© 2024. The Author(s).)

Introduction: Recently, a Geriatric Surgery Unit (GSU) was established in the Sheba Medical Center. The Unit's aims include: professional assessment of surgical candidates, approval of the surgical plan by a multidisciplinary team discussion (MTD), and meeting the specific needs of the geriatric patient undergoing surgery., Methods: We describe the establishment of the GSU and preliminary results from the first year of its activity (January-December 2022). The GSU team consisted of a geriatric nurse practitioner (NP), a geriatric physician, surgeons, anesthesiologists and a physiotherapist. Inclusion criteria for GSU assessment/treatment were age>80 years or substantial baseline geriatric morbidity., Results: In 2022, 276 patients were treated by the GSU: 110 underwent elective comprehensive preoperative assessment in the NP clinic and the rest were assessed urgently/semi-electively during their hospitalization. One hundred and fifteen cases (median age 86 (65-98) years) were brought to MTD and considered for elective cholecystectomy (46.1%), colorectal procedures (16.5%), hernia repair (13.9%), hepatobiliary procedures (9.6%) or other surgeries (13.9%); of those, 49 patients (median age 86 (72-98) years) eventually proceeded to surgery, following which the median length of hospital stay (LOS) was 3.5 (1-60) days and the rate of postoperative complications was 46.7%. After discharge, the median duration of follow-up was 2.5 (0-18) months during which 4 patients died. Compared with geriatric patients who underwent cholecystectomy during 2021-2023 without MTD (n=39), in the cases discussed by the MTD, patients (n=17) had a shorter LOS (2.0±0.9 vs. 2.4±2.1 days), less 30-day Emergency Department referrals (12.5% vs. 28.2%) and less 30-day re-admissions (6.2% vs. 15.4%; all p≥0.3)., Conclusions: Geriatric surgical patients require a designated professional approach to meet their unique perioperative needs. The effect of GSUs on perioperative outcomes merits further prospective studies.

Introduction: In select clinical scenarios, advanced techniques for volume manipulation and vascular reconstruction are needed for complete hepatic tumor removal. These highly complex liver resections (HCLRs) entail a heightened risk of severe complications. Here, we describe the results of HCLR performed in a 3-year time period., Materials and Methods: We conducted a retrospective analysis encompassing patients who underwent hepatic resections between June 15, 2020, and June 15, 2023. HCLR was defined according to previously established criteria, and included associating liver partition and portal vein ligation for staged hepatectomy. The outcomes of HCLR were compared to all non-HCLR performed within the same time frame., Results: Among 167 hepatic resections, 26 were considered HCLR, and all were major resections. Five utilized total vascular exclusion, with venovenous bypass in three, and hypothermic liver perfusion in three. Five resections included vascular reconstructions, and one included hypothermic circulatory arrest for extraction of a tumor extending to the right atrium. Of the non-HCLR, 38 (26.9%) were major, and 49 (34.7%) were performed laparoscopically. The rates of overall major postoperative complications were comparable between those who underwent HCLR versus non-HCLR. HCLR was associated with increased rates of biliary complications, readmissions, and reoperation. However, no postoperative 90-day mortality was documented within patients that underwent HCLR compared to two in the non-HCLR group., Conclusions: In expert hands, HCLR can be performed with acceptable complication profile, akin to that of major non-HCLR. Those with questionable resectability should be referred to tertiary hepato-pancreato-biliary centers., (© 2024 Wiley Periodicals LLC.)

Background: Surgical treatment of complex perianal fistula is technically challenging, associated with risk of failure, and may require multiple procedures. In recent years, several biologic agents have been developed for permanently eradicating anal fistulous disease with variable success. In this study, the treatment is an autologous whole-blood product created from the patients' blood. It forms a provisional matrix that was found to be safe and effective in healing acute and chronic cutaneous wounds., Objective: The study aimed to assess the efficacy and safety of an autologous blood clot product as a treatment for transsphincteric perianal fistulas., Design: A prospective single-arm study., Settings: A single tertiary medical center., Patients: Patients with simple or complex transsphincteric fistulas confirmed by MRI were included in the study. Cause was either cryptoglandular or Crohn's disease related (in the absence of active luminal bowel disease)., Intervention: The outpatient procedure was performed under general anesthesia and consisted of: 1) physical debridement and cleansing of the fistula tract; 2) suture closure of the internal opening; and 3) instillation of the autologous blood clot product into the entire tract., Main Outcome Measures: Safety and efficacy at 6- and 12-months after surgery., Results: Fifty-three patients (77% men) with a median age of 42 (20-72) years were included in the study. Three patients withdrew consent, and 1 patient was lost to follow-up. At the time of this interim analysis, 49 and 33 patients completed the 6- and 12-month follow-up period. Thirty-four of the 49 patients achieved complete healing (69%) at 6 months, but 20 of the 33 patients (60%) achieved healing after 1 year. All patients who achieved healing at 6 months remained healed at the 1-year mark. In a subgroup analysis of patients with Crohn's disease, 7 of 9 patients completed 1-year follow-up, with 5 patients (71%) achieving clinical remission. No major side effects or postoperative complications were noted, but 2 adverse events occurred (admission for pain control and coronavirus 2019 infection)., Limitations: Noncomparative single-arm pilot study., Conclusions: Treatment with an autologous blood clot product in perianal fistular disease was found to be feasible and safe, with an acceptable healing rate in both cryptoglandular and Crohn's disease fistula-in-ano. Further comparative assessment is required to determine its potential role in the treatment paradigm of fistula-in-ano. See Video Abstract ., Brazo Para Evaluar La Seguridad Y Eficacia De Rdver, Un Cogulo De Sangre Autlogo, En El Tratamiento De La Fstula Anal: ANTECEDENTES:El tratamiento quirúrgico de la fístula perianal compleja es técnicamente desafiante, se asocia con riesgo de fracaso y puede requerir múltiples procedimientos. En los últimos años, se han desarrollado varios agentes biológicos con el fin de erradicar permanentemente la enfermedad fistulosa anal con éxito variable. El tratamiento RD2-Ver.02 es un producto de sangre total autólogo creado a partir de la sangre de los pacientes, que forma una matriz provisional que resultó segura y eficaz para curar heridas cutáneas agudas y crónicas.OBJETIVO:Evaluar la eficacia y seguridad de RD2-Ver.02 como tratamiento para las fístulas perianales transesfinterianas.DISEÑO:Un estudio prospectivo de un solo brazo.LUGARES:Un único centro médico terciario.PACIENTES:Se incluyeron en el estudio pacientes con fístulas transesfinterianas simples o complejas confirmadas mediante resonancia magnética. La etiología fue criptoglandular o relacionada con la enfermedad de Crohn (en ausencia de enfermedad intestinal luminal activa).INTERVENCIÓN:El procedimiento ambulatorio se realizó bajo anestesia general y consistió en: 1) desbridamiento físico y limpieza del trayecto fistuloso; 2) cierre con sutura de la abertura interna; y 3) instilación de RD2-Ver.02 en todo el tracto.PRINCIPALES MEDIDAS DE VALORACIÓN:Seguridad y eficacia a los 6 y 12 meses después de la cirugía.RESULTADOS:Se incluyeron en el estudio 53 pacientes (77% varones) con una mediana de edad de 42 (20-72) años. Tres pacientes retiraron su consentimiento y un paciente se perdió durante el seguimiento. En el momento de este análisis intermedio, 49 y 33 pacientes completaron el período de seguimiento de 6 y 12 meses, respectivamente. Treinta y cuatro (34) pacientes lograron una curación completa (69%) a los 6 meses, mientras que 20 de 33 pacientes (60%) lograron una curación después de un año. Todos los pacientes que lograron la curación a los 6 meses permanecieron curados al año. En un análisis de subgrupos de pacientes con enfermedad de Crohn, 7/9 pacientes completaron un seguimiento de un año y 5 pacientes (71%) alcanzaron la remisión clínica. No se observaron efectos secundarios importantes ni complicaciones postoperatorias, mientras que ocurrieron 2 eventos adversos (ingreso para control del dolor e infección por COVID-19).LIMITACIONES:Estudio piloto no comparativo de un solo brazo.CONCLUSIONES:Se encontró que el tratamiento con RD2-Ver.02 en la enfermedad fístula perianal es factible y seguro, con una tasa de curación aceptable tanto en la fístula criptoglandular como en la de Crohn en el ano. Se requiere una evaluación comparativa adicional para determinar su papel potencial en el paradigma de tratamiento de la fístula anal. (Pre-proofed version )., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Colon and Rectal Surgeons.)

Background: The value of platelet characteristics as a prognostic factor in patients with pancreatic adenocarcinoma (PDAC) remains unclear., Methods: We assessed the prognostic ability of post-splenectomy thrombocytosis in patients who underwent left pancreatectomy for PDAC. Perioperative platelet count ratio (PPR), defined as the ratio between the maximum platelet count during the first five days following surgery and the preoperative level, was assessed in relation to long-term outcomes in patients who underwent left pancreatectomy for PDAC between November 2008 and October 2022., Results: A comparative cohort of 245 patients who underwent pancreaticoduodenectomy for PDAC was also evaluated. The median PPR among 106 patients who underwent left pancreatectomy was 1.4 (IQR1.1, 1.8). Forty-six had a PPR ≥ 1.5 (median 1.9, IQR1.7, 2.4) and 60 had a PPR < 1.5 (median 1.2, IQR1.0, 1.3). Patients with a PPR ≥ 1.5 had increased median overall survival (OS) compared to patients with a PPR < 1.5 (40 months vs. 20 months, p < 0.001). In multivariate analysis, PPR < 1.5 remained a strong predictor of worse OS (HR 2.24, p = 0.008). Among patients who underwent pancreaticoduodenectomy, the median PPR was 1.1 (IQR1.0, 1.3), which was significantly lower compared to patients who underwent left pancreatectomy ( p > 0.001) and did not predict OS., Conclusion: PPR is a biomarker for OS after left pancreatectomy for PDAC. Further studies are warranted to consolidate these findings.

Background: Computerized tomography (CT) is an integral part of the follow-up and decision-making process in complicated acute appendicitis (AA) treated non-operatively. However, repeated CT scans are costly and cause radiation exposure. Ultrasound-tomographic image fusion is a novel tool that integrates CT images to an Ultrasound (US) machine, thus allowing accurate assessment of the healing process compared to CT on presentation. In this study, we aimed to assess the feasibility of US-CT fusion as part of the management of appendicitis., Materials and Methods: We retrospectively collected data of consecutive patients with complicated AA managed non-operatively and followed up with US Fusion for clinical decision-making. Patients demographics, clinical data, and follow-up outcomes were extracted and analyzed., Results: Overall, 19 patients were included. An index Fusion US was conducted in 13 patients (68.4%) during admission, while the rest were performed as part of an ambulatory follow-up. Nine patients (47.3%) had more than 1 US Fusion performed as part of their follow-up, and 3 patients underwent a third US Fusion. Eventually, 5 patients (26.3%) underwent elective interval appendectomy based on the outcomes of the US Fusion, due to a non-resolution of imaging findings and ongoing symptoms. In 10 patients (52.6%), there was no evidence of an abscess in the repeated US Fusion, while in 3 patients (15.8%), it significantly diminished to less than 1 cm in diameter., Conclusion: Ultrasound-tomographic image fusion is feasible and can play a significant role in the decision-making process for the management of complicated AA.

Introduction: The optimal strategy to reduce short-term readmission rates following colectomy remains unclear. Identifying possible risk factors can minimize the burden associated with surgical complications leading to readmissions. Materials and Methods: A retrospective review of all adult patients who underwent colectomies between January 2008 and December 2020 in a large tertiary medical center was conducted. Data were collected from patient's medical charts and analyzed. Results: Overall, 2547 patients were included in the study (53% females; mean age 68.3 years). The majority of patients (83%, n  = 2112) were operated in an elective setting, whereas 435 patients (17%) underwent emergency colonic resection. Overall, the 30-day readmission rate was 8.3% ( n  = 218) with an overall 30-day mortality rate of 1.65% ( n  = 42). Multivariable analysis of possible risk factors for 30-day readmission demonstrated that patient age (odds ratio [OR] 0.98; P  = .002), length of stay before surgery (OR 1.01; P  = .003), and blood transfusion rate during hospitalization (OR 2.09; P  < .001) were all independently associated with an increased risk. Laparoscopic colectomy (OR 0.53; P  = .001) was associated with a reduced risk for readmission. Multivariable analysis of risk factors for mortality showed that age (OR 1.10; P  < .001), cognitive decline (OR 12.35; P  < .001), diabetes (OR 1.00; P  = .004), and primary ostomy formation (OR 2.80; P  = .006) were all associated with higher mortality. Conclusion: Patient age, history of cognitive decline, and blood transfusion along with a longer hospital stay were all correlated with an increased risk for 30-day patient readmission following colectomy.

Background: CA125 is a widely used serum marker for epithelial ovarian cancer which levels may also rise in benign conditions involving peritoneal irritation. We aimed to determine if serum CA125 levels can predict disease severity in patients presenting with acute diverticulitis., Methods: We conducted a single-center prospective observational study, analyzing CA125 serum levels in patients who presented to the emergency department with computerized tomography-proven acute left-sided colonic diverticulitis. Univariate, multivariate, and receiver operating characteristic (ROC) analyses were used to correlate CA125 serum levels at time of initial presentation with the primary outcome (complicated diverticulitis) and secondary clinical outcomes (need for urgent intervention, length of hospital stay (LOS) and readmission rates)., Results: One hundred and fifty-one patients were enrolled between January 2018 and July 2020 (66.9% females, median age 61 years). Twenty-five patients (16.5%) presented with complicated diverticulitis. CA125 levels were significantly higher among patients with complicated (median: 16 (7-159) u/ml) vs. uncomplicated (8 (3-39) u/ml) diverticulitis (p < 0.001) and also correlated with the Hinchey severity class (p < 0.001). Higher CA125 levels upon admission were associated with a longer LOS and a greater chance to undergo invasive procedure during the hospitalization. In patients with a measurable intra-abdominal abscess (n = 24), CA125 levels were correlated with the size of the abscess (Spearman's r = 0.46, p = 0.02). On ROC analysis to predict complicated diverticulitis, the area under the curve (AUC) for CA125 (AUC = 0.82) was bigger than for the leukocyte count (AUC = 0.53), body temperature (AUC = 0.59), and neutrophil-lymphocyte ratio (AUC = 0.70) - all p values < 0.05. On multivariate analysis of factors available at presentation, CA125 was found to be the only independent predictor of complicated diverticulitis (OR 1.12 (95% CI 1.06-1.19), p < 0.001)., Conclusions: The results from this feasibility study suggest that CA125 may accurately discriminate between simple and complicated diverticulitis, meriting further prospective investigation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The background of this study is to evaluate the impact of the assistant surgeon's in robotic-assisted proctectomy (RAP) on perioperative outcomes. A retrospective analysis of all patients who underwent RAP for rectal adenocarcinoma between 2011 and 2020 was conducted. Patient cohort was divided into three groups based on the assistant surgeon's training level: post-graduate years (PGY) 1-3 surgical residents (Group 1), PGY 4-5 surgical residents (Group 2), and board-certified general surgeons (Group 3). Overall, 175 patients were included in the study: 29 patients (17%) in Group 1, 84 (48%) in Group 2, and 62 (35%) in Group 3. The median tumor distance from the anal verge was 8 cm in all groups (p = 0.73). The median operative time was similar across all groups: 290, 291, and 281 min in Groups 1, 2, and 3, respectively (p = 0.69). In a multivariable analysis, the lack of association between assistant training level and procedure time maintained when adjusting for the year of operation (p = 0.84). Patients operated with junior residents as assistant surgeons (Group 1) had a more postoperative complications (p = 0.01) and a slightly longer hospital length of stay [7 days, interquartile range (IQR) 3], compared to those operated by assistant surgeons that were senior residents or attendings (6 IQR 2.5, and 6 IQR 2 in Groups 2 and 3, respectively; p = 0.02). Conversion rates (p = 0.12), intraoperative complications (p = 0.39), major postoperative complications (Clavien-Dindo ≥ 3; p = 0.32), 30-day readmission (p = 0.45), and mortality (p = 0.99) were similar between the groups. Robotic-assisted proctectomy performed with the assistance of a junior resident was found to be correlated with worse postoperative outcomes compared to more experienced assistants. No difference was seen in intraoperative outcomes., (© 2022. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Management of pilonidal sinus (PNS) disease has changed notably in the past decade, with the introduction of novel surgical techniques and technological innovation. In this study, we summarized our initial experience with sinus laser-assisted closure (SiLaC) of pilonidal disease. Methods: A retrospective analysis of a prospective database of all patients who underwent minimally invasive surgery combined with laser therapy for PNS between September 2018 and December 2020 was performed. Patients' demographics, clinical and perioperative data, as well postoperative outcomes were recorded and analyzed. Results: A total of 92 patients (86 males, 93.4%) underwent SiLaC surgery for pilonidal sinus disease during the study period. Patients' median age was 22 (range 16-62 years), and 60.8% of them previously underwent abscess drainage due to PNS. SiLaC was performed under local anesthesia in 85.7% of cases (78 patients) with a median energy of 1081 J (range 13-5035 J). One patient was lost to follow-up, leaving 91 patients for final analysis. The primary outcome was complete healing rate, standing at 81.3% (74/91 patients). In 8 patients (8.8%), there was minor incomplete healing that did not require reintervention. Recurrent/nonhealing disease was seen in 9 patients (9.9%), requiring reoperation in 7 patients (8.4%). Of those, 4 patients underwent repeat SiLaC and 3 patients underwent wide excision. Analysis of risk factors for PNS recurrence demonstrated that general anesthesia ( P  = .02) was associated with increased risk for recurrence along with a trend for increased risk in patients with significant hairiness ( P  = .078). No differences were seen in age ( P  = .621), gender ( P  = .475), median sinus length ( P  = .397), and energy used ( P  = .904). Conclusion: Primary healing rate after SiLaC surgery for chronic PNS was >80% in our series. Ten percent of patients did not achieve complete healing but did not require surgery due to lack of symptoms.

Laser Hemorrhoidoplasty (LHP) is a novel therapeutic option for hemorrhoids. In this study, we aimed to evaluate the post-operative outcomes of patients undergoing LHP surgery based on hemorrhoid grade. A retrospective analysis of a prospective database of all patients who underwent LHP surgery between September 2018 and October 2021 was performed. Patients' demographics, clinical perioperative data, and post-operative outcomes were recorded and analyzed. One hundred and sixty two patients that underwent laser hemorrhoidoplasty (LHP) were included. Median operative time was 18 min (range 8-38). Median total energy applied was 850 Joule (450-1242). Complete remission of symptoms following surgery was reported by 134 patients (82.7%), while 21 patients (13%) reported partial symptomatic relief. Nineteen patients (11.7%) presented with post-operative complications, and 11 patients (6.75%) were re-admitted following surgery. Post-operative complication rate was significantly higher in patients with grade 4 hemorrhoids compared to grades 3 or 2, due to a higher rate of post-operative bleeding (31.6% vs. 6.5% and 6.7%, respectively; p = 0.004). Furthermore, post-operative readmission rate (26.3% vs. 5.4% and 6.2%; p = 0.01) and reoperation rate were also significantly higher in grade IV hemorrhoids (21.1% vs. 2.2% and 0%; p = 0.001). Multivariate analysis found that grade IV hemorrhoids had a significantly higher risk for post-operative bleeding (OR 6.98, 95% CI 1.68-28.7; p = 0.006), 30-day readmission (OR 5.82, 95% CI 1.27-25.1; p = 0.018), and hemorrhoids recurrence (OR 11.4, 95% CI 1.18-116; p = 0.028). LHP is an effective treatment for hemorrhoids grades II-IV, but carries significant risk for bleeding and re-intervention in patients with grade IV hemorrhoids., (© 2023. Italian Society of Surgery (SIC).)

Purpose: Ileostomy is associated with various complications, often necessitating rehospitalization. High-output ileostomy is common and may lead to acute kidney injury (AKI). Here we describe the temporal pattern of readmission with AKI following ileostomy formation and identify risk factors., Methods: Patients that underwent formation of ileostomy between 2008 and 2021 were included in this study. Readmission with AKI with high output ileostomy was defined as readmission with serum creatinine > 1.5-fold compared to the level at discharge or latest baseline (at least stage-1 AKI according to Kidney Disease: Improving Global Outcome (KDIGO) criteria), accompanied by ileostomy output > 1000 ml in 24 h. Patient characteristics and perioperative course were assessed to identify predictors for readmission with AKI., Results: Of 1191 patients who underwent ileostomy, 198 (16.6%) were readmitted with a high output stoma and AKI. The mean time to readmission with AKI was 98.97 ± 156.36 days. Eighty-six patients (43.4%) had early readmission (within 30 days), and 66 (33%) were readmitted after more than 90 days. Over 90% of patients had more than one readmission, and 110 patients (55%) had 5 or more. Patient-related predictors for readmission with AKI were age > 65, body mass index > 30 kg/m 2 , and hypertension. Factors related to the postoperative course were AKI with creatinine > 2 mg/dl, postoperative hemoglobin < 8 g/dl or blood transfusion, albumin < 20 g/dl, high output stoma and need for loperamide, and length of hospital stay > 20 days. Factors related to early versus late readmissions and multiple readmissions were also analyzed., Conclusions: Readmission with AKI following ileostomy formation is a consequential event with distinct risk factors. Acknowledging these risk factors is the foundation for designing interventions aiming to reduce frequency of AKI readmissions in predisposed patient populations., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Intraoperative ultrasonography (IOUS) of the liver is a crucial adjunct in every liver resection and may significantly impact intraoperative surgical decisions. However, IOUS is highly operator dependent and has a steep learning curve. We describe the design and assessment of an artificial intelligence (AI) system to identify focal liver lesions in IOUS., Methods: IOUS images were collected during liver resections performed between November 2020 and November 2021. The images were labeled by radiologists and surgeons as normal liver tissue versus images that contain liver lesions. A convolutional neural network (CNN) was trained and tested to classify images based on the labeling. Algorithm performance was tested in terms of area under the curves (AUCs), accuracy, sensitivity, specificity, F1 score, positive predictive value, and negative predictive value., Results: Overall, the dataset included 5043 IOUS images from 16 patients. Of these, 2576 were labeled as normal liver tissue and 2467 as containing focal liver lesions. Training and testing image sets were taken from different patients. Network performance area under the curve (AUC) was 80.2 ± 2.9%, and the overall classification accuracy was 74.6% ± 3.1%. For maximal sensitivity of 99%, the classification specificity is 36.4 ± 9.4%., Conclusions: This study provides for the first time a proof of concept for the use of AI in IOUS and show that high accuracy can be achieved. Further studies using high volume data are warranted to increase accuracy and differentiate between lesion types., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Most Crohn's Disease (CD) patients will require surgical intervention over their lifetime, with considerably high rates of post-operative complications. Risk stratification with reliable prognostic tools may facilitate clinical decision making in these patients. Blood cell interaction based inflammatory markers have proven useful in predicting patient outcomes in oncological and benign diseases. The aim of this study was to investigate their prognostic value in CD patients undergoing surgery., Methods: A retrospective single institution study of CD patients who underwent surgery between the years 2008 and 2019 was conducted. Data were collected from medical records and analysed for association of Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Lymphocyte-to-Monocyte Ratio (LMR) and the modified Systemic Inflammatory Score (mSIS) with post-operative outcomes., Results: A total of 81 patients were included in the analysis. Half were females; mean age was 36 ± 15.54 years. Fifty seven percent (n = 46) were operated in expedited settings, with 23.5% developing post-operative complications. In elective patients, higher pre-operative NLR (P = 0.029) and PLR (P = 0.034) were associated with major post-operative complications, higher NLR (P = 0.029) and PLR (P = 0.034) were associated with re-operation and higher PLR correlated with Clavien-Dindo score (P = 0.032). In patients operated in expedited operations, higher pre-operative NLR (P = 0.021) and lower pre-operative LMR (P = 0.018) were associated with thromboembolic events and higher mSIS was associated with major post-operative complications (P = 0.032)., Conclusions: Blood cell interaction based inflammatory markers confer an association with post-operative complications in CD patients undergoing surgery. These indices may facilitate patient selection and optimization when considering the risks and benefits of surgical interventions., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis. In many occasions, several attempts of ERCP are performed until failure is declared and surgical treatment is applied, in many times following procedure-related complications. We present the results of surgical management of patients with choledocholithiasis following repeated failures of ERCP due to impaction of multiple large stones., Methods: Patients that underwent surgical treatment for choledocholithiasis following repeated ERCP attempts between January 2006 and December 2018 were retrospectively assessed. Post-ERCP complications were evaluated and the surgical approach, technique, and outcomes were assessed., Results: One hundred and two patients were operated on for choledocholithiasis following repeated failed ERCP. All the patients had at least 2 failed attempts (mean = 3.2 ± 1.7), and 25 (23.5%) suffered major ERCP-related complications. Following choledochotomy and stone extraction, bilioenteric anastomosis was done in the vast majority of patients (90.2%), most commonly choledochoduodenostomy (62%). Thirty-eight (37%) patients had minimally invasive procedure (laparoscopic n = 26, robotic assisted n = 12). Major post-operative complications (Clavien-Dindo ≥ 3) occurred in 24 patients (23.5%). Nine patients (8.8%) were re-operated and 10 (9.8%) were readmitted within 30 days from surgery. Three patients died within 30 days from surgery. Older patients had significantly more ERCP attempts and suffered higher post-operative mortality. During a median follow-up of 70 months, the only biliary complication was an anastomotic stricture in one patient., Conclusion: Surgery for CBDS after failure of ERCP is safe and provides a highly effective long-term solution., (© 2022. The Society for Surgery of the Alimentary Tract.)

Background: Histologic confirmation before pancreaticoduodenectomy (PD) for suspected pancreatic cancer is often performed. We assessed the yield of preoperative biopsy in these patients considering the associated complications., Methods: We retrospectively evaluated 216 patients that underwent PD for suspected carcinoma (CA) between 2012 and 2018. Post procedure complications and delay in surgery were assessed, as well as the postoperative diagnosis in relation to preoperative parameters., Results: Preoperative biopsy was performed in 142 patients (65.7%). Pathologic findings suggestive of CA were found in 106 (74.6%), while benign histology was found in 23 (16.1%), and non-diagnostic findings in 12 (8.4%). Seventy-four patients (34.3%) were operated without a preoperative biopsy. The time from diagnosis to surgery was significantly prolonged in those that underwent biopsy compared to patients that were taken straight to surgery (40±14 versus 18±15 days, P<0.001), and 18 patients (12.6%) suffered from clinically significant post procedure complications. Patients with a preoperative biopsy suggestive of CA, and those that were operated without a preoperative histologic confirmation had comparable rates of CA as a final pathological diagnosis (95.2% and 94.5%, respectively). Nevertheless, in patients with a benign or a non-diagnostic biopsy, the rates of pathologic diagnosis of CA were 69.6% and 73.6% respectively. Elevated levels of CA19-9 and a positive preoperative biopsy were associated with a final pathology of CA., Conclusions: Preoperative histology is not uniformly required in patients with suspected pancreatic cancer. If preoperative biopsy is performed, benign histology does not rule out cancer but warrants additional evaluation prior to surgery.

Background and Aims: While biopsy is the gold standard for liver fibrosis staging, it poses significant risks. Noninvasive assessment of liver fibrosis is a growing field. Recently, deep learning (DL) technology has revolutionized medical image analysis. This technology has the potential to enhance noninvasive fibrosis assessment. We systematically examined the application of DL in noninvasive liver fibrosis imaging., Methods: Embase, MEDLINE, Web of Science, and IEEE Xplore databases were used to identify studies that reported on the accuracy of DL for classification of liver fibrosis on noninvasive imaging. The search keywords were "liver or hepatic," "fibrosis or cirrhosis," and "neural or DL networks." Risk of bias and applicability were evaluated using the QUADAS-2 tool., Results: Sixteen studies were retrieved. Imaging modalities included ultrasound (n = 10), computed tomography (n = 3), and magnetic resonance imaging (n = 3). The studies analyzed a total of 40 405 radiological images from 15 853 patients. All but two of the studies were retrospective. In most studies the "ground truth" reference was the METAVIR score for pathological staging (n = 9.56%). The majority of the studies reported an accuracy >85% when compared to histopathology. Fourteen studies (87.5%) had a high risk of bias and concerns regarding applicability., Conclusions: Deep learning has the potential to play an emerging role in liver fibrosis classification. Yet, it is still limited by a relatively small number of retrospective studies. Clinicians should facilitate the use of this technology by sharing databases and standardized reports. This may optimize the noninvasive evaluation of liver fibrosis on a large scale., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Numerous surgical approaches and hemostatic techniques are used and have been described when operating on the traumatized liver. Despite a substantial decline in operative liver trauma, there still remains a debate on the optimal surgical approach, and goals, during the initial trauma laparotomy. Hepatic resection during the first operation, including the damage control settings, is advocated and practiced in only a select few institutions and remains highly controversial. Here, we describe our success with hepatic resection, repair, and/or hepatic vascular repair, during the trauma laparotomy with our emphasis on the collaboration between the trauma and hepatobiliary surgical teams., Case Series: From 207 patients with liver injuries during the study period, 7 patients had definitive liver resection or repair during the initial trauma laparotomy. One had hepatic tissue repair, 1 had hepatic vein repair, and 5 had liver resections. All the operations involved a hepatobiliary surgeon together with the trauma team. There were no fatalities in the liver operation group, no sepsis, or need for emergent angiography because of hemorrhage. Four patients needed endoscopic retrograde cholangiopancreatography (ERCP) and stenting because of biliary leak. Three patients were discharged home and 4 to rehabilitation., Discussion: Hepatic resection, and/or definitive hepatic repair, may be safe and beneficial to the patients during the initial operation even in a damage control setting when the patients' overall condition allows. We emphasize the benefit of collaboration with experienced and trained liver surgery, especially in lower volume trauma centers. ERCP is commonly needed for postoperative biliary leak and should be readily utilized.

Negative endoscopic retrograde cholangiopancreatography (ERCP) for suspected common bile duct stones (CBDS) may be associated with significant morbidity and should be avoided. Between 2010 and 2018, 85 patients who have undergone negative ERCP for suspected CBDS were retrospectively evaluated and compared with 318 patients with positive findings. Predictors for negative ERCP were assessed. Patients with negative ERCP were younger; had increased levels of serum amylase, alanine transaminase, and lactate dehydrogenase; and increased hemoglobin. Even though preprocedure computed tomography (CT) or ultrasonography demonstrating CBDS were highly predictive of positive findings on ERCP, of the 212 patients with CBDS on computed tomography or ultrasonography, 17 (8%) eventually had a negative ERCP, suggesting spontaneous stone passage. An increased serum amylase level was the only predictor for negative ERCP in multivariate analysis, including in patients with preprocedure CBDS on imaging. The data suggest that assessing serum amylase may assist in avoiding unnecessary examinations., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Over the years, the silastic ring vertical gastroplasty (SRVG) has shown poor long-term outcomes with both weight regain and complications. Therefore, most bariatric surgeons have been presented with the need to perform a successful and safe conversion procedure. Yet the preferred and recommended conversion surgery regarding weight loss, comorbidity improvement, and postoperative complications remains under debate., Objective: The aim of this study is to compare the outcomes of conversion from SRVG with either Roux-en-Y gastric bypass (RYGBP) or one anastomosis gastric bypass (OAGB)., Materials and Methods: A retrospective study was conducted from our bariatric surgery units' database. We reviewed the files of patients who underwent either a RYGBP or OAGB after a previous SRVG. Demographics, obesity-related comorbidities, BMI before and after the procedure, postoperative complications, and length of hospital stay were analyzed., Results: Between May 2008 and August 2018, fifty-four patients underwent conversion from a failed SRVG. Twenty-one patients underwent conversion to OAGB (39%), and thirty-three patients underwent conversion to RYGBP (61%). Major complications were reported in 9.5% of the OAGB group and 15.1% of the RYGBP group. At a mean follow-up of 28 months, the OAGB group achieved a 78.5% excess BMI loss compared with 57.6% in the RYGBP group (p = 0.137). One patient (4.7%) of the OGBP group and 5 (15.1%) of the RYGBP group needed reoperations due to complications (p = 0.224)., Conclusion: The OGBP is gaining popularity and evidence as an effective and safe procedure. Here we show the successful utilization of the OGBP, when compared with RYGBP, as a revisional procedure after SRVG.

Introduction: Accumulation of plasma mitochondrial DNA (mtDNA) following severe trauma has been shown to correlate with the development of systemic inflammatory response syndrome (SIRS) and may predict mortality. Our objective was to investigate the relationship between levels of circulatory mtDNA following pancreaticoduodenectomy (PD) and the postoperative course., Methods: Levels of plasma mtDNA were assessed by real-time PCR of the mitochondrial genes ND1 and COX3 in 23 consecutive patients who underwent PD 1 day prior to surgery, within 8 h after surgery, and on postoperative day (POD)1 and POD5. The abundance of mtDNA was assessed relative to preoperative levels and in relation to parameters reflecting the postoperative clinical course., Results: When pooled for all patients, the circulating mtDNA levels were significantly increased after surgery. However, while a significant (at least >2-fold and up to >20-fold) rise was noted in 11 patients, no change in mtDNA levels was noted in the other 12 following surgery. Postoperative rise in circulating mtDNA was associated with an increased rate of postoperative fever until day 5, decreased hemoglobin and albumin levels, and increased white blood cell counts. These patients also suffered from increased rates of delayed gastric emptying. No significant differences were demonstrated in other postoperative parameters., Conclusion: Circulating mtDNA surge is associated with an inflammatory response following PD and may potentially be used as an early marker for postoperative course. Studies of larger patient cohorts are warranted., (© 2021 The Author(s) Published by S. Karger AG, Basel.)

Background: Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons., Methods: In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds., Results: Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training., Conclusions: Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.

Background: Neoadjuvant FOLFIRINOX is a standard-of-care treatment for BRPC patients. Patients with gBRCAm who have demonstrated improved response to platinum-based chemotherapy may have impaired homologous repair deficiency. This study aimed to describe the pathologic complete response rate and long-term survival for patients with germline BRCA1 or BRCA2 mutation (gBRCAm) and borderline resectable pancreatic cancer (BRPC) treated with neoadjuvant FOLFIRINOX., Methods: A dual-center retrospective analysis was performed. Patients who had BRPC treated with neoadjuvant FOLFIRINOX followed by curative resection were identified from clinical databases. Pathologic complete response was defined as no viable tumor cells present in the specimen. Common founder Jewish germline BRCA1 or BRCA2 mutation was determined for available patients., Results: The 61 BRPC patients in this study underwent resection after neoadjuvant FOLFIRINOX. Analysis of BRCA mutation was performed for 39 patients, and 9 patients were found to be BRCA2 germline mutation carriers. The pathologic complete response rate was 44.4% for the gBRCAm patients and 10% for the BRCA non-carriers (p = 0.009). The median disease-free survival was not reached for the gBRCAm patients and was 7 months for the BRCA non-carriers (p = 0.03). The median overall survival was not reached for the gBRCAm patients and was 32 months for the BRCA non-carriers (p = 0.2). After a mean follow-up period of 33.7 months, all eight patients with pathologic complete response were disease-free., Conclusions: The study showed that gBRCAm patients with BRPC have an increased chance for pathologic complete response and prolonged survival after neoadjuvant FOLFIRINOX. The results support the benefit of exposing gBRCAm patients to platinum-based chemotherapy early in the course of the disease. Neoadjuvant FOLFIRINOX should be considered for BRCA carriers who have resectable pancreatic cancer.

Background: Recent data demonstrates that laparoscopic adjustable gastric banding (LAGB) is found to be associated with high rates of weight loss failure and long-term complications. Therefore, the search for the optimal revisional bariatric procedure is ongoing., Objective: We aim to assess the safety and efficacy of converting a failed LAGB to laparoscopic one anastomosis gastric bypass (OAGB) as a revisional procedure., Setting: Large, metropolitan, tertiary, university hospital., Methods: Retrospective review of patients who underwent OAGB after LAGB.Demographics, comorbidities, BMI before and after the procedure, complications, and length of stay were documented., Results: Fifty-seven patients underwent OAGB after LAGB. For 41 patients, the band was removed, and an OAGB was performed in a single procedure (71.9%), and 96.5% of the cases were completed laparoscopically. Postoperative complications occurred in 9 patients (15.7%), including one mortality. Average BMI decreased from 42.8 ± 7.0 to 31.3 ± 5.2 kg/m 2 at least 1 year after surgery, representing a mean %EWL of 64.5%. There was no statistical difference in complication rates between the 1-stage and 2-stage approach., Conclusions: Conversion of a failed LAGB to OAGB is effective but carries higher complication rates. Randomized controlled studies comparing different procedures are necessary to further clarify the optimal revisional bariatric operation.