Machine Learning Model Validated to Predict Outcomes of Liver Transplantation Recipients with Hepatitis C: The Romanian National Transplant Agency Cohort Experience.

BACKGROUND AND OBJECTIVES: In the early period after liver transplantation, patients are exposed to a high rate of complications and several scores are currently available to predict adverse postoperative outcomes. However, an ideal, universally accepted and validated score to predict adverse events in liver transplant recipients with hepatitis C is lacking. Therefore, we aimed to establish and validate a machine learning (ML) model to predict short-term outcomes of hepatitis C patients who underwent liver transplantation. MATERIALS AND METHODS: We conducted a retrospective observational two-center cohort study involving hepatitis C patients who underwent liver transplantation. Based on clinical and laboratory parameters, the dataset was used to train a deep-learning model for predicting short-term postoperative complications (within one month following liver transplantation). Adverse events prediction in the postoperative setting was the primary study outcome. RESULTS: A total of 90 liver transplant recipients with hepatitis C were enrolled in the present study, 80 patients in the training cohort and ten in the validation cohort, respectively. The age range of the participants was 12-68 years, 51 (56,7%) were male, and 39 (43.3%) were female. Throughout the 85 training epochs, the model achieved a very good performance, with the accuracy ranging between 99.76% and 100%. After testing the model on the validation set, the deep-learning classifier confirmed the performance in predicting postoperative complications, achieving an accuracy of 100% on unseen data. CONCLUSIONS: We successfully developed a ML model to predict postoperative complications following liver transplantation in hepatitis C patients. The model demonstrated an excellent performance for accurate adverse event prediction. Consequently, the present study constitutes the foundation for careful and non-invasive identification of high-risk patients who might benefit from a more intensive postoperative monitoring strategy.

Does the Overall Survival of the Resectable Periampullary Carcinomas Correlate with High Expression of p53 and ki67?

Introduction: Periampullary carcinomas represent a group of tumors that develop in a complex area, implying different anatomical structures. The most common histological type of periampullary carcinomas is the adenocarcinoma. The pancreatic type of periampullary adenocarcinomas has the worst prognosis. Immunohistochemical markers, such as ki-67 and p53, can be used in predicting survival. Material and method: we selected the patients with periampullary adenocarcinomas, intestinal or biliopancreatic type, with resectable tumors, and we performed immunohistochemical stains for ki-67 and p53 markers. The overall survival was analyzed according to the expression of immunohistochemical markers, TNM staging, tumor grade and perineural invasion. Results: Sixty-seven patients were included in the study. The median overall survival for the whole cohort was 12 months, with a 2-year survival rate of 25%. High rate of tumor proliferation (ki67 more than 80%) was significantly associated with shorter overall survival (median survival 3 months compared with 17 months for the group with ki67 index less than 80%). A high expression of p53 protein has been associated with low overall survival. The low survival was associated with poorly differentiated tumor grade and lymph node status. Conclusion: Both immunohistochemical expression of ki67 and p53 can be used as prognostic and predictive factors for overall survival of patients with resectable periampullary adenocarcinomas.

Proposal of a Preoperative CT-Based Score to Predict the Risk of Clinically Relevant Pancreatic Fistula after Cephalic Pancreatoduodenectomy.

Background and Objectives: Postoperative pancreatic fistula after cephalic pancreatoduodenectomy (CPD) is still the leading cause of postoperative morbidity, entailing long hospital stay and costs or even death. The aim of this study was to propose the use of morphologic parameters based on a preoperative multisequence computer tomography (CT) scan in predicting the clinically relevant postoperative pancreatic fistula (CRPF) and a risk score based on a multiple regression analysis. Materials and Methods: For 78 consecutive patients with CPD, we measured the following parameters on the preoperative CT scans: the density of the pancreas on the unenhanced, arterial, portal and delayed phases; the unenhanced density of the liver; the caliber of the main pancreatic duct (MPD); the preoperatively estimated pancreatic remnant volume (ERPV) and the total pancreatic volume. We assessed the correlation of the parameters with the clinically relevant pancreatic fistula using a univariate analysis and formulated a score using the strongest correlated parameters; the validity of the score was appreciated using logistic regression models and an ROC analysis. Results: When comparing the CRPF group (28.2%) to the non-CRPF group, we found significant differences of the values of unenhanced pancreatic density (UPD) (44.09 ± 6.8 HU vs. 50.4 ± 6.31 HU, p = 0.008), delayed density of the pancreas (48.67 ± 18.05 HU vs. 61.28 ± 16.55, p = 0.045), unenhanced density of the liver (UDL) (44.09 ± 6.8 HU vs. 50.54 ± 6.31 HU, p = 0.008), MPD (0.93 ± 0.35 mm vs. 3.14 ± 2.95 mm, p = 0.02) and ERPV (46.37 ± 10.39 cm3 vs. 34.87 ± 12.35 cm3, p = 0.01). Based on the odds ratio from the multiple regression analysis and after calculating the optimum cut-off values of the variables, we proposed two scores that both used the MPD and the ERPV and differing in the third variable, either including the UPD or the UDL, producing values for the area under the receiver operating characteristic curve (AUC) of 0.846 (95% CI 0.694-0.941) and 0.774 (95% CI 0.599-0.850), respectively. Conclusions: A preoperative CT scan can be a useful tool in predicting the risk of clinically relevant pancreatic fistula.

The Use of Mucolytic Agent in Percutaneous Drainage of Liver Abscess: A Case-Series Analysis.

Background: Liver abscess is a scarce but potentially fatal suppurative process. There is a general tendency for minimally invasive treatment, such as broad-spectrum antibiotherapy and percutaneous drainage. Multiloculated, multiple or incompletely liquefied abscesses often limit the efficacy of percutaneous drainage. This study aims to assess the effectiveness of percutaneous drainage and intracavitary instillation of a mucolytic agent for liver abscesses. Material and method: From our department database, we have identified patients with liver abscess admitted during the period 2015 - 2020, treated by ultrasound-guided percutaneous drainage and intracavitary instillation of mucolytic agent. Data regarding imaging appearance, drainage technique, inflammatory markers and clinical course were assessed. Results: Twenty-one patients with multiloculated liver abscesses, sized 8 to 17 cm, were percutaneously drained, with local anaesthesia, under ultrasound guidance. The bacteriological exam of the aspirate showed bacterial infection in 19 cases, mostly Klebsiella pneumoniae, and 2 fungal infections. Acetylcysteine in dilution 1: 1 with saline was instilled daily on the 12F or 14 F drainage catheter. Clinical and radiological resolution was achieved within 14 to 29 days. Two cases required supplementary drainage of a non-communicating residual cavity. There were no complications, periprocedural deaths or relapse at 3 months follow-up. Conclusions: Percutaneous drainage is effective even in the management of multiloculated liver abscesses, facilitated by the use of intracavitary mucolytic agent.

DLT Based Authentication Framework for Industrial IoT Devices.

The latest technological progress in the industrial sector has led to a paradigm shift in manufacturing efficiency and operational cost reduction. More often than not, this cost reduction comes at the price of dismissing information security, especially when multiple stakeholders are involved and the complexity increases. As a further matter, most of the legacy systems and smart factoring processes lack a security by design approach, making them highly vulnerable to cyber-attacks. Taking into consideration the aforementioned issues, we propose an architectural framework for Industrial Internet of Things (IIoT) that provides authentication and guaranteed integrity. Our proposal properly addresses the security by design principle while combining some of the emerging technologies like Secure Multi-Party Computation (SMPC) for grounded policy rules and Distributed Ledger Technology (DLT) for an immutable and transparent registry.

Laparoscopic Cholecystectomy in Cirrhotic Patients.

Laparoscopic cholecystectomy is the gold standard procedure in patients with cirrhosis and symptomatic gallbladder disease or acute cholecystitis. In this retrospective study we evaluated laparoscopic cholecystectomy in patients with cirrhosis based on Child-Pugh score as a predictor of morbidity. In the First Surgical Clinic of Iasi, from 01 jan 2010 to 31 jan 2020, we performed 111 laparoscopic cholecystectomies in Child-Pugh A, B, and C cirrhotic patients. Intraoperative difficulty (grade 3 Cuschieri) was experienced in 32 patients (28.8%). Highly vascular sub hepatic adherences have been reported in a quarter of all patients. Intraoperative incidents were more frequent 27 (24.3%) compared to laparoscopic cholecystectomy performed in other patient groups. The conversion rate to open cholecystectomy was 6.3% (7 cases). Mean operative time was 84 min. Mean duration of hospitalization stay was 4.7 days. The morbidity rate was 16.2% of patients and included bleeding, intraabdominal fluid collections and wound complications more common in patients with Child-Pugh Cirrhosis B and C. The results are dependent of the perioperative management of the liver function.

The Pancreatic Endocrine Tumors - Experience of First Surgical Clinic Iasi.

Pancreatic neuroendocrine tumors (PNETs) are rare and characterized by widely variable clinical presentation and often challenging surgical management. Methods: Retrospective study conducted during the last 15 years at the First Surgical Clinic of the Iasi St Spiridon University Hospital, and which included all the patients diagnosed with pancreatic endocrine tumors by immunohistochemistry. Results: There were 26 cases diagnosed with PNET. The male/female ratios was 7/19 and mean age 41.93 +- 2.48 years (range 20-79 years). Of the PNET cases 13 were insulinomas, 5 gastrinomas, 2 gastrinomas associated with other endocrine neoplasms (Wermer syndrome), 5 non-functional endocrine pancreatic tumors and 1 ACTHoma. Clinical manifestations depended on tumor type: hypoglycemia and Whipple triad for insulinoma, Zollinger Ellison syndrome and complicated peptic ulcer (hemorrhage, perforation) for gastrinoma, Cushing syndrome for ACTHoma. Biological diagnosis included biological markers (e.g. insulin, gastrin and cortisol). Tumor site and size at diagnosis were determined by ultrasound, CT-scan, angiography, PETscan, octreoscan and intraoperative ultrasound. Surgical procedures for PNET insulinomas were: tumor resection - 6 cases; left splenopancreatectomy - 3 cases; left spleen-preserving pancreatectomy - 2 cases; pancreaticoduodenectomy - 2 cases. We also present 4 cases of gastrinoma with multiple ulcers and multiple surgical interventions for hemorrhage and perforation with peritonitis. The two patients with Wermer syndrome also had ulcers complicated with hemorrhage and peritonitis and parathyroid adenoma. Nonfunctional pancreatic endocrine tumors were diagnosed in 5 women of which in 3 the tumors were located in the pancreatic tail (in which splenopancreatectomy and left pancreatectomy with spleen preservation were performed) and in 2 in the pancreatic head (in which pancreaticoduodenectomy and Beger type operation were performed). Conclusions: Knowledge of clinical signs of secreting tumors and exploring the patients are of crucial importance for management of PNETs. Immunohistochemistry is mandatory for confirming the diagnosis and assessing the proliferation and biological behavior of the tumor, thus facilitating the administration of specific therapy. Aggressive surgical treatment is indicated, even in advanced stages.

Abdominal Actinomycosis Mimicking Colon Cancer.

Introduction: Abdominal actinomycosis is a rare granulomatous inflammatory disease caused by a Gram-positive anaerobic bacterium Actinomyces israelii, manifesting as inflammatory mass, or abscess formation. Evolution is slow and steady in inflammatory contiguous extension without limit organ that lends itself to confusion with abdominal malignancies. Methods: We performed a retrospective study on the patients with abdominal actinomycosis operated in the First Surgical Clinic, "St. Spiridon" University Hospital Iasi; between 1980 - 2018 there have been 13 cases (4 men and 9 women) with a mean age 44.07 years admitted for abdominal tumors (7 cases) or pelvic inflammatory disease (6 cases). Results: We identified as predisposing factors: IUD maintained over 10 years (6 cases), foreign bodies 2 cases (a toothpick probably perforated colon, gallstones lost in peritoneum), diabetes (3 cases), immunodepression. All cases were operated by laparotomy (9 cases) or laparoscopic approach (4 cases). We describe five of these cases of actinomycosis that had been mimicking a colon cancer: ileo - cecal - 3 cases, transverse colon - one case and on the greater omentum - one case, followed by specific treatment with penicillin, with good evolution. Conclusions: Abdominal actinomycosis should always be included in the differential diagnosis of abdominal tumors. Preoperative diagnosis, difficult but possible, can avoid surgery. Treatment with antibiotics is necessary for the healing of the disease. Postoperative control is mandatory, with relapses possible.

Laparoscopic Management in Morgagni Hernia - Short Series and Review of Literature.

Morgagni hernia occurs after a congenital retrosternal diaphragmatic defect; it is a rare form of diaphragmatic hernia (1-3% of cases). In general, this pathology is diagnosed in children; in adults it is frequently discovered in emergency or incidentally. Methods: We prospectively evaluated a series of 8 patients admitted to First Surgical Clinic, St. Spiridon Hospital, Iasi during the period 2011-2017. Results: Out of 8 patients, 6 were operated on, one patient refusing surgery (followed periodically); the patient who was 91 years old had serious associated diseases that made surgery contraindicated. Symptomatology was nonspecific: in 5 cases Morgagni hernia was discovered during the exploration of an associated pathology, either with cardiopulmonary symptoms of dyspnea or palpitations. In 2 cases, the clinical aspect suggested an occlusive syndrome (the herniated organ is usually the transverse colon). The laparoscopic approach was used in all cases: two conversions were recorded due to the tight adherences of the herniated viscera (gastric, colon, epiplon). In 4 cases, the surgical cure of hernia was performed by suture and in 2 cases with prosthesis: dual mesh in one case and polypropylene mesh in another case. We did not register morbidity and the mean postoperative stay was 4 days (range 2-6 days). Conclusions: Hernia Morgagni betrays a rare pathology. The most common is asymptomatic but in complicated cases it is a cause of acute surgical abdomen. Surgical treatment is indicated even for asymptomatic cases due to serious complications Morgagni hernia may develop. The laparoscopic approach is ideal, as reduction of viscera in the abdomen is easy and the defect will be repaired by suturing or using a prosthesis, depending on its size.

Our initial experience with ventriculo-epiplooic shunt in treatment of hydrocephalus in two centers.

INTRODUCTION: Hydrocephalus represents impairment in cerebrospinal fluid (CSF) dynamics. If the treatment of hydrocephalus is considered difficult, the repeated revisions of ventriculo-peritoneal (VP) shunts are even more challenging. OBJECTIVE: The aim of this article is to evaluate the efficiency of ventriculo-epiplooic (VEp) shunt as a feasible alternative in hydrocephalic patients. MATERIAL AND METHODS: A technical modification regarding the insertion of peritoneal catheter was imagined: midline laparotomy 8-10cm long was performed in order to open the peritoneal cavity; the great omentum was dissected between its two layers; we placed the distal end of the catheter between the two epiplooic layers; a fenestration of 4cm in diameter into the visceral layer was also performed. A retrospective study of medical records of 15 consecutive patients with hydrocephalus treated with VEp shunt is also presented. RESULTS: Between 2008 and 2014 we performed VEp shunt in 15 patients: 5 with congenital hydrocephalus, 8 with secondary hydrocephalus and 2 with normal pressure hydrocephalus. There were 7 men and 8 women. VEp shunt was performed in 13 patients with multiple distal shunt failures and in 2 patients, with history of abdominal surgery, as de novo extracranial drainage procedure. The outcome was favorable in all cases, with no significant postoperative complications. CONCLUSIONS: VEp shunt is a new, safe and efficient surgical technique for the treatment of hydrocephalus. VEp shunt is indicated in patients with history of recurrent distal shunt failures, and in patients with history of open abdominal surgery and high risk for developing abdominal complications.

Early Spontaneous Graft Intra- and Perihepatic Hematoma after Liver Transplantation.

Hematoma of the graft is a life threatening complication of liver transplantation (LT) and there has been no overt conclusion in the literature about optimal management except in scarcely reported cases. It may be either intrahepatic or subcapsular, then again it may develop spontaneously or following parenchimal injuries or transhepatic percutaneous invasive manoeuvers. In this report we describe a rare case of large spontaneous graft intra- and perihepatic hematoma. A 62 year-old man underwent a whole graft orthotopic liver transplantation (OLT) for decompensated chronic liver disease due to alcoholic cirrhosis. The surgical procedure was uneventful. During the early postoperative course, routine Doppler ultrasound examination and CT-scan revealed an extrahepatic paracaval hematoma, 7 days after transplantation, which was stable and conservatively managed until the 18-th postoperative day, when rapidly expanding intraparenchimal hematoma involving the right hemiliver, several other perihepatic hematomas, significant right pleural effusion and hemorrhagic ascites were described. The patient was successfully treated conservatively (nonsurgically) with slow recovery of the liver allograft and discharged one month later in good general status.

The Romanian National Program for Liver Transplantation - 852 Procedures in 815 Patients over 17 Years (2000-2017): A Continuous Evolution to Success.

Background: Liver transplantation (LT) has become an established treatment for end-stage liver disease, with more than 20.000 procedures yearly worldwide. The aim of this study was to analyze the results of Romanian National Program of LT. Methods: Between April 2000 and April 2017, 817 pts received 852 LTs in Romania. Male/female ratio was 487/330, while adult/pediatric ratio was 753/64, with a mean age of 46 years (median 50 yrs; range 7 months - 68 yrs). Main LT indications were HBV cirrhosis (230 pts; 28.2%), HCC (173 pts; 21.2%), and HCV cirrhosis (137 pts; 16.8%). Waiting time and indications for LT, patient and donor demographics, graft features, surgical procedures, and short and long-term outcomes were analyzed. Results: DDLT was performed in 682 pts (83.9%): whole LT in 662 pts (81%), split LT in 16 pts (2.3%), reduced LT in 2 pts (0.2%), and domino LT in 1 pts (0.1%). LDLT was performed in 135 pts (16.5%): right hemiliver in 93 pts (11.4%), left lateral section in 28 pts (3.4%), left hemiliver in 8 pts (1%), left hemiliver with segment 1 in 4 pts (0.5%), and dual graft LDLT in 2 pts (0.2%). Overall major morbidity rate was 31.4% (268 pts), while perioperative mortality was 7.9% (65 pts). Retransplantation rate was 4.3% (35 pts): 27 whole LTs, 3 reduced LTs, 3 split LTs, and 2 LDLT. Long-term overall 1-, 3-, and 5-year estimated survival rates for patients were 87.9%, 81.5%, and 79.1%, respectively. One-, 3-, and 5-year overall mortality on waiting list also decreased significantly over time from 31.4%, 54.1% and 63.5%, to 4.4%, 13.9% and 23.6%, respectively. Conclusions: The Romanian National program for liver transplantation addresses all causes of acute and chronic liver failure or liver tumors in adults and children, using all surgical techniques, with good long-term outcome. The program constantly evolved over time, leading to decreased mortality rate on the waiting list.

Mesopancreas first dissection during pancreaticoduodenal resection: selective approach or paradigm?

BACKGROUND/AIMS: Pancreaticoduodenal resection is the procedure of choice for tumors of the pancreatic head and periampullary region. During pancreaticoduodenectomy resection, early neck division may be impossible or inadequate in case of hepatic artery anatomic variants, suspected involvement of the superior mesenteric vessels or intraductal papillary mucinous tumors. This paper aims to reveal the effectiveness of a modified posterior approach pancreaticoduodenectomy in selected indications and to assess the preliminary results. METHODOLOGY: We describe our early approach to the retropancreatic vasculature during pancreaticoduodenal resection by mesopancreas first dissection before any pancreatic or digestive transection. RESULTS: We used this approach in 45 patients. Thirty had hepatic artery anatomic variant. Hepatic artery reconstruction was required in 2 cases. In nine patients with intraductal papillary mucinous tumors the pancreaticoduodenal resection was extended to the body in 6 and totalized in 3 patients. In six patients with adenocarcinoma involving the portomesenteric axis, venous resection and reconstruction was necessary. CONCLUSIONS: Mesopancreas first dissection is useful tool in selected cases of pancreaticoduodenal resection to improve safety and radicality of the procedure.

Laparoscopic Approach to Primary Splenic Cyst: Case Report and Review of the Literature.

Splenic cysts are rare benign lesions of the spleen, often asymptomatic and incidentally discovered during imaging studies. While many splenic cysts remain asymptomatic and do not require intervention, surgical management becomes essential in cases of symptomatic cysts, large cysts, or when malignancy cannot be ruled out. Laparoscopic surgery has emerged as a minimally invasive and effective approach for treating splenic cysts, offering advantages such as shorter hospital stays, reduced postoperative pain, and faster recovery. In this case report, we describe our experience with laparoscopic surgery for a symptomatic splenic cyst in a young patient.

Endoscopic Vacuum-Assisted Closure (E-VAC) in Septic Shock from Perforated Duodenal Ulcers with Abscess Formations.

This case report underscores the importance of utilizing E-VAC (endoscopic vacuum-assisted closure) in the treatment of a perforated duodenal ulcer complicated by the formation of a subphrenic abscess and septic shock. It showcases how E-VAC can effectively mitigate the risk of further complications, such as leakage, bleeding, or rupture, which are more commonly associated with traditional methods like stents, clips, or sutures. As a result, there is a significant reduction in mortality rates. A perforated duodenal ulcer accompanied by abscess formation represents a critical medical condition that demands prompt surgical intervention. The choice of the method for abscess drainage and perforation closure plays a pivotal role in determining the patient's chances of survival. Notably, in patients with a high ASA (American Association of Anesthesiologists) score of IV-V, the mortality rate following conventional surgical intervention is considerably elevated. The management of perforated duodenal ulcers has evolved from open abdominal surgical procedures, which were associated with high mortality rates and risk of suture repair leakage, to minimally invasive techniques like laparoscopy and ingestible robots. Previously, complications arising from peptic ulcers, such as perforations, leaks, and fistulas, were primarily addressed through surgical and conservative treatments. However, over the past two decades, the medical community has shifted towards employing endoscopic closure techniques, including stents, clips, and E-VAC. E-VAC, in particular, has shown promising outcomes by promoting rapid and consistent healing. This case report presents the clinical scenario of a patient diagnosed with septic shock due to a perforated duodenal ulcer with abscess formation. Following an exploratory laparotomy that confirmed the presence of a subphrenic abscess, three drainage tubes were utilized to evacuate it. Subsequently, E-VAC therapy was initiated, with the kit being replaced three times during the recovery period. The patient exhibited favorable progress, including weight gain, and was ultimately discharged as fully recovered. In the treatment of patients with duodenal perforated ulcers and associated abscess formation, the successful and comprehensive drainage of the abscess, coupled with the closure of the perforation, emerges as a pivotal factor influencing the patient's healing process. The positive outcomes observed in these patients underscore the efficacy of employing a negative pressure E-VAC kit, resulting in thorough drainage, rapid patient recovery, and low mortality rates.

Laparoscopic Hartmann Procedure-A Surgery That Still Saves Lives.

BACKGROUND: A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. METHODS: The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. RESULTS: We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. CONCLUSIONS: The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.

A Debate on Surgical and Nonsurgical Approaches for Obstructive Sleep Apnea: A Comprehensive Review.

Regular and unobstructed breathing during the night is the prerequisite for an undisturbed and restful sleep. The most prevalent nocturnal breathing disturbance with morbid consequences is obstructive sleep apnea syndrome. The prevalence of obstructive sleep apnea (OSA) is increasing, and a significant number of patients with OSA are undiagnosed. On the other hand, the "obesity epidemic" is a growing concern globally. A sleep test is required to diagnose sleep apnea and to individualize therapy. A multidisciplinary approach is the key to success. This narrative review presents a debate on whether surgery is a friend or a foe in the treatment of sleep apnea. Depending on the type and severity of the apnea, the causal factor, and the presence of obesity and hypercapnia as well as the associated pathologies, the optimal therapeutic method is determined for each individual case. The article concludes that each case is unique, and there is no ideal method. Positive pressure ventilation, although a therapeutic gold standard, has its disadvantages extensively discussed in this paper. Nevertheless, it is necessary prior to any surgical intervention, either for the curative treatment of the causal factor of apnea or for elective surgery for another condition. The anesthetic risks associated with the presence of apnea and obesity should not be neglected and should form the basis for decision making regarding surgical interventions for the treatment of sleep apnea.

Challenges and Solutions in the Management of Hepatocellular Carcinoma Associated with Non-Alcoholic Fatty Liver Disease.

Non-alcoholic fatty liver disease (NAFLD) has gained attention in the last few years due to its increasing prevalence worldwide becoming a global epidemic. The increasing incidence of NAFLD and the concurrent increase in the number of hepatocellular carcinoma (HCC) cases at a global level is a matter of concern. HCC has several risk factors, of which NAFLD and its associated metabolic disturbances-type 2 diabetes mellitus, obesity, and dyslipidemia-are of great interest due to their accelerating rise in incidence worldwide. There is a high amount of data derived from basic and clinical studies that reveal the molecular pathways that drive NAFLD-associated HCC. Based on these findings, new prevention, surveillance, and treatment strategies are emerging. However, current data on treatment modalities in NAFLD-associated HCC are still scarce, though the results from non-NAFLD HCC studies are promising and could provide a basis for a future research agenda to address NAFLD/NASH patients. Clinicians should carefully assess all the clinical and radiological parameters and establish a prognosis based on the Barcelona Clinic Liver Cancer classification and discuss in a multidisciplinary team the treatment strategy. The specific factors associated with NAFLD-associated HCC which can have a negative impact on survival even in patients with early HCC, such as cardiovascular disease, type 2 diabetes, and obesity, should be taken into consideration. This review aims to discuss the latest recommendations regarding the diagnosis and treatment of NAFLD-associated HCC and the remaining challenges.

Gallstone Ileus. What therapeutic options are there?

Gallstone ileus is a rare disorder in emergency surgical practice with diagnosis usually difficult and only achieved at surgery. The current approaches are: enterolithotomy, cholecystectomy and fistula repair (one-stage surgery), enterolithotomy with cholecystectomy performed later (two-stage surgery) and only enterolithotomy (most reported surgical procedure). METHODS: The clinical, operative and follow-up data on 14 consecutive patients treated in our clinic for gallstone ileus was retrospectively reviewed. RESULTS: Gallstone ileus was recorded in 0.06% of all operations for biliary lithiasis and 1% of all enteric occlusions. There were 11 women and one men, with a mean age of 77.3 (range 67-100) years. There was a mean delay of 3.16 days for onset of symptoms to admission. Urgent laparotomy confirmed gallstone obstruction and a cholecysto-duodenal fistula (13 cases) or cholecysto-colonic fistula (1 case). We performed one stage surgery in 4 cases, enterolithotomy alone in 8 cases (one case operated initially in another surgical service), Hartman procedure, cholecystectomy and fistula repair in one case and a spontaneous evacuation of the gallstone with cholecystectomy and fistula repair later in another case. We recorded 2 deaths in patients with multiple comorbidities in which only enterolithotomy was performed and with 1 and 2 reinterventions, respectively. Postoperative stay was 9.4 days for cases with simple enterolithotomy and 18.6 days for cases with radical treatment. We did not record any recurrence. CONCLUSIONS: Although rarely encountered in surgical practice, gallstones ileus should be noted in the differential diagnosis of intestinal obstruction in patients with a past history of biliary disease, occlusive syndrome, pneumobilia and possibly ectopic gallstone. The one-stage procedure should be the offered to stabilized patients, but in cases with associated comorbidities, only enterolithotomy represent a best option. KEY WORDS: Gallstone ileus, Cholecystoduodenal fistula, Intestinal Obstruction.

Abdominopelvic Actinomycosis-The Diagnostic and Therapeutic Challenge of the Most Misdiagnosed Disease.

Abdominopelvic actinomycosis is a rare chronic or subacute bacterial infection caused by Actinomyces israelii, a Gram-positive anaerobic bacterium that normally colonizes the digestive and genital tracts, clinically presented as an inflammatory mass or abscess formation. METHODS: We reviewed the medical records of the patients from our clinic with abdominopelvic actinomycosis who underwent surgery between 2002 and 2022. In this period, 28 cases (9 men and 19 women) were treated. The mean age was 43.36 years and they were hospitalized for abdominopelvic tumors or inflammatory tumors in 15 cases and inflammatory disease in 13 cases. RESULTS: Causes of actinomycosis in the studied group were an intra-uterine contraceptive device in 17 cases, foreign bodies in 2 cases, diabetes in 4 cases, stenting of the bile duct in 1 case, and immunodepression. For 6 patients, we performed surgery by open approach and for 21 patients by a laparoscopic approach. For nine patients, abdominopelvic actinomycosis had been mimicking a colon malignancy (cecum and ascending colon, four cases; transverse colon, two cases; and on the greater omentum, three cases) and for six patients, a pelvic tumor (advanced ovarian cancer). After surgery the patients underwent specific treatment with antibiotics, with good results. In two cases we discovered and treated hepatic actinomycosis, one case by a laparoscopic approach and one case by a percutaneous approach. In our lot we noticed three recurrences that required reintervention in patients who had had short-term antibiotics due to non-compliance with treatment out of four such cases. CONCLUSIONS: For abdominopelvic malignancies, actinomycosis should be included in the differential diagnosis, as well as for inflammatory bowel diseases and bowel obstructions. We have a wide range of patients considering the rarity of this condition. Long-term antibiotics are necessary to prevent recurrence.