Allografts use in orthopedic surgery: trend change over the past 11 years from a regional tissue bank.

Allografts are the second most transplanted tissue in medicine after blood and are now increasingly used for both primary and revision surgery. Allografts have the advantages of lower donor site morbidity, availability of multiple grafts, and shorter operative time. The Banks represents the bridge between Donor and Recipient and guarantees the quality and safety of the distributed allografts Given the increasing interest in these tissues, a retrospective analysis of data collected from the Regional Musculoskeletal Tissue Bank registry over an 11-year period (2009-2019) was conducted. The statistical analyses used were the Shapiro-Wilk normality test and a Poisson regression model. From January 2009 to December 2019, a total of 14,199 musculoskeletal tissues stored in the Regional Musculoskeletal Tissue Bank were provided for surgical allograft procedures. In 2009, the number of allografts performed was 925; this figure has steadily increased to 1599 in 2019. Epiphyses were taken as the reference tissue with an almost constant trend over the period, while a significant increase was denoted for extensor mechanism allograft, ligaments, tendons and long bone corticals (p < 0.001), processed bone tissues had no change in trend (p = 0.841). There was also a gradual decrease in the rate of microbiological positivity, as determined by bacteriological and serological tests performed on the collected tissues. This phenomenon is due to improved sampling techniques and the training of a dedicated team. Thus, we have seen how the use of allografts in orthopedic surgery has increased over the past 11 years, uniformly in terms of tissue type, except for the noticeable increase in ligamentous tissue.

Evolution of ordered nanoporous phases during h-BN growth: controlling the route from gas-phase precursor to 2D material by in situ monitoring.

Large-area single-crystal monolayers of two-dimensional (2D) materials such as graphene and hexagonal boron nitride (h-BN) can be grown by chemical vapour deposition (CVD). However, the high temperatures and fast timescales at which the conversion from a gas-phase precursor to the 2D material appears, make it extremely challenging to simultaneously follow the atomic arrangements. We utilise helium atom scattering to discover and control the growth of novel 2D h-BN nanoporous phases during the CVD process. We find that prior to the formation of h-BN from the gas-phase precursor, a metastable (3 × 3) structure is formed, and that excess deposition on the resulting 2D h-BN leads to the emergence of a (3 × 4) structure. We illustrate that these nanoporous structures are produced by partial dehydrogenation and polymerisation of the borazine precursor upon adsorption. These steps are largely unexplored during the synthesis of 2D materials and we unveil the rich phases during CVD growth. Our results provide significant foundations for 2D materials engineering in CVD, by adjusting or carefully controlling the growth conditions and thus exploiting these intermediate structures for the synthesis of covalent self-assembled 2D networks.

Enhanced recovery after surgery (ERAS) program in octogenarian patients: a propensity score matching analysis on the "Lazio Network" database.

PURPOSE: The aim of this study was to evaluate the safety and compliance with the enhanced recovery after surgery (ERAS) protocol in octogenarian patients undergoing colorectal surgery in 12 Italian high-volume centers. METHODS: A retrospective analysis was conducted in a consecutive series of patients who underwent elective colorectal surgery between 2016 and 2018. Patients were grouped by age (≥ 80 years vs < 80 years), propensity score matching (PSM) analysis was performed, and the groups were compared regarding clinical outcomes and the mean number of ERAS items applied. RESULTS: Out of 1646 patients identified, 310 were octogenarians. PSM identified 2 cohorts of 125 patients for the comparison of postoperative outcomes and ERAS compliance. The 2 groups were homogeneous regarding the clinical variables and mean number of ERAS items applied (11.3 vs 11.9, p-ns); however, the application of intraoperative items was greater in nonelderly patients (p 0.004). The functional recovery was similar between the two groups, as were the rates of postoperative severe complications and 30-day mortality rate. Elderly patients had more overall complications. Furthermore, the mean hospital stay was higher in the elderly group (p 0.027). Multivariable analyses documented that postoperative stay was inversely correlated with the number of ERAS items applied (p < 0.0001), whereas age ≥ 80 years significantly correlated with the overall complication rate (p 0.0419). CONCLUSION: The ERAS protocol is safe in octogenarian patients, with similar levels of compliance and surgical outcomes. However, octogenarian patients have a higher rate of overall complications and a longer hospital stay than do younger patients.

Organ Donation after Damage Control Strategy in Trauma Patients: Experience from First Level Trauma Center in Italy.

BACKGROUND: Organ donation (OD) remains the only therapeutic option for end-stage disease in some cases. Unfortunately, the gap between donors and recipients is still substantial. Trauma patients represent a potential yet underestimated pool of organ donors. In this article, we present our data on OD after damage control strategy (DCS). MATERIALS AND METHODS: A retrospective, observational cohort study was conducted through a complete revision of data of consecutive adult trauma patients (>18 years old) who underwent OD after DCS between January 2018 and May 2021. Four subgroups were created [Liver (Li), Lungs (Lu), Heart (H), Kidneys (K)] to compare variables between those who donated the organ of interest and those who did not. RESULTS: Thirty-six patients underwent OD after DCS. Six patients (16.7%) were excluded: 2(5.6%) for missing data about admission; 4(11.1%) didn't receive DCS. Mean ISS was 47.2 (SD ± 17.4). Number of donated organs was 113 with an organs/patient ratio of 3.8. The functional response rate was 91.2%. Ten organs (8.8%) had primary nonfunction after transplantation: 2/15 hearts (13.3%), 1/28 livers (3.6%), 4/53 kidneys (7.5%) and 3/5 pancreases (60%). No lung primary nonfunction were registered. Complete results of subgroup analysis are reported in supplementary materials. CONCLUSION: Organ donation should be considered a possible outcome in any trauma patient. Aggressive damage control strategy doesn't affect the functional response rate of transplanted organs.

Impact of implementation of the ERAS program in colorectal surgery: a multi-center study based on the "Lazio Network" collective database.

BACKGROUND: ERAS implementation improved outcomes in patients undergoing colorectal surgery. The process of incorporating this pathway in clinical practice may be challenging. This observational study investigated the impact of systematic ERAS implementation on surgical outcomes in patients undergoing colorectal resections in a regional network of 10 institutions. METHODS: Implementation of ERAS pathway was designed using regular audits and a common protocol. All patients undergoing elective colorectal surgery between 2016 and 2017 were considered eligible. A collective database including 18 ERAS items, clinical and surgical data, and outcomes was designed. Univariate and multivariate analyses were performed for the following outcomes: morbidity, anastomotic leak, reinterventions, hospital stay, and readmissions. RESULTS: A total of 827 patients were included, and a mean of 11.3 ERAS items applied/patient was reported. Logistic regression indicated that an increased number of ERAS items applied reduced overall and severe morbidity (OR 0.86 and 0.87, respectively 95%CI 0.8197-0.9202 and 95%CI 0.7821-0.9603), hospitalization (OR 0.53 95%CI 0.4917-0.5845) and reinterventions (OR 0.84 95%CI 0.7536-0.9518) in the entire series. The same results were obtained for a prolonged hospitalization differentiating right-sided (OR 0.48 95%CI 0.4036-0.5801), left-sided (OR 0.48 95%CI 0.3984-0.5815), and rectal resections (OR 0.46 95%CI 0.3753-0.5851). An inverse correlation was found between the application of ERAS items and morbidity in right-sided and rectal procedures (OR 0.89 and 0.84, respectively 95%CI 0.7976-0.9773 and 95%CI 0.7418-0.9634). CONCLUSIONS: Systematic implementation of the ERAS pathway using multi-institutional audits can increase protocol adherence and improve surgical outcomes in patients undergoing colorectal surgery.

Recurrent incisional hernia, enterocutaneous fistula and loss of the substance of the abdominal wall: plastic with organic prosthesis, skin graft and VAC therapy. Clinical case.

Surgical wounds dehiscence is a serious post-operatory complication, with an incidence between 0.4% and 3.5%. Mortality is more than 45%. Complex wounds treatment may require a multidisciplinary management. VAC Therapy could be an alternative treatment regarding complex wound. VAC therapy has been recently introduced on skin's graft tissue management reducing skin graft rejection. The use of biological prosthesis has been tested in a contaminated field, better than synthetic meshes, which often need to be removed. The Permacol is more resistant to degradation by proteases due to its cross-links. Surgery is still considered the best treatment for digestive fistula. A 58 years old obese woman come to our attention, she was operated for an abdominal hernia. She had a post-operatory entero-cutaneous fistula. She was submitted to bowel resection, the anastomosis has been tailored and the hernia of the abdominal wall has been repaired with biological mesh for managing such condition. She had a wound dehiscence with loss of substance and the exposure of the biological prosthesis, nearly 20 cm diameter. She was treated first with antibiotic therapy and simple medications. In addiction, antibiotic therapy was necessary late associated to 7 months with advanced medications allowed a small reduction's defect. Because of its, treatment went on for two more months using VAC therapy. Antibiotic's therapy was finally suspended. The VAC therapy allowed the reduction of the gap, between skin and subcutaneous tissue, and the defect's size preparing a suitable ground for the skin graft. The graft, managed with the vac therapy, was necessary to complete the healing process.

Prospective study of effectiveness of ultrasound-guided radiofrequency ablation versus control group in patients affected by benign thyroid nodules.

CONTEXT: Ultrasound-guided radiofrequency ablation (RFA) of solid thyroid nodules (TNs) is a minimally invasive procedure that may induce a volume reduction of symptomatic solid benign TNs. OBJECTIVE: The aim of the study was to evaluate the effectiveness and safety of RFA in debulking benign TNs. DESIGN AND PATIENTS: Eighty-four consecutive patients with symptomatic and cytologically benign solid nodules were randomly assigned to either a single RFA session (group A; n = 42) or follow-up (group B; n = 42) at our center. Entry criteria were a solid thyroid nodule or predominantly solid (with a fluid component ≤ 30% of the volume), normal thyroid function, no autoimmunity, and no previous thyroid gland treatment. Three subgroups were formed according to the baseline volume of nodules: small (≤ 12 mL), medium (from 12 to 30 mL), or large (>30 mL). METHODS: In group A RFA was performed in a single session with the moving-shot technique. Volume and local symptom changes were evaluated 1 and 6 months after RFA. RESULTS: In group A, the volume decreased from 24.5.5 ± 19.6 to 8.6 ± 9.5 6 months after RFA (P = .001). The greatest volume reduction was in small nodules. The pressure symptom score improved only in medium and large nodules (P < .001), whereas the cosmetic score improved in all treated patients (P < .001). The rate of thyroid volumetric reduction was not statistically different between solid and predominantly solid nodules. Only one patient experienced permanent right paramedian vocal cord palsy with inspiratory stridor without dysphonia. In group B, nodule volume remained unchanged, whereas the symptom score was worse at the 6-month evaluation (P = .01). CONCLUSIONS: RFA is effective in reducing thyroid nodule volume. The best reduction rate was observed in small TNs. The thyroid volumetric reduction does not change according to the sonographic features. The mean treatment duration was longer in larger TNs.

The interaction of iron pyrite with oxygen, nitrogen and nitrogen oxides: a first-principles study.

Sulphide materials, in particular MoS(2), have recently received great attention from the surface science community due to their extraordinary catalytic properties. Interestingly, the chemical activity of iron pyrite (FeS(2)) (the most common sulphide mineral on Earth), and in particular its potential for catalytic applications, has not been investigated so thoroughly. In this study, we use density functional theory (DFT) to investigate the surface interactions of fundamental atmospheric components such as oxygen and nitrogen, and we have explored the adsorption and dissociation of nitrogen monoxide (NO) and nitrogen dioxide (NO(2)) on the FeS(2)(100) surface. Our results show that both those environmentally important NO(x) species chemisorb on the surface Fe sites, while the S sites are basically unreactive for all the molecular species considered in this study and even prevent NO(2) adsorption onto one of the non-equivalent Fe-Fe bridge sites of the (1 × 1)-FeS(2)(100) surface. From the calculated high barrier for NO and NO(2) direct dissociation on this surface, we can deduce that both nitrogen oxides species are adsorbed molecularly on pyrite surfaces.

Virtual ileostomy following rectal cancer surgery: a good tool to avoid unusefull stomas?

BACKGROUND/AIMS: Anastomotic leak is a life threatening complication following surgery for rectal cancer below peritoneal reflection. Colostomy or ileostomy following colorectal or coloanal anastomosis protect the patients from general peritonitis or sepsis secondary to anastomotic leak. METHODOLOGY: In this paper the experience of the last 100 cases of rectal cancer below the peritoneal reflection treated from 2004 to 2010 was reviewed. RESULTS: In 79 cases, primary anastomosis was performed. In 44/79 cases virtual ileostomy was prepared and in 35/79 cases, based on risk factors and intraoperative decision of the surgeon, an open ileostomy was performed. In 8/44 cases virtual ileostomy was opened, thus avoiding in 35/79 cases a second operation. CONCLUSIONS: The goal for a good clinical outcome of patients with virtual ileostomy is a strict postoperative follow-up focused on fever onset and quality of drainage discharge. In our experience virtual ileostomy is a good tool to avoid open ostomy at time of primary colorectal or coloanal anastomosis in a good number of cases.

Is laparoscopy safe and effective in nontraumatic acute abdomen?

BACKGROUND AND AIMS: Progress in laparoscopic experience has increased the number of laparoscopic procedures performed, even in emergency cases. Herewith, results in a prospective series of 300 patients laparoscopically treated for nontraumatic abdominal emergencies are presented with the intent to prove the safety and feasibility of laparoscopic approach in the treatment of acute abdomen. MATERIALS AND METHODS: From a prospective multicenter study performed between June 2008 and December 2009, the authors collected data on 300 patients with a provisional diagnosis of acute abdomen, laparoscopically treated or who underwent explorative laparoscopy. RESULTS: A correct diagnosis was made by means of laparoscopy in all 300 (100%) patients, and therapeutic laparoscopy was successfully performed in 270 (90%) patients. With laparoscopy, it was possible to modify the preoperative diagnosis and the treatment in 17 cases (5.6%). Upon statistical analysis, the conversion rate was correlated to the age of the patients (P<.0001) and to the operative time (P<.0001). The overall postoperative morbidity rate was 8%. Statistical analysis revealed that morbidity is correlated to the age of patients (P<.0001) and to the operative time (P<.0001). The mean hospital stay was 5.4 days. CONCLUSIONS: Laparoscopy has been shown to play a crucial role in the management of almost every abdominal emergency, offering, compared with the open approach, an initial diagnostic or explorative tool and a valid alternative in the treatment of the cause of acute abdomen with low morbidity and mortality rates.

Virtual ileostomy following TME and primary sphincter-saving reconstruction for rectal cancer.

Surgical management of rectal cancer has undergone a significant change during the past two decades. Low anterior resection (LAR) with total mesorectal excision (TME) is, at the moment, the "gold standard" for carcinoma of the mid or lower rectum. Because the most specific complication following rectal resection with anastomosis is symptomatic leakage, which is associated with 18% mortality rate, routine formation of a temporary stoma is suitable after sphincter-saving resection for anastomoses situated at or less than 5cm from the anal verge. Actually the preferred modes of fecal diversion following LAR with TME are loop ileostomy or loop transverse colostomy. Low anastomosis, preoperative radiation or chemoradiation, presence of intraoperative adverse events and male gender are independent risk factors for symptomatic anastomotic leakage. A defunctioning loop ileostomy or the classical "protective" colostomy requires subsequent reconstructive surgery with a significant postoperative morbidity. For these reasons we use an alternative to protect a high risk anastomosis with fashioning a proximal intraabdominal closed loop ileostomy called "virtual ileostomy". In a seven-year period from 1999 to 2005 a total of 107 patients underwent elective anterior resection of the rectum for carcinoma, in all cases was fashioned a virtual ileostomy. The incidence of symptomatic clinically evident anastomotic leakage was 13%; in all the cases (14 pts) the closed loop ileostomy was opened with a reduction of the originally planned number of ileostomies by over 80%. The procedure is easy to perform and well accepted by the patients. It avoids a second operation.

Reappraisal of a method of reconstruction after pancreatoduodenectomy.

BACKGROUND/AIMS: After pancreatoduodenectomy (PD), pancreatic leak and the functional pancreatic and gastrointestinal disorders are the most important complications. Still there is no single method which takes care of all of them. After identifying the various reasons behind these complications, the senior author started performing the present method in the 1980s. Since then we have been able to bring these complications to a very low incidence. The present study is designed to substantiate the claims of various advantages of this method of PD and reconstruction and to explain the rationale behind this method. METHODOLOGY: This is a retrospective study of 225 consecutive PD procedures done for periampullary cancers, during the period of 1993-2004. The shortterm and long-term results assessed were mortality rate, morbidity rate, early reoperation, survival, steatorrhea, pancreatic enzyme supplementation requirement, occurrence of bile gastritis, dumping, new onset of diabetes, marginal ulcers, cholangitis, postoperative weight trends and frequency of hospital readmission for symptom management. Follow-up was done 6 monthly in all the patients with the aim of diagnosis of recurrence and assessment of long-term gastrointestinal and pancreatic function and nutritional status. In addition, in 15 patients, upper gastrointestinal endoscopy (UGIE) with gastric and jejunal biopsy, 99Tc-HIDA scan, determination of fecal fat loss after a standard 100-g fat diet for three days, fecal elastase-1 measurement (ELISA) and MRCP were done to objectively document the changes in gastrointestinal and pancreatic function. The data were compared with the results available in the literature. RESULTS: The mean age was 56 years with a range of 27-85 years. There were 130 males and 95 females. Preoperatively 18 patients had diabetes and preoperative weight loss varied from 5-30 kilograms with a mean of 12 kilograms. Of all the PD cases 57 were for ampullary, 70 were for lower end cholangiocarcinoma and 98 were for pancreatic head cancer. The postoperative complications occurred in the form of intra-abdominal bleed (5), pancreaticojejunostomy leak (12), intra-abdominal abscess (4) and pneumonia (5). Delayed gastric emptying was not seen in any of the patients. In 8/12 patients with PJ leak the closure was achieved with the conservative treatment. The 30-day mortality was 6/225 (2.66%). The causes were sepsis in 3, intra-abdominal bleed in 2 and pulmonary embolism in 1 patient. There was no mortality related to PJ leak. The median follow-up was of 36 months. The overall 5-year survival for ampullary, lower end cholangio- and pancreatic head carcinoma were 65%, 25% and 20% respectively. After surgery none of the patients had clinical evidence of steatorrhea, gastritis, peptic ulcer disease, cholangitis, dumping and there was no new case of diabetes. After 6-12 months 80% of the patients gained weight similar to their preoperative levels. UGIE with gastric and jejunal biopsies, 99Tc-HIDA scan, fecal fat loss estimation, fecal elastase estimation and MRCP were done in 15 patients and were found to be normal. CONCLUSIONS: Our method of PD and reconstruction produces encouraging results with respect to PJ leak, mortality, DGE, malabsorption, bile gastritis, dumping, marginal ulcers and diabetes. We recommend this technique as a safe and effective method even to the low volume centers.

Adenocarcinoma of the pancreas--past, present and future.

Adenocarcinoma of the pancreas has always been a disease with a dismal prognosis. Almost every patient with this cancer dies of the tumor. Over the years there has been extensive advancement in the understanding of etiology, molecular biology, diagnosis and treatment of this disease. Presently, surgical resection is the only potentially curative option available for these patients. It is now clear that surgery alone cannot increase the survival of these patients. With the understanding of molecular biology of pancreatic cancer new management strategies are under a preclinical stage of development. These new diagnostic and therapeutic modalities hopefully will improve the outcome of patients with pancreatic cancer.