Anatomical variants of the intercostobrachial nerve and its preservation during surgery, a systematic review and meta-analysis.

BACKGROUND: The anatomic variants of the intercostobrachial nerve (ICBN) represent a potential risk of injuries during surgical procedure such as axillary lymph node dissection and sentinel lymph node biopsy in breast cancer and melanoma patients. The aim of this systematic review and meta-analysis was to investigate the different origins and branching patterns of the intercostobrachial nerve also providing an analysis of the prevalence, through the analysis of the literature available up to September 2023. MATERIALS AND METHODS: The protocol for this study was registered on PROSPERO (ID: CRD42023447932), an international prospective database for reviews. The PRISMA guideline was respected throughout the meta-analysis. A systematic literature search was performed using PubMed, Scopus and Web of Science. A search was performed in grey literature through google. RESULTS: We included a total of 23 articles (1,883 patients). The prevalence of the ICBN in the axillae was 98.94%. No significant differences in prevalence were observed during the analysis of geographic subgroups or by study type (cadaveric dissections and in intraoperative dissections). Only five studies of the 23 studies reported prevalence of less than 100%. Overall, the PPE was 99.2% with 95% Cis of 98.5% and 99.7%. As expected from the near constant variance estimates, the heterogeneity was low, I2 = 44.3% (95% CI 8.9%-65.9%), Q = 39.48, p = .012. When disaggregated by evaluation type, the difference in PPEs between evaluation types was negligible. For cadaveric dissection, the PPE was 99.7% (95% CI 99.1%-100.0%) compared to 99.0% (95% CI 98.1%-99.7%). CONCLUSIONS: The prevalence of ICBN variants was very high. The dissection of the ICBN during axillary lymph-node harvesting, increases the risk of sensory disturbance. The preservation of the ICBN does not modify the oncological radicality in axillary dissection for patients with cutaneous metastatic melanoma or breast cancer. Therefore, we recommend to operate on these patients in high volume center to reduce post-procedural pain and paresthesia associated with a lack of ICBN variants recognition.

Clinical outcomes for patients with cardiovascular diseases before, during, and after the COVID19 pandemic. A pooled analysis of 600.000 patients.

BACKGROUND: The unexpected virulence of the COVID19 pandemic brought to significant changes of generally accepted therapeutic approaches. The consequences of these changes were difficult to define during the pandemic period. METHODS: We analyzed the National Registries including 97% of hospital admissions in Italy, regarding data describing number of operations for aortic valve implantation or repair, carotid and coronary revascularization, AAA repair, and lower limb arterial reconstruction performed in the period 2015 to 2019 and in the pandemic years 2020, 2021, and 2022. Primary outcomes were number and type of surgical procedures, 30-days operative mortality. RESULTS: During the three years of the pandemic there was a statistically significant increase of the number of all-causes deaths in comparison with the mean of the previous five years (2015-2019). In Italy there was a total increase of all causes-deaths of 251.911 (+105900 in 2020; +66929 in 2021; and +79082 in 2022), and 73% of the excess of deaths was related with COVID19 infection and 27% occurred in COVID 19 negative patients. During the first year of the pandemic, worse clinical outcomes for hospitalized patients with CVD were registered. The medical system responded adequately and in the following two pandemic years clinical outcomes for hospitalized patients were similar with those of the pre-pandemic period. CONCLUSIONS: The unexpected virulence of COVID19 pandemic determined worse clinical outcomes for patients with CVD during the first year. The adopted preventive measures allowed in the following two pandemic years improved clinical outcomes, similar with those of the pre-pandemic period.

Trends towards increase of Cardiovascular diseases mortality in USA: A comparison with Europe and the importance of preventive care.

BACKGROUND: the aim of our study was to analyze exposure of the general population to established risk factors for cardiovascular disease (CVD), which might have determined the trend towards increased mortality rates related with CVD from 2015 to 2019 in USA. MATERIAL AND METHODS: We Analyzed epidemiological of data from the US National Health and Nutrition Examination Survey and from the European Health Interview Survey to determine trends for exposure to several established risk factors for CVD from 2000 to 2018-2019. Trends of prevalence of obesity, arterial hypertension, cigarettes smoking, high cholesterol level, diabetes in the period 2000 to 2018-2019 in USA were correlated with age adjusted mortality and burden related with CVD. We correlated these trends also with educational attainment, family income and national expenditure for preventive care. RESULTS: Cardiovascular Diseases Related Mortality And Burden Decreased Significantly In Usa In The Period 2000-2015; In The Period 2015-2019 there was a trend towards increasing mortality rates. The trend in the period 2015-2019 was associated with increased exposure to several established risk factors for CVD: obesity, diabetes, cigarettes smoking and arterial hypertension. Level of education attainment and family income, and national health expenditure for information, education and counseling were statistically correlated with reduced exposure to established risk factors. Similar trends were present in Western European countries. CONCLUSIONS: Attention is required to improve education and communication, health access and care for people with poor economic conditions, homeless, minorities, to reduce CVD related mortality and burden.

Occurrence of Colorectal Cancer After a Negative Colonoscopy in Patients With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis.

BACKGROUND/AIM: Despite the application of colorectal cancer (CRC) surveillance guidelines, the detection of early neoplastic lesions might be difficult in patients with inflammatory bowel disease (IBD). To explore the risk of post-colonoscopy CRC (PCCRC) in patients with IBD we performed a systematic review and meta-analysis. PATIENTS AND METHODS: A systematic literature search was performed (PROSPERO; no. CRD42023453049). We included studies reporting the 3-year PCCRC (PCCRC-3y) prevalence, according to World Endoscopy Organization (WEO)-endorsed definition, in IBD and non-IBD patients. As primary outcome we evaluated the PCCRC-3y prevalence, according to WEO definitions, in IBD- and non-IBD patients and calculated the odds ratio (OR). The secondary outcome was to assess risk factors for PCCRC development in IBD patients. RESULTS: Three retrospective observational cohort studies were included. The pooled PCCRC-3y rate in patients with IBD was 30.8% [95% confidence interval (CI)=24.4-37.5%] and in non-IBD patients was 6.8% (95%CI=6.2-7.4%). The PCCRC-3y occurrence in IBD patients was significantly higher than that in non-IBD patients (OR=6.04; 95%CI=4.04-9.4; I2=95%), but a high heterogeneity among studies was noted. Furthermore, patients with ulcerative colitis (UC) had a significantly higher prevalence of PCCRC than patients with Crohn's Disease (CD): 30.9% (95%CI=27.8-34.2%) vs. 22.3% (95%CI=18-27%), respectively (OR=1.6, 95%CI=1.2-2.2; I2=0%). CONCLUSION: One-third of CRC in IBD patients were PCCRC, and these numbers were significantly higher when compared with those in non-IBD patients. Furthermore, the prevalence of PCCRC in patients with UC was higher compared to those with CD. However, prospective studies are required to better characterize risk factors for PCCRC development in patients with IBD.

The role of education and information to prevent trends towards increase of cardiovascular mortality rates in Europe from 2015 TO 2019.

BACKGROUND: In Europe Cardio Vascular Disease (CVD) mortality rates decreased significantly in the last 25 years, with less decline in the last 5 years. The aim of our study was to analyze trends of risk factors which may explain plateauing of CVD mortality rates in the period 2015-2019 in Europe. METHODS: We analyzed data from the Global Burden Disease and EUROSTAT concerning trends of CVD mortality rates for 25 European countries and simultaneous changes of exposure to risk factors of the population RESULTS: CVD related mortality decreased significantly in the analyzed countries in the period 2000-2015; in the period 2015-2019 there was a trend towards plateauing of CVD related mortality rates, which was associated with an increased exposure to several established risk factors including cigarette smoking, obesity and arterial hypertension. A decrease in expenditure for information, education and counseling programs was documented in most countries in the same period. Level of exposure to risk factors was correlated with educational attainment . Exposure to risk factors in the interval 2014-2019 increased for people with lower education, whereas decreased in people with higher education (p<0.001). CONCLUSIONS: Organized information about risk factors for CVD have the potential to reduce mortality and burden, with diminished total health expenses. Education and information in this setting should consider the cultural and social level of the public.

Reduced atmospheric levels of PM2.5 and decreased admissions and surgery for Ischemic stroke in Italy.

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Colonic Resection, Stoma, or Self-expanding Metal Stents for Obstructive Left Colon Cancer: the CROSCO-1 study protocol.

BACKGROUND: Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes. METHODS: CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC. RESULTS: The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies. CONCLUSIONS: The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.

Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines.

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Temporary intravascular shunts and limb salvage in civilian vascular trauma.

Background: Temporary intravascular shunts (TIVS) may allow quick revascularization and distal reperfusion, reducing the ischemic time (IT) when an arterial injury occurs. Furthermore, TIVS temporarily restore peripheral perfusion during the treatment of concomitant life-threatening injuries or when patients require evacuation to a higher level of care. Notwithstanding, there are still disputes regarding the use of TIVS, in view of the paucity of evidence in terms of potential benefits and with regard to the anticoagulation during the procedure. The present study aimed to assess TIVS impact, safety, and timing on limb salvage in complex civilian vascular traumas. Patients and methods: Data were retrieved from the prospective database of our department, which included all patients hospitalized with a vascular injury of the extremities between January 2006 and December 2022. Patients undergoing TIVS during vascular injury management were included in group A, and those who could not postpone immediate care for TIVS insertion were included in group B (control group). Data concerning the times required for extremity revascularization or other surgical procedures such as orthopedic interventions and the time of limb ischemia were compared between the two groups. A comparison of the postoperative course between the two groups was also performed. Results: A total of 53 patients were included: group A (TIVS insertion, n = 31) and group B (control, n = 22). Revascularization time significantly differed (p = 0.002) between the two groups, which is lower in group A (4.17 ± 2.37 h vs. 5.81 ± 1.26 h). TIVS positively affected the probability of limb salvage (p = 0.02). At multivariate analysis, the factors independently associated with limb salvage were TIVS usage, the necessity of hyperbaric oxygen therapy, and the total IT. In group A, there were three deaths and one major amputation, and in group B, there were two deaths and four major amputations. Conclusions: The use of TIVS minimizes revascularization time and improves limb salvage probability. A multidisciplinary approach is recommended, and correct surgical timing is key to ensure the best outcome.

Systematic Review and Meta-Analysis of the Variants of the Obturatory Artery.

BACKGROUND: Knowledge of vascular anatomy and its possible variations is essential for performing embolization or revascularization procedures and complex surgery in the pelvis. The obturator artery (OA) is a branch of the anterior division of the internal iliac artery (IIA), and it has the highest frequency of variation among branches of the internal iliac artery. Possible anomalies of the origin of the obturator artery (OA) should be known when performing pelvic and groin surgery, where its control or ligation may be required. The purpose of this systematic review and meta-analysis, based on Sanudo's classification, is to analyze the origin of the obturator artery (OA) and its variants. METHODS: Thirteen articles published between 1952 and 2020 were included. RESULTS: The obturator artery (OA) was present in almost all cases (99.8%): the pooled prevalence estimate for the origin from the IIA axis was 77.7% (95% CI 71.8-83.1%) vs. 22.3% (95% CI 16.9-28.2%) for the origin from EIA axis. In most cases, the obturator artery (OA) originated from the anterior division trunk of the internal iliac artery (IIA) (61.6%). CONCLUSIONS: Performing preoperative radiological examination to determine the pelvic vascular pattern and having the awareness to evaluate possible changes in the obturator artery can reduce the risk of iatrogenic injury and complications.

Elective Endovascular Aneurysm Repair (EVAR) for the Treatment of Infrarenal Abdominal Aortic Aneurysms of 5.0-5.5 cm: Differences between Men and Women.

BACKGROUND: There is significant debate regarding the existence of sex-related differences in the presentation, treatment, and outcomes of men versus women affected by abdominal aortic aneurysm (AAA). The purpose of this study is to compare endovascular aneurysm repair (EVAR) of infrarenal AAAs with the current sex-neutral 5.0-5.5 cm-diameter threshold for intervention between the two sexes. METHODS: Retrospective review of consecutive cases from a single teaching institution over a period of five years of patients who had undergone elective EVAR for AAAs between 5.0 and 5.5 cm in diameter. Outcomes of interest were compared according to sex. RESULTS: Ninety-four patients were included in the analysis, with a higher prevalence of men (53%). Females were older at the time of repair, 78 ± 5.1 years, versus 71.7 ± 7 years (p < 0.01), and had higher incidence of underlying comorbidities, namely, arrhythmia, chronic kidney disease, and previous carotid revascularization. Women had higher incidence of immediate systemic complications (p = 0.021), post-operative AMI (p = 0.001), arrhythmia (p = 0.006), pulmonary oedema (p < 0.001), and persistent renal dysfunction (p = 0.029). Multivariate analysis for post-operative factors associated to mortality and adjusted for sex confirmed that AMI (p = 0.015), arrhythmia (p = 0.049), pulmonary oedema (p = 0.015), persistent renal dysfunction (p < 0.001), cerebral ischemia (p < 0.001), arterial embolism of lower limbs (p < 0.001), and deep-vein thrombosis of lower limbs (p < 0.001) were associated to higher EVAR-related mortality; a higher incidence of post-operative AMI (p = 0.014), pulmonary edema (p = 0.034), and arterial embolism of lower limbs (p = 0.046) were associated to higher 30-days mortality. In females there was also a higher rate of suprarenal fixation (p = 0.026), insertion outside the instruction for use (p = 0.035), and a more hostile neck anatomy with different proximal aortic diameter (p < 0.001) and angle (p = 0.003). CONCLUSIONS: A similar threshold of size of AAA for elective surgery for both males and females might not be appropriate for surgical intervention, as females tend to have worse outcomes. Further population-based studies are needed to guide on sex-related differences and intervention on AAA.

Therapeutic Strategies and Oncological Outcome of Peritoneal Metastases from Lung Cancer: A Systematic Review and Pooled Analysis.

The peritoneum is an unusual site of metastases from lung cancer, and optimal management at the moment remains unclear and mostly based on palliative strategies. Therefore, the aim of the study was to investigate demographic characteristics, management and overall survival of patients with peritoneal metastases from lung cancer (PCLC). A PRISMA-compliant systematic review and pooled analysis was performed searching all English studies published until December 2022. PROSPERO, CRD42022349362. Inclusion criteria were original articles including patients with peritoneal carcinomatosis from lung cancer, specifying at least one outcome of interest. Exclusion criteria were being unable to retrieve patient data from articles, and the same patient series included in different studies. Among 1746 studies imported for screening, twenty-one were included (2783 patients). Mean overall survival was between 0.5 and 5 months after peritoneal carcinomatosis diagnosis and 9 and 21 months from lung cancer diagnosis. In total, 27% of patients underwent first-line or palliative chemotherapy and 7% of them surgery. Management differs significantly among published studies. The literature on PCLC is scarce. Its incidence is low but appears to be substantially rising and is likely to be an underestimation. Prognosis is very poor and therapeutic strategies have been limited and used in a minority of patients. Subcategories of PCLC patients may have an improved prognosis and may benefit from an aggressive oncological approach, including cytoreductive surgery. Further investigation would be needed in this regard.

High-resolution anoscopy predictive modeling of anal canal cancer response after definitive chemoradiotherapy in COVID19 era.

PURPOSE: To develop a predictive index model, integrating both clinical and high-resolution anoscopy (HRA) features to further personalize the decision making process in anal canal carcinoma in COVID19 era. METHODS AND MATERIALS: We assess HRA parameters after definitive chemoradiotherapy in patients with anal canal malignant lesions. RESULTS: HRA features could be important to assess the effect of CRT and a risk stratification system should be introduced in clinical practice to better allocate therapeutic interventions. CONCLUSION: To our knowledge this is the first proposal for HRA findings in anal canal cancer after definitive CRT. We believe that a risk score can be useful to estimate the risk of treatment failure (in term of persistence disease and/or recurrence) and its clinical relevance should not to be underestimated.

Percutaneous cholecystostomy as bridge to surgery vs surgery in unfit patients with acute calculous cholecystitis: A systematic review and meta-analysis.

BACKGROUND: Acute cholecystitis is one of the most common causes of acute abdomen. Early laparoscopic cholecystectomy is the gold standard treatment, still burdened by a risk of intraoperative biliary duct injury. An alternative strategy to manage patients with severe acute cholecystitis is the percutaneous gallbladder drainage (PGBD). METHODS: The Italian Society of Emergency Surgery and Trauma performed a systematic review and meta-analysis with the aim to clarify controversies about the preoperative use of PGBD. We extracted 32 studies: 9 Randomized Control Trial Studies (RCTs) and 23 no RCTs. RESULTS OF CRITICAL OUTCOMES: The incidence of post-operative complications was lower in the PGBD associated at LC than in the LC alone (RCTs: RR 0.28, 95% CI 0.14 to 0.56, I2 = 63%). The incidence of the post-operative biliary leakage was higher in late PGBD' group (RCTs: RR 0.18, 95% CI 0.04 to 0.80). RESULTS OF OTHER OUTCOMES: The incidence of intraabdominal abscess, blood loss, conversion to open, subtotal cholecystectomy, operative time and wound infection was lower in PGBD' group. The total hospital stay was the same. CONCLUSION: A strong recommendation is performed to the use of the PGBD + LC than upfront LC to reduce biliary leakage (recommendation "strong positive") in high risk acute cholecystitis especially in patients with higher perioperative risks or longstanding acute cholecystitis. For post-operative complications a recommendation "positive weak" suggests that PGBD + LC could be used than upfront LC to reduce the rate of post-operative complications.

Endoscopic Stenting and Palliative Chemotherapy in Advanced Colorectal Cancer: Friends or Foes? An Analysis of the Current Literature.

BACKGROUND/AIM: Chemotherapy offers a clear benefit in terms of survival rates of stage IV metastatic colorectal cancer (CRC) patients, but this advantage might be mitigated by the theoretical risks of short- and mid-term complications in the cases of contextual self-expandable metal stent (SEMS) positioning, which might also affect survival rates. MATERIALS AND METHODS: We reviewed all available literature from Medline and Scopus databases to study the role of chemotherapy with or without the simultaneous administration of targeted therapy in increasing the risk of the complications after SEMS positioning and, eventually, in affecting the survival rates. RESULTS: Thirteen retrospective studies and 1 randomized controlled trial (RCT) were eligible for the present analysis. The study group consisted of a total of 682 patients. A total of 305 patients were treated with conventional chemotherapy, 212 with conventional chemotherapy also containing targeted therapy, and 165 with no chemotherapy administration. Chemotherapy administration did not increase the rate of SEMS-related complications and these complications did not affect the overall survival rates. CONCLUSION: Chemotherapy administration is not associated with a higher risk of SEMS-related complications and a reduction in the survival rates.

State-of-the-art surgery for sigmoid diverticulitis.

BACKGROUND: In the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease. PURPOSE: This article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis. CONCLUSION: Acute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann's procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann's procedure, and it is associated with a high rate of primary anastomosis.

Treatment in locally advanced rectal cancer: a machine learning bibliometric analysis.

A bibliometric analysis was performed using a machine learning bibliometric methodology in order to evaluate the research trends in locally advanced rectal cancer treatment between 2000 and 2020. Information regarding publication outputs, countries, institutions, journals, keywords, funding, and citation counts was retrieved from Scopus database. During the search process, a total of 2370 publications were identified. The vast majority of papers originated from the United States of America, reflecting also its research drive in the collaboration network. Neoadjuvant treatment was the topic most studied in the highly cited studies. New keywords, including neoadjuvant chemotherapy, multiparametric magnetic resonance imaging, circulating tumor DNA, and genetic heterogeneity, appeared in the last 2 years. The quantity of publications on locally advanced rectal cancer treatment since 2000 showed an evolving research field. The 'new' keywords explain where research is presently heading.