Predictive Factors for Difficult Laparoscopic Cholecystectomies in Acute Cholecystitis.

Laparoscopic cholecystectomy (LC) is the gold standard treatment in acute cholecystitis. However, one in six cases is expected to be difficult due to intense inflammation and suspected adherence to and involvement of adjacent important structures, which may predispose patients to higher risk of vascular and biliary injuries. In this study, we aimed to identify the preoperative parameters with predictive value for surgical difficulties. A retrospective study of 255 patients with acute cholecystitis admitted in emergency was performed between 2019 and 2023. Patients in the difficult laparoscopic cholecystectomy (DLC) group experienced more complications compared to the normal LC group (33.3% vs. 15.3%, p < 0.001). Age (p = 0.009), male sex (p = 0.03), diabetes (p = 0.02), delayed presentation (p = 0.03), fever (p = 0.004), and a positive Murphy sign (p = 0.007) were more frequently encountered in the DLC group. Total leukocytes, neutrophils, and the neutrophil-to-lymphocyte ratio (NLR) were significantly higher in the DLC group (p < 0.001, p = 0.001, p = 0.001 respectively). The Tongyoo score (AUC ROC of 0.856) and a multivariate model based on serum fibrinogen, thickness of the gallbladder wall, and transverse diameter of the gallbladder (AUC ROC of 0.802) showed a superior predictive power when compared to independent parameters. The predictive factors for DLC should be assessed preoperatively to optimize the therapeutic decision.

The Significance of Preoperative Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Systemic Inflammatory Index (SII) in Predicting Severity and Adverse Outcomes in Acute Calculous Cholecystitis.

The prediction of severity in acute calculous cholecystitis (AC) is important in therapeutic management to ensure an early recovery and prevent adverse postoperative events. We analyzed the value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic inflammatory index (SII) to predict advanced inflammation, the risk for conversion, and postoperative complications in AC. Advanced AC was considered the cases with empyema, gangrene, perforation of the gallbladder, abscesses, or difficulties in achieving the critical view of safety. A 3-year retrospective was performed on 235 patients admitted in emergency care for AC. The NLR was superior to the PLR and SII in predicting advanced inflammation and risk for conversion. The best predictive value was found to be at an NLR "cut-off" value of >4.19, with a sensitivity of 85.5% and a specificity of 66.9% (AUC = 0.824). The NLR, SII, and TG 13/18 correlate well with postoperative complications of Clavien-Dindo grade IV (p < 0.001 for all variables) and sepsis. For predicting early postoperative sepsis, TG 13/18 grading >2 and NLR > 8.54 show the best predicting power (AUC = 0.931; AUC = 0.888, respectively), although not significantly higher than that of the PLR and SII. The NLR is a useful biomarker in assessing the severity of inflammation in AC. The SII and PLR may be useful in the prediction of systemic inflammatory response.

When Not to Operate on Acute Cases-A Surgeon's Perspective on Rapid Assessment of Emergency Abdominopelvic Computed Tomography.

Clinical problem solving evolves in parallel with advances in technology and discoveries in the medical field. However, it always reverts to basic cognitive processes involved in critical thinking, such as hypothetical-deductive reasoning, pattern recognition, and compilation models. When dealing with cases of acute abdominal pain, clinicians should employ all available tools that allow them to rapidly refine their analysis for a definitive diagnosis. Therefore, we propose a standardized method for the quick assessment of abdominopelvic computed tomography as a supplement to the traditional clinical reasoning process. This narrative review explores the cognitive basis of errors in reading imaging. It explains the practical use of attenuation values, contrast phases, and windowing for non-radiologists and details a multistep protocol for finding radiological cues during CT reading and interpretation. This systematic approach describes the salient features and technical tools needed to ascertain the causality between clinical patterns and abdominopelvic changes visible on CT scans from a surgeon's perspective. It comprises 16 sections that should be read successively and that cover the entire abdominopelvic region. Each section details specific radiological signs and provides clear explanations for targeted searches, as well as anatomical and technical hints. Reliance on imaging in clinical problem solving does not make a decision dichotomous nor does it guarantee success in diagnostic endeavors. However, it contributes exact information for supporting the clinical assessments even in the most subtle and intricate conditions.

When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy.

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.

The Value of White Cell Inflammatory Biomarkers as Potential Predictors for Diabetic Retinopathy in Type 2 Diabetes Mellitus (T2DM).

The pathogenesis of diabetic retinopathy is still challenging, with recent evidence proving the key role of inflammation in the damage of the retinal neurovascular unit. This study aims to investigate the predictive value of the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte (PLR), lymphocyte-to-monocyte ratio (LMR), and systemic inflammation index (SII) for diabetic retinopathy (DR) and its severity. We performed a retrospective study on 129 T2DM patients, divided into three groups: without retinopathy (NDR), non-proliferative DR (NPDR), and proliferative DR (PDR). NLR, MLR, and SII were significantly higher in the PDR group when compared to NDR and NPDR (3.2 ± 1.6 vs. 2.4 ± 0.9 and 2.4 ± 1.1; p = 0.005; 0.376 ± 0.216 vs. 0.269 ± 0.083 and 0.275 ± 0.111, p = 0.001; 754.4 ± 514.4 vs. 551.5 ± 215.1 and 560.3 ± 248.6, p = 0.013, respectively). PDR was correlated with serum creatinine (OR: 2.551), NLR (OR: 1.645), MPV (OR: 1.41), and duration of diabetes (OR: 1.301). Logistic regression analysis identified three predictive models with very good discrimination power for PDR (AUC ROC of 0.803, 0.809, and 0.830, respectively): combining duration of diabetes with NLR, MLR, and, respectively, PLR, MPV, and serum creatinine. NLR, MPV, SII, and LMR were associated with PDR and could be useful when integrated into comprehensive risk prediction models.

Transabdominal Preperitoneal Versus Lichtenstein Procedure for Inguinal Hernia Repair in Adults: A Comparative Evaluation of the Early Postoperative Pain and Outcomes.

Inguinal hernia repairs are one of the most common procedures in general surgery. In addition to classical open surgery, laparoscopic techniques, such as transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) hernia repair, have gained acceptance and are increasingly used for inguinal hernia repairs, and these three techniques are the only standards for inguinal hernia repairs. This study aimed to compare the results of inguinal hernia repairs in adult patients using the TAPP patch technique and Lichtenstein techniques regarding the level of pain perceived one day after surgery and the number of days of hospitalization. A two-year study was performed on 129 patients who underwent TAPP vs. 109 patients who underwent Liechtenstein hernia repair. Our results revealed statistical significance for both variables (Tpain(233) = -7.12, p< 0.001, d=2.92; Tdays of hospitalization(233) = -31.34, p< 0.001, d=4.01). TAPP is a safe method for inguinal hernia repairs, allowing quick recovery and less postoperative pain than the classical Liechtenstein technique.

Gut Microbiota Dysbiosis in Diabetic Retinopathy-Current Knowledge and Future Therapeutic Targets.

Diabetic retinopathy is one of the major causes of blindness today, despite important achievements in diagnosis and therapy. The involvement of a gut-retina axis is thought to be a possible risk factor for several chronic eye disease, such as glaucoma, age-related macular degeneration, uveitis, and, recently, diabetic retinopathy. Dysbiosis may cause endothelial disfunction and alter retinal metabolism. This review analyzes the evidence regarding changes in gut microbiota in patients with DR compared with diabetics and healthy controls (HCs). A systematic review was performed on PubMed, Web of Science, and Google Scholar for the following terms: "gut microbiota" OR "gut microbiome" AND "diabetic retinopathy". Ultimately, 9 articles published between 2020 and 2022 presenting comparative data on a total of 228 T2DM patients with DR, 220 patients with T2DM, and 118 HCs were analyzed. All of the studies found a distinctive microbial beta diversity in DR vs. T2DM and HC, characterized by an altered Firmicutes/Bacteroidetes ratio, a decrease in butyrate producers, and an increase in LPS-expressing and pro-inflammatory species in the Bacteroidetes and Proteobacteria phyla. The probiotic species Bifidobacterium and Lactobacillus were decreased when compared with T2DM. Gut microbiota influence retinal health in multiple ways and may represent a future therapeutic target in DR.

Role of glutathione-S-transferase gene P1 in the diagnosis of prostate cancer in patients with 'grey level' prostate-specific antigen values.

Prostate cancer (PC) represents the second most frequent cancer diagnosis in men and, at the same time, is one of the top six causes of death worldwide. The aim of the present study was to evaluate the diagnostic value of glutathione-S-transferase gene P1 (GST-P1) in patients that fall within the 'grey area' of the prostate-specific antigen (PSA) values. A retrospective observational study on 80 patients with prostate abnormal volumes and PSA values in the range 4-10 ng/ml was performed. The prostate gland was extracted following transrectal ultrasonography, and GST-P1 gene expression was analysed. A histopathological examination was considered the gold standard for PC diagnosis. Among the 53 patients diagnosed with PC, 69.8% (n=37) were GST-P1-positive, whereas, among the 27 patients diagnosed with benign prostatic hyperplasia, 18.5% (n=5) were GST-P1-positive. The sensitivity for diagnosing PC in patients with PSA values between 4 and 10 ng/ml was 69.81%, and the specificity was 81.48%. The positive predictive value was 88.1% [95% confidence interval (CI), 74.37-96.02%] and the negative predictive value was 57.89% (95% CI, 40.82-73.69%). Collectively, these results show the potential of using GST-P1 gene expression in patients who are suspected of having PC, but where the PSA values are inconclusive.

Optimal Timing and Outcomes of Minimally Invasive Approach in Acute Biliary Pancreatitis.

BACKGROUND We analyzed the outcomes of early biliary decompression by a minimally invasive approach in acute biliary pancreatitis (ABP). MATERIAL AND METHODS A retrospective study was conducted on 143 patients with ABP who underwent biliary decompression by laparoscopic or endoscopic approach between January 2015 and March 2022. Data from the observation sheets and surgical protocols were analyzed in terms of demographic characteristics, clinical and paraclinical features at admission, comorbidities, therapeutic management, and outcomes. RESULTS The mean patient age was 62.3±11.4 years. Mild ABP had a higher frequency in men (75.5%) and urban areas (70.4%). The comorbidities associated with a higher risk of severe forms were diabetes mellitus (odds ratio [OR]: 11.250), chronic bronchopneumopathy (OR: 29.297), and ischemic coronary disease (OR: 2.784). The mean hospital stay was 7.6±3.8 days and was significantly higher in severe forms (10±2.4 days, P<0.001). The time from onset to presentation was significantly higher in severe vs mild forms (5.6 vs 1.8 days, P<0.001) and was associated with systemic and local complications. Creatinine over 2 mg/dL (OR: 4.821) and leukocytes >15 000/mmc at admission (OR: 3.533) were risk factors for systemic complications, while obesity was associated with increased local complications (OR: 5.179). None of the patients with an early presentation developed severe ABP. CONCLUSIONS Early biliary decompression, as soon as possible after onset, either by an endoscopic or minimally invasive approach, is a safe and effective procedure in ABP. The type of procedure and optimal timing should be individualized, according to the patient's local and general features.

Ocular Side Effects of Aromatase Inhibitor Endocrine Therapy in Breast Cancer - A Review.

BACKGROUND: Aromatase inhibitor therapy is currently the preferred choice in postmenopausal women with estrogen receptor positive breast cancer. This article reviews the ocular side effects of treatment with aromatase inhibitors (AIs) in patients with breast cancer. MATERIALS AND METHODS: A comprehensive search was performed on PubMed, Web of Science and Google scholar. RESULTS: After duplication removal, 14 clinical studies and 5 case reports, published between 2008 and 2021, were identified. Most frequently, AI treatment resulted in minor to moderate dry eye symptoms. "De novo" onset of Sjogren syndrome during AI therapy was also reported. Retinal and optic nerve side effects varied from mild, subclinical anatomic and functional impairment to severe decreased vision, secondary to hemi-central retinal artery occlusion, bilateral optic neuritis or uveitis with bilateral macular edema. CONCLUSION: Visual disturbances encountered during AI treatment may be underestimated. Ophthalmic screening is important for early detection and appropriate treatment.

Systematic review of the role of indocyanine green near-infrared fluorescence in safe laparoscopic cholecystectomy (Review).

With the widespread introduction of laparoscopic cholecystectomy, the incidence of iatrogenic main bile duct lesions has significantly increased, with incidences ranging from 0.2 to 1.5% according to current studies. Although there are studies regarding the use of indocyanine green (ICG) for improved visualization of the biliary anatomy, there is no consensus on the dose, timing and optimal mode of administration, or the indications in which ICG provides a real benefit through increased safety in laparoscopic cholecystectomy (LC). A systematic review was performed on articles in English published until March 2021, which were identified on PubMed, Springer Nature, Elsevier and Scopus via specific mesh terms: 'Indocyanine green'/'near-infrared fluorescence' and 'laparoscopic cholecystitis'. The most used method of administration of ICG was intravenously, only one study evaluated the efficiency of a near-infrared cholangiogram (NIRC) when ICG was administered directly in the gallbladder. The majority of the studies included in the review used 2.5 mg of ICG administered within 1 h before imaging. The intensity of the NIRC fluorescence signal was revealed to depend on several factors, with obesity and inflammation as the most clinically significant. NIRC was reported to be a simple, feasible, safe and cost-effective procedure, which may improve safety in difficult cases of LC. NIRC use in combination with white light has been demonstrated to be superior to white light alone in identifying extrahepatic biliary anatomy, thus decreasing the risk of intraoperative bile duct injuries (BDI). For its large-scale use, data on a higher number of patients to confirm its clinical value and specific indications is required.

Tyrosine kinase inhibitors in breast cancer (Review).

Anti-epidermal growth factor receptor (EGFR)-targeted therapy has been intensely researched in the last years, motivated by the favorable results obtained with monoclonal antibodies in HER2-enriched breast cancer (BC) patients. Most researched alternatives of anti-EGFR agents were tyrosine kinase inhibitors (TKIs) and monoclonal antibodies. However, excluding monoclonal antibodies trastuzumab and pertuzumab, the remaining anti-EGFR molecules have exhibited disappointing results, due to the lack of specificity and frequent adverse side effects. TKIs have several advantages, including reduced cardiotoxicity, oral administration and favorable penetration of blood-brain barrier for brain metastatic BC. Lapatinib and neratinib and recently pyrotinib (approved only in China) are the only TKIs from dozens of molecules researched over the years that were approved to be used in clinical practice with limited indications, in a subset of BC patients, single or in combination with other chemotherapy or hormonal therapeutic agents. Improved identification of BC subtypes and improved characterization of aggressive forms (triple negative BC or inflammatory BC) should lead to advancements in shaping of targeted agents to improve the outcome of patients.

Impact of modern personalized treatment of breast cancer on surgical attitude and outcomes.

Multimodal treatment of breast cancer has made steady progress in recent years. The involvement of modern oncology, diagnostic imaging techniques and surgical treatment, have brought a definite benefit to patients, defining the multidisciplinary treatment of breast cancer. The introduction of immunohistochemical testing and genetic screening has led to the prioritization of therapy according to their results and a correct approach to initiating treatment. The main aim of the present study was to conduct a comparative analysis through a retrospective study of the therapeutic means used in breast cancer with the statistical evaluation of the obtained results. To carry out the study, a group of 125 patients hospitalized during the period January 2015 to December 2020, were included, and the parameters were selected from the observation sheets. The results of the study demonstrated the superiority of multimodal treatment of breast cancer over surgical treatment as the only therapeutic management. The introduction of ultrasound-guided biopsies and conservative surgical options has led to increased diagnostic accuracy and a significant improvement in aesthetic outcome. The multidisciplinary approach to breast cancer allows an individualized treatment by performing immunohistochemical testing and through the use of neoadjuvant and adjuvant treatment combined with conservative surgical techniques with a more favorable cosmetic and oncological result, with reduced postoperative complications.

Significance of Neutrophil to Lymphocyte Ratio (NLR) and Platelet Lymphocyte Ratio (PLR) in Diabetic Foot Ulcer and Potential New Therapeutic Targets.

Diabetic foot ulcer (DFU) is a well-known complication of diabetes and a significant burden on the national health systems. The neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio are inexpensive and easily accessible biomarkers that have proved to be useful in several inflammatory, infectious and cardiovascular diseases. We carried out a comprehensive review examining the association of NLR and PLR with the onset and progression of DFU. PLR and NLR were significantly increased in patients with DFU, compared with a control group of T2DM patients without DFU, and correlate well with DFU severity, evaluated by Wagner and IWGDF grading scales. In patients with diabetic foot infections (DFI), elevated NLR and PLR were correlated with osteomyelitis, increased risk of amputation, and septic complications. The significance of the elevated value of these biomarkers in DFU is related to chronic hyperglycemia and low-grade systemic inflammation, atherosclerotic and vascular complications, and also the associated septic factor. Serial, dynamic follow-up can provide useful information in planning and monitoring DFU treatment, as well as in risk stratification of these vulnerable patients. Further randomized studies are needed to set the cut-off values with clinical significance.

Optimization of a GF-AAS method for lead testing in blood and urine: A useful tool in acute abdominal pain management in emergency.

Suspicion of lead poisoning is confirmed by its concentration in blood and protoporphyrin red blood cells. At low concentrations, lead influences the synthesis of the heme in the sense of lowering it. Acute and chronic lead intoxication is extremely polymorphic in regards to its clinical manifestations, with digestive, hematological, cardiovascular, renal hepatic and neurological features. The aim of the study was to evaluate the presence of lead in human whole blood and urine harvested before and during chelation treatment in the case of lead poisoning. An atomic absorption spectroscopic method for the analysis of lead was developed using graphite furnace atomic absorption spectrophotometer (GF-AAS), Varian Spectra AA-880 with a hollow cathode lead lamp and a deuterium lamp for background correction, coupled to a GTA-100 atomizer and a programmable sample dispenser. Standard calibration solutions were used for the range 10-100 µg/l. The linearity range was 10.0 to 100.0 µg/l with the correlation coefficient of 0.999. We established that the method can be applied for the determination of lead in whole blood and urine, and the results obtained are useful for monitoring chelation therapy in cases of acute lead poisoning, a neglected cause of abdominal colic pain in an emergency situation.

Acute surgical abdomen during the COVID-19 pandemic: Clinical and therapeutic challenges.

The present study investigated the effects of the COVID-19 pandemic on the clinical presentation and therapeutic management of acute surgical abdomen. A retrospective study of emergency hospitalizations with a diagnosis of acute surgical abdomen between April and July 2020 vs. a similar period in 2019 was performed. The observation sheets and the operating protocols were analyzed. Between April and July 2020, 50 cases of acute surgical abdomen were hospitalized and treated, compared to 43 cases in the same period last year. The main types of pathology in both groups included: Occlusions (60%, respectively 44.2% in 2019) and peritonitis (32%, respectively 41.8% in 2019). There was an increased rate of patients with colorectal cancers neglected therapeutically or uninvestigated, who presented during the pandemic period with emergencies for complications such as occlusion or tumor perforation (32 vs. 6.97%, P=0.0039). One case, with gastric perforation, was COVID-positive, with no pulmonary symptoms at admission. The number of postoperative infectious complications was lower during the pandemic (2 vs. 13.95%, P=0.0461). As the COVID-19 pandemic appears to be still far from ending, we should learn to adapt our surgical protocols to the new evidence. Oncological patients are a vulnerable group, who were neglected in the first months of the pandemic. SARS-Cov-2 infection may be a cause of abdominal pain and should be taken into account in different diagnoses of acute abdomen in surgical wards. Correct wearing of adequate personal protective equipment (PPE) and respecting strict rules of asepsis and antisepsis are required for preventing in-hospital transmission of infection.

Safety of Laparoscopic Cholecystectomy for Acute Cholecystitis in the Elderly: A Multivariate Analysis of Risk Factors for Intra and Postoperative Complications.

Background and Objectives: This study investigates the impact of age upon the safety and outcomes of laparoscopic cholecystectomy performed for acute cholecystitis, by a multivariate approach. Materials and Methods: A 2-year retrospective study was performed on 333 patients admitted for acute cholecystitis who underwent emergency cholecystectomy. The patients included in the study group were divided into four age subgroups: A ≤49 years; B: 50-64 years; C: 65-79 years; D ≥80 years. Results: Surgery after 72 h from onset (p = 0.007), severe forms, and higher American Society of Anesthesiologists Physical Status Classification and Charlson comorbidity index scores (p < 0.001) are well correlated with older age. Both cardiovascular and surgical related complications were significantly higher in patients over 50 years (p = 0.045), which also proved to be a turning point for increasing the rate of conversion and open surgery. However, the comparative incidence did not differ significantly between patients aged from 50-64 years, 65-79 years and over 80 years (6.03%, 9.09% and 5.8%, respectively). Laparoscopic cholecystectomy (LC) was the most frequently used surgical approach in the treatment of acute cholecystitis in all age groups, with better outcomes than open cholecystectomy in terms of decreased overall and postoperative hospital stay, reduced surgery related complications, and the incidence of acute cardiovascular events in the early postoperative period (p < 0.001). Conclusions: The degree of systemic inflammation was the main factor that influenced the adverse outcome of LC in the elderly. Among comorbidities, diabetes was associated with increased surgical and systemic postoperative morbidity, while stroke and chronic renal insufficiency were correlated with a high risk of cardiovascular complications. With adequate perioperative care, the elderly has much to gain from the benefits of a minimally invasive approach, which allows a decreased rate of postoperative complications and a reduced hospital stay.

Diabetic Retinopathy in Patients With Diabetic Foot Ulcer: A Systematic Review.

This review discusses the evidence on diabetic retinopathy (DR) in patients with diabetic foot ulceration (DFU). A systematic literature review was performed on PubMed, Medline, Springer Nature, and Scopus, following the PRISMA guidelines, using the following terms, individually or in combination: "diabetic foot ulcer" OR "diabetic foot syndrome" OR "DFU" and "diabetic retinopathy." The initial search yielded 648 articles published between 1975 and 2020. After applying exclusion and inclusion criteria, a total of 9 articles were analyzed, assessing the correlations between DR and DFU. In all cases, DR and especially proliferative diabetic retinopathy were significantly higher in the presence of DFU, though the frequency of DR showed large variability (22.5% to 95.6%). There was a significant correlation between advanced stages of DFU and increased frequency of DR and proliferative diabetic retinopathy. On the other hand, there is a risk of accelerated progression of DR in nonhealing DFUs, possibly related to chronic inflammation and associated infection. Hence, patients with DFUs should be monitored by an ophthalmologist, and those with DR should be promptly referred to a specialized diabetic foot clinic.

Acute Mesenteric Ischemia in COVID-19 Patients.

Acute mesenteric ischemia is a rare but extremely severe complication of SARS-CoV-2 infection. The present review aims to document the clinical, laboratory, and imaging findings, management, and outcomes of acute intestinal ischemia in COVID-19 patients. A comprehensive search was performed on PubMed and Web of Science with the terms "COVID-19" and "bowel ischemia" OR "intestinal ischemia" OR "mesenteric ischemia" OR "mesenteric thrombosis". After duplication removal, a total of 36 articles were included, reporting data on a total of 89 patients, 63 being hospitalized at the moment of onset. Elevated D-dimers, leukocytosis, and C reactive protein (CRP) were present in most reported cases, and a contrast-enhanced CT exam confirms the vascular thromboembolism and offers important information about the bowel viability. There are distinct features of bowel ischemia in non-hospitalized vs. hospitalized COVID-19 patients, suggesting different pathological pathways. In ICU patients, the most frequently affected was the large bowel alone (56%) or in association with the small bowel (24%), with microvascular thrombosis. Surgery was necessary in 95.4% of cases. In the non-hospitalized group, the small bowel was involved in 80%, with splanchnic veins or arteries thromboembolism, and a favorable response to conservative anticoagulant therapy was reported in 38.4%. Mortality was 54.4% in the hospitalized group and 21.7% in the non-hospitalized group (p < 0.0001). Age over 60 years (p = 0.043) and the need for surgery (p = 0.019) were associated with the worst outcome. Understanding the mechanisms involved and risk factors may help adjust the thromboprophylaxis and fluid management in COVID-19 patients.

Laparoscopic Surgery in COVID-19 Era-Safety and Ethical Issues.

(1) Background: The paper aims to review the available evidence regarding the health risk of the aerosolization induced by laparoscopy induced and impact of the COVID-19 pandemic upon minimally invasive surgery. (2) Materials and methods: A systematic review of the literature was performed on PubMed, Medline and Scopus until 10 July. (3) Results: Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. However, the only evidence of viral transmission through surgical smoke to medical staff is post-laser ablation of HPV-positive genital warts. The reports of SARS-CoV-2 infected patients who underwent laparoscopic surgery revealed the presence of the virus, when tested, in digestive wall and stools in 50% of cases but not in bile or peritoneal fluid. All surgeries did not result in contamination of the personnel, when protective measures were applied, including personal protective equipment (PPE) and filtration of the pneumoperitoneum. There are no comparative studies between classical and laparoscopic surgery. (4) Conclusions: Previously published data showed there is a possible infectious and toxic risk related to surgical smoke but not particularly proven for SARS-CoV-2. Implementing standardized filtration systems for smoke evacuation during laparoscopy, although increases costs, is necessary to increase the safety and it will probably remain a routine also in the future.