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.

Current Trends in Volume and Surgical Outcomes in Gastric Cancer.

Gastric cancer is ranked as the fifth most frequently diagnosed type of cancer. Complete resection with adequate lymphadenectomy represents the goal of treatment with curative intent. Quality assurance is a crucial factor in the evaluation of oncological surgical care, and centralization of healthcare in referral hospitals has been proposed in several countries. However, an international agreement about the setting of "high-volume hospitals" as well as "minimum volume standards" has not yet been clearly established. Despite the clear postoperative mortality benefits that have been described for gastric cancer surgery conducted by high-volume surgeons in high-volume hospitals, many authors have highlighted the limitations of a non-composite variable to define the ideal postoperative period. The textbook outcome represents a multidimensional measure assessing the quality of care for cancer patients. Transparent and easily available hospital data will increase patients' awareness, providing suitable elements for a more informed hospital choice.

Oesophageal carcinoma in the horn of Africa Ten year cumulative experience in two hospitals in Djibouti.

INTRODUCTION: In this paper we report on our experience of diagnosis, treatment and follow up of cases of cancer of the oesophagus treated in Balbala Cheiko Hospital and in the Djibouty Military Hospital. Oesophageal cancer, mainly squamous cellular type, is the prevalent cancer of the gastrointestinal tract (GIT) observed in our two Hospitals. Djibouti is a small pacific country located in the Horn of Africa in the tropics, bordered by Somaliland in the south, Ethiopia in the southwest, Eritrea in the north and the Red Sea and the Gulf of Aden in the east. Yemen lies across the Gulf of Aden. Djibouti is the principal maritime port for Ethiopia. The country was formerly French Somaliland and it became independent from France in June 1977. It is a multi-ethnic nation with a population of just over 900,000. MATERIAL AND METHODS: From January 2011 to April 2021, we observed 159 patients diagnosed with cancer of the oesophagus: 89 females representing 56 % and 70 males representing 44 %. An Oesophageal Cancer Card (see Annex 1) was completed for each patient. 107 patients (67.30%) reported regularly (twice a week) chewing of khat (see Annex 2) and 68 patients (42,76%) regularly smoked more than 20 cigarettes and drank more than three very hot cups of coffee or tea per day. All patients underwent an oesophagoscopy with biopsy. Squamous Cell Carcinoma (OSCC) was confirmed by histology in all cases, 89 of them being females (64%) which is surprisingly different from data reported in the literature which reports a general prevalence of males. 60 patients (37.7 % of the total) underwent surgery. The Ivor-Lewis operation was the most frequent type of surgery and was done in 44 patients (66.6%). RESULTS: Our ten years experience involved two hospitals serving a large area. Cancer of the oesophagus (OC) was the prevalent gastrointestinal cancer we observed, second only to female breast cancer. There are no facilities in the country for radiotherapy. It is very difficult to report on long term survival because most of patients live in rural areas which are very difficult to reach and they rarely return for medical check-ups. The best survival recorded was a 48 year old Afar male who was still alive 6 years after an Ivor-Lewis operation was performed for squamous carcinoma on 3 April 2014 and checked on September 2020. A further 6 patients (2 males and 4 females, 3 with adenocarcinoma and 3 with squamous cell carcinoma) recently checked are still alive and come in regularly for check-up. CONCLUSIONS: Oesophageal cancer is one of the most frequent cancers found in the Horn of Africa and our experience in Djibouti confirms the data of the literature 16,28,29. A peculiarity in our study is the high prevalence in the female population. Our recommendation is to set-up an oesophageal cancer unit (OCU) with a team of specialists: gastroenterologist, surgical oncologist, anaesthesiologists, pathologists, nutritionalists and trained nurses who could ensure, not only hospital support, but also the active post operative follow up of patients. The implementation of a National Cancer Register would be mandatory. KEY WORDS: Oesophageal Cancer, Ivor Lewis Operation, Follow up, Djibouti.