Current use of artificial intelligence in the diagnosis and management of acute appendicitis

INTRODUCTION

Acute appendicitis is a common and time-sensitive surgical emergency, requiring rapid and accurate diagnosis and management to prevent complications. Artificial intelligence (AI) has emerged as a transformative tool in healthcare, offering significant potential to improve the diagnosis and management of acute appendicitis. This review provides an overview of the evolving role of AI in the diagnosis and management of acute appendicitis, highlighting its benefits, challenges, and future perspectives.

EVIDENCE ACQUISITION

We performed a literature search on articles published from 2018 to September 2023. We included only original articles.

EVIDENCE SYNTHESIS

Overall, 121 studies were examined. We included 32 studies: 23 studies addressed the diagnosis, five the differentiation between complicated and uncomplicated appendicitis, and 4 studies the management of acute appendicitis.

CONCLUSIONS

AI is poised to revolutionize the diagnosis and management of acute appendicitis by improving accuracy, speed and consistency. It could potentially reduce healthcare costs. As AI technologies continue to evolve, further research and collaboration are needed to fully realize their potential in the diagnosis and management of acute appendicitis.

Artificial Intelligence to Early Predict Liver Metastases in Patients with Colorectal Cancer: Current Status and Future Prospectives

BACKGROUND

Artificial Intelligence (AI)-based analysis represents an evolving medical field. In the last few decades, several studies have reported the diagnostic efficiency of AI applied to Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) to early detect liver metastases (LM), mainly from colorectal cancer. Despite the increase in information and the development of different procedures in several radiological fields, an accurate method of predicting LM has not yet been found. This review aims to compare the diagnostic efficiency of different AI methods in the literature according to accuracy, sensibility, precision, and recall to identify early LM.

METHODS

A narrative review of the literature was conducted on PubMed. A total of 336 studies were screened.

RESULTS

We selected 17 studies from 2012 to 2022. In total, 14,475 patients were included, and more than 95% were affected by colorectal cancer. The most frequently used imaging tool to early detect LM was found to be CT (58%), while MRI was used in three cases. Four different AI analyses were used: deep learning, radiomics, machine learning, and fuzzy systems in seven (41.18%), five (29.41%), four (23.53%), and one (5.88%) cases, respectively. Four studies achieved an accuracy of more than 90% after MRI and CT scan acquisition, while just two reported a recall rate ≥90% (one method using MRI and CT and one CT).

CONCLUSIONS

Routinely acquired radiological images could be used for AI-based analysis to early detect LM. Simultaneous use of radiomics and machine learning analysis applied to MRI or CT images should be an effective method considering the better results achieved in the clinical scenario.

Neuraxial anesthesia in hepato-pancreatic-bilio surgery: a first western pilot study of 46 patients

The most common anesthetic approach in hepato-pancreatic-biliary (HPB) surgery is general anesthesia (GA), but it may result in increased morbidity and mortality and peri-operative risks especially in frail patients. The aim of this study was to assess the safety and effectiveness of neuraxial anesthesia (NA) in HPB in a pilot clinical series. This analysis was conducted on 46 consecutive patients undergoing HPB surgery in an Italian Tertial referral center. Data were prospectively collected and retrospectively analyzed. continuous spinal anesthesia (CSA), combined spino-epidural anesthesia (CSEA) and peridural anesthesia (PA) were used in major and minor hepatectomies and bilio-pancreatic surgery instead of GA. NA was evaluated by analyzing the surgical and anesthesiological short-term outcomes. 46 patients were considered eligible for the study between February 2018 and May 2020. The average age was 69.07 (±  9.95) years. 22 were males and 24 were females. According to the ASA score, 19 (41.30%) patients had ASA II, 22 (47.83%) had ASA III and 5 (10.87%) had ASA IV. 22 (47.83%) patients underwent CSA, 20 (43.48%) CSEA and 4 (8.69%) PA. We performed 8 major and 19 minor hepatectomies, 7 bilio-digestive derivations, 5 Whipple procedures, 4 iatrogenic biliary duct injuries, 2 splenopancreatectomies and 1 hepatic cyst fenestration. Clavien-Dindo ≥ 3 was observed in 3 patients. The conversion rate to endotracheal intubation occurring in 3 of 46 (6.52%) patients. After surgery, no local or pulmonary complications and delirium were reported in our series. The present study demonstrates that NA is a safe and feasible option in selected patients, if performed in referral centers by well-trained anaesthesiologists and surgeons.

Quantum technologies in space

Recently, the European Commission supported by many European countries has announced large investments towards the commercialization of quantum technology (QT) to address and mitigate some of the biggest challenges facing today's digital era - e.g. secure communication and computing power. For more than two decades the QT community has been working on the development of QTs, which promise landmark breakthroughs leading to commercialization in various areas. The ambitious goals of the QT community and expectations of EU authorities cannot be met solely by individual initiatives of single countries, and therefore, require a combined European effort of large and unprecedented dimensions comparable only to the Galileo or Copernicus programs. Strong international competition calls for a coordinated European effort towards the development of QT in and for space, including research and development of technology in the areas of communication and sensing. Here, we aim at summarizing the state of the art in the development of quantum technologies which have an impact in the field of space applications. Our goal is to outline a complete framework for the design, development, implementation, and exploitation of quantum technology in space.

Bone Marrow Stromal Cell Assays: In Vitro and In Vivo

Populations of bone marrow stromal cells (BMSCs, also known as bone marrow-derived "mesenchymal stem cells") contain a subset of cells that are able to recapitulate the formation of a bone/marrow organ (skeletal stem cells, SSCs). It is now apparent that cells with similar but not identical properties can be isolated from other skeletal compartments (growth plate, periosteum). The biological properties of BMSCs, and these related stem/progenitor cells, are assessed by a variety of assays, both in vitro and in vivo. Application of these assays in an appropriate fashion provide a great deal of information on the role of BMSCs, and the subset of SSCs, in health and in disease.

Impact of land use history on the arbuscular mycorrhizal fungal diversity in arid soils of Argentinean farming fields

Arbuscular mycorrhizal fungi (AMF) are a key soil functional group, with an important potential to increase crop productivity and sustainable agriculture including food security. However, there is clear evidence that land uses, crop rotations and soil features affect the AMF diversity and their community functioning in many agroecosystems. So far, the information related to AMF biodiversity in ecosystems like the Argentinean Puna, an arid high plateau where plants experience high abiotic stresses, is still scarce. In this work, we investigated morphological and molecular AMF diversity in soils of native corn, bean and native potato Andean crops, under a familiar land use, in Chaupi Rodeo (Jujuy, Argentina), without agrochemical supplements but with different histories of crop rotation. Our results showed that AMF morphological diversity was not only high and variable among the three different crop soils but also complemented by Illumina MiSeq data. The multivariate analyses highlighted that total fungal diversity is significantly affected by the preceding crop plants and the rotation histories, more than from the present crop species, while AMF communities are significantly affected by preceding crop only in combination with the effect of nitrogen and calcium soil concentration. This knowledge will give useful information on appropriate familiar farming.

Adrenal gland tumors in dairy cattle from Northern Italy: morphological and phenotypical characterization in comparison with human pathology

Bovine adrenal gland tumours are considered relatively common, although scarce data are available about their real incidence, pathological characterization, classification criteria and immunohistochemical profile. This study describes the morphological and immunophenotypical characteristics of 35 dairy cattle adrenal gland tumors from Northern Italy and compare them with human pathology. Macroscopical, histological, histochemical and immunohistochemical investigations were performed. Microscopically proliferative lesions were classified as focal hyperplasia (8/35), primary cortical tumors (15/35) , primary medullary tumors (12/35). The cortical tumors showed a highly heterogeneous spectrum of morphological aspects not matching the two major diagnostic categories of adenoma and carcinoma in either cattle or humans. The medullary tumors (7 neuroblastomas and 5 pheochromocytomas) showed morphological and immunophenotypical features largely overlapping with human counterparts. Although limited by the small number of neoplasms and the lack of evidence of metastases precluding a clear distinction between benign and malignant lesions, this study represents the first attempt to compare the bovine and the human pathology. The present data support the concept that adrenal tumors in cattle have distinctive features that deserve a species- specific classification.

Management of Complications of First Instance of Hepatic Trauma in a Liver Surgery Unit: Portal Vein Ligation as a Conservative Therapeutic Strategy

BACKGROUND

According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma.

METHODS

From June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first - line strategy for damage control surgery (DCS) in liver trauma.

RESULTS

26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure.In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%).

CONCLUSIONS

The improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.

[Biological risk in agriculture and construction workplaces: a survey on perception, knowledge and prevention measures.]

OBJECTIVES

Despite the potential presence in many workplaces, biological risk is little known and largely underestimated, except in healthcare environments. Objectives: To evaluate perception, knowledge and behaviors adopted for protection and prevention of biological risk, related also to the occupational activity, among construction and agricultural workers.

METHODS

Workers were recruited at farms and construction companies of Molise Region, Central Italy, which were visited within the surveillance activities planned by local institutions. A questionnaire was administered to workers to collect sociodemographic and occupational data, and concerning risk perception and knowledge, and awareness of available prevention measures, also related to the work activity.

RESULTS

total of 143 workers (73.4% males, 42.9±10.7 years old) were interviewed, and 56.6% were construction workers. Only 24% of workers believed that infectious diseases could be frequent and health threatening in carrying out the work activities; half of them declared to be exposed to biological hazards, but 70% were unworried. An underestimation of the severity of some pathologies, such as listeriosis, leptospirosis and viral hepatitis emerged, and only 70% of workers believed that tetanus is highly or very highly dangerous for health. Furthermore, 33% of workers said to have scarce or insufficient knowledge of biological risk, and 97.2%, 80.4% and 45.5% were aware that a vaccine is available for tetanus, hepatitis B and A, respectively. All workers undergone the tetanus vaccination and 39.2% the anti-hepatitis B.

CONCLUSIONS

Despite the high probability of exposure to biological agents, the results of the survey revealed a lack of perception and knowledge of the risk, as well as a poor awareness of available preventive measures among construction and agricultural workers. These data point out the need to activate information and training programs on exposure to biological agents and on both emerging and re-emerging infectious diseases potentially related to work activities, and to provide prevention procedures specific for these workplaces.

[The role of agentic capacities in turnover intentions among nurses]

OBJECTIVES

Voluntary turnover in the nursing profession is one of the main concerns in hospitals and it requests comprehensive research. This study contributes to explain the reasons related to turnover intention of nurses and provides causes for reflection to improve the working practice.

METHODS

161 nurses and 13 nursing coordinators, working in the wards of two Italian hospitals, participated in the study. A self-report questionnaire was administered to them in order to analyze the relationship between agentic capacities (self-regulation, anticipation, vicarious learning, self-reflection) and the intentions to leave the ward and the hospital.

RESULTS

The data show a negative association between self-regulation and the desire to leave the ward and the hospital, and a positive association between self-reflection and the intention to leave the ward. The results also show that organizational seniority has a negative effect on intentions to leave the ward and the hospital, while professional seniority has a positive effect only on the intention to leave the hospital. Finally, the nursing coordinators perceive to have a greater ability to manage their own emotional states and behavior, to prefigure future events and to learn from their own experience than nurses.

CONCLUSIONS

The study's results suggest actions and interventions to develop self-regulation of the nursing staff to reduce turnover intentions and improve the quality of the service offered taking into account seniority and professional organization.

Results following laparoscopic sleeve gastrectomy in elderly obese patients: a single center experience with follow-up at three years

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) represents the most performed bariatric surgical procedure worldwide. Morbid Overweight in elderly patients is becoming a significant health problem even in Italy. As well as in younger age groups, bariatric surgery could be indicated even in this subset of patients. However the advantages and results of LSG in patients over 60 years old have received minimal attention.

METHODS

The records of 375 patients underwent LSG between 2008 and 2016 were reviewed. In the entire series 18 patients were aged 60 years or older at the time of surgery. Since a 3 years follow-up was available for 12 patients out of the 18 aged over 60 we included in the study only these. General epidemiologic data, clinical findings, BMI and comorbidities surgical treatment and follow-up data were collected; postoperative measurements such as operative time, intraoperative complications, mortality rate, length of stay, incidence of early and late complications, Body mass Index (BMI), excess weight loss rate (EWL%) and comorbidities resolution were also recorded.

RESULTS

LSG was successfully performed for all geriatric patients. Global complications rate was 16.6% At 3 years mean BMI was 34.4±3.8 with a mean EWL% 66.1±31.9. Postoperative resolution of obesity comorbidities was observed; Hypertension (71.4%), type 2 Diabetes Mellitus (T2DM) (50.0%), obstructive sleep apnea syndrome (OSAS) (66.6%) respectively. No intraoperative complications or mortality were recorded.

CONCLUSIONS

LSG offered cure in geriatric patients affected by morbid obesity for weight loss and comorbidities resolution. Larger studies are necessary to analyze and minimize the incidence of postoperative complications associated to this surgical procedure in elderly patients.

Hairy Cell Leukemia: Preliminary Results with Alpha2 (r) Interferon

Ten patients with hairy cell leukemia are being treated at our institution with a therapeutic schedule of α2(r) interferon (2 × 106 IU/m2 s.c. three times per week). Five patients underwent splenectomy from 4 to 108 months before treatment; nonsplenectomized patients had spleens palpable 6 to 12 cm UCM. According to Quesada's response criteria, at the sixth month of therapy, one patient was considered a complete responder, 8 partial responders and one a minor responder, with no differences between splenectomized and nonsplenectomized patients. In nonsplenectomized patients the spleen returned to normal. Our data confirm that interferon, even at low dosages, is a very effective approach for hairy cell leukemia. No evidence was found to contraindicate such therapy.

Acute complications following endoscopic intragastric balloon insertion for treatment of morbid obesity in elderly patients. A single center experience

BACKGROUND

Obesity is a serious disease, with an increasing incidence also among subjects over 60 years old; surgical management has proven to be the most effective in the production of significant and durable weight loss. Intragastric balloon (IGB) treatment promotes a reduction of five to nine Body Mass Index (BMI) units in 6 months with an impressive improvement of obesity-associated comorbidities.

METHODS

Two hundred and twenty-five patients, 106 men (47.1%) and 119 women (52.9%), were evaluated at our institution to be submitted to a IGB positioning. Of these, 12 patients (8 women and 4 men) were more than 60 years old. For all patients BMI, comorbidities, weight loss and complications were recorded. χ2 test was used to evaluate differences in complications rate between elderly and other patients.

RESULTS

For the 12 elderly patients, we recorded a mean excess weight loss rate (EWL%) of 31.4. About complications, we recorded 2 severe esophagitis requiring IGB removal and 1 late gastric perforation. A higher complications rate was found in elderly population and the comparison with other patients revealed a significant difference (P<0.001).

CONCLUSIONS

Our results underline that IGB treatment in elderly patients is safe and effective in terms of weight loss and improvement in comorbidities. IGB can cause complications which, sometimes, can be severe such as esophageal damage and gastric perforation. For the management of complications, we highly recommend a close follow-up in all patients and a deepened instrumental study in every suspect case.

No Identical "Mesenchymal Stem Cells" at Different Times and Sites: Human Committed Progenitors of Distinct Origin and Differentiation Potential Are Incorporated as Adventitial Cells in Microvessels

A widely shared view reads that mesenchymal stem/stromal cells (“MSCs”) are ubiquitous in human connective tissues, can be defined by a common in vitro phenotype, share a skeletogenic potential as assessed by in vitro differentiation assays, and coincide with ubiquitous pericytes. Using stringent in vivo differentiation assays and transcriptome analysis, we show that human cell populations from different anatomical sources, regarded as “MSCs” based on these criteria and assumptions, actually differ widely in their transcriptomic signature and in vivo differentiation potential. In contrast, they share the capacity to guide the assembly of functional microvessels in vivo, regardless of their anatomical source, or in situ identity as perivascular or circulating cells. This analysis reveals that muscle pericytes, which are not spontaneously osteochondrogenic as previously claimed, may indeed coincide with an ectopic perivascular subset of committed myogenic cells similar to satellite cells. Cord blood-derived stromal cells, on the other hand, display the unique capacity to form cartilage in vivo spontaneously, in addition to an assayable osteogenic capacity. These data suggest the need to revise current misconceptions on the origin and function of so-called “MSCs,” with important applicative implications. The data also support the view that rather than a uniform class of “MSCs,” different mesoderm derivatives include distinct classes of tissue-specific committed progenitors, possibly of different developmental origin.

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CD146⁺ “MSCs” from different tissues exhibit different transcriptional profiles

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CD146⁺ “MSCs” from different tissues have different differentiation capacities

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CD146⁺ “MSCs” from different tissues organize blood vessels and become pericytes

Microbial agents in macroscopically healthy mammary gland tissues of small ruminants

Background

Health of mammary glands is fundamental for milk and dairy products hygiene and quality, with huge impacts on consumers welfare.

Methods

This study aims to investigate the microbial agents (bacteria, fungi and lentiviruses) isolated from 89 macroscopically healthy udders of regularly slaughtered small ruminants (41 sheep, 48 goats), also correlating their presence with the histological findings. Multinomial logistic regression was applied to evaluate the association between lesions and positivity for different microbial isolates, animal age and bacteria.

Results

Twenty-five samples were microbiologically negative; 138 different bacteria were isolated in 64 positive udders. Coagulase-negative staphylococci were the most prevalent bacteria isolated (46.42%), followed by environmental opportunists (34.76%), others (10.14%) and pathogens (8.68%). Most mammary glands showed coinfections (75%). Lentiviruses were detected in 39.3% of samples. Histologically, chronic non-suppurative mastitis was observed in 45/89 glands, followed by chronic mixed mastitis (12/89) and acute suppurative mastitis (4/89). Only 28 udders were normal. Histological lesions were significantly associated with the animal species and lentiviruses and coagulase-negative staphylococci infections. Goats had significantly higher risk to show chronic mixed mastitis compared to sheep. Goats showed a significantly lower risk (OR = 0.26; 95% CI [0.06-0.71]) of being infected by environmental opportunists compared to sheep, but higher risk (OR = 10.87; 95% CI [3.69-37.77]) of being infected with lentiviruses.

Discussion

The results of the present study suggest that macroscopically healthy glands of small ruminants could act as a reservoir of microbial agents for susceptible animals, representing a potential risk factor for the widespread of acute or chronic infection in the flock.

Biological risk among agriculture and construction workers in Molise Region, Central Italy

BACKGROUND

Biological risk is a significant issue in workplaces due to continuous modification of work organization and condition.

OBJECTIVES

In this pilot study, perception and knowledge of biological risk, as well as adoption of prevention measures were evaluated among construction and agriculture workers.

METHODS

A structured questionnaire was administered to workers to collect socio-demographic and employment information, in addition to data on risk perception and knowledge, and adoption of preventive measures, including those related to work activities.

RESULTS

Fifty-three workers aged 45.3±9.8 years participated in the study, 81% were male, and 70% were construction workers. Approximately 80% of participants declared that infectious diseases are neither frequent nor health-threatening in their occupational activity. The majority of workers considered some diseases, such as hepatitis A and B, leptospirosis and listeriosis, as posing a low risk to their health. Forty-seven % claimed to be unexposed to biohazards at their workplace, and 72% were not worried about them. Ninety-six % of the workers knew about vaccination for tetanus, but only 74% and 36% knew about the availability of vaccination for Hepatitis A and B, respectively. During lifetime, 94% of the workers received at least one vaccination. All workers had undergone tetanus vaccination, but only few received vaccine for influenza, hepatitis B and tuberculosis.

CONCLUSIONS

This pilot study in occupational settings revealed a poor perception of biological risk and a limited awareness of the severity of infectious diseases. Major knowledge gaps existed about the available preventive measures. It is essential to promote safety culture at the workplace also with regard to biological hazards. This requires improving information and education, conducting appropriate studies, and prompting health and safety professional actors to focus on occupational infectious disease problems.

Totally laparoscopic liver resection for colorectal metastasis located in Segment 7 in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a congenital condition consisting of a mirror image of transposition of the abdominal and thoracic organs occurring in about 1:5000 to 1:10 000 adults. We report on a 60-year-old male with a single colorectal liver metastasis in the Segment 7. The patients underwent a totally laparoscopic sub-segmentectomy. Intraoperative approach on a reverse posterior segment was difficult because of left-sided position of the liver. Postoperative course was uneventful and the patient was discharged after 5 days. To our knowledge, only a few cases of open liver resections in patients with SIT have been published. This is, therefore, the first case of laparoscopic liver resection for colorectal liver metastasis in a patient with SIT. We provide the readers with useful tips to perform minimally invasive liver surgery in such patients.

Negative pressure therapy alone or with irrigation in the management of severe peritonitis

BACKGROUND

Ogilvie was the first to publish on open abdomen (OA) for the treatment of the damages caused by penetrating abdominal wounds in war events. Research improved those devices that allow a controlled, homogeneous and continuous extraction of contaminated fluids from all abdominal recesses, which are nowadays the base of the "Open Abdomen" technique.

MATERIALS AND METHODS

From August 2012 to February 2016 at the Department of Emergency Surgery of Cardarelli Hospital in Naples, 40 patients affected by Severe Peritonitis have been treated with OA technique. 13 (32,5%) were treated with only the suction-drainage system, 27 patients (67,5%) were treated with suction drainage and irrigation system. Abthera® device was used in all patients.

RESULTS

The duration of treatment was 15 days in the first group, with 7 device's substitutions, while in the second group it was about 10 days with 4 substitutions At the end of the procedure we were able to perform primary fascia closure in 7 cases (53,8%) in the first group and in 23 cases (85.2%) in the second group. 4 patients (30,8%) died in the first group, and 7 (26%) in the second.

CONCLUSION

The suction/irrigation method seems to be appropriate to use in case of a surgical emergency that causes severe peritonitis. It is associated not only with lower death rates but also with better parameters, that are more frequently worse during prolonged treatments. Irrigation of abdominal cavity causes also less retraction of fascia recti which leads to a higher rate of direct fascia closure. Key Words: Emergency surgery, Irrigation, Open abdomen, Peritonitis.

An AT-barrier mechanically controls DNA reannealing under tension

Regulation of genomic activity occurs through the manipulation of DNA by competent mechanoenzymes. Force-clamp optical tweezers that allow the structural dynamics of the DNA molecule to be measured were used here to investigate the kinetics of mechanically-driven strand reannealing. When the force on the torsionally unconstrained λ-phage DNA is decreased stepwise from above to below the overstretching transition, reannealing occurs via discrete shortening steps separated by exponentially distributed time intervals. Kinetic analysis reveals a transition barrier 0.58 nm along the reaction coordinate and an average reannealing-step size of ∼750 bp, consistent with the average bp interval separating segments of more than 10 consecutive AT bases. In an AT-rich DNA construct, in which the distance between segments of more than 10 consecutive AT is reduced to ∼210 bps, the reannealing step reduces accordingly without changes in the position of the transition barrier. Thus, the transition barrier for reannealing is determined by the presence of segments of more than 10 consecutive AT bps independent of changes in sequence composition, while the length of the reannealing strand changes according to the distance between poly-AT segments at least 10 bps long.

Primary anastomosis in emergency surgery of left colon cancer

INTRODUCTION

Colorectal cancers are second leading cause of death in Western countries. There are about 1500 deaths per year in Italy due to colorectal cancer in both sex 1.

MATERIALS AND METHODS

224 patients, 127 women (56.7%) and 97 men (43.3%) underwent colorectal resection with primary anastomosis (RPA) in emergency due to occlusive left colon cancer between 2010 and 2016. Patients had a mean age of 67.2 year a BMI inferior than 30 Kg/m2 in 215 cases (96%) and a history of cardiovascular disease in 112 (50%) cases.

RESULTS

All patients with a regular postoperative course have had no more than 10 days of hospitalization except for four who suffered postoperative ileus which solved after no more 15 days. We have had 24 (10.7%) cases of morbidity for generic causes and 12 cases (5.4%) of post-operative complications. Pneumonia, which occurred in 12 cases (5.4%), was the most frequent.

CONCLUSION

The ideal technique does not actually exist. RPA is, when feasible, advisable for occlusive neoplastic cases, ensuring a low percentage of morbidity and mortality and respecting patient's quality of life.

"Commercial stem cells" damage medicine: medicine is aware

A recent Editorial in the NEJM on the flourishing of stem cell clinics providing unproven treatments ona commercial basis and the widespread use of fake cell therapies in the US resonates with worldwide concerns on unproven therapies and in Italy, with the recent and luckily finished “Stamina case”. The article brings into focus a resurgence of concern, awareness and willingness to stand up of the broad medical community, in a scenario in which fundamental values of science and medicine are at stake.

Segmentectomy: is minimally invasive surgery going to change a liver dogma?

Nowadays, the respective approach to hepatic resections (for malignant or benign liver lesions) is oriented toward minimal parenchymal resection. This surgical behavior is sustained by several observations that surgical margin width is not correlated with recurrence of malignancies. Parenchymal-sparing resection reduces morbidity without changing long-term results and allows the possibility of re-do liver resection in case of recurrence. Minimally invasive liver surgery (MILS) is performed worldwide and is considered a standard of care for many surgical procedures. MILS is associated with less blood loss, less analgesic requirements, and shorter length of hospital with a better quality of life. One of the more frequent criticisms to MILS is that it represents a more challenging approach for anatomical segmentectomies and that in most cases a non-anatomical resection could be performed with thinner resection margins compared with open surgery. But even in the presence of reduced surgical margins, oncological results in the short- and long-term follow-up seem to be the same such as open surgery. The purpose of this review is to try to understand whether chasing at any cost laparoscopic anatomical segmentectomies is still necessary whereas non-anatomical resections, with a parenchymal-sparing behavior, are feasible and overall recommended also in a laparoscopic approach. The message coming from this review is that MILS is opening more and more new frontiers that are still need to be supported by further experience.

Osteoblast-specific expression of the fibrous dysplasia (FD)-causing mutation Gsα(R201C) produces a high bone mass phenotype but does not reproduce FD in the mouse

We recently reported the generation and initial characterization of the first direct model of human fibrous dysplasia (FD; OMIM #174800), obtained through the constitutive systemic expression of one of the disease-causing mutations, Gsα(R201C) , in the mouse. To define the specific pathogenetic role(s) of individual cell types within the stromal/osteogenic system in FD, we generated mice expressing Gsα(R201C) selectively in mature osteoblasts using the 2.3kb Col1a1 promoter. We show here that this results in a striking high bone mass phenotype but not in a mimicry of human FD. The high bone mass phenotype involves specifically a deforming excess of cortical bone and prolonged and ectopic cortical bone remodeling. Expression of genes characteristic of late stages of bone cell differentiation/maturation is profoundly altered as a result of expression of Gsα(R201C) in osteoblasts, and expression of the Wnt inhibitor Sost is reduced. Although high bone mass is, in fact, a feature of some types/stages of FD lesions in humans, it is marrow fibrosis, localized loss of adipocytes and hematopoietic tissue, osteomalacia, and osteolytic changes that together represent the characteristic pathological profile of FD, as well as the sources of specific morbidity. None of these features are reproduced in mice with osteoblast-specific expression of Gsα(R201C) . We further show that hematopoietic progenitor/stem cells, as well as more mature cell compartments, and adipocyte development are normal in these mice. These data demonstrate that effects of Gsα mutations underpinning FD-defining tissue changes and morbidity do not reflect the effects of the mutations on osteoblasts proper.

Skeletal stem cells

Skeletal stem cells (SSCs) reside in the postnatal bone marrow and give rise to cartilage, bone, hematopoiesis-supportive stroma and marrow adipocytes in defined in vivo assays. These lineages emerge in a specific sequence during embryonic development and post natal growth, and together comprise a continuous anatomical system, the bone-bone marrow organ. SSCs conjoin skeletal and hematopoietic physiology, and are a tool for understanding and ameliorating skeletal and hematopoietic disorders. Here and in the accompanying poster, we concisely discuss the biology of SSCs in the context of the development and postnatal physiology of skeletal lineages, to which their use in medicine must remain anchored.

Skeletal stem cells in space and time

The nature, biological characteristics, and contribution to organ physiology of skeletal stem cells are not completely determined. Chan et al. and Worthley et al. demonstrate that a stem cell for skeletal tissues, and a system of more restricted, downstream progenitors, can be identified in mice and demonstrate its role in skeletal tissue maintenance and regeneration.

Spontaneous Age-related Changes of Peripheral Nerves in Cattle: Morphological and Biochemical Studies

Peripheral nerve function is significantly affected by ageing. During ageing process, multiple changes occur on tissue cells and extracellular matrix. The aim of this work was to study the ageing-associated changes of peripheral nerves in adult and old regularly slaughtered cattle compared with young calves, and correlate them to the features reported in humans and laboratory animals. Samples of axial dorsal metacarpal nerves from 44 cows were collected immediately after slaughtering. Each nerve was dissected and divided into two fragments: one used for morphological evaluation (n = 43) and the other one for biochemical analysis (n = 31). Axonal degeneration, demyelination, thickness of perineurium and endoneurium and increase of mast cells were the most important features detected. The mean amount of glycosaminoglycan quantitative content recorded in the samples increased with the age. Axonal degeneration, demyelination and thickness of endoneurium were positively and significantly correlated with biochemistry. The presence of changes affecting the different elements of the peripheral nerves, similar to that reported in humans and in laboratory species, the easy availability of the nerve tissue in this species, the considerable size of the samples and the life conditions more similar to humans than to laboratory animals, allows the authors to consider cattle as a potential good model for the comparative study of spontaneous ageing nerve lesions.

Lipid profile changes in patients undergoing bariatric surgery: a comparative study between sleeve gastrectomy and mini-gastric bypass

OBJECTIVE

To prospectively evaluate the effect of different types of bariatric surgery on lipid profile.

METHODS

Total cholesterol (TC), High-Density-Lipoprotein cholesterol (HDLc), Low-Density-Lipoprotein cholesterol (LDLc) and triglycerides (TG) levels were evaluated before surgery and at 3 different post-operative time-points (3, 6 and 12 months) in consecutive obese subjects undergoing mini-gastric bypass (MGB) or sleeve gastrectomy (SG).

RESULTS

At baseline, 74 MGB and 86 SG subjects were comparable for lipid profile and prevalence of hypercholesterolemia/hypertriglyceridemia. During the post-operative follow-up, both MGB and SG subjects showed significant changes in lipid profile. However, at 3 months, MGB patients showed higher changes in TC (β = 0.179, p = 0.022) and TG (β = 0.265, p = 0.001) than those undergoing SG. At 6-month post-operative follow-up, these differences were confirmed only for TC. After a 12-month follow-up, MGB and SG were entirely comparable for changes in lipid profile with the exception of HDLc, whose changes were higher in SG group (β = 0.130, p = 0.039). Overall, the probability to normalize lipid profile during the 12-month follow-up was similar in MGB and in SG patients (OR:1.24, 95%CI:0.41-3.76, p = 0.689).

CONCLUSION

Despites some differences at 3-6 post-operative months, during a 12-month follow-up, SG and MGB showed a similar efficacy in the improvement of lipid profile of obese patients.

The transition mechanism of DNA overstretching: a microscopic view using molecular dynamics

The overstretching transition in torsionally unconstrained DNA is studied by means of atomistic molecular dynamics simulations. The free-energy profile as a function of the length of the molecule is determined through the umbrella sampling technique providing both a thermodynamic and a structural characterization of the transition pathway. The zero-force free-energy profile is monotonic but, in accordance with recent experimental evidence, becomes two-state at high forces. A number of experimental results are satisfactorily predicted: (i) the entropic and enthalpic contributions to the free-energy difference between the basic (B) state and the extended (S) state; (ii) the longitudinal extension of the transition state and (iii) the enthalpic contribution to the transition barrier. A structural explanation of the experimental finding that overstretching is a cooperative reaction characterized by elementary units of approximately 22 base pairs is found in the average distance between adenine/thymine-rich regions along the molecule. The overstretched DNA adopts a highly dynamical and structurally disordered double-stranded conformation which is characterized by residual base pairing, formation of non-native intra-strand hydrogen bonds and effective hydrophobic screening of apolar regions.

Stem cells and bone: a historical perspective

Bone physiology and stem cells were tightly intertwined with one another, both conceptually and experimentally, long before the current explosion of interest in stem cells and so-called regenerative medicine. Bone is home to the two best known and best characterized systems of postnatal stem cells, and it is the only organ in which two stem cells and their dependent lineages coordinate the overall adaptive responses of two major physiological systems. All along, the nature and the evolutionary significance of the interplay of bone and hematopoiesis have remained a major scientific challenge, but also allowed for some of the most spectacular developments in cell biology-based medicine, such as hematopoietic stem cell transplantation. This question recurs in novel forms at multiple turning points over time: today, it finds in the biology of the "niche" its popular phrasing. Entirely new avenues of investigation emerge as a new view of bone in physiology and medicine is progressively established. Looking at bone and stem cells in a historical perspective provides a unique case study to highlight the general evolution of science in biomedicine since the end of World War II to the present day. A paradigm shift in science and in its relation to society and policies occurred in the second half of the XXth century, with major implications thereof for health, industry, drug development, market and society. Current interest in stem cells in bone as in other fields is intertwined with that shift. New opportunities and also new challenges arise. This article is part of a Special Issue entitled "Stem cells and bone".

Stem cells and bone diseases: new tools, new perspective

Postnatal skeletal stem cells are a unique class of progenitors with biological properties that extend well beyond the limits of stemness as commonly defined. Skeletal stem cells sustain skeletal tissue homeostasis, organize and maintain the complex architectural structure of the bone marrow microenvironment and provide a niche for hematopoietic progenitor cells. The identification of stem cells in the human post-natal skeleton has profoundly changed our approach to the physiology and pathology of this system. Skeletal diseases have been long interpreted essentially in terms of defective function of differentiated cells and/or abnormal turnover of the matrix that they produce. The notion of a skeletal stem cell has brought forth multiple, novel concepts in skeletal biology that provide potential alternative concepts. At the same time, the recognition of the complex functions played by skeletal progenitors, such as the structural and functional organization of the bone marrow, has provided an innovative, unifying perspective for understanding bone and bone marrow changes simultaneously occurring in many disorders. Finally, the possibility to isolate and highly enrich for skeletal progenitors, enables us to reproduce perfectly normal or pathological organ miniatures. These, in turn, provide suitable models to investigate and manipulate the pathogenetic mechanisms of many genetic and non-genetic skeletal diseases. This article is part of a Special Issue entitled Stem cells and Bone.

A randomized, double blind, placebo-controlled trial of alendronate treatment for fibrous dysplasia of bone

CONTEXT

Fibrous dysplasia (FD) is a rare skeletal disorder, resulting in deformity, fracture, functional impairment, and pain. Bisphosphonates have been advocated as a potential treatment.

OBJECTIVE

To determine the efficacy of alendronate for treatment of FD.

DESIGN

Two-year randomized, double-blind, placebo-controlled trial.

SETTING

Clinical research center.

PATIENTS

Forty subjects with polyostotic FD (24 adults, 16 children). Subjects were randomized and stratified by age.

INTERVENTIONS

Study drug was administered over a 24 month period in 6 month cycles (6 months on, 6 months off). Alendronate dosing was stratified: 40 mg daily for subjects >50 kg, 20 mg for 30-50 kg, 10 mg for 20-30 kg.

MAIN OUTCOME MEASURES

Primary endpoints were bone turnover markers, including serum osteocalcin, and urinary NTX-telopeptides. Secondary endpoints included areal bone mineral density (aBMD), pain, skeletal disease burden score, and functional parameters including the 9-min walk test and manual muscle testing.

RESULTS

Clinical data was collected on 35 subjects who completed the study. There was a decline in NTX-telopeptides in the alendronate group (P = .006), but no significant difference in osteocalcin between groups. The alendronate group had an increase in areal BMD in normal bone at the lumbar spine (P = .006), and in predetermined regions of FD (P < .001). There were no significant differences in pain scores, skeletal disease burden scores, or functional parameters between the groups.

CONCLUSIONS

Alendronate treatment led to a reduction in the bone resorption marker NTX-telopeptides, and improvement in aBMD, but no significant effect on serum osteocalcin, pain, or functional parameters.

A technical modification of video-assisted ablation for recurrent pilonidal sinus

AIM

The study evaluated, in a proof of concept, the usefulness of a prosthesis (plug) in addition to video assisted ablation of pilonidal sinus (VAAPS) for treatment of recurrent pilonidal sinus.

METHOD

This is a case series of recurrent complex pilonidal sinus treated by VAAPS plus plug positioning.

RESULTS

Four patients were analysed. All were successfully treated by this new approach. No difficulties in inserting the plug were identified. Complete healing was achieved in all cases. No infection or recurrence was reported during a limited follow-up.

CONCLUSION

This new technique allows a minimally invasive scarless approach to recurrent pilonidal sinus.

Constitutive expression of Gsα(R201C) in mice produces a heritable, direct replica of human fibrous dysplasia bone pathology and demonstrates its natural history

Fibrous dysplasia of bone (FD) is a crippling skeletal disease associated with postzygotic mutations (R201C, R201H) of the gene encoding the α subunit of the stimulatory G protein, Gs. By causing a characteristic structural subversion of bone and bone marrow, the disease results in deformity, hypomineralization, and fracture of the affected bones, with severe morbidity arising in childhood or adolescence. Lack of inheritance of the disease in humans is thought to reflect embryonic lethality of germline-transmitted activating Gsα mutations, which would only survive through somatic mosaicism. We have generated multiple lines of mice that express Gsα(R201C) constitutively and develop an inherited, histopathologically exact replica of human FD. Robust transgene expression in neonatal and embryonic tissues and embryonic stem (ES) cells were associated with normal development of skeletal tissues and differentiation of skeletal cells. As in humans, FD lesions in mice developed only in the postnatal life; a defined spatial and temporal pattern characterized the onset and progression of lesions across the skeleton. In individual bones, lesions developed through a sequence of three distinct histopathological stages: a primary modeling phase defined by endosteal/medullary excess bone formation and normal resorption; a secondary phase, with excess, inappropriate remodeling; and a tertiary fibrous dysplastic phase, which reproduced a full-blown replica of the human bone pathology in mice of age ≥1 year. Gsα mutations are sufficient to cause FD, and are per se compatible with germline transmission and normal embryonic development in mice. Our novel murine lines constitute the first model of FD.

Bariatric surgery is not contraindicated in obese patients suffering from glycogen storage disease type IXa. A case report with follow-up at three years

INTRODUCTION

Glucose storage disease type IXa (GSD IXa) is an uncommon condition presenting with childhood onset hepatomegaly, growth retardation, and often, fasting ketosis and hypoglycemia. Despite its benign course, the lack of dietary counseling may favor uncontrolled weight gain. We investigated the efficacy of bariatric surgery in one 17 years old female suffering from GSD IXa and morbid obesity.

PRESENTATION OF CASE

The diagnosis was GSD type IXa in a patient with a body mass index (BMI) of 45.5 kg/m². Onset of hypoglycemia was reported twice each month. She was treated her implanting an adjustable gastric banding through laparoscopy. Three years after surgery the patient presents a BMI of 30.1 kg/m² and an excess of weight loss (EWL) of 71.1%. Only once, following surgery, she had to deflate her band to allow a faster transit of food through her stomach, thus reaching a prompt euglycemic condition, due to an incoming hypoglycemic crisis.

DISCUSSION

Laparoscopic adjustable gastric banding (LAGB) is one of the most used approaches to treat morbid obesity. It is a restrictive procedure unable to affect the absorption of any nutrient, presenting a very low intra and perioperative complication rate. In our GSD IXa patient, it offered a prompt modification of food intake restriction whenever requested, thus avoiding hypoglycemia.

CONCLUSION

LAGB is effective in determining weight loss without inducing significant side effects or worsening hypoglycemia, in this morbid obese patient, suffering from GSD type IXa.

microRNA levels in paraffin-embedded indolent B-cell non-Hodgkin lymphoma tissues from patients chronically infected with hepatitis B or C virus

Background

Epidemiological evidence links Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) to B-cell non-Hodgkin lymphoma (B-NHL). These B-NHLs, particularly those associated with HCV, may represent a distinct sub-group with peculiar molecular features, including peculiar expression of microRNAs (miRs).

The aim of the present study was to search for miRs whose level in indolent B-NHL tissues could be associated with HBV or HCV infection.

Methods

Fourteen formalin fixed paraffin embedded (FFPE) tissues from HBV+, HCV+ and HBV-/HCV- indolent B-NHL patients were analyzed for levels of 34 selected miRs by quantitative Real-Time PCR. Reactive lymph nodes (RLNs) from HBV-/HCV- patients were included as non-tumor control. Statistical analysis of output data included Pearson and Spearman correlation and Mann-Whitney test and were carried out by the STATA software.

Results

MiR-92a was decreased exclusively in HBV-/HCV- B-NHLs, while miR-30b was increased in HBV+ and HCV+ samples, though only the HCV+ achieved full statistical significance. Analysis of a small subset of B-NHLs belonging to the same histological subtype (Nodal Marginal Zone Lymphoma) highlighted three miRs associated with HCV infection (miR-223, miR-29a and miR-29b) and confirmed decreased level of miR-92a in HBV-/HCV- samples also when considering this restricted B-NHL group.

Conclusions

Although caution is needed due to the limited number of analyzed samples, overall the results suggest that differences at the miR expression level exist between indolent B-NHLs developed in patients with or without HBV or HCV infection. The identification of three further miRs associated with HCV by analyzing histologically homogeneous samples suggests that variations of miR levels possibly associated with HBV or HCV may be obscured by the tissue-specific variability of miR level associated with the different histological subtypes of B-NHL. Thus, the identification of further miRs will require, in addition to an increased sample size, the comparison of B-NHL tissues with the same histological classification.

"Mesenchymal" stem cells

Two opposing descriptions of so-called mesenchymal stem cells (MSCs) exist at this time. One sees MSCs as the postnatal, self-renewing, and multipotent stem cells for the skeleton. This cell coincides with a specific type of bone marrow perivascular cell. In skeletal physiology, this skeletal stem cell is pivotal to the growth and lifelong turnover of bone and to its native regeneration capacity. In hematopoietic physiology, its role as a key player in maintaining hematopoietic stem cells in their niche and in regulating the hematopoietic microenvironment is emerging. In the alternative description, MSCs are ubiquitous in connective tissues and are defined by in vitro characteristics and by their use in therapy, which rests on their ability to modulate the function of host tissues rather than on stem cell properties. Here, I discuss how the two views developed, conceptually and experimentally, and attempt to clarify the confusion arising from their collision.

Recipient perioperative cholesterolaemia and graft cholesterol metabolism gene expression predict liver transplant outcome

BACKGROUND & AIMS

We analysed for the first time whether recipient perioperative serum total cholesterol (sTC) concentration is associated with liver transplantation outcome.

METHODS

We studied noncholestatic cirrhotics submitted to primary deceased-donor liver transplantation in a prospective group (n=140) from Rome and in a validation retrospective cohort (n=157) from Udine, Italy. Pre-ischaemia and post-reperfusion cholesterol metabolism gene mRNA was measured by RT-PCR in 74 grafts of the study group.

RESULTS

At Cox regression analysis, independently from confounders including recipient MELD score, the recipient pre-operative sTC pooled quintiles 2-5, compared with the lowest quintile showed HR (95% CI) and significances for overall graft loss (GL) of 0.215 (0.104-0.444) P<0.001 in the study group and 0.319 (0.167-0.610) P=0.001 in the validation cohort. Analysing sTC as a continuous variable, the risk of overall GL for every 10-mg/dl decrease in pre-operative sTC increased by 13% and by 9% in the study group and in the validation cohort respectively. In the study group, independent associations at multivariate analyses were: (a) high graft pre-ischaemia expression of INSIG-1, which indicates hepatocellular cholesterol depletion, with post-reperfusion graft necrosis; (b) GL with inadequate graft post-reperfusion response to cholesterol depletion, shown by a failure to reduce the PCSK9 to LDLR expression ratio; (c) GL with a relative increase of sTC on post-operative day-7, selectively because of the LDL fraction, which indirectly suggests poor cholesterol uptake from blood.

CONCLUSIONS

Low recipient pre-transplant sTC concentration, its post-operative day-7 increase and a genetically determined low graft cholesterol availability predict poor liver transplant outcome.

Plasma fatty acid lipidome is associated with cirrhosis prognosis and graft damage in liver transplantation

BACKGROUND

Knowledge regarding the plasma fatty acid (FA) pattern in patients with liver cirrhosis is fragmentary.

OBJECTIVE

We evaluated plasma FA lipidome and its association with the prognosis of cirrhosis and severity of liver graft damage after transplantation.

DESIGN

In this observational study, plasma FA lipidome was investigated in 51 cirrhotic patients before liver transplantation and in 90 age- and sex-matched healthy control subjects. In addition, we studied ischemia-reperfusion damage in the liver of 38 patients for whom a graft biopsy was available at transplantation. With the use of logistic regression, we modeled the presence of cirrhosis, the dichotomized model for end-stage liver disease score below and above the median, and the presence of severe liver graft ischemia-reperfusion damage.

RESULTS

The FA pattern was markedly altered in cirrhotic patients, who showed, compared with healthy controls, higher monounsaturated FAs, lower n-6 and n-3 polyunsaturated FAs, and undetectable cerotic acid. Plasma di-homo-γ-linolenic acid was independently associated with the presence of cirrhosis (OR: 0.026; 95% CI: 0.004, 0.196; P < 0.0001), severity of its prognosis (OR: 0.041; 95% CI:0.005, 0.376; P = 0.006), postreperfusion graft hepatocellular necrosis (OR: 0.921; 95% CI: 0.851, 0.997; P = 0.043), and sinusoidal congestion (OR: 0.954; 95% CI: 0.912, 0.998; P = 0.039). Associations of di-homo-γ-linolenic acid with the presence of cirrhosis and severity of its prognosis were confirmed also after false discovery rate correction.

CONCLUSIONS

Cerotic and di-homo-γ-linolenic acids may serve as markers of disease and prognosis in liver cirrhosis. Dietary supplementation with di-homo-γ-linolenic acid could be a reasonable interventional strategy to delay disease progression in liver cirrhosis.

Laparoscopic sleeve gastrectomy: efficacy of fibrin sealant in reducing postoperative bleeding. A randomized controlled trial

Staple line leakage and bleeding are worrisome complications of laparoscopic sleeve gastrectomy (LSG). Solutions such as buttressing, oversewing or roofing the staple line with gelatin matrix have been proposed with controversial results. Because the use of fibrin sealant has shown a possible benefit in reducing the reoperation rate due to early complication in patients (pts) undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP), this solution has been tested in 100 consecutive pts undergoing LSG. A clinical trial has been performed on 100 consecutive pts. Exclusion criteria from the study were considered ASA IV pts, treated or untreated malignancies at any stage, steroids or FANS assumption, previous sovramesocolic surgery and conversion to open surgery. All pts were randomized to receive (group A, 50 pts) or to not receive (group B, 50 pts) 4 ml of human fibrin sealant (Tisseel™, Baxter(®) Deerfield, IL, USA) sprayed along the suture line. Primary endpoint was the incidence of postoperative complications: leaks, bleeding of the staple line or stenosis of the gastric remnant. Significance was assigned at a p level <0.05. By considering pts in group A vs. pts in group B our results shown no significant difference in fistulas or strictures occurrence (p = 0.2). Bleeding was significantly higher in patients not sprayed with sealant (group A vs. group B, 1/7, p = 0.03). This randomized trial has so far shown the use of fibrin sealant in LSG to significantly reduce postoperative bleeding. Although a trend in reducing leak occurrence emerges, it does not reach statistical significance.

Pilonidal sinus surgery: could we predict postoperative complications?

Pilonidal sinus surgery could, as of now, be considered a surgery tailored more to the surgeon than to the patient. In an attempt to give to surgeons an objective instrument of decision, we have evaluated which variables could be considered predictive of postoperative complications after pilonidal sinus surgery. A prospective electronic database of all patients treated for sacrococcygeal pilonidal disease was analysed. Sex, age, obesity, smoking, recurrent disease, the presence of multiple orifices and the distance between the most lateral orifice and midline were recorded and correlated with the occurrence of postoperative complications (infection and recurrence); 1006 patients were evaluated. Excision with primary mid-line closure was performed on all the patients. Mean follow-up was 7·3 ± 3·6 years. A total of 158 patients with postoperative complications (infection and/or recurrence) were recorded during this period. A multivariate analysis showed that, after adjusting for major clinical and demographic characteristics, only a recurrent disease [odds ratio (OR): 3·41, 95% confidence interval (CI): 1·89-6·15, P < 0·001] and the distance of lateral orifice from midline (OR: 26·3, 95% CI: 12·2-56·7, P < 0·001) were independent predictors of overall postoperative complications. Focussing on the distance from midline, the receiver operative characteristic (ROC) analysis showed that the distance of lateral orifice from midline predicted 79·2% of complications and the Youden's test identified the best cut-off as 2·0 cm for this variable. An evidence-based tool for deciding on the type of surgical intervention could be developed and validated by further ad hoc prospective studies evaluating our results in comparison to other different types of surgical techniques. Our results support the use of these variables as an effective way to tailor pilonidal sinus surgery to the patient, so as to obtain the best results in patient care.

A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution

BACKGROUND

Today a variety of bariatric surgical procedures is available and, currently, it is difficult to identify the most effective option based on patient characteristics and comorbidities. Aim of this retrospective study is to evaluate the efficacy of four different techniques; Intragastric Balloon (IB), Laparoscopic Adjustable Gastric Banding (LAGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Mini Gastric Bypass (LMGB), performed in our unit along ten years.

PATIENTS AND METHODS

Starting from January 2005, 520 patients, 206 men (39.6%) and 314 women (60.4%) were treated at our institution. Among patients candidate to bariatric surgery 145 underwent IB, 120 underwent LAGB, 175 underwent LSG and 80 underwent LMGB. Follow up rate was 93.1% for IB at 6 months; 74.1% and 48% for LAGB at 36 and 60 months respectively; 72.8% and 58.1% for LSG at 36 and 60 months respectively; and 84.2% for LMGB at 36 months.

RESULTS

The period 2005-2014 has been considered. Mortality was 1/520 patients (0.19%). The excess weight loss rate (EWL%) has been 32.8 for IB at six months, 53.7 for LAGB and 68.1 for LSG, at 60 months respectively and 79.5 for LMGB at 36 months. Early major postoperative complications requiring surgery were 0.6% for IB and 1.1% for LSG whereas late major postoperative complications were 1.2% for IB, 4.1% for LAGB and 0.5% for LSG. Diabetes resolution rate was 0 for LAGB, 76.9% for LSG and 80% for LMGB at 36 months.

CONCLUSIONS

If more invasive procedures as LSG or LMGB may entail higher operative and peroperative risks, conversely, in skilled hands their efficacy remains undisputed, especially in the long term, presenting a very low rate of major complications. In general, the efficacy of a bariatric surgery unit seems improved by the capability to offer both different primary procedures and re-do surgery.

Wernicke encephalopathy in subjects undergoing restrictive weight loss surgery: a systematic review of literature data

The use of weight loss surgery is progressively increasing, and in recent years, restrictive bariatric surgery procedures have been more often used. Although thought to be associated with a lower incidence of post-operative side effects than malabsorpitive surgery, some cases of micronutrients deficiency have been reported because of an acquired thiamine deficiency; in this clinical setting, some cases of Wernicke encephalopathy (WE) have been described. Major determinants and predictors of this major neurological complication are currently unknown. The aim of this systematic review was to analyse literature data in order to address this issue. The main result of our systematic review was that persistent vomiting is the major determinant of WE in patients undergoing restrictive weight loss surgery. In addition, early thiamine supplementation can rapidly improve the clinical conditions, avoiding permanent deficiencies. On the other hand, given the wide variability of clinical and demographic characteristics, definite prognostic factors of WE occurrence and of clinical outcome cannot be identified. In conclusion, although our results are suggestive, further ad hoc prospective studies evaluating changes in micronutrients levels according to different types of surgery are needed.

An early onset of acute renal failure in a young woman with obesity and infertility who underwent gastric balloon positioning. A case report

INTRODUCTION

Although intragastric balloons have been in use for several years to achieve weight reduction in obese patients, acute renal failure after gastric balloon positioning is reported in few studies

CASE REPORT

A 32-year-old white infertile woman undergone Bioenterics Intragastric Balloon (BIB) positioning in an attempt to weight loss and improve her fertility status. After only six days of persisting vomiting acute renal failure was found. A complete recovery of renal function was obtained after 14 days.

CONCLUSION

Acute renal failure was due to persistent vomiting leading to dehydration. Physicians involved in BIB patients management must consider the possibility of major complications in all hyperemetic subjects. BIB removal, with a concomitant intravenous fluid replacement and minerals or vitamins supplementation has to be taken into account as an emergency procedure.

Establishment of bone marrow and hematopoietic niches in vivo by reversion of chondrocyte differentiation of human bone marrow stromal cells

Human bone marrow stromal cells (BMSCs, also known as bone marrow-derived "mesenchymal stem cells") can establish the hematopoietic microenvironment within heterotopic ossicles generated by transplantation at non-skeletal sites. Here we show that non-mineralized cartilage pellets formed by hBMSCs ex vivo generate complete ossicles upon heterotopic transplantation in the absence of exogenous scaffolds. These ossicles display a remarkable degree of architectural fidelity, showing that an exogenous conductive scaffold is not an absolute requirement for bone formation by transplanted BMSCs. Marrow cavities within the ossicles include erythroid, myeloid and granulopoietic lineages, clonogenic hematopoietic progenitors and phenotypic HSCs, indicating that complete stem cell niches and hematopoiesis are established. hBMSCs (CD146(+) adventitial reticular cells) are established in the heterotopic chimeric bone marrow through a unique process of endochondral bone marrow formation, distinct from physiological endochondral bone formation. In this process, chondrocytes remain viable and proliferate within the pellet, are released from cartilage, and convert into bone marrow stromal cells. Once explanted in secondary culture, these cells retain phenotype and properties of skeletal stem cells ("MSCs"), including the ability to form secondary cartilage pellets and secondary ossicles upon serial transplantation. Ex vivo, hBMSCs initially induced to form cartilage pellets can be reestablished in adherent culture and can modulate gene expression between cartilage and stromal cell phenotypes. These data show that so-called "cartilage differentiation" of BMSCs in vitro is a reversible phenomenon, which is actually reverted, in vivo, to the effect of generating stromal cells supporting the homing of hematopoietic stem cells and progenitors.

Preoperative workup in the assessment of adrenal incidentalomas: outcome from 282 consecutive laparoscopic adrenalectomies

Background

To confirm the efficacy of preoperative workup, the authors analyse the results of a multicentre study in a surgical series of patients diagnosed with an adrenal incidentaloma.

Methods

The retrospective review of a prospectively collected database was conducted. The data was obtained by six surgical units operating in the Campania Region, Italy. Five-hundred and six (506) adrenalectomies performed between 1993 and 2011 on 498 patients were analysed. Final histology in patients with a preoperative diagnosis of incidentaloma and studied according to guidelines (230/282 patients group A) was compared with final histology coming from patients presenting the same preoperative diagnosis but studied not according to guidelines (52/282 patients group B).

Results

In group A preoperative diagnosis was confirmed at final histology in 76/81 (93.8%) cases of subclinical functioning lesions presenting as an incidentaloma. The preoperative detection of pheochromocytoma and primary adrenocortical cancer (ACC) reached 91.6% and 84.6% respectively. In group B conversion rate to open surgery was higher than in group A (p = 0.02). One pheochromocytoma was missed at preoperative diagnosis whereas one ACC smaller than 4 centimetres (cm) and coming from an incidental lesion was discovered. In both groups a significant association between increasing dimensions of incidentaloma and cancer has been observed (p = 0.001).

Conclusions

This surgical series confirm the high efficacy of suggested guidelines. A significant preoperative detection rate of adrenal lesions presenting as incidentaloma is observed. The unnecessary number of adrenalectomies performed in understudied patients, causing higher morbidity, was not associated to a higher detection rate of primary adrenocortical cancer.