Laparoscopic cholecystectomy (LC) has become the standard management for gallstones. However, it is associated with postoperative elevations in liver enzymes. This scoping review of 52 studies involving over 28,000 patients was undertaken to evaluate the frequency, causes, and clinical significance of these conditions. Levels of ALT and AST increased in 75% to 82% of patients 24 to 48 h after surgery and returned to baseline by day 7. ALP, GGT, and bilirubin levels exhibited mild elevation in 10% to 30% of patients. Adverse events resulting from elevated pneumoperitoneum pressure (> 14 mmHg) and protracted surgical duration were markedly associated with enzyme-level imbalances. The transient alterations did not result in adverse clinical outcomes, suggesting that routine monitoring of liver enzymes may not be necessary for low-risk patients. The present review advocates for individualized perioperative assessment of high-risk patients and indicates the need for further research to optimize patient management strategies.

Ageism is an underrecognized form of discrimination that compromises equity, autonomy, and health outcomes for older adults. Inappropriate age-based assumptions can result in the underutilization of beneficial procedures, delayed interventions, and inequitable resource allocation. To conceptualize ageism in surgery by exploring its cognitive, systemic, and ethical underpinnings, and to propose actionable strategies to mitigate its impact on surgical decision-making and patient care. Through a conceptual framework, data from epidemiological studies, clinical trials, systematic reviews, and health policy reports were synthesized, providing proof for physicians' attitudes, systemic practices and ethical frameworks in perpetuating surgical ageism. Proof that cognitive biases can fuel ageism in surgery was demonstrated across multiple studies involving over 149,000 participants and more than 30 individual studies, each highlighting distinct biases that skew surgical decision-making, especially for older adults. Proof that systemic inequities contribute to surgical ageism was evidenced by studies on transplant referral, clinical trial exclusion, and ethical resource allocation frameworks, involving over 24,000 participants and multiple large-scale reviews. Finally, evidence supporting that educational strategies can mitigate ageism and the need for anti-ageism measures, was drawn from a range of studies involving over 20,000 participants across at least 80 studies. Surgical ageism stems from a confluence of cognitive, structural, and cultural factors. By addressing the drivers of ageism and implementing inclusive policies, the surgical community can promote person-centred care and uphold the dignity and rights of older adults in line with global health equity goals.

This systematic review and meta-analysis investigated the efficacy and safety of support rods and bridges in loop stoma formation, a practice frequently employed in colorectal surgery despite the associated complications and controversial efficacy. The aim of this study is to provide evidence-based guidance on their routine use. Adhering to the Cochrane Collaboration's recommendations, we conducted this systematic review and meta-analysis systematically searching PubMed, Scopus and Web of Science for randomized controlled trials (RCTs) evaluating the efficacy of rods/ bridges in loop ileostomies. Key outcomes assessed included stoma retraction, stoma/skin necrosis, peristomal dermatitis, infection, and mucocutaneous separation. This review included six studies encompassing 1,239 patients (195 ileostomy, 1,044 colostomy). Analysis revealed no statistically significant difference in stoma retraction (RR = 0.70, 95% CI [0.37 to 1.33], P = 0.28). Conversely, for stoma/skin necrosis, four studies were analyzed and showed a statistically significant difference favoring the non-rod/bridge group (RR = 5.04, 95% CI [1.72 to 14.73], P = 0.003). For peristomal dermatitis, three studies revealed a statistically significant difference favoring the non-rod/bridge group (RR = 2.01, 95% CI [1.55 to 2.60], P < 0.00001), with ostomy rod use identified as a significant risk factor (OR 3.42, p < 0.01). Outcomes for infection and mucocutaneous separation showed no significant difference. Based on the our results, routine rod/bridge use does not appear to reduce stoma retraction and may be associated with an increased risk of necrosis and dermatitis. That is why the routine use of rod/bridge does not appear to be justified, but the small number of the included studies limit the generalizability of these results. Trial sequential analysis indicated that future high-quality RCTs with diverse and larger populations and are recommended to obtain more rigorous evidence.

The post anesthesia care unit (PACU) was introduced to optimize intensive care unit (ICU) bed availability for patients requiring specialized perioperative care, providing comprehensive monitoring during the recovery phase in high-risk surgical patients. However, though several advantages of PACUs have been clearly demonstrated, no previous studies have investigated the overall costs. This retrospective study aimed at comparing the costs of postoperative monitoring in PACU and ICU after elective hepato-pancreatic-biliary (HPB) surgery at our hospital. A retrospective cohort study was conducted between January 2022 and December 2024. The investigations periods were divided according to the institution of PACU at our institution: before (January 1, 2022-May 31, 2023) and after (June 1, 2023-December 31, 2024). Three groups were identified: ICU 1 and 2, including all pt admitted to ICU before and after the institution of PACU, respectively, and PACU, including all pt admitted to PACU. The primary outcome was the cost of monitoring/pt. Secondary outcome was the overall hospital length of stay (LOS). 171 consecutive pt undergoing HPB surgery were included and divided into 49 pt belonging to ICU 1 group, 60 to ICU 2 and 62 to PACU. Multivariable analysis of monitoring cost revealed the following independent predictors: postoperative surveillance in PACU (P < 0.0001), duration of monitoring (P < 0.0001), male gender (P = 0.028) and severity of complications (P = 0.001), the latter resulting the only significant risk factor for prolonged LOS (P < 0.0001). PACU has emerged as a safe and efficient alternative to ICU in the postoperative surveillance of HPB surgical patients, with associated significant cost savings. Further research is required to identify specific criteria addressing the individual needs for postoperative admission to ICU or PACU.

The surgical management of pancreatic neck adenocarcinoma (neck PDAC) ranges from extended pancreaticoduodenectomy (ePD) to subtotal left pancreatectomy (sLP) and total pancreatectomy, with no clear consensus on the optimal approach. This study aimed to compare ePD and sLP in terms of perioperative and long-term outcomes. All patients who underwent ePD or sLP for neck PDAC were retrospectively reviewed and compared for perioperative and long-term outcomes. Forty-six patients were included: 18 (39.1%) underwent ePD and 28 (60.9%) sLP. ePD was associated with a higher rate of neoadjuvant treatment, longer operative time, and longer hospital stay. The most frequently involved lymph-node stations were #13-17 in the ePD group (44.4%) and #18 in the sLP group (42.9%). Overall survival (OS) was similar (p = 0.06), while disease-free survival (DFS) was longer in the sLP group (16 [9-22] vs 12 [5-18] months in the ePD group; p = 0.03). Due to the high rate of nodal metastases in station #13-17 and #18, both procedures may be inadequate as surgical treatment of neck PDAC. While sLP appears to offer better long-term outcomes, the heterogeneity of the study population limits generalizability. Larger prospective studies are needed to determine the most effective surgical approach.

Low anterior resection syndrome (LARS) is a disorder of bowel function that develops after sphincter-preserving surgery for rectal cancer. Transanal irrigation is a treatment for low anterior resection syndrome. This is a single-center prospective randomized controlled trial comparing stoma discharge reinfusion versus standard care 1 month following sphincter-preserving and temporary loop ileostomy surgery was performed. The primary endpoint was the proportion of patients with major LARS at 6 months after ileostomy reversal. Secondary endpoints included Glazer pelvic floor muscle (PFM) surface electromyography (SEMG) and microbiota analysis at 1 month after ileostomy reversal and Quality-of-Life Questionnaire Core 30 (QLQ C30) analysis during follow-up period. Of 60 randomized patients, 52 were included in the analysis (reinfusion group, n = 28; standard care group n = 24). The proportion of patients with major LARS was statistically lower after stoma discharge reinfusion compared with standard care at 6 months after ileostomy reversal (10.7% vs 41.7%, p = 0.01). Glazer PFM SEMG values were significantly higher 1 week prior to ileostomy reversal: phasic contractions (p = 0.04), tonic contractions (p = 0.02), and endurance contractions (p = 0.002); but there were no significant differences at 1 month after ileostomy reversal. QLQ C30 questionnaire showed higher functional scores, but symptom scores and global health status did not improve. Microbiota analysis revealed no significant differences in either beta or alpha diversity. Nevertheless, differentially abundant species were identified between LARS and no-LARS groups. Stoma discharge reinfusion reduced LARS severity and improved anal function and microbiota dysbiosis in patients who underwent sphincter-preserving surgery.Registration number and date of registration NCT05461248, 2022-07-14 ( http://www.clinicaltrials.gov ).

Despite the growing popularity of single-incision laparoscopic surgery (SILS), no large-scale meta-analysis has compared the incidence of incisional hernia (IH) between SILS and traditional laparoscopic surgery (TLS).We make a meta-analysis of randomized controlled trials (RCTs) to compare the risk of IH between SILS and TLS. We searched studies in PubMed, Web of Science, and EMBASE databases for RCTs that compared SILS to TLS and reported IHs with a minimum follow-up period of 6 months. The risk of bias was assessed using the ROBINS-II tool. We used the R software to summarize and compare the incidence of IH between SILS and TLS. Additionally, we conducted subgroup analyses to explore the impact of surgical (including procedure type, incision length, incision approach, incision direction, fascia closure, and operation time) and patient factors (including BMI, age, and race) on the incidence of IH. 37 RCT studies were included in this meta-analysis. In the single-arm analysis, the incidence of IH in the SILS group was 0.7% (95% CI 0.2-1.5%), and 0.3% (95% CI 0.1-0.8%) in the TLS group. SILS does not confer an increased risk of IH, with an OR of 1.52 (95% CI 0.98-2.36) and P = 0. 57. Only variations in surgical procedures significantly influenced the incidence of IH when comparing SILS and TLS. Our study did not demonstrate a statistically significant difference in the incidence of IH between the SILS and TLS groups. Therefore, SILS is a viable alternative for patients who require minimally invasive surgical interventions. However, future RCTs with larger sample sizes and extended follow-up periods are warranted to further validate the safety profile.

ICG-fluorescent guided laparoscopic adrenalectomy (LA) has recently been adopted by endocrine surgeons but is still in its infancy. Consequentially, the optimal use of it in imaging different tumors is yet to be defined. All patients undergoing ICG-fluorescent guided LA in our department, from June 2020 until May 2024, were included in this study. Administration of 5mg of ICG was executed in 2 stages, before and after dissection of the anatomic plane of the adrenal gland. Adrenal tumors were categorized according to their fluorescent properties when compared to normal adrenal gland as "hyperfluorescent" or "hypofluorescent". Patient demographics, indication for surgery, tumor size, operative time and intraoperative complications were measured. This study included 61 patients undergoing LA, 31 being left LA and 30 right LA. Indications for surgery included aldosteronoma, pheochromocytoma, cushing syndrome, non-secreting adrenal tumors, myelolipoma, metastasis and possible carcinoma. Mean operative time was 124 ± 24 min, mean dose of ICG injected was 10 mg (range 10-15 mg). Adrenal tumors were categorized as hyperfluorescent in 24 (39.4%) and hypofluorescent in 37 (60.6%) cases when compared to normal adrenal gland. Pheochromocytomas appeared hypofluorescent in 12/15 (80%) of cases while tumors of cortical origin were hypofluorescent in 21/38 (55%) of cases compared to normal adrenal gland. Adrenal tumors exhibit different levels of fluorescent intensity according to their origin. Pheochromocytomas appear hypofluorescent in 80% of the cases, a finding that may assist surgeons when performing cortical sparing LAs addressing pheochromocytomas.

Hemorrhoidal disease imposes a significant global healthcare burden. However, comprehensive analyses mapping its research landscape and technological evolution are lacking. This study employed advanced bibliometric techniques to characterize the knowledge structure, collaborative networks, research hotspots, and emerging trends in hemorrhoid therapy over the past two decades. A total of 2764 relevant publications were retrieved from the Web of Science Core Collection (WoSCC). Multi-tool bibliometric analysis and scientific visualization were conducted using VOSviewer (v1.6.19), CiteSpace (v6.2.R4), and Bibliometrix (v4.1.3). Analyses included publication trends, country/institutional contributions, author/institutional collaboration networks, journal co-citation analysis, keyword co-occurrence/clustering, thematic evolution, and burst detection. Annual publications showed a steady increase, signifying growing research interest. China and the United States were the dominant contributors. International collaboration networks displayed regional clustering. Core research domains identified through keyword co-occurrence and clustering included Rubber Band Ligation (RBL), hemorrhoidectomy (Milligan-Morgan, Ferguson, stapled), laser therapy, pain management, postoperative complications, and quality of life. Burst detection and thematic evolution mapping highlighted emerging frontiers such as minimally invasive techniques (Doppler-guided hemorrhoidal artery ligation [DG-HAL], laser hemorrhoidoplasty), day surgery/ambulatory management, evidence-based guidelines, and long-term outcomes/comparative effectiveness. This first multi-tool bibliometric analysis comprehensively delineates the global research architecture and dynamic evolution of hemorrhoid therapy. It confirms the established role of conventional surgical techniques while identifying a clear shift towards minimally invasive procedures and outpatient management. Key knowledge gaps persist in long-term efficacy comparisons and standardized guideline development. These findings provide researchers, clinicians, and policymakers with an evidence-based roadmap to guide future investigations, resource allocation, and clinical practice optimization in hemorrhoidal disease management.

Esophagogastric anastomosis during esophagectomy is a technically demanding step, carrying a high complication rate. Numerous techniques for anastomosis fashioning have been described, including hand-sewn (HS) and stapled (ST) anastomosis however, the optimal method remains uncertain.

This study aimed to evaluate the effects of Epidermal Growth Factor (EGF) on wound healing, inflammation, and apoptosis markers in a rat perianal fistula model and to compare these effects with conventional seton placement, Tarantula cubensis venom (Theranekron® D6), or a combination (S + T). We hypothesized that EGF could enhance epithelial and granulation tissue repair while limiting local inflammatory damage. A total of 28 male Wistar rats were randomly allocated to four groups (n = 7 each). Perianal fistulas were experimentally induced, and interventions were administered as follows: Group S (loose seton only), Group T (Tarantula venom subcutaneously, weekly), Group S + T (seton plus tarantula venom), and EGF (two doses of 15 µg EGF near the fistula tract). After a 30-day follow-up, the animals were euthanized and the perianal regions were excised. Re-epithelialization, granulation tissue, inflammatory cell infiltration, and Caspase-3 immunostaining were analyzed. Data were statistically assessed using Kruskal-Wallis and post-hoc tests (p < 0.05). The EGF group showed markedly higher re-epithelialization scores than did the seton alone (S) and tarantula venom (T) groups. Granulation tissue was predominantly absent or immature in EGF compared to the mature or overly fibrotic profiles in the S and T groups. Inflammatory cell infiltration was significantly lower in EGF, whereas T demonstrated increased inflammation and highest Caspase-3 activity (74%). EGF maintained a minimal apoptotic response (~ 8.6% Caspase-3). EGF administration promoted favorable wound healing parameters, including enhanced re-epithelialization, reduced inflammatory infiltration, and minimal apoptotic injury in a rat perianal fistula model. Tarantula venom contributed to greater tissue damage, and seton placement alone achieved moderate outcomes. These findings suggest that EGF shows promise as an adjunctive treatment for perianal fistulas. However, its translational potential requires further investigation in clinical practice.

Osler-Rendu-Weber syndrome is a genetic disease that involves organs, liver included, characterized by alterations in the vessel walls, making them more vulnerable to spontaneous rupture and bleeding indeed. Our aim is to report a case of patient with Osler-Rendu-Weber syndrome undergoing extended hepatectomy with biliary resection for hilar cholangiocarcinoma and a review of literature on liver resection performed in patients with this syndrome. Preoperative, intraoperative, postoperative, radiographic, and pathologic data of case report's patient were collected. Review of literature included studies from 2000 to 2024, searching them with following search keywords: (liver resection OR hepatectomy) AND (Osler-Rendu-Weber disease OR hereditary hemorrhagic telangiectasia). A 78-year-old woman with Osler-Rendu-Weber syndrome presented hilar lesion compatible with cholangiocarcinoma. Before surgery, the patient underwent embolization of an aneurysm in segment 6. A left extended hepatectomy with biliary resection was performed. Intraoperative blood loss was 500 cc. Post-operative course was uneventful and length of hospital stay was 10 days. 5 cases of liver resection in patient with this syndrome are reported in literature, including 2 cases of major hepatectomies. Major complications' rate was 60% (3 cases): two cases of post-operative bleeding and one case of ascites decompensation. In one case exitus, consequent to massive bleeding, was reported (20%). This is the first case of extended hepatectomy with biliary resection performed in patient with Osler-Rendu-Weber syndrome. This underlying condition makes surgical approach demanding and challenging also in high volume centers. Proper patient selection and management could allow treatment and execution of a safe liver resection in patients with this syndrome.

The suitability of laparoscopy for T4 colon cancer (CC) remains controversial. This study aims to compare the short-term and long-term oncological outcomes specifically for T4 CC.

The rising prevalence of gastric cancer in the upper third of the stomach has generated considerable interest in laparoscopic proximal gastrectomy (LPG). Traditional esophagogastric anastomosis after LPG has been associated with postoperative reflux issues. Despite the availability of various improved reconstruction techniques, there is still ongoing debate on the optimal approach. This network meta-analysis seeks to assess the reflux and nutritional outcomes associated with various reconstruction techniques subsequent to LPG.

Rouviere's sulcus (RS) is a horizontal anatomical structure that runs from the caudate process to the right hepatic lobe on the inferior face of the liver. This groove lies along the common bile duct. The study's objective was to identify the frequency, morphology, dimension, direction, and anatomic subtype of RS, as well as to evaluate its utility as a landmark for safe laparoscopic cholecystectomy. This is a prospective observational study conducted across multiple institutions. The study lasted six months (from July to December 2021) and included 192 patients with an age above 16 years with symptomatic gallstone who had a laparoscopic cholecystectomy. 192 patients with a mean age of 43.55 ± 11.33 years with a female-to-male ratio of 5:1 were analyzed. RS was present in 87.5% of cases, of which deep open type, deep closed type, scar type, and slit type RS were identified in 75%, 22.0%, 1.80%, and 1.2% cases, respectively. In 74.4% of cases, RS was transverse, in 24.4% of cases it was oblique, and in 1.2% of cases, it was vertical. In 97.02% of patients, the RS was at the same level, and in 2.97% of patients, it was lower than the critical view of safety. The most significant advantage of finding the RS is that the common bile duct is located below it, and the cystic duct and artery are located above it. Detection of RS is a predictor of safe laparoscopic cholecystectomy.

Primary hyperparathyroidism is primarily caused by single-gland pathology (80-85% of cases). According to the 2022 World Health Organization (WHO) guidelines (Erickson et al. in Endocr Pathol, 2022), single-gland pathologies include parathyroid adenoma, atypical parathyroid tumor and parathyroid carcinoma (Gurrado in J Clin Med 12:6297, 2023). The aim of this study is to identify differences or similarities of both pre-, intra- and post-operative characteristics between atypical parathyroid tumor and parathyroid adenoma/carcinoma, thereby establishing an appropriate follow-up protocol for atypical parathyroid tumor. We retrospectively analyzed 437 patients who underwent parathyroidectomy for primary hyperparathyroidism between 2012 and 2022 at the Thyroid Unit of ASST Santi Paolo e Carlo in Milan focusing our analysis on 352 patients with single-gland disease. Several pre-, intra-, and post-operative variables, including follow-up, were analyzed and compared using non-parametric statistical methods. Histological analysis identified 316 cases of PA (90%), 27 cases of atypical parathyroid tumor (7.7%), and 9 cases of parathyroid carcinoma (2.3%). Patients with atypical parathyroid tumor had significantly higher pre-operative PTH levels, intermediate calcium levels, falling between those of parathyroid adenoma and parathyroid carcinoma patients and larger gland diameter. No cases of disease persistence or recurrence were observed in patients with atypical parathyroid tumor after a mean follow-up of 42.8 months. APT exhibits biochemical and pathological features overlap with both PA and PC. However, the lack of recurrence or persistence suggests that APT behaves more similarly to PA than PC. The favorable evolution of APT in our case series could be a factor in favor of reducing the follow-up time for atypical tumors to a shorter period than the one recommended for carcinomas.

Significant disparities exist in axillary management between and within countries, particularly regarding patients undergoing neo-adjuvant chemotherapy (NAC) who present with nodal disease and subsequently become ycN0 after systemic treatment. The aim of this study was to evaluate the efficacy and safety of the single-tracer technique for clinically node-positive (cN +) breast cancer patients who achieve node-negativity (ycN0) after NAC and compare this approach with the dual-tracer technique. We included consecutive patients diagnosed with cT1-T2, cN1-N2 breast cancer who underwent NAC and achieved nodal disease regression (ycN0). The patients were divided into two groups: "dual tracer" technique for sentinel lymph node identification and "single tracer" technique. In both groups, axillary lymph node dissection (ALND) was performed in patients with positive sentinel lymph nodes. Out of the 76 patients included, 42 underwent sentinel lymph node removal using the dual-tracer technique, while 34 underwent the single-tracer technique. In the single-tracer group, an average of two lymph nodes were removed per patient versus an average of three lymph nodes per patient in the dual-tracer group (p = 0.001). No loco-regional recurrences have been reported in either group at a mean follow-up of 34 months. The single-tracer technique can be a reliable method for the axillary management in cN + breast cancer patients undergoing neo-adjuvant chemotherapy and achieving nodal disease regression (ycN0), in terms of loco-regional recurrences. This demonstrates that even if fewer sentinel lymph nodes are identified using the single tracer technique (and potentially the false negative rate of the procedure is higher), this does not impact on the rate of loco-regional recurrences. However, longer follow-up is required to confirm these findings.

This study aimed to analyze the incidence and risk factors of acute anastomotic leak (AL) in patients with colorectal cancer (CRC) during and after the COVID-19 pandemic. Active COVID-19 was evaluated as a risk factor of acute AL. A retrospective multicenter analysis was performed on 390 patients with CRC between April 2020 and October 2024. Patients were divided into acute AL (n = 27) and no acute AL (no AL) (n = 363) groups. In the acute AL group, there were 24 (88.8%) men and three (11.2%) women, with a median age of 63 (65-67) years. Twenty-seven patients in both groups had a previous COVID-19 infection and 15 patients (55.5%) who complained of COVID-19 had AL. The incidence of clinical AL was 6.9% (27/390), of which 11.1% (3/27) and 88.9% (24/27) were grade B and C, respectively. 24/27 (88.9%) had free AL with peritonitis requiring surgical re-intervention. Multivariate analysis showed that active COVID-19 infection (OR = 176, 95% CI 14.27-2172.57, p < 0.001) and serum albumin level < 3 g/dl (OR = 16.249, 95% CI 1.033-255.544, p = 0.04) were associated risk predictors of AL, while the laparoscopic approach (OR = 0.032, 95% CI 0.002-0.434, p = 0.01) and splenic flexure mobilization (OR = 0.022, 95% CI 0.003-4.844, p = 0.02) were protective. The incidence of AL after CRC surgery did not increase during or after the COVID-19 pandemic. Active COVID-19 and serum albumin levels < 3 g/dl were associated risk factors for AL, while the laparoscopic approach and splenic flexure mobilization were protective.

Conserving mastectomy is widely used due to its cosmetic benefits and the possibility of undergoing immediate breast reconstruction. The types of incisions vary, and the best method remains a topic of debate. In this study, we evaluate the impact of the incision type on complication outcomes. A retrospective analysis was conducted, considering all conserving mastectomies and dividing them into groups based on the incision type. A total of 290 patients were enrolled: 34 (11.7%) had a radial incision, 95 (32.8%) transverse incision with skin or NAC excision, 48 (16.6%) inframammary fold incision, 39 (13,4%) omega incision, 37 (12.8%) periareolar incision, and 37 (12.8%) Wise-pattern incision. Flap ischemia, NAC necrosis, and skin necrosis had a higher incidence rate in patients who underwent the Wise-pattern incision and periareolar incision, with relative p values of <0.001, 0.041, and 0.035, respectively. Considering only nipple-sparing mastectomies in breast cancer patients, overall complications, skin necrosis, and delay in adjuvant treatments showed a higher incidence in patients who underwent Wise-pattern incisions. The relative p values were 0.001, 0.004, 0.054, and 0.001, respectively. In multivariate analysis, inframammary fold incision reduced the risk of nipple necrosis, while Wise-pattern incision increased the risk (OR 0.656; 3.611-fold and p value were, respectively, 0.026 and 0.038). Wise-pattern incision and periareolar incision increase the incidence of complications as nipple areola complex (NAC) and skin necrosis but do not affect reconstruction failure. Inframammary fold incision reduces the risk of complications. The incision should be customized based on the tumor location, biology and extent, breast volume, ptosis, type of reconstruction, and risk factors.