The spectrum of pneumatosis intestinalis in the adult.A surgical dilemma

Pneumatosis intestinalis(PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition.Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging,even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated.Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier,identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.

Surgical complications of oncological treatments: A narrative review

Gastrointestinal complications are common in patients undergoing various forms of cancer treatments,including chemotherapy,radiation therapy,and moleculartargeted therapies.Surgical complications of oncologic therapies can occur in the upper gastrointestinal tract,small bowel,colon,and rectum.The mechanisms of action of these therapies are different.Chemotherapy includes cytotoxic drugs,which block the activity of cancer cells by targeting intracellular DNA,RNA,or proteins.Gastrointestinal symptoms are very common during chemotherapy,due to a direct effect on the intestinal mucosa resulting in edema,inflammation,ulceration,and stricture.Serious adverse events have been described as complications of molecular targeted therapies,including bowel perforation,bleeding,and pneumatosis intestinalis,which may require surgical evaluation.Radiotherapy is a local anti-cancer therapy,which uses ionizing radiation to cause inhibition of cell division and ultimately lead to cell death.Complications related to radiotherapy can be both acute and chronic.Ablative therapies,including radiofrequency,laser,microwave,cryoablation,and chemical ablation with acetic acid or ethanol,can cause thermal or chemical injuries to the nearby structures.Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication.Furthermore,it is important to know the stage and prognosis of the disease,and a multidisciplinary approach is necessary to personalize the surgical treatment.The purpose of this narrative review is to describe complications related to different oncologic therapies that may require surgical interventions.

Anastomotic leakage in rectal cancer surgery:Retrospective analysis of risk factors

BACKGROUND Anastomotic leakage(AL)after restorative surgery for rectal cancer(RC)is associated with significant morbidity and mortality.AIM To ascertain the risk factors by examining cases of AL in rectal surgery in this retrospective cohort study.METHODS To identify risk factors for AL,a review of 583 patients who underwent rectal resection with a double-stapling colorectal anastomosis between January 2007 and January 2022 was performed.Clinical,demographic and operative features,intraoperative outcomes and oncological characteristics were evaluated.RESULTS The incidence of AL was 10.4%,with a mean time interval of 6.2±2.1 d.Overall mortality was 0.8%.Mortality was higher in patients with AL(4.9%)than in patients without leak(0.4%,P=0.009).Poor bowel preparation,blood transfusion,median age,prognostic nutritional index<40 points,tumor diameter and intraoperative blood loss were identified as risk factors for AL.Location of anastomosis,number of stapler cartridges used to divide the rectum,diameter of circular stapler,level of vascular section,T and N status and stage of disease were also correlated to AL in our patients.The diverting ileostomy did not reduce the leak rate,while the use of the transanastomic tube significantly did.CONCLUSION Clinical,surgical and pathological factors are associated with an increased risk of AL.It adversely affects the morbidity and mortality of RC patients.

Therapeutic strategies in Crohn’s disease in an emergency surgical setting

Crohn’s disease(CD)remains a chronic,incurable disorder that presents unique challenges to the surgeon.Multiple factors must be considered to allow development of an appropriate treatment plan.Medical therapy often precedes or complements the surgical management.The indications for operative management of CD include acute and chronic disease complications and failed medical therapy.Elective surgery comes into play when patients are refractory to medical treatment if they have an obstructive phenotype.Toxic colitis,acute obstruction,perforation,acute abscess,or massive hemorrhage represent indications for emergency surgery.These patients are generally in critical conditions and present with intra-abdominal sepsis and a preoperative status of immunosuppression and malnutrition that exposes them to a higher risk of complications and mortality.A multidisciplinary team including surgeons,gastroenterologists,radiologists,nutritional support services,and enterostomal therapists are required for optimal patient care and decision making.Management of each emergency should be individualized based on patient age,disease type and duration,and patient goals of care.Moreover,the recurrent nature of disease mandates that we continue searching for innovative medical therapies and operative techniques that reduce the need to repeat surgical operations.In this review,we aimed to discuss the acute complications of CD and their treatment.

Endoluminal vacuum-assisted therapy as a treatment for anastomotic leakage in colorectal surgery

Anastomotic leakage(AL)has a wide range of clinical features ranging from radiological only findings to peritonitis and sepsis with multiorgan failure.An early diagnosis of AL is essential in order to establish the most appropriate treatment for this complication.Despite AL continues to be a dreadful complication after colorectal surgery,there has been no consensus on its management.However,based on patient’s presentation and timing of the AL,there has been a gradual shift to a more conservative management,keeping surgery as the last option Reoperation for sepsis control is rarely necessary especially in those patients who already have a diverting stoma at the time of the leak.A nonoperative management is usually preferred in these patients.There are several treatment options,also for patients without a stoma who do not require a reoperation for a contained pelvic leak,including recently developed endoscopic procedures,such as clip placement or endoluminal vacuum-assisted therapy.More conservative treatments could be an option in patients who are clinically stable or in presence of a small defect.

SARS-CoV-2 and the pancreas: What do we know about acute pancreatitis in COVID-19 positive patients?

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)can cause pancreatic damage,both directly to the pancreas via angiotensin-converting enzyme 2 receptors(the transmembrane proteins required for SARS-CoV-2 entry,which are highly expressed by pancreatic cells)and indirectly through locoregional vasculitis and thrombosis.Despite that,there is no clear evidence that SARS-CoV-2 is an etiological agent of acute pancreatitis.Acute pancreatitis in coronavirus disease 2019(COVID-19)positive patients often recognizes biliary or alcoholic etiology.The prevalence of acute pancreatitis in COVID-19 positive patients is not exactly known.However,COVID-19 positive patients with acute pancreatitis have a higher mortality and an increased risk of intensive care unit admission and necrosis compared to COVID-19 negative patients.Acute respiratory distress syndrome is the most frequent cause of death in COVID-19 positive patients and concomitant acute pancreatitis.In this article,we reported recent evidence on the correlation between COVID-19 infection and acute pancreatitis.

Artificial intelligence and its role in guiding liverdirected therapy for hepatocellular carcinoma:Is it ready for prime time?

Artificial intelligence(AI)is an innovative discipline in medicine,impacting both hepatology and hepato-pancreatobiliary surgery,ensuring reliable outcomes because of its repeatable and efficient algorithms.A considerable number of studies about the efficiency of AI in the management of hepatocellular carcinoma(HCC)have been published.While its diagnostic role is well recognized,providing large amounts of quantitative radiological HCC features,its use in HCC treatment is still debated.Innovative use of AI may help to select the best approach for each patient as it is able to predict the outcomes after resection and/or other treatments.In this review,we assess the role of AI in selecting the best therapeutic option and predicting long-term risks after surgical or interventional treatments for HCC patients.Further studies are needed to consolidate AI applications.