Influence of sarcopenia and frailty in the management of elderly patients with acute appendicitis

In developed countries,the average life expectancy has been increasing and is now well over 80 years.Increased life expectancy is associated with an increased number of emergency surgical procedures performed in later age groups.Acute appendicitis is one of the most common surgical diseases,with a lifetime risk of 8%.A growing incidence of acute appendicitis has been registered in the elderly population and in the oldest groups(>80 years).Among patients>50-year-old who present to the emergency department for acute abdominal pain,15%have acute appendicitis.In these patients,emergency surgery for acute appendicitis is challenging,and some important aspects must be considered.In the elderly,surgical treatment outcomes are influenced by sarcopenia.Sarcopenia must be considered a precursor of frailty,a risk factor for physical function decline.Sarcopenia has a negative impact on both elective and emergency surgery regarding mortality and morbidity.Aside from morbidity and mortality,the most crucial outcomes for older patients requiring emergency surgery are reduction in function decline and preoperative physical function maintenance.Therefore,prediction of function decline is critical.In emergency surgery,preoperative interventions are difficult to implement because of the narrow time window before surgery.In this editorial,we highlight the unique aspects of acute appendicitis in elderly patients and the influence of sarcopenia and frailty on the results of surgical treatment.

Trauma-induced“Macklin effect”with pneumothorax and large pneumomediastinum,disguised by allergy

A 56-year-old man presented spontaneously to the Emergency Department complaining of facial and neck oedema after assumption of nonsteroidal anti-inflammatory drugs(NSAIDS).The triage nurse assigned the patient to Accident&Emergency(A&E)doctor as probable allergic reaction to NSAIDS.Chest X-ray(CXR),ordered after 24 hours,revealed a huge subcutaneous chest and neck emphysema without clearly visible pneumothorax.Subsequent chest CT scan showed a small left pneumothorax and a large amount of air in the mediastinum.The patient was conservatively treated since he was eupnoeic and hemodynamically stable.The pathophysiology of pneumomediastinum was first described by Macklin in 1939.The Macklin effect involves alveolar ruptures with air dissection along bronchovascular sheaths to the mediastinum.In this case the patient did not report in his history a recent blunt thoracic trauma and the initial suspicion of an allergic reaction has prevented physicians to immediately achieve the correct diagnosis.

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.