Annali italiani di chirurgia最新文献

Aim: This study aimed to develop a reliable and efficient system for predicting and locating rib fractures in medical images using an ensemble of convolutional neural networks (CNNs).

Methods: We employed five CNN architectures-Visual Geometry Group Network 16 (VGG16), Densely Connected Convolutional Network 169 (DenseNet169), Inception Version 4 (Inception V4), Efficient Network B7 (EfficientNet-B7), and Residual Network Next 50 layers (ResNeXt-50)-trained on a dataset of 840 grayscale computed tomography (CT) scan images in .jpg format collected from 42 patients at a local hospital. The images were categorized into two groups representing healed and fresh fractures. The ensemble model was designed to improve predictive accuracy and robustness, utilizing techniques like gradient-weighted class activation mapping (Grad-CAM) for visualization of fracture locations.

Results: The ensemble model achieved an accuracy of 0.96, area under the curve (AUC) of 0.97, recall of 0.97, and F1 score of 0.96. Grad-CAM visualizations could effectively locate rib fractures, providing crucial assistance in diagnostics.

Conclusions: The ensemble model demonstrates high accuracy and robustness in fracture detection, underscoring its potential for enhancing diagnostic processes in clinical settings. Despite limitations such as the small dataset size and lack of diverse demographic representation, the results are promising for future clinical application.

Aim: This study aimed to explore the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing preventive colostomy following laparoscopic rectal cancer surgery. Additionally, the outcomes of LARS were analyzed to provide evidence for effective prevention and treatment strategies.

Methods: The medical records of 143 patients with laparoscopic rectal cancer who underwent preventive ostomy at the Zhujiang Hospital of Southern Medical University between January 2020 and October 2022 were retrospectively reviewed. All patients underwent ostomy reversal within 2 to 6 months post-surgery. The LARS score scale was used to evaluate the occurrence of LARS at 3, 6, and 12months post-surgery. Based on LARS scores, patients were divided into LARS and non-LARS groups. Clinical characteristics, including gender, TNM stage, and other related data, were compared between the two groups. Multivariate logistic regression analysis was conducted to identify risk factors for LARS, and the predictive performance of the regression model was evaluated using the receiver operating characteristic (ROC) curve.

Results: The LARS score demonstrated a significant decrease over time after surgery (p < 0.05). LARS was identified in 80 patients (55.94%) at 3 months post-surgery, with no new cases reported after this period. Statistically significant differences between the LARS and non-LARS groups were observed in body mass index (BMI), tumor distance from the anal margin, postoperative anastomotic fistula, and the timing of ostomy reversal (p < 0.05). The ROC curve analysis revealed that the logistic regression model predicting LARS had an area under the curve (AUC) of 0.809 (95% CI: 0.735-0.870), with a sensitivity of 76.25% and a specificity of 79.37%. Among the LARS patients 3 months post-surgery, 73.75% (59/80) showed improvement by 12 months. The improvement rate in patients with mild LARS (87.93%) was significantly higher than in those with severe LARS (36.36%) (p < 0.05).

Conclusions: The incidence of LARS is relatively high in patients undergoing preventive ostomy after laparoscopic rectal cancer surgery. Key factors associated with LARS include BMI, tumor distance from the anal margin, postoperative anastomotic fistula, and the timing of ostomy reversal. Over time, the incidence of LARS decreases, and outcomes improve, especially in patients with mild LARS.

Aim: Patient specific pre-contoured rods (PSRs) represent a relatively new technological development aimed at improving surgical outcomes and reducing complications in adult spinal deformity surgery. To date, only a limited number of studies have been published comparing PSRs with traditional spinal rods. In this paper, we compare the surgical, imaging, and clinical outcomes of PSRs and traditional spinal rods in a single-center case-matched study.

Methods: Thirty cases of adult spinal deformities (ASD) were retrospectively analysed. These included 10 patients who were operated on using UNiD™ (Adaptive Spine Intelligence, MedTronic, Minneapolis, MN, USA) PSRs and 20 operated on using traditional rods from January 2023 to August 2023. Minimum post-surgical follow-up was 6 months. General demographics and standard radiographic parameters, as well as Scoliosis Research Society (SRS)-22, Oswestry Disability Index (ODI) and Short Form Health Survey (SF-12) Scores, were measured at pre-operative examination and at 6-month follow-up. Follow-up imaging data were compared with software-planned correction goals. Intra-operative data and complications were also recorded.

Results: Patients in the two groups were matched in terms of age, body mass index (BMI), sex, type and severity of spinal deformity. The magnitude of the coronal deformity (p = 0.812) and preoperative sagittal imbalance (p = 0.845) were similar between the two groups. The number of fused levels (p = 0.439), osteotomies (p = 0.188), implant density (p = 0.880), and surgery duration (p = 0.299) were similar between the two groups. Sagittal correction goals set during preoperative planning were achieved in the PSRs group, with the exception of pelvic tilt (PT) (p = 0.042). In contrast, PT (p = 0.040), L1-S1 lordosis (p = 0.032) and global tilt (GT) (p = 0.001) remained significantly undercorrected in the control group at 6-month follow-up. Clinical outcomes (ODI and SF-12 Scores) and complication rates were similar between the two groups.

Conclusions: The use of PSRs improves the achievement of better post-operative spinopelvic alignment in adult spinal deformity surgery. Moreover, no significant differences were noted in terms of complications, operative times, and clinical outcomes compared to traditional spinal rods at 6-month follow-up.

Aim: Colorectal cancer (CRC) is one of the most prevalent malignancies, which is commonly treated with curative surgical resection, often leading to intraoperative hypothermia. Therefore, this study aimed to compare and analyze the risk factors for intraoperative hypothermia associated with laparoscopic and open CRC resections under general anesthesia.

Methods: This study included 120 CRC patients admitted between January 2023 and January 2024. Data from these patients were analyzed using logistic regression analysis to investigate the risk factors for hypothermia during CRC surgery. Additionally, surgical indicators such as, intraoperative bleeding volume, number of lymph nodes dissected, and operation time, and serum inflammatory markers like Interleukin-6 (IL-6) and Interleukin-8 (IL-8) were assessed and compared between the two surgical groups.

Results: The study group comprised 41 men and 79 women, with a mean age of 52.53 ± 8.90 years and an average body mass index (BMI) of 23.13 ± 3.32 kg/m2. The American Society of Anesthesiologists (ASA) score was measured as 1 for 62 (51.67%) patients and 2 for 58 (48.33%). Among them, 50 patients underwent open surgery, whereas 70 patients were treated with laparoscopic surgery. Gender, laparoscopic surgery, intraoperative fluid infusion volume, prolonged anesthesia, and intraoperative blood transfusion were determined as the independent risk factors for intraoperative hypothermia during CRC surgery under general anesthesia (p < 0.05). The intraoperative bleeding volume was significantly reduced (p < 0.01), with significantly longer operation time (p < 0.05) in patients treated with laparoscopic surgery compared to those with open surgery. However, the two groups had a similar number of lymph nodes dissected. Additionally, the levels of IL-6 and IL-8 in both laparoscopic and open surgery of patients increased significantly after surgery, but the extent of increase in the patients of laparoscopic surgery was significantly lower than that in the patients of open surgery (p < 0.05).

Conclusions: In conclusion, gender, surgical approach, intraoperative fluid infusion volume, prolonged anesthesia, and intraoperative blood transfusion are the potential risk factors for hypothermia during laparoscopic radical CRC surgery under general anesthesia.

Aim: Timing of chest tube removal post lung resection is variable in practice and often based on personal experience rather than evidence. The current practice in chest tube management among thoracic surgeons across Canada is so far unknown. Our primary aim was to assess the current status of chest tube removal in Canada in order to uncover potential shortcomings.

Methods: An online anonymous survey was emailed to members of Canadian Association of Thoracic Surgeons in order to better understand the status quo of the chest tubes' removal policy in the different departments preparing the grounds for suggesting a future uniformity. Data were collected and analysed with descriptive statistics. A linear regression analysis was performed in order to understand the factors related to chest tube removal.

Results: Sixty responses were received (44.4% response rate). Most surgeons place a single chest tube in both open (75%, 45/60) and minimally invasive lobectomies (93.3%, 56/60). Digital drainage systems are used by half of the surgeons surveyed. A quarter of the respondents report removing chest tubes regardless of drainage output. This practice was independent of the surgeons' number of years in practice (p = 0.127), number of lobectomies performed annually (p = 0.877), proportion of lobectomies performed minimally invasively (p = 0.259), whether digital drainage system is used (p = 0.141) and whether the surgeon is aware of the Enhanced Recovery after Surgery (ERAS) guideline (p = 0.374). Of those who remove chest tubes based on fluid output, thresholds vary widely; a significant proportion (86%, 37/43) uses a volume lower than the 450 mL/24 h threshold set out ERAS. Most respondents (77%) were interested in a clinical trial studying chest tube removal independent of drainage volume.

Conclusions: This study demonstrated ongoing diverse practice amongst thoracic surgeons in Canada with regards to post-operative chest tube management, indicating a much-needed area of research.

Aim: The objective of the study is to evaluate the performance of an innovative model of hospital activity known "Diffuse Hospital" (DH) that involved 3 hospital wards/departments (A, B and C) located throughout Italy and the Reference Hospital (RH) that organised the construction of this model.

Methods: An organisational retrospective observational study was conducted on the orthopaedic ward of each hospital from March 2022 to March 2023. Hospitals A, B and C had organisational differences in relation to the working relationship of healthcare professionals, the care pathways implemented, the presence or absence of an emergency department and the management of operating theatres. The primary indicator was the number of Diagnosis-Related Groups (DRGs) provided by the individual facilities. Additionally, a series of indicators were collected, and to enable comparison, these indicators were calculated in relation to the available resources.

Results: The total number of DRGs provided by the DH was 3904, broken down into 1187 at Hospital A, 1851 at Hospital B and 866 at Hospital C. The RH comparison standard recorded 1603 DRGs. Hospital B showed higher DRG indicators of 39.7, 2.5 and 30.9 percentage points, respectively, than the RH. In relation to theatre activities and healthcare staff, Hospitals A and C revealed lower scores than the standard.

Conclusions: The DH model may become a useful tool in healthcare policy strategies to enable national RHs to deliver treatments with high standards of care at a territorial level. The facilities involved in the DH organisational model produced different outcomes in terms of both efficiency and clinical outcomes. Where there is no direct management by the RH of healthcare staff, care pathways and operating theatres, replication of the standard is more difficult and outcomes are poorer. In the hospital where there is no need for emergency surgical activity and scheduling is concentrated within the week, better efficiency levels can be achieved.

Aim: This study aimed to explore influencing factors and develop a predictive model of endometrial polyps (EP) recurrence after hysteroscopic resection.

Methods: This retrospective study included 180 patients who underwent hysteroscopic resection for EP between January 2021 to December 2023. The patients were divided into a modeling group (n = 135) and a validation group (n = 45) in a 3:1 ratio. The patients in the modeling group were further divided into a recurrence group (n = 35) and a non-recurrence group (n = 100) based on whether their polyps recurred. General information on patients was compared between the two groups. Univariate and multiple logistic regression analyses were conducted to identify factors influencing EP recurrence post-hysteroscopic resection. A predictive model was developed, and the receiver operating characteristic (ROC) curve analysis was performed to determine the clinical utility of the model.

Results: Comparison of baseline characteristics between the modeling and validation groups showed no statistically significant differences (p > 0.05). However, 35 patients in the modeling group had recurrence, while 12 patients experienced recurrence in the validation group. Binary logistics regression analysis revealed matrix metalloproteinase-9 (MMP-9)/tissue inhibitor of metalloproteinase-1 (TIMP-1), hypoxia-inducible factor-1α (HIF-1α) and platelet-derived growth factor (PDGF) as independent predictors for polyp recurrence (p < 0.05). Furthermore, a model formula, p = eZ/1 + eZ, was developed. The slope of the calibration curve of this model in both groups were straight lines close to 1, indicating that the model's predicted recurrence risk strongly agreed with the actual risk. ROC analysis demonstrated that the area under the curve in the modeling group was 0.902, with standard error of 0.028 (95% confidence interval (CI): 0.885-0.954). The model yielded the Youden value of 0.79, with a sensitivity of 82.96% and a specificity of 95.66%. Moreover, the area under the curve in the validation group was 0.871, with a standard error of 0.040 (95% CI: 0.859-0.920). However, the model showed the Youden value of 0.59, with a sensitivity of 79.29% and a specificity of 79.96%. The Decision Curve Analysis (DCA) demonstrated significant clinical advantages of the model.

Conclusions: This study identified the influencing factors of EP recurrence and successfully constructed a predictive model based on these factors. After validation, the model demonstrates significant clinical utility.

Aim: The training of medical specialists is a decisive issue for the quality of medical practice. Autonomization in simple procedures and applying the peer education concept seem promising, particularly for general surgery. With this work, we wanted to assess whether there are differences between appendectomy operations performed by differently composed teams with the active involvement of resident doctors at a university centre.

Methods: We retrospectively analyzed the laparotomies and laparoscopic appendicectomies carried out at the Udine Surgery Clinic over a period of 10 years. The interventions were divided into groups according to the experience of the surgical team that performed them: G1 (consultant), G2 (senior resident + consultant), G3 (junior resident + consultant), and G4 (junior resident + senior resident).

Results: 510 appendectomy procedures were considered for the present analysis. 214 (42.0%) were performed by G1, 139 (27.3%) by G2, 79 (15.5%) by G3 and 78 (15.3%) by G4 group. No difference between the groups was shown in terms of complications, reinterventions, readmissions, length of stay, and duration of surgery. A statistically significant difference was shown in the age of the observed population with respect to the degree of experience of the surgical teams: younger patients were mainly operated on by more experienced teams, and in particular, pediatric laparoscopic appendectomy was performed mainly by consultants.

Conclusions: Appendectomy surgery can be performed by teams with varying levels of experience and is an example of an activity that can be used in Peer Education. It allows for the empowerment of younger residents and the autonomization of older residents in maintaining a medically, ethically, and legally correct standard of safe clinical practice.

Aim: The role of lymph node dissection (LND) in gastric adenocarcinoma (GAC) remained some controversy. This study reappraised the clinical implications of LND for GAC in terms of the numbers of total lymph node (TLN), positive lymph node (PLN) and negative lymph node (NLN).

Methods: A total of 106 GAC patients receiving an upfront gastrectomy (laparoscopic/laparotomy surgery, 19/87) with LND (D1/D1+/D2 dissection, 5/53/48) between Jan 2017 and Dec 2021 in Cathay General Hospital, Taipei were analyzed. The surgical-pathological T-/N-/M-status and cancer stage were determined according to the American Joint Committee on Cancer (AJCC) 8th edition. The numbers of TLN, PLN and NLN were recorded for analysis (TLN = PLN + NLN). The associations between prognosis and related variables, including pathological findings, the clinical implications of TLN/PLN/NLN and extent for LND, were all deeply studied.

Results: Advanced T-status (p < 0.001), N-status (p = 0.025), M-status (p = 0.001) and cancer stage (p = 0.001) had a negative effect on survival. The severity of N-status was associated with the progression of T-status (p < 0.001), M-status (p = 0.015) and cancer stage (p < 0.001). For all 106 GAC patients (p = 0.002/0.017) and the 25 T1 GAC patients (p = 0.052/0.015), those undergoing TLN >17 (≥18) had a more PLN and a higher rate of N(+) than those ≤17. For 65 N(+) GAC patients, an extension of TLN to ≥23 allowed the detection of a median value for PLN of 7, the N3-status. NLN >9 (≥10) was related to a better prognosis (p = 0.066) and lower HR (p = 0.073) for N(+) GAC patients. TLN with threshold value ≥20 owned the best power to distinguish NLN >9 (≥10) from ≤9 among N(+) GAC patients (p < 0.001). A D2 dissection could achieve these thresholds, including TLN ≥18 (p = 0.001) for GAC patients, TLN ≥23 (p = 0.028) for N(+) GAC patients, and NLN ≥10 (p = 0.012) as well as TLN ≥20 (p = 0.011) for N(+) GAC patients, more effectively than a D1/D1+ dissection.

Conclusions: A value of TLN ≥18 is necessary for de-novo GAC patients during gastrectomy to detect possible N(+) status, and ≥23 is recommended for N(+) GAC patients to identify the possible N3-status. A value of NLN ≥10 could reach a better survival for N(+) GAC patients and it requires a value of TLN ≥20 to achieve. A D2 dissection is recommended for GAC patients during gastrectomy. LND establishes adequate N-status staging and increases survival for GAC patients.

Aim: The use of upper eyelid lipofilling to prevent ocular complications in patients affected by facial nerve palsy is compared to other treatment options.

Case presentation: Ten patients treated with lipofilling of the upper eyelid, who were indicated for facial rehabilitation were identified from the Maxillo-facial Surgery Unit, Policlinico Umberto I. For all patients, fat harvested from the abdomen was processed with soft and short centrifugation.

Results: Satisfactory aesthetical and functional results were obtained in most cases. All patients reported a considerable reduction in the use of artificial tear drops and ointment for corneal lubrication. A second procedure was needed in one case to refill the eyelid, and in another one to correct poor aesthetical results. No patients developed postoperative ocular surface disorders.

Conclusions: The lipofilling of the upper eyelid procedure was easy to perform, leading to minimal complications rate. Given the small sample size and variability of samples collected in the current study, future studies involving larger cohorts are required to validate the efficacy of upper eyelid lipofilling in comparison to other treatments.