Publications by authors named "Federico Coccolini"

300 Publications

The LIFE TRIAD of emergency general surgery.

World J Emerg Surg 2022 07 25;17(1):41. Epub 2022 Jul 25.

Surgery Department, Radboud University Medical Center, Nijmegen, The Netherlands.

Emergency General Surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital by general emergency surgeons and other specialists. It is the most diffused surgical discipline in the world. To live and grow strong EGS necessitates three fundamental parts: emergency and elective continuous surgical practice, evidence generation through clinical registries and data accrual, and indications and guidelines production: the LIFE TRIAD.
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http://dx.doi.org/10.1186/s13017-022-00447-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9317062PMC
July 2022

Impact of operation duration on postoperative outcomes of minimally-invasive right colectomy.

Colorectal Dis 2022 Jul 12. Epub 2022 Jul 12.

Department of Digestive and Oncologic Surgery, Hospital Nord, CHU Saint-Etienne, Saint-Etienne, France.

Aim: Operation time (OT) is a key operational factor influencing surgical outcomes. The present study aimed to analyse whether OT impacts on short-term outcomes of minimally-invasive right colectomies by assessing the role of surgical approach (robotic [RRC] or laparoscopic right colectomy [LRC]), and type of ileocolic anastomosis (i.e., intracorporal [IA] or extra-corporal anastomosis [EA]).

Methods: This was a retrospective analysis of the Minimally-invasivE surgery for oncological Right ColectomY (MERCY) Study Group database, which included adult patients with nonmetastatic right colon adenocarcinoma operated on by oncological RRC or LRC between January 2014 and December 2020. Univariate and multivariate analyses were used.

Results: The study sample was composed of 1549 patients who were divided into three groups according to the OT quartiles: (1) First quartile, <135 min (n = 386); (2) Second and third quartiles, 135-199 min (n = 731); and (3) Fourth quartile ≥200 min (n = 432). The majority (62.7%) were LRC-EA, followed by LRC-IA (24.3%), RRC-IA (11.1%), and RRC-EA (1.9%). Independent predictors of an OT ≥ 200 min included male gender, age, obesity, diabetes, use of indocyanine green fluorescence, and IA confection. An OT ≥ 200 min was significantly associated with an increased risk of postoperative noninfective complications (AOR: 1.56; 95% CI: 1.15-2.13; p = 0.004), whereas the surgical approach and the type of anastomosis had no impact on postoperative morbidity.

Conclusion: Prolonged OT is independently associated with increased odds of postoperative noninfective complications in oncological minimally-invasive right colectomy.
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http://dx.doi.org/10.1111/codi.16243DOI Listing
July 2022

Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members.

World J Emerg Surg 2022 06 16;17(1):34. Epub 2022 Jun 16.

Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic.

Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine.

Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis.

Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years.
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http://dx.doi.org/10.1186/s13017-022-00424-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202986PMC
June 2022

Risk factors for necrotic cholecystitis during the COVID-19 pandemic: the ChoCO-WSES prospective collaborative study's experience.

Turk J Surg 2021 Dec 31;37(4):387-393. Epub 2021 Dec 31.

Department of Emergency and Metabolic Minimally Invasive Surgery, Poissy/Saint Germain en Laye Hospitals, France.

Objectives: During the COVID-19 pandemic, several studies have reported a decrease in in the admission surgical patients and emergency surgical procedures, and an increase in more severe septic surgical diseases, such as necrotic cholecystitis. It was probably due to to a critical delay in time-to- diagnosis and time-to-intervention resulting to limited access to the operating theatres as well as intensive care units. Early laparoscopic cholecystec- tomy is the standard of care for acute cholecystitis. Moreover early data from COVID-19 pandemic reported an increase in the incidence of necrotic cholecystitis among COVID-19 patients. The ChoCO-W prospective observational collaborative study was conceived to investigate the incidence and management of acute cholecystitis under the COVID-19 pandemic.

Material And Methods: The present research protocol was. conceived and designed as a prospective observational international collaborative study focusing on the management of patients with to the diagnosis of acute cholecystitis under the COVID-19 pandemic. The study obtained the approval of the local Ethics Committee (Nimes, France) and meet and conform to the standards outlined in the Declaration of Helsinki. Eligible patients will be prospectively enrolled in the recruitment period and data entered in an online case report form.

Results: The ChoCO-W study will be the largest prospective study carried out during the first period of the COVID-19 pandemic with the aim to inves- tigate the management of patients with acute cholecystitis, in the lack of studies focusing on COVID-19 positive patients.

Conclusion: The ChoCO-W study is conceived to be the largest prospective study to assess the management of patients presenting with acute chol- ecystitis during the COVID-19 pandemic and risk factors correlated with necrotic cholecystitis to improve the management of high-risk patients.
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http://dx.doi.org/10.47717/turkjsurg.2021.5507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9130934PMC
December 2021

Letter to the Editor: Western Trauma Association Critical Decision Algorithm for the Evaluation and Management of Traumatic Pneumothorax.

J Trauma Acute Care Surg 2022 Jun 1. Epub 2022 Jun 1.

General, Emergency and Trauma Surgery Dept., Pisa University Hospital Pisa, Italy.

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http://dx.doi.org/10.1097/TA.0000000000003659DOI Listing
June 2022

Intestinal Ischemia: Unusual but Fearsome Complication of COVID-19 Infection.

Biomedicines 2022 Apr 27;10(5). Epub 2022 Apr 27.

General, Emergency and Trauma Surgery Unit, Pisa University Hospital, 56124 Pisa, Italy.

The pathophysiology of gastrointestinal damage in coronavirus disease (COVID-19) is probably multifactorial. It is not clear whether the etiology of intestinal ischemia may be directly related to viral replication or may result from hyper-coagulability following SARS-CoV-2 infection.To confirm a pathogenic role of COVID-19, we retrospectively investigated the presence of SARS-CoV-2 virus in the ischemic bowel of five COVID-19 patients undergoing emergency surgery for intestinal ischemia in the period of March 2020-May 2021. Immunohistochemical positivity with weak intensity was observed in four out of five cases, but only one case was strongly positive both at immunohistochemistry and at molecular analysis. The histological alterations in the intestinal tissue samples showed similarity with the well-known alterations described in typical targetorgans of the virus (e.g., the lung). This observation suggests a similar mechanism of action of the virus. Further larger studies are, thus, required to confirm this preliminary finding. Clinicians should carefully monitor all COVID-19 patients for the possible presence of a SARS-CoV-2 intestinal infection, a potential cause of ischemia and bowel perforation.
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http://dx.doi.org/10.3390/biomedicines10051010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9138267PMC
April 2022

"Zooming" in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé?

Rev Assoc Med Bras (1992) 2022 13;68(6):847-852. Epub 2022 May 13.

Giresun University, Faculty of Medicine, Division of Endocrine Surgery - Giresun, Turkey.

Objective: Rescuing severe trauma cases is extremely demanding. The present study purposed to analyze the efficiency of trauma management at Emergency Centre, University Clinical Centre of Serbia, Belgrade, included outcome within 28 days.

Methods: This retrospective study involved 131 intensive care unit trauma cases with total Injury Severity Score ≥16, in terms of administrating the two strategies: (i) definitive surgical repair and (ii) damage control laparotomy.

Results: The damage control laparotomy cases revealed statistically higher Injury Severity Score and APACHE II scores, significant brain dysfunction, and hemorrhagic shock on arrival (p<0.001). In addition, the damage control laparotomy had a higher rate of respiratory complications, multiple organ deficiency syndrome, and surgical wound complications (p=0.017, <0.001, and 0.004, respectively), with more days on mechanical ventilation (p=0.003). Overall mortality was 29.8%. Although higher early mortality within ≤24 h in the damage control laparotomy (p=0.021) had been observed, no difference between groups (p=0.172) after the 4th day of hospitalization was detected.

Conclusions: Trauma patients have a high mortality rate in the 1st hours after the incident. Compelling evidence linking host and pathogen factors, such as mitochondrial apoptosis pathways, appears to correlate with loss of organ dysfunction, both cytopathologically and histopathologically. Adequate selection of patients necessitating damage control laparotomy, allowed by the World Society of Emergency Surgery, abdominopelvic trauma classifications, and improvements in resuscitation, may improve the results of severe trauma treatment.
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http://dx.doi.org/10.1590/1806-9282.20220216DOI Listing
July 2022

[Interpretation of acute abdomen in the immunocompromised patients: WSES/SIS-E/WSIS/AAST/GAIS guideline].

Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2022 03;34(3):239-244

General, Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa 56124, Italy. Corresponding author: Cui Yunfeng, Email: Zhang Yamin, Email: Federico Coccolini, Email:

World Society of Emergency Surgery (WSES), in conjunction with Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) developed guideline about the management of acute abdomen in immunocompromised patients, which was published in the World Journal of Emergency Surgery (WJES) on August 9, 2021. The guidelines elaborate on the definition, classification, diagnosis and treatment of immunocompromised patients. In addition, based on evidence-based medicine, it provides guidance and suggestion on the management of specific acute abdominal infections in immunocompromised patients, common acute abdominal infections in transplanted patients, patients with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS), as well as perioperative steroid management. An interpretation of the guideline was performed to accomplish a better understanding the current status and recommendations for the management of acute abdominal conditions in immunocompromised patients, and to make forward suggestions on its limitations.
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http://dx.doi.org/10.3760/cma.j.cn121430-20211008-01440DOI Listing
March 2022

The acute phase management of spinal cord injury affecting polytrauma patients: the ASAP study.

World J Emerg Surg 2022 04 25;17(1):20. Epub 2022 Apr 25.

Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy.

Background: Few data on the management of acute phase of traumatic spinal cord injury (tSCI) in patients suffering polytrauma are available. As the therapeutic choices in the first hours may have a deep impact on outcome of tSCI patients, we conducted an international survey investigating this topic.

Methods: The survey was composed of 29 items. The main endpoints of the survey were to examine: (1) the hemodynamic and respiratory management, (2) the coagulation management, (3) the timing of magnetic resonance imaging (MRI) and spinal surgery, (4) the use of corticosteroid therapy, (5) the role of intraspinal pressure (ISP)/spinal cord perfusion pressure (SCPP) monitoring and (6) the utilization of therapeutic hypothermia.

Results: There were 171 respondents from 139 centers worldwide. A target mean arterial pressure (MAP) target of 80-90 mmHg was chosen in almost half of the cases [n = 84 (49.1%)]. A temporary reduction in the target MAP, for the time strictly necessary to achieve bleeding control in polytrauma, was accepted by most respondents [n = 100 (58.5%)]. Sixty-one respondents (35.7%) considered acceptable a hemoglobin (Hb) level of 7 g/dl in tSCI polytraumatized patients. An arterial partial pressure of oxygen (PaO) of 80-100 mmHg [n = 94 (55%)] and an arterial partial pressure of carbon dioxide (PaCO) of 35-40 mmHg [n = 130 (76%)] were chosen in most cases. A little more than half of respondents considered safe a platelet (PLT) count > 100.000/mm [n = 99 (57.9%)] and prothrombin time (PT)/activated partial thromboplastin time (aPTT) < 1.5 times the normal control [n = 85 (49.7%)] in patients needing spinal surgery. MRI [n = 160 (93.6%)] and spinal surgery [n = 158 (92.4%)] should be performed after intracranial, hemodynamic, and respiratory stabilization by most respondents. Corticosteroids [n = 103 (60.2%)], ISP/SCPP monitoring [n = 148 (86.5%)], and therapeutic hypothermia [n = 137 (80%)] were not utilized by most respondents.

Conclusions: Our survey has shown a great worldwide variability in clinical practices for acute phase management of tSCI patients with polytrauma. These findings can be helpful to define future research in order to optimize the care of patients suffering tSCI.
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http://dx.doi.org/10.1186/s13017-022-00422-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9036814PMC
April 2022

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey.

World J Emerg Surg 2022 03 17;17(1):17. Epub 2022 Mar 17.

General Surgery, UMHAT St George Plovdiv, RIMU/Research Institute at Medical University of Plovdiv, Plovdiv, Bulgaria.

Background: The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness.

Methods: A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days.

Results: Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations.

Conclusion: Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.
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http://dx.doi.org/10.1186/s13017-022-00420-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8928018PMC
March 2022

Minimally invasive surgery in emergency surgery: a WSES survey.

World J Emerg Surg 2022 03 18;17(1):18. Epub 2022 Mar 18.

Emergency Surgery, University of Pisa, Pisa, Italy.

Background: The diffusion of minimally invasive surgery in emergency surgery still represents a developing challenge. Evidence about the use of minimally invasive surgery shows its feasibility and safety; however, the diffusion of these techniques is still poor. The aims of the present survey were to explore the diffusion and variations in the use of minimally invasive surgery among surgeons in the emergency setting.

Methods: This is a web-based survey administered to all the WSES members investigating the diffusion of minimally invasive surgery in emergency. The survey investigated personal characteristics of participants, hospital characteristics, personal confidence in the use of minimally invasive surgery in emergency, limitations in the use of it and limitations to prosecute minimally invasive surgery in emergency surgery. Characteristics related to the use of minimally invasive surgery were studied with a multivariate ordinal regression.

Results: The survey collected a total of 415 answers; 42.2% of participants declared a working experience > 15 years and 69.4% of responders worked in tertiary level center or academic hospital. In primary emergencies, only 28,7% of participants declared the use of laparoscopy in more than 50% of times. Personal confidence with minimally invasive techniques was the highest for appendectomy and cholecystectomy. At multivariate ordinal regression, a longer professional experience, the use of laparoscopy in major elective surgery and bariatric surgery expertise were related to a higher use of laparoscopy in emergency surgery.

Conclusions: The survey shows that minimally invasive techniques in emergency surgery are still underutilized. Greater focus should be placed on the development of dedicated training in laparoscopy among emergency surgeons.
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http://dx.doi.org/10.1186/s13017-022-00419-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8932166PMC
March 2022

It's time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review.

World J Emerg Surg 2022 03 17;17(1):15. Epub 2022 Mar 17.

Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future.

Methods: A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board.

Results: A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic.

Conclusion: This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.
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http://dx.doi.org/10.1186/s13017-022-00411-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8928637PMC
March 2022

Laparoscopic versus open colectomy for locally advanced T4 colonic cancer: meta-analysis of clinical and oncological outcomes.

Br J Surg 2022 03;109(4):319-331

Department of Surgery, Madonna del Soccorso General Hospital, San Benedetto del Tronto, Italy.

Background: The aim of this study was to review the early postoperative and oncological outcomes after laparoscopic colectomy for T4 cancer compared with open surgery.

Method: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for any relevant clinical study comparing laparoscopic and open colectomy as treatment for T4 colonic cancer. The risk ratio (RR) with 95 per cent c.i. was calculated for dichotomous variables, and the mean difference (m.d.) with 95 per cent confidence interval for continuous variables. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was implemented for assessing quality of evidence (QoE).

Results: Twenty-four observational studies (21 retrospective and 3 prospective cohort studies) were included, analysing a total of 18 123 patients: 9024 received laparoscopic colectomy and 9099 underwent open surgery. Laparoscopic colectomy was associated with lower rates of mortality (RR 0.48, 95 per cent c.i. 0.41 to 0.56; P < 0.001; I2 = 0 per cent, fixed-effect model; QoE moderate) and complications (RR 0.61, 0.49 to 0.76; P < 0.001; I2 = 20 per cent, random-effects model; QoE very low) compared with an open procedure. No differences in R0 resection rate (RR 1.01, 1.00 to 1.03; P = 0.12; I2 = 37 per cent, random-effects model; QoE very low) and recurrence rate (RR 0.98, 0.84 to 1.14; P = 0.81; I2 = 0 per cent, fixed-effect model; QoE very low) were found.

Conclusion: Laparoscopic colectomy for T4 colonic cancer is safe, and is associated with better clinical outcomes than open surgery and similar oncological outcomes.
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http://dx.doi.org/10.1093/bjs/znab464DOI Listing
March 2022

Positive peritoneal swab in SARS-CoV-2 patients undergoing abdominal emergency surgery: effect or cause?

Infection 2022 Aug 2;50(4):989-993. Epub 2022 Mar 2.

General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy.

Purpose: The presence of the SARS-CoV-2 in the peritoneal fluid is a matter of debate in the COVID-19 literature. The study aimed to report the prevalence of SARS-CoV-2 in the peritoneal fluid of patients with nasopharyngeal swab tested positive for SARS-CoV-2 undergoing emergency surgery and review the literature.

Methods: The present study was conducted between March 2020 and June 2021. Diagnosis of SARS-CoV-2 positivity was confirmed by preoperative real-time reverse transcriptase-polymerase chain reaction (RT-PCR).

Results: Eighteen patients with positive nasopharyngeal swabs were operated in emergency in two third-level Italian hospitals. In 13 of these patients (72%), a peritoneal swab was analyzed: SARS-CoV-2 RNA was found in the abdominal fluid of two patients (15%). Neither of them had visceral perforation and one patient died. In ten patients with negative peritoneal swabs, visceral perforation and mortality rates were 30% and 20%, respectively.

Conclusion: SARS-CoV-2 peritoneal positivity is rare. Abdominal surgery can, therefore, be safely performed in patients with COVID-19 using standard precautions. The correlation with a visceral perforation is not evaluable. The clinical outcomes seem uninfluenced by the viral colonization of the peritoneum. Assessment in large series to provide definitive answers about the involvement of the SARS-CoV-2 in the peritoneum will be challenging to coordinate.
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http://dx.doi.org/10.1007/s15010-022-01785-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8890010PMC
August 2022

Antibiotic Prophylaxis in Torso, Maxillofacial, and Skin Traumatic Lesions: A Systematic Review of Recent Evidence.

Antibiotics (Basel) 2022 Jan 21;11(2). Epub 2022 Jan 21.

General, Emergency and Trauma Surgery, Pisa University Hospital, 56100 Pisa, Italy.

Use of antibiotic prophylaxis (AP) in trauma patients is a common practice. However, considering the increasing rates of antibiotic resistance, AP use should be questioned and limited only to specific cases. We performed a systematic review of recent literature (from year 2000), aiming to summarize the state of the art on efficacy and appropriateness of AP in patients with traumatic injuries of torso, maxillofacial complex and skin (including burns). Twenty-six articles were selected. In thoracic trauma, AP could be useful in reducing infective complications in tube thoracostomy for penetrating trauma. In maxillo-facial trauma, AP could find a role in the peri-operative trauma setting in the case of a graft or prosthetic implant. In abdominal trauma, there is a lack of consensus on the definition of contamination, infection, antibiotic therapy, and prophylaxis. In burned patients, routine AP is not suggested. In the case of human bites to the extremities, AP could find an indication. Future studies should focus on the subcategories of patients at higher risk of infection, identifying those who would benefit from AP. Attention to antimicrobial stewardship and guidelines focused on AP in trauma are required, to reduce antibiotic abuse, and increase quality research.
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http://dx.doi.org/10.3390/antibiotics11020139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8868174PMC
January 2022

Early versus delayed defunctioning ileostomy closure after low anterior resection for rectal cancer: a meta-analysis and trial sequential analysis of safety and functional outcomes.

Int J Colorectal Dis 2022 Apr 21;37(4):737-756. Epub 2022 Feb 21.

Department of Surgical Science, University of Cagliari, Cagliari, Italy.

Purpose: We performed a systematic review and meta-analysis with trial sequential analysis (TSA) to answer whether early closure of defunctioning ileostomy may be suitable after low anterior resection.

Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, up to October 2021, for RCTs comparing early closure (EC ≤ 30 days) and delayed closure (DC ≥ 60 days) of defunctioning ileostomy. The risk ratio (RR) with 95% CI was calculated for dichotomous variables and the mean difference (MD) with 95% CI for continuous variables. The GRADE methodology was implemented for assessing Quality of Evidence (QoE). TSA was implemented to address the risk of random error associated with sparse data and/or multiple testing.

Results: Seven RCTs were included for quantitative synthesis. 599 patients were allocated to either EC (n = 306) or DC (n = 293). EC was associated with a higher rate of wound complications compared to DC (RR 2.56; 95% CI 1.33 to 4.93; P = 0.005; I = 0%, QoE High), a lower incidence of postoperative small bowel obstruction (RR 0.46; 95% CI 0.24 to 0.89; P = 0.02; I = 0%, QoE moderate), and a lower rate of stoma-related complications (RR 0.26; 95% CI 0.16 to 0.42; P < 0.00001; I = 0%, QoE moderate). The rate of minor low anterior resection syndrome (LARS) (RR 1.13; 95% CI 0.55 to 2.33; P = 0.74; I = 0%, QoE low) and major LARS (RR 0.80; 95% CI 0.59 to 1.09; P = 0.16; I = 0%, QoE low) did not differ between the two groups. TSA demonstrated inconclusive evidence with insufficient sample sizes to detect the observed effects.

Conclusion: EC may confer some advantages compared with a DC. However, TSA advocated a cautious interpretation of the results.

Prospero Register Id: CRD42021276557.
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http://dx.doi.org/10.1007/s00384-022-04106-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8860143PMC
April 2022

Knowledge, attitude, and practice of artificial intelligence in emergency and trauma surgery, the ARIES project: an international web-based survey.

World J Emerg Surg 2022 02 10;17(1):10. Epub 2022 Feb 10.

Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy.

Aim: We aimed to evaluate the knowledge, attitude, and practices in the application of AI in the emergency setting among international acute care and emergency surgeons.

Methods: An online questionnaire composed of 30 multiple choice and open-ended questions was sent to the members of the World Society of Emergency Surgery between 29th May and 28th August 2021. The questionnaire was developed by a panel of 11 international experts and approved by the WSES steering committee.

Results: 200 participants answered the survey, 32 were females (16%). 172 (86%) surgeons thought that AI will improve acute care surgery. Fifty surgeons (25%) were trained, robotic surgeons and can perform it. Only 19 (9.5%) were currently performing it. 126 (63%) surgeons do not have a robotic system in their institution, and for those who have it, it was mainly used for elective surgery. Only 100 surgeons (50%) were able to define different AI terminology. Participants thought that AI is useful to support training and education (61.5%), perioperative decision making (59.5%), and surgical vision (53%) in emergency surgery. There was no statistically significant difference between males and females in ability, interest in training or expectations of AI (p values 0.91, 0.82, and 0.28, respectively, Mann-Whitney U test). Ability was significantly correlated with interest and expectations (p < 0.0001 Pearson rank correlation, rho 0.42 and 0.47, respectively) but not with experience (p = 0.9, rho - 0.01).

Conclusions: The implementation of artificial intelligence in the emergency and trauma setting is still in an early phase. The support of emergency and trauma surgeons is essential for the progress of AI in their setting which can be augmented by proper research and training programs in this area.
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http://dx.doi.org/10.1186/s13017-022-00413-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8832812PMC
February 2022

Indocyanine Green (ICG) for the assessment of splenic perfusion during laparoscopic splenic artery aneurysmectomy. A case report.

Ann Ital Chir 2021 Oct 25;10. Epub 2021 Oct 25.

Case Report: We describe the case of a 54-year-old man with a 20mm splenic aneurysm, who underwent laparoscopic aneurysmectomy, without splenic removal. The residual splenic blood supply was assessed by using indocyanine green i.v. administration.

Clinical Findings: The patient presented at ED with abdominal pain, syncopal episode, and tachycardia. A CT scan with contrast showed hemoperitoneum with a 20mm splenic aneurysm, which was located at the bifurcation of the splenic and left gastroepiploic artery. Treatment and Outcome Laparoscopic surgery was then warranted. Abdominal exploration revealed a serohemorrhagic collection without active source of bleeding. After opening the gastro-colic ligament and obtaining vascular control of the splenic artery, the aneurysm was clipped and resected. No macroscopic modifications occurred to the spleen. This finding was confirmed by intravenous administration of indocyanine green. The operating time was 265 minutes. During the postoperative course, a grade A pancreatic fistula occurred. The patient was discharged on postoperative day seventh.

Clinical Relevance: The management of true splenic artery aneurysms should be patient-tailored, considering the location of the aneurysm, operative risks and the patient's age, life expectancy and clinical status. The use of ICG in splenic surgery helps delineate the splenic parenchyma and evaluate residual splenic vascularization.

Key Words: Indocyanine Green, Laparoscopy, Mini-invasive Surgery, Splenic Artery Aneurysm.
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October 2021

The WSES/SICG/ACOI/SICUT/AcEMC/SIFIPAC guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly.

World J Emerg Surg 2022 01 21;17(1). Epub 2022 Jan 21.

Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates.

Acute left colonic diverticulitis (ALCD) in the elderly presents with unique epidemiological features when compared with younger patients. The clinical presentation is more nuanced in the elderly population, having higher in-hospital and postoperative mortality. Furthermore, geriatric comorbidities are a risk factor for complicated diverticulitis. Finally, elderly patients have a lower risk of recurrent episodes and, in case of recurrence, a lower probability of requiring urgent surgery than younger patients. The aim of the present work is to study age-related factors that may support a unique approach to the diagnosis and treatment of this problem in the elderly when compared with the WSES guidelines for the management of acute left-sided colonic diverticulitis. During the 1° Pisa Workshop of Acute Care & Trauma Surgery held in Pisa (Italy) in September 2019, with the collaboration of the World Society of Emergency Surgery (WSES), the Italian Society of Geriatric Surgery (SICG), the Italian Hospital Surgeons Association (ACOI), the Italian Emergency Surgery and Trauma Association (SICUT), the Academy of Emergency Medicine and Care (AcEMC) and the Italian Society of Surgical Pathophysiology (SIFIPAC), three panel members presented a number of statements developed for each of the four themes regarding the diagnosis and management of ALCD in older patients, formulated according to the GRADE approach, at a Consensus Conference where a panel of experts participated. The statements were subsequently debated, revised, and finally approved by the Consensus Conference attendees. The current paper is a summary report of the definitive guidelines statements on each of the following topics: diagnosis, management, surgical technique and antibiotic therapy.
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http://dx.doi.org/10.1186/s13017-022-00408-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8781436PMC
January 2022

Robotic surgery in emergency setting: 2021 WSES position paper.

World J Emerg Surg 2022 01 20;17(1). Epub 2022 Jan 20.

Division of Digestive Surgery, University Hospitals of Geneva and Medical School, Geneva, Switzerland.

Background: Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery.

Methods: This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus.

Results: Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particularly valuable in emergency situations.

Conclusions: Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.
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http://dx.doi.org/10.1186/s13017-022-00410-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8781145PMC
January 2022

Antibiotic Prophylaxis for Surgical Site Infection in General Surgery: Oncological Treatments and HIPEC.

Antibiotics (Basel) 2021 Dec 30;11(1). Epub 2021 Dec 30.

General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy.

The procedure of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a combined surgical and oncological treatment for peritoneal carcinomatosis of various origins. Antibiotic prophylaxis is usually center-related and should be discussed together with the infectious disease specialist, taking into account the advanced oncologic condition of the patient, the complexity of surgery-often requiring multiorgan resections-and the risk of post-HIPEC neutropenia. The incidence of surgical site infection (SSI) after CRS and HIPEC ranges between 11 and 46%. These patients are also at high risk of postoperative abdominal infections and septic complications, and a bacterial translocation during HIPEC has been hypothesized. Many authors have proposed aggressive screening protocols and a high intra and postoperative alert, in order to minimize and promptly identify all possible infectious complications following CRS and HIPEC.
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http://dx.doi.org/10.3390/antibiotics11010043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8773423PMC
December 2021

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections.

World J Emerg Surg 2022 01 15;17(1). Epub 2022 Jan 15.

Department of Surgery, Texas Health Resources, Ft Worth, TX, USA.

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.
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http://dx.doi.org/10.1186/s13017-022-00406-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8761341PMC
January 2022

Sarcina Ventriculi infection: a rare but fearsome event. A Systematic Review of the Literature.

Int J Infect Dis 2022 Feb 25;115:48-61. Epub 2021 Nov 25.

Emergency Surgery Unit and Trauma Center, Pisa University Hospital, University of Pisa, Pisa, Italy.

Objectives: This study is aimed to report a case of SV-related gastritis and the results of a systematic literature review of SV infections.

Methods: Following a case presentation, we systematically searched different databases (MEDLINE, PubMed, Scopus, Web of Science, EMBASE, google scholar) for the items "sarcina," "ventriculi," "clostridium" with AND/OR.

Results: A total of 55 articles reporting 65 cases of Sarcina Ventriculi were found. Thus, 66 patients, including our case, were reviewed. The median age was 51 years (IQR: 0-87 years). Females accounted for 51% of cases. 68% of patients had one or more comorbidities. SV was isolated in the gastrointestinal tract (88%), respiratory (5%), urine (4%), and bloodstream (3%) systems. Upper endoscopy was performed in 52 patients (79%). Biopsies were obtained in all 52 cases and were normal in 23%. Surgery was warranted in 15 patients (23%), and specific antimicrobial therapy was delivered in 34 (52%) patients. Mortality was 14%. At follow-up, 88% of patients showed complete eradication of the SV infection.

Conclusions: Upper gastrointestinal biopsy positive for SV should prompt an evaluation of the clinical conditions, considering the risk of gastric perforation is not negligible. Antibiotic therapy may eradicate the infection and prevent complications. Emergency surgery is required in case of source control.
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http://dx.doi.org/10.1016/j.ijid.2021.11.027DOI Listing
February 2022

The "Torment" of Surgical Antibiotic Prophylaxis among Surgeons.

Antibiotics (Basel) 2021 Nov 6;10(11). Epub 2021 Nov 6.

General and Emergency Surgery Department, Bufalini Hospital, 47521 Cesena, Italy.

Surgical antibiotic prophylaxis (SAP) is one of the peri-operative measures for preventing surgical site infections (SSIs). Its goal is to counteract the proliferation of bacteria in the surgical site during intervention in order to reduce the risk of SSIs. SAP should be administered for surgical interventions where the benefit expected (prevention of SSIs) is higher compared to the risk (serious side effects, such as acute kidney injury,   infection, and the spread of antimicrobial resistance). In prescribing SAP, surgeons should have both the awareness necessary "to handle antibiotics with care", and the knowledge required to use them appropriately.
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http://dx.doi.org/10.3390/antibiotics10111357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8614853PMC
November 2021

Microsatellite and RAS/RAF Mutational Status as Prognostic Factors in Colorectal Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Ann Surg Oncol 2022 Jun 16;29(6):3405-3417. Epub 2021 Nov 16.

Unit of Surgical Oncology of the Esophagus and Digestive Tract, Surgical Oncology Department, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy.

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) leads to prolonged survival for selected patients with colorectal (CRC) peritoneal metastases (PM). This study aimed to analyze the prognostic role of micro-satellite (MS) status and RAS/RAF mutations for patients treated with CRS.

Methods: Data were collected from 13 Italian centers with PM expertise within a collaborative group of the Italian Society of Surgical Oncology. Clinical and pathologic variables and KRAS/NRAS/BRAF mutational and MS status were correlated with overall survival (OS) and disease-free survival (DFS).

Results: The study enrolled 437 patients treated with CRS-HIPEC. The median OS was 42.3 months [95% confidence interval (CI), 33.4-51.2 months], and the median DFS was 13.6 months (95% CI, 12.3-14.9 months). The local (peritoneal) DFS was 20.5 months (95% CI, 16.4-24.6 months). In addition to the known clinical factors, KRAS mutations (p = 0.005), BRAF mutations (p = 0.01), and MS status (p = 0.04) were related to survival. The KRAS- and BRAF-mutated patients had a shorter survival than the wild-type (WT) patients (5-year OS, 29.4% and 26.8% vs 51.5%, respectively). The patients with micro-satellite instability (MSI) had a longer survival than the patients with micro-satellite stability (MSS) (5-year OS, 58.3% vs 36.7%). The MSI/WT patients had the best prognosis. The MSS/WT and MSI/mutated patients had similar survivals, whereas the MSS/mutated patients showed the worst prognosis (5-year OS, 70.6%, 48.1%, 23.4%; p = 0.0001). In the multivariable analysis, OS was related to the Peritoneal Cancer Index [hazard ratio (HR), 1.05 per point], completeness of cytoreduction (CC) score (HR, 2.8), N status (HR, 1.6), signet-ring (HR, 2.4), MSI/WT (HR, 0.5), and MSS/WT-MSI/mutation (HR, 0.4). Similar results were obtained for DFS.

Conclusion: For patients affected by CRC-PM who are eligible for CRS, clinical and pathologic criteria need to be integrated with molecular features (KRAS/BRAF mutation). Micro-satellite status should be strongly considered because MSI confers a survival advantage over MSS, even for mutated patients.
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http://dx.doi.org/10.1245/s10434-021-11045-3DOI Listing
June 2022

Correction to: Team dynamics in emergency surgery teams: results from a first international survey.

World J Emerg Surg 2021 Nov 1;16(1):55. Epub 2021 Nov 1.

Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Polo Didattico "Cesare Brusotti" Viale Brambilla, 74, 27100, Pavia, Italy.

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http://dx.doi.org/10.1186/s13017-021-00397-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8561977PMC
November 2021

Massive aspiration syndrome: a possible indication for "emergent" veno-venous extracorporeal membrane oxygenation?: a case report.

J Med Case Rep 2021 Oct 8;15(1):499. Epub 2021 Oct 8.

Anaesthesia and Intensive Care Department, Major Trauma Centre "Maurizio Bufalini" Hospital, 47251, Cesena, Italy.

Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is usually performed in cases of severe respiratory failure in which conventional and advanced mechanical ventilation strategies are ineffective in achieving true lung-protective ventilation, thus triggering ventilatory-induced lung injury. If circulatory failure coexists, veno-arterial ECMO (VA-ECMO) may be preferred over VV-ECMO because of its potential for circulatory support. In VA-ECMO, the respiratory contribution is less effective and the complication rate is higher than in the VV configuration.

Case Presentation: The authors present a case in which VV-ECMO was performed in an emergency setting to treat a 68-year-old White male patient who experienced acute respiratory failure after massive aspiration. Despite intubation and intensive care unit admission, multiple organ failure occurred suddenly, thus prompting referral to a level-1 trauma center with an ECMO facility. The patient's condition slowly improved with VV-ECMO support along with standard treatment for hemodynamic impairment. VV-ECMO was discontinued on day 8. The patient was extubated on day 14 and discharged home fully recovered 34 days after the event.

Conclusions: Attention was focused on the decision to initiate VV-ECMO support even in the presence of severe hemodynamic derangement, although VA-ECMO could have provided better hemodynamic support but less effective respiratory support.
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http://dx.doi.org/10.1186/s13256-021-03050-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8499513PMC
October 2021

WSES project on decision support systems based on artificial neural networks in emergency surgery.

World J Emerg Surg 2021 09 26;16(1):50. Epub 2021 Sep 26.

Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy.

The article is a scoping review of the literature on the use of decision support systems based on artificial neural networks in emergency surgery. The authors present modern literature data on the effectiveness of artificial neural networks for predicting, diagnosing and treating abdominal emergency conditions: acute appendicitis, acute pancreatitis, acute cholecystitis, perforated gastric or duodenal ulcer, acute intestinal obstruction, and strangulated hernia. The intelligent systems developed at present allow a surgeon in an emergency setting, not only to check his own diagnostic and prognostic assumptions, but also to use artificial intelligence in complex urgent clinical cases. The authors summarize the main limitations for the implementation of artificial neural networks in surgery and medicine in general. These limitations are the lack of transparency in the decision-making process; insufficient quality educational medical data; lack of qualified personnel; high cost of projects; and the complexity of secure storage of medical information data. The development and implementation of decision support systems based on artificial neural networks is a promising direction for improving the forecasting, diagnosis and treatment of emergency surgical diseases and their complications.
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http://dx.doi.org/10.1186/s13017-021-00394-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8474926PMC
September 2021
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