Publications by authors named "Mauro Podda"

147 Publications

The Impact of COVID-19 on Kidney Transplant Recipients in Pre-Vaccination and Delta Strain Era: A Systematic Review and Meta-Analysis.

J Clin Med 2021 Sep 30;10(19). Epub 2021 Sep 30.

Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA.

Herein, we performed a meta-analysis of published clinical outcomes of corona virus disease 2019 (COVID-19) in hospitalized kidney transplant recipients. A systematic database search was conducted between December 1, 2019 and April 20, 2020. We analyzed 48 studies comprising 3137 kidney transplant recipients with COVID-19. Fever (77%), cough (65%), dyspnea (48%), and gastrointestinal symptoms (28%) were predominant on hospital admission. The most common comorbidities were hypertension (83%), diabetes mellitus (34%), and cardiac disease (23%). The pooled prevalence of acute respiratory distress syndrome and acute kidney injury were 58% and 48%, respectively. Invasive ventilation and dialysis were required in 24% and 22% patients, respectively. In-hospital mortality rate was as high as 21%, and increased to over 50% for patients in intensive care unit (ICU) or requiring invasive ventilation. Risk of mortality in patients with acute respiratory distress syndrome (ARDS), on mechanical ventilation, and ICU admission was increased: OR = 19.59, OR = 3.80, and OR = 13.39, respectively. Mortality risk in the elderly was OR = 3.90; however, no such association was observed in terms of time since transplantation and gender. Fever, cough, dyspnea, and gastrointestinal symptoms were common on admission for COVID-19 in kidney transplant patients. Mortality was as high as 20% and increased to over 50% in patients in ICU and required invasive ventilation.
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http://dx.doi.org/10.3390/jcm10194533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509345PMC
September 2021

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections.

World J Emerg Surg 2021 Sep 25;16(1):49. Epub 2021 Sep 25.

Department of general, Digestive and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal De Poissy/St Germain en Laye, Poissy, France.

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.
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http://dx.doi.org/10.1186/s13017-021-00387-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8467193PMC
September 2021

Evolution of Surgical Management of Hemorrhoidal Disease: An Historical Overview.

Front Surg 2021 30;8:727059. Epub 2021 Aug 30.

Department of Health Science, University of Catanzaro, Catanzaro, Italy.

Hemorrhoidal disease (HD) is the symptomatic enlargement and/or distal displacement of the normal hemorrhoidal cushions and is one of the most frequent diseases in colorectal surgery. Several surgical or office-based therapies are currently available, with the aim of being a more tailored approach. This article aimed to elucidate the historical evolution of surgical therapy for HD from ancient times, highlighting the crucial steps, controversies, and pioneers in the field. In contrast with the previous literature on the topic that is often updated to the 1990s, with the introduction of stapled hemorrhoidopexy and transanal hemorrhoidal dearterialization, this article describes all new surgical and office-based treatments introduced in the first 20 years of the 2000s.
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http://dx.doi.org/10.3389/fsurg.2021.727059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435716PMC
August 2021

A pandemic recap: lessons we have learned.

World J Emerg Surg 2021 09 10;16(1):46. Epub 2021 Sep 10.

Division of Trauma, Emergency Surgery, and Surgical Critical Care, LAC+USC Medical Center, Los Angeles, USA.

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.
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http://dx.doi.org/10.1186/s13017-021-00393-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8430288PMC
September 2021

Diagnosis of acute appendicitis based on clinical scores: is it a myth or reality?

Acta Biomed 2021 09 2;92(4):e2021231. Epub 2021 Sep 2.

Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy..

Background and aim of the work In April 2020, the World Society of Emergency Surgery (WSES) published the first update to the Jerusalem Guidelines on the diagnosis and treatment of acute appendicitis. In this review we have reported a summary of the contemporary evidence from the literature that led to the guidelines statements on the diagnostic strategies for appendicitis. Methods A systematic literature search was performed for studies published on the use of the most common clinical scores and imaging for the diagnosis of appendicitis. Results Alvarado, AIR and AAS scores are sufficiently sensitive (up to 99%) to exclude appendicitis, accurately identifying low-risk patients and decreasing the need for imaging and the negative appendectomy rates in such patients. Conversely, for young patients deemed to be at high-risk of appendicitis according to the scores, because of the high prevalence of the disease in this group of patients (~90%), a negative imaging scan cannot rule out appendicitis. The sensitivity and specificity of CT is reported at 0.91-0.94 and 0.90-0.95. The corresponding results for US are 0.78-0.88 and 0.81-0.94, respectively. Conclusions In young patients, a high-probability score for appendicitis may be used to select patients in which imaging is not needed. When the surgeon deems diagnostic imaging is still needed to confirm appendicitis despite the patient has been scored at high-risk, a conditional CT scan strategy is advised, with CT scan performed only after a negative or equivocal ultrasound scan.
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http://dx.doi.org/10.23750/abm.v92i4.11666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477120PMC
September 2021

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines.

World J Emerg Surg 2021 08 9;16(1):40. Epub 2021 Aug 9.

General Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey.

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), 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) joined guidelines about the management of acute abdomen in immunocompromised patients.
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http://dx.doi.org/10.1186/s13017-021-00380-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352154PMC
August 2021

Appendectomy during the COVID-19 pandemic in Italy: a multicenter ambispective cohort study by the Italian Society of Endoscopic Surgery and new technologies (the CRAC study).

Updates Surg 2021 Jul 4. Epub 2021 Jul 4.

Department of Surgical Sciences, University of Torino, corso AM Dogliotti 14, 10126, Torino, Italy.

Major surgical societies advised using non-operative management of appendicitis and suggested against laparoscopy during the COVID-19 pandemic. The hypothesis is that a significant reduction in the number of emergent appendectomies was observed during the pandemic, restricted to complex cases. The study aimed to analyse emergent surgical appendectomies during pandemic on a national basis and compare it to the same period of the previous year. This is a multicentre, retrospective, observational study investigating the outcomes of patients undergoing emergent appendectomy in March-April 2019 vs March-April 2020. The primary outcome was the number of appendectomies performed, classified according to the American Association for the Surgery of Trauma (AAST) score. Secondary outcomes were the type of surgical technique employed (laparoscopic vs open) and the complication rates. One thousand five hundred forty one patients with acute appendicitis underwent surgery during the two study periods. 1337 (86.8%) patients met the inclusion criteria: 546 (40.8%) patients underwent surgery for acute appendicitis in 2020 and 791 (59.2%) in 2019. According to AAST, patients with complicated appendicitis operated in 2019 were 30.3% vs 39.9% in 2020 (p = 0.001). We observed an increase in the number of post-operative complications in 2020 (15.9%) compared to 2019 (9.6%) (p < 0.001). The following determinants increased the likelihood of complication occurrence: undergoing surgery during 2020 (+ 67%), the increase of a unit in the AAST score (+ 26%), surgery performed > 24 h after admission (+ 58%), open surgery (+ 112%) and conversion to open surgery (+ 166%). In Italian hospitals, in March and April 2020, the number of appendectomies has drastically dropped. During the first pandemic wave, patients undergoing surgery were more frequently affected by more severe appendicitis than the previous year's timeframe and experienced a higher number of complications. Trial registration number and date: Research Registry ID 5789, May 7th, 2020.
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http://dx.doi.org/10.1007/s13304-021-01126-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255092PMC
July 2021

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project.

World J Emerg Surg 2021 07 2;16(1):35. Epub 2021 Jul 2.

UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy.

Background And Aims: Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

Methods: The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

Conclusions: The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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http://dx.doi.org/10.1186/s13017-021-00378-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8254305PMC
July 2021

Compliance with evidence-based clinical guidelines in the management of acute biliary pancreatitis: the MANCTRA-1 study protocol.

Updates Surg 2021 Oct 17;73(5):1757-1765. Epub 2021 Jun 17.

Department of Emergency Surgery, Azienda Ospedaliero-Universitaria Di Cagliari, University Hospital Policlinico Duilio Casula , Cagliari, Italy.

Despite existing evidence-based practice guidelines for the management of biliary acute pancreatitis (AP), the clinical compliance with recommendations is overall poor. Studies in this field have identified significant discrepancies between evidence-based recommendations and daily clinical practice. The most commonly reported gaps between clinical practice and AP guidelines include the indications for CT scan, need and timing of artificial nutritional support, indications for antibiotics, and surgical/endoscopic management of biliary AP. The MANCTRA-1 (coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis) study is aiming to identify the areas for quality improvement that will require new implementation strategies. The study primary objective is to evaluate which items of the current AP guidelines are commonly disregarded and if they correlate with negative clinical outcomes according to the different clinical presentations of the disease. We attempt to summarize the main areas of sub-optimal care due to the lack of compliance with current guidelines to provide the basis for introducing a number of bundles in AP patients' management to be implemented during the next years. The MANCTRA-1 study is an international multicenter, retrospective cohort study with the purpose to assess the outcomes of patients admitted to hospital with a diagnosis of biliary AP and the compliance of surgeons worldwide to the most up-to-dated international guidelines on biliary AP. ClinicalTrials.Gov ID Number: NCT04747990, Date: February 23, 2021. Protocol Version V2.2.
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http://dx.doi.org/10.1007/s13304-021-01118-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211303PMC
October 2021

Laparoscopic splenectomy as a definitive management option for high-grade traumatic splenic injury when non operative management is not feasible or failed: a 5-year experience from a level one trauma center with minimally invasive surgery expertise.

Updates Surg 2021 Aug 10;73(4):1515-1531. Epub 2021 Apr 10.

Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, UK.

Technique, indications and outcomes of laparoscopic splenectomy in stable trauma patients have not been well described yet. All hemodynamically non-compromised abdominal trauma patients who underwent splenectomy from 1/2013 to 12/2017 at our Level 1 trauma center were included. Demographic and clinical data were collected and analysed with per-protocol and an intention-to-treat comparison between open vs laparoscopic groups. 49 splenectomies were performed (16 laparoscopic, 33 open). Among the laparoscopic group, 81% were successfully completed laparoscopically. Laparoscopy was associated with a higher incidence of concomitant surgical procedures (p 0.016), longer operative times, but a significantly faster return of bowel function and oral diet without reoperations. No significant differences were demonstrated in morbidity, mortality, length of stay, or long-term complications, although laparoscopic had lower surgical site infection (0 vs 21%).The isolated splenic injury sub-analysis included 25 splenectomies,76% (19) open and 24% (6) laparoscopic and confirmed reduction in post-operative morbidity (40 vs 57%), blood transfusion (0 vs 48%), ICU admission (20 vs 57%) and overall LOS (7 vs 9 days) in the laparoscopic group. Laparoscopic splenectomy is a safe and effective technique for hemodynamically stable patients with splenic trauma and may represent an advantageous alternative to open splenectomy in terms of post-operative recovery and morbidity.
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http://dx.doi.org/10.1007/s13304-021-01045-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8397689PMC
August 2021

Belatacept in renal transplantation in comparison to tacrolimus and molecular understanding of resistance pattern: Meta-analysis and systematic review.

World J Transplant 2021 Mar;11(3):70-86

Department of Surgery, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom.

Background: The T-cell costimulation blocking agent belatacept has been identified as a possible substitute for calcineurin inhibitors, however, no consensus has been established against its use over the standard care agent Tacrolimus.

Aim: To evaluate the effectiveness of belatacept based maintenance immuno-suppressive regimens in comparison to tacrolimus in renal transplantion.

Methods: We did extensive search of all the available literature comparing the role of belatacept to tacrolimus in renal transplant recipients by searching the PubMed, Embase, Cochrane, Crossref, Scopus, clinical trials registry on October 5, 2020.

Results: The literature search identified four randomized controlled trials ( = 173 participants) comparing belatacept with tacrolimus. There was no significant difference in estimated renal function at 12 mo [mean difference 4.12 mL/min/1.73 m, confidence interval (CI): -2.18 to 10.42, = 0.20]. Further, belatacept group was associated with significant increase in biopsy proven acute rejection [relative risk (RR) = 3.27, CI: 0.88 to 12.11, = 0.08] and worse 12 mo allograft survival (RR = 4.51, CI: 1.23 to 16.58, = 0.02). However, incidence of new onset diabetes mellitus was lower with belatacept at 12 mo (RR = 0.26, CI: 0.07 to 0.99, = 0.05).

Conclusion: The evidence reviewed in this meta-analysis suggested that belatacept-based maintenance immunosuppression regimens were associated with an increased risk allograft loss in renal transplant recipients with equivalent renal functioning against standard tacrolimus; however, observed significantly reduced new onset diabetes mellitus after transplantation incidence and lower serum low density lipid profile levels in belatacept group. In addition, the adaptation of belatacept in renal transplantation has been forestalled by increased rates of rejection and resistance owing to development of various effector memory T cells through, parallel differentiation and immunological plasticity.
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http://dx.doi.org/10.5500/wjt.v11.i3.70DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009058PMC
March 2021

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

N Engl J Med 2021 03;384(9):880

University of Insubria, Varese, Italy

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http://dx.doi.org/10.1056/NEJMc2035865DOI Listing
March 2021

Changes in surgicaL behaviOrs dUring the CoviD-19 pandemic. The SICE CLOUD19 Study.

Updates Surg 2021 Apr 3;73(2):731-744. Epub 2021 Mar 3.

Department of General Surgery, Ospedale Di Vittorio Veneto, ULSS 2, Marca Trevigiana, Italy.

Background: The spread of the SARS-CoV2 virus, which causes COVID-19 disease, profoundly impacted the surgical community. Recommendations have been published to manage patients needing surgery during the COVID-19 pandemic. This survey, under the aegis of the Italian Society of Endoscopic Surgery, aims to analyze how Italian surgeons have changed their practice during the pandemic.

Methods: The authors designed an online survey that was circulated for completion to the Italian departments of general surgery registered in the Italian Ministry of Health database in December 2020. Questions were divided into three sections: hospital organization, screening policies, and safety profile of the surgical operation. The investigation periods were divided into the Italian pandemic phases I (March-May 2020), II (June-September 2020), and III (October-December 2020).

Results: Of 447 invited departments, 226 answered the survey. Most hospitals were treating both COVID-19-positive and -negative patients. The reduction in effective beds dedicated to surgical activity was significant, affecting 59% of the responding units. 12.4% of the respondents in phase I, 2.6% in phase II, and 7.7% in phase III reported that their surgical unit had been closed. 51.4%, 23.5%, and 47.8% of the respondents had at least one colleague reassigned to non-surgical COVID-19 activities during the three phases. There has been a reduction in elective (> 200 procedures: 2.1%, 20.6% and 9.9% in the three phases, respectively) and emergency (< 20 procedures: 43.3%, 27.1%, 36.5% in the three phases, respectively) surgical activity. The use of laparoscopy also had a setback in phase I (25.8% performed less than 20% of elective procedures through laparoscopy). 60.6% of the respondents used a smoke evacuation device during laparoscopy in phase I, 61.6% in phase II, and 64.2% in phase III. Almost all responders (82.8% vs. 93.2% vs. 92.7%) in each analyzed period did not modify or reduce the use of high-energy devices.

Conclusion: This survey offers three faithful snapshots of how the surgical community has reacted to the COVID-19 pandemic during its three phases. The significant reduction in surgical activity indicates that better health policies and more evidence-based guidelines are needed to make up for lost time and surgery not performed during the pandemic.
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http://dx.doi.org/10.1007/s13304-021-01010-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7926077PMC
April 2021

Do young patients with high clinical suspicion of appendicitis really need cross-sectional imaging? Proceedings from a highly controversial debate among the experts' panel of 2020 WSES Jerusalem guidelines.

J Trauma Acute Care Surg 2021 05;90(5):e101-e107

From the Department of Emergency Surgery (M.P., A.P.), Azienda Ospedaliero-Universitaria di Cagliari, University Hospital Policlinico Duilio Casula, Cagliari, Italy; Department of Surgery (R.A.), Linkoping University, Linkoping, Sweden; Department of Surgery (M.B.), University of Amsterdam, Amsterdam, The Netherlands; General, Emergency and Trauma Surgery (F.C.), Pisa University Hospital, Pisa, Italy; Department of Surgery (M.S.), Macerata Hospital, Macerata, Italy; Denver Health System-Denver Health Medical Center (E.E.M.), Denver, Colorado; Department of Surgery (M.S.), Letterkenny Hospital, Donegal, Ireland; Department of Surgery (F.A.-Z.), College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates; Department of Abdominal Surgery (M.T., A.L.), Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; Department of Upper GI Surgery (D.D.), Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom; Division of General Surgery (Y.K.), Rambam Health Care Campus, Haifa, Israel; Department of Gastrointestinal Surgery (K.S.), Stavanger University Hospital, Stavanger, Norway; Department of Surgery (G.A.), University Hospital Centre of Zagreb, Zagreb, Croatia; Section of Acute Care Surgery, Westchester Medical Center, Department of Surgery (R.L.), New York Medical College, Valhalla, New York; Acute Surgical Unit (M.K.), Canberra Hospital, ACT, Canberra, Australia; Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas (G.P.F.), SP, Brazil; Department of Surgery (R.T.B., E.T., H.V.G.), Radboud University Medical Center, Nijmegen, The Netherlands; Niguarda Hospital Trauma Center (O.C.), Milan, Italy; Department of Surgery (R.V.M.), University of Washington, Harborview Medical Center, Seattle, Washington; Department of Surgery (F.P.), Nicola Giannettasio Hospital, Corigliano-Rossano, and La Sapienza University o Rome, Rome, Italy; Department of Visceral Surgery (B.D.S.), Centre Hospitalier Intercommunal Poissy/Saint-Germain-en-Laye, Poissy, France; Division of Trauma and Acute Care Surgery, Department of General Surgery (C.A.O.), Fundación Valle del Lili, Cali, Colombia; Department of General Surgery and Trauma (L.A.), Bufalini Hospital, Cesena, Italy; Emergency and Trauma Surgery Department (F.C.), Maggiore Hospital of Parma, Parma, Italy; and Department of General Surgery (S.D.S.), University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy.

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http://dx.doi.org/10.1097/TA.0000000000003097DOI Listing
May 2021

Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score-matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial).

Int J Colorectal Dis 2021 Mar 17;36(3):589-598. Epub 2021 Jan 17.

Department of General Surgery, Santissima Trinità Hospital, ASSL Cagliari, Cagliari, Italy.

Purpose: The aim of this prospective multicenter study was to compare antibiotic therapy and appendectomy as treatment for patients with uncomplicated appendicitis confirmed by ultrasound and/or computed tomography.

Methods: The study was conducted from January 2017 to January 2018. Data regarding all patients discharged from the participating centers with a diagnosis of uncomplicated appendicitis were collected prospectively.

Results: Of the 318 patients enrolled in the study, 27.4% underwent antibiotic-first therapy, and 72.6% underwent appendectomy. The matched group was composed of 87 patients in both study arms. Of the 87 patients available of 1-year follow-up in the antibiotic-first group, 64 (73.6%) did not require appendectomy. The complication-free treatment success in the antibiotic-first group was 64.4%. A statistically significant higher complication-free treatment success was found in the appendectomy group: 81.8% in the pre-matching sample and 83.9% in the post-matching sample. Patients in the antibiotic-first group reported lower VAS scores compared to those treated with an appendectomy, both at discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs 2.1 ± 1.7). The mean of the days of absence from work was higher in the appendectomy group (β 0.63; 95% CI 0.08-1.18).

Conclusion: Although laparoscopic appendectomy remains the gold standard of treatment for uncomplicated appendicitis, conservative treatment with antibiotics is a safe option in most cases. Approximately 65% of patients treated with antibiotics are symptom-free at 1 year, without increased risk of adverse events should symptoms recur, and better outcomes in terms of less pain and shorter period of absence from work compared to patients undergoing an appendectomy.

Trial Registration: Clinicaltrials.gov identifier (NCT number): NCT03080103.
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http://dx.doi.org/10.1007/s00384-021-03843-8DOI Listing
March 2021

Complications and mortality in a cohort of patients undergoing emergency and elective surgery with perioperative SARS-CoV-2 infection: an Italian multicenter study. Teachings of Phase 1 to be brought in Phase 2 pandemic.

Updates Surg 2021 Apr 3;73(2):745-752. Epub 2021 Jan 3.

Ospedali Riuniti, Ancona, Italy.

Since the beginning of the pandemic due to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), several articles reported negative outcomes in surgery of infected patients. Aim of this study is to report results of patients with COVID-19-positive swab, in the perioperative period after surgery. Data of COVID-19-positive patients undergoing emergent or oncological surgery, were collected in a retrospective, multicenter study, which involved 20 Italian institutions. Collected parameters were age, sex, body mass index, COVID-19-related symptoms, patients' comorbidities, surgical procedure, personal protection equipment (PPE) used in operating rooms, rate of postoperative infection among healthcare staff and complications, within 30-postoperative days. 68 patients, who underwent surgery, resulted COVID-19-positive in the perioperative period. Symptomatic patients were 63 (92.5%). Fever was the main symptom in 36 (52.9%) patients, followed by dyspnoea (26.5%) and cough (13.2%). We recorded 22 (32%) intensive care unit admissions, 23 (33.8%) postoperative pulmonary complications and 15 (22%) acute respiratory distress syndromes. As regards the ten postoperative deaths (14.7%), 6 cases were related to surgical complications. One surgeon, one scrub nurse and two circulating nurses were infected after surgery due to the lack of specific PPE. We reported less surgery-related pulmonary complications and mortality in Sars-CoV-2-infected patients, than in literature. Emergent and oncological surgery should not be postponed, but it is mandatory to use full PPE, and to adopt preoperative screenings and strategies that mitigate the detrimental effect of pulmonary complications, mostly responsible for mortality.
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http://dx.doi.org/10.1007/s13304-020-00909-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778576PMC
April 2021

Endoscopic retrograde appendicitis therapy: the true proof of the pudding is in the eating.

Gastrointest Endosc 2020 12;92(6):1278-1279

Department of Emergency Surgery, Policlinico Universitario di Monserrato, University of Cagliari, Monserrato, Italy.

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http://dx.doi.org/10.1016/j.gie.2020.07.016DOI Listing
December 2020

Current status on the adoption of high energy devices in Italy: An Italian Society for Endoscopic Surgery and New Technologies (SICE) national survey.

Surg Endosc 2021 11 5;35(11):6201-6211. Epub 2020 Nov 5.

Department of General Surgery, Ospedale Civile, Adria, Italy.

Background: In the past three decades, different High Energy Devices (HED) have been introduced in surgical practice to improve the efficiency of surgical procedures. HED allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. This survey was designed to verify the current status on the adoption of HED in Italy.

Methods: A survey was conducted across Italian general surgery units. The questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. Only one member per each surgery unit was allowed to complete the questionnaire. For elective procedures, the survey included questions on thyroid surgery, lower and upper GI surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. Appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. The list of alternatives for every single question included a percentage category as follows: " < 25%, 25-50%, 51-75% or > 75%", both for open and minimally-invasive surgery.

Results: A total of 113 surgical units completed the questionnaire. The reported use of HED was high both in open and minimally-invasive upper and lower GI surgery. Similarly, HED were widely used in minimally-invasive pancreatic and adrenal surgery. The use of HED was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of HED in less than 25% of elective cholecystectomies. HED were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. Similarly, very few respondents declared to use HED in abdominal wall surgery and proctology. The distribution of the most used type of HED varied among the different surgical interventions. US HED were mostly used in thyroid, upper GI, and adrenal surgery. A relevant use of H-US/RF devices was reported in lower GI, pancreatic, hepatobiliary and breast surgery. RF HED were the preferred choice in proctology.

Conclusion: HED are extensively used in minimally-invasive elective surgery involving the upper and lower GI tract, liver, pancreas and adrenal gland. Nowadays, reasons for choosing a specific HED in clinical practice rely on several aspects, including surgeon's preference, economic features, and specific drawbacks of the energy employed.
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http://dx.doi.org/10.1007/s00464-020-08117-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644118PMC
November 2021

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes.

Surg Oncol 2020 Dec 28;35:344-350. Epub 2020 Aug 28.

Department of General Surgery, Kyoto University Hospital, Shogoin, Sakyo-ku, Kyoto, Japan.

Background: Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV).

Methods: Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics.

Results: Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004).

Conclusions: RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.
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http://dx.doi.org/10.1016/j.suronc.2020.08.025DOI Listing
December 2020

The COVID-19 pandemic should not take us back to the prelaparoscopic era.

J Trauma Acute Care Surg 2020 08;89(2):273-274

UO Chirurgia Generale, ASST Spedali Civili di Brescia, PO Montichiari, Brescia, Italy UO Chirurgia Generale e d'Urgenza, Policlinico Universitario, Università degli Studi di Cagliari, Cagliari, Italy UO Chirurgia Generale Ospedale, San Valentino, Montebelluna, Treviso, Italy.

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http://dx.doi.org/10.1097/TA.0000000000002783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342800PMC
August 2020

Laparoscopic Repair of Perforated Peptic Ulcer in the Elderly: An Interim Analysis of the FRAILESEL Italian Multicenter Prospective Cohort Study.

Surg Laparosc Endosc Percutan Tech 2020 Jul 14;31(1):2-7. Epub 2020 Jul 14.

Emergency Surgery and Trauma-Fondazione Policlinico Universitario "A. Gemelli" IRCCS.

Introduction: The number of elderly patients requiring emergency surgical intervention has increased dramatically. Perforated peptic ulcer (PPU) complications, such as perforation, have remained relatively stable and associated morbidity remains between 10% and 20%. Advances in perioperative care have greatly improved the outcomes of laparoscopic emergency surgery, allowing increasing numbers of patients, even the elderly, to undergo safe repair. The aim of this study was to evaluate the feasibility, safety, and outcome of laparoscopic gastric repair in the elderly using the database of the FRAILESEL (Frailty and Emergency Surgery in the Elderly) study.

Materials And Methods: This is a retrospective analysis carried out on data of the FRAILESEL study. Data on all the elderly patients who underwent emergency abdominal surgery for PPU from January 2017 to December 2017 at 36 Italian surgical departments were analyzed. Patients who underwent PPU repair were further divided into a laparoscopic gastroduodenal repair (LGR) cohort and an open gastroduodenal repair (OGR) cohort, and the clinicopathologic features of the patients in both the groups were compared.

Results: Sixty-seven patients fulfilled the inclusion criteria. Thirty-three patients (47.8%) underwent LGR. The LGR patients had less blood loss and shorter postoperative stay, even if the difference was not statistically significant. The mean operative time was significantively higher in the OGR (OGR 96.5±27.7 vs. LGR 78.6±16.3 P=0.000). The rate of death after laparoscopic surgery was similar to the rate of the open surgery. Multivariate analysis indicated that only age (P=0.018), admission haemoblogbin (Hb) level (P=0.006), platelet count (P=0.16), lactate level (P=0.47), and Mannheim Peritonitis Index (P=0.18) were independent variables associated with the risk of overall mortality.

Conclusions: LGR is safe and feasible in elderly patients with PPU and it is associated with better perioperative outcomes. However, patient selection and preoperative frailty evaluation in the elderly population are the key to achieving better outcomes.
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http://dx.doi.org/10.1097/SLE.0000000000000826DOI Listing
July 2020

Acute cholecystitis during COVID-19 pandemic: a multisocietary position statement.

World J Emerg Surg 2020 06 8;15(1):38. Epub 2020 Jun 8.

Department of Mini-Invasive and General Surgery, Cristo Re Hospital, Rome, Italy.

Following the spread of the infection from the new SARS-CoV2 coronavirus in March 2020, several surgical societies have released their recommendations to manage the implications of the COVID-19 pandemic for the daily clinical practice. The recommendations on emergency surgery have fueled a debate among surgeons on an international level.We maintain that laparoscopic cholecystectomy remains the treatment of choice for acute cholecystitis, even in the COVID-19 era. Moreover, since laparoscopic cholecystectomy is not more likely to spread the COVID-19 infection than open cholecystectomy, it must be organized in such a way as to be carried out safely even in the present situation, to guarantee the patient with the best outcomes that minimally invasive surgery has shown to have.
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http://dx.doi.org/10.1186/s13017-020-00317-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7278255PMC
June 2020

Immunological Basis of Genesis of Hepatocellular Carcinoma: Unique Challenges and Potential Opportunities through Immunomodulation.

Vaccines (Basel) 2020 May 23;8(2). Epub 2020 May 23.

Warwick Medical School, University of Warwick, Coventry CV4 7H, UK.

A majority of hepatocellular carcinoma (HCC) develops in the setting of persistent chronic inflammation as immunological mechanisms have been shown to play a vital role in the initiation, growth and progression of tumours. The index review has been intended to highlight ongoing immunological changes in the hepatic parenchyma responsible for the genesis and progression of HCC. The in-situ vaccine effect of radiofrequency (RF) is through generation tumour-associated antigens (TAAs), following necrosis and apoptosis of tumour cells, which not only re-activates the antitumour immune response but can also act in synergism with checkpoint inhibitors to generate a superlative effect with intent to treat primary cancer and distant metastasis. An improved understanding of oncogenic responses of immune cells and their integration into signaling pathways of the tumour microenvironment will help in modulating the antitumour immune response. Finally, we analyzed contemporary literature and summarised the recent advances made in the field of targeted immunotherapy involving checkpoint inhibitors along with RF application with the intent to reinstate antitumour immunity and outline future directives in very early and early stages of HCC.
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http://dx.doi.org/10.3390/vaccines8020247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7349974PMC
May 2020

Open abdomen closure methods for severe abdominal sepsis: a retrospective cohort study.

Eur J Trauma Emerg Surg 2020 May 6. Epub 2020 May 6.

Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy.

Purpose: The open abdomen (OA) procedure as part of damage control surgery represents a significant surgical advance in severe intra-abdominal infections. Major techniques used for OA are negative pressure wound therapy (NPWT) and non-NPWT. The aim of this retrospective study is to evaluate the effects of different abdominal closure methods and their outcomes in patients presenting with abdominal sepsis treated with OA.

Materials And Methods: We retrospectively analyzed clinical outcomes of patients affected by severe intra-abdominal sepsis treated with OA. Demographic features, mortality prediction score, abdominal closure methods, length of hospital stay, complications and mortality rates of patients were determined and compared.

Results: This study included 106 patients, of whom 77 underwent OA with NPWT and 29 with non-NPWT. OA duration was longer in NPWT patients (p = 0.007). In-hospital mortality rates in NPWT and in non-NPWT patients were 40.3% and 51.7%, respectively (p = 0.126), with an overall 30-day mortality rate of 18.2% and 51.7%, respectively (p = 0.0002). After emergency colorectal surgery, patients who underwent OA with NPWT had a lower rate of colostomy (p = 0.025).

Conclusions: NPWT is the best temporary abdominal closure technique to decrease mortality and colostomy rates in patients managed with OA for severe intra-abdominal infections.
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http://dx.doi.org/10.1007/s00068-020-01379-0DOI Listing
May 2020

Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines.

World J Emerg Surg 2020 04 15;15(1):27. Epub 2020 Apr 15.

UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA, USA.

Background And Aims: Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.

Methods: This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.

Conclusions: The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.
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http://dx.doi.org/10.1186/s13017-020-00306-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386163PMC
April 2020

Is the minimally invasive trauma surgeon the next (r)evolution of trauma surgery? Indications and outcomes of diagnostic and therapeutic trauma laparoscopy in a level 1 trauma centre.

Updates Surg 2020 Jun 26;72(2):503-512. Epub 2020 Mar 26.

Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK.

The aim of this study was to evaluate the trend in use, feasibility and safety of laparoscopy in a single level 1 European trauma centre. Laparoscopy in abdominal trauma is gaining acceptance as a diagnostic and a therapeutic tool as it reduces surgical invasiveness and may reduce post-operative morbidity. All trauma patients who underwent a laparoscopic procedure between January 2013 and December 2017 were retrospectively analysed. A sub-analysis of isolated abdominal trauma was also performed. There has been a significant increase in the use of this technique in the considered time period. A total of 40 patients were included in the study: 17 diagnostic laparoscopies and overall 32 therapeutic laparoscopies. Conversion rate was 15%. All patients were hemodynamically stable. The majority of patients were younger than 60 years, with an ASA score of I-II and sustained a blunt trauma. Mean ISS score was 17. Colon and diaphragm were the most commonly laparoscopically diagnosed injuries, while splenectomy was the most common operation. The average operating time was 106 min. There were no missed injuries, no SSI, no re-interventions and no mortality related to the surgical procedure. The average length of stay was 14 days. No significant difference was found in the isolated abdominal trauma group. Laparoscopy is an emergent safe and effective technique for both diagnostic and therapeutic purposes in selected stable abdominal penetrating or blunt trauma patients. However, these results need to be put in relation with the level of the centre and the expertise of the surgeon.
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http://dx.doi.org/10.1007/s13304-020-00739-0DOI Listing
June 2020

Is preoperative bowel preparation always superfluous?

Lancet 2020 03;395(10226):781-782

Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge CB2 0QQ, UK.

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http://dx.doi.org/10.1016/S0140-6736(20)30027-1DOI Listing
March 2020

The use of emergency laparoscopy for acute abdomen in the elderly: the FRAILESEL Italian Multicenter Prospective Cohort Study.

Updates Surg 2020 Jun 22;72(2):513-525. Epub 2020 Feb 22.

Department of General Surgery, Adria Civil Hospital, Adria, Italy.

As the world population is aging rapidly, emergency abdominal surgery for acute abdomen in the elderly represents a global issue, both in developed and developing countries. Data regarding all the elderly patients who underwent emergency abdominal surgery from January 2017 to December 2017 at 36 Italian surgical departments were analyzed with the aim to appraise the contemporary reality regarding the use of emergency laparoscopy for acute abdomen in the elderly. 1993 patients were enrolled. 1369 (68.7%) patients were operated with an open technique; whereas, 624 (31.3%) underwent a laparoscopic operation. The postoperative morbidity rate was 32.6%, with a statically significant difference between the open and the laparoscopic groups (36.2% versus 22.1%, p < 0.001). The reported mortality rate was 8.8%, with a statistically significant difference between the open and the laparoscopic groups (11.2% versus 2.2%, p < 0.001). Our results demonstrated that patients in the ASA II (58.1%), ASA III (68.7%) and ASA IV (88.5%) groups were operated with the traditional open technique in most of the cases. Only a small percentage of patients underwent laparoscopy for perforated gastro-duodenal ulcer repair (18.9%), adhesiolyses with/without small bowel resection (12.2%), and large bowel resection (10.7%). Conversion to open technique was associated with a higher mortality rate (11.1% versus 2.2%, p < 0.001) and overall morbidity (38.9% versus 22.1%, p = 0.001) compared with patients who did not undergo conversion. High creatinine (p < 0.001) and glycaemia (p = 0.006) levels, low hemoglobin levels (p < 0.001), oral anticoagulation therapy (p = 0.001), acute respiratory failure (p < 0.001), presence of malignancy (p = 0.001), SIRS (p < 0.001) and open surgical approach (p < 0.001) were associated with an increased risk of postoperative morbidity. Regardless of technical progress, elderly patients undergoing emergency surgery are at very high risk for in-hospital complications. A detailed analysis of complications and mortality in the present study showed that almost 9% of elderly patients died after surgery for acute abdomen, and over 32% developed complications.
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http://dx.doi.org/10.1007/s13304-020-00726-5DOI Listing
June 2020
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