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Purpose The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed. Methods This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson’s comorbidity index, P-POSSUM and CR-POSSUM were assessed. Results 259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson’s comorbidity index ≥ 6, altered mental status, and need for laparotomy were associated with major complications and mortality Conclusion Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson’s comorbidity index could be adopted to select patients for elective operation

Scop: De a explora literatura de specialitate actuală în ceea ce priveşte conceptele imposibilităţii de salvare şi al chirurgiei de salvare, în vederea identificării elementelor cheie pentru reducerea ratei de imposibilitate de salvare şi îmbunătăţirii rezultatelor, precum şi a verificării existenţei unei justificări pentru centralizarea pacienţilor care suferă complicaţii postoperatorii. Descoperiri recente: Este tot mai cunoscută necesitatea evaluării şi estimării ratei imposibilităţii de salvare la nivel de instituţii, regional şi naţional. Numeroşi factori influenţează imposibilitatea de salvare, iar toţi aceştia ar trebui luaţi în considerare şi analizaţi individual. Chirurgia de salvare reprezintă unul dintre aceşti factori. Chirurgia de salvare presupune un context de tratament chirurgical de urgenţă. Concluzii: Măsurarea ratei de imposibilitate de salvare ar trebui să devină un standard în programele de îmbunătăţire a calităţii. Implementarea tuturor factorilor clinici şi organizatorici implicaţi este cheia obţinerii unor rezultate mai bune. Gradul de pregătire pentru chirurgia de salvare reprezintă un pilon principal în acest proces. Centralizarea datelor privind managementul, auditul şi comunicarea este la fel de importantă precum centralizarea pacienţilor.

Background Frailty assessment has acquired an increasing importance in recent years and it has been demonstrated that this vulnerable profile predisposes elderly patients to a worse outcome after surgery. Therefore, it becomes paramount to perform an accurate stratification of surgical risk in elderly undergoing emergency surgery. Study design 1024 patients older than 65 years who required urgent surgical procedures were prospectively recruited from 38 Italian centers participating to the multicentric FRAILESEL (Frailty and Emergency Surgery in the Elderly) study, between December 2016 and May 2017. A univariate analysis was carried out, with the purpose of developing a frailty index in emergency surgery called “EmSFI”. Receiver operating characteristic curve analysis was then performed to test the accuracy of our predictive score. Results 784 elderly patients were consecutively enrolled, constituting the development set and results were validated considering further 240 consecutive patients undergoing colorectal surgical procedures. A logistic regression analysis was performed identifying different EmSFI risk classes. The model exhibited good accuracy as regard to mortality for both the development set (AUC = 0.731 [95% CI 0.654–0.772]; HL test χ2 = 6.780; p = 0.238) and the validation set (AUC = 0.762 [95% CI 0.682–0.842]; HL test χ2 = 7.238; p = 0.299). As concern morbidity, our model showed a moderate accuracy in the development group, whereas a poor discrimination ability was observed in the validation cohort. Conclusions The validated EmSFI represents a reliable and time-sparing tool, despite its discriminative value decreased regarding complications. Thus, further studies are needed to investigate specifically surgical settings, validating the EmSFI prognostic role in assessing the procedure-related morbidity risk.

Nipple-sparing mastectomy is now routinely performed 1-3 for primary invasive and in situ breast cancer when breast-conserving surgery is not indicated, even after neoadjuvant treatments. 4,5 Nevertheless, it is still contraindicated for T4 neoplasms, 6 cancer involving the retroareolar tissue, microcalcifications close to the subareolar region, malignant nipple discharge, or Paget disease. Nipple-sparing mastectomy is also performed in high-risk healthy patients 1 for riskreducing surgery. Different patterns of skin incision are described according to tumor location, breast volume, shape, and ptosis. 7,8 This surgical approach can even be used after breast conservation in case of positive margins, in

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Purpose of Review We reviewed the current literature to assess the feasibility of ultrasound-assisted and ultrasoundguided procedures for the treatment of post-traumatic complications and to address the indications and techniques of procedures. Recent Findings Non-operative strategies have been introduced in the treatment of severe trauma, and consequently, the incidence of some post-traumatic complications has increased. US can be useful both for the initial assessment of trauma patients and for the treatment of complications. Summary Ultrasound-guided and ultrasound-assisted procedures as a therapeutic tool in the management of post-trauma settings are probably underused, in comparison with their successful use in other acute settings. Some new possible fields of clinical researches are suggested.

Introduction The worldwide increase in morbidly obese patients with complex hernia raises controversies in the choice of the appropriate treatment timing: synchronous bariatric and abdominal wall surgery versus delayed abdominal wall surgery. We report an innovative tailored surgical treatment carried out at our Institution. Patient and Methods The approach provided the injection, 6 weeks before surgery, of 500 IU of botulinum toxin A on either side of the large abdominal wall muscles. Four weeks before surgery, pneumoperitoneum was inducted and out-patient daily sessions of progressive insufflation with ambient air were then carried out. Surgery was scheduled 48 days after botulinum injection. Sleeve gastrectomy and simultaneous posterior component separation with transversus abdominis release were performed. Two prosthetic meshes were placed sublay. Postoperative superficial surgical site infection was successfully treated with negative pressure wound therapy. At a 1-year follow-up, no hernia recurrence was recorded while total body weight loss was 31%. Discussion A delay in ventral hernia repair could worsen the quality of life of morbidly obese patients. In such high-risk patients, the choice of the best surgical strategy remains controversial. There is great concern in performing bariatric surgery simultaneously to hernia repair, although there is lack of evidence on which is the ideal treatment modality. Conclusion Synchronous bariatric surgery and complex ventral hernia repair should be approached in high-volume centres where a consolidated experience of multidisciplinary teamwork is available. Combined botulinum toxin A and preoperative progressive pneumoperitoneum administration allow for a safe resolution of loss of domain.