Artificial intelligence in the diagnosis and treatment of acute appendicitis: a narrative review

Artificial intelligence is transforming healthcare. Artificial intelligence can improve patient care by analyzing large amounts of data to help make more informed decisions regarding treatments and enhance medical research through analyzing and interpreting data from clinical trials and research projects to identify subtle but meaningful trends beyond ordinary perception. Artificial intelligence refers to the simulation of human intelligence in computers, where systems of artificial intelligence can perform tasks that require human-like intelligence like speech recognition, visual perception, pattern-recognition, decision-making, and language processing. Artificial intelligence has several subdivisions, including machine learning, natural language processing, computer vision, and robotics. By automating specific routine tasks, artificial intelligence can improve healthcare efficiency. By leveraging machine learning algorithms, the systems of artificial intelligence can offer new opportunities for enhancing both the efficiency and effectiveness of surgical procedures, particularly regarding training of minimally invasive surgery. As artificial intelligence continues to advance, it is likely to play an increasingly significant role in the field of surgical learning. Physicians have assisted to a spreading role of artificial intelligence in the last decade. This involved different medical specialties such as ophthalmology, cardiology, urology, but also abdominal surgery. In addition to improvements in diagnosis, ascertainment of efficacy of treatment and autonomous actions, artificial intelligence has the potential to improve surgeons' ability to better decide if acute surgery is indicated or not. The role of artificial intelligence in the emergency departments has also been investigated. We considered one of the most common condition the emergency surgeons have to face, acute appendicitis, to assess the state of the art of artificial intelligence in this frequent acute disease. The role of artificial intelligence in diagnosis and treatment of acute appendicitis will be discussed in this narrative review.

Management of acute diverticulitis in Stage 0-IIb: indications and risk factors for failure of conservative treatment in a series of 187 patients

Left-sided acute diverticulitis in WSES Stage 0-IIb preferentially undergoes conservative management. However, there is limited understanding of the risk factors for failure of this approach. The aim of this study was to investigate the factors associated with the decision to perform conservative treatment as well as the predictors of its failure. We included patients with a diagnosis of WSES diverticulitis CT-driven classification Stage 0-IIb treated in the Emergency Surgery Unit of the Agostino Gemelli University Hospital Foundation between 2014 and 2020. The endpoints were the comparison between the characteristics and clinical outcomes of acute diverticulitis patients undergoing conservative versus operative treatment. We also identified predictors of conservative treatment failure. A set of multivariable backward logistic analyses were conducted for this purpose. The study included 187 patients. The choice for operative versus conservative treatment was associated with clinical presentation, older age, higher WSES grade, and previous conservative treatment. There were 21% who failed conservative treatment. Of those, major morbidity and mortality rates were 17.9% and 7.1%, respectively. A previously failed conservative treatment as well as a greater WSES grade and a lower hemoglobin value were significantly associated with failure of conservative treatment. WSES classification and hemoglobin value at admission were the best predictors of failure of conservative treatment. Patients failing conservative treatment had non-negligible morbidity and mortality. These results promote the consideration of a combined approach including baseline patients' characteristics, radiologic features, and laboratory biomarkers to predict conservative treatment failure and therefore optimize treatment of acute diverticulitis.

Multiloculated omental cystic tumor hiding an angioleiomyoma: case report of a rare and atypical presentation and literature review

Angioleiomyoma is a rare benign tumor arising from vascular smooth muscle and generally located in the subcutaneous tissue of the extremities. We reported a rare case of an intra-abdominal localization originating from the small omentum in which progressive growth detected on radiological follow-up indicated surgical excision. Histology documented a cavernous angioleiomuscular tumor with uncertain potential for malignancy. Although angioleiomyoma is described as a benign tumor, the uncertain behavior for malignancy of this case could have led to neoplastic degeneration. Early diagnosis followed by surgical excision of the neoplasia is crucial.

Risk factors and outcomes of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Retrospective study of 75 single center cases

OBJECTIVE

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical gold standard in patients with ulcerative colitis (UC). Results are generally satisfactory but there is a significant rate of patients who experience postoperative complications. The aims of our study were to identify the pre- and intraoperative risk factors and their correlation with the reported outcomes.

PATIENTS AND METHODS

A retrospective study was conducted on the medical records of all consecutive patients undergoing restorative proctocolectomy with IPAA for UC in our center from 2010 to 2021. Pre- and intraoperative factors were examined and correlated with pouchitis, endoscopic pouchitis, pouch failure, anastomotic leak, postoperative complications classified according to Clavien-Dindo score and stoma outlet obstruction. A univariate and multivariate statistical analysis was performed.

RESULTS

Out of 75 patients undergoing 3- or 2-stage IPAA surgery, the coexistence of extraintestinal clinical manifestations and preoperative topical rectal stump therapy for active proctitis were significantly associated with the occurrence of pouchitis (OR=4.4, p=0.03 and OR=7.6, p=0.01). Endoscopic pouchitis was found to be related to preoperative topical rectal therapy (OR=10.2, p=0.007), but not to extraintestinal manifestations of disease. Anastomotic leak was found to be significantly related to pouch failure (OR=22.7, p=0.007). Surgical indication for malignancy increased the risk for early complications (Clavien-Dindo >2) (OR=16.0, p=0.04). Young age was associated with the occurrence of outlet stoma obstruction in patients with recent IPAA surgery (OR=0.97, p=0.05).

CONCLUSIONS

Based on observed results, an appropriate preoperative patient assessment aimed at detecting specific risk factors is crucial to identify early or prevent worse outcomes in patients undergoing IPAA surgery.

The impact of COVID-19 pandemic on IBD surgery: a single center experience

OBJECTIVE

The spread of COVID-19 pandemic forced the national healthcare system to reorganize almost all surgical services, in order to maintain an adequate therapeutic offer. At General Surgery department of Fondazione Policlinico Gemelli in Rome, surgical procedures were progressively reduced to provide beds and personnel for COVID-19. The aim of our study was to analyze the effect of one year of COVID-19 pandemic on Inflammatory Bowel Disease (IBD) surgery in a cohort of patients and evaluate post-operative short-term complications.

PATIENTS AND METHODS

Our team retrospectively analyzed the records of IBD patients who were referred to an IBD-related resective surgery from January 2020 to December 2020. These patients were compared to a comparable group of IBD patients who were operated from January 2019 to December 2019.

RESULTS

A total of 160 patients were included in the study. Median age was 44 (range 15-77). Patients were referred for Ulcerative colitis (23.1%) and Crohn's disease (76.9%). Eighty-three patients underwent surgery from January 2020 to December 2020, which constitutes a 4.6% increase in the number of patients compared to the same period in 2019. Median post-operative hospital stay increased (7 days in 2019 vs. 6 days in 2020). Laparoscopic was the most frequently performed procedure during both periods (49% in 2019 and 59% in 2020). Complication rates, reported as Clavien-Dindo score 3 or 4, slightly decreased in 2020 (6.5 in 2019 vs. 4.8 in 2020). PCR test for detection of COVID-19 infection was conducted in all the patients before the hospitalization. Two patients out of 70 were tested positive for COVID-19 and their surgeries were rescheduled.

CONCLUSIONS

There was no significant reduction in IBD resective surgeries at our center in 2020, nor a deterioration of the outcomes. A reduction of other elective surgical procedures had to be carried out and adequate protective measures for both patients and healthcare workers were established.

Malakoplakia of the appendix in a young healthy adult: a case report and literature review

Malakoplakia is a rare entity on inflammatory base that mostly occurs in immunocompromised individuals which is thought to be secondary to a bactericidal defect in macrophages. The genitourinary tract is typically affected. The appendix is a very rare localization. We report a case of malakoplakia in the appendix of a young healthy patient with a recent history of abdominal pain associated with diarrhea and nausea. The colonscopy and CT scan showed an extramucosal bumping mass pressing on the cecum and covered by normal mucosa. The patient underwent to laparoscopic appendectomy. The histology showed a malakoplakia of the appendix. Gastrointestinal localization of malakoplakia is often associated with preexisting diseases, which are probably responsible for an immune disorder underlying the etiopathogenesis of the disease. However, in our case, the patient had no comorbidities. Probably, a clinically unknown immune predisposition plays an important role. Further studies are needed to clarify this nexus.

Bowel perforation due to chronic idiopathic megacolon: Case report and literature review

INTRODUCTION AND IMPORTANCE

Chronic idiopathic megacolon is a rare condition characterized by an irreversible distension of the colon in the absence of organic disease. The pathogenesis of this condition is still unclear and the data in literatures are not consistent.

CASE PRESENTATION

We report a case of an 87-years-old woman affected by bowel perforation in chronic idiopathic megacolon. The patient underwent an emergency subtotal colectomy with terminal ileostomy. The postoperative was uneventful. At the histopathological examination, no organic cause of megacolon was found, so a diagnosis of idiopathic megacolon was done.

CLINICAL DISCUSSION

Idiopathic megacolon is difficult to diagnose due to the lack of specific clinical manifestations and pathological features. If not carefully investigated, can lead to severe complications such as perforation of the dilated bowel and subsequent peritonitis and sepsis, metabolic and electrolyte abnormalities. The protocols for management of IMC remains controversial. To achieve a good long-term outcome, early intervention is recommended.

CONCLUSION

Early diagnosis of idiopathic megacolon is needed to perform the best therapeutic strategy and prevent complications, but further studies are needed.