To map and critically appraise the current literature on Artificial Intelligence (AI) applications in emergency general surgery, with a focus on clinical decision-support tools for preoperative risk stratification and intraoperative assistance, and to identify ethical, structural, and regulatory barriers to implementation. A scoping review was conducted within the ARIES project, following established methodological frameworks. Relevant studies evaluating AI-based tools in emergency surgical settings were systematically identified and analyzed. The literature describes AI applications mainly in two domains: preoperative decision support, including risk prediction and diagnostic or triage models for acute abdominal and traumatic conditions, and intraoperative assistance, largely focused on computer vision–based systems for anatomical recognition, safety guidance, and navigation in minimally invasive emergency procedures. Additional contributions address training and telementoring platforms, as well as cross-cutting ethical, legal, and regulatory considerations relevant to AI adoption in emergency surgical care. AI has the potential to complement emergency surgeons’ clinical judgment, but its routine adoption in emergency surgical practice remains limited. Addressing methodological, ethical, and regulatory challenges, together with the development of robust data infrastructures and targeted training pathways, is essential to support safe, effective, and equitable implementation in acute care settings. In addition, the lack of dedicated investment and sustainable funding models for large-scale clinical implementation and prospective evaluation represents a critical barrier to the translation of AI from research into routine emergency surgical practice.

In the coming years, missions to the Moon and Mars shall be the new goals of space flight. The complexity of these missions due to the great distance from Earth and the unforeseen obstacles to settle on another planet have given rise to great concerns for crew health and survival. The need for advanced crew autonomy and a different approach to surgical emergency require new protocols and devices to help future crew medical officers and other crew members in a task of unprecedented difficulty. Hence, the increasing variety of schedules, devices, and protocols being developed. A serious health problem, such as an emerging surgical disease or severe trauma, can jeopardize the mission and survival of the entire crew. Many other difficulties are present in deep-space missions or settlements on other planets, such as communication and supply, also medical, delays, and shortage, and the presence of radiation. Progress in advanced technologies as well as the evolution of robotic surgery and the use of artificial intelligence are other topics of this review. In this particular area of research, even if we are still very far from an "intelligent robot", this evolution must be evaluated in the light of legislative and ethical considerations. This topic was presented at the annual meeting of the American College of Surgeons-Italy Chapter in 2021.

Although the risk of trauma in space is low, unpredictable events can occur that may require surgical treatment. Hemorrhage can be a life-threatening condition while traveling to another planet and after landing on it. These exploration missions call for a different approach than rapid return to Earth, which is the policy currently adopted on the International Space Station (ISS) in low Earth orbit (LEO). Consequences are difficult to predict, given the still scarce knowledge of human physiology in such environments. Blood loss in space can deplete the affected astronaut's physiological reserves and all stored crew supplies. In this review, we will describe different aspects of hemorrhage in space, and by comparison with terrestrial conditions, the possible solutions to be adopted, and the current state of the art.

This study is preliminary to an experiment to be performed onboard the International Space Station (ISS) and on Earth to investigate how low gravity influences the healing of sutured human skin and vein wounds. Its objective was to ascertain whether these tissue explants could be maintained to be viable ex vivo for long periods of time, mimicking the experimental conditions onboard the ISS. We developed an automated tissue culture chamber, reproducing and monitoring the physiological tensile forces over time, and a culture medium enriched with serelaxin (60 ng/mL) and (Zn(PipNONO)Cl) (28 ng/mL), known to extend viability of explanted organs for transplantation. The results show that the human skin and vein specimens remained viable for more than 4 weeks, with no substantial signs of damage in their tissues and cells. As a further clue about cell viability, some typical events associated with wound repair were observed in the tissue areas close to the wound, namely remodeling of collagen fibers in the papillary dermis and of elastic fibers in the vein wall, proliferation of keratinocyte stem cells, and expression of the endothelial functional markers eNOS and FGF-2. These findings validate the suitability of this new ex vivo organ culture system for wound healing studies, not only for the scheduled space experiment but also for applications on Earth, such as drug discovery purposes.

Wound healing is slowed in Space. Microgravity and possible physical factors associated with Space affect alterations in fibroblast, matrix formation, dysregulation in apoptosis and inflammation. The microbial populations settled on skin, space modules, in space suits, are also playing a pivotal role, as wound healing is also affected by the microbial community. We propose a perspective that includes four domines for the application of human skin microbiota for wound healing in Space: The natural antimicrobial properties of the skin microbiota, the crosstalk of the skin microbiota with the immune system during wound healing, the contribution of the microbiota in precision medicine, and the role of gut-skin and gut-brain axes. A stronger understanding of the connections and metabolic network among bacteria, fungi, the host’s immune system and the host metabolism will support the basis for a better wound healing in Space.

Acute cholecystitis in severely cardiopathic patients after major cardiac surgery represents a challenge for surgeons. Treatment with cholecystostomy, may offer a chance to these patients, however there is still a number of controversial issues on the topic: performance surgical techniques (transhepatic or transpapillary), optimal duration and timing of drain removal, the need for further tests before removal as well as the timing for definitive surgery. We therefore deemed it important to share our experience of a multidisciplinary approach for the definitive treatment of this patient with severe heart disease. A percutaneous cholecystostomy was the chosen strategy for a 58-year-old cardiopathic patient who had undergone surgery for hip replacement and had developed acute calculous cholecystitis a few days after surgery. Two weeks after discharge, a cholangiography through the cholecystostomy and an MRI cholangiopancreatography revealed the presence of stones in the cystic duct and in the ductus choledochus. The definitive treatment was decided after consulting with a multidisciplinary team. The choice was to perform an open cholecystectomy with simultaneous removal of the cholecystostomy, endoscopic removal of stones and sphincterotomy of the Oddi papilla. Currently, the patient is healthy and his heart function satisfactory. Although early cholecystectomy is the recommended choice for acute cholecystitis, a patient with severe co-morbidities may benefit from a bridging therapy before definitive surgery and a multidisciplinary approach can provide a safer solution.

Cimbanassi, Stefania MD; Chiara, Osvaldo MD; Leppaniemi, Ari MD; Henry, Sharon MD; Scalea, Thomas M. MD; Shanmuganathan, Kathirkamanathan MD; Biffl, Walter MD; Catena, Fausto MD; Ansaloni, Luca MD; Tugnoli, Gregorio MD; De Blasio, Elvio MD; Chieregato, Arturo MD; Gordini, Giovanni MD; Ribaldi, Sergio MD; Castriconi, Maurizio MD; Festa, Patrizio MD; Coccolini, Federico MD; di Saverio, Salomone MD; Galfano, Antonio MD; Massi, Massimo MD; Celano, Marilena MD; Mutignani, Massimiliano MD; Rausei, Stefano MD; Pantalone, Desiree MD; Rampoldi, Antonio MD; Fattori, Luca MD; Miniello, Stefano MD; Sgardello, Sebastian MD; Bindi, Francesca MD; Renzi, Federica MD; Sammartano, Fabrizio MD Author Information

HIV infection and alcohol use disorder are associated with deficits in neurocognitive function. Emerging evidence points to pro-inflammatory perturbations of the gut-brain axis as potentially contributing to neurocognitive impairment in the context of HIV and chronic heavy alcohol use. This study examined whether plasma markers of microbial translocation (LPS) from the gastrointestinal tract and related immune activation (sCD14, EndoCAb) were associated with neurocognition in 21 men living with HIV who were virally suppressed on antiretroviral therapy. All participants met federal criteria for heavy drinking and were enrolled in a randomized controlled trial (RCT) of a brief alcohol intervention. This secondary analysis utilized blood samples and cognitive scores (learning, memory, executive function, verbal fluency, and processing speed) obtained at baseline and three-month follow-up of the RCT. In generalized estimating equation models, LPS, sCD14, and EndoCAb individually were significant predictors of processing speed. In a model with all biomarkers, higher LPS and sCD14 both remained significant predictors of lower processing speed. These preliminary findings suggest that inflammation stemming from HIV and/or alcohol could have negative effects on the gut-brain axis, manifested as diminished processing speed. Associations of microbial translocation and immune activation with processing speed in heavy-drinking PLWH warrant further investigation in larger-scale studies.

Midgut malrotation is a congenital anomaly referring to either lack of or incomplete rotation of the fetal intestines around the axis of the superior mesenteric artery during fetal development. It is rare in adulthood and the true incidence is difficult to estimate because most patients are asymptomatic. The diagnosis is usually performed with several radiological and surgical methods. We report a case of a woman who presented with cramp-like abdominal pain localized to the right iliac fossa. The patient underwent abdominal ultrasound, radiological examination without and with contrast, and computed tomography with three-dimensional volume rendering reconstruction. Although small bowel followthrough is often enough to recognize the type of malrotation, using multimodal imaging may offer a better definition of this abnormality with a better definition of the kind of malrotation, by adding additional anatomical information. In our case, the imaging clearly showed malrotation of the small bowel with reverse rotation of the colon. Hence a multimodal imaging strategy proved useful for the diagnosis of intestinal malrotation in an adult afflicted by chronic cramp-like abdominal pain.

Lymphadenectomy and extended lymphadenectomy are still controversial issues in surgical oncology. The detection methods for metastatic lymph nodes include lymphoscintigraphy and radiolabelled antibody, but immunohistochemical sentinel lymph node (SLN) identification is commonly used. The potential diagnostic use of cell and tissue autofluorescence (AF) is well known. Here we review our studies on the application of AF-based techniques for diagnosing metastatic lymph nodes. We had previously demonstrated that AF imaging allows discrimination between hyperplastic and primary neoplastic lymph nodes. Our more recent studies show that the combination of autofluorescence microspectroscopy and multispectral imaging autofluorescence microscopy can be applied to the diagnosis of secondary neoplastic lymph nodes in gastric and colorectal cancer. These techniques have been validated by histochemical and immunohistochemical methods. Studies are in progress to select the best dye tracer for SLN identification, to improve image quality and to develop a software for automatic analysis of tissue AF to help the decision-making process during surgery.

As more humans travel to and spend more time in space, there is a lot to learn about the complex physiologic changes in extreme environmental conditions. Providing adequate medical care for spaceflight is a challenge for mission planners. It requires to decide what medical capability to provide in a way that meets the unique constraint of space flight. Some factors are to be accounted: the duration of the space mission , and the number of high-risk activities associated with it, space adaptation syndrome, cardiovascular deconditioning, bone demineralization and other events. The best possible care to the spaceflight crew must be weighed against the limited resource available on board spacecraft. Providing terrestrial standard of care in space requires careful planning and forethought. Simple and intuitive designs for equipment will aid in effective use, particularly for non medical user who may handle these items very infrequently. The current goal standard of management of traumatic injuries and other serious surgical problems is stabilization, damage control and rapid return to Earth, but during long missions return to Earth is not an option. Studies have been done to develop the techniques, procedures and equipment for basic surgery in space. NASA Medical Operations have developed a comprehensive methodology to guide the crewmembers remotely. This device is appropriate for low earth orbit and lunar missions, where near real-time (<5sec delay) communication is available. For the future, conventional operating room concept should be incorporated in the planning procedure. Unconventional diagnostic techniques will probably be required in peculiar condition, and although several studies have been done about skillness and feasibility, additional studies are required on these different tasks. One of these tasks is the healing of surgical wounds and its management in microgravity. Wound healing is a multiphase process, critical for the survival of the organism. Wound healing evolution in microgravity is relatively unknown, but the literature generally reports a delay in tissue repair with impairment of both inflammatory and remodelling phases. Unloading conditions can affect wound healing both indirectly, decreasing the capability of the organism to withstand injuries because of the functional alterations, and directly, changing the behaviour of the cells involved in ECM remodelling and tissue regeneration. Our studies demonstrate that both fibroblasts and endothelial cells exposed to microgravity show altered regulation of adhesion/migration and changes in expression of ECM molecules, that could lead to defective ECM remodelling. On the contrary, hypergravity (10xg) or pulsed Nd:YAG laser treatment seem to favour synthesis and assembly of ECM molecules, suggesting possible strategies for counteracting microgravity-induced effects on tissue repair and for treating chronic wounds and fibrotic scars.

Single-agent gemcitabine has been established as standard treatment for advanced pancreatic cancer since clinical studies have shown an improvement in overall survival and significant clinical benefit when compared to the best supportive care despite low overall objective response. Several phase II studies have tested other single agents and different gemcitabine-based regimens in pancreatic cancer, but both response and survival rates have remained low. Irinotecan, a topoisomerase I inhibitor currently approved for the treatment of metastatic colon cancer, has also demonstrated improved response rate in patients with pancreatic cancer. Our purpose was to determine the activity and toxicity of this regimen in patients with unresectable or metastatic pancreatic cancer. Patients with histologically confirmed pancreatic adenocarcinoma received gemcitabine 1000 mg/m2 plus irinotecan 100 mg/m2 IV on days 1, 8, and 15 of a 28-day cycle for 6-8 months. From February 2004 to April 2006, 33 patients were entered into this study, 32 of whom were evaluable for treatment response, toxicity, median time to progression, and median survival. Characteristics included a median age of 63 years (range 41-79), 21 males (64%), and 12 females (36%). One patient discontinued treatment due to adverse effects. The total number of cycles administered was 188 and the median number of cycles for patients was 5.6 (range 2-7). Thirty-two patients were assessable for toxicity and response. Grade 3 hematological toxicity occurred in 9% of patients and was primarily neutropenia. No grade >2 gastrointestinal toxicities or death due to treatment were observed. The most frequent nonhematological adverse event was fatigue. Ten patients responded to treatment with two complete responses (6.3%) and eight partial responses (25.0%), for an overall response rate of 31.3%; 11 patients achieved stable disease (34.3%). The median time to tumor progression and the median survival were 9.2 (95% CI: 6.0-12.4) and 11.8 (95% CI: 7.7-15.9) months, respectively, with a 2-year survival of 22%. On the basis of this trial, the combination of gemcitabine plus irinotecan, administered in a weekly schedule and at this dose, is well tolerated and offers encouraging activity in the treatment of advanced and/or metastatic pancreatic cancer.

The association between oxaliplatin and 5-fluorouracil (5-FU) has been extensively reported to improve prognosis of gastric cancer patients. The present study is aimed at evaluating response rate and the toxicity profile of the association with oxaliplatin, 5-FU/lecovorin and epirubicin in gastric cancer patients with locally advanced or metastatic disease. Thirty-six patients have been enrolled and 35 evaluated. The treatment schedule was oxaliplatin (100 mg m(-2)), 5-FU (400 mg m(-2)), leucovorin (40 mg m(-2)) and epirubicin (60 mg m(-2)) intravenously. administered every 3 weeks for 6 months, for a total of 185 therapy cycles . Response rate and toxicity were assessed according to the international WHO criteria. Every patient received a mean of 5.3 therapy cycles in a day-hospital setting. Sixteen of 35 patients (46%) showed an objective response, two complete response and 14 partial response. Median time to progression was 33 weeks with an overall median survival of 49 weeks. During the study, anaemia grade 3 and neutropenia grade 3 were observed in 9 and 11% of patients respectively. A grade 3 periferic sensorial neuropathy was observed in 6% of patients. No life threatening or cardiac toxicity was recorded. The regimen used showed anticancer activity against gastric carcinoma, a tolerable toxicity profile and excellent patient compliance.

Background & Aims: The lymphadenectomy and extended lymphadenectomy procedures have been points of controversy in surgical oncology. The methods available for the detection of metastatic lymph nodes are numerous. These include lymphoscintigraphy and radiolabeled antibody detection, but in most cancers the currently used technique is sentinel lymph node identification, performed primarily through the use of immunohistochemistry. We propose the application of autofluorescence (AF)-based techniques for lymph node evaluation in colorectal and gastric tumors. Methods: We studied 30 clinical cases: 15 colorectal cancers and 15 gastric cancers. All of the patients were in the advanced stages of the disease and were candidates for adjuvant therapy. Autofluorescence microspectroscopy and multispectral imaging autofluorescence microscopy have been used to analyze the AF emission of metastatic lymph node sections, excited with 365-mn wavelength radiation. The AF spectra were recorded in the range of 400-700 nm. Monochrome AF images were acquired sequentially through interference filters peaked at 450, 550, and 650 nm, and then combined together in a single red-green-blue image. The AF pattern and the emission spectrum of metastatic lymph nodes have unique characteristics that can be used to distinguish them from the normal ones. Results: The results, compared with standard histopathologic procedures and with specific staining methods, supplied a satisfactory validation of the proposed technique, revealing the possibility of improving the actual diagnostic procedures for malignant lymph node alterations. Conclusions: with the development of appropriate instrumentation, the proposed technique could be particularly suitable in intrasurgical diagnosis of metastatic lymph nodes.

We investigated the effects of metastasis, surgery and chemotherapy on both circulating dendritic cells (DCs) and monocyte-derived-DCs (MoDCs) in colorectal cancer (CRC) patients. Metastatic or nonmetastatic CRC patients had significantly reduced DC subsets compared to healthy subjects (p < 0.001). These cells were significantly higher in metastatic than in nonmetastatic patients. MoDCs were significantly lower in metastatic than healthy and nonmetastatic subjects (p < 0.001). Surgically treated patients had nearly one-half circulating DC subsets compared to healthy subjects (p < 0.001) while no difference was found between unoperated and healthy subjects. MoDCs obtained from tumor-bearing were significantly higher than in operated subjects. In both cases, MoDCs were significantly lower than in healthy subjects (p < 0.001). Circulating DCs and MoDCs were significantly lower in CRC patients, with or without chemotherapy, compared to healthy subjects (p < 0.001). Compared to untreated, chemotherapy-treated patients had 30% fewer DC subsets and lower MoDCs. Characterization of circulating DC subsets and MoDCs may elucidate CRC patients' immune system status.