Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2.

Although mycophenolate mofetil (MMF) monotherapy has been successfully used in liver transplant recipients suffering from calcineurin‐inhibitor (CNI)‐related chronic toxicity, still no consensus has been reached on its safety, efficacy and tolerability. We attempted the complete weaning off CNI in 42 individuals presenting chronic renal dysfunction and/or dyslipidemia and/or arterial hypertension and simultaneously introduced 1.5 gm/day MMF. CNI could be completely withdrawn in 41 cases. A total of 32 (75%) patients are currently on ≤1.5 gm/day of MMF. Mean follow‐up from the introduction of MMF is 31.5 months and mean length of follow‐up from the beginning of MMF monotherapy is 27.3 months. Renal function improved in 31/36 (89%) cases. Blood levels of cholesterol and triglycerides decreased in 13 of 17 (76%) and 15 of 17 (89%) patients, respectively. Arterial hypertension improved in 4 of 5 (80%) cases. A total of 8 patients showed a single episode of fluctuation of liver function tests during tapering off CNI. This feature was interpreted as an acute rejection (AR), based on the resolution of the clinical setting after escalation of MMF daily dose to 2 gm. A further patient developed a biopsy‐proven AR insensitive to MMF adjustment, requiring reinstitution of the CNI dose. No deaths or major toxicity requiring MMF discontinuation occurred. In conclusion, low dose MMF monotherapy is safe, effective, and well tolerated. Liver Transpl, 2007. © 2006 AASLD.

Objective: The aim of this study is to compare the clinical and cost-effective outcomes of the open Lichtenstein repair (OL) and laparoscopic trans-abdominal preperitoneal (TAPP) repair for bilateral inguinal hernias. Summary Background Data: A cost-effective analysis of laparoscopic versus open inguinal hernia repair is still not well addressed, especially regarding bilateral hernia. Methods: This is a clinical and cost-effectiveness analysis within a randomized prospective study conducted at Sanchinarro University Hospital. Cases of primary, reducible bilateral inguinal hernia were included and randomized using a simple randomization program. The outcome parameters included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio. Results: Between March 2013 and January 2017, 165 patients were enrolled in this study (81 of them underwent TAPP and 84 OL). The TAPP procedure had less early postoperative pain (P = 0.037), a shorter length of stay (P = 0.001), and fewer postoperative complications (P = 0.002) when compared with the OL approach. The overall cost of TAPP procedure was higher compared with the OL cost (1,683.93€ vs 1192.83€, P = 0.027). The mean QALYs at 1 year for TAPP (0.8094) was higher than that associated with OL (0.6765) (P = 0.018). At a willingness-to-pay threshold of 20,000 € and 30,000 €, there was a 95.38% and 97.96% probability that TAPP was more cost-effective relative to OL. Conclusions: The TAPP procedure for bilateral inguinal hernia appears to be more cost-effective compared with OL.