Objective: Surgical colonic emergencies frequently occur in elderly patients. In these cases a comprehensive preoperative assessment is crucial to tailor surgical invasiveness to individual risk profiles and potentially improve clinical outcomes. The aim of our study was to identify predictors of in-hospital mortality in octogenarians undergoing emergency colorectal resections, and compare the short-term outcomes between elderly and younger patients.Methods: This study included patients who underwent emergency colorectal resections at Our Department between January 2020 and December 2024. Exclusion criteria were age <18 years and palliative surgery. Patients were stratified into two cohorts: octogenarians (≥80 years, Group 1) and patients aged <80 years (Group 2). Baseline characteristics, perioperative variables, and short-term outcomes were compared and analyzed. A systematic review (PROSPERO: CRD420251050770) was conducted to identify the studies evaluating outcomes of emergency colorectal resections in octogenarians. MEDLINE (via PubMed), EMBASE, and EBSCOhost were searched from database inception to April 2025.Results: Group 1 and Group 2 included 82 and 130 patients with median ages of 84 and 67 years, respectively. The in-hospital mortality rate was 24% in octogenarians and 8% in younger patients (p < 0.001). Multivariate logistic regression identified hyperlactatemia as an independent negative prognostic factor for in-hospital mortality in octogenarians (p = 0.01). Through a systematic review of the literature we identified 12 publications, and the mortality rate ranged between 7.0 and 37.8%.Conclusions: Early identification of prognostic factors can improve clinical outcome in emergency scenarios. Our systematic review, the first reported in the literature, provides a comprehensive perspective in this field.

The Multiparametric Therapeutic Hierarchy (MTH) has been proposed as an evolution of the Barcelona Clinic Liver Cancer (BCLC) algorithm to better reflect the complexity of real-world hepatocellular carcinoma (HCC) management. While the BCLC often assumes idealised conditions, the MTH explicitly incorporates “treatment unfeasibility” as a variable in clinical decision-making, a concept this review seeks to examine and refine. We propose that unfeasibility should not be limited to absolute contraindications but should be understood as a multidimensional construct comprising four interacting dimensions: (1) Technical Feasibility; (2) Resources; (3) Equity; and (4) Values and Acceptability. This concept of unfeasibility adapts the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision (EtD) framework, originally designed for population-level guideline development, to individual-level clinical reasoning. At the point of care, the five EtD domains (Feasibility, Resources, Acceptability, Equity, and Values and Preferences) converge into a unified assessment of treatment feasibility for the specific patient. A precise mapping between our four dimensions and the original GRADE domains is provided. This approach is complementary to, rather than a departure from, GRADE methodology and is particularly relevant in settings characterised by low or very low certainty of evidence. Our analysis reveals a recurring inverse relationship between therapeutic efficacy and feasibility: the most effective treatments, such as liver transplantation, are often constrained by technical, resource-related, and systemic barriers. This tension results in widespread undertreatment across the HCC population. By defining unfeasibility as a key element of expert reasoning, this framework aims to enhance transparency in how multidisciplinary tumour boards weigh multiple considerations when making individualised treatment decisions under uncertainty, without prescribing decision rules or treatment recommendations.

Background: Percutaneous endoscopic gastrostomy (PEG) is a widely accepted procedure for long-term enteral nutrition. Although generally safe, rare but life-threatening complications can occur. We report a unique case of a triple gastro-colic fistula, identified during an emergency surgical intervention after radiological replacement of a PEG one year following its initial placement. Case presentation: An 83-year-old man with Parkinson's-related dysphagia underwent PEG placement. One year later, following catheter occlusion, it was replaced radiologically. The next day, the patient developed abdominal pain and diarrhea, and imaging revealed catheter misplacement into the transverse colon. Surgical exploration identified three chronic and dehiscent fistulous tracts involving the stomach, transverse colon, and sigmoid colon. The patient was treated with colonic resection, gastric double-layer suture, and surgical gastrostomy. Recovery was uneventful and the patient was discharged on postoperative day eight. Conclusion: This is the first reported case of a triple gastro-colic fistula following PEG placement. The case highlights that early recognition and multidisciplinary management of PEG-related complications are crucial. Prompt diagnosis and the availability of a specific Acute Care Department are essential for the effective management of such complex scenarios.

Background: Liver transplantation (LT) after severe polytrauma is exceptionally rare. When damage-control surgery fails, multiorgan resection may be required as a life-saving procedure, with emergency LT representing the ultimate salvage option for patients with uncontrollable hepatic hemorrhage or irreversible liver failure. We report, to our knowledge, the first documented case of concomitant liver transplantation, splenectomy, nephrectomy, and total pancreatectomy following severe abdominal trauma. Case presentation: A 19-year-old male sustained severe blunt abdominal trauma following a motorcycle-truck collision. Imaging revealed an AAST grade V liver injury with major vascular and biliary disruption, complete avulsion of the right renal artery (AAST V), splenic injury (AAST III) and an AAST grade II duodenal hematoma. Despite damage-control surgery, followed by splenectomy and right nephrectomy, definitive hemorrhage control could not be fully achieved. Given the persistent hepatic bleeding and the expected progression to acute liver failure secondary to extensive hepatic disruption, the patient underwent emergent LT. Due to concerns for progression of the duodenal injury, a planned second-look operation was performed 48 h later, revealing marked enlargement of the hematoma with impending duodenal wall rupture, prompting the decision to proceed with total pancreatectomy. The postoperative course was uneventful, and the patient was discharged 18 days after transplantation. At 29-month follow-up, both graft function and clinical status are excellent. Conclusions: Emergency LT may represent a feasible and life-saving strategy in highly selected patients with devastating abdominal trauma. This case demonstrates that, despite the extreme surgical complexity, favorable long-term outcomes can be achieved, supporting the non-futility of transplantation in carefully selected trauma recipients.

Background/Objectives: Salvage liver transplantation (SLT) is a well-established option for hepatocellular carcinoma (HCC) recurrence after liver resection. Laparoscopic microwave ablation (L-MWA) represents another curative strategy for early-stage HCC. However, its role within this therapeutic framework remains unexplored. Methods: Between 2014 and 2023, we treated 1341 patients with HCC using L-MWA. From this cohort, patients with Child-Pugh class A liver function, HCC within the Milan criteria, no contraindications to transplantation, and ≥12 months of follow-up were selected. SLT failure was defined as non-transplantable recurrence or death, resulting in the loss of a potentially curative therapeutic opportunity. The primary endpoint was overall survival (OS); secondary endpoints included predictors of survival and SLT failure. Results: A total of 341 patients met the inclusion criteria. Five-year OS was 62%. Independent predictors of poorer survival included the presence of cardiac disease or oesophageal varices, a Child-Pugh score of 6, tumour size, and elevated alpha-fetoprotein (AFP) levels. Treatment was successful in 255 patients (74.8%): 102 (29.9%) underwent SLT, 67 (19.6%) received alternative therapies, and 93 (27.3%) remained recurrence-free. Treatment failure occurred in 86 patients (25.2%) due to non-transplantable recurrence or death. Independent predictors of failure included older age, non-HBV aetiology, and elevated AFP levels. Five-year OS rates were 79% in the success group and 22% in the failure group (p < 0.001). Conclusions: A combined L-MWA and SLT strategy is safe and effective, yielding a 62% 5-year OS rate. This approach supports more efficient graft use with a consequent increase in the population transplant benefit. Improved selection may further reduce failure rates.