The LIFE TRIAD of emergency general surgery

Emergency General Surgery (EGS) was identified as multidisciplinary surgery performed for traumatic and non-traumatic acute conditions during the same admission in the hospital by general emergency surgeons and other specialists. It is the most diffused surgical discipline in the world. To live and grow strong EGS necessitates three fundamental parts: emergency and elective continuous surgical practice, evidence generation through clinical registries and data accrual, and indications and guidelines production: the LIFE TRIAD.

Psychological First Aid Training of Police Officers

A significant lack of evidence regarding the effectiveness of psychological first aid (PFA) training of first responders to emergency settings has been reported. The aim of the present study was to assess the effectiveness of a PFA training program on the feeling of confidence on providing help in crisis, knowledge, attitudes, and skills of police officers. Fifty police officers were trained in PFA, using an adapted version of the World Health Organization's program, and they were compared to a control group of 53 police officers. A PFA questionnaire was used to compare the two groups, before and after the implementation of the PFA training. Results revealed significant improvementson confidence, knowledge, attitudes, and skills of trained police officers, in comparison to controls. Thus, the present results suggest that PFA training programs are effective and should be offered to police officers in order to enhance their capacity to provide PFA in emergency settings.

Laparoscopic Management of Concomitant Sigmoid Colon Cancer and Type 2 Endoleak Following Endovascular Aneurysm Repair

The co-occurrence of abdominal aortic aneurysm (AAA) and colorectal malignancy creates a significant surgical dilemma over which entity should be addressed first. A 73-year-old male was referred to our hospital due to a painful pulsatile abdominal mass. Computed tomographic angiography revealed an infrarenal aortic aneurysm measuring 5.8 cm in diameter and incidentally, a synchronous mass lesion in the sigmoid colon. The patient underwent an emergency EVAR using a Gore Excluder endograft. Postoperative CT staging for colon cancer revealed a type 2 endoleak on the grounds of a patent wide inferior mesenteric artery. The patient underwent a standard laparoscopic left colectomy with high ligation of the inferior mesenteric artery in order to simultaneously address the ongoing type 2 endoleak. Follow-up examinations with computed tomographic angiography were performed confirming the resolution of the endoleak. Synchronous laparoscopic sigmoidectomy and high ligation of inferior mesenteric artery for type 2 endoleak treatment appears to be applicable with hopeful results.

Surgical Management of a Pancreaticopleural Fistula After Failed Endoscopic Therapy

Inflammatory diseases of the pancreas or pancreatic trauma result in ductal cell disruption, which in turn may lead to leakage of pancreatic fluid, mostly in the retroperitoneal space. Pancreatopleural fistulas are uncommonly encountered following pancreatic injury; however, they often prove a difficult problem to manage.

Herein, we present a rare case of a 68-year-old male suffering from a pancreaticopleural fistula (PF) between the pancreatic tail and the left pleural space one year following splenectomy for trauma. About three months after percutaneous drainage of a left pleural effusion and left upper quadrant abdominal collection and endoscopic pancreatic duct stent placement, surgical management was decided. Distal pancreatectomy and Roux-en-Y drainage of the pancreatic remnant were successfully performed.

It's time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review

BACKGROUND

Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future.

METHODS

A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board.

RESULTS

A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic.

CONCLUSION

This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.

Oncologic outcomes of patients with resectable primary gastric squamous cell carcinoma: a systematic review

Background

Primary gastric squamous cell carcinoma (PGSCC) is an uncommon type of gastric malignancy estimated to comprise around 0.04-0.5% of all gastric malignancies. PGSCC’s long-term survival has been quoted to range from 17-50% depending on stage, with surgery arguably representing the most useful modality for prolonging oncologic survival. Nevertheless, reliable data on its effectiveness are still lacking in the literature.

Method

A systematic literature search of the Medline, Cochrane library and Scopus databases was undertaken, to identify cases of surgically managed PGSCC reporting patient-related outcomes.

Results

In total, 23 case reports and 1 case series incorporating 38 patients were identified. Mean patient age was 61.2 years and the male/female ratio was 18:1. Most tumors were high-stage at the time of diagnosis, with the T4 stage predominating in the patient pool (n=15, 50%) along with a high percentage of lymphatic spread (N positive tumors, n=15, 47%). All patients underwent curative-intent surgical resection and were subsequently followed for an average of 30.7±14 months. Extrapolated survival data revealed a projected 3- and 5-year overall survival of 62.2% and 51.9%, respectively, while the 3-year probability for being disease-free was calculated to be 30.8%. T4 stage and lymphatic spread were found to be predictors of poor survival in univariate but not in multivariate analysis.

Conclusion

Notwithstanding the methodological limitations inherent to the present review, the obtained results, when superimposed on existing cross-sectional survival data, suggest significantly enhanced patient survival following surgery, solidifying its role in the management of patients with PGSCC.

Gallstone Ileus in Octogenarians: Is Cholecystectomy Really Needed?

Gallstone ileus is an uncommon complication of cholelithiasis and occurs when a gallstone migrates through a cholecystoenteric fistula and impacts within the gastrointestinal tract. Surgical intervention remains the treatment of choice, which consists of a full-thickness incision of the visceral wall and removal of the impacted gallstone. In this paper we present the treatment approach of 6 cases of gallstone ileus in octogenarians. In our cohort, intestinal obstruction was resolved through an enterotomy or gastrotomy and lithotomy/stone extraction in every patient. No cholecystectomies were undertaken. Despite the fact that gallstone ileus is diagnosed in small percent of patients suffering from gallstone disease, it accounts for a large proportion of intestine obstruction in patients older than 65 years old. Since accurate diagnosis and timely intervention are vital, providers should be familiar with the diagnostic approach and the treatment of this clinical entity.

Effect of silibinin on the expression of MMP2, MMP3, MMP9 and TIMP2 in kidney and lung after hepatic ischemia/reperfusion injury in an experimental rat model

PURPOSE

The protective effect of silibinin on kidney and lung parenchyma during hepatic ischemia/reperfusion injury (IRI) is explored.

METHODS

Sixty-three Wistar rats were separated into three groups: sham; control (45 min IRI); and silibinin (200 μL silibinin administration after 45 min of ischemia and before reperfusion). Immunohistochemistry and real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) were used to evaluate the expression levels of MMP2, MMP3, MMP9, and TIMP2 on kidney and lung.

RESULTS

Comparing sham vs. control groups, confirmed that hepatic IRI increased both renal and lung MMP2, MMP3, MMP9 and TIMP2 expressions starting at 180 min (p<0.001). Comparison of the control vs. silibinin groups showed a statistically significant decrease in the expression levels of MMP2, MMP3, and MMP9 and increase of TIMP2 in kidney and lung parenchyma. The starting point of this decrease was at 120 min after reperfusion, both for kidney and lung parameters, and it was statistically significant at 240 min (p<0.001) for kidney, while silibinin showed a peak of lung protection at 180 min after hepatic reperfusion (p<0.001).

CONCLUSIONS

Hepatic IRI causes distant kidney and lung damage, while a statistically significant protective action, both on kidney and lung parenchyma, is conveyed by the intravenous administration of silibinin.

Endoscopic versus surgical treatment for thoracopancreatic fistulas complicating chronic pancreatitis: A systematic review

BACKGROUND

Thoracopancreatic fistulae are a rare complication of chronic pancreatitis. The aim of the present study is to evaluate potential risk factors for endoscopic treatment failure and explore the safety of surgery when utilized either upfront or as a "bail-out" procedure after failed endoscopic treatment.

METHOD

A comprehensive literature search was conducted on the MedLine, Scopus, Embase, and Web of Knowledge databases for cases of thoracopancreatic fistulae. Data regarding patient demographics, fistula anatomy, and treatment interventions performed were extracted for further analysis.

RESULTS

The study pool consisted of 75 case reports and 19 case series published between the years 1972 and 2020. Duct disruption in the pancreatic body was most commonly encountered (41.1%), and a left pleural effusion was the most common manifestation (46%). Endoscopic treatment was attempted for 104 patients with an overall success rate of 42.3% (n = 44). Predictive factors for eventual success of endoscopic treatment were the ability of endoscopic retrograde cholangiopancreatography to diagnose the thoracopancreatic leak (odds ratio 9.76, 95% confidence interval 2.71-35.09, P < .001), the use of pancreatic duct stents (odds ratio 22.1, 95% confidence interval 7.92-61.61, P < .001), and the use of sphincterotomy (odds ratio 7.96, 95% confidence interval 2.1-30.1, P < .001). Conversely, the presence of pancreatic duct calculi was associated with endoscopic treatment failure (odds ratio 0.34, 95% confidence interval 0.12-0.94, P = .03). Pooled results suggest that surgical outcomes were comparable between the primary and salvage surgery groups.

CONCLUSION

A step-up approach from endoscopic management to salvage surgery may be effectively employed in cases of thoracopancreatic fistulae refractory to endoscopic treatment.

Mutant KRAS as a prognostic biomarker after hepatectomy for rectal cancer metastases: Does the primary disease site matter?

BACKGROUND

The prognostic implication of mutant KRAS (mKRAS) among patients with primary disease in the rectum remains unknown.

METHODS

From 2000 to 2018, patients undergoing hepatectomy for colorectal liver metastases at 10 collaborating international institutions with documented KRAS status were surveyed.

RESULTS

A total of 834 (65.8%) patients with primary colon cancer and 434 (34.2%) patients with primary rectal cancer were included. In patients with primary colon cancer, mKRAS served as a reliable prognostic biomarker of poor overall survival (OS) (hazard ratio [HR]: 1.58, 95% CI 1.28-1.95) in the multivariable analysis. Although a trend towards significance was noted, mKRAS was not found to be an independent predictor of OS in patients with primary rectal tumors (HR 1.34, 95% CI 0.98-1.80). For colon cancer, the specific codon impacted in mKRAS appears to reflect underlying disease biology and oncologic outcomes, with codon 13 being associated with particularly poor OS in patients with left-sided tumors (codon 12, HR 1.56, 95% CI 1.22-1.99; codon 13, HR 2.10 95% CI 1.43-3.08;). Stratifying the rectal patient population by codon mutation did not confer prognostic significance following hepatectomy.

CONCLUSIONS

While the left-sided colonic disease is frequently grouped with rectal disease, our analysis suggests that there exist fundamental biologic differences that drive disparate outcomes. Although there was a trend toward significance of KRAS mutations for patients with primary rectal cancers, it failed to achieve statistical significance.

A pandemic recap: lessons we have learned

On January 2020, the WHO Director General declared that the outbreak constitutes a Public Health Emergency of International Concern. The world has faced a worldwide spread crisis and is still dealing with it. The present paper represents a white paper concerning the tough lessons we have learned from the COVID-19 pandemic. Thus, an international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making. With the present paper, international and heterogenous multidisciplinary panel of very differentiated people would like to share global experiences and lessons with all interested and especially those responsible for future healthcare decision making.

Reevaluating the prognostic role of BRAF mutation in colorectal cancer liver metastases

INTRODUCTION

Mutations in the BRAF proto-oncogene have been shown to predict poor patient survival following curative-intent liver surgery for metastatic colorectal cancer. The aim of the present systematic review and meta-analysis is to evaluate the effect of mutated BRAF status (mutBRAF) on the overall (OS) and disease-free survival (DFS) in these patients.

METHODS

A comprehensive literature search was performed for studies reporting outcomes of patients undergoing curative-intent surgery stratified by BRAF mutation status. Subgroup analysis was performed to evaluate whether inclusion of KRAS mutation status significantly influenced the results.

RESULTS

Six studies incorporating 1857 patients with known BRAF status were identified. Pooled results revealed significantly worse OS (Hazard Ratio 2.8, 95% C.I. 2.09 to 3.77) and DFS (Hazard Ratio 2.29, 95% C.I. 2.09 to 3.77) in mutBRAF patients. Subgroup analysis revealed no statistically significant impact of including KRAS status testing on the obtained results.

CONCLUSIONS

Patients with metastatic colorectal cancer carrying BRAF mutations have significantly worse oncologic outcomes following surgery and more aggressive disease phenotype overall.

Appraisal of a Contact Tracing Training Program for COVID-19 in Greece Focusing on Vulnerable Populations

BACKGROUND

Contact tracing as an epidemiological strategy has repeatedly contributed to the containment of various past epidemics and succeeded in controlling the spread of disease in the community. Systematic training of contact tracers is crucial in ensuring the effectiveness of epidemic containment.

METHODS

An intensive training course was offered to 216 health and other professionals who work with vulnerable population groups, such as Roma, refugees, and migrants in Greece, by the scientific team of the postgraduate programme "Global Health-Disaster Medicine" of the Medical School, National and Kapodistrian University of Athens, with the support of the Swiss embassy in Greece. The course was delivered online due to the pandemic restriction measures and was comprised of 16 h over 2 days. The course curriculum was adapted in Greek using, upon agreement, a similar training course to what was developed by the Johns Hopkins University Bloomberg School of Public Health. Evaluation of the course was conducted in order to determine the short term satisfaction from participating in this training course.

RESULTS

A total of 70% of the course participants completed the evaluation questionnaires and all trainers gave feedback on the course. The training modules were ranked as extremely useful by the majority of the participants and over 50% of the participants specifically stated that the course content was directly related to their work with vulnerable groups. Content about the ethics of contact tracing and the effective communication skills presented were deemed most useful.

CONCLUSION

The course was well organised and provided the required skills for effective contact tracing. Many course participants intend to use some components in their work with vulnerable populations groups. Contact tracing efforts work best in a systematic and coordinated way and the provision of systematic and organised training can greatly increase its effectiveness.

p53 protein expression in synchronously occurring dedifferentiating stages of thyroid cancer in a patient with neurofibromas: A case report

Poorly differentiated thyroid carcinoma (PDTC) and anaplastic thyroid carcinoma (ATC) have been hypothesized to arise from well-differentiated thyroid carcinoma (WDTC) due to frequently reported synchronous and metachronous occurrence. Loss of normal p53 function has been implicated in this dedifferentiation process. The current case report presents a 60-year-old male with multiple neurofibromas who underwent total thyroidectomy due to multiple palpable thyroid nodules. Histopathological examination revealed three foci of predominantly papillary, but also follicular carcinoma growth pattern, and two lesions with histological features of insular and trabecular variant, with the larger one showing foci of anaplastic transition. Nuclear p53 protein accumulation, corresponding to mutant abnormally stabilized p53, was higher in more aggressive variants compared with WDTC. The somatic molecular events and downstream pathways of this dedifferentiation course have not been unraveled yet. The present case report demonstrated the simultaneous presence of three divergent histological subtypes in a single thyroid gland, with progressive enhancement of nuclear p53 protein expression, associated with mutant p53 protein, in the more aggressive variants. This is a rare case of progressive enhancement of mutant nuclear p53 protein expression in multifocal thyroid tumor areas consisting of WDTC, PDTC and ATC histological types, highlighting the possibility that WDTC can progress to PDTC and then ATC through an intricate procedure, involving loss of normal p53 function.

Current evidence on laparoscopic vs. open resection for gastric stromal tumours

Although the use of laparoscopic surgery is increasing, controversy still surrounds its application for malignant conditions. Gastrointestinal stromal tumours (GISTs) are less demanding in terms of lymphadenectomy, meaning that laparoscopic resection might have a more defined benefit when compared with open resection. To the best of our knowledge, no randomized study exists that compares the laparoscopic and open resection of GISTs. The current study aimed to examine the relevant literature by means of a systematic review. A systematic literature search was performed individually by two authors, in which three independent databases were searched using specific search-terms. Titles, abstracts and full texts were screened, as well as references to relevant articles, in order to comprise a comprehensive list of studies. Data were extracted using a detailed pre-agreed spreadsheet. Studies were evaluated according to the modified MINORS criteria. A total of 10 studies were included in the present review, yielding a total of 14 entries. The majority of studies reported significantly improved perioperative outcomes for the laparoscopic approach, including improved duration of operation, blood loss and length of hospital stay. Only four studies reported long-term outcomes and findings that were controversial, with some studies detecting no statistically significant differences, one reporting improved and one reporting worse disease-free and overall survival for the laparoscopic group. Three studies were deemed to be good quality, two of which had not reported significantly different long-term outcomes, while the third had reported significantly improved outcomes in the open resection group. While there is a clear benefit for performing laparoscopic surgery in patients with GIST with regards to perioperative outcomes, when it comes to long-term oncological outcomes, uncertainty over its application remains. The lack of randomized trials, as well as the poor reporting of retrospective studies, limits the amount of evidence that is currently available. Laparoscopic surgery for GIST is certainly safe, feasible and likely cost-effective; however, further studies are required to inform on whether this technique is superior to open resection.

Reevaluating the prognostic value of RAS mutation status in patients with resected liver metastases from colorectal cancer: A systematic review and meta-analysis

BACKGROUND

Although the value of Rat Sarcoma Oncogene (RAS) mutation status in predicting long-term outcomes in patients with colorectal liver metastases (CRLM) is widely accepted, the magnitude of its impact has recently been challenged by three large cohort studies. The aim of this meta-analysis is to reevaluate the impact of RAS mutations on overall survival (OS) and disease-free survival (DFS) in patients who underwent curative-intent resection of CRLM.

METHODS

A comprehensive literature search was performed for studies reporting outcomes of patients undergoing curative-intent surgery stratified by RAS mutation status. Exclusion criteria were defined a priori. Subgroup analysis was performed to evaluate the effect of publication date, sample size, and KRAS vs any RAS mutation on overall outcomes.

RESULTS

Ten studies incorporating 3115 patients with known RAS status were identified. Pooled results revealed significantly worse OS (Hazard Ratio 1.5, 95% CI 1.31-1.71) and DFS (Hazard Ratio 1.36, 95% CI 1.22-1.52) in RAS-mutated patients. Subgroup analyses revealed that studies including more than 300 patients or published after 2015 reported lower HR than their counterparts.

CONCLUSION

The results of this meta-analysis suggest that the prognostic value of RAS mutation status in patients with CRLM has been previously overestimated.

An Unusual Case of Mirizzi Syndrome With Double Spontaneous Gallbladder Fistulas With the Colon and the Duodenum Presenting As Acute Cholecystitis

The Mirizzi syndrome is amongst the rarest complications of long-standing gallstone disease. It is an even rarer occurrence when concurrent with a cholecystoenteric or cholecystoduodenal fistula and might not include an accompanying gallstone ileus. Chronic cholecystitis is the primary etiology, but pre-operative diagnosis is challenging due to its non-specific symptoms compared with acute cholecystitis. In this unusual case, the patient has a Csendes type Va Mirizzi syndrome associated with a double cholecystoduodenal and cholecystocolonic fistula, a rare presentation.

Review of the Literature on Leiomyoma and Leiomyosarcoma of the Adrenal Gland: A Systematic Analysis of Case Reports

BACKGROUND/AIM

To date few cases of smooth muscle-derived tumors of the adrenal gland have been reported and their treatment remains a medical challenge. The aim of this manuscript was to systematically review the literature and present the tumor characteristics and their management in order to provide a standardized approach to their diagnosis and management.

MATERIALS AND METHODS

We searched five databases (PubMed, Scopus, Elsevier, ResearchGate, Google scholar) for relevant articles published until March 2020.

RESULTS

Twenty-two cases of adrenal leiomyoma, four cases of adrenal smooth muscle tumor and forty-five cases of adrenal leiomyosarcoma were included.

CONCLUSION

We present the demographic, clinical, radiological, pathological and oncological characteristics and prognosis of tumors of the adrenal gland arising from smooth muscle cells, as well as describe the common clinical investigations and therapeutic modalities that have been reported as part of their management.

The Modulating Effect of Ursodeoxycholic Acid on Liver Tissue Cyclooxygenase-2 Expression Following Extended Hepatectomy

Introduction: Hepatic regeneration is a complex process involving a multitude of well-timed molecular operations. Ursodeoxycholic acid (UDCA) is postulated to exert a protective effect against oxidative stress and enzymatic degradation of the extracellular matrix, in turn potentiating the regenerative response. The aim of the present animal study is to evaluate the impact of UDCA administration in liver tissue expression of cyclooxygenase-2 (COX-2) in a setting of acute liver failure achieved by 80% hepatectomy.

Materials and methods: Twenty-four adult male Sprague-Dawley rats were randomly assigned to an experimental (UDCA) and a control group. Animals in the UDCA received oral pretreatment with UDCA for 14 days via feeding tube, while animals in the control group received saline. All animals underwent resection of approximately 80% of the liver parenchyma. Tissue and blood sample collection were performed 48 hours postoperatively.

Results: The postoperative mitotic index and Ki-67 levels were found to be elevated in the UDCA group (43±11.4 and 13.7±24.7 versus 31±16.7 and 7.6±5.7), albeit without any statistical significance. Pretreatment with UDCA significantly decreased COX-2 expression levels (p=0.28) as well as serum tumor necrosis factor α (TNFα) levels (37.3±10.9 pg/mL versus 75.4±14.4 pg/mL, p=0.004). COX-2 expression score was observed to be weakly correlated to Ki-67 levels in both groups. Although COX-2 expression score was not correlated with serum TNFα levels in the control group, animals pretreated with UDCA exhibited moderate correlation (r=0.45).

Conclusion: Preoperative administration of UDCA exerts a suppressive effect on tissue expression of COX-2 following 80% hepatectomy and enforces a positive correlation between COX-2 and serum TNFα levels, suggesting that UDCA preconditions liver tissue to display an enhanced regenerative response to circulating cytokines, most notably TNFα. The weak association of COX-2 with Ki-67 expression levels suggests that COX-2 may be of secondary importance during the early phases of liver regeneration.

The effect of the COVID pandemic lockdown measures on surgical emergencies: experience and lessons learned from a Greek tertiary hospital

Background

The COVID-19 pandemic caused a rise in healthcare demands leading to significant restructuring of hospital emergency departments worldwide. The aim of the present study is twofold: firstly, to discern any differences in regard to reason for surgical emergency department (SED) attendance and hospital admission during the pandemic and pre-pandemic eras in Greece, and secondly, to assess the impact of the lockdown measures implemented during the pandemic on SED patient attendance.

Methods

Since the beginning of the COVID-19 pandemic in Greece (1 March 2020) and up to 15 December 2020, the charts of all adult patients arriving at the SED of the third surgical department of the “Attikon” University Hospital (a tertiary referral center for surgical and COVID-19 cases) were retrospectively reviewed and broken down in four periods reflecting two nationwide lockdown (period A 1/3/2020 to 30/4/2020 and period D 16/10/2020 to 15/12/2020) and two interim (period B 1/5/2020 to 15/6/2020 and period C 15/9/2020 to 30/10/2020) periods. Demographic and clinical data were compared to those obtained from the same time periods of the year 2019.

Results

The total number of patients attending the SED decreased by 35.9% during the pandemic (from 2839 total patients in 2019 to 1819 in 2020). During the first lockdown, there was statistically significant reduction of motor vehicle accidents (p=0.04) and torso injuries (p=0.01). Contrarily, the rate of head injuries (p<0.001) and abdominal pain (p=0.04) were significantly increased. The same effect was observed regarding the rate of hospital admissions (p=0.002), although in terms of absolute numbers, admissions remained unchanged. During the second lockdown, there was a reduction in the number of perianal abscess cases (p=0.04) and hernia-related problems (p=0.001). An increase in the rate of fall injuries was also demonstrable (p=0.02). Overall, application of the lockdown led to a significant decrease in minor (p<0.001) and torso (p=0.001) injuries.

Conclusion

The burden of the new COVID-19 disease has left a noticeable imprint in the function of emergency departments worldwide. In Greece, SED attendance was significantly reduced during the pandemic, an effect that was even more pronounced during the lockdown implementation; nevertheless, the overall rate of hospital admissions remained the same, denoting that patient care was not altered.

The clinical significance of PD‑L1 in colorectal cancer (Review)

Colorectal cancer (CRC) is one of the most frequently encountered neoplasms and has a high rate of morbidity and mortality. Recent findings showing that tumor immune evasion is an important mechanism underlying propagation of a cancer have changed the landscape of medical oncology through identification of Programmed‑Death receptor 1 and its ligand (PD‑1 and PD‑L1) as novel targets for oncological immune therapies. PD‑1 is primarily expressed on peritumoral lymphocytes and when activated, it suppresses its immune functions. Conversely, PD‑L1 is primarily expressed on the tumor infiltrating front with the purpose of deregulating physiological cytotoxic immune responses. Numerous studies have linked PD‑L1 overexpression to specific adverse clinicopathological features, such as poor differentiation, lymphovascular invasion and worse overall survival in CRC patients. Nevertheless, there is no concrete evidence showing which patients may exhibit the maximal beneficial effects of PD‑1/PD‑L1 blockade therapy, and how these novel molecular targets may be optimally integrated into therapeutic regimens for management of CRC patients with resectable and generalized disease.

The management of surgical patients in the emergency setting during COVID-19 pandemic: the WSES position paper

BACKGROUND

Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers.

METHOD

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology.

RESULTS

Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts' opinion.

CONCLUSIONS

The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.

A Rare Case of a Metastatic Lung Squamous Cell Carcinoma to the Large Bowel and the Liver

Lung carcinoma is the leading cause of death worldwide, with almost 50% of the patients presenting with distant metastases at the moment of diagnosis. The most common metastases sites are the lymph nodes, the liver, the adrenal glands, the bones, and the brain. The gastrointestinal tract was considered an unusual site for lung metastases, and due to the asymptomatic progress of the disease, they are usually diagnosed at a late stage. In the present case study, the clinical presentation, the treatment, and outcome of a rare case of descending colon and liver metastases from a lung squamous cell carcinoma in a 72-year-old female, two years after the presentation of her primary tumor are reported. The present study aims to increase the awareness for early diagnosis and treatment of metastatic lung cancer to the gastrointestinal tract.

The interplay of KRAS mutational status with tumor laterality in non-metastatic colorectal cancer: An international, multi-institutional study in patients with known KRAS, BRAF, and MSI status

BACKGROUND

Although the prognostic relevance of KRAS status in metastatic colorectal cancer (CRC) depends on tumor laterality, this relationship is largely unknown in non-metastatic CRC.

METHODS

Patients who underwent resection for non-metastatic CRC between 2000 and 2018 were identified from institutional databases at six academic tertiary centers in Europe and Japan. The prognostic relevance of KRAS status in patients with right-sided (RS), left-sided (LS), and rectal cancers was assessed.

RESULTS

Of the 1093 eligible patients, 378 had right-sided tumors and 715 had left-sided tumors. Among patients with RS tumors, the 5-year overall (OS) and recurrence-free survival (RFS) for patients with KRASmut versus wild-type tumors was not shown to differ significantly (82.2% vs. 83.2% and 72.1% vs. 76.7%, respectively, all p > .05). Among those with LS tumors, KRAS mutation was associated with shorter 5-year OS and RFS on both the univariable (OS: 79.4% vs. 86.1%, p = .004; RFS: 68.8% vs. 77.3%, p = .005) and multivariable analysis (OS: HR: 1.52, p = .019; RFS: HR: 1.32, p = .05).

CONCLUSIONS

KRAS mutation status was independently prognostic among patients with LS tumors, but this association failed to reach statistical significance in RS and rectal tumors. These findings confirm reports in metastatic CRC and underline the possible biologic importance of tumor location.