Comparison of intracorporeal and extracorporeal anastomosis in laparoscopic right colectomy: an updated meta-analysis and trial sequential analysis

This meta-analysis was conducted to provide updated evidence regarding perioperative safety and efficacy, of IC and EC anastomosis in laparoscopic right colectomies. In this study, the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines were applied. The study protocol received a PROSPERO registration (CRD42020214596). A systematic literature search of the electronic scholar databases (Medline, Web of Science and Scopus) was performed. To reduce type I error, a trial sequential analysis (TSA) algorithm was introduced. The quality of evidence was evaluated based on the GRADE methodology. In total, 46 studies were included in this meta-analysis, Pooled comparisons and TSA confirmed that IC is superior in terms of incisional hernia (0.29; 95%CI: 0.19, 0.44), open conversion (0.45; 95%CI: 0.30, 0.67), reoperation (0.62; 95%CI: 0.46, 0.84]), LOS (- 0.76; 95%CI: - 1.03, - 0.49), blood loss (- 11.50; 95%CI: - 18.42, - 4.58), and cosmesis (- 1.71; 95%CI: - 2.01, - 1.42). Postoperative pain and return of bowel function were, also, shortened when the anastomosis was fashioned intracorporeally. The grading of most evidence ranged from 'low' to 'high'. Due to the discrepancy in the results of RCTs and non-RCTs, and the proportionally smaller sample size of the former, further randomized trials are required to increase the evidence of this comparison.

Billroth II anastomosis combined with brown anastomosis reduce reflux gastritis in gastric cancer patients

BACKGROUND

The surgeon performing a distal gastrectomy, has an arsenal of reconstruction techniques at his disposal, Billroth II among them. Braun anastomosis performed during a Billroth II procedure has shown evidence of superiority over typical Billroth II, in terms of survival, with no impact on postoperative morbidity and mortality.

AIM

To compare Billroth II vs Billroth II and Braun following distal gastrectomy, regarding their postoperative course.

METHODS

Patients who underwent distal gastrectomy during 2002-2021, were separated into two groups, depending on the surgical technique used (Billroth II: 74 patients and Billroth II and Braun: 28 patients). The daily output of the nasogastric tube (NGT), the postoperative day that NGT was removed and the day the patient started per os feeding were recorded. Postoperative complications were at the same time noted. Data were then statistically analyzed.

RESULTS

There was difference in the mean NGT removal day and the mean start feeding day. Mean total postoperative NGT output was lower in Braun group (399.17 mL vs 1102.78 mL) and it was statistically significant (P < 0.0001). Mean daily postoperative NGT output was also statistically significantly lower in Braun group. According to the postoperative follow up 40 patient experienced bile reflux and alkaline gastritis from the Billroth II group, while 9 patients who underwent Billroth II and Braun anastomosis were presented with the same conditions (P < 0.05).

CONCLUSION

There was evidence of superiority of Billroth II and Braun vs typical Billroth II in terms of bile reflux, alkaline gastritis and NGT output.

Central Pancreatectomy: Balancing between the Favorable Functional Results and the Increased Associated Morbidity

Introduction  Central pancreatectomy (CP) represents an organ-preserving type of pancreatic resection. The procedure has been associated with improved long-term functional results, but increased postoperative morbidity rates, compared with the more radical resection types. The purpose of the present study was to present the outcomes of three consecutive CPs performed in our department. Materials and Methods  Between January 2021 and January 2022, three patients (A, B, and C) were submitted to a CP in our department. Relevant patient data including data of the detailed preoperative assessment, operations notes, and recovery charts were prospectively collected and reviewed for all subjects. A scheduled follow-up, at the outpatient clinic, was conducted to assess the long-term functional results. Results  The postoperative course of patient A, a 56-year-old male, was complicated by a grade C postoperative pancreatic fistula that required a reoperation. Patient B, a 66-year-old female, developed a biochemical leak that resolved spontaneously while patient C, a 64-year-old male, had a completely uneventful recovery. The length of hospital stay for the three patients was 24, 12, and 8 days, respectively. Regarding the long-term results, patient B was lost to follow-up while both patient A and C were followed up, as outpatients, 21 and 10 months after the operation. During follow-up, in patient A, we did not record the presence of symptoms consistent with pancreatic exocrine insufficiency, the hemoglobin A1C (HbA1C) levels were 7.1% while no additional medications were needed to be prescribed to maintain the glycemic control following surgery. In patient C, a significant weight loss was recorded (body mass index reduction of 11 kg/m 2 ) without however the presence of malabsorption-specific symptoms. The HbA1C levels were 7.7% and optimal glycemic control was achieved with oral antiglycemic agents alone. Conclusion  CP should be regarded as a type of pancreatic resection with certain and very limited oncological indications. An approach of balancing the advantages out of the superior postoperative functional results with the drawbacks of the increased procedure-associated morbidity could highlight the patient group that could potentially experience benefits out of this limited type of resection.

Microvessel Density (MVD) in Patients with Osteosarcoma: A Systematic Review and Meta-Analysis

A meta-analysis was designed and conducted to estimate the effect of tumoral microvessel density (MVD) on the survival of patients with osteosarcoma. There was no difference between high and low MVD regarding the overall (OS) and disease-free (DFS) survival. Low MVD tumors displayed a lower DFS at the third year of follow-up. Although primary metastases did not affect the mean MVD measurements, tumors with a good chemotherapy response had a higher MVD value. Although no significant differences between tumoral MVD, OS and DFS were found, good adjuvant therapy responders had a significant higher vascularization pattern.

Comparison of ointment-based agents after excisional procedures for hemorrhoidal disease: a network meta-analysis of randomized controlled trials

INTRODUCTION

Efficient postoperative pain control is important after hemorrhoidal surgery. Although several locally applied medications have been used, current evidence regarding the optimal strategy is still conflicting. This network meta-analysis assessed analgesic efficacy and safety of the various topical medications in patients submitted to excisional procedures for hemorrhoids.

METHODS

The present study followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The last systematic literature screening was performed at 15 June 2023. Comparisons were based on a random effects multivariate network meta-analysis under a Bayesian framework.

RESULTS

Overall, 26 RCTs and 2132 patients were included. Regarding postoperative pain, EMLA cream (surface under the cumulative ranking curve (SUCRA) 80.3%) had the highest ranking at 12-h endpoint, while aloe vera cream (SUCRA 82.36%) scored first at 24 h. Metronidazole ointments had the highest scores at 7 and 14 days postoperatively. Aloe vera had the best analgesic profile (24-h SUCRA 84.8% and 48-h SUCRA 80.6%) during defecation. Lidocaine (SUCRA 87.9%) displayed the best performance regarding overall morbidity rates.

CONCLUSIONS

Due to the inconclusive results and several study limitations, further RCTs are required.

From Classic Whipple to Pylorus Preserving Pancreaticoduodenectomy and Ultimately to Pylorus Resecting - Stomach Preserving Pancreaticoduodenectomy: A Review

Pancreaticoduodenectomy is the procedure of choice for benign or malignant tumors of the periampullary region. The preservation of the pylorus has been established as the mostly utilized approach during pancreaticoduodenectomy among the majority of specialized, in the surgical treatment of pancreatic cancer, centers worldwide. The factors that influenced this predilection are the shorter operation times, the less intraoperative blood loss, the decreased technical difficulty, and the quite similar short- and long-term outcomes compared to the classic Whipple. However, there is a notable trend in the literature highlighting the increased incidence of delayed gastric emptying following pylorus preserving pancreaticoduodenectomy. Among other factors, pylorus dysfunction attributable to the surgical maneuvers has been implemented in the etiology of this complication. In an attempt to overcome this limitation of the pylorus preserving pancreaticoduodenectomy, pylorus resecting pancreaticoduodenectomy with the preservation of the stomach was proposed. In theory, pylorus resecting pancreaticoduodenectomy could maintain the advantages of organ sparing surgery, but at the same time guarantee a more seamless gastric emptying. Only three RCTs, to date, aimed to evaluate the approach with only one reporting results in favor of the pylorus resecting pancreaticoduodenectomy in regard to the incidence of delayed gastric emptying. Further well-designed prospective randomized studies are needed for an accurate assessment of the true role of each of these surgical alternatives on the treatment of pancreatic cancer.

Comparison of Selected Older and Younger Patients Regarding Optimal Surgical Treatment of Colorectal Cancer: A Prospective Cohort Study

BACKGROUND/AIM

Current evidence regarding the optimal management of older colorectal cancer patients, is conflicting. Functional deficits impact long-term survival prognosis, while frailty often results to optimal treatment postponement. Thus, the characteristics of this subgroup combined with treatment deviations further perplex optimal oncological management. The study aim was to compare survival and optimal surgery rates between older and younger colorectal cancer patients.

PATIENTS AND METHODS

This study was designed as a prospective cohort. All adult (³18 years) colorectal cancer patients operated, during the 2016-2020 period, in the Department of Surgery, University Hospital of Larissa, were considered as eligible. The primary endpoint of the study was the difference in terms of the overall survival between older (>70 year) and younger (<70 years) colorectal cancer patients.

RESULTS

Overall, 166 patients (60 younger and 106 older) were enrolled. Although the older subgroup displayed a higher rate (p=0.007) of ASA II and ASA III patients, mean CCI scores were comparable (p=0.384). The two subgroups were similar in terms of performed operations (p=0.140). No delay in surgery was noted. Most operations were performed using an open approach (open: 57.8% vs. laparoscopic: 42.2%), under an elective status (elective: 91% vs. emergency: 1.8%). There was no difference in terms of overall complications rate (p=0.859). Overall survival was similar (p=0.227) between the older and younger subgroups (25.68 vs. 28.48 months).

CONCLUSION

Older operated patients did not differ from their younger counterparts with regard to their overall survival. Due to several study limitations, further trials are required to confirm these findings.

Microvessel density in patients with gastrointestinal stromal tumors: A systematic review and meta-analysis

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are considered the most common mesenchymal tumors of the gastrointestinal tract. Microvessel density (MVD) constitutes a direct method of vascularity quantification and has been associated with survival rates in multiple malignancies.

AIM

To appraise the effect of MVD on the survival of patients with GIST.

METHODS

This study adhered to Systematic reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Electronic scholar databases and grey literature repositories were systematically screened. The Fixed Effects or Random Effects models were used according to the Cochran Q test.

RESULTS

In total, 6 eligible studies were identified. The pooled hazard ratio (HR) for disease free survival (DFS) was 8.52 (95%CI: 1.69-42.84, P = 0.009). The odds ratios of disease-free survival between high and low MVD groups at 12 and 60 mo did not reach statistical significance. Significant superiority of the low MVD group in terms of DFS was documented at 36 and 120 mo (OR: 8.46, P < 0.0001 and OR: 22.71, P = 0.0003, respectively) as well as at metastases rate (OR: 0.11, P = 0.0003).

CONCLUSION

MVD significantly correlates with the HR of DFS and overall survival rates at 36 and 120 mo. Further prospective studies of higher methodological quality are required.

BILE: A Literature Review Based Novel Clinical Classification and Treatment Algorithm of Iatrogenic Bile Duct Injuries

PURPOSES

The management of patients with iatrogenic bile duct injuries (IBDI) is a challenging field, often with dismal medico legal projections. Attempts to classify IBDI have been made repeatedly and the final results were either analytical and extensive but not useful in everyday clinical practice systems, or simple and user friendly but with limited clinical correspondence approaches. The purpose of the present review is to propose a novel, clinical classification system of IBDI by reviewing the relevant literature.

METHODS

A systematic literature review was conducted by performing bibliographic searches in the available electronic databases, including PubMed, Scopus, and the Cochrane Library.

RESULTS

Based on the literature results, we propose a five (5) stage (A, B, C, D and E) classification system for IBDI (BILE Classification). Each stage is correlated with the recommended and most appropriate treatment. Although the proposed classification scheme is clinically oriented, the anatomical correspondence of each IBDI stage has been incorporated as well, using the Strasberg classification.

CONCLUSIONS

BILE classification represents a novel, simple, and dynamic in nature classification system of IBDI. The proposed classification focuses on the clinical consequences of IBDI and provides an action map that can appropriately guide the treatment plan.

Isoperistaltic vs antiperistaltic anastomosis after right hemicolectomy: A comprehensive review

To optimize the efficiency of ileocolic anastomosis following right hemicolectomy, several variations of the surgical technique have been tested. These include performing the anastomosis intra- or extracorporeally or performing a stapled or hand-sewn anastomosis. Among the least studied is the configuration of the two stumps (i.e., isoperistaltic or antiperistaltic) in the case of a side-to-side anastomosis. The purpose of the present study is to compare the isoperistaltic and antiperistaltic side-to-side anastomotic configuration after right hemicolectomy by reviewing the relevant literature. High-quality literature is scarce, with only three studies directly comparing the two alternatives, and no study has revealed any significant differences in the incidence of anastomosis-related complications such as leakage, stenosis, or bleeding. However, there may be a trend towards an earlier recovery of intestinal function following antiperistaltic anastomosis. Finally, existing data do not identify a certain anastomotic configuration (i.e., isoperistaltic or antiperistaltic) as superior over the other. Thus, the most appropriate approach is to master both anastomotic techniques and select between the two configurations based on each individual case scenario.

Advanced trauma life support course for medical students. A new era?

Introduction

Trauma represents a major public health issue and is one of the leading causes of death and disability worldwide. A systematic approach toward dealing with trauma patients was facilitated through the ATLS program, which has become a milestone in trauma care. Our new ATLS course for medical students was set in motion in 2015. Our aim was to make medical students familiar with trauma patients interactively, through a program like ATLS, and here we present the results of this endeavor.

Methods

A two-day ATLS-Medical Student (MS) course was offered from November 2015 to July 2018, and analysis was performed retrospectively on the data gathered over a three-month period through online questionnaires. Before graduating, 261 newly qualified medical doctors were interviewed and evaluated as part of the ATLS course.

Results

After the course, the vast majority of medical students (251 MSs; 96.16%) felt more capable of managing severely injured patients and 58% of students felt that the medical services they offered were better due to the ATLS training. Regarding the educational fee for the course, 56.7% of the students reported that they felt the fee of 100 euros was fair.

Discussion

The interactive format of the course, which differs from more traditional methods of teaching, has been endorsed by medical students. Though they lack clinical experience, that does not prohibit them from acquiring more specialized or specific knowledge, enabling them to excel. Most of the students improved their skillset either in theoretical knowledge, practical skills, or even in the emotional component of the course, i.e., dealing with treating a severely injured patient. It was decided that the program would be re-evaluated and extended to all Greek Medical Schools.

Conclusion

The advantage of providing doctors with trauma training at the beginning of their careers is evident. For that reason, it was decided that the program would be re-evaluated and extended to all Greek Medical Schools.

Colorectal Cancer Liver Metastases: Is an R1 Hepatic Resection Accepted?

Metastatic colorectal cancer is associated with a rather dismal 5-year overall survival. The liver is the most commonly affected organ. Improved 5-year survival rates after successful hepatic resections for metastases confined to the liver have been reported. Certainly, a hepatectomy that results in an incomplete tumor resection, in terms of leaving macroscopic residual tumor in the future liver remnant, is not associated with survival benefits. However, the prognostic implications of a microscopically positive surgical margin or a clear margin of less than 1 mm (R1) on pathology are debatable. Although it has been a field of extensive research, the relevant literature often reports contradictory results. The purpose of the present study was to define, assess the risk factors for, and, ultimately, analyze the effect that an R1 hepatic resection for colorectal cancer liver metastases might have on local recurrence rates and long-term prognosis by reviewing the relevant literature. Achieving an R0 hepatic resection, optimally with more than 1 mm of clear margin, should always be the goal. However, in the era of the aggressive multimodality treatment of liver metastatic colorectal cancer, an R1 resection might be the cost of increasing the pool of patients finally eligible for resection. The majority of literature reports have highlighted the detrimental effect of R1 resections on local recurrence and overall survival. However, there are indeed studies that degraded the prognostic handicap as a consequence of an R1 resection in selected patients and highlighted the presence of RAS mutations, the response to chemotherapy, and, in general, factors that reflect the biology of the disease as important, if not the determinant, prognostic factors. In these patients, the aggressive disease biology seems to outperform the resection margin status as a prognostic factor, and the recorded differences between R1 and R0 resections are equalized. Properly and accurately defining this patient group is a future challenge in the field of the surgical treatment of colorectal cancer liver metastases.

Milligan-Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study

BACKGROUND

Several surgical techniques for the treatment of hemorrhoidal disease (HD) have been proposed. However, the selection of the most proper technique for each individual case scenario is still a matter of debate. The purpose of the present study was to compare the Milligan-Morgan (MM) hemorrhoidectomy and the hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) technique.

METHODS

A retrospective analysis of the prospectively collected database of patients submitted to HD surgery in our department was conducted. Patients were divided into two groups, the MM group and the HAL-RAR group. Primary end points were recurrence rates and patients' satisfaction rates. The Unpaired t test was used to compare numerical variables while the x² test for categorical variables.

RESULTS

A total of 124 patients were identified, submitted either to HAL-RAR or MM hemorrhoidectomy. Eight (8) patients were lost to follow up and were excluded from the analysis. Of the remaining 116 patients, 69 patients (54 males and 15 females-male / female ratio: 3.6) with a median age of 47 years old (range 18-69) were included in the HAL-RAR group while 47 patients (40 males and 7 females-male / female ratio: 5.7) with a median age of 52 years old (range 32-71) comprised the MM group. At a median follow up of 41 months (minimum 24 months-maximum 72 months), we recorded 20 recurrences (28.9%) in the HAL-RAR group and 9 recurrences in the MM group (19.1%) (p 0.229). The mean time from the procedure to the recurrence was 14.1 ± 9.74 months in the HAL-RAR group and 21 ± 13.34 months in the MM group. Patients with itching, pain or discomfort as the presenting symptoms of HD experienced statistically significantly lower recurrences (p 0.0354) and reported statistically significantly better satisfaction rates (6.72 ± 2.15 vs. 8.11 ± 1.99-p 0.0111) when submitted to MM. In the subgroup of patients with bleeding as the presenting symptom, patients satisfaction rates were significantly better (8.59 ± 1.88 vs. 6.45 ± 2.70-p 0.0013) in the HAL-RAR group.

CONCLUSIONS

In patients with pain, itching or discomfort as the presenting symptoms of HD, MM was associated with less recurrences and better patients satisfaction rates compared to HAL-RAR. In patients with bleeding as the main presenting symptom of HD, HAL-RAR was associated with better patients' satisfaction rates and similar recurrence rates compared to MM.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Microvessel density in differentiated thyroid carcinoma: A systematic review and meta-analysis

BACKGROUND

Microvessel density (MVD) has been proposed as a direct quantification method of tumor neovascularization. However, the current literature regarding the role of MVD in differentiated thyroid carcinoma (DTC) remains inconclusive.

AIM

To appraise the effect of tumoral MVD on the survival of patients with DTC.

METHODS

This meta-analysis was based on the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The electronic databases Medline, Web of Science, and Scopus were systematically screened. A fixed-effects or random-effects model was used, according to the Cochran Q test. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

A total of nine studies were included in the present study. Superiority of low MVD tumors in terms of 10-year disease free survival (OR: 0.21, 95%CI: 0.08–0.53) was recorded. Lowly vascularized thyroid cancers had a lower recurrence rate (OR: 13.66, 95%CI: 3.03–61.48). Moreover, relapsing tumors [weighed mean difference (WMD): 11.92, 95%CI: 6.32–17.52] or malignancies with regional lymph node involvement (WMD: 8.53, 95%CI: 0.04–17.02) presented with higher tumoral MVD values.

CONCLUSION

MVD significantly correlates with the survival outcomes of thyroid cancer patients. However, considering several study limitations, further prospective studies of higher methodological and quality level are required.

Extent of Surgical Resection for Gastric Cancer: The Safety Distance Between the Tumor and the Proximal Resection Margin

A potentially curative treatment scheme for gastric cancer is considered futile without a proper surgical resection. An oncological, surgical resection for gastric cancer prerequisites a proper resection of the stomach, and a D2 lymph node dissection followed by reconstruction of the gastrointestinal tract continuity. Recently, as the favorable impact of organ preserving surgery on functional outcomes has been increasingly appreciated; distal gastrectomy represents a valid alternative to total gastrectomy provided that the proper oncological principles are not violated. However, the appropriateness of distal gastrectomy as a valid type of resection becomes synonymous with achieving a negative proximal resection margin. The purpose of the present study was to assess the optimal distance between the tumor and the resection margin in a gastrectomy with curative intent, performed for gastric cancer, by reviewing the relevant literature. Having in mind, the well documented discrepancy between the gross and the pathologic boundaries of the tumor, pitfalls might be encountered. Current published guidelines have used a "safety distance" i.e., >4 or 5 cm between the proximal macroscopic tumor border and the proximal resection margin in order to guarantee a negative resection margin on pathology. An increased distance of safety is currently proposed in high-risk tumors such as tumors of the diffuse histological type.

An Unusual Cause of Biliary Peritonitis on the Background of Acute Pancreatitis: A Case Report

Introduction Acute pancreatitis can cause a wide variety of local complications, sometimes pretty unusual. In the present report, we present a rather unusual cause of biliary peritonitis on the background of acute pancreatitis.

Case Presentation A 41-year-old female patient with biliary acute pancreatitis and concomitant choledocholithiasis required an urgent laparotomy due to signs of sepsis and peritoneal irritation after a trial of conservative management. During laparotomy, the diagnosis of biliary peritonitis was established. Surprisingly, a residual gallstone obstructing the common bile duct at the level of the ampulla was causing bile to reflux, through the common channel, into the main pancreatic duct and subsequently into a partially ruptured acute pancreatic necrotic collection.

Conclusion Dealing with the unexpected is a constant challenge for the surgical team dealing with acute pancreatitis patients. Although deferring surgical intervention during the course of acute pancreatitis, as much as possible, is the ideal strategy, this is not always possible. Deciding the treatment strategy based on the patients' clinical condition represents the most appropriate approach.

The role of alginate dressings in wound healing and quality of life after pilonidal sinus resection: A randomised controlled trial

In this trial, we evaluated the role of alginate dressings in the secondary intention wound healing and quality of life (QoL) after pilonidal sinus resection. The study was designed as a prospective randomised controlled trial (RCT). In the experimental group, alginate dressings with silver and high‐G cellulose were introduced after elective pilonidal cyst excision, whereas in the control group, simple gauges were used. The primary end point was the difference in terms of the wound healing period. Blinding existed at the level of the investigator. Overall, 65 patients were included during the study period. Wound healing duration was comparable between the two groups (P = .381). No difference in postoperative pain scores or recovery outcomes was found. The experimental group was associated with reduced wound secretions at specific time end points. Similarly, no effect was identified, on overall Wound‐QoL or SF‐36 scores. Alginate dressings do not accelerate wound healing or improve QoL. Due to suboptimal sample size and several study limitations, further RCTs are required to confirm our findings.

Suprascapular glomus tumor: an unusual cause of chronic shoulder pain

Glomus tumors (GT) are rare mesenchymal tumors that develop in the subungual digital region. Extradigital GTs are very rare, with atypical clinical features. We report the case of a 63-year-old male with a five-year history of intermittent shoulder pain, where an excisional biopsy confirmed the diagnosis of a glomus tumor.

Prophylactic Administration of Alpha Blocker for the Prevention of Urinary Retention in Males Undergoing Inguinal Hernia Repair Under Spinal Anesthesia: Interim Analysis of a Randomized Controlled Trial

INTRODUCTION

This randomized controlled study aims to investigate the prophylactic effect of tamsulosin on the development of postoperative urinary retention (POUR) in men undergoing elective open inguinal hernia (IH) repair under spinal anesthesia. The study also focused on potentially predisposing factors for POUR.

METHODS

100 eligible patients were randomized into two groups. Patients in the experimental group were given two doses of tamsulosin 0.4 mg orally 24 hours and 6 hours before surgery. In the control group, two doses of placebo were administered, in the same manner as the study group. The following parameters were also recorded: the International Prostate Symptom Score (IPSS) questionnaire scores, the presence of scrotal hernia, operation duration, perioperative administration of IV opioids and/or atropine, postoperative pain, and preoperative anxiety.

RESULTS

Overall, the incidence of POUR was 37% (37/100) with no difference between the two groups. Among patients receiving tamsulosin, 39.2% (20/51) developed POUR, compared to 34.7% (17/49) in the control group. Preoperative patients' high anxiety visual analog scale (VAS) score (>51mm) (P=0.007) and the intraoperative use of atropine (P=0.02) were detected as risk factors for POUR.

CONCLUSION

This interim analysis of our prospective randomized trial showed no benefit from the prophylactic use of tamsulosin in preventing POUR after IH repair under spinal anesthesia. This type of anesthesia was also correlated with an overall high incidence of POUR. Preoperative anxiety and administration of atropine were identified as statistically significant factors for POUR. In patients with preoperative high anxiety, VAS score a different type of anesthesia may be used.

Iatrogenic Bile Duct Injuries: A Critical Appraisal of Classification Systems

Bile duct injuries represent the most dramatic complications after an open or laparoscopic cholecystectomy. The detrimental effects on patient quality of life and overall survival are the most obvious consequences of such injuries. An effective treatment strategy after accurate mapping of the injury type is the only method of averting these morbid consequences. Several classification systems have been proposed in an attempt to accurately describe and categorize bile duct injuries. The critical question is whether we truly need all these systems and whether each of these systems adds value to the existing knowledge base, or further obscures the field. Each classification system has several advantages to base its clinical utility on, but entails a reasonable number of limitations as well. Currently, a tailored approach adopting the classification system which provides the most appropriate guidance - either in terms of diagnosis or treatment decision making - appears to be the most justified option.

Reaching the Challenging Diagnosis of Complicated Liver Hydatid Disease: A Single Institution’s Experience from an Endemic Area

Background and Objectives: Hydatid disease (HD) remains a significant public health issue causing morbidity and mortality in many Mediterranean countries. Material and Methods: The present cohort study included 50 consecutive patients with liver hydatid disease who underwent surgery in a tertiary University Hospital. A total of 18 patients (36%) had a case of complicated HD, including simple communication of the cyst with the biliary tree (6 cases), rupture of the cyst into the biliary tree (6 cases), presence of a bronco-biliary fistula (2 cases), rupture of the cyst in the peritoneal cavity (2 cases), and rupture of the cyst and formation of a hepatic abscess (2 cases). Endoscopic retrograde cholangiopancreatography (ERCP) was pre-operatively performed on six patients. Results: The main clinical symptom presented was right upper quadrant pain in 16 patients (88%), which was associated with high fever (>39 °C) in 14 patients (78%). C-reactive protein (CRP) was the primary indicator of a complicated HD (p = 0.003); however, it was only elevated in 67% of cases. CRP was a more sensitive indicator of a rupture in the biliary tree cyst (p = 0.02). Computer tomography (CT) detected more cases (44%) of a complicated HD than ultrasonography (US) (25%); however, the difference was not statistically significant. Conclusions: For prevention and control of HD, a high suspicion of the disease leading to early referral to specialized centers, mainly in endemic areas, is required. Prior to surgical or percutaneous intervention, a combination of imaging and laboratory findings are essential in diagnosing a complicated case and avoiding unnecessary interventions.

The role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure: a systematic review

PURPOSE

This study was designed to summarize the current evidence regarding the role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure (CAF).

METHODS

The present systematic review of the literature was conducted on the basis of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint of our study was the CAF recurrence rate. Quality assessment was based on the RoB 2 tool and the Case Series Quality Checklist.

RESULTS

Overall, 5 studies and 102 patients were included. A considerably heterogeneity in the neuromodulation technique and setting was identified. The pooled recurrence rate was estimated at the level of 19% (16/84). Post-interventional pain and Wexner scores were considerably reduced. The 2-month healing rate was 72% (18/25), whereas 73.6% of patients were symptom-free at 6 months.

CONCLUSIONS

PTNS is an effective alternative for the non-operative management of CAF. Due to several limitations further larger and higher quality studies are required.

The Contribution of a Collagen Patch Coated With Fibrin Glue in Sealing Upper Gastrointestinal Defects: An Experimental Study

BACKGROUND/AIM

We aimed to evaluate the safety and efficacy of sealing primary upper gastrointestinal (GI) perforations with a collagen patch coated with fibrin glue (Tachosil^®).

MATERIALS AND METHODS

Thirty New Zealand rabbits were used in this study. An iatrogenic gastric perforation was created, and primary repair was performed on the control group. Tachosil^®, without suturing the deficit, was used in the intervention group.

RESULTS

Leakage was observed in 3 (20%) and 2 rabbits (13.3%) in the control and intervention group, respectively; however, the difference was not statistically significant (p=0.62). Moreover, adhesions formed in 10/15 and all rabbits in the intervention and control group, respectively (p=0.014); however, based on the Zuhlke adhesion's classification, there was no statistically significant difference between the two groups.

CONCLUSION

A collagen patch coated with fibrin glue is not a replacement but can be considered a safe option for the reinforcement of suturing, preventing leakages in the upper GI tract.

Quality of life deterioration and colorectal cancer staging in elderly patients. Which comes first?

PURPOSE

Never before the preoperative quality of life (QoL) score of colorectal cancer (CRC) patients was analyzed and linked directly to cancer staging according to pathology in specimens and, thereafter, in patients to estimate long-term prognosis. Our study attempted to give answers to these questions.

METHODS

This was a prospective study of 80 elderly patients who underwent major colorectal surgery for cancer in a single University's surgical department conducted between 01/2018 and 12/2018. All patients aged >65 years, diagnosed with a resectable CRC without metastatic disease undergoing an elective surgery were prospectively included. As exclusion criteria were considered age <65 years, an emergency operation, non-resectable tumor, stage IV CRC and American Society of Anesthesiologists (ASA) score IV. All patients were asked to answer a self-administered questionnaire of the validated Greek version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30.

RESULTS

Comparison of the mean score of EORTC QLQ-C30 showed stage I CRC was 87.62% (11.81%), 77.24% (12.91%) in stage II patients and 78.99% (15.25%) in stage III cancer. The mean difference between the three groups was statistically significant (p=0.002). Moreover, in post-hoc analysis, there was a statistically significant difference in the mean QLQ-C30 score between patients with stage I and stage II cancer (p=0.043) and between patients with stage I and stage III tumor (p=0.01), but this difference was not observed when comparing patients with stage II and III cancer (p=0.319).

CONCLUSION

Our study demonstrated a significant association between preoperative QoL and tumor staging as shown in the specimen's examination in elderly patients with CRC. More prospective studies are needed to elucidate how QoL and its fluctuations during the postoperative period can be correlated with long-term survival and disease progression in elderly CRC patients.

Intraoperative neuromonitoring in rectal cancer surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study is to evaluate the role of pelvic intraoperative neuromonitoring (pIONM) in rectal cancer surgery.

METHODS

A systematic review of the literature and a meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Overall, nine studies were identified. Quantitative analysis was performed only in three trials. Bilateral pIONM improved postoperative anorectal and urogenital functional outcomes. However, unilateral pIONM displayed a significant effect only on erectile function (p = 0.001).

CONCLUSIONS

Our findings suggest a positive effect of pIONM on postoperative functional outcomes and quality of life after rectal cancer surgery. Due to several limitations, further trials are required in order to elucidate the exact role of pIONM.

The Presence of Fungal and Parasitic Infections in Substances of Human Origin and Their Transmission via Transfusions and Transplantations: Protocol for Two Systematic Reviews

Background

The European Union Directives stipulate mandatory tests for the presence of any infections in donors and donations of substances of human origin (SoHO). In some circumstances, other pathogens, including fungi and parasites, may also pose a threat to the microbial safety of SoHO.

Objective

The aim of the two systematic reviews is to identify, collect, and evaluate scientific evidence for the presence of fungal and parasitic infections in donors and donations of SoHO, and their transmission via transfusion and transplantation.

Methods

An algorithmic search, one each for fungal and parasitic disease, was applied to 6 scientific databases (PubMed, EMBASE, Web of Science, Scopus, Cochrane Library [trials], and CINAHL). Additionally, manual and algorithmic searches were employed in 15 gray literature databases and 22 scientific organization websites. The criteria for eligibility included peer-reviewed publications and peer-reviewed abstract publications from conference proceedings examining the prevalence, incidence, odds ratios, risk ratios, and risk differences for the presence of fungi and parasites in donors and SoHO donations, and their transmission to recipients. Only studies that scrutinized the donors and donations of human blood, blood components, tissues, cells, and organs were considered eligible. Data extraction from eligible publications will be performed independently by two reviewers. Data synthesis will include a qualitative description of the studies lacking evidence suitable for a meta-analysis and a random or fixed-effect meta-analysis model for quantitative data synthesis.

Results

This is an ongoing study. The systematic reviews are funded by the European Centre for Disease Prevention and Control, and the results are expected to be presented by the end of 2021.

Conclusions

The systematic reviews will provide the basis for developing a risk assessment for fungal and parasitic disease transmission via SoHO.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020160090; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020160090 ; PROSPERO International Prospective Register of Systematic Reviews CRD42020160110; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020160110

International Registered Report Identifier (IRRID)

DERR1-10.2196/25674

Leiomyosarcoma of the spermatic cord presenting as an incarcerated inguinal hernia: a rare presentation of a rare condition

Leiomyosarcomas of the spermatic cord are rare malignancies with only sporadic cases (less than 150) reported in the literature. Preoperative diagnosis of a paratestical leiomyosarcoma is challenging. Clinicians do not typically consider inguinoscrotal lumps as underlying sarcomas due to their relatively low prevalence compared with hernias. As a result the diagnosis of a sarcoma of the paratesticular area is often hard to reach. Herein, we report a rare case of a leiomyosarcoma originating from the spermatic cord, masquerading as a strangulated inguinal hernia. Intraoperatively, a mass arising from the spermatic cord was found and excised. A supplementary orchiectomy with high ligation of the spermatic cord was also performed.

A rolling stone: vomiting of a gallstone without the presence of a biliary-enteric fistula

Gallstones may pass into the gastrointestinal tract spontaneously through the ampulla of Vater or through a biliary-enteric fistula. This report describes an extremely rare case of a patient vomiting a gallstone without the presence of a fistula between the gallbladder and the gastrointestinal tract. Furthermore, no imaging findings of gallstones disease appeared. The patient has been treated conservatively and all symptoms subsided. The patient remains asymptomatic 3 months after treatment and an elective laparoscopic cholecystectomy was arranged. Including this reported case, only three cases have been described in the literature worldwide. However, our case is the only one characterized by retrograde flow of the gallstones into the stomach without symptoms of bowel obstruction or other underlying pathologies.

Gastrointestinal Stromal Tumor (GIST) and Synchronous Intra-Abdominal Liposarcoma: A Report of Two Rare Cases and Literature Review

INTRODUCTION

Gastrointestinal stromal tumors (GISTs) quite frequently occur synchronously with other malignancies, with most cases being adenocarcinomas. GISTs and liposarcomas are both of mesenchymal origin, and their coexistence is extremely rare.

METHODS

We conducted a review of the current literature regarding the synchronous occurrence of GISTs and intra-abdominal liposarcomas. An electronic search of the literature was undertaken using MEDLINE (database provider PubMed). Furthermore, we present the first described case of an 86-year-old male with a GIST and synchronous liposarcoma, both located in the stomach, as well as a 66-year-old male with a gastric GIST and concurrent retroperitoneal liposarcoma.

RESULTS

A total of 5 cases of synchronous GIST and intra-abdominal liposarcoma have been reported in the literature to date, with the most recent cases included in the present study.

CONCLUSION

Further research is required to explain any possible correlation in the coexistence of these different neoplasms of the same origin. Meanwhile, R0 resection of both tumors remains the treatment of choice.

Gastrointestinal stromal tumors (GISTs) and synchronous intra-abdominal malignancies: case series of a single institution's experience

Background: Gastrointestinal stromal tumors (GISTs) quite often co-exist with other primary tumors, as seen in up to 33% of cases. In the literature such occurrences have primarily been described through case reports and rarely through case series, which is not sufficient to prove if there is an association between these two entities.

Materials and Methods: We conducted a retrospective study using medical and pathological records from sixty-nine patients who underwent surgical treatment for GIST in a single university surgical department between 2011 and 2019. Seven cases of GIST accompanying a synchronous primary tumor were identified and included in the study.

Results: Survival analysis comparing the overall survival of patients with single GIST versus patients with concurrent GIST and another primary tumor, has shown no statistically significant difference between these two groups (p = 0.19). However, when comparing the recurrence rate, patients with synchronous GISTs and another primary tumor have a statistically significant increased possibility for recurrence (p = 0.02). Statistical analysis comparing the size of GISTs between the two groups has shown that patients with single GIST have larger tumors than patients with synchronous tumors (p = 0.048).

Conclusions: The synchronous occurrence of GISTs and other intra-abdominal tumors is more common than previously considered, though it is not yet clear if there is a causal association for the concomitant occurrence. Further studies are required to elucidate the genetic and molecular mechanisms of carcinogenesis and progression associating GIST and synchronous tumors.

Hepatic brucelloma: a rare complication of a common zoonotic disease

Hepatic brucelloma (HB), a rare manifestation of brucellosis, refers to liver involvement in the form of abscess. A 35-year-old woman stockbreeder was admitted due to 1-month history of evening fever, sweating and weight loss, while she was on 3-week course of rifampicin/doxycycline for suspected brucellosis. On admission, she had hepatosplenomegaly and a systolic murmur, while cholestasis, increased inflammation markers and a strong-positive Wright-Coombs test were the main laboratory findings. As blood and bone marrow cultures were unrevealing, further investigation with CT imaging showed a central liver calcification surrounded by heterogeneous hypodense area being compatible with HB. Material from CT-guided drainage tested negative for Brucella spp. After failure to improve on a 10-week triple regiment, surgical excision was decided and Brucella spp were identified by PCR. Our case highlights challenges in establishing HB diagnosis, which should be considered on the right epidemiological context and when serological and radiological evidence favour its diagnosis.

Laparoscopic versus Robotic Peripheral Pancreatectomy: A Systematic Review and Meta-analysis

PURPOSE

The current systematic review and meta-analysis aimed to compare Laparoscopic Distal Pancreatectomy (LPD) with Robotic Distal Pancreatectomy (RDP) in terms of length of hospital stay (LOS), perioperative, postoperative and economic parameters.

METHODS

A systematic review of the literature was undertaken and data from studies fulfilling the predetermined inclusion criteria were extracted. Meta-analyses were performed to combine the results of various studies in the forms of Weighted Mean Difference (WMD), Odds Ratio (OR) and Risk Difference (RD), as appropriate.

RESULTS

A significantly lower LOS (WMD:0.75, 95%CI:0.17-1.33) and longer operative duration (WMD:-28.29, 95%CI:-49.98--6.6) for the RDP group was found. The rate of open conversion was higher in the LDP group (OR:2.38, 95%CI:1.75-3.22), while the rate of spleen preservation was lower (OR:0.49, 95%CI:0.31-0.79). No significant difference was noted in the intraoperative blood loss (WMD:34, 95%CI:-10.28-78.29), postoperative blood transfusion (OR:0.99, 95%CI:0.66-1.49) and overall morbidity analyses (OR:1.08, 95%CI:0.88-1.32). A significantly higher yield of lymph nodes was achieved in the RDP group (WMD:-2.09, 95%CI:-4.17--0.01), while no differences were found when positive resection margins (RD:0.02, 95%CI:-0.02-0.07) and specimen length (WMD:0.08, 95%CI:0.42-0.58) were considered. Finally, RDP was associated with significantly higher operative (WMD:-2733.42, 95%CI:-4189.77--1277.08) and total (WMD:-3799.68, 95%CI: -4438.39--3160.98) costs.

CONCLUSION

RDP seems to be a viable option for both benign and malignant pancreatic disorders, although there are concerns regarding economic parameters. Large randomized controlled trials will shed more light on the subject.

Asymptomatic Presacral Paraganglioma: Management of an Unpredictable Intraoperative Finding

Paragangliomas are rare neuroendocrine tumors originating from the embryological neural crest. We report a rare case of a patient with an asymptomatic presacral mass (incidentaloma) who experienced an unpredictable intraoperative hypertensive crisis after manipulation of the tumor. Presacral neoplasms pose a diagnostic and therapeutic challenge due to their obscure anatomical location and the difficulty in performing an R0 excision. Furthermore, the management of asymptomatic paragangliomas requires a high level of clinical suspicion and expertise due to potential life-threatening intraoperative complications.

Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study

PURPOSE

The purpose of the present study was a comparison of the systemic inflammatory response intensity through the estimation of C- reactive protein and albumin levels before and after open tension free inguinal hernia repair performed under different anesthetic alternatives.

PATIENTS AND METHODS

Totally, 125 inguinal hernia patients scheduled for unilateral primary open tension free inguinal repair unRomader local (50 patients), spinal (50 patients) and general anesthesia (25 patients) have been included in this prospective study.

RESULTS

The group of local anesthesia was associated with the higher postoperative serum levels of albumin compared to the group of general anesthesia (P 0.013). Local anesthesia was also associated with higher postoperative serum albumin levels compared to regional anesthesia but however the difference was not statistically significant (P 0.282). The group of local anesthesia was also associated with the lower postoperative levels of CRP compared to the regional (P 0.0094) and general anesthesia (P 0.0009) groups.

CONCLUSION

Local anesthesia proved superior to regional or general anesthesia for open tension free inguinal hernia repair in the given patient sample from the standpoint of the inflammatory and acute phase response.

Lymph node harvesting in gastric cancer: the crucial role of t stage

PURPOSE

Nodal status represents probably the most important determinant of gastric cancer prognosis. The purpose of the present study was to assess the impact of the primary tumor's T stage on lymph node harvesting after D1 resections for gastric cancer.

METHODS

Between January 2000 and January 2012, the medical files of patients who presented to our department with the diagnosis of gastric cancer and were submitted to a gastric resection with curative intent were retrospectively reviewed. A total of 134 gastric cancer patients (mean age 67.36±9.64 - 35 females and 99 males) were submitted to a gastrectomy in our department (total or subtotal) with curative intent. The distribution of the tumors within the stomach was as follows: upper third - 37 patients, middle third - 49 patients and lower third - 46 patients.

RESULTS

Lymph node retrieval was superior in advanced T stage patients (T3,T4a/T4b) compared to their low T stage (T1a/T1b,T2) counterparts (p=0.0008). Similar findings were encountered when the comparison was reduced to the subtotal gastrectomy subgroup (p=0.0047). However, although there was a distinct trend, statistical significance was not reached for the patient group submitted to total gastrectomy (p=0.1088).

CONCLUSION

The results of the present study seem to add another value i.e. tumor's T stage in the equation of lymph node retrieval in gastric cancer resection specimens. Lymph node retrieval in gastric cancer patients appeared to be dependent to the primary tumors T stage in the given patient sample.

Alveolar rhabdomyosarcoma with unusual cytogenetic findings: one more case and review of the literature

Alveolar rhabdomyosarcoma (ARMS), a histological subtype of rhabdomyosarcoma (RMS), is characterized by an unfavorable clinical outcome. In most ARMS cases, an indicative chromosomal alteration is identified. The recurrent translocation of FKHR with either PAX3 or PAX7 genes results in the encoding of chimeric transcription factors that boost tumorigenesis. Besides structural mutations, the copy number of these genes also contributes to the oncogenic activity. In our case, a 12-year-old female patient was diagnosed with a 4 cm pelvic mass. Histopathological examination indicated an alveolar type of RMS. Subsequent FISH analysis with a dual color break-apart probe identified positive signals of FKHR3 gene break, as well as the rare event of a synchronous aneuploidy and gene deletion of FKHR. Our findings lead to the conclusion that a systematic break-apart probe FKHR FISH analysis in ARMS, confirms the diagnosis and elucidates the full spectrum of genomic alterations of this malignancy.

Current role of lymphadenectomy in gastric cancer surgery

Gastric cancer is the sixth most common cancer worldwide with increased associated morbidity and mortality. Although a multimodality treatment approach is necessary, surgery is still considered as the standard of care. There is a longstanding intercontinental debate between Eastern and Western upper GI surgeons in regards to the proper type of lymphadenectomy that should accompany the resection of the primary tumor. While D2 gastrectomy was performed as the standard procedure in eastern countries, the increased morbidity and mortality attributed initially to the D2 lymphadenectomy by the Medical Research Council (MRC), the Dutch and the Italian randomized control trial without respective survival benefits had led Western surgeons towards a more limited lymphadenectomy. Only 15 years after the conclusion of its accrual, the Dutch trial reported a significant decrease in recurrence rate after D2 procedure and attributed the D2-associated morbidity and mortality to the spleno-pancreatectomy that was routinely performed in the D2 arm of the study. As the D2 lymphadenectomy can be safely and adequately performed while preserving the spleen and/or the pancreas, it has been suggested as the recommended procedure for patients with resectable gastric cancer.

Single incision laparoscopic fundoplication: A systematic review of the literature

BACKGROUND

Fundoplication, was first introduced as a surgical treatment method of gastroesophageal reflux disease. Consequently, several modifications of this method have been described, whereas laparoscopic fundoplication was recently introduced. Although single incision (SI) fundoplication was considered as an alternative to the conventional laparoscopic approach, several studies reported an increased operation duration, and high rates of multiport conversion and incisional hernia.

AIM

To provide a current overview of the technical variations and the postoperative outcomes of patients submitted to SI fundoplication.

METHODS

The present systematic review of the literature was designed and conducted on the basis of the PRISMA guidelines. A systematic screening of the electronic scholar databases (Medline, Scopus and Web of Science) was performed.

RESULTS

Literature search resulted in the identification of 19 studies. Overall, 266, 137 and 110 SI Nissen, Dor and Toupet fundoplications were reported, respectively. In the majority of the trials, standard laparoscopic instruments were used. The left liver lobe was displayed through the use of forceps, graspers, retractors, drains or even glue. Both intra-corporeal and extracorporeal suturing was described. Mean operative time was 136.3 min. Overall complication rate was 5.2% and the rate of incisional hernia was 0.9%. No mortality was reported.

CONCLUSION

Due to the methodological heterogeneity and the lack of high quality studies comparing multi to single access techniques and the several variations, we conclude that further well designed studies are necessary, in order to evaluate the role of SI fundoplication.

An enhanced outpatient modality for the treatment of hemorrhoidal disease: preliminary results

Surgical treatment of haemorrhoids is, primarily, performed on an outpatient basis, and as so, the reduction of the operative time and the hospitalization duration is necessary. In order to achieve these results, both the surgical procedure and the anaesthesia modality should be optimized. Therefore, in this randomized controlled trial, we proposed the hemorrhoidal arteries ligation under pudendal nerve block, as an enhanced outpatient modality, versus the standard of doppler guided hemorrhoidal arteries ligation under spinal anaesthesia. Preliminary results showed that the experimental group was characterized by a similar to the control arm, symptoms remission rate, a lower operation duration and an improved postoperative recovery.

Microvessel Density and Impact of Angiogenesis on Survival of Resected Pancreatic Cancer Patients: A Systematic Review and Meta-analysis

OBJECTIVES

Angiogenesis plays a major role in tumor progression and metastasis; however, its role in pancreatic cancer (PC) remains unclear. The aim of the study was to explore the cumulative evidence concerning the impact of microvessel density (MVD), an estimator of angiogenesis, on resected PC patients.

METHODS

A systematic review of literature and a meta-analysis of relevant reports were performed. Overall survival and disease-free survival were scrutinized.

RESULTS

One thousand five hundred patients were analyzed. Overall survival (hazard ratio, 2.0; 95% confidence interval, 1.57-2.54; P < 0.001) and disease-free survival (hazard ratio, 1.99; 95% confidence interval, 1.24-3.2; P = 0.004) were in favor of the low-MVD group. Use of CD105 antibody and of a computerized image analysis system was found to significantly reduce the heterogeneity. Disease staging, tumor location, and grading showed significant effect on survival.

CONCLUSIONS

High-MVD expression was strongly associated with poorer survival and recurrence among resected PC patients, demonstrating a negative prognostic value. Use of CD105 antibody and of a computerized image analysis system is recommended in future studies because they reduce heterogeneity of results. The potential role of MVD as a marker to select PC patients who would benefit from antiangiogenetic treatment should be further explored in clinical trials.

Techniques and Current Role of Sentinel Lymph Node (SLN) Concept in Gastric Cancer Surgery

Gastric cancer patients represent a rather divergent patient group and in certain carefully selected cases of early forms of gastric cancer the D2 gastrectomy could be considered a more radical procedure than the biological and oncological characteristics of the primary tumor on the gastric wall would require. As any unnecessary dissection increases morbidity without always respective survival benefits, an approach that could accurately predict and actually dictate the exact extent of lymph node dissection would be ideal. It is more than logical the assumption that the standard D2 lymphadenectomy could represent an overtreatment in distinct patients groups such as patients with early gastric cancer with favorable pathological characteristics and clinically negative nodes not suitable for endoscopic treatment because this early stage disease shows limited lymph node metastasis incidence and excellent overall survival. Considering that the D2 gastrectomy has a negative impact on the quality of life of gastric cancer patients due to the post-gastrectomy functional results, a concept of a more targeted lymph node dissection, when appropriate, is certainly appealing. It is yet to be proven whether sentinel lymph node navigation surgery can fulfill such expectations providing the appropriate balance between morbidity and oncological safety in selected gastric cancer patients.

Evidence of functional deficits at the single muscle fiber level in experimentally-induced renal insufficiency

Chronic kidney disease patients present with metabolic and functional muscle abnormalities, called uremic myopathy, whose mechanisms have not yet been fully elucidated. We investigated whether chronic renal insufficiency (CRI) affects skeletal muscle contractile properties at the cellular level. CRI was induced surgically in New Zealand rabbits (UREM), with sham-operation for controls (CON), and samples were collected at 3 months post-surgery, following euthanasia. All protocols had University Ethics approval following national and European guidelines. Sample treatments and evaluations were blinded. Maximal isometric force was assessed in 382 permeabilized psoas fibers (CON, n = 142, UREM, n = 240) initially at pH7, 10 °C ('standard' conditions), in subsets of fibers in acidic conditions (pH6.2, 10 °C) but also at near physiological temperature (pH7, 30 °C and pH6.2, 30 °C). CRI resulted in significant smaller average cross sectional areas (CSAs) by ∼11% for UREM muscle fibers (vs CON, P < 0.01). At standard conditions, UREM fibers produced lower absolute and specific forces (i.e. normalized force per fiber CSA) (vs CON, P < 0.01); force increased in 30 °C for both groups (P < 0.01), but the disparity between UREM and CON remained significant. Acidosis significantly reduced force (vs pH7, 10 °C P < 0.01), similarly in both groups (in UREM by -48% and in CON by -43%, P > 0.05). For the first time, we give evidence that CRI can induce significant impairments in single psoas muscle fibers force generation, only partly explained by fiber atrophy, thus affecting muscle mechanics at the cellular level.

Adhesion Prevention to Polypropylene Meshes Using Combined Icodextrin Four Percent and Dimetindene Maleate

BACKGROUND

The use of surgical meshes in ventral hernia repair has significantly reduced hernia recurrence rates. However, when placed intraperitoneally prosthetic materials can trigger the development of peritoneal adhesions. The present experimental study evaluated the combined icodextrin 4% and dimetindene maleate treatment in preventing peritoneal adhesion formation to polypropylene and titanium-coated polypropylene meshes.

MATERIALS AND METHODS

Sixty female white rabbits were divided into four groups. A 2 × 2 cm piece of mesh was fixed to intact peritoneum in all animals through a midline laparotomy. A lightweight polypropylene mesh was implanted in groups 1 and 2 and a titanium-coated polypropylene mesh in groups 3 and 4. Groups 2 and 4 were treated, intraoperatively, with intravenous dimetindene maleate (0.1 mg/kg) and intraperitoneal solution of icodextrin 4% (20 mL/kg) and for the next 6 d with dimetindene maleate intramuscularly. The observation period lasted 15 d. Adhesion scores, percentage of mesh affected surface, tissue hydroxyproline levels, and tissue histopathology were examined.

RESULTS

All animals in group 1 and 57% of animals in group 3 presented postoperative adhesions. The combination of antiadhesives significantly reduced the extent and severity of adhesions as well as the hydroxyproline levels in groups 2 and 4 compared with groups 1 and 3. On microscopic evaluation, animals in group 1 exhibited higher inflammation scores compared with group 2, whereas animals in groups 2 and 4 had better mesotheliazation compared with groups 1 and 3.

CONCLUSIONS

The combined administration of icodextrin 4% and dimetindene maleate reduces the extent and severity of adhesions and may be successfully used to prevent adhesion formation after mesh intraperitoneal placement.

Gastrointestinal stromal tumors and synchronous intra-abdominal malignancies: Review of the literature

PURPOSE

Gastrointestinal stromal tumors (GISTs) are the most frequent neoplasms of mesenchymal origin affecting the gastrointestinal tract. GISTs quite frequently co-exist with other primary tumors in up to 33% of the cases. Such occurrence has been mainly described in the literature in the form of case reports and rarely of case series which hasn't been sufficient to prove if there is any association between these two entities.

METHODS

We conducted a review of the current literature regarding the synchronous occurrence of GISTs and other intra-abdominal malignancies. An electronic search of the literature was undertaken using MEDLINE (database provider PubMed). A primary selection of relevant studies was based on the title and abstract, whereas a secondary selection was performed according to the full text of publications.

RESULTS

Ten retrospective case series were considered and overall 1108 GISTs patients were included. Synchronous intra-abdominal malignancies were found in 18% of all GISTs patients studied. The mean age was 70,5 years, affecting more the male gender (65%). The mean size of the concurrent GISTs were 18mm while the most common GIST-associated malignancy were gastric adenocarcinomas.

CONCLUSION

The synchronous occurrence of GISTs and other intra-abdominal primary tumors is more common that it has been considered and while it is not yet clear if there is a causal association for the concomitant occurrence of GIST with other malignancies a closer surveillance of GIST patients is needed due to their proved increased prevalence of a second primary tumor especially during the first year after diagnosis.

Haemangiopericytoma of the greater omentum: a rare tumour requiring long-term follow-up

Haemangiopericytomas (HPC) are highly vascularized tumours located in any part of the body where capillaries can be found. Since 2002, they have been re-classified under the umbrella 'extrapleural Solitary Fibrous Tumour (SFT)' and the term HPC is nowadays used to describe a growth pattern rather than a clinical entity. Their biological behaviour varies and they require a long-term follow-up since they may recur or metastasise several years after successful treatment. We present the case of a gentleman with HPC of the greater omentum initially appeared in 1998. HPC rarely develops in the greater omentum and only 20 cases have been described in the literature till today. Despite complete excision the mass re-appeared in 2011 and 2017, 13 and 19 years after initial treatment. Surgical management included en bloc excision of three lesions along with greater omentum. No further treatment was required.