Intraoperative Ultrasound: Bridging the Gap between Laparoscopy and Surgical Precision during 3D Laparoscopic Partial Nephrectomies

The use of 3D laparoscopic partial nephrectomy has emerged as a cornerstone in the surgical arsenal for addressing renal tumors, particularly in managing challenging cases characterized by deeply seated tumors embedded within the renal parenchyma. In these intricate scenarios, the utilization of intraoperative ultrasound (IOUS) acquires paramount importance, serving as an indispensable tool for guiding and meticulously monitoring the surgical process in real time. To further explore the efficacy of IOUS-guided techniques, we conducted a retrospective study comparing outcomes in patients who underwent partial nephrectomy with IOUS guidance (n = 60) between 2020 and 2022 with a cohort from 2018 to 2019 without IOUS guidance (n = 25). Our comprehensive analysis encompassed various post-operative parameters, including the duration until food resumption, analgesia requirements, and length of the hospital stay. While these parameters exhibited comparable outcomes between the two groups, notable distinctions emerged in the intraoperative metrics. The IOUS-guided cohort demonstrated significantly reduced blood loss, a shorter median operative duration, and diminished ischemia time (p = 0.001). These compelling findings underscore the undeniable benefits of IOUS-guided techniques in not only facilitating the attainment of negative surgical margins but also in enhancing procedural safety and precision, thereby contributing to improved patient outcomes in the management of renal tumors.

EM-transcriptomic signature predicts drug response in advanced stages of high-grade serous ovarian carcinoma based on ascites-derived primary cultures

Introduction: High-grade serous ovarian carcinoma (HGSOC) remains a medical challenge despite considerable improvements in the treatment. Unfortunately, over 75% of patients have already metastasized at the time of diagnosis. Advances in understanding the mechanisms underlying how ascites cause chemoresistance are urgently needed to derive novel therapeutic strategies. This study aimed to identify the molecular markers involved in drug sensitivity and highlight the use of ascites as a potential model to investigate HGSOC treatment options. Methods: After conducting an in silico analysis, eight epithelial-mesenchymal (EM)-associated genes related to chemoresistance were identified. To evaluate differences in EM-associated genes in HGSOC samples, we analyzed ascites-derived HGSOC primary cell culture (AS), tumor (T), and peritoneal nodule (NP) samples. Moreover, in vitro experiments were employed to measure tumor cell proliferation and cell migration in AS, following treatment with doxorubicin (DOX) and cisplatin (CIS) and expression of these markers. Results: Our results showed that AS exhibits a mesenchymal phenotype compared to tumor and peritoneal nodule samples. Moreover, DOX and CIS treatment leads to an invasive-intermediate epithelial-to-mesenchymal transition (EMT) state of the AS by different EM-associated marker expression. For instance, the treatment of AS showed that CDH1 and GATA6 decreased after CIS exposure and increased after DOX treatment. On the contrary, the expression of KRT18 has an opposite pattern. Conclusion: Taken together, our study reports a comprehensive investigation of the EM-associated genes after drug exposure of AS. Exploring ascites and their associated cellular and soluble components is promising for understanding the HGSOC progression and treatment response at a personalized level.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Prognostic Factors in Intrahepatic Cholangiocarcinoma - A Systematic Review

Introduction: intrahepatic cholangiocarcinoma (ICCA) are rare, aggressive cancers that develop in second order or smaller bile ducts. The aim of this review is to systematically review the most important prognostic factors affecting the long-term outcomes of these patients. Material and Methods: articles conducted on this issue, written in English, published between from January 2000 to December 2023 in Cochrane Library, PubMed, Embase, MedLine, Web of Science, Elsevier, Google Scholar were systematically researched and reviewed. Results: ICCA are usually late diagnosed cancers because of the asymptomatic character, and curative procedures are often not feasible, only 20 to 30% of patients being fit for surgery. With the prognostic of this aggressive malignancy being baleful, the most important risk factors but also prognosis factors seem to be represented by socioeconomic factors, morphological presentation, dimensions, number and extension of the tumor as well as resection margins. Conclusions: once these factors are widely recognized and identified in each case, the clinician will be able to find the best treatment for these patients in order to improve the long-term outcomes.

Is Marginal Donor an Efficient Solution for Expanding the Donor Pool for Liver Transplant?

Once the techniques of hepatobiliopancreatic surgery improved, liver transplantation widely extended in different hospitals; therefore, the need of grafts and automatically of liver donors reported a significant increase in the last decade. In this respect, attention was focused on increasing the liver donor pool. The aim of this review is to study the benefits of using marginal grafts in liver transplantation. With the advent of multiple methods of liver preservation, the use of grafts previously considered unsuitable has become possible. Thus, extended allocation criteria have emerged. However, the allocation of these grafts must be carefully considered and analyzed in the context of both recipient and donor factors.

Recurrence and Carcinogenetic Rates of Colorectal Polyps

AIM

to determin the recurrence rate of benign recto-colonic polyps in a 5-year interval, and compare the development rate of intrapolypoid carcinomatous lesions in polypectomized versus nonpolypectomized subjects.

MATERIAL AND METHOD

a group of 77 patients diagnosed with recto-colonic polypoid lesions during the period 2014-2019 underwent colonoscopy at the time of study initiation and then annually during a five-year interval. Results: The recurrence rate of polyps increased annually from 5 to 12.5%; the highest rate was noted in the last two years. The five-year cumulative risk of neoplastic lesions was 73% in patients without polypectomy and 20% among those with endoscopic resection (p 0.05). Comparing the recurrence rate of benign lesions (60%) in patients without neoplastic findings with the recurrence rate of adenomas in patients with benign lesions (40%), a higher risk of recurrence was found in the first category, and seemed to be influenced by the personal history of pre-existing adenomatous lesions.

CONCLUSION

an increased risk of colorectal polyps recurrence was reported during five year follow up; moreover, during the first three years an increased risk of malignant transformation was observed among cases in which endoscopic resection was not feasible when compared to those in which complete excision was feasible.

Prognostic Significance of Preoperative Inflammation Markers on the Long-Term Outcomes in Peritoneal Carcinomatosis from Ovarian Cancer

Ovarian cancer remains one of the most lethal gynaecological malignancies affecting women worldwide; therefore, attention has been focused on identifying new prognostic factors which might help the clinician to select cases who could benefit most from surgery versus cases in which neoadjuvant systemic therapy followed by interval debulking surgery should be performed. The aim of the current paper is to identify whether preoperative inflammation could serve as a prognostic factor for advanced-stage ovarian cancer. Material and methods: The data of 57 patients who underwent to surgery for advanced-stage ovarian cancer between 2014 and 2020 at the Cantacuzino Clinical Hospital were retrospectively reviewed. The receiver operating characteristic curve was used to determine the optimal cut-off value of different inflammatory markers for the overall survival analysis. The analysed parameters were the preoperative level of CA125, monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and systemic inflammation index (SII). Results: Baseline CA125 > 780 µ/mL, NLR ≥ 2.7, MLR > 0.25, PLR > 200 and a systemic immune inflammation index (SII, defined as platelet × neutrophil-lymphocyte ratio) ≥ 84,1000 were associated with significantly worse disease-free and overall survival in a univariate analysis. In a multivariate analysis, MLR and SII were significantly associated with higher values of overall survival (p < 0.0001 and p = 0.0124); meanwhile, preoperative values of CA125, PLR and MLR were not associated with the overall survival values (p = 0.5612, p = 0.6137 and p = 0.1982, respectively). In conclusion, patients presenting higher levels of MLR and SII preoperatively are expected to have a poorer outcome even if complete debulking surgery is performed and should be instead considered candidates for neoadjuvant systemic therapy followed by interval surgery.

Intrahepatic Cholangiocarcinoma - Where Do We Stand Today? Literature Review

Intrahepatic cholangiocarcinomas represent rare and aggressive malignancies developing from the second order bile ducts to the smaller biliary branches. The aim of this narrative review is to discuss about the main diagnostic and therapeutic challenges in order to help medical and surgical oncologists to gain familiarity in regard to this subject. Articles discussing about epidemiology, histology, diagnostic, perioperative management and surgery which were published from January 2000 to September 2023 included in Cochrane Library, PubMed, Embase, MedLine, Web of Science, Elsevier, Google Scholar databases were reviewed. Articles reviewed in the current paper came to demonstrate that the main problem in such cases is related to the fact that most cases remain asymptomatic for a long period of time and therefore are diagnosed in advanced stages of the disease when curative procedures are feasible after performing extended visceral sacrifice or even worse, are no longer possible; however, the most efficient therapeutic strategy in order to improve the long term outcomes remains radical surgery. In this respect, attention was focused on improving the accuracy of the diagnostic tools and on identifying non-surgical therapeutic options which might increase the chances of achieving complete resection. Intrahepatic cholangiocarcinoma represent rare aggressive tumors with poor outcomes especially if radical surgery is not feasible.

Hyponatremia as a Prognostic Factor in Advanced Stage Ovarian Cancer Patients

Background: hyponatremia represents one of the most commonly encountered conditions in hospitalized patients, multiple mechanisms being cited so far, neoplastic syndromes being an important cause. The aim of the current paper is to analyse the presence and influence of the short- and long-term outcomes of hyponatremia on ovarian cancer patients submitted to surgery for advanced stage ovarian cancer. Method: 57 patients diagnosed with advanced stage ovarian cancer were submitted to surgery between 2014-2020. The patients were further classified according to the preoperative value of sodium into two groups. Results: there were 21 cases with preoperative normal values of sodium and respectively 36 cases with hyponatremia. Patients with preoperative hyponatremia associated a significantly higher rate of early postoperative complications and a significantly poorer long-term outcome. Therefore, cases with hyponatremia reported a mean disease-free survival of 10.8 months and respectively a mean overall survival of 18.5 months while cases with normal natrium levels reported a mean disease-free survival of 31.4 months and respectively a mean overall survival of 49.7 months (p=0.0001 and p 0.001). Conclusions: patients with lower preoperative values of sodium have a higher risk of developing postoperative complications and a significantly poorer outcome when compared to cases presenting normal levels of sodium preoperatively.

Colorectal Cancer: From Risk Factors to Oncogenesis

Colorectal cancer is the second leading cause of cancer-related mortality worldwide. Numerous pathophysiological mechanisms, such as abnormal cell proliferation, cell differentiation, resistance to apoptosis, invasion of structures adjacent to colorectal tumor cells, and distant metastasis, are involved in colorectal carcinogenesis. These processes are initiated by the complex interaction of a number of genetic and environmental factors, including sedentary lifestyle, obesity, alcohol consumption, smoking, or gut microbiota. Despite the significant progress achieved in the diagnostic and therapeutic management of patients with colorectal cancer, there has been recently a noteworthy increase in the incidence of colorectal cancer in individuals below the age of 50 years. Early-onset colorectal cancer has a different frequency of oncogenic mutations, a higher prevalence of mucinous histology, a distinct deoxyribonucleic acid (DNA) methylation profile, a more distal location, and lower survival rates. A significant improvement in the prognosis of these patients can be achieved through the detection and removal of modifiable risk factors, along with the implementation of personalized screening strategies for individuals at high risk for this malignancy. Furthermore, gaining comprehension of the pathophysiological mechanisms by which these risk factors contribute to the process of oncogenesis may facilitate the discovery of novel therapeutic targets.

COVID-19-related Floating Thrombus in the Ascending Aorta - A Case Report

BACKGROUND/AIM

Multiple aortic mural thrombi at the level of the ascending aorta represent a rare condition, only isolated cases have been reported so far. The aim of the current article was to report the case of a 61-year-old patient diagnosed with this pathology.

CASE REPORT

A 61-year-old patient with history of COVID infection six months previously was initially diagnosed with acute upper right limb ischemia and submitted to Fogarty desobstruction. Furthermore, the patient was diagnosed with a free-floating mass in the ascending aorta, for which he was submitted to aortotomy and floating thrombi, measuring 5.6×1.5 cm and 3×1.5 cm, were completely removed. The postoperative outcomes were favorable; at the three month follow up the patient proved to have a perfect circulated aortic lumen and supra-aortic vessels.

CONCLUSION

immediate aortic desobstruction followed by reconstruction might be a lifesaving maneuver in ascending aortic thrombosis.

Gossypiboma, the Hidden Enemy of an Emergency Cesarean Hysterectomy-Case Report and Review of the Literature

Gossypiboma or textiloma is a rare medical situation that can complicate the favorable evolution of a surgical case, with repercussions for the patient's prognosis. The diagnosis can be difficult due to various clinical symptoms, the time elapsed since the surgical intervention, and the imaging often not being precise in detecting textilomas. Due to the medicolegal implications, the reporting of this event is inconsistent. We present a rare case of a 28-year-old woman who presented with vague pain in the left iliac fossa 11 months after an emergency cesarean hysterectomy was performed. The preoperative imaging examination identified the presence of a subhepatic mass with dimensions of 10 × 8 cm2 and another formation in the right iliac fossa with dimensions of 11 × 9 cm2. Exploratory laparotomy found the presence of a large subhepatic gossypiboma, intimately adherent to the hepatic angle of the colon and omentum and a second one adherent to the sigmoid colon, small intestine, and parietal peritoneum. The particularity of this case is given by the simultaneous presence of two textilomas with inconclusive evolution, which can make the differential diagnosis difficult to achieve. For a better assessment of the risk of occurrence of this pathology and the identification of a correct prevention strategy, we performed an extensive search and a review of all the articles published in the PubMed database, identifying 57 articles. In conclusion, emergency surgery increases the risk of this complication, and, as a result, prevention can be achieved by following existing protocols in the operating room.

Platelet to Lymphocyte Ratio as a Predictive Tool for the Perioperative and Postoperative Outcomes in Advanced Stage Ovarian Cancer

Background: platelet to lymphocyte ratio remains a significant prognostic factor in different malignancies. The aim of the current paper is to study the correlation between the preoperative values of platelet to lymphocyte ratio (PLR) and the postoperative outcomes in ovarian cancer patients. Method: we conducted a retrospective study on 57 patients submitted to cytoreductive surgery between 2014-2020. We determined the optimal cut off value of PLR for predicting survival outcomes by using the Receiver Operating Characteristic curve a value of 350 being obtained. The patients were further classified in two groups according to the PLR value. Results: there were 37 patients with PLR 350 and respectively 20 patients with PLR 350. Patients in the second group were significantly older and presented significantly higher rates of perioperative complications, a significantly higher level of circulating platelets, of CA125 and respectively a significantly lower level of circulating lymphocytes and of preoperative hemoglobin level. Meanwhile, patients in the second group reported a significantly poorer disease free and overall survival. Conclusions: ovarian cancer patients with higher preoperative levels of PLR trend to have a poorer early and long-term postoperative outcome. Therefore, in such cases more aggressive systemic therapies might be needed.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment

The last decades have brought impressive advances in liver transplantation. As a result, there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, immunosuppressive therapies and radiologically guided treatments have led to an improvement in the prognosis of these patients. However, the risk of complications remains significant, and the management of liver transplant patients requires multidisciplinary teams. The most frequent and severe complications are biliary and vascular complications. Compared to vascular complications, biliary complications have higher incidence rates but a better prognosis. The early diagnosis and selection of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. The development of minimally invasive techniques prevents surgical reinterventions with their associated risks. Liver retransplantation remains the last therapeutic solution for graft dysfunction, one of the main problems, in this case, being the low number of donors.

Uterovesical fistulas as obstetric complications: Diagnosis, management and prognosis (Review)

Urogenital fistulas are abnormal communications between the female genital and urinary tract; while such fistulas, which are the most commonly encountered, are located between the vagina and urinary bladder and are caused by the local extension of a tumoral process. Another frequently encountered cause is represented by the obstetric one, leading to the development of uterovesical fistulas. However, many questions regarding the diagnosis and management of uterovesical fistulas remain unanswered. Therefore, the aim of this article was to review the existent data so far, with special attention being focused on the pathogenic mechanisms leading to this complication, on the modalities of diagnosis, and on the possible therapeutic strategies. Therefore, according to the time of diagnosis, uterovesical fistulas can be classified as early fistulas, diagnosed in the first months postoperatively and late fistulas, diagnosed within several years from the initial surgical procedure. For early fistulas, a conservative therapeutic strategy can be taken in consideration, while in cases diagnosed after a longer period of time, a surgical approach should be taken into consideration. Meanwhile, although a surgical approach can cure most of the cases, attention should be given towards preventive strategies such as provision of quality obstetric care with improvements of surgical skills.

Sarcopenia and ovarian cancer

Defined as the loss of the muscular mass, sarcopenia is a common finding in neoplastic patients, multiple mechanisms such as nutritional deficiency, proinflammatory tumoral related status or physical inactivity being cited. However, the loss of the muscular mass in such cases is associated with significant impact in regard to the type of treatment in such cases; in consequence, as expected the disease-free survival and overall survival might be influenced. The aim of the current paper is to discuss about the most important mechanisms leading to sarcopenia in ovarian cancer patients as well as the impact on the long-term outcomes.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Acquired benign tracheo‑oesophageal fistula secondary to oesophageal stenting for post lye ingestion stenosis: A case report

Acquired benign trachea-oesophageal fistula is a rare benign pathological entity with varying aetiologies that most often occurs post-intubation. This case report presents the case of a female patient, 31 years old, admitted to the emergency room with sepsis syndrome following bilateral aspiration pneumonia caused by a large trachea-oesophageal fistula. The fistula was the result of intra-tracheal migration of an oesophageal stent placed for post lye ingestion stenosis. Esophageal diversion and partial resection with oesophageal patch to repair the tracheal defect, under general anaesthesia with ventilation using rigid bronchoscopy and high frequency jet ventilation (HFJV), followed at a later date by esophageal replacement with colic graft were the procedures performed with a view to curing the patient. In conclusion, complex cases always require a tailored approach. It is important to note that HFJV may be applied for a longer period of time and the oesophagus can be used as patch for the posterior tracheal wall in selected cases. Staged surgery is also an option when the patients' poor health status does not permit major surgery.

Is pelvic exenteration in the presence of liver metastases justified?

The presence of liver metastases in association with pelvic recurrence has been considered for a long period of time as the sign of systemic neoplastic impregnation and therefore, these patients were considered as candidates for palliative chemotherapy. However, in the last decades attention was focused on identifying patients who could benefit from surgery in such cases. The aim of the current paper is to discuss about the indications and contraindications of associating extended pelvic resections and liver resections in order to maximize the benefits in terms of survival for patients with advanced stage or recurrent rectal cancer.

Vascular reconstructions using synthetic prostheses after extended pancreatic resections for locally advanced pancreatic cancer

Pancreatic cancer represents one of the most aggressive malignancies affecting patients worldwide which are usually associated with high rates of vascular invasion. In order to achieve radical resection, in such cases extended vascular resections have been proposed with promising results. Once resected, the vascular structures should be reconstructed by direct re-anastomosis if a short length is resected or by placing a graft. The aim of the current paper is to review the most important aspects regarding the vascular reconstructions by using synthetic prostheses.

The influence of lymphocyte to monocyte ratio on the postoperative outcome of patients diagnosed with advanced stage ovarian cancer

Introduction: the lymphocyte to monocyte ratio has been widely investigated in patients with different malignancies and proved to have prognostic value for both early and long-term evolution. Aim: Current paper investigates the influence of this parameter on the perioperative course of patients submitted to surgery for advanced stage ovarian cancer. Material and methods: between 2016-2018 there were 34 patients diagnosed with advanced stage ovarian cancer who were submitted to surgery with curative intent and in whom this parameter was evaluated. Results: a low rate of this parameter seemed to be significantly associated with a more advanced stage at diagnostic (p=0,002), with higher risk of the presence of lymph node metastases (p=0,003), with larger residual tumor (p=0,002). Meanwhile, patients with a lower lymphocyte to monocyte ratio usually had a higher level of CA 125, but this fact did not have statistical significance (p=0,87). Conclusions: patients with a lower lymphocyte to monocyte rate are expected to present more aggressive ovarian tumors and therefore a personalized therapeutic strategy might be needed.

Pubic bone resection as part of extended pelvic resections for locally advanced or relapsed pelvic malignancies

For a long period of time, the presence of pubic bone invasion has been considered as the sign of an unresectable lesion and therefore, the patient was further submitted to radiotherapy alone or in association with chemotherapy. Even in these conditions, during irradiation a pubo-vesical leak might develop and therefore, aggressive surgery including resection of the pubic bone might be needed. The aim of the current paper is to discuss about the indications of extended pelvic resections including pubic bone resections.

The correlation between the preoperative number of lymphocytes and monocytes and the postoperative outcomes of gastric cancer patients

Gastric cancer remains an important health problem worldwide, being associated with poor rates of survival even if radical resection is achieved. Therefore attention was focused on identifying different prognostic markers which might provide a better selection of the patients and a more personalized therapeutic approach. One of the most widely investigated parameters in the last decade is represented by the preoperative hemogram, significant influence being given to the preoperative number of monocytes and lymphocytes. The aim of the current paper is to discuss about the correlation ship which might be established between these parameters and the overall prognostic in gastric cancer patients.

The impact of the presence of the aberrant right hepatic artery in pancreatoduodenectomy for pancreatic head cancer

An aberrant right hepatic artery usually originates from the superior mesenteric artery, it has an ascendant trajectory through the head of the pancreas or behind it and represents a technical challenge in pancreatic head tumors due to the fact that it needs to be carefully dissected and preserved in order to maintain an adequate blood supply for the right hemi-liver. Meanwhile, this dissection should be performed in an oncological manner in order to obtain the premises of a radical resection with negative margins. The aim of the current paper is to discuss about the influence of this anatomical arterial particularity and the possibility of obtaining a resection with curative intent in pancreatic head adenocarcinoma.

Is liver resection justified for ovarian sarcoma liver metastases?

Ovarian sarcoma represents an aggressive subtype of ovarian malignancies which is characterized by poor outcomes. However, it seems that applying the principles of radical surgery might increase the long-term outcomes especially if no residual disease is achievable. Even though, most cases will experience a recurrent disease. As expected a significant number of cases will present disseminated lesions and will be therefore submitted to palliative treatment. The aim of the current paper is to present two such cases, the first one being diagnosed with a metachronous metastatic liver lesion while the second one being diagnosed with synchronous liver metastases.

The impact of preoperative platelet count in vulvar cancer patients

The preoperative platelet count proved to be a significant prognostic factor for short term and long-term prognostic in gynecological cancers such as endometrial or ovarian cancer. However, more recently it has been supposed that this parameter could also influence the outcomes of vulvar cancer patients. The aim of the current paper is to study the influence of the preoperative platelet count on the perioperative outcomes in vulvar cancer patients submitted to surgery between June 2021 and May 2022 in “Cantacuzino” Clinical Hospital.

The effects of Curcuma longa on metabolic syndrome related to obesity

Once obesity has become a global health problem, the incidence of obesity related diseases also reported an increasing trend, one of the most serious such issues being represented of diabetes mellitus. Therefore it is widely known the fact that obese, diabetic patients are predisposed to the apparition of a significant number of complications, associated with significant economic impacts. The aim om the current paper is to discuss about the possible benefits of Curcuma longa administration in such patients.

Does the number of circulating platelets influence the postoperative evolution of endometrial cancer?

Endometrial cancer is a frequently encountered gynecologic malignancy with increasing incidence; in order to maximize the chances to achieve a long-term survival rate, attention was focused on better identifying the patients at risk to develop more aggressive forms of the disease. The aim of the current paper is to investigate the influence of the number of circulating platelets alone or in association with other biomarkers on the perioperative outcomes of endometrial cancer patients.

The influence of platelet counts on the postoperative outcome of patients with advanced stage ovarian cancer

Introduction: Ovarian cancer represents one of the most aggressive gynecological malignancies which is associated with poor rates of survival especially if surgery with curative intent is not feasible. Aim: The current paper analyzes the correlation ship between the preoperative number of platelets and the perioperative outcomes of patients submitted to primary cytoreduction for ovarian cancer. Material and methods: between 2016-2018, 34 patients with advanced stage ovarian cancer were submitted to surgery; among these patients there were 21 cases with a preoperative platelet number lower than 450.000/microliter and 13 cases with higher than 450.000/microliter values. Results: higher serum levels of platelets were significantly associated with more advanced stages at the time of the diagnostic, higher tumoral burden (defined as a peritoneal cancer index higher than 20) and lower rates of complete debulking surgery. Meanwhile, these patients reported a significantly higher rate of postoperative complications. Conclusions: patients presenting a platelet number higher than 450.000/microliter are associated with worse perioperative outcomes after debulking surgery for advanced stage ovarian cancer.

Do products containing Calendula officinalis have a positive role in treating uterine cervix disorders?

Once screening tests and national programs for early detection of cervical cancer have been widely developed, a significant number of patients are diagnosed with preneoplastic lesions at this level; therefore, in such cases, a conservative treatment is feasible, increasing therefore the possibility of fertility preservation and conceiving. Meanwhile, after performing an invasive maneuver at this level attention should be focused on obtaining an adequate healing process at this level. The aim of the current paper is to conduct a literature review regarding the benefits of Calendula officinalis in maximizing the healing process after local invasive procedures at the level of the uterine cervix as well as on human papilloma virus infection prevention.

The anti-inflammatory, anti-infectious and anticancerous effects of Thymus vulgaris

Thymus vulgaris represents a medical herb from the southern region of Europe with anti-infectious, anti-inflammatory and immunomodulatory effects. More recently an antiviral and anti-cancerous activity has been demonstrated. Therefore multiple products have been imagined in order to put in value all these properties. The aim of this paper is to discuss the mechanisms of action, properties and means of administration of this product.

Bismuth subgallate and cervico-vaginal disorders

Bismuth subgallate represents a salt which has been widely used in the last decades in gastroenterology and otorhinolaryngology for hemostatic, astringent, anti-inflammatory and antibacterial purposes. The product seems to be efficient also in terms of inducing a more rapid wound healing stimulating all the key points of this process. Once the benefits of bismuth subgallate administration have been widely demonstrated in topical administration at the level of the postoperative wounds in oto-rhinolaryngology, it was further investigated in treating other mucosal lesions such as cervico-vaginal ones especially due to the fact that the two types of mucosa present similar features. Therefore, this bismuth salt was successfully associated in the composition of vaginal topical products with promising results. The aim of the current paper is to discuss the properties, mechanisms of action and benefits of adding bismuth subgallate in topic vaginal products.

The correlation between the embryological development of the pancreas and the local extent of the pancreatic tumors

Progression reported so far in the field of hepato-bilio-pancreatic surgery leaded to a significant increase of the number of cases diagnosed with borderline or locally advanced pancreatic tumors which are successfully submitted to radical surgery. However, it has been observed that local invasion of the vascular structures respects the embryological and anatomical development of the pancreatic parenchyma. The aim of the current paper is to analyze the correlation ship between the embryological development of the pancreas, location, extent and possible therapeutic strategies in borderline or locally advanced pancreatic head cancer.

Does the preoperative thrombocytosis influence the postoperative outcomes in cervical cancer?

Cervical cancer still remains a significant health problem in our country, an increased number of patients being diagnosed with this pathology. In order to achieve the best management in such cases, a combination of surgery and radiation therapy has been widely proposed. However, different results have been achieved; therefore attention was focused on identifying patients who could benefit most from neoadjuvant radiation therapy and multiple prognostic factors have been studied. The aim of the current paper is to study the influence of the preoperative platelet count on the postoperative outcomes of cervical cancer patients; the study was conducted on a study group of 82 patients submitted to surgery between June 2021 and May 2022 in “Cantacuzino” Clinical Hospital and the patients were classified in two groups according to the number of circulating platelets, a cut off value of 450.000 platelets/microliter being used.

Glycemic Control in Patients Undergoing Treatment With Paritaprevir/Ombitasvir/Ritonavir and Dasabuvir for Chronic Hepatitis C Infection

BACKGROUND/AIM

Patients with hepatitis C virus (HCV)-associated cirrhosis are more prone to developing type 2 diabetes mellitus than patients with any other etiology of cirrhosis. The main objective of this study was to evaluate the impact of all oral antiviral treatment with ritonavir-boosted paritaprevir/ombitasvir and dasabuvir (OBV/PTV/r + DSV) in patients with chronic genotype 1b HCV infection.

PATIENTS AND METHODS

We retrospectively evaluated 806 patients who underwent antiviral therapy between December 2015 and July 2019. The laboratory data analyzed were liver function tests, kidney function tests, HCV viremia, fasting glucose levels, and glycosylated hemoglobin.

RESULTS

Patients with impaired glucose metabolism were predominantly male and of older age compared to patients with normal glucose tolerance, and also had higher levels of transaminases. Proteinuria and higher creatinine levels were found in patients with impaired glucose metabolism. Overall, we found a 98.01% rate of sustained virologic response (SVR), with a non-significant difference between patients with normal and abnormal glucose metabolism. A statistically significant difference in SVR rates in patients with low degrees of fibrosis (F0-F2) versus those with advanced degrees of fibrosis (F3-F4) was found in both groups. Antiviral treatment resulted in significant decreases in fasting glucose levels and glycosylated hemoglobin levels in all patients with impaired glucose metabolism at SVR.

CONCLUSION

Patients with pre-diabetes, as well as diabetic patients, achieved a better glycemic control after SVR obtained by ritonavir-boosted paritaprevir/ombitasvir and dasabuvir.

Resection of a Large Celiac Trunk Aneurysm Followed by Cadaveric Graft Reconstruction - A Case Report

BACKGROUND/AIM

Celiac artery aneurysms represent rare eventualities which remain symptomatic for a long period of time; however, once diagnosed, it should be carefully monitored due to the high risk of developing life-threatening complications. When it comes to the types of therapeutic strategies, both endovascular and surgical therapies can be taken in consideration.

CASE REPORT

Depending on the patency of the collateral network, simple ligation or graft placement should be performed. The aim of the current paper is to report the case of a patient diagnosed with a celiac trunk aneurysm who was successfully submitted to resection in association with iliac graft placement between the abdominal aorta and the common hepatic artery.

CONCLUSION

Whenever celiac artery aneurysm is diagnosed, it should be closely monitored and treated, resection and reconstruction being a feasible method in order to avoid the development of a life-threatening complication.

The Impact of COVID-19 Infection During the Postoperative Period After Surgery for Ovarian Cancer

BACKGROUND/AIM

The COVID-19 pandemic has significantly influenced the management of oncogynecologic patients in regard to time of diagnosis, to delay of treatment, therapeutic strategy and postoperative complications. The aim of the study was to investigate the impact of preoperative SARS-Cov2 infection on the postoperative outcome after debulking surgery for ovarian cancer.

PATIENTS AND METHODS

Between June 2021 and September 2021, 12 patients with antecedents of COVID-19 infection and ovarian cancer were submitted to surgery at "Dr. I. Cantacuzino" Hospital, Bucharest, Romania. Their outcomes were compared to those reported in a similar group of patients submitted to surgery during the same period in the absence of COVID-19 infection.

RESULTS

Although preoperative data showed no statistically significant differences between the two groups, intraoperative length and estimated blood loss were higher in the COVID-19 group and so were the postoperative complications, the most commonly encountered ones being reported by wound infection, postoperative hemoperitoneum and pneumonia. However, the differences did not reach statistical significance.

CONCLUSION

Preoperative COVID-19 infection seems to slightly increase the risk of postoperative complications after debulking surgery for ovarian cancer.

The Prevalence and Predictors of Restless Legs Syndrome in Patients with Liver Cirrhosis

Introduction and aim. Sleep disorders are highly prevalent in patients with liver cirrhosis. The aim of this study was to investigate the prevalence of restless legs syndrome (RLS), as well as its risk factors and possible predictors, in a cohort of patients with liver cirrhosis. Material and methods. We performed a cross-sectional prospective study over a period of 14 months and enrolled 69 patients with liver cirrhosis, after applying the inclusion and exclusion criteria. The cases of RLS were assessed according to the International Restless Legs Syndrome Study Group (IRLSSG) criteria and severity scale. Results. Out of the total number of patients, 55% fulfilled the criteria for RLS. Age, diabetes, severity of cirrhosis, serum creatinine, glomerular filtration rate (GFR), and mean hemoglobin were associated with the presence of RLS. Moreover, there was a significantly higher prevalence of RLS among patients with decompensated cirrhosis. From all the risk factors introduced into the multivariate analysis, only the GFR could predict the presence of RLS. Conclusions. This research shows that patients with liver cirrhosis have a high risk of RLS. Even though there are multiple risk factors associated with RLS, only the GFR could predict its occurrence in our cohort.

Monochorionic Diamniotic Twins with Bordering Cord Insertions: Images and Outcome

Twin pregnancy contributes to perinatal mortality, particularly monochorionic diamniotic twin pregnancy. Placental abnormalities are much more common in twin pregnancies than in singletons. In MCDA pregnancy, vascular anastomoses are always present and are accountable for severe complications such as Twin-to-Twin transfusion syndrome (TTTS). In TTTS, umbilical cords are usually inserted at a distance from each other. We present a rare type of MCDA pregnancy, TTTS gr 1 case with bordering umbilical cord insertions.

Fibular hemimelia

Fibular hemimelia is defined as a partial or complete absence of the fibula. Alongside fibular deformities, there is a wide spectrum of anomalies, foot deformities, and absent rays. A literature review showed only a handful of cases of prenatal diagnosis of fibular hemimelia. It is a rare disorder that might be isolated or associated with visceral anomalies.

Vascular Resections in Association With Pancreatic Resections for Locally Advanced Pancreatic Cancer

BACKGROUND/AIM

Locally advanced pancreatic cancer has been considered for a long period of time as an unresectable lesion and therefore, all patients have been traditionally addressed to the oncological services for palliative purposes. However, due to the wide usage of newer oncological agents in association with improved surgical techniques, radical surgical procedures became feasible. The aim of this study was to present the different surgical procedures that were performed in locally advanced pancreatic cancer patients in order to achieve radical resections.

PATIENTS AND METHODS

Between 2019 and 2020, six cases were submitted to pancreatic and vascular resections in Fundeni Clinical Hospital.

RESULTS

In all cases, surgery with curative intent was attempted; portal vein resection was performed in five cases, whereas arterial resection was performed in three cases. Reconstruction was performed by direct re-anastomosis, by placing cadaveric or synthetic grafts. The postoperative outcomes were favourable in all cases.

CONCLUSION

Vascular resections can be safely associated with pancreatic resections in cases presenting locally advanced pancreatic lesions, with acceptable morbidity rates.

Oncofertility and COVID-19: At the Crossroads between Two Time-Sensitive Fields

Background: COVID-19 infection has dominated our lives and left its mark on it. The impact on fertility is major, and the long-term consequences may be disastrous. When we talk about oncofertility, we are talking about those patients worried about the delay in receiving medical services (possible cancelation of surgery, decreased availability of medical services, reorientation of medical resources) due to COVID-19. Finally, patients’ worsening biological and reproductive statuses, associated with high levels of anxiety and depression, are closely related to social restrictions, economic impact, reorientation of medical resources, health policies, and fears of SARS-CoV-2 infection. Aim: We reviewed the current literature on fertility during the COVID-19 pandemic and its effect on cancer patients. Specifically, how cancer treatment can affect fertility, the options to maintain fertility potential, and the recovery options available after treatment are increasingly common concerns among cancer patients. Methods: A systematic literature search was conducted using two main central databases (PubMed^®/MEDLINE, and Web of Science) to identify relevant studies using keywords SARS-CoV-2, COVID-19, oncofertility, young cancer patient, cryopreservation, assisted reproductive techniques (ART), psychosocial, telemedicine. Results: In the present study, 45 papers were included, centered on the six main topics related to COVID-19. Conclusions: Fertility preservation (FP) should not be discontinued, but instead practiced with adjustments to prevent SARS-CoV-2 transmission. The increased risk of SARS-CoV-2 infection in cancer patients requires screening for COVID-19 before FP procedures, among both patients and medical staff in FP clinics, to prevent infection that would rapidly worsen the condition and lead to severe complications.

Pituitary adenoma apoplexy in pregnancy: Case report and literature review

Gestational pituitary apoplexy is an extremely rare condition. It is characterised by an unexpected headache, vomiting, nausea, and visual disturbances. Pituitary apoplexy in pregnancy and postpartum is a challenging diagnosis with symptoms overlapping multiple conditions. There is a limited number of articles presenting cases or case series of gestational pituitary apoplexy. This is a potentially life-threatening emergency which requires a high index of suspicion for its diagnosis. This article presents a case of postpartum pituitary apoplexy and outlines the current stage of clinical, imagistic diagnosis and management options. A 26-year-old primipara was submitted to a Caesarean section, with no perioperative incidents. Forty-eight hours later she reported the apparition of frontal and temporal throbbing headaches, nausea, photophobia, and she was diagnosed with a pituitary tumor measuring 33x10.5x15.5 mm. Although initially conservative treatment was proposed, the clinical outcome was not favourable, thus the patient was submitted to endoscopic transsphenoidal resection. The histopathological studies demonstrated the presence of a pituitary macroadenoma. At the 2-year follow-up, the patient is free of disease. Although it represents an extremely rare condition, gestational pituitary apoplexy should be suspected whenever headache and neurological disorders such as nausea and photophobia are reported during the postpartum period.

First-Trimester Diagnosis of Supernumerary Hemivertebra

Hemivertebra is a common cause of congenital scoliosis and results from a lack of formation of one-half of the vertebral body. This condition is very rare and can present as solitary or as a syndrome component: i.e., the split notochord syndrome, which often implies vertebral defects, from a bifid vertebra to hemivertebrae, or fused vertebrae. We describe a case of supernumerary lateral hemivertebra detected prenatally at 12 weeks of gestation and the ultrasonography specifics that lead to early and accurate diagnosis, monitoring during pregnancy, and follow-up at the 4-year period. The case is presented to specify the importance of an early assessment of fetal spine and diagnosis of various conditions, including hemivertebrae, considering the significant association with other anomalies (cardiovascular, urinary, skeletal, gastrointestinal, and central nervous systems), which are most commonly involved. Moreover, the need to counsel future parents on the risks implied by this anomaly is important for the obstetrician. We underline the inclusion of these types of congenital conditions in high-risk pregnancy because of the frequent association with high cesarean delivery rates, growth restriction, delivery before term, and higher morbidity rates.

Risk Factors for Pancreatic Cancer: Emerging Role of Viral Hepatitis

Pancreatic cancer is one of the most aggressive malignant neoplastic diseases. The incidence and mortality rates of this disease vary depending on geographical area, which might be explained by the different exposure to risk factors. To improve the prognosis of patients with pancreatic cancer, different approaches are needed for an earlier diagnosis. Identification of risk factors and implementation of screening strategies are essential for a better prognosis. Currently, the risk factors for pancreatic cancer fall into two broad categories, namely extrinsic and intrinsic factors. Extrinsic factors include alcohol consumption, smoking, a diet rich in saturated fats, and viral infections such as chronic infection with hepatitis B and C viruses. The pathophysiological mechanisms explaining how these hepatotropic viruses contribute to the development of pancreatic cancer are not fully elucidated. The common origin of hepatocytes and pancreatic cells in the multipotent endodermal cells, the common origin of the blood vessels and biliary ducts of the pancreas and the liver, or chronic inflammatory changes may be involved in this interaction. A careful monitoring of patients with viral liver infections may contribute to the early diagnosis of pancreatic cancer and improve the prognosis of these patients.

Vesico-uterine Fistula Following C-section - A Case Report and Literature Review

BACKGROUND/AIM

Vesico-uterine fistulas represent a rare type of genito-urinary fistulas; however, due to the increasing incidence of Caesarean section (C-section) in the last decade, this abnormal communication between the urinary and genital tracts has been reported more often after such surgical procedures. The aim of the current article was to report the case of a 28-year-old patient who was submitted to surgery for a vesico-uterine fistula seven years after a C-section.

CASE REPORT

The 28-year-old patient with a previous history of four vaginal deliveries and one C-section was self-presented to the Gynecology Department for cyclic hematuria and diagnosed with a vesico-uterine fistula after injecting methylene blue in the uterine cavity during hysteroscopy. The patient was further submitted to surgery, and a parcelar myometrectomy en bloc with parcelar cystectomy, cystography, and prophylactic salpingectomy was performed. The postoperative outcome was uneventful.

CONCLUSION

Although vesico-uterine fistulas represent rare events, they should be considered, especially in young patients with a previous history of C-section.