Women in spine surgery: can we change the society?

BACKGROUND: Although the number of educated women and physicians, and especially neurosurgeons, is increasing worldwide, the educational opportunities, careers, and beliefs concerning female neurosurgeon's status and abilities are undermined. To date, reported studies have focused on the conditions of the work environment, work-life balance, and the academic career of female neurosurgeons. In this study, we aimed to report the patients' viewpoint and how they choose spine physicians. METHODS: We conducted an international survey based on 19 questions in four languages (Bulgarian, Greek, English, and German). The responses of 413 individuals, unrelated to the medical field (sex, 315 female and 115 male individuals; one individual did not answer the question regarding the gender), were obtained. Except for the question regarding the patient's preference for the physician sex, the survey aimed to examine the factors that might be contributing to this choice, including education, age, heard/read recommendations/advertisements, knowledge regarding the work of the neurosurgeons/orthopedists, and their difference regarding spine surgery. RESULTS: The majority of the participants responded that they prefer male surgeons to treat their spine. The results showed a significant correlation between the choice of a male spine surgeon and heard/read advertisements/recommendations and knowledge regarding the work of the neurosurgeon. Despite the fact that education was not related to physician selection, it was an indirect factor that led to the final choice. CONCLUSION: Women in surgery, mainly in neurosurgery, are being treated by society in an unequal way. Female surgeons are still discriminated because of their gender. The most patients prefer female physicians to talk to, but still believe that they are incapable to perform spine surgery. We cannot stop this until we change our mindset and perception of reality.

Posthemithyroidectomy Hypothyroidism: Updated Meta-Analysis of Risk Factors and Rates of Remission.

INTRODUCTION: The aim of this study was to determine the incidence and risk factors for hypothyroidism, both clinical and subclinical, following hemithyroidectomy in preoperatively euthyroid patients, as well as hypothyroidism remission and its time of remission. MATERIALS AND METHODS: A search was performed in Medline (via PubMed), Web of Science, and the Cochrane Library using the keywords "hemithyroidectomy + postoperative + hypothyroidism" and "hemithyroidectomy + hormone supplementation". RESULTS: Fifty-four studies with a total of 9,999 patients were included. After a mean follow-up interval of 48.2 mo, the pooled hypothyroidism rate was 29%. The subclinical hypothyroidism rate was 79% of patients with hypothyroidism (18 studies). Moreover, a meta-analysis of 12 studies indicated a pooled hypothyroidism remission rate after hemithyroidectomy of 42% (95% CI: 24%-60%). Older patient age (MD = -2.54, 95% CI = -3.99, -1.10, P = 0.0006), female gender (OR = 0.69, 95% CI = 0.58, 0.82, P < 0.0001), higher preoperative thyroid-stimulating hormone levels (MD = -0,81, 95% CI = -0.96, -0.66, P < 0.00001), pathological preoperative anti-thyroid peroxidase antibodies (OR = 0.37, 95% CI = 0.24, 0.57, P < 0.00001) and anti-thyroglobulin antibodies (OR = 0.52, 95% CI = 0.36, 0.75, P = 00,005), and right-sided hemithyroidectomy (OR = 0.54, 95% CI = 0.43, 0.68, P < 0.00001) were associated with postoperative hypothyroidism development. In metaregression analysis, Asia presented a significantly higher hypothyroidism rate after hemithyroidectomy (34.6%, 95% CI = 29.3%-9.9%), compared to Europe (22.9%, 95% CI = 16.2%-29.5%, P = 0.037) and Canada (1.8%, 95% CI = -22.6%-26.2%, P = 0.013). CONCLUSIONS: Hypothyroidism is a frequent and significant postoperative sequela of hemithyroidectomy, necessitating individualization of treatment strategy based on the underlying disease as well as the estimated risk of hypothyroidism and its risk factors.

Laparoscopic vs. laparoscopically assisted pediatric inguinal hernia repair: a systematic review.

This systematic review aims to compare the two major principles of laparoscopic pediatric inguinal hernia repair: totally laparoscopic repairs (LR) and laparoscopically assisted repairs (LAR), to find out the optimal approach for pediatric patients. A systematic literature search was performed via Pubmed, Embase MEDLINE, and Cochrane databases on all studies published in the last 20 years reporting outcomes on these principles including recurrences, complications, and operative time. Prospective studies for either principle or retrospective comparative studies were considered eligible. Fischer's exact and Student's t test were used for statistical analysis with p value < 0.05 considered statistically significant. Twenty-one studies, including two thousand one hundred and ninety-six patients (LR: 1008), of ages ranging from 9 days to 18 years-old and a male to female ratio of 2.55:1, met our inclusion criteria. Follow-up period varied from 3 months to 8 years. Recurrence rates were similar between the two categories (LR: 1.68% vs. LAR: 1.59%, p > 0.05). As regards post-operative complications, transient hydrocele development was higher in laparoscopic repairs (LAR: 1.01% vs. LR: 3.17% p < 0.005) while wound healing problems were more frequent in laparoscopically assisted repairs (LAR: 1.17% vs. LR: 0.30%, p = 0.019). Mean operative time was lower in laparoscopically assisted repairs both in unilateral (LAR: 21.49 ± 13.51 vs. LR: 29.73 ± 11.05, p = 0.131) and bilateral cases (LAR: 28.01 ± 15.08 vs. LR: 39.48 ± 16.35, p = 0.101) but without statistically significant difference. Both principles are equally effective and safe as their recurrence and overall complications rates are equivalent. Transient hydrocele occurs more often in laparoscopic repairs while wound healing problems are associated mostly with laparoscopically assisted repairs.

Ectopic kidney injury due to blunt abdominal trauma.

Ectopic kidney is a relatively uncommon anatomic variation that is usually detected incidentally in patients undergoing imaging for an unrelated reason. Most cases are asymptomatic and are often revealed by a complication; however, ectopic kidney is generally associated with higher risk of traumatic injury, urinary tract infection, renal calculi and other urologic conditions. We report the case of a 65-year-old male patient with a post-traumatic renal laceration on a previously undiagnosed ectopic pelvic kidney, with successful conservative treatment.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece.

BACKGROUND: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Solitary abdominal wall hydatid cyst-a rare condition.

Hydatid disease is a parasitic infection by a tapeworm of the genus Echinococcus that usually presents in the liver and lungs. Presentation of the disease as a solitary abdominal wall lesion, however, is a rare entity and only nine cases have been reported in the literature thus far. We present the case of a 53-year-old Caucasian female presenting with a mass located in the left flank that was proven to be a solitary hydatid cyst intraoperatively.

"Security dilemma": active immunotherapy before versus after radiation therapy alone or chemo-radiotherapy for newly diagnosed glioblastoma.

Management of glioblastoma should be aggressive and personalised to increase the quality of life. Many new therapies, such as active immunotherapy, increase the overall survival, yet they result in complications which render the search for the optimal treatment stra-tegy challenging.

Gross total resection with fluorescence could lead to improved overall survival rates: a systematic review and meta-analysis.

INTRODUCTION: Glioblastoma cases are often treated with aggressive resection. Recent studies have suggested that extended surgical resection could improve survival. Improved extent of resection could be afforded by the use of fluorescence during surgery. We aimed to examine the effect of fluorescence on the results of gross total resection (GTR) and its impact on the overall survival (OS) and progression-free survival (PFS) rates. METHODS: We performed a literature search of studies published between 2000 and 2021. The study followed the PRISMA guidelines and focused on newly-diagnosed glioblastoma cases. The collected data were divided into two groups according to the fluorescence use: Group A (standard white-light use) and Group B (fluorescent-light use). RESULTS: The results showed a superiority of the fluorescence use during surgery for newly diagnosed glioblastoma cases concerning the procurement of GTR. Additionally, we highlighted the importance of GTR on the OS but not on the PFS rate. We found that the use of 5-aminolevulinic acid resulted in better OS rates compared to fluorescein sodium. CONCLUSION: GTR is a significant factor leading to improved OS; nevertheless, it was an apparently unrelated factor for estimating the PFS rate. Fluorescence use during surgery could lead to higher rates of complete resection and better OS rates.

Which is the Prognostic Value of the Mini Mental State Examination Test in Surgical Oncology?

INTRODUCTION: Cancer patients are usually subjected to numerous surgeries during their course of treatment. Recent studies suggest that anesthetic drugs such as propofol, benzodiazepines, and opioids are linked to cognitive impairment. AIM: The aim of the study was to show and compare the cognitive function of oncology patients who have undergone surgery and have been sedated with propofol, fentanyl and benzodiazepines. MATERIALS AND METHODS: In order to determine whether the cognition of oncological patients is being impaired, a mini-mental state examination (MMSE) test was obtained 6 to 24 hours pre- and postoperatively for the duration of one month from 8 eligible oncological patients and 7 non-oncological ones. Afterwards, the data were statistically processed with SPSS version 25.0 (Chicago, Ill. the USA). RESULTS: The analysis shows that there is statistically significant difference in the preoperative MMSE scores between oncological and non-oncological patients. CONCLUSIONS: Oncological patients compound a sensitive group for cognitive dysfunction, and indeed, MMSE test could be useful for cognitive evaluation. The present sample, however, is small, and the results could not be generalized. Therefore a more extensive study is needed.

Is serum gentamicin concentration modified with autologous cell-saved blood transfusion after total knee arthroplasty using tranexamic acid? A randomised control trial.

BACKGROUND: Self-transfusion has been proven as an effective management of blood loss after total knee arthroplasty (TKA). Considering that the high local concentration of antibiotic from bone cement is delivered intravenously through the self-transfusion process, systematic toxicity has never been evaluated. In addition, the effectiveness of self-transfusion with the routine concomitant use of other modern blood-salvage strategies, like tranexamic acid, should also be assessed. Therefore, we performed a randomised study to assess: 1) the safety of self-transfusion in TKA by comparing the gentamicin concentrations resulting from the use or not of autologous blood transfusion; 2) the efficacy of self-transfusion in TKA, with the concomitant administration of tranexamic acid. HYPOTHESIS: Self-transfusion in TKA elevates the serum gentamicin concentration and the potential risk of nephrotoxicity. METHODS: The serum concentration of aminoglycosides was measured in two groups of 20 patients each, after TKA, according to the use of self-transfusion. Hemoglobin, renal function and calculated blood loss were compared at several points in time between groups. RESULTS: The only time where there was a statistically significant difference in serum gentamicin, was at 48h postoperatively between groups [0.3 ug/mL±0.21, range: 0.15 to 0.72 vs. 0.14ug/mL±0.1, range: 0 to 0.35 (p=0.02)]. There were no significant differences in total blood loss [1341mL±501, range: 830 to 2230 vs. 1263mL±459 range: 840 to 2480 (p=0.67)] and need of allogeneic blood transfusion [3 units vs. 2 units] between groups. CONCLUSION: The use of autologous blood transfusion was found to be safe, in terms of nephrotoxicity of aminoglycosides after TKA, but it seemed to be ineffective as a blood salvage strategy, when used concomitantly with the administration of tranexamic acid. LEVEL OF EVIDENCE: II; low-powered randomised study. CLINICALTRIALS. GOV REGISTRATION NUMBER: NCT04505748.

Urinary bladder-containing incarcerated inguinoscrotal hernia: a case report.

Inguinoscrotal hernia containing the urinary bladder is a rare entity found in 1-4% of inguinal hernias, while patients rarely present symptoms of urinary dysfunction. We present the case of a 79-year-old Caucasian male with acute renal dysfunction and incarcerated inguinoscrotal hernia containing the entire urinary bladder. The patient presented in the surgical emergency department due to an incarcerated right inguinoscrotal hernia and deteriorated renal function. Preoperatively, ultrasound imaging was performed, which showed the presence of the whole bladder in the hernia sac. The bladder was repositioned to its anatomic position and hernia was repaired through a modified Lichtenstein technique. In patients with inguinoscrotal hernia and acute urinary tract symptoms, surgeons should be aware of the possibility of inguinal bladder hernia. Preoperative imaging can help in preventing intraoperative bladder damage.

Primary ectopic Merkel cell carcinoma without skin involvement-report of a case with prolonged survival.

Merkel cell carcinoma is a rare neuroendocrine malignancy that arises from the dermis, in cases of immunocompromised, middle-aged patients or on skin exposed to sunlight. It only rarely presents in extra-cutaneous locations. We present the case of a 63-year-old female with a mass in the adipose tissue of the upper arm, without skin involvement and concurrent axillary lymph node enlargement. She was treated with wide excision and lymph node dissection; pathology led to the diagnosis of Merkel cell carcinoma, and she was subsequently submitted to adjuvant radiotherapy. No signs of recurrence are present 8 years postoperatively. Primary Merkel cell carcinoma can rarely be located in the adipose tissue without skin involvement. In cases of high suspicion, preoperative MRI scan can show the extent of the lesion, as well as lymph metastases.

Spontaneous massive duodenal perforation after ovarian cancer treatment with bevacizumab.

Bevacizumab has been used as an effective drug for ovarian cancer. However, serious adverse effects, such as gastrointestinal perforation, can occur. Spontaneous gastrointestinal perforation is an uncommon, yet life-threatening complication related to bevacizumab administration. We present the case of a 65-year-old Caucasian female who presented with acute abdomen 10 days after the first administration of bevacizumab for ovarian cancer treatment, and she was diagnosed intraoperatively with a massive duodenal perforation. Bowel perforation after bevacizumab administration is a serious and potentially lethal complication. Careful follow-up of the patients is necessary in order to detect any signs of this condition in time.

Laparoscopic resection of giant adrenal malignant tumors, a case series and review of the literature.

Laparoscopic approach for suspected adrenal malignancies remains a controversial issue and it gets more controversial, when managing giant adrenal malignant tumors. The aim of this paper is to present five cases of patients with giant adrenal malignant tumors that underwent laparoscopic transabdominal lateral adrenalectomy in our department between 2010 and 2017. Literature is also reviewed in order to investigate the feasibility of laparoscopic resection in these cases.

Spontaneous rupture of a splenic artery aneurysm treated with a spleen-preserving procedure: a case report.

Splenic artery aneurysm is a rare and life-threatening condition, in case of spontaneous rupture. A rare case of such a rupture, treated successfully with an endovascular procedure, is presented. A 21-year-old man presented to the emergency department after an episode of loss of consciousness. After initial conservative treatment, he developed hemodynamic instability 12 hours later, with concurrent diffuse abdominal pain. Abdominal CT revealed a ruptured splenic artery aneurysm, which was immediately treated with coil embolization. The patient had an uneventful recovery and was discharged on the 12th day after the procedure. Although open surgery is the choice of treatment in cases of ruptured splenic artery aneurysms, endovascular embolization can also be considered a safe procedure with low complication and mortality rates.

Pleurodesis and Immunotherapy in NSCLC; Medical Thoracoscopy or VATS?

Introduction: Immunotherapy is a treatment option for non-small cell lung cancer advanced disease. However; immunotherapy in several patients induces orogonitis and effusion in different cavities. It is up to the treating physician to understand whether there is effusion due to adverse effect or disease progression. Pleurodesis in both cases might be a solution for recurrent pleura effusion. Patients and Methods: Three hundred and thirty seven non-small cell lung cancer patients with adenocarcinoma and pleura effusion during first line immunotherapy treatment underwent medical thoracoscopy or Video assisted thoracic surgery (VATS) for pleurodesis with talk poudrage. Uniportal medical thoracoscopy was performed under general with dual channel endotracheal tube in one hundred and eleven patients. Video assisted thoracic surgery was performed in one hundred and eighty seven patients and conversion from medical to VATS procedure was done to thirty nine patients. All patients had stage IV disease with pleura involvement and were under first line pembrolizumab treatment with 200mg (PD-L1 ≥ 50%). Results: The quantitative parameters of the study (expression, PY and cycle) were converted to an ordinal scale to facilitate the performance of statistical analysis. All parameters were examined as dependent against the parameter technique acting as independent to detect potential relationships. The results of multi Y versus X relationship revealed no statistically significant effect (p>0.05) of the three levels of technique against any response considered. Thus we can infer, quite safely, that the innovative operation (level 0) does not differ from the other two conventional methods (levels 2 and 3) through all parameters entered in the model. There was no significant difference between the different pleurodesis techniques. Discussion: Immunotherapy is known to induce in a number of patients pleura effusion and pericarditis. However; pleurodesis is efficient when the appropriate method is performed to every patient. Careful assessment in a case by case manner has to be performed for each patient before any procedure is performed.

Lymph node mapping helps in R0 resection for anaplastic thyroid carcinoma-report of a case with prolonged survival.

Anaplastic thyroid carcinoma is a rare tumor, consisting 1-2% of all thyroid malignancies and presenting a high mortality rate. Median survival for patients undergoing primary surgery is approximately 6.6 months. We present a case of a patient treated with R0 resection, including total thyroidectomy and lymphadenectomy of levels III, IV, VI and VII after cervical lymph node mapping, oral 131I administration, and radiotherapy. Proper preoperative research, R0 resection and relatively early diagnosis, led to good prognosis, as the patient is currently totally disease-free, twelve months postoperatively.

Primary greater omental torsion as a cause of acute abdomen-a rare case report.

Greater omental torsion is a rare entity that can cause acute abdominal pain, may mimick other abdominal pathologies, and is difficult to be diagnosed preoperatively. We present a case of a male patient with greater omental torsion mimicking the symptoms of acute appendicitis. A 31-year-old male patient presented with right scrotal pain, initially treated by the urologists, however, 24 h later, he presented right lower quadrant pain, with characteristics of acute appendicitis. After finding in ischemic inflammatory mass on McBurney incision, an exploratory laparotomy was performed, revealing torsion of the greater omentum. Torsion of the greater omentum can be a cause of acute abdomen and could be misdiagnosed with acute appendicitis. Preoperative diagnosis is not easy and resection of the affected tissue is the preferred treatment of choice.

Acute appendicitis as the first presentation of appendiceal metastasis of gastric cancer-report of a rare case.

Metastatic tumors of the appendix is a rare entity, whereas only limited data involving metastasis arising from gastric cancer has been reported. Herein, the case of gastric adenocarcinoma metastasis presenting as acute appendicitis is reported. A 53-year-old male, with a history of subtotal gastrectomy due to gastric adenocarcinoma 3 years before, was referred to the Emergency Department with symptoms of acute appendicitis. While this condition was confirmed intraoperatively, histology examination and comparison with the previously excised gastric specimen indicated that metastasis of gastric adenocarcinoma to the appendix was present. Metastatic appendiceal carcinoma arising from the stomach is an extremely rare condition, associated with poor prognosis. Aggressive treatment of the solitary lesion may present favorable results.

Convex-probe endobronchial ultrasound for thyroid biopsy a new hybrid method.

Nowadays we use novel diagnostic equipment for lung cancer. Bronchoscopy was the tip of the arrow for diagnosis, however; ultrasound systems have brought a revolution. We have the radial-endobronchial ultrasound for peripheral lesions and the convex probe endobronchial ultrasound for central lesions. Ultrasound endoscopic systems can be used for the diagnosis of any lesion that can be approached from the airways. In the current manuscript we will present two methods for the biopsy of thyroid gland. The first method is using anesthisiological tools and the second tools from the ear, nose and throat department.