Emergency inguinal hernioplasties in a tertiary public Hospital in Athens Greece, during the economic crisis.

BACKGROUND: Although the effect of the recent Greek economic crisis and austerity on the population's health and the health system effectiveness have been discussed a lot recently, data on common surgical conditions affecting large part of the population are missing. Using inguinal hernia as a model we investigated possible changes of citizens' attitude regarding the time of referral, the perioperative details and the intraoperative findings of the emergency hernioplasties. METHODS: The present retrospective study was conducted by a Department of Surgery in a tertiary public hospital of the Greek capital. We reviewed the records of all hernioplasties performed during two 5-year periods: 2005-2009 and 2012-2016, i.e. before and during the crisis focusing on the emergency ones (either incarcerated or strangulated). RESULTS: An equal number of hernioplasties was performed in both periods. During the crisis however, an emergency hernioplasty was significantly more probable (HR 1.269, 95% CI 1.108-1.1454, p = 0.001), at a younger age (p = 0.04), mainly in patients younger than 75 years old (p = 0.0013). More patients presented with intestinal ischemia (7 vs 18, p = 0.002), requiring longer hospitalization (5.2 vs 9.6 days, p = 0.04), with higher cost (560 ± 262.4€ vs 2125 ± 1180.8€ p < 0.001). In contrast the percentage of patients with intestinal resection, their hospitalization length and treatment-cost remained unchanged. During the crisis there was a non-significant increase of emergency patients requiring ICU postoperatively (0 vs 4, p = 0.07) and a non-significant 60% increase of emergency operations in migrants/refugees population (3.5% vs 5.8%, p = 0.28). Epidural anesthesia was significantly more frequent during the crisis. CONCLUSION: During the crisis: (i) the emergency hernioplasties increased significantly, (ii) more patients (exclusively Greek) presented with intestinal ischemia requiring longer hospitalization and higher treatment cost, (iii) the mean age of the urgently treated patients decreased significantly (iv) regional (epidural) anesthesia was more frequent. Although a direct causal relation could not be proven by the present study most observations can be explained by an increase of the patients who delayed the elective treatment of their hernia, and by a redistribution of the surgical workload towards big central hospitals. This can be prevented by adequately supporting the small district hospitals.

Pancreatic tuberculosis: a medical disease posing surgical dilemmas.

Pancreatic tuberculosis is a rare clinical setting manifesting in various ways. Most often, enlarged peripancreatic lymph nodes or growing tuberculomas compress adjacent organs, leading to biliary tract or gastrointestinal obstruction. Clinical examination, laboratory data, and imaging are all unspecific. Diagnosis is frequently misguided toward neoplasia requiring surgical intervention. However, the role of surgery in pancreatic tuberculosis ends in tissue sampling, abscess drainage, and bypassing obstruction. We present three cases of pancreatic tuberculosis: two caused by obstructive jaundice and the third caused by gastric outlet obstruction. All patients were operated on. Whipple's procedure was performed in one patient, and biliary and duodenal bypassing in the remaining patients. Diagnosis was decided by histopathology in all three cases. Medical treatment was effective in all patients. Although pancreatic tuberculosis is a medical disease, surgery is frequently used. Maintaining a high level of suspicion can assist in avoiding unnecessary laparotomies and solving this medical dilemma.