The impact of age on quality of life and frailty outcomes after parathyroidectomy in patients with primary hyperparathyroidism.

OBJECTIVE: Parathyroidectomy (PTx) improves quality of life (QoL) in patients with primary hyperparathyroidism (PHPT). Whether this effect is modified according to the patients' age is unknown. The aim of this study was to evaluate the impact of age on the effect of PTx on QoL and frailty in patients with PHPT, six months post-PTx. METHODS: This was a prospective cohort study, including patients with PHPT, admitted from January 2016 to December 2019, divided into two categories: younger (≤ 65 years old) and older (> 65 years old). QoL was assessed with the Pasieka questionnaire (PAS-Q) two days pre- and six months post-operatively. Frailty was also assessed at the same time intervals, with the Frailty Index (FI). RESULTS: One hundred and thirty-four patients (younger group: 96 patients, mean age 50.4 ± 9.8 years; older group: 38 patients, mean age 72.1 ± 4.9 years) were included. PTx resulted in a significant reduction in PAS-Q score in both groups. Notably, a greater reduction in "mood swings", "irritability", "itchy skin" and "feeling thirsty" PAS-Q domains was observed in the younger group. In contrast, a greater decrease in "bone pain", "tiredness", "weakness", "joint pain", "getting off chair" and "headaches" items was observed in the older group. Moreover, PTx led to a decrease in FI only in this group. CONCLUSIONS: PTx leads to an improvement in QoL both in older (> 65 years) and younger (≤ 65 years) patients with PHPT, attributed to a differential effect on PAS-Q items. Frailty improves only in the older group.

Bowel intussusception in adults: a report of three interesting cases and current trends for diagnosis and surgical management.

BACKGROUND: Bowel intussusception in adults remains a rare and constant diagnostic challenge for surgeons. It has an incidence of around 2-3 new cases per million per year, and its primary cause is benign or malignant neoplasms of the small bowel and colon. This report aims to outline the importance of high clinical suspicion regarding intussusception in adults presenting with abdominal pain in the emergency department.  Case report: This is a retrospective review of three cases of adult ileocecal intussusception that were treated in a single surgical department in three years (2015-2018). All patients underwent right hemicolectomy in keeping with the principles of surgical oncology. Each patient had a different clinical presentation, while, in terms of the underlining pathology, the first had an adenocarcinoma of the ascending colon, the second an adenocarcinoma of the ileocecal valve, and the third one an inflammatory fibroid polyp of the ileocecal valve, also known as Vanek's tumor. CONCLUSION: Large bowel intussusception in adults is quite an interesting entity, not only for its rarity but for its non-specific and atypical clinical presentation as well. High suspicion from the clinician's part and availability of a computed tomography scan is the key to diagnosis. It is not unusual for imaging modalities to be unable to identify the cause of the intussusception. Thus, surgery is always the preferred method of treatment, as, more often than not, a neoplasm of the small or the large bowel is the underlining pathology.  HIPPOKRATIA 2019, 23(1): 37-41.

Management of peritoneal hydatid cysts: A fourty-year experience.

BACKGROUND: Hydatid disease is a global problem. We report our experience with such cases where the dominant cysts were located outside the liver and lungs. In particular, these cysts were found in the peritoneum which is an uncommon location. METHODS: Between 1967 and 2007 a total of 34 patients were operated for primary or secondary peritoneal cysts. Most of the patients were asymptomatic or had atypical symptoms. The diagnosis was based on the preoperative history, rupture of the cysts, serology, ultrasound (USS) and computer tomography (CT). Open surgery was the procedure of choice with conservative (18 cysts) and radical (25 cysts) methods. RESULTS: The outcome of surgery was good without postoperative mortality or severe morbidity and the recurrence rate was 23.5%. CONCLUSIONS: Conservative surgery can provide good results in symptomatic peritoneal cysts. Radical therapy is also ideal but only in properly selected cases. The management of this situation is difficult requiring sound operative experience preferably with a one-stage procedure after an appropriate preoperative preparation.

Dermatofibrosarcoma protuberans: a case report and review of the literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) represents less than 0.1% of all tumors, but it is considered the most common skin sarcoma. Wide local excision (=5 cm) has been largely replaced by Mohs micrographic surgery; however, recurrence is not rare. Description of the case: A 35-year-old man presented with a large tumor on the upper side of his back and underwent local excision with the possible preoperative diagnosis of lipoma. Upon histological examination, the diagnosis of DFSP was made, and the patient underwent wide local excision with skin flap reconstruction and was referred for adjuvant radiotherapy.On twenty months follow-up, no recurrence has been observed. CONCLUSION: DFSP is the most common cutaneous sarcoma. It originates in the dermis and tends to infiltrate underlying structures, including muscles, tendons, fascia and bone. In our case, the tumor was confined to the skin and subcutaneous tissue, however, our patient underwent adjuvant radiotherapy to avoid a possible relapse that would infiltrate deeper structures. Long-term follow-up is strongly recommended. Hippokratia 2016, 20(1): 80-83.

Anal canal gastrointestinal stromal tumors - report of a rare case and review of the literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are considered as rare gastrointestinal tumors, and their location in the anal track is exceptionally unusual. We describe the case of a 28-year-old man with anal GIST, and a review of the cases that have been reported so far in the literature. CASE REPORT: The patient was referred for treatment of a gradually enlarging perianal mass. Clinical examination and imaging including orthosigmoidoscopy, transanal ultrasound, and magnetic resonance imaging (MRI) revealed a mass sized 7.5 cm in greatest diameter, in relation with the sphincters, which was excised under general anesthesia. His postoperative course was uneventful and he was discharged on the fourth postoperative day. Pathologic examination revealed characteristics of anal GISTs and further treatment with tyrosine kinase inhibitors was planned. CONCLUSION: Anal GISTs usually present with rectal bleeding and pain, and only sixteen cases have been reported in the literature. MRI is the radiologic examination of choice, while optimal treatment is considered surgery in combination with adjuvant therapy. Long-term follow-up is necessary. Hippokratia 2016, 20(4): 313-316.

Inhaled antibiotics in mechanically ventilated patients.

During the last decade, inhaled antibiotics, especially colistin, has been widely used worldwide as a therapeutic option, supplementary to conventional intravenous antibiotics, for the treatment of multidrug-resistant (MDR) Gram-negative nosocomial and ventilator-associated pneumonia (VAP). Antimicrobial aerosols are commonly used in mechanically ventilated patients with VAP, although information regarding their efficacy and optimal technique of administration has been limited. Recent studies showed that the administration of inhaled antibiotics in addition to systemic antibiotics provided encouraging results associated with low toxicity for the management of VAP mainly due to MDR Gram negative bacteria. Although the theory behind aerosolized administration of antibiotics seems to be sound, there are limited data available to support the routine use of this modality since very few randomized controlled trials (RCTs) have still examined the efficacy of this approach in patients with VAP. Additionally, this route of antibiotic delivery has not been approved until now neither by the FDA nor by the European Medicines Agency (EMEA) in patients with VAP. However, since the problem of VAP due to MDR bacteria has been increased worldwide RCTs are urgently needed in order to prove the safety, efficiency and efficacy of inhaled antimicrobial agents administered alone or in conjunction with parenteral antibiotics for the management of VAP in critically ill patients. Indeed, more data are needed to establish the appropriate role of inhaled antibiotics for the treatment of VAP.

The effect of intraoperative lavage with short chain fatty acids (SCFAs) on rectal anastomosis of rats receiving corticosteroids.

BACKGROUND: Anastomotic failure is one of the most frequent complications in rectal surgery. The present study aims to elucidate the effect of intraoperative lavage with short chain fatty acids (SCFAs) on rectal anastomosis of rats receiving corticosteroids. METHODS: Fifty male Wistar rats were divided into five groups. Group A (control group, without lavage and medication), group B (lavage with saline solution and no medication), group C (lavage with SCFAs and no medication), group D (lavage with saline solution and injection of 30mg/kg methylprednisolone 7 days pre-operatively and 4 days post-operatively), group E (lavage with a SCFAs and methylprednisolone). On the 4(th) postoperative day the animals were sacrificed and bursting pressure of the anastomosis, CRP, IL-6 and TNF-a were measured. RESULTS: Kruskal-Wallis variance analysis showed statistically significant differences between the groups (p<0.001). The bursting pressure of the anastomosis was lower in groups B and D, while it was higher in group C. TNF-a values displayed differences between group D and groups A, C, E. CONCLUSIONS: Intraoperative lavage with SCFAs increases anastomotic strength by increasing the bursting pressure of anastomosis in rats receiving corticosteroid, while lavage with saline solution decreases it. Rectal irrigation with short-chain fatty acids may improve anastomotic healing, especially in patients receiving corticosteroids.

Multi-drug-resistant gram-negative bacterial infection in surgical patients hospitalized in the ICU: a cohort study.

We sought to identify risk factors for postoperative infections, caused by multi-drug-resistant gram-negative bacteria (MDR-GNB) in surgical patients. This was a retrospective cohort study among patients hospitalized in the intensive care unit (ICU) for more than 5 days, following general surgical operations. Comparison of patients who developed infection caused by MDR-GNB with the remainder of the cohort showed that every minute of operative time, use of special treatments during hospitalization (antineoplastic, immunosuppressive or immunomodulating therapies), every day of metronidazole, and every day of carbapenems use, increased patients' odds to acquire an infection caused by MDR-GNB by 0.7%, 8.9 times, 9%, and 9%, respectively [OR (95% CI): 1.007 (1.003-1.011), p = 0.001; 8.9 (1.8-17.3), p = 0.004; 1.09 (1.04-1.18), p = 0.039; 1.09 (1.01-1.18), p = 0.023, respectively]. The above were adjusted in the multivariable analysis for the confounder of time distribution of infections caused by MDR-GNB. Finally, the secondary comparison, with patients that did not develop any infection, showed that patients who had received antibiotics, within 3 months prior to admission, had 3.8 times higher odds to acquire an infection caused by MDR-GNB [OR (95% CI): 3.8 (1.07-13.2), p = 0.002]. This study depicts certain, potentially modifiable, risk factors for postoperative infections in patients hospitalized in the ICU for more than 5 days.

Surgical management of rectal prolapse.

PURPOSE: Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Full-thickness rectal prolapse, mucosal prolapse and internal prolapse are three different clinical entities, which are often combined and constitute rectal prolapse. The aim of the study is to present our experience in the surgical management of rectal prolapse. METHODS: In a 6-year period (2004-2010), 27 patients were surgically treated for rectal prolapse. The majority of patients were women (25 women, two men) and their mean age was 72.36 years. The operations performed were two Delorme's procedures, five STARR (Stapled TransAnal Rectal Resection), 14 Wells procedures, two Wells combined with Thiersch, one Altemeier, one sigmoid resection combined with Wells and two Thiersch. RESULTS: An emergency sigmoidostomy was performed on a patient after Wells operation due to obstructive ileus. One death occurred on the 5th postoperative day due to pulmonary embolism. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation and one in a patient after Thiersch technique. The great majority of patients are completely relieved of symptoms. CONCLUSIONS: The application of different modalities in the treatment of rectal prolapse is attributed to the fact that cause, degree of prolapse and symptoms, vary from one patient to another. Successful approach depends on many factors, including the status of a patient's anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient.

A retrospective analysis of 2000 cases with colorectal carcinoma.

PURPOSE: Colorectal cancer (CRC) is a major cause of death in the western world and a leading cause of cancer-related death. It is one of the most common human malignancies with >300,000 cases both in the United States and in the European Union each year. The present study was conducted to assess differences in various variables of CRC, such as location of the tumor, differentiation, Dukes classification, 5-year survival and possible changes in these patterns during the examined period. METHODS: We collected data on 2000 patients with colorectal cancer, diagnosed and treated from 1960 to 2008 in 1st Propedeutic Surgical Clinic of Aristotle's University, Thessaloniki. RESULTS: Of 2000 cases reviewed, cancer was almost equal presented to both sexes, for all groups. Rectum was the most common tumor location in all analyzed groups (40.1%). The most common tumor differentiation was the moderate one (68.5%). Concerning tumor staging, Dukes' B tumors were most common (42.5%), and the cancer-related 5-year survival was increased by the time from 42 to 71%. CONCLUSION: In the past 20 years, considerable improvements have been made in colorectal cancer therapy, and patients had received more sophisticated and multidisciplinary treatments, resulting in a better 5-year survival rate.

Rectal endometriosis: a case report.

We present the case of a 45-year-old female patient who was admitted with a history of pelvic pain, constipation, and dysmenorrhea. CT scan and u/s images revealed cholelithiasis, benign nodular hyperplasia of segment IV of the liver and uterine fibromyoma. During laparotomy, firm adhesions between the posterior wall of the uterus and the rectum were found and the incisional biopsy reveals an undifferentiated adenocarcinoma. Then, total resection of the uterus was performed with en block resection of the adherent part of the rectum and part of the posterior wall of the vagina. The final histopathological report showed the presence of uterine fibromyoma, nodular hyperplasia of the liver and rectal endometriosis without any sign of malignancy. The patient after 5 years of follow up remains healthy. Rectal endometriosis represents an uncommon localization of pelvic endometriosis where the symptoms and clinical findings are non-specific making the definitive preoperative diagnosis difficult. Endometriosis should be included in the differential diagnosis of chronic pelvic pain in combination with defecation disorders in female patients of reproductive age.

Gossypiboma presenting as mesosigmoid abscess [corrected].

INTRODUCTION: The term "gossypiboma" is used to describe any mass of non-absorbable surgical material. It is estimated that this complication appears every 1.000-10.000 procedures. It may lead to peritonitis, acute abdominal pain, intraperitoneal abscess, bowel obstruction, or perforation. REPORT OF A CASE: We present the case of an 80-year-old female patient admitted for chronic abdominal pain and fever. A CT scan and MRI were performed with a probable diagnosis of carcinoma or pelvic abscess. A surgical history of hysterectomy and repair of abdominal wall hernia with a mesh were mentioned. RESULTS: Exploratory laparotomy revealed the presence of an irregular, soft mass with characteristics of an abscess located into the mesosigmoid. Hartman's sigmoidectomy was performed, and the patient's postoperative course was uneventful. The histopathological examination confirmed the diagnosis of gossypiboma. CONCLUSIONS: Retained foreign intraperitoneal materials often represent diagnostic dilemmas, since symptomatology is no specific and the time elapsed from surgery is long. The policy of prevention's importance is highly appreciated.

Surgical management of colorectal injuries: colostomy or primary repair?

PURPOSE: Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not. METHODS: From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair. RESULTS: The patients were five men and five women, with median age 40 years (20-55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients. CONCLUSIONS: Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

Changes in treatment of rectal cancer: increased use of low anterior resection.

PURPOSE: The most common surgical procedures for patients with rectal cancer are low anterior resection (LAR) or abdominoperineal excision (APE). The aim of the present study is to evaluate and report the changes in the incidence of LAR and APE in the surgical treatment of rectal cancer over the last 15 years in a single surgical department. METHODS: The patient sample consisted of 251 consecutive patients (mean age 65.17; age range 22-87) that underwent surgical treatment for rectal cancer in a single center from 1996 to 2010. This time frame was divided into three 5-year periods (1996-2000, 2001-2005 and 2006-2010). Patients were classified into one of the aforementioned groups, depending on the date of their treatment. RESULTS: In the first period (1996-2000), 71 patients were treated for rectal cancer. Among them, 32.4% (n = 23) underwent an abdominoperineal excision (APE) while 56.3% (n = 40) were treated with LAR. In the second period (2001-2005), included 102 patients, from which 29.4% (n = 30) received an APE and 60.8% (n = 62) underwent a LAR for their disease. In the final period (2006-2010), from the 78 patients, only 12.8% (n = 10) of them underwent APE, while 74.3% (n = 58) were treated with LAR. There was a statistically significant (chi-square test, P = 0.005) difference between the 3 periods of time concerning the performance of LAR and APE. CONCLUSIONS: According to the results of the present study, the rates of APE seem to decrease during the last 15 years, while LAR is more widely used in the surgical treatment of rectal cancer.

Inflammation of solitary caecal diverticula:a rare aetiology of acute abdominal pain [corrected].

Caecal diverticula are rare, representing the 3.6% of colonic diverticula. They may have congenital origin and remain asymptomatic, presenting as an accidental finding. We present a case of a 42-year-old Caucasian woman, admitted with a 12-h history of sudden onset of sharp right iliac fossa pain, anorexia, and nausea. There was leukocytosis (23.49 × 10(3)/µl) and increased C-reactive protein (11.76 mg/dl). CT scan showed an inflamed appendix. At laparotomy, a diffuse caecal phlegmon with an inflammatory solitary caecal diverticula was found. A limited right hemicolectomy was performed. Histological examination confirmed the caecal diverticulitis without malignancy. Post-operative period was uneventful. Three months later, endoscopy showed no diverticula or other pathologies. Solitary caecal diverticulum is very rare, but surgeons must bear this in mind in case of pain in right iliac fossa.

Contrasts and synergies in different biofuel reports.

The societal debate on biofuels is characterised by increased complexity. This can hinder the effective governance of the field. This paper attempts a quantitative bird's eye meta-analysis of this complexity by mapping different stakeholder perspectives and expected outcomes as seen in the secondary literature on biofuels, along the lines of the People-Planet-Profit framework. Our analysis illustrates the tension between stated and actual drivers of large scale biofuel development, especially for first generation biofuels. Although environmental (Planet) aspects have dominated the biofuel debate, their overall assessment is mostly negative with regard to first generation biofuels. By contrast, economic (Profit) aspects are the only ones that are assessed positively with regard to first generation biofuels. Furthermore, positive and negative assessments of biofuel development are strongly influenced by the differences in focus between different stakeholder clusters. Stakeholders who appear generally supportive to biofuel development (industry) focus relatively more on aspects that are generally assessed as positive (Profit). By contrast, non-supportive stakeholders (NGO's) tend to focus mainly on aspects that are generally assessed as negative (Planet). Moreover, our analysis of reference lists revealed few citations of primary scientific data, and also that intergovernmental organizations produce the most influential publications in the debate. The surprising lack of listed references to scientific (primary) data reveals a need to assess in which arena the transition of scientific data towards secondary publications takes place, and how one can measure its quality. This work should be understood as a first effort to take some control over a complex and contradictory number of publications, and to allow the effective governance of the field through the identification of areas of overlapping consensus and persisting controversy, without reverting to claims on technical detail.

Ileal pouch dysfunction.

The causes of pouch dysfunction are inflammatory, non-inflammatory and iatrogenic. The most common long-term complication is pouchitis. Diagnosis should be based on clinical symptoms, endoscopic appearance and histologic findings. Ciprofloxacin and metronidazole are the treatment of choice for pouchitis. Fistulae and perianal abscesses should be suspected to be an expression of misdiagnosed Crohn's disease. Strictures are confronted by endoscopic balloon dilatation. Patients who will be refractory to all forms of medical treatment should have surgical treatment such as faecal diversion or pouch revision.

The use of fibrin glue in the treatment of complex perianal fistulae: a case report.

We present a 71-year-old man with a horseshoe, complex perianal fistula. He was treated by a simple fistulotomy for the fistula at sixth hour, while fibrin sealant was applied for the complicated one. He is free of symptoms 24 months postoperatively.

Perianal fistulas.

The most common cause of anal fistula is anal gland sepsis, resulting in formation of anorectal abscess, particularly if the latter allowed bursting spontaneously or has been inadequately opened at operation. Surgical treatment of the fistula must intent to its healing or simply its drainage or its transformation to a simpler one. Superficial, low transsphincteric and intersphincteric fistulas are treated by the lay-open technique. The use of a loose seton allows time for any sepsis and induration to settle before a decision about further treatment is made. Also, the use of a tight seton in the management of complex fistula may avoid an early muscle division before any tissue scarring happened. The patient with a perianal fistula must have a steady trustful relationship with his surgeon and must be fully informed on the therapeutic plan and reassured for a favourable outcome.

Colonic cancer in a patient with intestinal malrotation: a case report.

We present a case of a 76-year-old patient with intestinal malrotation, with incomplete rotation of the small intestine and abnormal positioning of the duodenum and superior mesenteric vessels over the transverse colon. Furthermore, the patient suffered of a concomitant cancer of the ascending colon.