Obturator hernias: a systematic review of the literature.

PURPOSE: Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate. METHODS: After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined. RESULTS: A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair. CONCLUSION: OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.

Could FiLaC™ be effective in the treatment of anal fistulas? A systematic review of observational studies and proportional meta-analysis.

AIM: Fistula Laser Closure (FiLaC™) is a novel sphincter-preserving technique that is based on new technologies and shows promising results in repairing anal fistulas whilst maintaining external sphincter function. The aim of the present meta-analysis is to present the efficacy and the safety of FiLaC™ in the management of anal fistula disease. METHOD: The present proportional meta-analysis was designed using the PRISMA and AMSTAR guidelines. We searched MEDLINE, Scopus, clinicaltrials.gov, Embase, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar databases from inception until November 2019. RESULTS: Overall, eight studies were included that recruited 476 patients. The pooled success rate of the technique was 63% (95% CI 50%-75%). The pooled complication rate was 8% (95% CI 1%-18%). Sixty-six per cent of patients had a transsphincteric fistula and 60% had undergone a previous surgical intervention, mainly the insertion of a seton (54%). The majority had a cryptoglandular fistula. Operation time and follow-up period were described for each study. CONCLUSION: FiLaC™ seems to be an efficient therapeutic option for perianal fistula disease with an adequate level of safety that preserves quality of life. Nevertheless, randomized trials need to be designed to compare FiLaC™ with other procedures for the management of anal fistulas such as ligation of intersphincteric fistula tract, anal advancement flaps, fibrin glue, collagen paste, autologous adipose tissue, fistula plug and video-assisted anal fistula treatment.

Is the laparoscopic approach a safe choice for the management of acute appendicitis in pregnant women? A meta-analysis of observational studies.

INTRODUCTION: Acute appendicitis is a common and serious situation during pregnancy, because of the increased risk of fetal loss and perforation in the third trimester, as well as a diagnostic difficulty. During recent years laparoscopic approach has been introduced to clinical practice with encouraging results. The purpose of this meta-analysis is to compare the surgical and obstetrical outcomes between laparoscopic and open appendectomy during pregnancy. MATERIALS AND METHODS: MEDLINE, SCOPUS, Clinicaltrials.gov, CENTRAL and Google Scholar were searched for studies reporting on postoperative outcomes between laparoscopic and open appendectomy during pregnancy. The random effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when high heterogeneity was encountered, otherwise the fixed-effects (Mantel-Haenszel) model was implemented. RESULTS: Twenty-one studies that enrolled 6276 pregnant women are included in the present meta-analysis. Of these women, 1963 underwent laparoscopic appendectomy and 4313 underwent an open appendectomy. Women who underwent laparoscopic appendectomy demonstrated an increase in fetal loss risk, while neonates of women that underwent open appendectomy presented decreased Apgar score at five minutes after birth. All the rest outcomes were similar between the two groups. The time that each study took place seemed to affect the comparison of birth weight and postoperative hospital stay between the two groups. CONCLUSION: Laparoscopic appendectomy seems to be a relatively safe therapeutic option in pregnancy when it is indicated. Thus, it should be implemented in clinical practice, always considering the experience of the surgeon in such procedures. Nevertheless, the need of new studies to enhance this statement remains crucial.

Current clostridium difficile treatments: Lessons that need to be learned from the clinical trials.

Clostridium difficile infection (CDI) is the most common infectious disease cause of nosocomial diarrhea in adults in developed countries. Judging from the clinical trials on drugs used in CDIs, no approved treatment for recurrences exists, possibly indicating that a combination of treatment approaches are mandatory especially in severe infections, with current studies not being fully representative. Among the new strategies researched intensively fidaxomicin is presented, which demonstrates reduced CDI recurrences. Moreover, biotherapeutic strategies, mainly fecal microbiota transplantation but also competitive inhibition with non-toxigenic strains of C. difficile, and finally monoclonal antibodies against C. difficile toxins which offer protection against recurrences. Careful interpretation of the results based on lessons learned from previous trials conducted seems crucial. Questions are raised regarding how the results of future studies regarding new strategies researched will be managed and interpreted especially with regard to recurrence management as relevant data must be monitored for at least 30 days after end of treatment.

Targeting histone deacetylases in endometrial cancer: a paradigm-shifting therapeutic strategy?

OBJECTIVE: Endometrial cancer is increasingly prevalent in western societies and affects mainly postmenopausal women; notably incidence rates have been rising by 1.9% per year on average since 2005. Although the early-stage endometrial cancer can be effectively managed with surgery, more advanced stages of the disease require multimodality treatment with varying results. In recent years, endometrial cancer has been extensively studied at the molecular level in an attempt to develop effective therapies. Recently, a family of compounds that alter epigenetic expression, namely histone deacetylase inhibitors, have shown promise as possible therapeutic agents in endometrial cancer. The present review aims to discuss the therapeutic potential of these agents. MATERIALS AND METHODS: This literature review was performed using the MEDLINE database; the search terms histone, deacetylase, inhibitors, endometrial, targeted therapies for endometrial cancer were employed to identify relevant studies. We only reviewed English language publications and also considered studies that were not entirely focused on endometrial cancer. Ultimately, sixty-four articles published until January 2018 were incorporated into our review. RESULTS: Studies in cell cultures have demonstrated that histone deacetylase inhibitors exert their antineoplastic activity by promoting expression of p21WAF1 and p27KIP1, cyclin-dependent kinase inhibitors, that have important roles in cell cycle regulation; importantly, the transcription of specific genes (e.g., E-cadherin, PTEN) that are commonly silenced in endometrial cancer is also enhanced. In addition to these abstracts effects, novel compounds with histone deacetylase inhibitor activity (e.g., scriptaid, trichostatin, entinostat) have also demonstrated significant antineoplastic activity both in vitro and in vivo, by liming tumor growth, inducing apoptosis, inhibiting angiogenesis and potentiating the effects of chemotherapy. CONCLUSIONS: The applications of histone deacetylase inhibitors in endometrial cancer appear promising; nonetheless, additional trials are necessary to establish the therapeutic role, clinical utility, and safety of these promising compounds.

Minimally invasive management of hepatic cysts: indications and complications.

OBJECTIVE: Liver cysts are divided into congenital and acquired. Congenital cystic lesions include polycystic liver disease, simple cysts, duct related and ciliated hepatic foregut cysts. Acquired cystic lesions are divided into infectious and non-infectious. The infectious cysts are the hydatid cyst, the amoebic abscess, and the pyogenic abscess, whereas the non-infectious cysts are neoplastic cysts and false cysts. While modern medicine provides a lot of minimally invasive therapeutic modalities, there has emerged a pressing need for understanding the various types of liver cysts, the possible minimal therapeutic options along with their indications and complications. We aim is to clarify the role of minimally invasive techniques in the management of hepatic cysts. MATERIALS AND METHODS: A literature review was performed using the MEDLINE database. The search terms were: liver cyst, minimally invasive, laparoscopic, percutaneous, drainage and fenestration. We reviewed 82 English language publications articles, published until October 2017. RESULTS: Minimally invasive management of liver LC is an emerging field including many therapeutic modalities ranging from the percutaneous aspiration of pyogenic abscesses to laparoscopic hepatectomy for hepatic cystadenomas. The most used techniques are percutaneous drainage, laparoscopic fenestration, and laparoscopic hepatectomy. CONCLUSIONS: The application of the various minimally invasive approaches, as well as their indication and complications, depend on the type of the cystic lesion, its size and its position in the liver. Percutaneous drainage is mostly used in simple cysts, hydatid cysts, pyogenic abscesses and bilomas. Laparoscopic fenestration is mostly used in simple cysts and polycystic liver disease. Finally, laparoscopic hepatectomy is mostly used in polycystic liver disease, hydatid cysts, and cystadenomas.

Postoperative deep wound dehiscence of thoracotomy with isolation of Corynebacterium tuberculostearicum: surgical site infection or colonization?

OBJECTIVE: Infections with Corynebacterium tuberculostearicum are very rare as in most of the cases its isolation is associated with tissue colonization rather than infection. CASE REPORT: An 80-year old female patient was sent to the consultation hour of thoracic surgery for evaluation of a symptomatic persistent unilateral pleural effusion of her right lung. The differential diagnosis included either the presence of a chronic pleural empyema or the presence of malignancy. After excluding a malignancy, a decortication of the middle and lower lobe was performed, as the two lobes could not significantly re-expand. The course was further complicated by the presence of two-times deep wound dehiscence, which made necessary a rethoracotomy. The microbiologic results of the biopsies revealed the presence of only Corynebacterium tuberculostearicum with an initially questionable clinical relevance. As soon as the antibiotic treatment for Corynebacterium tuberculostearicum began, together with the use of vacuum-assisted therapy (VAC), the closure of the thoracotomy was accelerated. CONCLUSIONS: Clinically relevant surgical site infections with Corynebacterium species in thoracic surgery are difficult to distinguish. Nevertheless, its combined surgical and antibiotic treatment is warranted when its relevance is questionable due to its resistance to broad-spectrum antibiotics as well as to its potential for the complicated clinical course.

Cystic hygroma of the neck: single center experience and literature review.

OBJECTIVE: Malformations of the lymphatic system are recognized as benign congenital tumors that affect infant and children in the perinatal era. In children, these abnormalities usually found in the neck and the axillary region, but they can present in other parts of the body such as mediastinum, pelvis, retroperitoneum as well as in solid organs (e.g., adrenal glands, pancreas, stomach). Our aim is to report our experience on cystic hygromas via two cases and review the literature. MATERIALS AND METHODS: Herein we present two cases of cystic hygroma, the first of female children and the second of a female adult patient respectively. Both of these patients underwent surgical excision of the masses. RESULTS: After the procedure, both patients have recovered well, and no recurrence of the lesion has been noted during the follow-up period. CONCLUSIONS: Surgical treatment remains the gold-standard treatment for these tumors, while other modalities have been used with mixed results.

Nestin and CD146 expression in metaplastic breast cancer: stem-cell therapy in need? Lessons reported from a male patient.

OBJECTIVE: Metaplastic breast carcinomas represent a rare subtype of breast cancer exhibiting aggressive clinical features. They appear as highly chemoresistant tumors, therefore showing poor outcome and high rates of local recurrence or distant metastasis. CASE REPORT: A 37-year-old greek man was referred to our hospital for evaluation of a locally advanced, ulcerated, fixed, irregular and hard in consistency mass covering his left breast and chest wall. Further work out with CT and biopsy of the tumor revealed a triple negative metaplastic breast cancer classified as cT4cN3cM1. The patient received first line chemotherapy and afterward a palliative resection of the tumor. The histology revealed the presence of a combined triple negative adenocarcinoma with a predominant metaplastic squamous carcinoma and a spindle cell (sarcomatoid) carcinoma of the breast. In the tissue sample stem cell markers, nestin and CD146 (MCAM) were expressed, enhancing the theory that cancer cells of this tumor could possibly harbor stem cell properties. The patient received several chemotherapy regimens but died 6 months after the initiation of treatment. CONCLUSIONS: Metaplastic breast cancer consists of cells with stem cell properties. New targeted therapies are warranted in the view of the tumor's high resistance to conventional chemotherapy. Targeting nestin and CD146 might be a promising therapy as they seem to be implicated in the EMT pathway.

HIV patient with pseudomyxoma peritonei of extra-appendiceal origin is disease-free and alive 9 years after complete cytoreductive surgery.

OBJECTIVE: Pseudomyxoma peritonei (PMP) is a clinical syndrome that is mainly characterized by the presence of mucinous ascites that results from the rupture of a mucin-producing neoplasm. No reports exist so far regarding the management of this syndrome in HIV patients. CASE REPORT: A 54-year old male patient with a diagnosed atypical colitis developed additionally over time a complicated diverticulitis which was initially treated conservatively with antibiotics. Due to septic complication, the patient received a Hartmann resection. Six months after the first surgery a Hartmann reversal was tried; it, however, revealed peritoneal implants and a significant stenosis of the colon stump. Resection of these lesions confirmed histopathologically the presence of a low-grade pseudomyxoma peritonei. Five months later, a second try for a Hartmann reversal was performed. In the view of the slightly enlarged paracolic lymph nodes, a low anterior resection was performed with a primary descendorectostomy. Histopathological examination revealed no more signs of the tumor, which confirmed the completeness of the cytoreductive surgery by the first try for a Hartmann reversal. CONCLUSIONS: Completeness of cytoreductive surgery and low grade histology seem to be the most important factors for the prognosis in pseudomyxoma peritonei in immunocompromised patients as suggested by the long overall and progression free survival of the present patient.

Thyroid hormone receptor alpha (TRa) tissue expression in ductal invasive breast cancer: A study combining quantitative immunohistochemistry with digital slide image analysis.

BACKGROUND: In breast cancer, hormonal receptors hold promise for developing novel targeted therapies. The thyroid exerts its actions via the thyroid hormone receptors alpha and beta. The clinical significance of the expression of thyroid hormone receptors in breast cancer is unclear. MATERIAL AND METHODS: We studied thyroid hormone receptor alpha (TRa) expression in 82 samples from 41 women with ductal invasive breast cancer and no thyroid disease. We performed quantitative immunohistochemistry with digital image analysis and correlated TRa expression with clinicopathological parameters. RESULTS: TRa was expressed in both normal breast epithelium and breast cancer, but expression in breast cancer was significantly lower. TRa was expressed significantly less in larger and grade III tumors. Conversely, breast cancers with lymphovascular invasion showed increased TRa expression compared to cancers without lymphovascular invasion. TRa expression was not significantly different between node-positive and node-negative breast cancers, or among different hormonal profiles and intrinsic subtypes. DISCUSSION: This is the first-in-human study to combine quantitative immunohistochemistry with image analysis to study TRa expression in women with ductal invasive breast cancer and no clinical or biochemical evidence of thyroid dysfunction. We confirm that TRa is expressed in both normal and malignant breast epithelium and suggest that TRa expression is downregulated during breast carcinogenesis. Larger and higher grade breast cancers demonstrate partial loss in TRa expression. Alterations in TRa expression take place even in the absence of clinical or biochemical thyroid disease. The underlying mechanism of these findings and their potential significance in survival and relapse mandate further research.

Large thoracic tumour without superior vena cava syndrome.

A 62-year-old male with long-standing smoking history presented with haemoptysis. Plain chest X-ray showed abnormal findings proximate to the right pulmonary hilum. Bronchoscopy revealed a fragile exophytic tumour of the right wall of the lower third of the trachea, infiltrating the right main bronchus (75% stenosis) and the right upper lobar bronchus (near total occlusion). Contrast-enhanced chest computed tomography demonstrated a 7.2 × 4.9 cm tumour contiguous to the above-mentioned structures, mediastinal lymph node pathology, and a vessel coursing inferiorly to the left of the aortic arch and anterior to the left hilum. Despite the tumour constricting the right superior vena cava (SVC), no signs of SVC syndrome were present. In this case, the patient does not present with SVC syndrome, as expected due to the constriction of the (right) SVC caused by the tumour, since head and neck veins drain through the persistent left superior vena cava (PLSVC). PLSVC is the most common thoracic venous anomaly with an incidence of 0.3% to 0.5% of the general population and it is a congenital anomaly caused by the failure of the left anterior cardinal vein to regress and to consequently form the ligament of Marshall during foetal development. It is associated with absence of the left brachiocephalic vein and in 10% to 20% of cases the right SVC is absent. Two potential draining points of the PLSVC have been previously reported. In the majority of cases PLSVC drains directly into the coronary sinus, but less frequently it drains into the left atrium or the left superior pulmonary vein (LSPV). In cases where the PLSVC drains into the coronary sinus, congenital heart defects are rare. The patient usually remains asymptomatic and PLSVC is an incidental finding during radiographic imaging or medical procedures. When the PLSVC drains into the left atrium or the LSPV, a right-to-left shunt is formed; a condition usually asymptomatic. In some reported cases this PLSVC variant presents with persistent, unexplained hypoxia or cyanosis and embolisation causing recurrent transient ischaemic attacks and/or cerebral abscesses. This PLSVC variant is more often associated with absence of the right SVC and congenital heart abnormalities.

The potential effect of biological sealants on colorectal anastomosis healing in experimental research involving severe diabetes.

Colorectal anastomoses continuous to pose a significant challenge in current surgical practice. Anastomotic leakage remains one of the most frequent and dramatic complications of colorectal surgery, even in centres of high specialisation. Diabetes is a well-established independent factor which results in higher anastomotic leakage rates. Fibrin sealants have been applied in experimental and clinical studies for the prevention of anastomotic dehiscence. However, little is known regarding their impact on diabetic patients. Several fibrin sealants have been proposed as adjunct to standard surgical techniques to prevent leakage from colonic anastomoses following the reversal of temporary colostomies, approved for general haemostasis. This review summarises current advances in colorectal anastomoses and provides evidence that may strengthen the need for tissue sealants in colorectal anastomoses of diabetic patients. We searched Medline (1966-2016) and Scopus (2004-2016) for current evidence in the field. To date, there is no evidence to support the use of fibrin sealants as an adjunct in diabetic patients who undergo colorectal surgery. Experimental animal models with extreme diabetes could be of significant use in the present field and further research is needed prior to application of fibrin sealants in a clinical setting.

An unexpected metastasis of breast cancer mimicking wheal rush.

Breast cancer is the most common cancer among women and ranks second in cancer deaths worldwide. Breast cancer can metastasize to the skin but rarely, cutaneous metastases may be the first indication of the cancer. Skin metastases of breast cancer are usually found on the chest and close to the point of the mastectomy. We present the rare clinical entity of a breast cancer which was first diagnosed due to the skin metastasis away from the breast tumor. This is a rare case because the skin lesions usually appear simultaneously or secondary. Also, while the existing metastasis; the only symptom was the wheal rash.

The role of ThinPrep cytology in the investigation of ki-67 index, p53 and HER-2 detection in fine-needle aspirates of breast tumors.

PURPOSE: The aim of the current study was to compare the immunocytochemical expression of ki-67, HER-2 and p53 on ThinPrep (TP)-processed smears, obtained by preoperative fine-needle aspiration (FNA) biopsies from primary breast carcinoma with the immunohistochemical results obtained on the corresponding surgical samples. METHODS: FNA biopsies were collected from 119 female patients during a 31-month period. Subsequently, these patients underwent surgical resection of the tumors. RESULTS: The overall accuracy (OA) of the TP cytology for ki-67, p53 and HER-2 expression was 96, 99 and 97%, respectively. There was a strong positive correlation between immunohistochemistry and immunocytochemistry results for ki-67 (Spearman's test 0.875) for p53 (Cramer's phi test 0.965) and HER-2 (Kendall's tau test 0.891). CONCLUSION: This pilot study demonstrates that it is possible to monitor multiple molecular markers by using the TP cytology. Sample collection and storage is simple and permits the assortment of the FNA sample for both morphologic diagnosis and ancillary studies. The accuracy of TP technique in the evaluation of ki-67, p53 and HER-2 expression is comparable to those of the histological evaluation, and could be of paramount importance for the preoperative planning of treatment.

Glottic and supraglottic laryngeal cancer: epidemiology, treatment patterns and survival in 164 patients.

PURPOSE: To evaluate the effectiveness of different therapeutic managements in relation to clinical disease stage, the location of the lesion and to register the rate of disease recurrence of patients with glottic and supraglottic laryngeal cancer, and to also study some specific epidemiologic characteristics. METHODS: A series of 164 patients with laryngeal glottic and supraglottic squamous cell cancer (SCC) treated surgically, with radiation therapy (RT), chemotherapy or combination of these was analysed. After treatment, all patients were followed up for an average of 58 months. All data concerning the primary lesion, therapeutic management, recurrence, staging, 5-year overall survival and epidemiological characteristics such as smoking and alcohol abuse were recorded and analysed in combination with the follow up data. RESULTS: The therapeutic approach most commonly used was RT for stage I tumors and surgery for stages II, III and IV. Stage I and II patients treated with RT had high recurrence rate (60%). Patients with recurrence had 45.3% 5-year overall survival rate and average survival time 80 months, whereas patients with no recurrence had 77.4% 5-year overall survival rate and average survival time 173 months (p=0.0001). There was significant difference in survival between stage I and III (p=0.035), stage I and IV (p=0.0038) and stage II and IV (0.0156). The average overall survival time for non smokers was 195 months (median 1707rpar;, while for smokers it was 99 months (median 100; p=0.0047). The average overall survival time for alcohol abusers was 79 months (median 54), while for those who did not use alcohol it was 153 months (median 150; p=0.016). CONCLUSION: The 5-year overall survival rate was 61.3%. RT alone in stages I and II proved inferior in decreasing re-currences compared with surgery. Smokers had significantly shorter overall survival.

Dermatofibrosarcoma: a rare form of soft tissue. Management and review of the literature.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft tissue tumor of cutaneous origin of intermediate grade malignant potential. The incidence of DFSP is 0.1% of all cancers and 1% of all soft tissue sarcomas. We present the case of a 65years old female with a palpable, painful mass on the right thigh. A surgical excision of the lesion was done and the histopathology, as well as the immunohistochemical analysis with CD-34, confirmed the diagnosis of DFSP. Two years later, the patient is free of disease and no local recurrences or metastases have been found. Wide radical excision is the preferred surgical method for therapy of DFSP without distant metastasis. Furthermore, DFSP resists to conventional chemotherapy and radiation therapy, while, in cases of metastasis, therapy depends on cytogenesis and molecular biology of the tumor, so new therapeutic strategies are under research.

Gastrointestinal carcinoid tumors: diagnosis and treatment.

Carcinoid tumors are malignancies originating from neuroendocrine cells, most commonly encountered in the gastrointestinal tract, in a rate of 64%, with the majority affecting the ileum. Certain genetic syndromes sometimes include carcinoid tumors in their phenotype. These malignancies may be rather asymptomatic, although occasionally they behave aggressively. They are typically diagnosed due to the effects of a locally advanced disease, or when producing symptoms because of hormone secretion (carcinoid syndrome). A better understanding of their molecular biology and behavior is demanded so that these tumors to be diagnosed precociously and managed effectively.

Wilkie syndrome. What is this?

Superior mesenteric artery syndrome is extremely rare and is characterized by postprandial epigastric pain, nausea, vomiting and loss of appetite, with subsequent weight loss, which aggravates the condition of the patients. The syndrome is caused by compression of the third part of the duodenum in the angle between the aorta and the superior mesenteric artery. This review updates etiology, epidemiology, diagnosis, treatment and outcome of the superior mesenteric artery syndrome. Superior mesenteric artery syndrome is clearly defined and frequently associated with a wide range of predisposing conditions and surgical procedures.