The role of extended resection in locally recurrent colorectal cancer with invasion of the aortoiliac bifurcation: a rare clinical case.

Colorectal carcinoma (CRC) is the third most common cancer and the fourth deadliest. Despite recent advances in screening methods and preoperative imaging techniques, the threat of colorectal cancer remains at an all-time high. Moreover, even after curative treatment, disease recurrence occurs in up to 40% of all cases. However, half of patients with recurrent disease do not register any distant metastases. Therefore, much effort should be expended in identifying and evaluating these patients, as many of them are suitable candidates for en bloc resections with perioperative chemoradiation. In fact, it has recently been found that overall survival benefits greatly from extended resections, provided that free margins are achieved intraoperatively. In this case report, we will present a case of locally advanced recurrent colorectal cancer invading the aortoiliac axis and our approach to achieving a R0 resection.

Future of prostate imaging: Artificial intelligence in assessing prostatic magnetic resonance imaging.

Prostate cancer (Pca; adenocarcinoma) is one of the most common cancers in adult males and one of the leading causes of death in both men and women. The diagnosis of Pca requires substantial experience, and even then the lesions can be difficult to detect. Moreover, although the diagnostic approach for this disease has improved significantly with the advent of multiparametric magnetic resonance, that technology has certain unresolved limitations. In recent years artificial intelligence (AI) has been introduced to the field of radiology, providing new software solutions for prostate diagnostics. Precise mapping of the prostate has become possible through AI and this has greatly improved the accuracy of biopsy. AI has also allowed for certain suspicious lesions to be attributed to a given group according to the Prostate Imaging-Reporting & Data System classification. Finally, AI has facilitated the combination of data obtained from clinical, laboratory (prostate-specific antigen), imaging (magnetic resonance), and biopsy examinations, and in this way new regularities can be found which at the moment remain hidden. Further evolution of AI in this field is inevitable and it is almost certain to significantly expand the efficacy, accuracy and efficiency of diagnosis and treatment of Pca.

Prophylactic Central Neck Lymph Node Dissection Adds No Short-Term Benefit to Total Thyroidectomy for Differentiated Thyroid Cancer.

Background and Objectives: To answer the research question: "Is prophylactic central neck lymph node dissection (pCNLD) beneficial among differentiated thyroid carcinoma (DTC) patients?" Materials and Methods: This was a retrospective cohort study enrolling DTC patients treated at the University Hospital Kaspela, Bulgaria, from 30 January 2019 to October 2021. The predictor variable was presence of pCNLD (total thyroidectomy with vs. without pCNLD). The main outcome variables were postoperative complications (i.e., vocal cord paralysis, hypoparathyroidism, postoperative bleeding, and adjacent organ injury) and recurrence parameters. Appropriate statistics were computed with the significant level at p ≤ 0.05. Results: During the study period, 300 DTC patients (59.7% with pCNLD; 79.3% females) with an average age of 52 ± 2.8 years were treated. The mean follow-up period of the entire cohort was 45.8 ± 19.1 months. On bivariate analyses, TT with pCNLD, when compared to TT alone, required longer surgical time (mean difference: 9.4 min), caused nearly similar complications (except transient hypothyroidism: p = 0.04; relative risk, 1.32; 95% confidence interval, 1.0 to 1.73), and no significantly different recurrence events, time to recurrence, and recurrent sites. The benefit-risk analyses using the number needed to treat and to harm (NNT; NNH) also confirmed that TT plus pCNLD was not very beneficial in DTC management. Conclusion: The results of this study refute the benefit of pCNLD in DTC patient care with TT. Further well-designed studies in a larger cohort with a longer follow-up period are required to confirm this conclusion.

Clinical Outcomes of EUS-Guided Choledochoduodenostomy for Biliary Drainage in Unresectable Pancreatic Cancer: A Case Series.

Introduction. Pancreatic ductal adenocarcinoma (PDA) is associated with poor prognosis and 98% loss-of-life expectancy. 80% of patients with PDA are unfit for radical surgery. In those cases, emphasis is set on management of cancer-related symptoms, among which obstructive jaundice is most common. Endoscopic ultrasound-guided biliary drainage (EUS-BD) emerges as a valid alternative to the well-accepted methods for treatment of biliary obstruction. Patient Selection. Five consecutive patients with unresectable pancreatic malignancy, were subjected to EUS-BD, particularly EUS-guided choledochoduodenostomy (EUS-CDS). Ethics. Oral and written informed consent was obtained in all cases prior procedure. Technique. EUS-guided puncture of the common bile duct was performed, followed by advancement of a guidewire to the intrahepatic bile ducts. After dilation of the fistulous tract with a cystotome, a fully covered self-expandable metal stent was inserted below the hepatic confluence and extending at least 3 cm in the duodenum. Technical and clinical success was achieved in four patients without adverse events. In one patient procedure failed due to dislocation of the guidewire, with consequent biliary leakage requiring urgent surgery. Recovery was uneventful with no further clinical sequelae and there was no mortality associated with procedure. Discussion. Introduced in 2001, EUS-guided biliary drainage has become an accepted option for treatment of obstructive jaundice. According to recent guidelines published by European Society of Gastrointestinal Endoscopy (ESGE) in 2022, EUS-CDS is a preferred modality to percutaneous transhepatic biliary drainage (PTBD) and surgery in patients with failed ERCP, with comparable efficiency and better safety profile, which is supported by our experience with the procedure. Conclusions. Our case series suggests that EUS-CDS is an excellent option for palliative management of malignant distal biliary obstruction, emphasizes on the importance of adequate technique and experience for the technical success, and urges the need for future research on establishing the best choice for guidewire and dilation device.

Diverting ileostomy in low anterior resection: single center retrospective analysis.

<b> Introduction:</b> Low anterior resection (LAR) is the standard procedure for distal rectal cancer allowing anal sphincter preservation. Anastomotic leakage remains one of the most dangerous complications following LAR and its management is difficult. </br></br> <b>Aim:</b> This study reviews our experience of LAR with and without protective ileostomy (PI). </br></br> <b> Methods:</b> One hundred ninety-nine patients undergoing LAR resection for low rectal cancer in this centre during the period 2015-2019 were divided retrospectively into two groups. Group A underwent rectal resection and coloanal/rectal anastomosis with diverting ileostomy and group B without ileostomy. </br></br> <b> Results:</b> Among our patients, 20 had a covering ileostomy (stoma group);179 did not (control group). The stoma group comprised 14 men and 6 women ranging in age from 36 to 89 years (mean, 64.2 ± 10.5 years). Conventional v. minimally invasive surgery was 6/14. Anastomotic leakage occurred in 16/179 (8.93%) patients without a PI, and in 6/20 (30%) with a stoma (Tab. I.). Of the 16 patients experiencing an anastomotic leak, 3 (18.75%) from Group A and 5 (83.33%) from Group B were classified as Grade B leakage and were treated conservatively. As many as 13/16 (81.25%) in Group A and 1/6 (16.77%) in Group B were classified as Grade C leakage and required emergency surgery. </br></br> <b>Conclusion:</b> These results do not show a preventive effect on the occurrence of anastomotic leakage in low anterior resection, but may significantly reduce the need for further surgery due to septic complications in the early postoperative period. Selection of patients for protective ileostomy requires great care as its creation and closure are associated with severe complications.

Robotic-assisted colorectal surgery - initial results.

INTRODUCTION: The mini invasive procedure in colorectal surgery is gaining ground as an alternative to conventional surgery. Colorectal surgery has significantly evolved since the advent of the automatic stapler devices and subsequently with the minimally invasive approach. The next logical step - the robotic assisted surgery was developed to satisfy surgeons' needs to the area of colorectal surgery and to offer a new and safer method to patients. The evidence for benefits of its use in this area appears to be promising.

Prophylactic central lymph node dissection in differentiated thyroid cancer - benefits and risk.

INTRODUCTION: Papillary thyroid cancer is the most common thyroid malignancy. Lymph nodes involvement is common in differentiated thyroid cancer, and cervical lymph node micrometastases are observed in up to 85% of patients with papillary thyroid cancer during surgery. While the therapeutic central lymph node dissection has been accepted, the debate on the prophylactic in differentiated thyroid carcinoma (DTC) continues.

Comparison of short term results following robotic and laparoscopic total gastrectomy and D2 lymph node dissection.

INTRODUCTION: In the last decade, there has been a progressive shift from open to mini-invasive operative techniques for surgical resection of gastric cancer. Advanced equipment of surgical robots, with its 3D visualization, steady camera view, flexible instrument tips, attracts more and more practitioners in performing robotic gastrectomy with D2 dissection in gastric cancer patients. Thus, the comparison of some basic oncological as well as some surgical variables related to laparoscopic and robotic gastrectomy and D2 lymphadenectomy is necessary.

Initial presentation of renal cell carcinoma as a vaginal mass with excessive bleeding.

Introduction: Renal cancer is the seventh most common cancer in men and the tenth most common cancer in women. Renal cell carcinoma accounts for 3% of all adult malignancies and 85% of all primary renal tumours. It metastasizes most often to the lungs, liver, bones, and brain and very rarely to the vagina. Case report: We present a case of a 60-year-old patient, in whom the renal cell carcinoma manifested for the first time as an intense bleeding, soft tumour formation with dimensions 4/6 cm originating in the vagina. Discussion: Renal cell carcinoma metastasizes in about 30% of cases. Metastasizing can be lymphatic, hematogenous, transcoelomic, or by direct invasion. Most commonly it affects the lungs, bones, adrenal glands, liver, lymph nodes, and brain. Much less often, it metastasizes to the thyroid, orbit, nasal structures, vagina, gallbladder, pancreas, sublingual tissues, and soft tissues of distal extremities. Metastases can be synchronous and metachronous. The described cases in the literature of renal cell carcinoma manifested with vaginal metastases are isolated. Conclusions: We present an extremely rare case of renal cell carcinoma manifested by profuse genital bleeding from a vaginal metastasis. In such cases, especially if the vaginal lesion does not appear as the primary vaginal carcinoma, we must consider the possibility of metastasis from renal carcinoma.

Portal vein reconstruction during pancreaticoduodenal resection using an internal jugular vein as a graft.

Portal vein involvement by malignant tumours of the head of the pancreas is observed in almost 50% of the patients. In the past, this finding usually rendered the tumor inoperable. Over the past 30 years, the operative morbidity and mortality rate of pancreatectomy combined with portal vein resection has greatly decreased, and portal vein resection in pancreatic surgery has become a well-tolerated operative procedure in large-volume centres. Options for a venous reconstruction after SMV/PV resection include prosthetic, autologous or cryopreserved cadaveric vein grafts.Vascular resection and reconstruction provides great opportunity for R0 resection and improvement of oncological results in patients with pancreatic tumors and involvement of venous vessels, in the absence of distant metastases. If a longer graft length is required, there is the option of using either synthetic prosthesis or cryopreserved grafts. Their weak sides can be avoided by the use of jugular vein graft. Portal vein resection will be performed more often, safely and aggressively over the next years.

Total extra peritoneal inguinal hernia repair: a single-surgeon preliminary findings report.

INTRODUCTION: Inguinal hernia repair is one of the most frequent operations in general surgery. Various techniques have been used to repair inguinal hernias since the first reconstructive technique described by Bassini in 1887. In 1989 Lichtenstein reported a new technique: tension free inguinal hernia repair. Laparoscopic inguinal hernia repair was introduced in the early 1990s, and soon also became popular. Literature has shown the benefits of laparoscopy (in comparison with open repair) to be mostly related to the more minimally invasive nature of the surgery, having lower wound infection rates, faster recovery, and less postoperative pain. AIM: To evaluate our totally extraperitoneal (TEP) inguinal hernia repair initial results and compare them to literature data. MATERIALS AND METHODS: In a prospective review and analysis, we examined 61 cases of hernia repair via laparoscopy (specifically TEP), performed by a single surgeon, between April 2019 and December 2019 at the Kaspela University Hospital in Plovdiv. The centre's Institutional Review Board approved the study with no specific consents required due to the retrospective, minimal risk nature of the study. The routine informed consent required by the National Insurance Fund has been considered sufficient for the study objectives.The surgical outcome measures included operating time (hours/minutes), conversion, peritoneal injury, surgical emphysema; and the clinical outcome measures included postoperative seroma, post-operative infection, and post-operative chronic groin pain. RESULTS: Inguinal pain on discharge was characterized as mild by 56 (96.55%) patients and moderate by 2 (3.44%), there were no patients describing the pain as severe. The most frequently reported postoperative complications were annoyance and discomfort (10.34%), swelling (6.9%), seroma (3.44), hematoma (1.72%), paresthesia 1.72% (1); however, only those with seromas required special treatment. CONCLUSIONS: Limitations of the present study include the relatively small number of patients, all cases were operated on by a single surgeon and short postoperative follow-up period, but we are sharing our initial six months results. These results demonstrate that laparoscopic TEP inguinal hernia repair without mesh fixation is a reliable technique, which can reduce postoperative morbidity when applied by experienced surgeons.

Risk Factors for Anastomotic Leakage after Low Anterior Resection.

INTRODUCTION: Low anterior resection (LAR) is a standard surgical procedure for distal rectal carcinoma that allows creation of a colorectal anastomosis, with anal sphincter preservation and permanent colostomy avoidance. Anastomotic leakage (AL) is a potential complication of LAR present in 3% to 20% of cases leading to a significant increase in postoperative morbidity. AL represents a communication between the intra luminal and extra luminal compartments caused by a violation of the integrity of the intestinal wall. The risk factors of this procedure have been discussed and still remain a controversial issue. Prevention is the best management. Patients with predisposing factors should be paid special attention. AIM: Our objective was to identify and analyze the risk factors of anastomotic leakage after low anterior resection of rectal carcinoma. PATIENTS AND METHODS: This study included all patients who underwent low anterior resection for rectal cancer at the Department of Surgery of University Hospital Kaspela between 2011 and 2016. RESULTS: Low anterior resections were performed in 141 patients during the study period. Due to a positive air leak test on 16 patients, a protective ileostomy was created and these patients were eliminated from the study. The sex distribution of the remaining 125 patients was 69 men (55.2%) and 56 women (44.8%). The height of the anastomosis from the dentate line was 3.0 cm on an average (range 2.5 to 4 cm). CONCLUSION: Anastomotic leakage remains the most feared and serious complication after low anterior resection surgery. The evidence suggests that the main risk factors for anastomotic leakage at low anterior resection are the height of the anastomosis and the high ASA score.