Effect of an E-Prescription Intervention on the Adherence to Surgical Chemoprophylaxis Duration in Cardiac Surgery: A Single Centre Experience.

In our hospital, adherence to the guidelines for peri-operative antimicrobial prophylaxis (PAP) is suboptimal, with overly long courses being common. This practice does not offer any incremental benefit, and it only adds to the burden of antimicrobial consumption, promotes the emergence of antimicrobial resistance, and it is associated with adverse events. Our objective was to study the effect of an electronic reminder on the adherence to each element of PAP after cardiac surgery. We conducted a single center, before and after intervention, prospective cohort study from 1 June 2014 to 30 September 2017. The intervention consisted of a reminder of the hospital guidelines when ordering PAP through the hospital information system. The primary outcome was adherence to the suggested duration of PAP, while secondary outcomes included adherence to the other elements of PAP and incidence of surgical site infections (SSI). We have studied 1080 operations (400 pre-intervention and 680 post-intervention). Adherence to the appropriate duration of PAP increased significantly after the intervention [PRE 4.0% (16/399) vs. POST 15.4% (105/680), chi-square p < 0.001]; however, it remained inappropriately low. Factors associated with inappropriate duration of PAP were pre-operative hospitalization for <3 days, and duration of operation >4 h, while there were significant differences between the chief surgeons. Unexpectedly, the rate of SSIs increased significantly during the study (PRE 2.8% (11/400) vs. POST 5.9% (40/680), chi-square p < 0.019). The implemented intervention achieved a relative increase in adherence to the guideline-recommended PAP duration; however, adherence was still unacceptably low and further efforts to improve adherence are needed.

Peritoneal Pseudocyst Causing Acute Abdomen as a Complication of Cronh's Disease.

Peritoneal pseudocysts (PPs) in patients who are diagnosed with Crohn's disease (CD), is a rarely diagnosed entity with unknown epidemiology, etiology and pathogenesis. We present the case of a 30-year old male with known CD who presented with an acute abdomen because of a PP. PPs are developed as a complication caused in patients, suffering from mainly thee conditions. Firstly, PPs appear in patients with continuous ambulatory peritoneal dialysis (CAPD), they are also developed in patients with peritoneal trauma and finally in CD patients. Our case belongs to these three reported cases in our literature review, since it refers to a CD patient that developed PPs. He underwent emergency laparotomy and excision of the cyst, with good postoperative results. A literature review of 22 publications show that PPs often represent a diagnostic and therapeutic problem as it has a variable presentation and there are no data on what the best treatment option is - surgical excision or aspiration.

Primary gastric melanoma in adult population: a systematic review of the literature.

BACKGROUND: Primary gastric melanoma (PGM) is a rare malignant tumour of the stomach with poor prognosis. The aim of this systematic review was to assess the available literature on this entity and to highlight its biological behaviour and preferred treatment approach. METHODS: PubMed and Cochrane bibliographical databases were independently searched (last search: 2 February 2020) by two investigators for articles reporting on PGM in the adult population. RESULTS: Twenty-five studies met the inclusion criteria and concerned collectively 25 patients (18 males and seven females) with an age of 63.4 ± 8.97 years (mean ± standard deviation). Main symptoms included abdominal pain (64%), weight loss (48%) and hematemesis or melena (32%). The most frequent tumour location was the body of the stomach (54.2%). All tumours were surgically resected and the majority of the patients had a partial gastrectomy (52%). Median recurrence time was 5 months and 12% of patients reached 5-year survival landmark. CONCLUSION: PGM is a rare disease characterized by an aggressive malignant behaviour. Its differential diagnosis from a metastatic lesion is crucial. A prompt diagnosis and therapeutic approach are needed. Further studies are required to elucidate the optimal management of this clinical entity.

The Unexpected Diagnosis of Hepatic Tuberculosis in an Immunocompetent Patient.

BACKGROUND/AIM: Tuberculosis (TB) is a chronic infectious disease which affects millions. The most affected system is the respiratory. Thus, hepatic TB (HTB) without involvement of other organs is not common. Its clinical manifestations are not specific, and both imaging and histopathological findings are necessary for the diagnosis. The differential diagnosis includes primary and metastatic liver malignancies. Our aim is to describe the rare entity of HTB via a case presentation. Patient and Methods. We report a case of a 50-year-old female with abdominal pain, weight loss, fever, and anorexia. All imaging methods described a liver lesion. She underwent right lobe hepatectomy, and the histological evaluation demonstrated granuloma with central caseous necrosis. RESULTS: Seven months postoperatively, the patient remains fit and healthy. CONCLUSION: HTB is a rare entity with no specific symptoms, signs, and no laboratory nor imaging findings. It can be managed effectively if diagnosed in time or lead to death if left untreated.

Cardiovascular Effects of Metabolic Surgery on Type 2 Diabetes.

INTRODUCTION: Cardiovascular, together with renal disease, claims a significant proportion of morbidity and mortality in association with type 2 diabetes mellitus (T2DM) and obesity. To improve the long-term renal and cardiovascular outcome, there is the incorporation of bariatric surgery (BS), which seems to be a pivotal intervention. Areas Explored: Cohort studies and randomized controlled trial (RCT) research of BS among patients with T2DM, were conducted by screening, and then information on renal effects and the cardiovascular outcome was gathered. Metabolic surgery (MS) and BS reduce both mortality and the risk of cardiovascular disorder, chronic kidney diseases and albuminuria. MS refers to a surgical approach, the primary intent of which is the control of metabolic alterations/hyperglycemia in contrast to BS which is a mere weight-reduction therapy. Patients suffering from poor glycaemic control and other macro and micro-vascular diseases will benefit from a surgical approach. The approach implicates hypertension glomerular remission, gut microbiota shift, reduced renal inflammation and fewer instances of chronic cardiac remodelling. CONCLUSION: MS is beneficial where the main aim is to attain significant and long-lasting weight loss results. The RCTs have depicted the superiority which surgical mechanisms hold over medically- based therapy, for enhancing glycaemic control, and achieving remission of diabetes. This type of surgery improves life quality, reduces incidences of other obesity and diabetes related diseases like microvascular disases, sleep apnea, fatal disorder, and fatty liver disease.

A Clinicopathological Analysis of S100A14 Expression in Colorectal Cancer.

BACKGROUND/AIM: The calcium-binding protein S100A14 is involved in processes related to tumorigenesis and tumor propagation, such as proliferation, apoptosis, motility and invasiveness. Our aim was to investigate its role in colorectal cancer. PATIENTS AND METHODS: One hundred and seven patients (65 men and 42 women) were included in this study. They had been diagnosed with colorectal cancer and undergone complete resection of their primary tumor. Tissue samples from archival blocks of their normal and malignant colorectal tissues were used for immunohistochemical assessment of S100A14 expression. S100A14 levels were evaluated using image analysis and associated with various clinicopathological parameters and prognosis. RESULTS: S100A14 expression was reduced in malignant tissues when compared to normal intestinal mucosa in cases of T3-T4 tumors (p=0.017). Moreover, as far as S100A14 levels in malignant tissues are concerned, they were lower in T3-T4 tumors (p=0.001), N2 disease (p=0.034) and M1 disease (p=0.019). Finally, very high S100A14 production (>75th percentile) was associated with shorter disease-specific (HR=3.584, p=0.045) and relapse-free survival (HR=4.527, p=0.007) in multivariate survival analysis. CONCLUSION: S100A14 expression is decreased in advanced colorectal cancer. However, cases with very high S100A14 levels have a worse survival.

Anaplastic Thyroid Cancer: A Rare Entity Presented Clinically Only with Fever and Elevated CRP.

Anaplastic thyroid carcinoma (ATC) is a rare but almost invariably lethal disease. In this manuscript, we present a case where the dominant manifestation of ATC beside the goitre was elevated CRP values and a persistent low-grade fever. The patient underwent surgical removal of the tumour, chemotherapy and radiotherapy treatment. She is still alive and healthy 11 months after the surgery. We aim to demonstrate that ATC can be present with no specific symptoms or findings and to raise awareness towards an earlier diagnosis.

Triple-Negative Breast Cancer: The Progress of Targeted Therapies and Future Tendencies.

Triple-negative breast cancer (TNBC) is characterized by a lack of expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) and unfortunately is not associated with good prognosis. Treatment of breast cancer mainly depends on chemotherapy, due to the lack of specifically approved targeted therapies for TNBC. It is of paramount importance to find new therapeutic approaches, as resistance to chemotherapy frequently occurs. Herein, we present clinical studies published within the last five years, in order to reveal possible targeted therapies against TNBC. We aimed to discuss factors against TNBC, such as tyrosine kinase inhibitors, anti-androgens, poly ADP-ribose polymerase-1 (PARP-1) inhibitors, anti-angiogenic factors, immune checkpoints and histone deacetylase inhibitors (HDACI). Furthermore, the PI3K/AKT/mTOR pathway seems to be a promising field for the development of new anti-TNBC targeted therapies. Data from 18 clinical trials with patients suffering from TNBC were summarized and presented descriptively.

Screening and Risk Assessment of Coronary Artery Disease in Patients With Type 2 Diabetes: An Updated Review.

Current literature indicates that there is a strong correlation between coronary artery disease (CAD) and type 2 diabetes. The arteriosclerotic progression occurs earlier and in a greater extent in the diabetic than in the non-diabetic population. In diabetic subjects, the detection of arterial disease does not always precede the development of an acute arterial incident. Herein, we reviewed studies published within the last 5 years in order to reveal the risk factors for coronary artery disease in patients with type 2 diabetes. In addition, we aimed to discuss how to diagnose in an early stage or even screen the presence of coronary artery disease in asymptomatic diabetic patients. Possible blood markers as predictors of CAD, which are mostly related to the lipidemic profile of subjects, are included in this review. Less invasive imaging methods than conventional coronary angiography, included in the article, are gradually used more in the diagnosis of CAD and show high effectiveness. Data from 23 articles with 22,350 patients having type 2 diabetes were summarized and presented descriptively.

Multifocal Gastrointestinal Melanoma.

Primary mucosal melanoma is a rare disease, with a worse prognosis than cutaneous melanoma. We present a patient with primary melanoma of the stomach and small intestine, with good outcome after radical surgical excision and adjuvant ipilimumab therapy.

Pyloric Obstruction Caused by an Inflammatory Fibroid Polyp.

This is a case report of a 57-year-old woman who presented with abdominal pain and vomiting over a period of two months. Upper gastrointestinal endoscopies and biopsies were inconclusive, while abdomen computed tomography (CT) scan revealed a large mass arising from the pyloric antrum measuring about 6 × 4.8 cm imitating gastrointestinal stromal tumor (GIST). The patient underwent a laparotomy, and the tumor was totally resected with well-defined borders. The histopathological analysis revealed the mass to be an inflammatory fibroid polyp (IFP).

Enhanced Recovery After Surgery: Is It Time to Change Our Strategy Regarding Laparoscopic Colectomy?

Enhanced recovery after surgery or 'fast-track' methods are evidence-based protocols designed to standardize post-operative medical care, improve patient outcomes, promote early recovery, and reduce healthcare expenditure. Fast-track surgery is a multifunctional concept involving pre-, peri- and post-operative measures aiming to reduce the length of hospital stay and morbidity and complication rates, following elective abdominal surgery. Through the optimization of peri-operative care and the recovery process in adherence to these fast-track protocols, improved outcomes are reached, surgical trauma and post-operative stress are reduced, with less surgical pain, reduced complications, and shorter length of hospital stay. Fast-track care requires a multidisciplinary collaboration of all healthcare professionals, as well as a high rate of protocol compliance and a good organizational structure. Despite the existing evidence of the benefits of fast-track protocols in a variety of surgical procedures and the similar outcomes of laparoscopic colonic surgery compared to open surgery, clear evidence of the benefits of fast-track care after laparoscopic colonic surgery is yet to be clearly demonstrated.

Histopathological changes and onset of severe hepatic steatosis in rats fed a choline-free diet.

Hepatic steatosis significantly increases morbidity and mortality associated with major liver surgery. Several rodent models of hepatic steatosis have been previously reported, which aimed to investigate the effect of various pharmaceutical agents and interventional procedures on the pathophysiology of steatotic liver. The aim of the present study was to investigate the time frame of severe hepatic steatosis in rats after they were fed a choline-free diet and any associated histopathological changes. The duration of feeding with a choline-free diet required to develop severe hepatic steatosis was investigated in Wistar rats. The severity of hepatic steatosis in liver specimens was evaluated at 8, 10, 12 and 14 weeks following the onset of the choline-free diet. Comparisons were made with rats receiving standardized laboratory food. Feeding rats for 12-13 weeks with a choline-free diet led to 66% fatty liver infiltration, which exceeded 68% after 14 weeks. Prior to 8 weeks, the fatty infiltration reached 43%, with a gradual increase revealing a stronger rate from 8-12 weeks and a gradual decline after 14 weeks. At 12-13 weeks the fatty infiltration was considered representative of severe hepatic steatosis. Macrovesicular fatty infiltration revealed a significant increase at a steady rate between 8 and 14 weeks, with evidence of the onset of lobular inflammation and steatohepatitis after 14 weeks of feeding with the choline-free diet. Microvesicular fatty infiltration demonstrated a lower growth rate between 8 and 12 weeks while maintaining a steady rate between 12 and 14 weeks. Mixed fatty infiltration maintained its steady rate of hepatic parenchyma from 8.8-9.5%. Rats fed with the standard laboratory diet did not demonstrate fatty infiltration >4.5%, so they did not develop hepatic steatosis. Developing an ideal model of hepatic steatosis is a particular challenge. The findings of the present study indicate that severe hepatic steatosis in rodents may lead to the development of steatohepatitis after feeding with a choline-free diet for at least 14 weeks. This model is of particular interest in experimental liver surgery and associated surgical maneuvers, and is easily reproducible.

Abdominal Emergencies in Patients with Stage IV Melanoma: The Role of Surgery: A Single-centre Experience.

BACKGROUND/AIM: Metastatic melanoma is an aggressive disease with poor prognosis. Melanoma can potentially involve any organ. In this article, we report on a single-centre experience in emergency surgery for M1c melanoma. PATIENTS AND METHODS: Twenty-eight consecutive patients with M1c melanoma underwent surgical exploration due to abdominal emergencies. Pre-operative computed tomography confirmed the diagnosis and the location of the affected site. Pre-operative lactate dehydrogenase serum levels and post-operative histopathology findings were recorded. RESULTS: Intestinal obstruction was the most frequent intraoperative finding (75%). The ileum was most frequently affected (28.6%). Multifocal disease and extra-gastrointestinal tract metastases were present in 25% of cases each. Lactate dehydrogenase serum level was increased in 75% of the patients. Most patients underwent an enterectomy. CONCLUSION: Curative surgery for stage IV melanoma remains debatable, but surgery for patients presenting with abdominal emergencies appears to improve both survival rate and prognosis. Combined novel therapies and surgical resection is currently being studied with promising results.

Primary Hepatic Leiomyosarcoma: a Case Report and Review of the Literature.

BACKGROUND/AIM: Primary hepatic leiomyosarcoma is an extremely rare type of liver sarcoma with relatively poor prognosis, with about 50 cases having been reported in the literature. Potential origins of this tumor in the liver are the smooth muscle cells in the round ligament, intrahepatic blood vessels and intrahepatic bile ducts. There is no apparent sex predilection and there is a wide age range. The clinical presentation is not specific and the diagnosis depends on the expression of markers such as smooth muscle actin, desmin and vimentin by tumor cells. PATIENTS AND METHODS: Herein, we present a case of a bulky primary hepatic leiomyosarcoma in a 68-year-old female patient. The patient underwent resection of the exophytic mass en block with the hepatic segments III and IVB. CONCLUSION: Surgical resection is the most effective among the treatment options.

Rare Coexistance of Ileal Diverticulosis, Crohn's Disease and Small Bowel Adenocarcinoma: Report of a Case.

BACKGROUND/AIM: Adenocarcinoma is one of the most common malignant tumors of the small intestine complicating Crohn's disease. However, the coexistence of both conditions with diverticulosis of small bowel in young age makes this coincidence rare and clinical diagnosis very difficult. CASE REPORT: We report a case of a woman admitted to our Department with acute abdominal pain and fever. The surgical and histological investigation, revealed a rare coexistence that has never been mentioned in the published medical literature. CONCLUSION: Ileal diverticulosis is not frequent and often asymptomatic as well as adenocarcinoma of the small bowel. In this case, those diseases along with Crohn's disease led the patient to acute symptoms.

Targeting Histone Deacetylases in Malignant Melanoma: A Future Therapeutic Agent or Just Great Expectations?

BACKGROUND/AIM: Malignant melanoma is the most aggressive type of skin cancer, with increasing frequency and mortality. Melanoma is characterized by rapid proliferation and metastases. Malignant transformation of normal melanocytes is associated with imbalance between oncogenes' action and tumor suppressor genes. Mutations or inactivation of these genes plays an important role in the pathogenesis of malignant melanoma. Many target-specific agents improved progression-free survival but unfortunately metastatic melanoma remains incurable, so new therapeutic strategies are needed. The balance of histones' acetylation affects cell cycle progression, differentiation and apoptosis. Histone deacetylases (HDAC) are associated with different types of cancer. Histone deacetylase inhibitors (HDACI) are enzymes that inhibit the action of HDAC, resulting in block of tumor cell proliferation. A small number of these enzymes has been studied regarding their anticancer effects in melanoma. The purpose of this article was to review the therapeutic effect of HDACI against malignant melanoma, enlightening the molecular mechanisms of their action. MATERIALS AND METHODS: The MEDLINE database was used. The keywords/ phrases were; HDACI, melanoma, targeted therapies for melanoma. Our final conclusions were based on studies that didn't refer solely to melanoma due to their wider experimental data. Thirty-two articles were selected from the total number of the search's results. Only English articles published until March 2017 were used. RESULTS: Molecules, such as valproid acid (VPA), LBH589, LAQ824 (dacinostat), vorinostat, tubacin, sirtinol and tx-527, suberoyl bis-hydroxamic acid (SBHA), depsipeptide and Trichostatin A (TSA) have shown promising antineoplastic effects against melanoma. CONCLUSION: HDACI represent a promising agent for targeted therapy. More trials are required.

Early Experience in Starting a Laparoscopic Liver Resection Program in Greece.

BACKGROUND AND OBJECTIVES: Laparoscopic liver resections (LLRs) have gained wider acceptance during the decade as safe and efficient procedures in the management of several benign and malignant diseases when performed by experienced surgeons. We report our initial institutional experience with LLRs performed by 1 certified hepatobiliary surgeon. METHODS: Patients undergoing LLRs by 1 senior hepatobiliary surgeon in our Institution during the period from January 2012 through January 2017 were prospectively sampled and retrospectively analyzed for the purposes of this study. RESULTS: Forty-two of 175 patients (24%) who had surgery for liver tumors underwent LLR. Median age was 64 years; median body mass index and Charlson comorbidity index were 27.3 kg/m2 and 6.5, respectively. Patients underwent resections for benign (n = 22) or malignant (n = 20) lesions. Median total operating time was 115 minutes and liver resections included: 1 left hepatectomy, 11 bisegmentectomies, 7 segmentectomies, 5 wide wedge resections, 1 left lateral sectionectomy combined with segmentectomy and radiofrequency ablation, 15 liver cyst unroofing, 1 laparoscopic drainage of a pyogenic liver abscess, and 1 laparoscopic drainage of a hepatic hydatid cyst. Blood transfusion was needed in 10 patients. Six patients (14%) had postoperative complications, none of which necessitated reoperation. None of the patients was admitted to the intensive care unit after surgery, and the median hospital stay was 4 days. The tumor-free resection margin was documented in all primary or secondary oncologic cases. CONCLUSIONS: Careful patient selection and compliance with the international recommendations are the keys for the successful introduction and evolution of an LLR program with a certified hepatobiliary surgeon with laparoscopic experience.