A complex modality of achalasia, diverticulum and paraesophageal hernia treated through three-dimensional left thoracoscopy.

Herein, we report a case of a patient with recurrent dysphagia after an open transabdominal hernia repair for a Type IV paraesophageal hernia performed elsewhere. Subsequent work-up and medical records' review revealed the coexistence of a large left epiphrenic diverticulum in combination with achalasia synchronous to the recently repaired paraesophageal hernia. A three-dimensional left thoracoscopic diverticulectomy with a long esophagomyotomy was conducted under endoscopic guidance intraoperatively, with no perioperative complications. At 12 months' follow-up evaluation, the patient presents well with no documented recurrence. Cumulative experience from various medical specialties regarding esophageal motility disorders and endoscopic state-of-the-art techniques, when combined with minimally invasive surgical techniques, provide an effective management of esophageal motility syndromes, overall.

Utility of viscoelastic coagulation testing in liver surgery: a systematic review.

BACKGROUND: The objective of the current study was to summarize and evaluate all published evidence regarding viscoelastic testing in the field of liver surgery. METHODS: A systematic search of the literature was performed using Medline/PubMed, Scopus, Cochrane Library Central, Google Scholar, and clinicaltrials.gov databases. The following keywords were used:"Thromboelastography", "Thromboelastometry", "Viscoelastic tests OR testing", "Sonoclot Devices", "Point-of-care tests OR testing", "Coagulation OR Haemostasis OR Hemostasis", "Liver OR Hepatic Surgery", "Cirrhosis." RESULTS: A total of 12 studies analyzing 348 patients who underwent viscoelastic testing of coagulation during liver surgery for benign or malignant diseases were included; 7 (58.3%) studies reported on the use of thromboelastography (TEG), and 5 (41.7%) reported on rotational thromboelastometry (ROTEM). Viscoelastic testing (TEG and ROTEM) identified normo-, hyper- and hypo-coagulable status in 77% (n = 268/348), 18.4% (n = 64/348), and 4.6% (n = 16/348) of patients, respectively. In contrast, conventional coagulation tests indicated normo-coagulability in 111 patients (34.2% out of 325) and hypo-coagulability in 214 (65.8% out of 325) patients following liver resection. No patient (0% out of 291) experienced postoperative hemorrhage, whereas 5.8% (n = 17/291) experienced postoperative thromboembolic events. CONCLUSIONS: Global viscoelastic testing may be a reasonable adjunct to conventional coagulation testing to provide a more robust assessment of the coagulation status of patients undergoing liver surgery.

Minimally invasive esophagectomy for esophageal cancer in octogenarians. Clinical and oncological outcomes.

PURPOSE: Studies on patients undergoing esophagectomy for esophageal cancer have shown that thoracic and abdominal surgery may be performed safely in patients without an uppermost age cut-off. The aim of this study was to evaluate the morbidity and mortality of radical minimally invasive esophagectomy for cancer in patients over 80 years old. METHODS: A retrospective analysis of prospectively collected data over a period of 4 years was conducted. During the study period 184 esophagectomies were performed. A total of 12 octogenarians that underwent Minimally Invasive Esophagectomy (MIE) for cancer were included in the study. Our results were compared to the UK national outcomes as presented in the National Esophago-Gastric Cancer Audit (NOGCA) 2017 report. RESULTS: Median overall survival (OS) was 16.5 months (range: 6-38) and progression-free survival (PFS) 14.5 months (tange:3-38). 30-and 90-day postoperative mortality was zero. Postoperative complications included chest infection (CI) in 4 (33.3%) patients, anastomotic leakage (AL) in 3 (25%) and atrial fibrillation in 2 (16.7%). CONCLUSIONS: MIE should therefore be considered as an effective treatment strategy even in elderly patients over 80 years of age.

Associations between skeletal muscle mass index, nutritional and functional status of patients with oesophago-gastric cancer.

BACKGROUND AND AIMS: Cancer patients frequently suffer from disease-related malnutrition and functional decline. The aim of the current study is to investigate the association between traditional methods of nutritional assessment (unintentional weight loss, Patient Generated-Subjective Global Assessment, anthropometric measurements), functional assessment and muscle mass assessment in oesophago-gastric cancer patients prior to surgery. METHODS: A cross-sectional study was performed in 108 consecutive patients with oesophageal and gastric cancer who were admitted for surgery in the First Department of Surgery, Laikon General Hospital, Athens, Greece. The assessment of muscle mass was based on preoperative Skeletal Muscle Mass Index (SMI) values. The assessment of malnutrition was based on the Patient Generated Subjective Global Assessment, whereas laboratory markers and anthropometric measurements were also recorded. Muscle strength and physical performance were evaluated by measuring patients' handgrip strength and gait speed respectively. RESULTS: 76.8% of the study sample were severely malnourished and moderately or suspected of being malnourished, while the prevalence of low muscle mass was 49.1%. Age was significantly higher in low SMI patients compared to normal SMI individuals (67.2 ± 9.2 vs 60 ± 10.8, p < 0.001). Albumin was significantly lower in low SMI compared to normal SMI patients, as well as BMI, mid-upper arm circumference, calf circumference and corrected mid arm muscle area. Moreover, malnourished patients exhibited higher rates of low muscle mass (57.8% vs 42.2%, p = 0.022) than well-nourished patients. SMI was also significantly correlated with patients' handgrip strength and gait speed. CONCLUSIONS: Low muscle mass is strongly correlated with malnutrition and should be taken into consideration when evaluating the nutritional status of patients with oesophago-gastric cancer.

A type of neoplasia deadlier than gastric adenocarcinoma? Report of a case of primary gastric squamous cell carcinoma.

BACKGROUND: Primary gastric squamous cell carcinoma is an extremely rare malignancy with few case reports reported so far in the current medical literature. Its incidence varies between 0.04 and 0.07% of all gastric malignancies with a male predominance in the sixth decade of life. It has been found that this type of malignancy has a more aggressive behavior and associated poorer prognosis, when compared to gastric adenocarcinoma. Thus, the most appropriate management of this kind of neoplasia is still debatable due to the small number of reported cases. CASE PRESENTATION: We report the case of a 66-year-old man who underwent total gastrectomy with D2 lymphadenectomy for an ulcerative lesion in the fundus of the stomach that turned out to be primary gastric squamous cell carcinoma. CONCLUSIONS: Upon confirmation of this specific malignancy, the affected patients should be enrolled in strict follow-up protocols after curative surgery, since the risk for metastasis is high. Physicians should maintain high clinical suspicion in order to diagnose these tumors at an early stage, along with the need to rule out any other possible primary sites of squamous malignancy.

A case report on metastatic ileal neuroendocrine neoplasm to the breast masquerading as primary breast cancer: A diagnostic challenge and management dilemma.

RATIONALE: Metastatic neuroendocrine neoplasms (NENs) to the breast are very rare entities comprising only 1% to 2% of all metastatic breast tumors. In this article, we describe a case of a neuroendocrine ileal neoplasm metastatic to breast and liver, with breast metastatic tumor to be the initial manifestation of the disease. PATIENT CONCERNS: We herein report a rare case of a female patient admitted to our department with a palpable painful mass on her left breast. DIAGNOSIS: The surgical and histological investigation revealed a metastatic neuroendocrine neoplasm to the breast originated from terminal ileum. INTERVENTIONS: A left lumpectomy, right hemicolectomy, cholecystectomy, left hepatectomy along with liver metastasectomies (V, VI, VIII) plus radiofrequency ablation of lesions to the right liver lobe plus standard lymphadenectomy was performed. OUTCOMES: Considering the advanced stage of the disease, the patient received an adjuvant therapy of somatostatin analog plus everolimus. Under the guidance of oncological consultation, patients follow-up with CT and MRI scan and clinical re-evaluations in the first 3 and 6 months, substantiates no evidence of recurrence and she presents herself asymptomatic. LESSONS: An appropriate level of suspicion and selective immunohistochemistry in these cases, particularly where no prior history of a known primary neuroendocrine neoplasm occurs, may help to diagnose a previously undetected neuroendocrine tumor elsewhere in the body and provide guidance for the appropriate treatment selection.

Perioperative Management of Antiplatelet Therapy in Patients With History of Coronary Artery Disease Undergoing Surgery for Esophageal Cancer: A Single-center Experience.

AIM: To present the experience of the upper Gastrointestinal Unit of the Surgical Department of National and Kapodistrian University of Athens in order to inform surgeons of the exact harms and benefits associated with their decisions concerning management of antiplatelet therapy. MATERIALS AND METHODS: This was a single-center study of patients who underwent surgery for esophageal cancer and had concomitant coronary artery disease from 1/1/2005 to 31/7/2017. Patients were divided into two cohorts based on when their antiplatelet therapy was stopped (<7 vs. ≥7 days). Esophageal cancer was classified as esophageal only or as Siewert type I, II, or III based on tumor location at the gastroesophageal junction. A univariate logistic regression model was developed to assess the relationship between baseline variables and myocardial infraction, mortality, bleeding and stroke after the operation. For all tests, differences with a value of p<0.05 were considered significant. RESULTS: During the study period, 135 esophagectomies were performed for esophageal cancer. Almost 17% of them had concomitant coronary artery disease medically managed with antiplatelet therapy. No difference was found in terms of myocardial infarction, stroke or severe bleeding events between patients that stopped antiplatelet therapy for more or less than 7 days before esophagectomy. CONCLUSION: It is a reasonable approach to discontinue antiplatelet therapy for more than 7 days before surgery, especially in such a population of patients with esophageal cancer that require complex operations with high bleeding risk.

Robot-Assisted Retroperitoneal Lymphadenectomy in Testicular Cancer Treatment: A Systematic Review.

INTRODUCTION: Retroperitoneal lymph node dissection (RPLND) in testicular cancer is a documented treatment along with active surveillance and chemotherapy. This study aims to summarize the current evidence on the use of Robot-assisted RPLND (RARPLND) in comparison with the laparoscopic and open approach. MATERIALS AND METHODS: A search was conducted in the existing literature focusing on reports with outcomes of RARPLND for stage I-IIB testicular tumor. RESULTS: Eleven studies complied with the inclusion criteria, including 116 patients. The average follow-up of 21.2 months showed no retroperitoneal recurrence. The median lymph node yield was 22.3 and the overall positive rate was 26%. Complications were encountered in 8% of the patients. The robotic approach showed similar results to the laparoscopic approach and outperformed the open procedure in perioperative parameters. CONCLUSIONS: Relapse-free survival, nodal yield, and complication rates during RARPLND for clinical stage I-IIB are acceptable. Further studies are required to establish these findings and determine benefit from the use of robotic approach.

Laparoscopic Versus Open Adrenalectomy for Localized/Locally Advanced Primary Adrenocortical Carcinoma (ENSAT I-III) in Adults: Is Margin-Free Resection the Key Surgical Factor that Dictates Outcome? A Review of the Literature.

BACKGROUND: The aim of this study was to review the current literature on the role of laparoscopic adrenalectomy (LA) in the treatment of primary adrenocortical carcinoma (ACC; European Network for the Study of Adrenal Tumors [ENSAT] I-III) in adults. MATERIALS AND METHODS: Nonrandomized controlled trials published between January 1999 and February 2017 were identified by searching the Pubmed, EMBASE, Cochrane Library, and Google Scholar databases. Primary and secondary endpoints included surgical and pathological parameters (patients age, tumor size, ENSAT stage, type of surgical approach, and period of follow-up), surgical outcomes (operative time, estimated blood loss, length of hospital stay, conversion rate to laparotomy, R0 resection, and surgical margin's status), and oncological outcomes (rate of recurrence, disease-free survival [DFS], and overall survival [OS] rates). RESULTS: A total of 13 studies encompassing data on 1171 patients were included in the review. Compared with open approach, LA demonstrated lower tumor size, shorter operative time, lower intraoperative blood loss, shorter postoperative hospital stay, and equivalent local recurrence rates. No significant differences were observed between groups treated with an open or laparoscopic approach for the following criteria: R0 surgical resection status, tumor overall recurrence, and postoperative DFS and OS rates. CONCLUSIONS: LA appears to be equivalent to open method for localized/locally advanced primary ACC (ENSAT I-III) in terms of R0 resection rate, overall recurrence, DFS, and OS, therefore suggesting that the extent of surgery with adequate tumor resection is the predominant endpoint, rather than the surgical approach itself. Multicenter randomized controlled trials with long follow-up time periods exploring the long-term oncological outcomes are required to determine the benefits of the laparoscopic over the open approach in adrenocortical carcinoma.

Minimally Invasive Lymphadenectomy in Uterine Cervical Cancer: A Systematic Review.

BACKGROUND/AIM: The aim of this study was to review the current literature on the role of minimally invasive lymphadenectomy in the treatment of cervical cancer. MATERIALS AND METHODS: Non-randomized control trials published between January 2007 to May 2016 were identified by searching the Pubmed, EMBASE and Cochrane Library databases. Primary endpoints included operative outcomes (operative time, intraoperative blood loss, number of transfused patients and conversion rates), postoperative outcomes (length of postoperative hospital stay, postoperative morbidity and postoperative in-hospital mortality), and oncological outcomes (number of harvested lymph nodes, tumor recurrence, disease-free rates and overall survival rates). RESULTS: A total of 17 studies with a total of 1,676 patients were included in the review. Compared to the open approach, minimally invasive lymphadenectomy demonstrated a significantly larger number of harvested lymph nodes, longer operative time, lower intraoperative blood loss and shorter postoperative hospital stay. No significant differences were observed between groups treated with an open, laparoscopic or robotic approach for the following criteria: lymph node metastasis, postoperative morbidity, tumor recurrence and postoperative mortality. CONCLUSION: Although a technically demanding and time-consuming procedure, minimally invasive lymphadenectomy appears to be safe and feasible and may offer an alternative approach in staging and treatment of cervical cancer. Multicentre randomized controlled trials investigating its long-term oncological outcomes and its cost-effectiveness are required to determine the advantages of this procedure over the open approach in cervical cancer.