Spinal accessory nerve anatomy in the posterior cervical triangle: A systematic review with meta-analysis.

This study aimed to investigate the anatomy of the spinal accessory nerve (SAN) in the posterior cervical triangle, especially in relation to adjacent anatomical landmarks, along with a systematic review of the current literature with a meta-analysis of the data. Overall, 22 cadaveric and three prospective intraoperative studies, with a total of 1346 heminecks, were included in the analysis. The major landmarks relevant to the entry of the SAN at the posterior border of the SCM muscle (PBSCM) were found to be the mastoid apex, the great auricular point (GAP), the nerve point (NP), and the point where the PBSCM meets the upper border of the clavicle. The SAN was reported to enter the posterior cervical triangle above GAP in 100% of cases and above NP in most cases (97.5%). The mean length of the SAN along its course from the entry point to its exit point from the posterior triangle of the neck was 4.07 ± 1.13 cm. The SAN mainly gave off 1 or 2 branches (32.5% and 31%, respectively) and received either no branches or one branch in most cases (58% and 23%, respectively) from the cervical plexus during its course in the posterior cervical triangle. The major landmarks relevant to the entry of the SAN at the anterior border of the TPZ muscle (ABTPZ) were found to be the point where the ABTPZ meets the upper border of the clavicle and the midpoint of the clavicle, along with the mastoid apex, the acromion, and the transverse distance of the SAN exit point to the PBSCM. The results of the present meta-analysis will be helpful to surgeons operating in the posterior cervical triangle, aiding the avoidance of the iatrogenic injury of the SAN.

Revisiting Amyand's Hernia: A 20-Year Systematic Review.

PURPOSE: Protrusion of the appendix within an inguinal hernia is termed an Amyand's hernia. A systematic review of case reports and case series of Amyand's hernia was performed, with emphasis on surgical decision-making. METHODS: The English literature (2000-2019) was reviewed, using PubMed and Embase, combining the terms "hernia", "inguinal", "appendix", "appendicitis" and "Amyand". Overall, 231 studies were included, describing 442 patients. RESULTS: Mean age of patients was 34 ± 32 years (adults 57.5%, children 42.5%). 91% were males, while a left-sided Amyand's hernia was observed in 9.5%. Of 156 elective hernia repairs, 38.5% underwent appendectomy and 61.5% simple reduction of the appendix. 88% of the adult patients had a mesh repair, without complications. Of 281 acute cases, hernial complications (76%) and acute appendicitis (12%) were the most common preoperative surgical indications. Appendectomy was performed in 79%, more extensive operations in 8% and simple reduction in 13% of cases. A mesh was used in 19% of adult patients following any type of resection and in 81% following reduction of the appendix. Among acute cases, mortality was 1.8% and morbidity 9.2%. Surgical site infections were observed in 3.6%, all of which in patients without mesh implantation. CONCLUSION: In elective Amyand's hernia cases, appendectomy may be considered in certain patients, provided faecal spillage is avoided, to prevent mesh infection. In cases of appendicitis, prosthetic mesh may be used, if the surgical field is relatively clean, whereas endogenous tissue repairs are preferred in cases of heavy contamination.

A systematic review of splenic artery variants based on cadaveric studies.

PURPOSE: The splenic artery (SA) is the largest and most tortuous branch of the celiac trunk with a wide spectrum of variants, particularly in its terminal branches. METHODS: The current study presents a systematic review of the English literature on the SA variations, with emphasis on its terminal branching patterns. RESULTS: Thirty cadaveric studies (3132 specimens) were included in the analysis. The SA originated from the celiac trunk in 97.2%, from the abdominal aorta in 2.1% and from the superior mesenteric or the common hepatic artery in 0.7% of cases. A suprapancreatic course was observed in 77.4%, retropancreatic course in 17.8%, anteropancreatic course in 3.4% and intrapancreatic course in 1.3%. In the majority of cases, the SA bifurcated into superior and inferior lobar arteries (83.4%), with trifurcation and quadrifurcation in 11.3% and 2.7%, respectively. Five or more lobar branches (1.4%) and a single lobar artery (1.2%) were rarely identified. The distributed branching pattern was found in 72.7%, whereas the magistral pattern in 26.9%. The inferior and superior polar arteries (IPA and SPA) were found in 47.7% and 41.7% of cases, respectively, while polar artery agenesis was recorded in 28.2%. The SPA usually originated from the SA main trunk (53.6%) or from the superior lobar artery (33.1%). The IPA emanated mainly from the left gastroepiploic artery (53%), from the SA (23.5%) or the inferior lobar artery (21.9%). Intersegmental anastomoses between adjacent arterial segments were identified in 14.2%. CONCLUSION: Knowledge of the SA aberrations is important for surgeons and radiologists involved in angiographic interventions.

Normal anatomy, variants and factors associated with the cervical vagus nerve topography: a high-resolution ultrasound study.

PURPOSE: To describe the cervical vagus nerve (CVN) topography at the thyroid lobe (TL) level using high-resolution ultrasound and to investigate the possible association with anthropometric data, TL size, and thyroid disease. METHODS: We prospectively examined 550 CVNs in 275 (205 female, 70 male) individuals with normal thyroid (53/275, 19.3%), multinodular disease (167/275, 60.7%), and Hashimoto thyroiditis (55/275, 20%). The CVN location relative to the common carotid artery was recorded as typical (lateral position) and atypical (anterior, medial, and posterior position). The shortest distance between CVN and TL margin, the TL dimensions, and volume were measured. RESULTS: Normal thyroid subjects had lateral-positioned right CVNs in 100% and lateral/anterior/medial left CVNs in 81.1%, 15.1%, and 3.8%, respectively. CVN types did not differ significantly bilaterally between study groups. Asymmetry in CVN topography in all subjects was found in 22.2%, of which anterior CVN was the most common atypical position (64%), especially on the left side (82%). Significant gender, age, body mass, and BMI differences among CVN types were observed on the left side only. Among CVN types, no difference in TL dimensions, volume, and CVN-TL distance was found in all study groups. A weak negative correlation was recorded between CVN-thyroid distance and TL volume only on the left side (r = - 0.147, p = 0.01). CONCLUSION: Asymmetry in CVN topography is mainly due to the increased incidence of the anterior location of CVN on the left side. Age and anthropometric parameters are different on the left side possibly due to the increased prevalence of left CVN variants.

Unfinished Business: A Systematic Review of Stump Appendicitis.

BACKGROUND: Stump appendicitis is defined as interval inflammation of any residual appendicular tissue, after an appendicectomy. We present a systematic review of case series and case reports on stump appendicitis, emphasising on risk factors, diagnosis and surgical management. METHODS: The English literature (1945-2018) was reviewed, using PubMed, Embase and GoogleScholar, combining the terms "appendix", "appendicitis", "stump", "residual", "recurrent" and "retained". In total, 127 studies were included, describing 164 patients (males 59%, mean age 36 ± 17 years). RESULTS: Index surgery was open in 59% and laparoscopic in 38%. It was described as "difficult" or "complicated" in 31%. 20% of patients reported episodes of recurrent abdominal pain during the time interval between index and stump appendicitis (range 2 weeks to 60 years, median 2 years). Right lower quadrant pain was the most frequent complain (88%), leukocytosis was found in 56%, whereas 92% of patients underwent imaging testing, which was diagnostic or highly suspicious in 67.5%. Mean delay between beginning of symptoms and surgery was 2.4 ± 2.3 days. The operative approach was open in 61% and laparoscopic in 35% of cases. The operation was characterised as "difficult" or "complicated" in 45%. In the majority (88%), a completion stump appendicectomy was performed, with 11% requiring more extensive procedures. Mean length of resected stump was 3.1 ± 1.6 cm (range 0.5-10 cm). CONCLUSIONS: Stump appendicitis may occur following both open and laparoscopic approach, when the residual stump is > 0.5 cm. Its clinical significance lies in the delayed diagnosis, leading to higher incidence of complications and the need for more extensive surgery.

An anatomic anal sphincter-saving procedure for rectal cancers located at anorectal junction.

BACKGROUND: This study aims to present the feasibility of the open approach of hemilevator excision (HLE) as a promising alternative of the laparoscopic and/or robotic ones for the treatment of low rectal cancer extending to the ipsilateral puborectalis muscle. METHODS: A 60-year-old male patient with a high-grade differentiated rectal adenocarcinoma at the right side of the lower rectum invading puborectalis muscle. The proposed operation consists of a combination of extralevator abdomino-perineal excision (ELAPE), intersphicteric resection (ISR), and low anterior resection (LAR) since it resects the ipsilateral to tumor levator ani muscle (LAM) from its attachment at the internal obturator fascia and the deep part of ipsilateral external anal sphincter (EAS), while the distal part of dissection is completed in the intersphincteric space taking out the internal anal sphincter (IAS). At the contralateral side of the tumor, the dissection plane follows the classic route of LAR. RESULTS: Pathology proved the oncologic adequacy of resection. MRI at the fourth postoperative week showed clearly the right aspect of anorectal junction free of tumor. Anorectal manometry revealed a fair anorectal function which is in accordance with the findings of clinical assessment of patient after restoring large bowel continuity (post-op Wexner score, 7). CONCLUSION: This is the first case of the open HLE that seems to be a good alternative compared to ELAPE or conventional APR, as it offers oncologic adequacy and a fair anorectal function.

Oral Bacteria and Intestinal Dysbiosis in Colorectal Cancer.

The human organism coexists with its microbiota in a symbiotic relationship. These polymicrobial communities are involved in many crucial functions, such as immunity, protection against pathogens, and metabolism of dietary compounds, thus maintaining homeostasis. The oral cavity and the colon, although distant anatomic regions, are both highly colonized by distinct microbiotas. However, studies indicate that oral bacteria are able to disseminate into the colon. This is mostly evident in conditions such as periodontitis, where specific bacteria, namely Fusobacterium nucrelatum and Porphyromonas gingivalis project a pathogenic profile. In the colon these bacteria can alter the composition of the residual microbiota, in the context of complex biofilms, resulting in intestinal dysbiosis. This orally-driven disruption promotes aberrant immune and inflammatory responses, eventually leading to colorectal cancer (CRC) tumorigenesis. Understanding the exact mechanisms of these interactions will yield future opportunities regarding prevention and treatment of CRC.

Intestinal microbiota and colorectal cancer: a new aspect of research.

Colon holds a complex microbial community, which is crucial for maintaining homeostasis and regulating metabolic functions, supporting the intestinal barrier and controlling immune responses. Previous studies have supported a link between intestinal microbiota and colorectal cancer (CRC). Based on these fndings, the present review analyzed the numerous interactions that occur between microbiota and CRC, starting from the role of intestinal microbiota in colonic homoeostasis. Intestinal microbiota is a cause of CRC and involves various mechanisms such as chronic inflammation, the production of genotoxins causing DNA impairment and/or the biosynthesis of toxic compounds. Moreover, basic metabolic factors such as short-chain fatty acids (SCFAs) and bile acids are included in CRC pathogenesis. Different pathogenic pathways have been reported among different CRC regions (proximal or distal). Variations in the microbial populations are reported between the CRC from these colonic sites, possibly reflecting the bacterial dysbiosis and bioflm distribution. Bowel preparation is essential prior to colonoscopy and surgery; there is, however, minor consensus on the effects of this procedure on intestinal microbiota, notably with regard to the long-term outcomes. With regard to the therapeutic strategy in CRC, the intestinal microbiota is further involved in the modulation of the host response to chemotherapeutic agents (5-fluorouracil and irinotecan) by the interference with drug efcacy and by adverse effects and associated toxicity. In addition, the newly emerged research on CRC immunotherapy reveals an important interplay between intestinal microbiota and the immune system, which includes the possibility of targeting microbiota for the enhancement of anticancer treatment. Additional studies will further clarify the interaction between microbiota and CRC, resulting in the development of alternative therapeutic strategies by manipulating microbiota composition.

Obesity, Persistent Organic Pollutants and Related Health Problems.

The present review aims to delve into persistent organic pollutants (POPs) , as xenobiotics, in correlation to human health. POPs exhibit a group of common characteristics, including lipophilicity, persistence to decomposition and bioaccumulation in tissues. POPs have been thoroughly studied by former researchers, as they offer a particular interest in the elucidation of metabolic, endocrine and immune perturbation caused by their synergy with intracellular mechanisms. Herein particular focus is attributed to the relationship of POPs with obesity provocation. Obesity nowadays receives epidemic dimensions, as its prevalence elevates in an exponential degree. POPs-induced obesity rotates around interfering in metabolic and endocrinal procedures and interacting with peroxisome-proliferator and retinoic receptors. Moreover, polymorphisms in CYP gene families exert a negative result, as they incapacitate detoxification of POPs. Obesity could be deemed as a multidimensional condition, as various factors interact to lead to an obesogenic result. Therefore, concomitant disorders may occur, from mild to lethal, and get intensified due to POPs exposure. POPs exact function mechanisms remain rather enigmatic, thus further investigation should be prospectively performed, for a more lucid picture of this issue, and, consequently for the establishment of alternative solutions.

Current and Future Trends of Colorectal Cancer Treatment: Exploring Advances in Immunotherapy.

Cancer of the colon and rectum (CRC) has been identified among the three most prevalent types of cancer and cancer-related deaths for both sexes. Even though significant progress in surgical and chemotherapeutic techniques has markedly improved disease-free and overall survival rates in contrast to those three decades ago, recent years have seen a stagnation in these improvements. This underscores the need for new therapies aiming to augment patient outcomes. A number of emerging strategies, such as immune checkpoint inhibitors (ICIs) and adoptive cell therapy (ACT), have exhibited promising outcomes not only in preclinical but also in clinical settings. Additionally, a thorough appreciation of the underlying biology has expanded the scope of research into potential therapeutic interventions. For instance, the pivotal role of altered telomere length in early CRC carcinogenesis, leading to chromosomal instability and telomere dysfunction, presents a promising avenue for future treatments. Thus, this review explores the advancements in CRC immunotherapy and telomere-targeted therapies, examining potential synergies and how these novel treatment modalities intersect to potentially enhance each other's efficacy, paving the way for promising future therapeutic advancements.

Exploring Gut Microbiome Composition and Circulating Microbial DNA Fragments in Patients with Stage II/III Colorectal Cancer: A Comprehensive Analysis.

BACKGROUND: Colorectal cancer (CRC) significantly contributes to cancer-related mortality, necessitating the exploration of prognostic factors beyond TNM staging. This study investigates the composition of the gut microbiome and microbial DNA fragments in stage II/III CRC. METHODS: A cohort of 142 patients with stage II/III CRC and 91 healthy controls underwent comprehensive microbiome analysis. Fecal samples were collected for 16S rRNA sequencing, and blood samples were tested for the presence of microbial DNA fragments. De novo clustering analysis categorized individuals based on their microbial profiles. Alpha and beta diversity metrics were calculated, and taxonomic profiling was conducted. RESULTS: Patients with CRC exhibited distinct microbial composition compared to controls. Beta diversity analysis confirmed CRC-specific microbial profiles. Taxonomic profiling revealed unique taxonomies in the patient cohort. De novo clustering separated individuals into distinct groups, with specific microbial DNA fragment detection associated with certain patient clusters. CONCLUSIONS: The gut microbiota can differentiate patients with CRC from healthy individuals. Detecting microbial DNA fragments in the bloodstream may be linked to CRC prognosis. These findings suggest that the gut microbiome could serve as a prognostic factor in stage II/III CRC. Identifying specific microbial markers associated with CRC prognosis has potential clinical implications, including personalized treatment strategies and reduced healthcare costs. Further research is needed to validate these findings and uncover underlying mechanisms.

Ultrasound morphometry of the cervical vagus nerve for daily clinical practice: Reference values for cross sectional area and fascicle count.

INTRODUCTION: High resolution ultrasound (US) of the cervical vagus nerve (CVN) is clinically relevant in the diagnostic workup and during neurostimulation therapy of several neurologic diseases. This prospective study aims to provide reference data of the cross-sectional area (CSA) and fascicle count of the normal CVN and to investigate their possible association with anthropometric data in a large cohort of patients. METHODS: A total of 657 CVNs in 330 individuals without history of neurological disease were examined using US (7-15Mhz). The CVN fascicle count and CSA inside the hyperechoic epineurium at the level of the thyroid lobes were measured. Three CSA measurements were performed to calculate the mean value. Anthropometric data were recorded. RESULTS: The mean fascicle count was 2.4 ± 1.1 (right) and 2 ± 1 (left) (paired t- test, p < 0.001). Two CVN patterns were identified: A single hypoechoic fascicular structure (26.2 % right, 36.3 % left) and a honeycomb structure of 2-6 discrete fascicles (72.3 % right, 63.7 % left). Right CVN mean CSA was larger compared to left (2.3 ± 1 mm2 and 1.8 ± 0.8 mm2 respectively, t-test, p-0.000). There was no difference in the CSA values between sex and no correlation to age or height. A positive correlation between the CSA and weight and BMI was found (Pearson's correlation, p = 0.01 right and p = 0.05 left). CONCLUSION: The right CVN has larger CSA and contains more fascicles than the left. CVN is usually mono- or oligo-fascicular with a honeycomb appearance. The CSA increased with increasing BMI but no age and sex specific differences were noted.

Achieving a Textbook Outcome in Colon Cancer Surgery Is Associated with Improved Long-Term Survival.

BACKGROUND: Colon cancer surgery is a complex clinical pathway and traditional quality metrics may exhibit significant variability between hospitals and healthcare providers. The Textbook Outcome (TO) is a composite quality marker capturing the fraction of patients, in whom all desired short-term outcomes of care are realised. The aim of the present study was to assess the TO in a series of non-metastatic colon cancer patients treated with curative intent, with emphasis on long-term survival. METHODS: Stage I-III colon cancer patients, who underwent curative colectomy following the Complete Mesocolic Excision principles, were retrospectively identified from the institutional database. TO was defined as (i) hospital survival, (ii) radical resection, (iii) no major complications, (iv) no reintervention, (v) no unplanned stoma and (vi) no prolonged hospital stay or readmission. RESULTS: In total, 128 patients (male 61%, female 39%, mean age 70.7 ± 11.4 years) were included in the final analysis. Overall, 60.2% achieved a TO. The highest rates were observed for "hospital survival" and "no unplanned stoma" (96.9% and 97.7%), while the lowest rates were for "no major complications" and "no prolonged hospital stay" (69.5% and 75%). Older age, left-sided resections and pT4 tumours were factors limiting the chances of a TO. The 5-year overall and 5-year cancer-specific survival were significantly better in the TO versus non-TO subgroup (81% vs. 59%, p = 0.009, and 86% vs. 65%, p = 0.02, respectively). CONCLUSIONS: Outcomes in colon cancer surgery may be affected by patient-, doctor- and hospital-related factors. TO represents those patients who achieve the optimal perioperative results, and is furthermore associated with improved long-term cancer survival.

Unraveling the Role of Molecular Profiling in Predicting Treatment Response in Stage III Colorectal Cancer Patients: Insights from the IDEA International Study.

BACKGROUND: This study aimed to investigate the molecular profiles of 237 stage III CRC patients from the international IDEA study. It also sought to correlate these profiles with Toll-like and vitamin D receptor polymorphisms, clinicopathological and epidemiological characteristics, and patient outcomes. METHODS: Whole Exome Sequencing and PCR-RFLP on surgical specimens and blood samples, respectively, were performed to identify molecular profiling and the presence of Toll-like and vitamin D polymorphisms. Bioinformatic analysis revealed mutational status. RESULTS: Among the enrolled patients, 63.7% were male, 66.7% had left-sided tumors, and 55.7% received CAPOX as adjuvant chemotherapy. Whole exome sequencing identified 59 mutated genes in 11 different signaling pathways from the Kyoto Encyclopedia of Genes and Genomes (KEGG) CRC panel. On average, patients had 8 mutated genes (range, 2-21 genes). Mutations in ARAF and MAPK10 emerged as independent prognostic factors for reduced DFS (p = 0.027 and p < 0.001, respectively), while RAC3 and RHOA genes emerged as independent prognostic factors for reduced OS (p = 0.029 and p = 0.006, respectively). Right-sided tumors were also identified as independent prognostic factors for reduced DFS (p = 0.019) and OS (p = 0.043). Additionally, patients with tumors in the transverse colon had mutations in genes related to apoptosis, PIK3-Akt, Wnt, and MAPK signaling pathways. CONCLUSIONS: Molecular characterization of tumor cells can enhance our understanding of the disease course. Mutations may serve as promising prognostic biomarkers, offering improved treatment options. Confirming these findings will require larger patient cohorts and international collaborations to establish correlations between molecular profiling, clinicopathological and epidemiological characteristics and clinical outcomes.

Role of telomere length in human carcinogenesis (Review).

Cancer is considered the most important clinical, social and economic issue regarding cause­specific disability­adjusted life years among all human pathologies. Exogenous, endogenous and individual factors, including genetic predisposition, participate in cancer triggering. Telomeres are specific DNA structures positioned at the end of chromosomes and consist of repetitive nucleotide sequences, which, together with shelterin proteins, facilitate the maintenance of chromosome stability, while protecting them from genomic erosion. Even though the connection between telomere status and carcinogenesis has been identified, the absence of a universal or even a cancer­specific trend renders consent even more complex. It is indicative that both short and long telomere lengths have been associated with a high risk of cancer incidence. When evaluating risk associations between cancer and telomere length, a disparity appears to emerge. Even though shorter telomeres have been adopted as a marker of poorer health status and an older biological age, longer telomeres due to increased cell growth potential are associated with the acquirement of cancer­initiating somatic mutations. Therefore, the present review aimed to comprehensively present the multifaceted pattern of telomere length and cancer incidence association.

Cancer-Associated Fibroblasts: The Origin, Biological Characteristics and Role in Cancer-A Glance on Colorectal Cancer.

The therapeutic approaches to cancer remain a considerable target for all scientists around the world. Although new cancer treatments are an everyday phenomenon, cancer still remains one of the leading mortality causes. Colorectal cancer (CRC) remains in this category, although patients with CRC may have better survival compared with other malignancies. Not only the tumor but also its environment, what we call the tumor microenvironment (TME), seem to contribute to cancer progression and resistance to therapy. TME consists of different molecules and cells. Cancer-associated fibroblasts are a major component. They arise from normal fibroblasts and other normal cells through various pathways. Their role seems to contribute to cancer promotion, participating in tumorigenesis, proliferation, growth, invasion, metastasis and resistance to treatment. Different markers, such as a-SMA, FAP, PDGFR-ß, periostin, have been used for the detection of cancer-associated fibroblasts (CAFs). Their detection is important for two main reasons; research has shown that their existence is correlated with prognosis, and they are already under evaluation as a possible target for treatment. However, extensive research is warranted.

Renoprotective Effect of Vardenafil and Avanafil in Contrast-Induced Nephropathy: Emerging Evidence from an Animal Model.

The potential renoprotective effects of vardenafil (VAR) have been evaluated in a very limited number of studies using acute kidney injury animal models other than contrast-induced nephropathy (CIN) with promising results, while avanafil (AVA) has not been evaluated in this respect before. The purpose of this study was to evaluate for the first time the potential renoprotective effect of VAR and AVA in a rat model of CIN. Twenty-five male Wistar rats were equally assigned into five groups: control, CIN, CIN+N-acetyl cysteine (NAC) (100 mg/kg/day) as a positive control, CIN+VAR (10 mg/kg/day) and CIN+AVA (50 mg/kg/day). CIN was induced by dehydration, inhibition of prostaglandin and nitric oxide synthesis as well as exposure to the contrast medium (CM). Serum Cr (sCr) levels were measured at 24 and 48 h after CIN induction. At 48 h of CM exposure, animals were sacrificed. Matrix metalloproteinase (MMP) 2 (MMP-2) and MMP-9, kidney injury molecule 1 (KIM-1) and cystatin-C (Cys-C) were measured on renal tissue. Histopathological findings were evaluated on kidney tissue. All treatment groups had close to normal kidney appearance. sCr levels subsided in all treatment groups compared to CIN group at 48 h following CIN induction. A significant decline in the levels of MMP-2, MMP-9, KIM-1 and Cys-C compared to CIN group was observed. These results provide emerging evidence that VAR and AVA may have the potential to prevent CIN.

Sonoanatomy of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves: a practical guide for US-guided injections.

The ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves are the major sensory nerves that may be involved in chronic groin and genital pain with a significant impact on the quality of life of patients. The diagnosis remains clinical, and US-guided diagnostic injections using an anesthetic may aid in confirming the clinical suspicion. The anatomy of the peripheral nerves can be successfully studied using imaging. High-resolution ultrasound is increasingly used in the clinical setting for visualizing small peripheral nerves, and magnetic resonance imaging provides an anatomical overview of the relationship between small nerves and surrounding structures. In this pictorial assay, we review the anatomy and clinical relevance of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. We summarize the various techniques for ultrasound identification, and present the ultrasound-guided infiltration techniques for injecting the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves. Corresponding magnetic resonance images and clinical photos of the probe placement technique are provided for anatomical correlation. This paper is aimed to serve as a practical technical guide for physicians to familiarize themselves with the ultrasound anatomy of the major inguinal sensory nerves and to enable successful ultrasound identification and ultrasound-guided diagnostic or therapeutic infiltrations for pain management of the ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal nerves.

Morphology of the sulcus of the caudate process (Rouviere's sulcus) in a Greek population and a systematic review with meta-analysis.

The purpose of this study was to determine the prevalence and to investigate the morphology of the sulcus of the caudate process in a Greek population, along with a systematic review and meta-analysis of the literature. Overall, 103 consecutive patients undergoing laparoscopic cholecystectomy were included in the analysis. The sulcus was present in 91% and three morphological variants were identified (groove 69%, slit 21% and scar 10%). The sulcus had a horizontal course in 90% of patients and a mean length of 25 ± 13 mm. The meta-analysis included 27 surgical and 11 cadaveric studies with 6661 cases in total. The pooled prevalence of the sulcus was 80% and did not differ significantly among various geographical regions. Concerning sulcus subtypes, the binary "open/fused" classification was used to unify the heterogeneous data. The "open" type was more frequent than the "fused" (64.5% vs 35.5%). A horizontal course was observed in 53.5% and an oblique in 45.7%. The sulcus contained the right portal pedicle in 38%, the right posterior portal pedicle in 37%, and the right posteroinferior pedicle in 23.5%. In conclusion, the sulcus of the caudate process is a very helpful anatomical landmark in hepatectomy and laparoscopic cholecystectomy and can be identified in the majority of patients. However, various classifications for the morphological variants and diverse terminology cause discrepancy in the literature and create the need for a single classification system. The proposed 3-tier classification (groove, slit, scar) is simple and easy to remember and avoids ambiguous nomenclature.

Investigation of Microbial Translocation, TLR and VDR Gene Polymorphisms, and Recurrence Risk in Stage III Colorectal Cancer Patients.

Gut microbial dysbiosis and microbial passage into the peripheral blood leads to colorectal cancer (CRC) and disease progression. Toll-like (TLR) and vitamin D (VDR) receptors play important role in the immune modulation and polymorphisms that may increase CRC risk and death rates. The aim of the current study was to demonstrate the prognostic value of microbial DNA fragments in the blood of stage III CRC patients and correlate such microbial detection to TLR/VDR polymorphisms. Peripheral blood was collected from 132 patients for the detection of microbial DNA fragments, and TLR/VDR gene polymorphisms. In the detection of various microbial DNA fragments, TLR and VDR polymorphisms was significantly higher compared to healthy group. Homozygous individuals of either TLR or VDR polymorphisms had significantly higher detection rates of microbial DNA fragments. Mutational and MSI status were significantly correlated with TLR9 and VDR polymorphisms. Significantly shorter disease-free survival was associated with patients with BRAF mutated tumors and ApaI polymorphisms, whereas shorter overall survival was associated with the detection of C. albicans. The detection of B. fragilis, as demonstrated by the multivariate analysis, is an independent poor prognostic factor for shorter disease-free survival. TLR/VDR genetic variants were significantly correlated with the detection of microbial fragments in the blood, and this in turn is significantly associated with tumorigenesis and disease progression.