Milligan-Morgan hemorrhoidectomy vs. hemorrhoid artery ligation and recto-anal repair: a comparative study.

BACKGROUND: Several surgical techniques for the treatment of hemorrhoidal disease (HD) have been proposed. However, the selection of the most proper technique for each individual case scenario is still a matter of debate. The purpose of the present study was to compare the Milligan-Morgan (MM) hemorrhoidectomy and the hemorrhoidal artery ligation and rectoanal repair (HAL-RAR) technique. METHODS: A retrospective analysis of the prospectively collected database of patients submitted to HD surgery in our department was conducted. Patients were divided into two groups, the MM group and the HAL-RAR group. Primary end points were recurrence rates and patients' satisfaction rates. The Unpaired t test was used to compare numerical variables while the x2 test for categorical variables. RESULTS: A total of 124 patients were identified, submitted either to HAL-RAR or MM hemorrhoidectomy. Eight (8) patients were lost to follow up and were excluded from the analysis. Of the remaining 116 patients, 69 patients (54 males and 15 females-male / female ratio: 3.6) with a median age of 47 years old (range 18-69) were included in the HAL-RAR group while 47 patients (40 males and 7 females-male / female ratio: 5.7) with a median age of 52 years old (range 32-71) comprised the MM group. At a median follow up of 41 months (minimum 24 months-maximum 72 months), we recorded 20 recurrences (28.9%) in the HAL-RAR group and 9 recurrences in the MM group (19.1%) (p 0.229). The mean time from the procedure to the recurrence was 14.1 ± 9.74 months in the HAL-RAR group and 21 ± 13.34 months in the MM group. Patients with itching, pain or discomfort as the presenting symptoms of HD experienced statistically significantly lower recurrences (p 0.0354) and reported statistically significantly better satisfaction rates (6.72 ± 2.15 vs. 8.11 ± 1.99-p 0.0111) when submitted to MM. In the subgroup of patients with bleeding as the presenting symptom, patients satisfaction rates were significantly better (8.59 ± 1.88 vs. 6.45 ± 2.70-p 0.0013) in the HAL-RAR group. CONCLUSIONS: In patients with pain, itching or discomfort as the presenting symptoms of HD, MM was associated with less recurrences and better patients satisfaction rates compared to HAL-RAR. In patients with bleeding as the main presenting symptom of HD, HAL-RAR was associated with better patients' satisfaction rates and similar recurrence rates compared to MM.

Computed tomography-guided percutaneous cholecystostomy: a single institution's 6-year experience.

Background: Acute cholecystitis (AC) is an emergency commonly managed by a surgical department. The interventional part of the standard treatment algorithm includes laparoscopic or open cholecystectomy. Percutaneous cholecystostomy (PC) under imaging guidance is recommended as the first-line approach in the subset of high-risk patients for perioperative complications, as a bridging therapy to elective surgery or as a definitive solution. The aim of the present study was to evaluate the mortality and morbidity of PC performed under computed tomographic (CT) guidance in patients at high surgical risk. Methods: Medical and imaging records from all consecutive patients who underwent a CTPC between 2015 and 2020 were reviewed. Adult patients with a definite indication for CTPC were recruited and mortality 7 and 30 days post-procedure was recorded. Variables potentially affecting those outcomes were retrieved and included in our analysis. Results: Eighty-six consecutive patients at high risk for surgical management were identified and included in the present study. Most patients (58.1%) were diagnosed with AC, while 14 (16.3%) had concurrent AC and cholangitis, 13 (15.2%) gallbladder empyema, and 9 (10.4%) hydrops. The 7- and 30-day mortality rates were 16.3% (14/86) and 22.1% (19/86), respectively, and were significantly associated with patients' hospitalization in the intensive care unit (P<0.05). Other parameters investigated, such as age, sex, diagnosis, catheter diameter, and duration of hospital stay were not significantly associated with our primary outcome. Conclusion: PC is a safe alternative to surgery in patients with high perioperative risk, thus providing acceptable mortality rates.

Primary Cervical Carcinosarcoma: Report of a Rare Case.

Background Carcinosarcomas are malignant mixed Müllerian tumors (MMMT), containing both epithelial and mesenchymal components. Carcinosarcomas of the uterine cervix comprise an extremely rare histopathological entity, with less than 150 cases reported in the literature to date. Materials and Methods A 79-year-old postmenopausal female patient was referred to our gynecological department due to a pelvic mass and vaginal bleeding. A cervical curettage was performed and the histological report revealed a malignant neoplasm with high cellularity consisting of two components; the first was a chondrosarcoma and the latter a adenocarcinoma. A diagnosis of MMMT was confirmed through immunohistochemical (IHC) staining. Neoadjuvant chemotherapy and radiotherapy were implemented, and a year later the patient underwent a radical hysterectomy and oncological pelvic lymph node dissection. She remains disease-free 12 months postoperatively. Conclusion Primary cervical carcinosarcomas are extremely rare tumors demonstrating a bipartite profile. Preoperative diagnosis with appropriate immunochemistry testing of this rare entity is crucial to decision making.

Meta-analysis of robot-assisted versus video-assisted McKeown esophagectomy for esophageal cancer.

We aim to review the available literature on patients with esophageal cancer treated with robot-assisted (RAME) or video-assisted McKeown's esophagectomy (VAME), to compare the efficacy and safety of the two approaches. Original research studies that evaluated perioperative and oncologic outcomes of RAME versus VAME were identified, from January 1990 to July 2022. The 90-day mortality, the R0 resection rate, the dissected lymph nodes, the perioperative parameters, and the complications were calculated according to a fixed and a random effect model. The Q statistics and I2 statistic were used to test for heterogeneity among the studies. Seven studies were included, incorporating a total of 1617 patients treated with RAME or VAME. The 90-day mortality was similar between the two groups. No difference was found regarding the R0 resection rate and the number of dissected lymph nodes. In addition, the perioperative parameters, along with the total complications were similar between RAME and VAME. Nonetheless, the incidence of postoperative pneumonia was higher in the VAME group (OR:0.67 [95% CI: 0.49, 0.93]; p = 0.02). Finally, our outcomes were further validated by sensitivity analysis including only studies performing propensity score-matched analysis. Our meta-analysis showed that RAME was equivalent to VAME in terms of safety, feasibility, and oncologic adequacy. These results should be interpreted with caution due to the small number of included studies. New Randomized Controlled trials, that are currently active, will provide further evidence with greater clarity to assess the effectiveness and safety of RAME for esophageal cancer.

Surgical Repair of Iatrogenic Duodenal Injuries with a Roux-en-Y Duodenojejunostomy: A Physiology-oriented Approach.

Introduction: Iatrogenic duodenal injuries represent a condition associated with high morbidity and even mortality. Management is still controversial with a lack of consensus among experts regarding the optimal treatment. The purpose of the present study was to test and assess the results of a certain reconstruction technique. Material and Methods: Four patients (2 males and 2 females) of a mean age of 83 years with iatrogenic duodenal injuries underwent surgical repair of the duodenal perforation, with a two-layer duodenojejunostomy and a Roux-en-Y jejunal loop. Results: Three out of four patients (75%) had a rapid and uncomplicated recovery (13 days mean postoperative length of hospital stay), while the fourth patient died in the ICU due to ARDS three weeks later, without however evidence of anastomotic leak. Conclusion: A variety of surgical repair techniques have been proposed to date; however, with controversial results. A repair using an isolated jejunal Roux-en-Y loop seems to fulfill all the optimal prerequisites for a successful anastomotic outcome and proved efficient in its certain form for the given patient sample.

Radiotherapy and Breast Reconstruction: What Is the Ideal Timing? A Narrative Review.

INTRODUCTION: Women undergoing mastectomy choose to pursue breast reconstruction (BR) in order to reduce their body image distress.Adjuvant chest wall irradiation is associated with a negative cosmetic outcome. The aim of our review was to identify the optimal timing of BR relating to radiotherapy delivery. MATERIALS AND METHODS: Using Cochrane Library, Embase, PubMed, Springer, Wanfang and CNKI, we performed a non-systematic review of articles published up to August 2021. RESULTS: There is no hard evidence in favor of immediate, delayed or 2-stage BR when post-mastectomy radiation is indicated. Immediate and 2-stage BR seem to be valid alternatives to delayed BR. CONCLUSIONS: Further research is essential in order to assess clinician and patient reported aesthetic outcomes and determine the optimal timing of BR in view of post-mastectomy radiotherapy, in breast cancer survivors.

Surgical versus non-operative initial management of post-endoscopic retrograde cholangiopancreatography perforation: a systematic review and meta-analysis.

BACKGROUND: In the present study we performed a systematic review and meta-analysis regarding the initial management of perforations following endoscopic retrograde cholangiopancreatography (ERCP). METHOD: A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. RESULT: In total, 10 comparative studies and 223 patients with post-ERCP perforations were included in the present study. In type I and II perforations, the success rate of initial surgical management was higher compared to the non-operative management (NOM) group (P=0.09 and P=0.02, respectively). There was no statistically significant difference in mortality rates or length of hospital stay between initial surgical and NOM management for any type of perforation. CONCLUSIONS: The current meta-analysis demonstrated the significance of the initial management of patients with post-ERCP perforations. Whether a surgical or an endoscopic approach is chosen, the patient should immediately be evaluated by an experienced surgeon or endoscopist.

Metastatic rectal cancer in the ampulla of Vater: A unique case.

BACKGROUND: A metastatic lesion located in the ampulla of Vater is considered extremely rare, with only 32 cases reported globally. CASE: A 65-year-old patient was primarily diagnosed with a rectal adenocarcinoma. Twenty-four months later as part of the oncological follow-up, the patient was diagnosed with a single secondary tumor in the ampulla of Vater. After undergoing a pancreaticoduodenectomy (Whipple procedure), the patient experienced an uneventful recovery and received adjuvant chemotherapy. Sixteen months later the patient remained disease-free. CONCLUSION: To the best of our knowledge, the present case represents the first reported metastatic tumor in the ampulla of Vater, originating from a rectal adenocarcinoma. This case underlines the critical role of immunohistochemistry in arriving at a correct diagnosis in order to guide clinical decision-making.

Cutaneous soft tissue sarcomas: survival-related factors.

Cutaneous sarcomas are a heterogeneous group of rare mesenchymal neoplasms representing less than 1% of malignant tumors. Histology report remains the cornerstone for the diagnosis of these tumors. The most important clinicopathologic parameters related to prognosis include larger tumor size, high mitotic index, head and neck location, p53 mutations, depth of infiltration and histological grade, vascular and perineural invasion as well as the surgical margins status. Applying advanced biopsy techniques might offer more precise assessment of surgical margins, which constitutes a significant precondition for the management of these tumors. The management of cutaneous soft tissue sarcomas requires a multidisciplinary approach. Surgery remains the standard treatment, nonetheless adjuvant therapy may be required, consisting of radiotherapy, chemotherapy, and molecular targeted therapies to improve treatment outcomes. The role of molecular profiling in the treatment of uncontrolled disease is promising, but it may be offered to a relatively small proportion of patients and its use is still considered experimental in this setting. Due to the rarity of the disease, there is a need for knowledge and experience to be shared, pooled, organized and rationalized so that recent developments in medical science can have a major impact on the disease course. Multicenter clinical trials are needed to improve the care of patients with cutaneous sarcomas.

Iatrogenic Bile Duct Injuries: A Critical Appraisal of Classification Systems.

Bile duct injuries represent the most dramatic complications after an open or laparoscopic cholecystectomy. The detrimental effects on patient quality of life and overall survival are the most obvious consequences of such injuries. An effective treatment strategy after accurate mapping of the injury type is the only method of averting these morbid consequences. Several classification systems have been proposed in an attempt to accurately describe and categorize bile duct injuries. The critical question is whether we truly need all these systems and whether each of these systems adds value to the existing knowledge base, or further obscures the field. Each classification system has several advantages to base its clinical utility on, but entails a reasonable number of limitations as well. Currently, a tailored approach adopting the classification system which provides the most appropriate guidance - either in terms of diagnosis or treatment decision making - appears to be the most justified option.

Reaching the Challenging Diagnosis of Complicated Liver Hydatid Disease: A Single Institution's Experience from an Endemic Area.

Background and Objectives: Hydatid disease (HD) remains a significant public health issue causing morbidity and mortality in many Mediterranean countries. Material and Methods: The present cohort study included 50 consecutive patients with liver hydatid disease who underwent surgery in a tertiary University Hospital. A total of 18 patients (36%) had a case of complicated HD, including simple communication of the cyst with the biliary tree (6 cases), rupture of the cyst into the biliary tree (6 cases), presence of a bronco-biliary fistula (2 cases), rupture of the cyst in the peritoneal cavity (2 cases), and rupture of the cyst and formation of a hepatic abscess (2 cases). Endoscopic retrograde cholangiopancreatography (ERCP) was pre-operatively performed on six patients. Results: The main clinical symptom presented was right upper quadrant pain in 16 patients (88%), which was associated with high fever (>39 °C) in 14 patients (78%). C-reactive protein (CRP) was the primary indicator of a complicated HD (p = 0.003); however, it was only elevated in 67% of cases. CRP was a more sensitive indicator of a rupture in the biliary tree cyst (p = 0.02). Computer tomography (CT) detected more cases (44%) of a complicated HD than ultrasonography (US) (25%); however, the difference was not statistically significant. Conclusions: For prevention and control of HD, a high suspicion of the disease leading to early referral to specialized centers, mainly in endemic areas, is required. Prior to surgical or percutaneous intervention, a combination of imaging and laboratory findings are essential in diagnosing a complicated case and avoiding unnecessary interventions.

Quality of life deterioration and colorectal cancer staging in elderly patients. Which comes first?

PURPOSE: Never before the preoperative quality of life (QoL) score of colorectal cancer (CRC) patients was analyzed and linked directly to cancer staging according to pathology in specimens and, thereafter, in patients to estimate long-term prognosis. Our study attempted to give answers to these questions. METHODS: This was a prospective study of 80 elderly patients who underwent major colorectal surgery for cancer in a single University's surgical department conducted between 01/2018 and 12/2018. All patients aged >65 years, diagnosed with a resectable CRC without metastatic disease undergoing an elective surgery were prospectively included. As exclusion criteria were considered age <65 years, an emergency operation, non-resectable tumor, stage IV CRC and American Society of Anesthesiologists (ASA) score IV. All patients were asked to answer a self-administered questionnaire of the validated Greek version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30. RESULTS: Comparison of the mean score of EORTC QLQ-C30 showed stage I CRC was 87.62% (11.81%), 77.24% (12.91%) in stage II patients and 78.99% (15.25%) in stage III cancer. The mean difference between the three groups was statistically significant (p=0.002). Moreover, in post-hoc analysis, there was a statistically significant difference in the mean QLQ-C30 score between patients with stage I and stage II cancer (p=0.043) and between patients with stage I and stage III tumor (p=0.01), but this difference was not observed when comparing patients with stage II and III cancer (p=0.319). CONCLUSION: Our study demonstrated a significant association between preoperative QoL and tumor staging as shown in the specimen's examination in elderly patients with CRC. More prospective studies are needed to elucidate how QoL and its fluctuations during the postoperative period can be correlated with long-term survival and disease progression in elderly CRC patients.

Differences in surgical oncology practice in Greece and Cyprus between the first and second COVID-19 pandemic waves: Lessons from a paradigm shift.

The SARS-CoV-2 (COVID-19) pandemic has led to the implementation of certain restrictions and rearrangements regarding the surgical oncology operations, thus affecting the surgical lists, the availability of surgical time, along with the consultations of oncologic patients. The purpose of the present study was to identify the differences in surgical oncology practices in Greece and Cyprus between the first and second pandemic waves. We designed a questionnaire for surgeons treating surgical oncology patients. A total of 104 surgeons participated in the present study by answering our questionnaire. According to our outcomes, there was a significant shift between the two waves in patients' willingness to undergo surgery and to present to consultations. Nonetheless, the availability of surgical services remained limited. The consequent mismatch in patients' needs and the availability of healthcare services, we demonstrate herein, is alarming and should be taken into consideration by the policymakers.

Gastrointestinal Stromal Tumor (GIST) and Synchronous Intra-Abdominal Liposarcoma: A Report of Two Rare Cases and Literature Review.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) quite frequently occur synchronously with other malignancies, with most cases being adenocarcinomas. GISTs and liposarcomas are both of mesenchymal origin, and their coexistence is extremely rare. METHODS: We conducted a review of the current literature regarding the synchronous occurrence of GISTs and intra-abdominal liposarcomas. An electronic search of the literature was undertaken using MEDLINE (database provider PubMed). Furthermore, we present the first described case of an 86-year-old male with a GIST and synchronous liposarcoma, both located in the stomach, as well as a 66-year-old male with a gastric GIST and concurrent retroperitoneal liposarcoma. RESULTS: A total of 5 cases of synchronous GIST and intra-abdominal liposarcoma have been reported in the literature to date, with the most recent cases included in the present study. CONCLUSION: Further research is required to explain any possible correlation in the coexistence of these different neoplasms of the same origin. Meanwhile, R0 resection of both tumors remains the treatment of choice.

Effects of Monochromatic Illumination with LEDs Lights on the Growth and Photosynthetic Performance of Auxenochlorella protothecoides in Photo- and Mixotrophic Conditions.

This study examined the effects of monochromatic illumination (blue, red, green and yellow) employing light-emitting diodes (LEDs), trophic conditions (photoautotrophic and mixotrophic), and nitrogen availability (high and low peptone concentration) on the growth and biochemical composition of Auxenochlorella protothecoides. The results revealed that mixotrophic conditions did not favor A. protothecoides, giving lower growth rates compared to heterotrophy (dark conditions). However, mixotrophy gave significantly higher growth rates compared to photoautotrophy. The best light wavelengths for mixotrophic cultivation were that of white and red. In all cases investigated in this study, high peptone concentration (4 g/L) resulted in decreased growth rates. Regarding the biochemical composition of A. protothecoides, the strongest effect, irrespective of trophic conditions, was caused by nitrogen availability (peptone concentration). Specifically, at nitrogen replete conditions (4 g/L peptone), biomass was rich in proteins (32-67%), whereas under deplete conditions (0.5 g/L peptone), A. protothecoides accumulated mainly carbohydrates (up to 56%). Mixotrophic conditions generally favored higher carbohydrate content, whereas photoautotrophic conditions favored higher protein content. The different illumination spectra did not have any clear effect on the biochemical composition (metabolites content), except that, in all trophic conditions, the use of the green spectrum resulted in higher chlorophyll b content. Chlorophyll a fluorescence studies revealed that the trophic conditions and the high peptone concentrations impacted the photosystem II (PSII) performance, and also affected plastoquinone re-oxidation kinetics and the heterogeneity of the PSII reaction centers.

Intraoperative neuromonitoring in rectal cancer surgery: a systematic review and meta-analysis.

PURPOSE: The aim of this study is to evaluate the role of pelvic intraoperative neuromonitoring (pIONM) in rectal cancer surgery. METHODS: A systematic review of the literature and a meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Overall, nine studies were identified. Quantitative analysis was performed only in three trials. Bilateral pIONM improved postoperative anorectal and urogenital functional outcomes. However, unilateral pIONM displayed a significant effect only on erectile function (p = 0.001). CONCLUSIONS: Our findings suggest a positive effect of pIONM on postoperative functional outcomes and quality of life after rectal cancer surgery. Due to several limitations, further trials are required in order to elucidate the exact role of pIONM.

A rolling stone: vomiting of a gallstone without the presence of a biliary-enteric fistula.

Gallstones may pass into the gastrointestinal tract spontaneously through the ampulla of Vater or through a biliary-enteric fistula. This report describes an extremely rare case of a patient vomiting a gallstone without the presence of a fistula between the gallbladder and the gastrointestinal tract. Furthermore, no imaging findings of gallstones disease appeared. The patient has been treated conservatively and all symptoms subsided. The patient remains asymptomatic 3 months after treatment and an elective laparoscopic cholecystectomy was arranged. Including this reported case, only three cases have been described in the literature worldwide. However, our case is the only one characterized by retrograde flow of the gallstones into the stomach without symptoms of bowel obstruction or other underlying pathologies.

Laparoscopic versus Robotic Peripheral Pancreatectomy: A Systematic Review and Meta-analysis.

PURPOSE: The current systematic review and meta-analysis aimed to compare Laparoscopic Distal Pancreatectomy (LPD) with Robotic Distal Pancreatectomy (RDP) in terms of length of hospital stay (LOS), perioperative, postoperative and economic parameters. METHODS: A systematic review of the literature was undertaken and data from studies fulfilling the predetermined inclusion criteria were extracted. Meta-analyses were performed to combine the results of various studies in the forms of Weighted Mean Difference (WMD), Odds Ratio (OR) and Risk Difference (RD), as appropriate. RESULTS: A significantly lower LOS (WMD:0.75, 95%CI:0.17-1.33) and longer operative duration (WMD:-28.29, 95%CI:-49.98--6.6) for the RDP group was found. The rate of open conversion was higher in the LDP group (OR:2.38, 95%CI:1.75-3.22), while the rate of spleen preservation was lower (OR:0.49, 95%CI:0.31-0.79). No significant difference was noted in the intraoperative blood loss (WMD:34, 95%CI:-10.28-78.29), postoperative blood transfusion (OR:0.99, 95%CI:0.66-1.49) and overall morbidity analyses (OR:1.08, 95%CI:0.88-1.32). A significantly higher yield of lymph nodes was achieved in the RDP group (WMD:-2.09, 95%CI:-4.17--0.01), while no differences were found when positive resection margins (RD:0.02, 95%CI:-0.02-0.07) and specimen length (WMD:0.08, 95%CI:0.42-0.58) were considered. Finally, RDP was associated with significantly higher operative (WMD:-2733.42, 95%CI:-4189.77--1277.08) and total (WMD:-3799.68, 95%CI: -4438.39--3160.98) costs. CONCLUSION: RDP seems to be a viable option for both benign and malignant pancreatic disorders, although there are concerns regarding economic parameters. Large randomized controlled trials will shed more light on the subject.

Asymptomatic Presacral Paraganglioma: Management of an Unpredictable Intraoperative Finding.

Paragangliomas are rare neuroendocrine tumors originating from the embryological neural crest. We report a rare case of a patient with an asymptomatic presacral mass (incidentaloma) who experienced an unpredictable intraoperative hypertensive crisis after manipulation of the tumor. Presacral neoplasms pose a diagnostic and therapeutic challenge due to their obscure anatomical location and the difficulty in performing an R0 excision. Furthermore, the management of asymptomatic paragangliomas requires a high level of clinical suspicion and expertise due to potential life-threatening intraoperative complications.