Preoperative tumor marking with indocyanine green (ICG) prior to minimally invasive colorectal cancer: a systematic review of current literature.

Aim: To describe the currently available evidence regarding the efficacy and safety of preoperative tumor marking using indocyanine green (ICG) prior to laparoscopic or robotic colorectal resections. Methods: A systematic search for relevant studies was conducted using the following databases: Embase (OVID), MEDLINE® (OVID), APA PsycInfo (OVID), Global Health (OVID) and HMIC Health Management Information Consortium (OVID) through June 2022 reported according to PRISMA 2020 guidelines. Primary outcome was the detection rate of the tumor sites preoperatively marked with ICG. Secondary outcomes were timing of ICG injection in days prior to the operation and technique-related complications. Results: Eight single center studies, published between 2008 and 2022, were identified yielding a total of 1,061 patients, of whom 696 were preoperatively tattooed with ICG. Injection dosage of diluted ICG ranged from 0.1-1.5 ml. Four studies used the saline test injection method prior to ICG injection. When the marking was placed within one week, the visualization rate was 650/668 (97%), whereas when it was longer than one week, the detection rate was 8/56 (14%). No severe complications were reported. Conclusion: Preoperative tumor marking using ICG prior to minimally invasive colorectal resections is safe and effective, allowing intraoperative tumor site location when performed up to a week prior to surgery without disturbing the surgical view in potential mild complications.

En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach.

BACKGROUND: Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm. METHODS: This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy. RESULTS: During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation. CONCLUSIONS: The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.

High Intratumoral i-tRF-GlyGCC Expression Predicts Short-Term Relapse and Poor Overall Survival of Colorectal Cancer Patients, Independent of the TNM Stage.

Colorectal cancer (CRC), one of the most prevalent types of cancer, requires the discovery of new tumor biomarkers for accurate patient prognosis. In this work, the prognostic value of the tRNA fragment i-tRF-GlyGCC in CRC was examined. Total RNA extraction from 211 CRC patient cancer tissue specimens and 83 adjacent normal tissues was conducted. Each RNA extract was subjected to in vitro polyadenylation and reverse transcription. A real-time quantitative PCR assay was used to quantify i-tRF-GlyGCC in all samples. Extensive biostatics analysis showed that i-tRF-GlyGCC levels in CRC tissues were significantly lower than in matched normal colorectal tissues. Additionally, the disease-free survival (DFS) and overall survival (OS) time intervals were considerably shorter in CRC patients with high i-tRF-GlyGCC expression. i-tRF-GlyGCC expression maintained its prognostic value independently of other established prognostic factors, as shown by the multivariate Cox regression analysis. Additionally, survival analysis after TNM stage stratification revealed that higher i-tRF-GlyGCC levels were linked to shorter DFS time intervals in patients with TNM stage II tumors, as well as an increased probability of having a worse OS for patients in TNM stage II. In conclusion, i-tRF-GlyGCC has the potential to be a useful molecular tissue biomarker in CRC, independent of other clinicopathological variables.

MicroRNA-675-5p Overexpression Is an Independent Prognostic Molecular Biomarker of Short-Term Relapse and Poor Overall Survival in Colorectal Cancer.

Colorectal cancer (CRC) is the main cause of cancer-related deaths globally, highlighting the importance of accurate biomarkers for early detection and accurate prognosis. MicroRNAs (miRNAs) have emerged as effective cancer biomarkers. The aim of this study was to investigate the prognostic potential of miR-675-5p as a molecular prognostic biomarker in CRC. For this reason, a quantitative PCR assay was developed and applied to determine miR-675-5p expression in cDNAs from 218 primary CRC and 90 paired normal colorectal tissue samples. To assess the significance of miR-675-5p expression and its association with patient outcome, extensive biostatistical analysis was performed. miR-675-5p expression was found to be significantly downregulated in CRC tissue samples compared to that in adjacent normal colorectal tissues. Moreover, high miR-675-5p expression was associated with shorter disease-free (DFS) and overall survival (OS) in CRC patients, while it maintained its unfavorable prognostic value independently of other established prognostic factors. Furthermore, TNM stage stratification demonstrated that higher miR-675-5p levels were associated with shorter DFS and OS intervals, particularly in patients with CRC of TNM stage II or III. In conclusion, our findings suggest that miR-675-5p overexpression constitutes a promising molecular biomarker of unfavorable prognosis in CRC, independent of other established prognostic factors, including TNM staging.

Pancreaticoduodenectomy as a feasible choice for periampullary malignancy in octogenarians.

The efficacy and safety of pancreaticoduodenectomy (PD) has not been yet studied in octogenarians in Greece. The present study reviewed records of all consecutive patients that underwent PD at the 4th Surgical Department of Attikon University Hospital (Athens, Greece) between January 1st, 2010 and December 31st, 2019. Differences between two age groups (group Y <80 years; group O >80 years) were analyzed. Study endpoints were length of stay, overall morbidity, 30-day mortality and overall survival (OS). There were 198 patients in Group Y (mean age, 65 years) and 20 patients in Group O (mean age, 82 years). Octogenarians had worse American Society of Anesthesiology score (>2; 31.3 vs. 65%; P=0.018). Median stay was not significantly different between the two groups (14 days vs. 16 days; P=0.307), neither was the 30-day mortality (6.1 vs. 5.0%; P>0.99). Median OS was similar between the two groups (35 months vs. 28 months; P=0.577). In a tertiary center in Greece, morbidity and mortality rates after PD were similar between the two groups. Patients should not be denied a PD, solely based on advanced age.

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration.

Background: Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome. Methods: The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed. Results: Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C). Conclusion: Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.

Advanced trauma life support course for medical students. A new era?

Introduction: Trauma represents a major public health issue and is one of the leading causes of death and disability worldwide. A systematic approach toward dealing with trauma patients was facilitated through the ATLS program, which has become a milestone in trauma care. Our new ATLS course for medical students was set in motion in 2015. Our aim was to make medical students familiar with trauma patients interactively, through a program like ATLS, and here we present the results of this endeavor. Methods: A two-day ATLS-Medical Student (MS) course was offered from November 2015 to July 2018, and analysis was performed retrospectively on the data gathered over a three-month period through online questionnaires. Before graduating, 261 newly qualified medical doctors were interviewed and evaluated as part of the ATLS course. Results: After the course, the vast majority of medical students (251 MSs; 96.16%) felt more capable of managing severely injured patients and 58% of students felt that the medical services they offered were better due to the ATLS training. Regarding the educational fee for the course, 56.7% of the students reported that they felt the fee of 100 euros was fair. Discussion: The interactive format of the course, which differs from more traditional methods of teaching, has been endorsed by medical students. Though they lack clinical experience, that does not prohibit them from acquiring more specialized or specific knowledge, enabling them to excel. Most of the students improved their skillset either in theoretical knowledge, practical skills, or even in the emotional component of the course, i.e., dealing with treating a severely injured patient. It was decided that the program would be re-evaluated and extended to all Greek Medical Schools. Conclusion: The advantage of providing doctors with trauma training at the beginning of their careers is evident. For that reason, it was decided that the program would be re-evaluated and extended to all Greek Medical Schools.

Intrapericardial Hernia after Transdiaphragmatic Approach of Intrathoracic IVC.

Trauma and abdominal surgery that involves the diaphragm and pericardium rarely ends up in post-operative visceral herniation into the pericardial cavity. Urgent intervention is crucial to restore the cardiac output and prevent bowel strangulation. A case of a patient with intrapericardial hernia following nephrectomy for renal cell carcinoma and en block resection of an IVC neoplasmatic thrombus via transdiaphragmatic approach is presented.

Case Report: Sacral Nerve Root Pelvic Neural Retraining, With Long-Term Sustainability After the Device Explantation.

Introduction: Sacral-Nerve-Neuromodulation (SNM) is an effective treatment increasingly used in patients with urinary (UI) and fecal incontinence (FI). The way it acts in the body at its full potential have not yet been elucidated. The authors review the literature on SNM and the way it possibly works, relating it to a case with an unusually favorable outcome. Case Presentation: A female presented with UI and FI. Operated for meningocele as a neonate. It the age of 5 bilateral Cohen ureter reimplantation performed for persistent urinary infections due to vesicourethral reflux. At the age of 13, she started complaining about UI associated with a hyper functional detrusor muscle. After a diary incontinence evaluation with a standardized questionnaire, SNM was applied at the age of 18 and was retained for 4 years. She was re-evaluated with a yearly follow-up. Results: The patient retained the positive effect of SNM even after its removal and in addition showed signs of improvement. The patient developed the sensation of fillingness of the bladder and the rectum, which she never had before the SNM implantation, sensation which she retained 29 months after (last follow-up) device removal, allowing her to control her voids. Discussion: The modern literature hypothesis that SNM contributes to the plasticity of the nerves through the stimulated area is supported by the present case, in which the SNM effect remained and led to improvements even after its removal. Device settings are presented as they may correlate with the result. This reinforces and expands the frontiers of SNM application and research.

Brief Report on a Novel Reconstruction Technique Following Pancreaticoduodenectomy.

MINI-ABSTRACT: Although pancreaticoduodenectomy (PD) has significantly improved and is considered a safe procedure, it is still associated with increased rates of morbidity. The aim of the present study is to evaluate an alternative reconstruction technique following PD. This technique uses an isolated hepaticojejunal anastomosis and presents low postoperative morbidity rates.

Effect of high-dose steroids on anastomotic complications after proctocolectomy with ileal pouch-anal anastomosis.

This review was designed to determine whether "high-dose" steroid therapy (> or =20 mg prednisone/day) increases the likelihood of anastomotic complications after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The hospital records of 100 patients undergoing proctocolectomy with IPAA were reviewed. Patient characteristics were analyzed to determine what factors were associated with higher rates of anastomosis-related complications. Seventy-one of our patients were given diverting ileostomies, whereas the remaining 29 underwent a single-stage procedure. Fifty-four percent of the patients in our review were taking steroids preoperatively, 39 of whom were on high-dose therapy. The overall anastomosis-related complication rate was 14%. There was no significant difference in complication rates with respect to age, steroid use, steroid dose, use of a diverting ileostomy, type of anastomosis, duration of disease, or presence of backwash ileitis. A trend toward higher leakage rates was found in patients undergoing single-stage procedures (10.3% vs. 2.8%, P=0.14) as well as in patients undergoing single-stage procedures on high-dose steroids (22% vs. 5.0, P=0.22). Nevertheless, neither of these trends was found to be statistically significant, which was likely influenced by the small sample size. Our data suggest that there may be an increase in anastomotic leakage rates in patients on high-dose steroids undergoing a single-stage proctocolectomy with IPAA. Nevertheless, our rate was not as high as the rates seen by other investigators and did not reach statistical significance. During preoperative counseling, patients on high-dose steroids should be informed of this uncertain but real risk of anastomotic leakage.