The Effectiveness of Adipose Tissue-Derived Mesenchymal Stem Cells Mixed with Platelet-Rich Plasma in the Healing of Inflammatory Bowel Anastomoses: A Pre-Clinical Study in Rats.

Introduction: Multiple factors have been linked with increased risk of anastomotic leak in bowel surgery, including infections, inflammatory bowel disease, patient comorbidities and poor surgical technique. The aim of this study was to investigate the positive effect, if any, of adipose derived mesenchymal stem cells (MSCs) mixed with platelet-rich plasma (PRP) in the healing of bowel anastomoses, in an inflammatory environment after establishment of experimental colitis. Materials and Methods: Thirty-five male Wistar rats were divided into five groups of seven animals: normal controls, colitis controls, PRP, MSCs, and PRP+MSCs. All groups underwent laparotomy, one-cm segmental colectomy and anastomosis in situ. In the colitis group, colectomy was performed at the affected area. Colitis was previously established by transrectal administration of 2,4,6-trinitrobenzene sulfonic acid (TNBS) except for the normal controls. Post-mortem histopathological, tissue hydroxyproline and anastomotic bursting pressure (ABP) assessments were performed. The Mann-Whitney U test was used to assess statistical significance differences between groups. Results: No perioperative mortality was noted. Tissue hydroxyproline and ABP were significantly increased in the group of PRP+MSCs compared to colitis controls (p = 0.0151 and p = 0.0104, respectively). Inflammatory cell infiltration was lower and fibroblast activity higher in PRP+MSCs group, but not statistically significant (p > 0.05). Neoangiogenesis (p = 0.0073) and anastomotic area epithelialization (p = 0.0182) were significantly higher in PRP + MSCs group compared to colitis controls. Discussion: The synergistic effect of the PRP and MSCs is apparently responsible for the improved healing markers in bowel anastomoses even on inflammatory bowel. This gives hope for primary anastomoses and stoma saving in many emergency and/or elective circumstances, especially in immunocompromised or malnourished patients, even in cases with inflammation or peritonitis. Clinical studies should follow in order to support the clinical application of PRP+MSCs in gastrointestinal anastomoses.

Indications for the surgical management of pancreatic trauma: An update.

Pancreatic trauma is rare compared to other abdominal solid organ injuries, accounting for 0.2%-0.3% of all trauma patients. Moreover, this type of injury may frequently be overlooked or not readily appreciated on initial clinical examinations and investigations. The organ injury scale determines the severity of the trauma. Nonetheless, there are conflicting recommendations for the best strategy in severe cases. Overall, conservative management of induced severe traumatic pancreatitis is adequate. Modern imaging modalities such as ultrasound scanning and computed tomography scanning can detect injuries in fewer than 60% of patients. However, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) have diagnostic accuracies approaching 90%-100%. Thus, management options include ERCP and stent placement or distal pancreatectomy in cases of complete gland transection and wide drainage only for damage control surgery, which can prevent mortality but increases the risk of morbidity. In the majority of cases, surgical intervention is not required and should be reserved for only severe grade III to grade V injuries.

Circulating microRNAs and Clinicopathological Findings of Papillary Thyroid Cancer: A Systematic Review.

BACKGROUND/AIM: Papillary thyroid cancer (PTC) is the most common endocrine malignancy with a rising incidence. There is a need for a non-invasive preoperative test to enable better patient counselling. The aim of this systematic review was to investigate the potential role of circulating microRNAs (miRNAs) in the diagnosis and prognosis of PTC. MATERIALS AND METHODS: A systematic literature search was performed using MEDLINE, Cochrane, and Scopus databases (last search date was December 1, 2021). Studies investigating the expression of miRNAs in the serum or plasma of patients with PTC were deemed eligible for inclusion. RESULTS: Among the 1,533 screened studies, 39 studies met the inclusion criteria. In total, 108 miRNAs candidates were identified in the serum, plasma, or exosomes of patients suffering from PTC. Furthermore, association of circulating miRNAs with thyroid cancer-specific clinicopathological features, such as tumor size (13 miRNAs), location (3 miRNAs), extrathyroidal extension (9 miRNAs), pre- vs. postoperative period (31 miRNAs), lymph node metastasis (17 miRNAs), TNM stage (9 miRNAs), BRAF V600E mutation (6 miRNAs), serum thyroglobulin levels (2 miRNAs), 131I avid metastases (13 miRNAs), and tumor recurrence (2 miRNAs) was also depicted in this study. CONCLUSION: MiRNAs provide a potentially promising role in the diagnosis and prognosis of PTC. There is a correlation between miRNA expression profiles and specific clinicopathological features of PTC. However, to enable their use in clinical practice, further clinical studies are required to validate the predictive value and utility of miRNAs as biomarkers.

Preoperative Hyponatremia Indicates Complicated Acute Appendicitis.

Introduction: Acute appendicitis is the most common surgical emergency. Early detection of patients with complicated appendicitis leads to prompt surgical management and better outcome. This study investigated the relationship between the severity of acute appendicitis and the presence of preoperative hyponatremia. Materials and Methods: We retrospectively reviewed the medical files of adult patients operated on for acute appendicitis over a 6-year period. Hyponatremia was defined as serum sodium level of ≤135 mEq/L. Patients were classified into complicated appendicitis and noncomplicated appendicitis according to operative findings and/or histopathology reports. Results: A total of 129 patients were identified and included in this study. Complicated appendicitis was found more frequently in female patients and older patients. Hyponatremia was found significantly more frequently in patients with complicated appendicitis (p < 0.001) and also in patients with perforation than without perforation (p=0.047). Conclusions: The present study demonstrated that preoperative hyponatremia is associated with complicated appendicitis. Serum sodium levels, a routine, low-cost laboratory test, could act as an accessory marker aiding surgeons in earlier identification of gangrenous or perforated acute appendicitis.

The Impact of COVID-19 on the Training of Surgical Residents in Greece: Results of a Survey Conducted One Year after the Onset of the Pandemic.

Background: The coronavirus disease (COVID-19) pandemic is an ongoing crisis. In light of mounting concerns about the training of surgical residents, we examined surgical residents perceptions regarding the pandemic's impact on their training. Methods: We developed an anonymous online questionnaire comprising 15 multiple-choice questions, which we sent via email to residents educated and employed in northern Greece hospitals. Our survey took place in January and February of 2021. Results: A total of 124 residents across a broad spectrum of surgical fields completed the questionnaire. The majority (51.6%) reported a significant decline in the number of operations performed weekly during the pandemic. Approximately 38% of the respondents stated that their surgical skills have been negatively affected to a significant extent, and 35.5% reported that their theoretical knowledge had deteriorated to a moderate extent. Almost half of them reported that they were satisfied with the online courses and a total of 67.7% affirmed the need to prolong their clinical training. Conclusions: The aims and scope of a surgical department include the provision of high-quality training to young surgeons. The impact of the pandemic on routine surgical activities has been dramatic. Our results clearly indicate that young surgeons have been significantly affected in terms of their training.

Non-Operative Management of Delayed Splenic Rupture 4 Months Following Blunt Abdominal Trauma.

BACKGROUND Delayed splenic rupture is a rare complication of non-operative management of a primary splenic trauma which, without proper clinical vigilance, may result in life-threatening events. It usually occurs 4-8 days after injury and, in most cases, surgery is the treatment of choice. Since non-operative management of splenic trauma, which allows splenic salvage, has become increasingly popular, the same approach could also be applied in delayed splenic rupture. We herein present a case of delayed splenic rupture that occurred 4 months after the trauma and was successfully managed non-operatively. CASE REPORT A 32-year-old woman presented with diffuse abdominal pain, chest pain, and dyspnea 4 months after sustaining minor thoracoabdominal blunt trauma due to a car accident. That event was inadequately investigated and was not admitted for further monitoring. Computerized tomography revealed a rupture of a splenic hematoma in the context of the previous splenic trauma. She was closely monitored and remained hemodynamically stable. She was discharged and followed up, with no reported relapse of her clinical condition. CONCLUSIONS Delayed splenic rupture occurring 4 months after the primary splenic trauma is extremely rare. Due to its prolonged delay, delayed rupture of the spleen can easily be overlooked and not be included in the original differential diagnosis. Negligence of this event can result in dreaded complications with hemodynamic instability or even death. Furthermore, its higher mortality rate compared to primary splenic rupture highlights the importance of proper clinical vigilance. Non-operative management should be attempted in hemodynamically stable patients.

Robot-Assisted Thyroidectomy Versus Open Thyroidectomy in the Treatment of Well Differentiated Thyroid Carcinoma.

BACKGROUND: The incidence of thyroid cancer has increased worldwide during the last decade, becoming the most common endocrine malignancy and accounting for 3.8% of new cancer diagnosis. Surgical resection, namely conventional thyroidectomy, remains at the frontline of therapy, as surgical outcomes are undoubtedly successful. Minimally invasive techniques gained popularity through the years, in terms of feasibility, safety, and cosmesis. However, endoscopic approach could be characterized by some limitations concerning thyroid surgery. Robotic technology with its unique features was introduced to overcome these limitations. Since then, robotic thyroidectomy has been used for both benign and malignant thyroid disease. DATABASE: This study presents the use of robot-assisted transaxillary thyroidectomy in well-differentiated thyroid carcinoma through an extensive review of the literature in the PubMed database, including previous meta-analyses and case series. CONCLUSION: In terms of oncological efficacy, morbidity, and quality of life, outcomes seem comparable in thyroid cancer patients undergoing either open or robotic thyroidectomy. Surgical completeness also appears similar. Moreover, the rates of locoregional recurrence and survival outcome at 5 years are similar between the former and the latter, thus confirming the oncological value of robotic thyroidectomy for differentiated thyroid cancer. In order for more surgeons to adopt robotic approaches several issues need to be resolved, namely: expansion of robotic thyroidectomy in treating larger well-differentiated carcinomas and neck dissection, equipment costs, and prolonged operation times.

Undiagnosed Endoscopy Capsule Retention Causing Delayed Intestinal Obstruction in a Patient with a Small Bowel Neuroendocrine Tumor.

BACKGROUND Capsule endoscopy has played a significant role in small bowel investigation, providing the opportunity of detecting neoplastic lesions to a greater degree and at an earlier stage than other diagnostic procedures. Failure to excrete the capsule with the feces within 48 h can lead to capsule retention with increased risk of further complications such as bowel obstruction and perforation. Capsule retention can remain undetected in case of incomplete follow-up and poor patient compliance. Acute small bowel obstruction as late as many months following capsule endoscopy investigation is very rare, with only a few cases reported in the published literature. We herein report a rare case of prolonged capsule retention which remained undiagnosed, resulting in small bowel obstruction 6 months after the initial investigation. CASE REPORT An 82-year-old woman presented with abdominal pain and symptoms suggestive of intestinal obstruction. The patient history included a capsule endoscopy investigation because of episodes of abdominal pain 6 months prior to admission. Both the outcome of the investigation and the excretion of the capsule remained undetermined due to her history of dementia and follow-up failure. Radiologic investigations identified the capsule causing small bowel obstruction. Upon surgery, the capsule was found to be impacted in a stenotic small bowel lesion, and a segmental small bowel resection was performed. Histologic examination revealed the presence of a stenotic small bowel neuroendocrine tumor. CONCLUSIONS Appropriate follow-up is necessary to diagnose the complication of capsule retention which, if it remains unrecognized, can cause life-threatening complications as late as many months after capsule endoscopy.

Perioperative Antibiotic Prophylaxis: An Educative Intervention Significantly Increases Compliance.

BACKGROUND: Implementation of guidelines in daily clinical practice is often suboptimal, mainly due to doctors' poor compliance with them. Perioperative antibiotic prophylaxis (PAP) is many times administered in patients undergoing elective surgery without proper indication or for longer time than needed. Aim of this study is to investigate the effect of a simple intervention on the compliance of the medical staff with the American Society of Health-System Pharmacists (ASHP) guidelines concerning PAP administration. METHODS: A prospective 3-month audit took place including routine surgical procedures (laparoscopic cholecystectomy, inguinal hernia repair and thyroidectomy). An intervention aiming to educate the medical staff was implemented. The intervention included the demonstration of a poster and the training of the medical staff over the guidelines. A re-audit recorded the changes in daily clinical practice. RESULTS: The compliance rate regarding the number of PAP doses significantly increased from 0% before the intervention to 68.8% after the intervention for hernia repair and to 53.1% for laparoscopic cholecystectomy. The adherence rate in thyroidectomies increased from 25% to 50%, but without statistical significance. No significant difference was found for other parameters of PAP administration, namely the type of antibiotic used and the timing of the dose administration. Regarding secondary outcomes, hospitalization days were reduced, and cost of antibiotics was significantly decreased (P < 0.05). CONCLUSIONS: A simple intervention intending to educate the medical staff was successful in achieving significant improvement on the compliance rate with the PAP guidelines, highlighting the importance of promoting adherence to the already existing, well-established guidelines.

A case of acute abdomen caused by spontaneous rupture of a splenic abscess secondary to cancer of the splenic flexure.

Splenic abscesses are rare, difficult to diagnose, difficult to treat and usually appear in immunosuppressed patients. We present the case of a 64-year-old patient with left pleuritic chest pain, anorexia and fever with rigors diagnosed with splenic abscess due to splenic flexure colon cancer. The abscess spontaneously ruptured and the patient was operated on for acute abdomen. Splenectomy and Hartmann's hemicolectomy were performed. The patient was discharged from the hospital and referred to the oncologic department. Continuous spread of infection and especially initiating from a cancer lesion is a usual mechanism of splenic abscess formation. Although computed tomography-guided percutaneous drainage is the treatment of choice, an exploratory laparotomy was necessary in this case because of the rupture of the abscess. It is important for the clinicians to include splenic abscesses and their complications in the differential diagnosis of acute abdomen.

B-Lymphoblastic Lymphoma of the Small Bowel: An Extremely Rare Occurrence.

B-lymphoblastic lymphoma is a neoplasm of immature B cells and is characterized by aggressive behavior and disease progression. Common sites of involvement are skin, lymph nodes, bone, soft tissues, breast, and the mediastinum. Gastrointestinal lesions are rarely encountered and therefore not fully described. We herein report the case of a 28-year-old male, who presented with abdominal pain and CT scan showed a tumor involving the small bowel and its mesentery. He underwent emergency laparotomy and enterectomy. Histopathology report revealed B-lymphoblastic lymphoma affecting the small bowel and the adjacent mesentery. This is the first documented case of a small bowel tumor diagnosed as B-lymphoblastic lymphoma in published literature.

Platelet rich plasma effectiveness in bowel anastomoses: A systematic review.

BACKGROUND: Anastomotic leak constitutes a major problem in abdominal surgery. Technical insufficiency, topical or systemic factors contribute to disrupted healing of the performed bowel anastomosis and result in anastomosis leakage, with detrimental effects on patient postoperative outcomes. Despite the investigation of several factors and the invention of protective materials, the ideal agent to prevent anastomotic leaks is yet to be determined. AIM: To study the effect of platelet rich plasma (PRP) on the healing of bowel anastomoses. METHODS: A systematic literature search was performed in PubMed, EMBASE, and Scopus databases to identify studies investigating the effect of PRP application on bowel anastomosis. RESULTS: Eighteen studies were eligible with a total population of 712 animals including rats (14 studies), rabbits (2 studies) and pigs (2 studies). No postoperative complications were reported following PRP application. Fourteen out of 18 studies reported a statistically significant higher anastomosis bursting pressure in PRP groups compared to control either in healthy animals or animal models with underlying condition or intervention, such as intraperitoneal chemotherapy or peritonitis. Similar results were reported by ten studies in terms of tissue hydroxyproline levels. One study reported significant increase in collagen deposition in PRP groups. PRP application resulted in significantly decreased inflammatory cell infiltration in the presence of peritonitis or intraperitoneal chemotherapy (6 studies). CONCLUSION: The application of PRP is associated with improved bowel anastomosis outcomes, especially in animal models having an underlying condition affecting the normal healing process. PRP application seems to augment the normal healing process under these circumstances. However, further studies are needed to investigate the potential role of PRP on bowel anastomosis healing, especially in clinical settings.

Cutaneous manifestations of mantle cell lymphoma: an extensive literature review.

Mantle cell lymphomas account for about 2 to 10% of non-Hodgkin B-cell lymphomas. Despite the cellular maturity of B-cell lymphomas, the disease is aggressive in the majority of cases and its course is unpredictable. The clinical presentation is variable, and multiple nodal and extranodal manifestations have been described. Cutaneous infiltration is an uncommon (2-6%) location of the disease. An extensive review of the literature was performed, and 24 case reports and five case series were found describing cutaneous locations. These data were thoroughly studied in order to present their clinical and laboratory characteristics in this review.

PAK1 Expression in Pancreatic Cancer: Clinicopathological Characteristics and Prognostic Significance.

BACKGROUND: Improvement of the management of pancreatic cancer requires a better understanding of the genetic and molecular changes responsible for the development of the disease. The family of p21-activated kinases (PAKs) and especially PAK1 appears to mediate many cellular processes that contribute to the development and progression of pancreatic cancer, but the clinical relevance of PAK1 expression with the disease still remains unclear. Aim of the study was to assess the clinical value and the potential prognostic significance of PAK1 in pancreatic adenocarcinoma. METHODS: We investigated the relationship between the PAK1 expression and the clinical and histopathologic characteristics of pancreatic cancer patients and the potential significance of PAK1 on survival. We examined tissue samples from 51 patients operated for pancreatic cancer. PAK1 expression was investigated with immunohistochemistry and correlated to clinicopathological parameters. RESULTS: PAK1 was detected in all tumor samples and high expression was found in most patients. High PAK1 expression was also associated with younger age and well-differentiated tumors, but no association was found between PAK1 expression and Tumor-Node-Metastasis stage as well as deceased or alive status on follow-up. Moderate to high PAK1 expression favored higher 6-month and 1-year survival and low PAK1 expression 2-year survival but without statistical significance. CONCLUSIONS: Our results indicate that PAK1 could potentially be used as a prognostic marker in pancreatic cancer. Further studies could clarify whether utilization of PAK1 in therapeutic protocols for the treatment of pancreatic cancer will render them more effective.

The Immunohistochemical Expression MTA 1 Protein and its Prognostic Value in Pancreatic Cancer.

Purpose/aim: To examine with immunohistochemical assay MTA1 protein expression levels in pancreatic cancer tissues defining its prognostic value. MATERIAL AND METHODS: The specimens derived from 51 patients who underwent surgery. The levels of MTA1 protein were compared with the age of the patients, their survival, and prognosis. Also, we studied clinical and histopathological factors such as the degree of tumor differentiation and its stage in correlation with MTA1 protein levels. In parallel, there was correlation between the expression of the ΜΤΑ1 protein and the aforementioned factors regarding survival rate. Furthermore, we independently correlated the patient's survival in relation to whether they had undergone adjuvant chemotherapy or not. RESULTS: It has been found to be low, moderate, or high expression of MTA1 levels in 48 out of 51 cancer tissues. Specifically, 49.0% of patients had low expression, 33.3% moderate, and 11.8% high expression of MTA1. Regarding the expression of MTA1 protein in correlation with various clinical and histopathological factors, a statistically significant correlation was observed with the degree of differentiation (p = 0.0068) and with the stage of the disease (p = 0.0173), but not with survival (p = 0.0740) or the age of them (p = 0.1547). Finally, it was found that overexpression of the MTA1protein is a prognostic factor for shorter survival in patients with pancreatic cancer (average 4.67 ± 0.95 months). CONCLUSIONS: MTA 1 protein may constitute an important prognostic marker in pancreatic cancer and could improve prognosis and treatment.

A Time Course of Bevacizumab (Anti-VEGF) Effect on Rat Peritoneum: Relations Between Antiadhesive Action and Fibrin Regulation Enzymes.

BACKGROUND: To investigate the early and late antiadhesive effect and any changes of fibrin matrix regulation enzymes on rat peritoneum, after local administration of bevacizumab. METHODS: Rats were subjected to cecal abrasion. Bevacizumab (5 mg/kg) against placebo was given intraperitoneally. On the 2nd, 14th, and 28th postoperative days adhesions were scored, and tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), matrix metalloproteinase-9 (MMP-9), degree of fibrosis, and angiogenesis were measured in abrased cecum and in intact parietal peritoneum. RESULTS: Bevacizumab significantly reduced adhesions up to 15% on the 2nd, 52.5% on the 14th, and 55% on the 28th postoperative day, and significantly increased tPA concentrations in peritoneum. PAI-1 was decreased, and a significantly higher tPA/PAI-1 ratio along with an increase of MMP-9 was measured at all time points. Fibrosis and angiogenesis were significantly lower on the 14th and 28th postoperative days. CONCLUSIONS: Local bevacizumab administration has a strong early and late antiadhesive action on rat peritoneum, mediated by changes in the tPA/PAI-1 and MMP balance in favor of fibrinolysis up to 28 days after operations.

Meckel's Diverticulum Enterolith: An Extremely Rare Cause of Intestinal Obstruction.

Meckel's diverticulum is usually asymptomatic but occasionally presents with complications. Formation of an enterolith inside a Meckel's diverticulum is very uncommon and dislodgement of such a stone causing obstruction is extremely rare. We herein present a case of a 48-year-old man who presented with small bowel obstruction. Preoperative radiologic studies revealed a stone-like lesion in the right lower quadrant. Upon laparotomy, an inflamed Meckel's diverticulum was found as well as a 2.5 cm stone obstructing the terminal ileum. The stone was removed and the diverticulum was excised. The differential diagnosis of acute intestinal obstruction should include this extremely rare clinical entity especially when the combination of small bowel obstruction with radiopaque stone-like finding on preoperative x-rays is present.

Huge echinococcal cyst of the liver managed by hepatectomy: Report of two cases.

INTRODUCTION: Echinococcocal cysts are predominantly located in the right liver. They are usually solitary and asymptomatic, but large cysts can cause compression symptoms. CASE REPORTS: We report two cases of huge (25cm and 20cm in diameter, respectively) echinococcal cysts located in the left liver, which presented as a large palpable mass causing compression symptoms. Diagnosis was established with CT scan showing a cystic mass with the characteristic daughter cysts and reactive layer (pericystic wall) consisting of fibrous connective tissue and calcifications. Both patients were treated radically with left hepatectomy and had uneventful postoperative course and no recurrence upon follow-up. DISCUSSION: The treatment of liver echinococcal cysts represent a unique surgical challenge. Even though conservative approaches are less technically demanding, the radical approach with resection has better outcome with less recurrences, when performed by experienced surgeons. CONCLUSION: Resection rather than drainage is the management of choice for such huge liver echinococcal cysts.

Consensual intercourse resulting in an extensive rectovaginal tear: an extremely rare occurrence.

INTRODUCTION: Rectovaginal tears are usually associated with the insertion of foreign bodies, accidental trauma, and nonconsensual intercourse. AIM: The aim of this study was to describe an extremely rare case of extensive rectovaginal tear as a result of consensual vaginal and anal intercourse. METHODS: A case is presented along with review of the literature. RESULTS: A 20-year-old woman presented with acute perineal pain and minor vaginal bleeding following consensual vaginal and anal intercourse. No insertion of sex toy or any other object was reported. Vaginal and rectal examination revealed a ruptured posterior vaginal wall with wide communication with the rectum, without involvement of the anal sphincters. Surgical treatment with primary repair of the tear and diverting colostomy was performed. CONCLUSIONS: Although consensual intercourse is usually associated with minor genital trauma, rare but potentially serious injuries can occur. Clinicians should be aware of the possibility of such injuries because failure to identify them can lead to delayed treatment and poor outcome.