The place of splenectomy in the therapeutic management of patients with infective endocarditis and splenic abscess: A single center experience and a literature review.

INTRODUCTION: Infective endocarditis(IE) has a low incidence, but it remains a serious disease with high mortality rates. Only 5 % of these patients will develop a splenic abscess, and the number of patients that have IE and a splenic abscess requiring surgery is low. The current guidelines recommend that splenectomy should be performed prior to valve replacement, but there is no strong evidence to support this statement and no evidence to clearly endorse the order in which the surgical interventions should be performed. The objective of this review and case series is to establish the proper treatment strategy, to assess the adequate order of the surgical interventions and to clarify the role of percutaneous drainage in the management of these patients. MATERIAL AND METHODS: All patients with infective endocarditis and splenic abscess who underwent surgery in our institution, between January 2008 and December 2020 were included in this study, excluding patients which had cardiac device related endocarditis. Literature review on the matter included a number of 30 studies which were selected from the PubMed database. RESULTS: Assessing the literature and case series no reinfection was reported for simultaneously performing splenectomy(S) and valvular surgery(VS) nor for VS followed by S. CONCLUSION: Percutaneous drainage of the splenic abscesses is a feasible solution as definitive therapy in high-risk patients or as bridge therapy. Additional studies are needed, even though they are difficult to conduct, therefore a national/international infectious endocarditis register may be of use to clarify these challenges.

Propensity Score-Matched Analysis of Minimal Invasive Surgery versus Open Surgery for Colorectal Cancer in Older Patients.

Introduction: Currently, surgeons deal with an older patient cohort, confronting new challenges brought by the raised life expectancy. This population is unrepresented in surgical trials; therefore, the optimal therapy is still a matter of debate. The efficacy of open versus minimal invasive management of colorectal cancer (CRC) in an elderly cohort is not clearly established. The current study assesses the minimal invasive approach in elderly patients undergoing colorectal surgery. Material and Methods: The General Surgery Department database was inquired between 2012 and 2015 using the following filters: age â?¥ 65 and rectal or colon adenocarcinoma. After applying the exclusion criteria, 975 cases were obtained: 842 underwent open surgery (OS) and 133 underwent minimal invasive surgery (MIS). A propensity score matching was performed to reduce patient selection bias. Results: After the propensity score matching, the MIS group had a shorter postoperative hospital stay than the OS group (p = 0.025). From the preoperative variables, the presence of chronic lung disease was significantly higher in the OS group (p = 0.039). The presence of chronic lung disease positively associates with the Clavien-Dindo classification (p 0.001) and with the number of days from surgery to discharge (p = 0.028). Conclusion: The chronological age alone should not be a limit to MIS granting that it showed no inferiority to the OS in terms of postoperative morbidity, correlating with lower postoperative stay in the elderly. Further prospective studies are needed to assess the outcome of MIS in elderly population.

The Impact of Screening and Surgery on Life Expectancy in Breast Cancer - A Mathematical Model Case Study in the European Union.

Background: In the last 20 years in European Union states, the life expectancy did not change much. In the period 2012-2021 the average life expectancy remained almost constant at 82 years. Breast cancer represents the main cause of death by cancer in women The purpose of this research is to identify o identify and measure the influence of some medical interventions and procedures related to breast cancer on life expectancy. In our article, the target group is the feminine population from 27 EU countries. Methodology: For the analysis several indicators provided by Eurostat were considered: life expectancy for female population as a dependent variable and breast cancer screenings, surgical operations and procedures performed in hospitals (partial and total excision) were used as independent variables. The research used a mathematical model (regression panel) for 27 EU countries, for a 10 year period, to evaluate the impact of each independent variable on the life expectancy in EU as a whole. Results: From a statistical point of view, screening has a significant effect on life expectancy. On the other hand, surgical interventions have a role in the overall medical process and positively influence life expectancy. The panel model has shown that partial interventions contribute less than screening procedures to increase life expectancy. Conclusion: The development of mathematical models in health care is useful in the process of improving health care quality. In our days, the measurement and quantification of some medical methods is particularly difficult due to so many variables and observations. In these difficult circumstances, the mathematical models could bring some clarifications and structure.

Safety and Efficacy of Simultaneous Resection of Gastric Carcinoma and Synchronous Liver Metastasis-A Western Center Experience.

Background and objectives: Gastric cancer (GC) is often diagnosed in the metastatic stage. Palliative systemic therapy is still considered the gold standard, even for patients with resectable oligometastatic disease. The aim of the current study is to assess the potential benefit of up-front gastric and liver resection in patients with synchronous resectable liver-only metastases from GC (LMGC) in a Western population. Materials and Methods: All patients with GC and synchronous LMGC who underwent gastric resection with or without simultaneous resection of LMs between January 1997 and December 2016 were selected from the institutional records. Those with T4b primary tumors or with unresectable or more than three LMs were excluded from the analysis. All patients who underwent emergency surgery for hemorrhagic shock or gastric perforation were also excluded. Results: Out of 28 patients fulfilling the inclusion criteria, 16 underwent simultaneous gastric and liver resection (SR group), while 12 underwent palliative gastric resection (GR group). The median overall survival (OS) of the entire cohort was of 18.81 months, with 1-, 3- and 5-year OS rates of 71.4%, 17.9% and 14.3%, respectively. The 1-, 3- and 5-year OS rates in SR group (75%, 31.3% and 25%, respectively) were significantly higher than those achieved in GR group (66.7%, 0% and 0%, respectively; p = 0.004). Multivariate analysis of the entire cohort revealed that the only independent prognostic factor associated with better OS was liver resection (HR = 3.954, 95% CI: 1.542-10.139; p = 0.004). Conclusions: In a Western cohort, simultaneous resection of GC and LMGC significantly improved OS compared to patients who underwent palliative gastric resection.

Is There a Role for Minimally Invasive Surgery in Cervical Cancer Treatment: Carry on, Discard, or Modify? A Literature Review and Case Series Presentation.

Oncological surgery is constantly evolving. Recommendations and guidelines are updated periodically in light of new research. Since surgery is a key step in the treatment of cervical cancer in Romania and considering the new findings, this study aims to assess the new guideline recommendations and the surgical treatment options available. The paradigm shift that took place in 2018 left the question: does minimally invasive surgery still play a role in the treatment of cervical cancer? K ouml;hler surgical technique seems to address some of the issues raised by the minimally invasive surgery with good results. H ouml;ckel proposes total mesometrial excision to decrease the risk of recurrence. This study presents 3 cases of cervical cancer patients with stages ranging from IB1 to IIIB that had undergone total mesometrial excision and vaginal cuff closure using the laparoscopic approach to minimize the risk of local recurrence. The case series presented showed that it is feasible and safe to merge these techniques. Further prospective studies are needed in order to assess the risk and benefits of these techniques.

Endoscopic Retrograde Cholangiopancreatography in Acute Biliary Pancreatitis: Urgent vs. Delayed and the Outcome of Same-Admission Cholecystectomy.

Introduction: Acute pancreatitis (AP) represents a major burden for the medical system, associating important morbidity and mortality rates. This paper is focused on debatable aspects of the management of biliary AP, namely indications, timing and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) on the hand and, on the other hand, same-admission cholecystectomy as a preventive measure for recurrent disease. Material and methods: This is a retrospective study including 108 patients with biliary AP in whom ERCP was performed, treated in the Clinical Emergency Hospital of Bucharest between 2016 and 2020. According to the urgency of the ERCP, we divided the patients into two groups: urgent versus delayed ERCP. Results: Urgent ERCP was performed in 52 patients, while delayed ERCP was performed in 56 patients; the hospital stay was higher in the urgent group than in the delayed group (10 days vs 8 days, p = 0.299) with no difference in morbidity rates. The mean time between ERCP and surgery was 5 days, without significant difference between the groups. The laparoscopic approach was the preferred method, with a conversion rate of 7%. Conclusion: ERCP with stone extraction followed by same-admission laparoscopic cholecystectomy is a safe therapeutic option, that prevents recurrent pancreatitis. The timing of the procedures remains debatable, further prospective studies being needed to achieve statistical significance.

Laparoscopic Cholecystectomy in Cirrhotic Patients: A Retrospective Study.

Introduction: Cirrhosis is a leading cause of morbidity and mortality around the world. Although cirrhotic patients are considered to have a higher risk for surgical procedures than non-cirrhotic ones, there are certain pathologies such as gallstones cholecystitis that cannot be treated otherwise. The focus of this study is to evaluate the main characteristics of the patients with lithiasic cholecystitis and liver cirrhosis and to assess if there is a correlation between them and postoperative morbidity evaluated with Dindo-Clavien classification. Material and Methods: This is a retrospective study. The database from General Surgery Department of Fundeni Clinical Institute was queried between 2014-2018 using as key words "cirrhosis" and "cholecystitis". The initial interrogation reveled 57 cases out of which 3 were excluded since other resections were associated. Results: This study identified that Dindo-Clavien classification positively correlates with the open approach (0.405, p=0.002), emergency surgery (0.599, p=0.000), acute cholecystitis (0.476, p=0.000), high MELD score (0.291, p=0.008) and Child score (0.346, p=0.007) and furthermore with high levels of total bilirubin (0.220, p=0.047), high INR (0.286, p=0.010), the presence of ascites (0.303, p=0.022) and portal hypertension (0.266, p=0.044). It also correlates negatively with the levels of hemoglobin (-0.295, p=0.044). Conclusion: Adequate estimation of perioperative mortality and morbidity is generally limited by the retrospective nature of most studies and the patient's selection criteria. Emergency surgery, acute cholecystitis and the open approach carry the highest risk for unfavorable results of cholecystectomy in cirrhotic patients.

Laparoscopic Hartmann s Reversal: A Single Center Experience.

Minimally invasive colorectal surgery showed multiple advantages in terms of morbidity, surgeons applied this approach to Hartmann reversal considering improving the reversal rate and postoperative outcome. The database from Fundeni Clinical Institute, General Surgery Department, was analyzed, selecting the laparoscopic Hartmann reversals. Nine cases were reported with a median age of 63 years, mean BMI 29 and three of them with prior open Hartmann surgery. The average operative time was 223 minutes, without any case necessitating ileostomy diversion. No anastomotic leakage was reported. The laparoscopic approach seems to be an attainable alternative in the reversal of Hartmann procedure, considering the experience of the surgical team and the patient's characteristics. Further studies are needed in order to confirm its superiority on larger case series.

Short-term Outcome of Robotic and Laparoscopic Surgery for Gynecological Malignancies: A Single-center Experience.

Objectives: Minimally invasive surgery (MIS) has become the preferred option for many gynecologic pathologies since complication rate and postoperative recovery time have decreased considerably. Postoperative complications remain an important aspect when using the MIS approach, if they are not timely or accurately diagnosed and treated. The main aim of the study is to first assess their incidence, followed by identifying possible risk factors. Furthermore, the secondary aim is to identify if the type of MIS approach used, robotic or laparoscopic, may render some additional benefits. Materials and Methods: The database of the General Surgery Department was queried between 2008 and 2019 for patients with gynecologic pathology: 2907 cases were identified. An additional selection was performed using the following filters: MIS and neoplasia. All emergency surgeries were excluded. One hundred and ninety-eight cases were obtained. Results: The majority of complications were urological (11.6%) with only 7.07% requiring a specific urological procedure. The second most common was lymphorrhea 4.5%. Dindo-Clavien classification correlates positively with the postoperative hospital stay (PHS) (P = 0.000), the type of surgery (P = 0.046), the primary tumor location (P = 0.011), conversion rate (P = 0.049), the expertise of the lead surgeon (P = 0.012), and the operative time (P = 0.002). The urological complications correlate positively with the type of surgery (P = 0.002), the tumor location (P = 0.001), early reintervention (P = 0.000), operative time (P = 0.006), postoperative hemorrhage (P = 0.000), pelvic abscess (P = 0.000), venous thrombosis (P = 0.011), and postoperative cardiac complications (P = 0.002). Laparoscopic and robotic approaches were comparatively assessed. The PHS (P = 0.025), the type of surgery performed (P = 0.000), and primary tumor location (P = 0.011) were statistically significantly different. Conclusion: Postoperative complications reported after MIS for gynecological malignancies show similar incidence as in the current literature, also taking into consideration those for the open approach. The robotic approach seems to be able to perform more complex surgeries with no difference in the postoperative complication rates. The expertise of the lead surgeon in gynecology correlates with lower postoperative complications. Further prospective studies are needed to confirm these results.

The seen and the unseen: Molecular classification and image based-analysis of gastrointestinal cancers.

Gastrointestinal cancers account for 22.5% of cancer related deaths worldwide and represent circa 20% of all cancers. In the last decades, we have witnessed a shift from histology-based to molecular-based classifications using genomic, epigenomic, and transcriptomic data. The molecular based classification revealed new prognostic markers and may aid the therapy selection. Because of the high-costs to perform a molecular classification, in recent years immunohistochemistry-based surrogate classification were developed which permit the stratification of patients, and in parallel multiple groups developed hematoxylin and eosin whole slide image analysis for sub-classifying these entities. Hence, we are witnessing a return to an image-based classification with the purpose to infer hidden information from routine histology images that would permit to detect the patients that respond to specific therapies and would be able to predict their outcome. In this review paper, we will discuss the current histological, molecular, and immunohistochemical classifications of the most common gastrointestinal cancers, gastric adenocarcinoma, and colorectal adenocarcinoma, and will present key aspects for developing a new artificial intelligence aided image-based classification of these malignancies.