The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece.

BACKGROUND: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

The Expression Patterns and Implications of MALAT1, MANCR, PSMA3-AS1 and miR-101 in Esophageal Adenocarcinoma.

Esophageal adenocarcinoma (EAC) is a malignant tumor with poorly understood molecular mechanisms. This study endeavors to elucidate how the long non-coding RNAs (lncRNAs) MALAT1, MANCR and PSMA3-AS1, as well as the microRNA miR-101, exhibit specific expression patterns in the pathogenesis and prognosis of EAC. A total of 50 EAC tissue samples (tumors and lymph nodes) and a control group comprising 26 healthy individuals were recruited. The samples underwent quantitative reverse transcription-polymerase chain reaction (qRT-PCR) analyses. The relative expression levels of MALAT1, MANCR, PSMA3-AS1, and miR-101 were ascertained and correlated with various clinicopathological parameters including TNM staging, tumor characteristics (size and grade of the tumor) lymphatic invasion, disease-free (DFS) and overall survival (OS) of EAC patients. Quantitative analyses revealed that MALAT1 and MANCR were significantly upregulated in EAC tumors and positive lymph nodes when compared to control tissues (p < 0.05). Such dysregulations correlated positively with advanced lymphatic metastases and a higher N stage. DFS in the subgroup of patients with negative lymph nodes was higher in the setting of low-MANCR-expression patients compared to patients with high MANCR expression (p = 0.02). Conversely, miR-101 displayed a significant downregulation in EAC tumors and positive lymph nodes (p < 0.05), and correlated negatively with advanced tumor stage, lymphatic invasion and the grade of the tumor (p = 0.006). Also, patients with low miR-101 expression showed a tendency towards inferior overall survival. PSMA3-AS1 did not demonstrate statistically significant alterations (p > 0.05). This study reveals MALAT1, MANCR, and miR-101 as putative molecular markers for prognostic evaluation in EAC and suggests their involvement in EAC progression.

The Impact of Nutritional and Functional Status on Postoperative Outcomes following Esophageal Cancer Surgery.

Malnourished patients undergoing esophagectomy have increased risk of postoperative complications. The aim of the current study was to identify nutritional and functional risk factors for postoperative complications in patients with esophageal and gastroesophageal junction cancer who underwent esophagectomy. Seventy patients who were admitted at the First Department of Surgery, Laikon General Hospital, Athens, Greece, were included in this study. Laboratory data and data regarding nutritional and functional status were recorded preoperatively. Postoperative complications were graded according to Clavien-Dindo classification. Thirty-seven patients (52.9%) developed postoperative complications. Albumin and Geriatric Nutritional Risk Index (GNRI) levels were lower in patients who developed major complications compared to patients who did not develop postoperative complications (3.90 ± 0.44 vs 4.18 ± 0.37 g/dL, p = 0.014 and 107.40 ± 15.76 vs 114.98 ± 12.26, p = 0.050 respectively). Major complications were associated with higher percentage of weight loss (12.1 ± 11.1 vs 6.2 ± 7.5%, p = 0.019) and with low handgrip strength (80 vs 16.9%, p = 0.006). Albumin (3.93 ± 0.18 vs 4.15 ± 0.41 g/dL, p = 0.019) and low muscle mass (22.6 vs 2.8%, p = 0.016) were significantly associated with anastomotic leakage occurence. The incorporation of patients' nutritional and functional status in the preoperative risk assessment might increase prognostic ability concerning postoperative complications of patients undergoing esophagectomy.

Radiation-Induced Esophageal Cancer: Investigating the Pathogenesis, Management, and Prognosis.

One of the most serious late side effects of irradiation is the promotion of tumorigenesis. Radiation-induced esophageal cancer (RIEC) can arise in a previously irradiated field, mostly in patients previously irradiated for thoracic malignancies such as breast cancer, Hodgkin and non-Hodgkin lymphomas, head and neck cancers, lung cancer, or previous esophageal cancer. RIEC is rare and accounts for less than 1% of all carcinomas of the esophagus. There are little data available in the current literature regarding pathogenesis, diagnosis, treatment, and outcome of esophageal cancer developed in a previously irradiated field. RIEC seems to represent a biologically aggressive disease with a poor prognosis. Although it is difficult to perform radical surgery on a previously irradiated field, R0 resection remains the mainstay of treatment. The use of neoadjuvant and adjuvant chemoradiotherapy remains very helpful in RIEC, similarly to conventional esophageal cancer protocols. The aim of this article is to elucidate this rare but challenging entity.

Gastrectomy for Cancer: A 15-Year Analysis of Real-World Data from the University of Athens.

Background and Objectives: Encouraging data have been reported from referral centers following gastrointestinal cancer surgery. Our goal was to retrospectively review patient outcomes following gastrectomy for gastric or gastroesophageal junction (GEJ) cancer at a high-volume unit of the University of Athens. Methods: The enrollment period was from June 2003 to September 2018. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Cox proportional hazard models were constructed to identify variables independently associated with time-to-event outcomes. Results: A total of 205 patients were analyzed. R0 resection was achieved in 183 (89.3%) patients and was more likely to occur following neoadjuvant chemotherapy (p = 0.008). Recurrence developed in 46.6% of our cohort and the median disease-free survival was 31.2 months. On multivariate analysis, only staging (HR = 2.15; 95% CI: 1.06-4.36) was independently associated with increased risk of recurrence. All-cause mortality was 57.2% and the median time of death was 40.9 months. On multivariate regression, staging (HR: 1.35; 95% CI: 1.11-1.65) and recurrence (HR: 2.87; 95% CI: 1.32-6.22) predicted inferior prognosis. Conclusions: Gastrectomy at the University of Athens has yielded favorable outcomes for patients with GEJ cancer.

Eosinophilic Esophagitis and Achalasia: Two Distinct Nosologic Entities or a Possible Etiopathogenic Association?

BACKGROUND: Despite the fact that researchers have made significant progress in elucidating the pathophysiology of esophageal diseases, the understanding of esophageal motility alterations in patients with eosinophilic esophagitis (EoE) is in its infancy and current published medical literature remains rather scarce on this topic. A growing body of scientific data regarding associations between esophageal motor disorders, such as achalasia and EoE, exists nowadays. SUMMARY: It seems that the association of EoE and achalasia does not constitute a cause and effect relationship, as it is not clear whether esophageal motility abnormalities are the result of EoE or vice versa. As such, there is no universally accepted treatment algorithm for patients presenting with both of these entities. Key Messages: The aim of this article is to review the existing data on achalasia-like motility disorders in patients with EoE, highlighting a possible association between these 2 esophageal disorders. Moreover, we seek to describe the clinical presentation in such cases, diagnostic modalities to be used, and current treatment strategies in patients suspected to suffer from both disorders.

Evaluation of molecular and genetic predisposing parameters at diverticular disease of the colon.

BACKGROUND: Diverticular disease (DD) refers to the presence of diverticula throughout the gastrointestinal (GI) tract, mainly along colon. DD might evolve into diverticulitis that is accompanied by severe clinical presentation, which includes abscess formation, perforation, stricture, obstruction and/or fistula. AIM: The aim of the present review is to summarize the role of molecular and genetic factors in DD development, as well as their possible contribution towards new prognostic indicators, diagnostic algorithms and new therapeutic approaches. METHODS AND RESULTS: Except from common predisposing parameters, several genetic mutations, immune factors, neurotransmitters, hormones and protein dysfunctions have been associated to the early onset of DD symptoms, pathogenesis and prognosis of the disease. Specific structural changes in the colonic wall, altered matrix composition and compromised motility have been verified as possible pathogenic factors for the development of DD. Dysregulation in peristaltic activity and reduced ability of the longitudinal muscle to relax following contraction has been also associated with DD evolution. In addition, it has been suspected that genetic defects combined with alterations in intestinal microbiota might play an important role in diverticulitis presentation.

Microvascular grafting to enhance perfusion in colonic long-segment oesophageal reconstruction.

PURPOSE: Oesophagectomy with long-segment colon reconstruction is the first-line treatment when the stomach is not available. Supercharging of the newly formed conduit can improve vascular function utilizing intraoperative perfusion imaging system, following thoracoscopic oesophagectomy for distal-oesophageal and gastroesophageal junction cancer. The purpose of this study is to examine the safety and efficacy of microvascular augmentation of left colonic interposition following oesophagectomy for oesophageal cancer. METHODS: A retrospective analysis of 156 consecutive oesophagectomies between January 2016 and July 2018 was performed. All oesophagectomies involving left colon interposition with microvascular augmentation were included in the study. In all cases, oesophageal mobilization was performed thoracoscopically in prone position and the left colon was used as neo-oesophagus in an isoperistaltic fashion. Conduit perfusion was assessed with the Spy system and neck supercharging was performed using microsurgical technique. RESULTS: A total of n = 5 (3.2%) patients were identified. Two cases had delayed and 3 had immediate reconstruction. The conduit was microsurgically augmented in 3 cases with both venous and arterial anastomoses (supercharging) and in 2 cases with venous anastomosis only (superdrainage). No anastomotic leak was identified. One case developed left recurrent laryngeal nerve palsy with associated aspiration pneumonia. CONCLUSIONS: Supercharged colonic interposition is a safe way of oesophageal reconstruction when long-segment interposition graft is needed. In oesophageal cancer and in the absence of a viable stomach with intact gastroepiploic arcade, it should be considered a feasible option with favourable outcomes, when the expertise and facilities are available. Use of intraoperative perfusion imaging reveals improved conduit blood supply post-supercharging.

Intrathoracic hand-sewn esophagogastric anastomosis in prone position during totally minimally invasive two-stage esophagectomy for esophageal cancer.

Utilization of totally minimally invasive esophagectomy for cancer is on the rise. Esophagogastric anastomosis is mechanically or robotically performed routinely; little report exists of hand-sewn esophagogastric anastomosis. This is the largest so far study with thoracoscopic hand-sewn esophagogastric anastomosis during fully minimally invasive two-stage esophagectomy for esophageal cancer in prone position. Consecutive two-stage totally minimally invasive esophagectomies for cancer were performed by one surgical team, from September 2016 to March 2019. All operations were technically identical in terms of patient positioning, surgical approach, extend of lymphadenectomy and type of anastomosis formed. Primary end points were anastomotic leak and anastomotic stricture rate, while secondary end points were 30-day and 90-day mortality rates. From the overall n = 80 patients, n = 67 were males, while n = 13 were females. Mean age was 64.6 years. Mean length of stay was n = 14 days. There were no conversions to open. Mean operating time was 420 minutes with no blood loss over 200 mL noted. Pulmonary and cardiac complication rate was 23.75% and 2.5%, respectively. Anastomotic leak rate was 2.5%. Anastomotic strictures were seen in 12.5% of cases. 30-day and 90-day mortality rate was 2.5% and 5%, respectively, with none accounted for ischemic conduit complications. Intrathoracic anastomosis in totally minimally invasive esophagectomy is challenging and accountable for most of the mortality associated with the procedure. In thoracoscopic two-stage esophagectomy, a mechanical anastomosis is usually preferred; this is believed to be due to the complexity of manual anastomosis associated with the thoracoscopic approach. We aim to present our series of completely hand-sewn intrathoracic anastomosis utilizing a totally minimally invasive approach with favorable outcomes. With this study, reproducibility of the anastomosis is shown that can potentially favor a change in the practice of esophageal surgeons worldwide.

Cervical Twin Heterotopic Pregnancy: Overview of Ectopic Pregnancies and Scanning Detection Algorithm.

Background: Ectopic pregnancy is the leading cause of gestation-related deaths during the first trimester. Cervical twin heterotopic pregnancies, when ectopic, constitute a small and rare part of gynecological surgery. Case Presentation: A 30-year-old pregnant woman (gravida 3, para 2) presented with mild pain in the lower abdomen and traces of bleeding per vaginum for three days. Transvaginal ultrasonography revealed a balloon-shaped cervical canal with a visible gestational sac measuring 3.5 × 3.9 cm. A second gestational sac was seen in the uterine cavity. The measurements of the gestational sacs corresponded to 7 + 4 weeks' pregnancy. A decision for medical abortion with mifepristone and misoprostol was made. However, due to an incomplete abortion and continuous bleeding, a curettage was performed. Conclusions: Spontaneous heterotopic pregnancy with the ectopic pregnancy located in the cervix is an extremely rare clinical condition requiring urgent treatment in order to reduce maternal mortality and morbidity and preserve fertility.

Breast Cancer Apoptosis and the Therapeutic Role of Luteolin.

Breast cancer represents one of the three most common gynecological cancers, with each subtype having distinct risk profile and treatment strategies. Optimal therapy for each case depends not only on tumor subtype and cancer stage, but also on patient preferences. Thus, the final therapeutic choice seems complicated to be reached. In addition, frequent relapses and the aesthetic effects have led to the search for more effective and less invasive methods. Surgical interventions have become less complex and new hormonal and chemotherapeutic drugs are established, that promise great results, either combined to surgical treatment or used exclusively. Luteolin is a representative of natural flavonoid that has proven to modulate various signaling pathways involved in cancer development. Recent data demonstrate that luteolin induces apoptotic cell death via antioxidant activity, acting as an anticancer agent against various types of human malignancies including breast cancer. The aim of this review is to summarize latest data considering the therapeutic role of luteolin in breast cancer.

Staged esophagectomy: surgical legacy or a bailout option?

Staged esophagectomy was developed in the mid-twentieth century in an attempt to reduce high rates of postoperative morbidity and mortality. Nowadays, the operation has almost been abandoned due to its significant disadvantages, especially the need for multiple surgeries, inability of patients to feed between operations, and morbidity of esophageal stoma. However, staged esophagectomy is still occasionally useful for very high-risk patients and in particular cases, for example multiple cancers of the aerodigestive tract and emergent esophagectomy. Staged esophagectomy is based on the division of surgical stress into two operations, which gives the patient time to recover before final restoration. Gastric tube ischemic preparation may be a more important mechanism in staged esophagectomy. This approach may survive and expand with the application of ischemic gastric pre-conditioning through embolization or laparoscopic ligation of the gastric arteries, which is a less explored and promising technique.

Gynecological Benignities Causing Obstructive Uropathy. Review of the Literature.

BACKGROUND/AIM: Obstructive uropathy is defined the clinical entity that is characterized by changing the structural and functional feature of the urinary system due to interruption of normal urinary runoff. Gynecological benignities could rarely cause obstructive uropathy. Material and Methods: In this study the incidence and the severity of obstructive uropathy caused by gynecological benignities, was investigated. Additionally, we examined the spectrum of the contigent therapeutical procedures, in order to contend with this severe clinical entity, as well as the dangerous for life complication of urosepsis. Results: Gynecological benignities can cause obstructive uropathy. These conditions are rarely faced, composing a challenging problem for physicians. In the spectrum of these conditions are included adnexal masses, leiomyomas, pelvic inflammatory disease and endometriosis. Conclusions: Obstructive uropathy due to gynecological benignities is a very rare, difficult and challenging condition and physicians should always consider the existence of uropathy in such cases.

Irreversible electroporation in a case of pancreatic leiomyosarcoma: a novel weapon versus a rare malignancy?

BACKGROUND: Primary pancreatic leiomyosarcoma is an extremely rare entity that needs high clinical suspicion in order to diagnose it at an early stage. Clinical characteristics, diagnosis, and management still remain challenging and controversial, especially in advanced stages, when tumor invades adjacent vessels and organs or gives distant metastases. CASE PRESENTATION: Herein, we describe a case of a 57-year-old woman suffering from advanced pancreatic leiomyosarcoma with thrombosis of the superior mesenteric vein, as well as liver lesions which were suspicious for metastasis. Multidisciplinary team decided for upfront chemotherapy to assess tumor response. Follow-up imaging after the completion of chemotherapy led tumor board to decide for subsequent surgical exploration. The patient underwent exploratory laparotomy and irreversible electroporation ablation of the pancreatic tumor. Postoperative course was uneventful, and she was discharged 10 days later with a plan to receive adjuvant therapy. To the best of our knowledge, this is the first case of pancreatic leiomyosarcoma ever reported, treated with this novel technique of irreversible electroporation that could be an alternative and feasible way for the management of these rare malignancies. CONCLUSIONS: In conclusion, primary pancreatic leiomyosarcoma is a rare and highly malignant tumor associated with poor prognosis. Nowadays, R0 surgical resection remains the cornerstone treatment, combined with adjuvant and/or neoadjuvant chemotherapy prior to resection. In the advanced setting, when major vessel invasion and distant metastases occur, chemotherapy along with irreversible electroporation ablation could be a helpful and possibly effective modality for the management of this highly aggressive tumor.

A type of neoplasia deadlier than gastric adenocarcinoma? Report of a case of primary gastric squamous cell carcinoma.

BACKGROUND: Primary gastric squamous cell carcinoma is an extremely rare malignancy with few case reports reported so far in the current medical literature. Its incidence varies between 0.04 and 0.07% of all gastric malignancies with a male predominance in the sixth decade of life. It has been found that this type of malignancy has a more aggressive behavior and associated poorer prognosis, when compared to gastric adenocarcinoma. Thus, the most appropriate management of this kind of neoplasia is still debatable due to the small number of reported cases. CASE PRESENTATION: We report the case of a 66-year-old man who underwent total gastrectomy with D2 lymphadenectomy for an ulcerative lesion in the fundus of the stomach that turned out to be primary gastric squamous cell carcinoma. CONCLUSIONS: Upon confirmation of this specific malignancy, the affected patients should be enrolled in strict follow-up protocols after curative surgery, since the risk for metastasis is high. Physicians should maintain high clinical suspicion in order to diagnose these tumors at an early stage, along with the need to rule out any other possible primary sites of squamous malignancy.

The evolution and impact of the "damage control orthopedics" paradigm in combat surgery: a review.

The idea of damage control (DC) is grounded on a sequential therapeutic strategy that supports physiological restoration over anatomic repair in critically injured patients. This concept is firstly described as damage control surgery (DCS) for war-wounded patients with abdominal exsanguinating trauma. The goal was to avoid prolonged operative times and prevent the outset of the lethal cycle of hypothermia, acidosis and coagulopathy. Damage control orthopedics (DCO) is also based on this concept and it is applied in the treatment of some polytrauma patients with pelvic and long bones fractures as to avoid the "second hit" of a lengthy definitive operation and eliminate initial morbidity and mortality. It is in favor of primary fracture stabilization utilizing provisional external fixation. When the patient is in stable condition, conversion to definitive open reduction and intramedullary nailing can be done. This stepwise approach should be considered as a part of the resuscitation process, and it follows the saying "do no further harm".

Reply to the Letter to the Editor: Comment to Jejunal Diverticulitis Mimicking Small Bowel Perforation: Case Report and Review of the Literature.

Dear Editor, We thank the authors of this letter to the editor for the valuable information that they provided. We are familiar to the fact that conservative management is gaining ground against surgical treatment and this fact is mentioned in our article. This fact is better highlighted through the references that the authors of the letter to the editor provided and their comments.

Jejunal Diverticulitis Mimicking Small Bowel Perforation: Case Report and Review of the Literature.

Jejunal diverticulitis is a rare entity with a higher prevalence among patients between 60 and 70 years. Jejunal diverticula are most often considered an incidental finding, but, they can have complications such as diverticulitis, perforation, abscess, generalized peritonitis, fistula, obstruction and bleeding.Setting the diagnosis still remains challenging. Physicians should be aware of their existence and the clinical suspicion should be raised, especially in the setting of acute abdominal pain where jejunal diverticulitis should be included in the differential diagnosis. A small amount of free air adjacent to the small bowel can be confusing and easily misdiagnosed as small bowel perforation, but, it can actually be found as a result of the inflammation itself without macroperforation or complications.This fact can change the therapeutic strategy to less aggressive, conservative treatments. We present a case of a patient coming to the emergency department with acute abdominal pain, signs of peritonitis, a small amount of extraluminal air, and jejunal diverticulitis without perforation was diagnosed on laparotomy, and a review of the current literature.

Programmed Death Ligand 1: Unveiling its Impact on Endometrial Carcinogenesis.

Endometrial cancer is a commonly diagnosed gynecological malignancy presenting an increasing incidence worldwide. The immune response plays a crucial role in the mechanisms underlying carcinogenesis and the progression of tumors. In recent times, there has been a discernible surge in the acknowledgment of the importance of programmed death ligand 1 (PDL1) in evading the immunological response of the host and promoting the growth of malignancies. The primary aim of this review is to consolidate the existing corpus of evidence pertaining to the role of PDL1 in the etiology and progression of endometrial cancer and investigate the molecular mechanisms involved in the expression of PDL1 in cells impacted by endometrial cancer. Finally, the association between PDL1 expression and clinical outcomes, as well as the potential therapeutic uses of targeting the PDL1 pathway are being analyzed.

Development and internal validation of a clinical prediction model for serious complications after emergency laparotomy.

PURPOSE: Emergency laparotomy (EL) is a common operation with high risk for postoperative complications, thereby requiring accurate risk stratification to manage vulnerable patients optimally. We developed and internally validated a predictive model of serious complications after EL. METHODS: Data for eleven carefully selected candidate predictors of 30-day postoperative complications (Clavien-Dindo grade > = 3) were extracted from the HELAS cohort of EL patients in 11 centres in Greece and Cyprus. Logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) was applied for model development. Discrimination and calibration measures were estimated and clinical utility was explored with decision curve analysis (DCA). Reproducibility and heterogeneity were examined with Bootstrap-based internal validation and Internal-External Cross-Validation. The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) model was applied to the same cohort to establish a benchmark for the new model. RESULTS: From data on 633 eligible patients (175 complication events), the SErious complications After Laparotomy (SEAL) model was developed with 6 predictors (preoperative albumin, blood urea nitrogen, American Society of Anaesthesiology score, sepsis or septic shock, dependent functional status, and ascites). SEAL had good discriminative ability (optimism-corrected c-statistic: 0.80, 95% confidence interval [CI] 0.79-0.81), calibration (optimism-corrected calibration slope: 1.01, 95% CI 0.99-1.03) and overall fit (scaled Brier score: 25.1%, 95% CI 24.1-26.1%). SEAL compared favourably with ACS-NSQIP in all metrics, including DCA across multiple risk thresholds. CONCLUSION: SEAL is a simple and promising model for individualized risk predictions of serious complications after EL. Future external validations should appraise SEAL's transportability across diverse settings.