The Impact of Change Management in the Greek National Health System: A Quantitative Study

INTRODUCTION

 Serious changes took place in Greece due to the economic crisis of 2008, which led to significant changes in Greece's health sector. The reforms and changes that were made to the National Health System (NHS) aimed to improve it, provide quality services to its users, and adapt it to Greece's new external environment. The aim of this study was to assess the management of these changes by the leadership of the NHS and to examine their effectiveness.

MATERIAL AND METHODS

The survey was based on quantitative research methods, using a questionnaire as a research tool. The sample population comprised employees of a tertiary-care public hospital in northern Greece.

RESULTS

 We recruited a sample size of 100 participants for the survey. The questionnaire's Cronbach's alpha was equal to 0.724. The overall change management was moderate, and Greece's NHS did not follow a specific change-management model that provided principles facilitating the success of the effort. The most serious problems identified by using the questionnaire were the following: the changes were not structured and clear, the management set unrealistic goals and objectives, the changes to the NHS were made without the appropriate financial support, and there is uncertainty about the future of health care in Greece.

CONCLUSION

The present study showed that changes cannot be made randomly; rather, they require careful planning and organization. Further changes, continuous feedback, and development are required to improve the status of Greece's healthcare system.

Gastrointestinal Stromal Tumors: Our Ten-Year Experience of a Single-Center Tertiary Hospital

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal neoplasms of the gastrointestinal tract. They have variable clinical presentation, prognosis, and molecular characteristics. Here, we present the results of our retrospective study including patients operated on for GIST during the last decade.

METHODS

All the patients who underwent GIST resection during the decade 2008-2018 were included in the study. The diagnosis was based on the pathology report. All the data were collected and analyzed statistically using the Statistical Package for Social Science v25.0. Finally, after having applied the proper search terms, a comprehensive review of articles published in the Medline database was held.

RESULTS

Thirty-two patients (sixteen women) were included in the study with a mean age of 69.6 years old (SD = 13.9). Twenty-one patients had a GIST in the stomach, eight in the small intestine, and three had an extra GIST. Of the 29 patients contacted, 21 were alive with a mean survival time of 74.3 months (SD = 49.6 months, min: 3.0 months, max: 161.0 months), whereas eight patients passed away. Finally, 13 patients were treated with tyrosine kinase inhibitors (TKIs) of whom only one died, while 9 patients passed away from those treated with surgery alone (p = 0.031).

CONCLUSIONS

Our results were in concordance with the existing data in the literature. GISTs require patient-based therapeutical management depending on the histology of the tumors. Gastric tumors present a better prognosis than those localized in the intestine, while the use of TKIs has led to an improvement in patient survival rate.

Bowel Perforation in Vascular Ehlers-Danlos Syndrome: Case Report and Comprehensive Review

INTRODUCTION

Ehlers-Danlos syndromes (EDS) comprise a rare variety of genetic disorders, affecting all types of collagen. Herein, we describe a case of the vascular type of EDS, with coexisting segmental absence of intestinal musculature, while simultaneously performing a narrative review of the existing literature.

CASE PRESENTATION

A 23-year-old male patient with a history of multiple abdominal operations due to recurrent bowel perforations and the presence of a high-output enterocutaneous fistula was admitted to our surgical department for further evaluation and treatment. After detailed diagnostic testing, the diagnosis of vascular-type EDS (vEDS) was made and a conservative therapeutic approach was adopted. In addition, a comprehensive review of the international literature was carried out by applying the appropriate search terms.

RESULTS

The diagnosis of vEDS was molecularly confirmed by means of genetic testing. The patient was treated conservatively, with parenteral nutrition and supportive methods. Thirty-four cases of bowel perforation in vEDS have been reported so far. Interestingly, this case is the second one ever to report co-existence of vEDS with Segmental Absence of Intestinal Musculature.

CONCLUSIONS

Establishing the diagnosis of vEDS promptly is of vital significance in order to ensure that patients receive appropriate treatment. Due to initial non-specific clinical presentation, EDS should always be included in the differential diagnoses of young patients with unexplained perforations of the gastrointestinal tract.

Minimally Invasive Treatments of Benign Thyroid Nodules: A Network Meta-Analysis of Short-Term Outcomes

Background: Image-guided thermal ablation interventions are novel thermal-based modalities used for the treatment of benign thyroid nodules. Methods: We conducted a systematic review and a Bayesian network meta-analysis, examining studies using thermal ablation interventions in the treatment of benign nodular thyroid disease (PROSPERO CRD42022367680). The primary endpoints included volume reduction rate (VRR), and symptomatic score and cosmetic score improvement. Secondary endpoints included vocal disturbances, laryngeal nerve palsy, hypothyroidism, and nodular regrowth (defined by increased nodular volume of >50% for thermal ablation or new nodules arising in remaining thyroid tissue conventional surgery [CS]). Results: We included 16 studies (3 randomized controlled trials [RCTs] and 13 comparative case series), describing radiofrequency ablation (RFA), laser ablation (LA), microwave ablation (MWA), high-intensity focus ultrasound (HIFU), and CS, respectively. The review included data from 4112 patients followed for a mean of 11.9 months. Meta-analyses showed no significant differences among RFA, LA, MWA, HIFU, and CS regarding any of the primary endpoints of VRR, symptomatic score, and cosmetic score. In examining the surface under the cumulative ranking area (SUCRA) ranking, CS (SUCRA, 98.49), LA (SUCRA, 51.58), and MWA (SUCRA, 57.0) were identified as the three interventions that were most likely to result in the largest VRR, symptomatic and cosmetic score reduction. RFA, relative risk (RR) 0.19 [95% credibility interval (CI): 0.06 to 0.48], LA RR 0.23 [CI: 0.06 to 0.79], and MWA RR 0.25 [CI: 0.09 to 0.60] were associated with the greatest reduction in risk for postintervention vocal complications compared with CS, with RFA (SUCRA, 61.62) being ranked as the highest in safety. RFA RR 0.05 [CI: 0.00 to 0.40] and MWA RR 0.16 [CI: 0.02 to 0.73] were associated with a reduced risk of transient laryngeal nerve injury compared with CS. RFA RR 0.00 [CI: 0.00 to 0.00] and MWA RR 0.00 [CI: 0.00 to 0.03] were associated with a reduced risk of hypothyroidism occurrence compared with CS, with RFA (SUCRA, 99.86) yielding the highest safety ranking. RFA was associated with a reduced risk for nodular regrowth RR 0.09 [CI: 0.00 to 0.85], compared with CS. Conclusion: We have comprehensively reviewed the published literature on the efficacy and safety of thermal ablation modalities for benign thyroid nodules. Important research gaps remain regarding a paucity of both long-term data and high-quality RCTs.

Visualization of the recurrent laryngeal nerve alone versus intraoperative nerve monitoring in primary thyroidectomy: a framework approach to a missing typology

INTRODUCTION

Surgical studies evaluating a device or technology in comparison to an established surgical technique should accurately report all the important components of the surgical technique in order to reduce the risk of intervention bias. In the debate of visualization of the recurrent laryngeal nerve alone (VONA) versus intraoperative nerve monitoring (IONM) during thyroidectomy, surgical technique plays a key role in both strategies. Our aim was to investigate whether the surgical technique was considered as a risk of intervention bias by relevant meta-analyses and reviews and if steps of surgical intervention were described in their included studies.

METHODS

We searched PUBMED, CENTRAL-Cochrane library, PROSPERO and GOOGLE for reviews and meta-analyses focusing on the comparison of IONM to VONA in primary open thyroidectomy. Τhen, primary studies were extracted from their reference lists. We developed a typology for surgical technique applied in primary studies and a framework approach for the evaluation of this typology by the meta-analyses and reviews.

RESULTS

Twelve meta-analyses, one review (388,252 nerves at risk), and 84 primary studies (128,720 patients) were included. Five meta-analyses considered the absence of typology regarding the surgical technique as a source of intervention bias; 48 primary studies (57.14%) provided information about at least one item of the typology components and only 1 for all of them.

DISCUSSION

Surgical technique of thyroidectomy in terms of a typology is underreported in studies and undervalued by meta-analyses comparing VONA to IONM. This missing typology should be reconsidered in the comparative evaluation of these two strategies.

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-Gly^GCC 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-Gly^GCC in all samples. Extensive biostatics analysis showed that i-tRF-Gly^GCC 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-Gly^GCC expression. i-tRF-Gly^GCC 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-Gly^GCC 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-Gly^GCC has the potential to be a useful molecular tissue biomarker in CRC, independent of other clinicopathological variables.

Looking for the Ideal Probiotic Healing Regime

Wound healing is a multi-factorial response to tissue injury, aiming to restore tissue continuity. Numerous recent experimental and clinical studies clearly indicate that probiotics are applied topically to promote the wound-healing process. However, the precise mechanism by which they contribute to healing is not yet clear. Each strain appears to exert a distinctive, even multi-factorial action on different phases of the healing process. Given that a multi-probiotic formula exerts better results than a single strain, the pharmaceutical industry has embarked on a race for the production of a formulation containing a combination of probiotics capable of playing a role in all the phases of the healing process. Hence, the object of this review is to describe what is known to date of the distinctive mechanisms of each of the most studied probiotic strains in order to further facilitate research toward the development of combinations of strains and doses, covering the whole spectrum of healing. Eleven probiotic species have been analyzed, the only criterion of inclusion being a minimum of two published research articles.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases.

AIM

To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance.

METHODS

After a thorough research of the international literature of a period of more than 30 years of published “case reports” concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist.

RESULTS

Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas.

CONCLUSION

For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Surgical Management of Groove Pancreatitis: A Case Report

Groove pancreatitis (GP) is a chronic type of pancreatitis involving the groove area between the head of the pancreas, the duodenum, and the common bile duct. Alcohol abuse is one of the main pathogenetic factors, although its etiology is not clearly defined. Differential diagnosis of pancreatic disorders remains difficult. The lack of diagnostic management and the restrictive number of patients are the main barriers. This article presents a case of a 37-year-old male diagnosed with GP after several episodes of epigastric pain and vomiting, with a history of chronic alcohol consumption. The patient's radiological and laboratory results excluded the possibility of malignancy and suggested the diagnosis of groove pancreatitis with duodenal stenosis. After initial conservative treatment failed, surgical management was decided. A gastroenteroanastomosis was made in order to bypass the duodenum aiming for a total resolution of the symptoms and an uneventful recovery of the patient. Although most studies suggest pancreatoduodenectomy (Whipple's procedure) as the treatment of choice, a less major procedure can be performed in evidence of malignancy absence.

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Predictive Factors for Mortality and Length of Hospital Stay after Cardiac Surgery

Background: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are widely accepted indices positively correlated with disease severity, progression, and mortality. In this study, we tested whether NLR and PLR could predict mortality and length of hospital stay (LOS) after cardiac surgery. Methods: NLR and PLR were calculated on days 0, 3, 5, and 7 postoperatively. A ROC curve was generated to assess their prognostic value; multivariate logistic analysis identified independent risk factors for 90-day mortality. Results: Analysis was performed on 179 patients’ data, 11 of whom (6.15%) died within 90 days. The discriminatory performance for predicting 90-day mortality was better for NLR7 (AUC = 0.925, 95% CI:0.865–0.984) with the optimal cut-off point being 7.10. NLR5 and PLR3 also exhibited a significant strong discriminative performance. Similarly, a significant discriminative performance was prominent for PLR3, NLR5, and NLR7 with respect to LOS. Moreover, NLR7 (OR: 2.143, 95% CI: 1.076–4.267, p = 0.030) and ICU LOS (OR:1.361, 95% CI: 1.045–1.774, p = 0.022) were significant independent risk factors for 90-day mortality. Conclusions: NLR and PLR are efficient predictive factors for 90-day mortality and LOS in cardiac surgery patients. Owing to the simplicity of determining NLR and PLR, their postoperative monitoring may offer a reliable predictor of patients’ outcomes in terms of LOS and mortality.

Subcapsular Biloma following Endoscopic Retrograde Cholangiopancreatography and Endoscopic Biliary Sphincterotomy: A Case Report with a Mini Review of Literature

A biloma is a loculated, extrahepatic, intra-abdominal bile collection. It is an unusual condition with an incidence of 0.3-2% and is usually a result of choledocholithiasis, iatrogenic injury or abdominal trauma causing disruption to the biliary tree. Rarely, it will occur spontaneously, resulting in spontaneous bile leak. We herein present a rare case of biloma as a complication of endoscopic retrograde cholangiopancreatography (ERCP). A 54-year-old patient experienced right upper quadrant discomfort, following ERCP, endoscopic biliary sphincterotomy and stenting for choledocholithiasis. Initial abdominal ultrasound and computed tomography revealed an intrahepatic collection. Percutaneous aspiration under ultrasound guidance of yellow-green fluid confirmed the diagnosis, indicated infection and contributed to effective management. Most likely, a distal branch of the biliary tree was injured during the insertion of the guidewire through the common bile duct. Magnetic resonance image/magnetic resonance cholangiopancreatography contributed in the diagnosis of two seperate bilomas. Even though post ERCP biloma is an unusual complication, differential diagnosis of patients with right upper quadrant discomfort following an iatrogenic or traumatic event should always include biliary tree disruption. A combination of radiological imaging for diagnosis and minimal invasive technique to manage a biloma can prove to be successful.

Buried bumper syndrome: A critical analysis of endoscopic release techniques

Buried bumper syndrome (BBS) is the situation in which the internal bumper of the gastrostomy tube, due to prolonged compression of the tissues between the external and the internal bumper, migrates from the gastric lumen into the gastric wall or further, into the tract outside the gastric lumen, ending up anywhere between the stomach mucosa and the surface of the skin. This restricts liquid food from entering the stomach, since the internal opening is obstructed by gastric mucosal overgrowth. We performed a comprehensive search of the PubMed literature to retrieve all the case-reports and case-series referring to BBS and its management, after which we focused on the endoscopic techniques for releasing the internal bumper to re-establish the functionality of the tube. From the “push” and the “push and pull T” techniques to the most sophisticated-using high tech instruments, all 10 published techniques have been critically analysed and the pros and cons presented, in an effort to optimize the criteria of choice based on maximum efficacy and safety.

Right Paraduodenal Hernia as a Cause of Acute Abdominal Pain in the Emergency Department: A Case Report and Review of the Literature

Paraduodenal hernias (PDHs) represent an unusual cause of acute abdominal pain in the Emergency Department (ED) and are associated with high morbidity attributable to a challenging clinical and radiological diagnosis, as signs and symptoms mimic other frequent causes of acute abdominal pain. We report a right paraduodenal hernia in a 37-year-old female patient who presented to the ED complaining of abdominal pain located in the right lower abdomen and hypogastrium, accompanied by nausea. During diagnostic work up, the abdominal computed tomography scan revealed the presence of small bowel malrotation with concomitant right paraduodenal hernia. These findings were confirmed intraoperatively. We performed a brief literature review about the clinical manifestations and treatment options of right paraduodenal hernias, which retrieved only 30 articles related to this condition. Prompt diagnosis, radiological or intraoperative, of paraduodenal hernias is crucial because nearly 50% will progress to small bowel obstruction. Therefore, it is essential for every clinician to account for them in the differential diagnosis of acute abdominal pain in the ED.

Endothelial Damage and Muscle Wasting in Cardiac Surgery Patients

This is a post-hoc analysis to assess the effect of anesthesia, surgical trauma, and extracorporeal circuit on endothelial integrity, microvascular permeability, and extracellular fluid balance, as well as on skeletal muscle catabolism, in patients undergoing elective cardiac surgery. We included 127 well-nourished patients undergoing “on-pump” elective cardiac surgery. One day prior to surgery (D0) and again on postoperative day 7 (POD7), body mass index, body composition assessment, hand-grip strength (HGS), and mid-upper arm muscle circumference (MAMC) were measured. Patients were assigned to early recovery (ER) and late recovery (LR) groups, depending on the duration of ICU stay (cut-off 48 hours). The magnitude of change (Δ) in all parameters studied was assessed in ER versus LR groups, regarding (i) epithelial tissue dysfunction (Δ-Extra-Cellular Water percentage (Δ-ECW%), Δ-Phase Angle (Δ-PhA)), (ii) skeletal muscle mass catabolism (Δ-Skeletal muscle mass reduction%, Δ-Hand Grip Strength (Δ-HGS) and Δ-Mid Upper-Arm Muscle Circumference (Δ-MAMC)). Baseline measurements were similar in both groups. A significant difference was observed in all Δ-parameters studied (Δ-ECW%, Δ-PhA and muscle catabolism, Δ-HGS, Δ-MAMC), the worse results being correlated to the LR group. The results raise the issue that patients with early recovery may silently have pathological conditions, continuing even on the day of discharge - further research should be planned.

Gastrocolic fistula in Crohn's disease: A case report and review of the literature

Gastrointestinal fistulas constitute a rare type of abdominal fistula and an uncommon complication in the setting of Crohn's disease. In this case presentation we study the treatment of a gastrointestinal fistula between the transverse colon and the stomach in a patient with Crohn's disease and present a review of the available literature. A 53-year-old female patient with history of Crohn's disease presented to the Emergency Department of our Hospital due to reported abdominal pain and clinical symptoms of incomplete ileus with no other specific symptoms. Imaging investigation included plain radiography and computed tomography of the abdomen and revealed mural thickening of the transverse colon for an approximately 10 cm long segment, with the possible presence of gastrocolic fistula. During the exploratory laparotomy, an inflammatory mass was found in the middle of the transverse colon and the communication with the stomach was confirmed. Excision of the affected part of the transverse colon and cuneiform resection of the stomach in the area of the fistula was performed. The patient presented smooth and uncomplicated postoperative period and was discharged on the 10th postoperative day. Gastrointestinal fistulas are an uncommon complication of Crohn's disease, often with an intense clinical manifestation from the upper and lower digestive tract. Surgical treatment, either open or laparoscopic, of gastrointestinal fistulas due to Crohn's disease is the "gold-standard" method, both to control the disease and avoid further complications.

A Four-Probiotic Regime to Reduce Surgical Site Infections in Multi-Trauma Patients

Investigations that focused on the protective role of probiotics against Surgical Site Infections (SSI) in multiple-trauma (MT) patients are generally few, probably due to the complexity of the concept of trauma. We aimed to assess the efficacy of a four-probiotic regime to reduce the incidence of SSI in MT patients, with a brain injury included. MT patients, being intubated and expected to require mechanical ventilation for >10 days, were randomly allocated into placebo (n = 50) or probiotic treatment (n = 53) comprising Lactobacillus acidophilus LA-5 (1.75 × 109 cfu), Lactiplantibacillus plantarum UBLP-40 (0.5 × 109 cfu), Bifidobacterium animalis subsp. lactis BB-12 (1.75 × 109 cfu), and Saccharomycesboulardii Unique-28 (1.5 × 109 cfu) in sachets. All patients received two sachets of placebo or probiotics twice/day for 15 days and were followed-up for 30 days. The operations were classified as neurosurgical, thoracostomies, laparotomies, orthopedics, and others; then, the SSI and the isolated pathogen were registered. A total of 23 (46.0%) and 13 (24.5%) infectious insults in 89 (50 placebo patients) and 88 (53 probiotics-treated) operations (p = 0.022) were recorded, the majority of them relating to osteosynthesis—17 and 8, respectively. The most commonly identified pathogens were Staphylococcus aureus and Acinetobacter baumannii. Our results support published evidence that the prophylactic administration of probiotics in MT patients exerts a positive effect on the incidence of SSI.

The rare entity of ectopic pancreatic tissue in the gallbladder: A case report

Introduction

and importance: Ectopic pancreatic tissue (EPT) is a rare clinical entity, which is defined as the presence of pancreatic tissue without any anatomic or vascular connection with the main body of the pancreas. EPT could be found anywhere in the gastrointestinal tract; most commonly in stomach. The aim of this study is to present a rare case report of EPT located in the gallbladder.

Case presentation

A 37-year-old woman was scheduled in our surgical department for elective laparoscopic cholecystectomy due to symptomatic chololithiasis. Preoperative ultrasound imaging was indicative only for the presence of multiple stone tin the gallbladder's fundus. The patient had an uneventful recovery and discharged the first postoperative day. Surprisingly, the final pathology report of the specimen referred the existence of EPT in the subserosa territory, as an incidental finding.

Clinical discussion

EPT is almost impossible to be diagnosed preoperatively due to its various clinical presentation and the low discriminating power of all the usual imaging tests. However, given the potential malignant transformation of the EPT, physicians should be aware of this clinical entity and consider cholecystectomy immediately when it is highly suspected.

Conclusion

EPT in the gallbladder is a very rare finding. There are no established “gold standard” techniques to identify it preoperatively. The patients are either asymptomatic or presenting with non-specific symptoms and almost always the pathology examination, after cholecystectomy, establishes the definite diagnosis.

•

Ectopicpancreatic tissue (EPT) is very uncommon, especially in the gallbladder.

•

Preoperative diagnosis of EPT, although very important due to its potential malignant transformation, is almost impossible.

•

Only awareness of this entity and further research may enlighten more its clinical significance.

The impact of age on quality of life and frailty outcomes after parathyroidectomy in patients with primary hyperparathyroidism

OBJECTIVE

Parathyroidectomy (PTx) improves quality of life (QoL) in patients with primary hyperparathyroidism (PHPT). Whether this effect is modified according to the patients' age is unknown. The aim of this study was to evaluate the impact of age on the effect of PTx on QoL and frailty in patients with PHPT, six months post-PTx.

METHODS

This was a prospective cohort study, including patients with PHPT, admitted from January 2016 to December 2019, divided into two categories: younger (≤ 65 years old) and older (> 65 years old). QoL was assessed with the Pasieka questionnaire (PAS-Q) two days pre- and six months post-operatively. Frailty was also assessed at the same time intervals, with the Frailty Index (FI).

RESULTS

One hundred and thirty-four patients (younger group: 96 patients, mean age 50.4 ± 9.8 years; older group: 38 patients, mean age 72.1 ± 4.9 years) were included. PTx resulted in a significant reduction in PAS-Q score in both groups. Notably, a greater reduction in "mood swings", "irritability", "itchy skin" and "feeling thirsty" PAS-Q domains was observed in the younger group. In contrast, a greater decrease in "bone pain", "tiredness", "weakness", "joint pain", "getting off chair" and "headaches" items was observed in the older group. Moreover, PTx led to a decrease in FI only in this group.

CONCLUSIONS

PTx leads to an improvement in QoL both in older (> 65 years) and younger (≤ 65 years) patients with PHPT, attributed to a differential effect on PAS-Q items. Frailty improves only in the older group.

Composite Paraganglioma of the Celiac Trunk: A Case Report and a Comprehensive Review of the Literature

Introduction

Composite paragangliomas consist of two components, paraganglioma and ganglioneuroma, representing a rare subgroup of paragangliomas. The purpose of the study is to describe a case of composite paraganglioma of the celiac trunk and a brief review of the existing literature.

Case Presentation

A 64-year-old female patient with a history of epigastric abdominal pain and a 51 mm-diameter tumor found in a Computerized Tomography of the abdomen was admitted to our surgical department for further evaluation and treatment. After a brief preoperative surgical assessment, the patient underwent a mini-laparotomy for the excision of this tumor. After having the results of the pathology report, a comprehensive review of the international literature was carried out by applying the appropriate search terms.

Results

As it was found intraoperatively, the tumor was located at the cephalad aspect of the common hepatic artery, over the portal vein and the inferior vena cava. A negative-margin resection was achieved and the tumor was sent for pathology analysis. The final pathology report revealed a composite paraganglioma, with α paraganglioma and a ganglioneuroma component. Seventeen cases of extra-adrenal composite paraganglioma have been reported in the international literature so far. This case was the first one found in the area of the celiac trunk.

Conclusions

Composite paragangliomas comprise rare and potentially malignant tumors with variable prognosis. Establishing their diagnosis promptly is of vital significance. Due to the first-described location of the composite paraganglioma in our case, the differential diagnosis of tumors in this area should also include composite paragangliomas.

Autosomal dominant pseudohypoparathyroidism type 1B due to STX16 deletion: a case presentation and literature review

INTRODUCTION

Pseudohypoparathyroidism (PHP) is a heterogeneous group of rare, genetically related, endocrine disorders, characterized by end-organ resistance to parathyroid hormone (PTH) action and other G protein-coupled receptors (GPCRs) related hormones. The clinical variants of PHP are classified according to the presence of features of Albright's Hereditary Osteodystrophy (AHO) and in vivo response to exogenous PTH. Autosomal dominant PHP1b is often caused by a deletion in the Syntaxin-16 (STX16) gene, leading to a loss of methylation in the A/B exon of the guanine nucleotide-binding protein a-stimulating polypeptide (GNAS) complex. Herein, we present a case of a 41-year-old man with familiar PHP1b due to a maternal inherited 3-kb STX16 deletion, who was referred to us for consultation by artificial reproductive technology specialists.

EVIDENCE ACQUISITION

A bibliographic search was performed in electronic databases (PubMed and Cochrane Library) to identify similar cases.

EVIDENCE SYNTHESIS

Twenty studies (case-series or reports) were eligible. These studies included collectively 120 patients; 46 patients (38.3%) presented with symptoms of hypocalcemia; 38 were asymptomatic (31.7%); data for 36 patients (30%) were unavailable. Thyroid-Stimulating hormone (TSH) resistance was documented in 25 occasions (21%); growth hormone deficiency in 2 (1.7%); 3 patients shared features of the AHO (2.5%); 6 had abnormal bone mineral density test (5%). Notable is the development of tertiary hyperparathyroidism in 3 individuals (2.5%).

CONCLUSIONS

The present review confirms the heterogeneity in the clinical spectrum of familiar PHP1b. Future research should focus on the molecular characterization of the GNAS disorders, leading to a facile diagnosis and appropriate genetic counseling.

Translation of the Pasieka's Parathyroid Assessment of Symptoms Questionnaire (PAS-Q) for Use in the Greek Population

INTRODUCTION

In Europe, primary hyperparathyroidism is mainly considered an asymptomatic disorder, although there is evidence that patients' health-related quality of life is impaired. This aspect is mostly evaluated using Pasieka's Questionnaire: a disease-specific diagnostic tool. The purpose of this study was to translate the Pasieka's Questionnaire into the Greek language and adapt it to the Greek population.

MATERIALS AND METHODS

Pasieka's Questionnaire consists of 13 questions. Two bilingual, native Greek experts were selected for step one, each of whom offered a blinded Greek version of the questionnaire. In the second step, these two versions were merged into one which was retranslated back into the English language (step three) by two bilingual translators (English native speakers). In the fourth step, a committee was formed to draft the pre-final version of the questionnaire which was then submitted to the co-authors for final approval. Finally, after the approval of the final version, 50 patients with primary hyperparathyroidism were recruited for the pilot study of the questionnaire.

RESULTS

All 13 questions of the Pasieka's Questionnaire were translated without any major discrepancy. A high level of internal consistency was achieved (Cronbach's alpha was 0.904) and agreement between test-retest was excellent for every question.

CONCLUSION

The Greek version of Pasieka's Questionnaire was validated and can be applied to evaluate the health-related quality of life of patients with primary hyperparathyroidism in Greek-speaking populations.

Rubber band ligation of hemorrhoids: is the procedure effective for the immunocompromised, hemophiliacs and pregnant women?

Background

Rubber band ligation (RBL) is an effective, well-established, non-surgical option for symptomatic grade II-III hemorrhoid treatment. However, few reports exist about the benefit and risks of RBL in high-risk patients. We herein evaluated the effectiveness and safety of RBL in hemophiliac, human immunodeficiency virus (HIV)-positive and pregnant patients vs. other patients.

Methods

We retrospectively evaluated the effectiveness of RBL, during the period 2001-2021, in 3 distinct patient categories deemed high-risk and thus not suitable for anesthesia and/or surgical management of their hemorrhoids: hemophiliacs, HIV-positive patients, and pregnant women. These were compared to matched controls, selected from our outpatient pool, who had no major comorbidities and who had opted for RBL as the primary method of treatment.

Results

There were 3 study groups (44 with hemophilia, 29 HIV-positive patients, and 45 pregnant women) and controls respectively matched for grade, sex and age (2 for each one in the study groups). Hemophilia patients needed up to 6 RBL sessions for relief of symptoms (3.22 sessions/patient) compared to controls, who needed up to 4 sessions (1.88 sessions/patient, P<0.001); in the other 2 groups there was no difference. There were 3 minor complications: one minor bleeding in a hemophilia patient, a thrombosis in an HIV-positive patient, and severe rectal pain in a control patient. Patients were followed-up for at least 1 year.

Conclusion

RBL is a safe and effective procedure in hemophiliacs, HIV-positive patients and pregnant women, with low complication rates for grade I-III hemorrhoids, similar to those in healthy matched controls.

Double ipsilateral parathyroid adenomas, with one supernumerary and ectopic at the same time: a case report

Background

Double adenomas (DA) represents a distinct clinical entity of primary hyperparathyroidism (PHPT). DA may follow various embryologic distribution patterns and could be supernumerary and/or ectopic.

Case presentation

We describe the first case of PHPT which comes as a result of double ipsilateral adenoma, of which one was both ectopic and supernumerary. A 45 year-old Greek male patient with diagnosed PHPT due to a single lower right parathyroid adenoma was admitted to our department for surgical treatment. The preoperative tests (neck US, Sestamibi scan) were conclusive for single gland disease. The patient underwent focused parathyroidectomy. The frozen section revealed a parathyroid adenoma with a slight possibility for parathyroid carcinoma. Ten minutes after the excision, intact PTH (iPTH) dropped >50% related to preoperative values and was within normal range. Right hemithyroidectomy with additional ipsilateral central neck dissection was performed, because of the possibility for parathyroid carcinoma. The final pathology report showed that the first excised tissue proved to be a parathyroid adenoma, while a second subcapsular one and a normal right upper parathyroid gland were also found.

Conclusions

Preoperative localization of DA using routine imaging tests and the utility of intraoperative parathyroid hormone assay are still unreliable in detecting multiple adenomas. Furthermore, a slight possibility of a second and simultaneously supernumerary and ectopic adenoma maybe present. Therefore, it would be advisable to establish the use of more advanced imaging tests (such as 4D-CT, 4D-MRI) or other diagnostic tools when DA are suspected.

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

BACKGROUND

Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.

METHODS

This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.

FINDINGS

Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05-2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).

INTERPRETATION

Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.

FUNDING

DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant.