Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study

BACKGROUND

Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours.

METHODS

In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186.

FINDINGS

Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039).

INTERPRETATION

Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation.

FUNDING

None.

Clinicopathological Characteristics and Outcomes of Patients With Endometriosis-Related Hemorrhagic Ascites: An Updated Systematic Review of the Literature

The presence of ascites is a common clinical presentation in gynecologic oncology patients. Hemorrhagic ascites (HA) due to endometriosis is a rare presentation that can be easily misdiagnosed as ovarian malignancies. The present study aims to update the currently available knowledge on the characteristics of patients presenting with HA due to endometriosis.

A systematic search was conducted for articles published from January 2000 to July 2020 using the Medline, Scopus, and Google Scholar databases along with the references of the full-text articles retrieved. Papers describing cases of women over 18 years with or without previous history of endometriosis were assessed. Only cases with histologically proven hemorrhagic ascites of endometriosis origin were included.

Twenty-nine studies (27 case reports and two case series) comprising 32 patients were evaluated. The mean patients’ age was 32 years, while six of the patients had a previous history of endometriosis. The mean amount of drained ascitic fluid was 4,200 mL, whereas three patients underwent thoracentesis due to pleural effusions. The treatment options included not only medical but also surgical therapies. Fertility preservation was achieved in 27 patients, while two of them achieved pregnancy with in vitro fertilization (IVF) techniques.

Endometriosis-related hemorrhagic ascites is a relatively rare expression of the disease. Endometriosis-related hemorrhagic ascites should be considered in the differential diagnosis (DD) of women with ascites and clinical suspicion of endometriosis. The available literature is limited to case reports and case series and thus indicates further research in the field to decode the pathophysiology of the disease and decide on the optimal treatment.

To block, or not to block … is it still the question? Effectiveness of alpha- and beta-blockade in phaeochromocytoma surgery: an institutional analysis

INTRODUCTION

Phaeochromocytomas/paraganglioma (PPGL) surgery was historically associated with significant risks of perioperative complications. The decreased mortality (<3.0%) had been attributed in part to optimal preoperative alpha-blockade. The value of alpha-blockade in decreasing morbidity is being challenged. The aim of our study is to present an institutional experience of preoperative alpha-blocking of PPGL and its effect on cardiovascular stability and postoperative morbidity.

METHODS

A retrospective study using data from our institutional database was conducted. All patients undergoing adrenalectomy for PPGL from October 2011 to September 2020 were included. All patients were routinely alpha-blocked. Intraoperative cardiovascular instability (ICI) was assessed through number of systolic blood pressure (SBP) episodes >160mmHg, SBP <90mmHg, the need for vasoactive drugs and volume of intraoperative crystalloids administered. Morbidity was also evaluated.

RESULTS

A total of 100 consecutive patients undergoing surgery were identified of whom 53 patients had complete anaesthetic records available for analysis. Thirty-two patients (60%) had at least one episode with an SBP >160mmHg. Nine (17%) cases had no intraoperative hypotensive episodes, while 3 (6%) patients had >10 intraoperative episodes of an SBP <90mmHg. Twenty-one (40%) patients received vasoactive drugs during surgery. The median volume of intraoperative crystalloids was 2 litres (1-4). Postoperatively, no patient experienced cardiovascular complications, including arrhythmia or myocardial ischaemia. Only two were admitted to an intensive care unit (ICU) and one 30-day readmission occurred.

CONCLUSIONS

Cardiac instability remained significant in PPGL surgery despite optimal alpha- and beta-blockade. While omitting blockade would appear empirically questionable, a randomised controlled trial (RCT) of surgery with and without alpha-blockade will provide an answer.

Surgical management of primary hyperparathyroidism during pregnancy: a systematic review of the literature

OBJECTIVE

Gestational primary hyperparathyroidism (PHPT) is an endocrinological disorder with serious outcomes for both women and neonates. The aim of our study was to present the current evidence concerning the perioperative outcomes of pregnant women with PHPT who underwent parathyroidectomy during pregnancy.

METHODS

A meticulous systematic review of the literature published before February 2020 and all studies which presented perioperative and pregnancy outcomes off pregnant women who underwent parathyroidectomy for PHPT, were included.

RESULTS

A total of 53 were finally included, which reported 92 pregnant women who had parathyroidectomy during their pregnancy. A total of 46 patients were hospitalized due to significant complications of PHPT before their parathyroidectomy. With regards to surgical approach, 52.2% of patients underwent minimally invasive parathyroidectomy (MIP), while bilateral neck exploration (BNE) was 41.3% of cases. Only 4 women was not cured, whereas transient hypocalcemia was occurred in 18 patients. All cases proceeded to deliveries of healthy neonates, after their parathyroidectomy.

CONCLUSIONS

Parathyroidectomy during pregnancy is a safe and effective treatment option with minimum complications and probably should be considered as the treatment of choice in specific group of pregnant women with PHPT.

To block, or not to block … is it still the question? Effectiveness of alpha- and beta-blockade in phaeochromocytoma surgery: an institutional analysis

INTRODUCTION

Phaeochromocytomas/paraganglioma (PPGL) surgery was historically associated with significant risks of perioperative complications. The decreased mortality (<3.0%) had been attributed in part to optimal preoperative alpha-blockade. The value of alpha-blockade in decreasing morbidity is being challenged. The aim of our study is to present an institutional experience of preoperative alpha-blocking of PPGL and its effect on cardiovascular stability and postoperative morbidity.

METHODS

A retrospective study using data from our institutional database was conducted. All patients undergoing adrenalectomy for PPGL from October 2011 to September 2020 were included. All patients were routinely alpha-blocked. Intraoperative cardiovascular instability (ICI) was assessed through number of systolic blood pressure (SBP) episodes >160mmHg, SBP <90mmHg, the need for vasoactive drugs and volume of intraoperative crystalloids administered. Morbidity was also evaluated.

RESULTS

A total of 100 consecutive patients undergoing surgery were identified of whom 53 patients had complete anaesthetic records available for analysis. Thirty-two patients (60%) had at least one episode with an SBP >160mmHg. Nine (17%) cases had no intraoperative hypotensive episodes, while 3 (6%) patients had >10 intraoperative episodes of an SBP <90mmHg. Twenty-one (40%) patients received vasoactive drugs during surgery. The median volume of intraoperative crystalloids was 2 litres (1-4). Postoperatively, no patient experienced cardiovascular complications, including arrhythmia or myocardial ischaemia. Only two were admitted to an intensive care unit (ICU) and one 30-day readmission occurred.

CONCLUSIONS

Cardiac instability remained significant in PPGL surgery despite optimal alpha- and beta-blockade. While omitting blockade would appear empirically questionable, a randomised controlled trial (RCT) of surgery with and without alpha-blockade will provide an answer.

A rare case of extrahepatic biliary mucinous cystic neoplasm in a middle-aged woman: A case report

Biliary mucinous cystic neoplasms are very rare tumors of the biliary tract with malignant potential. Preoperative diagnosis is challenging, as clinical, biochemical and radiological features are not specific. Surgical resection with negative margins is the gold standard treatment for these uncommon lesions. A 55-year-old woman presented at the Third Department of Surgery (Attikon University Hospital, Athens, Greece) with a history of mild right upper quadrant (RUQ) abdominal pain and jaundice. A 2-cm lesion in the distal common bile was identified by imaging. Following discussion in our multidisciplinary board meeting the patient underwent a pylorus preserving pancreatoduodenectomy, and histopathological examination revealed an ovarian-stromal type intraductal mucinous cystic neoplasm of the extra hepatic biliary. Since biliary mucinous cystic neoplasms are characterized by malignant transformation and high rates of recurrence, surgical resection with negative margins is the treatment of choice for both non-invasive and invasive biliary mucinous cystic neoplasms.

Primary thyroid teratoma in adults: A case report and systematic review of the literature

Extragonadal germ cell tumors are uncommon in adults and only 2-5% of teratomas develop in extragonadal sites. Primary thyroid teratomas represent <0.1% of all primary thyroid gland neoplasms. In the present report, a case of primary thyroid teratoma in a 65-year-old female is described. Furthermore, the current literature regarding patients who were diagnosed with primary thyroid teratoma and underwent surgical resection was systematically reviewed. A total of 15 studies of 27 patients (age range, 17-65 years). Growing mass or neck swelling were the primary symptoms in 14 patients (51.8%). Only one (5.5%) patient was preoperatively diagnosed with malignant thyroid teratoma. All patients underwent thyroidectomy, but 6 cases had more advanced surgery, including lymph node dissection. A total of 12 patients received a combination of adjuvant chemoradiation postoperatively, 10 (45.4%) patients reported recurrence of disease and 8 (29.6%) were postoperatively diagnosed with distant metastases. A total of 9 (39.1%) patients died due to progression of the disease. In conclusion, primary thyroid teratomas are rare and difficult to diagnose preoperatively. In particular, malignant cases are very aggressive tumors with a considerably poor prognosis, even after surgical resection combined with adjuvant chemoradiation.

The Modulating Effect of Ursodeoxycholic Acid on Liver Tissue Cyclooxygenase-2 Expression Following Extended Hepatectomy

Introduction: Hepatic regeneration is a complex process involving a multitude of well-timed molecular operations. Ursodeoxycholic acid (UDCA) is postulated to exert a protective effect against oxidative stress and enzymatic degradation of the extracellular matrix, in turn potentiating the regenerative response. The aim of the present animal study is to evaluate the impact of UDCA administration in liver tissue expression of cyclooxygenase-2 (COX-2) in a setting of acute liver failure achieved by 80% hepatectomy.

Materials and methods: Twenty-four adult male Sprague-Dawley rats were randomly assigned to an experimental (UDCA) and a control group. Animals in the UDCA received oral pretreatment with UDCA for 14 days via feeding tube, while animals in the control group received saline. All animals underwent resection of approximately 80% of the liver parenchyma. Tissue and blood sample collection were performed 48 hours postoperatively.

Results: The postoperative mitotic index and Ki-67 levels were found to be elevated in the UDCA group (43±11.4 and 13.7±24.7 versus 31±16.7 and 7.6±5.7), albeit without any statistical significance. Pretreatment with UDCA significantly decreased COX-2 expression levels (p=0.28) as well as serum tumor necrosis factor α (TNFα) levels (37.3±10.9 pg/mL versus 75.4±14.4 pg/mL, p=0.004). COX-2 expression score was observed to be weakly correlated to Ki-67 levels in both groups. Although COX-2 expression score was not correlated with serum TNFα levels in the control group, animals pretreated with UDCA exhibited moderate correlation (r=0.45).

Conclusion: Preoperative administration of UDCA exerts a suppressive effect on tissue expression of COX-2 following 80% hepatectomy and enforces a positive correlation between COX-2 and serum TNFα levels, suggesting that UDCA preconditions liver tissue to display an enhanced regenerative response to circulating cytokines, most notably TNFα. The weak association of COX-2 with Ki-67 expression levels suggests that COX-2 may be of secondary importance during the early phases of liver regeneration.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

Diagnosis, surgical treatment and postoperative outcomes of hepatic endometriosis: A systematic review

Endometriosis is characterized by the presence of endometrial-like tissue and stroma in extra-uterine locations. Hepatic endometriosis (HE) is one of the rarest forms of extrapelvic endometriosis. We aimed to summarize the existing evidence on HE with special consideration to natural history, diagnosis and surgical treatment. Three electronic databases were systematically searched for articles published up to March 2019. All appropriate observational studies and case reports addressing cases of women with HE were considered eligible for inclusion. A total of 27 studies which comprised 32 patients with HE were included. Mean age of patients was 39.7 years. Ten (62.5%) were nulliparous and 24 (75%) were women of reproductive age. Eleven patients (36.7%) had a history of pelvic endometriosis of various sites. Abdominal pain was the primary symptom in 28 patients (87.5%). Preoperative diagnosis of endometriosis was available for 5 patients and 6 underwent a preoperative diagnostic procedure. Cyst resection, minor and major liver resections were performed in 14/31, 9/31 and 8/31 patients, respectively. Preoperative diagnosis of HE is challenging due to variable radiologic features and clinical symptomatology. Nonetheless, it should be considered in the differential diagnosis of a liver mass especially in premenopausal women with a history of endometriosis. The type of resection of the endometriotic lesion is based on the extent and the location of the disease and presented with favourable outcomes concerning morbidity, symptom relief and recurrence.

The Effects of Ursodeoxycholic Acid Pretreatment in an Experimental Setting of Extended Hepatectomy: A Feasibility Study

Introduction Liver regeneration is an exceptionally complex process, orchestrated by a multitude of growth factors and cytokines. Tumor necrosis factor-alpha (TNF-a) and interleukin-6 (Il-6) have a pivotal role in the initiation of the regenerative response. Ursodeoxycholic acid (UDCA) exhibits a liver protective effect that enhances liver growth after injury. The aim of the present study is to evaluate the effect of UDCA in the circulating levels of TNF-a and Il-6 in rats undergoing extended 80% hepatectomy. Materials and methods Twenty-two male Sprague Dawley rats were randomly assigned in an experimental (UDCA group) and a control group. Mice in the UDCA-group received oral pretreatment of UDCA for two weeks preoperatively at a dosage of 25 mg/kg/day. An 80% hepatic resection was performed in both groups by resecting the middle, inferior right, and left lateral liver lobes. The experiment ended 48 hours postoperatively. Results UDCA pretreatment significantly depressed circulating levels of both TNF-a and Il-6 after the conclusion of the experiment as compared to the control group (p=0.001 and p=0.01, respectively). Furthermore, TNF-a levels were significantly reduced before the institution of liver injury (p=0.02). Mice in the UDCA-group exhibited better liver growth as demonstrated by significantly increased Ki-67 and mitotic rate (p=0.04 and p=0.02, respectively). Finally, the liver regeneration rate (LRR) was significantly elevated in the experimental group (UDCA group, 54.5% vs control group, 35.8%; p=0.002) signifying enhanced liver growth kinetics. Conclusion UDCA reduces the expression of TNF-a and Il-6 during the priming phase of liver regeneration. An 80% hepatectomy model of acute liver failure exhibited enhanced liver regeneration in the experimental group, plausibly due to the immunomodulatory effects of UDCA.

Safety and efficacy of synchronous panniculectomy and endometrial cancer surgery in obese patients: a systematic review of the literature and meta-analysis of postoperative complications

Panniculectomy combined with gynaecological surgery constitutes an alternative approach for endometrial cancer (EC) in obese patients. The present study aimed to assess the current knowledge concerning the safety and efficacy of combining panniculectomy in surgical management of EC. Four electronic databases were systematically searched for articles published up to May 2019. A total of five studies, of which two were non-comparative and three comparative, were included. Meta-analysis of complications among panniculectomy and conventional laparotomy group revealed no difference in either intra- or post-operative complication rates. Moreover, no difference was reported in surgical site complications (p=0.59), while wound breakdown rates were significantly elevated in the laparotomy group (p=0.02). Panniculectomy combined surgery for the management of EC appears to be a safe procedure and results in comparable outcomes compared with conventional laparotomy with regard to complications and improved wound breakdown rates.

Primary gastric melanoma in adult population: a systematic review of the literature

BACKGROUND

Primary gastric melanoma (PGM) is a rare malignant tumour of the stomach with poor prognosis. The aim of this systematic review was to assess the available literature on this entity and to highlight its biological behaviour and preferred treatment approach.

METHODS

PubMed and Cochrane bibliographical databases were independently searched (last search: 2 February 2020) by two investigators for articles reporting on PGM in the adult population.

RESULTS

Twenty-five studies met the inclusion criteria and concerned collectively 25 patients (18 males and seven females) with an age of 63.4 ± 8.97 years (mean ± standard deviation). Main symptoms included abdominal pain (64%), weight loss (48%) and hematemesis or melena (32%). The most frequent tumour location was the body of the stomach (54.2%). All tumours were surgically resected and the majority of the patients had a partial gastrectomy (52%). Median recurrence time was 5 months and 12% of patients reached 5-year survival landmark.

CONCLUSION

PGM is a rare disease characterized by an aggressive malignant behaviour. Its differential diagnosis from a metastatic lesion is crucial. A prompt diagnosis and therapeutic approach are needed. Further studies are required to elucidate the optimal management of this clinical entity.

Robotic-assisted parathyroidectomy and short-term outcomes: a systematic review of the literature

Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these patients.

Cyst of the Canal of Nuck in adult females: A case report and systematic review

Defects in the Canal of Nuck are rare abnormalities of the female genitalia, which are typically detected and repaired in young age. In the present report, a case of a Nuck cyst in a 40-year old female patient is described. Additionally, the current literature concerning cases of women with hydrocele of Nuck canal was systematically reviewed. A total of 16 case reports of 16 patients with Nuck hydrocele (mean age of 35.18 years), have been reported to date. A right inguinal mass was noted in 13 patients (81.3%) whereas in 3 patients a left-sided mass was noted. The surgical approach was open in 13 cases and laparoscopic in 3 cases. Two cases underwent hydrocelectomy and inguinal ring ligation, whereas in 7 cases a simple cystectomy was performed. In 2 cases the round ligament was excised along with the hydrocele. In one of these 2, ligamentum rotundum necrosis and presence of a haemorrhagic cyst of the canal of Nuck were identified. Hernia repair and hydrocelectomy was performed in 5 cases. A cyst of the Canal of Nuck is relatively rare, but should be considered during the diagnosis of inguinal masses in female patients.

The impact of preoperative sarcopenia on postoperative complications following esophagectomy for esophageal neoplasia: a systematic review and meta-analysis

Esophageal cancer is characterized by profound changes in body composition due to dysphagia and generalized cachexia. Sarcopenia or muscle wasting is a component of cachexia associated with poor postoperative performance status. The skeletal muscle index (SMI) calculated by computed tomography scans at the level of the third lumbar vertebra is an easily quantifiable and reproducible measure of sarcopenia. The aim of this meta-analysis is to investigate the impact of preoperative sarcopenia (low SMI) on postoperative complications after esophagectomy for neoplastic lesions. In this context, a comprehensive literature search was undertaken to identify studies reporting short-term postoperative outcomes in relation to their preoperative SMI values. Cumulative risk ratios (RR) and risk differences (RD) and their respective 95% confidence intervals (CIs) were calculated using a random-effect model. A total of 11 studies incorporating 1,979 total patients (964 patients with sarcopeniaversus 1,015 without sarcopenia) were included in the final analysis. The results demonstrated a significant increase in overall morbidity (RR 1.16, 95% CI 1.01-1.33), respiratory complications (RR 1.64, 95% CI 1.21-2.22) and anastomotic leaks (RR 1.39, 95% CI 1.10-1.76) in patients with sarcopenia. No statistically significant difference was noted in overall mortality (RD 0, 95% CI -0.02-0.02) or Clavien-Dindo grade III or greater complications (RR 1.17, 95% CI 0.96-1.42). The above results demonstrate the validity of the SMI as a predictive factor for post-esophagectomy complications. Although the risk associated with sarcopenia is not prohibitive for surgery, patients with low SMI require closer vigilance during their postoperative course due to the increased propensity for respiratory and anastomotic complications.

Mixed Adenoneuroendocrine Carcinoma (MANEC) of the Gallbladder: A Systematic Review of Outcomes Following Surgical Management

BACKGROUND/AIM

Mixed adenoneuroendocrine carcinomas (MANEC) are uncommon tumors exhibiting both adenocarcinomatous and neuroendocrine differentiation. They most commonly arise in the colon, appendix, rectum or stomach, however, a limited number of MANECs have been reported to originate in the gallbladder (gMANEC). The aim of our systematic review was to accumulate the existing data on gMANEC with special attention to the clinicopathological characteristics, surgical approach, recurrence and survival rates of patients diagnosed with this rare malignancy.

MATERIALS AND METHODS

A comprehensive search of the literature was undertaken.

RESULTS

A total of 15 studies (14 case reports and 1 case series), which comprised 19 patients who successfully underwent surgical treatment for gMANEC were included in our systematic review. During a median follow-up of 8 months (range=2-48 months) the overall survival was 87% and the recurrence rate was 21%.

CONCLUSION

Achievement of complete surgical resection is the mainstay of the therapeutic management. Additionally, the stage of the disease and the histopathological mapping of these tumors affect decision-making for adjuvant chemotherapy and seem to define the prognostic course of each patient.

Infantile hepatic hemangioma: current state of the art, controversies, and perspectives

Infantile hepatic hemangioma (IHH) is a common vascular tumor, distinctive for its perinatal presentation, rapid growth during the first year of life, and subsequent involution. Although they generally follow a benign course, some tumors have been reported to undergo malignant transformation. The diagnosis of IHH is based on patient's medical history, physical examination, and imaging. Moreover, the management of this vascular tumor is based on clinical presentation and includes observational, medical, surgical, and radiological interventional treatment options. The present review presents the currently available data in the literature on the diverse aspects of the terminology, epidemiology, clinical presentation, pathogenesis, diagnosis, indications for surgery, malignant potential, and long-term outcomes of these tumors.Conclusion: No formal guidelines have yet been established for the treatment of these hepatic lesions, and the therapeutic strategies implemented vary widely from simple observation to medical, radiological, and surgical interventions in the prism of multidisciplinary teams.What is Known:• Infantile hepatic hemangioma is the most common benign tumor of the liver in infancy, but despite its benign nature, it can present with life-threatening complications.• The treatment strategies range from simple observation to a series of medical, surgical, and radiological interventions.What is New:• This review gives an overview of the developments and current status about the management of IHH.• The aim of this study is to clear up the confusion and controversy that exists about terminology, diagnosis, and treatment of IHH.

Massive subcutaneous emphysema after traumatic pneumothorax

A simple case/asymptomatic pneumothorax not deemed to necessitate drainage can quickly change, and patient safety can be compromised. Chest tube insertion with increased suction is considered a safe and efficient strategy in patients with extensive subcutaneous emphysema following traumatic pneumothorax.

Comparison between robotic and open liver resection: a systematic review and meta-analysis of short-term outcomes

Minimally invasive liver surgery has evolved significantly during the last 2 decades. A growing number of published studies report outcomes from robotic liver resections (RLR). The aim of our meta-analysis was to evaluate short-term outcomes after RLR vs. open liver resection (OLR). A systematic search of Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases for articles published from January 2000 until November 2018 was performed. Ten non-randomized retrospective clinical studies comprising a total of 1248 patients were included in our meta-analysis. Four hundred and fifty-eight patients underwent RLR and 790 underwent OLR. RLRs were associated with lower overall morbidity rates (p =0.006) and shorter hospital stay (p <0.00001), whereas OLRs were associated with shorter operative time (p =0.003). No differences were shown between the two groups with regard to blood loss, blood transfusion requirements, R0 resection and mortality rates. Cumulative conversion rate was 4.6% in the RLR group. Due to limited available data, further prospective randomized studies are needed to better determine the potential beneficial role of the robotic approach in the treatment of malignant and benign hepatic tumors.

Liver Transplantation for Giant Hepatic Hemangioma: A Systematic Review

INTRODUCTION

Despite their benign nature, liver hemangiomas (LH) are lesions that can cause major complications requiring intervention. Liver transplantation (LT) has been suggested as an effective treatment option in selected patients with giant LHs causing severe symptoms and cannot be treated otherwise. The aim of our study was to investigate the indications, aspects and post-operative outcomes of patients with a LH who underwent LT.

MATERIALS AND METHODS

A meticulous search of the literature was performed. Studies presenting cases of LT due to LH were evaluated. Studies presenting patients characteristics and symptoms, aspects of the disease, transplantation indications and details were selected.

RESULTS

Fifteen studies were included in the present review that involved 16 patients. Among them, 4 were male while the remaining 12 were female with a mean age of 39.9 ± 8.7 years. The main indications for LT included respiratory distress, massive hemorrhage, Kasabach-Merritt syndrome, and unsuccessful previous treatment strategies. Four patients were transplanted from living donors and the remaining 12 from cadaveric donors. No post-operative deaths were reported and all patients returned to normal activity. No deaths during the long-term follow-up were reported.

CONCLUSIONS

LH is an extremely rare indication for LT. Nevertheless, the currently available data suggest that LT is a safe and efficient treatment in the management of symptomatic or complicated LH in selected patients.

Metastatic squamous cell carcinoma to the pancreas: Report of an extremely rare case

Secondary pancreatic lesions are very uncommon. Resection of these metastatic lesions with a curative intent has been reported in selected patients; however, the survival benefit from these procedures has yet to be clearly determined. A 78-year-old male patient presented to our department with obstructive jaundice. Three years prior to presentation the patient had undergone right pneumonectomy, due to stage IIA, low-grade squamous cell lung carcinoma. After resection, the patient received adjuvant chemotherapy, with no evidence of local or systemic recurrence over the following 3 years. Abdominal computer tomography on admission revealed a 3-cm lesion located at the head of the pancreas, causing biliary obstruction. Endoscopic ultrasound biopsy revealed malignant cells, suspicious for squamous cell carcinoma. Due to the limited extent of the metastatic disease and in view of the patient's good condition, surgical resection was proposed and the patient successfully underwent pancreaticoduodenectomy. Histological examination of the resected specimen confirmed a squamous cell carcinoma, with an immunochemical profile similar to that of the primary lung tumor. Therefore, pancreatic resection with curative intent may be feasible in selected patients with secondary metastatic tumors. However, further studies are required in order to determine the benefit of these major procedures in terms of survival outcomes.

Management of MANEC of the colon and rectum: A comprehensive review of the literature

Mixed adeno-neuroendocrine carcinoma (MANEC) is a rare pathological diagnosis recently acknowledged by the World Health Organization in 2010. MANEC is a neoplasm characterized by significant histological heterogeneity and is characterized by the simultaneous presence of both adenocarcinomatous and neuroendocrine differentiation; their definition includes each component found in at least 30% of the tumor. Colorectal MANEC constitutes an uncommon type of malignant tumor. The true prevalence of colorectal MANEC has not been precisely defined and published studies are limited to case reports and small case series. The aim of the present review was to accumulate the existing evidence on colorectal MANEC with special attention to the clinicopathological characteristics, management and survival rates of patients diagnosed with this malignancy. A total of 20 studies (16 case reports and 4 retrospective cohorts) reported outcomes for patients with colorectal MANEC and were finally considered eligible for analysis. The results of the present study show that patients with early stage MANEC have more favorable survival compared to those diagnosed in advanced stages. Due to its neuroendocrine nature, which is characterized by rapid progression, MANEC is diagnosed in advanced stages in the majority of cases and thus potentially explains the poor survival rates. Because of its aggressive nature and high recurrence rate, adjuvant chemotherapy constitutes a critical part of the treatment and significantly improves survival. Further larger studies are needed in order to establish guidelines for the treatment of these rare lesions.

De Garengeot's Hernia: Report of a Rare Surgical Emergency and Review of the Literature

This is a report of a case who was admitted and operated on for a strangulated femoral hernia. The hernia sac contained a gangrenous appendix, which was excised and the hernia was repaired with sutures without complication. De Garengeot's hernia, although very rare, should be included in the differential diagnosis of cases with strangulated hernia and should receive the optimal treatment.

Non traumatic liver herniation due to persistent cough mimicking a pulmonary mass

BACKGROUND

Non traumatic liver herniation through a diaphragmatic defect is rare.

CASE REPORT

A 44 year old woman presented with lower lobe opacity at the right lung. Chest Computed tomography (CT) demonstrated a round tumor adjacent to the right diaphragm. Percutaneous needle biopsy revealed liver tissue. A small liver herniation through a diaphragmatic defect was detected in saggital and coronal CT views but no traumatic rupture of the diaphragm or endometriosis were documented.

CONCLUSIONS

The patient suffered from gastroesophageal reflux disease and increased transdiaphragmatic pressure from paroxysmal cough due to aspirations may have provoked the diaphragmatic rupture.