Naviculocuneiform joint arthrodesis in a cohort of 36 patients.

BACKGROUND: Arthrodesis of the naviculocuneiform joint (NCJ) can be performed in isolation or in conjunction with arthrodesis of other joints, often in the presence of deformity. In the literature there is relative rarity of articles reporting on results and complications of NCJ arthrodesis. PATIENTS AND METHODS: Thirty-six patients (36 feet) with symptomatic NCJ arthritis underwent arthrodesis. Mean age was 59.1 years (SD 13.1; range 26-78) and 24 were women. Adjuvant procedures were performed simultaneously in 29 patients, whilst 17 had planovalgus and 1 had cavovarus foot deformity. RESULTS: Union of the NCJ arthrodesis was achieved in 35 out of 36 (97.2 %) patients, whilst one patient developed non-union. Mean time to union was 13.1 weeks (SD 3.8; range 8-24). Two patients (5.6 %) developed deep infection and 5 patients (13.9 %) required secondary surgical procedures. Twenty-three patients (63.9 %) rated the outcome as good or excellent, 11 (30.6 %) as fair and 2 (5.6 %) as poor. CONCLUSIONS: NCJ arthrodesis was part of a more complex procedure in most of the patients. Whilst union was achieved in almost all patients and complication rate was acceptable, only 64 % rated their outcome as good or excellent. LEVEL OF CLINICAL EVIDENCE: IV.

Near-infrared cholangiography with intragallbladder indocyanine green injection in minimally invasive cholecystectomy.

Laparoscopic cholecystectomy (LC) remains one of the most commonly performed procedures in adult and paediatric populations. Despite the advances made in intraoperative biliary anatomy recognition, iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems. A series of methods have been proposed to prevent bile duct injury, among them the use of indocyanine green (ICG) fluorescence. The most commonly reported method of ICG injection is the intravenous administration, while literature is lacking studies investigating the direct intragallbladder ICG injection. This narrative mini-review aims to assess the potential applications, usefulness, and limitations of intragallbladder ICG fluorescence in LC. Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy, as well as special issues regarding its use. Literature search retrieved four prospective cohort studies, three case-control studies, and one case report. In the three case-control studies selected, intragallbladder near-infrared cholangiography (NIRC) was compared with standard LC under white light, with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography (IOC). In total, 133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC. Literature includes several reports of intragallbladder ICG administration, but a standardized technique has not been established yet. Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping, overwhelming limitations of IOC including intervention and radiation exposure, as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence. Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Deep Fungal Infections of the Upper Extremity - A Review.

Deep fungal infections are rare in the upper extremity. Vessel and nerve infection, synovitis, tenosynovitis, myofasciitis, arthritis and osteomyelitis have been discovered in literature. Treatment in most cases includes surgical procedure and antifungal agent use. Amputation is the final, most devastating for patient's functionality, solution. Intravenous antifungal drugs, frequently followed by oral administration, are important ancillary agents both for the initial treatment and the prevention of recurrence. We therefore performed a review of the current literature, in order to assemble the dispersed results of different studies and clarify the various aspects of upper extremity fungal infections.

Biliary Anatomy Visualization and Surgeon Satisfaction Using Standard Cholangiography versus Indocyanine Green Fluorescent Cholangiography during Elective Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration.

Effect of Intraperitoneal Chemotherapy with Regorafenib on IL-6 and TNF-α Levels and Peritoneal Cytology: Experimental Study in Rats with Colorectal Peritoneal Carcinomatosis.

Cytoreductive surgery (CRS), combined with hyperthermic intraperitoneal chemotherapy, has significantly improved survival outcomes in patients with peritoneal carcinomatosis from colorectal cancer (CRC). Regorafenib is an oral agent administered in patients with refractory metastatic CRC. Our aim was to investigate the outcomes of intraperitoneal administration of regorafenib for intraperitoneal chemotherapy (IPEC) or/and CRS in a rat model of colorectal peritoneal metastases regarding immunology and peritoneal cytology. A total of 24 rats were included. Twenty-eight days after carcinogenesis induction, rats were randomized into following groups: group A: control group; group B: CRS only; group C: IPEC only; and group D: CRS + IPEC. On day 56 after carcinogenesis, euthanasia and laparotomy were performed. Serum levels of interleukin-6 (IL-6) and tumor necrosis factor α (TNF-α) as well as peritoneal cytology were investigated. Groups B and D had statistically significant lower mean levels of IL-6 and TNF-α compared to groups A and C, but there was no significant difference between them. Both B and D groups presented a statistically significant difference regarding the rate of negative peritoneal cytology, when compared to the control group, but not to group C. In conclusion, regorafenib-based IPEC, combined with CRS, may constitute a promising tool against peritoneal carcinomatosis by altering the tumor microenvironment.

The Effectiveness of Ultrasound-Guided, Continuous, Bilateral Erector Spinae Plane Block in Perioperative Pain Management of Patients Undergoing Colorectal Surgery: A Randomized, Controlled, Double Blind, Prospective Trial.

Open and laparoscopic colorectal surgeries, while essential in the management of various colorectal pathologies, are associated with significant postoperative pain. Effective perioperative pain management strategies remain an anesthesiologic challenge. The erector spinae plane block (ESPB), a novel peripheral nerve block, has gained attention for its potential in providing analgesia for a wide variety of surgeries. This study aimed to evaluate the effectiveness of continuous, bilateral ultrasound-guided ESPB in perioperative pain management of patients undergoing colectomy. This prospective, randomized, controlled, double-blind trial included 40 adult patients scheduled for elective open or laparoscopic colectomy. Patients undergoing open colectomy as well as patients undergoing laparoscopic colectomy were randomly allocated into two groups: the ESPB group (n = 20) and the control group (n = 20). All patients received preoperatively ultrasound-guided, bilateral ESPB with placement of catheters for continuous infusion. Patients in the ESPB group received 0.375% ropivacaine, while patients in the control group received sham blocks. All patients received standardized general anesthesia and multimodal postoperative analgesia. Pain scores, perioperative opioid consumption, and perioperative outcomes were assessed. Patients in the ESPB group required significantly less intraoperative (p < 0.001 for open colectomies, p = 0.002 for laparoscopic colectomies) and postoperative opioids (p < 0.001 for open colectomies, p = 0.002 for laparoscopic colectomies) and had higher quality of recovery scores on the third postoperative day (p = 0.002 for open and laparoscopic colectomies). Patients in the ESPB group did not exhibit lower postoperative pain scores compared to those in the control group (p > 0.05 at various time points), while patients in both groups reported comparable satisfaction scores with their perioperative pain management (p = 0.061 for open colectomies, and p = 0.078 in laparoscopic colectomies). No complications were reported. ESPB is a novel and effective strategy in reducing perioperative opioid consumption in patients undergoing colectomy. This technique, as part of a multimodal analgesic plan and enhanced recovery after surgery protocols, can be proven valuable in improving the comfort and satisfaction of patients undergoing colorectal surgery.

Two case reports of mesenteric and retroperitoneal actinomycosis and a narrative review of the relevant literature.

Introduction: Actinomycosis is an uncommon subacute or chronic suppurative bacterial granulomatous infectious disease with clinical heterogeneity. The majority of actinomycosis cases were of extra-abdominal origin, with oro-cervico-facial cases representing 55%, abdominopelvic representing 20%, and thoracic representing 15% of total reports. Currently, abdominal actinomycosis incidence is approximately 1 case per 119,000 people, being found three times more frequently among males. We report two rare clinical presentations of abdominal actinomycosis affecting the mesentery and the retroperitoneum, respectively. Case Report 1: A 58-year-old Caucasian male presented to our clinic with abdominal pain in the right upper quadrant. Pre-operative evaluation, although inconclusive, showed a mesocolic mass infiltrating the right and transverse colon. The patient underwent exploratory laparotomy. After partial resection of the mass, the histopathology report demonstrated mesenteric actinomycosis. Case Report 2: A 40-year-old Caucasian male presented to our clinic complaining about a mucopurulent material from an orifice at the right inguinal region. After appropriate work-up, a large abdominopelvic, stellate mass (75 x 22.8 mm) in the retroperitoneum was revealed. Surgery along with the appropriate antibiotics was used to treat the patient. Conclusion: Preoperative suspicion and diagnosis of actinomycosis are very challenging, with a high rate of misdiagnosis often resulting in delayed treatment. Our case reports highlight that abdominal actinomycosis should always be part of differential diagnosis, especially when there is involvement of multiple organs. The gold standard treatment of actinomycosis is surgical excision with prolonged antibiotic treatment.

The Role of Adipose Tissue Mesenchymal Stem Cells in Colonic Anastomosis Healing in Inflammatory Bowel Disease: Experimental Study in Rats.

(1) Background: A surgical operation on an inflamed bowel is, diachronically, a challenge for the surgeon, especially for patients with inflammatory bowel disease. Adipose tissue-derived mesenchymal stromal cells are already in use in clinical settings for their anti-inflammatory properties. The rationale of the current study was to use AdMSCs in high-risk anastomoses to monitor if they attenuate inflammation and prevent anastomotic leak. (2) Methods: a total of 4 groups of rats were subjected to a surgical transection of the large intestine and primary anastomosis. In two groups, DSS 5% was administered for 7 days prior to the procedure, to induce acute intestinal inflammation. After the anastomosis, 5 × 106 autologous AdMSCs or an acellular solution was injected locally. Macroscopic evaluation, bursting pressure, hydroxyproline, and inflammatory cytokine expression were the parameters measured on the 8th post-operative day. (3) Results: Significantly less intra-abdominal complications, higher bursting pressures, and a decrease in pro-inflammatory markers were found in the groups that received AdMSCs. No difference in VEGF expression was observed on the 8th post-operative day. (4) Conclusions: AdMSCs attenuate inflammation in cases of acutely inflamed anastomosis.

Supramalleolar osteotomies for ankle arthritis: a systematic review.

INTRODUCTION: We investigated the mid-term outcomes of supramalleolar osteotomies regarding "survivorship" [before ankle arthrodesis (AA) or total ankle replacement (TAR)], complication rate and adjuvant procedures required. MATERIAL AND METHODS: PubMed, Cochrane and Trip Medical Database were searched from January 01, 2000. Studies reporting on SMOs for ankle arthritis, in minimum of 20 patients aged 17 or older, followed for a minimum of two years, were included. Quality assessment was performed with the Modified Coleman Methodology Score (MCMS). A subgroup analysis of varus/valgus ankles was performed. RESULTS: Sixteen studies met the inclusion criteria, with 866 SMOs in 851 patients. Mean age of patients was 53.6 (range 17-79) years, and mean follow-up was 49.1 (range 8-168) months. Of the arthritic ankles (646 ankles), 11.1% were classified as Takakura stage I, 24.0% as stage II, 59.9% as stage III and 5.0% as stage IV. The overall MCMS was 55.2 ± 9.6 (fair). Eleven studies (657 SMOs) reported on "survivorship" of SMO, before arthrodesis (2.7%), or total ankle replacement (TAR) (5.8%) was required. Patients required AA after an average of 44.6 (range 7-156) months, and TAR after 36.71 (range 7-152) months. Hardware removal was required in 1.9% and revision in 4.4% of 777 SMOs. Mean AOFAS score was 51.8 preoperatively, improving to 79.1 postoperatively. Mean VAS was 6.5 preoperatively and improved to 2.1 postoperatively. Complications were reported in 5.7% (44 out of 777 SMOs). Soft tissue procedures were performed in 41.0% (310 out of 756 SMOs), whereas concomitant osseous procedures were performed in 59.0% (446 out of 756 SMOs). SMOs performed for valgus ankles failed in 11.1% of patients, vs 5.6% in varus ankles (p < 0.05), with disparity between the different studies. CONCLUSIONS: SMOs combined with adjuvant, osseous and soft tissue, procedures, were performed mostly for arthritic ankles of stage II and III, according to the Takakura classification and offered functional improvement with low complication rate. Approximately, 10% of SMOs failed and patients required AA or TAR, after an average of just over 4 years (50.5 months) after the index surgery. It is debatable whether varus and valgus ankles treated with SMO reveal different success rates.

Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome.

PURPOSE: Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation. METHODS: Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months. RESULTS: The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.). CONCLUSION: Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome. LEVEL OF EVIDENCE: Level II.

Anaplastic testicular seminoma presenting as a hydrocele, in a 36-year-old patient with a family history of anaplastic seminoma.

Testicular cancer is the solid tumor with the greatest incidence in men between 15 and 44 years old. Its main histological type is germ cell tumor, that is divided into seminomatous and non-seminomatous tumors. Seminoma, consisting 55% of testicular cancer, manifests in the fourth decade of men's life and a rare type of it is the anaplastic seminoma (5% to 15% of testicular seminoma). Diagnosis is based on clinical examination, testicular ultrasound, magnetic resonance imaging, tumor markers measurement and pathological examination, while treatment of choice is radical orchiectomy, with or without retroperitoneal lymphadenectomy, potentially followed by radiotherapy or chemotherapy. We present the case of a 36-year-old male patient, whose father suffered from anaplastic seminoma and visited the hospital due to a painless hydrocele. The testicle was swollen and hard on palpation, while cytological examination of the drained fluid detected neoplasm, potentially seminoma. Tumor markers measurement, as well as abdominal and pelvic computerized tomography scans, were evaluated and the patient was staged as IIA, according to the American Joint Commission on Cancer. Radical orchiectomy with high ligation of the seminal vesicle was performed and the pathological examination showed anaplastic testicular seminoma. Postoperatively, four cycles of chemotherapy with bleomycin, etoposide and platinum (BEP) were performed and no signs of recurrence were present after 1 year. In conclusion, anaplastic seminoma has a good prognosis and is suggested to be treated with radical orchiectomy, with or without retroperitoneal lymphadenectomy, potentially followed by radiotherapy or chemotherapy.

Amyand's Hernia as a Random Finding in Acute Abdominal Pain and the Role of Thorough Investigation: a Case Report.

Objective:Amyand's hernia is a rare clinical entity, in which the sac of an inguinal hernia contains the appendix. Its incidence is less than 1% of all inguinal hernia cases. Clinical presentation is not specific and can mislead clinical suspicion towards inguinal hernia incarceration. Different classifications have been proposed, with significant importance for the surgical management plan. The main factors to take into consideration include hernia sac content and macroscopic appearance of the appendix, intra-abdominal inflammation, the possibility of hernia recurrence, and patient's general situation and comorbidities. Materials and methods: A 60-year-old male patient with previous history of tension-free right inguinal hernia repair with mesh and cholelithiasis presented to the Emergency Department complaining of acute abdominal pain localized at the right lumbar and right iliac region and a right groin easily reducible mass. The patient had an abdominal CT performed 48 hours ago that revealed cholelithiasis and a recurrent right inguinal hernia containing the appendix. Because of the consistent pain in the right abdomen despite the easily reducible hernia, a high suspicion of a coexisting pathology was raised and a new abdominal CT scan with intravenous and per os contrast agent was ordered. The latter showed an Amyand's hernia and cholelithiasis, but also detected lithiasis of the right ureter with upstream dilatation as the main cause of abdominal pain. Results:The patient was subsequently treated with ureteral stent placement and the following day laparoscopic hernia repair with a transabdominal preperitoneal (TAPP) approach and cholecystectomy were performed. The patient was discharged from hospital on the second postoperative day without complications. Conclusion:Surgeons should be aware of different types of Amyand's hernia and have to include this entity in the differential diagnosis of right iliac fossa abdominal pain combined with a groin mass to avoid intraoperative complications and suboptimal management. It is equally important, though, to exclude other causes of abdominal pain. This case report reviews a rare entity of right inguinal hernia recurrence presenting as Amyand's hernia during the investigation of right abdominal and iliac fossa pain, that was finally attributed to ureteric colic. Special attention should be given to the thorough investigation of abdominal pain causes.

Neuroprotective effect of Src kinase in hypoxia-ischemia: A systematic review.

Background: Hypoxic-ischemic encephalopathy (HIE) is a major cause of neonatal morbidity and mortality worldwide. While the application of therapeutic hypothermia has improved neurodevelopmental outcomes for some survivors of HIE, this lone treatment option is only available to a subset of affected neonates. Src kinase, an enzyme central to the apoptotic cascade, is a potential pharmacologic target to preserve typical brain development after HIE. Here, we present evidence of the neuroprotective effects of targeting Src kinase in preclinical models of HIE. Methods: We performed a comprehensive literature search using the National Library of Medicine's MEDLINE database to compile studies examining the impact of Src kinase regulation on neurodevelopment in animal models. Each eligible study was assessed for bias. Results: Twenty studies met the inclusion criteria, and most studies had an intermediate risk for bias. Together, these studies showed that targeting Src kinase resulted in a neuroprotective effect as assessed by neuropathology, enzymatic activity, and neurobehavioral outcomes. Conclusion: Src kinase is an effective neuroprotective target in the setting of acute hypoxic injury. Src kinase inhibition triggers multiple signaling pathways of the sub-membranous focal adhesions and the nucleus, resulting in modulation of calcium signaling and prevention of cell death. Despite the significant heterogeneity of the research studies that we examined, the available evidence can serve as proof-of-concept for further studies on this promising therapeutic strategy.

Hemobilia Caused by Arterioportal Fistula Following Percutaneous Liver Biopsy Complicated by Acute Cholecystitis and Review of the Literature.

We present a case of a 44-year-old male with chronic hepatitis B that visited the Emergency Department due to epigastric pain after a liver biopsy. The ultrasonography revealed signs of bleeding in the bile ducts. and angiography visualized an arterioportal fistula. Selective right hepatic artery branch embolization was performed, and the bleeding was controlled. Although, the clinical picture was initially improved, the patient presented later with acute abdomen, obstructive jaundice and fever. The patient underwent cholecystectomy with bile duct exploration and placement of a Kehr's T tube in the common bile duct. The postoperative course was uneventful. We also review the relevant literature concerning arterioportal fistula manifested as hemobilia as well as acute cholecystitis occurring after hemobilia.

The Effect of Ultrasound-guided Bilateral Erector Spinae Plane Block With and Without Dexmedetomidine on Intraoperative and Postoperative Pain in Laparoscopic Cholecystectomies: A Randomized, Controlled, Double-blind, Prospective Trial.

BACKGROUND: Laparoscopic cholecystectomy is the most common surgical procedure performed in the Western world. While it is performed with minimally invasive procedures, patients often complain of moderate to severe postoperative pain, and the role of the anesthesiologist for its effective management remains crucial. Modern anesthesiology practices have embraced trunk blocks which can contribute to perioperative, multimodal analgesia. There is emerging literature about the favorable effect of erector spinae plane block in the reduction of pain after laparoscopic cholecystectomy. OBJECTIVE: The aim of this study was to explore the efficacy of preoperative bilateral erector spinae plane block when dexmedetomidine is added in the local anesthetic mixture in patients undergoing elective laparoscopic cholecystectomy. STUDY DESIGN: This study is a double-blind, randomized, controlled, prospective study. SETTING: Georgios Papanikolaou General Hospital of Thessaloniki, Greece. METHODS: After Local Ethics Committee approval (No: 1146/7.10.2019, October 2019) and in accordance with the principles outlined in the Declaration of Helsinki, the study was submitted to clinicaltrials.gov with reference number: NCT04587973. Sixty patients were randomized into 3 equal groups. Erector spinae plane block was performed in Group C with normal saline (N/S) 0.9%, in Group DR with ropivacaine 0.375% and dexmedetomidine 1 mcg/kg, and in Group R with ropivacaine 0.375%. The perioperative opioid consumption, pain intensity, time of first mobilization, hospitalization days, and satisfaction score of patients were recorded. Statistical analysis was performed with ANOVA, Kruskal-Wallis and Spearman test, as appropriate. RESULTS: The perioperative opioid consumption was significantly lower in Groups R and DR as compared to Group C (P < 0.001). The median numerical rating scale (NRS) scores of patients at all time points were statistically different between Groups C and DR, as well as between groups C and R. Satisfaction score was significantly higher in Group DR as compared to Group C (P < 0.001), and mobilization time was significantly shorter in group DR in comparison to Group C as well as in Group R as compared to Group C (P = 0.015 and P = 0.035, respectively). Intraoperative remifentanil consumption was lower in Group DR in comparison to Group R (P < 0.001). There was no difference in postoperative nausea and vomiting and duration of hospital stay of patients. LIMITATIONS: The limitation of the study is the small sample size of the patients recruited, which may be the reason why no statistically significant differences were found in postoperative morphine consumption and postoperative NRS scores between Groups R and DR and in postoperative nausea and vomiting among the 3 groups. CONCLUSION: Erector spinae plane block performed either with ropivacaine or with a combination of ropivacaine and dexmedetomidine is a novel and safe method, which was found to be more effective compared to standard analgesia protocols in patients undergoing laparoscopic cholecystectomy and thus, it can improve the quality of perioperative analgesia.

The feasibility and effect of intraperitoneal administration of regorafenib on peritoneal carcinomatosis from colorectal cancer in the rat.

AIM: Our goal was to investigate the potential use and efficacy of regorafenib for IPEC in an animal model of colorectal derived peritoneal metastases. Twenty four male rats were included. Carcinogenesis was induced in all rats through intraperitoneal injection of cancer. MATERIAL AND METHODS: Cells at T0. At T1(Day 28) they were randomly allocated 1:1:1:1 into 4 groups and underwent median laparotomy and the corresponding intervention. Specifically, Group A: no other intervention; Group B: cytoreductive surgery; Group C: intraperitoneal chemotherapy with regorafenib; and Group D: cytoreductive surgery and intraperitoneal chemotherapy with regorafenib. At T2 (Day 56) rats were euthanized and laparotomy was performed for further investigation. The primary outcome was the experimental Peritoneal Cancer Index (ePCI) at T2. Secondary outcomes include relative change of body weight between T1 and T2, weight of the ascites, anastomotic leak/peritonitis and death. RESULTS: The ePCI was significantly lower in Group D as opposed to all other groups. Comparing Group C versus Group A we found a trend towards lesser tumor progression, but no significant difference. Growth of rats in Group D was significantly least affected compared to all other groups. Animals undergoing CRS in Group B developed less ascites than Group A and C. Less ascites was found in Group D compared to Group A and C. CONCLUSIONS: Intraperitoneal chemotherapy with regorafenib combined with cytoreductive surgery may impair metastases' progression. KEY WORDS: Regorafenib, Chemotherapy, Cytoreductive surgery, Colorectal cancer, Intraperitoneal injection.

The Influence of Smoking on Healing of Scaphoid Non-union after a Vascularized Pedicle Bone Flap Operation: A Review and Meta-analysis.

Background: The purpose of this study is to compare the vascularized bone flaps (VBF) that are used in operations for scaphoid non-union in smokers and non-smokers and to scrutinize if the better biological potential of the VBFs can counteract the negative influence of smoking on healing. Materials and Methods: Our study included articles published until 2016, with scaphoid non-union patients who were operated on with a VBF or a VBG. Results: Eighteen articles met eligibility criteria with 335 non-smokers and 136 smokers totally. Healing of the scaphoid non-union was significantly more probable in the non-smoking group (OR=5.54, p<0.001). Patients with avascular necrosis in the proximal pole of the scaphoid (AVNPP) and non-AVNPP showed that non-smoking favors a better healing rate in both of these subgroups (p<0.001 and p<0.001, respectively). Non-smokers have 11 times and the non-AVNPP patient's 7.7 times greater probability of healing of the non-union. Meta-analysis of the data for time for healing showed a longer time in the smokers' group by 2.46 weeks, though non-statistically significant. The analysis could not prove that smoking is a predisposing factor for the development of AVNPP (spearman=0.094, p<0.05). Despite that, preoperative smoking cessation proved to be an inadequate healing moderator (OR=3.5, p=0.268). Finally, VBFs showed a significantly better healing rate compared with nVBGs in smokers (p=0.001). Conclusions: A hand surgeon should always take into consideration that smoking negatively influences the healing potential of a scaphoid non-union despite the theoretically superior biological background that VBFs offer. In patients who refuse to quit smoking, a VBF may be considered a better choice than a conventional graft.

Necrotizing Fasciitis of the Upper Extremity - A Review.

Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.

Total hip arthroplasty for an intracapsular femoral neck fracture of high-femoral amputee.

Femoral neck fractures in transfemoral amputees are not common and management is associated with surgical technique and post-operative rehabilitation challenges. A 61-year-old Caucasian, male, above-knee amputee (following mangled extremity trauma 8 months before) who mobilized with a prosthesis presented to the emergency department with a right femoral neck fracture (Garden III). The patient underwent cementless total hip replacement (THR), using the lateral (Hardinge's) approach. No additional instrument was used to manipulate the residual femoral stump. The absence of the distal limb required careful preparation of the femoral canal, taking into consideration the position of the lesser trochanter, in order to appropriately align the femoral prosthesis regarding anteversion. Postoperative recovery was uneventful. Six months later, the patient was ambulating using his prothesis and had almost returned to his pre-injury activity status. Satisfactory results can be obtained after THR in trans-femoral amputees.

The Influence of Smoking on Healing of Scaphoid Non-union after a Vascularized Pedicle Bone Flap Operation: A Review and Meta-analysis.

Background: The purpose of this study is to compare the vascularized bone flaps (VBF) that are used in operations for scaphoid non-union in smokers and non-smokers and to scrutinize if the better biological potential of the VBFs can counteract the negative influence of smoking on healing. Materials and Methods: Our study included articles published until 2016, with scaphoid non-union patients who were operated on with a VBF or a VBG. Results: Eighteen articles met eligibility criteria with 335 non-smokers and 136 smokers totally. Healing of the scaphoid non-union was significantly more probable in the non-smoking group (OR=5.54, p<0.001). Patients with avascular necrosis in the proximal pole of the scaphoid (AVNPP) and non-AVNPP showed that non-smoking favors a better healing rate in both of these subgroups (p<0.001 and p<0.001, respectively). Non-smokers have 11 times and the non-AVNPP patient's 7.7 times greater probability of healing of the non-union. Meta-analysis of the data for time for healing showed a longer time in the smokers' group by 2.46 weeks, though non-statistically significant. The analysis could not prove that smoking is a predisposing factor for the development of AVNPP (spearman=0.094, p<0.05). Despite that, preoperative smoking cessation proved to be an inadequate healing moderator (OR=3.5, p=0.268). Finally, VBFs showed a significantly better healing rate compared with nVBGs in smokers (p=0.001). Conclusions: A hand surgeon should always take into consideration that smoking negatively influences the healing potential of a scaphoid non-union despite the theoretically superior biological background that VBFs offer. In patients who refuse to quit smoking, a VBF may be considered a better choice than a conventional graft.