Observation Safely Reduces the Use of the Computerized Tomography in Medium-to-Low-Risk Patients with Suspected Acute Appendicitis: Results of a Randomized Controlled Trial.

Objectives-The objective was to compare the effectiveness of observation in standard-of-care computed tomography (CT) in adult patients with suspected acute appendicitis (AA). Methods-Patients with clinically suspected AA and inconclusive diagnosis after primary clinical examination, laboratory examination, and transabdominal ultrasound (TUS) were eligible for the study, and they were randomized (1:1) to parallel groups: observation-group patients were observed for 8-12 h and then, repeated clinical and laboratory examinations and TUS were performed; CT group (control group) patients underwent abdominopelvic CT scan. The study utilized Statistical Analysis System 9.2 for data analysis, including tests, logistic regression, ROC analysis, and significance evaluation. Patients were enrolled in the study at Vilnius University Hospital Santaros Klinikos in Lithuania between December 2018 and June 2021. Results-A total of 160 patients (59 men, 101 women), with a mean age of 33.7 ± 14.71, were included, with 80 patients in each group. Observation resulted in a reduced likelihood of a CT scan compared with the CT group (36.3% vs. 100% p < 0.05). One diagnostic laparoscopy was performed in the observation group; there were no cases of negative appendectomy (NA) in the CT group. Both conditional CT and observation pathways resulted in high sensitivity and specificity (97.7% and 94.6% vs. 96.7% and 95.8%). Conclusions-Observation including the repeated evaluation of laboratory results and TUS significantly reduces the number of CT scans without increasing NA numbers or the number of complicated cases.

Ultrasound-guided percutaneous laser ablation for papillary thyroid microcarcinoma: a literature review.

The incidence of papillary thyroid microcarcinoma has been increasing worldwide. However, the optimal management strategy remains a topic of discussion and varies from an active follow-up to a thyroidectomy. New thermoablation techniques for selected cases seem to be sufficiently effective but minimally invasive. One of the newest thermoablation methods is ultrasound-guided percutaneous laser ablation. There are already some data showing promising results of this method in the management of papillary thyroid microcarcinomas. In this article, we review recent papers and conclude on the current status of the ultrasound-guided percutaneous laser ablation technique for the management of papillary thyroid microcarcinomas.

High-grade well-differentiated neuroendocrine tumour of the cecum diagnosed following incisional hernia repair: a case report.

High-grade well-differentiated neuroendocrine tumour tumours (NETs) of gastrointestinal tract are rare; they can arise in any part of the digestive system and usually present in advanced stages. Low incidence and wide heterogeneity in the biological behaviour of such lesions pose a diagnostic and therapeutic challenge. Loco-regional NETs should be resected whenever feasible, potentially with a curative intent. Management of a metastatic disease is often more complex, primarily aimed at the alleviation of symptoms, prevention of further complications, and prolongation of survival. Current literature describing the optimal treatment plan for such patients is sparse and further studies are necessary to enhance our understanding of the disease. Here we present a case of high-grade well-differentiated cecal NET with an associated carcinoid syndrome that was diagnosed following the incisional hernia repair.

Significance of BRAF V600E Mutation and Cytomorphological Features for the Optimization of Papillary Thyroid Cancer Diagnostics in Cytologically Indeterminate Thyroid Nodules.

BACKGROUND: Ultrasound guided fine needle aspiration biopsy with cytologic analysis is an initial step in diagnostic of thyroid nodules. Unfortunately, up to 30% of biopsies are indeterminate and diagnostic surgery is required. The aim of this study was to estimate the diagnostic value of BRAF V600E mutation status combined with cytomorphological features for diagnosis of papillary thyroid cancer (PTC) in cytologically indeterminate thyroid nodules. METHODS: A prospective study analyzed patients who had ultrasound suspicious thyroid nodules, underwent fine needle aspiration and cytological examination, and were classified according to the Bethesda system. Patients from indeterminate diagnostic categories were examined for BRAF V600E mutation and 22 cytomorphological features, and underwent thyroid surgery. A binary logistic regression model was used to evaluate the diagnostic utility. RESULTS: A total of 219 patients met study criteria. After histological examination, 77 (35.2%) patients were diagnosed with PTC and 142 (64.8%) with benign nodular thyroid disease. According to logistic regression model, significant features for PTC diagnosis were: liquid colloid consistency, papillary structures, eosinophilic colloid bodies, and BRAF V600E mutation. Risk groups classified by this model have sensitivity of 80.5% (95% CI: 69.9 to 88.7), specificity of 99.3% (95% CI: 96.1 to 100), positive predictive value of 98.4% (95% CI: 89.8 to 99.8), negative predictive value of 90.4% (95% CI: 85.7 to 93.7), and accuracy of 92.7% (95% CI: 88.4 to 95.8) for PTC diagnosis. CONCLUSIONS: Evaluation of BRAF V600E mutation status combined with cytomorphological features for diagnosis of PTC in cytologically indeterminate thyroid nodules can significantly improve diagnostic accuracy and reduce the number of diagnostic operations (calculator available at www.ptc-calc.we2host.lt).

Laparoscopic distal resection of the pancreas. Can be all resections of body and tail of the pancreas called the same?

INTRODUCTION: Distal resection of the pancreas is a routine procedure in high-volume centres. However, the volume of this procedure can vary. This variation plays a very important role in laparoscopic approach of pancreatic surgery and can be a real challenge if the anatomical situation is underestimated. AIM OF THE STUDY: To present our experience in minimally invasive treatment of the pancreatic tumours and to discuss different approaches to different anatomical situations. MATERIAL AND METHODS: We performed a retrospective analysis of patients, who underwent laparoscopic pancreas resection for pancreatic cancer in our hospital since 2014 to 2016 February. According to extension of operation, patients were divided into two groups: distal pancreatectomy and left hemipancreatectomy for cases that required preparation of the portal vein. Demographic characteristics, and operative and postoperative data were compared between both groups. RESULTS: Out of 16 patients, distal pancreatectomy was performed for 7 (43.8%) and left hemipancreatectomy for 9 (56.2%) patients. For 1 (14.3%) laparoscopic distal pancreatectomy and for 2 (22.2%) laparoscopic left hemipancreatectomy patients surgical conversion to laparotomy was performed. The average operation time was 205 (195-245) min for distal pancreatectomy and 412.5 (280-520) min for left hemipancreatectomy group (p = 0.001), blood loss 125 (20-250) ml and 250 (50-1800) ml accordingly (p = 0.138). Totally postoperative fistula occurred in 7 (43.8%) cases; out of them, 5 (71.4%) patients were from the left hemipancreatectomy group. CONCLUSIONS: Laparoscopic left hemipancreatectomy is more complicated than distal pancreatectomy. Extension and technique selection of distal resection of the pancreas depends on the Yonsei criteria and tumour relation to the portal vein.

The utility of the Bethesda category and its association with BRAF mutation in the prediction of papillary thyroid cancer stage.

PURPOSE: This study aims to determine the utility of the Bethesda category and its association with BRAF mutation in prediction of the papillary thyroid cancer (PTC) stage. METHODS: A prospective study analyzed patients who had ultrasound-suspicious thyroid nodules, underwent FNA and cytological examination, and were classified according to the Bethesda system. Patients from Undetermined Significance Or Follicular Lesion Of Undetermined Significance (AUS/FLUS), Follicular Neoplasm or Suspicious for a Follicular Neoplasm (FN/SFN), Suspicious for Malignant Cells (SMC), and Positive for Malignant Cells (PMC) groups were examined for the BRAF mutation and had a thyroid surgery. Demographical and histological features and stage of the disease were evaluated for PTC patients in accordance with the Bethesda category and its association with BRAF mutation. RESULTS: Three hundred eight of all patients underwent operation. One hundred forty-three (46.4%) of them were diagnosed with PTC. In 14 (9.8%) PTC cases, FNA biopsies were classified as AUS/FLUS, 23 (16.1%) as FN/SFN, 41 (28.7%) as SMC, and 65 (45.5%) as PMC. I-II stages of PTC were diagnosed for 88 (61.5%) patients and III-IVA for 55 (38.5%). Patients from the SMC and PMC groups had larger tumors, higher incidence of lymph node metastases, classical PTC type, B-type Raf (BRAF) positive, and III-IVA stage cancer, than patients from the AUS/FLUS and FN/SFN groups. When comparing 27 (18.9%) BRAF-negative patients from the AUS/FLUS and FN/SFN groups with 116 (81.1%) BRAF-negative patients from the SMC and PMC groups and all BRAF-positive patients, the prediction of more aggressive histological features and stage was slightly improved. CONCLUSIONS: Higher Bethesda categories are associated with higher stages of PTC. Association of the Bethesda category with BRAF mutation can slightly improve the value of stage prediction.

Laparoscopic approach in the treatment of large leiomyoma of the lower third of the esophagus.

Leiomyoma of the lower third of the esophagus is a relatively rare disorder but the most common benign tumor of the esophagus. We present a case of an involuted esophageal leiomyoma, 11 cm in size, treated by the laparoscopic approach. The preoperative computed tomogram visualized a mass 3 × 1.5 cm in diameter in the lower esophagus without an eccentric lumen or compression of nearby organs. Resection of the tumor was indicated according to the patient's symptoms and to exclude malignancy. Laparoscopic enucleation of esophageal leiomyoma was performed. The overall operative time was 205 min. The diagnosis of leiomyoma was established on histopathology and immunohistochemistry staining. The patient resumed the intake of a normal diet on the 5th postoperative day and was discharged from hospital 8 days after the surgery. We have found this minimally invasive operation to be an effective and well-tolerated treatment option, determined by the experience of the surgeon.

The value of the repeated examination of BRAF V600E mutation status in diagnostics of papillary thyroid cancer.

INTRODUCTION: Nodular thyroid disease is one of the most frequently diagnosed pathologies of the adult population in iodine-deficient regions. Approximately 30% of thyroid aspirates are classified as nondiagnostic/unsatisfactory or indeterminate. However, patients with indeterminate cytology still undergo surgery. The object of this study was to determine the diagnostic value of re-examining the BRAF V600E mutation in papillary thyroid carcinoma patients. MATERIAL AND METHODS: All patients underwent ultrasound guided fine-needle aspiration of a thyroid nodule. They were assigned to one of the four groups (indeterminate or positive for malignant cells) of the Bethesda System for Reporting Thyroid Cytopathology. Genetic investigation of the BRAF V600E mutation was performed for all of the fine-needle aspiration cytology specimens. All of the patients underwent surgery. Subsequently, histological investigation of the removed tissues was performed. Additional analysis of the BRAF V600E mutation from the histology specimen was then performed for the initially BRAF-negative cases. RESULTS: Two hundred and fourteen patients were involved in the study. One hundred and six (49.53%) patients were diagnosed with thyroid cancer. Of these 106 patients, 95 (89.62%) patients were diagnosed with papillary thyroid cancer. The BRAF V600E mutation was positive in 62 (65.26%) and negative in 33 (34.74%) histologically confirmed papillary thyroid cancer cases. After the genetic investigation, a total of 74 (77.89%) papillary thyroid cancer cases were positive for the BRAF V600E mutation and 21 (22.11%) were negative. CONCLUSIONS: Repeated examination of the BRAF V600E mutation status in the fine-needle aspiration may potentially increase the sensitivity of papillary thyroid cancer diagnostics.

Laparoscopic approach in the treatment of large epiphrenic esophageal diverticulum.

Epiphrenic diverticulum of the lower third of the esophagus is a relatively rare disorder. We present the case of a large, 7.5 cm diameter esophageal epiphrenic diverticulum treated by the laparoscopic approach. Surgery was indicated by the severity of the patient's symptoms and size of the diverticulum. A laparoscopic transhiatal diverticulectomy with a myotomy and Dor fundoplication was carried out. The overall operative time was 180 min. The patient tolerated the surgery well and was discharged from hospital 4 days after the surgery. From the 10(th) postoperative day the patient resumed a regular diet. Four weeks after the operation the patient had no complaints, symptoms of dysphagia or vomiting. The laparoscopic approach in the treatment of a large, 7.5 cm epiphrenic diverticulum of the esophagus is feasible, safe and well tolerated by the patient.

Minimally invasive management of pancreatic pseudocysts.

INTRODUCTION: The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PP) are the current minimally invasive management options. Indications, and early and late results of endoscopic and laparoscopic approaches are being discussed. AIM: To present experience in treatment of PP by laparoscopic pseudocystogastrostomy (LPGS) and endoscopic pseudocystogastrostomy (EPGS) and to compare results, feasibility and safety. MATERIAL AND METHODS: THIRTY PATIENTS UNDERWENT SURGICAL INTERVENTION: 18 patients - LPGS (group I), 12 - EPGS (group II). Groups were compared by age, gender, pancreatic pseudocysts's age, diameter and localization, as well as intraoperative, early and late postoperative complications. RESULTS: GENDER DISTRIBUTION, GROUP I: 14 (77.8%) men and 4 (22.2%) women, group II: 4 (33.3%) men and 8 (66.7%) women, p = 0.02. Average cyst diameter: group I - 149.9 ±52.1 mm, group II - 119 ±37.9 mm, p = 0.07. Average time between diagnosis and operation performance: group I - 12 (3-60) months, group II - 8 (2-36) months, p = 0.19. Neither in group I nor in group II did intraoperative complications occur. Early postoperative complications were divided into minor and major. Early minor complications: group I - 2 (11.1%), group II - 0, p = 0.5. Early major complications: group I - 0, group II - 2 (16.7%), p = 0.15. Late postoperative complications: group I - 0, group II - 1 (8.3%), p = 0.4. In group I there was no case, whereas in II group there was 1 (8.3%) case of recidivation, p = 0.4. CONCLUSIONS: For selected patients both minimally invasive methods are equally safe an effective. For comprehensive evaluation of methods prospective trials are needed.

Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis.

INTRODUCTION: One of the most important requirements in treatment of acute necrotizing pancreatitis is minimized invasion. AIM: We are presenting experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, comparing our results to other studies, evaluating feasibility and safety, discussing advantages and disadvantages of this method. MATERIAL AND METHODS: We performed a retrospective analysis of 13 patients who had acute necrotizing pancreatitis with large fluid collections in retroperitoneal space and underwent retroperitoneal necrosectomy. RESULTS: There were eight males and three females aged between 24 and 60 years, average age was 42.8 ±9.2 years. The most common cause of pancreatitis was alcohol, 10 patients (76.9%). Average time between diagnosis and performance of operation was 25.7 ±11.3 days. One patient underwent eight repeated interventions: two retroperitoneal necrosectomies; five laparotomies; ultrasound-guided drainage. One patient underwent four reinterventions: lumbotomy; revision; two lavages. Three patients had two reinterventions: one had laparotomy and tamponation; one had two repeated retroperitoneal necrosectomies; third had one repeated retroperitoneal necrosectomy and one had ultrasound-guided drainage. Three patients needed one additional retroperitoneal necrosectomy. Five patients did not required additional interventions. 61.5% of our patients did not require more than one reintervention. Postoperative stay varied from 9 to 94 days, average 50.8 ±32.6 days. CONCLUSIONS: Minimally invasive techniques should be considered as first-choice surgical option in treating patients with acute necrotizing pancreatitis. Pancreatic necrosis occupying less than 30% and with massive fluid collections in the left retroperitoneal space can be safely managed by minimally invasive retroperitoneal necrosectomy.