Small Bowel Diverticulosis and COVID-19: Awareness Is the Key: A Case Series and Review of the Literature.

Small bowel non-Meckelian diverticulosis is a rare condition with only a few published cases despite being described over 200 years ago. In the midst of the COVID-19 pandemic, studies suggested that many patients may experience gastrointestinal manifestations. Intestinal symptoms could worsen the inflammation and infection associated with small bowel diverticulitis. Here we present three cases: one with inflammation and rupture in a COVID-19 patient and another as an asymptomatic detection. The third case involved recurrence after the first laparoscopic lavage approach. Furthermore, we provide a mini-review of the literature to emphasize the importance of considering this entity in the differential diagnosis of an acute abdomen. In the majority of cases involving small bowel diverticula, conservative management is the preferred approach. However, when complications arise, surgical intervention, including enteroctomy and primary anastomosis, may be necessary to achieve optimal outcomes.

Comparison between upfront surgery and neoadjuvant chemotherapy in patients with locally advanced gastric cancer: A systematic review.

BACKGROUND: Gastric cancer (GC) is a major health concern worldwide. Surgical resection and chemotherapy is the mainstay treatment for gastric carcinoma, however, the optimal approach remains unclear and should be different in each individual. Chemotherapy can be administered both pre- and postoperatively, but a multidisciplinary approach is preferred when possible. This is particularly relevant for locally advanced GC (LAGC), as neoadjuvant chemotherapy (NAT) could potentially lead to tumor downsizing thus allowing for a complete resection with curative intent. Even though the recent progress has been impressive, European and International guidelines are still controversial, thus attenuating the need for a more standardized approach in the management of locally advanced cancer. AIM: To investigate the effects of NAT on the overall survival (OS), the disease-free survival (DFS), the morbidity and the mortality of patients with LAGC in comparison to upfront surgery (US). METHODS: For this systematic review, a literature search was conducted between November and February 2023 in PubMed, Cochrane Library and clinicaltrials.gov for studies including patients with LAGC. Two independent reviewers conducted the research and extracted the data according to predetermined inclusion and exclusion criteria. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to form the search strategy and the study protocol has been registered in the International Prospective Register of Systematic Reviews. RESULTS: Eighteen studies with 4839 patients with LAGC in total were included in our systematic review. Patients were separated into two groups; one receiving NAT before the gastrectomy (NAT group) and the other undergoing upfront surgery (US group). The OS ranged from 41.6% to 74.2% in the NAT group and from 30.9% to 74% in the US group. The DFS was also longer in the NAT group and reached up to 80% in certain patients. The complications related to the chemotherapy or the surgery ranged from 6.4% to 38.1% in the NAT group and from 5% to 40.5% in the US group. Even though in most of the studies the morbidity was lower in the NAT group, a general conclusion could not be drawn as it seems to depend on multiple factors. Finally, regarding the mortality, the reported rate was higher and up to 5.3% in the US group. CONCLUSION: NAT could be beneficial for patients with LAGC as it leads to better OS and DFS than the US approach with the same or even lower complication rates. However, patients with different clinicopathological features respond differently to chemotherapy, therefore currently the treatment plan should be individualized in order to achieve optimal results.

Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience.

The median arcuate ligament syndrome (MALS) is recognized as a rare clinical entity, characterized by chronic post-prandial abdominal pain, nausea, vomiting, and unintentional weight loss. Due to its vague symptomatology, it is mainly regarded as a diagnosis of exclusion. Patients can often be misdiagnosed for several years before a correct diagnosis is established, also due to a medical team's clinical suspicion. We present a case series of two patients who suffered from MALS and were treated successfully. The first patient is a 32-year-old woman, presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years. The second patient, a 50-year-old woman, presented with similar symptomatology, with the symptoms lasting for the last five years. Both cases were treated by laparoscopic division of the median arcuate ligament fibers, which alleviated extrinsic pressure from the celiac artery. Previous cases of MALS were retrieved from PubMed, to assemble a better diagnostic algorithm and propose a treatment method of choice. The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice, along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.

Diagnostic work-up and advancement in the diagnosis of gastroenteropancreatic neuroendocrine neoplasms.

Neuroendocrine neoplasms (NENs) are a heterogeneous group of neoplasms ranging from well-differentiated, slowly growing tumors to poorly differentiated carcinomas. These tumors are generally characterized by indolent course and quite often absence of specific symptoms, thus eluding diagnosis until at an advanced stage. This underscores the importance of establishing a prompt and accurate diagnosis. The gold-standard remains histopathology. This should contain neuroendocrine-specific markers, such as chromogranin A; and also, an estimate of the proliferation by Ki-67 (or MIB-1), which is pivotal for treatment selection and prognostication. Initial work-up involves assessment of serum Chromogranin A and in selected patients gut peptide hormones. More recently, the measurement of multiple NEN-related transcripts, or the detection of circulating tumor cells enhanced our current diagnostic armamentarium and appears to supersede historical serum markers, such as Chromogranin A. Standard imaging procedures include cross-sectional imaging, either computed tomography or magnetic resonance, and are combined with somatostatin receptor scintigraphy. In particular, the advent of 111In-DTPA-octreotide and more recently PET/CT and 68Ga-DOTA-Octreotate scans revolutionized the diagnostic landscape of NENs. Likewise, FDG PET represents an invaluable asset in the management of high-grade neuroendocrine carcinomas. Lastly, endoscopy, either conventional, or more advanced modalities such as endoscopic ultrasound, capsule endoscopy and enteroscopy, are essential for the diagnosis and staging of gastroenteropancreatic neuroendocrine neoplasms and are routinely integrated in clinical practice. The complexity and variability of NENs necessitate the deep understanding of the current diagnostic strategies, which in turn assists in offering optimal patient-tailored treatment. The current review article presents the diagnostic work-up of GEP-NENs and all the recent advances in the field.

Neutrophil-to-lymphocyte ratio as a prognostic factor for survival in patients with colorectal liver metastases: A systematic review.

BACKGROUND: The inflammatory response to tumor has been proven to be closely related to the prognosis of colorectal cancer. Neutrophil to lymphocyte ratio (NLR) is a widely available inflammatory biomarker that may have prognostic value for patients with colorectal liver metastasis (CRLM). AIM: To assess the role of NLR as a prognostic factor of survival and tumor recurrence in patients with CRLM. METHODS: A systematic literature search of PubMed, Cochrane Library and clinicaltrials.gov was conducted by two independent researchers in order to minimize potential errors and bias. Conflicts were discussed and settled between three researchers. Studies including patients undergoing different types of medical interventions for the treatment of CRLM and evaluating the correlation between pretreatment NLR and disease-free survival (DFS) and overall survival (OS) were included in the review. Nineteen studies, involving 3283 patients matched our inclusion criteria. RESULTS: In the studies included, NLR was measured before the intervention and the NLR thresholds ranged between 1.9 and 7.26. Most studies used 5 as the cut-off value. Liver metastases were treated with hepatectomy with or without chemotherapy regimens in 13 studies and with radiofrequency ablation, radioembolization, chemoembolization or solely with chemotherapy in 6 studies. High NLR was associated with decreased OS and DFS after liver resection or other medical intervention. Moreover, high NLR was associated with poor chemosensitivity. On the contrary, CRLM patients with low pretreatment NLR demonstrated improved OS and DFS. NLR could potentially be used as a predictive factor of survival and tumor recurrence in patients with CRLM treated with interventions of any modality, including surgery, chemotherapy and ablative techniques. CONCLUSION: NLR is an inflammatory biomarker that demonstrates considerable prognostic value. Elevated pretreatment NLR is associated with poor OS and DFS in patients with CRLM who are submitted to different treatments.

Mental health well-being and functional adjustment in colorectal cancer patients: a prospective cohort study.

BACKGROUND: Colorectal cancer significantly affects the quality of life of patients, while at the same time contributing to the development of symptoms of psychopathology. The aim of this prospective study, is to investigate the role of the disease in the quality of life of patients with colon cancer and in the appearance of symptoms of anxiety and depression, as well as the connection of the above characteristics during the recovery process, given the distress symptoms experienced by the patients. METHODS: In the present study, HADS, FACT - C, well as the DT are use, in a sample of 118 patients of an average age of 70.5 ± 8.5 years, which were submitted to partial or total colectomy surgery. RESULTS: Moderate levels of anxiety (M = 8.25, SD = 3.87) and low levels of depression (M = 6.90, SD = 2.97) and distress (M = 5.84, SD = 2.60) emerged preoperatively, while the improvement was significant of patients' quality of life level 6 months after surgery. At the same time, a significant negative effect of the patients' distress level preoperatively on their quality of life, during the recovery process was observed. CONCLUSION: Preoperative anxiety is not considered to be an element that affects the functionality and the psychological and physical adaptation to the disease of patients with colon cancer. On the contrary, the feelings of distress they experience can be a predictive factor of their quality of life after the partial or total colectomy surgery.

Management of Hepatocellular Carcinoma in the Era of Individualized Therapy: The Experience of a Greek Tertiary Center.

Background: The treatment of hepatocellular carcinoma (HCC) in the era of individualized therapy mandates a multidisciplinary approach and therefore the cooperation of physicians from multiple medical specialties. Treatment selection is based on the stage of the disease. The most prominent staging system is the Barcelona Clinic Liver Cancer (BCLC) classification system. Methods: We conducted a retrospective cohort study of patients with HCC treated in our department. Patients were originally staged based on the BCLC classification system. However, a multidisciplinary team refined the BCLC classes, using clinical data and biomarkers to tailor an individualized course of treatment. Results: The study population was 63 patients who were BCLC staged at diagnosis as follows: very early (5 patients, 7.9%), early (38 patients, 60.3%), intermediate (14 patients, 22.2%), and advanced (6 patients, 9.5%). Thirty-two patients (50.8%) were treated with surgery and 31 patients (49.2%) with locoregional treatments. The 1-year, 3-year, and 5-year survival rates in the surgery group were 81.3%, 52.9%, and 18.9%, respectively, whereas in the locoregional treatment group, the 1-year, 3-year, and 5-year survival rates were 71.0%, 38.7%, and 19.0%, respectively. The mean overall survival was 35.42 ± 23.54 months for the surgery group and 28.42 ± 23.0 months for the locoregional treatment group. In the surgery group, the mean overall survival of the patients treated with surgery alone was 26.68 ± 21.97 months compared to 48.18 ± 20.26 months for the patients treated with surgery followed by locoregional treatment for recurrence. Conclusion: In this study, patients treated with hepatic resection had higher survival rates than patients treated with locoregional treatments. However, this superiority did not reach statistical significance (P=0.426). Thus, locoregional treatments are highlighted as a valuable alternative to surgery, particularly when hepatic resection is not feasible. Finally, patients who received locoregional treatment following surgery had significantly higher survival compared to patients treated with surgery alone (P=0.038).

Prospective validation of the Emergency Surgery Score in emergency general surgery: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. METHODS: This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. RESULTS: A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). CONCLUSION: This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. LEVEL OF EVIDENCE: Prognostic study, level III.

Role of innovative 3D printing models in the management of hepatobiliary malignancies.

Three-dimensional (3D) printing has recently emerged as a new technique in various liver-related surgical fields. There are currently only a few systematic reviews that summarize the evidence of its impact. In order to construct a systematic literature review of the applications and effects of 3D printing in liver surgery, we searched the PubMed, Embase and ScienceDirect databases for relevant titles, according to the PRISMA statement guidelines. We retrieved 162 titles, of which 32 met the inclusion criteria and are reported. The leading application of 3D printing in liver surgery is for preoperative planning. 3D printing techniques seem to be beneficial for preoperative planning and educational tools, despite their cost and time requirements, but this conclusion must be confirmed by additional randomized controlled trials.

Primary malignant melanoma of the ascending colon.

Malignant gastrointestinal melanoma is usually a metastatic lesion. We report the case of a 67-year-old female patient who presented with intermittent abdominal pain, fever, rigor and diarrhoea. CT scan of the abdomen revealed a large mass at the right iliac fossa with features concerning for intra-abdominal abscess. Exploratory laparotomy confirmed the preoperative diagnosis of abscess, and a right hemicolectomy was performed. Histopathological examination of the surgical specimen was indicative of malignant melanoma, and immunohistochemical examination showed positivity to S100 protein, Melan-A, HMB-45 and vimentin. A series of postoperative clinical, laboratory and imaging examinations revealed no suspicious lesions in the skin, eye, leptomeninges or other sites. Therefore, the diagnosis of primary colonic melanoma was confirmed. Only 36 additional cases of primary colonic melanoma have been reported to date. These rare neoplasms are challenging to diagnose and usually require a multidisciplinary treatment approach, including surgery, chemotherapy and possibly immunotherapy or radiotherapy.

Condylomata acuminata within perianal fistulae tracts: report of two cases.

The commonest sights of appearance of condylomata acuminata are in the genital and anal regions. Herein we present two cases of condylomata within perianal fistulae tracts, resulting in recurrence in one case and a malignant-like tumour in the second. To our knowledge, these are the first cases reported in the literature.

Concurrent appendiceal and umbilical endometriosis: a case report and review of the literature.

INTRODUCTION: Endometriosis affects 3 to 10 percent of women of reproductive age. Most of the time it involves the pelvis; however, sites of endometriosis have been reported almost anywhere in the body. Appendiceal and primary umbilical endometriosis are considered rare loci, making accurate diagnosis elusive. Here we present the case of a 46-year-old woman with concurrent appendiceal and umbilical endometriosis. CASE PRESENTATION: A 46-year-old Greek woman presented with a large mass in the lower abdomen adhering to the surrounding organs. She reported recurrent lower abdominal and pelvic pain and the presence of a dark-blue hard nodule at the umbilicus. She had no previous medical, surgical or gynecological history. Her physical examination and laboratory test results were without any significant findings. The laparotomy revealed a fibromatose uterus adhering to the rectum and a urinary cyst and a palpable mass in the vermiform appendix. A hysterectomy and an appendectomy were performed. The umbilical mass was also excised. Pathology revealed endometriosis of the umbilicus and the appendix. The postoperative period was uneventful and she was discharged. CONCLUSIONS: Endometriosis, although rare, should always be considered in women of reproductive age, presenting with cyclic pain. The diagnosis is, most of the time, difficult and requires a high degree of clinical suspicion. The clinical doctor should be aware that endometriosis can sometimes be multifocal, thus a thorough investigation is required in all cases.