Adenocarcinoma of the third portion of the duodenum in a man with CREST syndrome

Abstract Background CREST (Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodactyly and Telangiectasias) syndrome has been rarely associated with other malignancies (lung, esophagus).This is the first report of a primary adenocarcinoma of the third portion of the duodenum in a patient with CREST syndrome. Case presentation A 54-year-old male patient with CREST syndrome presented with colicky postprandial pain of the upper abdomen, diminished food uptake and a 6-Kg-body weight loss during the previous 2 months. An ulcerative lesion in the third portion of the duodenum was revealed during duodenoscopy, with a diagnosis of adenocarcinoma on biopsy specimen histology. The patient underwent a partial pancreatoduodenectomy. No adjuvant therapy was instituted and follow-up is negative for local recurrence or metastases 21 months postoperatively. Conclusion CREST syndrome has been associated with colon cancer, gastric polyps, familial adenomatous polyposis (FAP) syndrome and Crohn's disease; however, this is the first report of a primary adenocarcinoma of the duodenum in a patient with CREST syndrome. However, any etiologic relationship remains to be further investigated.</p

Safety and effectiveness of outpatient laparoscopic cholecystectomy in a teaching hospital: a prospective study of 110 consecutive patients

Abstract Background The aim of this study was to evaluate the safety and efficacy of outpatient laparoscopic cholecystectomy (OLC) in a day surgery unit in a teaching hospital. OLC was offered to patients with symptomatic cholelithiasis who met the following established inclusion criteria: ASA (American Society of Anesthesiology) physical status classification class I and II; age: 18 - 70 years; body mass index (BMI) 2; patient acceptance and cooperation (informed consent); presence of a responsible adult to accompany the patient to his residency; patient residency in Athens. The primary study end-point was to evaluate success rates (patient discharge on the day of surgery), postoperative outcome (complications, re-admissions, morbidity and mortality) and patient satisfaction. A secondary endpoint was to evaluate its safe performance under appropriate supervision by higher surgical trainees (HSTs). Findings 110 consecutive patients, predominantly female (71%) and ASA I (89%) with a mean age 40.6 ± 8.1 years underwent an OLC. Surgery was performed by a HST in 90 patients (81.8%). A mean postoperative pain score 3.3 (range 0-6) occurred in the majority of patients and no patient presented postoperative nausea or vomiting. Discharge on the day of surgery occurred in 95 cases (86%), while an overnight admission was required for 15 patients (14%). Re-admission following hospital discharge was necessary for 2 patients (1.8%) on day 2, due to persistent pain in the umbilical trocar site. The overall rate of major (trocar site bleeding) and minor morbidity was 15.5% (17 patients). At 1 week follow-up, 94 patients (85%) were satisfied with their experience undergoing OLC, with no difference between grades of operating surgeons. Conclusions This study confirmed that OLC is clinical effective and can be performed safely in a teaching hospital by supervised HSTs.</p

Η έκφραση του συνδέτη του μορίου προγραμματισμένου κυτταρικού θανάτου PD-L1 (programmed cell death ligand-1) στον κολο-ορθικό καρκίνο

Εισαγωγή: Η εισαγωγή νέων φαρμάκων που στοχεύουν στο ανοσοποιητικό σύστημα φαίνεται να αλλάζει το τοπίο στην αντιμετώπιση του καρκίνου. Πέντε ανοσολογικά σημεία ελέγχου έχουν εντοπιστεί ως πιθανοί στόχοι της ανοσοθεραπείας: το μόριο του προγραμματισμένου κυτταρικού θανάτου PD-1 (programmed cell death), ο συνδέτης του PD-L1 (PD ligand), η πρωτεΐνη 4 σχετιζόμενη με τα κυτταροτοξικά Τ-λεμφοκύτταρα CTLA4 (cytotoxic T-lymphocyte associated protein 4), το γονίδιο ενεργοποίησης των λεμφοκυττάρων LAG-3 (lymphocyte activation gene) και η διοξυγενάση της ινδολαμίνης IDO (indoleamine 2,3-dioxygenase). Στόχος: Να μελετηθεί η έκφραση του μορίου PD-L1 σε παθολογοανατομικά δείγματα από γαστρικό και κολο-ορθικό καρκίνο. Μέθοδος: Η έκφραση του μορίου PD-L1 μετρήθηκε με ειδική ανοσοϊστοχημική μέθοδο και βαθμονομήθηκε σε ένα σύστημα τριών επιπέδων: α) έκφραση &lt; 1% (απουσία έκφρασης), β) έκφραση 1-49% (χαμηλή έκφραση) και γ) έκφραση &gt; 50% (υψηλή έκφραση). Όλα τα δείγματα γαστρικού καρκίνου ήταν αρνητικά για έκφραση του μορίου PD-L1, οπότε και δεν συμπεριλαμβάνονται στη μελέτη. Αποτελέσματα: Μελετήθηκαν 32 δείγματα ασθενών με κολο-ορθικό καρκίνο, 16 άνδρες και 16 γυναίκες, με μέση ηλικία 71,4 έτη (45-93). Ιστολογικά, τα περισσότερα νεοπλάσματα ήταν μέτριας διαφοροποίησης (24) και λιγότερα χαμηλής διαφοροποίησης (8). Η έκφραση του μορίου PD-L1 ήταν απούσα σε 21 ασθενείς (65,6%), χαμηλή σε 5 (15,6%) και υψηλή σε 6 ασθενείς (18,75%). Σε όλους τους ασθενείς με υψηλή έκφραση του PD-L1 ανευρέθηκε υψηλή μικροδορυφορική αστάθεια (MSI-high). Συμπεράσματα: Η έκφραση του μορίου PD-L1 ανευρίσκεται συνήθως αυξημένη στην υπο-ομάδα των ασθενών με κολο-ορθικό καρκίνο που έχει μικροδορυφορική αστάθεια.Introduction: The development of new therapeutic agents aiming at pathways of the immune system seem to change the treatment of several cancers. Five immune check-points have been found as possible targets of immunotherapy: the programmed cell death molecule PD-1, its ligand PD-L1, cytotoxic T-lymphocyte associated protein 4 (CTLA4), the lymphocyte activation gene (LAG-3) and indoleamine 2,3-dioxygenase (IDO). Aim: To study the expression of PD-L1 in histological specimens of gastric and colorectal cancers. Methods: The expression of PD-L1 was measured with a standardized immunohistochemical method and was categorized in three levels: a) expression &lt; 1% (absence of expression), b) expression 1-49% (low expression), and c) expression &gt; 50% (high expression). All specimens of gastric cancers were negative for expression of PD-L1 and were not included finally in this study. Results: Thirty-two (32) specimens of patients with colorectal cancer were studied, 16 males and 16 females, with a medium age of 71,4 years (45-93). Histologically, most cancers were moderately differentiated (24) and the remaining (8) were poorly differentiated. Expression of PD-L1 was absent in 21 patients (65,6%), low in 5 (15,6%) and high in 6 patients (18,75%). All patients with a high expression of PD-L1 expressed high microsatellite instability (MSI-high). Conclusion: High expression of PD-L1 is usually associated with high microsatellite instability in patients with colorectal cancer

Case of a sigmoid colon cancer with metachronous metastases to the mesorectum and the abdominal wall

Abstract Backround Sigmoid colon cancer metachronous metastases commonly occur in the liver and lungs with sporadic reports also to the spleen, stomach, thyroid gland, abdominal wall and upper urinary tract. This is a rare case of metachronous metastases invading the mesorectum and the abdominal wall. Case presentation A 72-year-old female underwent sigmoidectomy for stage I (T2N0 M0) sigmoid colon cancer in May 2008. In June 2009, an abdominal computed tomography scan revealed a tumor 2 cm in size at the lower anterior mesorectum and a second mass 2 cm in size at the anterior abdominal wall midline. Total colonoscopy showed no mucosal lesion. The serum carcinoembryonic antigen level was normal. A biopsy of the mesorectum tumor showed similar histologic characteristics with the primary tumor. Since no other site of recurrence was identified, an abdominoperineal resection was attempted. During the operation and after the removal of the incision recurrence, sinus bradycardia and signs of myocardial ischemia were noticed. A loop transverse colostomy was immediately perfomed and the operation was terminated. Postoperative cardiologic examination revealed an acute myocardium infract. Chemo-radiation of the mesorectum tumor and re-evaluation for surgical excision was decided. Conclusion Metachronous metastasis of the mesorectum from sigmoid colon cancer is extremely rare. Although patterns of lymphatic spread from rectal cancer to sigmoid colon have recently been demonstrated, there is no evidence of metachronous mesorectum invasion from sigmoid colon cancer. This could be the issue for future trials.</p

Nonepiphyseal Giant Cell Tumor of the Rib: A Case Report

A case of a 32-year-old female patient with a giant cell tumor originating in the middle part of the left 10th rib is presented. On X-rays and CT, the tumor caused a well-defined osteolysis with nonsclerotic borders. On MRI, it exhibited intermediate signal intensity on T1 sequences and central high signal and peripheral intermediate signal on T2 sequences. On contrast-enhanced MR images both central and peripheral-periosteal enhancement was noted. Thanks to its small size (2 × 1.3 cm), the lesion was easily resected en bloc with a part of the affected rib. The patient is free of recurrence for 3 years after the operation

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections. Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.Peer reviewe

WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in hospitals worldwide. The cornerstones of effective treatment of IAIs include early recognition, adequate source control, appropriate antimicrobial therapy, and prompt physiologic stabilization using a critical care environment, combined with an optimal surgical approach. Together, the World Society of Emergency Surgery (WSES), the Global Alliance for Infections in Surgery (GAIS), the Surgical Infection Society-Europe (SIS-E), the World Surgical Infection Society (WSIS), and the American Association for the Surgery of Trauma (AAST) have jointly completed an international multi-society document in order to facilitate clinical management of patients with IAIs worldwide building evidence-based clinical pathways for the most common IAIs. An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting information was shared by an international task force from 46 countries with different clinical backgrounds. The aim of the document is to promote global standards of care in IAIs providing guidance to clinicians by describing reasonable approaches to the management of IAIs.Peer reviewe

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

Background The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. Methods A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. Results Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. Conclusion Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened

Correction to: Two years later: Is the SARS-CoV-2 pandemic still having an impact on emergency surgery? An international cross-sectional survey among WSES members

Background: The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods: A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results: 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions: The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years

COVID-19 infection is a significant risk factor for death in patients presenting with acute cholecystitis: a secondary analysis of the ChoCO-W cohort study

Background: During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy.” Methods: The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality. Results: The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection (p &lt; 0.001), postoperative complications (p &lt; 0.001), and type (open/laparoscopic) of surgical intervention (p = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%). Conclusions: COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients