Η πιθανή ευεργετική αυξητικών παραγόντων στην επούλωση πειραματικά δημιουργηθείσας και εκταμθείσας ενδομητριωσικής εστίας στο παχύ έντερο επίμυων

Σκοπός: Η αξιολόγηση της πιθανής ευεργετικής δρασης του πλάσματος εμπλουτισμένου με αιμοπετάλια (Platelet rich plasma-PRP) και του συγκολλητικού παράγοντα ινώδους (TISSEEL, Baxter Healthcare Corporation, Deerfield, IL) στην επούλωση του εντέρου μετά το “ξύρισμα”-εφαπτομενική εκτομή πειραματικά επαγόμενης ενδομητριωτικής εστίας παχέος εντέρου. Σχεδίαση μελέτης: Τυφλή τυχαιοποιημένη πειραματική μελέτη. Ζώα: Τριάντα θήλεις αρουραίοι Sprague-Dawley (SD). Παρεμβάσεις: Επαγωγή πειραματικής ενδομητρίωσης του παχέος εντέρου με αυτόλογη μεταμόσχευση ενδομητρικού ιστού σε όλα τα ζώα (1η χειρουργική επέμβαση). Τριάντα αρουραίοι τυχαιοποιήθηκαν σε 1 από τις 3 ομάδες σύμφωνα με την θεραπευτική παρέμβαση: PRP (ομάδα I, ν = 10), TISSEEL (ομάδα II, n = 10) ή κανένας παράγοντας (ομάδα III, ν=10) εφαρμόστηκαν στην “ξυρισμένη” επιφάνεια του παχέος εντέρου (2η χειρουργική επέμβαση). Μετρήσεις και κύρια αποτελέσματα: Η ενδομητρίωση του παχέος εντέρου επάχθηκε με επιτυχία σε όλα τα ζώα. Τέσσερις ημέρες μετά τη 2η χειρουργική επέμβαση, τα ζώα υπέστησαν ευθανασία και πραγματοποιήθηκε ιστολογική εξέταση. Η ιστολογική εξέταση έδειξε ότι σε σύγκριση με την ομάδα ελέγχου, η εναπόθεση κολλαγόνου βρέθηκε σε σημαντικά υψηλότερη έκφραση τόσο στην ομάδα του PRP όσο και σε αυτή του TISSEEL (p = .011 και p = .011, αντίστοιχα). Η διαταραχή της αρχιτεκτονικής των στιβάδων του παχεός εντέρου ήταν στατιστικά πιο έντονη στην ομάδα ελέγχου συγκριτικά με την ομάδα TISSEEL (p = .033) ενώ παρατηρήθηκε πιο εξεσημασμένος σχηματισμός νέων αιμοφόρων αγγείων στην ομάδα του TISSEEL σε σύγκριση με την ομάδα ελέγχου (p = .023). Δεν ανιχνεύθηκαν ιστολογικές ενδείξεις υπολειμματικής ή υποτροπιάζουσας νόσου. Συμπέρασμα: Τόσο η χρήση του PRP όσο και του TISSEEL φαίνεται να είναι ασφαλής και να σχετίζεται με βελτίωση της επούλωσης των ιστών μετά την αποψίλωση ενδομητριωσικής εστίας παχέος εντέρου, που αποδίδεται στην αυξημένη εναπόθεση κολλαγόνου, στη νεοαγγείωση και την προστασία της ακεραιότητας των στιβάδων του παχέος εντέρου. Στο πεδίο αυτό, κλινικές δοκιμές απαιτούνται για να επιβεβαιώσουν την αποτελεσματικότητα του PRP και του TISSEEL στην κλινική πράξη.Study objective: To examine the potential beneficial effect of platelet rich plasma (PRP) and fibrin sealant (TISSEEL; Baxter Healthcare Corporation, Deerfield, IL) on bowel wound healing after shaving of an experimentally induced endometriotic lesion. Design: Single-blind randomized experimental study (Canadian Task Force classification I). Setting: Certified animal research facility. Animals: Thirty female Sprague-Dawley rats. Interventions: Experimental colonic endometriosis was induced by transplanting endometrial tissue to all animals (first surgery). Thirty rats were then randomized to 1 of 3 groups according to treatment: PRP (group I, n = 10), fibrin sealant (group II, n = 10), or no agent (group III, n = 10) was applied after shaving of the endometriotic nodule (second surgery). Measurements and Main Results: Colonic endometriosis was successfully induced in all subjects. Four days following the second surgery, the animals were euthanized, and microscopic evaluation was performed. The pathologist was blinded to the treatment method. Histopathologic analysis revealed that compared with the control group, collagen disposition was found in significantly higher expression in both the PRP and fibrin sealant groups (p = .011 and p = .011, respectively). Distortion of the integrity of the colon layers was statistically more pronounced in the control group compared with the fibrin sealant group (p = .033) while greater new blood vessel formation was observed in the fibrin sealant group compared with control (p = .023). No histologic evidence of residual or recurrent disease was detected. Conclusion: Both PRP and fibrin sealant appear to be safe and associated with improved tissue healing during shaving for the excision of colonic endometriosis, attributed to the enhanced collagen disposition, neovascularization, and protection of the integrity of colon layers. Clinical trials are warranted to confirm the feasibility of PRP and fibrin sealant in the clinical setting

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

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

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Endometriosis of the Canal of Nuck: A Systematic Review of the Literature

Endometriosis is a common benign gynecological condition defined as the presence of endometrial tissue in tissues outside the uterine cavity. Apart from the common sites of endometriosis, rare sites other have also been reported including the liver, the thoracic cavity, the muscles, nerves, and more rarely in a patent Nuck canal. We aim to evaluate the clinical presentation, diagnostic features, and management of the Nuck endometriosis. A meticulous search of three electronic databases was performed until May 2020 for articles reporting cases of Nuck endometriosis. A total of 36 patients from 20 studies were analyzed. Median age of patients was 36 years with 33 women being of reproductive age. A right-sided lesion was identified in 30 cases (83.3%), while all patients suffer from a groin mass with cyclic pain in a proportion of 22%. All the patients finally underwent surgery for investigation of the lesion and fixation of the defect. Five cases of malignancy were detected at final pathology. All of them were alive with a median reported overall survival of 37 months. Nuck endometriosis should be included in the differential diagnosis of female patients with groin swelling. An evaluation by a gynecologist is important when endometriosis is suspected

The effect of growth factor-enriched agents in the healing of colon after resection of experimentally induced colonic endometriosis: an experimental rat model

Study objective: To examine the potential beneficial effect of platelet rich plasma (PRP) and fibrin sealant (TISSEEL; Baxter Healthcare Corporation, Deerfield, IL) on bowel wound healing after shaving of an experimentally induced endometriotic lesion. Design: Single-blind randomized experimental study (Canadian Task Force classification I). Setting: Certified animal research facility. Animals: Thirty female Sprague-Dawley rats. Interventions: Experimental colonic endometriosis was induced by transplanting endometrial tissue to all animals (first surgery). Thirty rats were then randomized to 1 of 3 groups according to treatment: PRP (group I, n = 10), fibrin sealant (group II, n = 10), or no agent (group III, n = 10) was applied after shaving of the endometriotic nodule (second surgery). Measurements and Main Results: Colonic endometriosis was successfully induced in all subjects. Four days following the second surgery, the animals were euthanized, and microscopic evaluation was performed. The pathologist was blinded to the treatment method. Histopathologic analysis revealed that compared with the control group, collagen disposition was found in significantly higher expression in both the PRP and fibrin sealant groups (p = .011 and p = .011, respectively). Distortion of the integrity of the colon layers was statistically more pronounced in the control group compared with the fibrin sealant group (p = .033) while greater new blood vessel formation was observed in the fibrin sealant group compared with control (p = .023). No histologic evidence of residual or recurrent disease was detected. Conclusion: Both PRP and fibrin sealant appear to be safe and associated with improved tissue healing during shaving for the excision of colonic endometriosis, attributed to the enhanced collagen disposition, neovascularization, and protection of the integrity of colon layers. Clinical trials are warranted to confirm the feasibility of PRP and fibrin sealant in the clinical setting.Σκοπός: Η αξιολόγηση της πιθανής ευεργετικής δρασης του πλάσματος εμπλουτισμένου με αιμοπετάλια (Platelet rich plasma-PRP) και του συγκολλητικού παράγοντα ινώδους (TISSEEL, Baxter Healthcare Corporation, Deerfield, IL) στην επούλωση του εντέρου μετά το “ξύρισμα”-εφαπτομενική εκτομή πειραματικά επαγόμενης ενδομητριωτικής εστίας παχέος εντέρου. Σχεδίαση μελέτης: Τυφλή τυχαιοποιημένη πειραματική μελέτη. Ζώα: Τριάντα θήλεις αρουραίοι Sprague-Dawley (SD). Παρεμβάσεις: Επαγωγή πειραματικής ενδομητρίωσης του παχέος εντέρου με αυτόλογη μεταμόσχευση ενδομητρικού ιστού σε όλα τα ζώα (1η χειρουργική επέμβαση). Τριάντα αρουραίοι τυχαιοποιήθηκαν σε 1 από τις 3 ομάδες σύμφωνα με την θεραπευτική παρέμβαση: PRP (ομάδα I, ν = 10), TISSEEL (ομάδα II, n = 10) ή κανένας παράγοντας (ομάδα III, ν=10) εφαρμόστηκαν στην “ξυρισμένη” επιφάνεια του παχέος εντέρου (2η χειρουργική επέμβαση). Μετρήσεις και κύρια αποτελέσματα: Η ενδομητρίωση του παχέος εντέρου επάχθηκε με επιτυχία σε όλα τα ζώα. Τέσσερις ημέρες μετά τη 2η χειρουργική επέμβαση, τα ζώα υπέστησαν ευθανασία και πραγματοποιήθηκε ιστολογική εξέταση. Η ιστολογική εξέταση έδειξε ότι σε σύγκριση με την ομάδα ελέγχου, η εναπόθεση κολλαγόνου βρέθηκε σε σημαντικά υψηλότερη έκφραση τόσο στην ομάδα του PRP όσο και σε αυτή του TISSEEL (p = .011 και p = .011, αντίστοιχα). Η διαταραχή της αρχιτεκτονικής των στιβάδων του παχεός εντέρου ήταν στατιστικά πιο έντονη στην ομάδα ελέγχου συγκριτικά με την ομάδα TISSEEL (p = .033) ενώ παρατηρήθηκε πιο εξεσημασμένος σχηματισμός νέων αιμοφόρων αγγείων στην ομάδα του TISSEEL σε σύγκριση με την ομάδα ελέγχου (p = .023). Δεν ανιχνεύθηκαν ιστολογικές ενδείξεις υπολειμματικής ή υποτροπιάζουσας νόσου. Συμπέρασμα: Τόσο η χρήση του PRP όσο και του TISSEEL φαίνεται να είναι ασφαλής και να σχετίζεται με βελτίωση της επούλωσης των ιστών μετά την αποψίλωση ενδομητριωσικής εστίας παχέος εντέρου, που αποδίδεται στην αυξημένη εναπόθεση κολλαγόνου, στη νεοαγγείωση και την προστασία της ακεραιότητας των στιβάδων του παχέος εντέρου. Στο πεδίο αυτό, κλινικές δοκιμές απαιτούνται για να επιβεβαιώσουν την αποτελεσματικότητα του PRP και του TISSEEL στην κλινική πράξη

Robotic versus laparoendoscopic single-site hysterectomy: a systematic review and meta-analysis

Εισαγωγή / Σκοπός: Η λαπαροσκοπική ή ρομποτική υστερεκτομή μίας οπής εμφανίζει σημαντικά πλεονεκτήματα που σχετίζονται κυρίως με το μετεγχειρητικό κοσμητικό αποτέλεσμα, τις επιπλοκές που σχετίζονται με το τραύμα και την μετεγχειρητική νοσηρότητα. Σκοπός της παρούσας μελέτης ήταν να αξιολογηθεί η σκοπιμότητα της ρομποτικής και της λαπαροσκοπικής υστερεκτομής μίας οπής σε ασθενείς με καλοήθεις ή κακοήθεις πρώιμου σταδίου γυναικολογικές παθήσεις και να συγκριθούν οι δύο προσεγγίσεις. Υλικά και Μέθοδοι: Πραγματοποιήθηκε συστηματική αναζήτηση τεσσάρων ηλεκτρονικών βάσεων δεδομένων για μελέτες που δημοσιεύθηκαν έως τον Σεπτέμβριο του 2019. Συμπεριλήφθηκαν μελέτες που παρέθεταν αποτελέσματα για γυναίκες που υποβλήθηκαν σε ρομποτική ή λαπαροσκοπική υστερεκτομή μίας οπής. Αποτελέσματα: Συμπεριλήφθηκαν συνολικά 6 μελέτες με 412 ασθενείς. Μεταξύ αυτών, 150 γυναίκες υποβλήθηκαν σε ρομποτική υστερεκτομή μίας οπής, ενώ 262 έλαβαν λαπαροσκοπική υστερεκτομή. Ούτε ο συνολικός χρόνος λειτουργίας ούτε ο συνολικός χρόνος υστερεκτομής διέφεραν μεταξύ των 2 ομάδων (355 ασθενείς MD 17,47 λεπτά, 95% CI - 5,82 έως 40,76, p = 0,14 και 285 ασθενείς MD 6,41 λεπτά, 95% CI - 10,24 έως 23,06, p = 0,45, αντίστοιχα). Η ρομποτική προσέγγιση παρουσίασε σημαντικά χαμηλότερη απώλεια αίματος καθώς και παραμονή στο νοσοκομείο σε σύγκριση με τη λαπαροσκοπική (287 ασθενείς MD - 10,84 ml 95% CI - 20,35 έως - 1,32, p = 0,03, 328 ασθενείς MD - 0,32 ημέρες, 95% CI - 0,44 έως - 0,19, p <0,00001, αντίστοιχα). Δεν βρέθηκε σημαντική διαφορά όσον αφορά τα ποσοστά των μείζονων ή των συνολικών μετεγχειρητικών επιπλοκών. Συμπέρασμα: Η παρούσα μετα-ανάλυση υποστηρίζει τη χρήση ρομποτικής υστερεκτομής μίας οπής, καθώς σχετίζεται με ταχύτερη ανάρρωση και συγκρίσιμους χρόνους επέμβασης καθώς και ποσοστά επιπλοκών σε σύγκριση με την αντίστοιχη λαπαροσκοπική προσέγγιση. Ωστόσο, λόγω του περιορισμένου αριθμού των περιλαμβανόμενων μελετών και της αναδρομικής τους φύσης, τα προαναφερθέντα αποτελέσματα πρέπει να αξιολογούνται με προσοχή και απαιτούνται περαιτέρω μελέτες στο συγκεκριμένο πεδίο.Background/ Aim: Single-site hysterectomy (SSH) laparoscopic or robotic presented distinct advantages with regards to postoperative cosmetic outcome, wound-related complications and morbidity. We aimed to evaluate the feasibility of robotic and laparoscopic SSH in patients with benign or early-stage malignant gynecological conditions and to compare the two approaches. Materials and Methods: A systematic search of four electronic databases for articles published up to September 2019 was performed. Studies reporting outcomes for women who underwent robotic or laparoscopic SSH were considered eligible. Results: A total of 6 studies with 412 patients were included. Among them, 150 women had robotic SSH, whereas 262 had laparoscopic SSH. Neither total operative time nor total hysterectomy time were found different among the 2 groups (355 patients MD 17.47 min, 95% CI − 5.82 to 40.76, p = 0.14 and 285 patients MD 6.41 min, 95% CI − 10.24 to 23.06, p = 0.45, respectively). Robotic approach presented significantly lower blood loss and hospital stay compared to laparoscopic (287 patients MD − 10.84 ml 95% CI − 20.35 to − 1.32, p = 0.03, 328 patients MD − 0.32 days, 95% CI − 0.44 to − 0.19, p < 0.00001, respectively). No difference was found with regards to major or overall postoperative complications. Conclusion: The present meta-analysis supports the use of robotic SSH, since it was related to faster recovery and comparable operative times and complication rates compared to laparoscopic. Nonethe- less, due to the limited number of the included studies and their retrospective nature, the aforementioned outcomes must be interpreted with caution and further larger volume studies are needed in the field

Is There a Role of Elevated CA 19-9 Levels in the Evaluation of Clinical Characteristics of Mature Cystic Ovarian Teratomas? A Systematic Review and Meta-analysis

The role of preoperative CA 19-9 levels in patients with ovarian mature cystic teratoma (MCT) and the association of elevated levels of the biomarker with patients' and tumor characteristics were evaluated. Four electronic databases were searched for articles published up to September 2019. Trials that evaluated the significance of elevated CA 19-9 in patients with ovarian MCTs and publications with > 20 patients were considered eligible for inclusion. Seven studies that included 995 patients with an ovarian MCT who were evaluated with elevated (n = 364) or normal (n = 631) CA 19-9 levels were included. Mean tumor size was significantly increased in patients with elevated CA 19-9 levels (p = 0.038). The rate of ovarian torsion was significantly increased in the elevated CA 19-9 group (p = 0.04). The present study highlights the importance of CA 19-9 as a marker in the diagnosis of MCT, and a meta-analysis supports that it could raise a high degree of clinical suspicion of early recognition of torsion and early surgical management due to complications related to increased size. Nonetheless, the diagnostic value of CA 19-9 is still limited and CA 19-9 can still serve only as a supplementary diagnostic tool in patients with MCTs

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

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

Maternal cardiac troponin levels in pre-eclampsia: a systematic review

Objective: We systematically review the literature for potential alterations in cardiac troponin I (cTnI) in patients who suffer from pre-eclampsia.Methods: We used the Medline (1966-2015), Scopus (2004-2015), Popline (1974-2015), ClinicalTrials.gov (2008-2015) and Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2015) databases for our primary search; we also employed the reference lists of the full-text articles that we retrieved electronically.Results: We included nine studies involving 719 women. Five of these studies suggested that cTnI increases in pre-eclamptic patients above the normal threshold. However, all studies reported outcomes at a single time point, and they failed to perform consecutive measurements to observe whether this effect was long lasting and whether it evolved during the course of pregnancy.Conclusions: Current evidence suggests that cTnI might be elevated in pre-eclamptic pregnant women, although this observation is not always reported. Future studies are necessary to consistently observe cTnI levels throughout the prenatal period and during the first few postnatal weeks. A concurrent evaluation of other cardiovascular hemodynamic parameters could be of use in mechanistic models for predicting future cardiovascular morbidity in these women

The impact of subclinical hypothyroidism on anthropometric characteristics, lipid, glucose and hormonal profile of PCOS patients: a systematic review and meta-analysis

Objective: Subclinical hypothyroidism (SCH) is encountered in 10-25% of women with PCOS. To date, it remains unclear whether this coexistence influences the severity of metabolic and hormonal profile of these patients. The purpose of our systematic review is to investigate this potential relation. Methods: We systematically searched Medline, Scopus, ClinicalTrials. gov, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases together with reference lists from included studies. All prospective and retrospective observational cohort studies that investigated the impact of subclinical hypothyroidism on hormonal and metabolic parameters of PCOS patients were included. The methodological quality of studies was assessed with the Ottawa-Newcastle criteria. Statistical meta-analysis was performed with the RevMan 5.3 software. Results: Twelve studies were finally included in the present review, which enrolled 2341 PCOS patients. Among them, 577 had subclinical hypothyroidism, whereas the remaining 2077 were PCOS women with normal thyroid function. The presence of SCH significantly affected HDL (MD -3.92 mg/dL 95% CI: -6.56, -1.29) and triglycerides levels (26.91 mg/dL 95% CI: -3.79, 50.02). HOMA-IR was also affected (MD 0.82 95% CI: 0.15, 1.50). On the other hand, LDL, fasting glucose and 2-h OGTT were not influenced. Similarly, prolactin, FSH, LH, LH/FSH ratio and sex hormone-binding globulin remained unaffected. Conclusion: Subclinical hypothyroidism does not influence the hormonal profile of women with PCOS. On the other hand, it results in mild metabolic abnormalities, which are not clinically important in a short-term setting