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

Expression of Toll-like receptors (TLRs) in the lungs of an experimental sepsis mouse model

Introduction: Sepsis is a condition characterized by high mortality rates and often accompanied by multiple-organ dysfunction. During sepsis, respiratory system may be affected and possibly result in acute respiratory distress syndrome (ARDS). Toll-like receptors (TLRs), as a first line defense against invading pathogens, seem to be highly expressed in septic states. Therefore, expression of TLRs in the lungs of a sepsis animal model could indicate the involvement of the respiratory system and appear as a severity index of the clinical course. Once the involvment of TLRs in the septic state is validated, further studies could lead to the development of efficient therapy for sepsis through modulation of the TLRs' function. Aim: To study the expression of TLRs, in the lungs and the intestine of septic mice. Secondarily, to define the role of TLRs in ARDS/ALI and mulitorgan failure. Experimental design: Prospective, randomized, controlled, interventional study. Setting: Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Greece, Subjects: Male C57BL/6J mice, 12 to 14 weeks of age Methods: A total of 90 C57BL/6J mice were studied. The animals were divided into 3 sepsis (S) groups (24h, 48h and 72h) and 3 control (C) groups (24h, 48h and 72h), each consisting of 12 mice. The S-groups were subjected to cecal ligation and puncture (CLP) while the C-groups had a sham operation performed. Blood samples were drawn from all groups. Total blood count analysis was performed along with the measurement of certain biochemical markers. Additionally, lung tissues were harvested and the expression of TLRs, namely TLR2, TLR3, TLR 4 and TLR7 were evaluated by means of immunofluorescence (IF) and qrt-PCR (quantitative-Polymerase Chain Reaction). Results: WBCs and lymphocytes were increased in all S-groups compared to the corresponding C-groups, while RBCs showed a gradual decline in S-groups with the lowest levels appearing in the S72 group. Only, monocytes were higher in S-groups, especially between S48-C48 and S72-C72. Creatinine, IL-10 and IL-6 levels were significantly increased in the S-groups compared to the corresponding C-groups (S24 vs C24, S48 vs C48 and S72 vs C72). IF showed that expression of TLRs 2, 3, 4 and 7 was increased in all S-groups compared to the time-adjusted C-groups. Similarly, qRT-PCR revealed that expression of all TLRs was higher in all S-groups compared to their respective C-groups in both lungs and intestine. Comparing lung and intestinal tissues from S-groups, TLRs 2 and 4 were found increased in the lung at 24, 48 and 72 hours, whereas TLR 3 was higher in the intestine at all time points examined. Finally, TLR 7 levels were significantly higher in the intestinal tissues at 24 hours (p<0.0001), while lungs predominated at 48 hours. TLRs seem to be highly expressed in the lungs of septic mice, therefore suggesting a potential role in the pathogenesis of ARDS during sepsis. While more studies need to be conducted in order to completely understand the underlying mechanisms, TLRs may represent a promising target for establishing novel therapeutic strategies in the treatment of sepsis.Εισαγωγή: Η σήψη χαρακτηρίζεται από υψηλά ποσοστά θνητότητας και συχνά συνοδεύεται από πολυ-οργανική ανεπάρκεια. Κατά την σήψη το αναπνευστικό σύστημα μπορεί να επηρεαστεί οδηγώντας στην εμφάνιση Συνδρόμου Οξείας Αναπνευστικής Δυσχέρειας (ARDS). Οι υποδοχείς ανάλογοι των Toll (Toll Like Receptors) ως τμήματα της πρώτης γραμμής άμυνας του οργανισμού ενάντια στους παθογόνους μικροοργανισμούς παρουσιάζουν σημαντική έκφραση κατά την σήψη. Η έκφραση των TLRs στους πνεύμονες πειραματόζωων σε κατάσταση σήψης θα ήταν ενδεικτική της συμμετοχής των TLRs στο αναπνευστικό σύστημα και επίσης να αποτελέσουν δείκτη της βαρύτητας και της κλινικής πρόγνωσης. Εφόσον αποδειχθεί η συμμετοχή των TLRs στο πνευμονικό παρέγχυμα κατά την σήψη, περαιτέρω μελέτη θα μπορούσε να καταλήξει στην ανάπτυξη θεραπείας μέσω της μεταβολής της λειτουργίας των TLRs.Σκοπός: Να μελετηθεί η έκφραση των υποδοχέων TLRs σε εντερικούς και πνευμονικούς ιστούς σε σηπτικά μοντέλα μυών. Επίσης να προσδιοριστεί ο ρόλος των υποδοχέων TLRs στο ARDS/ALI και το σύνδρομο πολυοργανικής ανεπάρκειας.Πειραματικός σχεδιασμός: Προοπτική, τυχαιοποιημένη, ελεγχόμενη μελέτη παρέμβασης.Τοποθεσία: Κέντρο Πειραματικής Χειρουργικής, Ίδρυμα Ιατροβιολογικών Ερευνών Ακαδημίας Αθηνών.Πειραματόζωα: Άρρενες μύες C57BL/6J ηλικίας 12 έως 14 εβδομάδων. Μέθοδος: Χρησιμοποιήθηκαν 90 πειραματόζωα που χωρίστηκαν σε τρεις σηπτικές ομάδες (ομάδες S) και τρεις ομάδες ελέγχου (ομάδες C). Οι ομάδες S υπεβλήθησαν σε απολίνωση και νύξη του τυφλού, ενώ οι ομάδες C υπεβλήθησαν σε ψευδή επέμβαση. Δείγματα αίματος ελήφθησαν από όλα τα πειραματόζωα ώστε να αναλυθούν για συγκεκριμένους δείκτες. Δείγματα πνευμονικού και εντερικού ιστού λήφθηκαν μετά την ευθανασία στις 24, 48 και 72 ώρες, και εξετάσθηκαν μέσω ανοσοφθορισμού και ποσοτικής PCR πραγματικού χρόνου για την έκφραση των TLR 2, 3, 4 και 7.Αποτελέσματα: Τα λευκά αιμοσφαίρια και τα λεμφοκύτταρα αυξήθηκαν σε όλες τις ομάδες S συγκριτικά με τις αντίστοιχες ομάδες C, ενώ τα ερυθρά είχαν μια σταδιακή πτωτική πορεία στις ομάδες S με την μεγαλύτερη αύξηση στην ομάδα S72. Τα μονοκύτταρα ήταν υψηλότερα στις ομάδες S συγκριτικά με τις ομάδες C και πιο χαρακτηριστικά ανάμεσα στις ομάδες S48-C48 και S72-C72. H κρεατινίνη, η IL-6 και η IL-10 ήταν σημαντικά υψηλότερες στις ομάδες S συγκριτικά με τις αντίστοιχες ομάδες C (S24-C24, S48-C48 και S72-C72). Ο ανοσοφθορισμός έδειξε αυξημένη έκφραση των TLRs 2, 3, 4 και 7 στις ομάδες S συγκριτικά με τις αντίστοιχες ομάδες C. Παρόμοια αποτελέσματα είχε και η ποσοτική PCR πραγματικού χρόνου για την έκφραση όλων των TLRs που μελετήθηκαν σε δείγματα ιστών πνεύμονα και εντέρου. Συγκριτικά στους δύο αυτούς ιστούς από τις ομάδες S, οι TLRs 2 και 4 ήταν αυξημένοι στον πνεύμονα στις 24, 48 και 72 ώρες, ενώ ο TLR 3 ήταν υψηλότερος στο έντερο σε όλες τις χρονικές περιόδους. Τέλος, τα επίπεδα του TLR 7 ήταν σημαντικά υψηλότερα στο έντερο στις 24 ώρες ενώ στον πνεύμονα η υψηλότερη συγκέντρωση του ήταν στις 48 ώρες. Οι TLRs φαίνεται πως εκφράζονται σημαντικά στους πνεύμονες των μυών σε σήψη, εύρημα που δικαιολογείται από έναν πιθανό ρόλο τους στην παθογένεση του ARDS κατά την σήψη. Παρότι περαιτέρω μελέτες απαιτούνται για να κατανοηθεί πλήρως ο μηχανισμός, οι TLRs θα μπορούσαν να αποτελούν υποσχόμενο στόχο για την δημιουργία νέων θεραπευτικών στρατηγικών στην θεραπεία της σήψης

Ανατομικές παραλλαγές της αγγείωσης του ήπατος

Εισαγωγή: Η ανατομία της αιμάτωσης του ήπατος ενδιέφερε τους ιατρούς ανά τους αιώνες και περιγράφεται από την αρχαιότητα σύμφωνα με τις επιστημονικές αντιλήψεις της εποχής. Στην σύγχρονη εποχή η γνώση της ανατομίας του ήπατος και των παραλλαγών της είναι σημαντική για την θεραπεία των παθήσεων και την μεταμόσχευση ήπατος. Σκοπός: Ο σκοπός της παρούσας μελέτης αποτελεί η αναφορά στις ανατομικές παραλλαγές της αγγείωσης του ήπατος, τις κυριότερες κατηγοριοποιήσεις και η ενημέρωση του σύγχρονου χειρουργού και αναγνώστη για την επίπτωση της κάθε παραλλαγής. Δίνεται έμφαση στην κλινική σημασία των παραλλαγών. Μέθοδος: Ανασκόπηση της υπάρχουσας βιβλιογραφίας στην Αγγλική γλώσσα μέσω των βάσεων MEDLINE και SCOPUS. Αποτελέσματα – Συμπεράσματα: Εκτός από την τυπική ανατομία της αιμάτωσης του ήπατος, υπάρχει πλήθος ανατομικών παραλλαγών των ηπατικών αρτηριών, της πυλαίας φλέβας και των ηπατικών φλεβών. Η γνώση των συχνότερων παραλλαγών είναι αναγκαία για την σωστή διάγνωση και αντιμετώπιση των παθήσεων τους ήπατος.Introduction: Vascular anatomy of the liver has been in the focus of the physicians of all eras and it has been described since the ancient times based on the scientific understanding of the respective period. At present, knowing the liver anatomy and its anatomic variations is important for the treatment of liver disease and liver transplantation. Aim: The aim of this thesis is to report the anatomical variations in hepatic vasculature, the main classifications used for these variations and to inform currently practicing surgeons and readers on the incidence of any given anatomic variation. Special emphasis is put on the clinical significance of the anatomic variations. Methods: Literature review using the online databases MEDLINE and SCOPUS. Results – Conclusion: Apart from the typical vascular anatomy of the liver, there is a plethora of anatomic variations of the hepatic arteries, the portal vein and the hepatic veins. The knowledge of the more frequent of these variations is necessary for setting the right diagnosis and treat accordingly any liver disease

Ιστικός και ποσοτικός προσδιορισμός των TLRs στο έντερο και στους πνεύμονες σε σηπτικά μοντέλα μυών

Εισαγωγή: Η σήψη χαρακτηρίζεται από υψηλά ποσοστά θνητότητας και συχνά συνοδεύεται από πολυ-οργανική ανεπάρκεια. Κατά την σήψη το αναπνευστικό σύστημα μπορεί να επηρεαστεί οδηγώντας στην εμφάνιση Συνδρόμου Οξείας Αναπνευστικής Δυσχέρειας (ARDS). Οι υποδοχείς ανάλογοι των Toll (Toll Like Receptors) ως τμήματα της πρώτης γραμμής άμυνας του οργανισμού ενάντια στους παθογόνους μικροργανισμούς παρουσιάζουν σημαντική έκφραση κατά την σήψη. Η έκφραση των TLRs στους πνεύμονες πειραματόζωων σε κατάσταση σήψης θα ήταν ενδεικτική της συμμετοχής των TLRs στο αναπνευστικό σύστημα και επίσης να αποτελέσουν δείκτη της βαρύτητας και της κλινικής πρόγνωσης. Εφόσον αποδειχθεί η συμμετοχή των TLRs στο πνευμονικό παρέγχυμα κατά την σήψη, περαιτέρω μελέτη θα μπροούσε να καταλήξει στην ανάπτυξη θεραπείας μέσω της μεταβολής της λειτουργίας των TLRs. Σκοπός: Να μελετηθεί η έκφραση των υποδοχέων TLRs σε εντερικούς και πνευμονικούς ιστούς σε σηπτικά μοντέλα μυών. Επίσης να προσδιοριστεί ο ρόλος των υποδοχέων TLRs στο ARDS/ALI και το σύνδρομο πολυοργανικής ανεπάρκειας. Πειραματικός σχεδιασμός: Προοπτική, τυχαιοποιημένη, ελεγχόμενη μελέτη παρέμβασης. Τοποθεσία: Κέντρο Πειραματικής Χειρουργικής, Ίδρυμα Ιατροβιολογικών Ερευνών Ακαδημίας Αθηνών. Πειραματόζωα: Άρρενες μύες C57BL/6J ηλικίας 12 έως 14 εβδομάδων Μέθοδος: Χρησιμοποιήθηκαν 90 πειραματόζωα που χωρίστηκαν σε τρεις σηπτικές ομάδες (ομάδες S) και τρεις ομάδες ελέγχου (ομάδες C). Οι ομάδες S υπεβλήθησαν σε απολίνωση και νύξη του τυφλού, ενώ οι ομάδες C υπεβλήθησαν σε ψευδή επέμβαση. Δείγματα αίματος ελήφθησαν από όλα τα πειραματόζωα ώστε να αναλυθούν για συγκεκριμμένους δείκτες. Δείγματα πνευμονικού και εντερικού ιστού λήφθηκαν μετά την Διδακτορική Διατριβή Ιατρού Μπακόπουλου Ανάργυρου 18 ευθανασία στις 24, 48 και 72 ώρες, και εξετάσθηκαν μέσω ανοσοφθορισμού και ποσοτικής PCR πραγματικού χρόνου για την έκφραση των TLR 2, 3, 4 και 7. Αποτελέσματα: Τα λευκά αιμοσφαίρια και τα λεμφοκύτταρα αυξήθηκαν σε όλες τις ομάδες S συγκριτικά με τις αντίστοιχες ομάδες C, ενώ τα ερυθρά είχαν μια σταδιακή πτωτική πορεία στις ομάδες S με την μεγαλύτερη άυξηση στην ομάδα S72. Τα μονοκύτταρα ήταν υψηλότερα στις ομάδες S συγκριτικά με τις ομάδες C και πιο χαρακτηριστικά ανάμεσα στις ομάδες S48-C48 και S72-C72. H κρεατινίνη, η IL-6 και η IL-10 ήταν σημαντικά υψηλότερες στις ομάδες S συγκρiτικά με τις αντίστοιχες ομάδες C (S24-C24, S48-C48 και S72-C72). Ο ανοσοφθορισμός έδειξε αυξημένη έκφραση των TLRs 2, 3, 4 και 7 στις ομάδες S συγκριτικά με τις αντίστοιχες ομάδες C. Παρόμοια αποτελέσματα είχε και η ποσοτική PCR πραγματικού χρόνου για την έκφραση όλων των TLRs που μελετήθηκαν σε δείγματα ιστών πνεύμονα και εντέρου. Συγκριτικά στους δύο αυτούς ιστούς από τις ομάδες S, οι TLRs 2 και 4 ήταν αυξημένοι στον πνεύμονα στις 24, 48 και 72 ώρες, ενώ ο TLR 3 ήταν υψηλότερος στο έντερο σε όλες τις χρονικές περιόδους. Τέλος, τα επίπεδα του TLR 7 ήταν σημαντικά υψηλότερα στο έντερο στις 24 ώρες ενώ στον πνεύμονα η υψηλότερη συγκέντρωση του ήταν στις 48 ώρες. Οι TLRs φαίνεται πως εκφράζονται σημαντικά στους πνεύμονες των μυών σε σήψη, εύρημα που δικαιολογείται από έναν πιθανό ρόλο τους στην παθογένεση του ARDS κατά την σήψη. Παρότι περαιτέρω μελέτες απαιτούνται για να κατανοηθεί πλήρως ο μηχανισμός, οι TLRs θα μπορούσαν να αποτελούν υποσχόμενο στόχο για την δημιουργία νέων θεραπευτικών στρατηγικών στην θεραπεία της σήψης.Introduction: Sepsis is a condition characterized by high mortality rates and often accompanied by multiple-organ dysfunction. During sepsis, respiratory system may be affected and possibly result in acute respiratory distress syndrome (ARDS). Toll-like receptors (TLRs), as a first line defense against invading pathogens, seem to be highly expressed in septic states. Therefore, expression of TLRs in the lungs of a sepsis animal model could indicate the involvement of the respiratory system and appear as a severity index of the clinical course. Once the involvment of TLRs in the septic state is validated, further studies could lead to the development of efficient therapy for sepsis through modulation of the TLRs&apos; function. Aim: To study the expression of TLRs, in the lungs and the intestine of septic mice. Secondarily, to define the role of TLRs in ARDS/ALI and mulitorgan failure. Experimental design: Prospective, randomized, controlled, interventional study. Setting: Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Greece, Subjects: Male C57BL/6J mice, 12 to 14 weeks of age Methods: A total of 90 C57BL/6J mice were studied. The animals were divided into 3 sepsis (S) groups (24h, 48h and 72h) and 3 control (C) groups (24h, 48h and 72h), each consisting of 12 mice. The S-groups were subjected to cecal ligation and puncture (CLP) while the C-groups had a sham operation performed. Blood samples were drawn from all groups. Total blood count analysis was performed along with the measurement of certain biochemical markers. Additionally, lung tissues were harvested and the expression of TLRs, namely TLR2, TLR3, TLR 4 and TLR7 were evaluated by means of immunofluorescence (IF) and qrt-PCR (quantitative-Polymerase Chain Reaction). Διδακτορική Διατριβή Ιατρού Μπακόπουλου Ανάργυρου 20 Results: WBCs and lymphocytes were increased in all S-groups compared to the corresponding C-groups, while RBCs showed a gradual decline in S-groups with the lowest levels appearing in the S72 group. Only, monocytes were higher in S-groups, especially between S48-C48 and S72-C72. Creatinine, IL-10 and IL-6 levels were significantly increased in the S-groups compared to the corresponding C-groups (S24 vs C24, S48 vs C48 and S72 vs C72). IF showed that expression of TLRs 2, 3, 4 and 7 was increased in all S-groups compared to the time-adjusted C-groups. Similarly, qRT-PCR revealed that expression of all TLRs was higher in all S-groups compared to their respective C-groups in both lungs and intestine. Comparing lung and intestinal tissues from S-groups, TLRs 2 and 4 were found increased in the lung at 24, 48 and 72 hours, whereas TLR 3 was higher in the intestine at all time points examined. Finally, TLR 7 levels were significantly higher in the intestinal tissues at 24 hours (p&lt;0.0001), while lungs predominated at 48 hours. TLRs seem to be highly expressed in the lungs of septic mice, therefore suggesting a potential role in the pathogenesis of ARDS during sepsis. While more studies need to be conducted in order to completely understand the underlying mechanisms, TLRs may represent a promising target for establishing novel therapeutic strategies in the treatment of sepsis

Pneumothorax as a rare complication during laparoscopic total extra-peritoneal inguinal hernia repair: A case report and review of the literature

Totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal repair are the two most commonly performed types of laparoscopic hernia repair procedures. Herein, we present a rare case of pneumothorax and pneumomediastinum that ensued during a TEP inguinal hernia repair. A 73-year-old man presented for elective laparoscopic right-sided hernia repair. After intubation, a 10-mm and two 5-mm trocars were placed in the peri-umbilical and midline area, respectively. A balloon dissector was inserted from the 10-mm trocar to develop the retro-rectus space and carbon dioxide was insufflated up to a pressure of 14 mmHg. About 55 min after insufflation, the patient presented subcutaneous emphysema, oxygen saturation dropped from 100% to 96% and pCO2 increased to 55 mmHg. Due to concerns for pulmonary embolism, he immediately underwent a chest computed tomography, which revealed pneumothorax, pneumomediastinum and subcutaneous emphysema extended throughout the neck, thorax and upper abdomen. The patient was successfully treated conservatively with oral analgesia and supplemental oxygen and was discharged on the 4th post-operative day without any further complications

An extremely rare clinical manifestation of acute appendicitis in a nonagenarian patient: lessons still to be learned

Abstract Acute appendicitis is associated with a relatively high mortality rate among elderly patients due to the unusual clinical presentation that often leads to misdiagnosis and, in turn, severe complications. This report describes an extremely uncommon clinical manifestation of acute appendicitis in an elderly patient - a subcutaneous abdominal wall abscess initially treated as cellulitis. Despite the initial misdiagnosis, contrast-enhanced computed tomography revealed a circumscribed inflammatory process of the appendix that was in close proximity to the abdominal wall. The patient underwent a surgical drainage of the abscess, received broad-spectrum antibiotics, and was discharged on day 12 following an uneventful course. Diagnosis of acute appendicitis in elderly patients is challenging due to the atypical clinical presentation and co-existing comorbidities that can be misleading. Early application of high-resolution imaging techniques is necessary to identify the cause of acute abdomen in the elderly population

The Immunology of Hepatocellular Carcinoma

Liver cancer is the third leading cause of cancer death worldwide. Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver. Liver resection or transplantation offer the only potentially curative options for HCC; however, many patients are not candidates for surgical resection, either due to presentation at advanced stages or poor liver function and portal hypertension. Liver transplantation is also limited to patients with certain characteristics, such as those that meet the Milan criteria (one tumor ≤ 5 cm, or up to three tumors no larger than 3 cm, along with the absence of gross vascular invasion or extrahepatic spread). Locoregional therapies, such as ablation (radiofrequency, ethanol, cryoablation, microwave), trans-arterial therapies like chemoembolization (TACE) or radioembolization (TARE), and external beam radiation therapy, have been used mainly as palliative measures with poor prognosis. Therefore, emerging novel systemic treatments, such as immunotherapy, have increasingly become popular. HCC is immunogenic, containing infiltrating tumor-specific T-cell lymphocytes and other immune cells. Immunotherapy may provide a more effective and discriminatory targeting of tumor cells through induction of a tumor-specific immune response in cancer cells and can improve post-surgical recurrence-free survival in HCC. We herein review evidence supporting different immunomodulating cell-based technology relative to cancer therapy in vaccines and targeted therapies, such as immune checkpoint inhibitors, in the management of hepatocellular carcinoma among patients with advanced disease

Gallstone Ileus in Octogenarians: Is Cholecystectomy Really Needed?

Gallstone ileus is an uncommon complication of cholelithiasis and occurs when a gallstone migrates through a cholecystoenteric fistula and impacts within the gastrointestinal tract. Surgical intervention remains the treatment of choice, which consists of a full-thickness incision of the visceral wall and removal of the impacted gallstone. In this paper we present the treatment approach of 6 cases of gallstone ileus in octogenarians. In our cohort, intestinal obstruction was resolved through an enterotomy or gastrotomy and lithotomy/stone extraction in every patient. No cholecystectomies were undertaken. Despite the fact that gallstone ileus is diagnosed in small percent of patients suffering from gallstone disease, it accounts for a large proportion of intestine obstruction in patients older than 65 years old. Since accurate diagnosis and timely intervention are vital, providers should be familiar with the diagnostic approach and the treatment of this clinical entity

The Immunology of Hepatocellular Carcinoma

Liver cancer is the third leading cause of cancer death worldwide. Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver. Liver resection or transplantation offer the only potentially curative options for HCC; however, many patients are not candidates for surgical resection, either due to presentation at advanced stages or poor liver function and portal hypertension. Liver transplantation is also limited to patients with certain characteristics, such as those that meet the Milan criteria (one tumor &amp; LE; 5 cm, or up to three tumors no larger than 3 cm, along with the absence of gross vascular invasion or extrahepatic spread). Locoregional therapies, such as ablation (radiofrequency, ethanol, cryoablation, microwave), trans-arterial therapies like chemoembolization (TACE) or radioembolization (TARE), and external beam radiation therapy, have been used mainly as palliative measures with poor prognosis. Therefore, emerging novel systemic treatments, such as immunotherapy, have increasingly become popular. HCC is immunogenic, containing infiltrating tumor-specific T-cell lymphocytes and other immune cells. Immunotherapy may provide a more effective and discriminatory targeting of tumor cells through induction of a tumor-specific immune response in cancer cells and can improve post-surgical recurrence-free survival in HCC. We herein review evidence supporting different immunomodulating cell-based technology relative to cancer therapy in vaccines and targeted therapies, such as immune checkpoint inhibitors, in the management of hepatocellular carcinoma among patients with advanced disease.&lt;/p&gt

Management of Morgagni&apos;s Hernia in the Adult Population: A Systematic Review of the Literature

Background Morgagni’s hernia (MH) is defined by the protrusion of abdominal viscera through an anterior retrosternal diaphragmatic defect. The objective of this study was to systematically review current literature on MHs in adult population and assess their clinical characteristics and therapeutic approach. Methods PubMed and Cochrane bibliographical databases were searched (last search: 15(th) January 2021) for studies concerning MHs. Results Inclusion criteria were met by 189 studies that included 310 patients (61.0% females) with an age of 57.37 +/- 18.41 (mean +/- SD) years. Pulmonary symptoms, abdominal pain, and nausea-vomit were among the most frequent symptomatology. MHs were predominantly right-sided (84.0%), with greater omentum (74.5%) and transverse colon (65.1%) being the most commonly herniated viscera. The majority of cases underwent an open procedure, while 42.3% of patients had a minimally invasive procedure. Abdominal approach was mostly preferred, while a thoracic one was chosen at 20.6% of cases and a thoracoabdominal at 3.2%. Thirty-day postoperative complications were recorded at 29 patients and 30-day mortality was 2.3%. Conclusions MH is a rare type of congenital diaphragmatic hernia which rarely manifests in adult population with atypical pulmonary and gastrointestinal symptoms. Surgery is the gold standard for their management. Open surgical approach is preferable in emergency cases, while laparoscopic surgery is favored in elective setting and is associated with shorter hospitalization. Further studies are crucial in order to elucidate etiology and optimal therapeutic approach