Patient outcomes following surgical management of thyroid nodules classified as Bethesda category III (AUS/FLUS)

Introduction: The Bethesda classification system for reporting thyroid cytopathology is the standard for interpreting fine needle aspirate (FNA). Because of its heterogeneity and inconsistent reporting, atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS), known as Bethesda category III, is the most controversial category. Thyroid nodules that fall within Bethesda categories III–IV have an overall risk of malignancy of between 15 and 40%. The aim of this study was to determine the malignancy rate in Bethesda III nodules. Material and methods: A retrospective study was performed for 1166 patients who underwent thyroid surgery for multinodular goitre (MNG) or solitary nodular goitre (SNG) in our institution between June 2010 and May 2020. Data retrieved included demographic characteristics of the patients, FNB cytology, thyroid function test results, type of thyroidectomy, and final histology results. Results: During the study period, 29.5% (344/1166) of patients with an FNA categorized as AUS/FLUS underwent thyroid surgery. Of these 344 patients, 190 were diagnosed with MNG and 154 with SNG. Incidental malignancy was found in 35 of 190 cases of MNG (18.42%) and 31 of 154 cases of SNG (20.13%). The most common malignant tumour type in either category was the follicular variant of papillary thyroid carcinoma. Conclusions: The current study demonstrates that patients with a FNA categorized as AUS/FLUS may have a higher risk of malignancy than traditionally believed. Reconsideration may be necessary to guidelines that recommend observation or repeat FNA in this category of patients

Thyroid abscess as a complication of percutaneous ethanol ablation of cystic thyroid nodules

Not required for Clinical Vignette

Risk of surgical site infections after colorectal surgery and the most frequent pathogens isolated: a prospective single-centre observational study

Aim To identify risk factors for developing surgical site infections (SSIs) based on a prospective study of patients undergoing colorectal surgery. Methods Between November 2019 and January 2021, 133 patients underwent elective operation for colorectal cancer in our institution. The following variables were recorded for each patient: age, gender, body mass index (BMI), American Society of Anesthesiologists Classification (ASA class), duration of surgery, wound classification, skin preparation regimens, surgical approach, comorbidities (hypertension, diabetes, cardiovascular disease, respiratory disease, chronic steroid use), and pathogens responsible for surgical site infection. Univariate analysis was performed using χ2 tests for categorical variables. Results A total of 65 males and 68 females were enrolled. Postoperative SSI was diagnosed in 29 (21.8%) cases. Fifty five patients were >70 years old, and SSIs were significantly more frequent in this group (p=0.033). There were 92 patients with BMI <30kg/m2 and 87 with ASA class ≤2; SSIs occurred significantly less frequently in these patients (p=0.021 and p=0.028, respectively). Open surgery was performed in 113 patients; 35 (out of 113; 31%) wound infections were classified as contaminated or dirty, and SSI occurred more often in these two groups (p=0.048 and p=0.037, respectively). Nineteen patients had diabetes and 36 used steroids continuously; SSI was significantly more frequent in these patients (p=0.021 and p=0.049, respectively). Conclusion Following colorectal cancer procedures SSIs were significantly more common among patients over 70 years old, BMI≥30kg/m2 , ASA score>2, with diabetes and chronic steroid use, undergoing open, dirty or contaminated surgery. Escherichia coli and Enterococcus spp. were the two most common pathogens isolated

Surgical Therapy of Hepatocellular Carcinoma: State of the Art Liver Resection

Hepatocellular carcinoma (HCC) represents the third most common cause of cancer-related death, showing incremental growth rates throughout the last decades. HCC requires multidisciplinary approach in a group of patients suffering from underlying chronic liver disease, usually in the setting of cirrhosis. The mainstay of treatment in resectable cases is surgery, with anatomic and non-anatomic liver resections widely implemented, as well as liver transplantation in well-selected individuals. Nowadays, there is a variety of liver parenchyma transection devices used by hepatobiliary surgeons in specialized centers, which has significantly improved postoperative outcomes in HCC patients. Therefore, hepatectomy is considered safe and feasible and should be the main therapeutic option for HCC patients, candidates for resection. Liver resection utilizing cavitron ultrasonic aspirator in combination with bipolar radiofrequency ablation is safe and effective for the treatment of HCC with favorable clinical and oncological outcomes

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

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p &lt; 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

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

Μελέτη του φλεγμονώδους διηθήματος στις νεοπλασματικές παθήσεις του παγκρέατος

Εισαγωγή Το αδενοκαρκίνωμα του παγκρέατος (PDAC) είναι ανθεκτικό στην ανοσοθεραπεία. Για να κατανοήσουμε τους μηχανισμούς που οδηγούν στην κακή ανταπόκριση σε αυτού του τύπου τη θεραπεία, απαιτείται καλύτερη κατανόηση του ανοσοποιητικού τοπίου του PDAC. Η παρούσα εργασία στοχεύει στη μελέτη του ανοσοποιητικού προφίλ στο PDAC σε σχέση με τη χωρική ετερογένεια του μικροπεριβάλλοντος του όγκου (TME) σε ακέραιους ιστούς. Μέθοδοι Πραγματοποιήθηκε multiplex in situ ανάλυση σε 42 δείγματα PDAC για την εκτίμηση έκφρασης γονιδίων και πρωτεΐνών σε επίπεδο κυττάρου στο: (α) κέντρο του όγκου (TC), (β) στο διηθητικό μέτωπο (IF), και σε (γ) φυσιολογικό παρέγχυμα δίπλα στον όγκο. Αποτελέσματα Παρατηρήσαμε: (α) εμπλουτισμό του μικροπεριβάλλοντος του όγκου με υποπληθυσμούς Τ κυττάρων με εξαντλημένο και γηρασμένο φαινότυπο στο TC, IF β) κυρίαρχη ανοσοαπόκριση τύπου 2 στο TME, η οποία είναι πιο έντονη στο TC γ) αναδυόμενο ρόλο του άξονα CD47-SIRP και (δ) παρόμοιο ανοσολογικό προφίλ και σύνθεση του φλεγμονώδους διηθήματος στο ΤΜΕ ανεξάρτητα από τη χορήγηση ή μη νεοεπικουρικής χημειοθεραπείας. Συμπέρασμα Αυτή η μελέτη αποκαλύπτει την ύπαρξη δυσλειτουργικών Τ λεμφοκυττάρων με ειδική χωρική κατανομή, ανοίγοντας έτσι μια νέα διάσταση στην αλληλεπίδραση όγκου-στρώματος στο PDAC, με πιθανό αντίκτυπο στην αποτελεσματικότητα των ανοσορυθμιστικών θεραπευτικών μεθόδων.Background Pancreatic ductal adenocarcinoma (PDAC) is resistant to single-agent immunotherapies. To understand the mechanisms leading to the poor response to this treatment, a better understanding of the PDAC immune landscape is required. The present work aims to study the immune profile in PDAC in relationship to spatial heterogeneity of the tissue microenvironment (TME) in intact tissues. Methods Serial section and multiplex in situ analysis were performed in 42 PDAC samples to assess gene and protein expression at single-cell resolution in the: (a) tumor center (TC), (b) invasive front (IF), (c) normal parenchyma adjacent to the tumor. Results We observed: (a) enrichment of T cell subpopulations with exhausted and senescent phenotype in the TC, IF; (b) a dominant type 2 immune response in the TME, which is more pronounced in the TC (c) an emerging role of CD47-SIRP axis and (d) a similar immune cell topography independently of the neoadjuvant chemotherapy. Conclusion This study reveals the existence of dysfunctional T lymphocytes with specific spatial distribution, thus opening a new dimension both conceptually and mechanistically in tumor-stroma interaction in PDAC with potential impact on the efficacy of immune-regulatory therapeutic modalities

Evaluation of inflammatory infiltrate in neoplastic diseases of the pancreas

Pancreatic ductal adenocarcinoma (PDAC) is resistant to single-agent immunotherapies. To understand the mechanisms leading to the poor response to this treatment, a better understanding of the PDAC immune landscape is required. The present work aims to study the immune profile in PDAC in relationship to spatial heterogeneity of the tissue microenvironment (TME) in intact tissues. Methods: Serial section and multiplex in situ analysis were performed in 42 PDAC samples to assess gene and protein expression at single-cell resolution in the: (a) tumor center (TC), (b) invasive front (IF), (c) normal parenchyma adjacent to the tumor. Results: We observed: (a) enrichment of T cell subpopulations with exhausted and senescent phenotype in the TC, IF; (b) a dominant type 2 immune response in the TME, which is more pronounced in the TC (c) an emerging role of CD47-SIRP axis and (d) a similar immune cell topography independently of the neoadjuvant chemotherapy. Conclusion: This study reveals the existence of dysfunctional T lymphocytes with specific spatial distribution, thus opening a new dimension both conceptually and mechanistically in tumor-stroma interaction in PDAC with potential impact on the efficacy of immune-regulatory therapeutic modalities.Εισαγωγή: Το αδενοκαρκίνωμα του παγκρέατος (PDAC) είναι ανθεκτικό στην ανοσοθεραπεία. Για να κατανοήσουμε τους μηχανισμούς που οδηγούν στην κακή ανταπόκριση σε αυτού του τύπου τη θεραπεία, απαιτείται καλύτερη κατανόηση του ανοσοποιητικού τοπίου του PDAC. Η παρούσα εργασία στοχεύει στη μελέτη του ανοσοποιητικού προφίλ στο PDAC σε σχέση με τη χωρική ετερογένεια του μικροπεριβάλλοντος του όγκου (TME) σε ακέραιους ιστούς. Μέθοδοι: Πραγματοποιήθηκε multiplex in situ ανάλυση σε 42 δείγματα PDAC για την εκτίμηση έκφρασης γονιδίων και πρωτεΐνών σε επίπεδο κυττάρου στο: (α) κέντρο του όγκου (TC), (β) στο διηθητικό μέτωπο (IF), και σε (γ) φυσιολογικό παρέγχυμα δίπλα στον όγκο. Αποτελέσματα: Παρατηρήσαμε: (α) εμπλουτισμό του μικροπεριβάλλοντος του όγκου με υποπληθυσμούς Τ κυττάρων με εξαντλημένο και γηρασμένο φαινότυπο στο TC, IF β) κυρίαρχη ανοσοαπόκριση τύπου 2 στο TME, η οποία είναι πιο έντονη στο TC γ) αναδυόμενο ρόλο του άξονα CD47-SIRP και (δ) παρόμοιο ανοσολογικό προφίλ και σύνθεση του φλεγμονώδους διηθήματος στο ΤΜΕ ανεξάρτητα από τη χορήγηση ή μη νεοεπικουρικής χημειοθεραπείας. Συμπέρασμα: Αυτή η μελέτη αποκαλύπτει την ύπαρξη δυσλειτουργικών Τ λεμφοκυττάρων με ειδική χωρική κατανομή, ανοίγοντας έτσι μια νέα διάσταση στην αλληλεπίδραση όγκου-στρώματος στο PDAC, με πιθανό αντίκτυπο στην αποτελεσματικότητα των ανοσορυθμιστικών θεραπευτικών μεθόδων