The importance of prehabilitation of patients prior to esophagectomy

Scop: Momentan, nu există un standard de aur referitor la preoptimizarea pacienților înainte de esofagectomie, în timp ce multiple studii raportează rezultate postoperatorii îmbunătățite după implementarea diverselor programe de pregătire. Una dintre principalele probleme rămâne aderența la programul de pregătire; un program la domiciliu poate ajuta semnificativ cu aceasta problema, făcând preoptimizarea mai accesibilă. Material și metode: Prin studiul de față raportăm o serie de pacienți înrolați într-un program de pregătire preoperatorie la domiciliu. Studiul a demarat în 2022 și este în curs de desfășurare. Programul de pregătire cuprinde optimizarea nutrițională (alimentație hiperproteică și suplimente proteice precum pudra de proteine sau băuturi proteice, suplimentare cu micronutrienți, montare jejunostomie de alimentație la nevoie), terapie fizică (plimbări zilnice și exerciții fizice ușoare), terapie respiratorie (exerciții inspiratorii și expiratorii folosind spirometrul de exerciții), șsi optimizare psihologica (suportul familiei și a prietenilor). Rezultate: Douăzeci și unu de pacienți au fost incluși în studiu. Câteva din beneficiile percepute includ status nutrițional și respirator îmbunătățit la internare, impact psihologic pozitiv prin implicarea directă a pacientului în procesul de tratament, mobilizarea postoperatorie independenta mai precoce, rata de complicații pulmonare postoperatorii mai scăzută. Concluzii: Preoptimizarea pacienților înainte de esofagectomie poate îmbunătăți semnificativ rezultatele postoperatorii. Programele bazate la domiciliu pot fi soluția pentru implementarea pe scară largă.Aim: There is currently no standard of care regarding prehabilitation programs before esophagectomy, while several studies report improved postoperative outcomes with different programs. One of the main issues remains the difficulties with adherence to the programs; a home-based approach might significantly help with this issue, making prehabilitation more affordable and patient-friendly. Methods: We report a prospective series of cases that were enrolled in a home-based prehabilitation program. The study started in 2022 and is ungoing. The prehabilitation program includes nutritional optimization (protein-rich foods and supplements like protein powder or protein drinks, micronutrient supplements, feeding jejunostomy – when needed), physical therapy (daily walks and basic exercises), respiratory training (Inspiratory and expiratory muscle training - spirometer) and psychological optimization (family and friends support). Results: Twenty-one patients were enrolled in our study. Some of the perceived benefits of the prehabilition program includes: better nutritional and physical status at admission, psychological benefit due to the patient being involved into the treatment process, earlier postoperative independent mobilization, lower postoperative pulmonary complications. Conclusions: Prehabilitation in patients undergoing esophagectomy can significantly improve outcomes. Home-based programs are efficient and might be the solution for implementing prehabilitation on a large scale

A step-by-step laparoscopic suturing skills educational program for surgical resident trainees

Scop: Modelul educațional see one - do one – teach one s-a dovedit ca fiind ineficient în învățarea tehnicilor de chirurgie minim invaziva. Sutura laparoscopică este o tehnică esențială în chirurgia minim invazivă, dar în același timp dificil de învățat. Scopul studiului nostru este să dovedească necesitatea și fezabilitatea unui model de training etapizat pentru introducerea rezidenților din specialitățile chirurgicale în bazele suturii laparoscopice. Material și metode: Studiul nostru este un studiu prospectiv care a inclus rezidenți din specialități chirurgicale fără experiență anterioara în sutura laparoscopică. Au fost organizate trei sesiuni separate de training, pe diferite nivele de dificultate: aptitudini de baza în sutura laparoscopică: exerciții dedicate manipulării acului și efectuării nodurilor chirurgicale; aptitudini intermediare în sutura laparoscopică: suturi continue și întrerupte folosind fire monofilament, multifilament pe materiale sintetice și biologice; aptitudini avansate în sutura laparoscopică: efectuarea anastomozelor intestinale terminoterminale și laterolaterale. Rezultate: Douăzeci de participanți au fost incluși în primele două sesiuni, respectiv 10 participanți fiind incluși în a treia sesiune. Cinci participanți au fost înrolați consecutiv în toate cele 3 sesiuni de training. Comparativ cu participanții care nu au urmat programul etapizat, cei 5 participanți au avut timpi de execuție mai rapizi și tehnică chirurgicală de calitate mai bună, indiferent de anul de rezidențiat. Concluzii: Modelul de training propus permite participanților să învețe noile principii într-o manieră graduală, permițând învățarea eficientă a tehnicilor complexe de sutură, dovedind astfel eficacitatea modelului educațional.Aim: The see one - do one - teach one apprenticeship model has been proved to be ineffective in teaching minimally invasive surgical skills. Laparoscopic suturing is an essential technique for minimally invasive surgery, but as well a very difficult skill to learn. The aim of our study is to prove the necessity and the feasibility of a step-by-step training model for teaching surgical residents the basic of laparoscopic suturing. Methods: We have conducted a prospective study that included surgical residents without previous experience in laparoscopic suturing. Three separate training sessions were organized, based on different competency levels: basic skills in laparoscopic suturing: exercises for needle manipulation and knot tying; intermediate laparoscopic suturing skills: interrupted and continuous sutures using multifilament, monofilament, and barbed wires on synthetic and biologic material; advanced laparoscopic suturing skills: end-to-end and side-to-side intestinal anastomoses. The activity of the participants was evaluated by 5 trainers. Results: Twenty participants were enrolled in the first two sessions and 10 participants were enrolled in the third session. Five participants have consecutively participated in all three training sessions. Compared to the participants that did not follow the step-up program, the 5 participants had faster execution times and higher quality suturing, regardless of their year of study. Conclusions: Our proposed training model allows the trainee to get acquainted with the new patterns of movement in a gradual manner, allowing them to efficiently learn complex suturing skills, proving to be an effective teaching method

Iatrogenic bile duct injuries – the road to consensus

Scop: Leziunile iatrogene de cale biliară după colecistectomia laparoscopică reprezintă o problemă serioasă care trebuie manageriată corect din punct de vedere diagnostic și al unui tratament prompt. Multiple clasificări au fost dezvoltate și utilizate pentru descrierea acestor leziuni. Material și metode: Studiul nostru este un studiu de tip retrospectiv descriptiv cu scopul de a identifica rolul unei clasificări uniforme și complete, dar și implicarea acesteia în managementul leziunilor de cale biliară. Au fost incluși pacienți referați în centru nostru terțiar, pentru tratamentul leziunilor de cale biliară survenite după colecistectomia laparoscopică, pe o perioadă de 10 ani (2011-2020). Rezultate: O sută de pacienți au fost incluși în studiu; 15% din leziuni au fost întâmpinate la cazuri operate primar în serviciul nostru. În 73% din cazuri, leziunile nu au fost clasificate, în 23% din cazuri s-a utilizat clasificarea Strasberg, în 3% din cazuri clasificarea Bismuth, iar în 1% din cazuri clasificarea ATOM. După reclasificarea retrospectivă a tuturor cazurilor, s-a observat că clasificarea Straberg, dar chiar și clasificarea Hannover suprasimplifică complexitatea leziunii. Tratamentul în majoritatea cazurilor a fost derivația biliodigestivă (60% din cazuri). Concluzii: Clasificarea ATOM realizează o descriere comprehensivă a leziunilor biliare, putând ghida astfel tratamentul corespunzător în funcție de severitatea fiecărei leziuni. O clasificare uniformă ar trebui adoptată la scară largă pentru a asigura un limbaj comun în discuția referitoare la leziunile de cale biliară.Aim: Iatrogenic bile duct injuries after laparoscopic cholecystectomy represent a significant problem, that needs to be addressed correctly in terms of diagnosis and prompt treatment. Several classifications have been developed and used to describe these lesions. Methods: Our study is a retrospective descriptive study that aims to identify the role of an uniform and comprehensive classification and its implication on the consecutive management of the bile duct injury. We have included patients diagnosed with bile duct injury after laparoscopic cholecystectomy, referred to a tertiary centre, in a ten-year period (2011-2020). Results: We included in our study 100 patients; 15% of the BDI occurred in our center. No classification system was used in 73% of patients; 23% of the BDI were classified by the Strasberg system, 3% were classified by the Bismuth classification, 1% being classified by the ATOM classification. After retrospectively classifying all BDI, we observed that especially the Strasberg classification, as well as Hannover, over-simplifies the characteristics of the injury. Most main bile duct injuries underwent a bilio-digestive anastomosis (60%), as a definitive treatment. Conclusions: The ATOM classification performs a comprehensive description of the bile duct injury and subsequent guidance of the correct treatment according to the severity of each lesion. A consistent classification should be adopted, in order to assure a uniform discussion on iatrogenic bile duct injuries

Can Tumor-Infiltrating Lymphocytes (TILs) Be a Predictive Factor for Lymph Nodes Status in Both Early Stage and Locally Advanced Breast Cancer?

The status of axillary lymph nodes is an important prognostic factor in the outcome of breast cancer tumors. New trials changed the attitude towards axillary clearance. In the era of development of new immune therapies for breast cancer, it is important to identify a biomarker that can predict lymph node status. Tumor-infiltrating lymphocytes (TILs) are a valuable indicator of the immune microenvironment that plays the central role in new anticancer drugs. Although the correlation between TILs and response to chemotherapy was established by previous studies, our retrospective study investigated the correlation between TILs and lymph node status. We analyzed data on 172 patients. According to stage, patients were divided in two groups: patients who underwent primary surgical treatment (breast-conserving or mastectomy and sentinel lymph node (SLN) biopsy +/− axillary clearance in conformity with lymph node status) and patients who received chemotherapy prior to surgical treatment (breast-conserving or mastectomy + axillary clearance). We showed a good inverse correlation between TILs and lymph nodes status for both early stage and locally advanced breast cancers. Moreover, TILs are a predictor for positive lymph nodes in the axilla in patients undergoing axillary clearance after SLN biopsy, with no statistical difference between the intrinsic or histological subtype of breast cancers. We also obtained a significant correlation between TILs and response to chemotherapy with no significative difference according to histological subtype. Although further data have still to be gathered before meeting the criteria for clinical utility, this study demonstrates that TILs are one of the most accredited forthcoming biomarkers for breast cancer (BC) patients

Emergency Pancreatoduodenectomy: A Non-Trauma Center Case Series

(1) Background: Emergency pancreatoduodenectomy (EPD) is a rare procedure, especially in non-trauma centers. Pancreatoduodenectomy is a challenging intervention, that has even higher risks in emergency settings. However, EPD can be a life-saving procedure in selected cases. (2) Methods: Our study is a single-center prospective consecutive case series, on patients that underwent emergency pancreatoduodenectomies in our surgical department between January 2014 to May 2021. (3) Results: In the 7-year period, 4 cases were operated in emergency settings, out of the 615 patients who underwent PD (0.65%). All patients were male, with ages between 44 and 65. Uncontrollable bleeding was the indication for surgery in 3 cases, while a complex postoperative complication was the reason for surgery in one other case. In three cases, a classical Whipple procedure was performed, and only one case had a pylorus-preserving pancreatoduodenectomy. The in-hospital mortality rate was 25% and the morbidity rate was 50%; the two patients that registered complications also needed reinterventions. The patients who were discharged had a good long-term survival. (4) Conclusion: EPD is a challenging procedure, rare encountered in non-traumatic cases, that can be a life-saving intervention in well-selected cases, offering good long-term survival

The Role of IL-22 in Wound Healing. Potential Implications in Clinical Practice

Wound healing is a complex process that is mediated and influenced by several cytokines, chemokines, and growth factors. Interleukin-22 (IL-22) is a cytokine that plays a critical role in tissue regeneration. Our study is a systematic review that addressed the implications of IL-22 in the healing of wounds caused by external factors. Thirteen studies were included in our review, most of them being experimental studies. Three clinical studies underlined the potential role of IL-22 in day-to-day clinical practice. IL-22 plays a central role in wound healing, stimulating the proliferation, migration, and differentiation of the cells involved in tissue repair. However, overexpression of IL-22 can cause negative effects, such as keloid scars or peritoneal adhesions. The results of the presented studies are promising, but further research that validates the roles of IL-22 in clinical practice and analyzes its potential implication in surgical healing is welcomed

Corrosive esophageal strictures – methods of esophageal conduit reconstruction

Scop: Tratamentul definitiv al stenozelor caustice esofagiene rămâne tratamentul chirurgical, mai ales atunci când tratamentul endoscopic eșuează. Modalitatea ideala de abord chirurgical rămâne o controversă între esofagectomie cu reconstrucție cu conduct gastric sau colonic, și esofagoplastie cu interpoziție de colon. Material și metode: Studiul nostru constă într-un review al literaturii de specialitate pe modalitățile de reconstrucție esofagiană în stenozele caustice și rezultatele postoperatorii asociate, cât și o prezentare a unei serii de cazuri din experiența proprie a centrului nostru. Rezultate: Literatura medicală raportează cazuri tratate prin ambele tehnici chirurgicale, rezultatele postoperatorii favorizând esofagoplastia prin morbimortalitatea perioperatorie mai redusa comparativ cu esofagectomia; în același timp, unii autori preferă esofagectomia pentru a elimina riscul dezvoltării în timp a unui carcinom scuamos esofagian. Raportăm 2 cazuri cunoscute cu ingestie de substanță caustică în scop suicidar, care au dezvoltat stenoze esofagiene severe; ambele cazuri au necesitat pregătire preoperatorie nutrițională – în primul caz s-a montat o jejunostomie, iar în al doilea caz s-a efectuat o gastrostomie endoscopică. În primul caz, s-a efectuat esofagectomie prin triplu abord cu reconstrucție folosind grefon colic stâng, iar in al doilea caz s-a practicat o esofagoplastie cu reconstrucție folosind grefon colic drept ascensionat retrosternal. Primul caz a dezvoltat o fistula anastomotică tratată cu succes conservativ. Concluzii: Tratamentul chirurgical al stenozelor esofagiene caustice trebuie să implice decizii personalizate, bazate pe caracteristicilor fiecărui pacient. Bypass-ul folosind grefon colic ascensionat retrosternal, cât și esofagectomia cu reconstrucție folosind grefon colic sunt opțiuni viabile de tratament.Aim: The definitive treatment of corrosive esophageal strictures remains the surgical treatment, especially when endoscopic treatment fails. The ideal surgical approach remains a controversy between esophagectomy and reconstruction with gastric or colonic conduit and esophageal bypass through colon interposition. Methods: Our study consists in a literature review based on the modalities of esophageal conduit reconstruction in corrosive strictures and the associated postoperative results, as well as a case series from our centre’s experience. Results: The medical literature reports cases treated through both approaches, the postoperative results favouring esophageal bypass due to a lower postoperative morbidity and mortality rate; at the same time, some authors prefer esophagectomy in order to eliminate the risk of squamous cell carcinoma development. We report 2 cases of corrosive substance ingestion in suicidal purposes, that developed severe esophageal strictures; both cases needed preoperative nutritional preparation – in the first case, a jejunostomy was performed, while in the second case, an endoscopic gastrostomy was performed. The first case underwent McKeown esophagectomy with left colon reconstruction, while the second case underwent esophageal bypass with retrosternal right colon interposition. The first case developed an anastomotic fistula that was treated with conservative treatment. Conclusions: The surgical treatment of corrosive esophageal strictures needs to be a personalized choice based on each patient’s characteristics. Esophageal bypass with retrosternal colonic conduit, as well as esophagectomy with colonic conduit reconstruction are viable options to be considered

Preventing Breast Cancer-Related Lymphedema: Feasibility of Axillary Reverse Mapping Technique

Introduction. Our study aimed to determine the feasibility of axillary reverse mapping (ARM) technique, the identification rate of ARM nodes and their metastatic involvement, as well as to identify the factors that influence the identification and metastatic involvement. Material and methods. In total, 30 breast cancer patients scheduled for axillary lymph node dissection were enrolled in our study. The lymphatic nodes that drain the arm were identified by injecting 1 mL of blue dye in the ipsilateral upper arm; then, the ARM nodes were resected along with the other lymph nodes and sent for histological evaluation. Results. Identification of ARM node was successful in 18 patients (60%) and 22.22% of the identified ARM lymph nodes had metastatic involvement. Patients with identified ARM nodes had a significant lower BMI and a statistically significant relationship between axillary lymph node status and ARM node metastases was proven. Most of ARM lymph nodes (96.3%) were found above the intercostobrachial nerve, under the axillary vein and lateral to the thoracodorsal bundle. Conclusions. The ARM procedure is easy to reproduce but might not be appropriate for patients with a high BMI. The rate of metastatic involvement of ARM nodes is significant and no factor can predict it, showing that the preservation of these nodes cannot be considered

The impact of glycogen storage restoration in elective liver resections

Ocluzia temporara a aportului vascular pe de o parte si pierderile sanguine importante, pe de alta parte, reprezinta componente cheie ale chirurgiei hepatice. Totodata, aceste strategii de management vor produce alterari ale functiei hepatice in postoperator. Studiul nostru isi propune sa elucideze efectul refacerii rezervelor de glicogen la pacientii propusi pentru rezectii hepatice elective asupra evolutiei biologice si a insuficientei hepatice postoperatorii.Temporary occlusion of blood inflow for resection on one hand and important blood loss on the other hand is a common strategy in liver surgery. However, hepatic vascular occlusion will undoubtedly impair liver function and anemia will produce systemic imbalances. Our study was designed to elucidate the effect of hepatocellular glycogen storages in alleviation of liver ischemia - reperfusion injury during intraoperative haemodynamic liver injuries for elective hepatectomies, the postoperative impairement and consecutive biologic liver failure

The Multifaceted Role and Regulation of Nlrp3 Inflammasome in Colitis-Associated Colo-Rectal Cancer: A Systematic Review

Colitis-associated colo-rectal cancer remains the leading cause of mortality in inflammatory bowel diseases, with inflammation remaining one of the bridging points between the two pathologies. The NLRP3 inflammasome complex plays an important role in innate immunity; however, its misregulation can be responsible for the apparition of various pathologies such as ulcerative colitis. Our review focuses on the potential pathways of upregulation or downregulation of the NLRP3 complex, in addition to evaluating its role in the current clinical setting. Eighteen studies highlighted the potential pathways of NLRP3 complex regulation as well as its role in the metastatic process in colo-rectal cancer, with promising results. Further research is, however, needed in order to validate the results in a clinical setting