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

Minimally invasive transcervical esophagectomy with mediastinal lymphadenectomy for cancer. A Comparison with standardized techniques

Εισαγωγή/Σκοπός Η χειρουργική παραμένει πρωτοπόρος στον αλγόριθμο της θεραπείας του καρκίνου του οισοφάγου. Συγκεκριμένα, η οισοφαγεκτομή δύο σταδίων (Ivor Lewis) ή τριών σταδίων (McKeown), η οποίες συνδυάζουν κοιλιακή και θωρακική προσπέλαση, είναι η επεμβάσεις εκλογής παγκοσμίως για τη θεραπεία του καρκίνου του μέσου ή κατώτερου οισοφάγου, καθώς και της καρδιο-οισοφαγικής συμβολής. Η διαθωρακική οισοφαγεκτομή όμως, έχει διαχρονικά συσχετιστεί με αυξημένα ποσοστά μετεγχειρητικής νοσηρότητας, κυρίως αναπνευστικών επιπλοκών. Η ελάχιστα επεμβατική οισοφαγεκτομή προσφέρει αξιοσημείωτη βελτίωση στα κλινικά αποτελέσματα των ασθενών που υποβάλλονται σε οισοφαγεκτομή καθώς και σημαντική μείωση των αναπνευστικών επιπλοκών σε σχέση με την ανοικτή οισοφαγεκτομή. Η ελάχιστα επεμβατική διατραχηλική οισοφαγεκτομή με ταυτόχρονο λεμφαδενικό καθαρισμό του μεσοθωρακίου αποφεύγει την είσοδο στο θώρακα, κάτι το οποίο μπορεί περεταίρω να μειώσει τις αναπνευστικές επιπλοκές σε σχέση με τις άλλες τεχνικές ελάχιστα επεμβατικής οισοφαγεκτομής. Υλικό και Μέθοδος Η μέθοδος αυτή αναφέρεται σε διατραχηλική κινητοποίηση του οισοφάγου με συνοδό λεμφαδενικό καθαρισμό του ανωτέρου και μέσου μεσοθωρακίου, ακολουθούμενη από διακοιλιακό-διασκελιάιο ολοκλήρωση της κινητοποίηση του κατώτερου θωρακικού οισοφάγου, λεμφαδενικού καθαρισμού στην άνω κοιλία και το κατώτερο μεσοθωράκιο αλλά και προετοιμασία και διατομή του στομάχου για αποκατάσταση της συνέχειας του πεπτικού. Αποτελέσματα H υιοθέτηση των ελάχιστα επεμβατικών τεχνικών στην διατραχηλική προσπέλαση, όπως η λαπαροσκόπηση/θωρακοσκόπηση ή η ρομποτική θωρακοσκόπηση έχουν κάνει εφικτή την ριζική λεμφαδενική κένωση του μεσοθωρακίου και κατ’ επέκταση την ριζική οισοφαγεκτομή. Αυτή η πρωτοπόρος χειρουργική προσέγγιση με αποφυγή της θωρακοτομής ή θωρακοσκόπησης επιτρέπει την πρόσβαση στο μεσοθωράκιο χωρίς αποκλεισμό του ενός πνεύμονα (δεξιού), όπως συμβαίνει στην διαθωρακική οισοφαγεκτομή. Ασθενείς με προηγούμενες επεμβάσεις στο θώρακα, ασθενείς με μείζονα αναπνευστική ανεπάρκεια ή επιβαρυντικές συνοσηρότητες που δεν είναι δυνατό να υποβληθούν σε διαθωρακική οισοφαγεκτομή, έχουν πλέον την πρόσβαση σε μια επέμβαση ριζική, χωρίς εκπτώσεις στην έκταση της λεμφαδενικής κένωσης. Συμπέρασμα Η ελάχιστα επεμβατική διατραχηλική οισοφαγεκτομή με ταυτόχρονη λεμφαδενική κένωση του μεσοθωρακίου για καρκίνο είναι μια ασφαλής και εφικτή χειρουργική προσέγγιση η οποία προσφέρει κλινικά και ογκολογικά αποτελέσματα σε βάθος χρόνου.Background/Aim Pulmonary complications remain the most common problem following transthoracic esophagectomy for the treatment of esophageal and gastro-esophageal junction cancer. Minimally invasive approach has significantly improved clinical outcomes; however, respiratory distress is still significant. Minimally invasive transcervical esophagectomy avoids thoracic access, which may provide a decrease in pulmonary complications after esophagectomy. Material and Methods Transcervical esophagectomy refers to transcervical esophageal mobilization and mediastinal lymphadenectomy followed by a transhiatal gastric and distal-esophageal mobilization, abdominal and lower mediastinal lymphadenectomy. Adoption of innovative minimally invasive techniques for the transcervical or transhiatal approach, such as laparoscopy or robotic-assisted mediastinoscopy have made possible radical transmediastinal approach for radical esophagectomy. Results This novel approach with avoidance of thoracotomy or thoracoscopy can omit one lung ventilation as in transthoracic esophagectomy. Patients with previous thoracic surgery, impaired respiratory system and major comorbidities which were unable to undergo transthoracic esophagectomy become candidates for radical esophagectomy with promising results. Conclusion Minimally invasive transcervical esophagectomy is a safe and feasible approach and may act as a valuable alternative to open or minimally invasive transthoracic esophagectomy, with no thoracic access, minimal thoracic trauma, lower rates of pulmonary complications, and favorable clinical and oncological outcomes

Laparoscopic repair of Amyand's hernia complicated with acute appendicitis. Report of a case

The presence of vermiform appendix in an inguinal hernia sac is known as Amyand's hernia. Amyand's hernia complicated with acute appendicitis is an extremely rare entity with challenging diagnosis and large debate about the optimal treatment option. We report a case of a 58-year-old man presenting to the Emergency Department with an incarcerated right inguinal hernia. At laparoscopy, an inflamed appendix was identified within the inguinal canal, representing an indirect Amyand's hernia. A laparoscopic appendicectomy was performed followed by a trans-abdominal pre-peritoneal mesh repair of the aforementioned hernia. We report this rare clinical entity raising physicians' awareness to include acute appendicitis within an Amyand's hernia in the differential diagnosis of incarcerated inguinal hernias, along with a successful minimally invasive surgical approach

An extraordinary rare anastomotic band causing food bolus obstruction following uneventful minimally invasive esophagectomy: endoscopic treatment

The most common long-term complication post esophagectomy implicating the esophagogastric anastomosis is stricture-induced stenosis leading to late postoperative dysphagia. Herein, we present a case of a male patient readmitted to our Upper Gastrointestinal Department due to a food bolus obstruction through an anastomotic epithelial band arisen from a prior esophagogastric anastomosis performed 5 months earlier. A band transection in between two hemostatic clips placed on both sides of the band, followed by a release and fragmentation of the foreign body into several pieces led to its final transoral removal endoscopically. The patient experienced a direct resolution of his dysphagia and discharged on the same day. At 6 months follow-up, he remains symptom-free. In conclusion, endoscopic state-of-the-art techniques when combined with standard hemostatic surgical principles in a minimally invasive manner are excellent tools for the management of post-esophagectomy syndromes

Minimally Invasive Transcervical Esophagectomy With Mediastinal Lymphadenectomy for Cancer. A Comparison With Standardized Techniques

Pulmonary complications remain the most common problem following transthoracic esophagectomy. Minimally invasive approach has significantly improved clinical outcomes; however, respiratory distress is still significant. Minimally invasive transcervical esophagectomy with mediastinal lymphadenectomy avoids thoracic access, which may decrease pulmonary complications. Transcervical esophagectomy refers to transcervical esophageal mobilization and mediastinal lymphadenectomy followed by a transhiatal gastric and distalesophageal mobilization, abdominal and lower mediastinal lymphadenectomy. Adoption of innovative minimally invasive techniques for the transcervical or transhiatal approach, such as laparoscopy or robotic-assisted mediastinoscopy have made possible transmediastinal approach for radical esophagectomy. This novel approach with avoidance of thoracotomy or thoracoscopy can omit one lung ventilation as in transthoracic esophagectomy. Patients with previous thoracic surgery, impaired respiratory system, and major comorbidities, who are unable to undergo transthoracic esophagectomy, become candidates for radical esophagectomy with promising results. Minimally invasive transcervical esophagectomy for esophageal cancer is a safe and feasible approach and may be a valuable alternative with promising clinical and oncological outcomes

Bochdalek hernia with intrathoracic spleen treated by robotic-assisted mesh repair utilizing indocyanine green contrast media intraoperatively. A case report

Bochdalek hernias are usually diagnosed in newborns. However, they can occur in adults. Few reports exist regarding robotic repair of such hernias. We present a case of a female patient with symptomatic Bochdalek hernia, including the spleen. Patient was successfully treated by robotic-assisted surgical mesh with the use of indocyanine green (ICG). An 80-year-old female patient presented with dyspnea, angina and intermittent abdominal pain. She had loss of appetite and 15-kg weight loss within 3 months. Past medical history was unremarkable. Imaging revealed a left Bochdalek hernia. The patient underwent robotic-assisted surgery; hernia contents included stomach, parts of colon, omentum and remarkably the spleen. Sac was dissected free. Patency of organs was assessed with ICG. Diaphragmatic defect was repaired with mesh. Bochdalek hernias should be surgically repaired. Minimally invasive therapy is safe and effective. Intraoperative ICG use can provide excellent results with favorable clinical outcomes

Over-the-scope-clip treatment of gastrobronchial fistula following minimally invasive oesophagectomy: a novel approach

Gastrobronchial fistulae (GBF) following minimally invasive oesophagectomy (MIO) is a rare entity, with an estimated incidence of 0.3-1.5% according to the published literature. It could present with persistent cough (Ohno’s sign), chest pain, haemoptysis and recurrent pneumonia. Barium swallow examination remains the most sensitive investigation in 78% of the cases; the main stay of management is surgical and in some cases endoscopic (stent insertion). We report a rare case of a GBF 1 month after two-stage MIO for cancer of the gastro-oesophageal junction, which was successfully treated for the first time with an over-the-scope-clip

Is idiopathic granulomatous mastitis a surgical disease? The jury is still out

Idiopathic granulomatous mastitis (IGM), is a rare entity of chronic inflammatory disorder of the breast of unknown etiology. Very few cases have been described so far, almost exclusively in women. Here we describe a case of IGM in a 53-year-old man presented with a right breast mass, progressively enlarging during the last 6 months. Due to the findings of clinical examination and CT-scan, the suspicion for a potentially malignant lesion was given and the decision for surgical resection was made. Microscopic analysis of the specimen showed non-caseating granulomas around mammary lobules, findings compatible with IGM. The patient is recurrence-free at 18-month follow-up. IGM is a rare benign inflammatory breast disease, usually seen in females of reproductive age. Establishing a diagnosis can be challenging for a surgeon and requires a high index of suspicion as most patients are initially misdiagnosed by their primary care physicians. Steroids and immunosuppressive drugs are considered as fundamental treatment modalities but they are correlated with increased rates of disease response and recurrence. On the contrary, surgical resection demonstrated significantly superior results compared to steroid-alone treatment in terms of recurrence and post-treatment recovery