Hidradenitis suppurativa and Langerhans cell histiocytosis are rare disorders that can reveal similar clinical manifestations, making differential diagnosis difficult. A definitive diagnosis requires biopsy and histological confirmation in suspicious cases. The complex pathophysiology of these diseases has still not been understood, therefore the treatment is still a challenge for physicians. It is seen with predilection in the intertriginous areas of the body, predominantly in the axillary region, rarely requiring a surgical procedure. However perineal, perianal, and gluteal HS usually necessitates some form of surgical treatment. Langerhans cell histiocytosis (histiocytosis X) is a very rare systemic disease manifested by clonal cell proliferation of histiocytic-dendritic nature, with pseudonodular manifestation that deeply infiltrates the hypodermis and ulcerates the epidermis on the surface. Langerhans cells are dendritic, antigen-presenting cells localized in the suprabasal regions of the squamous epithelium of the skin and mucous membranes, which help regulate the immune system. In this report, we present our experience with extensive gluteal, perineal, and perianal hidradenitis suppurativa and Langerhans cell histiocytosis cases, including our treatment methods and outcomes.

Introduction Infections caused by multidrug-resistant bacteria (MDR) occur more frequently after pancreaticoduodenectomy (PD) compared to other abdominal surgeries, and infective complications are a leading cause of postoperative morbidity following PD. Pre-operative biliary stent (PBS) placement often leads to biliary contamination, which in turn plays a significant role in postoperative infections. The aim of this study is to evaluate the impact of MDR contamination on short-term postoperative outcomes in patients undergoing PD and to examine the relationship between MDR bacteria, PBS, and bile contamination. Methods This is a retrospective study based on a prospectively maintained database comprising 825 consecutive patients who underwent pancreaticoduodenectomy (PD) between January 2010 and December 2020 at our center. All procedures were conducted with a standardized resection by a dedicated group of surgeons in a specialized pancreatic surgery unit, and the patients were managed according to the same perioperative enhanced recovery protocol. Results MDR bacteria were present in 17.5% of bile cultures, exclusively within the stented group. In our multivariate analysis, the development of a major postoperative complication (MPC) was correlated with the presence of MDR bacteria in the bile (OR 1.66, 95% CI: 1.1-2.52; p = 0.02). MDR bacteria were detected early in the surgical drainage in 144 out of 825 patients (12.1%), with 72.2% having a previous biliary stent placement and 27.8% without stents (p < 0.001). In our multivariate analysis, the development of an MPC was associated with the presence of MDR bacteria in the drainage (OR=1.81, 95% CI: 1.21-2.73, p= 0.0042). Conclusions We demonstrated that MDR contamination worsens the short-term outcomes of patients undergoing PD. Specifically, when MDR bacteria are present in both the bile and drainage, there is a statistically significant increase in the incidence of major postoperative complications (MPC). Our data suggest that the majority of MDR surgical site infections stem from biliary contamination resulting from the placement of a pre-operative biliary stent (PBS).

Background: Robot-assisted laparoscopic surgery robot-assisted surgical system has gained significant popularity over open and laparoscopic interventions. However, given its high costs, it remains unclear what clinical advantages robot-assisted laparoscopic surgery offers over conventional laparoscopic surgery. Objective: This umbrella review aims to synthesize and compare the clinical outcomes of robot-assisted laparoscopic surgery versus conventional laparoscopic surgery for five surgical procedures. Inclusion criteria: All systematic reviews and meta-analyses published in the past five years that compared the clinical outcomes of conventional laparoscopic surgery and robot-assisted laparoscopic surgery for cholecystectomy, colectomy, hysterectomy, nephrectomy and/or prostatectomy were included. Methods: A systematic literature search was conducted in PubMed and Scopus. The quality of all included reviews was assessed with the AMSTAR 2 quality assessment tool. Each review’s study characteristics (and a list of primary sources) were extracted, along with the quantitative and qualitative data for the following ten clinical outcomes: blood loss, rate of conversion to open surgery, hospitalization costs, incisional hernia rate, intraoperative complication rate, postoperative complication rate, length of hospital stay, operative time, readmission rate and wound infection rate. Results: Fifty-two systematic reviews and (network) meta-analyses were included in this umbrella review, covering more than 1,288,425 patients from 1046 primary sources published between 1996 and 2022. The overall quality of the included reviews was assessed to be low or critically low. Robot-assisted laparoscopic surgery yielded comparable results as conventional laparoscopic surgery in terms of blood loss, conversion to open surgery rate, intraoperative complication rate, postoperative complication rate, readmission rate and wound infection rate for most surgical procedures. While the hospitalization costs of robot-assisted laparoscopic surgery were higher and the operative times of robot-assisted laparoscopic surgery were longer than conventional laparoscopic surgery, robot-assisted laparoscopic surgery reduced the length of hospital stay of patients in nearly all cases. Conclusion: Robot-assisted laparoscopic surgery achieved comparable results with conventional laparoscopic surgery for cholecystectomy, colectomy, hysterectomy, nephrectomy and prostatectomy based on ten clinical outcomes. Further research is needed to prove that robot-assisted laparoscopy is as safe and reliable as conventional laparoscopic surgery.

Although COVID-19 primarily affects the respiratory system, it can have various effects on other organs, including the cardiovascular system. COVID-19 can lead to a prothrombotic status, promoting bloodclotting, which can potentially affect native vessels and implanted de-vices. The exact mechanisms by which it leads to increased clotting are not yet fully understood but may involve inflammation, endothelial dysfunction, and a hyperactive immune response. In the present report, we describe a case of an acute aortic stent-graft thrombosis four days after resolution of Sars-Cov2 infection. The patient required emergent explantation of the stent-graft, after the failure of endovascular bailout procedures.

Due to the still large number of patients diagnosed with pelvic neoplasms (colorectal, gynecological, and urological) in advanced stages right from the initial diagnosis, surgery represents the mainstay of treatment, often implying wide, eventually multi-organ resections in order to achieve negative surgical margins. Perineal wound morbidity, particularly in extralevator abominoperineal excision, leads to complications and local infection rates of up to 40%. Strategies to reduce postoperative wound complications are pursued to address this issue.The VRAM flap remains the gold standard for autologous reconstruction after pelvic oncological resection; it was initially designed for abdominal wall defects and later expanded for large pelvic tissue defects.The flap's application is based on its physical characteristics, including abundant tissue and a generous skin paddle, which effectively obliterates dead space after exenterations. The generous skin paddle offers good cosmetic and functional outcomes at the recipient site.This article describes the case of a patient histopathologically diagnosed with stage IIIA squamous cell carcinoma of the uterine cervix who received multimodal onco-surgical treatment. The surgical mainstay of this treatment is pelvic exenteration. Pelvic reconstruction after this major surgery was performed using a vertical flap with the rectus abdominis.

Transforaminal lumbar interbody fusion (TLIF) is a commonly used technique for treating lumbar degenerative diseases. Here, we developed a fully computer-supported pipeline to predict the cage height and the degree of lumbar lordosis subtraction from the pelvic incidence (PI-LL) after TLIF surgery through preoperative X-ray images. The automated pipeline included two primary stages. First, a deep learning model was used to extract essential features from X-ray images. Second, five machine learning algorithms were trained to identify the optimal models to predict the interbody cage height and postoperative PI-LL. Lasso regression and support vector regression exhibited superior performance for predicting the interbody cage height and postoperative PI-LL, respectively. For cage height prediction, the root mean square error (RMSE) was calculated as 1.01, and the model achieved the highest accuracy at a height of 12 mm, with exact prediction achieved in 54.43% (43/79) of cases. In most of the remaining cases, the prediction error of the model was within 1 mm. In addition, the model demonstrated adequate performance for predicting PI-LL, with an RMSE of 5.19 and an accuracy of 0.81 for PI-LL stratification. In conclusion, the interbody cage height and postoperative PI-LL can be reliably predicted using artificial intelligence and ML models.

Abstract: The pursuit of youth and attractiveness is a fundamental desire in contemporary society. For many individuals, the appearance of visible signs of aging, such as skin laxity, gravitational changes in facial and neck soft tissues, and loss of harmonious proportions, can be psychologically distressing. The choice of effective methods for addressing these changes depends on their specific characteristics, the patient's anatomical features, and the type of facial aging. The introduction of 3D imaging to determine the hyoid bone level, the volume of soft tissue structures in the cervico-mental area, ptosis of subplatysmal structures, and the volume of submandibular glands, in addition to ultrasound study of the submental projection at the preoperative stage, are key for taking the best decision regarding preoperative planning. This case report aims to illustrate how modern imaging techniques are a fundamental part of the preoperative assessment of the mid and lower third of the face to ensure the most favorable aesthetic outcomes for each patient. Key message: To attain harmonious results in surgical correction of age-related facial and neck changes, it is crucial to consider the patient's anatomical features and the extent of age-related alterations. A comprehensive facial analysis, taking into account the type of facial aging and employing a CT scan and ultrasound examination of the soft tissues in the chin region, facilitates the development of an individualized plan tailored to achieve the patient's desired outcome.

This article examines the evolution of bariatric surgery, with a focus on emerging technologies such as robotics and laparoscopy. In the case of gastric bypass, no significant differences have emerged between the two techniques in terms of hospitalization duration, weight loss, weight regain, or 30-day mortality. Robotic surgery, while requiring more time in the operating room, has been associated with lower rates of bleeding, mortality, transfusions, and infections. In revisional bariatric surgery, the robotic approach has shown fewer complications, shorter hospital stays, and a reduced need for conversion to open surgery. In the case of sleeve gastrectomy, robotic procedures have required more time and longer post-operative stays but have recorded lower rates of transfusions and bleeding compared to laparoscopy. However, robotic surgeries have proven to be more costly and potentially more complex in terms of post-operative complications. The review has also addressed the topic of the single anastomosis duodeno-ileal switch (SADIS), finding comparable results between robotic and laparoscopic techniques, although robotic procedures have required more time in the operating room. Robotic technology has proven to be safe and effective, albeit with slightly longer operating times in some cases.

Gastroesophageal (GE) junction adenocarcinoma is an aggressive malignancy of growing incidence and is associated with public health issues such as obesity and GERD. Management has evolved over the last 2 decades to incorporate a multidisciplinary approach including endoscopic intervention, and neoadjuvant chemotherapy/ chemoradiation and minimally invasive or more limited surgical approaches. Surgical approaches include esophagectomy, total gastrectomy, and more recently proximal gastrectomy. This review analyzes the evidence for and applicability of these varied approaches in management as well areas of continued controversy and investigation.

Most abdominopelvic structures can find their way to a groin hernia. However, location, and relative fixation are important for migration. Gastric outlet obstruction (GOO) from a stom-ach-containing groin hernia (SCOGH) is exceedingly rare. In the current report, we present a 77-year-old man who presented with GOO from SCOGH to our facility. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) of patient presenting with SCOGH since it was first reported in 1802. Ninety-one cases of SCOGH were identified (85 inguinal and 6 femoral) over the last two centuries (1802-2023). GOO from SCOGH occurred in 48% of patients in one review and 18% in our world literature review, but initial presentation ranged from completely asymptomatic to peritonitis. Man-agement varied from entirely conservative treatment to elective hernia repair to emergent lap-arotomy. Only one case of laparoscopic management was documented. Twenty-one deaths from SCOGH were reported, with most occurring in early manuscripts (1802-1896 [n=9] and 1910-1997 [n=10]). In the recent medical era, outcomes for patients with this rare clinical presentation are satisfactory and treatment ranging from conservative, non-operative management to surgical repair should be tailored towards patients’ clinical presentation.

Tracheal agenesis (TA) is a rare congenital anomaly with the incidence of 1 per 50,000 newborns. It appears at birth with severe respiratory distress, cyanosis, and inaudible crying. Prompt esophageal intubation and long-term management of the esophageal airway is essential to overcome the catastrophic condition. In the long-term management, external stenting of the esophageal airway has been reported promising to support the fragile esophageal wall and “trachealize,” which technique was implanted from the surgery for tracheomalacia. We experienced a case of an infant with tracheal agenesis whose respiratory status was stabilized after trachealization of the esophagus using external stenting technique. The stenting was performed based on a lesson learned in the extensive experience in the surgical treatment for tracheomalacia and the surgical techniques for successful stenting in are herein described.

Different prognostic scores have been applied to identify patients with non-small cell lung cancer who have a higher probability of poor outcome. In this study we evaluated whether Naples Prognostic Score, a novel index which considers both inflammatory and nutritional values, was associated with long-term survival. The study is a retrospective propensity score matching analysis of patients who underwent curative surgery for non-small cell lung cancer from January 2016 to December 2021. The score considered four pre-operative parameters: neutrophil to lymphocyte ratio, lymphocyte to monocyte ratio, serum albumin and total cholesterol. Kaplan-Meier method and Cox regression analysis were performed to evaluate the relation between the score and disease-free survival, overall survival and cancer-related survival. A total of 260 patients were selected for the study, reduced to 154 after propensity score matching. Post-propensity Kaplan-Meier analysis showed a significant correlation between Naples Prognostic Score and overall survival (p=0.018) and cancer-related survival (p=0.007). Multivariate Cox regression analysis further validated the score as an independent prognostic indicator for both these survivals (p=0.007 and p=0.010 respectively). Naples Prognostic Score proved to be an easily achievable prognostic factor of long-term survival in patients with non-small cell lung cancer after surgical treatment.

The study aimed to review the management of pediatric digestive duplications (DD) with regards to clinical presentation, operative procedures and complications in a single institution in Bucharest, Romania. A retrospective analysis was performed using patient records from ‘Grigore Alexandrescu’ Emergency Children’s Hospital from 2013 to 2023. All patients with a postoperative diagnosis of DD were selected. A total of 39 children (19 boys, 20 girls) with DD have been treated in our hospital in the past 10 years. Only N=5 of them have been diagnosed antenatally. In N=22 cases patients were referred to our hospital for tumors, while N=17 cases involved an acute setting. Comorbidities were encountered in N=16 patients. Duplications involved several parts of the digestive tract: ileal (N=19), colonic (N=10), esophageal (N=2), jejunal (N=2), gastric (N=2), duodenal (N=1), ileocecal (N=1), esogastric (N=1) and rectal (N=1). Two of the duplications were intraluminal, while the rest were cystic. There were N=28 open interventions and N=11 laparoscopies. Conversion was needed in N=2 cases due to (a) overdistended bowel and (b) dense adhesions between the ileum and the tumor. The tumor was resected in N=17 cases, while intestinal resection was required in N=22 cases. A drain was used in N=21 patients. The average hospital stay for open procedures was 10 days and for laparoscopic procedures 8 days. Complications arose in N=7 patients who had an open procedure and N=1 patient who had a laparoscopic procedure. There were no mortalities. With a low rate of antenatal diagnosis (12.82%), 43.58% of DD appeared in an acute setting. Open procedures were favored in acute cases and patients with comorbidities, but required a longer hospital stay. Laparoscopic management had a 18.18% conversion rate and a low rate of complications (9.09%).

Backround: FNH is a common benign liver lesion, mostly solitary, and with no evidence of malignant transformation over time. The diagnosis can usually be made by imaging modalities with distinct features in MRI- and CT-scans. Case series: We present a case series of three patients with solitary liver tumors which were highly suspicious to be large FNH, based on radiological features. The patients were sent to our center for second opinion and probable treatment. Indication for resection was given because of nonconclusive radiologic imaging in the first, substantial growth progression in the second and elevated AFP in the third case. Histology revealed well to poor differentiated HCCs. Discussion: FNH tends to show a distinct pattern in imaging modalities, but HCC can mimic FNH. The MRI-scan using hepatotropic contrast agent is the most sensitive imaging modality to diagnose FNH. AFP is usually not elevated in FNH. Asymptomatic FNH does not require surgery but a reliable diagnosis is crucial. In case of an uncertain diagnosis surgery should be offered to patients. Conclusion: In cases with a progression in size, an elevated level of AFP should be suspicious. A second opinion at a center for hepato-biliary surgery with HCC/FNH-experienced radiologists and surgeons is reasonable. Generally, an over-therapy via surgery should be avoided and follow-ups of a newly diagnosed FNH including measurement of AFP are advisable to detect alterations.

Study design : Technical note. Objectives: To present a new spinal shortening technique for tethered cord syndrome. Background : Tethered cord syndrome (TCS) is a debilitating condition of progressive neurological decline. Surgical detethering for TCS is a gold standard. However, symptomatic retethering of TCS has been reported in 5%–50% of patients after initial release. To solve this problem, posterior spinal shortening osteotomy has been reported. This technique has risks of massive blood loss and neurological deterioration. The authors hereby report a new safe spinal shortening technique for tethered cord syndrome. Materials and Methods : A 31-year-old man with gait disturbance was referred to our hospital. After the delivery, he underwent surgical untethering of spinal cord in another hospital. He had hyperreflexia of Achilles tendon reflex and muscle weakness of bilateral legs (MMT 3-4). He also had urinary and bowel incontinence, and total sensory loss below L5.Anteroposterior lumbar radiogram indicates partial laminectomy of L3 and L4. Lumbar MRI showed retethering of spinal cord. Results: He underwent new spinal shortening technique for tethered cord syndrome under the guidance of O-arm navigation. First, from anterior approach disectomy from T12 to L3 was performed. Second, from posterior Ponte osteotomy was done from T12 to L3, shorten the spinal column 15 mm. The patient was successfully treated surgically. Postoperative lumbar MRI showed the tension of spinal cord was released. Manual muscle testing results and sensory function of the left leg had recovered almost fully on final follow-up at one year. Conclusions/Level of Evidence: Retethered spinal cord after initial untethering was difficult to treat. This new spinal shortening technique was effective and very safe technique to release the tension of spinal cord. Level V.

Background: Appendicitis is a common cause of emergency department visits and appendectomies in the US, with 250,000 appendectomies performed annually. Current diagnostic methods, such as clinical findings, lead to inaccuracies and missed diagnoses, increasing morbidity and mortality. The only solution is surgery, but current hematological tests are not reliable and may lead to unnecessary surgery if the underlying etiology is self-limiting or requires medical treatment. This study explores the role of MRI as a diagnostic modality that can replace US/CT and supplement traditional clinical diagnostic signs while avoiding ionizing radiation and intravenous contrast medium. The purpose of this meta-analysis is to determine the accuracy of MRI as a diagnostic modality in diagnosing appendicitis, addressing concerns about diagnostic modalities and their adverse effects, and addressing the necessity and success of relevant interventions. Methods: Medical literature was comprehensively searched and reviewed without restrictions to particular study designs, or publication dates using PubMed, Cochrane Library, and Google Scholar databases for all relevant literature formulated in English. The extraction of necessary data proceeded after specific inclusion and exclusion criteria were applied. Meta Analysis was performed for 5206 patients, with 35 RCTs being selected. Analysis was done using the QualSyst tool, wherein two writers independently assessed the caliber of each study as well as the use of the Cochrane tool for bias risk apprehension. The statistical software packages RevMan (Review Manager, version 5.3), SPSS (Statistical Package for the Social Sciences, version 20), and Excel in Stata 14 were used to perform the statistical analyses along with other analytical software. Results: MRI had an overall sensitivity of over 95%, an overall specificity of 94.2% with a PPV of 0.875 in comparison to CT scan in the diagnosis and intervention regarding appendicitis. Conclusion: These findings strongly suggest that MRI is a reasonable alternative to CT for the diagnosis of appendicitis in hospitals with appropriate access to this technology for reasons about accuracy, reliability, and reproducibility as well as addressing safety concerns.

Objectives: Chylothorax is a relatively rare condition of lymphatic fluid accumulation in the thoracic cavity due to a leakage from the thoracic duct or its tributaries. Patients present with dyspnea, malnutrition, and immunosuppression. Treatment can be conservative or surgical, depending on etiology and clinical course. The optimal management algorithm for chylothorax is still controversial. Methods: This is a retrospective study of all patients with chylothorax treated at our Department of Thoracic Surgery during the 10-year period. Results: A total of 14 patients were identified for the study. Nine patients had chylothorax after lung or esophageal cancer surgery. Four patients had chylothorax in advanced lymphoma. One patient had chylothorax after blunt chest trauma. A conservative approach was initiated in most patients (92%), including pleural drainage, nil per mouth, total parenteral nutrition, and somatostatin 0.1 mg bid subcutaneously. Surgical treatment was indicated in patients with thoracic drain production >800 mL per day beyond the fifth day of treatment and those with blunt thoracic trauma. Two patients had thoracic duct ligation via right-sided thoracotomy, and five patients had video-assisted thoracoscopic thoracic duct ligation with the immediate arrest of chylous leakage. Conclusion: Chylothorax should be treated conservatively initially. Surgical treatment should not be delayed in case of failure beyond the fifth day. In our series of patients, a video-assisted thoracoscopic approach for thoracic duct ligation proved to be minimally invasive, highly efficient, and well tolerated by patients and, therefore, should be the preferable route of surgical treatment.

Presenting a case report about an occurrence of duodeno-duodenal intussusception in a 17-year-old female patient. Intussusception is typically observed in children. The patient has a history of recurrent pain and vomiting for four days. During the examination tenderness in the epigastric area worsened when the legs were elevated. An initial X-ray of the abdomen was done and the findings were normal. Subsequent ultrasound and abdominal CECT scans of the abdomen revealed intussusception involving the 2^nd, 3^rd, and 4^th part of the duodenum ampulla of Vater and pancreas without any identifiable cause for this condition. There was no abnormal thickening of the wall. This case shows how using radiological imaging and surgical management helps to prevent severe complications in cases like duodeno-duodenal intussusception in adults.

The quest for surgical advancements regarding the enhancement of the submental and cervicofacial regions has witnessed a remarkable upsurge in recent years. Informed patients are actively seeking sophisticated plastic surgery techniques to achieve comprehensive rejuvenation in these specific areas. Our clinical practice encounters an annual influx of approximately 400 patients, with 20% of them aged over 60, seeking facial rejuvenation encompassing the details of lower third of the face and neck. Common concerns expressed by these patients include sagging of the jawline, the emergence of deep perioral wrinkles, and the formation of "marionette lines" within the lower third of the face. Furthermore, the manifestation of age-related signs, including neck laxity, submental adipose accumulation, "witch's chin" deformity, and weakened platysma musculature, is frequently encountered within this intricate anatomical domain. This review aims to summarize the recent technical improvements, historical evolution, indications, postoperative care and challenges for facial rejuvenation of the lower third of the face and neck. Lastly, the application of minimally invasive procedures as part of a comprehensive approach to an aging face will also be discussed.

Introduction: Bone fractures may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture. Bone cancer can be primarily or secondary to metastasis. Case presentation: We report a rare case of left humerus fracture in a 59-year-old male patient due to metastatic renal cell carcinoma. Our patient had no important past medical history. He suffered from two months of left arm pain, moderate disability and fever at night. Analgesics consumption resulted in minimal relieve. Trauma history was negative. X-ray of the left arm showed an osteolytic lesion with humerus fracture. Abdominal computed tomography with contrast showed right renal mass.Radical right nephrectomy was performed in addition to alignment nailing of the left humerus fracture with biopsy. Pathology report documented clear cell carcinoma with metastatic bone. The treatment was completed by chemotherapyDiscussion: Secondary bone tumors are metastatic lesions which have spread from other organs, most commonly carcinomas of the breast, lung, and prostate, and rarely from kidney. In some cases, bone metastasis could be the first symptoms of renal cell carcinoma. Conclusion: suspected pathological bone fractures should be investigated completely. It may hide a tumor as a cause.

Colorectal cancer is a frequent neoplasm in western countries, mainly due to dietary and behavioral factors. Its incidence is growing in developing countries for the westernization of foods and lifestyles. An increased incidence rate is observed in patients under 45 years of age. In last years the mortality for CRC is decreased, but this trend is slowing. The mortality rate is reducing in those countries where prevention and treatments have been implemented. The survival is increased to over 65%. This trend reflects earlier detection of CRC through routine clinical examinations and screening, more accurate staging through advances in imaging, improvements in surgical techniques and advances in chemotherapy and radiation. The most important predictor of survival is the stage at diagnosis. The screening programs are able to reduce incidence and mortality rates of CRC. The aim of this paper is to provide a comprehensive overview of incidence, mortality and survival rate for CRC.

Introduction: Antitumor host immune response is an important factor, but its role is not fully established. The role of tumor infiltrating lymphocytes (TIL) in breast cancer as an immunological biomarker has been significantly explored over the past years. The number of patients treated with neoadjuvant chemotherapy (NAC) increased and identification of a biomarker to predict the probability of pCR (pathological complete response) is a high priority. Materials and methods: We evaluated 334 cases of BC treated with NAC followed by surgical resection from 2020-2022 in Ist Clinic of Oncological Surgery, Oncological Institute "Prof Dr I Chiricuta" Cluj Napoca. Of the above, 122 cases were available for histological evaluation both in pre-NAC biopsy and post-NAC resection tissue. Evaluation of biopsy fragments and resection parts using hematoxylin eosin (H&amp;E). The TIL evaluation took place according to the recommendations of the International TIL Working Group (ITILWG). Results: There was a strong association between elevated levels of pre-NAC TIL. At the same time, there is a statistically significant correlation between stromal TIL and tumor grade, the number of lymph node metastases, the molecular subtype, and the number of mitoses (p &lt;0.005). Intratumoral TIL showed a significant correlation with tumor size, distant metastasis, molecular subtype, number of mitosis, stage and lymph node metastasis (p&lt;0.005). We also demonstrated that high pre-NAC TILs represent a strong predictive marker for pCR. Conclusion: This study reveals the role of TIL as a predictive biomarker in breast cancer not only for the well-established TNBC (triple negative breast cancer) and HER2+ (Her2 overexpressed) subtypes but also in Luminal A and B molecular subtypes. In this scenario, the evaluation of TILs as novel predictive and therapy-predicting factors should become a routinely performed analysis that could guide clinicians into the choice of the most appropriate therapy.

Small bowel non-Meckelian diverticulosis is a rare condition with only few published cases despite being described over 200 years ago. In the midst of the COVID-19 pandemic, studies suggested that a lot of patients may experience gastrointestinal manifestations. Intestinal symptoms could worsen the inflammation and infection associated with small bowel diverticulitis. Here, we present two cases: one with inflammation and rupture in a COVID-19 patient and the other as an asymptomatic detection. Furthermore, we provide a mini-review of the literature to emphasize the importance of considering this entity in the differential diagnosis of an acute abdomen.

Chronic Mesenteric Ischemia (CMI) arises from the inability to achieve adequate intestinal blood flow after meals, leading to an imbalance between oxygen and metabolite supply and demand. The true incidence of CMI remains uncertain. However, the occurrence of mesenteric artery occlusive disease (MAOD) is relatively common among the elderly population. Delays in diagnosing CMI can often be attributed to several factors, including the variability of patient symptoms, the range of potential causes for chronic abdominal pain with weight loss. Mikkelson pioneered the introduc-tion of a surgical treatment for occlusive lesions of the superior mesenteric artery (SMA) in 1957. The inaugural performance of endovascular revascularization (ER) for visceral vessels took place in 1980. The literature has documented two types of endovascular revascularization (ER) methods: percutaneous transluminal angioplasty (PTA) and primary stenting (PMAS). Despite the limited quality of available evidence, the consensus among experts is strongly in favor of PMAS over PTA alone for the treatment of atherosclerotic mesenteric artery stenosis. There are several key areas of focus for chronic mesenteric ischemia (CMI) treatment. Randomized controlled trials comparing different stent types, such as covered stents versus bare metal stents, are needed to evaluate effi-cacy, patency rates, and long-term outcomes in CMI patients.

Penile augmentation using filler injections is a growing trend; however, the foreign body reaction can cause complications such as ulcer and necrosis of the penis, which can requires reconstruction. The existing method of reconstruction of the penis focused on filling the deficit. We report a case involving a scrotal flap and autologous augmentation using a de-epithelialization technique for a soft tissue defect caused by delayed infection after a penile filler injection. The defect was reconstructed and an augmentation effect was achieved. The patient was a 41-year-old man who received an injection of Aquafilling® (Biomedica, Prague, Czech Republic) 7 years previously and developed a delayed infection. After debridement, the penile defect spanned the entire shaft, and the circumference of the penis was 7.5 cm. Using a bilateral scrotal flap technique, the inferior margins of both flaps were rolled inward after de-epithelialization to achieve autologous augmentation. No infection or flap necrosis occurred during the 3-month follow-up period after surgery. Additionally, the penis circumference was expanded to 12 cm, and the patient indicated that he was very satisfied with the result. This surgical technique can be widely applied as treatment for penile defects.

Abdominal entry is the critical initial step of laparoscopic surgery as it is associated with unexpected complications. Acceptable working space is a prerequisite for safe minimal access surgery. Direct trocar insertion (DTI) technique has been often reported to be time-consuming and capable of causing injuries. We aim to facilitate conventional DTI employing an easy-to-use self-designed abdominal wall-lifting device, OneShot-M. We tested its safety in a porcine model. 18 pigs were randomized into three groups (n=6): open laparoscopy (Group A), DTI (Group B), DTI using OneShot-M (Group C), suitable for a 5-mm trocar. Outcomes were access time, entry-related minor and major complications. Median access time was shorter in C (43 seconds; range: 35-49 seconds), followed by B (82.5; 72-90) and A (190.5; 182-240). Statistically significant differences in procedural time between techniques were detected (p-value = 0.0005). Pairwise comparisons exhibited a statistically significant difference between A and C in terms of access time. Only one difficulty in entry was seen in C; pigs experienced several occurrences in A and B. This pilot study suggests that OneShot-M appears to be a technically feasible, fast and safe method for pneumoperitoneum induction in a porcine model, as it provides sufficient exposure of the operative field without access-related complications. Further clinical studies are needed.

This study aimed to evaluate the optimal extent of lymphadenectomy in patients with nonfunctioning pancreatic neuroendocrine neoplasms. We retrospectively analyzed the clinicopathological data of patients with nonfunctioning pancreatic neuroendocrine neoplasms who underwent surgical resection. We investigated the frequency of metastases at each lymph node station according to tumor location and analyzed the factors contributing to poor overall survival (OS) and disease-free survival (DFS). Overall, data of 84 patients were analyzed. For pancreatic head tumors, metastases at stations 8, 13, and 17 were found in one (3.1%), four (12.5%), and three (9.3%) patients, respectively. However, none of the other stations showed metastases. For pancreatic body and tail tumors, only metastases at station 11 were found in two (5.1%) patients. Additionally, multivariate DFS and OS analyses showed that lymph node metastasis was the only independent prognostic factor. Lymph node metastasis was found near the primary tumor and was the only independent factor of poor prognosis in patients with nonfunctioning pancreatic neuroendocrine neoplasms after undergoing curative surgery. Peri-pancreatic lymphadenectomy might be recommended for nonfunctioning pancreatic neuroendocrine neoplasms.

Thyroid surgery has been for years one of the most common elective procedures performed in general surgery. In the last 25 years, there have been significant advances in the diagnosis and treatment of thyroid disorders, and new technologies are being implemented. The aim of this study was to ana-lyze 25 years of experience in thyroid surgery in the Department of General, Minimally Invasive and Endocrine Surgery at the Medical University of Wroclaw in terms of demographic changes, indica-tions for surgical treatment, the type of thyroid surgery performed and complications. The impact of recent advances on changes in endocrine surgery was evaluated. For this purpose, clinical material from the years 1996-2020 was analyzed, with a total of 3748 patients (7285 RLN at risk of injury). Period I included the years: 1996-2003, period II: 2011-2015 and 2018-2020. Results: In the last 25 years, the percentage of patients operated on for thyroid cancer has increased threefold (p <0.00001); the extent of thyroid surgery has changed: in 1996-2003, subtotal thyroid operation was performed in more than 90% of patients vs. 1.7% of total thyroid gland surgery; 2011-2015 and 2018-2020 were more than 94% of total thyroid surgery vs. 4% of subtotal surgery (p<0.00001). The increase in the extent of surgery did not affect the percentage of total amount recurrent laryngeal nerve palsy (RLN palsy) (5.17% vs. 4.38% p = 0.1785), it did affect the percentage of transient RLN palsy in group II vs. group I (0.41% vs. 1.34%, p<0.00001), while the percentage of permanent RLN palsy in group I was statistically significantly higher than in group II (4.77% vs. 3.05%, p=0.0016). An increase in the percentage of postoperative clinical hypoparathyroidism in group II was observed: 4.84% vs. 8.93% (p<0.00001). Conclusions: Over 25 years, there has been a significant increase in the number of sur-geries performed for thyroid cancer, the range of surgeries from partial resections to total excision of the thyroid gland has changed, and the increased range of surgeries did not have a statistically signifi-cant effect on the number of vocal fold paralysis, but increased the percentage of postoperative hypo-parathyroidism. Intraoperative neuromonitoring had a significant impact on changing the scope of surgery and preventing complications.

Background: Abdominal wall hernias are a common condition that is seen in daily general surgery patients. However, still more researches are needed to be conducted regarding hernias. The aim of this study is to see the prevalence of hernias among patients admitted to the Department of Surgery of a tertiary care center. Methods: A descriptive cross-sectional study was performed among patients who admitted to the department of surgery in a tertiary care center between 1 August 2023 and 20 September 2023. All patients data were extracted to an excel sheet. Results: We had 760 patients who visited in this period. Only 272 patients (27.9 %) were diagnosed with hernias. We found 52.6 % of patients were male and 47.4 % of patients were female. The age between 46- 60 years old was the most to have hernias (97 patients). Inguinal hernias were the common among other types. Diabetes mellitus, hypertension, COPD, and hydrocele were found in 10.7 % of all patients. Conclusion: The prevalence of hernias in this study was nearly to other studies that conducted in the same conditions. Early diagnosis and patient’s education are the corner stone to prevent morbidities and mortalities.

(1) Background: The stylohyoid syndrome, known as classical Eagle Syndrome (cES), is characterized by calcificatication of the stylohyoid chain with numerous nonspecific symptoms, mainly pain. This study introduces Minimally Invasive Cervical Styloidectomy (MICS). (2) Methods: MICS was performed on sixty-five patients diagnosed with classical Eagle syndrome. Patients underwent meticulous differential diagnosis. Surgical plans were established based on the findings from neck angioCT. (3) Results: The healing process was uneventful without significant complications. The overall success rate was 97.0%, with a follow-up of a minimum of six months. In one case, the surgery did not yield the desired improvement. In one case, a partial relapse of symptoms was observed. (4) Conclusions: MICS is a straightforward and efficient surgical treatment technique for stylohyoid syndrome.

Cardiac surgery is a modern science in the history of medicine. The impact in cardiac disease, in term of treatment and prognosis, has made this discipline indispensable in the global health. In recent decades, the greatest investment has been dispensed in technological and material improvement, for increase the life expectancy. This surgery must address different epidemiological aspects dictated by the geography and economic-social conditions of the global populations. For this reason, it is progressively important to address the cardiac surgery accessibility disparity. Many scientific paper and international meetings have studied how cardiac surgery can increase accessibility in various countries around the world. In this review we analyze all the challenges, solutions and suggestions to make this surgery accessible to the entire global population, with the purpose to reducing the disparity across the all seven continents. For a long time, high-income countries have invested in technological capabilities and experimental advancement, not caring about unequal access in the rest of the world. We believe that it is time to reverse the growth trajectory, placing – as a priority – the accessibility and distribution of a surgical science, too significant for the right to health of all the people of the world. This is the real new challenge in cardiosurgery.

Extreme cytoreductive surgery (eCRS) may sometimes be required to achieve complete cytoreduction, which is one of the most important prognostic factors. This study investigated the impact of eCRS on survival and peri-postoperative outcomes. Malignant peritoneal mesothelioma (MPM) patients who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) were retrospectively examined. Patients who underwent CRS-HIPEC were divided into eCRS and less extensive CRS (leCRS) groups. Resection of ≥5 organs or ≥3 small bowel anastomoses was defined as eCRS. Survival and perioperative outcomes of both groups were compared.In the study including 31 patients, eCRS-HIPEC was used in 15 patients. Complete cytore-duction (CC score 0/1) was achieved in all 31 patients. Compared with LeCRS, mean length of stay, length of stay in the intensive care unit, mean peritoneal cancer index (PCI), and intraoperative blood loss were higher in the eCRS group. Additionally, the risk of developing complications was observed to be more frequent and the duration of surgery was longer. Rates of serious complications and morbidity were similar in patients undergoing eCRS compared with leCRS. In patients with high PCI and multiple organ involvement, complete cytoreduction can be achieved by performing eCRS and equivalent survival results can be achieved with low PCI..

Cryosurgery has emerged as a promising method for harvesting veins, but the suitability of these cryostripped veins as grafts remains a subject of investigation. This study delves into uncharted territory by conducting an immunohistochemical analysis and exploring the molecular aspects of venous samples obtained through cryostripping. Existing literature lacks comprehensive data on the components of varicose veins' walls, particularly in relation to protein expression. Furthermore, little is known about the proliferation rate of endothelial cells within varicose veins, which we scrutinize alongside an assessment of CD34 endothelial reactivity. Materials and Methods: Our study encompassed 109 samples procured using the cryostripping method, which involves catheterizing veins with a specialized probe cooled to -85°C. Molecular profiling of the intima and endothelium was conducted using two key markers: CD34 and Ki67. Results: Immunoreactivity for CD34 was discernible across all three layers of the varicose vein walls that were excised using cryostripping. Notably, the endothelial cell layer exhibited intense and uniform positivity in 36 out of the 109 samples under investigation. In contrast, the results regarding Ki67 expression, whether pertaining to the intima or endothelium, remain inconclusive. Conclusions: Our findings advocate for the utilization of CD34 as a reliable marker to assess the morphological and molecular integrity of excised venous specimens. As the use of cryosurgery-harvested veins as grafts gains traction, this research contributes valuable insights into their potential viability for transplantation, opening new avenues for further exploration in the field of vascular surgery.

The scalp is a unique anatomical region with distinct challenges for reconstruction, especially in cases of melanoma excision. This study explores the utilization of the O-Z flap technique as an alternative approach for patients with melanoma, where traditional free flap reconstruction may not be feasible due to age or underlying health conditions. However, in this case, the patient had a history of angina and was unwilling to undergo a long operation due to his advanced age. This study highlights the importance of following NCCN guidelines for melanoma resection margins based on tumor thickness and underscores the value of staged resection planning to minimize deficits. This requires an individualized approach as each patient may have different circumstances (general health condition, age, compliance, etc.). So we planned a staged excision first. In the first surgery, we would resect the tumor minimally and then determine the exact size of the tumor. Then, in the second surgery, we resected it with a safety margin according to the guidelines. The O-Z flap, a local flap with an "O"-shaped defect and "Z"-shaped incision line, is introduced as a reconstructive option. The surgical procedure, advantages, and limitations of this approach are discussed. This study provides valuable insights into achieving successful scalp reconstruction while considering aesthetic outcomes and patient-specific factors.

(1) Background: The aim of this study is to investigate the diagnostic-therapeutic problem of pelvic recurrence of rectum cancer, highlighting current surgical standards and the possible role of the minimally invasive approach. This retrospective analysis of our surgical case study wishes to enter this debate while suggesting a possible line of action, based on the site of recurrence; (2) Methods: We examined, retrospectively, all the patients diagnosed, between 2008 and 2018, with cancer of the rectum at the "Pietro Valdoni" Department of Surgery and monitored their follow-up for 5 years. The sample consisted of 368 patients with rectal neoplasm, 136 females and 232 males, with an average age of 65.8 (ranging from 37 to 86); (3) Results: In 103 of the cases, the neoplasm was located in the upper rectum (28%), in 119 cases in the middle rectum (32.3%), in 102 cases in the lower rectum (27.7%), in 31 cases (8.4%) at the level of the right/sigma junction and in 13 cases it was not possible to define the site with certainty (3.5%); (4) Conclusions: The discussion re-mains open as to which approach is best at surgical level, whether laparoscopic, robotic or open-air. Our experience informs us that the most dangerous site remains on the anastomotic site.

Metabolic surgery can promote comprehensive physiological improvements to alleviate metabolic disorders, particularly for patients with type 2 diabetes. Nevertheless, the therapeutic scope has been limited owing to unexpectedly inconsistent surgical outcomes. Therefore, this study to overcome these obstacles by determining the fundamental mechanism underlying the conflicting outcomes. The surgical anatomy, clinical course, and outcomes of various metabolic surgeries, including modified duodenal-jejunal bypass (DJB) procedures, were compared to understand the specific surgical patterns from different perspectives comprehensively. Patients in the nonobese group were exclusively included to prevent confounding effects from overweight patients with type 2 diabetes. Following intestinal anastomosis, the epithelial identity of the succeeding intestine was replaced by that of the proximal epithelium owing to altered crosstalk between the epithelium and opposing mesenchymal cells. Subsequent intestinal compensatory proliferation and rapid turnover rate accelerate the spread of the replaced epithelium. The main factors contributing to inconsistent outcomes of metabolic surgery are inadequate duodenal exclusion and inappropriate biliopancreatic limb length. Replacement of enteroendocrine cells during regeneration can lead to inconsistent outcomes in metabolic surgery. The type and density of enteroendocrine cells distributed at the terminal end of the proximal intestine play a significant role in diverse outcomes of metabolic surgery.

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract with a 1-3% prevalence in general population. The surgical management of symptomatic MD is well described in the literature, but there is still no consensus on the indication for prophylactic resection of incidental asymptomatic MD. To address this issue, we extensively reviewed the current literature and report our experience with laparoscopic management of an unusual case of MD causing ileal volvulus and acute peritonitis two weeks after a laparoscopic appendectomy for acute gangrenous appendicitis performed in another hospital. A 50-year-old man presented to the emergency department with acute and severe abdominal pain, vomiting and constipation. He had undergone a laparoscopic appendectomy for acute appendicitis two weeks before in another hospital. The patient was apyretic, distressed, and sought an antalgic position. The abdomen was mildly distended, tender, and the Blumberg sign was mildly positive in the central quadrants. The clinical picture deteriorated with fever, peritonismus, and leukocytosis. A CT scan showed an ileo-ileal adhesion near the ileocolic junction and dilatation of the upstream loops with air-fluid levels. Through an urgent laparoscopy, a necrotic mass, the MD, was wedge-resected and the surrounding ileal volvulus derotated. The postoperative course was uneventful. There is no definitive consensus on the appropriate management of incidental asymptomatic MD, although several studies have attempted to identify guiding criteria. Features of the MD, patient’s risk factors, clinical presentation, and surgical approach need to be considered to establish definitive guidelines for the management of incidental asymptomatic MD. In the absence of definitive guidelines, personal expertise and judgement are the main resources for the surgeon approaching an incidental asymptomatic MD.

The accurate assessment of wound size is a critical step in advanced wound care management. This study aims to introduce and validate a Light Detection and Ranging (LiDAR) technique for measuring wound size. Twenty-eight wounds treated from December 2022 to April 2023 at the Chunganam National University Hospital were analyzed. All wounds were measured using three techniques; conventional ruler methods, the LiDAR technique, and ImageJ analysis. Correlation analysis, linear regression, and Bland-Altman plot analysis were conducted to validate the accuracy of the newly introduced method. The measurement results (Mean ± Standard deviation) obtained using the Ruler method, LiDAR technique, and ImageJ analysis were 112.99 ± 110.07 cm², 73.59 ± 72.97 cm², and 74.29 ± 72.15 cm², respectively. The Pearson correlation coefficient was higher in the LiDAR application (0.995) than the conventional ruler methods (Mean difference; -5.0000 cm2), as was the degree of agreement (Mean difference; 38.6933 cm2). Wound size measurement using LiDAR is a simple and reliable method that allows practitioners to conveniently assess wounds with a flattened and irregular shape. However, non-flattened wounds cannot be assessed owing to the technical limitations of LiDAR.

Irrigation and debridement using an irrigation solution is a fundamental step during the surgi-cal treatment of both acute and chronic periprosthetic joint infection (PJI). However, there is no consensus on the optimal solution, nor is there sufficient evidence on optimal irrigation time and combination of solutions. Therefore, it is necessary to determine which solution or combi-nation of solutions is most efficacious against biofilm, as well as the optimal irrigation time. We conducted an experimental in vitro model by inoculating stainless steel discs with ATCC strains of methicillin-susceptible Staphylococcus aureus, methicillin-resistant S. aureus, Pseudomonas aeru-ginosa, and a clinical strain of Staphylococcus epidermidis. The discs were all irrigated with com-monly used antiseptic solutions (10% and 3% povidone iodine, hydrogen peroxide, 3% acetic ac-id, and Bactisure™) for 1 min, 3 min, and 5 min and their combinations for 9 min (3 min each) vs. sterile saline as a positive control. We evaluated the reduction in biofilm based on colony form-ing unit (cfu) counts and, in combination assays, also based on cell viability and scanning elec-tron microscopy. All antiseptics alone reduced more than 90% of cfu counts after 1 min of irriga-tion; the worst results were for hydrogen peroxide and 3% acetic acid. When solutions were combined, the best results were observed for all those starting with acetic acid, in terms of both reduction of log cfu/ml counts and viable cells. We consider that a combination of antiseptic so-lutions, particularly that comprising the sequence acetic acid+povidone iodine+hydrogen per-oxide, would be the best option for chemical debridement during PJI surgery.

Abstract: (1) Background: Surgery is the best curative option for Gastric Cancer (GC). However, morbimortality associated with surgery still a significant problem. Thus, it is essential to determine the preoperative surgical risk, to optimize outcomes in higher risk patients. (2) Methods: Patients who underwent curative gastrectomy between January 2010 and December 2013 were included, obtaining a sample of 131 patients, and the acuity of the scales understudy was evaluated. The predictive power of the scales was evaluated through calibration and discrimination. (3) Results and Conclusions: Regarding mortality, the scales demonstrated good calibration, with POSSUM and P-POSSUM obtaining the best O:E ratio. The scales presented good discrimination, with POSSUM showing the best result. Considering morbidity, the scales showed good calibration and discrimination. POSSUM and P-POSSUM seem to have potential in predicting morbidity and mortality when applied to the studied population, but there is a need for further studies in this area.

Robotic surgery is a rapidly developing and evolving surgical technique. This literature review evaluates the advantages and disadvantages in the context of gallbladder disease comparing robotic Cholecystectomy to the well-established laparoscopic Cholecystectomy. Significant advantages are reduced operative blood loss, hospital stays and post operative pain, alongside increased patient satisfaction and improved visualization and precision compared to the laparoscopic approach. Disadvantages include lack of tactile feedback, significant cost attributed to equipment, training requirements and increased procedural time due to the set-up sequences. The implementation of robotic surgery also poses significant changes for the training of future surgeons. Whilst it can standardize training and increases opportunity for simulation, the concern is the loss of traditional skills. Currently the evidence base remains mixed however the use of robotics in the right setting, with suitably trained operatives and appropriate patients can enable improved outcomes for patients with gallbladder disease. There is a lot of scope for development including the implementation of tactile feedback to aid operative technique and artificial intelligence to aid patient safety. Likely broadening the use and potential benefit of robotic surgery not only for cholecystectomy but many surgical specialties.

Purpose: To explore parents’ perceptions of the educational intervention programme regarding their children’s postoperative pain management. Design and Methods: A qualitative descriptive study was conducted. Thirty-two parents whose children underwent inpatient elective surgery were recruited from the two intervention groups (received an educational booklet and a video, with or without an hour of face-to-face teaching session) for this qualitative evaluation of the intervention. Participants were asked to comment on the content and delivery methods of the intervention via individual face-to-face semi-structured interviews. Thematic analysis was used to identify themes from the data. Results: Three themes were generated from 32 participants’ interview data: current pain management practices, experiences and benefits of the educational intervention, and suggestions to improve pain management. Conclusions: Our findings suggested that the educational intervention in children’s postoperative pain management was helpful for parents and their children. However, it is necessary to improve educational materials and equip healthcare professionals with non-pharmacological pain relief methods. Practice Implications: Our findings reveal the current challenges in extensively adopting non-pharmacological pain relief methods. Healthcare professionals can do more to routinely integrate pharmacological and non-pharmacological pain management strategies in relieving pain effectively. Future research could develop technology-based programmes to increase ease of access. Trial Registration Number: ISRCTN24910957.

Early debridement and stabilization for pyogenic spondylodiscitis allow early mobilization of the patient and prevent subsequent spinal deformity. Tantalum (Ta) trabecular metal (TM) components have several potential advantages over conventional implant materials, such as its uniformity and structural continuity, strength, low stiffness, high porosity, high coefficient of friction and tantalum trabecular metal enhances the host defense mechanism by increasing leukocyte chemotaxis, phagocytosis, and the bacterial killing rate. A single-stage surgery with a tantalum trabecular metal cage combining two different approaches is sufficient to maintain vertebral stability. This retrospective cohort study included 57 patients, 31 (54%) patients were treated with single-stage debridement and reconstruction with trabecular metal cages, and 26 (45.6%) patients received spine surgery without trabecular metal cages received surgery between January 2018 and March 2021 in our tertiary academic teaching hospital. The CRP values dropped borderline significantly in the TM cage group compared with the non-TM cage group postoperatively. In patients with spondylodiscitis, it is advisable to perform single-stage debridement and reconstruction with a trabecular metal cage, which allows abscess drainage and rapid mobilization, prevents deformity.

(1) Importance of problem: Breast cancer accounted for 685.000 deaths globally in 2020, and half of all cases occur in women with no specific risk factor beside gender and age-group. During last 4 decades we see a reduction by 40% of age-standardized breast cancer [1], which in turn means that the number of mastectomies performed for younger women increased, raising the need for adequate breast reconstructive surgery. Advances in oncological treatment have made it possible to limit the extent of what represents radical surgery for breast cancer, yet in the past decade, we see a marked trend toward mastectomy in breast conserving surgery eligible patients [2]. Prophylactic mastectomy has also registered an upward trend [3,4]. This trend together with new indication for breast reconstruction like chest feminization in transgender patients [5] have increased the need for breast reconstruction surgery. (2) Purpose: The purpose of this study is to analyze the types of reconstructive procedures, their indications, their limitations, their functional results and the safety profiles when used during the integrated treatment plan of the oncologic patient; (3) Methods: We conducted an extensive literature review of the main reconstructive techniques, especially the autologous procedures, summarized the findings and presented a few cases from our own experience for exemplification of the usage of breast reconstruction in oncologic patients. (4) Conclusions: Breast reconstruction has become a necessary step in the treatment of most breast cancers and many reconstructive techniques are now routinely practiced. Microsurgical techniques are considered the "gold standard", but they are not accessible to all services, from a technical or financial point of view, so pediculated flaps remain the safe and reliable option, along with alloplastic procedures, to improve the quality of life of these patients.

Surgical knots are sequences of half-knots (H) or half-hitches (S), defined by their number of throws, by an opposite or similar rotation compared with the previous one and for half-hitches, whether sliding (s) or blocking (b). Opposite rotation results in (more secure) symmetric (s) knots, similar rotation in asymmetric (a) knots, and changing active and passive ends has the same effect as changing rotation. Loop security is the force to keep tissue together after a first half-knot or sliding half-hitches. With polyfilament sutures H2, H3, SSs and SSsSsSs have a loop security of 10, 18, 28 and 48 Newton (N), respectively. With monofilament sutures, they are only 7, 16, 18 and 25N. Since many knots can reorganise, the definition of knot security as the force at which the knot opens or the suture breaks should be replaced by the clinically more relevant percentage of clinically dangerous and insecure knots. Secure knots with polyfilament sutures require a minimum of 4 or 5 throws, but the risk of destabilisation is high. With monofilament sutures, only 2 symmetric+4 asymmetric blocking half-hitches are secure. In conclusion, half-hitch sequences are recommended since mandatory for monofilament sutures, adding flexibility for loop security with less risk of destabilisation.

Crohn's disease (CD) is a chronic, immune-mediated inflammatory bowel disease characterized by transmural damage of various parts of the gastrointestinal tract. The aim of the study is to present our experience in pre-surgical diagnosis, selection of surgical tactics and volume of intervention in different variants of gastrointestinal tract lesions and disease activity. We undertook cross-sectional, retrospective-prospective study of 64 children who underwent surgery due to complicated CD. We analyzed CD activity via PCDAI, medications used, inflam-mation localization, and changes in mass-growth parameters at pre-surgery stage. Three patients from the group of 44 children with two-stage surgical treatment later showed inefficacy of GEBD in post-operative period. The disease progression was revealed and, therefore, subtotal colectomy was required. Three children had secondary adhesion of surgical wounds by means of active immunosuppressive therapy at preoperative period, and five patients developed suture sinuses at post-operative period. Early adhesive intestinal obstruction was revealed in 3 (4.7%) cases, and they required re-surgery. Personalized approach to the surgical treatment of children with complicated CD has shown its efficacy due to the small percentage of postoperative complications with re-surgery. There was significant improvement in mass-growth parameters, recovery of albumin levels, and anemia decrease in 96.9% of cases in the long-term postoperative period (6 months or more). Two children (3.1%) had the narrowing of anastomotic zone lumen, thus, without any obstruction. These cases were associated with violations in drug treatment

Manifestation of cystic hygroma in adulthood is very rare. In this study, we reported a rare case of Cervical Cystic Hygroma in Adults. We report 20 years old male with a diagnosis of left-side neck cystic Hygroma and discuss the presentation, diagnosis, and clinical, radiological, and operative aspects of it.

Background and Objectives: The current study aimed to determine the impact of fasciotomy on mortality and morbidity in children and adults with crush-related AKI following the 2023 Kahramanmaraş earthquakes. Materials and Methods: The study included individuals who had suffered crush injuries after the 2023 Kahramanmaraş earthquakes and were identified as having acute kidney injury (AKI). Patients with AKI were divided into two groups based on age: those under 18 years and those over 18 years. A comparative analysis was conducted between the mortality and morbidity rates of patients who underwent fasciotomy and those who did not. Disseminated intravascular coagulopathy (DIC), sepsis, and adult respiratory distress syndrome (ARDS) have all been identified as contributors to morbidity. Results: The study was conducted with a total of 40 patients (21 males and 19 females) aged between four and 83 years. A total of 21 patients underwent fasciotomy and the patients underwent varying numbers of fasciotomy, ranging from zero to 11. The mortality rate was 12.5%, corresponding to five adult patients. No instances of mortality were reported in the paediatric cohort. The application of fasciotomy in instances of crush-induced AKI did not result in elevated levels of mortality in either the paediatric or adult demographic. Within the adult population, a substantial difference in the duration of dialysis was observed between individuals who underwent fasciotomy and those who did not. A statistically significant increase in the number of fasciotomy incisions was observed in patients diagnosed with sepsis compared with those without sepsis. The study found a significant positive correlation between the number of fasciotomy incisions and dialysis days. Conclusions: Neither adult nor paediatric patients with crush-induced AKI showed an increased risk of death after fasciotomy. The number of fasciotomy incisions significantly correlated with the development of sepsis. Despite experiencing delays in hospital admission for paediatric patients, the incidence of both crush syndrome and mortality rates among children remained relatively low.

Postoperative adhesive arachnoiditis is an inflammatory response of the spinal leptomeninges that occurs after surgery, resulting in scar formation in the avascular nature of the arachnoid layer. Clinical manifestations of this condition include pain, sensory deficits, motor dysfunction, reflex abnormalities, and bladder/bowel impairments. In MRI scans, the signs of postoperative adhesive arachnoiditis can vary, but some specific indicators can assist surgeons in locating the lesion and planning surgical interventions more accurately. In this report, we reported a 37-year-old man with postoperative adhesive arachnoiditis after two surgeries for Chiari I malformation, demonstrating that the gradually-forming the delta cord sign with sequential syringomyelia. During the intraoperative examination, we identified the presence of the delta cord sign, which was formed by an arachnoid scar that was tethering the dorsal spinal cord to the dura. This discovery allowed us to precisely pinpoint the location of the arachnoid scar, thereby providing valuable guidance to avoid any unnecessary exploration of innocent structures during the procedure. Other localization signs were also reviewed.

Background and objectives: Thoracolumbar fracture – dislocations (AO type C) are rare injuries that occur due to very high-energy trauma, and the result is transitional and rotational instability of the spinal column and neurological impairment. Several reduction maneuvers have thus far been published, each of which can be of use in certain specific situations. We developed a novel modification to the previously described reduction technique. Materials and methods: This is a retrospective review of the management of thoracic AO type C fracture-dislocations managed with a modified novel reduction technique. The success of the reduction and intraoperative iatro-genic complications such as dural tear and screw pull out were the outcomes analyzed. Results: A total of 4 cases were successfully reduced with this novel reduction technique. We did not note any complications such as a dural tear or screw failure with this modified novel reduction tech-nique. Conclusion: The novel modification to the reduction technique employed in the management of thoracic fracture-dislocations resulted in a successful reduction without the risk of iatrogenic complications due to the reduction maneuver.

Introduction: Postoperative epidural hematomas of the cervical and thoracic spine can pose a great risk of rapid neurological impairment and sometimes require immediate decompressive surgery. Case Report: We present the case of a young patient operated on for stabilization of a two-level thoracic vertebra fracture who developed total paralysis due to an epidural hematoma postoperatively. The course of epidural hematoma was quickly reversed with the help of a con-servative technique that prevented revision surgery. The patient regained complete neurology on follow-up without any recurrent episodes. Conclusion: There is a role of similar maneuvers as described in this case to be employed in the management of postoperative epidural hematomas. However, prolonged watchful waiting should still be discouraged, and patients should remain ready for revision surgery if there are no early signs of rapid recovery.

Background/Aim: Rapid onset of facial ptosis can impact physical appearance and compromise the outcomes of facelift procedures. The level of vitamin D has a potential correlation with collagen formation and its deficiency with inflammatory processes that affect the breakdown of hyaluronic acid. This study aims to investigate the potential relationship between accentuated facial ptosis in women and low levels of vitamin D. Furthermore, it aims to explore preventive measures or strategies to slow down facial ptosis and enhance the longevity of facelift results. Materials and Methods: The study was focused on monitoring the vitamin D levels in women and men with advanced facial ptosis and comparing them with a control group. Results: Notably, a direct association between gender and serum vitamin D levels was observed, indicating less sustainable outcomes in women. Conclusion: Women face additional challenges in the aging process due to hormonal shifts after menopause or premenopausal, which are associated with osteoporosis and lower vitamin D levels.

Objective: To evaluate the effect of care bundles on treatment compliance and intestinal barrier function in patients with refractory septic shock in the intensive care units (ICUs). Methods: In this retrospective study, the clinical data of 94 patients with refractory septic shock admitted to our hospital between June 2020 and April 2022 were collected. Patients with routine nursing were included in the routine group, and those with care bundles were assigned to the care bundles group, with 47 cases in each group. Outcome measures included nursing efficiency, treatment compliance, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHE II) score, intestinal barrier function, inflammation factor level, treatment outcome and complications. Results: Care bundles resulted in significantly higher nursing efficiency and treatment compliance versus routine care (P<0.05). Patients receiving care bundles showed significantly higher SOFA scores and APACHE II scores than those receiving routine care (P<0.05). Intestinal fatty-acid binding protein (I-FABP), diamine oxidase (DAO), lactate, endotoxin, and intestinal dysfunction scores in the care bundles group were significantly lower than those in the conventional group after treatment (P<0.05). Care bundles were associated with significantly lower levels of procalcitonin (PCT) and hypersensitive C-reactive protein (hsCRP), shorter time to symptom relief, ICU treatment time, and duration of mechanical ventilation, and lower 28-d morbidity and mortality versus routine care (P<0.05). Patients in the care bundles group had a significantly lower incidence of complications than those in the routine group (P<0.05). Conclusion: Care bundles effectively enhance treatment compliance, improve intestinal barrier function and treatment outcomes, reduce the inflammatory response, and decrease the risk of SOFA score, APACHE II score, and complications in patients with refractory septic shock.

Non-alcoholic fatty liver disease (NAFLD) has gained attention in the last few years due to its increasing prevalence worldwide becoming a global epidemic. This review aims to discuss the latest recommendations regarding diagnosis and treatment of NAFLD-associated HCC and the remaining challenges. Thus, there is a high amount of data derived from basic and clinical studies that revealed the molecular pathways which drive NAFLD-associated hepatocellular carcinoma (HCC). Based on these findings, new prevention, surveillance and treatment strategies are emerging. However, current data on treatment modalities in NAFLD-associated HCC are still scarce, but based on subgroup analysis results from non-NAFLD HCC studies are promising and could provide a basis for future research agenda to address NAFLD/NASH patients. Conclusion: Due to the pandemic proportions that NAFLD gained in the last few years, there is a high amount of data derived from basic and clinical studies that revealed the molecular path-ways which drive NAFLD-associated HCC. Based on these findings, new prevention, surveillance and treatment strategies could be developed at an individual level.

The alterations of coagulation status in patients with Severe Burn Injury are associated with serious complications, increased morbidity and mortality. This study aims to compare Rotational Thromboelastometry(ROTEM)–a Viscoelastic Coagulation Assays(VCAs) with Conventional Coagulation Assays(CCAs) including Prothrombin time(PT), Activated Partial Thromboplastin time(aPTT), International normalized ratio(INR), Complete Blood Count(CBC) and Coagulation Factors during the early five post- burn days in Survivors and Non- Survivors with Severe Burn Injury in order to correlate these results with Burn Coagulopathy and Prognosis. Seventeen Sur-vivors and ten Non- Survivors, with a mean Total Burn Surface Area(TBSA) of 33,78% were in-cluded in our study. Even though CCAs measurements were abnormal, they were unable to detect overall burn patients’ coagulopathy. On the contrary, VCAs from day 2 to day 5 took pathological values, especially for Non- survivors. Those changes were underlined through pathological values of Coagulation Factors. As a result, CCAs were considered poor indicators of coagulation status in burn injury, whereas VCAs were more accurate in demonstrating coagulation alterations from the early post- burn period and detecting patients in greater risk of mortality. These advantages of VCAs could be used for timely intervention in high risk patients and for the guidance of blood product transfusions.

Enophthalmos is a severe complication of primary reconstruction following orbital floor frac-tures, oncological resections or maxillo-facial syndromes. The goal of secondary reconstruction is to re-store symmetrical globe positions to recover function and aesthetics. In this article we pre-sent a method of computer-assisted orbital floor reconstruction using a mirroring technique and a customized titanium or high-density polyethylene mesh, printed using computer aided manufac-turing techniques. This reconstructive protocol involves 4 steps: mirroring of the healthy orbit at the affected site, vir-tual design of a patient specific orbital floor mesh, computer-assisted manufacturing (CAD) of the implant, and surgical insertion of the device. Using a computed tomography data set, the un-injured side of the craniofacial skeleton was reflected onto the contralateral injured side, and a reconstructive orbital floor prosthesis was virtually designed on the mirrored orbital bone sur-face. The solid-to-layer (.STL) files of the prosthesis were then manufactured using Direct Metal Laser Sintering (DMLS) or Computer Numerical Control (CNC) methods, leading to the produc-tion of 10 titanium meshes and 2 high density polyethylene (HDPE) implants. Clinical outcomes were assessed using 3dMD photogrammetry and computed tomography measures in 14 treated patients. The technique described here appears to be a viable method to correct complex orbital floor de-fects needing delayed reconstruction. This article represents the prosecution of a previous study, which is part of a wider experimental protocol for orbital floor reconstruction using comput-er-assisted design-computer-assisted manufacturing (CAD-CAM) technology

Background: The heterogeneity of rectal biopsy techniques encourages us to search for a surgical and pathological standardisation of this diagnostic technique to exclude Hirschsprung’s disease. The varying amount of information on the anatomopathology report prompts us to compile a template concerning the anatomopathology report for diagnostic rectal biopsies for colleague surgeons and pathologists working on Hirschsprung’s disease. Methods: We gathered the anonymous biopsy information and its pathology information from five hospitals of all patients in which rectal biopsies were taken to diagnose Hirschsprung’s disease over two years (2020-2021). Results: 82 biopsies: 20 suction (24,4%), 31 punch (37.8%) and 31 open biopsies (37,8%) were taken. Of all biopsies 69 were conclusive (84,2%), 13 were not (15,8%). In the suction biopsy group 60% were conclusive, 40% not, for punch biopsy 87% and 13% respectively and for open biopsy 97% and 3%. Inconclusive results were due to insufficient submucosa in 6/8 suction biopsies, 4/4 punch and 0/1 open biopsies. An insufficient amount of submucosa was the reason for an inconclusive result in 6/20 cases (30%) after suction biopsy, 4/31 (12,9%) after punch biopsy and 0 cases (0%) after open biopsy. We had one case with major postoperative bleeding post suction biopsy; there were no further adverse effects after biopsy. Conclusions: Diagnostic rectal biopsies in children are safe. Non-surgical biopsies are more likely to give inconclusive results, due to less submucosa present in the specimen. Open biopsies are especially useful when previous non-surgical biopsies are inconclusive. An experienced pathologist is a key factor for the result. The anatomopathology report should specify the different layers present in the specimen, the presence of ganglion cells and hypertrophic nerve fibers, their description and a conclusion.

Objective: To study the factors affecting the time of umbilical cord shedding in premature infants.Methods: A total of 151 premature infants who were born in the obstetrics department of a Class III hospital in Hefei from November 2020 to June 2021 were selected as subjects. All premature infants and their families met the complete inclusion criteria. A total of 33 related factors from 3 aspects, including the birth situation of premature infants, the condition of premature infants in hospital and the condition of pregnant mothers, were collected for univariate analysis and multiple Logistic regression analysis. The relevant factors affecting the umbilical cord shedding time of premature infants were screened through the univariate analysis results, and the main factors affecting the umbilical cord shedding time of premature infants were screened through the multiple Logistic regression analysis results.it was found that the weight, gestural age, admission age, whether the premature infants were combined with NRDS, the use of antibiotics, the duration in the warm box, the initial temperature in the warm box, the duration of light therapy, the degree of Apgar for 1 minute, the maternal education level had an effect on the time of umbilical cord shedding of premature infants (P < 0.05). Through Logistic multiple regression analysis, it was screened that the duration of premature infants in the incubator was the main factor affecting the umbilical cord shedding time of premature infants (P < 0.05).Conclusion: Factors such as premature infants' weight, gestural age, admission age, whether they are combined with NRDS, antibiotic use, duration in the incubator, initial temperature in the incubator, duration of phototherapy, Apgar level of 1 minute, and maternal education level will affect the umbilical cord shedding time of premature infants. Among them, duration in the incubator is the main factor affecting the umbilical cord shedding time of premature infants.

Objective: To evaluate the effect of care bundles on treatment compliance and intestinal barrier function in patients with refractory septic shock in the intensive care units (ICUs). Methods: In this retrospective study, the clinical data of 94 patients with refractory septic shock admitted to our hospital between June 2020 and April 2022 were collected. Patients with routine nursing were included in the routine group, and those with care bundles were assigned to the care bundles group, with 47 cases in each group. Outcome measures included nursing efficiency, treatment compliance, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHE II) score, intestinal barrier function, inflammation factor level, treatment outcome and complications. Results: Care bundles resulted in significantly higher nursing efficiency and treatment compliance versus routine care (P<0.05). Patients receiving care bundles showed significantly higher SOFA scores and APACHE II scores than those receiving routine care (P<0.05). Intestinal fatty-acid binding protein (I-FABP), diamine oxidase (DAO), lactate, endotoxin, and intestinal dysfunction scores in the care bundles group were significantly lower than those in the conventional group after treatment (P<0.05). Care bundles were associated with significantly lower levels of procalcitonin (PCT) and hypersensitive C-reactive protein (hsCRP), shorter time to symptom relief, ICU treatment time, and duration of mechanical ventilation, and lower 28-d morbidity and mortality versus routine care (P<0.05). Patients in the care bundles group had a significantly lower incidence of complications than those in the routine group (P<0.05). Conclusion: Care bundles effectively enhance treatment compliance, improve intestinal barrier function and treatment outcomes, reduce the inflammatory response, and decrease the risk of SOFA score, APACHE II score, and complications in patients with refractory septic shock.

(1) Background: Melanoma is the most aggressive tumor located at the skin level and the man-agement of this pathology requires a correct staging as well as a modern oncological treatment, adapted to each patient. The main objective of the study is to determine the variability of lymphatic drainage in the case of melanomas located on the trunk; (2) Methods: This retrospective study in-cluded 62 cases of melanoma located on the trunk operated between July 2019 and March 2023 in which SLNB was performed and a total of 84 lymph node were excised; (3) Results: Patients had an average age of 54.5 years old, while melanomas had a mean Breslow index of 2.3 mm. The distri-bution of trunk melanomas was: upper trunk 54 cases, lower trunk 30 cases (64.3 % vs. 35.7%). The type of anesthesia chosen was general anesthesia in 53 cases, respectively spinal anesthesia in 9 cases (85.5% vs. 14.5%, p<0.001). The number of sentinel lymph nodes was 54 for melanomas lo-cated on the upper trunk, 8 cervical and 46 axillary, respectively 30 sentinel lymph nodes in cases of melanomas of the lower trunk, 16 at the axillary level and 14 at the inguinal level; (4) Conclusions: Lymph node involvement in melanoma represents an important prognostic factor and the different lymphatic drainage pathways in relation to the location of the primary tumor represents an im-portant objective in the management of this pathology.

Abdominal injuries in children caused by guns are a rare clinical entity globally. But, in countries with undefined legal regulations and in the war zones urban violence is a great social problem among older children and adolescents. This manuscript provides details regarding two cases of severe gunshot injuries in young children. The injuries were very complicated and included damage to the parenchymatous and hollow organs as well as major blood vessels. The clinical presentation on admission was very serious and dramatic, but the patients survived. However, one patient developed numerous complications that required repeated surgical interventions and long treatment. The article provides a detailed description of injuries and how to treat them. Patient care requires a multidisciplinary approach, and the initial decision on further treatment depends on the patient's hemodynamic stability.

Background: Parathyroid imaging techniques are used in patients with biochemically confirmed primary hyperparathyroidism (pHPT) to detect the localization of enlarged parathyroid gland(s) (PTG) and thereby to allow more focused, unilateral or minimally invasive parathyreoidectomy (PTX), instead of classical bilateral neck exploration (BNE). Although the preferred sequence of imaging continues to evolve, ultrasonography (US) is usually the first line modality, followed by 99mTc sestamibi parathyroid scan (SPS). However, both tests may have suboptimal localizing accuracy with considerable rate of non-localized cases. Therefore, more accurate four-dimensional computed tomography scan (4D-CT) has been employed for PTG imaging. Currently, there is a paucity of data evaluating the utility of 4D-CT in low case-load settings. Aim: To evaluate the impact of PTG imaging, using 4D-CT in conjunction with it’s intraoperatively displayed results, on the outcomes of surgical PTX. Our primary outcome was sensitivity of 4D-CT in comparison to US and SPS for preoperative PTG adenoma localization. The secondary outcomes were the need for redo surgery and morbidity. Additionally, the characteristics of surgical PTX, i.e. operative time, number of removed parathyroid glands, and rate of simultaneous thyroid surgery, were assessed. Methods: A single-center retrospective analysis of surgically treated patients with pHPT from 01/2010 to 01/2021 was conducted. Evaluation of impact of the preoperative imaging modalities on the results of surgical treatment was carried out. Results: During the study period 290 PTX were performed, 45 cases were excluded due to surgery for secondary, tertiary or recurrent HPT, or due to use of alternative imaging techniques; the remaining 245 patients were included in the study. US was carried out for PTG imaging in 236 (96.3%), SPS in 93 (38.0%), and 4D-CT in 52 patients (21.2%). The use of 4D-CT was associated with a significantly higher rate of successful localization of enlarged PTG (49 cases, 94.2%) compared to US and SPS (74 cases, 31.4%, and 54 cases, 58.1%, respectively). We distinguished between three groups of patients based on preoperative imaging: 1) PTG lateralization via US or SPS in 106 (43.3%) cases, 2) precise localization of PTG via 4D-CT in 49 (20.0%) patients, and 3) in 90 cases (36.7%) PTG imaging failed to localize enlarged gland. The group of 4D-CT localization had significantly shorter operative time, lower rate of simultaneous thyroid resections, as well as lower rate of removal of ≥2 PTG, compared to the other groups. The 4D-CT imaging was also associated with the lowest perioperative morbidity and with the lowest median PTH in one month follow-up; however, compared to the other groups, these differences were statistically not significant. Implementation of 4D-CT (since 01/2018) decreased the need for redo surgery (from 11.5% to 7.3%), and significantly increased the annual case load of PTX at our institution (from 15.3 to 41.0), compared to the period before 4D-CT diagnostics. Conclusions: 4D-CT imaging enabled to precisely locate almost 95% of enlarged PTG in patients with pHPT. Accurate localization and intraoperatively displayed imaging results are useful guides for surgeons in making PTX a faster and safer procedure in a low volume center.

Background: The standard surgical approach to amputation has failed to evolve significantly over the past century. Consequently, standard amputations often fall short with regards to improving the quality-of-life (QoL) for patients. A modified amputation has been designed at both the transtibial (TTA) and transfemoral (TFA) level that incorporates agonist-antagonist myoneural interface (AMI) constructs to provide patients with a novel alternative to standard amputation. Here, we present the patient reported outcome measures (PROMs) amongst our lower extremity AMI amputees and demonstrate an overall significant improvement in their physical and mental wellbeing. Methods: Four PROMs surveys, 1) EQ-5D-3L, 2) Lower Extremity Functional Scale (LEFS), 3) PROMIS-57, 4) Short Form-36 (SF-36), and 5) Sickness Impact Profile (SIP), were administered to lower extremity AMI amputees pre-operatively (baseline) and at 6 weeks, 3 months, 6 months, 9 months, 12 months, 24 months, 36 months, and 48 months post-operatively between June 24th, 2018, and December 15th, 2022. The surveys were either administered during a clinic visit or emailed at the encounter timepoint. Study data was collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Brigham and Women’s Hospital. Analyses of collated data were performed by fitting a linear mixed model using SAS version 9.4 (SAS Institute, Cary, NC). Results: The cohort’s baseline and 12-month post-operative responses were compared to determine score improvement. The cohort demonstrated a significantly improved EQ-5D-3L index value (p<0.0001) and EQ VAS (p<0.0001) at 12-months post-operatively (n=22) when compared to baseline (n=28). The LEFS score significantly improved at 12-months post-operatively compared to baseline (p<0.0001) with a mean of 59.04 ± 3.14 (SE) at 12-months and a mean of 31.96 ± 2.84 (SE) at baseline. AMI patients demonstrated significantly improved scores across PROMIS-57 domains at 12-months compared to baseline scores; the p-value was <0.0001 for all domains except for the Depression domain where p=0.0181. The health domain scores significantly improved from baseline to 12-months post-operation for all SF-36 domains. Lastly, the SIP indicated a significant decrease in overall dysfunction from baseline to 12-months post-operation (p<0.0001). Conclusions: Modified lower extremity amputation with AMI construction has the potential to provide amputees with increased quality-of-life when compared to the pre-operative state. However, further investigation is necessary to determine whether the patient reported outcome measures of the AMI amputee cohort are superior to those who receive a standard amputation.

Abstract: Chemical burns are one of the most dangerous and aggressive types of burns as they can cause significant tissue damage, leading to pain, inflammation, necrosis, and scarring. We present a burn case report associated with the use of Acellular Dermal Matrix (MatriDerm® MedSkin Solution Dr. Suwelack AG, Billerbeck, Germany) for the reconstruction of a Hallux after the patient was mistakenly administered intramuscular Nitric Acid at another institution. The patient presented with a third degree burn that compromised the medial aspect of the hallux’s skin, the distal phalanx and nail bed. Early debridement was performed, and Negative Pressure Wound Therapy (NPWT VAC, 3M, US) was used to preserve and promote tissue viability. Eight days later, the patient was taken to the OR, and Acellular Dermal Matrix and split-thickness skin graft were used to reconstruct her right hallux’s defect. The patient achieved adequate clinical evolution and was discharged with complete reconstruction of the burned area. Acellular Dermal Matrix proved to be an important and viable option for reconstructive surgery after a chemical burn, and further studies are warranted to ensure its routine usage in this kind of lesions. Keywords: chemical burn, acellular matrix, hallux reconstruction, NPWT

Orthognathic surgery is used to modify anomalies in maxillomandibular position; this process can significantly affect the anatomy of the airway and cause functional changes. This study aims to define the impact of mandibular maxillary movement on the airway of subjects with dentofacial deformity. A retrospective study was conducted on subjects with Angle class II (CII group) and Angle class III (CIII group) dentofacial deformities. The subjects were treated by bimaxillary surgery; for all of them, planning was performed with software and 3D printing. Cone beam computed tomography (CBCT) was obtained 21 days before surgery and 6 months after surgery and was used for planning and follow-up with the same conditions and equipment. Was used the superimposition technique to obtain the maximum and minimum airway areas, and total airway volume. The data were analyzed with the Shapiro-Wilk test and Student’s t-test, while Spearman's test was used to correlate the variables, considering a value of p&lt;0.05. Seventy-six subjects aged 18 to 55 years (32.38 ± 10.91) were included: 46 subjects were in CII group, treated with a maxillo-mandibular advancement, and 30 subjects were in the CIII group, treated with a maxillary advancement and a mandibular setback. In CII group, a maxillary advancement of +2.45 mm (±0.88) and a mandibular advancement of +4.25 mm (±1.25) were observed, with a significant increase in all the airway records. In the CIII group, a maxillary advancement of +3.42 mm (±1.25) and a mandibular setback of -3.62 mm (±1.18) was noted, with no significant changes in the variables measured for the airway (p&gt;0.05). It may be concluded that maxillo mandibular advancement is an effective procedure to augment the airway area and volume in the CII group. On the other hand, in subjects with mandibular prognathism and Angle class III operated with the maxillary advancement and mandibular setback lower than 4 mm it is possible to not reduce the areas and volume in the airway.

Background and Objectives: Jehovah's Witnesses (JW) reject the transfusion of blood components based on their religious beliefs even if they are in danger of harm or death. In cardiac surgery, this significantly reduces the margin of safety and leads to ethical conflicts. Informed consent should be carefully documented and the patient's family should be involved. This study aims to compare the postoperative course of JW who underwent major cardiac surgery with a similar population of non-Witnesses (NW). Patients and Methods: Demographic, procedural, and postoperative data of all consecutive JW who underwent cardiac surgery at our institution were obtained from the records. They were compared with a propensity score matched group of NW. Anemic JW were treated with erythropoietin and/or iron as needed. Cardiac surgery was performed by experienced surgeons using median sternotomy and cardiopulmonary bypass. Common blood-sparing techniques were routinely used. Periprocedural morbidity and mortality were statistically evaluated for both groups. Results: 32 JW and 64 NW were part of the matched dataset showing no demographic or procedural differences. EPO was used preoperatively in 34.4% and postoperatively in 15.6% of JW but not in NW. Preoperative hemoglobin levels were similar (JW, 8.09±0.99 mmol/l; NW, 8.18±1.06; p=0.683). JW did not receive any transfusions except for one who revoked, while NW transfusion rates were 2.5±3.1 units for red cells (p&lt;0.001) and 0.3±0.8 for platelets (p=0.018). Postoperative levels differed significantly for hemoglobin (JW, 6.05±1.00 mmol/l; NW, 6.88±0.87; p&lt;0.001), and hematocrit (JW, 0.29±0.04; NW, 0.33±0.04; p&lt;0.001) but not for creatinine. Early mortality was similar (JW, 6.3%; NW, 4.7%; p=0.745). There were more pacemakers and pneumonias in JW, while all other postoperative conditions were not different. Conclusions: Real-world data indicate that Jehovah's Witnesses can safely undergo cardiac surgery provided that patients are preconditioned and treated by experienced surgeons who use blood-saving strategies. Postoperative anemia is observed but does not translate into a worse clinical outcome. This is consistent with other studies.

Background and Objectives: Intramedullary spinal cord tumors (IMSCT) are rare entities. Especially, a location in the upper cervical spine as a highly eloquent region carries the risk of postoperative neurological deficits, such as tetraparesis or respiratory dysfunction. Evidence for respiratory dysfunction is scarce. The aim of this study was to describe the early and late postoperative clinical course of this highly eloquent tumours. Patients and Methods: This is a single-centre retrospective cohort study. We included 35 patients with IMSCT at levels of craniocervical junction to C4 who underwent surgical treatment between January 2008 and December 2022. The authors analysed the patients' preoperative status, tumour- and surgery-specific characteristics, and follow-up functional status. Results: The study cohort included 22 patients with grade II ependymoma (62.9%), 2 low-grade astrocytomas (5.7%), 2 glioblastomas (5.7%), 6 hemangioblastomas (17.1%), 2 metastases (5.7%), and 1 patient with partially intramedullary schwannoma (2.9%). Gross total resection was achieved in 76% of patients. Early dorsal column related symptoms and motor deterioration occurred in 64% and 44% of patients, respectively. At a follow-up of 3.27 ± 3.83 years, 43% and 33% of patients preserved postoperative sensory and motor deterioration, respectively. The median McCormick Scale grade was 2 in the preoperative and late postoperative periods, respectively (p=0.0897, α=0.05). Only two out of 35 patients (5.7%) developed new intermittent respiratory dysfunction, of whom two were transient. There were no surgery-related deaths. Conclusions: The surgery of IMSCT of the upper cervical spine could be performed without major procedure-related risk. Roughly a half of the patients develop new neurological deficit in the immediate postoperative period. However, most of the patients still maintain functional independence. The rate of respiratory insufficiency is low and is strongly influenced by the rapid neurological deterioration in high-grade tumours.

Introduction: Ehlers-Danlos syndromes (EDS) constitute a rare entity of genetic disorders, affecting the collagen of all types all. Herein, we describe a case of vascular type of EDS, with coexisting segmental absence of intestinal musculature, while performing simultaneously a narrative review of the existing literature. Case Presentation: A 23-year-old male patient with a history of multiple abdominal operations due to recurrent bowel perforations and the presence of high-output enterocutaneous fistula was admitted to our surgical department for further evaluation and treatment. After detailed diagnostic testing, the diagnosis of vascular type of EDS (vEDS) was made and a conservative therapeutic approach was adopted. In addition, a comprehensive review of the international literature was carried out by applying the appropriate search terms. Results: The diagnosis of vEDS was molecularly confirmed by means of genetic testing. The patient was treated conservatively, with parenteral nutrition and supportive methods. Thirty-four cases of bowel perforation in vEDS have been reported so far. Interestingly, this case is the second one ever to report with co-existence of vEDS with Segmental Absence of Intestinal Musculature. Conclusions: Establishing the diagnosis of vEDS promptly is of vital significance in order to ensure that patients receive appropriate treatment. Due to initial non-specific clinical presentation, EDS should always be included in the differential diagnoses of young patients with unexplained perforations of the gastrointestinal tract.

Lung cancer remains the leading cause of cancer-related death worldwide. The involvement of lymph nodes by the tumor has a strong impact on survival of patients. For this reason, lymphadenectomy plays a crucial role in the staging and prognosis of NSCLC, to define the most appropriate therapeutic strategies concerning the stage of the disease. To date, the benefit, in terms of survival, of the different extents of lymphadenectomy remains controversial in the scientific community. It is recognized that metastatic involvement of mediastinal lymph nodes in lung cancer is one of the most significant prognostic factors, in terms of survival, and it is therefore mandatory to identify patients with lymph node metastases who may benefit from adjuvant therapies, to prevent distant disease and local recurrences. The purpose of this review is to evaluate, the role of lymphadenectomy in early-stage NSCLC in terms of efficacy and accuracy, comparing systematic, sampling and lobe-specific lymph node dissection and analyzing the existing critical issue, through a search of the most relevant articles published in the last decades.

Background: This systematic umbrella review aims to investigate whether provide an analysis of guidelines regarding the treatment of diverticular abscesses summarizing the evidences from the best available practice. Material and methods: A systematic literature search was performed until using the Cochrane Overviews of Reviews model for search the ‘Clinical Practice Guidelines’; at the end of initial search only 12 guidelines, whose characteristics are reported in the following table were included in this analysis. The quality of the guidelines was assessed by adopting the 2017 updated version of the “Appraisal of Guidelines for Research and Evaluation II” (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses. Conclusions: Currently, a lot of scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only, few guidelines, suggest the use of percutaneous drainage for abscess with a diameter greater than 4 cm .The difference among guidelines is the consequence of the different selection of scientific evidences. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.

Background: This systematic review aims to investigate whether percutaneous transhepatic gallbladder drainage (PTGDB), as definitive treatment, is superior to emergency cholecystectomy (EC) in high-risk patients with acute cholecystitis (AC). Material and methods: A systematic literature search was performed until December 2022 using Scopus, Medline/PubMed and Web of Science databases in order to compare PTGDB as definitive treatment vs EC in AC. Results: Seventeen studies (1 Randomized Control Trials and 16 observational studies) have been included with a total of 783,672 patients (32,634 treated with PTGDB vs 4,663 who underwent laparoscopic cholecystectomy, 343 who underwent open cholecystectomy and 746,032 who underwent cholecystectomy, but without laparoscopic or open approach being specified). The quality assessment (ROBINS-I) of the not randomized studies showed a serious risk, differently the evaluation of the randomized study (RoB 2) showed a low risk of bias. Analysis of the results shows that PTGDB, despite being minimally invasive, do not have different incidence of complications than EC (RR 0.77 95% CI [0.44 to 1.34]; I2 = 99%; P=0.36). A lower postoperative mortality was reported in patients who underwent EC (2.37%) than in PTGDB group (13.78 %) (RR 4.21; 95% CI [2.69 to 6.58]; P < 0.00001), furthermore the risk of hospital readmission for biliary complications (RR 2.19 95% CI [1.72 to 2.79]; I2 = 48 %; P<0.00001) and hospital stay (MD 4.29 95% CI [2.40 to 6.19]; P<0.00001) were lower in EC group. Conclusions: No advantage in using PTGDB as a definitive treatment over EC in the management of critically ill patients with AC has been demonstrated; the results of our systematic review and meta-analysis suggest using EC as the treatment of first choice, even for very high-surgical-risk patient in which PTGDB should be reserved. The major limitation of this systematic review and meta-analysis is associated to a low quality of evidence for the serious bias in the not randomized studies. For this reason, new high powered and well-designed clinical trials are needed to recommend PTGDB as definitive treatment in patients unfit for surgery or those who refuse to undergo surgery.

Gastric cancer is among the top 5 causes of cancer-related death worldwide. Preoperative chemotherapy has been established as an option in patients with locally advanced gastric cancer. However, chemotherapy yields variable results, owing to the cellular and molecular heterogeneity of this disease. Identifying patients who did or did not respond to preoperative therapy can allow clinicians to alter treatment modalities and provide important information related to prognostication. Pathologic response to preoperative therapies, called Tumor Response Grade (TRG), has been evaluated to quantify treatment response. Multiple systems for TRG have been established. However, literature has demonstrated inconsistent results for TGR systems and prognosis, possibly due to variability in interpretation of tumor response between systems and interobserver variability. Radiographic response to preoperative therapies using RECIST 1.1 criteria and endoscopically-assessed tumor response have demonstrated association with survival; however their use in gastric cancer remains challenging given the inability to accurately and consistently identify and measure the tumor, especially in the setting of neoadjuvant therapy where treatment-related changes can obscure the gastric wall layers. This review is focused on summarizing the available literature related to evaluating TRG in gastric cancer, as well as providing a brief overview on the use of radiographic and endoscopic methods to assess response to preoperative therapies. Lastly, we outline future directions regarding the use of a universal TRG system to guide care and assist with prognosis.

Background: Primary lymphedema is a chronic condition caused by a developmental abnormality of the lymphatic system and its malfunction. Different surgical options such as physiologic and excisional procedures have been proposed. The aim of this study was to present a complete algorithm for the treatment of primary lower extremity lymphedema: Primary LYmphedema Multidisciplinary Approach (P-LYMA). Methods: Nineteen patients were treated according to the P-LYMA. Patients underwent pre- and post-operative complex decongestive therapy (CDT). Different physiologic and excisional procedures were performed independently or in combination. The primary outcome was the circumferential reduction rate (CRR). The Lymphedema Quality of Life Score (LeQOLiS), reduction in the number of episodes of cellulitis, length of stay, and complications were recorded. Results: The mean CRR calculated was 72.8±19.6% after twelve months. The episodes of cellulitis per year decreased from a mean of 1.9±0.8 preoperative to 0.4± 0.6 throughtout follow-up. Two patients experienced minor complications. Mean hospitalization time was 5 days. Patients’ quality of life (LeQOLi score) drastically improved from 70.4±11.6 to 24.2 ±13.9 at twelve months post-op. Conclusion: The P-LYMA algorithm allows to maximize surgical results and improve the quality-of life in patients who suffer from primary lymphedema. CDT is mandatory to optimize results.

(1) Background: Retroareolar breast tumors, although common, rarely develop into malignancies. This case report presents the case of a 54-year-old woman with a superficial breast tumor, high-lighting the significance of considering a wide range of possibilities when evaluating breast lumps. (2) Methods: The patient presented with a progressively enlarging, ulcerating superficial mass in her left breast. To determine the nature of the tumor and results confirmed the presence of a Grade II superficial infiltrating ductal carcinoma. To address the condition, the patient un-derwent a modified radical mastectomy under general anesthesia. Following the surgery, she was prescribed tamoxifen, an estrogen receptor modulator, in accordance with the current guidelines. (3) Results: The patient experienced a smooth recovery without any complications and displayed no signs of recurrence or metastasis during follow-up visits. This positive outcome highlights the importance of early detection and proactive management in improving patient prognosis. (4) Conclusions: This case report underscores the significance of conducting a comprehensive ex-amination and maintaining a high index of suspicion for breast lumps. This report contributes to the existing body of literature on the diverse presentations of breast cancer.

IntroductionOne rare cause of appendicitis is mucocele which may have a neoplastic or non-neoplastic source. Simple appendectomy or right hemicolectomy may be necessary, sometimes medication may be prescribed to manage symptoms. In this study, we reported a rare case with Mucocele of the Appendix managed by antibiotic therapy and simple appendectomy.Case PresentationA 60-year-old female with a seven-month history of right lower quadrant pain. A physical exam showed tenderness and rebound tenderness in the McBurney’s point. In her CT-Scan tubular mass measured 105 * 37 mm in RLQ is noted suggested for mucocele appendicitis. Appendectomy performed through McBurney incision and the pathology was mucocele of the appendix with mucin-secreting mucosal hyperplasia.ConclusionMalignancy of the appendix is extremely rare. Appendiceal tumors have a low prevalence; But due to the nature of these tumors, which can also be malignant, they should be given importance and careful follow-up is mandatory. As the Surgical community continues to learn more about this condition, it is essential that patients remain informed and proactive about this situation. With timely diagnosis and treatment, mucocele appendix can be successfully managed and treated.

Two-stage surgery is unintentionally necessary when total tumor removal cannot be accomplished in the first surgery, although, it has not yet been established how to leave the tumor for the next surgery. There is a risk of postoperative hemorrhage in the residual tumor, especially in hypervascular tumors. We report a case of hypervascular choroid plexus papilloma in which preservation of intratumoral venous drainage was considered important to avoid hemorrhagic complications during a two-stage surgery. In hypervascular tumor resection, to prevent postoperative hemorrhage associated with a residual tumor, it may be important to preserve venous drainage of the tumor.

Background and Objectives: The aim of this study is to investigate the diagnostic-therapeutic prob-lem of pelvic recurrence of rectum cancer, highlighting current surgical standards and the possi-ble role of the minimally invasive approach. This retrospective analysis of our surgical case study wishes to enter this debate while suggesting a possible line of action, based on the site of recur-rence. Materials and Methods: We examined, retrospectively, all the patients diagnosed, between 2008 and 2018, with cancer of the rectum at the "Pietro Valdoni" Department of Surgery and monitored their follow-up for 5 years. The sample consisted of 368 patients with rectal neoplasm, 136 females and 232 males, with an average age of 65.8 (ranging from 37 to 86). In 103 of the cases, the neo-plasm was located in the upper rectum (28%), in 119 cases in the middle rectum (32.3%), in 102 cases in the lower rectum (27.7%), in 31 cases (8.4%) at the level of the right/sigma junction and in 13 cases it was not possible to define the site with certainty (3.5%). Results: We examined all patients diagnosed with cancer of the rectum between 2008 and 2018 at the "Pietro Valdoni" Department of Surgery retrospectively and monitored their follow-up for 5 years. The sample consists of 368 patients with rectal neoplasm, 136 females and 232 males. Conclusions: The discussion remains open as to which approach is best at surgical level, whether laparoscopic, robotic or open-air. Our experience informs us that the most dangerous site remains on the anastomotic site.

(1) Background: This case report focuses on a 46-year-old female patient diagnosed with a rare and aggressive form of breast cancer known as rapidly growing, ulcerated breast cancer. The patient exhibited rapid progression of the disease, experiencing discomfort and noticeable changes in the size and texture of the affected breast over a short period of time; (2) Methods: An intensive neoadjuvant chemotherapy regimen was employed as the primary treatment approach. The patient's response to this treatment was closely monitored and assessed. Various diagnostic tests and imaging techniques were utilized to evaluate the extent of the disease and track its response to the chemotherapy; (3) Results: The patient's response to the neoadjuvant chemotherapy regimen was remarkable, resulting in a complete pathologic response. This outcome, although unusual in rapidly growing, ulcerated breast cancers, highlights the effectiveness of neoadjuvant chemotherapy in managing large, locally advanced breast cancers; (4) Conclusions: The multidisciplinary approach employed in managing this complex breast cancer case proved to be crucial to the patient's favorable outcome. Despite the aggressive nature of the disease and the challenges posed by the rapid growth and ulceration, the patient achieved a positive result. This case contributes to the limited clinical literature on such unusual and aggressive breast cancer cases, providing valuable insights for future clinical practice.8

Lymphedema is a chronic and debilitating disease that affects up to 250 million patients worldwide. Recent advances in understanding its pathophysiology, along with improved diagnosis and microsurgical techniques, have enhanced our ability to cope with the challenging task of treating this disease. This review provides an overview of the disease from a surgeon's point of view, including existing imaging modalities used for preoperative assessment, as well as surgical procedures used in its treatment. Advantages and drawbacks of various existing modalities used for pre or intraoperative assessment of lymphatic vessels are discussed. Lymphedema treatment has shifted from palliative debulking procedures (liposuction and direct excision) to those aimed at restoring lymphatic flow and countering the pathophysiology of the disease (lymphaticovenous anastomosis and vascularized lymph node transfer). A combination of both approaches can result in a synergistic benefit for patients and are discussed in this review. Despite recent advances, some controversies persist, and further studies are needed to better define surgical treatment algorithms.

The reconstructive ladder is a well-established concept in Plastic Surgery proposed to achieve wound closure using a stepladder approach from simple to complex procedures and it continues to evolve from when it was presented for the first time. We describe a new surgical technique that allows skin excision and primary wound closure avoiding donor site morbidity from skin grafts and avoiding large scars from loco-regional flaps: the parallelogram excision technique. Fifteen patients with skin lesions underwent this procedure. Six months' follow-up results showed a) good scar healing, b) total excision of lesions, and c) patient acceptance and satisfaction from the usage of this technique. We conducted a geometrical analysis of the parallelogram’s design to study the optimal geometrical condition to achieve all these three factors. We propose that the parallelogram excision of skin lesions proves to be a unique new wound closure technique that may add a new rung to the reconstructive ladder.

Osteoporotic spinal fractures represent an increasingly widespread health problem in our aging society. We aimed to investigate the treatment options for low-energy spinal fractures in the el-derly and their impact on mortality, focusing on surgical stabilization using minimally invasive and open techniques. We evaluated 1356 patients over 50 years of age with compression frac-tures sustained due to low energy trauma treated at a single trauma center. We compared the mortality of patients following stable and operated/non-operated unstable compression frac-tures and the eligibility to surgery using the open and minimally invasive approach. The pa-tients received surgical or conservative care according to severity and eligibility to surgery. The mortality hazard ratio of patients who underwent screw fixation was 1.02 (P > .91), of patients who refused surgery was 1.68 (P < .001) and that of patients with anesthesiological contraindica-tion was 1.57 (P = .08), compared to conservatively treated patients with stable fractures. The dif-ference in mortality between open and minimally invasive surgeries was not significant, but the number of patients eligible for surgery with the minimally invasive procedure was significantly higher (OR: 0.25; P < .001). Spinal stability after fractures may be an important predictor of sur-vival in patients with low-impact fractures.

Although a slight imbalance between oxidative and antioxidative mediators is part of normal physiology that enables cell aging and the removal of dead cells, burns disturb this equilibrium locally and systemically. Topical burn dressings may attenuate local and systemic oxidative stress and positively influence the post-burn clinical course. This review integrated knowledge regarding the impact of burn dressings on oxidative stress. Using keywords and in-text searches, literature was identified from PubMed, Google Scholar, and Google articles, and studies on local or topical applications of wound dressings and associated oxidative stress were selected. As im-balances between oxidative mediators and antioxidative agents significantly contribute to organ dysfunction and healing disturbance, we investigated oxidative stress on organs, metabolic changes, clinical results, and oxidative parameters influenced by applied dressings. We found positive local and systemic effects of external burn dressings in laboratory and animal tests; however, such studies were rare in humans. Nevertheless, we identified successful cases of semi-occlusive, occlusive, and biologically active dressings that reduce oxidative stress in hu-man burns. In particular, we highlight promising clinical and laboratory results from lac-tate-releasing dressings. Our review provides an invaluable resource for future development and clinical applications of burn dressings.

We present our experience with the implantation of flow diverter stents (FDSs) for the management of intern carotid artery (ICA) dissections in tortuous tonsillar loop segments. 16 patients (10 women, 62.5%; mean age 39±8 years; median baseline NIHSS 13; median ASPECTS 8.5) with acute ischemic stroke due to ICA dissection in a tortuous tonsillar loop segment, with/without large intracranial vessel thrombotic occlusion, from 6/2015−2/2022 were included in this retrospective study under a waiver of informed consent. An FDS device was deployed from the petrous ICA toward the upper cervical ICA, completely covering the tonsillar loop. Stentriever-assisted thrombectomy was performed when indicated. A dual antiplatelet regimen was used during and after the procedure. Thrombocyte inhibition levels were evaluated before, during, and after the intervention. The ICA occlusion/near occlusion was successfully recanalized in all 16 patients with postangioplasty residual stenosis of 34±14% (range 0−50%). Stent-assisted embolectomy was performed in 15/16 patients (93.7%), achieving revascularization (TICI 2b−3) in all. There were no procedural complications and no intraprocedural embolic events; one asymptomatic petechial hemorrhage was detected. At 3-month follow-up, mRS 0−2 was seen in all patients. This report provides pilot data for a subsequent study on the use of flow diverter stents for ischemic cerebrovascular conditions. Our encouraging preliminary results await confirmation from further experience and prospective randomized studies.

Background: We designed a prospective study of diagnostic accuracy which compared pelvic MRI and 3D-EAUS versus pelvic MRI alone in the preoperative evaluation and postoperative outcomes of patients with perianal fistulas. Methods: The sample size was 72 patients and was divided into two imaging groups. MRI alone was performed in the first group. Both MRI and 3D-EAUS were performed in a parallel fashion in the second group. Surgical exploration took place after two weeks and was the standard reference. Park’s classification, presence of a concomitant abscess or a secondary tract and location of the internal opening were recorded. All patients were re-evaluated for complete fistula healing and fecal incontinence six months postoperatively. All the collected data was subjected to statistical analysis. Results: Group MRI included 36 patients with 42 fistulas. Group MRI + 3D-EAUS included 36 patients with 46 fistulas. The adjusted sensitivity and negative predictive value were 1.00 for most fistula types in the group of combined imaging. The adjusted specificity improved on intersphincteric fistulas in the same group. The adjusted balanced accuracy improved on all fistula types, except for rectovaginal. The combination of imaging methods showed improved diagnostic accuracy only on the detection of a secondary tract. Healing rate at six months was 100%. Fecal incontinence at six months didn’t present a statistically significant difference between the two groups (Fisher's exact test p-value &gt; 0.9). Patients with complex perianal fistulas had a statistically significant higher probability to undergo a second surgery (x² test p-value=0.019). Conclusion: The combination of pelvic MRI and 3D-EAUS showed improved metrics of diagnostic accuracy and should be used in the preoperative evaluation of all patients with perianal fistulas, especially in those with complex type.

Background A limited lymphadenectomy may make patients with esophageal squamous cell carcinoma (ESCC) at risk for missing occult nodal disease. This study aimed to determine an effective threshold of lymph nodes (LNs) for evaluation of the quality of lymphadenectomy and discuss the impact of adjuvant chemotherapy on pN0 patients. Methods Patients treated surgically for ESCC between 2010 and 2018 in Sichuan Cancer Hospital were included. NPV (Negative Predictive Value) based on a beta-binomial distribution was developed to assess the confidence of node-negative disease. Kaplan-Meier curves were plotted to compare survival differences among groups. Results When patients had >21 LNs examined, the probability of false-negative findings was estimated at <10%, and NPV was estimated at a high level (>86.5%). For patients with LNs removed ≤21, 5-year OS (or DFS) in postoperative chemotherapy group vs that in surgery group was 65.3% vs 54.6%, p = 0.041 (or 59.2% vs 46.6%, p = 0.033). But for patients with >21 LNs, there were no statistical differences (p = 0.683 for OS or p = 0.942 for DFS). Conclusion Only pN0 patients who were at high risk of occult lymph node metastasis (examined LNs ≤21) could benefit from postoperative chemotherapy.

Background: Craniofacial injuries are thought to be commonly associated with traumatic brain injury (TBI), but there is conflicting evidence in the literature. The objective of this retrospective cohort study is to evaluate the incidence of TBI in patients with craniofacial trauma. Methods: The study included 2982 consecutive patients with either solitary or concurrent diagnoses of TBI and facial fractures, seen and evaluated at a single level II trauma center between January 1, 2010 and December 31, 2020. Continuous variables were compared against whether the patient had one or both diagnoses.Results: Of the target population, 55.8% had a solitary diagnosis of TBI, 30.28% had a solitary diagnosis of facial fractures, and 13.92% had concurrent diagnoses of both TBI and facial fractures. Patients with concurrent diagnoses had a significantly longer mean length of stay (LOS) compared to those with solitary diagnoses (9.92 ± 16.33 days vs. 6.21 ± 10.96 days, p&lt;0.01), but age (p=0.68) and ICU LOS (p=0.09) did not differ significantly between the two groups. Conclusions: Trauma to the face should be given special attention due to the close relationship between facial bones and the brain. Patients with concurrent diagnoses of TBI and facial fractures had worse hospital outcomes than those with solitary diagnoses of either TBI or facial trauma.

The Covid-19 pandemic has produced a change in the way of living, socializing and a modification in Health Systems around the world. A multicentre retrospective study was carried out to study orofacial trauma in one of the regions most affected during the first wave of the pandemic, with the participation of the five main tertiary hospitals in Madrid. The aim of this study is to evaluate the epidemiology of orofacial surgical trauma during the 1 year of COVID pandemic and compared to de prior year. Age, sex, mechanism, localization, and treatment were studied. P-value <0.05 was considered statically significative. Reduction of 39.36% (<0.001) in maxillofacial fractures was observed, without significance change in sex, localization or treatment. Significant increase in age (35,92 vs. 40,26) (p = 0.006) was observed. Significant decline in mechanism was noted (p = 0.025), decreasing personal violence (41% vs 35%) and sports (14% vs 8%); increasing in falls (27% vs 35%), precipitation (2 vs 5%), and traffic accidents (12% vs 13%). The mandible was the most frequent fractured bone. The COVID pandemic has produced epidemiological variations in orofacial trauma, making it necessary to monitor social and legal changes that may require reorganization to adjust to population needs.

Abstract Introduction Minimally invasive approaches to oncological liver resection is common in many hepatobiliary centres. This study aims to compare the key oncological and survival outcomes of patients with colorectal liver metastases (CRLM) undergoing laparoscopic or open resections using propensity score matching (PSM). Methods A single-centre retrospective study was performed using a prospective database of patients undergoing liver resection for CRLM between January 2016 and December 2019. Different co-variates were selected for matching using PSM. Pre-matching and post-matching analyses were compared. Surgical and survival outcomes were analysed. Results In total, 303 patients who met the inclusion criteria were identified: 214 underwent open liver resection (OLR) and 91 laparoscopic liver resection (LLR). LLR had a significantly reduced length of intensive treatment unit (ITU) and overall in-patient stay but longer pringle and operative times. In the unmatched cohort, the median overall and disease-free survival time was significantly longer in patients undergoing laparoscopic compared with open surgery. A PSM model demonstrated significantly reduced blood loss and length of hospital stay, with a significantly greater Pringle and operative time in the LLR group. Differences seen in overall and disease-free survival were lost with propensity score matching, possibly due to lack of bi-lobar disease within the minimally invasive group. Conclusion In selected patients with CRLM, LLR presents similar survival and oncological outcomes with the advantages of the short-term results associated with the laparoscopic approach.

Background: Skin and soft tissue infections (SSTI) are common presentations to the emergency department. However, this is less common after contact with contaminated water, both salt or fresh. This review presents the diagnosis and the management of water-related soft tissue sepsis in this vulnerable and difficult to treat subgroup of necrotizing soft tissue sepsis. Methods: A summative literature overview regarding bacterial and fungal SSTI after contact with contaminated water, with practical diagnostic and management aspects addressed. Results: The literature indicates that these remain difficult to treat wounds and organisms. An approach using appropriate diagnostic tools with both medical and surgical management strategies is provided. Conclusion: SSTI due to water contamination of wounds involve unusual organisms with unusual resistance patterns and require a nuanced and directed diagnostic approach with adaptation of the normal antibiotic or antifungal selection to achieve cure, along with aggressive debridement and wound care.

Abstract Background. There is an inherent limit in the accuracy of our measurements, set by nature itself and predicted by Heisenberg's uncertainty principle, which defines the properties of nature in the microcosmos. There is a fundamental limit to the accuracy with which complementary phys-ical quantities of a particle can be predicted from their initial conditions. As classical physics is essentially considered at borderline of quantum mechanics, so the power of uncertainty princi-ple is limited in describing everyday life perceived or managed phenomena. Method. In this study, we apply Heisenberg's uncertainty principle to children under diagnostic uncertainty re-garding appendicitis. We analyze this phenomenon in clinical practice. Results. Medical practice is full of uncertainty. False negative decisions correlate with delays in treatment and adverse outcomes in children with atypical appendicitis. On the other hand, false-positive surgery deci-sions result in negative appendectomies. With improvement of technology, the incidence of complicated appendicitis or negative appendectomies due to diagnostic uncertainty has de-creased but cannot be ignored or eliminated. Conclusion. According to the principle, there is a fundamental limit to the accuracy with which the complementary variables of negative appen-dectomy and complicated appendicitis can be observed or measured simultaneously. What does all this mean for the physician?

Background: Thoracic endovascular aortic repair (TEVAR) has become the standard treatment for blunt thoracic aortic injury (BTAI). Some small observational studies revealed aortic morphological changes after TEVAR in patients with BTAI. However, these studies were limited by the rarity of the condition and small sample sizes. To address this gap, the current study aims to conduct a systematic review and meta-analysis of existing literature to provide evidence on the degree of immediate and long-term aortic diameter change following TEVAR for BTAI. Methods: This systematic review and meta-analysis of studies published up to March 2023, was conducted in accordance with the PRISMA statement. Studies eligible for inclusion were studies evaluating aortic diameter change post-TEVAR in BTAI patients. Results: 14 articles, including 353 patients, were included after review. Treatment and measurement protocols varied among individual studies resulting in high heterogeneity of the results. Our meta-analysis demonstrated an immediate post-intervention dilation 2.41 mm and 2.63 mm of the proximal and distal aortic necks’, respectively, as well as continuous dilation of the respective regions at a rate of 0.35 mm/year and 0.49 mm/year. Conclusion: TEVAR in BTAI leads to immediate post-intervention and continuous aortic dilation and morphological changes with possible future important clinical consequences.

Pseudomyxoma peritonei (PMP) is a rare malignant growth characterized by the production of mucin and the potential for peritoneal relapse. This study aimed to investigate the immunohistochemical and biological characteristics of mucin in patients with cellular and acellular PMP. We prospectively analyzed mucin specimens obtained from our patient cohort and described the composition and type of mucin present in each sample. A metagenomic analysis of the samples was performed to investigate the bacterial composition of the PMP microbiome. Secreted mucins 2 and 5AC and membrane-associated mucin-1 were the primary components of mucin in both cellular and acellular tumor specimens. The metagenomic study revealed a predominance of the phylum Proteobacteria and the genus Pseudomonas. Notably, Pseudomonas plecoglossicida, a species not previously reported in the human microbiome, was found to be the most abundant organism in the mucin of pseudomyxoma peritonei. Our findings suggest that the presence of MUC-2 and mucin colonization by Pseudomonas is a characteristic feature of both cellular and acellular disease. These results may have significant implications for the diagnosis and treatment of this rare entity.

INTRODUCTION: Achalasia is a pathology with an incidence of 1 in 100,000 inhabitants per year. There are very limited data on achalasia in the obese population, especially in those undergoing bariatric surgery. The approach of choice for cases of achalasia is fundoplication to correct the reflux; however, lacking a fundus due to a previous gastrectomy, an alternative that offers optimal results should be chosen. Here we present the surgical approach in a case of esophageal achalasia and a history of vertical sleeve gastrectomy, where we performed simultaneous Heller's cardiomyotomy and laparoscopic Roux-en-Y gastric bypass, as well as the results obtained. CASE PRESENTATION: 44-year-old woman with no chronic degenerative diseases, with a previous record of vertical sleeve gastrectomy 5 years ago, who started 1 year and 5 months earlier with dysphagia to liquids, then to solids, in addition to weight loss of 10 kilograms in 4 months. The BMI before vertical sleeve gastrectomy was 32 kg/m2, her BMI at the time of admission was 20 kg/m2; she also presented regurgitation and generalized weakness. After analyzing the surgical options, it was decided to perform a Heller cardiomyotomy and a Roux-en-Y gastric bypass. DISCUSSION AND CONCLUSIONS: The procedure turned out to be safe and successful in treating achalasia symptomatology, in addition to complete resolution of the reflux symptom.

Temporomandibular joint disorders (TMD) are characterized by their multifactorial etiology and pathogenesis. A 3-year prospective study was conducted in a Portuguese TMD department to study the prevalence of different TMD signs and symptoms and their association with risk factors and comorbidities. Five hundred ninety-five patients were included using an online database: EUROTMJ. Most patients were female (80.50 %), with a mean age of 38.20±15.73 years. The main complaints were temporomandibular joint (TMJ) clicking (13.26%), pain (12.49%), and masticatory muscle tension (12.15%). The main clinical findings were myalgia (74%), TMJ clicking (60-62%) and arthralgia (31-36%). Risk factors such as clenching (60%) and bruxism (30%) were positively associated with TMJ pain and myalgia. Orthodontic treatment (20%) and wisdom tooth removal (19%) were positively associated with TMJ clicking, while jaw trauma (6%) tracheal intubation (4%) and orthognathic surgery (1%) were positively associated with TMJ crepitus, limited man-dibular range of motion and TMJ pain, respectively. 42.88% of TMD patients had other associated chronic diseases, most of them were mental behavioral or neurodevelopmental disorders (33.76%), namely, anxiety (20%) and depression (13%). The authors also observed a positively association of mental disorders with the degree of TMJ pain and myalgia. Online database seems to be a relevant scientific instrument for healthcare providers who treat TMD. The authors expect that EUROTMJ database can serve as a milestone for other TMD departments.

Background: Knowledge of vascular anatomy and its possible variations is essential for performing embolization or revascularization procedures and complex surgery in the pelvis. The obturator artery (OA) is a branch of the anterior division of the internal iliac artery (IIA), and it has the highest frequency of variation between branches of the internal iliac artery. Possible anomalies of the origin of the obturator artery (OA) should be known when performing pelvic and groin surgery, where its control or ligation may be required. The purpose of this systematic review and meta-analysis, based on Sanudo’s classification, is to analyse the origin of the obturator artery (OA) and its variants. Methods: Thirteen articles, published between 1952 and 2020, were included in this systematic review and meta-analysis. Results: The obturator artery (OA) was present in almost all cases (99.8%): the pooled prevalence estimate for internal iliac artery (IIA) was 77.7% (95% CI 71.8% – 83.1%) vs 22.3% (95% CI 16.9% – 28.2%) for the external iliac artery (EIA). In most cases, the obturator artery (OA) originated from the anterior division trunk of the internal iliac artery (IIA) (61.6%). Conclusion: Performing preoperative radiological studies to know the pelvic vascular pattern and having awareness to evaluate possible changes in the obturator artery can reduce the risk of iatrogenic injury and complications

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

Introduction Currently, the increase in the percentage of obese people observed along with the development of civilization, reaching the level of a global pandemic, has forced the search for methods of effective and permanent obesity treatment. Obesity is a multifactorial disease, it coexists with many disease entities and requires multidisciplinary treatment. Obesity leads to metabolic changes in the form of metabolic syndrome, which includes, among others, atherogenic dyslipidemia. The proven relationship between dyslipidemia and cardiovascular risk enforces the need to effectively improve the lipid profile of obese patients. Laparoscopic sleeve gastrectomy is a method of surgical treatment of morbid obesity which improves bariatric and metabolic parameters. The aim of the study was to assess the effectiveness of laparoscopic sleeve gastrectomy (LSG) in improving lipid profile parameters in 1-year follow-up. Material and Methods Bariatric parameters of 196 patients who underwent laparoscopic sleeve gastrectomy as well as lipid profile of total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), non-NDL, and triglycerides (TG) in 1-year observation were analyzed. Results Improvements in bariatric parameters were observed in patients after LSG. Total cholesterol, low-density lipoprotein (LDL), triglycerides and non-HDL levels decrease were observed along with the increase of high-density lipoprotein (HDL) cholesterol level. Conclusions Sleeve gastrectomy is an effective method of treating obesity and improving the lipid profile in obese patients.

Introduction: Austere environments include the wilderness and many lower-and-middle-income countries, many of these facing unrest and war. The access to advanced diagnostic equipment is often unaffordable even if available and is often liable to breakdown. This short review paper examines the options available to medical professionals to undertake clinical and point of care diagnostic testing in resource constrained environments and also illustrates the development of mobile advanced diagnostic equipment. The aim is to provide an overview of the spectrum and functionality of these devices beyond clinical acumen.

Abstract: Background: Trauma is the leading cause of morbidity and mortality in young patients, acute surgical conditions cause morbidity and mortality in patients of all ages. Computed tomography scan (CT) assist greatly in the investigation and management of these patients with blunt and penetrating trauma, facilitating early diagnosis and expedites early appropriate treatment of these patients. Acute non-traumatic surgical conditions also mimic non-surgical pathologies and differentiating the two is important because management is different and any delay in surgical intervention results in high morbidity and some may even result in mortality. Method: Literature review of the role of multidetector CT scan (MDCT) in managing acute surgical emergencies and trauma-diagnosis in the trauma patient and patients presenting with acute surgical emergencies. The focus is on the role of the MDCT in the management of these patients. Results highlight that the use of MDCT expedites management of these patients, allowing early surgical intervention and preventing unnecessary surgical interventions where the intervention is not indicated, based on the MDCT results. Conclusion: This paper emphasizes the important role that is played by the MDCT in the management of the above patients.

Piriform fossa and/or esophageal injuries caused by calibration tubes are relatively rare and re-main unelucidated. Herein, we report the case of a 36-year-old woman with morbid obesity, sleep apnea, and menstrual abnormalities who was scheduled to undergo laparoscopic sleeve gastrectomy (LSG). We inserted a 36-Fr Nelaton catheter made of natural rubber as a calibration tube during the surgery. However, excessive resistance was observed. We confirmed a submuco-sal layer detachment of approximately 5 cm from the left piriform fossa to the esophagus using intraoperative endoscopy. Additionally, LSG was performed using an endoscope as the guiding calibration tube. We inserted a nasogastric tube under endoscopy with a guidewire before com-pleting the surgery, hoping for a guiding effect on saliva flow. After 17 months, the patient suc-cessfully lost weight postoperatively without complaints of neck pain or discomfort during swallowing. Therefore, if the damage is limited to the submucosal layer, as in this case, conserva-tive therapy should be considered, which is similar to the concept of not requiring suture closure in endoscopic submucosal dissection. This case highlights the risk of iatrogenic injuries to the pi-riform fossa and/or esophagus during LSG and the importance of careful calibration tube inser-tion to prevent them.