Introduction: Small intestine tumours represent ~3% of gastrointestinal neoplasms and 0.6% of all cancers, despite the extensive intestinal surface. Diagnosis is often delayed (up to two years for malignant tumours) due to non-specific symptoms, necessitating heightened clinical awareness and improved diagnostics. Purpose: This study investigated the prevalence, characteristics, and clinical presentation of small intestine tumours in patients undergoing enterectomy. Methodology: A retrospective study was conducted at the Surgical Department of a tertiary center in Athens, including patients who underwent primarily emergency enterectomy during the period 2014–2024. All relevant medical records and pathology reports were evaluated, and statistical analysis was performed using IBM SPSS Statistics Version 26. A literature review (2000–2025) was also conducted. Results: Among the participants (N=62), 37.1% underwent enterectomy for obstruction and 29% for incidental tumor detection. The mean resection length and mean tumour size were 30.1 and 5.7 cm, respectively. Malignancy was detected in 79% of cases, with lymph node metastases in 25% and pT4 staging in 42.9%. Histological types included gastrointestinal stromal tumours (21%), metastatic tumours (17.7%), neuroendocrine tumours (14.5%), lymphomas (9.7%), and adenocarcinomas (9.7%). R0 resection was achieved in 88.1% of cases. Procedures were mostly emergency-based in patients with advanced disease at diagnosis. Conclusions: Small intestine tumours are rare but clinically significant, often presenting late. Our findings align with the current literature, confirming the predominance of malignancy and emergency presentations. Geographic and histological variations may reflect genetic and environmental influences. Early diagnosis and tailored surgical management could improve outcomes.
Background: Colorectal cancer (CRC) represents one of the most frequent malignancies worldwide and one of the leading causes of cancer-related mortality. Over the years the treatment options include radiotherapy, chemotherapy and surgery. Immune checkpoint inhibitors (ICIs) show favorable efficacy in microsatellite instability (MSI-H) CRC, however there is no clear benefit in microsatellite-stable tumors (MSS). Since only around 15% of colorectal cancers are MSI-H and the remaining 85% are MSS, the limited efficacy of ICIs in MSS tumors remains a therapeutic challenge. This narrative review aims to examine the mechanisms of therapeutic resistance to ICIs in MSS CRC overall, to summarize the available clinical evidence, and to discuss possible strategies to enhance immunotherapy efficacy. Attention is also given to the evolving role of surgery within modern multifactor management including the potential interaction of immunotherapy across resectable, borderline resectable and metastatic disease settings. Methods: A narrative review was conducted using Pubmed, Scopus and Web of Science databases. The literature search included articles published up to May 2026. The following keywords were used: “microsatellite stable”, “colorectal cancer”, “immune checkpoint inhibitors”, “immunotherapy” and “colectomy”. Narrative reviews, retrospective studies, and systematic reviews in English were considered eligible for inclusion. Results: MSS CRC is characterized by chromosomal instability involving large-scale genomic alterations and is associated with a low tumor mutational burden (ΤΜΒ) and limited neoantigen formation, contributing to the limited efficacy of ICIs. Many molecular pathways are responsible for this condition such as Wnt/β-catenin pathway, Mitogen-Activated Protein Kinase (MAPK) pathway and the transforming growth factor-β (TGF-β) pathway. Some trials (IMblaze370, KEYNOTE-016) highlight the limited efficacy of ICIs as monotherapy in MSS CRC and investigate the combined treatments to overcome the resistance. Surgery remains the cornerstone of CRC treatment; however, a non-operative (watch-and-wait) approach may be safe alternative to surgery in selected patients with MSS CRC. Conclusions: ICIs have changed the management of MSI-H CRC but remain ineffective as monotherapy in MSS CRC. Combination treatments targeting the tumor microenvironment, angiogenesis and oncogenic signaling pathways represent promising direction for improving immunotherapy efficacy. In this context, surgery continues to play a central role in the management of colorectal cancer. Patients with resectable disease, locally advanced and selected cases of metastatic diseases may benefit from this multidisciplinary approach. Beyond its established cytoreductive effect, surgical intervention may help modify the tumor microenvironment and reduce systemic immunosuppressive signaling. Surgery may also improve the responsiveness to immunotherapy. Future studies are needed to better define patient selection, optimal treatment choice and the role of multidisciplinary teams in the decision between systemic and locoregional therapies.
Indocyanine green (ICG) fluorescence is emerging as a valuable aid during laparoscopic adrenalectomy (LA), providing intraoperative assistance in the identification of the adrenal vein and the delineation of adrenal anatomy and tumour margins. Herein, we describe our standardised technique of injecting ICG at two different stages of LA, including patient selection and stepwise execution. We also share our experience, having performed over 67 ICG fluorescence-guided LAs, along with practical tips for overcoming initial technical difficulties. We believe that ICG in LA may play a role in the teaching process of junior surgeons, in challenging cases of LA as an assisting adjunct, and in selected cases of cortical-sparing LA.
Surgical decision-making is a complex, high-stakes process requiring a blend of clinical expertise, emotional regulation, situational awareness, and rapid judgment. Like pilots, surgeons often rely on both established protocols and instinct when navigating crisis situations. While structured frameworks—such as “Avoid, Trap, Mitigate”—enhance decision quality, emotional factors like hunger, anger, loneliness, tiredness, pain, and stress (HALT-PS) can significantly impair judgment. These emotions may cause errors of omission, commission, or flawed planning, contributing to surgical complications or “Never Events.” Simulation-based training, team communication, and adaptive protocols derived from aviation have been shown to enhance crisis performance and mitigate human error. Over-reliance on technology without contingency planning, such as robotic tools, further jeopardises outcomes. Ultimately, the surgeon bears the burden of decisions that can determine life or death. Recognising and mitigating emotional and systemic vulnerabilities is vital for safe, patient-centred surgical care.
Background: Advances in modalities such as Virtual Reality (VR) laparoscopic simulators have led to their widespread implementation in surgical training. Various modules exist, spanning across basic tasks and even segmented procedures. For one of the most common surgical procedures performed, laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair, a structured training curriculum can be developed for future surgeons, and shorten the learning curve of training. Practicing the associated techniques in a complication-free environment, prior to application in the operating theatre, is a crucial aspect of safe and effective training, which can be achieved through VR simulators. Material and Methods: The development of the program will include an arm of ten expert general surgeons and an arm of thirty novice general surgery trainees performing a group of three tasks at a single Simulation Center. Analysis of their performance will be used to test face and construct validity of the program. Data acquired will also be assessed based on Messick’s framework. Results: Data from the development will be analysed to formulate the preliminary curriculum proposal. The success baseline will be defined according to experts’ performance data and will be adjusted to novices’ level (±1 SD). A Delphi consensus will ultimately be conducted to formulate the final curriculum parameters. Conclusions: In light of technological advances that reshape medical education, VR simulators are transformative in surgical skill acquisition while engaging trainees effectively. In order to utilise their full potential in effective training, evidence-based curricula are necessary. They can contribute to skill acquisition to a predetermined level of proficiency before progression to more challenging cases and can objectively evaluate each trainee. Such validated training curricula will result in more efficient skill acquisition and retention, ultimately contributing to better patient outcomes.
Opioids are a cornerstone treatment for chronic pain in oncology patients, yet individual response varies widely due to genetic differences in CYP2D6 enzyme activity, which governs the metabolism of codeine and tramadol. Patients are classified into four metaboliser phenotypes, each associated with distinct efficacy and side-effect profiles. The current study proposes a research protocol integrating genetic and clinical data through machine learning models (WEKA, Omics-CNN) to predict individual opioid response. Patients from the Hippocration Pain Unit will undergo CYP2D6 genotyping and standardized pain assessment. The aim is to develop a predictive tool to support personalised, evidence-based opioid prescribing in cancer pain management.
NTHL1 polyposis syndrome (or FAP-3 syndrome) is a rare familial polyposis syndrome with only 72 reported cases worldwide from 50 different families. A 54-year-old male presented with a change in bowel habits and an incidence of blood in the stools. Colonoscopy demonstrated over 60 polyps and a suspicious cecal lesion with high grade dysplasia on biopsy. Genetic panel testing tested positive for NTHL1 mutation. Subsequently he was operated on with a subtotal colectomy in order to manage the cecal lesion and the polyposis syndrome. A colorectal adenocarcinoma with a squamous feature of the cecum was diagnosed. The patient was the first of his family with a cancer diagnosis. Finally, he was released after 10 days with no major complications. His family was informed about the inheritance characteristics of the syndrome and was advised properly. This is a rare case of familial polyposis syndrome with an NTHL1 gene mutation. APC and MUTYH are the most common gene mutations among patients with FAP. Clinicians should be aware of such mutations and advise patients and families properly.
Background: Pelvic exenteration (PE) is a radical, potentially curative procedure for locally advanced and recurrent pelvic malignancies, associated with significant morbidity. This study presents the perioperative outcomes of PE surgery performed at our center. Material and Methods: In this retrospective, single-center cohort study, all patients undergoing PE surgery between 1 January 2024 and 1 September 2025 were included.No specific inclusion or exclusion criteria were applied. Data, including operative and reconstruction techniques, perioperative complications and pathology outcomes, were collected and analysed; no inferential statistics were performed. Results: The cohort included 18 patients, with a mean age of 62 (range 40-76). Sixteen patients had rectal cancer cancer (recurrent in 8 (44%) and primary in 8 (44%) patients) and two patients had recurrent cervical cancer. The principal procedure was total pelvic exenteration, with or without low sacrectomy (8 (44%) and 6 (33%) patients, respectively). Other procedures included abdominosacral resection, palliative PE, high subcortical sacrectomy, extended lateral pelvic sidewall excision, and extralevator abdominoperineal resection. Urinary reconstruction was primarily via ileal conduit (16 patients (88.9%) and flap reconstruction via bilateral gluteal flap (7 patients (38.9%). Most tumours were staged as T4 (83%- 15 patients) and an R0 resection was achieved in 16 patients (89%). The mean hospital stay was 36 days (range 18-68). All patients experienced complications, graded as Clavien-Dindo II (61%- 11 patients), IIIa (3 patients (17%), or IIIb (4 patients (22%). The most common were bloodstream infections (10 patients (56%) and superficial abdominal wound infections (9 patients (50%). Re-operation was required in four patients (22%) due to the following: anastomotic leak, burst abdomen, flap haematoma with dehiscence, and postoperative intra-abdominal bleeding. Conclusions: PE, while a highly morbid procedure, can achieve high rates of R0 resection in patients with advanced or recurrent pelvic disease. The high incidence of complications underscores the complexity of these cases and highlights the necessity for their management in specialised, high-volume centers with multidisciplinary support.
Selecting the optimal management of uncomplicated acute appendicitis in adults presents a contemporary medical challenge. Traditionally, appendectomy has been the cornerstone, but recent literature explores non-operative management (NOM) using antibiotics as a viable alternative. The Antibiotics versus Surgery for Uncomplicated Acute Appendicitis (ASAA) trial, Appendicitis Acuta (APPAC) trial, Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial and the Conservative versus Open Management of Acute uncomplicated Appendicitis (COMMA) trial have contributed conflicting results, fueling the ongoing debate. The decision between antibiotics and surgery hinges on factors like treatment success, recurrence rates, cost, and quality of life. While some studies suggest comparable outcomes between NOM and appendectomy, others highlight the challenges of NOM, including high failure rates and the potential for recurrent appendicitis. Patient perspectives play a crucial role in this dilemma, with shared decision-making emerging as a key consideration. Despite growing evidence favouring antibiotics-first approaches and the 2020 update of the World Society of Emergency Surgery (WSES) guidelines recommending NOM, uncertainties persist. Factors influencing NOM success, such as the presence of appendicolith, need careful consideration. Ultimately, the ideal approach involves a shared decision-making process, integrating patient values and preferences.
Surgeons often encounter intense physical and cognitive demands, heavy workloads, critical life-or-death decisions, and emotional distress arising from patient outcomes. All these factors contribute to a gradual decline in the well-being and quality of life for practitioners and, simultaneously, to increasing rates of depression and burnout among surgeons, resulting in severe ramifications for patient care. Considering the positive effects of surgeons’ well-being on providing the best care for patients, the concept of work-life integration is becoming a targeted goal for today’s surgeons. The basic components of a well-being state—physical and mental health, work-life integration, professional support, and a supportive institutional environment—affect patient care and ultimately determine surgeons’ quality of life. In this regard, individuals, societies, and organisations should implement strategies and programs that foster well-being.
Introduction: Liver, lymph node, lung and peritoneal metastases are the most common sites of the metastatic sites of gastric cancer. Isolated rectal metastasis of gastric cancer is one of the rare metastases observed in case reports in the literature. Case Report: A 58-year-old male patient was admitted to the outpatient clinic with dyspeptic symptoms. Gastroscopy revealed a mass approximately 5 cm in diameter on the lesser curvature of the stomach. Surgery was planned as no distant metastasis was observed on abdominal tomography. The patient underwent total gastrectomy and the histopathology report of D2 lymph node dissection was consistent with T4aN3a adenocarcinoma. During adjuvant treatment, the patient was admitted to the emergency room with ileus symptoms three months after surgery. The patient underwent emergency surgery and no signs of peritoneal or distant metastasis were detected during exploration. Low anterior resection was performed as a mass was detected in the rectum. The histopathology report was of rectal metastasis of gastric cancer, and the patient was discharged without any complications. Conclusion: Isolated rectal metastasis of gastric cancer is a rare condition and should be kept in mind when patients who have undergone surgery for gastric cancer present with ileus symptoms. Rectal metastasis may cause ileus by creating a mass effect or may negatively affect the patient’s surveillance because it is considered a distant metastasis.
Introduction: Caustic sclerosing cholangitis represents a rare postoperative complication occurring after surgical treatment of liver hydatid cyst. It has been hypothetically attributed to the caustic effect of the scolicidal agent injected into the cyst for sterilisation, subsequently diffusing into the biliary tree through a cysto-biliary fistula. Materials and Methods: We present a case series of 3 patients with caustic sclerosing cholangitis, observed following surgical treatment of liver hydatid cysts among 268 patients. Sterilisation of cyst content was performed using intracystic injection of 2% formalin solution in 2 cases. Caustic sclerosing cholangitis was diagnosed at 2, 3, and 7 months post-surgery by retention jaundice caused by irregular strictures of intra- and/or extra-hepatic bile ducts. Following hydatid cyst treatment, all 3 cases died, respectively, 2, 4, and 6 years after the intervention. Patients died from secondary biliary cirrhosis and 1 patient died from septic shock. Despite its relative rarity (3/268 of cases in our study), the severity of this iatrogenic complication and the unproven efficacy of cyst sterilisation maneuvers have discouraged us for years from using the intracystic injection of scolicidal solution technique for hydatid cyst sterilisation. Discussion: Caustic sclerosing cholangitis progresses rapidly and is generally devoid of effective treatment, subsequently leading to the development of secondary biliary cirrhosis, or even cholangiocarcinoma. Conclusion: Caustic sclerosing cholangitis is a rare and serious iatrogenic complication questioning the safety of intracystic sterilisation. Mechanical protection, combined with preoperative albendazole treatment, appears to be an effective alternative to avoid this complication.
Mixed Neuroendocrine-Non-Neuroendocrine Neoplasm (MiNEN) of the oesophagus is an especially rare malignancy. It is composed of an adenomatous and a neuroendocrine aspect. Each histologic subtype contributes at least 30% of the immunohistopathologic features to the complex profile of these mixed neoplasms. Given the small number of cases in the existing literature and the lack of international guidelines, diagnosis and treatment may vary among different centers; however, a combined approach based on surgical resection and systemic therapies is usually the preferred pathway. In this paper, we present the case of a 68-year-old male who was initially diagnosed with oesophageal adenocarcinoma and was treated with neoadjuvant chemotherapy and oesophagectomy. After the histopathologic examination of the specimen, the tumour was histologically characterised as MiNEN and the patient underwent adjuvant therapy. Multimodal management and tailored treatment are essential in these complex cases since preoperative staging poses challenges and limitations.
Many patients are diagnosed with pancreatic lesions nowadays. The differential diagnosis of pancreatic lesions is broad, including both benign and malignant causes. Endoscopic ultrasound (EUS) is a useful diagnostic tool for investigating such lesions, as it offers the advantage of obtaining specimens for histological examination. Here, we present a case of a patient with the rare diagnosis of pancreatic tuberculosis.
As the global population ages, the incidence of major surgical interventions in elderly patients—those aged 70 years and older—has increased significantly. By 2050, the number of people aged 60 and above is expected to reach 2.1 billion, necessitating a deeper understanding of the unique challenges faced by this demographic in surgical contexts. This study explores the morbidity and mortality associated with major surgeries in the elderly, emphasizing the impact of comorbidities, reduced physiological resilience, and the importance of preoperative and postoperative care. A comprehensive review of existing literature was conducted, focusing on perioperative morbidity, mortality rates, and factors such as cardiovascular, pulmonary, and renal function. The findings underscore the necessity of a multidisciplinary approach in managing surgical patients in this age group, highlighting the role of frailty as a more accurate predictor of surgical outcomes than chronological age. Despite advances in surgical techniques and anesthetic management, the elderly remain at higher risk of postoperative complications and mortality. The study advocates for individualised care strategies and improved preoperative assessment tools to optimize surgical outcomes and reduce the burden on healthcare systems.
Managing a short proximal colonic segment after an extensive left sided colon resection may be challenging. Total colectomy with ileorectal anastomosis (TC-IRA) is an option, but at the cost of sacrificing the whole colon and the ileocecal valve. Two organ- preserving alternatives are the Deloyers procedure (DP), which involves mobilisation and cranio-caudal rotation of the right colon around the axis of the ileocolic vessels and the retroileal trans-mesenteric method described by Turnbull. DP has been shown to be safe, with fewer postoperative bowel movements (average 3.5 with a median of 2-3 in DP versus average 4-6 with a median of 5 in TC-IRA) and equivalent anastomotic leak rates (<5%) compared with TC-IRA. Herein, we present a patient with a left colon adenocarcinoma, who was initially planned for a laparoscopic left hemicolectomy but intraoperatively converted to a laparoscopic assisted Deloyers procedure due to adverse intraoperative findings. This case highlights the feasibility of minimally invasive, assisted techniques in salvage settings and underscores the importance of colorectal surgeons being well-versed in this procedure, both open and laparoscopically, as it helps preserve colonic physiology and leads to improved functional outcomes.
Background: The intention to leave the profession among nurses often arises from dissatisfaction or a lack of professional fulfillment. The departure of nurse anaesthetists has significant implications for healthcare delivery, as their role in anaesthesia and perioperative care is both specialised and indispensable. The process of replacing nurse anaesthetists is time-intensive, requiring extensive training and adaptation to new working environments. Methods: A cross-sectional survey was conducted among 194 Greek nurse anaesthetists working in public hospitals in Greece to examine factors influencing turnover intentions. A total of 111 completed questionnaires were collected using a structured tool that assessed demographics, job satisfaction, perceived stress, and intention to leave. The study assessed work-related stress, work-family conflict, psychological empowerment, organisational commitment, work commitment, job satisfaction, and turnover intentions using a structured questionnaire. Results: A total of 111 anaesthesia nurses participated in the study. The results revealed that high levels of perceived stress and low job satisfaction were significantly associated with increased intention to leave the current position (p < 0.05). Additionally, work–family conflict was found to be a strong predictor of turnover intention (p < 0.05), particularly among participants with caregiving responsibilities. Statistically significant associations were also observed between intention to leave and variables such as age, years of experience, and type of employment. Nurses with fewer years in the profession and those in temporary contracts were more likely to consider leaving. These findings highlight the multidimensional nature of turnover intention, shaped by both occupational stressors and personal circumstances.Conclusions: In contrast to prevailing theoretical frameworks, nurse anaesthetists’ turnover intentions appear to be unaffected by work-related stress and work-family conflict. Instead, psychological empowerment and organisational commitment serve as primary determinants of retention. Although job satisfaction does not directly influence nurses’ intention to leave the profession, it may contribute to decisions regarding workplace transitions within the healthcare sector.
Immune checkpoint inhibitors (ICI) have been approved for the treatment of a variety of malignancies. Immune-related adverse events are rare and might affect a lot of different organs including the intestines. Enterocolitis is a common complication characterised by symptoms such as diarrhoea, abdominal pain, and vomiting. In rare circumstances, bowel perforation, obstruction, or even toxic megacolon might appear. The proper therapeutic management of these conditions is based on case reports or case series. Conservative management is the standard of care in the case of ileus, however, the safety of performing a bowel anastomosis has not been answered yet. This study aims to raise awareness among the medical community, and specifically surgeons, regarding the intestinal complications of ICI, as the uprising administration of these targeted therapies makes this knowledge necessary.
Background: To investigate the incidence of post-transplant malignancies in paediatric recipients of solid organ transplants. Materials and Methods: We searched MEDLINE, Scopus and Web of Science up to January 2025 for observational studies reporting on cancer incidence in children who underwent solid organ transplantation (SOT). Data extraction and quality assessment were performed by two independent reviewers. Data on incidence rates, types of malignancies, and patient demographics were extracted and analysed. Results: Sixteen studies with a total of 26,310 paediatric transplant recipients were included. The cumulative incidence of cancer after kidney transplantation ranged from 10.2% at 15 years to 27% at 25 years. For liver transplantation, the incidence was 22% at 25 years, with a range from 3.4% to 7.1% incidence of post-transplant lymphoproliferative disorders (PTLD). Following heart transplantation, the incidence was 30.5% at 10 years. Conclusions: Paediatric solid organ transplant recipients face a significant risk of developing cancer, particularly PTLD. Regular monitoring and early intervention are essential for improving long-term outcomes.
Open abdomen (OA) is indicated in numerous medical settings, such as trauma, abdominal sepsis, severe acute pancreatitis, and intra-abdominal hypertension. Managing an open abdomen presents a complex and challenging scenario for surgeons, requiring specialised techniques and comprehensive decision-making to prevent complications, especially in obese patients, due to increased morbidity and mortality rates. Herein we describe the use of vertical mesh-mediated fascial traction (VMMFT) in combination with negative pressure wound therapy (NPWT) to prevent fascial retraction and manage OA in a super-super obese patient who developed abdominal compartment syndrome following a massive abdominal ventral hernia repair. A 55-year-old male with a BMI of 62 kg/m2 underwent emergency exploratory laparotomy for a massive ventral hernia with bowel strangulation. Postoperatively, he developed abdominal compartment syndrome, necessitating relaparotomy and temporary abdominal closure. A traction device was introduced to facilitate vertical mesh-mediated fascial traction (VMMFT). On postoperative day six, fascial closure was achieved without complications. This case highlights the efficacy of VMMFT combined with NPWT in preventing fascial retraction, promoting abdominal wall expansion, and reducing the need for complex reconstructions. Further studies are warranted to assess its broader clinical and economic impact.
