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.
