Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

The median arcuate ligament syndrome(MALS)is recognized as a rare clinical entity,characterized by chronic post-prandial abdominal pain,nausea,vomiting,and unintentional weight loss.Due to its vague symptomatology,it is mainly regarded as a diagnosis of exclusion.Patients can often be misdiagnosed for several years before a correct diagnosis is established,also due to a medical team’s clinical suspicion.We present a case series of two patients who suffered from MALS and were treated successfully.The first patient is a 32-year-old woman,presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years.The second patient,a 50-year-old woman,presented with similar symptomatology,with the symptoms lasting for the last five years.Both cases were treated by laparoscopic division of the median arcuate ligament fibers,which alleviated extrinsic pressure from the celiac artery.Previous cases of MALS were retrieved from PubMed,to assemble a better diagnostic algorithm and propose a treatment method of choice.The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice,along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.

Comparison between upfront surgery and neoadjuvant chemotherapy in patients with locally advanced gastric cancer:A systematic review

BACKGROUND Gastric cancer(GC)is a major health concern worldwide.Surgical resection and chemotherapy is the mainstay treatment for gastric carcinoma,however,the optimal approach remains unclear and should be different in each individual.Chemotherapy can be administered both pre-and postoperatively,but a multidisciplinary approach is preferred when possible.This is particularly relevant for locally advanced GC(LAGC),as neoadjuvant chemotherapy(NAT)could potentially lead to tumor downsizing thus allowing for a complete resection with curative intent.Even though the recent progress has been impressive,European and International guidelines are still controversial,thus attenuating the need for a more standardized approach in the management of locally advanced cancer.AIM To investigate the effects of NAT on the overall survival(OS),the disease-free survival(DFS),the morbidity and the mortality of patients with LAGC in comparison to upfront surgery(US).METHODS For this systematic review,a literature search was conducted between November and February 2023 in PubMed,Cochrane Library and clinicaltrials.gov for studies including patients with LAGC.Two independent reviewers conducted the research and extracted the data according to predetermined inclusion and exclusion criteria.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to form the search strategy and the study protocol has been registered in the International Prospective Register of Systematic Reviews.RESULTS Eighteen studies with 4839 patients with LAGC in total were included in our systematic review.Patients were separated into two groups;one receiving NAT before the gastrectomy(NAT group)and the other undergoing upfront surgery(US group).The OS ranged from 41.6%to 74.2%in the NAT group and from 30.9%to 74%in the US group.The DFS was also longer in the NAT group and reached up to 80%in certain patients.The complications related to the chemotherapy or the surgery ranged from 6.4%to 38.1%in the NAT group and from 5%to 40.5%in the US group.Even though in most of the studies the morbidity was lower in the NAT group,a general conclusion could not be drawn as it seems to depend on multiple factors.Finally,regarding the mortality,the reported rate was higher and up to 5.3%in the US group.CONCLUSION NAT could be beneficial for patients with LAGC as it leads to better OS and DFS than the US approach with the same or even lower complication rates.However,patients with different clinicopathological features respond differently to chemotherapy,therefore currently the treatment plan should be individualized in order to achieve optimal results.

Inverted Meckel’s diverticulum manifested as adult intussusception: Age does not matter

Adult intussusception due to Meckel’s diverticulum (MD) is an uncommon cause of intestinal obstruction. However, the surgeon should still be suspicious of this condition since the non specific symptoms and the rarity of it make a preoperative diagnosis uncertain. Considering the secondary nature of adult intussusception and the necessity of early surgical intervention to avoid morbidity and mortality, we report two cases of intussusception due to MD in adults. A diverticulectomy using a TA stapler was performed in the first patient. In the second patient extensive fibrosis of the adjacent mesentery and thickening of jejunal mucosa were observed, so a segmental resection of the small bowel or affected ileal part and a hand-sewn anastomosis was performed. The postoperative period along with the long term follow-up was uneventful for both patients. The decision between diverticulectomy vs bowel resection can be based on the intussuscepted bowel condition. Early surgical intervention may ensure a favorable outcome.

Liposarcoma of the stomach: A rare case report

Liposarcoma is the most common soft tissue sarcoma and accounts for 15%-20% of all mesenchymal malignancies. The tumor occurs most frequently in the limbs, retroperitoneum and rarely has a visceral location. We report a case of a gastric liposarcoma in a male patient. A 68 years old male patient was admitted to hospital for abdominal discomfort and fullness lasting for a month. He reported rare episodes of vomiting. The CT examination revealed a large epigastric mass (8 cm x 4 cm) involving the lesser curvature of the stomach, in contact with the pancreas and gallbladder. Fatty areas within the mass were evident. A total gastrectomy together with cholecystectomy was performed. The histopathological diagnosis was a well differentiated liposarcoma. The patient did not undergo any adjuvant treatment, he is under close follow up and two years later he is disease free. We report this case due to the rarity of this tumor in the stomach (nine cases reported in the literature).

Role of autophagy in gastric carcinogenesis

Gastric cancer represents a common and highly fatal malignancy,and thus a pathophysiology-based reconsideration is necessary,given the absence of efficient therapeutic regimens.In this regard,emerging data reveal a significant role of autophagy in gastric oncogenesis,progression,metastasis and chemoresistance.Although autophagy comprises a normal primordial process,ensuring cellular homeostasis under energy depletion and stress conditions,alterations at any stage of the complex regulatory system could stimulate a tumorigenic and promoting cascade.Among others,Helicobacter pylori infection induces a variety of signaling molecules modifying autophagy,during acute infection or after chronic autophagy degeneration.Subsequently,defective autophagy allows malignant transformation and upon cancer establishment,an overactive autophagy is stimulated.This overexpressed autophagy provides energy supplies and resistance mechanisms to gastric cancer cells against hosts defenses and anticancer treatment.This review interprets the implicated autophagic pathways in normal cells and in gastric cancer to illuminate the potential preventive,therapeutic and prognostic benefits of understanding and intervening autophagy.

α2-Heremans-schmid glycoprotein(fetuin A)downregulation and its utility in inflammatory bowel disease

AIM To investigate the impact of inflammatory bowel disease (IBD) on α2-Heremans-Schmid Glycoprotein(AHSG/fetuin A) and potential associations with disease and patient characteristics.METHODS AHSG serum levels were determined in treatment-na?ve newly-diagnosed patients, 96 with ulcerative colitis(UC), 84 with Crohn's disease (CD), 62 with diarrheapredominant or mixed irritable bowel syndrome (IBS, D- and M- types) and 180 healthy controls (HC), by an enzyme linked immunosorbent assay (ELISA).All patients were followed for a minimum period of 3 years at the Gastroenterology Department of the University Hospital of Larissa, Greece. C-reactive protein(CRP), anti-glycan antibodies, anti-Saccharomyces cerevisiae mannan antibodies Ig G, anti-mannobioside carbohydrate antibodies Ig G, anti-laminariobioside carbohydrate antibodies Ig G and anti-chitobioside carbohydrate antibodies Ig A were also determined via immunonephelometry and ELISA, respectively.RESULTS The mean ± SE of serum AHSG, following adjustment for confounders, was 0.32 ± 0.02 g/L in IBD, 0.32 ± 0.03 g/L in CD and 0.34 ± 0.03 g/L in UC patients, significantly lower than in IBS patients(0.7 ± 0.018 g/L) and HC (0.71 ± 0.02 g/L) (P < 0.0001, in all cases). AHSG levels were comparable between the CD and UC groups. Based on AHSG levels IBD patients could be distinguished from HC with about 90% sensitivity and specificity. Further adjusted analysis verified the inverse association between AHSG and penetrating, as well as stricturing CD (partial correlation coefficient: -0.45 and -0.33, respectively) (P < 0.05). After adjusting for confounding factors, inverse correlations between AHSG and CRP and the need for anti-TNFα therapy or surgery, were found (partial correlation coefficients:-0.31,-0.33,-0.41, respectively, P < 0.05, in all cases). Finally, IBD individuals who were seropositive, for at least one marker, had AHSG levels falling within the two lower quartiles (OR = 2.86, 95%CI: 1.5-5.44, P < 0.001) while those with at least two serological markers positive exhibited AHSG concentrations within the lowest quartile (OR = 5.03, 95%CI: 2.07-12.21, P < 0.001), after adjusting for age, sex and smoking.CONCLUSION AHSG can be used to distinguish between IBD and IBS patients or HC while at the same time "predicting" complicated disease behavior, need for therapy escalation and surgery. Moreover, AHSG may offer new insights into the pathogenesis of IBD, since it is involved in key processes.

Large solitary retroperitoneal echinococcal cyst:A rare case report

Echinococcal disease remains a problem within some endemic areas. Echinococcal cysts usually involve the liver and lungs, but any other organ can potentially be involved. Extrahepatic localization is reported in 14%-19% of all cases of abdominal hydatid disease. We report the case of a large echinococcal cyst localized in the lower pelvis. A 28-year-old woman was admitted to a surgical ward with lower abdominal pain and discomfort lasting for a month. Ultrasonography and computed tomography scanning revealed a large retroperitoneal cystic mass (9 cm × 4 cm) in contact with the left ovary and left ureter. There were no cysts in any other location. Serological tests were positive for Echinococcus. The patient was operated on and the entire cyst was excised intact. Histopathological results confirmed the diagnosis of echinococcosis. Antihelminthics were administered postoperatively and the patient was discharged after 6 d, and is now being closely followed up. Total cystectomy when possible represents the treatment of choice for large extrahepatic echinococcal cysts.

Neutrophil-to-lymphocyte ratio as a prognostic factor for survival in patients with colorectal liver metastases: A systematic review

BACKGROUND The inflammatory response to tumor has been proven to be closely related to the prognosis of colorectal cancer.Neutrophil to lymphocyte ratio(NLR)is a widely available inflammatory biomarker that may have prognostic value for patients with colorectal liver metastasis(CRLM).AIM To assess the role of NLR as a prognostic factor of survival and tumor recurrence in patients with CRLM.METHODS A systematic literature search of PubMed,Cochrane Library and clinicaltrials.gov was conducted by two independent researchers in order to minimize potential errors and bias.Conflicts were discussed and settled between three researchers.Studies including patients undergoing different types of medical interventions for the treatment of CRLM and evaluating the correlation between pretreatment NLR and disease-free survival(DFS)and overall survival(OS)were included in the review.Nineteen studies,involving 3283 patients matched our inclusion criteria.RESULTS In the studies included,NLR was measured before the intervention and the NLR thresholds ranged between 1.9 and 7.26.Most studies used 5 as the cut-off value.Liver metastases were treated with hepatectomy with or without chemotherapy regimens in 13 studies and with radiofrequency ablation,radioembolization,chemoembolization or solely with chemotherapy in 6 studies.High NLR was associated with decreased OS and DFS after liver resection or other medical intervention.Moreover,high NLR was associated with poor chemosensitivity.On the contrary,CRLM patients with low pretreatment NLR demonstrated improved OS and DFS.NLR could potentially be used as a predictive factor of survival and tumor recurrence in patients with CRLM treated with interventions of any modality,including surgery,chemotherapy and ablative techniques.CONCLUSION NLR is an inflammatory biomarker that demonstrates considerable prognostic value.Elevated pretreatment NLR is associated with poor OS and DFS in patients with CRLM who are submitted to different treatments.