Cic edizioni internazionali
Il Giornale di Chirurgia

Laparoscopic Roux-en-Y gastric bypass in the treatment of obesity: evidence based update through randomized clinical trials and
meta-analyses

Review, 5 - 17
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Bariatric surgery was introduced in 1953, but during the last 20 years its popularity has increased after the development of significant Romaevidenced based breakthroughs in the field. Currently, approximately 150 long-term randomized clinical trials and 40 meta-analyses support and give credibility to the surgical approaches for the treatment of obesity and its related metabolic disturbances. Bariatric surgery has demonstrated improved outcomes compared to medical treatment, conduct therapy, and endoscopic procedures. Roux-en-Y gastrojejunostomy (RYGB) and Sleeve gastrectomy (SG) are the surgical procedures most frequently performed, due to their satisfactory results and security profile. There is sufficient evidence in medical literature to perform these procedures when indicated; however, there are still several controversies regarding technical aspects that need to be further explored.

Retroperitoneal sarcomas: from diagnosis to treatment.
Case series and review of the literature

Review, 18 - 33
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Background. Retroperitoneal sarcoma is a rare malignancy arising from mesenchymal cells, most commonly presented as an abdominal mass and is associated with poor prognosis. The most effective treatment modality for retroperitoneal sarcomas is complete surgical resection, including sometimes adjacent organs infiltrated by the tumor. Radiotherapy is frequently applied and has shown some benefit, while the role of chemotherapy and molecular-targeted agents is still not clear. Local recurrence is common for retroperitoneal sarcomas and still remains the main cause of death. The major factors associated with the overall survival are tumor grade, histological subtype, complete macroscopic excision and multifocality.
Aim. To report our experience via the presentation of patients with retroperitoneal sarcomas managed in our department during the period 2014-18; and to review the current literature.
Patients and methods. Eight patients appeared with chronic non-specific complaints including abdominal distension and changes in bowel or bladder habit, while one patient presented with acute abdominal pain due to mass rupture. All of the patients underwent surgical resection of the tumor.
Results. Among the patients, seven were operated for primary disease and one only for recurrent. The most common histologic type was liposarcoma (well-differentiated, dedifferentiated), found in five patients; followed by leiomyosarcoma found in two cases. Fibrous histiocytoma was found in only one case. The masses were removed with macroscopically clear margins (R0 and R1 resections) in four cases. In five patient cases adjuvant therapy was required. Three patients are still alive and free of disease.
Conclusions. Retroperitoneal sarcomas present to be a therapeutic challenge based on their location, their extent at the time of diagnosis and the high risk of local recurrence or distant metastasis. Their management requires a multidisciplinary approach, with the surgical resection remaining the mainstay of curative treatment, combined with surveillance for early detection of recurrence or metastases.

The discriminative properties of erythrocyte anisocytosis in patients with resectable malignant pancreatic masses compared with an age and gender matched control group

Original Article, 34 - 39
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Introduction. Red cell distribution width (RDW) is a parameter that reflects the heterogeneity in the size of the circulating erythrocytes.
Elevated levels of RDW have been found related to various pathologic conditions including cancers. We hypothesized that elevated RDW levels might correspond to advanced stages of pancreatic cancer.
Methods. The medical files and pathology reports of patients who underwent Whipple procedure were evaluated in a retrospective casecontrol study. The relationship of RDW to age, gender, cancer antigen 19-9 (CA 19-9), blood hemoglobin levels, stage of the tumor, tumor size, tumor grade, number of lymph nodes with metastasis, the status of lymphovascular and perineural invasion were investigated. A oneto-two, age- and- gender matched group of seemingly healthy patients was used to compare the levels of RDW between the patients of pancreatic head malignancy and healthy people. ROC (receiver operating characteristics) curves analysis was conducted to define a threshold to discriminate malignant pancreatic head tumors from healthy control subjects. Then, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+LR), and negative likelihood ratio (−LR) were calculated.
Results. The median age was 61 years (IRQ 54.75-69). The median RDWs were 15.20% (IQR 13.20-19.50) vs 13.00 (IQR 12.60-13.48) in the pancreas adenocancer and the control group, respectively, p=0.000). There was significant relationship between RDW and the grade of the tumor, p=0.026. An RDW level of 14% was obtained as a result of the ROC curves analysis and the positive predictivity about malignancy was 70.73% with a negative predictive rate of 89.95% compared with the healthy group of patients.
Conclusion. The elevated levels of RDW in patients with a pancreatic mass may point to a possible malignancy; however, an elevated RDW in a patient with a malignant pancreatic head mass is related to the grade of the disease, not the stage.

Diagnostic and therapeutic role of laparoscopy in perforated peptic ulcer in the elderly patients

Original Article, 40 - 45
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Aim. The purpose of this study is to analyze the outcome of elderly patients with perforated peptic ulcer comparing laparoscopic treatment versus open approach.
Methods. In our General and Emergency Surgery Unit in the last 3 years, 20 elderly patients with perforated peptic ulcer were performed. We considered elderly all patients over the age of 65 years (10 females and 10 males; the mean age was 75 years). 16 patients (80%) were submitted to laparoscopic repair with omentoplasty and 4 (20%) to open repair. The patients were classified using the Boye's score which influenced the choice of surgical treatment and the outcoEmergency Romame. The two groups were compared in terms of operative surgery times, complication rate, mortality and postoperative outcomes.
Discussion. Perforated peptic ulcer is a common abdominal disease that is treated by surgery. The potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear and the major advantages may be observed in cases with peritonitis secondary as a perforated peptic ulcer where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and the repair. With the age the risks of comorbidities increases multidisease syndrome. Elderly patients suffer from frailty syndrome. All these factors make the elderly patient a major challenge for a laparoscopy treatment.
Conclusion. The laparoscopic approach is an effective method for treatment of perforated peptic ulcer in the elderly with a great diagnostic and therapeutic role. Nowadays more prospective randomized studies are needed to evaluate the effectiveness of laparoscopic versus open repair.

The role of laparoscopic surgery in isolated adrenal metastasis:
our personal experience

Original Article, 46 - 490
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Background. Over the past 25 years, mini-invasive adrenalectomy has become the treatment of choice for most adrenal diseases, and even adrenal malignancies in selected cases. The aim of this retrospective evaluation is to assess the effectiveness of laparoscopic adrenalectomy as a treatment of choice for adrenal metastases.
Methods. From 2008 to 2018, 207 laparoscopic adrenalectomies have been performed in our Department of Surgery. Among these, in 12 cases the indication to adrenalectomy was metastatic adrenal lesion.
Results. The right adrenal gland was removed in 8 cases and the left adrenal gland in 4 cases. A complete resection (R0) was achieved in all patients. The median operative time was 130.6 ± 23.3 min. The median postoperative hospitalization was 3.5±2.0 days. Only one patient showed postoperative grade II complications, according to Clavien-Dindo classification. All patients underwent follow-up at 6-12-18 months without showing disease recurrence. There was no intra and perioperative mortality. Conversion to laparotomic surgery has never been performed. Mean tumor size was 2.4 cm ±1.6 cm.
Conclusions. Laparoscopic adrenalectomy for metastasis permits to achieve similar results to the open approach in term of oncological outcomes, but gaining in terms of postoperative hospitalization, intra and post-operative complications as well a greater patient compliance.

Advances in bioengineering of complex tissues: state of the art of mucosae decellularization protocols

Original Article, 50 - 65
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The loss or deficiency of a tissue or organ is a serious health problem and severely affects the patients’ quality of life.
In the near future, an option for solving this problem will be the development of bio-derived extracellular matrices (ECM) from huPlastic Romaman or animal tissues and their usage for in vitro or in vivo cellular reseeding. Many researchers are working on this development. Nowadays, different decellularization protocols have been developed to manufacture ECMs but there is not yet a consensus about the most efficient procedures.
This review aims to describe the state of the art in the field of decellularization of complex mucosal tissues, analizing and comparing the most recent and most valiant articles published about this procedure.

An analysis of missed cases with surgical emergencies admitted in non-surgical departments. Case series and а review of the literature

Original Article, 66 - 72
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Introduction. The delayed diagnosis in emergency surgery can be associated with significant morbidity and mortality and often lead to litigations. The aim of the present work is to analyse the outcome in cases with non-trauma surgical emergencies wrongly admitted in non-surgical departments.
Methods. A retrospective trial in two independent University hospitals was conducted. The first group encompassed the patients worked-up in the Surgical unit of Emergency department (2014-2018). The second one included all cases visited Emergency department (2018). Only cases with acute abdomen and delayed diagnosis and operation were included. The analysis included the proportion of the delayed diagnosis, time between admission and operation, intraoperative diagnosis, complications and mortality rate.
Results. In the first group there were 30 194 visits in the surgical unit with 15 836 hospitalizations (52.4%). Twenty patients of the last (0.13%) were admitted in the Clinic of Infectious disease and subsequently operated. The mean delay between hospitalization and operation was 3 days (1-10). Seventeen patients (85%) were operated with mortality of 10%. In the second group, there were a total of 22 760 visits with 11 562 discharged cases. Of the last, 1.7% (n=192) were re-admitted in a surgical ward, 25 of which underwent urgent surgery (0.2%).
Conclusions. The missed surgical cases represent only a small proportion of the patients in emergency department. The causes for wrong initial admissions in our series were misinterpretation of the symptoms, insufficient clinical examination and underuse of US and CT. The careful clinical assessment, point-of care US and CT may decrease the rate of the delayed diagnosis.

The evolution of robotic arm-assisted arthroplasty in Greece

Original Article, 73 - 78
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Background. The robotic arm-assisted (Mako) arthroplasty was introduced in Greece in January 2014, through the years of financial crisis. The purpose of this study is to demonstrate its evolution per procedure throughout the years.
Materials and methods. Data regarding type of procedure: partial knee arthroplasty (PKA), total knee arthroplasty (TKA) and total hip arthroplasty (THA) were collected from the official distributor of the Mako platform in Greece. The number of Mako arthroplasties were calculated annually and monthly per procedure type from January 2014 to December 2018.
Results. A total of 1081 robotic arm-assisted arthroplasties have been performed in Greece in two private hospitals. Mako cases showed overall 163.06% increase, while THA showed 235.1% increase, during the study period. On the other hand PKA showed 61% decrease, while in during one year (2017-2018) TKA showed 402% increase.
Conclusions. Introducing robots into the orthopedic operating theater may improve precision, could lead to lower complication rates and finally may offer higher patient satisfaction scores. However, the total growth of robotic arm-assisted arthroplasties in Greece should be interpreted with caution, since all surgeries were performed in private institutions and, therefore, the economic burden of these procedures may have been withstood by specific social class patients.

Current role of open surgery in adrenal tumors

Original Article, 79 - 83
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Aim. The aim of this retrospective evaluation is to assess the current role of open adrenalectomy, in particular in cases of adrenocortical carcinoma (ACC).
Materials and methods. From January 2009 to May 2019, 26 open out of 233 adrenalectomies were performed in our Academic Department. Open adrenalectomy was performed by the anterior approach. A midline abdominal incision or a subcostal surgical incision was used to reach the peritoneal cavity. The resection was defined R0 if the margins of the sample were negative for malignancy.
Results. Open adrenalectomy was performed in 26 patients: 10 men and 16 women with a mean age of 61±25.3 years and a mean BMI of 28.4±2.9. The right adrenal gland was removed in 15 cases
Romaand the left in 11 cases.We reported 18 diagnosis of malignant pathology. The other diagnosis concerned 5 cases of pheochromocytoma, 1 case of Cushing's disease and 2 cases of hyperaldosteronism. Mean tumor size was 7.7±5.5. Mean operative time was 160 min (range=110-205 minutes). Mean postoperative stay was 7±2 days. Only 3 (10%) patient showed postoperative grade II complications, according to Clavien-Dindo classification. Midline abdominal incision was used in 18 patients, subcostalsurgical incision in 5 patients and bilateral subcostal surgical incision in 3 patients. 3 right nephrectomy was necessary to remove the entire tumor mass. An en bloc R0 tumor resection was accomplished in all cases.There was no intra and perioperative mortality. All patients recovered well from surgery. The mean follow-up period was 15 (range=6-48) months.
Conclusion. In conclusion, our retrospective study points out the role of open adrenalectomy as the treatment of choice in selected cases with known or suspected malignant adrenal tumors and with size greater than 12 cm.

Preoperative fasting - “nihil per os” a difficult myth to break down: a randomized controlled study

Original Article, 84 - 93
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Introduction. For several years the scientific anaesthesia societies declared a preoperative fast of 6 hours for solid foods and 2 hours for clear liquids before elective surgical interventions to be sufficient. The aim of this study is to identify the extent of the gap that exists between the preoperative fasting time required and that actually encountered in operating rooms.
Patients and methods. The safety and clinical applicability of a reduction of the preoperative fasting time was investigated through the use of oral solutions enriched with maltodextrin and their effects on the pre- and postoperative well-being that this may have on patients who are candidates for elective abdominal surgery. The study was conducted in two successive phases (I and II) and patients divided into two groups (A and B).
Discussion. Clinical practice is slow to change, in fact, in our study the duration of fasting was an average of 19 hours for solids and 13 hours for liquids. The duration of the fasting did not show differences in the various surgical departments, demonstrating that it is a transversal practice and is not only limited to abdominal surgery in which the utility of fasting would theoretically be greater. Among Group patients A, the fasting time for liquids was about 9 hours. This shows that the time is certainly shorter but not much different when compared to the fasting time for liquids in group B which was on average 14 hours. It is important how difficult it is to achieve good compliance from patients when trying to reduce the time of preoperative fasting based on scientific evidence that is now well established.
Conclusion. The use of carbohydrate-enriched drinks up to 2 hours after induction of anaesthesia appears to be a safe procedure. The use of these solutions reduces the catabolic response to surgery and contributes to maintaining a pre-operative state of well-being by reducing feelings of hunger and thirst and the state of preoperative anxiety.

Sentinel lymph node biopsy with intraoperative touch imprint cytology (TIC) in breast cancer: experience of a mild-volume center

Original Article, 94 - 98
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Although considered the gold standard in treatment of EBC, sentinel node biopsy still remains a debated issue. What to do in case of positive sentinel node and the need of intraoperative histological examination are the most topics under discussion. In this study we have retrospectively evaluate our case series of 359 sentinel node biopsy in the managing of breast cancer from January 2011 to December 2018, focusing on the TIC technique for performing intraoperative examination. It results in 12,8% “FALSE NEGATIVE” rate, in which only 4,2% in macrometastases, with an overall sensitivity of 68,4% (macrometastases: 86%; micrometastases: 11%), overall specificity of 98,7% and an overall accuracy of 89,7%. The intraoperative examination of SLN allows to reduce delayed surgery procedures and greater therapeutic safety in case of mastectomy. The TIC method can be considered valid, simple and rapid in identifying macrometastases, also allowing to avoid under-staging. The low sensitivity for micrometastases is not a limit, considering that recent evidence has drastically reduced the indications for ALND in these cases. Further ongoing trials and the possible validation of NOMOGRAMMS and SCORE are necessary to identify low risk cases in which to definitively omit the ALND and/or even the SLNB itself.

Spontaneous transdiaphragmatic intercostal hernia: clinical considerations and management

Clinical practice, 99 - 102
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Most diaphragmatic ruptures are due to the traumatic or penetrating injury, while the spontaneous diaphragmatic rupture is considered uncommon. The spontaneous transdiaphragmatic hernia is a consequence of violent coughing, vomiting that increase the thoracoabdominal pressure causing the diaphragmatic rupture. Even rarer is the concomitant prolapse of abdominal viscera into the thoracic subcutis through the chest wall, a condition known as spontaneous transdiaphragmatic intercostal hernia. Herein, we present a rare case of spontaneous transdiaphragmatic intercostal hernia presenting as a thoracoabdominal emergency.

Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study

Clinical practice, 103 - 109
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Purpose. The purpose of the present study was a comparison of the systemic inflammatory response intensity through the estimation of C- reactive protein and albumin levels before and after open tension free inguinal hernia repair performed under different anesthetic alternatives.
Patients and methods. Totally, 125 inguinal hernia patients scheduled for unilateral primary open tension free inguinal repair unRomader local (50 patients), spinal (50 patients) and general anesthesia (25 patients) have been included in this prospective study.
Results. The group of local anesthesia was associated with the higher postoperative serum levels of albumin compared to the group of general anesthesia (P 0.013). Local anesthesia was also associated with higher postoperative serum albumin levels compared to regional anesthesia but however the difference was not statistically significant (P 0.282). The group of local anesthesia was also associated with the lower postoperative levels of CRP compared to the regional (P 0.0094) and general anesthesia (P 0.0009) groups.
Conclusion. Local anesthesia proved superior to regional or general anesthesia for open tension free inguinal hernia repair in the given patient sample from the standpoint of the inflammatory and acute phase response.

Minilaparotomic incision for haemorrhagic corpus luteum:
a case report

Clinical practice, 110 - 113
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Corpus luteum cyst rupture with consequent hemoperitoneum is a common cause of admission to the emergency room.
This condition is frequently misdiagnosed because of overlapping of clinical findings in acute gynecologic diseases. However, an incorrect identification may lead to delay in surgical treatment, which can Romabe a life-threatening condition.
Ultrasound (US) is the first technique used for diagnosis that can confirm or dismiss the presence of intraperitoneal fluid. Secondly, the contrast-enhanced computed tomography (CT) is the quickest way to identify the site of active bleeding and to establish the correct management of the clinical condition.
Herein, we report a case of a 19-years-old girl with acute abdominal pain correctly identified by diagnostic images and treated with mini-invasive surgery techniques in order to quickly act without clinic and aesthetic sequelae.

Conservative management of streptococcal necrotizing periorbital fasciitis following primary VZV infection

Methods, Techniques, Drugs, 114 - 117
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A 45-year old male patient, with a past history of illicit drug abuse and hepatitis C, presented with a 2 day history of worsening eyelid edema. Examination of the globe was impossible due to eyelid fusion caused by extensive soft tissue damage. Based on the examination, a diagnosis of necrotic fasciitis secondary to VZV infection was Romamade. The patient received empirical treatment with intravenous acyclovir, meropenem and vancomycin. CT imaging demonstrated no ocular involvement. Lesions were cultivated, revealing presence of Streptococcus pyogenes. Intravenous clindamycin was added to his course. Improvement was gradually observed. The patient received treatment for a total of 21 days, resulting in excellent final outcome. His final visual acuity was 0.9 on a Snellen chart, without signs of ocular inflammation. No surgical intervention was required and lesions fully healed with conservative management. Clinical outcomes depend on prompt treatment initiation, whilst delay in the diagnosis can prove fatal.

Relief of hemorrhoid symptoms: pilot study of a new topical ally

Methods, Techniques, Drugs, 118 - 125
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Aim. The pathogenesis of hemorrhoids involves vascular congestion, fragmentation of supporting tissues and, in many cases, increased resting anal pressure. A new ointment (Hemolen®) has been devised to control hemorrhoids symptoms acting on all the pathophysiologic mechanisms involved.
Methods. Pilot study on patients with grade I-III hemorrhoids. The ointment was applied twice daily for 30 days and follow-up visits were scheduled 7 days (T1), 14 days (T2) and 30 days (T3) after recruitment (T0). Signs and symptoms (bleeding, discomfort, itching, edema, thrombosis, congestion, inflammation, pain) were evaluated at each visit using dedicated scores and VAS scale. Resting anal pressure was measured at time T0, 1 hour after the first application and at T1. Use of painkiller was recorded.
Results. 48 patients (25 females; mean age 47±15.8 years) were enrolled; 52.1% of them had II degree hemorrhoids and 27.1% had III degree hemorrhoids. The severity scores significantly dropped from T0 to each scheduled visit and a significant reduction of resting anal pressure was observed from T0 to 1 hour after application (z=13.5; p<0.001) and from T0 to T1 (z=6; p<0.001). The comparison of the resting pressure among whole time series showed a significant reduction (Fr=124.4; p=<0.001). Use of pain-killers decreased significantly from T0 to T1 (p<0.001) and from T1 to T2 (p=0.001). Conclusion. The new ointment tested in the present study is safe and effective for the management of hemorrhoid symptoms in the early stages hemorrhoids, during the acute phases and in patients with more severe hemorrhoids awaiting surgery. Prospective, randomized controlled trials are needed to confirm these encouraging results.

Topical use of tranexamic acid in primary total knee arthroplasty: a comparative study

Methods, Techniques, Drugs, 126 - 130
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Introduction. Perioperative blood management represents a major issue in knee arthroplasty. The aim of the present observational study is to compare two different methods of topical tranexamic acid (TXA) administration (periarticular and intraarticular) in primary knee arthroplasty.
Patients and methods. The present is an observational comparative study. A total of 66 consecutive patients receiving topical injection of TXA after unilateral primary knee arthroplasty due to osteoarthritis were recorded. Patients were divided into two groups:
group 1; periarticular injection of TXA and group 2; intraarticular injection.
Results. Transfusion rate in group 1 was found to be 15%, compared to 44% in group 2 (p-value= 0.015). In transfused patients the mean received blood units were 1.2 (SD=0.44) in group 1, compared to 1.06 (SD=0.24; p-value=0.34) in group 2. The mean hospital stay of group 1 patients was 7.94 days (SD=2.79), compared to 9.58 days (SD=3.26; p-value=0.03) in group 2.
Discussion. The main findings of the study are that statically significant higher transfusion rates, as well as longer in-hospital stay were found in the intraarticular group, when compared to the periarticular group. According to these two parameters the present study has shown that the topical periarticular TXA injection is superior to the intraarticular one. Further research is of utmost importance in order to conclude to the optimum combination of knee arthroplasty perioperative blood management.

Insights in clinical examination and diagnosis of Athletic Pubalgia

Mini-review, 131 - 135
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Athletic pubalgia presents with groin and/or pubic pain mainly in athletes. The purpose of this review is to analyze, by evaluating current literature, the clinical examination and differential diagnosis of athletic pubalgia, in an effort to better understand this clinical entity. Diagnosis is challenging due to the anatomical complexity of the groin area, the biomechanics of the pubic Romasymphysis region and the large number of potential sources of groin pain. Clinical examination and medical history are of utmost importance. Differential diagnosis includes intra-and-extra-articular hip and intra-abdominal pathology, as well as non-myoskeletal disorders, such as femoroacetabular impingement (FAI), acetabular labral tears, osteitis pubis, adductor muscles injuries and true inguinal hernia. A thorough clinical examination should be performed in such cases, including the “Resisted sit-up” and the “Single or Bilateral Resisted Leg Adduction” test. Regarding imaging, Magnetic resonance imaging (MRI) should be performed when athletic pubalgia is suspected, especially in athletes. Other imaging techniques, such as plain radiographs and ultrasonography may add to the diagnostic process.

Vol. XLI (No. 1) 2020 January - February

  1. Laparoscopic Roux-en-Y gastric bypass in the treatment of obesity: evidence based update through randomized clinical trials and meta-analyses
    Morales-Maza J., Rodriguez-Quintero J.H., Sanchez-Morales G.E., Sanchez Garcia-Ramos E., Romero-Velez G., Aguilar-Frasco J.L., Pimienta-Ibarra A.S., Alvarez-Bautista F.E., Leon P., Hernandez-Acevedo J.D., Del Angel-Millan G., Sierra M.
  2. Retroperitoneal sarcomas: from diagnosis to treatment. Case series and review of the literature
    Mantas D., Garmpis N., Polychroni D., Garmpi A., Damaskos C., Liakea A., Sypsa G., Kouskos E.
  3. The discriminative properties of erythrocyte anisocytosis in patients with resectable malignant pancreatic masses compared with an age and gender matched control group
    Akturk O.M., Çakir M.
  4. Diagnostic and therapeutic role of laparoscopy in perforated peptic ulcer in the elderly patients
    Giordano A., Prosperi P., Alemanno G., Bergamini C., Bruscino A., Valeri A.
  5. The role of laparoscopic surgery in isolated adrenal metastasis: our personal experience
    Frattolillo G., Paradiso G., Scarano Catanzaro V., Giordano L., Avantifiori R., D'Ermo G., Letizia C., De Toma G.
  6. Advances in bioengineering of complex tissues: state of the art of mucosae decellularization protocols
    Rizzo M.I., Contardi C., Esposito M., Zama M.
  7. An analysis of missed cases with surgical emergencies admitted in non-surgical departments. Case series and а review of the literature
    Popivanov G., Cirocchi R., Popov G., Stefanovski P., Andonova R., Kjossev K., Tonchev P., Tabakov M., Penkov M., Ivanov P., Mutafchiyski V.
  8. The evolution of robotic arm-assisted arthroplasty in Greece
    Koutserimpas C., Dretakis K.
  9. Current role of open surgery in adrenal tumors
    Chiappini A., Frattolillo G., Paradiso G., De Gori A., Scarano Catanzaro V., Avantifiori R., Fiori E., De Toma G.
  10. Preoperative fasting - “nihil per os” a difficult myth to break down: a randomized controlled study
    Panebianco A., Laforgia R., Volpi A., Punzo C., Vacca G., Minafra M., Di Salvo M., Pezzolla A.
  11. Sentinel lymph node biopsy with intraoperative touch imprint cytology (TIC) in breast cancer: experience of a mild-volume center
    Marano A., Sodano B., Vitiello C., Martini A.M., Baldassarre F., Siciliano A., Iannaci G.
  12. Spontaneous transdiaphragmatic intercostal hernia: clinical considerations and management
    Lonardo M.T., Frezzotti F., Collalti M., Natili A., Metere A.
  13. Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study
    Symeonidis D., Diamantis A., Baloyiannis I., Tzovaras G., Tepetes K.
  14. Minilaparotomic incision for haemorrhagic corpus luteum: a case report
    Leanza V., Mininni C., Di Grazia F.M., Genovese F., Carbonaro A., Leanza G., Palumbo M.
  15. Conservative management of streptococcal necrotizing periorbital fasciitis following primary VZV infection
    Kontou E., Bontzos G., Triantafyllou D., Garnavou-Xirou C., Ragkousis A., Xirou T.
  16. Relief of hemorrhoid symptoms: pilot study of a new topical ally
    Gaj F., Bianchi F.P., Passannanti D., Telesco D.
  17. Topical use of tranexamic acid in primary total knee arthroplasty: a comparative study
    Besiris G.TH., Koutserimpas C., Karamitros A., Karaiskos I., Tsakalou D., Raptis K., Kourelis K., Paxinos O., Kotsirakis A., Vlasis K.
  18. Insights in clinical examination and diagnosis of Athletic Pubalgia
    Koutserimpas C., Ioannidis A., Konstantinidis M.K., Makris M.C., Antonakopoulos F., Mazarakis A., Papagelopoulos P.J., Vlasis K., Konstantinidis M.K.
Last Viewed articles: la lista degli ultimi x visitati.
  1. Insights in clinical examination and diagnosis of Athletic Pubalgia
    Koutserimpas C., Ioannidis A., Konstantinidis M.K., Makris M.C., Antonakopoulos F., Mazarakis A., Papagelopoulos P.J., Vlasis K., Konstantinidis M.K.
  2. Topical use of tranexamic acid in primary total knee arthroplasty: a comparative study
    Besiris G.TH., Koutserimpas C., Karamitros A., Karaiskos I., Tsakalou D., Raptis K., Kourelis K., Paxinos O., Kotsirakis A., Vlasis K.
  3. Relief of hemorrhoid symptoms: pilot study of a new topical ally
    Gaj F., Bianchi F.P., Passannanti D., Telesco D.
  4. Conservative management of streptococcal necrotizing periorbital fasciitis following primary VZV infection
    Kontou E., Bontzos G., Triantafyllou D., Garnavou-Xirou C., Ragkousis A., Xirou T.
  5. Minilaparotomic incision for haemorrhagic corpus luteum:
    a case report

    Leanza V., Mininni C., Di Grazia F.M., Genovese F., Carbonaro A., Leanza G., Palumbo M.
  6. Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study
    Symeonidis D., Diamantis A., Baloyiannis I., Tzovaras G., Tepetes K.
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