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PurposeParaduodenal hernias (PDH), also called mesocolic hernias, account for up to 53% of all internal hernias, but they cause only 0.2–0.9% of all cases of intestinal obstruction. This is the first systematic review of all reported cases so far, investigating their clinical presentation, radiological imaging, and treatment outcomes.MethodsAfter a detailed search in PubMed and Medline, using the keywords “paraduodenal hernia”, 115 studies matched our criteria. A review of these reports was conducted and the full texts were examined.ResultsA total of 159 patients were included in our analysis, with 69.8% and 30.2% of them suffering from either a left or a right PDH, respectively. Mean age at diagnosis was 44.1 years, with a 2/1 male/female ratio. PDH were associated with non-specific symptoms and signs; abdominal pain being the most common. Computed tomography (CT) scan of the abdomen was the most frequently used diagnostic modality. Regardless of PDH localization, all patients were operated on, with approximately one-third of them undergoing a laparoscopic operation, which was associated with a significantly decreased morbidity rate as well as length of hospital stay, compared with the open repair.ConclusionsPDH are not usually associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of knowledge and clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair, seeming to be the optimum treatment strategy.

Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these patients.

Introduction A colorectal inflammatory myofibroblastic tumour (IMT) is a rare but benign entity masquerading as a malignant tumour. Although the lung is considered the most common site of occurrence, IMTs may arise in diverse extrapulmonary locations. We describe a case of a colonic IMT in a patient who presented in the emergency setting. Case History A 77-year-old man was admitted at our emergency department with acute abdominal pain. Physical examination revealed vague tenderness of the lower abdomen and non-palpable masses. Preoperative evaluation revealed a mass in the right lower quadrant of the abdomen, possibly originating from the terminal ileum, 1-2cm from the caecum. Owing to the clinical impression of a potentially malignant lesion, the patient underwent subtotal colectomy and omentectomy. The pathology report suggested the morphological and immunohistochemical features were more compatible with a colonic IMT. Conclusions A colorectal IMT is a rare clinical entity that can easily mimic a highly malignant tumour and cannot be distinguished clinically or radiologically. An accurate diagnosis is based on histological examination and surgical resection is therefore usually required.

NOABSTRACTPain remains the most common reason patients seek assistance in emergency rooms. However, the level of pain management during emergencies, and subsequently during disasters and mass casualty incidents, remainsdisturbing.A cross-sectional study was conducted using a structured anonymous questionnaire among a random sample of doctors working in different tertiary hospitals of Athens and of rural regions. The data were analysed using descriptive statistics and statistical significance tests via R-Studio, version 1.4.1103.The aforementioned sample yielded101 questionnaires. Results show suboptimal knowledge and attitudes regarding acute pain management among emergency healthcare providers in Greece. The majority of responders are unaware of the term multimodal analgesia (52%), of newer pain treatment methods (59%), they have not attended pain management seminars (84%), nor are they aware of pain treatment protocols in their workplace (74%). Participants appeared to disregard successful pain relief due to time constraints (58%), while leaving certain parts of the population (children under 3 years of age −75%, pregnant women-48%) significantly undertreated in terms of analgesia. Demographic correlations showed that clinical experience and pain management education were associated with older and more experienced emergency healthcare workers. Specialties with a previous core training containing pain education (anaesthesiologists, emergency physicians) again showed better results in the majority of the questions.Educational programs/seminars along with standardised algorithms should be developed in order to cover existing needs and misconceptions.

Laparoscopic sleeve gastrectomy (LSG) represents a promising alternative option for the surgical treatment of morbid obesity. Its standard technique includes the longitudinal division of the stomach along a bougie of varying diameter. We report in this retrospective study our experience with LSG being performed with the use of intra-operative endoscopy instead of the bougie. Twenty-five consecutive patients (18 women, seven men) with a mean age of 40.2 years and mean body weight of 152.1 kg were submitted to LSG with intra-operative endoscopy in our hospital. The mean preoperative BMI was 53.5 kg/m 2 . There were no conversions. Mean operative time was 117.5 min. There was no morbidity or mortality. The mean loss of excess body weight (EBW) at 3 months post-op was 19 ± 1.8 kg, at 6 months was 28.6 ± 4.5 kg, and at 1 year post-op was 48.9 ± 3.7 kg (min 11–max 92). In other words the patients had lost 30 ± 5%, 45 ± 7.7%, and 60.8 ± 4.3% of their EBW, respectively. The mean excess body weight loss at the day of the last visit to our outpatient clinic was 52.3 ± 4.3 kg which corresponded to 66.4 ± 4.3% of the total excess weight. LSG with intra-operative endoscopic guidance is a safe and efficient alternative method to treat morbid obesity and is a viable option for surgical units familiar with endoscopic techniques.

(1) Background: The Hypotension Prediction Index (HPI) is an algorithm that predicts hypotension, defined as mean arterial pressure (MAP) less than 65 mmHg for at least 1 min, based on arterial waveform features. We tested the hypothesis that the use of this index reduces the duration and severity of hypotension during noncardiac surgery. (2) Methods: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized 1:1 to standard of care or hemodynamic management with HPI guidance with a goal directed hemodynamic treatment protocol. The trigger to initiate treatment (with fluids, vasopressors, or inotropes) was a value of HPI of 85 (range, 0–100) or higher in the intervention group. Primary outcome was the amount of hypotension, defined as time-weighted average (TWA) MAP less than 65 mmHg. Secondary outcomes were time spent in hypertension defined as MAP more than 100 mmHg for at least 1 min; medication and fluids administered and postoperative complications. (3) Results: We obtained data from 99 patients. The median (IQR) TWA of hypotension was 0.16 mmHg (IQR, 0.01–0.32 mmHg) in the intervention group versus 0.50 mmHg (IQR, 0.11–0.97 mmHg) in the control group, for a median difference of −0.28 (95% CI, −0.48 to −0.09 mmHg; p = 0.0003). We also observed an increase in hypertension in the intervention group as well as a higher weight-adjusted administration of phenylephrine in the intervention group. (4) Conclusions: In this single-center prospective study of patients undergoing elective noncardiac surgery, the use of this prediction model resulted in less intraoperative hypotension compared with standard care. An increase in the time spent in hypertension in the treatment group was also observed, probably as a result of overtreatment. This should provide an insight for refining the use of this prediction index in future studies to avoid excessive correction of blood pressure.

Background and AimsPain is one of the commonest reasons a patient seeks assistance in the emergency department (ED). The goal of the study is to assess the key points of acute pain management in the emergency and the disaster setting.MethodsThe inclusion criteria used were: a) articles referring to acute pain management in the ED, the disaster and the prehospital setting, b) research that focused on pain assessment methods during emergencies, c) guidelines on pain therapy protocols and methods of pain alleviation, d) studies analyzing reasons behind pain under-treatment in the ED. The exclusion criteria were: a) studies referring to chronic pain management, b) research on pain treatment outside the emergency setting.Three major themes were identified: a) acute pain perceptions, b) acute pain assessment and c) acute pain treatment.ResultsOn acute pain perceptions, literature search highlights problems related to healthcare systems and misconceptions among healthcare workers, rendering pain alleviation, during emergencies and disaster, disregarded. On pain assessment, numerous studies emphasize the need for standardized self-reporting pain measurement tools, when it comes to evaluate a patient’s pain intensity and severity. Various treatment modalities exist that can successfully guarantee pain alleviation in almost any setting. Lessons acquired from environmental and military disasters emphasize on the use of interventional techniques, like peripheral nerve blocks.Abstract B56 Table 1Studies of peripheral nerve blocks for analgesia in the EDConclusionsThe problem of pain management extends far beyond a single country or a single ED. Physicians should recognize pain as a true emergency and treat it as such.

Carotid body (CB) paragangliomas are rare neoplasms, usually benign. This study deals with our 10-year experience in their surgical treatment and the evaluation of its effectiveness, without preoperative embolization. During a 10-year period, from 1995 to 2004, we studied the medical records of 11 patients with CB tumors, 8 males and 3 females, whom only one had bilateral tumors. Their age ranged from 23 to 65 years (mean 35 years) and all had a palpable neck mass. Only two of the patients were asymptomatic on admission to our department. Twelve tumors were surgically resected and no patient underwent preoperative selective embolism of his tumor. Two patients had carotid endarterectomies with venous patch angioplasty. No one of the patients underwent radiotherapy or chemotherapy. Perioperative mortality was zero. No stroke or any other cerebral event was observed. One patient, with a grade III tumor, had an injury of the internal carotid artery that was repaired with a vein patch. Three patients had temporal cranial nerve lesions that resolved within 3 months. No malignancy was found even in a 10-year follow-up. Early surgical treatment is strongly recommended in almost all patients. Their resection is a very challenging operation with good postoperative results. Preoperative embolism of the tumor does not need to be a routine procedure. To exclude malignancy, long term follow-up is necessary.

The assumption of reference station conditions is investigated for the first time across 60 rock stations belonging to the broadband and accelerometric networks of the National Observatory of Athens. We include in our assessment all stations that have some probability of lying on rock, based on existing data or beliefs, provided their data have been publicly available for long enough to yield a substantial number of recordings. No studies on site effects have been conducted before for the ensemble of stations. Furthermore, almost no ad hoc field campaigns have been performed to characterise them. The first step is to compile all readily available information per station from publicly available external sources, i.e. geology, topography, housing, Vs30 estimates, and any other known metadata. The second step is to analyse geological maps to derive the geological unit and age; to combine this external information with internal information (namely questioning network staff to access the operator's first-hand experience of the sites); and to better describe geology, geomorphology, and station installation details. The third and largest step is to compile the first Greek ground motion dataset on rock and to perform a detailed analysis of the recordings to estimate site-specific amplification to assess the local site response for each station. A strong-motion dataset of over 7500 recordings is developed and curated for this purpose, dating from 2012 to 2023. It is visually inspected and meticulously processed on a waveform-specific basis in the time and frequency domains, paying special attention to signal quality and strength. Single-station amplification functions using horizontal-to-vertical spectral ratios (HVSRs) are then estimated from the database. Considering that “true” reference sites should have low, flat amplification with no directional dependence, the analysis goes beyond the usual path of combining the two horizontal components into a mean HVSR. It also assesses the directional sensitivity of the HVSR to identify departure from the 1D assumption, corrects the HVSR for the vertical amplification effect, and uses clustering techniques to select groups of stations with different response characteristics. This data-derived characterisation is combined with the previously compiled station metadata to evaluate the stations' overall capacity as reference sites. This results in a qualitative ranking of the stations. The least and most adequate reference stations are showcased to facilitate a better use of seismic data in future seismological and hazard applications.