Search Results (66)

Background/Objectives: Incomplete intertrochanteric proximal femur fractures pose a management dilemma regarding the choice between surgery and conservative care. This study compared radiographic and functional outcomes between surgical fixation and conservative treatment and evaluated whether immediate full weight-bearing (FWB) can be performed by conservatively managed patients. Methods: This is a retrospective cohort study of consecutive patients aged ≥ 60 who presented with MRI-confirmed incomplete intertrochanteric fractures at a tertiary trauma center and rehabilitation unit from 2010 to 2020. Clinical outcomes were compared between conservatively managed and surgically treated patients. The primary outcome was radiographic bone union at 3 months; the secondary outcomes included secondary displacement, mobility at discharge, hospital length of stay, and mortality at 3 months and 1 year. Results: Forty-two patients met the inclusion criteria: 10 were managed conservatively, and 32 were managed operatively. Baseline age and sex distributions were similar between groups. At 3 months post-injury, bone union rates were 100% in both groups, with no incidences of secondary displacement regardless of whether a course of protected weight-bearing was prescribed. Functional mobility at discharge and length of stay were comparable. Mortality at 3 months and 1 year did not differ significantly between groups. Conclusions: The preliminary findings of this retrospective cohort study demonstrated managing MRI-diagnosed incomplete intertrochanteric proximal femur fractures conservatively to be feasible. Despite the limited sample size, all included patients who were treated conservatively achieved bone union by 3 months without secondary displacement. Their clinical outcomes were also comparable to the outcomes of those who were treated with surgical fixation. However, given the small sample size and lack of randomization, further investigation is warranted before clinical application. Full article

Background and Clinical Significance: Proliferative fasciitis (PF) is an infrequent benign fibroblastic/myofibroblastic proliferation that may closely resemble a soft tissue sarcoma, creating a diagnostic dilemma out of proportion to its biological behaviour. Because no single clinical, histological or immunohistochemical feature is diagnostic, accurate classification depends on the integration of complementary findings. We describe a challenging case of PF involving the lower leg and present a practical clinicopathological approach to its evaluation. Case Presentation: A 34-year-old man presented with a painless subcutaneous nodule on the lateral aspect of the left lower leg, discovered incidentally. Clinical examination suggested a benign superficial soft-tissue lesion, and because no features raised suspicion for malignancy, complete excision was performed without preoperative imaging. Gross examination revealed a 1.9 × 1.6 × 0.7 cm fascial-based lesion composed of spindle cells and scattered ganglion-like cells within a variably myxoid stroma. Focal nuclear pleomorphism, typical mitotic activity (2 mitoses/10 high-power fields), and limited extension into adjacent adipose tissue broadened the differential diagnosis. Immunohistochemistry demonstrated focal SMA positivity, weak focal desmin and S100 expression, absence of CD31 and CD34 staining, and a low Ki-67 proliferative index (approximately 2–3%). Negative surgical margins, together with integration of the clinical presentation, gross findings, histomorphology, and immunophenotype, supported the diagnosis of proliferative fasciitis. The patient remains free of local recurrence four months after surgery. Conclusions: PF should be considered in the differential diagnosis of superficial spindle-cell proliferations showing deceptively aggressive histological features. Careful clinicopathological correlation remains the cornerstone of diagnosis and helps distinguish this benign entity from its malignant mimics. The clinicopathological framework proposed in this report may assist pathologists in the systematic evaluation of similar diagnostically challenging lesions. Full article

The high recurrence rate of glioblastoma after surgical resection and conventional chemotherapy remains a major obstacle to effective treatment. Mitochondria-targeted long-acting local chemotherapy represents a promising therapeutic strategy to tackle this dilemma. In this study, a mitochondria-penetrating peptide (mito) was conjugated with lonidamine (LND), a mitochondrial hexokinase II inhibitor, to construct an amphiphilic peptide–drug conjugate (LND-mito) that could self-assemble into supramolecular hydrogels. This design achieves sustained localized release and mitochondria-targeted delivery, generating a tumor-selective oxidative phosphorylation inhibitor with 19-fold higher potency than LND. Our results demonstrated that LND-mito efficiently targeted tumor cell mitochondria, induced robust reactive oxygen species generation, decreased mitochondrial membrane potential, and activated mitochondrial apoptosis, ultimately markedly inhibiting glioma growth and prolonging postoperative survival in orthotopic glioma-bearing mice. Collectively, this study offers a promising therapeutic strategy for glioma management, while simultaneously informing the design of high-efficacy, low-toxicity local sustained-release delivery platforms for malignant tumors. Full article

Florid cemento-osseous dysplasia (FCOD) is a benign fibro-osseous condition typically presenting as multifocal, sclerotic masses throughout the jaws. While often asymptomatic, the hypovascular nature of the dysplastic bone predisposes it to secondary infection, which can mimic more aggressive pathologies. We present a complex diagnostic challenge involving a 76-year-old female with a history of intravenous ibandronic acid therapy for 18 months. The patient presented with a purulent mandibular fistula and exposed bone, leading to an initial clinical suspicion of Stage 2 Medication-Related Osteonecrosis of the Jaw (MRONJ). Radiographic evaluation, however, revealed generalized “cotton-wool” opacities across all four quadrants, characteristic of FCOD, with multifocal mixed radiolucent–radiopaque changes and a localized demarcated sequestrum in the symptomatic area. Accordingly, the diagnostic reasoning progressed from an initial clinical suspicion of MRONJ, to radiologic consideration of infected FCOD, and finally to exclusion of plasma cell neoplasia by immunohistochemical evaluation. The diagnostic dilemma intensified during histopathological analysis, which revealed an unusually dense, sheet-like infiltration of plasma cells within the fibro-osseous stroma. This striking plasmacytosis initially raised suspicion for a plasma cell neoplasm, such as plasmacytoma or multiple myeloma. To differentiate reactive inflammation from malignancy, immunohistochemical staining for kappa and lambda light chains was performed, demonstrating a polyclonal pattern that confirmed a reactive process. The final diagnosis was determined as FCOD with superimposed secondary osteomyelitis. Following conservative surgical debridement and targeted antibiotic therapy, the patient showed clinical resolution and remained stable at a 6-month follow-up. Recognizing these overlaps is essential for preventing over-treatment and ensuring appropriate management in elderly patients with complex medical backgrounds. Full article

Pancreatic ductal adenocarcinoma (PDAC) remains a highly lethal malignancy. The identification and management of precursor lesions, particularly the increasingly common intraductal papillary mucinous neoplasms (IPMNs), pose a significant challenge, creating a profound clinical dilemma between intercepting pancreatic ductal adenocarcinoma and avoiding surgical overtreatment. This literature review aims to synthesize the latest evidence to facilitate a transition from purely morphology-based surveillance toward a biologically informed risk stratification paradigm. This approach could provide a personalized risk-stratification algorithm that optimizes therapeutic management and enables timely intervention for pancreatic cancer. By using PubMed, Embase, Scopus, and Web of Science, we analyzed and summarized key findings from recent literature (2020–2025), including cohort studies, mechanistic analyses, evidence-based guidelines, and systematic reviews on cyst fluid biomarkers (CEA panels, DNA/RNA sequencing), and emerging AI applications. Prospective and multicenter studies consistently report that NOD is independently associated with high-risk stigmata, cyst progression, and malignant transformation. Mechanistic research suggests a bidirectional interplay between the evolving neoplasia and pancreatic endocrine dysfunction. Updated guidelines underscore the need for more precise diagnostic algorithms. Recent work demonstrates that advanced cyst fluid markers—CEA panels, DNA/RNA sequencing, and multi-omic signatures—significantly improve diagnostic accuracy. Furthermore, explainable AI models show encouraging performance in predicting malignancy and assisting patient triage. Risk stratification in PCLs is shifting from morphology-based assessment toward integrated, multimodal approaches combining clinical, endocrine, imaging, molecular, and computational data. Recent evidence positions new-onset diabetes as a clinically accessible and biologically plausible marker of high-risk IPMNs. Similarly, molecular assays and AI-enhanced analytics provide an additional layer of diagnostic precision. The development of personalized risk prediction algorithms could improve early detection of malignancy while reducing unnecessary surgical resections. Full article

Background and Clinical Significance: Cystic mesenteric lymphangiomas are rare benign growths of the mesenteric lymphatic vessels. This entity poses a diagnostic dilemma due to the wide array of symptoms with which patients present. Usually, these patients are diagnosed before the age of 5 years old. Case Presentation: In this report, we present a young adult male with longstanding gastrointestinal complaints and a small bowel obstruction who subsequently underwent exploratory laparotomy with significant bowel resection, and pathology revealed a diagnosis of cystic mesenteric lymphangioma. Conclusions: The presence of small bowel obstruction without prior abdominal surgeries should raise suspicion of congenital pathologies and warrants prompt surgical intervention. Full article

Background and Objectives: The management of localized ileocecal Crohn’s disease (CD) is undergoing a significant paradigm shift from traditional “step-up” medical escalation toward proactive early surgical intervention. With the evolution of surgical therapies as well as various minimally invasive procedures, as well as a better understanding of inflammatory bowel diseases, surgery is playing a more important role in the treatment of inflammatory bowel disease. One of the most common occurrences in Crohn’s disease, the ileocecal localization can present with a lot of dilemmas regarding the optimal treatment in both adult patients and pediatric patients alike. One of the biggest challenges remains the decision between early surgery and continuous biological treatment, which can prove a challenge from multiple standpoints ranging from cost-efficiency to recurrence rate. This review highlights the latest changes in surgical management in ileocecal Crohn’s disease, focusing primarily on the anastomotic type, comparison with biological therapy, early aggressive surgery and pediatric surgery. Materials andMethods: After respecting the review criteria, 16 articles were included in our study, which emphasize the importance and the recent trends in the surgical management of the ileocecal disease. Results: All 16 articles met criteria for good quality, suggesting a low risk of bias, focusing primarily on early surgery, the role of Kono-S anastomosis as well as pediatric considerations. Conclusions: While the choice of the Kono-S anastomosis remains debatable, significant progress has been made in terms of early surgery which improves the long-term outcomes in patients while minimizing the risk of morbidity and mortality. Full article

Background/Objectives: In periarticular knee surgery, such as osteotomies, ligament reconstruction, and fracture fixation, surgeons face a dilemma: ensuring the safety of the popliteal artery (PA) while securing adequate surgical access to the bone. While macroscopic anatomical studies suggest knee flexion protects the PA, they often fail to account for physiological muscle tension in living knees. This study aimed to quantitatively evaluate the dynamic positional changes in the PA and the vastus medialis and lateralis muscles (VM and VL, respectively) using Open Magnetic Resonance Imaging (MRI) to determine the optimal limb position for each surgical step. Methods: Twenty-three living knees were evaluated using Open MRI. The shortest perpendicular distances from the posterior aspect of the femur and tibia to the PA, and from the femoral cortex to the posterior border of the VM and VL, were measured at 10° knee-flexed position (representing the extended position) and 90° knee-flexed position. Results: The PA shifted significantly away from the bone in 90° knee-flexed position compared to extension at the distal femur (0 and 1 cm proximal to the intercondylar line (Blumensaat’s line)) and the proximal tibia (0, 1, and 2 cm distal to the joint line) (Q < 0.05). Conversely, both the VM and VL moved significantly closer to the femur in flexion at all measured levels (0–4 cm) (Q < 0.05), often causing the muscles to compress tightly against the bone. Conclusions: The vascular safety margin is maximized in flexion, whereas surgical exposure for the distal femur is optimized in extension due to vastus muscle relaxation. We suggest performing superficial exposure and femoral plate insertion in extension, and surgical maneuvers involving the posterior cortex in flexion to minimize neurovascular and soft tissue complications. Full article

Background: Acute appendicitis in girls presenting with lower abdominal pain remains a frequent diagnostic dilemma because of the overlap in clinical presentation with gynaecological and non-surgical causes. This study aimed to evaluate the diagnostic performance of IL-6 and CD64 and to compare them with classical inflammatory markers and the Alvarado score. Methods: We conducted a prospective observational diagnostic-accuracy study over a three-year period (December 2022 to December 2025) at the First University Paediatric Surgery Clinic, General Hospital of Thessaloniki “Georgios Gennimatas”. Consecutive girls aged ≤16 years presenting with lower abdominal pain were included. The primary outcome was appendicitis (yes/no), defined by the final clinical diagnosis and, where applicable, intraoperative and/or histopathological confirmation. Diagnostic performance was assessed using ROC curves and AUCs with 95% confidence intervals estimated by the DeLong method. The prespecified primary regression model included the Alvarado score and IL-6; IL-6 was summarised on its original scale and log1p-transformed only for regression analyses to account for right-skewness. Additional multivariable models were exploratory. Results: Of 74 initially assessed cases, one was excluded (appendiceal neuroendocrine tumour, NET G1), yielding a final sample of 73 girls: 37 with appendicitis and 36 without appendicitis. IL-6 was higher in the appendicitis group (median 19.41 vs. 4.10 pg/mL) and showed moderate discrimination (AUC 0.696). CRP showed lower to borderline performance (AUC 0.595), whereas CD64 did not demonstrate useful discrimination (AUC 0.521). The Alvarado score had the highest discriminatory ability (AUC 0.885). In the subset with complete data, adding IL-6 to the Alvarado score did not materially improve discrimination. Conclusions: IL-6 showed moderate diagnostic performance as a standalone biomarker and may be useful as an adjunct, particularly when a clinical score is unavailable or unreliable. CD64 did not add meaningful diagnostic information in this setting. Larger, prespecified studies are required to determine clinically useful cut-offs and to clarify whether IL-6 offers incremental value beyond established clinical assessment. Full article

Liver transplantation (LT) is the definitive treatment for patients with end-stage liver disease. Since its inception in the 1960s, transplant medicine has undergone substantial advances in surgical technique, immunosuppression, organ preservation, and organ allocation policies. According to the 2023 WHO census, approximately 47,180 LT procedures occur worldwide each year, with living donors contributing to up to 23% of cases. Additional milestones include the expansion of transplant eligibility to patients with hilar cholangiocarcinoma and advanced colorectal liver metastasis, the incorporation of viscoelastic testing into perioperative blood management algorithms, and the increasing use of mechanical circulatory support for pre-transplant optimization. In parallel, medical training has evolved to meet the complexities associated with these high-risk procedures. Structured fellowship programs now provide focused expertise, and guide investigations to resolve complex clinical dilemmas. Experience accumulated over decades has improved clinicians’ ability to manage the expanding spectrum of comorbidities seen in contemporary transplant candidates. Key perioperative challenges include accurate assessment of fluid status, optimization of intravascular volume, management of vasoplegia, intraoperative renal replacement therapy, treatment of right-ventricular failure, and the mitigation of severe lactic acidosis. As transplant recipients increasingly present at older ages and with multiple comorbidities, perioperative management has become more demanding. One emerging strategy for select high-risk patients involves performing concurrent surgical procedures within a single operative session. This narrative review focuses on the intraoperative management of five variables that proved challenging during the first case of concurrent liver transplantation and off-pump coronary artery bypass surgery in our institution. Full article

Background and Objectives: Elderly patients frequently receive antiplatelet therapy, creating a clinical dilemma between bleeding risk and cardiovascular protection during surgery. We evaluated the association between preoperative antiplatelet therapy and postoperative bleeding and cardiovascular events using multicenter observational data. Materials and Methods: We conducted a retrospective cohort study using standardized OMOP-CDM databases from 10 tertiary hospitals. Patients aged ≥65 years undergoing surgery were classified by preoperative aspirin or clopidogrel exposure. Propensity score matching was performed within each site. Hazard ratios (HRs) were estimated using Cox regression and pooled using meta-analytic techniques. Results: A total of 1464 exposed patients and 7038 matched comparators were analyzed. Across sites, hazard ratios varied without a statistically significant pooled association. The pooled HR for postoperative events was 1.01 (95% CI 0.57–1.78, p = 0.967). Covariate balance improved substantially after matching. Conclusions: Preoperative antiplatelet therapy was not associated with a consistent increase in postoperative bleeding or cardiovascular events in elderly surgical patients. These findings support individualized perioperative management rather than routine discontinuation. Full article

Background: Inguinoscrotal sarcomas are a rare sarcoma subtype. The treatment of choice is radical inguinal orchiectomy with wide local resection of the surrounding soft tissues. However, consensus regarding prognostic factors is lacking. We present our experience at a referral sarcoma center concerning the management, oncologic results, and prognostic factors pertaining to this disease. Methods: We conducted a retrospective analysis of patients who underwent surgery for inguinoscrotal sarcomas between 2005 and 2023 at a sarcoma referral hospital. Results: The study included 39 patients. The most frequent histology was liposarcoma. Seven patients required surgical reconstruction with a microvascularized free flap. Four patients presented major postoperative complications. Mean follow-up was 46 months. Overall survival rates were 97.4%, 81.7%, and 64.8% at one, three, and five years. High-grade tumors were correlated with worse overall and disease-free survival. Conclusions: The chance finding of a sarcoma in the inguinal region poses a diagnostic and therapeutic dilemma when considering options for treatment with curative intent. Vascular and muscle resection followed by vascular and/or free flap reconstruction may be necessary to achieve complete surgical resections; therefore, a multidisciplinary approach is needed. A preoperative biopsy should be performed to establish the histological grade, which may be the main prognostic factor. Full article

Background and Objectives: Porcelain aorta is an anatomy-driven high-risk phenotype characterized by extensive calcification of the ascending aorta, which complicates surgical aortic valve replacement by increasing embolic and technical hazards during cannulation and cross-clamping. As transcatheter aortic valve implantation (TAVI) expands into younger and low-surgical-risk populations, porcelain aorta creates a distinct clinical dilemma: optimizing short-term procedural safety while ensuring durable long-term outcomes and preserving future treatment options. Materials and Methods: We performed a targeted literature search of MEDLINE/PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL), with the last search conducted on 31 January 2026. We synthesized contemporary clinical evidence on TAVI in patients with imaging-defined porcelain aorta, focusing on neurological outcomes, procedural strategies to reduce embolic risk, access considerations, valve performance, cerebral embolic protection, and implications for lifetime valve management (including coronary access and feasibility of future valve-in-valve interventions). Results: The evidence base specific to porcelain aorta in the contemporary TAVI era is limited and largely observational. Across published cohorts, TAVI avoids direct ascending aortic cannulation and cross-clamping and is generally associated with favorable early safety, with a recurring directional signal toward lower neurological risk compared with surgical strategies that require manipulation of a severely calcified ascending aorta. Interpretation is constrained by heterogeneity in porcelain-aorta definitions, patient selection, valve platforms and access routes, as well as, variability in neurological endpoint definitions and adjudication. Conclusions: In patients with porcelain aorta, TAVI is frequently favored because it minimizes ascending aortic manipulation and may mitigate neurological and procedural hazards. In younger and low-risk patients, Heart Team decision-making should incorporate lifetime management principles, including access planning, preservation of future coronary access, and procedural strategies to reduce embolic risk (with consideration of cerebral embolic protection when appropriate). Full article

Background: Advances in breast reconstruction have transformed the recovery pathway for women undergoing mastectomy. What was once viewed mainly as a cosmetic option is now recognized as part of modern oncologic care, restoring not only body image but also confidence and quality of life. Yet, surgeons still face the same central dilemma: choosing between implant-based (IBR) and autologous reconstruction (ABR), particularly when postmastectomy radiotherapy (PMRT) is planned. Methods: We reviewed major studies published between 2014 and 2024, combining evidence from observational cohorts and recent meta-analyses that together report on more than 60,000 reconstructed breasts. Outcomes of interest included surgical complications, reconstructive failure, BREAST-Q patient-reported domains, and the impact of PMRT on both techniques. Data were interpreted in light of contemporary reconstructive innovations such as prepectoral implants, acellular dermal matrices, and robotic or sensory-nerve–enhanced autologous procedures. Results: Autologous reconstruction generally provided higher satisfaction and better psychosocial and sexual well-being, particularly in patients who received PMRT. Implant-based reconstruction offered faster recovery and shorter hospitalization but was more vulnerable to capsular contracture and reconstructive loss after irradiation. Across all eligible cohorts, reconstruction—immediate or delayed—did not increase local recurrence or compromise overall survival when adjuvant therapy was delivered without delay. Conclusions: Both IBR and ABR are oncologically safe and contribute meaningfully to recovery after mastectomy. Future progress will depend on combining precise surgical execution with new technologies—prepectoral implant positioning, robotic flap harvest, and sensory nerve coaptation—to achieve durable, natural, and patient-centered reconstruction. Full article

Brown tumors (BTs) are rare osteolytic lesions that typically occur in association with primary or secondary hyperparathyroidism (PHP and SHP). Excessive secretion of parathyroid hormone induces increased bone resorption, resulting in lesions characterized by fibrosis, vascularization, and hemosiderin deposition. The most common sites include the jaws, ribs, pelvis, and long bones. Clinical manifestations may involve pain, swelling, or pathological fractures. We present the case of a mandibular BT in a 48-year-old female with chronic renal failure and secondary hyperparathyroidism. The patient exhibited progressive mandibular swelling with radiological features resembling an aggressive odontogenic or malignant lesion. Laboratory analysis confirmed markedly elevated parathyroid hormone levels, while scintigraphy demonstrated increased focal uptake in the mandible and ribs. Histopathological evaluation revealed multinucleated giant cells within a fibrous stroma, consistent with BT. Despite initiation of systemic endocrine therapy, the lesion continued to enlarge, necessitating complete surgical excision of the mandibular mass. This case underscores the diagnostic dilemmas of mandibular BT, which may closely mimic aggressive jaw pathologies. Importantly, while many BTs regress after systemic management of hyperparathyroidism, this case illustrates that surgical excision may be unavoidable in patients with unstable systemic status or progressive local disease. Comprehensive clinical, radiological, laboratory, and histopathological evaluation remains essential to ensure timely diagnosis and appropriate treatment. Full article