Dionysios Prevezanos

Primary hepatic perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms that involve both melanocytic and smooth muscle differentiation. Primary hepatic PEComas remain a challenging condition for radiologists, pathologists, and surgeons. Our review provides an updated, clinically oriented synthesis of the available evidence on primary hepatic PEComas, integrating recent developments in diagnosis, imaging, histopathology, molecular biology, prognostic stratification, surgical and systemic treatment, and long-term surveillance. Although the majority of hepatic PEComas generally exhibit a slowly progressive clinical course, a small subgroup of them is characterized by aggressive biological behavior with an increased risk of recurrence, distant metastases, and disease-related mortality. As PEComas can resemble other hypervascular liver lesions such as hepatocellular carcinoma and hemangioma, preoperative diagnosis based on imaging techniques can be very difficult. Furthermore, the final diagnosis is usually made by histopathological examination of the surgical specimen, which reports characteristic expression of both smooth muscle markers and melanocytic markers such as HMB-45 and Melan-A. Although mTOR inhibitors have demonstrated antitumor activity in advanced PEComas, evidence specifically supporting their use in primary hepatic PEComas remains limited. Prognostic stratification, treatment selection, and long-term follow-up of primary hepatic PEComa remain major challenges. Further multicenter studies are needed to improve risk assessment and develop evidence-based guidelines for the management of these rare primary liver neoplasms.

Background/Objectives: Primary biliary neuroendocrine tumors (PBilNETs) are exceptionally rare biliary tract neoplasms that are frequently misdiagnosed preoperatively as cholangiocarcinoma because of overlapping clinical and radiological findings. This systematic review aimed to summarize overall evidence regarding presentation, diagnostic evaluation, surgical management, and outcomes of PBilNETs. Methods: A systematic search of PubMed, Scopus, and Embase databases was performed according to PRISMA guidelines for studies published between January 2000 and December 2025. Studies including adult patients with histologically confirmed and surgically treated PBilNETs were eligible. Data regarding demographics, symptoms, imaging findings, surgical treatment, histopathology, immunohistochemistry, and outcomes were extracted and analyzed. Results: Fifty-eight studies involving 79 patients met the inclusion criteria. Median age at diagnosis was 49 years, with female predominance. Obstructive jaundice, abdominal pain, and pruritus were the most common presenting symptoms. Most tumors originated from the hilar or extrahepatic bile ducts. Preoperative diagnosis was challenging, as most lesions were initially considered cholangiocarcinomas. Surgical resection was the main therapeutic approach and included bile duct excision with biliary reconstruction, pancreaticoduodenectomy, or hepatic resection according to tumor location. Histopathological analysis demonstrated predominantly well- or moderately differentiated neuroendocrine neoplasms with frequent chromogranin A and synaptophysin positivity. Favorable long-term outcomes were reported, with high postoperative survival and limited recurrence during follow-up. Conclusions: PBilNETs remain diagnostically challenging because of their rarity and nonspecific presentation; however, they appear to exhibit a less aggressive biological behavior than conventional biliary adenocarcinomas. Surgical resection remains the cornerstone of treatment, while further multicenter studies are required to optimize diagnostic and therapeutic strategies. The findings also support an individualized multidisciplinary approach integrating clinical presentation, advanced imaging, histopathological grading, and immunohistochemical profiling to optimize personalized management of these rare tumors.

Background/Objectives: Liver metastasis develops in approximately 50% of patients with colorectal cancer. Invasion of the biliary tract from colorectal liver metastasis (CRLM) is rarely reported. Preoperative diagnosis remains elusive, prohibiting optimal surgical management. The objective of this systematic review was to summarize the clinical, radiological, pathological, and treatment characteristics of ibCRLM and describe the reported outcomes. Methods: A systematic literature search of the Medline, Embase, Web of Science, CENTRAL, and CINAHL databases was undertaken for studies reporting clinical outcomes of patients with ibCRLM, up to May 2026. An individual patient data analysis approach was utilized. Results: Thirty-eight case reports and 10 case-series, incorporating 228 patients with biliary involvement from CRLM, were identified. Mean age was 62.4 ± 10.9 years, with a male-to-female ratio of 3.2:1. The majority of metastatic lesions were metachronous in 71.1% and solitary in 59.1% of patients. Surgical treatment was implemented in 89.2% of patients. Major hepatectomy was the most common procedure, being performed in 46.2% of patients, followed by minor hepatectomy in 38.7% and pancreatoduodenectomy in 4.3%. After a median follow-up of 52.5 months (range 2–164 months), the survival rate was 60.5%. Non-survivors were found to have significantly more synchronous CRLM (50% versus 0, p = 0.008), while a single patient did not receive any curative-intent treatment and died 20 days following CRLM presentation. Conclusions: IbCRLM is a distinct clinicopathological presentation of CRLM with characteristic radiological and pathological features. The available evidence suggests that selected patients may achieve favorable long-term outcomes following complete surgical resection, although these findings should be interpreted with caution given the limitations of the available literature.

Intestinal duplication cysts (IDCs) are rare congenital anomalies, most commonly arising in the small intestine. A particularly uncommon subtype, completely isolated duplication cysts (CIDCs), has an independent blood supply and lacks communication with the native bowel. Although IDCs are typically benign, malignant transformation—including low-grade mucinous neoplasms (LGMNs)—has been reported only rarely. A Caucasian male with a history of infant colostomy for ileus, later reversed, presented with an abdominal wall mass at the former stoma site. Imaging demonstrated a well-encapsulated cystic lesion originating above the posterior rectus sheath, and complete surgical excision was achieved uneventfully. Histopathology revealed a mucin-secreting epithelial lining with low-grade dysplasia, consistent with LGMN, with immunohistochemistry excluding alternative gastrointestinal neoplasms. The patient recovered without complications and showed no recurrence on follow-up. This represents the first documented CIDC with LGMN in the abdominal wall, highlighting the importance of early identification and surgical management.

Background: Laparoscopic cholecystectomy is considered the gold standard surgical technique for the treatment of gallbladder diseases worldwide. Nonetheless, despite its safety and popularity, it comes with certain complications. Duodenal injury is an extremely rare, but potentially fatal complication. The rarity of duodenal injuries, combined with under-reporting of incidents, has resulted in a scarcity of references in the international literature. Case Presentation: We present the case of a 72-year-old male patient, initially subjected to laparoscopic cholecystectomy that was intraoperatively converted to open cholecystectomy. During the laparoscopic approach, the patient experienced a major duodenal injury, which was treated intraoperatively using primary suturing. Upon postoperative failure of the indicated surgical treatment, extended individualized salvage surgery was performed, with an ultimately favorable outcome. Methods: When assessing the overall implications of this case, we conducted a review of the published literature in English, published up to November 2025 on patients with duodenal injury after exclusively laparoscopic cholecystectomy. Results: We then categorized the 105 cases described based on the therapeutic approach: surgical, conservative, and endoscopic, with a view to attempt to classify the available therapeutic options based on the time of diagnosis, the patient’s performance status, and the size and location of the injury. Conclusions: While laparoscopic cholecystectomy is a common surgical procedure, duodenal injuries remain rare. The treatment approach highly depends on the time of injury recognition, site and extent of the injury and patient’s status. Treatment should be personalized based on the aforementioned parameters.

Introduction: The surgical management of giant incisional hernias remains a challenge, particularly in cases involving extensive defects and altered abdominal wall anatomy. The Transverse Abdominis Release (TAR) technique, particularly the Madrid modification, has emerged as a preferred approach for posterior compartment separation, allowing for wide medial mobilization while preserving neurovascular integrity. While anterior component separation (ACS) can further facilitate closure, it is associated with significant postoperative complications, including bulging, herniation, wound dehiscence, and core instability, making its use controversial. This case underscores the importance of proper pre-/post-operative management and surgical technique to avoid further complications. Case report: A 74-year-old male with a history of ruptured abdominal aortic aneurysm repair presented with a giant midline incisional hernia, with a defect measuring 17.5 cm in width, containing the left lobe of the liver and intestinal loops. Preoperative botulinum toxin injections were administered under ultrasonographic guidance, resulting in a 2.5 cm reduction in the fascial defect. A posterior approach was prioritized, utilizing Transverse Abdominis Release (TAR) with PTFE mesh reinforcement. Due to the persistent tension on the anterior sheath, limited anterior compartment separation was performed, but only to the extent necessary, given its association with high morbidity. Results: The patient had an uneventful postoperative recovery, with drain removal on day five and discharge on day eight. A minor seroma at the right costal margin was successfully managed with aspiration. Importantly, by prioritizing posterior compartment separation over extensive anterior release, we minimized the risks of wound-related complications. At 12-month follow-up, no recurrence or major complications were observed. Conclusions: This case highlights the superior role of posterior compartment separation (TAR) in achieving durable and tension-free closure of giant incisional hernias, particularly in complex cases following major vascular surgeries. Although anterior component separation remains an option, its routine use should be reconsidered due to the increased risk of complications. This case reinforces the necessity of a tailored, multidisciplinary approach, emphasizing posterior reinforcement over anterior techniques to optimize patient outcomes.

Background/Objectives: The surge in migration from the Middle East and North Africa due to conflicts has significantly impacted healthcare systems, particularly in Greece. This study investigates how the sharp increase in refugees and migrants after July 2015 has strained the surgical departments of the Greek National Health System (NHS). Methods: A retrospective analysis was conducted on 229 patients treated at the emergency department of a public hospital in Athens, Greece. Data were compared between two periods: January 2012–July 2015 (pre-July 2015) and July 2015–December 2018 (post-July 2015), with July 2015 chosen as the cutoff due to a significant influx of immigrants during that time. Results: Patients’ demographic details, diagnoses, and surgical interventions were analyzed. Results indicated a significant rise in surgical cases, with 72.5% of patients requiring procedures, notably for appendicitis (23.6%), cholecystitis (10.9%), lower extremity thrombophlebitis (9.6%), perianal abscess (8.3%), and inguinal hernia (5.7%). Post-July 2015, there was a notable increase in perianal abscess (12.2%), inguinal hernia (8.4%), and cholelithiasis (6.1%). However, the average hospital stay of 3.9 days remained unchanged. Conclusions: The findings reveal the profound economic and operational pressures on the NHS during the refugee crisis, highlighting the urgent need for resource optimization and policy reforms. Future studies should address long-term healthcare impacts to support more sustainable healthcare models amidst ongoing and future migration challenges.

Background: Abnormalities in the canal of the Nuck are rare clinical entities with presentation in the early adulthood of females. Given their rarity, they can be misdiagnosed with a strangulated inguinal hernia. Methods: Herein, we report a young female with painful swelling of the right inguinal hernia and its surgical approach. Results: A 37-year-old female presented to the emergency department with pain in the right lower abdominal quadrant and an edematous inguinal mass. Physical examination showed a palpable inguinal mass, setting the suspicion for possible incarcerated inguinal hernia. Laboratory exams were within normal ranges. The patient was subsequently treated surgically. During the operation, a cystic well-rounded mass was identified and completely excised. The mesh and plug technique was the chosen technique for the restoration of the inguinal canal. The hospitalization length was one day, and the post-operative course was uneventful. Conclusions: Although a Nuck cyst is a rare entity, it should be taken into consideration in female adults who present with an inguinal mass.

Hepatocellular carcinoma (HCC) remains one of the most common malignancies and the third cause of cancer-related death worldwide, with surgery being the best prognostic tool. Among the well-known causative factors of HCC are chronic liver virus infections, chronic virus hepatitis B (HBV) and chronic hepatitis virus C (HCV), aflatoxins, tobacco consumption, and non-alcoholic liver disease (NAFLD). There is a need for the development of efficient molecular markers and alternative therapeutic targets of great significance. In this review, we describe the general characteristics of HCC and present a variety of targeted therapies that resulted in progress in HCC therapy.