Stefanos Bitsianis

Background and Objectives: Vascular access in cancer patients with limited mobility remains a persistent clinical challenge, although both devices and insertion methods have improved considerably. We present our clinical experience with at-home PICC placement, supported by real-world data from routine practice, in oncology patients unable to attend hospital care, exploring its feasibility, safety, and practical applicability. Materials and Methods: All PICC insertions were performed at patients’ bedside by a trained surgeon using sterile technique. A single- or double-lumen PICC catheter was inserted under ultrasound guidance, magnetic tracking, and intracavitary ECG confirmation to secure optimal venous entry and accurate tip positioning. Results: A total of 28 PICC lines were successfully inserted in 26 oncologic patients. Two patients required catheter re-insertion, one following accidental removal and one due to infection. In 26 of 28 cases (92.9%), insertions were completed on the first attempt, while two cases required a second attempt. Insertion in the Green Zone per the ZIM classification was achieved in 26 of 28 cases (92.9%), and only two required insertions in the Yellow Zone. The basilic vein was chosen in 75% of patients. A total of 23 single-lumen and five double-lumen catheters were inserted. In terms of complications, four cases of systemic infection occurred more than 15 days after insertion and were not considered insertion-related; two patients developed localized edema requiring anticoagulation, and four catheter occlusions were managed conservatively. Conclusions: At-home PICC placement appears to be a feasible and clinically applicable approach when performed by qualified and credentialed professionals. These observations, derived from real-world clinical experience, suggest a potential role for this model in selected patient populations. Using proper sterile technique and real-time tip confirmation tools, this intervention may contribute to improved continuity of care and reduced hospital visits in selected patients. These observations suggest a potential role for expanding outpatient vascular access programs in selected patient populations.

Background/Objectives: Ulcerative colitis (UC) is a chronic inflammatory bowel disease in which alterations in the gut microbiota and dietary lipid composition play a central role; this study aimed to evaluate the effects of synbiotics, omega-3 polyunsaturated fatty acids, and their combination on clinical, macroscopic, microbiological, and histopathological outcomes in dextran sodium sulfate (DSS)-induced colitis in Wistar rats. Methods: Seventy-two male Wistar rats were randomly allocated to four groups (n = 18/group) and received 5% DSS in drinking water for eight days to induce colitis. Following DSS withdrawal and histological confirmation of colitis in sentinel animals, groups were treated for 8 days as follows: DSS (control), DSS-S (synbiotics, Ecologic^® 825), DSS-Ω3 (omega-3 fatty acid-enriched diet, ProSure^®), or DSS-S&Ω3 (combined therapy). Eight rats per group were sacrificed on days 4 and 8 post-DSS. Body weight, Disease Activity Index (DAI), distal colon length, hematologic parameters, bacterial translocation to the liver and mesenteric lymph nodes, histological colitis score, and myeloperoxidase (MPO)-positive cell counts were assessed. Results: DSS induced severe colitis characterized by diarrhea, rectal bleeding, and extensive mucosal erosions. After 8 days of treatment, the DSS-S&Ω3 group showed the greatest body-weight recovery (206.1→222.9 g, p < 0.05 vs. other groups), significantly preserved distal colon length, and the largest reduction in DAI (p < 0.05). Both the DSS-S and DSS-S&Ω3 groups demonstrated reduced bacterial translocation compared with DSS. The DSS-Ω3 group demonstrated persistent MPO-positive neutrophil infiltration compared with the DSS-S and DSS-S&Ω3 groups, whereas combined therapy was associated with lower MPO-positive cell counts. Histological colitis scores were significantly improved only in the DSS-S&Ω3 group (p < 0.05). Conclusions: In this DSS colitis model, the DSS-S&Ω3 group demonstrated superior clinical and histological outcomes compared with DSS-S or DSS-Ω3 alone, supporting further evaluation of combined synbiotic and omega-3 therapy as an adjunctive approach in ulcerative colitis.

Background and Objectives: Intraperitoneal onlay mesh (IPOM) reduces ventral/incisional hernia recurrence but raises concern for adhesions and infection, particularly when the operative field is not strictly clean. We aimed to determine how contamination severity modulates the peritoneal response to intraperitoneal polypropylene mesh. Materials and Methods: In a prospective, randomized, blinded rat study, 60 male Wistar rats were allocated to three groups (n = 20/group) and evaluated at postoperative day (POD) 4 and POD 8 (n = 10/timepoint): A, clean mesh placement; B, small-bowel resection with end-to-end anastomosis without spillage (“potentially septic”); and C, mesh placement followed by intraperitoneal inoculation with Escherichia coli and Staphylococcus aureus (“controlled contamination”). The primary outcome was adhesion severity (Van der Ham scale, 0–3). Secondary outcomes included semi-quantitative histological scores (0–4) for neutrophil infiltration, fibroblast proliferation, neoangiogenesis, and collagen deposition. Prespecified non-parametric analyses were applied. Results: All animals completed follow-up; no pre-sacrifice deaths occurred. Adhesion severity showed no statistically significant differences between Groups A and B at either timepoint (mean POD4: 0.3 vs. 0.6; POD8: 0.4 vs. 0.8; p > 0.05). In contrast, Group C demonstrated markedly higher adhesion scores (mean POD4: 2.3; POD8: 2.4; both p < 0.001 vs. Groups A and B), with a substantially greater proportion of grade 2–3 adhesions. Histological parameters paralleled these findings: at both POD4 and POD8, Group C showed significantly higher neutrophil, fibroblast, neoangiogenesis, and collagen scores compared with Groups A and B (all p < 0.001). No statistically significant within-group temporal differences were observed between POD4 and POD8. Conclusions: In this experimental model, intraperitoneal polypropylene mesh demonstrated similar early biological response patterns in clean and controlled contamination settings, whereas established intra-abdominal sepsis was associated with a marked escalation of inflammation, fibroproliferation, and adhesion formation. These findings suggest that selective use of synthetic intraperitoneal mesh may be considered when contamination is controlled, while caution is warranted in frankly septic environments.

Background/Objectives: Ogilvie’s syndrome, or acute colonic pseudo-obstruction (ACPO), is defined by acute colonic dilatation without mechanical obstruction and carries a risk of ischemia and perforation if not promptly managed. Treatment strategies include conservative supportive care, neostigmine administration, colonoscopic decompression, and combinations of these approaches. The aim of this study was to compare the relative effectiveness of these interventions for symptom resolution using a network meta-analysis. Methods: A systematic search of PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and grey literature was conducted from inception in February 2025 to November 2025. Prospective cohort and case–control studies evaluating conservative supportive care, neostigmine, colonoscopic decompression, or their combinations were included. A random-effects network meta-analysis was performed using odds ratios (ORs) with 95% confidence intervals (CIs). Treatment ranking was assessed using surface under the cumulative ranking curve (SUCRA) values. Risk of bias was evaluated using the Newcastle–Ottawa Scale (NOS). Results: Four studies comprising 172 patients were included. Compared with supportive care alone, supportive care combined with neostigmine was associated with higher odds of symptom resolution (network OR 13.86, 95% CI 3.06–62.83). Supportive care combined with colonoscopic decompression demonstrated an even greater effect (network OR 65.65, 95% CI 11.70–368.50). Colonoscopic decompression versus neostigmine yielded a network OR of 4.74 (95% CI 1.17–19.25). SUCRA rankings indicated that colonoscopic decompression combined with supportive care had the highest probability of being the most effective strategy. Conclusions: Active interventions, particularly colonoscopic decompression or neostigmine combined with supportive care, were associated with a higher incidence of symptom resolution compared to supportive care alone. Larger comparative studies are needed to confirm these findings and refine treatment selection.

Background and Objectives: Bile duct injury is a relatively rare, but critical complication of laparoscopic cholecystectomy and is most commonly attributed to misinterpretation of biliary anatomy. Intraoperative biliary imaging may enhance anatomical recognition and reduce operative uncertainty, yet the optimal imaging modality remains debated. This study aimed to compare conventional intraoperative X-ray cholangiography with two fluorescence-based techniques—intravenous and intracholecystic indocyanine green fluorescence cholangiography—with respect to biliary visualization, perioperative outcomes, and surgeon satisfaction during elective laparoscopic cholecystectomy. Materials and Methods: This prospective, single-center, single-blind randomized controlled trial included 240 adult patients scheduled for elective laparoscopic cholecystectomy between June 2021 and December 2022. Participants were randomized equally to standard intraoperative cholangiography, intravenous indocyanine green fluorescence cholangiography, or intracholecystic indocyanine green fluorescence cholangiography. The primary outcome was successful visualization of predefined extrahepatic biliary landmarks, including the critical junction. Secondary outcomes included cholangiography duration, perioperative complications, postoperative inflammatory markers, and surgeon satisfaction assessed using a five-point Likert scale. This study was registered at ClinicalTrials.gov (NCT04908826). Results: Visualization rates of the critical junction and major extrahepatic bile ducts were comparable among three groups, with no statistically significant differences observed. Both fluorescence-based techniques achieved a 100% technical success rate, whereas standard cholangiography failed in a small proportion of cases. Cholangiography duration was significantly shorter in the fluorescence groups compared with standard cholangiography (p < 0.001). Surgeon satisfaction scores were significantly higher for both fluorescence approaches, with a slight preference for intravenous administration. Perioperative complication rates and postoperative inflammatory markers were com-parable among groups. Conclusions: Intravenous and intracholecystic indocyanine green fluorescence cholangiography are non-inferior to conventional intraoperative cholangiography for biliary anatomy visualization and offer advantages in procedural efficiency and surgeon satisfaction. Fluorescence-based imaging represents a safe and effective alternative for intraoperative biliary mapping during elective laparoscopic cholecystectomy.

Background/Objectives: Obesity remains a major global health burden, with metabolic–bariatric surgery being the most efficient long-term treatment strategy. However, both variability in perioperative care and postoperative complications persist. To address these challenges, the EUropean PErioperative MEdical Networking (EUPEMEN) protocol for bariatric surgery was developed to standardize care and enhance perioperative outcomes across European healthcare settings. Methods: The protocol was formulated through close collaboration among experts from multiple disciplines, involving surgeons, anesthetists, nurses, and nutritionists. Its development included a literature review, expert consensus, and the creation of structured perioperative guidelines covering the preoperative, intraoperative, and postoperative phases. Focus areas include patient education, nutritional optimization, early mobilization, opioid-sparing analgesia, and minimally invasive surgical techniques, supported by educational materials and manuals. Technical activities included the development of detailed multimodal rehabilitation manuals translated into five languages, the creation of an open-access online learning platform, training of future educators through a “train the trainer” approach, organization of multiplier promotional events, international collaboration meetings to refine the protocol, and revision and standardization of existing perioperative care guidelines to ensure evidence-based, unified practices across Europe. Results: Implementation of the EUPEMEN protocol aims to reduce postoperative complications, enhance recovery, and decrease hospitalization time. Standardized rehabilitation pathways and access to free educational platforms promote consistent care delivery across diverse healthcare environments. Key strategies include early oral intake, limited use of invasive devices, and comprehensive patient preparation. Conclusions: The EUPEMEN protocol introduces an evidence-based, multidisciplinary framework for optimizing perioperative management in bariatric surgery. While variability in resources and adherence may present potential obstacles, its application holds significant promise for improving perioperative outcomes. Future studies are necessary to assess its long-term impact and adaptability in different healthcare settings.

Background/Objectives: The safety of intraperitoneal mesh placement in contaminated fields remains controversial because of the increased risk of inflammation and adhesion formation. N-acetyl-L-cysteine (NAC) has antioxidant, pro-fibrinolytic and antibiofilm actions that could attenuate this response. The aim of this study is to determine whether NAC reduces mesh-related inflammation in a septic model created by intraperitoneal Escherichia coli (E.coli) inoculation. The primary comparison was prospectively defined between E. coli–inoculated animals treated with NAC (D) and those without NAC (B). Groups without E. coli (A,C,E) are presented for context and were compared previously. Methods: In this randomized, double-blind experimental model (five groups, n = 20 per group), all rats underwent midline laparotomy with intraperitoneal placement of a composite mesh, followed by standardized ciprofloxacin administration. The septic groups received intraperitoneal E. coli, while the NAC-treated groups additionally received intraperitoneal NAC (150 mg/kg). Serum levels of IL-1α, IL-6, and TNF-α were measured on postoperative days 7, 14, and 21. On day 21, adhesions were graded using the Modified Diamond system, histology (inflammatory infiltration, fibrosis, neovascularization) was scored, and mesh cultures were obtained. Cytokine data were analyzed with repeated-measures ANOVA, while categorical or ordinal outcomes were assessed using χ² or Fisher’s exact tests with Bonferroni-adjusted pairwise comparisons. Results: E. coli inoculation significantly increased adhesion burden and worsened histologic scores compared with controls (both p < 0.001). NAC administration in the septic model significantly reduced adhesions and improved all histologic domains relative to E. coli alone (all p ≤ 0.003), with values comparable to controls (non-significant across domains). For cytokines, there was a significant overall group effect for IL-1α, IL-6, and TNF-α (all p < 0.001), without a main effect of time or time × group interaction. Pairwise contrasts showed lower IL-1α (p = 0.024), IL-6 (p < 0.001), and TNF-α (p < 0.001) levels in group D versus B, and lower IL-6 and TNF-α in group D versus A (both p < 0.001). Mesh culture positivity rate was higher in group B than A (p < 0.001) and showed a non-significant reduction in group D versus B (p = 0.10). No perioperative deaths occurred. Conclusions: NAC attenuated septic, mesh-associated inflammation—normalizing adhesions and histology and reducing IL-6 and TNF-α— supporting its role as a host-directed adjunct alongside antibiotics. Further translational studies are warranted to define the optimal dose, timing, and clinical indications.

Adipose tissue micrografts (ATM) and dermis micrografts (DMG) have emerged as promising autologous therapies in regenerative wound care, leveraging mechanically disaggregated cell–matrix constructs to modulate the wound microenvironment and promote tissue repair. This scoping review systematically analyzed clinical studies investigating ATMs and DMGs in acute and chronic wounds. Eight studies, comprising randomized controlled trials, observational studies, and case series, were identified, involving diverse wound types such as burns, ulcers, surgical dehiscence, and posttraumatic defects. All interventions utilized mechanical disaggregation (Rigenera^® system) to produce micrografts, which were applied via perilesional injection, scaffold-assisted delivery, or topical administration. Outcomes consistently demonstrated accelerated re-epithelialization, enhanced angiogenesis, improved scar remodeling, and low complication rates. In select studies, micrografts were combined with platelet-rich fibrin or stromal vascular fraction, suggesting potential synergistic effects. While one randomized trial showed superior healing outcomes with DMGs over collagen scaffolds, others yielded mixed results, likely reflecting heterogeneity in methodology and outcome measures. Overall, the available clinical evidence supports the safety, feasibility, and biological activity of micrograft-based therapies. However, larger, standardized, and mechanistically driven studies are required to validate their efficacy and define optimal protocols across wound etiologies.

Background/Objectives: Despite advancements in surgery, esophagectomy remains one of the most challenging and complex gastrointestinal surgical procedures, burdened by significant perioperative morbidity and mortality rates, as well as high financial costs. Recognizing the need for standardized care provided by a multidisciplinary healthcare team, the EUropean PErioperative MEdical Networking (EUPEMEN) initiative developed a dedicated protocol for perioperative care of patients undergoing esophagectomy, aiming to enhance recovery, reduce morbidity, and homogenize care delivery across European healthcare systems. Methods: Developed through a multidisciplinary European collaboration of five partners, the protocol incorporates expert consensus and the latest scientific evidence. It addresses the entire perioperative pathway, from preoperative preparation to hospital discharge and postoperative recovery, emphasizing patient-centered care, risk mitigation, and early functional restoration. Results: The implementation of the EUPEMEN esophagectomy protocol is expected to improve patient outcomes through a day-by-day structured prehabilitation plan, meticulous intraoperative management, and proactive postoperative rehabilitation. The approach promotes reduced postoperative complications, earlier return to oral intake, and shorter hospital stays, while supporting multidisciplinary coordination. Conclusions: The EUPEMEN protocol for esophagectomy provides a comprehensive guideline framework for optimizing perioperative care in esophageal surgery. In addition, it serves as a practical guide for healthcare professionals committed to advancing surgical recovery and standardizing clinical practice across diverse care environments across Europe.

Hepatectomies play a crucial role in the multidisciplinary management of primary and secondary liver malignancies but are associated with significant risks, including 30-day mortality, morbidity, prolonged hospitalization, and increased resource utilization. Optimizing perioperative care remains a challenge; however, enhanced recovery programs have shown improved patient outcomes. The EUPEMEN (EUropean PErioperative MEdical Networking) protocol focuses on improving the perioperative management of liver resections through the establishment of interdisciplinary principles based on practical experience and theoretical frameworks from five European countries. This paper outlines the core elements of the EUPEMEN protocol, emphasizing strategies to minimize surgical stress, optimize perioperative care, and enhance postoperative recovery. The protocol is systematically designed to reduce postoperative mortality and morbidity, shorten hospital stays, and improve patient outcomes. The EUPEMEN guidelines address inconsistencies in surgical practice across Europe and are structured for implementation in various healthcare environments. “The protocol’s approach is designed to support improvements in perioperative care standards in liver resections and may serve as a practical and efficient tool for healthcare professionals, pending further clinical validation. The EUPEMEN protocol offers a standardized, evidence-based framework to enhance perioperative management in hepatectomies. By integrating multidisciplinary principles, the main target is to eliminate complications, improve surgical outcomes, and promote faster recovery. Its implementation across diverse clinical settings may contribute to advancing perioperative care standards for liver resections in Europe.