Epidemiology and management of trauma patients in a Greek multispecialty hospital in the absence of a dedicated trauma center.

PURPOSE: In the absence of dedicated trauma centers, surgical emergency departments in hospitals assigned as trauma centers accept a huge load of trauma patients. In this audit, we aim to document and assess the epidemiologic data of trauma patients and their injuries in order to give a picture of the impact of trauma in the workload of a surgical department in the Greek healthcare system. METHODS: During a period of 2 years, we managed 6,041 trauma patients in the accident and emergency (A&E) department based on the Advanced Trauma Life Support (ATLS) protocols. We retrospectively reviewed the emergency department registry and the admissions. RESULTS: 47.56 % of the patients seen in the A&E department were trauma patients. The mean age of the trauma patients was 44.52 years (range 15-106 years). The majority were men (60.4 %). The leading cause of trauma was motor and vehicle accidents, followed by slip and fall accidents, physical assault, fall from height, and vehicle pedestrian accidents. The majority of the patients were discharged from the hospital. Only 29 (4.6 %) out of 624 patients who were admitted to the general surgery department underwent an operation, while the rest were admitted for observation. On the other hand, patients were admitted to other departments only when surgical treatment was necessary. CONCLUSIONS: In the absence of level one trauma centers, in multispecialty urban hospitals, the coordination of trauma burdens the general surgery team. This has financial and administrative implications. The collection of important epidemiologic data from these hospitals is mandatory in order to develop national prevention measures against injuries.

[Laparoscopic versus endoscopic primary management of choledocholithiasis. A retrospective case-control study]. / Primär laparoskopische, einzeitige versus endoskopische Therapie der Choledocholithiasis. Eine retrospektive Fall-Kontroll-Studie.

BACKGROUND: The aim was to present the long-term results of one-stage laparoscopic procedure for the management of common bile duct (CBD) lithiasis in comparison with the primary endoscopic approach via ERCP. PATIENTS AND METHODS: A retrospective case-control study was performed to determine the outcome of patients treated for CBD lithiasis (04/1997 - 11/2011). Data of patients with choledocholithiasis undergoing the two treatment modalities - laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE + LC, group A, n = 101) versus endoscopic retrograde cholangiopancreatography/sphincterotomy and laparoscopic cholecystectomy (ERCP/S + LC, group B, n = 116) were matched according to their clinical characteristics. Patients of group A underwent either laparoscopic choledochotomy or transcystic exploration. The policy was to convert to open choledochotomy only after the sequential application of the two treatment modalities (laparoscopic/endoscopic procedure) had failed. RESULTS: No significant difference in morbidity was found between the groups (group A 8% versus group B 11.2%). Conversion to another procedure was mandatory in 12 out of 101 and 17 out of 116 patients of groups A and B, respectively. The mean follow-up period was 7.8 years (range 1-12 years). Effective laparoscopic treatment of CBD stones (cholecystectomy and CBD clearance) was possible in 89 of the 101 patients in group A (88.1%) compared with 99 of the 116 patients in group B (85.4%) after the endoscopic approach. CONCLUSIONS: This study showes that both - primary endoscopy and one-stage laparoscopic management of CBD lithiasis - are highly effective and safe with comparable results.

Severe monobacterial necrotizing soft tissue infection by group A Streptococcus: A surgical emergency.

Eight percent of necrotizing soft tissue infections (NSTI) are attributable to group A Streptococci (GAS), and among these, 50% develop streptococcal toxic shock syndrome. The reported mortality associated with NSTI reaches 32%. We present cases of two healthy individuals with minor GAS skin infection which developed to a rapidly progressed NSTI and sepsis despite of the antibiotic treatment, aiming to discuss the lessons learned from the course and management of these patients.

Major liver resections for primary liver malignancies in the elderly.

PURPOSE: The aim of our prospective study was to assess the results of major hepatic resections for primary liver tumours in patients 75 years of age or older. METHODS: From 10/1999 to 04/2006, 23 patients with non-cirrhotic livers > or = 75 years presented to our department to undergo curative resection for primary liver malignancies. Data were collected prospectively. Patients were assigned to two groups. Group A included those with resectable tumours, while Group B was made up of those with unresectable lesions. RESULTS: Fourteen patients had intrahepatic cholangiocarcinoma while 9 had hepatocellular carcinoma. Comorbidities were present in every case. Morbidity and hospital mortality rates for group A patients were 25% and 8%, respectively. The corresponding rates for group B patients were 9% and 9%. The 1-, 2-, and 3-year cumulative group A survival was 71%, 51% and 26% for cholangiocarcinoma and 80%, 60% and 60% for hepatocellular carcinoma, respectively. The corresponding group B survival was 45%, 18% and 0%. CONCLUSION: Advanced age does not seem to negatively affect the outcome of liver resections for malignancies. Hepatic resections in patients 75 years of age or older may be carried out with relative safety as long as patients are appropriately selected.

Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study.

BACKGROUND: The current prospective randomized controlled clinical study aimed to assess the short- and long-term results of recurrent inguinal hernia repair, and to compare the results for transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) procedures with those for open tension-free repair. METHODS: For this study, 82 patients were randomly assigned to undergo TAPP (group A, n = 24), TEP (group B, n = 26), or open Lichtenstein hernioplasty (group C, n = 32). All the patients with recurrent inguinal hernias had undergone previous repair using conventional open procedures. Physical examination showed Nyhus type II hernia in the vast majority of the patients (59%). High-risk patients (American Society of Anesthesiology [ASA] III or IV); coagulation disorders; previous abdominal or pelvic surgery; and irreducible, congenital, and massive scrotal or sliding hernias were excluded from the study. RESULTS: There was a statistically significant difference (p = 0.001) in operating time favoring the open procedure. The intensity of postoperative pain was greater in the open hernia repair group 24 h, 48 h, and 7 days after surgery (p = 0.001), with a greater consumption of pain medication among these patients (p < 0.004). The median time until return to work was 14 days for group A, 13 days for Group g, and 20 days for group C. The comparison was in favor of laparoscopically treated patients. Nine recurrences (4 in the laparoscopic groups and 5 in the open group) were documented within 3 years of follow-up evaluation. CONCLUSION: Laparoscopic inguinal hernia repair (TAPP or TEP) is the method of choice for dealing with recurrent inguinal hernia.

Adjuvant chemotherapy with cisplatin, etoposide, fluorouracil and leucovorin for gastric carcinoma.

PURPOSE: The aim of this study was to evaluate the efficacy of cisplatin, etoposide, 5-fluorouracil (5-FU), and leucovorin (L; CEFL) combination chemotherapy given as adjuvant treatment to patients with stage III gastric cancer. PATIENTS AND METHODS: A total of 33 patients who had undergone curative resection for stage III gastric adenocarcinoma were enrolled in our adjuvant chemotherapy protocol to receive 6 cycles of CEFL starting within 8 weeks from surgery. CEFL consisted of cisplatin 30 mg/m2 on days 1-3; 5-FU 300 mg/m2 continuous infusion on days 1-3; and etoposide 90 mg/m2 on days 1-3. Cycles were repeated every 4 weeks. Relapse-free survival (RFS) and overall survival (OS) were estimated using Kaplan-Meier method. Comparison between groups was carried out using log-rank test. RESULTS: Treatment was completed by 30 (91%) patients. After a mean follow-up of 31 months 15 (50%) patients have relapsed. Mean RFS was 31 months (range 6 to 114+). Patients with stage IIIA disease had longer RFS that those with stage IIIB (37 vs. 25 months, p>0.05). Mean OS was 35 months (range 4 to 114+), while stage IIIA patients survived longer than IIIB ones (42 vs. 27 months, p>0.05). Principal side effects of therapy were from the bone marrow and the gastrointestinal tract. There were 2 treatment-related deaths due to neutropenic sepsis. CONCLUSION: CEFL regimen appears to be an effective adjuvant treatment for patients with stage III gastric carcinoma as it prolongs both RFS and OS. However, its pronounced myelotoxicity requires the prophylactic use of granulocyte colony stimulating factor (G-CSF).