The importance of postoperative analgesia after major thoracic surgery interventions, protocols, applications, and the following evaluation of the patient's quality of life.

OBJECTIVES: Major thoracic surgery procedures constitute a standard method of diagnosis and/or therapy against lung, mediastinal cancer and other non-malignant manifestations of the respiratory system. Such patients' recovery and rehabilitation depend directly from the applied postoperative analgesia, with purpose to determine an optimum and long-term quality of life. BACKGROUND: Our database consists of 300 individuals, submitted to major thoracic surgery procedure during a 2 - year period of time (between December 2016 and December 2018) at the "Thoracic Surgery Department" of "Theageneio" Cancer Hospital, Thessaloniki. METHODS: Every operative method is accompanied with three different types of postoperative analgesia, depending on the demands of the surgical approach: Each patient's postoperative management and evaluation is performed via usage of three "Quality of Life" (QoL) Questionnaires and the "VAS-Visual Analog Scale" for pain, leading to the determination of the "QoL Index". RESULTS: Each patient answers the Questionnaires in 4 specific time intervals. The differentiation in their answers is the key point to extract important information about their postoperative health evolution. A detailed questionnaire evaluation follows, both individually and in groups, according to the subgroup of each patient's pain treatment, a combined study which is applied in this form for the first time. CONCLUSIONS: The measure of a "QoL" index is widely taken into account as one of the most accurate indicators of a patient's health evolution. The results supply us with significant information which is added to the initial management strategy, mainly regarding pain symptomatology and eventual complications and discomforts, while they indicate us towards a thorough realization of each patient's "follow up" individually and the achievement of an optimal Quality of Life level.

Horner's Syndrome: An Uncommon Complication of Thyroidectomy and Selective Lateral Neck Dissection.

BACKGROUND: Horner's Syndrome is defined by myosis, enophthalmos, lack of sweating and eyelid ptosis, as well as vascular dilatation of one half of the face, caused by damage of the ipsilateral cervical sympathetic chain. It is known that Horner's syndrome is an unusual complication of thyroidectomy and selective lateral neck dissection. Its exact pathophysiology is not totally explained and its treatment remains conservative. CASE PRESENTATION: A 27-year-old man developed one-sided partial eyelid ptosis, enophthalmos and myosis two hours after a total thyroid gland excision and a selective lateral neck dissection for papillary carcinoma. A clinical diagnosis of Horner's syndrome was formed. He was treated conservatively and presented with an incomplete recovery at a 2-month follow up. CONCLUSIONS: The present case report underlines the adjacent anatomical correlation between the thyroid gland, the celluloadipose tissue and the cervical sympathetic trunk throughout thyroidectomy and selective lateral neck dissection. Every surgeon should be familiar with the potential complications in order to preoperatively counsel patients, as well as avoid them during the surgical procedure.

Laparoscopic Excision of an Adrenal Ganglioneuroma Presented as an Incindentaloma of the Retro Peritoneum.

Adrenal ganglioneuroma (GN) is a benign tumor of retro-peritoneum that is presented as an incidentaloma. GNs most commonly have been diagnosed by imaging examinations notably by CT scan. Differential diagnosis from other malignant adrenal tumors is often difficult. The only examination that confirms diagnosis is only the histopathological one. Surgical excision of a GN has been proposed as the best solution for both diagnostic and therapeutic purposes. This case report is about a 68-year old male patient presenting with a non-typical abdominal pain. The imaging investigation showed an incidentaloma over 4cm at its large axis. The patient underwent laparoscopic excision of the tumor. We present the steps followed during the diagnosis the appropriate treatment and the follow up examinations as a result of this rare finding.

Laparoscopic Cholecystectomy with Freehand Laparoscopic Camera Controller.

INTRODUCTION: Free hand laparoscopic camera controller (FHLCC) is a new innovative robotic device that has been recently implemented and adopted in laparoscopic surgery, providing the surgeon more comfort in carrying out his surgical skills without the difficulties related to the mutual understanding of the movements of the camera. CASE PRESENTATION: We report the first case of laparoscopic cholecystectomy performed in our hospital with the aid of the free hand laparoscopic camera controller. CONCLUSION: Free hand laparoscopic camera controller provides the surgeon comfort in carrying out his surgical skills without the difficulties related to the mutual understanding of the movements of the camera. It combines the benefits of minimally invasive and robotic assisted surgery, increases efficiencies and improves patient recovery times.

Total thyroidectomy without the use of drainage - case series of 66 patients.

AIM: The aim of this series is to study the need of drainage use after total thyreoidectomy. MATERIAL AND METHODS: Retrospective study of a series of patients who underwent total thyroidectomy from 2005 up to 2013. The presence or not of hematomas, seromas and hemorrhage were recorded. RESULTS: Out of the 66 patients included in this series, only one case of post-operative hematoma was recorded. Neither a hemorrhage nor a seroma were identified despite the volume, the underlying pathology and the co-morbidity of the patients involved. CONCLUSION: In our experience a thyroidectomy with adequate hemostasis does not require the use of drains.

Intrajejunal migration of adjustable gastric band: a case report.

Introduction. Laparoscopic gastric banding is a first line bariatric procedure that is performed worldwide and can achieve substantial weight loss. Despite its many advantages, as the least invasive bariatric procedure, it has several complications like gastric prolapse, stoma obstruction and migration of the gatstric band. Rarely are these complications life threatening, but re-operation is usually the only treatment. Case presentation. We report a rare case of intrajejunal migration of an adjustable gastric band that was placed laparoscopically four years ago. Conclusion. Gastric band migration is a rather common complication of laparoscopic gastric banding, but intrajejunal migration is very rare and requires high clinical suspicion, close follow-up and thorough pre-operative investigation so as to avoid intraoperative surprises and retrieve the displaced gastric band safely.

Treatment of early rectal cancer.

The treatment of rectal cancer has undergone a tremendous surgical evolution over the past century. In the past three decades, transanal excision has emerged as a popular treatment option for T1 and selected T2 rectal adenocarcinomas, allowing less morbidity for early cancers. The surgical options offered to the patient are the Parks' per anal excision and the transanal endoscopic microsurgery (TEM).

Emergency treatment of complicated colorectal cancer in the elderly. Should the surgical procedure be influenced by the factor 'age'?

The complication rate in patients affected by colorectal cancer (CRC) is high and the prognosis especially in the elderly patients is poor. The aim of this retrospective study is to compare the complicated CRC outcome between elderly patients and a group of patients younger than 70 years old, treated at the same time period. Between 1997 and 2007, 24 patients older than 70 years old with CRC (Group A), in an emergency situation, were operated on by the same team of surgeons. During the same time period, 20 patients, aged less than 70 years (Group B), with similar clinical and surgical findings, were operated on. All patients had undergone emergency procedures for occlusion, perforation and haemorrhage. We compared both groups in terms of preoperative health status, morbidity and mortality rates. According to ASA classification, Group A was considered of greater intraoperative danger (P = 0.01). Despite the fact that there was no statistically significant difference between the two groups, patients aged > 70 years presented higher morbidity and mortality rates. This fact is probably due to their overall health status. The surgical approach of patients with complicated CRC should not be influenced by the patient's age.

Pancreatic lipoma: a not so rare entity.

Pancreatic neoplasms are well-known pathological entities with generally poor prognosis. Mesenchymal tumors comprise 1 to 2% of all pancreatic tumors, and lipomas are a very rare variant of them. There are benign mesenchymal tumors consisting of mature adipose cells and thin collagen capsule. Most of the cases are generally published as sporadic case reports. The present review aims to elucidate the morphological entity named pancreatic lipoma, which is nearly unknown to most of surgeons. We estimate that pancreatic lipomas may be more common than previously realized, as small incidental lipomas may not have been reported in the literature to date.

Mega-obese patients weighing more than 250 kg: a problematic group.

BACKGROUND AND AIMS: The population with a BMI of 70kg/m2 or greater has been described and categorized as mega-obese. Mega-obese patients weighing more than 250kg constitute a special group of mega-obese patients that present more intra- and post-operative problems than other suprasuperobese. MATERIAL AND METHODS: This is a retrospective analysis of 7 mega-obese patients weighing more than 250 kg, who underwent bariatric surgery. Patients' medical records were reviewed for length of stay, complications, co-morbidities, and weight loss. RESULTS: Five patients were men and 2 were women. Co-morbidities included sleep apnoea syndrome (7 patients [100%]), venous ulcers (4 patients [57.1%]), post-thrombotic venous syndrome (3 patients [42.9%]), symptomatic cholelithiasis (3 patients [42.9%]), cellulites (3 patients [42.9%]), hypertension (4 patients [57.1%]), cardiac insufficiency (3 patients [42.9%]), and diabetes mellitus (1 patient [14.3%]). The length of stay averaged 15.3 days. Three patients presented short-term complications, 2 with long-term complications. Overall weight loss was 42.8% of excess body weight 6 months after surgery and 80.8% 2 years after surgery (when follow-up was completed). CONCLUSIONS: Bariatric operations are safe and effective in the mega-obese population weighing more than 250 kg. Some minor modifications to the traditional techniques may be necessary, especially concerning equipment. Treatment of patients weighing more than 250 kg is problematic, presenting a relatively high percentage of short- and long-term complications, together with various intra-operative problems.

Intracerebroventricular infusion of neuropeptide Y modulates VIP secretion in the fasting conscious dog.

Intracerebroventricular (icv) injection of neuropeptide Y (NPY), which is a widely-distributed neurotransmitter, into the paraventricular nuclear area has been shown previously to increase secretion of insulin and glucagon from the pancreatic islets. Vasoactive intestinal polypeptide (VIP) is a 28-amino-acid peptide that is associated with the mobilisation of energy during situations of energy depletion, such as fasting and exercise. VIP has also been reported to alter insulin and glucagon levels in a glucose-dependent manner. The aim of this study was to determine whether icv infusion of NPY affected VIP secretion in dogs. Intracerebroventricular injections (0.5 ml) were administered through a stereotactic apparatus to six healthy dogs. This prototype epicranial apparatus was positioned surgically to allow the easy and exact localisation of the third ventricle for infusion or sampling. Doses of 5, 10, and 25 microg NPY, dissolved in artificial cerebrospinal fluid (aCSF), were infused for a total of 30 min using a Harvard infusion pump. For control experiments, aCSF alone was injected. Blood samples were taken 15 min before icv injection (basal), immediately after injection, and at 5, 10, 15, 30, 45, 60, 90, and 120 min after, to determine the levels of glucose, insulin, glucagon, and VIP. Intracerebroventricular infusion of NPY resulted in a short-term increase in VIP secretion, followed by a more gradual and lengthier decrease in VIP levels. The secretion of insulin and glucagon increased significantly with all three doses of NPY. Intracerebroventricular infusion of NPY increased secretion of insulin and glucagon from the pancreas. The rapid change in the levels of VIP suggested the possibility of neural regulation by NPY.

Spontaneous abdominal wall endometriosis: a case report.

Endometriosis is the presence of endometrial glands and stroma outside the uterus. Spontaneous abdominal wall endometriosis (AWE) is any ectopic endometrium found superficial to the peritoneum without the presence of any previous scar. Rarely, endometriosis represents a disease of specific interest to the general surgeon, on account of its extrapelvic localisations. We describe a case with spontaneous AWE presenting as a painful mass with cyclic symptoms. A 28-year-old woman presented to the day-surgery division of our department, suffering from a painful mass in the left lower abdominal quadrant. A mobile mass of 5 x 4 cm was identified. The initial diagnosis was lipoma and excision was planned. During the operation two masses were spotted, very close to one another, and were excised within healthy limits. Pathology revealed endometrial glands surrounded by a disintegrating mantle of endometrial stroma and fibrous scar tissue in which there was a scattering of leucocytes. The woman had no scars. She was discharged from hospital after 2 hours. Two years after the excision she is free of disease and no recurrence has been observed. Spontaneous AWE is rare, accounting for 20% of all AWEs. The triad ; mass, pain and cyclic symptomatology helps in the diagnosis, but unfortunately it is not present in all cases. Spontaneous endometriomas are usually diagnosed by pathology and the treatment of choice is surgical excision.

Synchronous and metachronous adenocarcinomas of the large intestine.

BACKGROUND AND AIM: The synchronous and consecutive (metachronous) development of two or more primary adenocarcinomas accounts for 3 to 5% of cases of colorectal cancer. Aim of this study is to review our experience in the management of patients with synchronous and metachronous lesions, and reach conclusions regarding their optimal diagnosis, treatment and follow-up. PATIENTS AND METHODS: Between 1987 and 2004, 12 patients (seven men and five women, mean age 67.5 years, range 47-83 years) with synchronous (three patients) and metachronous (nine patients) lesions were treated, comprising 4.3% of all patients submitted to surgery for colorectal cancer. The diagnosis lag for metachronous lesions ranged from 1.5 to 14 years. All three patients with synchronous cancers had two lesions. RESULTS: Staging colonoscopy and abdominal CT was conducted in 10 patients while the remaining two underwent only abdominal CT due to their critical condition at presentation. Surgery had curative intent in 10 patients and palliative in two. The mean postoperative hospital stay was 21 days (10-49 days). The postoperative mortality was zero. Patients survival after curative procedures was 80% for the first year, 60% for the third and 50% for the fifth year. After palliative surgery, survival was 50% for the first year, and zero for the third. CONCLUSIONS: Patients with colorectal cancer must be followed up regularly after surgery. Follow up aims at early diagnosis and treatment of metachronous lesions that can appear many years after diagnosis of the primary lesion. Preoperative colonoscopy is an invaluable diagnostic (biopsy) and staging (exclusion of synchronous lesions, localization of the primary) modality, dictating the surgical approach. Additionally, it contributes to cancer prevention allowing the discovery and removal of small polyps before their transformation.

Impact of porcine Orexin A on glucagon plasma concentrations in pigs.

In 1998, Orexin A was added to the long list of orexigenic neuropeptides of the brain's physiology. Orexin A is involved in the central control of appetite and in energy homeostasis, as well as in the regulation of many other physiological functions. It is produced by a small cluster of the brain's neurons, located mainly in and around the lateral hypothalamic area. This site is known to be involved in regulating feeding in mammals. An intracerebroventricular injection of Orexin A into the rat's brain causes an impressive increase in the consumption of food, while an intravenous injection induces changes on glucagon plasma concentrations in rats. In addition, there are signs of changes on glucagon plasma concentrations when Orexin A acts on individual pancreatic islets of rats. In this study, we investigated the potential effects of the central administration of porcine Orexin A on glucagon plasma concentrations in pigs, and examined whether these changes are associated with the possible effect of the neuropeptide on the enteroinsular axis.

Laparoscopic placement of ventriculoperitoneal shunts: an innovative simplification of the existing techniques.

Ventriculoperitoneal shunting (VPS) remains one of the alternative choices for the surgical treatment of hydrocephalus. During the last two decades laparoscopy has been utilized to facilitate the placement of the abdominal portion of the shunt. We describe a minimally invasive laparoscopic technique, which facilitates the rapid, safe and direct placement of the peritoneal component of the VPS. A side frontal ventricular catheter is placed through a small burr hole and connected to the valve at the postauricular region. An infra-umbilical trocar is placed, using the Hasson technique, and after the pneumoperitoneum is established, a 10-mm laparoscope is introduced for identification of a VPS entry side free of adhesions. A 5-mm skin incision is made at the decided point of catheter insertion, usually at the right upper quadrant. Using a tunneler, the VPS catheter is placed subcutaneously from abdomen insertion point, to the postauricular region, where it is connected to the valve. A split type, 10-12 Fr and 12-15 cm long metallic puncture cannula, like those used for suprapelvic percutaneous bladder drainage, is introduced into the abdomen. Under direct laparoscopic vision the peritoneal portion of the VPS is passed into the abdomen through the cannula. The catheter is leaded to a desirable location by pointing the needle accordingly. Alteration of the position of the catheter can also be attained by entraining the catheter with the laparoscope and without using auxiliary graspers. The function of the VPS is confirmed under direct visualization. Suturing the abdominal and cranial incisions completes the procedure. We used this technique in a series of 12 patients with excellent outcome. There were no intra- or postoperative complications and no mortalities. Our technique is less invasive than a minilaparotomy, embraces all laparoscopic benefits and does not require auxiliary forceps or guidewires. It uses easy available materials with low cost, and attains an easy, rapid, and safe placement of the abdominal portion of the VPS.

The effect of porcine Orexin A on insulin plasma concentrations in pigs.

Orexin A is a member of a wider family of orexigenic neuropeptides that have been recently discovered. They are produced by a small group of neurons located in the area of the brain, round the nucleus of the fornix (posterior hypothalamus), in the paraventricular nucleus, the dorsomedial nucleus, the ventromedial hypothalamus, as well as in the lateral hypothalamic region; these are sites that are known to be involved in regulating feeding in mammals. Orexin A is a neuropeptide, which is involved in appetite regulation and energy homeostasis. An intracerebroventricular (i.c.v.) injection of Orexin A in the brain of rats causes an impressive increase in food consumption. In addition, a subcutaneous or intravenous (IV) injection of Orexin A produces changes on insulin plasma concentrations in rats. Recent research suggests that Orexin A is also involved in regulating many other physiological functions. In this study, we examined the potential effects of the central administration of porcine Orexin A on insulin plasma concentrations in pigs, and whether these changes are connected with the possible effect of the neuropeptide on the enteroinsular axis.

The use of three different mesh materials in the treatment of abdominal wall defects.

Various prosthetic materials have been proposed for the repair of abdominal wall defects. These materials offer tension-free repair and significantly lower recurrence rate. Their respective properties are related to such complications as seroma, infection, fistula formation, intestinal adhesions and removal. We compared the final outcome in treating abdominal wall defects in 56 patients with three different prosthetic materials: conventional polypropylene in a preperitoneal location, expanded polytetrafluoroethylene mesh, and hydrophilic membrane coated polyester mesh in an intraperitoneal location. The hydrophilic coated polyester group exhibited the lowest complication rate and the polypropylene group the highest.