Sublay or onlay incisional hernia repair along with abdominoplasty: which is better? Long-term results.

PURPOSE: Estimation and comparison of results after incisional hernia repair (IHR) modo onlay or sublay with abdominoplasty in patients who lost the weight following Roux-en-Y Gastric Bypass (RYGB). Analysis and comparison of changes in quality of life (QL) of these patients prior to RYGB, before and after simultaneous IHR and abdominoplasty. METHODS: Clinical analysis involved 40 patients with abdominal disfigurement (following RYGB and massive weight loss) after one-time IHR sublay method with abdominoplasty-group 1 or IHR onlay method with abdominoplasty-group 2. We evaluated postoperative results and long-term QL changes (DAS24, SF-36 scales). RESULTS: We noted abnormal wound healing (2), pneumonia (3) and dysesthesia (3) in patients from group 1, and abnormal wound healing (2), seroma (2), pneumonia (2), and dysesthesia (4) in group 2. Quality of life was improved in the functional, esthetic and psychological aspects. CONCLUSIONS: One stage incisional hernia repair by onlay as well as sublay method with abdominoplasty are safe surgical methods improving the functioning of patients after major weight loss following RYGB. Sublay hernia repair and abdominoplasty was connected with longer time of the: operation, drainage, analgesic agents use, time to mobilization and to full oral diet than the onlay method. Significant improvement of the quality of life was noted after every subsequent step of surgical treatment in both groups. Reduction of the risk of BMI re-growth after bariatric surgery is related to the need for constant, specialized care for these patients at every stage of follow-up after bariatric surgery.

Serum levels of ADAM10, ADAM12, ADAM17 AND ADAM28 in colorectal cancer patients.

Colorectal cancer is the third most common cancer in the world. Our study analyzed the potential significance of serum levels of selected adamalysines (ADAM10, ADAM12, ADAM17, ADAM28) in colorectal cancer patients. The study was performed on a group of 85 colorectal cancer patients (48 men, 37 women). Serum protein concentrations were measured by ELISA. The ADAMs serum level changes were analyzed according to selected clinical parameters (BMI, sex, age, clinical stage of disease). The following ranges of concentration of analyzed proteins were obtained: ADAM10 min=1.7, max=321.8 [ng/ml]; ADAM12 min=0.6, max=26.7 [ng/ml]; ADAM17 min=0.4, max=9.8 [ng/ml]; ADAM28 min=17.1, max=1545.8 [ng/ml]. In addition, it was stated that there is a relationship between the serum level of ADAM28 and the degree of the clinical stage (p less than 0.04). The obtained results could be the starting point for further research into the role of adamalysines in the development of colorectal cancer, as well as the potential predictive and prognostic value of these proteins.

Corrigendum to "Expression and Clinical Significance of Cancer Stem Cell Markers CD24, CD44, and CD133 in Pancreatic Ductal Adenocarcinoma and Chronic Pancreatitis".

[This corrects the article DOI: 10.1155/2017/3276806.].

Expression and Clinical Significance of Cancer Stem Cell Markers CD24, CD44, and CD133 in Pancreatic Ductal Adenocarcinoma and Chronic Pancreatitis.

Cancer stem cells (CSC) play an important role in pancreatic carcinogenesis and prognosis. The study aimed at examining the expression of CD24, CD44, and CD133 in human PDAC and CP in order to evaluate its clinicopathological correlations and the clinical significance. Surgical specimens from 23 patients with PDAC and 15 patients with chronic pancreatitis after pancreatic resection were stained with CD24, CD44, and CD133 antibodies. The intensity of staining was scored from 0 (negative) to 3 (strongly positive). Results. Mean CD24 staining score in PDAC was 1.38 ± 0.76 and was significantly higher than that in CP: 0.70 ± 0.53 (p < 0.01); CD44 score in PDAC was 2.23 ± 0.42 and was significantly higher than that in CP: 1.87 ± 0.55 (p < 0.05); CD133 score 0.93 ± 0.58 was not different from CP: 0.71 ± 0.43 (p > 0.05). CD44 immunoreactivity was significantly higher (p < 0.05) in pT1 and pT2 patients together as regards pT3: 2.45 ± 0.37 versus 2.06 ± 0.38 as well as in N0 patients compared to N1 patients: 2.5 ± 0.38 versus 2.04 ± 0.34. Conclusions. CD24 and CD44 are upregulated in human pancreatic cancer compared to chronic pancreatitis. CD44 immunoreactivity decreases with the tumor advancement and may represent the negative PDAC prognostic factor. Each CSC marker was differently related to PDAC advancement. CD133 may lack clinical significance in PDAC.

Perfusion disturbances of kidney graft parenchyma evaluated with contrast-enhanced ultrasonography in the immediate period following kidney transplantation.

PURPOSE: Graft parenchyma perfusion disturbances (GPPD) in transplanted kidneys are common in the early postoperative period. Rapid and accurate diagnosis can guide proper treatment, preventing graft dysfunction. METHODS: One hundred and eighty patients, who underwent kidney transplantation (KTx), were examined in the immediate postoperative period using real-time ultrasonography (B-mode) with color and power Doppler (US-CD/PD) and B-flow ultrasound, as well as with an additional protocol of contrast-enhanced ultrasonography (CE-US). Regions of GPPD were localized and measured. The number and size of these areas were compared between the two acquisition techniques. Follow-up examinations were carried out 6 months postoperatively. RESULTS: CE-US revealed more GPPDs and showed them more precisely than the B+US-CD/PD/B-flow technique. Moreover, in the CE-US examination, ischemic foci had statistically significant higher echogenicity in comparison to normal parenchyma, were larger and better visualized (better circumscribed) than in B+US-CD/PD/B-flow. CONCLUSION: CE-US allows the visualization of GPPD caused by occlusion of small arteries. It is a noninvasive, safe, real-time method, which has many advantages over standard B+US-CD/PD/B-flow examinations, and we recommend it as a routine diagnostic procedure in the early postoperative period following KTx.

The diagnostic value of contrast-enhanced ultrasonography in the assessment of perirenal hematomas in the early post-operative period after kidney transplantation.

BACKGROUND: Routine B-mode ultrasound examination (rB-US) is a current standard for the assessment of the transplanted kidney(KTx) in the early post-operative period. The alteration of perirenal hematoma (PH) echostructure over time limits their detectability and size assessment with rB-US. The aim of this study was to evaluate the diagnostic value of contrast-enhanced ultrasound (CE-US) in diagnosing PH of KTx in the early post-operative period. METHOD: Routine B-US and CE-US of KTx, performed in 102 patients in the early post-operative period, were analyzed. CE-US was performed after intravenous administration of 2.4 mL of sulfur hexafluoride solution. The data were analyzed with respect to the occurrence and thickness of PH. RESULT: The difference in echogenicity between PH and kidney parenchyma was modest in rB-US (mean of 5.7 dB). However, in CE-US, the difference in echogenicity was significantly increased (mean of 31.4 dB). Routine B-US did not allow PH to be recognized in 18 patients. The application of CE-US results in a twofold increase in PH detection when compared with rB-US (33.3% vs. 15.7%). CONCLUSION: US-CE examination is a valuable method for detection and assessment of PH size. Compared with rB-US, this technique may substantially increase the detectability of hemorrhagic complications in the direct post-operative period.

Disturbances of kidney graft perfusion as indicators of acute renal vein thrombosis in contrast-enhanced ultrasonography.

INTRODUCTION: The aim of this study was to evaluate the usefulness of contrast-enhanced ultrasound (US-CE) to diagnose acute renal vein thrombosis (ARVT), acute rejection episodes (ARE), or acute tubular necrosis (ATN) in kidney grafts. MATERIALS AND METHODS: We analyzed 171 US-CE among kidney transplantation patients in the early postoperative period. Patients underwent US-CE following a standard diagnostic protocol including real-time ultrasound (B-mode) and color Doppler ultrasound with spectral flow analysis. Tissue perfusion was analyzed based upon time-intensity curves for two regions: the renal cortex and the renal pyramids. RESULTS: Of 14 patients, in whom standard ultrasound showed high resistance parameters in the renal artery, three showed ARVT and 11 had ATN or ARE, which were confirmed by biopsy. Among patients with ARVT, the US-CE showed a lack of contrast perfusion into the cortex and renal pyramids. Patients with ARE/ATN showed slower contrast inflow into the parenchyma with reduced but still present perfusion. The differences in mean signal intensity values were significant for both the cortex and the renal pyramids: cortex: -53.8±5.4 dB versus -35.0±3.5 dB (P<.05) and pyramids: -54.8±5.4 dB versus -37.0±3.5 dB (P<.05). CONCLUSION: US-CE is a noninvasive method that provides easy, reliable differentiation of ARVT from ARE/ATN.

Contrast-enhanced sonography of postbiopsy arteriovenous fistulas in kidney grafts.

PURPOSE: To assess the usefulness of contrast-enhanced ultrasonography (CE-US) in the visualization of a kidney graft following a biopsy that was complicated by an arteriovenous fistula (AVF). METHODS: Four postrenal transplant patients who had developed AVFs following graft biopsy were examined using standard US and CE-US. Additionally, follow-up examinations were conducted using CE-US, at 4-6 weeks and 10-12 weeks following fistula closure. RESULTS: The fistulas were detected using color Doppler US, Power Doppler US, and B-flow technique. Reduced parenchymal flow was only detected in one case using standard flow visualization techniques. CE-US allowed for the visualization of regions of disturbed parenchymal perfusion that were not visible in the standard examinations. At follow-up, B-mode ultrasound and standard flow examinations appeared normal. However, all contrast-enhanced images showed clearly demarcated residual regions of reduced parenchymal perfusion, in areas where the fistulas had been previously present. CONCLUSIONS: A posttraumatic AVF reduces parenchymal perfusion in the affected region. CE-US examination may help in monitoring fistulas during the active phase and following spontaneous closure.

Plasma glucose after stomach or jejunum glucose infusion in Roux-en-Y gastric bypass patients--a possible implication for early satiety mechanism.

BACKGROUND: Morbidly obese patients undergoing gastric bypass surgery experience early satiety soon after the surgery; the mechanism of this effect is poorly understood. As blood glucose concentration plays a role in appetite regulation in humans, we hypothesized that after gastric bypass surgery glucose absorbed mainly in jejunum leads to a greater rise in plasma glucose that if it is ingested in stomach. MATERIAL AND METHODS: 24 non-diabetes morbidly obese patients (15 women, 9 men, mean age [± SD] 35.6 ± 11.9 years, body weight 140.7 ± 33.1 kg, BMI 46.8 ± 8.3 kg/m²) undergoing Roux-en-Y gastric bypass surgery were given 10 ml of 40% glucose solution to the stomach before its size reduction and to the jejunum after gastro-jejunal anastomosis was formed. RESULTS: After jejunal infusion blood glucose increased more rapidly and was ∼30% higher than after stomach infusion. Moreover, this increase was less pronounced in more obese patients. CONCLUSION: In patients after Roux-en-Y gastric bypass surgery glucose absorbed in jejunum leads to greater rise in plasma glucose concentration than if it is ingested in stomach. This phenomenon may help explain satiety feeling occurring early in gastric bypass surgery patients.

The repair of incisional hernia following Roux-en-Y gastric bypass-with or without concomitant abdominoplasty?

BACKGROUND: Incisional hernia, found in up to 25% of patients, is a typical complication of open bariatric surgery. METHODS: Open Roux-en-Y gastric bypass (RYGB) was performed in 204 patients. They have been followed-up for at least 6 months. Thirty-two patients in whom incisional hernia was diagnosed were divided into two groups-they were scheduled for hernia repair or hernia repair with abdominoplasty. The surgery was performed, on average, 20 months after RYGB operation. Fourteen patients [mean body mass 86.4 kg, mean body mass index (BMI) 30.0 kg/m(2)] have had hernias repaired. The mean duration of hospital stay was 7.2 days. Hernia repair along with abdominoplasty was performed in 18 patients with mean body mass 89.4 kg and BMI 31.5 kg/m(2). The mean duration of hospital stay was 8.7 days. RESULTS: Both examined groups were similar in body mass, BMI, age, and duration of hospital stay (p > 0.05), as well as gender distribution. The wound infection was diagnosed in six patients. CONCLUSION: The simultaneous abdominoplasty does not prolong the time of hospital stay of the patients undergoing incisional hernia repair. Infection is the most frequent complication of incisional hernia repair.

Rad-by-rad (bit-by-bit): triumph of evidence over activities fostering fear of radiogenic cancers at low doses.

Large segments of Western populations hold sciences in low esteem. This trend became particularly pervasive in the field of radiation sciences in recent decades. The resulting lack of knowledge, easily filled with fear that feeds on itself, makes people susceptible to prevailing dogmas. Decades-long moratorium on nuclear power in the US, resentment of "anything nuclear", and delay/refusal to obtain medical radiation procedures are some of the societal consequences. The problem has been exacerbated by promulgation of the linear-no-threshold (LNT) dose response model by advisory bodies such as the ICRP, NCRP and others. This model assumes no safe level of radiation and implies that response is the same per unit dose regardless of the total dose. The most recent (June 2005) report from the National Research Council, BEIR VII (Biological Effects of Ionizing Radiation) continues this approach and quantifies potential cancer risks at low doses by linear extrapolation of risk values obtained from epidemiological observations of populations exposed to high doses, 0.2 Sv to 3 Sv. It minimizes the significance of a lack of evidence for adverse effects in populations exposed to low doses, and discounts documented beneficial effects of low dose exposures on the human immune system. The LNT doctrine is in direct conflict with current findings of radiobiology and important features of modern radiation oncology. Fortunately, these aspects are addressed in-depth in another major report-issued jointly in March 2005 by two French Academies, of Sciences and of Medicine. The latter report is much less publicized, and thus it is a responsibility of radiation professionals, physicists, nuclear engineers, and physicians to become familiar with its content and relevant studies, and to widely disseminate this information. To counteract biased media, we need to be creative in developing means of sharing good news about radiation with co-workers, patients, and the general public.

Randomized clinical trial of postoperative hernia prophylaxis in open bariatric surgery.

BACKGROUND: Postoperative hernia following bariatric procedures is more common than in other groups of surgical patients, and remains a serious problem. Gastric bypass is the most often performed bariatric procedure and, despite the increasing popularity of a laparoscopic approach, many morbidly obese patients are still offered open procedures. The aim of this study was to assess the effects of prophylactic polypropylene mesh in morbidly obese patients undergoing gastric by-pass surgery. METHODS: The study randomized 74 patients undergoing open Roux-en-Y gastric bypass into two groups: wound closure with (n = 36) or without (n = 38) a polypropylene mesh. Mean(s.d.) body mass and body mass index in the mesh group were 137.3(24.5) kg and 46.2(7.1) kg/m(2) and in the non-mesh group were 139.0(24.9) kg and 46.8(7.6) kg/m(2) respectively. In the non-mesh group, the wound was closed with a polypropylene suture. Patients in the mesh group had in addition a polypropylene mesh inserted in a sublay manner. RESULTS: Patients were followed up for at least 6 (range 6-38) months. Hernia developed in eight patients in the non-mesh group but in none in the mesh group. The duration of hospital stay was similar in both groups: mean(s.d.) 8.4(3.2) and 10.3(5.9) days (P = 0.092). There were no serious complications in either group. CONCLUSION: The use of a mesh prevented hernia development and did not lengthen hospital stay.

Diagnostic difficulties in long-standing insulinoma with near-normal plasma insulin levels.

Insulinoma tumors are often difficult to detect, as the symptoms largely precede occurrence of a visualized tumor. We report the case of an insulinoma patient with long delayed diagnosis and marked adaptation to extreme hypoglycemia. The patient with a 7-yr history of seizures was found to have plasma glucose concentration during a starvation test as low as 16 mg/dl, with no clinically significant symptoms and concomitant normal plasma insulin levels: 10-30 microIU/ml. All attempts to localize a tumor with repeated abdominal ultrasound examinations or computed tomography scanning were unsuccessful. The patient did not tolerate the introduced oral treatment with diazoxide. Once it had become technically available, endoscopic ultrasonography of the pancreas was performed. It revealed a 10 mm tumor in the pancreatic head. The tumor was subsequently removed surgically. During the operation plasma insulin concentration rose almost 15-fold, which confirmed the insulin-secreting character of the growth. Microscopic examination revealed benign insulinoma, with partially trabecular structure. One month after the operation the patient had normal plasma glucose values of 60-120 mg/dl, but she constantly complained of excessive thirst, which occurred soon after the operation and slowly subsided in the following weeks. In conclusion, the present report demonstrates that insulinoma should be considered and searched for in every case of hypoglycemia associated with normal insulin levels. It also confirms the essential role of endoscopic ultrasonography in the diagnosis of insulin-secreting tumors.

Usefulness of p16 and K-ras mutation in pancreatic adenocarcinoma and chronic pancreatitis differential diagnosis.

BACKGROUND: The differentiation of chronic pancreatitis (CP) from pancreatic adenocarcinoma (PA) remains a great challenge. The purpose of the study was to compare the prevalence of p16 and K-ras mutation in PA and CP in order to evaluate their usefulness in differential diagnosis of those diseases. METHODS: The study included 44 patients who underwent Whipple resection or distal pancreatectomy for PA (23 subjects) or CP (21 subjects). DNA from pancreatic tissue was analysed for K-ras mutation (codon 12) and p16 mutations with PCR amplifications. RESULTS: The K-ras gene mutation has been shown in 17 (73,9%) cases with pancreatic adenocarcinoma which was significantly more often than in chronic pancreatitis - 9 (42,8%) (p<0,01). Prevalence of p16 mutations in patients with PA was 18 (78,3%) and with CP - 7 (33,3%) (p<0,01). K-ras and p16 mutations together have been observed in 16 (69,6%) cases in patients with PC and only in 3 (14,3%) - with CP (p<0,01). No statistically significant association between K-ras or p16 mutations and tumor size, sex or patient age has been observed. CONCLUSION: It is suggested that simultaneous measurement of K-ras and p16 mutations may provide an additional tool in differential diagnosis of chronic pancreatitis and pancreatic adenocarcinoma.

Prognostic factors in the operative and palliative treatment of pancreatic cancer.

Recent studies have emphasized the importance of patient selection for the surgical resection of pancreatic adenocarcinoma based on reproducible prognostic factors. The aim of the study was to investigate the prognostic factors affecting long-term survival in patients with resectable and nonresectable pancreatic cancer and to evaluate their prognostic value. Forty six patients (25 women, 21 men, aged 44-80) with ductal adenocarcinoma of the pancreas were reviewed. Primary tumor size and regional enlargement of lymph nodes was assessed with enhanced CT scan. 13 patients were treated conservatively, 9 with standard Whipple procedure (pancreatoduodenectomy) and 24 - with palliative surgery. Survival probabilities were computed using univariate Kaplan-Meier analysis. Log-rank test was used to compare survival between groups. Overall median survival was 6 months with a 4 years survival of 2.2%. There was no difference in survival time (ST) between patients aged 65 years or younger and older (p=0.71). MeanST in patients after Whipple procedure was 10.3, after palliative surgery - 9.4 and after conservative treatment - 4.4 months (p<0.05). Thirty-day surgical mortality was 9.4%. ST was significantly longer in patients with tumors 3 cm or less of diameter compared with larger ones (p<0.05). Presenting signs and symptoms, like jaundice, diabetes, alkaline phosphatase, aspartate and alanine aminotransferase elevation and history of cholecystectomy did not have any significant impact on survival. The only significant independent factors improving survival were: operative treatment and tumor size smaller than 3 cm.