Robotic versus laparoscopic surgery for colorectal disease: a systematic review, meta-analysis and meta-regression of randomised controlled trials.

INTRODUCTION: Robotic surgery (RS) is gaining prominence in colorectal procedures owing to advantages like three-dimensional vision and enhanced dexterity, particularly in rectal surgery. Although recent reviews report similar outcomes between laparoscopic surgery (LS) and RS, this study investigates the evolving trends in outcomes over time, paralleling the increasing experience in RS. METHODS: A systematic review, meta-analysis and meta-regression were conducted of randomised controlled trials exploring postoperative outcomes in patients undergoing RS or LS for colorectal pathology. The primary outcome measure was postoperative complications. Risk of bias was evaluated using the Cochrane Collaboration's assessment tool. Randomised controlled trials were identified from the PubMed®, Embase® and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases via the Cochrane Central Register of Controlled Trials. RESULTS: Of 491 articles screened, 13 fulfilled the inclusion criteria. Meta-analysis of postoperative complications revealed no significant difference between RS and LS (relative risk [RR]: 0.96, 95% confidence interval [CI]: 0.79 to 1.18, p=0.72). Meta-regression analysis of postoperative complications demonstrated a significant trend favouring RS over time (yearly change in Ln(RR): -0.0620, 95% CI: -0.1057 to -0.0183, p=0.005). Secondary outcome measures included operative time, length of stay, blood loss, conversion to open surgery, positive circumferential resection margins and lymph nodes retrieved. The only significant findings were shorter operative time favouring LS (mean difference: 41.48 minutes, 95% CI: 22.15 to 60.81 minutes, p<0.001) and fewer conversions favouring RS (RR: 0.57, 95% CI: 0.37 to 0.85, p=0.007). CONCLUSIONS: As experience in RS grows, evidence suggests an increasing safety profile for patients. Meta-regression revealed a significant temporal trend with complication rates favouring RS over LS. Heterogeneous reporting of complications hindered subgroup analysis of minor and major complications. LS remains quicker. Rising adoption of RS coupled with emerging evidence is expected to further elucidate its clinical efficacy.

An unusual case of a completely eroded gastric band and port tubing removed via endoscopy alone.

Bariatric surgery is an established intervention providing significant health benefits to patients with obesity. As a result, the National Institute for Health and Care Excellence now recommends bariatric surgery for those that fulfil the eligibility criteria, while emphasising the need for multidisciplinary care before and after surgery. The UK National Bariatric Surgery Registry shows gastric band procedures to be the second most common bariatric procedure performed in the UK. Gastric band erosion is a known potential complication treated primarily by laparoscopic removal of band and repair of stomach. To our knowledge, we present the first case of a partially eroded gastric band with separate gastric fistulation of the port tubing. The band was removed via endoscopy without the need for a cutaneous exploration as the port had previously been removed at incisional hernia surgery. Owing to the fact that the tubing and band were both evident within the lumen of the stomach, complete band erosion was inferred and therefore endoscopic removal thought to be indicated. In actual fact, there was separate erosion of the band and tubing; more specifically, the gastric band clasp had not eroded fully and while endoscopic removal was still possible, it was challenging and required the band to be divided. This case highlights the importance of careful patient selection, involvement of multidisciplinary care prior and after surgery and close follow-up to facilitate timely identification and management of complications.

A rare case of simultaneous pneumoperitoneum and pneumomediastinum with a review of the literature.

Simultaneous pneumoperitoneum and pneumomediastinum is a rare clinical occurrence. It has been reported in the literature as a complication of various medical and dental procedures. To our knowledge, we present the first case of a non-iatrogenic and traumatic simultaneous pneumoperitoneum and pneumomediastinum in a previously independent 91-year-old man who presented to hospital with back and chest wall pain following mechanical fall from standing. A new radiological diagnosis of diverticular disease with possible perforation was made following admission. Despite appropriate management and supportive measures, the patient died 12 days after admission from a kidney injury.

Expression of the epidermal growth factor system in endometrial cancer.

The aim of our study was to describe the expression of c-erbB-1, c-erbB-2, c-erbB-3 and c-erbB-4 in endometrial cancer tissue and its correlation with clinicopathologic features and prognosis of the patients. One hundred and six cases of endometrial cancer were identified from the archives of the Department of Obstetrics and Gynecology of the University of Patras. Tissue specimens from endometrial lesions were immunostained for c-erbB-1, c-erbB-2, c-erbB-3 and c-erbB-4. Statistical analyses were performed using the chi square test, Kaplan-Meier method and Cox analysis. We found a significant association between c-erbB-1 expression and patient survival. A reverse correlation was found between tumor grade and c-erbB-1 expression. Tumor grade was not significantly correlated with the expression of the remaining three receptors. Stage of the tumor showed no relationship with the expression of these receptors. The ability to predict increased risks of advanced disease, recurrence, and death from abnormal molecular markers detected in curettage or endometrial biopsy specimens will facilitate pretreatment referral of these patients to gynecologic oncologists for definitive surgical treatment.

Fallopian tube malignant mixed müllerian tumor (carcinosarcoma): a case report with immunohistochemical profiling.

We report a case of malignant mixed müllerian tumor (MMMT) (carcinosarcoma) of the right fallopian tube in a 69-year-old woman presenting with abdominal pain and an adnexal mass. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, received adjuvant chemotherapy and is without evidence of disease 12 months postoperatively. The tumor involved the fallopian tube and was composed of in situ and invasive high-grade serous and undifferentiated carcinoma, leiomyosarcoma, rhabdomyosarcoma and undifferentiated sarcoma. Immunohistochemically, the epithelial and mesenchymal cells expressed CD56, Leu-7 and p53. The epithelial elements expressed nuclear WT1 and calretinin while the mesenchymal cells showed negative nuclear and strong cytoplasmic staining. HBME was observed focally in carcinoma. The expression of mesothelial-associated antigens WT1, calretinin and HBME in MMMT likely reflects the common embryologic derivation of the mesothelium and urogenital ridge. Loss of nuclear WT1 expression in the mesenchymal component may be involved in MMMT tumorigenesis.

Synchronous primary cancers in a woman with scleroderma: a case report.

BACKGROUND: Scleroderma is a chronic, multisystem, autoimmune disease. Previous studies have shown an increased risk of malignancy in scleroderma; the most common cancers were lung cancer and breast cancer. CASE: The patient, a 43-year-old nulliparous premenopausal Greek woman with scleroderma, presented with a history of abdominal pain and atypical vaginal bleeding. She underwent total hysterectomy with bilateral salpingo-oophorectomy, total omentectomy, appendectomy and pelvic lymph node dissection. The histopathology revealed synchronous primary cancers of the endometrium and left ovary. She underwent postoperative chemotherapy and remains well without evidence of disease 25 months after surgery. CONCLUSION: Synchronous primary cancers of the endometrium and ovary are relatively uncommon in the general population. Only a few cases of cancer of the female genital tract in women with scleroderma have been reported in the English literature.

Mid-trimester maternal serum AFP levels in predicting adverse pregnancy outcome.

OBJECTIVE: In this prospective study, we investigated the association between mid-trimester maternal serum alpha-fetoprotein AFP (MSAFP) levels and adverse pregnancy outcome in a South-Western Greek population. MATERIALS AND METHODS: 110 healthy Greek women with spontaneous pregnancies, investigated for MSAFP levels between the 13th and 24th week of gestation and followed for adverse pregnancy outcome. AFP levels > 2.0 multiples of the median value for gestation were considered abnormal. Statistical analysis was performed by Pearson's chi-square test. RESULTS: Elevated MSAFP levels were detected in a total of 27 of the 110 women studied (24.5%). Among them, only four women (14.8%) developed pregnancy complications. CONCLUSION: Multiparameter testing of placental function in the mid-trimester (uterine artery Doppler, placental morphology and MSAFP screening) may allow us to identify women with increased risk of developing severe placental insufficiency and pregnancy complications.

A case of body stalk anomaly at 12 weeks of gestation.

We report a case of body stalk anomaly which was diagnosed at 12 weeks of gestation on a first trimester scan. The fetus displayed multiple anomalies characteristic of body stalk syndrome including abdominal wall defect, kyphoscoliosis, deformities of the lower limbs and a single umbilical artery. Body stalk anomaly is a rare congenital anomaly with a series of similar clinical manifestations and poor prognosis. The first trimester scan can estimate the risk for chromosomal abnormalities and may also reveal major congenital abnormalities.

Texture analysis of perimenopausal and post-menopausal endometrial tissue in grayscale transvaginal ultrasonography.

The aim of this study was to investigate the feasibility of texture analysis in characterizing endometrial tissue as depicted in two-dimensional (2D) grayscale transvaginal ultrasonography. Digital transvaginal ultrasound endometrial images were acquired from 65 perimenopausal and post-menopausal women prior to gynaecological operations; histology revealed 15 malignant and 50 benign cases. Images were processed with a wavelet-based contrast enhancement technique. Three regions of interest (ROIs) were identified (endometrium, endometrium plus adjacent myometrium, layer containing endometrial-myometrial interface) on each original and processed image. 32 textural features were extracted from each ROI employing first and second order statistics texture analysis algorithms. Textural features-based models were generated for differentiating benign from malignant endometrial tissue using stepwise logistic regression analysis. Models' performance was evaluated by means of receiver operating characteristic (ROC) analysis. The best logistic regression model comprised seven textural features extracted from the ROIs determined on the processed images; three features were extracted from the endometrium, while four features were extracted from the layer containing the endometrial-myometrial interface. The area under the ROC curve (A(z)) was 0.956+/-0.038, providing 86.0% specificity at 93.3% sensitivity using the cut-off level of 0.5 for probability of malignancy. Texture analysis of 2D grayscale transvaginal ultrasound images can effectively differentiate malignant from benign endometrial tissue and may contribute to computer-aided diagnosis of endometrial cancer.

Combined inherited thrombophilia and adverse pregnancy outcome.

Inherited thrombophilia has been suggested as a possible condition of increased susceptibility to adverse pregnancy outcomes. In our prospective study, we investigated the association between combined inherited thrombophilia and adverse pregnancy outcome in the South-Western Greek population. Three hundred and ninety-six healthy Greek women with spontaneous pregnancies were investigated for combinations of the three commonest thrombophilic mutations (Factor II G20210A, Factor V Leiden and MTHFR C677T) and followed for adverse pregnancy outcomes. Statistical analysis was performed by Pearson's chi-square test. Four women (1%) had the FV Leiden/MTHFR T677T double genotype and two women (0.5%) had the FII G20210A/MTHFR T677T double genotype. Although the small number of cases of combined inherited thrombophilia, it seems that the presence of FV Leiden/MTHFR T677T double genotype increases the risk for placental abruption.

Expression of the epidermal growth factor system in endometrial cancer after adjuvant tamoxifen treatment for breast cancer.

The aim of our study was to describe the expression of cerbB-1, cerbB-2, cerbB-3 and cerbB-4 in endometrial cancer tissue and its correlation with clinicopathologic features and prognosis of endometrial cancer patients diagnosed during or after tamoxifen treatment for breast cancer. Thirteen tamoxifen-related endometrial cancers were identified from the archives of the Department of Obstetrics and Gynecology of the University of Patras, Medical School. Tissue specimens from endometrial lesions were immunostained for cerbB-1, cerbB-2, cerbB-3 and cerbB-4. For cerbB-1, five cases were positive and eight were negative. For cerbB-2, ten cases were positive and three were negative. For cerbB-3, nine cases were positive and four were negative. For cerbB-4, eight cases were positive and five were negative. However, a limitation of our study is that the number of cases was small, and further investigations are necessary to allow a more focused evaluation of cerbB-1, cerbB-2, cerbB-3 and cerbB-4 status, as a prognostic factor for endometrial cancer after tamoxifen treatment.

Is dosage of hormone replacement therapy related with endometrial polyp formation?

PURPOSE OF INVESTIGATION: To evaluate the effect of different doses of hormone replacement therapy (HRT) on endometrial polyp formation. METHODS: 398 menopausal women were initially evaluated through transvaginal ultrasound and patients who already had endometrial polyps were excluded from the study. One hundred and six (26.6%) eligible patients were enrolled and randomized into two groups of 53 patients to receive two different doses of HRT. RESULTS: Six patients with endometrial polyps were detected in the first group and one patient in the second one (p = 0.0502 for total chi-square and p = .1172 for chi-square with continuity correction) after a mean duration of treatment of 26 months and 28,5 months, respectively. There was no difference in the mean number or the mean volume of the polyps between the two subgroups with positive results. CONCLUSION: Our study showed that endometrial polyp formation may be related with HRT dosage.

Women younger than 50 years with endometrial cancer.

PURPOSE OF INVESTIGATION: The purpose of the study was to evaluate if known risk factors for endometrial cancer in menopausal women are also related to endometrial cancer in younger ages. METHODS: Eighty-one patients with a mean age of 46.3 years diagnosed with endometrial cancer (EC) (histologically confirmed) from January of 1992 to December of 2004 were included in the study. The EC group of patients was compared with 100 patients (control group) randomly selected from the gynecologic clinic (inclusion criteria: age 43-48 years) without any endometrial cancer diagnoses that were evaluated for the same factors. RESULTS: Mean BMI was 34.4 kg/m2 (SD = 8.8) in the first group and 28.3 (SD = 7.6) in the second one (p < 0.001). None of the women in the EC group reported any history of oral contraception. With the exception of hypertension and ovarian cancer (probably related to small numbers) all other comparisons were statistically significant (although some only marginally). DISCUSSION: From the results of our study, it seems that body mass index (BMI), parity, type of menstrual cycles, history of polycystic ovarian (PCO) syndrome and diabetes are possibly related to endometrial cancer in women younger than 50 years of age, and the strongest relation was found with increased BMI. Also, there was no increased incidence of hypertensive disease in the EC group. CONCLUSION: Prospective studies are needed for final conclusions.

Synchronous primary endometrial and ovarian cancers: a case report.

Synchronous primary cancers of the endometrium and ovary are relatively uncommon in the general population. The patient, a 49-year-old postmenopausal Greek woman, presented with abdominal pain and a pelvic mass. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy, appendectomy and pelvic lymph node dissection. The histopathology revealed synchronous primary cancers of the endometrium and right ovary. She underwent postoperative chemotherapy. Thirty-nine months after surgery, she remains well without evidence of recurrence.

Primary peritoneal psammocarcinoma: a case presenting synchronously with bowel carcinoma.

BACKGROUND: Psammocarcinomas are rare epithelial tumors usually originating from the ovarian surface epithelium or the peritoneum. In our case, a peritoneal psammocarcinoma was incidental surgical finding during laparotomy. CASE: An 83-year-old woman underwent surgery for bowel obstruction. Intraoperativelly, a bowel carcinoma was documented. Notable were numerous small disseminated peritoneal nodules that studded the omentum and bowel serosa. At reintervention, similar nodules were observed in the serosal surface of the two ovaries, uterus, left salpinx, and omentum. The nodules corresponded histologically to psammocarcinoma of peritoneal origin. Despite not receiving adjuvant treatment, the patient is still alive 53 months following the second operation, without signs of metastases or disease recurrence. CONCLUSION: Though unpredictable, psammocarcinomas might run an indolent course, and decisions regarding management should be individualized.

Correlation of mammographic appearance and molecular prognostic factors in high-grade breast carcinomas.

The aim of our study was to evaluate the association between the mammographic appearance and the biologic characteristics of high-grade breast carcinomas. Three hundred and twenty patients with breast carcinomas were studied. Histological examination showed 83 (26%) high-grade ductal carcinomas. Immunohistochemistry was carried out by using antibodies against estrogen receptor (ER), progesterone receptor (PR), HER-2/neu, p53 and cathepsin D. In 60/83 high-grade carcinomas we studied the mammographic appearance. Asymmetric density with poorly defined margins without microcalcifications was the major mammographic finding in 49/60 (approximately 82%) high-grade ductal carcinomas. HER-2/neu positivity (68.7%) and p53 positivity (48.2%) were statistically correlated with asymmetric density with poorly defined margins without microcalcifications in high-grade carcinomas. We observed loss of ER and PR receptors in 50%, whereas loss of PR receptors was observed in 65% of high-grade breast carcinomas. Cathepsin D (> 20%) was detected in 38.5% of high-grade carcinomas. Our findings suggest a significant relationship between mammographic appearance and biologic markers in high-grade breast carcinomas.

Immunohistochemical detection of HPV proteins and c-erbB receptors in cervical lesion specimens from young women.

The intention of the present study was to assess immunohistochemically the expression of c-erbB receptor family in cervical carcinoma specimens of young women. Simultaneously, HPV was detected in the same specimens using immunohistochemical assays. Seventy-five cervical intraepithelial and invasive cancer specimens were assessed retrospectively. Positive c-erbB-2 immunostaining was revealed in 11.7% of tumor specimens, while for c-erbB-3 and c-erbB-4 receptor the corresponding figures were 32% and 49.3%, respectively. Concerning HPV infection-markers, positive immunostaining was found in 31% of cases, while coilocytes were detected in 64% of patients. The correlation of c-erbB receptor expression with malignant aggressiveness in cervical cancer cells concurs with similar data regarding other neoplasias, thus rendering these receptors an important predictive factor and future therapeutic target.

Polycystic ovarian syndrome, insulin resistance and thickness of the endometrium.

INTRODUCTION: Disorders possibly associated with insulin resistance (IR) are hyperandrogenemia, hirsutism, irregular menstrual cycles, central obesity and polycystic ovarian syndrome (PCOS). It is known that PCOS is related to a high risk of endometrial hyperplasia after many years of estrogen stimulation from anovulation. OBJECTIVES: The purpose of the study was to estimate the thickness of the endometrium in women with IR without a diagnosis of PCOS and in women with PCOS without IR. STUDY DESIGN: Three groups of women included in the study: 15 women diagnosed as IR without PCOS, 16 women diagnosed as PCOS without IR and 20 women used as controls matched for age and body mass index (BMI) with the previous patients. Thickness of the endometrium was estimated in all cases with a transvaginal ultrasound in three consecutive measures during a cycle. RESULTS: The mean thickness of the endometrium was statistically higher in the PCOS group (11.1mm), and in the IR group (9.6mm), compared with the control group (6.2mm) (F=13.1, p<0.001). CONCLUSIONS: It is concluded that both in women diagnosed as having insulin resistance without PCOS, and in women with PCOS without insulin resistance, the ultrasonographically estimated thickness of the endometrium is relatively high and a closer follow-up of these women is required in order to detect those in risk to develop hyperplasia and/or atypia.