Low-Profile Altura Endograft System for Endovascular Abdominal Aorta Aneurysm Repair. Preliminary Results in Elective and Emergent Situations.

BACKGROUND: The objective of this study was to assess the Altura endoprosthesis outcomes up to 12 months for patients affected by infrarenal abdominal aortic aneurysms (AAA) either in elective or emergent situations. METHODS: This was a single-center retrospective study identifying all patients undergoing endovascular aneurysm repair (EVAR) with the Altura endoprosthesis from January 2021 to August 2022. Outcomes evaluated included mortality, technical and clinical success (freedom from procedure-related death, endoleak, migration, thrombosis, and reintervention), and the freedom from reintervention rate. RESULTS: A total of 34 (25 elective and 8 emergent) patients who underwent AAA with Altura endoprosthesis were retrospectively reviewed. The technical success of the Altura endograft either in elective or emergent situations was 100%. There was no inhospital mortality, but 1 (3%) patient who underwent AAA repair emergently, died unexpectedly 7 days after the discharge due to massive pulmonary embolism. The clinical success and the freedom from reintervention during the median follow-up of 12 months (interquartile range [IQR] 12-18), were 97%. One patient presented with disabling intermittent claudication at third month postoperatively, and the computed tomographic angiography (CTA) revealed thrombosis of one of the iliac endografts (3%). The patient underwent femorofemoral bypass with an uneventful postoperative course and immediate relief of the symptoms. One type II endoleak was spontaneously resolved on the sixth month. Sac shrinkage (>3 mm) was registered in 12 patients (35%), but the sac size was stable in the remaining 22 (65%) patients. CONCLUSIONS: The preliminary outcomes of the Altura endograft seem to be promising, suggesting that the endograft could be safely used either in elective or emergent situations. Further studies with a major number of participants are needed to document its technical and clinical performance, especially in emergency situations that could be amenable to improvement.

The impact of donor liver allograft fibrosis on patients undergoing liver transplantation.

BACKGROUND: The utilization of extended criteria liver allografts (ECD) shortens time to transplantation. OBJECTIVE: To characterize the effect of liver allograft fibrosis on graft and patient survival after liver transplantation (LT), with particular attention to fibrosis progression. METHODS: Retrospective database search of donor and recipient liver allograft histology of liver transplants performed between 2007 and 2011. Donor and patient characteristics were analyzed. RESULTS: One hundred and one patients underwent LT with donor liver allografts with early-stage fibrosis (stage 1 fibrosis and stage 2 fibrosis). The level of liver fibrosis did not progress in 40% of the patients tested, and there was a regression of fibrosis in 30%. At a median follow-up of 71 months, of 101 patients transplanted with fibrotic livers, 63 patients (63%) were alive with functioning initial grafts, six patients (6%) were retransplanted, and 35 patients expired. The graft survival rates were 82% and 69% at 1 and 5 years, respectively. Graft survival differences were not found to be statistically significant between the degrees of liver allograft fibrosis: 5-year graft survival (73% for stage 1 fibrosis and 62% for stage 2 fibrosis, P = .24). The entire fibrosis group was further compared with a control group of 208 consecutive primary liver transplant patients with allografts having no fibrosis. The 5-year graft survival was not significantly different between the groups (69% for the fibrosis group vs 75% for the nonfibrosis group, P = .19). Survival was also not statistically different between the groups (5-year survival of 73% for the fibrosis group vs 79% for the nonfibrosis group, P = .2). In patients with HCV, graft survival differences were not found to be statistically significant with the use of early-stage fibrotic livers: 5-year graft survival of 60% for fibrosis group vs 70% for the nonfibrosis group, P = .22). CONCLUSION: This study demonstrates that allografts with early-stage fibrosis achieve acceptable long-term survival after liver transplantation. Given these preliminary results, the use of organs with early-stage fibrosis warrants further studies at a larger scale to validate these results.

Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis.

OBJECTIVE: To examine the outcomes from minimal access retroperitoneal pancreatic necrosectomy (MARPN) and open pancreatic necrosectomy (OPN) for severe necrotizing pancreatitis in a single center. BACKGROUND: The optimal management of severe pancreatic necrosis is evolving with a few large center single series. METHODS: Between 1997 and 2013, patients with necrotizing pancreatitis at the Liverpool Pancreas Center were reviewed. Outcome measures were retrospectively analyzed by intention to treat. RESULTS: There were 394 patients who had either MARPN (274, 69.5%) or OPN (120, 30.5%). Complications occurred in 174 MARPN patients (63.5%) and 98 (81.7%) OPN patients (P < 0.001). OPN was associated with increased postoperative multiorgan failure [42 (35%) vs 56 (20.4%), P = 0.001] and median (inter-quartile range) Acute Physiology and Chronic Health Evaluation II score 9 (6-11.5) vs 8 (5-11), P < 0.001] with intensive care required less frequently in MARPN patients [40.9% (112) vs 75% (90), P < 0.001]. The mortality rate was 42 (15.3%) in MARPNs and 28 (23.3%) in OPNs (P = 0.064). Both the mortality and the overall complication rates decreased between 1997-2008 and 2008-2013 [49 (23.8%) vs 21 (11.2%) P = 0.001, respectively; and 151 (73.3%) vs 121 (64.4%), P = 0.080, respectively). Increased mortality was independently associated with age (P < 0.001), preoperative intensive care stay (P = 0.014), and multiple organ failure (P < 0.001); operation before 2008 (P < 0.001) and conversion to OPN (P = 0.035). MARPN independently reduced mortality odds risk (odds ratio = 0.27; 95% confidence interval = 0.12-0.57; P < 0.001). CONCLUSIONS: Increasing experience and advances in perioperative care have led to improvement in outcomes. The role of MARPN in reducing complications and deaths within a multimodality approach remains substantial and should be used initially if feasible.

Management and Outcome of 64 Patients with Pancreatic Serous Cystic Neoplasms.

BACKGROUND: The optimal management approach to pancreatic serous cystic neoplasms (SCNs) is still evolving. METHODS: Consecutive patients with SCN managed at the Liverpool Pancreas Cancer Centre between 2000 and 2013 were retrospectively reviewed. RESULTS: There were 64 patients consisting of 39 women (60.9%) and 25 men (39.1%). Forty-seven patients (73.4%) had surgical removal and 17 (26.6%) were observed. The possibility of a non-SCN malignancy was the predominant indication for resection in 27 (57.4%) patients. Postoperative morbidity occurred in 26 (55.3%) patients with 2 (4.3%) deaths. An increased risk of resection was associated with patient's age (p = 0.011), diagnosis before 2009 (p < 0.001), pain (p = 0.043), possibility of cancer (p = 0.009) and a solid SCN component on imaging (p = 0.002). Independent factors associated with resection were a diagnosis before 2009 (p = 0.005) and a solid SCN component (p < 0.001). Independent factors associated with shorter time to surgical resection were persistent pain (p = 0.003) and a solid SCN component (p = 0.007). CONCLUSION: There was a reduction in the proportion of resections with the application of an observe-only policy for asymptomatic patients with more definite features of SCN. Improved criteria are still required in the remainder of patients with uncertain features of SCN in deciding for intervention or surveillance.

Metzenbaum-assisted liver resection: a safe and effective liver resection technique.

AIM: We hereby present and evaluate a technique for hepatic parenchymal transection based on the application of Metzenbaum scissors and clips during liver ischemia. METHODS: Our technique was retrospectively evaluated in 32 noncirrhotic, noncholestatic patients with intrahepatic cholangiocarcinoma and 32 patients with hepatocellular carcinoma (23 of whom cirrhotic, 71.9%). Patient data were retrieved from our Hepatobiliary Surgery Database. Type and duration of vascular clamping, blood transfusion requirements, marginal status and immediate postoperative complications were analyzed. RESULTS: Twenty-seven extended (>4 liver segments; 42.2%) and 37 nonextended (≤4 liver segments; 57.8%) liver resections were analyzed. Warm liver ischemia duration was 14 (interquartile range: 11-17.8) min. Thirty-three patients (51.6%) were transfused with a median of 2 (1.5-3) units of packed red blood cells. Tumor-free margins were achieved in 90.6% of cases (n = 58). The overall morbidity rate was 18.8% with a 4.7% mortality rate. Our technique allowed for excellent identification and safe dissection and preservation, or ligation of major liver vessels. CONCLUSIONS: The proposed technique is simple, fast, safe and with low cost. It is associated with limited postoperative complications while from an oncologic standpoint it enables the surgeon to achieve a high percentage of tumor-free margins while protecting major vascular structures.

Complex cystic liver lesions: classification, diagnosis, and management.

Cystic liver disease has been increasingly reported in the literature, with a prevalence as high as 15-18%. Hepatic cysts are usually discovered incidentally, while their characterization and classification rely on improved imaging modalities. Complex cystic liver lesions comprise a wide variety of novel, re-introduced, and re-classified clinical entities. This spectrum of disorders ranges from non-neoplastic conditions to benign and malignant tumors. Their clinicopathological features, prognostic factors, and oncogenic pathways are incompletely understood. Despite representing a heterogeneous group of disorders, they can have similar clinical and imaging characteristics. As a result, the diagnosis and management of complex liver cysts can become quite challenging. Furthermore, inappropriate diagnosis and management can lead to high morbidity and mortality. In this review, we aim to offer up-to-date insight into the diagnosis, classification, and management of the most common complex cystic liver lesions.

Co-culture of primary human tumor hepatocytes from patients with hepatocellular carcinoma with autologous peripheral blood mononuclear cells: study of their in vitro immunological interactions.

BACKGROUND: Many studies have suggested that the immune response may play a crucial role in the progression of hepatocellular carcinoma (HCC). Therefore, our aim was to establish a (i) functional culture of primary human tumor hepatocytes and non-tumor from patients with hepatocellular carcinoma (HCC) and (ii) a co-culture system of HCC and non-HCC hepatocytes with autologous peripheral blood mononuclear cells (PBMCs) in order to study in vitro cell-to-cell interactions. METHODS: Tumor (HCC) and non-tumor (non-HCC) hepatocytes were isolated from the liver resection specimens of 11 patients operated for HCC, while PBMCs were retrieved immediately prior to surgery. Four biopsies were obtained from patients with no liver disease who had surgery for non malignant tumor (normal hepatocytes). Hepatocytes were either cultured alone (monoculture) or co-cultured with PBMCs. Flow cytometry measurements for MHC class II expression, apoptosis, necrosis and viability (7AAD) were performed 24 h, 48 h and 72 h in co-culture and monocultures. RESULTS: HCC and non-HCC hepatocytes exhibited increased MHC-II expression at 48h and 72h in co-culture with PBMCs as compared to monoculture, with MHC II-expressing HCC hepatocytes showing increased viability at 72 h. PBMCs showed increased MHC-II expression (activation) in co-culture with HCC as compared to non-HCC hepatocytes at all time points. Moreover, CD8+ T cells had significantly increased apoptosis and necrosis at 48h in co-culture with HCC hepatocytes as compared to monocultures. Interestingly, MHC-II expression on both HCC and non-HCC hepatocytes in co-culture was positively correlated with the respective activated CD8+ T cells. CONCLUSIONS: We have established an in vitro co-culture model to study interactions between autologous PBMCs and primary HCC and non-HCC hepatocytes. This direct interaction leads to increased antigen presenting ability of HCC hepatocytes, activation of PBMCs with a concomitant apoptosis of activated CD8+ T cells. Although, a partially effective immune response against HCC exists, still tumor hepatocytes manage to escape.

Review of the molecular profile and modern prognostic markers for gastric lymphoma: how do they affect clinical practice?

Primary gastric lymphoma is a rare cancer of the stomach with an indeterminate prognosis. Recently, a series of molecular prognostic markers has been introduced to better describe this clinical entity. This review describes the clinical importance of several oncogenes, apoptotic genes and chromosomal mutations in the initiation and progress of primary non-Hodgkin gastric lymphoma and their effect on patient survival. We also outline the prognostic clinical importance of certain cellular adhesion molecules, such as ICAM and PECAM-1, in patients with gastric lymphoma, and we analyze the correlation of these molecules with apoptosis, angiogenesis, tumour growth and metastatic potential. We also focus on the host-immune response and the impact of Helicobacter pylori infection on gastric lymphoma development and progression. Finally, we explore the therapeutic methods currently available for gastric lymphoma, comparing the traditional invasive approach with more recent conservative options, and we stress the importance of the application of novel molecular markers in clinical practice.

Multicentric evaluation of a clinical and prognostic scoring system predictive of survival after resection of intrahepatic cholangiocarcinomas.

OBJECTIVE: To develop a clinical and prognostic scoring system predictive of survival after resection of intrahepatic cholangiocarcinomas (ICC). PATIENTS: Two hundred and one consecutive ICC patients (83 from Essen, Germany, 54 from New York, USA and 64 from Chiba, Japan). The scoring systems were developed utilizing the data set from Essen University and then applied to the data sets from Mount Sinai Medical Center and Chiba University for validation. Eighteen potential prognostic factors were evaluated. Statistical analysis included multivariable regression analyses with the Cox proportional hazard model, power analysis, internal validation with structural equation modelling bootstrapping and external validation. The prognostic scoring model was based mainly in pathological and demographical variables, whereas the clinical scoring model was based mainly in radiological and demographical variables. RESULTS: Gender (P=0.0086), UICC stage (P=0.0140) and R-class (P=0.0016) were predictive of survival for the prognostic scoring model, while gender (P=0.0023), CA 19-9 levels (P=0.0153) and macrovascular invasion (P=0.0067) were predictive of survival for the clinical scoring model. Prognostic points were assigned as follows: female:male=1:2 points, UICC (I-II):UICC (III-IV)=1:2 points and R0:R1=1:2 points. Clinical points were allocated as follows: female:male=1:2 points, CA 19-9 (<100 U/ml):CA 19-9 (> or =100 U/ml)=1:2 points and no macrovascular invasion:macrovascular invasion=1:2 points. Prognostic groups with 3-4, 5 and 6 points (P=0.000001) and clinical groups with 3-4 and 5-6 points (P=0.0103) achieved statistically significant difference. CONCLUSIONS: We propose a clinical and prognostic scoring system predictive of long-term survival after surgical resections for ICC.

Prospective appraisal of a 2-day training course on laparoscopic sleeve gastrectomy: the ELTC experience.

BACKGROUND: The increasing role of laparoscopic sleeve gastrectomy (LSG) in the treatment of morbid obesity dictates the need for greater acquaintance with this type of surgery. This study was designed to evaluate the impact of a 2-day LSG course and a 4-day laparoscopic bariatric mini-training program on the knowledge and training gained by participating surgeons. METHODS: A total of 73 trainees (31 residents and 42 surgeons) completed a question survey immediately after completion of the respective courses. Questions probed demographic data, training experience before and after course completion, evaluation of course content, and operative experience. RESULTS: All residents and four of the general surgeons found the laparoscopic bariatric mini-training program to be of value with respect to future professional orientations. Seven surgeons started performing LSGs, while another five surgeons decided to occupy themselves with various types of laparoscopic bariatric procedures. The most useful parts of the course included the identification and treatment of complications, the use of new instrumentation, and surgical demonstrations (video or live), as decided by more than 80% of the participants. On a 1-5 scale, the presentation of novel knowledge was evaluated to be ≥ 3 by all participants. CONCLUSION: The 2-day LSG course offered participants high-quality novel knowledge and excellent training quality, and exerted impact on their personal career.

Surgical resection for advanced gallbladder carcinoma. The Mount Sinai experience.

BACKGROUND/AIMS: Advanced gallbladder cancer (GC) carries dismal prognosis, due to its extent at diagnosis and the low R0 resection performance rate. METHODOLOGY: Thirty-two GC patients referred to our Department with an intention to treat between 1993 and 2005. All patients had advanced T stage (> or = T3). Pathological findings, surgical procedures and survival data were analyzed. RESULTS: Seventeen radical procedures (16 hepatectomies and 1 cholecystectomy with common bile duct resection), 4 palliative procedures (12.5%) and 11 surgical explorations (34.4%) were performed (53.1%, resectability rate). Hepatectomies were performed with 0% mortality, 11.8% morbidity and 94.1% resectability rate. The respective 1-, 3- and 5- year survival rates were 71.4%, 28.6% and 14.3%. Radical lymph node dissection (p = 0.03), absence of perineural tumor invasion (p = 0.03) and patients' age <70 years (p < 0.01) were non-independently associated with favorable prognosis in the hepatectomy-treated group of GC patients. CONCLUSIONS: GC patients with stage > or = IIA should be treated with hepatectomy combined with radical lymphadenectomy in order to achieve better staging and disease control. Incorporating the caudate lobe, more than 4 liver segments, or part of the extrahepatic biliary tree in the resection specimen in selected patients, might help eliminate perineural metastatic spread and achieve improved overall survival.

Use of rituximab in combination with conventional chemotherapy for the treatment of non-Hodgkin's lymphoma of the head and neck.

BACKGROUND: Rituximab, an anti-CD20 chimeric monoclonal antibody that specifically depletes mature B cells, is an effective single agent in the treatment of relapsed or refractory indolent lymphomas, and has been shown to improve the survival rate of elderly patients with diffuse large-B-cell lymphoma when used in combination with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP). PATIENTS AND METHODS: The combined effect of rituximab and CHOP has been comparatively studied against CHOP alone in 18 elderly patients with non-Hodgkin's lymphoma of the head or neck treated in the 1st Department of Otolaryngology at Hippokration Hospital between January 1998 and January 2004. RESULTS: Response rates were 91% and 100% in patients treated with rituximab plus CHOP and with CHOP alone, respectively. Overall survival and disease-free survival rates were 91% in the rituximab plus CHOP group, compared with 83% and 60%, respectively, in the CHOP alone group (p=0.75 and p=0.24 for the differences between the groups, respectively). The rituximab plus CHOP therapy was generally well tolerated, with few adverse events reported. CONCLUSION: The results of this small case series, although not statistically significant, suggest that rituximab in combination with CHOP may represent an effective treatment option for elderly patients with non-Hodgkin's lymphoma of the head and neck.

BCL-2, p53 and HLA-DR antigen expression in surgically treated parotid cancer patients.

Our objective was to investigate the prognostic significance of bcl-2 protein, p53 protein and HLA-DR antigen expression in a group of surgically treated parotid cancer patients. We studied bcl-2, p53 and HLA-DR immunohistochemical expression in paraffin-embedded surgically removed tissue specimens derived from 26 patients with parotid cancer and 9 patients with Warthin parotid tumors operated between 2000 and 2006 at the Hippokration Hospital of Athens. The staining results were correlated with the patients' clinicopathological characteristics and clinical outcome. Bcl-2 expression was associated with a significantly decreased survival in patients with advanced tumor stage (P = 0.04), high grade lesions (P = 0.02), or cervical node involvement (P = 0.03). Radiotherapy was associated with a significantly improved recurrence-free survival among patients with negative tumor staining for either bcl-2, or both HLA-DR and bcl-2 [HLA-DR(-)/Bcl-2(-)] (P = 0.04 for both comparisons). Classical clinicopathologic factors failed to show prognostic value both in the univariate and the multivariate analyses performed. Our results suggest that bcl-2 can be used to identify locally advanced or histologically aggressive tumors with a lower survival probability following the application of standard treatment modalities. Furthermore, bcl-2(+) patients should be considered for more aggressive adjuvant treatment protocols, since conventional radiotherapy often fails to decrease relapse rates in this setting of patients.

Liver histology in ICU patients dying from sepsis: a clinico-pathological study.

AIM: To determine end-stage pathologic changes in the liver of septic patients dying in the intensive care unit. METHODS: Needle liver biopsies obtained immediately after death from 15 consecutive patients with sepsis and no underlying liver disease were subjected to routine histological examination. Liver function tests and clinical monitoring measurements were also recorded. RESULTS: Liver biochemistries were increased in the majority of patients before death. Histology of liver biopsy specimens showed portal inflammation in 73.3%, centrilobular necrosis in 80%, lobular inflammation in 66.7%, hepatocellular apoptosis in 66.6% and cholangitis/cholangiolitis in 20% of patients. Mixed hepatitic/cholestatic type of liver injury was observed in 6/15 (40%) patients and hepatitc in 9/15 (60%). Steatosis was observed in 11/15 (73.3%) patients affecting 5%-80% of liver parenchyma. Among the histological features, the presence of portal inflammation in liver biopsy was associated with increased hospitalization in the ICU prior death (P=0.026). CONCLUSION: Features of hepatitis and steatosis are the main histological findings in the liver in the majority of patients dying from sepsis.

Subclinical peritonitis due to perforated sigmoid diverticulitis 14 years after heart-lung transplantation.

Acute complicated diverticulitis, particularly with colon perforation, is a rare but serious condition in transplant recipients with high morbidity and mortality. Neither acute diverticulitis nor colon perforation has been reported in young heart-lung grafted patients. A case of subclinical peritonitis due to perforated acute sigmoid diverticulitis 14 years after heart-lung transplantation is reported. A 26-year-old woman, who received heart-lung transplantation 14 years ago, presented with vague abdominal pain. Physical examination was normal. Blood tests revealed leukocytosis. Abdominal X-ray showed air-fluid levels while CT demonstrated peritonitis due to perforated sigmoid diverticulitis. Sigmoidectomy and end-colostomy (Hartmann's procedure) were performed. Histopathology confirmed perforated acute sigmoid diverticulitis. The patient was discharged on the 8th postoperative day after an uneventful postoperative course. This is the first report of acute diverticulitis resulting in colon perforation in a young heart-lung transplanted patient. Clinical presentation, even in peritonitis, may be atypical due to the masking effects of immunosuppression. A high index of suspicion, urgent aggressive diagnostic investigation of even vague abdominal symptoms, adjustment of immunosuppression, broad-spectrum antibiotics, and immediate surgical treatment are critical. Moreover, strategies to reduce the risk of this complication should be implemented. Pretransplantation colon screening, prophylactic pretransplantation sigmoid resection in patients with diverticulosis, and elective surgical intervention in patients with nonoperatively treated acute diverticulitis after transplantation deserve consideration and further studies.

Molecular markers (PECAM-1, ICAM-3, HLA-DR) determine prognosis in primary non-Hodgkin's gastric lymphoma patients.

AIM: To investigate the prognostic significance of PECAM-1, ICAM-3 and HLA-DR antigens in patients with primary non-Hodgkin's gastric lymphoma. METHODS: We immunohistochemically studied PECAM-1, ICAM-3 and HLA-DR antigen expression in 36 B-cell MALT-type primary gastric lymphoma patients. Ten non-malignant and ten healthy gastric tissue specimens were used as controls. Clinicopathological and survival data were correlated with the staining results. RESULTS: HLA-DR antigen expression was detected in 33 gastric lymphoma patients (91.7%) and 6 non-malignant patients (54.5%). PECAM-1 stained tumor cells of 10 patients (27.8%), endothelial cells of 9 patients (25%) and inflammatory infiltrate of 4 patients (40%) with benign gastric disease. ICAM-3 expression was observed on the tumor cells of 17 patients (47.2%), while 5 non-malignant patients (50%) were stained positive as well. None of the healthy controls was stained for any of the genes studied. In the multivariate analysis, HLA-DR antigen and PECAM-1 were proved to be statistically significant independent prognostic factors associated with a favourable and an unfavourable prognosis respectively (P=0.009 and P=0.003). In the univariate analysis, PECAM-1(+)/ICAM-3(-) and HLA-DR(-)/ICAM-3(-) patients exhibited a significantly decreased overall survival compared to those with the exactly opposite gene expression patterns (P=0.0041 and P=0.0091, respectively). Those patients who were HLA-DR(+)/ICAM-3(+)/PECAM-1(-) (n=8) had a significantly higher survival rate compared to the rest of the group (n=24) (P=0.0289). CONCLUSION: PECAM-1, ICAM-3 and HLA-DR are representative markers of tumor expansion potential and host immune surveillance respectively. Their combined use may help us to identify high-risk patients who could benefit from more aggressive therapeutic protocols.

Laparoscopic versus open splenectomy in patients with beta thalassemia major.

BACKGROUND: Laparoscopic splenectomy is considered the standard of care for the removal of the spleen in benign diseases. There are not sufficient data for the routine application of this technique in patients with beta thalassemia major. MATERIALS AND METHODS: Twenty-eight consecutive beta thalassemia major patients who underwent elective splenectomy were randomized for open and laparoscopic splenectomy. Patient demographics, operative time, intraoperative and postoperative complications, conversion rate, transfusions, and length of stay were recorded. RESULTS: There was no mortality in this series. There was no difference in complication rates between the two groups. Operative time was markedly increased in the group treated laparoscopically, as was the need for blood transfusions. Median hospital stay was decreased in the laparoscopic group (5 days) compared to the open group (6.5 days). CONCLUSIONS: Laparoscopic splenectomy in patients with beta thalassemia major is feasible; however, it is more time consuming and bleeding occurs more often.

Two-trocar laparoscopic-assisted appendectomy versus conventional laparoscopic appendectomy in patients with acute appendicitis.

BACKGROUND: In order to reduce abdominal trauma and operative costs we have adopted a two-trocar laparoscopic-assisted appendectomy for patients with acute appendicitis. In the current study, the proposed technique is prospectively evaluated against conventional laparoscopic appendectomy with respect to feasibility, safety, and postoperative outcome. MATERIALS AND METHODS: Between July 2001 and July 2003, 83 consecutive patients were admitted with clinically diagnosed acute appendicitis and were randomly assigned to two-trocar laparoscopic-assisted appendectomy (n = 40, 48.2%) or conventional laparoscopic appendectomy (n = 43, 51.8%). RESULTS: Two-trocar laparoscopic-assisted appendectomy was successfully completed in 30 patients (80.1%). Four patients initially scheduled for two-trocar laparoscopic-assisted appendectomy (10.8%) were converted to laparotomy due to excessive body weight (BMI > or = 40), while an additional 5-mm infraumbilical trocar was inserted in another 3 patients (8.1%). The procedure was associated with decreased operative time and more rapid return to normal activity compared to laparoscopic appendectomy (P < 0.001 and P = 0.038, respectively). There was no statistically significant difference regarding the duration of hospitalization or the morbidity rate between the two groups. Conversion of the initial procedure was associated with increased wound infection rate and higher morbidity (P = 0.032 and P = 0.018, respectively). CONCLUSION: Two-trocar laparoscopic-assisted appendectomy represents a promising minimally invasive procedure for the treatment of acute appendicitis. It is fast and easy to perform, and it is expected to decrease the overall cost of laparoscopic appendectomy. Its only contraindication is excessive body weight; it remains to be evaluated in the setting of perforated appendicitis and retrocecally located appendices.

Complete endoscopic axillary lymph node dissection without liposuction for breast cancer: initial experience and mid-term outcome.

AIM: To present our initial experience with complete endoscopic axillary lymph node dissection (EALND) in 4 breast cancer patients with respect to feasibility, safety, and clinical outcome. PATIENTS AND METHODS: Between January 2003 and March 2004, 4 women consented to be treated with lumpectomy followed by complete (level I, II, and III) EALND without liposuction, at the Laparoendoscopic Unit of Athens Medical School. All 4 patients presented with a solitary breast cancer lesion smaller than 2 cm in diameter and a negative clinical and sonographic lymph node status (<1 cm). RESULTS: All the operations were completed endoscopically in less than 70 minutes (44 to 69 min). The axillary lymph node harvest ranged between 12 and 21 nodes. No lymphedema, motor nerve damage, seroma formation, or wound complications were observed. Prolonged hospitalization, owing to persistent lymphorrhoea was required for 1 patient. During a mean follow-up of 21.3 months, 2 patients reported mild hypoesthesia-paresthesia along the upper medial part of the respective arm, whereas no tumor recurrences were documented. CONCLUSIONS: Although partial EALND has not been established as the treatment of choice for axillary management, complete EALND seems to be a feasible and effective minimally invasive treatment modality, which could be safely applied in patients with positive sentinel node biopsy, treated in specialized centers.