First report of clear cell renal carcinoma metastasizing to the ischiorectal fossa 17 years after radical nephrectomy: an additional reason for lifelong follow-up.

Renal cell carcinoma has a high propensity for metastatic spread. There are several case reports of metastatic renal cell carcinomas associated with rare metastatic sites, in many cases more than ten years after the initial diagnosis. We present a 60-year-old man with perianal pain and a mass in the ischiorectal space, revealed by computed tomography. The patient had a history of clear cell renal carcinoma operated on 17 years ago. A wire localization surgical excision of the ischiorectal fossa mass was performed. The pathological report revealed a metastatic clear cell renal carcinoma. To our knowledge, this is the first case of a clear cell renal carcinoma metastasizing to the ischiorectal fossa reported in the literature. We therefore recommend that any newly discovered mass in any site of a patient with a history of renal cell carcinoma should be carefully explored and biopsied.

Sleeve gastrectomy: have we finally found the holy grail of bariatric surgery? A review of the literature.

OBJECTIVE: Laparoscopic sleeve gastrectomy has become one of the most commonly performed bariatric operations. It is essentially a restrictive bariatric operation; however, a series of hormonal changes occurring postoperatively contribute to decreased appetite and reduced food intake. PATIENTS AND METHODS: This is a literature review of recent articles published on Pubmed, Medline and Google Scholar databases in English. RESULTS: Although, laparoscopic sleeve gastrectomy is commonly performed worldwide, there is still a lack of standardization regarding the surgical technique. Standardizing the surgical technique is essential in order to minimize postoperative complications and offer patients the best long-term weight loss. CONCLUSIONS: Laparoscopic sleeve gastrectomy appears to be an effective bariatric operation. It is relatively easy to perform, well tolerated by the patients and very effective regarding long-term excessive weight loss and resolution of the comorbidities, with minimum nutritional deficiencies.

Anesthesia management for the super obese: is sevoflurane superior to propofol as a sole anesthetic agent? A double-blind randomized controlled trial.

OBJECTIVE: General anesthesia in obese patients is both challenging and demanding. With the rates of obesity in the general population increasing, more patients undergo bariatric surgery. The aim of this study was to compare the performance, effectiveness and recovery from anesthesia of sevoflurane and propofol in combination with remifentanil, with and without bispectral index (BIS) monitoring in super obese patients undergoing bariatric surgery. PATIENTS AND METHODS: In this prospective, double-blind, randomized, controlled study a total of 100 super obese patients (body mass index, BMI > 50 kg/m2) undergoing bariatric surgery were randomly allocated in four groups: a sevoflurane group (n = 25), a sevoflurane with BIS monitoring group (n = 25), a propofol group (n=25) and a propofol with BIS monitoring group (n=25). Hemodynamic parameters, depth of anesthesia, recovery from anesthesia and postoperative pain were recorded. RESULTS: The mean age of patients was 37.7 ± 9.2 years and the median BMI was 57.86 ± 9.33. There were no statistically significant differences between the four groups with respect to patient characteristics, comorbidities and duration of surgery. The intraoperatively mean arterial pressure was significantly higher in both propofol groups. No significant difference was observed between the four groups in respect to heart rate changes during anesthesia. Although the time to eye-opening and extubation was significantly shorter in both propofol groups, recovery from anesthesia, assessed with the Aldrete, Chung and White recovery scores, was significantly faster in sevoflurane groups. No significant difference was observed in postoperative pain between the four groups. CONCLUSIONS: Although both propofol and sevoflurane provide adequate general anesthesia, sevoflurane may be preferable in super obese patients because of superior hemodynamic stability and faster recovery from anesthesia.

Outcome of transplantation in renal allograft recipients from cadaveric donors with standard and expanded criteria: a single-center experience.

INTRODUCTION: The increasing number of patients requiring kidney transplantation and the lack of available organs has led to the utilization of kidneys from expanded criteria donors (ECD). AIM: The comparison of the clinical outcome of renal transplantation, performed in a single center, between allograft recipients from standard (SCD) and expanded criteria donors (ECD). PATIENTS AND METHODS: Data from 215 cadaveric renal transplantations performed during a 16 year period at the University Hospital of Patras were retrospectively studied. Donors' and recipients' characteristics (gender, age, history of hypertension and diabetes mellitus, cold ischemia time, post-transplant and long term graft function) were analyzed. RESULTS: Grafts from donors with expanded criteria (ECD, n = 53) were allocated to older recipients whereas grafts from donors with standard criteria (SCD, n = 162) were allocated to younger recipients. The mean cold ischemia time was 1,146 min and was similar between the two groups of patients. Patients' survival rates were similar between allograft recipients from SCD and ECD up to the 5(th) post-transplant year of follow-up. Graft survival was significantly better in allograft recipients from SCD during a 5-year follow-up period. A significantly lower eGFR was noted in allograft recipients from ECD in comparison to those from SCD throughout the observation period. Cold ischemia time was positively correlated to the development of DGF, while patients with DGF had significantly worse graft function throughout the observation period. CONCLUSION: Patient survival from ECD is comparable to that from SCD but graft survival is significantly lower. However, since renal function of recipients from ECD is adequate for long term period, grafts from ECD should be used in older patients.

Parameters influencing blood erythropoietin levels of renal transplant recipients during the early post-transplantation period.

AIM: Renal transplantation is accompanied by restoration of renal function and endogenous erythropoietin production. The purpose of this study was to investigate the time-related changes of endogenous erythropoietin secretion in the early renal post-transplant period and the influence of various parameters to this process. METHODS: Fifty-eight patients were enrolled in the study and followed up for 3 months after successful renal transplantation. Erythropoietin levels were measured at regular intervals and correlated with renal function, cold ischemia time and immunosuppressive regimen used. RESULTS: Two peaks of serum erythropoietin levels were observed: an early peak that occurred within two days after transplantation and a late one, between weeks 2 and 4, which resulted in increased blood hemoglobin levels. Factors that were found to correlate with erythropoietin levels were delayed graft function, cyclosporine use and prolonged cold ischemia time. Serum creatinine did not correlate to erythropoietin levels although the reduction of serum creatinine preceded the rise of erythropoietin levels. Normal hemoglobin values were restored about three months after successful renal transplantation. CONCLUSION: Serum erythropoietin levels increase during the early post-transplantation period resulting in correction of anemia three months after a successful renal transplantation. Restoration of allograft function is a prerequisite for erythropoietin secretion, while cold ischemia time and immunosuppressive regimen affect graft function.

General principles of hepatectomy in colorectal liver metastases.

Hepatic resection for colorectal liver metastases remains the only therapeutic option that improves long-term survival and offers potential cure. By conventional resectability criteria, only a limited number of patients with metastatic disease can be subjected to surgical intervention. In the past decade, better understanding of the natural history of the disease, the introduction of new chemotherapy agents and the advances in surgical techniques have led to more patients being eligible for surgery. Neoadjuvant chemotherapy can reduce the size of the metastases, allowing operation on patients who were previously considered inoperable. Major resections can nowadays be safely performed with the development of new less-invasive techniques and with the use of supplementary tools like ablation techniques. Using portal vein embolization to induce hypertrophy of future liver remnant and combining it with two-staged hepatectomy allow more patients with advanced disease to undergo potentially curative surgery. Careful selection of patients and aggressive surgery in experienced centers improve survival rates.

Gastrografin administration in the treatment of postoperative delayed gastric emptying.

Five cases of delayed gastric emptying (DGE) are reported. Three patients had pancreatic head carcinoma and underwent a Whipple operation during which truncal vagotomy and gastrectomy were performed. The remaining two patients underwent vagotomy and gastrectomy because of benign peptic ulcer. In one of the pancreatectomy cases, the pylorus was at first preserved, but after DGE developed, a gastrectomy was carried out, which did not result in any improvement. The duration of DGE was 16-72 days, during which time the patients were under total parenteral or enteral nutrition. There were no other major complications. The patients received prokinetic agents (metoclopramide, erythromycin) but without any improvement. Finally, all patients were treated with Gastrografin, 40 ml every two hours, via a nasogastric tube. In all cases, gastric motility was restored within 20-36 hours.

Liver resection for metastatic non-colorectal non-neuroendocrine hepatic neoplasms.

AIMS: Major liver surgery can be performed safely and hepatic resection for metastatic disease is increasingly carried out. However, the role of liver resection for hepatic metastases from non-colorectal, non-neuroendocrine (NCNN) cancers is unknown. Our aim was to evaluate our experience from hepatectomies for NCNN metastases. A retrospective study of 170 patients with liver resection performed the last 8 years was performed in two liver units in affiliated university hospitals. METHODS: Eighteen patients underwent liver resection for NCNN tumours. Origins included kidney (n=6), breast (n=4), gastric tumours (n=4), intestinal leiomyosarcoma (n=2) and malignant melanoma and in one patient a metastatic papillary of unknown origin was found. Eleven patients underwent a hepatic lobectomy and seven had local resections. Ten hepatectomies were performed at the same time with the primary tumour resection (synchronous resections) with five of those in an en bloc fashion with the primary tumour. RESULTS: There were no post-operative deaths and the peri-operative morbidity was minimal. During a median follow-up time of 3.2 years, 14 patients are alive with one of them having developed pulmonary metastases. CONCLUSION: In carefully selected patients with NCNN liver metastasis, liver resection can prolong survival as well and improve quality of life.

Simple (non-parasitic) liver cysts: clinical presentation and outcome.

Non-parasitic hepatic cysts are frequent and usually asymptomatic. Investigation must differentiate from parasitic or neoplastic cysts. Ultrasonography, computed tomography, magnetic resonance imaging and serology do not always ensure a definitive diagnosis, where as other diagnostic methods offer little assistance. Symptoms, complications or uncertain diagnosis make treatment necessary. Various techniques have been used in management of non-parasitic hepatic cysts. Both surgical and recent minimally invasive methods such as laparoscopy and percutaneous aspiration with sclerotherapy are discussed and evaluated. Treatment of choice or indications for each method remains a controversial subject that requires further study.

Conversion of unresectable hepatoma to resectable. Report of a case and review of the literature.

One of the most important reasons that hepatocellular carcinoma displays a poor prognosis, is the low resectability rate at the time of the diagnosis. In this study, we report a case of unresectable hepatocellular carcinoma converted to resectable after transcatheter arterial chemoembolization. In addition a review of the literature is attempted.

Pancreatic carcinoma is characterized by elevated content of hyaluronan and chondroitin sulfate with altered disaccharide composition.

The amount and the types of glycosaminoglycans (GAGs) present in human pancreatic carcinoma were examined and compared with those in normal pancreas. Human pancreatic carcinoma contained increased levels (4-fold) of total GAGs. Particularly, this carcinoma is characterized by a 12-fold increase of hyaluronan (HA) and a 22-fold increase in chondroitin sulfate (CS) content. CS in pancreatic carcinoma exhibited an altered disaccharide composition which is associated with marked increase of non-sulfated and 6-sulfated disaccharides. Dermatan sulfate (DS) was also increased (1.5-fold) in carcinoma, whereas heparan sulfate (HS), the major GAG of normal pancreas, becomes the minor GAG in pancreatic carcinoma without significant changes in the content and in molecular size. In all cases, the galactosaminoglycans (GalGAGs, i.e. CS and DS) derived from pancreatic carcinomas were of lower molecular size compared to those from normal pancreas. The results in this study indicate, for the first time, that human pancreatic carcinoma is characterized by highly increased amounts of HA and of a structurally altered CS.

Relative risk of cancer in sonographically detected thyroid nodules with calcifications.

PURPOSE: The aim of this prospective study was to evaluate the significance of sonographically detected thyroid calcifications in the diagnosis of thyroid cancer. METHODS: One hundred eighty-eight patients with thyroid disease, including 37 with thyroid cancer, were included in the study. Each patient underwent preoperative, high-resolution sonography to evaluate the thyroid gland for the presence of calcifications. RESULTS: The highest incidence of calcification was found in thyroid cancer (54%), followed by multinodular goiter (40%), solitary nodular goiter (14%), and follicular adenomas (12%). The incidence of cancer was significantly higher in calcified nodules (29%) than in noncalcified nodules in the entire group (14%) (p = 0.019), with a relative risk of 2.5. In the group of solitary thyroid nodules, the incidence of cancer in the calcified nodules (55%) was higher than in the nodules without calcification (23%) (p = 0.016). Multiple noncalcified thyroid nodules harbored cancer in only 5% of cases. Compared with multiple noncalcified thyroid nodules, the solitary calcified nodules demonstrated a relative risk of 22.8. In both the solitary and multiple nodules, the relative risk in the presence of calcification was about the same, around 4. Patients younger than 40 years with calcified nodules constituted a high-risk group, with a relative risk of 3.8 versus 2.5 in patients older than 40 years with calcified nodules. CONCLUSIONS: The detection of thyroid calcifications by sonography is diagnostically valuable, especially in cases involving a solitary nodule or a young person. The presence of calcifications in these cases should raise the suspicion of malignancy. The low incidence of cancer in patients with multiple noncalcified thyroid nodules suggests that a more conservative approach may be appropriate in such cases.

Bile leakage following T-tube removal in orthotopic liver transplantation.

BACKGROUND/AIMS: Biliary tract complications constitute a common cause of post-operative morbidity after orthotopic liver transplantation. Bile leakage following T-tube removal, even if uncommon, can also seriously influence post-operative recovery. This report outlines the diagnostic and therapeutic policy used to treat this complication in a large liver transplantation center. METHODOLOGY: Fourteen consecutive cases of bile leakage after T-tube removal are presented. Abdominal pain was the most common symptom and acute abdomen developed in one third of the patients. Ultrasonography was the most common imaging technique used. RESULTS: Five patients were treated conservatively with or without percutaneous drainage of the biloma and 9 patients underwent an exploratory laparotomy. Ligation of the T-tube tract was the most common technique used. All patients had an uneventful clinical course. CONCLUSIONS: Clinical signs are the most important factor in the diagnosis of this complication, and should be treated surgically if the patient does not improve within 24-48 hours under conservative management. Inadequate fibrous T-tube tract formation due to immunosuppression or the underlying disease could be an explanation for the development of this complication.

Surgical treatment of non-parasitic hepatic cysts: report of 12 cases.

OBJECTIVE: To present our experience of non-parasitic hepatic cysts. DESIGN: Retrospective study. SETTING: University Hospital, Greece. SUBJECTS: 12 consecutive patients with symptomatic non-parasitic hepatic cysts operated on during the 7-year period 1990-97 inclusive. INTERVENTIONS: Wide unroofing of the hepatic cysts. MAIN OUTCOME MEASURES: Persistence or recurrence of symptoms and recurrence of cysts. RESULTS: Symptoms persisted or recurred in 2/12 patients and cysts recurred in 2/9 who had ultrasound scans. CONCLUSION: Surgical treatment of non-parasitic hepatic cysts was effective and safe.

Peritoneal echinococcosis.

Peritoneal echinococcosis is rare, even in areas where hydatid disease is endemic. Although the liver and lungs are the organs most commonly involved, peritoneal echinococcosis, either primary or secondary, represents an uncommon but significant manifestation of the disease. We reviewed the medical records of 121 patients with abdominal echinococcosis operated on in our department over the past 12 years. Peritoneal echinococcosis was found in 17 patients, usually combined with liver disease. The presenting symptoms were mostly atypical, and a few cases were discovered accidentally during routine follow-up after operations for hepatic echinococcosis. Surgery remains the best curative or palliative treatment for peritoneal echinococcosis, although anthelmintics can be an effective alternative for the treatment of small and asymptomatic cysts.

Long-term results after liver transplantation for primary hepatic epithelioid hemangioendothelioma.

BACKGROUND: Hepatic epithelioid hemangioendothelioma (PHEHE) is a multifocal, low-grade malignant neoplasia characterized by its epithelial-like appearance and vascular endothelial histogenesis. The outcome of 16 patients treated with orthotopic liver transplantation (OLT) is the subject of this report. METHODS: A retrospective study of 16 patients with HEHE (7 men, 9 women) with ages ranging from 24 to 58 years (mean 37 +/- 10.6 years). Follow-up intervals ranged from 1 to 15 years (median of 4.5 years). RESULTS: Actual patient survival at 1, 3, and 5 years was 100, 87.5, and 71.3%, respectively. Disease-free survival at 1, 3, and 5 years was 81.3, 68.8, and 60.2%, respectively. The 90-day operative mortality was 0. Involvement of the hilar lymph nodes or vascular invasion did not affect survival. The 5-year survival of HEHE compares favorably with that of hepatocellular carcinoma at the same stage (stage 4A): 71.3 versus 9.8% (p = 0.001) CONCLUSIONS: The long-term survival obtained in this series justifies OLT for these tumors even in the presence of limited extrahepatic disease.

Distribution and changes of glycosaminoglycans in neoplasias of rectum.

The content, composition and physicochemical characteristics of glycosaminoglycans in human rectum and rectum carcinoma were investigated by chemical analyses, enzymic treatments, chromatographic and electrophoretic techniques. The overall glycosaminoglycan content was increased about 2 fold in neoplastic tissues compared to nonneoplastic tissues. The absolute amounts of chondroitin sulfate, hyaluronic acid and dermatan sulfate significantly increased but the amounts of heparan sulfate decreased in neoplastic tissues compared with nonneoplastic tissues. In addition an increased fraction of keratan sulfate and undersulfated chondroitin was identified in neoplastic tissues. HPLC analysis of chondroitinase AC and ABC digests showed a marked increase in delta di-6S and delta di-OS disaccharides in tumor chondroitin sulfate, revealing significant alterations on the sulfation pattern. The results indicate that specific glycosaminoglycan alterations occur in human rectum carcinoma and suggest that proteoglycan metabolism is also altered in this carcinoma.

Conservative surgery in the treatment of hepatic hydatidosis.

OBJECTIVE: To examine the morbidity, mortality and recurrence rate after a modified conservative operation in the treatment of hepatic hydatidosis. DESIGN: Prospective open study. SETTING: University hospital, Greece. SUBJECTS: 67 Consecutive patients with hepatic hydatidosis, operated on between 1985 and 1990. INTERVENTION: The liver was mobilised and abdominal cavity isolated with pads soaked in 15% saline solution. Hydatid fluid was aspirated from the cysts which were widely deroofed, sterilised with 15% saline, and then oversewn with a braided absorbable suture. Drains were left in place and a third of patients also had omentoplasty (n = 22). MAIN OUTCOME MEASURES: Morbidity, mortality and recurrence rate. RESULTS: One patient died (1%), 4 developed complications (6%), and there were 3 recurrences (6%). It made no difference whether an omentoplasty was added or not. CONCLUSION: Conservative surgery achieves satisfactory results in the treatment of hepatic hydatidosis.