Comparison of the laparoscopic versus open surgery in patients aged over 75 years old with colorectal cancer. Short- and Mid-term outcomes.

PURPOSE: The benefit of minimally invasive surgery in colorectal cancer patients has been established, however it is not clear whether these advantages apply to older patients as well. The aim of this study was to review short- and mid-term outcomes in elderly patients, over the age of 75 years, with colorectal cancer. METHODS: This was a retrospective study of selected patients over the age of 75 who underwent laparoscopic and open surgery for colorectal cancer between February 2013 and January 2018 in a tertiary referral center. All patients were categorized in two groups: Group 1 included patients who had open procedure (OP) and Group 2 those who underwent laparoscopic procedure (LP). Demographic, clinical, short- and midterm postoperative data were collected and analyzed between the two study groups. RESULTS: A total of 78 patients were included in our cohort; 39 (50%) were operated with LP. The LP was equally safe in comparison with the OP, considering the similar postoperative complications [9 patients (34.6%) in LP and 5 patients (18.5%) in OP (p=0.224)], including anastomotic leakage in 2 patients (7.7%) in LP and 1 patient (3.7%) in OP group (p=0.61). The median postoperative hospital stay favored the laparoscopic approach (6 days in LP group and 8 days in OP group; p=0.001). The number of harvested lymph nodes were without statistically significant differences [LP group retrieved 20.0 nodes in comparison with 20.5 nodes in OP group (p= 0.816)]. The overall survival analysis showed no difference between the two approaches in 12 and 24 postoperative months (p=0.098 and 0.387, respectively).

Neoadjuvant chemoradiotherapy in rectal cancer and anorectal sphincter dysfunction: Review of the literature.

PURPOSE: The purpose of this article was to review the current medical literature regarding deterioration of anorectal function in patients receiving neoadjuvant chemoradiotherapy before surgery for locally advanced rectal cancer. METHODS: We reviewed the current literature including research studies, electronic database PUBMED-MEDLINE, published research results and metanalysis papers from high-volume institutes, collecting and comparing the different results. Pathophysiology as well as emerging solutions for treating anorectal sphincter dysfunction were researched in order to provide an insight of this complex issue. RESULTS: All available data suggest that neoadjuvant radiation therapy impairs internal anal sphincter function mostly through nerve damaging mechanisms, as nerves are more susceptible to damage than muscular fibers. CONCLUSION: Current radiotherapy recommendations are oriented in exclusion of anal canal from radiation field when oncologically safe or using new sphincter-sparing techniques for neoadjuvant radiotherapy aiming to improve the patient quality of life receiving radiation therapy prior to surgery. However, more well designed studies are required to assess the pathophysiology as well as treatment options for this complex matter, which strongly affects the quality of life of rectal cancer patients.

Sudden 'cure' of type two diabetes due to pancreatic insulinoma: A case report.

Insulinomas are rare tumors of the islet cells of the pancreas and are the most common cause of endogenous hyperinsulinism. Although they usually present with symptoms of hypoglycemia, sometimes they can have vague symptoms. We present the case of a 62-year-old diabetic female who was diagnosed with a large insulinoma after being investigated for the 'cure' of her diabetes. We also review the literature regarding insulinomas in patients with diabetic. A 62-year-old, obese woman with type 2 diabetes mellitus was initially investigated for an unexplained normalization of her blood glucose levels after the cessation of antidiabetic medication due to an episode of severe hypoglycemia. She remained without antidiabetics for three months maintaining normoglycemia, and thereafter, she started experiencing frequent but less severe hypoglycemic episodes. She did not change her diet habits or level of activity and did not lose any weight. The patient underwent further investigation with a supervised 72 h fasting test, which resulted in the biochemical diagnosis of endogenous hyperinsulinism. Imaging studies revealed the presence of a large insulinoma in the head of the pancreas. Finally, the patient underwent a pylorus preserving Whipple procedure, which reversed the aforementioned 'normalization' of glucose levels and the underlying diabetes mellitus reappeared. Insulinomas are rare tumors causing hypoglycemia. Even more rarely are found in diabetic patients, making the diagnosis more challenging and probably delayed, as the symptoms are masked by the presence of diabetes, thereby leading to a more advanced disease diagnosis.

The Effect of Perioperative Ischemia and Reperfusion on Multiorgan Dysfunction following Abdominal Aortic Aneurysm Repair.

Abdominal aortic aneurysms (AAAs) are relatively common and are potentially life-threatening medical problems. The aim of this review is to provide an overview of the effect of I/R injury on multiorgan failure following AAA repair. The PubMed, CINAHL, EMBASE, Medline, Cochrane Review, and Scopus databases were comprehensively searched for articles concerning the pathophysiology of I/R and its systemic effects. Cross-referencing was performed using the bibliographies from the articles obtained. Articles retrieved were restricted to those published in English. One of the most prominent characteristics of AAA open repair is the double physiological phenomenon of ischemia-reperfusion (I/R) that happens either at the time of clamping or following the aortic clamp removal. Ischemia-reperfusion injury causes significant pathophysiological disturbances to distant organs, increasing the possibility for postoperative multiorgan failure. Although tissue injury is mediated by diverse mechanisms, microvascular dysfunction seems to be the final outcome of I/R.

The effect of warm liver ischaemia & reperfusion injury on circulating plasma lipid levels & lipolytic enzyme activity in rat & the impact of ischaemic preconditioning.

BACKGROUND & OBJECTIVES: Ischaemia/reperfusion (I/R) associated with major liver surgery compromises liver function. Ischaemic preconditioning (IPC) may be effective in minimizing hepatic I/R injury. This study aimed to investigate the impact of liver ischaemic manipulations on lipid metabolism in rat during the process of liver recovery after liver surgery. METHODS: Sixty three male Wistar rats were assigned to three groups: the sham group, the I/R group which underwent warm ischaemia and reperfusion (I/R), and the IPC group. The animals were subdivided in 3 groups [1 st , 3 rd and 7 th postoperative day (PO)]. Hepatic lipase (HL) and total lipase (TL) activity and the levels of aspartate and alanine transaminases (AST, ALT), triglycerides, HDL and cholesterol were measured in plasma. RESULTS: There was no significant difference in the activity of HL and TL between the groups. Significant higher levels of HDL (P<0.0001) were observed in the IPC group when compared to the other groups on the 3 rd PO day. Triglycerides (P<0.0001) and HDL (P=0.003) in the IPC group were higher than the sham group on the 7 th PO day while HDL was also higher in the I/R group. Significantly higher cholesterol levels were found in the I/R and IPC groups on the 7 th PO day, which were not observed in the sham group. There was a similar curve for triglycerides in the sham and IPC groups while there were significantly higher levels of triglycerides on day 7 for the I/R group. The levels of HDL in the IPC group were higher on the 3 rd and 7 th PO day, compared to day 1. INTERPRETATION & CONCLUSION: Warm ischaemia and I/R injury do not seem to affect lipolytic enzyme activity after the 1 st PO day despite the effects on plasma lipids. IPC seems to prevent accumulation of triglycerides and cholesterol in plasma.

The effect of hepatectomy on plasma lipolytic enzyme activity and circulating lipid levels: an experimental study on Wistar rat.

BACKGROUND/AIMS: The aim of this experimental study was to investigate the effect of liver resection and resulting transient hepatic steatosis on circulating lipid levels and plasma lipolytic enzyme activity. METHODOLOGY: Forty-eight male Wistar rats were assigned to the sham (Group A=21) or the hepatectomy group (Group B=27) and were further subdivided according to the day they were sacrificed (POD 1, 3 and 7). We measured hepatic lipase (HL) and total lipase (TL) activity and plasma levels of AST, ALT, triglycerides, HDL and cholesterol. RESULTS: There were no significant differences in the activities of HL and TL between the groups. Nevertheless, significant differences were observed in the levels of HDL (p=0.001) and cholesterol (p=0.001) on the 1st POD, and in triglycerides (p=0.045) on the 7th POD. A significant drop in the levels of HDL and cholesterol on the 1st POD was followed by a rapid recovery (3rd POD) and maintenance of these levels in group B until the 7th POD, while high levels of triglycerides (TG) were observed only on POD 7. CONCLUSIONS: After hepatectomy the activities of the lipolytic enzymes recover early and remain stable during regeneration. HDL and cholesterol levels are reversely proportional to the liver stress.

Late polypropylene mesh susceptibility to infection during intra-abdominal sepsis.

PURPOSE: To evaluate the susceptibility of high-density polypropylene mesh to contamination, 1 year after experimental hernia repair. METHODS: Wistar rats were randomized into two groups: one experimental group (n = 20) and another control group (n = 10). Mesh hernia repair was performed with intra-abdominal (group I, n = 10) or subcutaneous (group II, n = 10) implantation of grafts. The three groups were exposed to an intra-abdominal E. coli administration after 1 year of operation. After 24 hr, the meshes and peritoneum were sampled from the experimental and control groups, respectively, in order to assess bacterial inoculation. Immunoreaction to E. coli inoculation was also evaluated after 24 hr by measuring serum interleukin-6 (IL-6) and C-reactive protein (CRP) levels. RESULTS: Bacteriological analysis revealed increased contamination in groups I and II when compared with the control group (p = .001 and .007, respectively). IL-6 levels were increased in both groups I and II compared with the control group, 24 hr after E. coli injection (p = .034 and .022, respectively), while there was no statistically significant difference between groups concerning the concentration of CRP. CONCLUSIONS: Polypropylene mesh is vulnerable to bacterial inoculation during intra-abdominal sepsis 1 year after mesh placement.

Safety and effectiveness of outpatient laparoscopic cholecystectomy in a teaching hospital: a prospective study of 110 consecutive patients.

BACKGROUND: The aim of this study was to evaluate the safety and efficacy of outpatient laparoscopic cholecystectomy (OLC) in a day surgery unit in a teaching hospital. OLC was offered to patients with symptomatic cholelithiasis who met the following established inclusion criteria: ASA (American Society of Anesthesiology) physical status classification class I and II; age: 18 - 70 years; body mass index (BMI) < 30 kg/m2; patient acceptance and cooperation (informed consent); presence of a responsible adult to accompany the patient to his residency; patient residency in Athens. The primary study end-point was to evaluate success rates (patient discharge on the day of surgery), postoperative outcome (complications, re-admissions, morbidity and mortality) and patient satisfaction. A secondary endpoint was to evaluate its safe performance under appropriate supervision by higher surgical trainees (HSTs). FINDINGS: 110 consecutive patients, predominantly female (71%) and ASA I (89%) with a mean age 40.6 +/- 8.1 years underwent an OLC. Surgery was performed by a HST in 90 patients (81.8%). A mean postoperative pain score 3.3 (range 0-6) occurred in the majority of patients and no patient presented postoperative nausea or vomiting. Discharge on the day of surgery occurred in 95 cases (86%), while an overnight admission was required for 15 patients (14%). Re-admission following hospital discharge was necessary for 2 patients (1.8%) on day 2, due to persistent pain in the umbilical trocar site. The overall rate of major (trocar site bleeding) and minor morbidity was 15.5% (17 patients). At 1 week follow-up, 94 patients (85%) were satisfied with their experience undergoing OLC, with no difference between grades of operating surgeons. CONCLUSIONS: This study confirmed that OLC is clinical effective and can be performed safely in a teaching hospital by supervised HSTs.

The combined effect of erythropoietin and granulocyte macrophage colony stimulating factor on liver regeneration after major hepatectomy in rats.

BACKGROUND: The liver presents a remarkable capacity for regeneration after hepatectomy but the exact mechanisms and mediators involved are not yet fully clarified. Erythropoietin (EPO) and Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF) have been shown to promote liver regeneration after major hepatectomy.Aim of this experimental study is to compare the impact of exogenous administration of EPO, GM-CSF, as well as their combination on the promotion of liver regeneration after major hepatectomy. METHODS: Wistar rats were submitted to 70% major hepatectomy. The animals were assigned to 4 experimental groups: a control group (n = 21) that received normal saline, an EPO group (n = 21), that received EPO 500 IU/kg, a GM-CSF group (n = 21) that received 20 mcg/kg of GM-CSF and a EPO+GMCSF group (n = 21) which received a combination of the above. Seven animals of each group were killed on the 1st, 3rd and 7th postoperative day and their remnant liver was removed to evaluate liver regeneration by immunochemistry for PCNA and Ki 67. RESULTS: Our data suggest that EPO and GM-CSF increases liver regeneration following major hepatectomy when administered perioperatively. EPO has a more significant effect than GM-CSF (p < 0.01). When administering both, the effect of EPO seems to fade as EPO and GM-CSF treated rats have decreased regeneration compared to EPO administration alone (p < 0.01). CONCLUSION: EPO, GM-CSF and their combination enhance liver regeneration after hepatectomy in rats when administered perioperatively. However their combination has a weaker effect on liver regeneration compared to EPO alone. Further investigation is needed to assess the exact mechanisms that mediate this finding.

Gastric glomus tumor: a case report.

Gastric glomus tumors are rare mesenchymal tumors of the gastrointestinal tract. We describe a 72-year-old patient who presented with episodes of melena and was subsequently investigated for a tumor of the antrum of the stomach. Surgical resection revealed a 2 x 2 x 1.7 cm well circumscribed submucosal tumor, extending into the muscularis propria. The histopathologic examination of the specimen demonstrated a glomus tumor of the stomach. We discuss the preoperative investigation, the diagnostic problems and the surgical treatment of the patient with this rare submucosal lesion.

Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump.

OBJECTIVES: To evaluate the impact of the length of the isolated jejunal loop and the type of pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy. METHODS: One hundred thirty-two consecutive patients who underwent a pancreaticoduodenectomy were studied according to the length of the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and the type of pancreaticojejunostomy (invagination vs duct to mucosa). RESULTS: The use of the long isolated jejunal loop was associated with a significantly lower pancreatic leakage rate compared with the use of a short isolated jejunal loop (4.34% vs 14.2%, P < 0.05). In addition, the use of duct-to-mucosa technique was associated with significantly lower incidence of postoperative pancreatic fistula compared with the invagination technique (4.2% vs 14.5%, P < 0.05). Finally, patients with a short isolated jejunal loop compared with patients with a long loop had increased morbidity (50.7% vs 27.5%, P < 0.05) and prolonged hospital stay (16.3 +/- 1.9 days vs 10.2 +/- 2.3 days, P < 0.05). Overall mortality rate was 1.5%. CONCLUSIONS: The use of a long isolated jejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreased pancreatic leakage rate after pancreaticoduodenectomy.

Esophagopericardial fistula as a rare complication after total gastrectomy for cancer.

BACKGROUND: Esophagopericardial fistula is a rare but life-threatening complication of benign, malignant or traumatic esophageal disease. It is most commonly associated with benign etiology and carries a high mortality rate which increases with delay in diagnosis. CASE PRESENTATION: We present a case of an esophagopericardial fistula as a rare complication in a 53-year-old male patient, 7 months after total gastrectomy for an adenocarcinoma of the esophagogastric junction. CONCLUSION: The prognosis of esophagopericardial fistula is poor, especially when it is associated with malignancy.

A novel technique for gaining extra length of the abdominal esophagus.

During gastrectomies for carcinomas of the esophagogastric junction, it is often desirable to gain additional length of the abdominal esophagus to construct an intra-abdominal esophagojejunal anastomosis. In this report, we describe a technique of esophageal mobilization that combines transhiatal dissection with transection of both vagus nerves at 3 points: first, at a level 2 cm to 3 cm below tracheal bifurcation; second, 3 cm to 5 cm above the hiatus; and, finally, at the level of the hiatus. Using this technique in 11 patients with carcinoma of the esophagogastric junction, we achieved lengthening of the abdominal esophagus by 3.7 cm +/- 1.2 cm (mean +/- standard deviation). In all cases, the additional esophageal length permitted the completion of an oncologically adequate resection and the execution of a safe intra-abdominal esophagojejunal anastomosis.

A rare coexistence of adrenal cavernous hemangioma with extramedullar hemopoietic tissue: a case report and brief review of the literature.

BACKGROUND: Cavernous hemangiomas of the adrenal gland are rare, benign, non-functioning neoplastic tumors. To our knowledge, 55 cases have been reported in the literature to date. CASE PRESENTATION: We report the first case of a large, non-functioning adrenal cavernous hemangioma that was incidentally found during the preoperative staging workup of a 75 year old woman with left breast adenocarcinoma. Imaging with US, CT scan and MRI showed a heterogeneous 8 cm mass with non-specific radiological features that was located on the left adrenal gland. The mass was surgically excised and pathology revealed an adrenal hemangioma with areas of extramedullar hemopoiesis. CONCLUSION: Although adrenal hemangiomas are rare and their preoperative diagnosis is difficult, they should always be included in the differential diagnosis of adrenal neoplasms.

Does clamping during liver surgery predispose to thrombosis of the hepatic veins? Analysis of 210 cases.

AIM: To test whether clamping during liver surgery predisposes to hepatic vein thrombosis. METHODS: We performed a retrospective analysis of 210 patients who underwent liver resection with simultaneous inflow and outflow occlusion. Intraoperatively, flow in the hepatic veins was assessed by Doppler ultrasonography during the reperfusion phase. Postoperatively, patency of the hepatic veins was assessed by contrast-enhanced CT angiography, when necessary after 3-6 mo follow up. RESULTS: Twelve patients (5.7%) developed intraoperative liver remnant swelling. However, intraoperative ultrasonography did not reveal evidence of hepatic vein thrombosis. In three of these patients a kinking of the common trunk of the middle and left hepatic veins hindering outflow was recognized and was managed successfully by suturing the liver remnant to the diaphragm. Twenty three patients (10.9%) who developed signs of mild outflow obstruction postoperatively, had no evidence of thrombi in the hepatic veins or flow disturbances on ultrasonography and contrast-enhanced CT angiography, while hospitalized. Long term assessment of the patency of the hepatic veins over a 3-6 mo follow-up period did not reveal thrombi formation or clinical manifestations of outflow obstruction. CONCLUSION: Extrahepatic dissection and clamping of the hepatic veins does not predispose to clinically important thrombosis.

Intussusception of the bowel in adults: a review.

Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment. This condition is frequent in children and presents with the classic triad of cramping abdominal pain, bloody diarrhea and a palpable tender mass. However, bowel intussusception in adults is considered a rare condition, accounting for 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction. Eight to twenty percent of cases are idiopathic, without a lead point lesion. Secondary intussusception is caused by organic lesions, such as inflammatory bowel disease, postoperative adhesions, Meckel's diverticulum, benign and malignant lesions, metastatic neoplasms or even iatrogenically, due to the presence of intestinal tubes, jejunostomy feeding tubes or after gastric surgery. Computed tomography is the most sensitive diagnostic modality and can distinguish between intussusceptions with and without a lead point. Surgery is the definitive treatment of adult intussusceptions. Formal bowel resection with oncological principles is followed for every case where a malignancy is suspected. Reduction of the intussuscepted bowel is considered safe for benign lesions in order to limit the extent of resection or to avoid the short bowel syndrome in certain circumstances.

Mixed acinar-endocrine carcinoma of the pancreas: a case report and review of the literature.

INTRODUCTION: Pancreatic tumors usually display either a ductal, an acinar or an endocrine differentiation. Mixed exocrine and endocrine pancreatic tumors are extremely rare. There have been a few reports of the rare entity of mixed acinar-endocrine carcinoma of the pancreas, where the endocrine cells represent more than 30% of the tumor. We herein describe a case of such a pancreatic tumor in an asymptomatic patient. CASE PRESENTATION: A 74-year-old male patient with no evident clinical symptoms was referred for surgical resection of a large mass located on the pancreatic head, which was confirmed by an abdominal U/S, CT and MRI. FNA of the mass under endoscopic ultrasound guidance showed the cytology specimen to comprise of cells with morphological and immunohistochemical characteristics of endocrine pancreatic neoplasms. The patient underwent a modified Whipple's procedure and his post-operative course was uneventful. Pathological examination of the tumor revealed a mixed acinar-endocrine carcinoma of the pancreas. CONCLUSION: Mixed tumors of the pancreas are extremely rare and their clinical features and pathogenesis remain unclear. The endocrine component seems to influence their prognosis favorably.Therefore, aggressive surgical therapy remains the only well established line of treatment for these tumors. Further accumulation of clinical cases will help clarify the clinical course and the optimal therapy for these unusual tumors.

Transdiaphragmatic approach facilitates resection of large (>12 cm) liver tumors.

BACKGROUND/PURPOSE: Various (mostly transthoracic) techniques have been proposed to facilitate access to large tumors located in the upper part of the liver, close to the confluence of the major hepatic veins. The purpose of this study was to investigate the safety and efficacy of a transdiaphragmatic mobilization technique for resection of such tumors. METHODS: Twenty-one patients, with tumors ranging from 12 to 22 cm in diameter, underwent liver resections using our technique of diaphragmatic splitting, with the intention of achieving adequate exposure of the inferior vena cava and the hepatocaval junction. RESULTS: The technique described provided, in all patients, an effective method to achieve the vascular control required for a safe liver resection. Median weight of the excised tumors was 1100 g (range, 817-2860 g). CONCLUSIONS: Large liver tumors (>12 cm) in the upper part of the liver may be approached through a standard bilateral subcostal incision, combined with splitting of the hemidiaphragm, without the need for any kind of thoracic incision.

Intermittent obstructive jaundice following gastric band placement.

Complications of laparoscopic adjustable gastric banding occur in 10 - 20% of patients. However, hepatobiliary complications of this procedure are very rare. We report a unique case of gastric band misplacement around the hepato-duodenal ligament. The patient developed obstructive jaundice several months after the gastric band placement and suffered recurrent episodes of obstructive jaundice and cholangitis that were initially erroneously attributed to fatty infiltration of the liver. Further diagnostic work-up demonstrated the presence of the gastric band in the hepatic hilum. Exploratory laparotomy confirmed the diagnosis, and the band was removed. Jaundice reversed and hepatic function was restored following removal of the occluding band.