Anemia and stroke: Where do we stand?

Anemia seems to have a clear relationship with cerebrovascular events (CVEs), as there is a direct connection between central nervous system, blood supply, and tissue oxygen delivery. Anemia is considered a hyperkinetic state which disturbs endothelial adhesion molecule genes that may lead to thrombus formation. Furthermore, blood flow augmentation and turbulence may result in the migration of this thrombus, thus producing artery-to-artery embolism. It is for this reason that anemia is characterized as "the fifth cardiovascular risk factor." Anemia is consistently present in patients with acute stroke, ranging from 15% to 29%, while the mortality rate was significantly higher in patients suffering from anemia at the time of admission. Different types of anemia (sickle cell disease, beta thalassemia, iron deficiency anemia [IDA]) have been associated with increased cardiovascular and CVE risk. The relation between hemoglobin level and stroke would require further investigation. Unfortunately, treatment of anemia in cardiovascular and cerebrovascular disease still lacks clear targets and specific therapy has not developed. However, packed red blood cell transfusion is generally reserved for therapy in patients with CVEs. What is more, treatment of IDA prevents thrombosis and the occurrence of stroke; although iron levels should be checked, chronic administration favors thrombosis. Regarding erythropoietin (EPO), as there is lack of studies in anemic stroke patients, it would be desirable to utilize both neuroprotective and hematopoietic properties of EPO in anemic stroke patients. This review aims to clarify the poorly investigated and defined issues concerning the relation of anemia and CVEs.

Is management of hyperglycaemia in acute phase stroke still a dilemma?

INTRODUCTION: Close monitoring of blood glucose levels during the immediate post-acute stroke phase is of great clinical value, as there is evidence that the risk of neurological deterioration is associated with both hyper- and hypoglycaemia. The aim of this review paper is to summarise the evidence on post-stroke blood glucose management and its impact on clinical outcomes, during the early post-acute stage. FINDINGS: Post-stroke hyperglycaemia has been associated with increased cerebral oedema, haemorrhagic transformation, lower likelihood of recanalisation and deteriorating neurological state. Thus, hyperglycaemia during an acute stroke may result in poorer clinical outcomes, infarct progression, poor functional recovery and increased mortality rates. Although hypoglycaemia may also lead to poorer outcomes via further brain injury, it can be readily reversed by glucose administration. In most patients, the goal of regular treatment is euglycaemia and for acute-stroke patients, a reasonable approach is to target control of glucose level at 100-150 mg/dL. CONCLUSION: Both hypoglycaemia and hyperglycaemia may lead to further brain injury and clinical deterioration; that is the reason these conditions should be avoided after stroke. Yet, when correcting hyperglycaemia, great care should be taken not to switch the patient into hypoglycaemia, and subsequently aggressive insulin administration treatment should be avoided. Early identification and prompt management of hyperglycaemia, especially in acute ischaemic stroke, is recommended. Although the appropriate level of blood glucose during acute stroke is still debated, a reasonable approach is to keep the patient in a mildly hyperglycaemic state, rather than risking hypoglycaemia, using continuous glucose monitoring.

Minimally Invasive Video-Assisted Total Thyroidectomy (mi V.A.T.T.) - Case Series of 48 Patients.

PURPOSE: The first report of miVATT was published in 1998 by Miccoli, leading to a revolution in the field of thyroid surgery. This prospective study aims to evaluate the technique with regard to our department's experience over a four-year period. MATERIAL-METHODS: Between September 2009 and October 2013, 48 adult patients (37 females, 11 males) with a mean age of 41.3 (± 11.6) years underwent scheduled miVATT for benign thyroid lesions. Selection criteria included thyroid volume <15 ml and nodules not exceeding 3.5 cm of diameter. Thyroiditis, previous neck surgery and previous irradiation, mediastinal goiter and involvement in another clinical study constituted the exclusion criteria. The procedure we performed was miVATT as described by Miccoli with the only additions being the use of the Harmonic Scalpel and the fixation of the endoscope on a holding device. Also, no drains were applied. RESULTS: No conversions to open surgery were needed. Operation time for total thyroidectomy was 71.23 min (± 23.81) with a mean hospitalization of 1.14 days (± 0.4). Five patients (10.4%) exhibited transient hypocalcemia, whereas there were no recurrent laryngeal nerve palsies. Post-operative pain was mild and the final aesthetic result was considered excellent by the patients. CONCLUSION: miVATT is a safe and feasible alternative to the conventional thyroidectomy when performed in carefully selected patients by experienced surgeons.

Surgical management of gastrointestinal stromal tumors: a single centre's experience.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) represent 85% of all mesenchymal neoplasms that affect the gastrointestinal track. Aim of this study is to report a case series of 18 GISTs treated surgically in a single centre and to discuss the diagnostic and therapeutic issues regarding these tumors. CASE SERIES: A retrospective search of the unit's medical records from 2002 to 2014 was carried out, to collect all cases diagnosed and treated for GISTs. Demographics and clinical features was obtained for all relevant cases. RESULTS: Eighteen cases (18) of GIST were identified. Eleven tumors were located in the stomach, 3 tumors in the duodenum and 4 tumors in the jejunum. The mean age at diagnosis was 62.5 (range 42-81) years, while the male to female ratio was 1.57/1 (11 males/7 females). Patients presented with a variety of symptoms and all underwent surgery. The 5-year-survival rate of these patients was 50%. CONCLUSION: Due to non-specific presentation of GISTs, initial diagnosis of these tumors may be delayed. High clinical suspicion and knowledge of their characteristics are essentials in order to achieve an early diagnosis and lead patients to surgery as soon as possible. Hippokratia 2015, 19 (1): 73-75.

Total thyroidectomy without the use of drainage - case series of 66 patients.

AIM: The aim of this series is to study the need of drainage use after total thyreoidectomy. MATERIAL AND METHODS: Retrospective study of a series of patients who underwent total thyroidectomy from 2005 up to 2013. The presence or not of hematomas, seromas and hemorrhage were recorded. RESULTS: Out of the 66 patients included in this series, only one case of post-operative hematoma was recorded. Neither a hemorrhage nor a seroma were identified despite the volume, the underlying pathology and the co-morbidity of the patients involved. CONCLUSION: In our experience a thyroidectomy with adequate hemostasis does not require the use of drains.

Abdominoperineal resection for rectal cancer: is the pelvic drain externalization site an independent risk factor for perineal wound healing?

Aim. The aim of this paper is to investigate if the insertion of the pelvic drainage tube via the perineal wound could be considered as an independent risk factor for perineal healing disorders, after abdominoperineal resection for rectal malignancy. Patients and Methods. The last two decades, 75 patients underwent elective abdominoperineal resection for malignancy. In 42 patients (56%), the pelvic drain catheter was inserted through the perineal wound (PW group), while in the remaining 33 (44%) through a puncture skin wound of the perineum (SW group). Patients' data with respect to age (P = 0.136), stage (P > 0.05), sex (P = 0.188) and comorbidity (P = 0.128) were similar in both groups. 25 patients (PW versus SW: 8 versus 17, P = 0.0026) underwent neoadjuvant radio/chemotherapy. Results. The overall morbidity rate was 36%, but a significant increase was revealed in PW group (52.4% versus 9%, P = 0.0007). In 33.3% of the patients in the PW group, perineal healing was delayed, while in the SW group, no delay was noted. Perineal healing disorders were revealed as the main source of increased morbidity in this group. Conclusion. The insertion of the pelvic drain tube through the perineal wound should be considered as an independent risk factor predisposing to perineal healing disorders.

Selective embolization for massive upper gastrointestinal bleeding deriving from gastric angiodysplasia.

Transcatheter arterial embolization is a valuable, minimally invasive method, used as treatment for upper gastrointestinal bleeding, after failed primary endoscopic approach. It is a safe and effective procedure, but it's use is limited because of relatively high rates of rebleeding and mortality. The aim of this paper is to present a case of severe, massive upper gastrointestinal bleeding deriving from gastric angiodysplasia, which was treated successfully with superselective embolization. The patient recovered from the haemorrhagic shock and avoided emergency surgical intervention.

The effects of tacrolimus on colonic anastomotic healing in rats.

AIM: The aim of this experimental study is to investigate the effects of tacrolimus on colonic anastomotic healing after subcutaneous administration. MATERIALS AND METHODS: Forty Albino-Wistar male rats were divided into two groups, with two equal subgroups each. They all underwent colonic resection followed by a single-layer, inverted colon anastomosis and were injected subcutaneously with either 1 ml of 0.9% NaCl solution or tacrolimus (0.1 mg/kg body weight) depending on their group. Half of the rats were sacrificed on the fourth postoperative day, while the remaining half were sacrificed on the eighth postoperative day. Macroscopical and histological assessment was performed, while anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were evaluated. RESULTS: On the fourth postoperative day, the bursting pressures (217.00 ± 11.12, p < 0.001), the fibroblast activity (2.80 ± 0.42, p = 0.022), the neoangiogenesis (2.10 ± 0.32, p = 0.007) and the tissue hydroxyproline concentration (254.23 ± 67.10, p = 0.001) were significantly higher in the tacrolimus-treated animals. Furthermore, tacrolimus significantly decreased the inflammatory cell infiltration (1.50 ± 0.53, p < 0.001) and the tissue collagenase I concentration (4.16 ± 0.76, p = 0.002). On the eighth day, the bursting pressure (264.00 ± 32.61, p < 0.001) and the hydroxyproline tissue concentration (331.04 ± 55.56, p = 0.002) were significantly higher in the tacrolimus subgroups. The inflammatory cell infiltration (1.20 ± 0.42, p < 0.001) and the collagenase I concentration (1.61 ± 0.83, p < 0.001) were significantly lower. In addition, the adhesion formation score was significantly lower (1.20 ± 0.92, p = 0.065). CONCLUSION: Tacrolimus, when injected subcutaneously, promotes healing of colonic anastomoses in rats. It impairs not only inflammatory response but also collagen degradation, resulting to increased anastomotic strength on the fourth as well as on the eighth postoperative day.

Defunctioning ileostomy closure following low anterior resection by chemotherapy.

AIM: The aim of this study is to review the time between formation and closure of loop ileostomies following total mesorectal excision in patients with rectal cancer. PATIENTS AND METHODS: A retrospective study of 170 patients who underwent low anterior resection for rectal cancer, between 1990 and 2009. Loop ileostomies were created in 8 patients. RESULTS: Of the 8 patients with defunctioning loop ileostomies, 4 received adjuvant chemo-radiotherapy, 3 received neo-adjuvant chemo-radiotherapy and 1 did not receive anything. There was 12.5% morbidity. The time from formation to closure for the patient with no adjuvant therapy was 3 months and for those with adjuvant therapy was 7 months. This was a significant delay. CONCLUSION: Time between formation and closure of loop ileostomy following anterior resection of rectum is significantly delayed by adjuvant chemotherapy.

Progress in rectal cancer staging and treatment.

Colorectal cancer poses a worldwide major health issue. Rectal cancer has somewhat distanced itself from colonic cancer as a different oncologic entity, due to differences in diagnosis and treatment. Several developments over the last years have improved screening, diagnostics, pre-operative therapy, surgical techniques and postoperative patient care. The multidisciplinary approach to rectal cancer, mainly through the co-operation of surgeons, oncologists and radiologists, seems to be one of the most important steps in the management of that disease.

Laparoscopic right hemicolectomy due to colon cancer.

AIM: The aim of this study is to present our patients with laparoscopic right hemicolectomy due to cancer. PATIENTS AND METHODS: Between 2005 and 2009, laparoscopic right hemicolectomy for cancer was performed in 9 patients. RESULTS: The average operative time was 168 min. The average hospital stay was 5.3 days. There was one conversion (11.1%) to an open procedure. There were no postoperative complications. All the patients remain so far with no signs of tumor recurrence. CONCLUSION: Laparoscopic right hemicolectomy for cancer in the hands of an experienced laparoscopic surgeon is a safe and efficient procedure.

Laparoscopic sigmoidectomy for colon cancer.

The aim of this study is to report our experience with laparoscopic sigmoidectomy due to cancer. Between 2007 and 2009, laparoscopic sigmoidectomy for cancer was performed in 3 patients. The average operative time was 176 min. The average hospital stay was 10.2 days. There was one anastomotic leak. The patient was subjected to laparotomy and a Hartmann's procedure and drainage of the peritoneal cavity was performed. In conclusion, laparoscopic sigmoidectomy for cancer is a safe and efficient procedure.

Anastomotic leakage following low anterior resection for rectal cancer.

AIM: Aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication. PATIENTS AND METHODS: Between 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME). RESULTS: A total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy. CONCLUSION: The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

Metachronous colorectal cancer.

AIM: In this study, we present our patients with metachronous colorectal cancer. PATIENTS AND METHODS: In the period between 1990 and 2009, 670 patients with colorectal cancer were treated. RESULTS: Metachronous cancer was developed in 4 (0.6%) patients. The time interval between index and metachronous cancer was 28 months to 22 years (mean 146 months). CONCLUSION: Metachronous colorectal cancer is a potential risk that proves the necessity of postoperative colonoscopic control of all patients with colorectal cancer.

Brain metastases in colorectal cancer.

AIM: The aim of this study is the presentation of brain secondaries associated with colorectal cancer. PATIENTS AND METHODS: In the period between 1990 and 2009, 670 patients with colorectal cancer were treated. RESULTS: From 670 patients, 5 patients were identified with brain metastases. The incidence was 0.73%. The median interval between the colorectal cancer and the development of the brain secondaries was 7.5 months. Median survival after the diagnosis of brain metastases was 4.3 months. CONCLUSION: Brain metastases associated with colorectal cancer are relatively rare, but also a frequent cause of death.

Large bowel obstruction due to endometriosis.

We report on three cases of premenopausal female patients with large bowel endometriosis causing intermittent obstruction.

Circumferential stapled procedure for bleeding ano-rectal varices.

AIM: Aim of this study is to demonstrate that the circumferential stapled procedure for rectal varices is a feasible and suitable method of controlling bleeding varices. PATIENTS: Between 2004 and December 2007, four patients underwent the procedure as an emergency, with the intention of controlling haemorrhage. RESULTS: Four patients underwent this procedure, with successful control of bleeding achieved in all. No further rebleeding was observed in the follow-up period. CONCLUSION: The stapled disruption of bleeding rectal varices in patients with portal hypertension seems a very useful and effective procedure.