Perioperative radiotherapy versus surgery alone for retroperitoneal sarcomas: a systematic review and meta-analysis.

Background There is no clear evidence on whether radiotherapy (RT) improves treatment result in patients with retroperitoneal sarcomas (RPS). Methods A systematic literature search was performed using PubMed, Scopus and CENTRAL databases. Data were retrieved from published comparatives studies in patients with RPS undergoing surgery alone or RT plus surgery. The primary endpoints were the 5-year OS and the median OS. The secondary endpoints were the recurrence-free survival (RFS) and the R0-resection rate. Continuous outcomes were calculated by means of weighted mean difference (WMD). Results Ten out of 374 articles were analyzed. The median OS and the 5-year survival were significantly increased in patients treated with RT and surgery, compared to patients treated with surgery alone (p < 0.00001, p < 0.001). Median RFS was significantly increased in patients treated with either preoperative (p < 0.001) or postoperative (p = 0.001) RT compared to patients that underwent surgery alone. Finally, median R0-resection rate was similar between the two groups (p = 0.56). Conclusion RT along with radical surgery could be the standard of care in at least a subgroup of patients with RPS.

The Role of TAMIS (Transanal Minimally Invasive Surgery) in the Management of Advanced Rectal Cancer - One Shared Story of Three Exceptional Cases.

Purpose of the study: The current gold standard for contemporary treatment of rectal cancer is total mesorectal excision (TME), achieving excellent local disease control and low recurrence rates. However, TME may be associated with postoperative mortality and quality of life deterioration. Therefore, the need to develop less radical treatment strategies has emerged. Transanal minimally invasive surgery (TAMIS) is currently indicated only for early rectal cancer. However, local excision following chemoradiation has yielded promising clinical outcomes in selected cases with more advanced disease. Materials and methods: We describe three cases of patients with advanced rectal cancer, who were managed with TAMIS, either due to patients' unwillingness to tolerate permanent colostomy or due to significant comorbidities. Results: Two of the three patients who also received adjuvant chemoradiation are still in remission for 18 and 15 months respectively. The third patient died early after hospital release due to unrelated causes. Conclusions: Local excision utilizing minimally invasive techniques, alongside with chemoradiotherapy and close follow up can be a viable alternative in carefully selected rectal cancer patients with advanced disease who deny permanent colostomy or are ineligible for major operations.

ki-67 and Topoisomerase IIa proliferation markers in colon adenocarcinoma.

Aberrant cell proliferation is a major cause in the development and progression of carcinogenic process. Epithelia characterized by increased mitotic rates accumulate easily gross numerical and structural chromosomes (polysomy/aneuploidy) and specific gene (deletions, amplifications, point mutations, translocations) deregulations that lead to their progressive neoplastic and finally malignant transformation. Molecules that are critical for evaluating the proliferation status of the corresponding tissues include mainly ki-67 (cytogenetic band: 10q26.2), and also Topoisomerase IIa/Topo IIa (cytogenetic band: 17q21.2). Both of them demonstrate different expression patterns in every cell cycle phase and their estimated expression as Nuclear Labeling Index (NLI) is a very useful tool for assessing the aggressiveness of the examined pre- and malignant tissues. In fact, ki-67 expression increases as a cell progresses through the cell cycle, with highest expression being seen in G2/M phase cell, whereas Topo IIa is expressed in proliferating cells in the late S phase with a peak in G2-M phases. Concerning colon adenocarcinoma, high expression levels of them seem to correlate with advanced disease and also with modified response rates to specific chemotherapeutic agents, such as doxorubicin, an inhibitor of Topo IIa. In the current molecular review we explored the role of these proliferative markers in colon adenocarcinoma and their influence in the tumor biological behavior.

Large Enterolith Complicating a Meckel Diverticulum Causing Obstructive Ileus in an Adolescent Male Patient.

We present a unique case of a 16-year-old male patient who was eventually diagnosed with a large enterolith arising from a Meckel's diverticulum. The enterolith had caused intermittent intestinal symptoms for three years before resulting in small bowel obstruction requiring surgical intervention. Meckel's enterolith ileus is very rare with only few cases described in the literature. To our knowledge, this is only the second case of Meckel's enterolith which had caused intermittent symptoms over a period of time, before resulting in ileus, and the first case where the intermittent symptoms lasted several years before bowel obstruction. The patient had been evaluated with colonoscopy, computerized tomography (CT), and magnetic resonance imaging enterography (MRIE); a calcified pelvic mass had been found, but no further diagnosis other than calcification was established. The patient presented at our emergency department, with symptoms of obstructive ileus and underwent exploratory laparotomy, where a large enterolith arising from a Meckel's diverticulum (MD) was identified, causing the obstruction. A successful partial enterectomy, enterolith removal, and primary end-to-end anastomosis took place; the patient was permanently relieved from his long-standing symptoms. Consequently, complications of Meckel's diverticulum and enterolithiasis have to be included in the differential diagnosis of abdominal complaints.

Complete traumatic main pancreatic duct disruption treated endoscopically: a case report.

INTRODUCTION: Pancreatic injury is uncommon and the management remains controversial. The integrity of the main pancreatic duct is considered the most important determinant for prognosis. CASE PRESENTATION: A 19-year-old Greek man was referred to our tertiary referral centre due to blunt abdominal trauma and an associated grade III pancreatic injury. He was haemodynamically stable and his initial treatment was conservative. Due to deterioration in his clinical symptomatology he underwent an endoscopy 20 days postinjury, where a stent was placed in the proximal pancreatic duct remnant and a bulging fluid collection of the lesser sac was drained transgastrically. He made an uneventful recovery and remains well 7 months postinjury, but a stricture with upstream dilatation of his main pancreatic duct has developed. CONCLUSIONS: The clinical status of the patient rather than the grade of pancreatic injury should be the principal determinant to guide treatment. Endoscopic stenting and drainage is an attractive minimally invasive procedure and it may obviate the need for surgery. However, further investigation is required regarding the safety and outcome.

Bilateral obturator pyomyositis with visceral involvement in an immunocompetent adult patient treated without surgery.

BACKGROUND: Primary pyomyositis is a rare bacterial infection that affects large muscle groups mainly in immunocompromised patients. Treatment options include antibiotic treatment with surgical or radiologic interventions. CASE: A 22-year-old immunocompetent athlete was diagnosed with bilateral obturator muscle pyomyositis involving pelvic floor muscles and the urinary bladder after muscle injury during training. Intravenous antibiotic treatment was administered, resulting in eradication of the infection. CONCLUSION: This is the first case of bilateral obturator pyomyositis with coexisting involvement of pelvic floor muscles (levator ani) and viscera (urinary bladder) treated exclusively and with success by the administration of appropriate antibiotic therapy. A non-operative approach may could be attempted for the avoidance of postoperative morbidity and complications, especially when early clinical suspicion and diagnostic work-up lead to early diagnosis.

A multimodal approach to acute biliary pancreatitis during pregnancy: a case series.

The treatment of acute biliary pancreatitis during pregnancy remains controversial. We present our experience of treating 7 pregnant women with acute biliary pancreatitis and verified or suspected choledocholithiasis, by using magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and sphincterotomy followed by laparoscopic cholecystectomy. MRCP was performed in all patients to confirm the presence of common bile duct stones, their size and number. ERCP and sphincterotomy were performed without the use of radiation. The procedure was terminated only when all stones (the number clarified at MRCP), were retrieved into the duodenum. All patients underwent laparoscopic cholecystectomy the following day. Neither post-ERCP nor postoperative major complications were noted. All but one patient reached a healthy natural-term labor. One patient had a planned cesarean section on 35th week. The combination of MRCP, nonradiation ERCP, and immediate laparoscopic cholecystectomy provides definite treatment and seems to put both mother and fetus at lower risk than presumed.

The impact of ischemic preconditioning on hemodynamic, biochemical and inflammatory alterations induced by intra-abdominal hypertension: an experimental study in a porcine model.

PURPOSE: Intra-abdominal hypertension (IAH) has several pathophysiologic implications on human organs and systems. The aim of this experimental study was to investigate whether ischemic preconditioning (IP), namely the application of IAH for a small period of time prior to establish pneumoperitoneum, can attenuate the hemodynamic, biochemical and inflammatory alterations observed during IAH. METHODS: Twenty-four pigs were divided into three groups: group A (control group), group B (pneumoperitoneum of 30 mmHg) and group C (ischemic preconditioning, consisting of pneumoperitoneum of 25 mmHg for 15 min and subsequent pneumoperitoneum of 30 mmHg). Hemodynamic (central venous pressure, cardiac index, mean arterial pressure, heart rate, stroke volume index, systemic vascular resistance index, global end-diastolic index, intrathoracic blood index and extravascular lung water index), biochemical (serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), alkaline phosphatase (ALP), γ-glutamyl transpeptidase (γ-GT), urea and creatinine) and inflammatory (tumour necrosis factor-α, interleukin (IL)-6, IL-10 and C-reactive protein) parameters were measured. RESULTS: (a) Hemodynamics: The increase of central venous pressure monitoring and heart rate and the decrease of cardiac index, mean arterial pressure, stroke volume index, global end-diastolic volume index and intrathoracic blood volume index with the establishment of pneumoperitoneum were attenuated by IP. Systemic vascular resistance index and extravascular lung water were not affected. (b) Urea significantly increased with the pneumoperitoneum. IP, however, attenuated this effect. Οther biochemical parameters (SGOT, SGPT, ALP, γ-GT and creatinine) had a similar upward trend during IAH, which was reversed with IP. (c) Inflammatory parameters: CRP was increased with pneumoperitoneum, an effect that was attenuated with the application of IP. Νo significant differences were observed for interleukins. CONCLUSIONS: Ischemic preconditioning seems to attenuate the pathophysiologic alterations of several hemodynamic, biochemical and inflammatory parameters observed during IAH.

A tailored approach to the management of perforations following endoscopic retrograde cholangiopancreatography and sphincterotomy.

BACKGROUND: The management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations remains controversial. Τhe aim of the study was to determine the incidence of perforations following ERCP, their characteristics, operative and non-operative management options and clinical outcome. METHODS: A retrospective review of ERCP-related perforations, during a 21-year period, was performed. Each perforation was categorized into types I to IV according to the location, mechanism and radiographic evaluation of the injury. Comparisons were made between patients treated operatively and non-operatively. RESULTS: Forty-four perforations (0.4%) occurred in 9,880 procedures. They were mainly caused by the passage of the endoscope (type I) in 7 (16%) and sphincterotomy (type II) in 30 (68%) patients. The management was non-operative in 32 (72%) and operative in 12 patients. In multivariate analysis, only the type of perforation (type I: endoscope-related) was found significant for predicting operative treatment. The hospital stay was longer for patients requiring an operation (median, 24 vs 9 days). The overall mortality was 2/44 (4.5%). There was no death in the non-operative group. CONCLUSIONS: The need for immediate operative intervention should be based on the type of injury and clinical findings. Patients with type I perforations should be treated surgically and primary repair should be tried. Patients with type II injuries may be treated initially non-operatively. Delayed operative intervention will be required in a minority of these patients.

Synchronous gastric adenocarcinoma and gastrointestinal stromal tumor (GIST) of the stomach: a case report.

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract (1%), and stomach is the most common location involved. However, the co-existence of gastric adenocarcinoma and GIST is very rare. A case of an 80-year-old male with a simultaneous presentation of a gastric adenocarcinoma and GIST is presented. Various hypotheses have been proposed in order to explain this rare simultaneous development, but even though it's cause has not been proven yet.

Is the routine use of drainage after elective laparoscopic cholecystectomy justified? A randomized trial.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for the surgical treatment of cholelithiasis. However, the use of drainage after elective LC in literature remains controversial. METHODS: A randomized study was performed in Larnaka General Hospital. The purpose of the study was to evaluate drainage of the gallbladder bed after elective LC. One hundred sixteen patients were randomly allocated in two groups, sustained an uneventful LC, and were included in the study after an informed consent was obtained. Sixty-three patients were included in drainage group (YD) and 53 patients in nondrainage group (ND). Drain tubes, made of polyethylene, were placed at the end of the procedure in the patients of YD group. Postoperative pain was assessed using two scales: a 10-point visual analog scale and a 5-point verbal response scale. The two groups were evaluated and compared regarding postoperative pain, the time needed for surgery, length of postoperative hospital stay, the postoperative collection of fluid in the subhepatic space, and the incidence of postoperative complications. Chi-square and t-tests were used to evaluate the data, and statistical significance was established at P < .05. RESULTS: The mean operative time in YD patients was 6.9 minutes longer compared with ND patients (P = .056). The postoperative pain was higher in the YD group by more than one point on the average in the visual analog scale both at 6 and 24 hours (P = .01 and <.001, respectively). When measured with the verbal response scale, the difference in the reported pain was very significant at 24 hours (mean level for YD 1.24 and for ND 0.75). The proportion of patients staying in hospital for >2 days was higher in the YD group: 28.6% of the patients versus 13.2% in the ND group (P = .05). Subhepatic fluid was more often observed in the YD group (47% versus 34% in the ND), but the difference was not statistically significant. There was no statistical difference in the rate of wound infections, shoulder pain, nausea, vomiting, and respiratory infections between the two groups. CONCLUSIONS: Our results indicate that routine drainage of gallbladder bed after elective LC may not be justified. Drainage causes more postoperative pain, prolongs the operative time and hospital stay, increases the occurrence of fluid in the subhepatic space, and does not protect from other complications.

A solid pseudopapillary tumor of the pancreas treated with laparoscopic distal pancreatectomy and splenectomy: a case report and review of the literature.

INTRODUCTION: Laparoscopic distal pancreatectomy has been described for more than a decade now and has been considered technically feasible, safe, and with reproducible outcomes. It seems to exhibit several benefits of minimally invasive surgery and should be performed in carefully selected patients. CASE PRESENTATION: We report the case of a 55-year-old Greek woman with a solid pseudopapillary tumor of the tail of the pancreas. She underwent a laparoscopic distal pancreatectomy and splenectomy. The histopathologic examination finally revealed a cystic-solid pseudopapillary neoplasm of the pancreas. Solid pseudopapillary tumors of the pancreas are rare and affect predominantly young women. These tumors are of unclear pathogenesis and low malignancy, and surgical resection offers an excellent chance for long-term survival. CONCLUSION: This case report indicates that in selected centers and for selected patients, laparoscopic distal pancreatectomy is feasible. The benign characteristics of these tumors make them ideal for laparoscopic excision.

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.

Ischemia as a possible effect of increased intra-abdominal pressure on central nervous system cytokines, lactate and perfusion pressures.

INTRODUCTION: The aims of our study were to evaluate the impact of increased intra-abdominal pressure (IAP) on central nervous system (CNS) cytokines (Interleukin 6 and tumor necrosis factor), lactate and perfusion pressures, testing the hypothesis that intra-abdominal hypertension (IAH) may possibly lead to CNS ischemia. METHODS: Fifteen pigs were studied. Helium pneumoperitoneum was established and IAP was increased initially at 20 mmHg and subsequently at 45 mmHg, which was finally followed by abdominal desufflation. Interleukin 6 (IL-6), tumor necrosis factor alpha (TNFa) and lactate were measured in the cerebrospinal fluid (CSF) and intracranial (ICP), intraspinal (ISP), cerebral perfusion (CPP) and spinal perfusion (SPP) pressures recorded. RESULTS: Increased IAP (20 mmHg) was followed by a statistically significant increase in IL-6 (p = 0.028), lactate (p = 0.017), ICP (p < 0.001) and ISP (p = 0.001) and a significant decrease in CPP (p = 0.013) and SPP (p = 0.002). However, further increase of IAP (45 mmHg) was accompanied by an increase in mean arterial pressure due to compensatory tachycardia, followed by an increase in CPP and SPP and a decrease of cytokines and lactate. CONCLUSIONS: IAH resulted in a decrease of CPP and SPP lower than 60 mmHg and an increase of all ischemic mediators, indicating CNS ischemia; on the other hand, restoration of perfusion pressures above this threshold decreased all ischemic indicators, irrespective of the level of IAH.