Association between the increase in incidence of papillary thyroid carcinoma in Crete and exposure to radioactive agents.

The mean gamma-ray distribution in Crete during the years after the nuclear accident at Chernobyl and its correlation with the Papillary Thyroid Cancer (PTC) distribution was identified. A total of 4285 patients underwent total thyroidectomy in our centre between 1990 and 2012. Data of gamma-ray (nSv/h) distribution were selected from the Greek Statistical Authorisation. A geo-spatial statistical model was used to estimate the expected number of patients with PTC and Kriging interpolation prediction model to estimate their distribution. Geographical weighted regression was performed to estimate the risk of PTC in relation to gamma ray distribution. All factors that were examined were found to be statistically significant for PTC distribution in Crete. Gamma-ray was determined as a significant risk factor (OR = 2.89; 95% CI = 1.682-4.989; p value = 0.03). There is a significant correlation between gamma-ray exposure and the increased prevalence of the PTC suggesting that the former may have been a significant risk factor.

[Laparoscopic sleeve gastric resection: experience of Bariatric Department in University of Cyprus, Greece].

Experience of laparoscopic sleeve gastric resection performance for morbid obesity was summarized. Indications for the method application, the operation procedure details, its mechanism of action, securing the body mass reduction, are adduced. The efficacy and security of the intervention were estimated.

Assessment of the effect of surgery on the kinetics of circulating tumour cells in patients with operable breast cancer based on cytokeratin-19 mRNA detection.

AIMS: The aim of this study was to evaluate the effect of surgery on the kinetics of CTCs in breast cancer patients. METHODS: The detection of CK-19 mRNA-positive CTCs in the blood by RT-PCR was analysed in 104 stage 0-IIIA patients at 4 time-points: prior to surgery, upon completion, 24 h after surgery and 15 days after surgery. Furthermore, a late sample was assessed prior to initiation of adjuvant chemotherapy in a subgroup of 53 patients. As negative controls, peripheral blood was obtained from 50 female patients undergoing excision of benign breast lesions and from 11 female patients receiving surgery for early-stage colorectal cancer. RESULTS: A significant percentage of blood samples from breast cancer patients (14.4%) were negative for CK-19 preoperatively but turned transiently positive early postoperatively. However, no significant difference in CK-19 mRNA detection was noted among the first 4 examined time-points. There was no significant correlation between CK-19 mRNA-positive cells and classic prognostic factors. A significant increase in CK-19 mRNA-positivity (32.1%) was observed in a late sample of the subgroup of 53 patients before adjuvant chemotherapy after a median of 54 days, postoperatively. CONCLUSIONS: Surgery may result in CTC detection in a small proportion of early breast cancer patients. There is no clear correlation to indicate which patients are expected to have detectable CTCs. Although CTCs are detected in a small proportion of patients during the perioperative period, the detection rate may increase over time and with longer follow-up.

Safety, quality and excellence in bariatric surgery.

The prevalence of obesity has increased three-fold in the past two decades. In Europe, 150.000.000 adults and 15.000.000 children are currently affected and obesity epidemic is responsible for approximately 1,000,000 deaths annually. Bariatric surgery for the severely obese has resulted in an overall of 61% weight reduction, across all procedures and has been shown to ameliorate or significantly improve many of the obesity-related comorbidities. Surgery is a serious intervention with procedural risks. Safety, quality and efficacy of the service offered to the morbidly obese patients, from both surgeons and hospitals are therefore, of outmost importance, to ensure optimal outcome of the surgical intervention, with the lowest possible risk for complications and mortality. An institution that can be certified by an independent organization, as capable to undertake the management of morbidly obese patients with outstanding results, is a Centre of Excellence (COE) in Bariatric and Metabolic surgery. The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has described the requirements for both surgeons and institutions in order to offer outstanding bariatric surgical management and, therefore, to become Centres of Excellence. European Accreditation Council for Bariatric Surgery (EAC-BS) is an independent organization, established by IFSO officials and leading bariatric surgeons in Europe, for quality control in bariatric surgery and data collection and analysis. Surgeons and institutions fulfilling the requirements and willing to become a Centre of Excellence in Bariatric Surgery may apply to the EAC-BS for evaluation. The creation of a European network of COEs will be of great value in promoting safety, quality and excellence in bariatric and metabolic surgery.

Predictive factors of operative or nonoperative management of blunt hepatic trauma.

AIM: Nonoperative management (NOM) has revolutionized the care of blunt hepatic trauma patients. The aim of the present study was to identify and evaluate the predictors of NOM of these patients. METHODS: The Trauma Registry data of 55 consecutive adult patients admitted with blunt hepatic trauma over a 4-year period was reviewed. Patients were divided into immediately operated (OP-group) and selected for NOM (NOM-group). Factors analyzed were: demographics, injury mechanism, initial vital signs, liver injury grade, concomitant injuries, and total injury severity scoring systems. RESULTS: Concomitant abdominal trauma, high Injury Severity Score (ISS), low International Classification of Diseases 9(th) revision Injury Severity Score (ICISS), and low probability of survival (Ps) were predictors for operative management. Compared to NOM-patients (66%, N=36), OP-patients (34%, N=19) suffered more frequently concomitant abdominal injuries (84.2% vs 47.2%, P=0.004) and were more severely totally injured as expressed by higher ISS (25 vs 20, P=0.01), lower ICISS (0.51 vs 0.74, P=0.003), and lower Ps (0.81 vs 0.98, P=0.005). NOM resulted in lower intensive care unit admission and mortality rates (47.2% vs 78.9%, P=0.002 and 2.7% vs 15.8%, P=0.03, respectively). NOM-success rate was 92%. CONCLUSION: NOM of blunt hepatic trauma is safe and efficient. Concomitant abdominal trauma, ISS, ICISS, and Ps are predictors for operative or nonoperative management.

Management of blunt hepatic and splenic trauma in a Greek level I trauma centre.

BACKGROUND AND PURPOSES: Non-operative management (NOM) has revolutionized the care of blunt hepatic and splenic trauma patients. The objective of this study is to evaluate treatment of such patients in a Greek level I trauma centre, to identify factors that are important for selecting them for NOM and to investigate for predictors of NOM failure. MATERIAL AND METHODS: We reviewed the Trauma Registry data of 96 consecutive adult patients admitted with blunt liver and/or splenic injuries over a 4-year period. RESULTS: Immediately operated patients (32.3%) had lower diastolic arterial pressure (p = 0.02), lower International Classification of Diseases -9th revision Injury Severity Score (ICISS) (p = 0.01), and a higher grade of splenic injury (p = 0.002) than NOM patients. NOM success rate was 80%. No predictors of NOM failure were found ; however, isolated splenic trauma patients failed NOM more frequently than hepatic patients (p = 0.02). CONCLUSIONS: NOM of adult blunt hepatic and splenic trauma patients is safe and efficient. Haemodynamic stability, ICISS and the grade of splenic injury are important for selecting these patients for NOM while splenic trauma patients need more intense observation.

Rhabdomyolysis following laparoscopic gastric bypass.

Rhabdomyolysis is a rare complication of serious surgical procedures, and constitutes a clinical and biochemical syndrome, caused by injury and destruction of skeletal muscles. It is accompanied by pain in the region of the referred muscle group, increase in creatine phosphokinase levels, myoglobinuria, often with severe renal failure, and finally multi-organ system failure and death, if not treated in time. The main risk factor in the development of postoperative rhabdomyolysis is prolonged intraoperative immobilization of the patient. Morbidly obese patients who undergo laparoscopic bariatric operations should be considered high-risk for rhabdomyolysis, from extended immobilization and pressure phenomena in the lumbar region and gluteal muscles. We report a 20-year-old woman with BMI 51, who underwent a prolonged laparoscopic Roux-en-Y gastric bypass. Postoperatively, she presented severe myalgia in the gluteal muscles and lumbar region, oliguria and creatine phosphokinase levels that reached 38,700 U/L. She was treated with intensive hydration and analgesics, and did not develop acute renal failure because diagnosis and treatment were attained immediately.

Psychological condition and quality of life in patients with morbid obesity before and after surgical weight loss.

BACKGROUND: Bariatric surgery results in significant weight loss, improvement or cure of accompanying illnesses, and may lead to important changes in psychological conditions. The aim of this paper is to study the changes in the psychological and emotional lives of patients as well as quality of life during the first 2 years after vertical banded gastroplasty (VBG). METHODS: The study population comprised 59 patients, 45 women (76.3%) and 14 men, between 18 and 64 years old. Patients were asked to complete an SCL-90R questionnaire before VBG. 2 years after VBG, patients were again asked to complete an SCL-90R as well as a BAROS questionnaire. Comparisons were made between loss of weight, alteration in the psychological condition and quality of life postoperatively, within the parameters of sex, age, marital status, level of education, duration of obesity and family history of obesity. RESULTS: Women had a greater degree of depression from obesity than their male counterparts before the procedure (P=0.001), while their postoperative emotional improvement was more marked (P=0.008). The General Mental Health Index was higher in female than male patients (P=0.008). At 2 years after VBG, BMI was significantly reduced (P<0.001). Oversensitivity in personal relationships and anxiety affected patients more both pre- and postoperatively. The averages of all the indexes of the subgroups of the SCL-90R, which relates to psychological condition of patients, showed a statistically significant reduction at 2 years following VBG, indicative of the improvement of the patients' psychosomatic condition. The more weight patients lost, the more their quality of life improved, as evaluated by the BAROS (P<0.001). CONCLUSIONS: The bariatric surgery most satisfactorily improved the patients' psychosomatic condition, as well as their quality of life, during the first 2 years after VBG.

Experience with benign splenic disease.

PURPOSE: In the ongoing effort to improve patient treatment, a deeper understanding of the symptomatology, physical signs and management options of rare splenic, non-traumatic, benign diseases is extremely important. PATIENTS AND METHODS: The records of eight consecutive patients with benign splenic conditions, other than injury and abscess, were reviewed retrospectively in order to analyse the clinical presentation, diagnostic methodology and therapeutic procedures applied in these rare conditions. Of the eight patients, three were diagnosed with splenic hydatid cyst, two with pseudocysts, one with splenic epidermoid cyst, one with wandering spleen and one with infraction of an ectopic spleen with situs inversus of other intra-abdominal organs. RESULTS: Upper abdominal pain was the most common presenting symptom and a tender palpable mass in the left upper abdominal quadrant, the predominant clinical finding. Pre-operative CT scanning confirmed the diagnosis in six patients, but failed to reveal the splenic pathology in the remaining two cases. Seven patients underwent splenectomy while saving splenic parenchyma was feasible in only one patient (12,5%). CONCLUSIONS: Splenic, non-traumatic, benign diseases have vague clinical presentation and may create diagnostic difficulties. Although spleen saving intervention can be applied in selected cases, splenectomy would be required in most patients.

Pylorus-preserving pancreaticoduodenectomy with external pancreatic remnant drainage.

BACKGROUND: Pancreaticoduodenectomy is the mainstay of surgical treatment for various benign and malignant diseases of the head of the pancreas and the periampullar region. The incidence of postoperative morbidity remains significantly high. Various modifications have been advocated for the restoration of the digestive continuity and drainage of bile and pancreatic ducts in order to diminish this high morbidity rate. METHODS: A new modification with the combination of an end-to-end duodenojejunal anastomosis and creation of an external pancreatic fistula following pylorus-preserving pancreaticoduodenectomy is described. Our initial experience with this modification in seven patients is reported and its advantages are discussed. RESULTS: There was no mortality, while morbidity was 29%, including postoperative pneumonia and psychosis in one patient, and intra-abdominal abscess in another patient. No significantly delayed gastric emptying was observed and no patient developed diabetes, anastomotic ulcer or reflux cholangitis postoperatively. CONCLUSIONS: The reported technique seems to be a safe modification of restoration after pancreaticoduodenectomy, with maintenance of anatomical gastrointestinal continuity, avoidance of complications from anastomosis with the pancreatic remnant, as well as maintenance of endocrine pancreatic function. However, long-term follow-up and larger comparative studies are needed to evaluate the impact of this modification on morbidity and mortality, including long-term nutritional complications.

Pre- and postoperative psychological characteristics in morbidly obese patients.

BACKGROUND: Quality of life is poor in morbidly obese patients, because of impaired physical and psychosocial functioning. Surgical treatment offers long-term weight reduction and amelioration of most associated comorbidities. Studies of the effect of weight loss on patients' mental well-being are required, because discrimination and psychopathologic consequences represent a heavy burden. PATIENTS AND METHODS: 53 patients were interviewed 48 hours before vertical banded gastroplasty (VBG) by the psychiatric team and completed the self-administered SCL-90-R questionnaire. Correlations of patients' age, educational level, employment, duration of obesity and family conditions were investigated and compared with the degree of obesity 10-12 months postoperatively. 35 patients returned to psychiatric follow-up and completed the same questionnaire, and the various psychopathologic characteristics were compared to the preoperative ones. RESULTS: Females had statistically significant higher scores in all psychopathologic parameters studied; more obvious differences were seen in depression (P < 0.001), paranoid ideation (P < 0.001) and interpersonal sensitivity (P < 0.001). Correlations of several demographic characteristics with the patients' preoperative BMI were negative. 10-12 months following VBG, statistically significant improvement in the parameters of phobic anxiety, obsessions-compulsions, paranoid ideation and interpersonal sensitivity (P < 0.05) were found. CONCLUSION: Pre-existing psychopathology was more obvious among females, and improved significantly following successful weight loss 1 year postoperatively.

Primary psoas abscess. Report of three cases.

BACKGROUND: Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians. PATIENTS AND METHODS: We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36-51 years were admitted with fever, abdominal pain and a palpable tender mass. RESULTS: The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor. CONCLUSIONS: A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.

Left ventricular function and cardiopulmonary performance following surgical treatment of morbid obesity.

BACKGROUND: It is well established that morbid obesity affects the respiratory system and the diastolic function of the heart. During exercise, cardiopulmonary reserve is exhausted because of augmented requirements, leading to a significant intolerance. A study was undertaken to investigate the influence of body weight loss on the characteristics of the left ventricle (LV) and on exercise capacity in obese patients before and 6 months, following vertical banded gastroplasty (VBG). METHODS: 16 morbidly obese individuals (BMI > 40 kg/m2) scheduled for VBG were studied. A symptom-limited cardiopulmonary exercise test and a complete transthoracic echocardiogram were performed 1 day before operation and 6 months postoperatively (after the patients achieved a body weight loss of > 20% of their pre-operative values). RESULTS: Exercise duration increased significantly 6 months following surgery. The mean O2 consumption at peak exercise (peak VO2) and at the anaerobic threshold (VO2AT) was significantly higher after weight loss. 6 months after VBG the LV thickness decreased significantly. Regarding the diastolic indices, isovolumic relaxation time (IVRT) and early/late (E/A) velocity ratio, there was a significant improvement after weight loss. Simple linear regression analysis revealed that peak VO2 and VO2AT were significantly correlated with IVRT and E/A velocity ratio. CONCLUSIONS: Weight loss after VBG improves the cardiac diastolic function and this is associated with an improvement in cardiopulmonary exercise performance. Left ventricular filling variables could be considered among the most important determinants of exercise intolerance in obese individuals.

Obesity-associated disorders before and after weight reduction by vertical banded gastroplasty in morbidly vs super obese individuals.

BACKGROUND: The amount of excess weight which must be lost in order to cure or to improve disorders associated with obesity remains unknown. This study was designed to compare super obese and morbidly obese patients in terms of weight reduction following VBG and to investigate the effects of postoperative weight changes to preexisting co-morbidities. METHODS: 125 patients underwent VBG. Group A consisted of 80 morbidly obese patients (64%) and group B consisted of 45 super obese patients (36%). Preoperative examination was planned to identify and determine the severity of any disorders associated with obesity, that the patients may have had. Following VBG, all patients were followed-up at regular time periods, for at least 2 and up to 4 years. The progress of preexisting co-morbidities was evaluated and carefully recorded. RESULTS: Among the 80 patients of Group A, there were 240 total co-morbidities (3 per patient), and in group B there were 196 co-morbidities (4.35 per patient) preoperatively. Dyspnea during fatigue and arthritis were found at statistically higher incidence in the super obese category. At the end of the second postoperative year, greater weight loss in terms of number kilograms was seen in patients in group B, but these patients did not reach a BMI lower than 35, while patients in group A had mean BMI below 30. In group A, 66% of the co-morbidities completely resolved, 19% significantly diminished and 15% remain unchanged. In group B, the respective percentages were 53%, 27.5% and 19.5%. However, after weight reduction by VBG a significant number of co-morbidities remain in the super obese patients (92 or 2.044 per/patient), and this is believed to be due to the greater remaining excess weight. CONCLUSION: Reduction of body weight by VBG is associated with resolution or improvement of a significant number of the obesity-associated disorders. However, super obese patients remain obese after surgery, and this results in two-fold higher remaining morbidity.

Nuclear grading in invasive ductal breast carcinomas.

Nuclear grade (NG) was studied in cytologic material obtained from 120 fine-needle aspiration biopsies of breast lesions and compared with the NG observed in the nuclear grade of surgical biopsies of the same lesions. All lesions included were invasive breast carcinomas diagnosed cytologically and confirmed histologically. Cytologic aspirates and tissue sections were graded by cytologists and pathologists, respectively, using a multiheaded microscope. Fisher's modification of Black's NG scheme was used. An agreement was observed between the NG of cytologic material and that of surgical biopsies in 93.33% of tumors, and an interesting exercise would be to correlate the NG with other significant factors for the prognosis of breast carcinomas. The purpose of this study was to assign and correlate the NG of ductal carcinomas of the breast in fine-needle aspiration biopsies and tissue specimens from the same patients.

Continuous spinal anesthesia/analgesia for perioperative management of morbidly obese patients undergoing laparotomy for gastroplastic surgery.

BACKGROUND: The authors determined prospectively the safety of continuous spinal anesthesia combined with general anesthesia and the efficacy of postoperative pain relief with continuous spinal analgesia for morbidly obese patients undergoing vertical banded gastroplasty. METHODS: 27 patients (13 men, 14 women) with a mean body mass index (BMI) of 50.4 +/- 7.8 and several co-morbidities were studied. All patients were anesthetized with the same anesthetic regimen, which included midazolam, fentanyl, propofol, muscle relaxants, nitrous oxide, isoflurane and intrathecal bupivacaine. Postoperative pain relief was provided for 5 days and all patients received the same regimen, which included intrathecal bupivacaine, fentanyl and intravenous tenoxicam. The intrathecal analgesic regimen was administered continuously through a pump which had the facility of providing bolus doses when requested in predetermined lockout intervals. Intra-operative monitoring included hemodynamic and respiratory parameters. Additional postoperative monitoring included respiratory rate, degree of sedation, sensory level of anesthesia, motor response and intensity of pain. RESULTS: Intraoperative anesthetic technique was safe and provided satisfactory results in the immediate postoperative period. Furthermore, the postoperative analgesia regimen provided effective analgesia in all patients. The mean doses of fentanyl and bupivacaine infused intrathecally for the first 24 postoperative hours were 14.1 +/- 2.0 microg.h(1) and 0.7 +/- 0.1 mg.h(1) respectively, while the requirements of analgesia decreased progressively with time. The technique provided effective analgesia with low pain scores, which was reflected by ease in mobilizing and performing physical exercises with the physiotherapist. Only minor complications related to anesthesia and analgesia were encountered. CONCLUSION: To our knowledge, this technique of anesthesia and postoperative analgesia has not been described before in morbidly obese patients. This regimen merits further controlled trials to establish its place in the perioperative management of morbidly obese patients.

P53 expression in patients with malignant and benign breast diseases.

Immunohistochemical expression of p53 protein was studied in FNA specimens of 20 breast ductal carcinomas, 20 fibroadenomas and 20 atypical ductal hyperplasia of the breast. Nine cases of breast carcinomas (45%), five fibroadenomas (25%) and four atypical ductal hyperplasia (20%) were found to be p53-immuno-positive. A statistically significant difference was found among p53 staining index of breast carcinomas (mean 72.55%), fibroadenomas (mean 41.2%) and atypical ductal hyperplasia (mean 34%). Variations in p53 expression among individual breast carcinomas was found, and these variations may correlate with prognosis.

Organisation of a trauma registry in a regional Greek university hospital: the first two years experience.

OBJECTIVE: To design and implement a hospital trauma registry so as to be able to monitor the care of injured patients. SETTING: Teaching hospital, Greece. SUBJECTS: All patients admitted with trauma from January 1997. MAIN OUTCOME MEASURES: Design of a suitable form, establishment of inclusion and exclusion criteria, injury severity scoring, finding money and personnel, and getting suitable computer hardware and software for reliable collection and analysis of data. RESULTS: We experienced great difficulty in getting funding, so were unable to employ dedicated staff to collect the data, though we have had a part-time secretary to coordinate the registry whose salary has been paid by a pharmaceutical company. We have to rely on junior doctors to collect the data, which works well when they are enthusiastic (though not all are). We decided to use the data collection form used by the UK Trauma Network. We are trying to collect sufficient data to code severity by more than one system, but at present this is causing problems because busy nurses and doctors do not like filling in forms. Software has also been a problem as most of it is in English and translation is a considerable workload. The calculations are still being done manually while we work with two computer programmers to develop our own. We have submitted a research protocol to the Ministry of Health which has been accepted and this will guarantee our expenses for the next two years. CONCLUSIONS: Implementing a philosophy of continuous quality improvement is never easy, and we expect funding to be a permanent source of anxiety. Our progress so far has been good, but not as good as we hoped; however, we are optimistic that as people see the value of continuous monitoring of the system they will become more enthusiastic and supportive.

Disorders associated with clinically severe obesity: significant improvement after surgical weight reduction.

BACKGROUND: Surgical treatment for patients with clinically severe obesity mainly aims to reduce morbidity. METHODS: Sixty-two patients were examined for disorders associated with morbid obesity before and after surgical weight reduction by vertical banded gastroplasty. All patients were followed-up for 12 to 48 months. RESULTS: At the end of the first postoperative year, 84% of the patients had lost at least 50% of their excess weight. Of the 218 weight-related pathologic conditions existing before the operation, 131 (60%) were completely cured, 50 (23%) showed significant improvement, and only 37 (17%) remained unchanged. The same percentages were obtained for patients followed tip for 24, 36, and 48 postoperative months. CONCLUSIONS: Surgical treatment of clinically severe obesity has a significant effect on the health of the patients by eliminating the associated disorders.

Cysts of the adrenal gland: diagnosis and management.

OBJECTIVE: Cysts of the adrenal gland are rare, but with the wider application of sonography and computed tomography more adrenal cysts are detected incidentally. To gain more insight into this entity, five such cases are reported and their diagnostic approach and management are discussed. PATIENTS AND METHODS: The records of five patients with six cysts of the adrenal glands seen at our department from 1987 till 1995 are reviewed. There were four males and one female and their age ranged from 24 to 72 years, with a mean age of 43 years. One patient had a primary hydatid cyst of the right adrenal gland, which was preoperatively thought to arise from the liver or the right kidney. A second patient had a very large pseudocyst of the left adrenal gland, which is the largest ever reported in the literature. The other four cysts in three patients were found incidentally during sonography or computed tomography. RESULTS: The hydatid cyst with a rim of normal adrenal tissue was excised. The large pseudocyst was removed together with the adrenal gland. In the cases of the incidentally found cysts, observation of the patient with regular follow-up was decided upon. All patients are in good condition and without symptoms 2 to 10 years after the initial diagnosis. CONCLUSIONS: Adrenal cysts are rare and their diagnosis may pose problems. Symptomatic adrenal cysts should be operated, but small, asymptomatic, non-functional cysts with benign characteristics may be treated conservatively with regular follow-up by sonography or computed tomography and hormonal evaluation.