[show abstract][hide abstract] ABSTRACT: BACKGROUND: Intra-abdominal hypertension (IAH) can have a profound impact on the cardiovascular system. We hypothesized that natriuretic peptides (Nt-pro-ANP and Nt-pro-BNP) are produced in response to the cardiovascular changes observed in an experimental model of IAH. MATERIALS AND METHODS: Eleven female pigs were enrolled in this study. Four experimental phases were created: a baseline phase for instrumentation (T1); two subsequent phases (T2 and T3), in which helium pneumoperitoneum was established at 20 and 35 mm Hg, respectively; and the final phase (T4), in which abdominal desufflation took place. Hemodynamic parameters and concentrations of Nt-pro-ANP and Nt-pro-BNP were measured. RESULTS: Central venous pressure and pulmonary capillary wedge pressure increased significantly during the elevation of intra-abdominal pressure (IAP) and returned to baseline after abdominal desufflation. Right and left transmural pressures remained unaffected by the elevation of IAP. Cardiac output decreased in phases T2 and T3 and was restored to baseline levels after abdominal desufflation. Systemic and pulmonary vascular resistances increased significantly with IAH and decreased after abdominal desufflation. Nt-pro-ANP did not change significantly in comparison to baseline. Nt-pro-BNP increased significantly in comparison to baseline at T3 and T4. Peak Nt-pro-BNP levels at T3 (peak IAP) correlated positively with indices of afterload at this time point, that is, systemic vascular resistance and pulmonary vascular resistance (r(2) = 0.38, P = 0.042 and r(2) = 0.55, P = 0.009, respectively). A strong negative correlation between Nt-pro-BNP and cardiac output at T3 was also demonstrated (r(2) = 0.58, P = 0.006). CONCLUSIONS: IAH resulted in cardiovascular compromise. The unchanged Nt-pro-ANP concentrations might reflect unaltered atrial stretch with IAH, despite the elevation of right atrial filling pressure. The significant increase of Nt-pro-BNP in response to high levels of IAP may reflect left ventricular strain and dysfunction due to the severe IAH and provide an alternative marker in the monitoring of IAH.
Journal of Surgical Research 03/2013; · 2.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: Introduction. Retroperitoneal sarcomas comprise a small proportion of all soft tissue sarcomas, and multiple factors influence their clinical behavior. Histopathological type and grade as well as complete surgical resection especially on the first operative attempt are well recognized as the main prognostic factors. Multifocality is another prognostic factor, which compromises therapy and finally makes prognosis worse due to multiple adverse implications. Case Presentation. A rare case of a 65-year-old male patient suffering from a multifocal retroperitoneal liposarcoma successfully treated in our hospital is presented herein. Discussion. Also, general considerations for these tumors are discussed, and especially multifocality is underlined as an ominous sign of retroperitoneal sarcomas behavior. Despite multifocality, once again complete surgical excision remains the mainstay of treatment of these patients, as long as further systemic and local therapies do not provide durable results.
[show abstract][hide abstract] ABSTRACT: Introduction. To present our experience regarding the use of pancreatic stump occlusion technique as an alternative management of the pancreatic remnant after pancreatoduodenectomy (PD). Methods. Between 2002 and 2009, hospital records of 93 patients who had undergone a Whipple's procedure for either pancreatic-periampullary cancer or chronic pancreatitis were retrospectively studied. In 37 patients the pancreatic duct was occluded by stapling and running suture without anastomosis of the pancreatic remnant, whereas in 56 patients a pancreaticojejunostomy was performed. Operative data, postoperative complications, oncological parameters, and survival rates were recorded. Results. 2/37 patients of the occlusion group and 9/56 patients of the anastomosis group were treated for chronic pancreatitis, whereas 35/37 and 47/56 patients for periampullary malignancies. The duration of surgery for the anastomosis group was significantly longer (mean time 220 versus 180 minutes). Mean hospitalization time was 6 days for both groups. The occlusion group had a lower morbidity rate (24% versus 32%). With regard to postoperative complications, a slightly higher incidence of pancreatic fistulas was observed in the anastomosis group. Conclusions. Pancreatic remnant occlusion is a safe, technically feasible, and reducing postoperative complications alternative approach of the pancreatic stump during Whipple's procedure.
[show abstract][hide abstract] ABSTRACT: Rectal bleeding combined with the presence of a rectal mass has been traditionally associated with the presence of malignant disease. Cap polyposis is a relatively young and still undefined rare entity which mainly involves the rectosigmoid. It is characterized by the presence of inflammatory polyps. In this case report, we present a patient who was diagnosed with a solitary cap polyp of the rectum during the investigation of a bleeding rectal mass. The patient's age and the absence of family history were not in favor of malignancy, despite the strong initial clinical impression. After confirmation of the diagnosis, the patient underwent a snare excision and remains asymptomatic. Cap polyposis, although rare, should be suspected and, when diagnosed, should be treated according to location, number of polyps and severity of symptoms.
World journal of gastrointestinal surgery. 06/2012; 4(6):157-62.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The choice of incision in any surgery is determined by access to the surgical field, particularly when oncologic resection is required. Special consideration is also given to postoperative pain and its sequelae, fewer complications in the early post-operative period and a lower occurrence of incisional hernias. The aim of this study was to compare two types of incision, a right-sided Kocher's incision (KI) and a midline incision (MI), for patients undergoing right hemicolectomy, by focusing on on both short-term and long-term results. METHODS: The hospital records for 213 patients who had undergone right hemicolectomy for a rightsided adenocarcinoma between 1995 and 2009 were retrospectively studied. In total, 113 patients had been operated via KI and 100 patients via MI. Demographic details, operative data (explorative access to the peritoneal cavity, time of operation), recovery parameters (time with intravenous analgesic medication, time to first oral fluid intake, first solid meal, time to discharge), and oncologic parameters (lymph-node harvest, tumor, node, metastasis (TNM) stage, and resection margins) were analyzed. Post-operative complications were also recorded. The two groups were retrospectively well matched with respect to demographic parameters and the oncologic status of the tumor. RESULTS: The median length of the MI was slightly longer (120 versus 100 mm, P < 0.05). The median duration of the surgery for the KI group was significantly shorter (70 versus 85 minutes, P < 0.001). In three patients we performed wedge resection of liver metastasis, and in one patient we performed a typical right hepatectomy, which lasted 190 minutes. No major operative complications were noted. There was no immediate or 30-day post-operative mortality. The KI group had a significantly shorter median hospital stay (5 days) than the MI group (8 days). All patients underwent wide tumor excision, and clear resection margins were obtained in all cases. No significant differences in analgesia requirement or early postoperative complications were noted. Late post-operative complications includedt hree cases of obstructive ileus (a single episode of each that resolved conservatively) and two cases of incisional hernias. CONCLUSIONS: The KIn approach for right-sided colon cancer is technically feasible, safe, andl very well tolerated overal. It can achieve the same standards of tumor resection and surgical field accessibility as the MI, with a reduction in post-operative recovery time.
World Journal of Surgical Oncology 06/2012; 10(1):101. · 1.09 Impact Factor
[show abstract][hide abstract] ABSTRACT: Hepatocellular carcinoma and cholangiocarcinoma constitute the majority of primary malignant tumors located in the liver, with hepatocellular carcinoma accounting for approximately 80% of these tumors and cholangiocarcinoma representing the remaining 20%. Both are aggressive malignancies, heterogeneous in terms of biological activities and clinical behavior, with dismal outcomes and an increasing incidence worldwide. Radical surgical resection remains the gold standard to date, as adjuvant therapeutic modalities have failed to show a consistent and adequate curative response. However, radical surgical resection is not feasible in most of the patients with such tumors, as tumor size or functional status of the parenchyma does not permit extended hepatic resection. In addition, patients who undergo curative resection often have a high rate of relapse. Multimodal therapeutic approaches, such as the combination of invasive methods (surgical resection, radiofrequency ablation, and two-step or three-step procedures with intermittent portal vein embolization) with interferon-α, systemic chemotherapy, or transarterial catheter embolization, may prolong survival in some patients, but have, however, failed to demonstrate satisfactory results. Therefore, an obvious need emerges for the discovery of new biomarkers to understand the events leading to hepatocarcinogenesis, to relate different phenotypes with differences in clinical behavior and prognosis, and, if possible, to predict response rates to adjuvant therapeutic modalities or, furthermore, to establish novel mechanism-based treatments for hepatic tumors.
European journal of gastroenterology & hepatology 03/2012; 24(3):223-8. · 1.66 Impact Factor
[show abstract][hide abstract] ABSTRACT: Introduction. A peritoneal inclusion cyst is a very rare mesenteric cyst of mesothelial origin usually asymptomatic. A rare case of an 82-year-old white Caucasian female with a femoral hernia containing a large peritoneal inclusion cyst, mimicking strangulated hernia, is presented herein. Case Presentation. The patient was admitted to our hospital suffering from a palpable groin mass on the right, which became painful and caused great discomfort for the last hours. Physical examination revealed a tender and tense, irreducible groin mass. An inguinal operative approach was selected and the mass was found protruding through the femoral ring. After careful dissection it turned out to be a large unilocular cyst, containing serous fluid, probably originating from the peritoneum. McVay procedure was used to reapproximate the femoral ring. Histologic examination showed a peritoneal inclusion cyst. Discussion. Peritoneal inclusion cysts are usually asymptomatic but occasionally present with various, nonspecific symptoms according to their size. Our case highlights that high index of clinical suspicion and careful exploration during repair of a hernia is mandatory in order to reach the correct diagnosis about hernia's contents.
[show abstract][hide abstract] ABSTRACT: Pancreatic adenocarcinoma is the 5th leading cause of cancer-related death in Western countries and insulinomas are rare endocrine neoplasms of the pancreas. The concurrent appearance of pancreatic adenocarcinoma and insulinoma is very rare and to the best of our knowledge has never been reported again. Herein, we present such an occurrence in a 74-year-old man. Resection of a mass in the uncinate process of the pancreas revealed pancreatic adenocarcinoma with severe desmoplastic reaction. Two years later, due to symptomatology persistence the patient was re-examined and a new 2 cm mass in the uncinate process was found leading to surgery, which demonstrated a 2 cm endocrine islet-cell tumor. Establishing a diagnosis in patients with insulinoma is difficult and the imaging studies still have low sensitivity and specificity except for intra-operative ultrasonography, which is the most accurate method detecting 90% of these lesions.
World Journal of Surgical Oncology 01/2011; 9:7. · 1.09 Impact Factor
[show abstract][hide abstract] ABSTRACT: A 67-year-old male patient with diabetes mellitus and nephritic syndrome under cortisone treatment was admitted to our hospital with fever and severe perianal pain. Upon physical examination, a perianal abscess was identified. Furthermore, the scrotum was gangrenous with extensive cellulitis of the perineum and left lower abdominal wall. Crepitations between the skin and fascia were palpable. A diagnosis of Fournier's gangrene was made. He was treated with immediate extensive surgical debridement under general anesthesia. The patient received broad-spectrum antibiotics, and repeated extensive debridements were performed until healthy granulation was present in the wound. Due to the fact that his left testicle was severely exposed, it was transpositioned into a subcutaneous pocket in the inner side of the left thigh. He was finally discharged on the 57th postoperative day. Fournier's gangrene is characterized by high mortality rates, ranging from 15% to 50% and is an acute surgical emergency. The mainstay of treatment should be open drainage and early aggressive surgical debridement of all necrotic tissue, followed by broad-spectrum antibiotics therapy.
[show abstract][hide abstract] ABSTRACT: An intestinal fistula in the "open abdomen" is called "enteroatmospheric" and is a great challenge for the surgeon because of the high mortality and morbidity rates associated with it. This report is a study of the surgical strategy for treating patients with enteroatmospheric fistulae.
During a 3-year period (2005-2007), two males and one female patient with a mean age of 63 years were referred to our surgical department for management of enteroatmospheric fistulae that developed after operations carried out for severe peritonitis, which was a consequence of sigmoid diverticulum rupture in two cases and disruption of an entero-enteric Roux-en-Y anastomosis after total gastrectomy for cancer in one.
All patients were appropriately supported in a surgical intensive care unit, with administration of total parenteral nutrition and appropriate antibiotics to eliminate secondary infections. Several re-operations were necessary to treat the enteroatmospheric fistulae. Eventually, all patients were discharged after a lengthy hospital stay (45-145 days).
The essential principles of our operative strategy are: (1) early intervention; (2) a lateral surgical approach via the circumference of the open abdomen to avoid further damage to the exposed viscera; (3) excision of the involved bowel loop with an end-to-end anastomosis; (4) temporary abdominal closure and coverage of the open abdomen with an absorbable mesh, promoting tissue granulation; (5) skin grafting attempts; and (6) selective use of vacuum-assisted closure.
[show abstract][hide abstract] ABSTRACT: Leakage from pancreatojejunal anastomosis continues to be a major source of morbidity in pancreatic surgery. In the present study, we test the hypothesis that a safe, sutureless pancreatojejunal anastomosis can be constructed using a synthetic surgical sealant.
Ten pigs weighing 20 to 25 kg underwent distal pancreatectomy and anastomosis of the pancreatic remnant with a jejunal limb with the use of an absorbable surgical sealant. Integrity of the anastomosis was checked on the 10th postoperative d by means of an autopsy study and histological examination.
One animal died on the 3rd postoperative d of peritonitis. The remaining 9 animals had an uneventful postoperative course. Gross and microscopic pathological examination revealed intact pancreatojejunal anastomosis in all surviving animals.
Following distal pancreatectomy in pigs, pancreatojejunal anastomoses with the use of sealant are technically feasible. During a 10-d observation period, the sealant appeared to prevent anastomotic dehiscence and allow normal anastomotic healing.
Journal of Surgical Research 06/2008; 153(2):282-6. · 2.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: Experimental findings have demonstrated a beneficial role of retrograde blood flow from hepatic veins that takes place during the Pringle maneuver in liver resections. The cytoprotective effect of hepatovenous back-perfusion has not been evaluated in humans. A randomized prospective study was designed to compare the response of liver cells to ischemic-reperfusion injury during the application of two different ischemic procedures: inflow versus inflow plus outflow vascular occlusion of the liver.
Forty patients were randomly allocated to undergo liver resection using the continuous Pringle maneuver (n = 20) or inflow plus outflow vascular occlusion of the liver by selective hepatic vascular exclusion (n = 20). Liver function was assessed on postoperative days 1 to 6. Response of liver cells to I/R injury was evaluated by measuring interleukins IL-6 and IL-8 at 3, 12, 24, and 48 hours after reperfusion. Oxidative stress was assessed by measuring malondialdehyde levels.
Both groups were comparable regarding ischemic time, operative time, and extent of liver resection. Patients in whom retrograde blood flow to the liver took place during the Pringle maneuver showed better liver function postoperatively and less severe hepatic I/R injuries compared with those undergoing liver resection using both inflow and outflow vascular occlusion. Oxidative stress was significantly lower in the Pringle maneuver group compared with the inflow plus outflow vascular occlusion group (mean [+/- SD] malondialdehyde 8 +/- 2.1 micromol/L in the Pringle group versus 14.7 +/- 1.8 micromol/L in the selective hepatic vascular exclusion group 30 min after reperfusion, p < 0.01).
Back perfusion via hepatic veins contributes to attenuation of I/R damage during the Pringle maneuver and should be preferred if possible during liver resection.
Journal of the American College of Surgeons 12/2003; 197(6):949-54. · 4.50 Impact Factor
[show abstract][hide abstract] ABSTRACT: Trials of adjuvant systemic therapy in high risk patients with Dukes' B2 and C colon cancer utilizing 5-fluorouracil-based regimens have been ongoing since the 1960s. The aim of this study was to compare the combination of 5-FU and leucovorin with the combination of 5-FU and alfa-2b interferon (IFN) in patients who had undergone "curative" resection foronocarcinoma.
A total of 322 patients with histologically proven adenocarcinoma of the colon, Dukes' stage B2 and C, were entered in the study. They were randomized to A) leucovorin 20 mg/m2 rapid intravenous injection and 5-FU 425 mg/m2 IV days 1-5 every 28 days for six cycles or B) 5-FU 600 mg/m2 24-hour infusion for five days, then 600 mg/m2 IV once a week and IFN 5 MU subcutaneously three times a week for six months.
There was no statistically significant difference in either disease-free survival or overall survival. Toxicity was the same in the two groups with the exception of flu-like syndrome, which was universal in IFN-treated patients.
There was no difference in disease-free survival or overall survival between the two combinations in any patient subset. Toxicity was greater with the 5-FU+IFN combination because of the flu-like syndrome. These data do not support the use of IFN in combination with 5-FU as systemic adjuvant therapy for patients with locally advanced colon carcinoma.