Hellēnikē cheirourgikē. Acta chirurgica Hellenica 05/2012; 83(1):47-49.
ABSTRACT: Background-AimGastrointestinal angiolipomas are rare benign lipomatous lesions first described by Bowen in 1912 and differentiated histologically
by Howard in 1960. Duodenal angiolipomas represent a rare pathological condition that can lead to severe gastrointestinal
bleeding; they may be treated successfully surgically and occasionally endoscopically. We report the 3rd case of duodenal
angiolipoma to be reported in the literature between 1964 and 2010.
MethodDatabases from Pubmed and Medline were searched using a list of keywords such as angiolipomas, gastrointestinal bleeding,
duodenal angiolipomas and references from review articles. Results: 21 reported cases of gastrointestinal angiolipomas have
been reported, including 1 case of the oesophagus, 3 of the stomach, 2 of the duodenum, 7 of the small intestine, 2 of the
caecum, 4 of the large intestine and 2 cases of the rectum.
ConclusionIt is important to include the presence of angiolipomas in the differential diagnosis of gastrointestinal bleeding. These
benign lesions may lead to severe bleeding. Careful evaluation and preoperative work up of the patient will determine the
treatment of choice and reduce postoperative complications.
Key wordsAngiolipomas–Gastrointestinal tract–Duodenum–Upper Gastrointestinal bleeding
Hellēnikē cheirourgikē. Acta chirurgica Hellenica 04/2012; 83(4):214-218.
Hellēnikē cheirourgikē. Acta chirurgica Hellenica 04/2012; 83(1):43-46.
ABSTRACT: Aim -BackgroundSomatostatinomas is a very rare neuroendocrine tumour of the gastrointestinal tract, first described in the pancreas in 1977
and in the duodenum in 1979. We present the case a 67-year-old woman with duodenal somatostatinoma that was resected with
a pancreaduodenectomy procedure and also provide a brief review of the literature.
MethodDatabases from Pubmed and Medline were searched using a list of keywords such as somatostatinoma, duodenum, pancreas, neuroendocrine
tumour and references from review articles. The study of such a case and those in the literature provides useful knowledge
into the clinical management and diagnosis of these patients.
ResultsThe search of the literature yielded 348 articles, 92 reviews, 175 case reports, 328 journal articles, 6 clinical trials,
1 editorial, 21 comparative studies and 3 multicenter studies. Forty-five articles related to type-1 neurofibromatosis were
found, 5 associated with von Hippel-Lindau disease and 33 associated with multiple endocrine neoplasia type-1. Around 201
cases of somatostatinoma were reported
ConclusionTwo different symptomatic presentations can be found that include the inhibitory syndrome in pancreatic somatostatinomas,
whereas tumours arising from the duodenal wall are usually associated with mechanical enteric obstructive symptoms. The clinical
symptoms are often variable and non-specific; many somatostatinomas are found incidentally during cholecystectomy or during
gastrointestinal imaging studies. Surgery is the standard treatment and it is also preferred in metastatic disease providing
diagnosis is made early. Patients with metastatic somatostatinoma display 5-year postoperative survival rates of 30-60% as
opposed to those without metastasis whose 5-year survival rate approaches 100%.
Key wordsSomatostatinoma-Duodenum-Pancreas-Neuroendocrine tumor-GEP-NET
Hellēnikē cheirourgikē. Acta chirurgica Hellenica 04/2012; 82(4):261-268.
ABSTRACT: This article reviews the various techniques of vascular occlusion that can be applied to reduce blood loss during liver resection
and liver transplantation as well as the level of current evidence in regard to their application. Hepatoduodenal ligament
occlusion can be either continuous or intermittent. The impact on cardiac preload, cardiac index, systemic vascular resistance
and splanchnic congestion is minimal. Hemihepatic or segmental vascular occlusion selectively interrupts inflow to the tumour
bearing hemi-liver/segment, offers obvious demarcation of the resection limits, protects the remnant liver from ischaemia
and avoids splanchnic congestion and haemodynamic consequences. Should backflow from the hepatic veins cause major blood loss
during portal clamping or should the tumour infiltrate the IVC or caval-hepatic junction, total hepatic vascular exclusion
(THVE) may be applied. THVE is associated with haemodynamic intolerance in 10–20% of patients and requires close haemodynamic
monitoring and anesthetic expertise. Alternatively extraparenchymal hepatic vein occlusion allows THVE without interruption
of the IVC flow. Infrahepatic inferior vena caval clamping may be used in order to reduce backflow bleeding during portal
clamping is to reduce CVP with minor negative haemodynamic consequences. The future of pharmacological strategies lessening
or preventing ischaemia/reperfusion injury lies in a combination of drugs acting on several steps of the ischaemia/reperfusion
injury cascades. Separating the molecular basis and differences after ischaemia/reperfusion injury in normal and marginal
organs will finally lead to strategies for preconditioning, and organ preservation.
KeywordsHepatoduodenal ligament occlusion-Hemihepatic vascular occlusion-Segmental vascular occlusion-Total hepatic vascular exclusion-Extraparenchymal hepatic vein occlusion-Infrahepatic inferior vena caval clamping
Hellēnikē cheirourgikē. Acta chirurgica Hellenica 04/2012; 82(5):310-317.
ABSTRACT: Aim-BackgroundAlbeit uncommon, pancreatic trauma is associated with high morbidity and mortality and strict criteria for its management
is lacking. The objective of this study is to review and evaluate the role of intraoperative imaging, current management practice
and the potential complications of both the surgical and non-surgical approach in regard to this entity.
MethodsThe present review pooled the data of studies published in the English literature mainly during the last decade. Fifteen reviews
and eleven clinical studies were identified in the following databases: medline, pubmed, scholar google, scopus.
ResultsThe patient’s haemodynamic status, integrity of the pancreatic duct, site of duct injury and presence of a concomitant duodenal
injury are the major determinant factors in deciding final management. Intraoperative radiological techniques for the evaluation
of the pancreatic duct integrity include: i) intraoperative cholangiogram, ii) intraoperative pancreatography by cannulation
of the duct and iii) intraoperative Endoscopic Retrograde Cholangiopancreatography (ERCP) which is the most accurate method
for defining ductal injury. The spectrum of pancreatic injuries ranges from simple contusions or lacerations which are managed
nonoperatively or with external drainage, to major injuries with disruption of the pancreatic duct which are best treated
by pancreatic resection. Complex pancreatoenteral anastomoses have also been advocated in the literature but are ill-advised
as they are related to high rates of postoperative complications and are particularly time consuming at acute phase. In combined
pancreatoduodenal injuries, each organ merits its own management depending on the severity of injury, with pancreatoduodenectomy
being reserved for pancreatic head maceration and destruction of the ampulla of Vater. In our systematic review, the overall
morbidity of pancreatic trauma was found to be 40%. Morbidity increased with a higher grade of injury (grade I and II: 27%,
grade III: 56%, grade IV and V: 69%). The rate of surgical complications for all grades was 46% (grade I and II: 7%, grade
III: 57%, grade IV, V: 67%). The Non-Operative Management (NOM) morbidity rate for all grades of injury was found to be 33%.
NOM is mainly reserved for low grade injuries and haemodynamically stable patients with no concomitant injuries. We found
that NOM complication rates for low grade injuries reached 33%, while for high grade injuries this rose to 50%.
ConclusionThe principles for the management of pancreatic trauma have not been clearly delineated. Existing reports are retrospective
and single centre with a limited number of patients. Prospective, multicentre trials are warranted to ascertain strict criteria
and evaluate the current recommendations.
KeywordsPancreatic injury–Management of pancreatic trauma–Intraoperative pangreatography–Surgical techniques
Hellēnikē cheirourgikē. Acta chirurgica Hellenica 04/2012; 82(6):358-373.
ABSTRACT: Aim-BackgroundNecrotizing soft tissue infection (NSTI) is a rapidly progressive soft tissue infection with high morbidity and mortality
rates. It has an incidence of approximately 1000 cases per year in the United States. Severe invasive group A Streptococcus
infections associated with bacteraemia and septic shock have occurred with increasing incidence. Early recognition and prompt
medical and surgical intervention are necessary to reduce morbidity and mortality rates. We present two cases of fulminant
group A streptococcal necrotizing soft tissue infections.
MethodDuring the last year, two patients were admitted to our clinic with fulminant necrotizing soft tissue infection caused by
streptococcus pyogens. The initial lesions progressed rapidly to NSTI associated with sepsis, despite the immediate antibiotic
therapy. An aggressive and extensive surgical debridement of necrotic tissue was performed. Postoperatively, continuous saline
dressings were applied as well as antibiotic coverage. A plastic surgery consult was obtained to discuss closure options.
ResultsDespite the initial antibiotic therapy, there were no signs of improvement until an aggressive surgical intervention was performed
that showed immediate signs of recovery.
ConclusionEarly diagnosis and treatment of fulminant soft tissue infections is imperative for a patient’s survival. The cornerstone
of therapy of NSTI is surgical debridement, combined with appropriate antibiotic therapy and careful patient monitoring.
KeywordsStreptococcus pyogens-Necrotizing soft tissue infection (NSTI)-Bacteraemia-Septic shock-Surgical intervention
Hellēnikē cheirourgikē. Acta chirurgica Hellenica 04/2012; 82(3):213-219.
ABSTRACT: Aim-BackgroundLiver resection is one of the last fortresses to resist the invasion of laparoscopic surgery. Limitations to a wider application
of the procedure include the significant learning curve, the demand for sophisticated equipment and some technical issues
related to the inability to laparoscopically reproduce manipulations of the open approach. The main goal of this review is
to present the global experience to date concerning laparoscopic liver resection (LLR) and provide answers to the main questions
surrounding this technique.
MethodsA literature search for cited English publications was performed via Pubmed using laparoscopic liver or hepatic resection
as key words. All titles and abstracts were screened and those related to the theme of this review article were selected.
ResultsThe main questions addressed and answered considering LLR were: What are the indications and contraindications for LLR, which
LLRs are technically feasible, how safe and effective is the LLR procedure and is LLR an oncologically safe technique?
ConclusionsThe indications and contraindications remain the same as those for the open approach but the feasibility depends on technical
issues. Totally LLR appears safe for lesions located in the anterior and lateral segments but is also viable for central and
posterior segments. With careful patient selection, experience and good equipment, good results can be expected from LLR in
terms of morbidity and mortality as well as in oncological safety. More studies are necessary in order to prove that this
approach should eventually replace part of the open liver surgery.
KeywordsLaparoscopic liver resection-Laparoscopic hepatectomy-Minimally invasive liver surgery
Hellēnikē cheirourgikē. Acta chirurgica Hellenica 04/2012; 82(5):318-324.