Modern stapled Longo procedure vs. conventional Milligan-Morgan hemorrhoidectomy: a randomized controlled trial

BACKGROUND AND AIMS

Postoperative pain is the most distressing sequela of conventional hemorrhoidectomy. A modern alternative of circumferential mucosectomy has been proposed to reduce the pain in this procedure.

PATIENTS AND METHODS

This controlled trial included 80 patients with second to fourth degree hemorrhoidal disease operated on over a 2-year period. The patients were randomly allocated to undergo either the stapled Longo procedure (group 1) or Milligan-Morgan hemorrhoidectomy (group 2) under epidural anesthesia. The operating time, postoperative pain scores at 3, 6, 12, and 24 h, analgesic consumption, hospital stay, and complication rate were recorded. At follow-up the outcome and patient satisfaction were evaluated.

RESULTS

The mean operating time in group 1 was shorter than in group 2, postoperative pain scores at all time points and the mean epidural morphine requirement was lower, and mean hospital stay was shorter. The complication rate did not differ (three cases of postoperative bleeding in group 1 and two cases in group. At follow-up no recurrence or complains were recorded except three cases of mild incontinence (one in group 1 and two in group 2). The patients in group 1 (95%) were more satisfied than in group 2 (89%).

CONCLUSION

The Longo procedure is thus a simple, safe, and effective method that entails less postoperative pain, more satisfaction, and shorter hospital stay than the standard Milligan-Morgan hemorrhoidectomy.

Role of bevacizumab in colorectal cancer growth and its adverse effects: a review

Angiogenesis affects both wound healing and malignant cell growth through nutrients and oxygen. Vascular endothelial growth factor (VEGF) is the most important element involved in this complex process. Inhibition of VEGF influences angiogenesis and may restrict tumor growth and metastatic ability. Modern anti-angiogenic therapy is based on this theory. Bevacizumab is a recombinant humanized monoclonal antibody (immunoglobulin G1) which binds with VEGF-A forming a large molecule. It can not be bound with VEGF tyrosine kinase receptors preventing VEGF-A incorporation; thus its activity is inhibited inducing blockage of VEGF-mediated angiogenesis. Bevacizumab, in combination with chemotherapy or other novel targeted therapeutic agents, is currently used more frequently in clinical practice, mainly for managing advanced colorectal cancer. It is also used for managing other malignancies, such as breast cancer, pancreatic cancer, prostate cancer, non small-cell lung cancer, metastatic renal carcinoma and ovarian tumors. Although it is generally considered a safe treatment, there are reports of some rare side effects which should be taken into account. Recent experiments in rats and mice show promising results with a wider therapeutic range.

Complete dehiscence of the abdominal wound and incriminating factors

OBJECTIVE

To find out the causes of abdominal wound dehiscence.

DESIGN

Retrospective study.

SETTING

University hospital, Greece.

SUBJECTS

Abdominal wound dehiscence occurred in 89 cases out of 19,206 major abdominal operations including 4671 emergencies during the past 15 years (0.5%).

INTERVENTIONS

In the study group 14 local and systemic risk factors were analysed and compared with those in a control group of 89 patients who had similar procedures without dehiscence.

MAIN OUTCOME MEASURES

Statistical analysis using the chi square test.

RESULTS

Significant factors (p < 0.05) included age over 65 years, emergency operation, cancer, haemodynamic instability, intra-abdominal sepsis, wound infection, hypoalbuminaemia, ascites, obesity, and steroids. Risk factors that were not significant included sex, anaemia, diabetes mellitus and pulmonary disease. Overall morbidity and mortality were 30% and 16%, respectively. The mortality and the possibility of dehiscence seem to correlate directly with the number of risk factors.

CONCLUSION

Patients with these risk factors require more attention and special care to minimise the risk of its occurrence.

Pathophysiological consequences of obstructive jaundice and perioperative management

BACKGROUND

Obstructive jaundice is a common problem in daily clinical practice. Understanding completely the pathophysiological changes in obstructive jaundice remains a challenge for planning current and future management.

DATA SOURCES

A PubMed was searched for relevant articles published up to August 2016. The effect of obstructive jaundice on proinflammatory cytokines, coagulation status, hemodynamics and organ functions were evaluated.

RESULTS

The effects of obstructive jaundice included biliary tree, the hepatic cell and liver function as well as systemic complications. The lack of bile in the gut, the disruption of the intestinal mucosal barrier, the increased absorption of endotoxin and the subsequent endotoxemia cause proinflammatory cytokine production (TNF-α, IL-6). Bilirubin induces systemic inflammatory response syndrome which may lead to multiple organ dysfunction syndrome. The principal clinical manifestations include hemodynamic instability and acute renal failure, cardiovascular suppression, immune compromise, coagulation disorders, nutritional impairment, and wound healing defect. The proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.

CONCLUSION

The perioperative management is an essential measure in improving the outcome after the appropriate surgical operation in jaundiced patients especially those with malignancy.

Management of gallstone ileus

BACKGROUND/PURPOSE

Gallstone ileus is an uncommon complication of cholelithiasis in the elderly with a high morbidity and mortality rate. This study aims to clarify the current surgical management.

METHODS

In a retrospective survey over the past 11 years there were 9 patients with gallstone ileus, all elderly (mean age, 77 years), among 2242 cholecystectomies (0.4%) and 243 operated small intestinal obstructions (3.7%). Urgent laparotomy confirmed gallstone obstruction and a cholecystoduodenal (89%) or cholecystocolonic (11%) fistula. The operation included enterolithotomy alone (3 high-risk cases) or plus fistula repair and cholecystectomy (6 cases). There were 3 postoperative complications including wound dehiscence, wound infection, and obstructive jaundice (morbidity, 37.5%) and 1 death due to myocardial infarction (mortality, 11%). On follow-up (mean, 5 years), 6 patients with cholecystectomy (in 1 case it was performed 2 months after the initial operation) and 1 patient with enterolithotomy alone are well; there was 1 death from an unrelated cause after 1 year.

CONCLUSION

It seems that a one-stage procedure (enterolithotomy plus fistula repair and cholecystectomy), when feasible, should be the first choice. Enterolithotomy alone should be reserved for only unstable and difficult cases.

A Review of Primary Thyroid Lymphoma: Molecular Factors, Diagnosis and Management

Purpose/aim: To focus on current aspects of primary thyroid lymphoma (PTL), which is a rare clinical entity usually manifested by a rapidly growing mass in the neck that can cause pressure symptoms.

MATERIALS AND METHODS

Relevant papers in PubMed published through June 2017 were selected to track updated information about PTL with an emphasis on diagnosis and novel therapeutic management.

RESULTS

The most frequent cases include non-Hodgkin lymphoma derived from B-cells, mainly diffuse large B-cell lymphoma (DLBCL) followed by mucosa-associated lymphoid tissue (MALT) lymphoma or a mixed type. Other subtypes are less common. Lymphomas derived from T-cells and Hodgkin lymphomas are extremely rare. Hashimoto's autoimmune thyroiditis has been implicated as a risk factor for lymphoma. At the molecular level, the Wnt5a protein and its receptor Ror2 are involved in the course of the disease. Ultrasonography, fine needle aspiration (FNA) biopsy, and core or open biopsy combined with new diagnostic facilities contribute to an accurate diagnosis. An increased potential exists for a cure without the need for a radical surgical procedure. Modern chemoradiation therapy plus the monoclonal antibody rituximab, which acts against CD20, have limited the need for surgical interventions and provide an excellent outcome in most cases. However, some cases have resulted in treatment failure or recurrence.

CONCLUSIONS

A multidisciplinary approach must be used to define the management policy in each case. Future efforts by researchers are likely to be focused on the molecular level.

Safety of bowel resection for colorectal surgical emergency in the elderly

OBJECTIVE

Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study.

PATIENTS AND METHODS

In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma.

RESULTS

The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction.

CONCLUSION

Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.

Management of ingested foreign bodies. How justifiable is a waiting policy?

Foreign body ingestion is a commonly seen accident in emergencies, usually in children (80%), elderly, mentally impaired, or alcoholic individuals, whereas it may occur intentionally in prisoners or psychiatric patients. According to the literature, 90% of ingested foreign bodies pass through the gastrointestinal tract without complications, 10% to 20% necessitate endoscopic removal, whereas only 1% of them will finally need surgical intervention. In clinical practice, we often face the dilemma of choosing the appropriate treatment modality. We present 13 cases treated in our department, emphasizing in a "waiting and close observation" policy. Among these cases, only 1 patient needed to be operated because of obstruction of ileocecal valve by a large coin. Indications for treatment where applicable are also being discussed.

Risk factors influencing conversion of laparoscopic to open cholecystectomy

BACKGROUND

Conversion of laparoscopic to open cholecystectomy is required in certain cases for the safe completion of the operation. Some factors contribute more to the need for conversion.

METHODS

Over a 13-year period, the laparoscopic cholecystectomy procedure was attempted in 1263 patients whose mean age was 54 years and 28% being male. The conversion was necessary in 98 cases whose mean age was 60 years, with 42% being male. All data were studied retrospectively. Six factors were examined statistically for a possible correlation with the conversion rate, as well as the trend of it over time.

RESULTS

The main reason for conversion was the unclear anatomy owing to previous inflammation, followed by bleeding and choledocholithiasis suspicion, gallbladder carcinoma, bile duct injury, or spilled gallstones. The overall conversion rate was 7.75%. It was significantly increased in males (11.6%) and the elderly (12.4 %), gallbladder inflammation (29%), and morbid obesity (50%). Conversion rate did not change significantly in the first half period (8.1%) of the study, the second half-period (7.6%), in patients with diabetes mellitus (6.7%), or hematological disorders (6%).

CONCLUSIONS

The risk for the conversion of laparoscopic cholecystectomy increases significantly in males, the elderly, obese patients, and when inflammation is present. This observation remains unchanged over time. Diabetes mellitus and hematologic disorders do not predispose in a higher risk for conversion.

Considerations concerning laparoscopic cholecystectomy in the extremely elderly

BACKGROUND

Since octogenarians become a growing part of the population and surgical care is possible in them, this study was conducted to evaluate the outcome of laparoscopic cholecystectomy in patients 80 years of age and over.

METHODS

From June 1993 to May 2006, a total of 1263 patients underwent a laparoscopic cholecystectomy, applying the four-trocar American technique; 21 among them were >/=80 years. We retrospectively reviewed patients' age, gender, indication for surgery, comorbid conditions, American Society of Anesthesiologists (ASA) score, conversion to open procedure, postoperative complications, and length of hospital stay.

RESULTS

The mean age in the >/=80 group was 82.5+/-3 and 57% were women, while in the <80 group 72% of patients were women. Recurrent biliary colic was the most frequent (62%) indication for surgery among the elderly patients. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed preoperatively in 6 elderly patients (29%); there were 4 cases of acute calculus pancreatitis and 2 cases of acute cholangitis. A high surgical risk (ASA score of III and IV) was estimated in 11 patients (52%) from the >/=80 group versus 32% in the <80 group (P =0.047). Conversion rate was higher (19%) and hospital stay was longer (4.9 days) in the >/=80 group, compared to younger patients (P =0.01). Mortality was zero and morbidity was 14% versus 3% in the <80 group (P =0.03), including 1 case of postoperative bleeding, 1 case of wound infection, and 1 case of pulmonary atelectasis, respectively.

CONCLUSIONS

Laparoscopic cholecystectomy in the extremely elderly is safe and well tolerated; however, it is associated with a higher conversion rate, increased morbidity, and a longer hospital stay.

Current opinion on lymphadenectomy in pancreatic cancer surgery

BACKGROUND

Adenocarcinoma of the pancreas exhibits aggressive behavior in growth, inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%. Curative resection is the only potential therapeutic opportunity.

DATA SOURCES

A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma.

RESULTS

Despite recent advances in chemotherapy, radiotherapy or even immunotherapy, surgery still remains the major factor that affects the outcome. The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial. Four prospective, randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection. The exact lymph node status, including malignant spread and the total number retrieved as well as the lymph node ratio, is the most important prognostic factor. Positive lymph nodes after pancreatectomy are present in 70%. Paraaortic lymph node spread indicates poor prognosis.

CONCLUSIONS

Undoubtedly, a standard lymphadenectomy including >15 lymph nodes must be no longer preferred in patients with the usual head location. The extended lymphadenectomy does not have any place, unless in randomized trials. In cases with body or tail location, the radical antegrade modular pancreatosplenectomy gives promising results. Nevertheless, accurate localization and detailed examination of the resected specimen are required for better staging.

The effect of bevacizumab on colon anastomotic healing in rats

PURPOSE

The aim of the study was to investigate the effect of angiogenesis inhibition by bevacizumab, a monoclonal anti-vascular endothelial growth factor (VEGF) antibody, on the healing process of colonic anastomoses in rats, assessing some specific involved factors. This new agent is used mainly in metastatic colorectal cancer. The angiogenesis plays an important role in both wound healing and metastatic invasion and spread of malignant cells. There has not been any evidence assessing the optimal time for its safe use in operated patients.

MATERIALS AND METHODS

Forty Wistar rats were randomly allocated into four equal groups. A colonic anastomosis was performed in all rats. Half of them received intraoperatively a single dose of bevacizumab 5 mg/body weight and the rest received placebo. The animals were sacrificed on the 7th (Avastin 7th, placebo 7th) and 14th (Avastin 14th, placebo 14th) postoperative day. The anastomosis was resected and sent for histological study and for tissue biochemical assays (VEGF, endothelin-1 (ET-1), C-reactive protein (CRP), pro-oxidant-antioxidant balance (PAB), carbonylated proteins, hydroxyproline) using specific enzyme-linked immunosorbent assay kits. For statistical analysis, the Mann-Whitney U test was used (of statistical significance when P < 0.05).

RESULTS

No complication or anastomotic dehiscence was observed. Histology did not reveal statistically significant differences between groups concerning degree of inflammation, fibroblasts, collagen, and fibrosis. Likewise, hydroxyproline levels did not differ. However, some statistically significant differences were found in VEGF, CRP and carbonyl proteins (Avastin 7th vs placebo 7th, placebo 14th vs placebo 7th), ET-1, and PAB (Avastin 14th vs Avastin 7th), which did not finally affect the collagen synthesis marker hydroxyproline, nor did the anastomotic strength.

CONCLUSIONS

Bevacizumab, when administered intraoperatively, has no significant effect on colon anastomotic healing in rats despite a transient mild ischemia.

Does emergency surgery affect resectability of colorectal cancer?

OBJECTIVE

Emergency surgery for colorectal cancer is common in daily practice, and is mainly implied by bowel obstruction. It is related to increased morbidity and mortality. Its relation with the stage and respectability of the disease is uncertain. This study aims to further clarify these parameters.

PATIENTS AND METHODS

Over the past 24-year period 121 patients had an emergency operation (12%) from a total of 1009 patients with colorectal carcinoma. There were 59 men (48.8%) and 62 women (51.2%) with a mean age of 68 years (range 21-93); 61 patients (50.4%) were > or = 70-years-old. The data of all these patients were studied retrospectively in comparison with those who underwent elective surgery. Emergency cases were further divided into two age groups (> or = 70 and < 70 years) and compared. The tumour location was mainly in the left colon, whereas obstruction was the predominant reason for acute presentation.

RESULTS

On operation, absence of macroscopic spread was noted in 57.8% of emergency cases and 72% of elective cases (p < 0.05). The resectability rates were 75% and 90% respectively (p < 0.05), and were not significantly affected by the age factor. There were no differences in the grade of malignant cell differentiation or in the depth of microscopic invasion (p > 0.05) in either group. For emergency operations, the morbidity was 20% (24 patients) and the 30-day mortality rate was 5.8% (7 patients). Both parameters were higher in patients > or = 70-years-old.

CONCLUSION

Emergency surgery for colorectal carcinoma is related to lower resectability and to higher--but acceptable--postoperative morbidity and mortality rates, when compared with elective surgical management.

Role of stenting in the palliation of gastroesophageal junction cancer: A brief review

Gastroesophageal junction cancer has an increasing incidence in western countries. It is inoperable when first manifested in more than 50% of cases. So, palliation is the only therapeutic option for the advanced disease to relieve dysphagia and its consequences in weakened patients with an estimated mean survival under 6 mo. This article has tried to identify trends focusing on current information about the best palliative treatment, with an emphasis on the role of stenting. Self-expanding stent placement, either metal or plastic, is the main management option. However, this anatomical location creates some particular problems for stent safety and effectiveness which may be overcome by properly designed novel stents. The stents ensure a good quality of life and must be preferred over other alternative methods of loco-regional modalities, i.e., external radiation, laser thermal or photodynamic therapy. Although stent placement is generally a simple, safe and effective method, there are sometimes complications, increasing the morbidity and mortality rate. Bypass operative procedures have now been abandoned as a first choice. The stomach instead of the colon must be used for a bypass operation when it is needed. Chemotherapy, despite the toxicity, and intraluminal radiation (brachytherapy) have a well-defined role.

Isolated complete avulsion of the gallbladder (near traumatic cholecystectomy): a case report and review of the literature

INTRODUCTION

Injury of the gallbladder after blunt abdominal trauma is an unusual finding; the reported incidence is less than 2%. Three groups of injuries are described: simple contusion, laceration, and avulsion, the last of which can be partial, complete, or total traumatic cholecystectomy.

CASE PRESENTATION

A case of isolated complete avulsion of the gallbladder (near traumatic cholecystectomy) from its hepatic bed in a 46-year-old Caucasian man without any other sign of injury is presented. The avulsion was due to blunt abdominal trauma after a car accident. The rarity of this injury and the stable condition of our patient at the initial presentation warrant a description. The diagnosis was made incidentally after a computed tomography scan, and our patient was treated successfully with ligation of the cystic duct and artery, removal of the gallbladder, coagulation of the bleeding points, and placement of a drain.

CONCLUSIONS

Early diagnosis of such injuries is quite difficult because abdominal signs are poor, non-specific, or even absent. Therefore, a computed tomography scan should be performed when the mechanism of injury is indicated.

New trends in diagnosis and management of gallbladder carcinoma

Gallbladder (GB) carcinoma, although relatively rare, is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis. It is closely associated with cholelithiasis and long-standing large (> 3 cm) gallstones in up to 90% of cases. The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes, GB wall calcification (porcelain) or mainly mucosal microcalcifications, and GB polyps ≥ 1 cm in size. Diagnosis is made by ultrasound, computed tomography (CT), and, more precisely, magnetic resonance imaging (MRI). Preoperative staging is of great importance in decision-making regarding therapeutic management. Preoperative staging is based on MRI findings, the leading technique for liver metastasis imaging, enhanced three-phase CT angiography, or magnetic resonance angiography for major vessel assessment. It is also necessary to use positron emission tomography (PET)-CT or 18F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake. Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6% of cases. Multimodality treatment is needed, including surgical resection, targeted therapy by biological agents according to molecular testing gene mapping, chemotherapy, radiation therapy, and immunotherapy. It is of great importance to understand the updated guidelines and current treatment options. The extent of surgical intervention depends on the disease stage, ranging from simple cholecystectomy (T1a) to extended resections and including extended cholecystectomy (T1b), with wide lymph node resection in every case or IV-V segmentectomy (T2), hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y, and adjacent organ resection if necessary (T3). Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery, but much attention must be paid to avoiding injuries. In addition to surgery, novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy (neoadjuvant-adjuvant capecitabine, cisplatin, gemcitabine) have yielded promising results even in inoperable cases calling for palliation (T4). Thus, individualized treatment must be applied.

The role of laparoscopic surgery in gastric cancer

The laparoscopic surgery in gastric cancer is applied with increasing frequency nowadays; noticeable reports come mainly from Korea and Japan with satisfactory results. This review presents briefly the issue by evaluating its role. A PubMed search of relevant articles published up to 2010 was performed to identify current information. Most data come from Far East, where gastric cancer occurs more often, and the proportion of early gastric cancer is high. Laparoscopic approach includes both the diagnostic laparoscopy and laparoscopic resection. Laparoscopic gastrectomy has currently limited application for gastric cancer in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.

Abdominal wall sinus due to impacting gallstone during laparoscopic cholecystectomy: an unusual complication

During laparoscopic cholecystectomy, perforation of the gallbladder can occurs in < or = 20% of cases, while gallstone spillage occurs in < or = 6% of cases. In most cases, there are no consequences. Gallstones can be lost in the abdominal wall as well as the abdomen during extraction of the gallbladder. The fate of such lost gallstones, which can lead to the formation of an abscess, an abdominal wall mass, or a persistent sinus, has not been studied adequately. Herein we report the case of a persistent sinus of the abdominal wall after an emergent laparoscopic cholecystectomy in an 82-year-old woman with gangrenous cholecystitis and perforation of the friable wall in association with an empyema of the gallbladder. The culture of the obtained pus was positive for Escherichia coli. After a small leak of dirty fluid from the wound of the epigastric port site of 4 months' duration, surgical exploration under local anesthesia revealed that the sinus was caused by spilled gallstones impacting into the abdominal wall between the posterior sheath and left rectus abdominalis muscle. The removal of the stones resulted in complete healing. Long-term complications after laparoscopic cholecystectomy involving the abdominal wall are rare but important possible consequences that could be avoided.

Robot-Assisted Thyroidectomy Versus Open Thyroidectomy in the Treatment of Well Differentiated Thyroid Carcinoma

BACKGROUND

The incidence of thyroid cancer has increased worldwide during the last decade, becoming the most common endocrine malignancy and accounting for 3.8% of new cancer diagnosis. Surgical resection, namely conventional thyroidectomy, remains at the frontline of therapy, as surgical outcomes are undoubtedly successful. Minimally invasive techniques gained popularity through the years, in terms of feasibility, safety, and cosmesis. However, endoscopic approach could be characterized by some limitations concerning thyroid surgery. Robotic technology with its unique features was introduced to overcome these limitations. Since then, robotic thyroidectomy has been used for both benign and malignant thyroid disease.

DATABASE

This study presents the use of robot-assisted transaxillary thyroidectomy in well-differentiated thyroid carcinoma through an extensive review of the literature in the PubMed database, including previous meta-analyses and case series.

CONCLUSION

In terms of oncological efficacy, morbidity, and quality of life, outcomes seem comparable in thyroid cancer patients undergoing either open or robotic thyroidectomy. Surgical completeness also appears similar. Moreover, the rates of locoregional recurrence and survival outcome at 5 years are similar between the former and the latter, thus confirming the oncological value of robotic thyroidectomy for differentiated thyroid cancer. In order for more surgeons to adopt robotic approaches several issues need to be resolved, namely: expansion of robotic thyroidectomy in treating larger well-differentiated carcinomas and neck dissection, equipment costs, and prolonged operation times.

Current Molecular and Genetic Aspects of Pancreatic Cancer, the Role of Metastasis Associated Proteins (MTA): A Review

Purpose/aim: To focus on current molecular and genetic aspects and MTA proteins, since pancreatic cancer is a lethal malignant with poor prognosis. Early diagnosis is essential step, contributing to potential curative resection.

MATERIALS AND METHODS

A PubMed search of relevant articles published up to August 2016 was performed to identify current information about pancreatic cancer regarding molecular biomarkers, with emphasis on carcinogenesis, novel therapeutic targets, and MTA proteins.

RESULTS

Understanding the mechanisms involved in the process of carcinogenesis at the molecular level and the recognition of various oncogenes has opened new horizons for both diagnosis and targeted therapy. Metastasis associated (MTA) proteins (MTA1, MTA2, MTA3) comprise a well-established family of biomarkers. The oncogene MTA1 and its expression product MTA1 protein are the most important and adequately studied in the current research. It defines the growth, local invasiveness, lymphatic spread, and metastatic capacity of various malignancies such as colorectal or gastric cancer including also pancreatic cancer. This protein is associated with malignant potential and biological behavior. Consequently, it could contribute to cancer detection since the first stages of carcinogenesis, as well as in prediction of its malignant differentiation grade. The pre-operative information of the possibility of lymph node involvement may also affect the attempt and the extent of curative resection and lymphadenectomy.

CONCLUSIONS

Carcinogenesis and implicated oncogenes, either activators or repressors, concentrate much research interest, as well as being useful as biomarkers and for targeted therapy. MTA proteins could become useful diagnostic and prognostic biomarkers in current management of pancreatic cancer.

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Primary hyperparathyroidism (pHPT) is the third most common endocrine disease. The surgical procedure aims for permanent cure, but recurrence has been reported in 4%-10% of pHPT patients. Preoperative localization imaging is highly valuable. It includes ultrasound, computed tomography (CT), single-photon-emission CT, sestamibi scintigraphy and magnetic resonance imaging. The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months. Ongoing hypercalcemia during this period is defined as persistence, and recurrence is defined as hypercalcemia after six months of normocalcemia. Vitamin D is a crucial factor for a good outcome. Intraoperative parathyroid hormone (PTH) monitoring can safely predict the outcomes and should be suggested. PTH ≤ 40 pg/mL or the traditional decrease ≥ 50% from baseline minimizes the likelihood of persistence. Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology. Risk factors for recurrence are cardiac history, obesity, endoscopic approach and low-volume center (at least 31 cases/year). Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/ recurrence. A 6-mo calcium > 9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up. 18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation. With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement, the recurrence rate has dropped to 2.5%-5%. Six-month serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL indicate a risk of recurrence. Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels are predictors of multiglandular disease, which brings an increased risk of persistence and recurrence. Bilateral neck exploration was considered the gold-standard diagnostic method. Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques. Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence. Long-term follow-up, even up to 10 years, is necessary.

Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients

BACKGROUND

elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years.

METHODS

from January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were ≥ 65 years old.

RESULTS

elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged ≥ 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged ≥ 65 years.

CONCLUSIONS

open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization.

Helicobacter pylori infection in patients undergoing appendectomy

AIMS

Helicobacter pylori has been found in the upper gastrointestinal tract; it is incriminated as aetiological factor in various pathological conditions. This prospective study assesses the presence of this microorganism in the appendix flora and the possible role of its infection in the pathogenesis of acute appendicitis.

METHODS

H. pylori was investigated in 46 consecutive patients undergoing emergent appendectomy for presumed acute appendicitis. Blood sample for serological test of H. pylori infection was drawn before operation. The removed appendix specimen was stained for H. pylori; confirmation was made by PCR (Polymerase Chain Reaction) analysis. The intensity of inflammation was determined pathologically grading from no inflammation to gangrenous appendicitis. Statistical analysis was made using the chi-square test.

RESULTS

Seropositivity for H. pylori infection was found in 18 patients (39%), but the microbe was detected in just two appendix specimens (4%). In all seropositive patients acute appendicitis was confirmed by the pathology study; serous (33%) and purulent or gangrenous (67%). The latter incidence in the seronegative patients was 50%. There were found eight specimens (17%) negative for inflammation dealing all with seronegative patients.

CONCLUSIONS

It seems that H. pylori colonizes the appendix in small proportion and is unlikely to be associated in direct correlation with acute appendicitis. However, seropositive patients with acute inflammation are likely to suffer from purulent or gangrenous form.

Intraperitoneal administration of bevacizumab intraoperatively does not affect abdominal wound healing in rats

BACKGROUND

Bevacizumab is a monoclonal antibody targeted at vascular endothelial growth factor (VEGF) to treat advanced colorectal cancer as well as other malignancies, but the ideal time point for its administration in patients scheduled for surgery is not well defined due to serious concerns regarding possible side effects on wound healing. Therefore, we conducted an experimental study in rats to clarify this issue.

METHODS

Four groups of 10 Wistar rats each underwent a 4-cm midline laparotomy and closure of the wound in 2 layers. In the treatment groups (A and B), bevacizumab (Avastin(®)) received a single dose of 5 mg/kg i.p., and an equal amount of saline was given to the control groups (C and D). Groups A and C were sacrificed on the 7th postoperative day, and groups B and D on the 14th postoperative day. Wounds were inspected by two independent observers upon sacrifice and results were recorded; wound tissues were sent for histology to assess the degree of fibrosis and measurement of tissue hydroxyproline levels. Serum levels of endothelin-1, C-reactive protein, pro-oxidant/antioxidant balance and carbonylated proteins were also determined. For statistical analysis, the Mann-Whitney U test was used.

RESULTS

Wound healing did not differ among groups both on the 7th and the 14th postoperative days, and there was also no significant difference regarding the degree of inflammation, fibroblast proliferation and collagen synthesis, as well as hydroxyproline and biochemical marker levels among the groups.

CONCLUSIONS

Intraperitoneal bevacizumab administered intraoperatively does not significantly affect abdominal wound healing in rats.