Thrombocytopenia following implantation of different types of bioprosthetic aortic valves in severe aortic valve stenosis replacement

Aim

The use of bioprosthetic valves in the surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) of severe aortic stenosis has been associated with post-implantation thrombocytopenia, usually reversible and rarely combined with severe bleeding events. The purpose of this study was to compare the grade of thrombocytopenia and the presence of bleeding events following the implantation of bioprosthetic valves, where either surgery (Solo, Perceval, Trifecta) or transcatheter method (self-expandable TAVI) was followed.

Methods

89 patients with severe aortic stenosis were included in the study. All patients underwent either SAVR or TAVI. In each group 3 different types of bioprosthetic valves were used [59 patients in SAVR group: Solo (14), Perceval (27), Trifecta (18), 30 patients in TAVI group: Evolut R (10), Portico (15), Acurate (5)]. All patients had normal or slightly reduced platelet count at baseline. Patients previously receiving anticoagulants, patients with a primary blood disorder affecting the number of platelets, as well as patients with a post-surgery complication that could affect the number of platelets (e.g., HIT syndrome, etc.) were excluded from the study. Blood samples were taken in the morning before intervention and every morning during the first week of follow-up. Platelet count values before and after implantation were compared with paired t-test (SPSS V21.0, Inc., Chicago, IL, USA), while the reduction of platelets was compared between the 4 different valves with independent t-test. P-values of <0.05 were considered significant.

Results

Mean age was 76.8±5.1 years. There was no statistically significant difference between the 2 groups of patients concerning the baseline characteristics and the administered anticoagulants. Statistically significant reduction of the blood count was observed in all groups [Solo: 136±80x103/μl (p=0.009), Perceval: 129±75x103/μl (p<0.001), Trifecta: 74±32x103/μl (p<0.001, TAVI: 60±103μl)]. There was no observed statistically significant difference between Solo and Perceval group (p=0.85) or Solo and Trifecta group (p=0.053), but in the case of Perceval and Trifecta group, a statistically significant difference was noted (p=0.047). A statistically significant difference in both SAVR and TAVI groups was demonstrated (p=0.040) regarding blood count reduction. There was no occurrence of any major bleeding events. 3 patients (3.3%) presented mild bleeding disorders (1 patient epistaxis and 2 patients mild hematuria).

Conclusion

Both methods, surgical and transcatheter severe aortic stenosis replacement and all the different bioprosthetic valves that were implanted, were associated with statistically significant reduction of platelet count post-implantation. This reduction was linked to the procedure due to endothelial damage, shear stress injury, inflammation-related platelet consumption, and was not associated with clinically significant bleeding events.

Funding Acknowledgement

Type of funding sources: None.

Routine podiatry assessment as a potential preventive tool for atrial fibrillation screening in diabetics

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Atrial fibrillation (AF) is a common heart arrhythmia predominantly in advanced age patients and in diabetic’s type II (DMPII). Even if the risk of stroke in AF in DMPII is relative high, 25% of AF patients remains undiagnosed and also cryptogenic AF is very common in the diabetic population. During a 12-month study project, podiatrists and podologists performed foot pulse-checks in their routine podiatry assessment, when encountering visual symptoms that suggest an underlying circulatory disorder in diabetics. This simple non-invasive method aims to increase screening and diagnosis of AF from allied health professionals, in order to reveal patients with previously undiagnosed AF and patients with cryptogenic Af, challenging the potential reduction of AF complications and mainly of stroke.

Purpose 

Early detection of AF in diabetics from allied health professionals during routine podiatry assessment. Revealing of previously undiagnosed AF contributes to stroke and other AF complications incidence reduction in the diabetics population.

Methods 

During a 12-month study, 2 podiatrists and 6 podologists performed foot pulse-checks on diabetics, during their annual foot screening appointments, since they have been trained from medical doctors to spot rhythm abnormalities during pulse palpation of the foot arteries. They have been also trained to confirm their pulse palpation evidence thought Doppler ultrasound wave assessments during evaluation of arterial blood supply (anterior-posterior tibial arteries and ramifications) of the diabetic foot. During the study 300 diabetics (mean age 60 years old, 180 males, 120 females) had their feet pulse-tested. Spss statistical software had been used. 

Results 

17% of diabetics during foot pulse-checks presents undiagnosed AF. There was no statistically significant difference (p < 0.05) between sex  (males and females AF screening percents were similar). 

Conclusion(s) 

Early detection and properly managed during AF screening reduces AF complications and specifically stroke incidence. Opportunistic podiatric detection of previously undiagnosed and cryptogenic AF from allied professionals is a non invasive, safe, fast and economic method with potential contributions in this direction. More studies must be designed in order to support the routine podiatry assessment, as a useful Screening diagnostic tool of AF for reducing cardiovascular complications incidence in diabetics but also in the general population.

The impact of nationwide lockdown on acute coronary syndromes hospitalization rate in the Western Macedonia regional hospital of Greece

Funding Acknowledgements

Type of funding sources: None.

Introduction

 World Health Organization declared the Covid-19 outbreak a global pandemic on March 11, 2020. The pandemic is associated with more than 75 million cases and more than 1.5 million deaths worldwide. Greece implemented a nationwide lockdown on March 23, 2020, to control the pandemic wave and prevent reducing morbidity and mortality due to Covid-19. During this period, acute coronary syndromes (ACS) hospitalization in the cardiology department was reduced. In addition, the second pandemic wave also led to a new national lockdown on November 7, 2020, although it was implemented 15 days earlier in the relative regional hospital area due to high viral load.

Purpose

 Our study evaluated the number of hospitalized patients with ACS during the nationwide lockdown period, comparing them with the previous years (period 2018 and 2019).

Material and Methods

 Data recordings regarding ACS (unstable angina, NSTEMI, STEMI) hospitalization rates in the Cardiology department were collected from the hospital"s register. Each year"s data analysis interval included the periods of the nationwide lockdown of 2020; March 23 to May 3 and October 14 to December 10. Statistical analysis was performed between periodic groups using the chi-square test (IBM SPSS Statistics software, version 23.0).

Results

 During 2018, the number of patients hospitalized for ACS was 81 and consisted of 39,1% of the total hospitalizations in the Cardiology Department. In 2019 the number of patients hospitalized for ACS was 62 and consisted the 48,8% of the total hospitalizations, while in 2020, the number of patients hospitalized for ACS was 30 and consisted the 27,5% of the total hospitalizations. Furthermore, there was a statistically significant difference (p < 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October-December 2020) and the COVID-19-free period of the previous year (March to May and October to December 2019). There was no statistically significant difference (p > 0,05) regarding ACS event hospitalization rate between the period of lockdown (March to May and October to December 2020) and the COVID-19-free period of the year 2018 (March to May and October to December). Finally, there was no statistically significant difference (p > 0,05) in ACS event hospitalization rate between March to May and October to December regarding the years 2018 and 2019.

Conclusion

 Our results are in compliance with the ESC"s comparative survey regarding the observed worldwide reduction of hospitalizations for ACS during the COVID-19 lockdown era, suggesting a potential impact of lockdown in both non-environmental and environmental risk factors for cardiovascular disease. Factors of the relative epidemiological reduction are complexed and puzzled, while morbidity and mortality of ACS remained relatively stable even after the lockdown, so future studies are necessary to further investigate them.

Anemia and stroke: Where do we stand?

Anemia seems to have a clear relationship with cerebrovascular events (CVEs), as there is a direct connection between central nervous system, blood supply, and tissue oxygen delivery. Anemia is considered a hyperkinetic state which disturbs endothelial adhesion molecule genes that may lead to thrombus formation. Furthermore, blood flow augmentation and turbulence may result in the migration of this thrombus, thus producing artery-to-artery embolism. It is for this reason that anemia is characterized as "the fifth cardiovascular risk factor." Anemia is consistently present in patients with acute stroke, ranging from 15% to 29%, while the mortality rate was significantly higher in patients suffering from anemia at the time of admission. Different types of anemia (sickle cell disease, beta thalassemia, iron deficiency anemia [IDA]) have been associated with increased cardiovascular and CVE risk. The relation between hemoglobin level and stroke would require further investigation. Unfortunately, treatment of anemia in cardiovascular and cerebrovascular disease still lacks clear targets and specific therapy has not developed. However, packed red blood cell transfusion is generally reserved for therapy in patients with CVEs. What is more, treatment of IDA prevents thrombosis and the occurrence of stroke; although iron levels should be checked, chronic administration favors thrombosis. Regarding erythropoietin (EPO), as there is lack of studies in anemic stroke patients, it would be desirable to utilize both neuroprotective and hematopoietic properties of EPO in anemic stroke patients. This review aims to clarify the poorly investigated and defined issues concerning the relation of anemia and CVEs.

Is management of hyperglycaemia in acute phase stroke still a dilemma?

INTRODUCTION

Close monitoring of blood glucose levels during the immediate post-acute stroke phase is of great clinical value, as there is evidence that the risk of neurological deterioration is associated with both hyper- and hypoglycaemia. The aim of this review paper is to summarise the evidence on post-stroke blood glucose management and its impact on clinical outcomes, during the early post-acute stage.

FINDINGS

Post-stroke hyperglycaemia has been associated with increased cerebral oedema, haemorrhagic transformation, lower likelihood of recanalisation and deteriorating neurological state. Thus, hyperglycaemia during an acute stroke may result in poorer clinical outcomes, infarct progression, poor functional recovery and increased mortality rates. Although hypoglycaemia may also lead to poorer outcomes via further brain injury, it can be readily reversed by glucose administration. In most patients, the goal of regular treatment is euglycaemia and for acute-stroke patients, a reasonable approach is to target control of glucose level at 100-150 mg/dL.

CONCLUSION

Both hypoglycaemia and hyperglycaemia may lead to further brain injury and clinical deterioration; that is the reason these conditions should be avoided after stroke. Yet, when correcting hyperglycaemia, great care should be taken not to switch the patient into hypoglycaemia, and subsequently aggressive insulin administration treatment should be avoided. Early identification and prompt management of hyperglycaemia, especially in acute ischaemic stroke, is recommended. Although the appropriate level of blood glucose during acute stroke is still debated, a reasonable approach is to keep the patient in a mildly hyperglycaemic state, rather than risking hypoglycaemia, using continuous glucose monitoring.

Surgical management of gastrointestinal stromal tumors: a single centre's experience

BACKGROUND

Gastrointestinal stromal tumors (GISTs) represent 85% of all mesenchymal neoplasms that affect the gastrointestinal track. Aim of this study is to report a case series of 18 GISTs treated surgically in a single centre and to discuss the diagnostic and therapeutic issues regarding these tumors.

CASE SERIES

A retrospective search of the unit's medical records from 2002 to 2014 was carried out, to collect all cases diagnosed and treated for GISTs. Demographics and clinical features was obtained for all relevant cases.

RESULTS

Eighteen cases (18) of GIST were identified. Eleven tumors were located in the stomach, 3 tumors in the duodenum and 4 tumors in the jejunum. The mean age at diagnosis was 62.5 (range 42-81) years, while the male to female ratio was 1.57/1 (11 males/7 females). Patients presented with a variety of symptoms and all underwent surgery. The 5-year-survival rate of these patients was 50%.

CONCLUSION

Due to non-specific presentation of GISTs, initial diagnosis of these tumors may be delayed. High clinical suspicion and knowledge of their characteristics are essentials in order to achieve an early diagnosis and lead patients to surgery as soon as possible. Hippokratia 2015, 19 (1): 73-75.

Selective embolization for massive upper gastrointestinal bleeding deriving from gastric angiodysplasia

Transcatheter arterial embolization is a valuable, minimally invasive method, used as treatment for upper gastrointestinal bleeding, after failed primary endoscopic approach. It is a safe and effective procedure, but it's use is limited because of relatively high rates of rebleeding and mortality.

The aim of this paper is to present a case of severe, massive upper gastrointestinal bleeding deriving from gastric angiodysplasia, which was treated successfully with superselective embolization. The patient recovered from the haemorrhagic shock and avoided emergency surgical intervention.

The effects of tacrolimus on colonic anastomotic healing in rats

AIM

The aim of this experimental study is to investigate the effects of tacrolimus on colonic anastomotic healing after subcutaneous administration.

MATERIALS AND METHODS

Forty Albino-Wistar male rats were divided into two groups, with two equal subgroups each. They all underwent colonic resection followed by a single-layer, inverted colon anastomosis and were injected subcutaneously with either 1 ml of 0.9% NaCl solution or tacrolimus (0.1 mg/kg body weight) depending on their group. Half of the rats were sacrificed on the fourth postoperative day, while the remaining half were sacrificed on the eighth postoperative day. Macroscopical and histological assessment was performed, while anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were evaluated.

RESULTS

On the fourth postoperative day, the bursting pressures (217.00 ± 11.12, p < 0.001), the fibroblast activity (2.80 ± 0.42, p = 0.022), the neoangiogenesis (2.10 ± 0.32, p = 0.007) and the tissue hydroxyproline concentration (254.23 ± 67.10, p = 0.001) were significantly higher in the tacrolimus-treated animals. Furthermore, tacrolimus significantly decreased the inflammatory cell infiltration (1.50 ± 0.53, p < 0.001) and the tissue collagenase I concentration (4.16 ± 0.76, p = 0.002). On the eighth day, the bursting pressure (264.00 ± 32.61, p < 0.001) and the hydroxyproline tissue concentration (331.04 ± 55.56, p = 0.002) were significantly higher in the tacrolimus subgroups. The inflammatory cell infiltration (1.20 ± 0.42, p < 0.001) and the collagenase I concentration (1.61 ± 0.83, p < 0.001) were significantly lower. In addition, the adhesion formation score was significantly lower (1.20 ± 0.92, p = 0.065).

CONCLUSION

Tacrolimus, when injected subcutaneously, promotes healing of colonic anastomoses in rats. It impairs not only inflammatory response but also collagen degradation, resulting to increased anastomotic strength on the fourth as well as on the eighth postoperative day.

Large bowel obstruction due to endometriosis

We report on three cases of premenopausal female patients with large bowel endometriosis causing intermittent obstruction.

Laparoscopic right hemicolectomy due to colon cancer

AIM

The aim of this study is to present our patients with laparoscopic right hemicolectomy due to cancer.

PATIENTS AND METHODS

Between 2005 and 2009, laparoscopic right hemicolectomy for cancer was performed in 9 patients.

RESULTS

The average operative time was 168 min. The average hospital stay was 5.3 days. There was one conversion (11.1%) to an open procedure. There were no postoperative complications. All the patients remain so far with no signs of tumor recurrence.

CONCLUSION

Laparoscopic right hemicolectomy for cancer in the hands of an experienced laparoscopic surgeon is a safe and efficient procedure.

Anastomotic leakage following low anterior resection for rectal cancer

AIM

Aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.

PATIENTS AND METHODS

Between 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME).

RESULTS

A total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy.

CONCLUSION

The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

Influence of the stable prostacyclin analog iloprost on the healing of colonic anastomosis in rats

AIM

The aim of this study was to investigate whether iloprost injected intraperitoneally immediately after colon resection can improve anastomotic healing on the fifth and eighth postoperative days.

METHODS

Forty Wistar rats were randomised into 2 equal groups. After the resection of a 1 cm segment of transverse colon, an end to end sutured anastomosis was generated. From the day of the operation, group 1 (control) received intraperitoneal 3 cc saline solution once daily until sacrifice, while group 2 (iloprost) received iloprost in a dose of 2 mg/kg body weight intraperitoneally once daily until sacrifice. Each group was further randomly divided into 2 equal subgroups and animals were sacrificed on the fifth (subgroup A), and eighth (subgroup B) postoperative days. After sacrifice, anastomoses were examined macroscopically and were measured for bursting pressures and tissue hydroxyproline levels while anastomotic healing process was evaluated histopathologically.

RESULTS

None of the rats exhibited any clinical evidence of leakage and there were no instances of peri-anastomotic abscess or peritonitis. Bursting pressure on the fifth postoperative day was significantly higher in the iloprost group than in the control group (P<0.001), while on the eighth postoperative day, bursting pressure was higher in the iloprost group but not significantly different (P=0.165). On both the fifth and eighth postoperative days rats in the iloprost group developed significantly more marked neo-angiogenesis and, in parallel with this, there was a trend showing a higher inflammatory cell infiltration.

CONCLUSION

The intraperitoneal administration of iloprost promoted neo-angiogenesis and enhanced colonic healing on the fifth postoperative day.

Effect of iloprost on impaired anastomotic healing caused by 5-fluorouracil plus leucovorin

PURPOSE

This experimental study was designed to investigate whether iloprost can reverse impaired colonic healing caused by immediate postoperative intraperitoneal administration of 5-fluorouracil plus leucovorin.

METHODS

Eighty Wistar rats were randomized into four groups. After resection of a 1-cm segment of transverse colon, an end-to-end sutured anastomosis was generated. Rats received saline solution (Group 1), 5-fluorouracil plus leucovorin (Group 2), iloprost (Group 3), and 5-fluorouracil plus leucovorin plus iloprost (Group 4) intraperitoneally from the day of operation and once daily until killing. Each group was further randomized into two subgroups. Subjects were killed on the fifth (Subgroup a) and eighth (Subgroup b) postoperative days. After killing, anastomoses were examined macroscopically and graded histologically. Rats were measured for anastomotic bursting pressures and tissue hydroxyproline levels.

RESULTS

The leakage rate of the anastomoses was significantly higher in the 5-fluorouracil plus leucovorin group compared with the other groups (P = 0.049). Bursting pressure was significantly lower in 2a subgroup (5-fluorouracil plus leucovorin, postoperative Day 5) than in 4a (5-fluorouracil plus leucovorin plus iloprost, postoperative Day 5; P < 0.001). Adhesion formation was significantly higher in all b subgroups compared with the Control b subgroup. Neoangiogenesis was significantly higher in iloprost and iloprost plus 5-fluorouracil plus leucovorin subgroups compared with the 5-fluorouracil plus leucovorin subgroups. Hydroxyproline levels, collagen deposition, fibroblasts, and white cell count were significantly higher in the iloprost plus 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8) compared with the 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8).

CONCLUSIONS

The immediate postoperative, intraperitoneal administration of iloprost counteracts and reverses the negative effects of 5-fluorouracil plus leucovorin chemotherapy and protects colonic healing in rats.

Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years

BACKGROUND

The aim of our study was to assess our early and long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids.

METHODS

Our study covers the time period from 1998 to 2002 and consists of 56 consecutive patients (33 men) with fourthdegree haemorrhoids who underwent stapled haemorrhoidopexy.

RESULTS

During the postoperative period, 6 patients (10.7%) experienced pain for 7-14 days, which was treated with oral analgesia. Ten patients (17.8%) experienced gas incontinence and two of them also reported soiling. The incontinence subsided within 3-8 weeks. Median follow-up was 72.1 months (range, 55-86 months). Recurrence of the haemorrhoidal disease occurred in 33 patients (58.9%). The overall reintervention rate was 42.8%, as 24 patients required excisional haemorrhoidectomy by the Milligan-Morgan technique at a later stage.

CONCLUSIONS

Stapled haemorrhoidopexy seems to be a safe, low-pain but ineffective technique for the treatment of fourth-degree haemorrhoids, as it is accompanied by high recurrence and reintervention rates in the long term.

Effect of 5-Fluorouracil plus Interferon on the Integrity of Colonic Anastomoses Covering with Fibrin Glue

BACKGROUND

It has been well established that the immediate postoperative intraperitoneal administration of chemotherapeutic agents such as 5-fluorouracil (5-FU) after curative colon resection for colon cancer destroys disseminated cancer cells and inhibits micrometastases but also inhibits anastomotic healing. On the other hand, the application of fibrin glue constitutes a physical barrier around the anastomosis and may prevent anastomotic leakage. The purpose of this experimental study was to determine the effect of 5-FU plus interferon (IFN)-alpha-2a on the integrity of colonic anastomoses covered with fibrin glue when injected intraperitoneally immediately after colon resection.

MATERIALS AND METHODS

Sixty rats were randomized to one of four groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. Rats of the control and the fibrin glue groups were injected with 6 ml of 0.9% sodium chloride (NaCl) solution intraperitoneally. Rats in the 5-FU + IFN and the 5-FU + IFN + fibrin glue groups received 5-FU plus IFN intraperitoneally. The colonic anastomoses of the rats in the fibrin glue and in the 5-FU + IFN + fibrin glue groups were covered with fibrin glue. All rats were sacrificed on the 8th postoperative day, and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded, and the anastomoses were graded histologically.

RESULTS

Only the 5-FU + IFN group had anastomoses rupture, and the rupture rate (33%) in this group was significantly greater than in the other groups, where there were no ruptures (P = 0.015). The adhesion formations score was, on average, significantly higher in rats of the 5-FU + IFN group compared with the control group (P = 0.006) and the 5-FU + IFN + fibrin glue group (P = 0.010). Bursting pressures were significantly lower in the control group when compared to the fibrin glue and 5-FU + IFN + fibrin glue group (P < 0.001). Rats in the 5-FU + IFN + fibrin glue group developed significantly more marked neoangiogenesis than rats in the other groups. Inflammatory cell infiltration, collagen deposition, and fibroblast activity did not differ significantly among the four groups (P = 0.856, P = 0.192 and P = 0.243, respectively).

CONCLUSION

The immediate postoperative intraperitoneal administration of 5-FU plus IFN impairs colonic healing. However, when the colonic anastomoses were covered with fibrin glue, the injection of 5-FU plus IFN had no adverse effects on the integrity of the anastomoses.

The effect of insulin-like growth factor I on healing of colonic anastomoses in cortisone-treated rats

PURPOSE

This study was designed to investigate whether intraperitoneally injected insulin-like growth factor I is able to protect colonic healing from the adverse effects of hydrocortisone therapy.

METHODS

Eighty female Wistar rats were randomized into four groups (20 rats each). After resection of a segment of transverse colon, an end-to-end anastomosis was performed. Hydrocortisone (5 mg/kg body weight) was injected intramuscularly in rats of cortisone (Group B) and insulin-like growth factor I + cortisone (Group D) groups once daily for seven days before and after the operation. Insulin-like growth factor I (2 mg/kg body weight) was intraperitoneally injected in rats of the insulin-like growth factor I (Group C) and the insulin-like growth factor I + Cortisone (Group D) groups immediately after operation and on the second, fourth, and sixth postoperative days. Rats were killed on the seventh postoperative day. Anastomoses were graded macroscopically and histologically, and bursting pressures and anastomotic hydroxyproline levels were recorded. Statistical analyses were performed by using Fisher's exact test for the comparison of proportions and ANOVA for the comparison of means among groups with subsequent post-hoc analysis using Bonferroni correction.

RESULTS

Leakage rate was significantly higher in the cortisone (Group B) group. Bursting pressures were significantly lower in the cortisone group, whereas they were significantly higher in the insulin-like growth factor I and insulin-like growth factor I + cortisone groups (Group C and D). Histology revealed a significant decrease of inflammatory cell infiltration, neoangiogenesis, and fibroblast activity in the cortisone group compared with the control group, whereas these parameters were significantly higher in the insulin-like growth factor I and insulin-like growth factor I + cortisone groups. Hydroxyproline levels were significantly higher in the insulin-like growth factor I and insulin-like growth factor I + cortisone groups.

CONCLUSIONS

Hydrocortisone inhibits the healing of colonic anastomoses. However, insulin-like growth factor I given intraperitoneally mediates the deleterious effects of cortisone and protects colonic healing in rats.

The healing of colon anastomosis covered with fibrin glue after early postoperative intraperitoneal chemotherapy

BACKGROUND

After colon resection for colonic cancer, the administration of antineoplastic agents may prolong survival by killing residual cancer calls and preventing metastasis, but may also slow anastomotic healing. This study was designed to determine the effects of 5-fluorouracil (5-FU) and leucovorin (LEV), injected intraperitoneally, on the healing of colonic anastomoses with or without fibrin glue (FG) covering.

METHODS

Sixty rats were randomized to one of four groups. After resection of a transverse colon segment, an end-to-end sutured anastomosis was performed. Rats in the 5-FU+LEV and the 5- FU+LEV+FG groups received 5-FU+LEV intraperitoneally. The colonic anastomoses of the rats in the FG group and in the 5-FU+LEV+FG group were covered with fibrin glue. All rats were killed on postoperative day 8. Bursting pressure measurements were recorded and the anastomoses were examined macroscopically and histologically.

RESULTS

The leakage rate of the anastomoses was significantly different among groups. Specifically, the leakage rate was significantly higher in the 5-FU+LEV group (40%) than in the FG and in the 5-FU+LEV+FG groups where there were no leakages (p=0.017). The mean adhesion formation score was significantly higher in rats of the 5-FU+LEV group, compared to the control (p=0.023), the FG (p=0.006) and the 5-FU+LEV+FG (p=0.006) groups. Bursting pressures were significantly lower in the 5-FU+LEV group than in the other groups (p<0.001). Also, bursting pressures were significantly lower in the control group compared to the FG and 5-FU+LEV+FG groups (p<0.001). Rats in the 5-FU+LEV+FG group had significantly greater neoangiogenesis and fibroblast activity than those in the 5-FU+LEV group (p=0.025).

CONCLUSION

The early intraperitoneal postoperative administration of 5-fluorouracil plus leucovorin impaired colonic wound healing. However, the application of fibrin glue prevented the deleterious effect of chemotherapy.

Prognostic significance of CEA levels and positive cytology in peritoneal washings in patients with colorectal cancer

OBJECTIVE

The aims of this prospective study were to determine carcinoembryonic antigen (CEA) levels and incidence of cytology in peritoneal washings of patients with colorectal cancer, correlate the results with various histopathological factors and determine their significance as prognostic factors of the disease.

METHODS

From 1992 to 1999, 98 patients with adenocarcinoma of the colon or intraperitoneal rectum underwent curative surgery and enrolled in this study.

RESULTS

Overall, 25 (26.3%) of 95 patients were found to have positive cytology. The proportion of patients with positive cytology was higher in the recurrence group (36.4%) than in the groups of 5-year survival and hepatic metastases (24.6% and 26.3%, respectively), but this difference was not significant. The 5-year survival group had the lowest peritoneal CEA levels compared with the other groups, but this difference was not significant. Peritoneal cytology and CEA level alone were not sensitive, specific or accurate enough indicators in predicting survival, hepatic metastases or local recurrence. The analysis of patients with positive cytology and high peritoneal CEA level revealed that their combination can predict local recurrence with accuracy of 85%.

CONCLUSIONS

The presence of free malignant cells, as detected by cytology and CEA level, in the peritoneal cavity of patients with resectable colorectal cancer had no detectable impact on survival, hepatic metastases or local recurrence rate. However, local recurrence can be predicted with accuracy of 85% in patients who have positive cytology and high peritoneal CEA level at the same time.

Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids

BACKGROUND

Stapled haemorrhoidopexy (SH) is associated with low postoperative pain but, when performed for advanced piles, carries high recurrence rates. The aim of our study was to assess our long-term results after SH for third-degree haemorrhoids.

METHODS

A total of 126 consecutive patients (67 men and 59 women) with third-degree haemorrhoids underwent SH in our unit between 1998 and 2002. Of these, 120 (95.2%) were followed up in the outpatient department after a median interval of 61.5 months (range, 38-84 months).

RESULTS

During the postoperative period, 7 patients (5.8%) experienced pain for 5-12 days, which was treated with oral analgesia. Seven patients (5.8%) experienced gas incontinence and one of them also reported soiling; the incontinence subsided within 2-8 weeks. Recurrence of the haemorrhoidal disease occurred in 8 patients (6.6%).

CONCLUSIONS

SH is a safe, low-pain and, in the long-term, effective technique for the treatment of third-degree haemorrhoids.

Stapled haemorrhoidopexy for haemorrhoids in combination with lateral internal sphincterotomy for fissure-in-ano

The aim of this prospective study is to describe the combined technique and results of stapled haemorrhoidopexy and lateral internal sphincterotomy for patients suffering from prolapsing 3rd-degree haemorrhoids and chronic fissure-in-ano. During the period from 1999 to 2004, 26 patients underwent combined surgical treatment for anal fissure and prolapsing symptomatic haemorrhoids. Preoperative and postoperative clinical evaluation and the patient's degree of satisfaction were recorded. Early complications included faecal urgency (3 patients) and pain (2 patients). Complete continence was restored within 10 weeks in all patients except 1 who had persisting incontinence to flatus. All fissures healed completely within 4 weeks. No haemorrhoidal or fissure recurrence has been observed during follow-up. The combination of stapled haemorrhoidopexy and lateral internal sphincterotomy is a safe and effective procedure for the treatment of prolapsing 3rd-degree haemorrhoids and chronic anal fissures.

Thoracic splenosis twenty-nine years after traumatic splenectomy mimicking intrathoracic neoplasm

Thoracic splenosis refers to a condition of ectopic splenic tissue in the thoracic cavity. It is usually a consequence of splenic tissue seeding in the pleural cavity after thoracoabdominal trauma. A rare case of thoracic splenosis, in a 62-year-old man who had had a traumatic splenectomy due to thoracoabdominal trauma 29 years earlier, is reported. The patient, a heavy smoker, was admitted for evaluation of a left-side thoracic lesion discovered on a plain chest film. Bronchoscopy, CT scan and needle biopsy proved inconclusive for the diagnosis. Exploratory thoracotomy was necessary to establish the diagnosis. During the operation, a thoracic splenosis was confirmed. To date, only 28 cases of thoracic splenosis have been reported in the literature. The purpose of this report is to present a new case of splenosis of the thoracic cavity simulating intrathoracic neoplasm.

Pneumomediastinum after dilatation of anal stricture following stapled hemorrhoidopexy

Stapling procedure is a new technique for the surgical management of prolapsing haemorrhoids. Some articles have reported severe adverse effects of this operation. We describe a case of an excessive staple-line stenosis followed stapled haemorrhoidopexy. Proctoscopic dilatation resulted in complications of retropneumoperitoneum, pneumomediastinum, subcutaneous emphysema and perianal abscess. Drainage of the abscess was performed, allowing quick recovery. After discharge from the hospital, the patient continued to perform periodic dilatation. Simple proctoscopic dilatation was conducted in an outpatient setting.

Effects of steroid on the healing of colonic anastomoses in the rat

BACKGROUND

The aim of this experimental study was to evaluate the effects of steroid on colonic anastomosis in a rat model.

METHODS

Forty female Wistar rats were randomised into two groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. In the rats of the control group 2 ml of solution 0.9% NaCl was injected once daily intraperitoneally perioperatively. Rats of the steroid group received intraperitoneally once daily, and on the same perioperative days, hydrocortisone (5 mg/kg body weight in 2 ml solution NaCl). All the rats were sacrificed on the 8th postoperative day and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded and anastomoses were graded histologically.

RESULTS

Dehiscence rate was significantly higher in the steroid group than in the control group (p<0.001). Mean bursting pressure was significantly lower in the steroid group compared to the control group (p<0.001). Colonic healing process assessed as inflammatory cell infiltration and collagen deposition was significantly lower in the steroid group than in the control group (p<0.001, p=0.03 respectively).

CONCLUSIONS

Perioperative steroid treatment adversely affects healing of colonic anastomoses in the rat.

The failed intraperitoneal colon anastomosis after colon resection

BACKGROUND

The purpose of this study is to present the incidence of anastomotic leakage after colon resection and intraperitoneal anastomosis for colorectal cancer.

PATIENTS AND METHODS

In the last ten years, 205 patients underwent colonic resection with intraperitoneal anastomosis for colon cancer. The surgical management of colorectal cancer consisted of 66 right hemicolectomies, 3 transverse colectomies, 17 left hemicolectomies, 98 sigmoid colectomies and 21 high anterior resections of the rectum. Diagnosis of leakage was made by clinical features, blood vessel examinations and abdominal CT-scans.

RESULTS

Anastomotic leakage occurred in 5 out of 205 patients (2.4%). One of these patients underwent emergency surgery and the other 4 elective surgery; 3 by manual, 2 by mechanical suture. Three patients with anastomotic leakage were reoperated on days 4, 5 and 7, and 2 patients were treated conservatively. Two of the patients (20%) with anastomotic leakage died due to sepsis.

CONCLUSIONS

Even though the rate of anastomotic leakage in patients with intraperitoneal anastomosis after colon resection for colorectal cancer is low, it remains a significant complication and a major cause of postoperative morbidity and mortality.

Abdominal wall metastasis following treatment of rectal cancer

We present a 60-year-old man with a metastatic subcutaneous lump in the left lower quadrant of the abdomen, from rectal cancer, which was treated three years earlier with low anterior resection of the rectum. Excision of the abdominal wall metastasis was accomplished with negative histological margins, but six months later a new abdominal wall mass was detected. The patient underwent surgery again, in which the abdominal wall metastasis was resected en bloc with adherent portion of small bowel, along with inguinal lymph node dissection. The patient's condition deteriorated 10 months after the initial diagnosis, presenting again with abdominal wall cancer and dying from disseminated peritoneal disease.

Anastomotic leakage following anterior resection for rectal cancer

BACKGROUND

The aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.

PATIENTS AND METHODS

During the last ten years, 93 patients underwent anterior resection of the rectum for rectal cancer. Low anterior resection with total mesorectal excision (TME) was performed in 72, and high anterior resection in 21 patients. The definition of the anastomotic leakage was based on clinical features, peripheral blood investigations and abdominal CT scan.

RESULTS

Clinically apparent anastomotic leakage developed in 9 patients (9.7%). Four patients were managed conservatively and five operatively. Postoperative mortality among the patients with anastomotic leakage was not recorded.

CONCLUSIONS

The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low. It remains however the most serious complication following rectal resection for cancer.

Radio-frequency ablation of hepatic metastases from colorectal cancer

BACKGROUND

The aim of our study is to present the preliminary results of an ongoing radio-frequency (RF) ablation study in patients with hepatic metastases from colorectal cancer.

PATIENTS AND METHODS

From November 2003, two patients affected with metachronous liver metastases from colorectal cancer were treated with RF ablation. The mean age of the patients was 66 years (58 and 74 years). Tumours were unifocal right-lobe lesions in one patient and bifocal in the second patient. Under general anaesthesia, a Radionics 200-W RF generator was used to ablate lesions with H2O-cooled electrodes via laparotomy. Patients' follow-up ranged from two to five months including evaluation of salient clinical, radiological and laboratory parameters.

RESULTS

The patients experienced moderate-to-severe pain in the right abdomen lasting for 2-3 days and mild fever for 3-6 days after treatment. During the follow-up period no local recurrence was observed.

CONCLUSIONS

RF ablation emerges to be a promising method for the treatment of hepatic metastases from colorectal cancer.

Is TNM classification related to early postoperative morbidity and mortality after colorectal cancer resections?

BACKGROUND

To examine the role of TNM staging system as a predictive factor for postoperative morbidity and mortality, after colorectal cancer resections.

PATIENTS AND METHODS

During the last ten years, 368 patients with colorectal cancer were referred to our institution. All patients, who underwent primary treatment elsewhere or defunctioning colostomy only, or who did not undergo surgical therapy were excluded from the analysis. The early postoperative outcomes registration of the remaining 351 patients (197 men, median age 66.2 years) was retrospectively linked to TNM stage.

RESULTS

TNM stage had a poor prognostic value for the early postoperative morbidity rate. In addition, according to the statistical analysis, the proportion of early postoperative mortality proved to be higher in patients with TNM stage III or IV colorectal cancer.

CONCLUSIONS

TNM classification could be considered as a reliable predictor of early postoperative mortality, but has no role in the prediction of early postoperative morbidity after colorectal resections.

Survival after curative resection for rectal cancer by the end of the 20th century

BACKGROUND

The aim of this study was to define the survival rates in patients with rectal carcinoma treated with curative resections.

PATIENTS AND METHODS

Between 1993 and 1998, 54 patients with rectal cancer underwent curative resection by conventional technique. Tumour location, TNM staging and tumour differentiation were evaluated. Among the 54 patients, 14 underwent high anterior resection, 28 low anterior resection, 7 abdominoperineal resection and 5 underwent local excision. Survival rates were calculated using the Kaplan-Meier method and long-range analysis.

RESULTS

Five-year survival was 70.4%. The survival rate statistically significantly decreased with increasing TNM tumour stage (p=0.009). Patients with poor differentiation of the tumour had the lowest 5-year survival (33%) compared to patients with moderate (72%) and good (78%) tumour differentiation. Sex and age did not affect survival. Location of the tumour in the distal end of the rectum and mucinous characteristics are poor prognostic factors affecting survival.

CONCLUSIONS

Curative resection combined with chemoradiotherapy, whenever necessary, is accompanied with acceptable 5-year survival rates.

Five-year survival after curative resection for adenocarcinoma of the colon

BACKGROUND

The purpose of this study was to evaluate the 5-year survival of patients with colon adenocarcinoma that underwent elective or emergency curative surgical treatment.

PATIENTS AND METHODS

Between 1993 and 1998, 80 patients underwent a potentially curative colonic resection based on mobilisation along anatomic planes. Among the patients, 26 underwent right colectomy, 3 transverse colectomy, 13 left colectomy and 38 sigmoidectomy. All patients classified as TNM stage III underwent adjuvant chemotherapy. The Kaplan-Meier method was used to analyse survival.

RESULTS

Overall 5-year survival was 69.5%. Patient's sex and age, mucinous characteristics of the tumour and tumour location did not significantly affect survival. Patients with higher Duke's classification and TNM stage had significantly worse 5-year survival (p=0.025 and p=0.007, respectively). Although patients with good tumour differentiation had the highest 5-year survival, this difference was not statistically significant (p=0.211).

CONCLUSIONS

The treatment of colon adenocarcinoma with curative resection by the end of the 20th century is accompanied with acceptable rates of overall 5-year survival.

Repair of parastomal hernia with the use of polypropylene mesh extraperitoneally

Parastomal hernia is the most frequent complication of colostomy. Many surgical techniques have been postulated and prosthetic surgery seems to represents the first-choice treatment. The aim of this study is to report the surgical treatment of 4 patients that developed parastomal hernia, 3-10 months after abdominoperineal excision of the rectum and permanent sigmoidostomy due to carcinoma of the rectum. The repair was made with the use of polypropylene mesh extraperitoneally. One case of limited skin necrosis occurred without any serious consequences. No recurrence has been recorded among the patients, up to this day (follow-up period: 36 months). In conclusion, the suturing of fascial defect and the use of polypropylene mesh extraperitoneally is effective in the treatment of parastomal hernia.

Synchronous polyps in patients with colorectal cancer

BACKGROUND

The aim of this study is to underscore the incidence of synchronous polyps in patients with colorectal cancer and to emphasise the importance of their perioperative detection and management.

PATIENTS AND METHODS

Three hundred and seven patients underwent a potentially curative resection for colorectal cancer during the last ten years. A total of 129 synchronous polyps were detected in 72 of the patients (23.5%). Complete preoperative colonoscopy was performed in 62 of the patients. Forty-three polyps (33.4%) in 37 patients were removed preoperatively, while 69 polyps (53.4%) in 25 patients were included in the surgical specimen. In 10 patients the colon was evaluated postoperatively and 17 polyps (13.1%) were removed via endoscopy.

RESULTS

A total of 81 polyps were detected in different surgical segments than the index cancer. Furthermore, 15 polyps were detected in the right colon of 55 patients with left colon cancer.

CONCLUSIONS

Synchronous polyps in patients with colorectal cancer are a frequent event. Thus, all patients should undergo a perioperative colonoscopy and endoscopic polypectomy, if feasible. The planned surgical procedure may alter as a consequence of the colonoscopic findings in some of the patients.

Locally recurrent rectal cancer after curative resection

BACKGROUND

To determine the incidence of local recurrence, after curative resection for rectal cancer, with the application of total mesorectal excision (TME).

PATIENTS AND METHODS

During the last ten years, 120 patients underwent curative resection for rectal cancer. As a rule, except for the cases that underwent high anterior resection, TME was applied. In terms of local relapse, routine TME, preoperative radiotherapy, tumour's stage, differentiation grade and number of positive nodes were taken into account.

RESULTS

Eight patients (6.7%) presented with local relapse. At 5 years, 91.9% of patients were free of local recurrence and the actuarial disease-free survival was 81%. A significant association between routine TME, tumour's stage, differentiation grade, lymph node invasion and local recurrence was observed. Conversely, preoperative radiotherapy appeared to play no protective role.

CONCLUSIONS

The curative resection of rectal cancer, with the application of TME, has led to a very low incidence of local relapse during the last few years.

Anaemia as a symptom of right colon cancer

BACKGROUND

The aim of our study is to determine the proportion of iron deficiency anaemia in patients with right colon cancer at diagnosis and to remind of the need of investigation of the large bowel in patients presenting with anaemia.

PATIENTS AND METHODS

From 1988 to 2003, 86 patients with right colon cancer underwent operative management.

RESULTS

Seventy-five patients (87.2%) with right colon cancer had anaemia at diagnosis. The mean Ht value was 33.00% (ranging from 16 to 47%).

CONCLUSIONS

Iron deficiency anaemia is a common symptom of right colon cancer. During the evaluation of patients with iron deficiency anaemia, examination of the right colon is needed.

Age-associated prognosis following curative resection for colorectal cancer

BACKGROUND

The aim of this study is to determine the age-associated prognosis in patients who underwent curative resection for colorectal cancer.

PATIENTS AND METHODS

Between 1993 and 1999, a total of 136 patients underwent curative surgical procedures for colorectal cancer. The study population was divided into three groups according to the age of the patients. Group A: patients younger than 45 years, group B: patients between 45 and 75 years and group C: patients older than 75 years. Tumour location, Dukes' staging, tumour differentiation and five-year survival were evaluated.

RESULTS

There was no significant association between age and tumour staging or tumour differentiation (p=0.990, p=0.753 and p=0.308, respectively). The overall survival at 5 years was 85.7% for the young patients, 77.5% for the middle-aged patients and 62.5% for the elderly patients.

CONCLUSIONS

This aged-grouped study indicates that prognosis is comparable between younger and middle-aged patients whereas in elderly patients it is worsening but not statistically significantly.

Healing of colon anastomoses covered with fibrin glue after immediate postoperative intraperitoneal administration of 5-fluorouracil

PURPOSE

The aim of this experimental study was to investigate whether covering the colonic anastomoses with fibrin glue can protect the colonic healing from the adverse effects of 5-fluorouracil (5-FU), when it is injected intraperitoneally immediately after colon resection.

METHODS

Sixty-four rats were randomized to one of four groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. Rats of the control group and the fibrin glue group were injected with 6 ml of solution 0.9 percent NaCl intraperitoneally. Rats in the 5-FU and the 5-FU + fibrin glue groups received 5-FU intraperitoneally. The colonic anastomoses of the rats in the fibrin glue group and in the 5-FU + fibrin glue group were covered with fibrin glue. All rats were killed on the 8th postoperative day and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded and the anastomoses were graded histologically.

RESULTS

The leakage rate of the anastomoses was significantly higher in the rats of the 5-FU group than in those of the fibrin glue group and those of the 5-FU + fibrin glue group (37.5 percent vs. 0 percent, P = 0.020). The adhesion formation score was significantly higher in rats of the 5-FU group than in the other groups. Bursting pressures were also significantly lower in the 5-FUgroup than in the other groups ( P < 0.001). Rats in the 5-FU + fibrin glue group developed significantly more marked neoagiogenesis than rats in the other groups. Rats in the 5-FU + fibrin glue group also presented significantly more fibroblast activity than those in the 5-FU group. ( P = 0.004)

CONCLUSIONS

The immediate postoperative, intraperitoneal administration of 5-FU inhibited wound healing. However, when the colonic anastomoses were covered with fibrin glue, the injection of 5-FU had no adverse effects on the healing of the anastomoses.

Effects of the use of fibrin glue around the colonic anastomosis of the rat

BACKGROUND

This study was aimed at examining whether the addition of fibrin glue to a sutured colonic anastomosis improves its healing or not.

METHODS

We studied the effect of adding fibrin glue on a sutured colonic anastomosis. Thirty-six Wistar rats were randomized into two groups of 18 rats each. A sutured anastomosis was performed in all rats. Fibrin glue was applied around the anastomosis of the rats of group B. Rats were sacrificed on the eighth postoperative day.

RESULTS

The rate of anastomotic leakage was found not to be significantly different between the two groups. The mean bursting pressure of the colonic anastomoses was significantly higher in group B (fibrin-treated) than in group A.

CONCLUSION

Fibrin glue application around a sutured anastomosis provides a safer anastomosis which is stronger than the sutured one.

Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study

OBJECTIVE

To compare stapled haemorrhoidectomy with Milligan-Morgan haemorrhoidectomy.

DESIGN

Prospective open study.

SETTING

Teaching hospital, Greece.

PATIENTS

85 patients with prolapsing haemorrhoids were invited to choose between stapled and Milligan-Morgan haemorrhoidectomy. 48 chose the former and 37 the latter.

INTERVENTIONS

Operation. Postoperatively, the patients were given analgesics on demand, and were discharged as soon as their condition and particularly their pain had improved.

MAIN OUTCOME MEASURES

Patients' symptoms and their opinion about the procedures, which were recorded during their follow-up which lasted for 6 months.

RESULTS

Stapling resulted in a significantly shorter operating time, and less postoperative pain and other symptoms, than Milligan-Morgan excision (p < 0.001). Postoperative complications, and mean time in hospital did not differ significantly between the two groups. During the follow-up period there was no significant difference in the incidence of recurrences between the two groups. Six months after the operation, significantly more patients in the stapled group had residual skin tags-external haemorrhoids than in the Milligan-Morgan group, and all these patients had fourth degree haemorrhoids.

CONCLUSIONS

Stapled haemorrhoidectomy is a promising method of treatment for prolapsing third degree haemorrhoids. Its effectiveness is questionable for fourth degree ones. Initially, the results are as good as after Milligan-Morgan haemorrhoidectomy, especially for third degree haemorrhoids. However, more patients and longer follow-up periods are required for its long-term efficacy to be confirmed.

Long-term evaluation of sclerotherapy for haemorrhoids. A prospective study

BACKGROUND

Sclerotherapy is one of the older methods of conservative treatment of haemorrhoids. It has been widely used and the early results are considered satisfactory although the long-term results are not as good as expected.

AIMS

The evaluation of long-term results of sclerotherapy in patients with symptomatic 1st and 2nd degree haemorrhoids.

METHODS

From 1990 until 1996, 240 outpatients, 154 men and 86 women, with symptomatic 1st and 2nd degree haemorrhoids, underwent sclerotherapy. The most common symptoms were bleeding for patients with 1st degree haemorrhoids and prolapse for patients with 2nd degree. After 3 years all patients were called and examined and their symptoms were recorded. 38 patients were excluded.

RESULTS

3 years after sclerotherapy 20 patients (20.2%) with 1st degree haemorrhoids and 9 patients (8.7%) with 2nd degree were symptoms free. 42 patients (42.4%) with 1st degree haemorrhoids and 66 patients (64.1%) with 2nd degree were worse, and the remainder were either improved or unchanged. Bleeding and prolapse were the most frequent recurrent symptoms.

CONCLUSION

The frequency of recurrent symptoms 3 years after sclerotherapy for symptomatic 1st and 2nd degree haemorrhoids is high. Sclerotherapy appears to be an inappropriate method of treatment for symptomatic 1st and especially 2nd degree haemorrhoids.