A. K. Sakantamis

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.

Postoperative adhesion prevention using a statin-containing cellulose film in an experimental model.

Intraperitoneal adhesions are a common problem in abdominal surgery. The aim of this study was to compare the effectiveness of Statofilm, a novel antiadhesive film based on cross‐linked carboxymethylcellulose and atorvastatin, with that of sodium hyaluronate–carboxymethylcellulose (Seprafilm®) in the prevention of postoperative intraperitoneal adhesions in rats.

Complicated liver echinococcosis: 30 years of experience from an endemic area.

Background and Aims: Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis. Material and Methods: A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed. Results: Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated. Conclusions: Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Amyand's hernia-a vermiform appendix presenting in an inguinal hernia: a case series

IntroductionA vermiform appendix in an inguinal hernia, inflamed or not, is known as Amyands hernia. Here we present a case series of four men with Amyands hernia.Case presentationsWe retrospectively studied 963 Caucasian patients with inguinal hernia who were admitted to our surgical department over a 12-year period. Four patients presented with Amyands hernia (0.4%). A 32-year-old Caucasian man had an inflamed vermiform appendix in his hernial sac (acute appendicitis), presenting as an incarcerated right groin hernia, and underwent simultaneous appendectomy and Bassini suture hernia repair. Two patients, Caucasian men aged 36 and 43 years old, had normal appendices in their sacs, which clinically appeared as non-incarcerated right groin hernias. Both underwent a plug-mesh hernia repair without appendectomy. The fourth patient, a 25-year-old Caucasian man with a large but not inflamed appendix in his sac, had a plug-mesh hernia repair with appendectomy.ConclusionA hernia surgeon may encounter unexpected intraoperative findings, such as Amyands hernia. It is important to be prepared and apply the appropriate treatment.

Does Emergency Surgery Affect Resectability of Colorectal Cancer

Abstract 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 > 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 (> 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 > 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.

Effect of Experimentally Induced Liver Cirrhosis on Wound Healing of the Post-Extraction Tooth Socket in Rats

Background: Wound healing in liver cirrhosis is known to be impaired possibly due to liver insufficiency and subsequent malnutrition status; however, there is no study to examine healing effectiveness of the tooth socket following an extraction in such patients. Materials and Methods: Irreversible cirrhosiswas induced in 30 Wistar rats by repetitive weekly doses of CCl4 and continuous administration of phenobarbital in a 12-week course was monitored by body weight measurement and ascites development, and was proved histologically. One week later, cirrhotic and control rats were subjected to extractions of two maxillary grinders on each side, one side by simple method, the other by surgical method. Half of the animals of each subgroup were sacrificed on the 10th post-extraction day, whereas the other half on the 30th post-extraction day, and histological sections were examined from all tooth sockets for wound-healing activity. Results: A malnutrition status was detected in cirrhotic rats with significant difference in their body weight. Several histological parameters of socket healing were not statistically different between cirrhotic and control animals. However, a significant delay on epithelialization and cancellous bone formation was detected on the 10th post-extraction day for either simple or surgical extractions in cirrhotic animals. Conclusions: Liver cirrhosis in rats provokes a significant delay on epithelialization and mature cancellous bone formation and consecutively on early socket wound healing after a tooth extraction.

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.

Laparoscopic cholecystectomy in adult patients with beta-thalassemia or sickle cell disease.

Sickle cell disease is a hereditary hemolytic anemia in which the sickle hemoglobin (HbS) substitutes for the normal adult hemoglobin (HbA). Beta-thalassemia is another hereditary hemolytic anemia in which the reduction of beta chain synthesis produces a marked decrease in normal HbA, with a compensatory increase in fetal hemoglobin (HbF). It is well-known that cholelithiasis, which is due to pigmented stones from increased hemoglobinolysis and bilirubin release, is more common in patients with sickle cell disease or thalassemia than in the general population; it occurs at younger age and is often symptomatic, requiring cholecystectomy. In addition, the modern appropriate management of patients with homozygous beta-thalassemia dealing mainly with secondary hemosiderosis and its consequences has increased survival time, prolonging life. Therefore, more patients may suffer from pigmented gallstone disease [5]. Laparoscopic cholecystectomy with its undoubted advantages of minimally invasive surgery has been advocated in such patients. However, the safety and outcome depend largely on some disease-related factors, which should be managed effectively. It has been performed safely and proven superior to open cholecystectomy in patients with sickle cell disease [6]. A standard protocol of operative preparation and postoperative care, including blood transfusion if hemoglobulin is less than 9 or 10 g/dl, adequate rehydration, analgesia, and oxygen therapy, has been proposed [1, 3, 9]. This care is essential to minimize the risk of complications. Cholecystectomy, either open or laparoscopic, in a patient with sickle cell disease predisposes to specific complications (i.e., acute chest or thoracic syndrome and painful vasoocclusive limb, abdominal, or neurological crisis) [1, 3]. Increased monitoring and peroperative care should be employed to reduce morbidity and possibly mortality from this vasoocclusive crisis by sickled erythrocytes [7, 10]. Hematologists must refer well-prepared patients with symptomatic cholelithiasis, and also those with acute cholecystitis [1], for elective laparoscopic cholecystectomy early [2]. Nevertheless, a rare but potentially lethal complication of portal vein thrombosis has been reported after prolonged laparoscopic surgery combined with cholecystectomy, splenectomy, and appendectomy in a patient with sickle cell disease [8]. In patients with beta-thalassemia, care must be taken during laparoscopic cholecystectomy to prevent liver injury; hepatomegaly and pigmented cirrhosis may cause some operative difficulty, but this will be overcome with increased experience [4, 5]. Likewise, systemic complications of iron overload such as myocardial hemosiderosis may occur, making appropriate preparation necessary. Our laparoscopic experience in such patients with hereditary hematological disorders is based on 28 adult patients with a mean age of 23 years (range, 14–32). All patients suffered from symptomatic cholelithiasis and were referred by hematologists for elective laparoscopic cholecystectomy during a 6-year period (1999– 2004). Thirteen patients had homozygous or major beta-thalassemia, and 15 patients had homozygous or major sickle cell disease. Diagnosis of gallstone disease was based on clinical presentation and ultrasound scanning. All laparoscopic procedures were completed successfully. In all thalassemic patients, pigment cirrhosis and fibrosis in the Calot s triangle were noted and liver biopsy was taken. During the same period, a total of 922 laparoscopic cholecystectomies were performed in our department. Laparoscopic cholecystectomy was performed in the same way in all patients using the four-trocar technique according to the ‘‘American’’ variable and at a stable intraabdominal pressure of 12 mmHg of carbon dioxide pneumoperitoneum. The mean duration of the operation was 65 min (range, 45–80). All patients recovered well without any disease-related complications or death. Postoperatively, one thalassemic patient experienced a transient liver dysfunction due to local ischemia from inadvertent right artery ligation presenting with fever, leukocytosis, and liver function test abnormality; another patient with sickle cell disease had mild amylasemia without clinical or imaging evidence of acute pancreatitis. The morbidity rate was 7%. The mean hospital stay was 3.8 days (range, 2–13). Per-operatively in cooperation with hematologists, our patients were hyperhydrated, transfused if necessary, well oxygenated, and monitored closely for arterial blood gases and pH for 24 h in the intensive care unit. Surg Endosc (2005) 19: 1668–1669 DOI: 10.1007/s00464-005-0373-5

Early Propranolol Administration Does Not Prevent Development of Esophageal Varices in Cirrhotic Rats

Background and Aims: Variceal bleeding is the most serious complication of portal hypertension associated with high mortality. This study was conducted to investigate any protective effect of early propranolol administration in the development and degree of esophageal varices in cirrhotic rats with portal hypertension. This topic is controversial in the literature. Methods: For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl4) administration. This operation enhances the development of cephalad collaterals, responsible for the induction of esophageal varices. After 2 weeks of CCl4 administration, the rats were randomly separated into 2 groups. In group I, propranolol was continuously administered intragastrically throughout the study, whereas in group II normal saline (placebo) was administered instead. Cirrhosis was detected clinically by ascites development. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis, measuring the following parameters: portal pressure, total number of submucosal veins, total submucosal vessel area, mean cross-sectional submucosal vessel area, relative submucosal area (percentage) occupied by vessels and area of the single most dilated submucosal vein. Results: The statistical analysis revealed no statistically important difference between the 2 groups for the morphometrically studied parameters. However, portal venous pressure was lower in group I. Conclusion: Early propranolol administration did not protect rats from developing esophageal varices, despite the fact that a significant decrease in portal pressure was detected.

Current management of diverticular disease complications.

Diverticular disease is a common problem in the western population and sometimes leads to serious complications such as hemorrhage, bowel stenosis, obstruction, abscesses, fistulae, bowel perforation, and peritonitis. The severity of these complications can differ, and it is not always clear which procedure is indicated in each case and what measures should be followed before bringing the patient into the operating room. Certain operations have high rates of morbidity and mortality, especially in compromised patients. Along with advancements in imaging and minimally invasive techniques, the indications for surgery have currently being adapted to “damage limitation” or “down-staging” protocols, which seem to offer improved results. There are still some questions to be solved in the following years by prospective studies, such as the usefulness of laparoscopic lavage in purulent peritonitis or of Hartmann’s procedure in fecal peritonitis. These indications, based on current literature, are systematically discussed in the present review.