Andreas Manouras

Duodenal obstruction caused by pancreatic head carcinoma: palliation with self-expandable endoprostheses☆☆☆★

BACKGROUND The risks of palliative operative intervention of gastric outlet obstruction for advanced pancreatic head carcinoma has been reported to be quite high. The present study reports the results of attempted endoscopic palliation of duodenal obstruction in these patients. METHODS Ten patients with endoscopically documented malignant duodenal strictures from pancreatic head carcinoma in whom self-expandable endoprostheses were placed are retrospectively analyzed. In three patients with jaundice, biliary stents were also placed. Standard esophageal type (not membrance coated) Wallstent self-expandable endoprostheses were used. PATIENTS Gastric outlet obstruction was relieved in all patients after implantation of duodenal endoprostheses, and jaundice was palliated in those with additional biliary obstruction after bile duct stenting. One case of gastric ulceration was the major complication. No recurrence of gastric outlet obstruction was noted in the follow-up period of 1 to 5 months. CONCLUSION The preliminary data suggest that self-expandable duodenal endoprostheses can effectively relieve gastric outlet obstruction in patients with advanced pancreatic head carcinoma.

Predictive value of procalcitonin for bowel ischemia and necrosis in bowel obstruction.

BACKGROUND To our knowledge, the predictive value of procalcitonin for bowel strangulation has been evaluated in only 2 experimental studies that had conflicting results. The objective of this study was to evaluate the value of procalcitonin for early diagnosis of intestinal ischemia and necrosis in acute bowel obstruction. METHODS We performed a prospective study of 242 patients with small- or large-bowel obstructions in 2005. A total of 100 patients who underwent operation were divided into groups according to the presence of ischemia (reversible and irreversible) and necrosis, respectively, as follows: ischemia (n = 35) and nonischemia groups (n = 65) and necrosis (n = 22) and nonnecrosis groups (n = 78). Data analyzed included age, sex, vital signs, symptoms, clinical findings, white blood cell count, base deficit, metabolic acidosis, procalcitonin levels on presentation, the time between symptom onset and arrival at the emergency department and the time between arrival and operation, and the cause of the obstruction. RESULTS Procalcitonin levels were greater in the ischemia than the nonischemia group (9.62 vs 0.30 ng/mL; P = .0001) and in the necrosis than the non-necrosis group (14.53 vs 0.32 ng/mL; P = .0001). Multivariate analysis identified procalcitonin as an independent predictor of ischemia (P = .009; odds ratio, 2.252; 95% confidence interval, 1.225-4.140) and necrosis (P = .005; odds ratio, 2.762; 95% confidence interval, 1.356-5.627). Using receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) of procalcitonin for ischemia and necrosis was 0.77 and 0.87, respectively. A high negative predictive value for ischemia and necrosis of procalcitonin levels <0.25 ng/mL (83% and 95%, respectively) and a positive predictive value of procalcitonin >1 ng/mL were identified (95% and 90%, respectively). CONCLUSION Procalcitonin on presentation is very useful for the diagnosis or exclusion of intestinal ischemia and necrosis in acute bowel obstruction and could serve as an additional diagnostic tool to improve clinical decision-making.

Results using the AO hook plate for dislocations of the acromioclavicular joint

The AO Hook plate has been used for stabilization of acromioclavicular joint dislocations. We present our experience of this newly introduced device in a general hospital, since there are not many papers in the literature reporting on this. A total of 16 patients were treated with the AO Hook plate between November 2001 and November 2003 at Princess Alexandra Hospital in Harlow, UK. For functional assessment 6 months after removal of the plate, the constant score and the pain visual analogue score were used. The pain visual analogue score ranged from 0 to 6 (mean: 0.87) and the constant score ranged from 78 to 100 (mean: 96.4). In one instance, a patient developed instability after removal of the plate. The use of this device results in excellent functional outcome for the treatment of acromioclavicular joint dislocations.

Electrothermal bipolar vessel sealing system is a safe and time-saving alternative to classic suture ligation in total thyroidectomy.

Total thyroidectomy is associated with minimal morbidity. The electrothermal bipolar vessel sealing system is an adjunct to the surgical technique, recently made available to thyroid surgery.

Modified Radical Mastectomy With Axillary Dissection Using the Electrothermal Bipolar Vessel Sealing System

HYPOTHESIS The use of the electrothermal bipolar vessel sealing system is feasible, safe, and effective in modified radical mastectomy with axillary dissection in terms of lymph vessel sealing, hemostasis, and perioperative complications. DESIGN Prospective study. SETTING University surgical department. PATIENTS Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system. MAIN OUTCOME MEASURES Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis). RESULTS The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days. CONCLUSIONS In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications.

Unintentional parathyroidectomy during total thyroidectomy

Unintentional parathyroidectomy during thyroidectomy has been evaluated in a few studies. Moreover, the impact of the surgeons experience and operative technique has not been evaluated. Our aim was to identify the incidence of unintentional parathyroidectomy during total thyroidectomy, its clinical consequences, and factors affecting its occurrence.

Novel hemostatic devices in thyroid surgery: electrothermal bipolar vessel sealing system and harmonic scalpel

Accurate and efficient hemostasis is one of the first priorities of the thyroid surgeon to prevent or minimize complications, including injury to the laryngeal nerves or parathyroid glands, perioperative hemorrhage and the potentially life-threatening hematoma. Means to prevent and control intra- or postoperative bleeding therefore remain a topic of utmost importance. Although thyroidectomy is one of the most common surgical procedures, the safest, most efficient and cost-effective way to achieve hemostasis is debated by endocrine surgeons and otorhinolaryngologists. In our opinion, there is no substitute for meticulous surgical technique and hemostasis, while experience in such operations is essential for the best outcome with the fewest complications. Ties, suture-ligations, monopolar/bipolar diathermy, clips, and hemostatic agents/sealants or tissue adhesives have been used. Over the last 10 years, innovative hemostatic devices, such as the electrothermal bipolar vessel sealing system and ultrasonically activated shears, have been developed and have been welcome adjuncts to the thyroid surgeon’s armamentarium. In this review we aim to cover both novel and well-established traditional techniques of hemostasis in thyroid surgery, with specific focus on the bipolar vessel sealer and harmonic scalpel.

Thyroid surgery with the new harmonic scalpel: A prospective randomized study

BACKGROUND Despite their safety and effectiveness in thyroid surgery, the previous harmonic scalpel instruments are considered large and cumbersome by several surgeons. An innovative technical improvement of the device has been made available since 2008. The objective of this study was to compare the results of total thyroidectomy using the new harmonic scalpel (FOCUS) with that with the previously available device (HARMONIC ACE). METHODS A prospective randomized study of all total thyroidectomies between February and July 2008 was conducted. Patients (n = 90) were randomized to undergo total thyroidectomy with FOCUS (group A, n = 45) or HARMONIC ACE (group B, n = 45). RESULTS No significant differences were identified between the 2 groups in terms of demographics, reoperative thyroid surgery, thyroid gland weight and diameter, pathologic diagnosis, preoperative and postoperative serum PTH and calcium levels, postoperative complications, duration of hospital stay, and final outcome. The mean operative time was less in group A than group B (63 ± 7 min vs 76 ± 8 min, P = .009). CONCLUSION The new harmonic scalpel is a useful adjunct to the armamentarium of the thyroid surgeon. It is safe, effective, and hand friendly, offering great capabilities for delicate tissue grasping and dissection. Use of this device decreased operative time compared with the previously available instrument.

Implantation of microballoons in the management of fecal incontinence.

PURPOSE: The implantation of expandable microballoons has proved successful for the treatment of stress urinary incontinence. This led us to test its effectiveness in the treatment of severe fecal incontinence. METHODS: Six patients (four male), of average age of 43 (range, 29–60) years, with severe fecal incontinence, underwent implantation of expandable microballoons in the submucosa of the anal canal. The implantation was performed under intravenous sedation as an outpatient procedure. Anal manometry, endosonography, and incontinence assessment with a scoring system were performed before and after the implantation. RESULTS: With a mean follow-up of 8.6 (range, 7–12) months, the incontinence scores improved in all patients from an average of 16.16 (standard deviation: ± 1.6) before the implantation to an average of 5 (standard deviation: ± 1.26) after the procedure. The anal pressure at rest was not improved in any patient (mean: 50.16 before treatment to a mean of 53 after treatment). No significant adverse events were associated with the procedure, and no serious postim-plantation complications were noted. DISCUSSION: Anal implantation of expandable microballoons seems to be a simple, safe, and effective method that restores the fecal continence without hindering normal defecation.

Association of Helicobacter Pylori Infection and Colon Cancer

Background Gastrin has been shown to exert carcinogenic effect to the epithelium of the colon. This study examines whether hypergastrinemia and H. pylori infection -especially infection by the CagA+ strain- are statistically associated with colorectal cancer and examine possible correlations with the colorectal cancer stage and lymph node metastasis. Methods In this prospective case-control study, fasting serum samples from 93 consecutive patients with colorectal cancer treated in a university surgical clinic were preoperatively collected and serum levels of gastrin were measured. A group of 20 age matched hernia patients were used as controls. The pathology report of the specimens was documented and statistical analysis of the data where performed with the spss 17 statistical suite. Results H. pylori IgG antibodies was reported in 66/93 (71%) in the colorectal cancer group and 13/20 patients in the control group (65%), the difference having non-statistical significance (P = n.s). The prevalence of cagA protein expression in the anti- H. pylori IgG+ patients were higher in the colorectal cancer group (56% positivity), when compared to the control group (38,4% positivity) but the difference was not of statistical significance (P = n.s). The mean levels of serum gastrin levels in the two groups did not significantly differ (Ca group 51.1 ± 36.6 pg/mL vs Control 49.8 ± 17.6 P = n.s.). Patients with lymph node metastasis had higher serum gastrin levels than patients without metastasis and this difference was statistically significant. (53.6 vs 41.06 pg/mL P = 0.025). Conclusions Although the serum gastrin levels were not statistically different between the TNM stages of our patient cohort, our data found that serum gastrin levels were significantly higher in patients with lymph node metastasis. Whether gastrin is implicated in the ability of cancer cells to metastasize to the lymph nodes merits further research.