Antonios Athanasiou

From diagnosis to treatment of hepatocellular carcinoma: An epidemic problem for both developed and developing world

Hepatocellular carcinoma (HCC) is the most frequent primary liver malignancy and the third cause of cancer-related death in the Western Countries. The well-established causes of HCC are chronic liver infections such as hepatitis B virus or chronic hepatitis C virus, nonalcoholic fatty liver disease, consumption of aflatoxins and tobacco smocking. Clinical presentation varies widely; patients can be asymptomatic while symptomatology extends from right upper abdominal quadrant paint and weight loss to obstructive jaundice and lethargy. Imaging is the first key and one of the most important aspects at all stages of diagnosis, therapy and follow-up of patients with HCC. The Barcelona Clinic Liver Cancer Staging System remains the most widely classification system used for HCC management guidelines. Up until now, HCC remains a challenge to early diagnose, and treat effectively; treating management is focused on hepatic resection, orthotopic liver transplantation, ablative therapies, chemoembolization and systemic therapies with cytotocix drugs, and targeted agents. This review article describes the current evidence on epidemiology, symptomatology, diagnosis and treatment of hepatocellular carcinoma.

Inferior mesenteric arteriovenous fistula: case report and world-literature review.

Arteriovenous fistulas between the inferior mesenteric artery and vein are rare, with only 26 primary and secondary cases described in the literature. Secondary fistulas occur following operations of the left hemicolon and manifest as abdominal pain, abdominal mass, gastrointestinal bleeding, colonic ischemia and portal hypertension. Symptom intensities are flow-dependent, and can range from minimal symptoms to severe heart failure due to left to right shunt. Diagnosis is usually established by radiological or intraoperative examination. Treatment options include embolization and/or surgical resection. Therapeutic decisions should be adapted to the unique characteristics of the fistula on an individual basis. A new case of a primary arteriovenous fistula is described and discussed along with a complete review of the literature. The patient in this report presented with signs and symptoms of colonic ischemia without portal hypertension. The optimal treatment for this patient required a combination of embolization and surgical operation. The characteristics of these rare inferior mesenteric arteriovenous fistulas are examined and some considerations concerning diagnostic and therapeutic strategies that should be followed are presented.

The ideal porcine model for major liver resection

Dear Editor, We read with great interest the recent publication by Bucur et al., which reports a simplified technique for 75% and 90% hepatic resection with hemodynamic monitoring in porcine model. According to the article, there were two study groups. The first group included 16 animals that underwent 75% hepatectomy based on the computed tomography volumetric study, with resection of the left lateral, left medial and the right medial hepatic lobes. The second group included six animals that underwent 90% hepatectomy with additional resection of right lateral lobe. During the procedures, hemodynamic monitoring was performed by measuring the portal vein pressure and flow and hepatic artery pressure and flow. This study concludes that the described technique is simple and easily applicable for extended hepatectomy in porcine model. Furthermore, the portal vein and hepatic artery flow decreased more after 90% hepatectomy than after 75%, whereas the portal vein and hepatic artery pressure increased more following 90% compared with 75% resection. However, after an extended research of the literature, we came to the conclusion that we disagree with their analysis for the following reasons. To begin with, this study does not give any information regarding the survival rate of the animals postoperatively. It is unreliable to evaluate a surgical technique only with the survival rate during the procedure. Furthermore, the authors have not included in the study any liver function tests, hemodynamic assessment, histopathologic examination of the remnant liver and postoperative management of the animals. Without these important parameters, how can the medical community analyze and assess accurately the above surgical technique? Moreover, the authors have not described the statistical analysis which they used to analyze the results of the experiment. Last but not least, there is a significant difference in the number of animals between the two groups (16 animals underwent 75% hepatectomy, whereas only six animals underwent 90% hepatectomy), which means that this study has low statistical power and low reliability. As a consequence, there is an overestimate of the effect size and low reproducibility rate of the results as well. According to the literature, several surgical techniques for extended hepatectomy in porcine model have been reported.

Role of platelet-rich plasma in ischemic heart disease: An update on the latest evidence.

Myocardial infarction is the most common cause of congestive heart failure. Novel strategies such as directly reprogramming cardiac fibroblasts into cardiomyocytes are an exciting area of investigation for repair of injured myocardial tissue. The ultimate goal is to rebuild functional myocardium by transplanting exogenous stem cells or by activating native stem cells to induce endogenous repair. Cell-based myocardial restoration, however, has not penetrated broad clinical practice yet. Platelet-rich plasma, an autologous fractionation of whole blood containing high concentrations of growth factors, has been shown to safely and effectively enhance healing and angiogenesis primarily by reparative cell signaling. In this review, we collected all recent advances in novel therapies as well as experimental evidence demonstrating the role of platelet-rich plasma in ischemic heart disease, focusing on aspects that might be important for future successful clinical application.

Rapunzel Syndrome: A Rare Presentation with Giant Gastric Ulcer

The Rapunzel syndrome refers to an uncommon and rare form of trichobezoar that extends past the stomach into the small intestines. The Rapunzel syndrome is usually found in young female patients with a history of psychiatric disorders, mainly trichotillomania and trichophagia. We describe a case of Rapunzel syndrome in a 15-year-old girl who presented with abdominal pain, vomiting, and weight loss. We performed a surgical laparotomy and successfully removed a huge trichobezoar extending into the small intestine.

Postoperative Abdominal Adhesions: Clinical Significance and Advances in Prevention and Management

Postoperative adhesions remain one of the more challenging issues in surgical practice. Although peritoneal adhesions occur after every abdominal operation, the density, time interval to develop symptoms, and clinical presentation are highly variable with no predictable patterns. Numerous studies have investigated the pathophysiology of postoperative adhesions both in vitro and in vivo. Factors such as type and location of adhesions, as well as timing and recurrence of adhesive obstruction remain unpredictable and poorly understood. Although the majority of postoperative adhesions are clinically silent, the consequences of adhesion formation can represent a lifelong problem including chronic abdominal pain, recurrent intestinal obstruction requiring multiple hospitalizations, and infertility. Moreover, adhesive disease can become a chronic medical condition with significant morbidity and no effective therapy. Despite recent advances in surgical techniques, there is no reliable strategy to manage postoperative adhesions. We herein review the pathophysiology and clinical significance of postoperative adhesions while highlighting current techniques of prevention and treatment.

Wernicke’s encephalopathy after sleeve gastrectomy. Where do we stand today? A reappraisal

Q1 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 Dear Editor, We read with great interest the recent publication of Saab et al. [1], which reports a case of Wernicke’s encephalopathy 3 weeks after sleeve gastrectomy (SG). The authors discuss a case of rapid Wernicke’s encephalopathy due to thiamine deficiency in a 27-year-old female patient after SG. According to the authors, Wernicke’s encephalopathy was suspected due to the history of recent bariatric surgery, current presentation, and abnormal neurologic findings. This case is interesting because it describes a rare but serious complication of bariatric surgery with significant morbidity and mortality in a very short postoperative time after the procedure. According to our recent search of the literature, there are 3 additional cases of Wernicke’s encephalopathy after SG. The first case by Scarano et al. [2], describes a 37-year-old woman with a late development of Wernicke’s encephalopathy and severe polyneuropathy 3 months after SG. About 6 months after onset of neurologic picture, her symptoms partially improved with thiamine treatment. In the second case, Sharabi and Bisharat [3], describe a 43-year-old female patient who underwent SG and suffered from Wernicke’s encephalopathy and paralytic ileus. Thiamine supplementation was administered with gradual improvement in her encephalopathy; however, she was readmitted 3 months later with a profound ileus, developed multisystem organ failure, and died. The third case reported by Cerutti et al [4], described the manifestation of central and peripheral neurologic deficits and psychogenic anorexia in a 33-year-old man who presented 18 weeks after SG. Because of the patient’s history, the clinical examination, and the findings with brain magnetic resonance imaging, he

Splenectomy is not indicated in living donor liver transplantation

We read with great interest the recent publication by Ito et al. published in the November 2016 issue of Liver Transplantation, which concludes that splenectomy is not indicated in living donor liver transplantation. The authors retrospectively reviewed 395 patients who underwent living donor liver transplantation (LDLT), including 169 (42.8%) patients with simultaneous splenectomy and 226 (57.2%) patients with spleen preservation. According to their findings, simultaneous splenectomy increased the incidence of reoperation for postoperative hemorrhage within the first week and did not increase the platelet count in the early postoperative period. Furthermore, the incidence of lethal infectious disease, intraoperative blood loss, and operation time were significantly higher in the splenectomy group. Last but not least, the incidence of small-for-size syndrome (SFSS) was comparable between groups. However, we cannot agree with their analysis for a number of reasons, which are analyzed in the following paragraphs. LDLT has become an effective and sufficient treatment for end-stage liver disease. However, its wider application in the last decade has been limited due to the safety of the donor and graft size mismatching. The latter, also called SFSS, is associated with prolonged cholestasis and coagulopathy postoperatively, presence of severe ascites, and encephalopathy. The main mechanisms for the pathogenesis of SFSS are excessive portal flow and pressure through a small graft in combination with low arterial perfusion and outflow obstruction. Several approaches have been described in the literature in order to prevent excess graft inflow, such as shunt operation, splenic artery ligation/embolization, splenectomy, and hepatic vein outflow modification. According to Ito et al., the indications for simultaneous splenectomy in their study were as follows: first, severe thrombocytopenia (platelet count < 303 10 L) in order to decrease the incidence of postoperative hemorrhage, and second, the improvement of the tolerance and adherence to pegylated interferon and ribavirin therapy for hepatitis C virus (HCV) by preventing postoperative thrombocytopenia among HCV-positive recipients. The aforementioned indications for simultaneous splenectomy do not have any correlation with the prevention of SFSS. Splenectomy improves the outcome of a graft by reducing the portal pressure and flow and by increasing the vascular compliance of the graft. According to the literature, the main indications for simultaneous splenectomy during LDLT are portal venous pressure of 20mm Hg after reperfusion and hypersplenism (platelet count< 7.53 10/lL and a leukocyte count <3500/lL). Gyoten et al. recently reported that in LDLT, the preoperative assessment of spleen volume to graft volume is a reliable predictor of portal vein hypertension after reperfusion of the transplanted liver, and for this reason, it can be used to specify the indication for splenectomy before reperfusion. Furthermore, this study has not mentioned any measurement of the portal venous pressure or portal venous flow intraoperatively, which means that the medical community cannot evaluate correctly the effect of splenectomy to the portal hyperperfusion. According to the literature, many studies have shown that splenectomy improves the vascular compliance of the graft and increases hepatic serotonin, which plays a significant role to the hepatic perfusion via vasodilatory effects. Hepatic serotonin improves microcirculation and promotes liver regeneration by stimulating the endothelial cells to release vascular endothelial growth factor, and it also protects the liver Address reprint requests to Antonios Athanasiou, M.D., Ph.D., Department of Surgery, Mercy University Hospital, 4 Bonan House, Blackmore Lane, Sullivan’s Quay, Cork, Ireland. Telephone: 1 353838634135; FAX: 1 353210745621; E-mail: antwnis_athanasiou@hotmail.com

Porcine models for the study of small-for-size syndrome

Dear Editor, We read with great interest the recent publication by Mohkam et al. [1] published in the November 2016 issue of the Journal of Hepato-Biliary-Pancreatic Sciences. The authors describe the porcine models that have been used for the study of small-for-size syndrome (SFSS) after liver transplantation (LT) or extended hepatectomy and also the various modalities of portal inflow modulation (PIM). While this is an interesting review of the literature which provides to the readers the opportunity to understand better the advantages and disadvantages of each porcine model, we disagree with the conclusion of the manuscript that subtotal hepatectomy (i.e. resection of all segments except segment 1) without inflow occlusion, left trisectionectomy with inflow occlusion, and LT of a right lateral section including the caudate lobe in a larger recipient, appeared to be the most suitable porcine models for studying SFSS. Our research of the literature and our previous experiments for the study of SFSS in swine model revealed that only after 80% hepatectomy the porcine model is suitable for studying the SFSS [2–6]. Extended hepatectomy including the left lateral lobe (LLL), left medial lobe (LML), right medial lobe (RML), and partial resection of the right lateral lobe (RLB), is the most appropriate model for study of SFSS [2–5]. The liver remnant weight ratio after the aforementioned hepatectomy is 20–25%. This percentage of liver mass in combination with portal hypertension and hyperperfusion leads to a decrease of the hepatic portal vascular bed with significantly higher flow and pressure per grammar of hepatic tissue. As a result, the injury to the sinusoidal endothelial cell leads to severe hepatocellular damage. The liver function test, the survival rate, the portal hemodynamic changes and clinical and histological findings 7 days postoperatively are similar with the clinical presentations of SFSS. Our experience has shown that the aforementioned porcine model can easily be reproduced, with very low rates of surgical complications and potentially reversible liver damage [2, 3, 7]. Furthermore, we disagree with the statement of Mohkam et al. [1] that splenic artery ligation and splenectomy are not appropriate for portal inflow modulation in swine. The authors report it was recently demonstrated that neither splenic artery ligation, nor splenectomy had any effect on portal venous flow in animals undergoing left trisectionectomy or subtotal hepatectomy; however, there is no publication from Mohkam et al. which reports the aforementioned statement. Our experience regarding the modulation of portal inflow in porcine model has shown that SFSS can be successfully prevented after extended hepatectomy by simultaneous splenectomy [2]. Moreover, Hisakura et al. [6] have shown similar results after 80% hepatectomy and splenectomy.

Metastasis to Sartorius Muscle from a Muscle Invasive Bladder Cancer

Bladder cancer constitutes the ninth most common cancer worldwide and approximately only 30% of cases are muscle invasive at initial diagnosis. Regional lymph nodes, bones, lung, and liver are the most common metastases from bladder cancer and generally from genitourinary malignancies. Muscles constitute a rare site of metastases from distant primary lesions even though they represent 50% of total body mass and receive a large blood flow. Skeletal muscles from urothelial carcinoma are very rare and up to date only few cases have been reported in the literature. We present a rare case of 51-year-old patient with metastases to sartorius muscle 8 months after the radical cystectomy performed for a muscle invasive bladder cancer.