Basilios Papaziogas

Complete dehiscence of the abdominal wound and incriminating factors

OBJECTIVE To find out the causes of abdominal wound dehiscence. DESIGN Retrospective study. SETTING University hospital, Greece. SUBJECTS Abdominal wound dehiscence occurred in 89 cases out of 19,206 major abdominal operations including 4671 emergencies during the past 15 years (0.5%). INTERVENTIONS In the study group 14 local and systemic risk factors were analysed and compared with those in a control group of 89 patients who had similar procedures without dehiscence. MAIN OUTCOME MEASURES Statistical analysis using the chi square test. RESULTS Significant factors (p < 0.05) included age over 65 years, emergency operation, cancer, haemodynamic instability, intra-abdominal sepsis, wound infection, hypoalbuminaemia, ascites, obesity, and steroids. Risk factors that were not significant included sex, anaemia, diabetes mellitus and pulmonary disease. Overall morbidity and mortality were 30% and 16%, respectively. The mortality and the possibility of dehiscence seem to correlate directly with the number of risk factors. CONCLUSION Patients with these risk factors require more attention and special care to minimise the risk of its occurrence.

Study of the carrying angle of the human elbow joint in full extension: a morphometric analysis

This study measured the carrying angle of the elbow joint in full extension in 600 students, using the supplementary angle to that between the longitudinal axis of the arm and that of the forearm. The mean carrying angle was 12.88°±5.92: 10.97°±4.27 in men and 15.07°±4.95 in women. The carrying angle changes with skeletal growth and maturity. The angle is always greater on the side of the dominant hand. We confirmed the inverse relationship between the carrying angle and the intertrochanteric diameter. Also, the type of constitution influences the value of the carrying angle, especially in women.

The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones

Background: Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting. Methods: Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients. Results: In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced. Conclusions: These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.

Incidence of abdominal wall hernias in patients undergoing aortic surgery for aneurysm or occlusive disease.

Background: The aim of this study was to compare the incidence of abdominal and incisional hernias in patients with abdominal aortic aneurysm (AAA) versus patients with aortoiliac occlusive disease (AOD). Patients and methods: The study included retrospectively 121 patients, who underwent elective aortic surgery due to AAA (n = 63) or AOD (n = 58) in the period between January 1998 and January 2000. The patients were examined for the presence of abdominal hernias upon admission, as well as for the development of incisional hernias on follow-up. Results: The incidence of inguinal hernias was significantly higher in the group AAA (21/6–33.3%) compared to the group with AOD (6/58–10,3%) (p < 0.01). The incidence of other abdominal wall hernias (umbilical, epigastric or miscellaneous hernias) was also significant higher in AAA group. Furthermore, the incidence of inguinal hernias was significantly higher in the subgroup of patients with an aneurysm diameter more than 6 cm (41.5% vs 18.2%, p < 0.05). The mean ...BACKGROUND The aim of this study was to compare the incidence of abdominal and incisional hernias in patients with abdominal aortic aneurysm (AAA) versus patients with aortoiliac occlusive disease (AOD). PATIENTS AND METHODS The study included retrospectively 121 patients, who underwent elective aortic surgery due to AAA (n = 63) or AOD (n = 58) in the period between January 1998 and January 2000. The patients were examined for the presence of abdominal hernias upon admission, as well as for the development of incisional hernias on follow-up. RESULTS The incidence of inguinal hernias was significantly higher in the group AAA (21/6-33.3%) compared to the group with AOD (6/58-10.3%) (p < 0.01). The incidence of other abdominal wall hernias (umbilical, epigastric or miscellaneous hernias) was also significant higher in AAA group. Furthermore, the incidence of inguinal hernias was significantly higher in the subgroup of patients with an aneurysm diameter more than 6 cm (41.5% vs 18.2%, p < 0.05). The mean follow-up of the patients was 1.7 +/- 0.3 years. 7 cases of incisional hernia were noted in the AAA group (11.1%) and only 2 cases in the AOD group (3.4%) (p < 0.05). The size of the aneurysm had no influence on the incidence of incisional hernias in the AAA group. CONCLUSION We conclude that there seems to be an increased incidence of abdominal wall hernias as well as postoperative incisional hernias in patients undergoing aortic surgery for aneurysm disease compared with aortoiliac occlusive disease.

Primary malignant melanoma of the small intestine: report of a case.

Abstract.The small intestine is the most common site of gastrointestinal (GI) metastases from cutaneous malignant melanoma; however, primary malignant melanoma originating in the small intestine is extremely rare. We report the case of a 72-year-old man found to have a primary malignant melanoma in the ileum. The patient presented with anorexia, weight loss, diffuse colicky abdominal pain, and episodic rectal bleeding. A preoperative diagnosis of a small intestinal tumor was based on the findings of enteroclysis and computed tomography scanning. This diagnosis was confirmed at laparotomy and an enterectomy was performed. Histopathological examination of the resected specimen clarified the exact nature of the lesion, confirming the diagnosis of melanoma. A thorough postoperative investigation did not reveal a primary lesion in the skin, anus, oculus, or any other location. Thus, we diagnosed this tumor as a primary lesion. One year after his operation, the patient remains well without any evidence of recurrence. Primary malignant melanoma of the small intestine is an extremely rare lesion, which must be differentiated from other intestinal tumors.

Systemic endotoxaemia following obstructive jaundice: the role of lactulose

BACKGROUND Obstructive jaundice is often accompanied by bacterial translocation and subsequent sepsis. The effect of lactulose in preventing that process was evaluated in an experimental model. Obstructive jaundice was induced in 23 rabbits after common bile duct ligation. METHODS Animals were divided into two groups. Group A of 11 animals-controls and group B of 12 rabbits, which received 2 ml/kg of lactulose p.o. by a nasogastric tube. Blood was sampled daily, before and after operation. Samples were applied for culture and for estimation of endotoxins (LPS), tumor necrosis factor (TNFa), and malondialdehyde (MDA). RESULTS Mean (+/-SD) survival of animals of group A was 3.08+/-0.19 days compared to 5.36+/-0.41 days of animals of group B. Serum concentrations of LPS and TNFa of each day of treatment remain constant in animals of group A; they were steadily decreased in animals of group B reaching statistical significance on the fourth day. Similar changes were not found for MDA. CONCLUSION The administration of lactulose may prevent systemic endotoxaemia and the subsequent inflammatory response in an experimental model of obstructive jaundice, so as to extend survival. These results merit further clinical evaluation.

Effect of Time on Risk of Perforation in Acute Appendicitis

Abstract Introduction: The aim of this study was to quantify the role of time between symptom onset and surgery on the changing risk of perforation, and to evaluate the possible factors leading to delay to the operation. Patients and methods: The files of 169 patients who underwent appendectomy in our clinic over a two-year period (May 2004-June 2006) were reviewed. The relative risk of perforation was calculated according to the “time-table” method. Time was divided into intervals, initially of 12 hours and, later on, of 24 hours. Results: 18 patients were found to have perforated appendicitis. The time from symptom-onset to first examination (“symptom onset to presentation” time, “SOP” time) was longer for patients with perforation than for those without (p = 0.047). On the other hand, the time from initial examination in the emergency department to the operating room (“ER to OR” time) was shorter for patients with perforation than for those without (p = 0.027). Overall time from symptom onset to operating room, showed no statistical difference between patients with rupture and those without. The risk of perforation was negligible within the first twelve hours of untreated symptoms, but then increased to 8% within the first twenty-four hours. It then decreased to approximately 1.3% to 2% during 36 to 48 hours, and subsequently rose again to approximately 6% (7.6% to 5.8%) for each ensuing 24-hour period. In multivariate analysis, neither the “SOP” nor the “ER to OR” time remained significant contributors to the probability of an individual to suffer from appendiceal perforation. Conclusion: When time matters and the risk of adverse outcomes can be reduced, we should change our current approach to care. Surgeons should be mindful of delaying surgery beyond 24 hours of symptom onset in patients with assumed appendicitis.

Secondary Aortoduodenal Fistula with a Fatal Outcome: Report of Six Cases

Secondary aortoenteric fistulas (AEFs) are a well-known but uncommon cause of gastrointestinal hemorrhage. They usually occur secondary to reconstructive surgery of an abdominal aneurysm. We report six cases of secondary aortoduodenal fistulas, involving patients who, despite presenting with classic “herald bleeding,” died as a result of delayed operative intervention. We also discuss the pathogenesis, clinical presentation, and diagnosis of AEFs, emphasizing the value of clinical suspicion and negative endoscopy in establishing the diagnosis and the need for early operative intervention.

Carcinoma developing in ectopic pancreatic tissue in the stomach: a case report

The development of pancreatic tissue outside the confines of the main gland, without anatomic or vascular connections between them, is a congenital abnormality referred to as heterotopic pancreas. A heterotopic pancreas in the gastrointestinal tract is usually discovered incidentally and the risk of its malignant transformation is extremely low. In this study, we describe the first case of endoepithelial carcinoma arising in a gastric heterotopic pancreas of a 56-year old woman in Greece. She presented with epigastric pain, periodic nausea and vomiting. Esophagogastroduodenoscopy revealed an ulcerated lesion in the gastric antrum, biopsies of which showed intense epithelial dysplasia with incipient malignant degeneration. The pathology report of the distal gastrectomy specimen demonstrated a 2 cm in diameter ulcerative mass in the gastric antrum. Microscopically, an endoepithelial (in situ) carcinoma of the gastric antrum was determined, which in places turned into an microinvasive endomucosal adenocarcinoma. It also incidentally demonstrated heterotopic pancreatic ducts, detected within the mucosa to the muscularis propria of the same region of the stomach, in which an endoepithelial (in situ) carcinoma was evolving. The follow-up course was uneventful 6 months postoperatively.

Malignant Fibrous Histiocytoma of the Abdominal Cavity: Report of a Case

Malignant fibrous histiocytoma (MFH) is a soft-tissue sarcoma originating from fibroblast cells, characterized by a high rate of metastasis or recurrence. This tumor rarely develops in the gastrointestinal tract, with no more than 30 cases described in the literature. We report a case of MFH of the abdominal cavity in a 45-year-old woman who presented with epigastric pain, anorexia, and weight loss. A computed tomography (CT) scan of the abdomen revealed multiple solid tumors in the peritoneal cavity. We performed exploratory laparotomy and found at least 15 solid whitish tumors attached to the wall of the small intestine, as well as to the parietal peritoneum. There were three metastases in the liver. All of the tumors were excised, most of which were about 10 cm in diameter. Histopathological findings indicated a stromal tumor consisting of spindle cells, and immunohistochemical examination of the resected specimens established the definite diagnosis of a pleomorphic MFH. The patient had an uneventful postoperative course and was given adjuvant chemotherapy. She is currently well 2 years after her operation. We review the clinical picture of this tumor in the abdominal cavity, and discuss its diagnosis, pathogenesis, and treatment.