Christos Damaskos

Comparison Between Minimally Invasive and Open Pancreaticoduodenectomy: A Systematic Review.

Introduction: Minimally invasive approaches (laparoscopic or robotic) are used in various operations. Our aim was to compare them with the open approach in pancreaticoduodenectomy. Methods: We conducted a search for articles published in MEDLINE database comparing minimally invasive (laparoscopic or robotic) with open pancreaticoduodenectomy on June 15, 2014. Results: Our search yielded 136 articles. We excluded 122 articles and we took into consideration 14 (10 for laparoscopic and 4 for robotic pancreaticoduodenectomies). Most cases were related to malignant diseases and tumors treated with minimally invasive operations tended to be smaller. There were relatively high conversion rates in both laparoscopic (0% to 15%) and robotic procedures (4.5% to 10%). There were no significant differences regarding resection margins, rates of pancreatic fistula formation, bile leak, and delayed gastric emptying, reoperation rates, and intraoperative and postoperative mortality. On the contrary, blood loss was less in minimally invasive than open operations, although this difference was not always significant. Moreover, totally laparoscopic and robotic procedures lasted longer than the open ones, whereas hand-assisted laparoscopic procedures did not. However, the findings regarding the number of the retrieved lymph nodes, the length of hospital stay, and costs were inconclusive and controversial. Conclusions: Laparoscopic and robotic pancreaticoduodenectomy are feasible, safe, and oncologically equivalent alternatives to open pancreaticoduodenectomy. Minimally invasive operations have the advantage of the less blood loss, but totally laparoscopic and robotic procedures last longer than open procedures.

Histone deacetylase (HDAC)-1, -2, -4 and -6 expression in human pancreatic adenocarcinoma: associations with clinicopathological parameters, tumor proliferative capacity and patients' survival.

BackgroundHistone deacetylases (HDACs) have been associated with malignant tumor development and progression in humans. HDAC inhibitors (HDACIs) are currently being explored as anti-cancer agents in clinical trials. The present study aimed to evaluate the clinical significance of HDAC-1, −2, −4 and −6 protein expression in pancreatic adenocarcinoma.MethodsHDAC-1, −2, −4 and −6 protein expression was assessed immunohistochemically on 70 pancreatic adenocarcinoma tissue specimens and was statistically analyzed with clinicopathological characteristics and patients’ survival.ResultsEnhanced HDAC-1 expression was significantly associated with increased tumor proliferative capacity (p = 0.0238) and borderline with the absence of lymph node metastases (p = 0.0632). Elevated HDAC-4 expression was significantly associated with the absence of organ metastases (p = 0.0453) and borderline with the absence of lymph node metastases (p = 0.0571) and tumor proliferative capacity (p = 0.0576). Enhanced HDAC-6 expression was significantly associated with earlier histopathological stage (p = 0.0115) and borderline with smaller tumor size (p = 0.0864). Pancreatic adenocarcinoma patients with enhanced HDAC-1 and −6 expression showed significantly longer survival times compared to those with low expression (p = 0.0022 and p = 0.0113, respectively), while a borderline association concerning HDAC-2 expression was noted (p = 0.0634).ConclusionsThe present study suggested that HDACs may be implicated in pancreatic malignant disease progression, being considered of clinical utility with potential use as therapeutic targets.

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.

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

Trends in white blood cell and platelet indices in a comparison of patients with papillary thyroid carcinoma and multinodular goiter do not permit differentiation between the conditions

ABSTRACT Aim: Carcinogenesis has been related to systematic inflammatory response. Our aim was to study white blood cell and platelet indices as markers of this inflammatory response in thyroid cancer and to associate them with various clinicopathological parameters. Methods: We included 228 patients who underwent thyroidectomy within a period of 54 months, 89 with papillary thyroid carcinoma and 139 with multinodular hyperplasia. We examined potential links between white blood cell and platelet indices on the one hand and the type thyroid pathology and various clinicopathological parameters on the other. Results: No significant differences were detected between thyroid cancer and multinodular hyperplasia and no significant associations were detected with regard to lymphovascular invasion and tumor size. However, the mean platelet volume was higher in multifocal tumors, while the platelet count, plateletcrit, and platelet-to-lymphocyte ratio were increased in cases with extrathyroidal extension and in T3 tumors. Additionally, T3 tumors had lower platelet distribution width. These associations demonstrated low accuracy in predicting these pathological features, but they were found to provide a satisfying negative predictive value, with the exception of the mean platelet volume. Conclusions: White blood cell and platelet indices cannot assist in distinguishing benign goiter from thyroid cancer. However, they can provide information about tumor multifocality, extrathyroidal extension, and presence of a T3 tumor, and they may be used as a means to exclude these pathological characteristics, especially the last two, in papillary thyroid carcinoma.

Mitral valve prolapse: an underestimated cause of sudden cardiac death—a current review of the literature

Mitral valve prolapse (MVP) is a common valve abnormality in general population. Despite the general belief of a benign disorder, several articles since the 1980s report sudden cardiac death (SCD) in MVP patients, with a substantial percentage of asymptomatic young individuals. The problem is to detect those patients at increased risk and implement methods that are suitable to prevent cardiac arrest. This review investigates the correlation between MVP and SCD, the understanding of the pathophysiology, the strategies for detecting those at risk and treatment options. A complete literature survey was performed using PubMed database search to gather available information regarding MVP and SCD. A total of 33 studies met selection criteria for inclusion in the review. MVP is an underrated cause of arrhythmic SCD. The subset of patients with malignant MVP who may be at greater risk for SCD is characterized by young women with bileaflet MVP, biphasic or inverted T waves in the inferior leads, and frequent complex ventricular ectopic activity with documented ventricular bigeminy or ventricular tachycardia (VT) and premature ventricular contractions (PVCs) configurations of outflow tract alternating with fascicular origin or papillary muscle. MVP is a common condition in the general population and is often encountered in asymptomatic individuals. The existing literature continues to generate significant controversy regarding the association of MVP with ventricular arrhythmias and SCD. Early echocardiography and cardiac magnetic resonance (CMR) are essential, as is a greater understanding of the potential electrophysiological processes of primary arrhythmogenesis and the evaluation of the genetic substrate.

Correlation between the function of regenerating liver parenchyma and the small for size syndrome

r e f e r e n c e s Dear Editor, We thank Drs Moris and Schadde for their great interest in our recent publication entitled “The beneficial role of simultaneous splenectomy after extended hepatectomy: experimental study in pig”, as published for the Journal of Surgical Research in February 2017. The authors have several questions and comments. As far as the first point is concerned, according to the literature, the most accurate method to evaluate the liver regeneration 7 d after hepatectomy in porcine model is the histologic analysis of hepatocyte regeneration by studying the mitotic index and Ki-67 index. The liver regeneration is related with liver/body weight ratio; however, hepatocellular function recovery takes place before the liver regeneration process. In our study, there was an increase in liver volume in both groups; however, the difference between the two groups was not statistically significant. As Moris and Schadde state correctly, hypoxia may have a key role as a trigger to liver regeneration. Schadde et al. recently showed that pharmacologically induced hypoxic signaling increases the liver regeneration with the same mechanism as parenchymal transection or portal vein ligation. However, more studies need to be performed to shed more light in this field of liver regeneration. To their third point, we strongly agree with the authors that hepatic stellate cells are principal regulating elements of sinusoidal blood flow and immune response mainly because they generate growth stimuli to hepatocytes or collagen synthesis and liver fibrosis. Numerous studies during the last years have depicted the crucial role of stellate cell in both initiation and termination of liver regeneration. As far as the fourth point is concerned, indocyanate green and (99m)technetium-labelled hepato imino diacetic acid (HIDA) scintigraphy may be used for the study of liver regeneration post and small for size syndrome post extended hepatectomy. However, according to the literature, there is not any experimental study in porcine model, which has used the aforementioned techniques for the study of the small for size liver syndrome.

Erythropoietin and sildenafil protect against ischemia/reperfusion injury following testicular torsion in adult rats

Testicular torsion/detorsion causes severe tissue damage due to ischemia/reperfusion injury. The present study investigated the protective effect of erythropoietin and sildenafil against ischemia/reperfusion injury following unilateral testicular torsion/detorsion in adult rats. A total of 28 adult male rats were included, and were divided into the following groups: Group A (n=5), sham operated; groups B (n=5), C (n=5), D (n=5) and E (n=8), undergoing right testis torsion and detorsion after 90 min. Group B received no drug treatment. Rats in the groups C and D received low-dose (1,000 IU/kg) or high-dose (3,000 IU/kg) erythropoietin, while those in group E received sildenafil (0.7 mg/kg), through intraperitoneal injection after 60 min of torsion. The right testis was extracted 24 h after detorsion, and the tissue was subjected to histopathological examination and immunohistochemical assessment of cleaved caspase-3 expression. Histological alterations and the quality of spermatogenesis were scored according to the Cosentino and the Johnsen scoring systems, respectively. The results demonstrated normal testicular architecture in group A, while the other groups showed ischemic cellular damages, with the worst scores observed in group B. Groups D and E presented better scores compared with group C. Regarding the quality of spermatogenesis, the best scores were observed in group A, and the worst in group B. Groups C, D and E presented similar results, which were improved in comparison to group B, however, not compared to group A. Furthermore, cleaved caspase-3 levels were lower in groups A, D and E, with equal results observed. Group C had higher levels of cleaved caspase-3 compared with these groups, but lower than group B, which presented the highest cleaved caspase-3 levels. In conclusion, erythropoietin and sildenafil protect testis from ischemia/reperfusion injury by decreasing cellular damage and attenuating apoptosis.

Castleman’s disease of the spleen

Abstract Introduction: Castleman’s disease (CD), also known as giant or angiofolicular lymphoid hyperplasia or lymphoid hamartoma, is a group of atypical lymphoproliferative disorders that share common lymph node histological features and may be localized either to a single lymph node (unicentric) or occur systemically (multicentric). Patient and Method: Herein, we present a rare case of a of 75-year-old female patient who was referred to our department and after a thorough work-up, underwent splenectomy with synchronous resection of an accessory spleen, splenic artery lymph nodes, and splenic hilar lymph nodes due to splenic involvement in a multicentric CD. Results: The pathology of the specimens led to the conclusion that it was a case of polycentric HHV-8-positive CD, affecting the spleen, the accessory spleen, and the lymph nodes. Conclusions: Incidence of this rare condition is believed to be approximately 0.001–0.05%. CD has been linked to the human immunodeficiency virus (HIV), human herpes virus 8 (HHV-8), and is associated with malignancies. The pathogenesis mechanism is considered to be a dysregulation and hypersecretion of cytokines, either idiopathic or secondary to a viral infection, with the latter considered the most frequent. Solid organ involvement is very rare as is splenic involvement.

Refractive Nightmares Revisited: Calcification of a Multifocal Intraocular Lens

Background/Aim: Cataract is the leading cause of reversible blindness and visual impairment worldwide. Although cataract surgery using phacoemulsification and intraocular lens (IOL) implantation is one of the commonest surgical procedures, IOL opacification remains a potential complication that can affect the visual outcome of the operation. Case Report: A 50-year-old female patient presented to our clinic complaining of glare and blurry vision in her right eye over the previous 6 weeks. She had undergone bilateral refractive lens exchange elsewhere 9 months earlier. Her unaided distance visual acuity was 8/10 in the right eye and 10/10 in the left. On slit-lamp examination, we observed the presence of in-the-bag, multifocal, hydrophobic acrylic IOLs bilaterally. Specifically, calcified deposits within the substance of the IOL were observed. Conclusion: To our knowledge, this is the first case of spontaneous calcification of a hydrophobic multifocal IOL and all cataract/refractive surgeons should be aware of this rare complication.