Christos Tsalikidis

Liver Regeneration Following Radiofrequency Ablation

BACKGROUND Radiofrequency ablation (RFA) of the liver leads to reduction of liver parenchymal volume. We sought to evaluate the regenerative response of the liver following RFA. MATERIALS AND METHODS Thirty healthy New Zealand white rabbits were subjected to a single session liver RFA using a cool-tip electrode after midline laparotomy. The regenerative process of the liver was assessed at various time-points (0 h, 48 h, 1 wk, 3 wk, 10 wk) in terms of computed tomography-based liver volume measurements, histological examination, hepatocyte mitotic activity, and serum biochemistry. RESULTS According to computed tomography-measurements, intact liver volume was gradually restored to the initial liver volume by the 10th week, while liver ablated volume was confined down to 50% of the initial ablated volume. At histology, inflammation, edema, and hepatocellular necrosis in the intact liver parenchyma, noted at 48 h, started to regress by 1 wk. Mitotic activity, initiated by 48 h, was substantially increased at 1 wk and remained high up to the 10th week. Serum transaminase levels were elevated up to 1 wk. CONCLUSIONS Liver RFA triggers a slow but sustained regenerative response of the liver with subsequent delayed restoration of parenchymal volume, while the ablated volume is gradually condensed.

Refusal of Cancer-Directed Surgery by Breast Cancer Patients: Risk Factors and Survival Outcomes

&NA; A retrospective search of the Surveillance Epidemiology and End Results database was performed to identify risk factors and eventual outcomes of patients refusing breast cancer–directed surgery. An incidence of 0.64% and an increasing trend were found. Age, ethnicity, marital status, stage, and lack of insurance were independent risk factors. Refusing surgery was associated with 2.42 times higher risk of mortality. Background: It has been reported that some patients with breast cancer may refuse cancer‐directed surgery, but the incidence in the United States is not currently known. The purpose of this study was to identify the incidence, trends, risk factors, and eventual survival outcomes associated with refusal of recommended breast cancer–directed surgery. Patients: A retrospective review of the Surveillance Epidemiology and End Results (SEER) database between 2004 and 2013 was performed. Patients who underwent cancer‐directed surgery were compared with patients in whom cancer‐directed surgery was refused, even though it was recommended. Results: Of 531,700 patients identified, 3389 (0.64%) refused surgery. An increasing trend was observed from 2004 to 2013 (P = .009). Older age (50‐69: odds ratio [OR] 4.96; 95% confidence interval, 1.23‐19.96; P = .024, ≥ 70 years: OR 17.27; 95% CI, 4.29‐69.54; P < .001), ethnicity (P < .001), marital status (single: OR 2.28; 95% CI, 1.98‐2.62; P < .001, separated/divorced/widowed: OR 2.26; 95% CI, 2.01‐2.53; P < .001), higher stage (II: OR 2.05; 95% CI, 1.83‐2.3; P < .001, III: OR 2.2; 95% CI, 1.87‐2.6; P < .001, IV: OR 13.3; 95% CI, 11.67‐15.16; P < .001), and lack of medical insurance (OR 2.11; 95% CI, 1.59‐2.8; P < .001) were identified as risk factors associated with refusal of surgery. Survival analysis showed a 2.42 higher risk of mortality in these patients. Conclusion: There has been an increasing rate of patients refusing recommended surgery, which significantly affects survival. Age, ethnicity, marital status, disease stage, and lack of insurance are associated with higher risk of refusal of surgery.

Soluble E-cadherin as a diagnostic and prognostic marker in gastric carcinoma.

ABSTRACT OBJECTIVE: Modifications in E-cadherin (E-Cad) expression are associated with dedifferentiation, progression, metastases and poor prognosis in many types of tumors. The aim of the present study was to identify a potential association of the pre- and post-operative soluble E-Cad levels (sE-Cad) with the clinicopathological parameters of patients with gastric cancer. PATIENTS AND METHODS: Serum sE-Cad levels were determined in 99 gastric cancer patients and 78 healthy volunteers using ELISA. RESULTS: Levels of sE-Cad were significantly increased in gastric cancer patients compared with these levels in healthy controls (p < 0.001). For the evaluation of the diagnostic significance of sE-Cad the area under the receiver operating characteristic (ROC) curve (AUC) was 0.835, while the optimal cut-off point of 9.9 μg/mL was determined to classify gastric cancer patients, which yielded sensitivity of 72.7%, specificity of 80.8% and accuracy of 76.3%. Poor differentiation (p = 0.009) and the presence of distant metastases (p < 0.001) were the two significant independent prognostic determinants for high sE-Cad levels in multivariate linear regression analysis. The preoperative levels of sE-Cad also proved helpful in classifying patients according to the choice treatment (curative versus palliative) (AUC, 0.656); when the optimal cut-off point was set at 17.60 μg/mL, the sensitivity was 57%, the specificity was 83% and accuracy was 75%. Survival was shorter in patients with increased sE-Cad (median, 7 months vs 39 months, p = 0.0002), although multivariate Cox regression analysis demonstrated a marginal prognostic significance of sE-Cad for survival (adjusted HR = 1.68, 95% CI = 0.93 to 3.02, p = 0.072). CONCLUSIONS: Serum sE-Cad levels could be considered as a diagnostic and prognostic marker in gastric cancer patients as well as a tool to select a treatment approach. The prognostic value of sE-Cad on overall survival requires further study. РЕЗЮМЕ ЦЕЛЬ: При многих типах опухолей изменения в экспрессии Е-кадерина связываются с дедифферен- цировкой, с развитием опухолей, метастазов и с плохим прогнозом. Настоящее исследование ставит себе целью найти возможные корреляции доопера- тивных и постоперативных уровней растворимого Е-кадерина с отдельными клиникопатологическими параметрами у пациентов с раком желудка. ПАЦИЕНТЫ И МЕТОДЫ: Сывороточные уровни растворимого Е-кадерина определены посредством энзимосвязанного иммуносорбентного теста (ELISA) у 99 пациентов с раком желудка и у 78 здоровых индивидов. РЕЗУЛЬТАТЫ: Уровни Е-кадерина оказались сигнифи- кантно повышенными у пациентов с раком желудка по сравнению с уровнями Е-кадерина у здоровых лиц (р < 0.001). Чтобы оценить диагностическое значение растворимого Е-кадерина измерена пло- щадь под кривой рабочей характеристики (ROS) - 0.835 при оптимальной пороговой стоимости (cut-off point) - 9.9 мкг/мл в целях категоризации пациентов с раком желудка. Кривая показала 72.7% чувствительности, 80.8% специфичности и 76.3% точности. Многофакторный линейный регрессионный анализ показал, что обе сигнификантные независи- мые прогностические детерминанты высоких уровней растворимого Е-кадерина это плохая дифференциа- ция (р = 0.009) и наличие отдаленных метастазов (р < 0.001). Дооперативные уровни растворимого Е-кадерина способствовали обнаружению пациентов с неоперабельным заболеванием, а также и пациен- тов, подвергнутых паллиативной резекции (площадь под кривой, 0.656); когда оптимальная пороговая стоимость (cut-off point) определена на 17.60 мкг/ мл, чувствительность - 57%, специфичность - 83%, а точность - 75%. Выживаемость меньшая у пациентов с повышенными уровнями Е-кадерина (7 мес./ 39 мес, р=0.0002), несмотря на то, что многофакторный регрессионный анализ Сох показал незначительную прогностическую сигнификантность растворимого Е-кадерина по этому показателю (корригированный HR = 1.68, 95% CI=0.93 до 3.02, р = 0.072). ВЫВОДЫ: Сывороточные уровни растворимой формы Е-кадерина могут служить диагностиче- ским и прогностическим маркером у пациентов с раком желудка, как и служить средством для идентификации выбранной терапии. Дополнительные исследования необходимы в целях оценки их прогно- стической стоимости для общей выживаемости.

Cutaneous metastasis at a surgical drain site after gastric cancer resection.

Cutaneous metastasis from intra-abdominal malignant solid tumours such as gastric adenocarcinoma is very rare. Here, we report the case of a 76-year-old male patient with a T4N2M0, poorly differentiated, signet-ring cell gastric carcinoma, who underwent potentially curative resection of the tumour and developed cutaneous metastasis at the site of the surgical drain 4 months after the operation while he was on chemotherapy. The lesion involved the skin and the subcutaneous fat only. A CT scan revealed local recurrence at the resection bed but no distant metastases. The patient died 1 month later. It is concluded that the development of cutaneous metastasis after gastric carcinoma resection indicates tumour recurrence or disseminated disease and is associated with poor prognosis.

Endoscopically Assisted Transumbilical Single-Incision Laparoscopic Gastric Resection for GIST Treatment

ABSTRACT Purpose: Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs <5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection. Methods: Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy. Results: The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed. Conclusion: The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.

Coagulation and fibrinolysis activation after single-incision versus standard laparoscopic cholecystectomy: a single-center prospective case-controlled pilot study.

Laparoscopic cholecystectomy is associated with attenuated acute-phase response and hypercoagulable state compared with the open procedure. Single-incision laparoscopic cholecystectomy is a new technique aiming to minimize the invasiveness of the procedure. By comparing the degree of coagulation and fibrinolysis activation after conventional multiport (CLC) and single-incision (SILC) laparoscopic cholecystectomy, we aimed to determine whether the reduced incision size induces a lower thrombophilic tendency. Thirty-two adult patients with noncomplicated symptomatic cholelithiasis were nonrandomly assigned to CLC or SILC. Prothrombin fragment 1 + 2 (F1 + 2), thrombin–antithrombin complexes (TAT), D-dimers, fibrinogen, and von Willebrand factor levels were measured at baseline, at 1st, and 24th hour, postoperatively. Twenty-six patients were finally included in the study. Fifteen patients underwent CLC (male/female: 5/10) and 11 underwent SILC (male/female: 1/10). There were no perioperative complications. An almost similar postoperative pattern and degree of activation of coagulation and fibrinolysis pathways was noted in both groups. No statistically significant differences were found between SILC and CLC for F1 + 2, TAT, D-dimers, fibrinogen, and von Willebrand factor levels, duration of surgery, length of hospital stay, and postoperative morbidity. A similar pattern and extent of coagulation and fibrinolysis activation is present in SILC and CLC, and therefore there is no difference in tendency for thrombosis. Thromboembolic prophylaxis should be considered in SILC as recommended for CLC, pharmacologic or mechanical, considering the hemorrhagic risk and the presence of additional thromboembolism risk factors. SILC appears to be a safe, feasible technique that can be recommended for its potential advantages in cosmesis and reduced incisional pain.

Synchronous Breast and Rectal Cancers in a Man

Breast cancer in men is relatively rare and its coexistence with other primary non-breast cancers exceptional. Here, we report the case of a 50-year-old man who presented with symptoms of rectal adenocarcinoma and in whom a synchronous, asymptomatic cancer of the left breast was found incidentally at physical examination.

Synchronous Carcinoma of the Ampulla of Vater and Colon Cancer

Carcinoma of the papilla of Vater is a relatively rare tumor and its coexistence with other primary sporadic cancers is very exceptional. Here we report the case of a 76-year-old man who presented with painless obstructive jaundice, pathologically elevated liver function tests and increased serum levels of carbohydrate antigen 19-9 and carcinoembryonic antigen. Endoscopic retrograde cholangiography revealed a large polypoid mass in the ampulla of Vater. A large tumor in the ascending colon was also incidentally detected by abdominal computed tomography. Endoscopic biopsies from both lesions showed adenocarcinomas. Metastases to the liver and to the hepatoduodenal ligament and hepatic artery lymph nodes were found during surgery. Right colectomy and a biliary bypass were performed. Histological analysis showed an ampullary adenocarcinoma with metastases to regional lymph nodes and the liver and a colonic adenocarcinoma with local invasion into the pericolic fat. Treatment with gemcitabine plus cisplatin was suggested postoperatively. The association of sporadic ampullary and colonic adenocarcinomas and the mutually increased risk of developing either a synchronous or a metachronous tumor following each other should be considered in patients with primary ampullary or colorectal cancer during the preoperative evaluation and postoperative follow-up of these patients.

Silibinin Improves TNF-α and M30 Expression and Histological Parameters in Rat Kidneys After Hepatic Ischemia/Reperfusion

ABSTRACT Background: Remote kidney damage is a sequel of hepatic ischemia–reperfusion (I/R) injury. Silibinin is the main ingredient of the milk thistle plant seed extract with known antioxidant and hepatoprotective activity. Our study investigates the nephroprotective potential of intravenously administered silibinin, as a lyophilized SLB-hydoxypropyl-beta-cyclodextrin product, in hepatic I/R injury. Material and methods: 63 Wistar rats were divided into three groups: Sham (virtual intervention); Control (45 min ischemia and reperfusion); and Silibinin (200 μL intravenous silibinin administration after 45 min of ischemia). Kidney tissues were collected to determine TNF-α, M30 and histopathological changes at predetermined time intervals. Results: Comparing Sham vs. Control groups, proved that hepatic I/R injury increased renal TNF-α and M30 expression. Deterioration was observed in hyperemia/filtration of renal parenchyma and tubules, cortical filtration, tubular necrosis and edema (tissue swelling index). Intravenous silibinin administration and comparison of the Control vs. Silibinin groups showed a statistically significant decrease in TNF-α levels at 240 min following I/R (p < 0.0001), and in M30 at 180 min (p = 0.03) and 240 min (p < 0.0001). Renal parameters have significantly decreased in: hyperemia/filtration of renal parenchyma at 120 min (p = 0.003), 180 min (p = 0.0001) and 240 min (p = 0.0002); hyperemia/filtration of renal tubules at 120 min (p = 0.02), 180 min (p = 0.0001) and 240 min (p = 0.0005); cortical filtration (240 min - p = 0.005); tubular necrosis (240 min - p = 0.021); and edema (240 min - p = 0.001). Conclusion: Our study confirms that hepatic I/R injury causes remote renal damage while the intravenous administration of silibinin leads to statistically significant nephroprotective action.

The necessity of a well-structured and qualitative training program for laparoscopic colectomy remains critical

Laparoscopic colorectal surgery (LCS) is considered as an efficient and safe technique for the management of benign and malignant colonic disorders, presenting all the benefits of minimally invasive surgery such as, reduced blood loss, less postoperative pain, earlier recovery of bowel transit, reduced hospitalization, improved cosmesis, and lower risk of incisional hernia.