Dimitrios Dardamanis

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.

Transanal polypectomy using single incision laparoscopic instruments.

Transanal excision of rectal polyps with laparoscopic instrumentation and a single incision laparoscopic port is a novel technique that uses technology originally developed for abdominal procedures from the natural orifice of the rectum. Transanal endoscopic microsurgery (TEM) is a well established surgical approach for certain benign or early malignant lesions of the rectum, under specific indications. Our technique is a hybrid technique of transanal surgery, a reasonable method for polyp resection without the need of the sophisticated and expensive instrumentation of TEM which can be applied whenever endoscopic or conventional transanal surgical removal is not feasible.

Bilateral synchronous breast carcinomas followed by a metastasis to the gallbladder: a case report.

BackgroundBreast cancer is usually associated with metastases to lungs, bones and liver. Breast carcinoma metastasizing to the gallbladder is very rare.Case presentationA 59-year-old woman presented with bilateral synchronous breast lesions. A palpable, retroareolar solid lesion of diameter equal to 5 cm was present in the right breast, and a newly developed, non-palpable lesion with microcalcifications (diameter equal to 0.7 cm) was present in the upper outer quadrant of the left breast. Modified radical mastectomy was performed on the right breast and lumpectomy after hook-wire localization was performed on the left breast, combined with lymph node dissection in both sides. The pathological examination revealed invasive lobular carcinoma grade II in the right breast and invasive ductal carcinoma grade I in the left breast. Chemotherapy, radiation therapy, trastuzumab and letrozole were appropriately administered. At her 18-month follow-up, the patient was free of symptoms; the imaging tests (chest CT, abdominal U/S, bone scan), biochemical tests, blood cell count and tumor markers were also normal. At the 20th month after surgery however, the patient developed symptoms of cholecystitis and underwent cholecystectomy. The histopathological examination revealed metastasis of the lobular carcinoma to the gallbladder.ConclusionThis extremely rare case confirms on a single patient the results of large series having demonstrated the preferential metastasis of lobular breast cancer to the gallbladder. Symptoms of cholecystitis should not be neglected in such patients, as they might indicate metastasis to the gallbladder.

Incidence, Risk Factors, and Outcome of Portal Vein Thrombosis After Laparoscopic-Assisted Splenectomy in β-Thalassemia Patients: A Prospective Exploratory Study

BACKGROUND Portal vein system thrombosis (PVT) is an infrequent but potentially serious complication after laparoscopic splenectomy. Patients with β-thalassemia are at higher risk as they have splenomegaly and hypercoagulability. SUBJECTS AND METHODS Forty-eight β-thalassemia patients who underwent hand-assisted laparoscopic splenectomy or laparoscopic splenectomy were studied prospectively with pre- and postoperative Doppler ultrasonography or computed tomography scanning. RESULTS The incidence of PVT was 8.3% (95% confidence interval [CI] 0.2%-16.4%) (4 of 48 patients). Spleen weight was the only independent factor associated with the presence of PVT. The odds ratio for spleen weight (100 g increase) was 1.46 (95% CI 1.10-1.94, P=.010). Receiver operator characteristic curve analysis showed that the optimal cutoff of spleen weight to the prediction of PVT was 1543 g. Thrombosis resolution was observed after a median of 165 days. CONCLUSIONS Patients with β-thalassemia who undergo laparoscopic-assisted splenectomy are at high risk of postoperative PVT. Close postoperative surveillance and aggressive coagulation prophylaxis are needed in these patients. Larger studies are required to confirm the present findings.

Secondary breast lymphoma diagnosed by vacuum-assisted breast biopsy: a case report

IntroductionBreast lymphoma, either as a manifestation of primary extranodal disease or as secondary involvement, is a rare malignancy, and its diagnosis, prognosis, and treatment have not been clearly defined. On the other hand, Vacuum-assisted breast biopsy (VABB) is a minimally invasive technique with ever-growing use for the diagnosis of mammographically detected, non-palpable breast lesions.Case presentationA symptom-free, 56-year-old woman presented with a non-palpable BI-RADS 4B lesion without microcalcifications. She had a positive family history for breast cancer and a history of atypical ductal hyperplasia in the ipsilateral breast four years ago. She reported having been treated for non-Hodgkin lymphoma 12 years ago. With the suspicion of breast cancer, mammographically guided VABB with 11-gauge probe (on the stereotactic Fishers table) was performed. VABB made the diagnosis of a non-Hodgkin, grade II, B-cell germinal-center lymphoma. VABB yielded enough tissue for immunohistochemistry/WHO classification.ConclusionThis is the first case in the literature demonstrating the successful diagnosis of breast lymphoma by VABB, irrespectively of the level of clinical suspicion. It should be stressed that VABB was able to yield enough tissue for WHO classification. In general, lymphoma should never be omitted in the differential diagnosis, since no pathognomonic radiologic findings exist for its diagnosis.

Vacuum-assisted breast biopsy in close proximity to the skin: a case report

IntroductionVacuum-assisted breast biopsy is a minimally invasive technique used increasingly for the assessment of mammographically detected, non-palpable breast lesions. The effectiveness of vacuum-assisted breast biopsy has been demonstrated on lesions both with and without microcalcifications. Given that the position of the lesion represents a major factor in stereotactic vacuum-assisted breast biopsy, targeting lesions in close proximity to the skin (superficial lesions) has been described as a problematic issue.Case presentationA 53-year-old woman presented with a newly developed, non-palpable lesion in her left breast. The lesion consisted of widely spread microcalcifications located approximately 5 mm from the skin. The lesion was isoechoic on ultrasound examination. Vacuum-assisted breast biopsy was scheduled (on the Fischers table, using 11-gauge probes, under local anaesthesia). The vacuum-assisted breast biopsy probe was inserted antidiametrically into the breast, the probe reached the lesion and effort was made to excise the microcalcifications. As only a small proportion of the microcalcifications were excised an accurate diagnosis could not be expected. However, with the probe having entered the breast antidiametrically, the probe tip underlying the skin could be palpated. Following the palpation of the tip, the exact point was marked by a pen, the probe was removed and the patient was transferred to the surgery room to have the remaining lesion removed by a spindle-form excision under local anaesthesia. The mammogram of the removed specimen confirmed the total excision of the suspicious microcalcifications.ConclusionIsoechoic superficial lesions can be localized with a hook-wire and open breast biopsy under general or local anaesthesia can be performed. However, vacuum-assisted breast biopsy might offer an alternative solution and serve as an alternative approach to localize the lesion. The clinical significance of the present exploratory effort remains to be assessed in the future.

Fracture of the spike of the circular stapler: an unexpected cause of conversion of a laparoscopic vertical banded gastroplasty.

Laparoscopic vertical banded gastroplasty (LVGB), is a safe and efficient bariatric operation, with low intraoperative complications. We report an unusual cause of conversion of a LVGB to an open procedure due to the fracture of the spike of the circular stapler during gastric penetration.