Efstathios T Pavlidis

Role of bevacizumab in colorectal cancer growth and its adverse effects: A review

Angiogenesis affects both wound healing and malignant cell growth through nutrients and oxygen. Vascular endothelial growth factor (VEGF) is the most important element involved in this complex process. Inhibition of VEGF influences angiogenesis and may restrict tumor growth and metastatic ability. Modern anti-angiogenic therapy is based on this theory. Bevacizumab is a recombinant humanized monoclonal antibody (immunoglobulin G1) which binds with VEGF-A forming a large molecule. It can not be bound with VEGF tyrosine kinase receptors preventing VEGF-A incorporation; thus its activity is inhibited inducing blockage of VEGF-mediated angiogenesis. Bevacizumab, in combination with chemotherapy or other novel targeted therapeutic agents, is currently used more frequently in clinical practice, mainly for managing advanced colorectal cancer. It is also used for managing other malignancies, such as breast cancer, pancreatic cancer, prostate cancer, non small-cell lung cancer, metastatic renal carcinoma and ovarian tumors. Although it is generally considered a safe treatment, there are reports of some rare side effects which should be taken into account. Recent experiments in rats and mice show promising results with a wider therapeutic range.

Current Opinion on Lymphadenectomy in Pancreatic Cancer Surgery

BACKGROUND Adenocarcinoma of the pancreas exhibits aggressive behavior in growth, inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%. Curative resection is the only potential therapeutic opportunity. DATA SOURCES A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS Despite recent advances in chemotherapy, radiotherapy or even immunotherapy, surgery still remains the major factor that affects the outcome. The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial. Four prospective, randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection. The exact lymph node status, including malignant spread and the total number retrieved as well as the lymph node ratio, is the most important prognostic factor. Positive lymph nodes after pancreatectomy are present in 70%. Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS Undoubtedly, a standard lymphadenectomy including >15 lymph nodes must be no longer preferred in patients with the usual head location. The extended lymphadenectomy does not have any place, unless in randomized trials. In cases with body or tail location, the radical antegrade modular pancreatosplenectomy gives promising results. Nevertheless, accurate localization and detailed examination of the resected specimen are required for better staging.

Amyand's hernia-a vermiform appendix presenting in an inguinal hernia: a case series

IntroductionA vermiform appendix in an inguinal hernia, inflamed or not, is known as Amyands hernia. Here we present a case series of four men with Amyands hernia.Case presentationsWe retrospectively studied 963 Caucasian patients with inguinal hernia who were admitted to our surgical department over a 12-year period. Four patients presented with Amyands hernia (0.4%). A 32-year-old Caucasian man had an inflamed vermiform appendix in his hernial sac (acute appendicitis), presenting as an incarcerated right groin hernia, and underwent simultaneous appendectomy and Bassini suture hernia repair. Two patients, Caucasian men aged 36 and 43 years old, had normal appendices in their sacs, which clinically appeared as non-incarcerated right groin hernias. Both underwent a plug-mesh hernia repair without appendectomy. The fourth patient, a 25-year-old Caucasian man with a large but not inflamed appendix in his sac, had a plug-mesh hernia repair with appendectomy.ConclusionA hernia surgeon may encounter unexpected intraoperative findings, such as Amyands hernia. It is important to be prepared and apply the appropriate treatment.

The role of laparoscopic surgery in gastric cancer

The laparoscopic surgery in gastric cancer is applied with increasing frequency nowadays; noticeable reports come mainly from Korea and Japan with satisfactory results. This review presents briefly the issue by evaluating its role. A PubMed search of relevant articles published up to 2010 was performed to identify current information. Most data come from Far East, where gastric cancer occurs more often, and the proportion of early gastric cancer is high. Laparoscopic approach includes both the diagnostic laparoscopy and laparoscopic resection. Laparoscopic gastrectomy has currently limited application for gastric cancer in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.

Autoimmune pancreatitis versus pancreatic cancer: a comprehensive review with emphasis on differential diagnosis.

BACKGROUND Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis with a discrete pathophysiology, occasional diagnostic radiological findings, and characteristic histological features. Its etiology and pathogenesis are still under investigation, especially during the last decade. Another aspect of interest is the attempt to establish specific criteria for the differential diagnosis between autoimmune pancreatitis and pancreatic cancer, entities that are frequently indistinguishable. DATA SOURCES An extensive search of the PubMed database was performed with emphasis on articles about the differential diagnosis between autoimmune pancreatitis and pancreatic cancer up to the present. RESULTS The most interesting outcome of recent research is the theory that autoimmune pancreatitis and its various extra-pancreatic manifestations represent a systemic fibro-inflammatory process called IgG4-related systemic disease. The diagnostic criteria proposed by the Japanese Pancreatic Society, the more expanded HISORt criteria, the new definitions of histological types, and the new guidelines of the International Association of Pancreatology help to establish the diagnosis of the disease types. CONCLUSION The valuable help of the proposed criteria for the differential diagnosis between autoimmune pancreatitis and pancreatic cancer may lead to avoidance of pointless surgical treatments and increased patient morbidity.

Role of stenting in the palliation of gastroesophageal junction cancer: A brief review

Gastroesophageal junction cancer has an increasing incidence in western countries. It is inoperable when first manifested in more than 50% of cases. So, palliation is the only therapeutic option for the advanced disease to relieve dysphagia and its consequences in weakened patients with an estimated mean survival under 6 mo. This article has tried to identify trends focusing on current information about the best palliative treatment, with an emphasis on the role of stenting. Self-expanding stent placement, either metal or plastic, is the main management option. However, this anatomical location creates some particular problems for stent safety and effectiveness which may be overcome by properly designed novel stents. The stents ensure a good quality of life and must be preferred over other alternative methods of loco-regional modalities, i.e., external radiation, laser thermal or photodynamic therapy. Although stent placement is generally a simple, safe and effective method, there are sometimes complications, increasing the morbidity and mortality rate. Bypass operative procedures have now been abandoned as a first choice. The stomach instead of the colon must be used for a bypass operation when it is needed. Chemotherapy, despite the toxicity, and intraluminal radiation (brachytherapy) have a well-defined role.

Inadvertent insertion of a nasogastric tube into the brain: case report and review of the literature

The inadvertent insertion of a nasogastric tube (NGT) into the brain of a trauma patient with skull base fractures is reported. A 52-year-old male with head trauma was referred following a car accident with an NGT in situ. Serosanguineous fluid was withdrawn from the NGT, which was considered to be an indication of gastrointestinal bleeding, and cold saline lavage was performed. Skull X-rays revealed intracranial position and coiling of the NGT and pneumocranium. The NGT was immediately removed manually. The patient finally went through neurosurgical operation because of an extradural hematoma, with normal postoperative course and outcome.

Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients.

Background: Elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years. Methods: From January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were ≥ 65 years old. Results: Elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged ≥ 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged ≥ 65 years. Conclusions: Open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization.

Tension pneumoperitoneum: a rare complication of upper gastrointestinal endoscopy.

The combination of acute abdominal distension with hemodynamic instability following an endoscopic procedure should raise the suspicion of tension pneumothorax. Immediate needle decompression may be life saving.

Current management of diverticular disease complications.

Diverticular disease is a common problem in the western population and sometimes leads to serious complications such as hemorrhage, bowel stenosis, obstruction, abscesses, fistulae, bowel perforation, and peritonitis. The severity of these complications can differ, and it is not always clear which procedure is indicated in each case and what measures should be followed before bringing the patient into the operating room. Certain operations have high rates of morbidity and mortality, especially in compromised patients. Along with advancements in imaging and minimally invasive techniques, the indications for surgery have currently being adapted to “damage limitation” or “down-staging” protocols, which seem to offer improved results. There are still some questions to be solved in the following years by prospective studies, such as the usefulness of laparoscopic lavage in purulent peritonitis or of Hartmann’s procedure in fecal peritonitis. These indications, based on current literature, are systematically discussed in the present review.