Eleftherios Spartalis

De Garengeot's hernia in a 60-year-old woman: A case report

IntroductionDe Garengeot first described the presence of the appendix within a femoral hernia in 1731.Case presentationWe report the case of a 66-year-old Caucasian woman who presented with acute appendicitis within an incarcerated femoral hernia. This is the first reported case of de Garengeots hernia in the Balkan area.ConclusionsAppropriate management without incurring any delay for radiological imaging can be promising for an uneventful postoperative course. The treatment of choice of this disease entity is emergency surgery and consists in simultaneous appendectomy through the hernia incision and primary hernia repair. In patients with large hernia defects or in older people the use of mesh for repairing the hernia defect can be an excellent choice.

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.

Indications, limitations and maneuvers to enable extended hepatectomy: Current trends

The liver is a solid organ with a wide variety of primary benign or malignant tumors as well as metastatic lesions. Surgical resection of these tumors remains the only curative modality. Several limitations, however, do not allow the performance of these operations. This review evaluates the indications and limitations regarding these extended hepatic resections, as well as describing all the manipulations that increase the candidates for such operations. A thorough review of the literature was performed in order to define indications for extended hepatectomy, as well as to present all methods that contribute to increasing the volume of the future remnant liver. The role of portal vein ligation, portal vein embolization, two-stage hepatectomy, and in situ liver transection are evaluated in the setting of indications and results. Extended hepatectomies are a necessity due to oncological reasons. All methods developed in order to increase the volume of the remnant liver are safe and efficient. in situ liver transection is a novel and revolutionary two-step procedure for extended hepatic resections. Further clinical studies are required to estimate long-term results and the oncological basis of this technique.

The ideal porcine model for major liver resection

Dear Editor, We read with great interest the recent publication by Bucur et al., which reports a simplified technique for 75% and 90% hepatic resection with hemodynamic monitoring in porcine model. According to the article, there were two study groups. The first group included 16 animals that underwent 75% hepatectomy based on the computed tomography volumetric study, with resection of the left lateral, left medial and the right medial hepatic lobes. The second group included six animals that underwent 90% hepatectomy with additional resection of right lateral lobe. During the procedures, hemodynamic monitoring was performed by measuring the portal vein pressure and flow and hepatic artery pressure and flow. This study concludes that the described technique is simple and easily applicable for extended hepatectomy in porcine model. Furthermore, the portal vein and hepatic artery flow decreased more after 90% hepatectomy than after 75%, whereas the portal vein and hepatic artery pressure increased more following 90% compared with 75% resection. However, after an extended research of the literature, we came to the conclusion that we disagree with their analysis for the following reasons. To begin with, this study does not give any information regarding the survival rate of the animals postoperatively. It is unreliable to evaluate a surgical technique only with the survival rate during the procedure. Furthermore, the authors have not included in the study any liver function tests, hemodynamic assessment, histopathologic examination of the remnant liver and postoperative management of the animals. Without these important parameters, how can the medical community analyze and assess accurately the above surgical technique? Moreover, the authors have not described the statistical analysis which they used to analyze the results of the experiment. Last but not least, there is a significant difference in the number of animals between the two groups (16 animals underwent 75% hepatectomy, whereas only six animals underwent 90% hepatectomy), which means that this study has low statistical power and low reliability. As a consequence, there is an overestimate of the effect size and low reproducibility rate of the results as well. According to the literature, several surgical techniques for extended hepatectomy in porcine model have been reported.

The Role of NSAIDs in Breast Cancer Prevention and Relapse: Current Evidence and Future Perspectives

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) have received considerable interest as potential chemopreventive agents. The aim of this review is to summarize the accumulated knowledge on the effect of NSAIDs on breast cancer incidence and natural history, and the underlying pathophysiology. NSAIDs mainly block inflammation by inhibiting cyclooxygenase enzymes, leading to lower prostaglandin synthesis. The latter has been reported to affect breast cancer risk through hormonal and inflammation-related pathways. Intensity, dose, frequency, duration, and timing of administration may also be significant. There is currently enough evidence to support a role of NSAIDs in breast cancer prevention and relapse, which deserves further large-scale experimental and clinical investigation.

Primary parotid gland lymphoma: a case report

IntroductionMucosa associated lymphoid tissue lymphomas are the most common lymphomas of the salivary glands. The benign lymphoepithelial lesion is also a lymphoproliferative disease that develops in the parotid gland. In the present case report, we describe one case of benign lymphoepithelial lesion with a subsequent low transformation to grade mucosa associated lymphoid tissue lymphoma appearing as a cystic mass in the parotid gland.Case presentationA 78-year-old Caucasian female smoker was referred to our clinic with a non-tender left facial swelling that had been present for approximately three years. The patient underwent resection of the left parotid gland with preservation of the left facial nerve through a preauricular incision. The pathology report was consistent with a low-grade marginal-zone B-cell non-Hodgkin lymphoma (mucosa associated lymphoid tissue lymphoma) following benign lymphoepithelial lesion of the gland.ConclusionsSalivary gland mucosa associated lymphoid tissue lymphoma should be considered in the differential diagnosis of cystic or bilateral salivary gland lesions. Parotidectomy is recommended in order to treat the tumor and to ensure histological diagnosis for further follow-up planning. Radiotherapy and chemotherapy should be considered in association with surgery in disseminated forms or after removal.

Platelet-Rich Plasma in Surgical Oncology

We read with great interest the article titled “Breast Reconstruction With Autologous Fat Graft Mixed With Platelet-Rich Plasma” by Gentile et al. This welldesigned clinical protocol evaluated the effects related to the use of fat grafting with platelet-rich plasma (PRP) in the improvement of fat volume in breast reconstruction. Study included patients with unilateral breast hypoplasia, patients affected by breast soft tissue defects after prosthesis removal, and others affected by outcomes of breast cancer reconstruction. After a thorough search of the literature, we found no reported evidence of PRP application on tumor excision sites. Is there any established contraindication? Much research is now devoted to determining the impact of growth factors on tumor development and progression, and the reciprocal influences of tumor products on the stromal microenvironment. A more detailed understanding of the complex parameters that govern the interactions between the tumor and vascular compartments has already helped improve anti-angiogenic strategies, not only for cancer treatment but also for preventing recurrence. The secretory proteins contained in the α-granules of platelets include platelet-derived growth factor (PDGF-AA, BB, and AB isomers), transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), platelet-derived endothelial growth factor (PDEGF), and many others. It is a fact that the release of these growth factors stimulates angiogenesis. PDGF and VEGF induce tumor lymphangiogenesis, leading to enhanced rate of nodal metastasis. Patients with breast tumors positive for PDGF have a significantly lower response rate to chemotherapy as well as significantly shorter duration of survival. In addition, patients with breast cancer who had elevated plasma PDGF levels have a significantly shorter survival. EGFR (HER) and other members of the ErbB receptor family regulate several cell biology processes, including proliferation, survival, differentiation, and tumorigenesis. TGF-β ligand is a multifunctional growth factor that regulates various cell behavior, such as cell differentiation, migration, and apoptosis. For all these reasons mentioned above, we consider the use of PRP not yet indicated in patients undergoing resection for cancer, because of the presence of growth factors that could promote tumor proliferation. Even after a tumor is excised and in order to achieve optimal survival, we must implement every single evidence-based guideline while, at the same time, exclude any maneuver, the indication of which has not been established yet. Therefore, we strongly believe that the authors should have considered this important point and analyzed it in their article; otherwise, inclusion of patients affected by outcomes of breast cancer reconstruction should have been avoided. The role of PRP in surgical oncology deserves further experimental investigation and largescale prospective randomized clinical trials.

Hepatocellular carcinoma in patients co-infected with hepatitis C virus and human immunodeficiency virus.

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) share a common route of transmission so that about one third of HIV infected individuals show HCV co-infection. Highly active antiretroviral therapy has offered a longer and better life to infected patients. While has removed AIDS-related diseases from the list of most common causes of death their place has been taken by complications of HCV infection, such as cirrhosis, end stage liver disease and hepatocellular carcinoma (HCC). HIV/HCV co-infection requires complex management, especially when HCC is present. Co-infected patients with HCC undergo the same therapeutic protocol as their mono-infected counterparts, but special issues such as interaction between regimens, withdrawal of therapy and choice of immunosuppressive agents, demand a careful approach by specialists. All these issues are analyzed in this minireview.

Role of platelet-rich plasma in ischemic heart disease: An update on the latest evidence.

Myocardial infarction is the most common cause of congestive heart failure. Novel strategies such as directly reprogramming cardiac fibroblasts into cardiomyocytes are an exciting area of investigation for repair of injured myocardial tissue. The ultimate goal is to rebuild functional myocardium by transplanting exogenous stem cells or by activating native stem cells to induce endogenous repair. Cell-based myocardial restoration, however, has not penetrated broad clinical practice yet. Platelet-rich plasma, an autologous fractionation of whole blood containing high concentrations of growth factors, has been shown to safely and effectively enhance healing and angiogenesis primarily by reparative cell signaling. In this review, we collected all recent advances in novel therapies as well as experimental evidence demonstrating the role of platelet-rich plasma in ischemic heart disease, focusing on aspects that might be important for future successful clinical application.

Rapunzel Syndrome: A Rare Presentation with Giant Gastric Ulcer

The Rapunzel syndrome refers to an uncommon and rare form of trichobezoar that extends past the stomach into the small intestines. The Rapunzel syndrome is usually found in young female patients with a history of psychiatric disorders, mainly trichotillomania and trichophagia. We describe a case of Rapunzel syndrome in a 15-year-old girl who presented with abdominal pain, vomiting, and weight loss. We performed a surgical laparotomy and successfully removed a huge trichobezoar extending into the small intestine.