Evangelos Menenakos

Reinforcing the staple line during laparoscopic sleeve gastrectomy: prospective randomized clinical study comparing two different techniques. Preliminary results.

BackgroundSleeve gastrectomy involves the creation of small gastric reservoir based on lesser curvature of the stomach, which is fashioned by a longitudinal gastrectomy that preserves the antrum and pylorus together with its vagal innervation. The main complications in the early postoperative course are bleeding and gastric leak. In order to reduce these complications the staple line can be reinforced in many different ways. The purpose of this study was to randomly compare two different techniques in laparoscopic sleeve gastrectomy (LSG): buttressing the staple line at the gastroesophageal junction (angle of Hiss) with Gore Seamguard and staple-line suturing with PDS 2.0.MethodsBetween July 2009 and July 2010, 90 patients were prospectively and randomly enrolled in the two different techniques of handling the staple line during LSG. Forty-eight of these patients belonged in group A (application of Gore Seamguard) and 42 in group B (application of a continuous suture). Operative and postoperative complications were recorded.ResultsPostoperative leak affected two patients in group A (4.2%) and bleeding occurred in one patient of group A (2%). Total complication rate was 6.2% for group A. No major surgical complication occurred in group B. The differences between the two groups did not reach statistical significance.ConclusionsNo significant difference is evidenced in terms of bleeding and postoperative leak between the two techniques of enhancing the staple line in LSG. Suturing of the staple line may be more time consuming but costs are considerably less.

Time-dependent mitochondrial-mediated programmed neuronal cell death prolongs survival in sepsis.

Objective:To investigate whether apoptosis is a possible mechanism of brain dysfunction occurring in septic syndrome. Design:Experimental prospective study. Setting:Laboratory of Surgical Research at the University of Athens. Subjects:Male pathogen-free Wistar rats. Interventions:Rats (n = 112) were subjected to sepsis by cecal ligation and puncture. Sham-operated animals (n = 40) underwent the same procedure but without ligation or puncture. Septic animals were either randomly divided (n = 62) in six groups and studied at 6, 12, 24, 36, 48, and 60 hrs after the operation or monitored (n = 50) for 48 hrs as a survival study group. Sham-operated animals were killed at 6, 12, 24, 36, 48, and 60 hrs after the procedure. Brain and cecum were then removed and postfixed in paraffin sections. Apoptosis was evaluated by light microscopy in hematoxylin and eosin-stained specimens and by transmission electron microscopy. In paraffin-embedded sections, immunostaining for bax, bcl-2, cytochrome c, and caspase-8 was done. Measurements and Main Results:In septic rats, increased apoptosis was detected in neurons of the CA1 region of the hippocampus, in choroid plexus, and in Purkinje cells of the cerebellum. Bax immunopositivity was found decreased after the septic insult (p = .03). Bax immunoreactivity was altered as the septic syndrome evolved; it was up-regulated in the early stages (6–12 hrs) and progressively decreased in the late phases (p = .001). Cytochrome c presented a similar regional pattern of expression and was found to be the sole gene marker carrying an independent prognostic role (p = .03). Both bcl-2 and caspase-8 expression remained at constant levels at all times evaluated. Conclusions:There is evidence that more neurons undergo apoptosis during sepsis than in normal brain tissue in certain sites where the blood-brain barrier is compromised. In this phenomenon, mitochondrial gene regulators such as bax and products such as cytochrome c seem to play important regulating and prognostic roles, respectively.

Endoscopic Management of a Relapsing Hepatic Hydatid Cyst with Intrabiliary Rupture: A Case Report and Review of the Literature

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas. Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intrabiliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree. Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.

Apoptosis in cells of bronchoalveolar lavage: a cellular reaction in patients who die with sepsis and respiratory failure.

Objective Apoptosis represents a physiologic clearance mechanism in human tissues. The role of apoptosis has not been examined in lung cell populations, such as alveolar macrophages of septic patients, an organ frequently insulted in these patients. This study was designed to examine the effect of sepsis on the apoptosis of alveolar macrophages. Design Prospective study. Setting Intensive care unit and surgical intensive care and trauma unit of a large university hospital in Athens, Greece. Patients Bronchoalveolar lavage was obtained from 20 consecutive patients who met the criteria for sepsis, admitted to two intensive care units. Bronchoalveolar lavage was obtained from nine volunteers without lung disease who served as controls. Interventions None. Measurements and Main Results The specimens were analyzed by using annexin V binding, terminal deoxynucleotidyl transfer-mediated deoxyuridine 5-triphosphate nick end labeling (TUNEL), DNA laddering, light microscopy, and immunohistochemistry. Spontaneous apoptosis of bronchoalveolar lavage cells and particularly of alveolar macrophages was significantly decreased in septic patients compared with nonseptic controls. This finding was confirmed by using morphologic criteria and the TUNEL method. Furthermore, gel electrophoresis of DNA obtained from bronchoalveolar cells revealed that DNA fragmentation was not necessarily associated with apoptotic cell death. The bcl-2 gene was minimally expressed in the control group. An inverse correlation was found between the percentage of apoptotic alveolar macrophages and the severity of sepsis. Conclusions The prolonged survival of lung cells in septic patients and especially of alveolar macrophages may be attributable to the inhibition of apoptosis. This seems to represent an initial attempt of the host to increase the defense capacity to kill the invading microorganism, resulting in an unbalanced tissue load of cells and an uncontrolled release of toxic metabolites. Furthermore, the inhibition of apoptosis in septic patients may explain why lung function is impaired, leading to sepsis-induced acute respiratory distress syndrome and death.

Bougie insertion: A common practice with underestimated dangers

INTRODUCTION Esophageal perforation after bariatric operations is rare. We report two cases of esophageal perforation after bariatric operations indicating the dangers of a common practice - like insertion of esophageal tubes - and we describe our management of that complication. PRESENTATION OF CASE A 56 year old woman who underwent laparoscopic sleeve gastrectomy and a 41 year old woman who underwent laparoscopic adjustable gastric banding respectively. In both operations a bougie has been used and led to esophageal perforation. DISCUSSION The insertion of bougie and especially of inflated bougie is a common practice. It is an invasive procedure that in most cases is performed by the anesthesiologist team. CONCLUSION Bougie insertion is an invasive procedure with risks and should always be attempted under direct supervision of surgical team or should be inserted by a surgeon.

Emphysematous pyelonephritis, a rare cause of pneumoperitoneum: a case report and review of literature

IntroductionEmphysematous pyelonephritis is a gas-producing necrotizing bacterial infection that involves the renal parenchyma and perirenal tissue.Case presentationWe report on a case of a 55 year old Caucasian male with no prior medical history presented with left flank pain and malaise. He was diagnosed with emphysematous pyelonephritis, and was successfully treated in our department. The case is presented along with a literature review.ConclusionPrompt diagnosis and early treatment is crucial because of the high rate of mortality. Therapeutic modalities and prognostic factors regarding emphysematous pyelonephritis remain controversial.

Fatal Chest Injury with Lung Evisceration during Athletic Games in Ancient Greece

The “Olympic idealism” that dominates modern athletic culture is a myth. The true aims of the athletes in ancient Greece were rewards and life-long appointments to various positions in the military or the city administration. Competitions in the athletic games included, among others, wrestling, boxing, and pangration (a combination of wrestling and boxing). Occasionally, these games resulted in severe trauma or death. Two cases of extreme violence resulting in fatal chest trauma are presented and commented on from both surgical and social points of view.

Short Leukocyte Telomere Length Precedes Clinical Expression of AtherosclerosisNovelty and Significance: The Blood-and-Muscle Model

Rationale: Short telomere length (TL) in leukocytes is associated with atherosclerotic cardiovascular disease (ASCVD). It is unknown whether this relationship stems from having inherently short leukocyte TL (LTL) at birth or a faster LTL attrition thereafter. LTL represents TL in the highly proliferative hematopoietic system, whereas TL in skeletal muscle represents a minimally replicative tissue. Objective: We measured LTL and muscle TL (MTL) in the same individuals with a view to obtain comparative metrics for lifelong LTL attrition and learn about the temporal association of LTL with ASCVD. Methods and Results: Our Discovery Cohort comprised 259 individuals aged 63±14 years (mean±SD), undergoing surgery with (n=131) or without (n=128) clinical manifestation of ASCVD. In all subjects, MTL adjusted for muscle biopsy site (MTLA) was longer than LTL and the LTL-MTLA gap similarly widened with age in ASCVD patients and controls. Age- and sex-adjusted LTL (P=0.005), but not MTLA (P=0.90), was shorter in patients with ASCVD than controls. The TL gap between leukocytes and muscle (LTL-MTLA) was wider (P=0.0003), and the TL ratio between leukocytes and muscle (LTL/MTLA) was smaller (P=0.0001) in ASCVD than in controls. Findings were replicated in a cohort comprising 143 individuals. Conclusions: This first study to apply the blood-and-muscle TL model shows more pronounced LTL attrition in ASCVD patients than controls. The difference in LTL attrition was not associated with age during adulthood suggesting that increased attrition in early life is more likely to be a major explanation of the shorter LTL in ASCVD patients. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02176941.

Adhesion Formation: Intraperitoneal Catheters in Surgical Practice

To compare the adhesion formation, in a rat model, of commercially available materials used as intraperitoneal catheters in clinical practice, pieces of polyurethane, Teflon, silicone, and polyvinyl chloride (PVC) were placed intraperitoneally in 36 female Wistar rats randomly assigned into four groups. Adhesion development was quantitated according to Nairs classification system (NCS). According to NCS, polyurethane showed the least adhesion formation, while the highest scores were found in the PVC group. Comparing the thickness and the firmness of adhesions in the four groups, significant differences were found, with the polyurethane group developing none or filmy and mild adhesions. In contrast, almost all the rats in the Teflon group developed thick and dense adhesions. Thus, polyurethane caused the least adhesion formation among the four materials evaluated, and can be used more extensively for the construction of catheters for prolonged intraperitoneal use.

Effects of lazaroid U-74389G on intestinal ischemia and reperfusion injury in porcine experimental model

BACKGROUND The readmission of molecular oxygen into an ischemic tissue promotes the oxidation of resuscitated tissue with certain pathophysiologic mechanisms. MATERIALS AND METHODS Twenty four pigs (male or female) were randomized in this study. The animals were allocated to four groups with an equal number (n = 6) in each group: (1) control group-ischemia for 30 min and reperfusion for 60 min. (2) control group-ischemia for 30 min and reperfusion for 120 min. (3) ischemia for 30 min and immediate iv injection of lazaroid U-74389G and reperfusion for 60 min. (4) ischemia for 30 min and immediate iv injection of lazaroid U-74389G and reperfusion for 120 min. RESULTS We investigated further the role of an antioxidant molecule such as U-74389G and we concluded that there is statistically significant relation in MDA (malondialdeyde), TNF -α (tumor necrosis factor-α) measurement in tissue, while the histological score in the groups that the lazaroid was administered was improved. CONCLUSIONS In many emergency clinical situations, such as reperfusion of the intestine, the role of U-74389G can be protective.