Evangelos Misiakos

Surgical Treatment for Splenic Hydatidosis

Abstract. Splenic involvement is rare in patients with hydatid disease even in endemic countries. The spleen is the third most commonly involved organ after the liver and the lung. In our series splenic echinococcosis represents 5.8% of abdominal hydatid disease. During the last 22 years, 14 patients were operated on for splenic hydatid cysts in our department. In 10 patients the spleen was the only location of hydatid disease; in 2 patients there was concomitant liver hydatid disease; one patient had disseminated intraabdominal disease; and one patient had a coexisting hydatid cyst in the quadriceps femoris muscle. Plain abdominal films, ultrasonography, and computed tomography scans were most useful for establishing the diagnosis. All patients underwent splenectomy alone or combined with management of cysts at other sites, except for two patients who underwent omentoplasty and one patient who underwent external drainage. One patient died during the early postoperative period (mortality rate 7%), and three patients had minor complications. Splenic hydatid disease should be included in the differential diagnosis when a splenic cyst is identified, especially in patients with a history of hydatid disease. Surgery remains the treatment of choice to avoid serious complications.

Current treatment for colorectal liver metastases

Surgical resection offers the best opportunity for survival in patients with colorectal cancer metastatic to the liver, with five-year survival rates up to 58% in selected cases. However, only a minority are resectable at the time of diagnosis. Continuous research in this field aims at increasing the percentage of patients eligible for resection, refining the indications and contraindications for surgery, and improving overall survival. The use of surgical innovations, such as staged resection, portal vein embolization, and repeat resection has allowed higher resection rates in patients with bilobar disease. The use of neoadjuvant chemotherapy allows up to 38% of patients previously considered unresectable to be significantly downstaged and eligible for hepatic resection. Ablative techniques have gained wide acceptance as an adjunct to surgical resection and in the management of patients who are not surgical candidates. Current management of colorectal liver metastases requires a multidisciplinary approach, which should be individualized in each case.

Hereditary Nonpolyposis Colorectal Cancer (Lynch Syndrome): Criteria for Identification and Management

Hereditary nonpolyposis colorectal carcinoma (HNPCC), or Lynch syndrome, is an autosomal dominant syndrome accounting for 5 to 10% of the total colorectal cancer population. Patients with this syndrome develop colorectal carcinoma at an early age, but disease onset can happen in all age groups. Usually the carcinomas are synchronous or metachronous, and most of them arise proximal to the splenic flexure. The prognosis is better than for the sporadic form of cancer, and there is increased risk for cancer development in certain extracolonic sites, such as the endometrium, ovary, stomach, small bowel, hepatobiliary tract, ureter, and renal pelvis. Most patients with HNPCC have a mutation in one of two DNA mismatch repair genes, hMSH2 or hMLH1. More than 90% of colorectal carcinoma patients with hMSH2 or hMLH1 demonstrate high-frequency microsatellite instability (MSI-H). If a patient is suspected to belong to an HNPCC family, the first screening test should be immunohistochemistry for the detection of hMLH1 and hMSH2 proteins, and if it is indicative, it should be followed by genomic sequencing for the identification of mutations in the mismatch repair genes. Genetic counseling and surveillance for high risk HNPCC family members should begin at age 25. Surveillance includes annual colonoscopy of the entire large bowel, with fecal occult blood testing performed twice a year. Systematic surveillance and individually designed treatment of affected patients may help to detect cancers at an earlier stage and subsequently improve the prognosis of the disease further.

Surgical treatment of perianal abscess and fistula-in-ano in childhood, with emphasis in children older than 2 years☆

BACKGROUND Anal sepsis in children ranges from perianal abscess to fistula-in-ano. It is mostly observed in boys younger than 2 years. Most are treated conservatively. In contrast, anal sepsis in older children presents significant similarities to that of adults and is predominantly treated surgically. We report our outcomes after surgical treatment of anal abscess and fistula-in-ano in children older than 2 years. PATIENTS AND METHODS Ninety-eight (98) children were operated on for anal abscess (46 patients; 47%) and/or fistula-in-ano (52 patients; 53%). Incision and drainage of the abscess was performed as outpatients. In patients with fistulas, fistulotomy was the main treatment approach. All patients were healthy without risk factors for anal sepsis. RESULTS In patients with anal abscess treated with incision and drainage, low recurrence (13%) or fistula formation rates were observed. Most anal fistulas were simple entities. Significant involvement of the anal sphincter was found in 3 (6%) of 52 patients. An abscess cavity between the anal canal and the perianal skin was found in 4 (8%) of 52 patients, and an enlarged cryptic gland was found in 5 (10%) of 52 cases. Fistulotomy was performed in all patients with additional seton placement in 3 (6%) of 52 and a cryptotomy in 5 (10%) of 52 patients. CONCLUSIONS Anal abscesses in children are easily treated by incision and drainage with low recurrence of perianal sepsis. Fistulas can be treated successfully in most patients with a fistulotomy, whereas complex fistulas are uncommon.

Total thyroidectomy for the treatment of thyroid diseases in an endemic area.

Introduction: Thyroidectomy is a common operation with very low mortality and an acceptable morbidity rate. Total thyroidectomy has become the predominant type of surgery used today for the treatment of thyroid diseases. In this retrospective study, we analyzed the complications of thyroid surgery according to the operative technique used in our department. Material and Methods: A retrospective analysis was performed for all patients who underwent thyroid surgery during the previous 11 years. The period under study was divided into two sections: phase A (1995–1999) and phase B (2000–2005). Patient characteristics, type of operation, histologic diagnoses and postoperative complications were compared in the two study periods according to the type of surgery. Results: A total of 264 patients between the ages of 18 and 89 underwent thyroid surgery during the study period (133 in phase A and 131 in phase B). Overall histopathological diagnoses were nodular goiter (54.9%), hyperplastic nodules (14.7%), adenoma (8.3%), thyroid cancer (18.2%), and Hashimoto thyroiditis (3.8%). Total thyroidectomy was performed in 91 patients in phase A versus 115 patients in phase B (P < 0.001), whereas the use of subtotal thyroidectomy and lobectomy decreased over time. A trend toward increased morbidity was noted in phase B. Seven patients had hypocalcemia in phase A, whereas 11 patients had hypocalcemia in phase B. Similarly, 5 patients had some degree of vocal cord paralysis in phase A, compared with 7 in phase B (P > 0.05). Morbidity was significantly increased in the case of cancer or reoperation. Conclusion: Despite the slightly higher risk of complication associated with total thyroidectomy, this has gradually replaced more conservative approaches for the treatment of both benign and malignant thyroid diseases. Reoperations and surgery for thyroid cancer carried a higher risk of complications.

Renal artery rupture following cutting balloon angioplasty for fibromuscular dysplasia: a case report

IntroductionAngioplasty with the use of cutting balloons has been suggested by some case reports and small series for the treatment of renal artery stenoses that are resistant to conventional balloon catheters. Based on this limited experience, the use of this technology has been suggested as safe. Herein, we report a renal artery rupture following angioplasty with a cutting balloon. The complication was salvaged with a stent graft.Case presentationA 30-year-old white female patient with resistant hypertension caused by a severe renal artery stenosis attributed to fibromuscular dysplasia, was submitted to conventional balloon angioplasty without success. Dilatation of the lesion with a cutting balloon resulted in arterial rupture, with concomitant retroperitoneal hematoma.ConclusionCutting balloon angioplasty of renal artery lesions resistant to conventional balloon angioplasty should not be considered as safe as previously thought. When proceeding with such a procedure, a stent graft should be available for immediate use.

Microcatheter Use for Difficult Percutaneous Biliary Procedures

Percutaneous biliary drainage procedures in patients with nondilated ducts are demanding, resulting in lower success rates than in patients with bile duct dilatation. Pertinent clinical settings include patients with iatrogenic bile leaks, diffuse cholangiocarcinomas, and sclerosing cholangitis. We describe a method to facilitate these procedures with the combined use of a 2.7-Fr microcatheter and a 0.018–in. hydrophilic wire.

Screening for or Prevention of Local Ipsilateral Recurrence and Contralateral Breast Cancer After Breast-Conserving Surgery?

In the June issue of the Journal, Gorechlad et al. reported the occurrence of local failures following breastconserving surgery (BCS). They concluded that following free-resection margins and adjuvant radiation therapy, the overall rates of recurrence of a new ipsilateral breast cancer (IBC) or contralateral breast cancer (CBC) 5 years after treatment were very low. Furthermore, physical exam and mammography allowed for early detection of IBC and CBC and, thus, the authors noted that annual screening magnetic resonance imaging (MRI) is unlikely to improve overall survival. Although these findings are consistent with those from other recent retrospective studies, we would highlight potential higher risks of IBC and CBC and decreased overall survival for specific subsets of patients. Local control is important for long-term survival; this notion is supported by objective evidence. Indeed, accumulating evidence suggests that IBC and CBC may be the first isolated events to be observed during the long-term follow-up period. Instead of screening after BCS to detect these local failures at an early stage, prevention of these events may be a more effective approach in improving clinical outcomes for these women. The study by Gorechlad et al. may have been subject to bias and limited by several factors. First, it is well known that the median follow-up of 5.4 years is short; many local failures occur after 5 years and, thus, at least 10 years or 15 years follow-up is required for the assessment of local events. Second, the small sample size did not allow for subgroup analysis, to observe whether and which subsets of patients were at higher risk of local failures. Third, by including only those patients with free-resection margins in this retrospective analysis, selection bias cannot be excluded. How can we prevent local failures? It is clear that BCS is the preferred procedure for carefully selected patients with localized disease. A more aggressive surgery including contralateral prophylactic mastectomy (CPM) is likely to benefit only high-risk patients. Currently, a trend toward extensive surgery in unselected women occurs in some countries. For example, the current landscape in the extent of surgery is best delineated by the data of the Surveillance, Epidemiology and End Results (SEER) database for breast cancer patients treated in the USA. The rate of CPM has dramatically increased by 150% between 1998 and 2003. This finding suggests a surgical overtreatment rather than a targeted selection of high-risk women who may benefit from bilateral mastectomy (BM). Is risk stratification into high, moderate and low risk for IBC and/or CBC feasible today? There are several challenges and limitations in the identification of high-risk patients. Even following current guidelines, recommendation for appropriate surgery, radiation, and systemic adjuvant therapies including empirical chemotherapy and the new standard targeted agents trastuzumab and aromatase inhibitors (AIs) for selected patients, the long-term local failure rate is substantial for certain subgroups. Accumulating evidence suggests that among all patients treated for localized breast cancer, the subgroup of women with inherited mutations in BRCA1 or BRCA2 (BRCA) cancer susceptibility genes face the highest risk of IBC and CBC. Genetic testing identifies BRCA mutation carriers and has been integrated into the diagnostic work-up of patients with family history. Effective surgical interventions are increasingly used in clinical practice for primary prevention in both healthy women with BRCA mutations and patients with unilateral breast cancer. The risk of CBC among BRCA mutation carriers in a recent study by Metcalfe et al. was 3% annually or 29.5% at 10 years after unilateral breast surgery. In this study, CPM was very effective at reducing this risk by up to 97%. However, it should be noted that level-I evidence from randomized trials on the efficacy of CPM relative to BCS is still lacking. Another subgroup at increased risk of IBC and/or CBC is one with patients who have basal-like breast cancer. This subtype, defined on the basis of global gene expression profiling data using microarrays, approximates the triple-negative cancer. The term ‘‘triple negative’’ concerns patients with human epidermal growth factor receptor 2 (HER2), estrogen receptor (ER) and/or progesterone receptor (PR) negative status (HER2/HER/PR-negative). In the most recent study by Ngyyen et al., the IBC rate after a median follow-up of 70 months was 7.1% for the basal-like subtype. It is likely that long-term survivors with a triple-negative (HER2/ER/PR) tumor or a basallike subtype face a high risk of IBC and CBC given that trastuzumab and tamoxifen or AIs, which reduce both distant and local recurrences, are ineffective in these patients. Objective evidence has shown that all types of recurrence, including local, locoregional and distant, are important for long-term survival. Therefore, any effort should be made preoperatively to identify patients at high risk, because they might benefit from a personalized surgical strategy aimed at reducing local failure. This treatment strategy may have important clinical implications not Annals of Surgical Oncology 15(12):3617–3619 Published by Springer Science+Business Media, LLC 2008 The Society of Surgical Oncology, Inc.

Seclusion of an Abdominal Aortic Aneurysm in the Presence of an Unusual Horseshoe Kidney A Case Report

The coexistence of horseshoe kidney and abdominal aortic aneurysm is rare, and technical challenges during aneurysm repair are significant. This is a report of a case of an infrarenal aortic aneurysm associated with a horseshoe kidney with a parenchymatous isthmus draining to a third ureterocaliceal system and an anomalous vascular supply. Surgical management consisted of aneurysm exclusion and use of a bifurcation graft to the common iliac arteries. Arterial supply to the isthmus remained intact during operation and the postoperative clinical outcome was satisfactory.

Hartmann’s Procedure in the Treatment of Acute Colonic Conditions

The aim of this study is to assess the safety of Hartmann’s procedure in the management of acute colonic conditions, in terms of postoperative morbidity and mortality associated with the two-stage procedure. Between 1975 and 1994, 80 patients underwent emergency Hartmann’s procedure in our department. Colonic obstruction and/or perforation due to carcinoma was present in 49 cases (61.2%) whereas the procedure was used for palliation in 9 cases (11.3%). Perforation due to diverticulitis was present in 19 cases (23.7%) and obstruction due to radiation enteritis was present in 3 cases (3.8%). Complications developed in 20 patients (morbidity rate: 25%). Eight patients (10%) died in the immediate postoperative period. Colorectal continuity was reestablished in 51 patients. Postoperative morbidity and mortality were 31 and 3.9%, respectively. In conclusion, Hartmann’s procedure is an optimal emergency procedure for complications of carcinoma or diverticulitis of the left colon and including subsequent restoration of bowel continuity has acceptable morbidity and mortality rates.