Ioannis Petrakis

LigaSure versus clamp‐and‐tie thyroidectomy for benign nodular disease

LigaSure is an alternative bipolar diathermy system (BDS) combining vessel sealing with reduced thermal spread, which has been successfully used in many abdominal operations; however, there is a little experience in open thyroidectomy. This study compares the efficacy and the advantages of the LigaSure BDS when used for total thyroidectomy for benign thyroid disease with the conventional clamp‐and‐tie technique.

The PI3K/Akt/mTOR pathway is activated in murine lupus nephritis and downregulated by rapamycin

BACKGROUND The mammalian target of rapamycin (mTOR) inhibitor, rapamycin, has been shown to inhibit the progression of murine lupus nephritis by virtue of its potent immunosuppressive properties. The phosphoinositol-3-kinase (PI3K)/Akt pathway is a major upstream activator of mTOR and has been implicated in the propagation of cancer and autoimmunity. However, the activation status of the PI3K/Akt/mTOR pathway in lupus nephritis has not been studied so far. METHODS In NZBW/F1 female mice, we examined the glomerular expression of Akt and mTOR by immunofluorescence and western blot. We also searched for specific phosphorylations of these kinases known to ensue during activation of the PI3K/Akt/mTOR pathway. In parallel, we examined the therapeutic role of rapamycin either before or after the development of overt lupus nephritis. RESULTS We found that in untreated mice, as opposed to healthy controls, Akt and mTOR were over-expressed and phosphorylated at key activating residues. Rapamycin prolonged survival, maintained normal renal function, normalized proteinuria, restored nephrin and podocin levels, reduced anti-dsDNA titres, ameliorated histological lesions, and reduced Akt and mTOR glomerular expression activation. CONCLUSIONS These results suggest that: (i) the PI3K/Akt/mTOR pathway is upregulated in murine lupus nephritis, thus justifying treatment with rapamycin; (ii) rapamycin not only blocks mTOR but also negatively regulates the PI3K/Akt/mTOR pathway; and (iii) rapamycin is an effective treatment of murine lupus nephritis. Examination of the PI3K/Akt/mTOR pathway may offer new insights into the pathogenesis of lupus nephritis in humans and may lead to more individualized and less toxic treatment.

Cutaneous melanoma in the elderly: epidemiology, prognosis and treatment.

The incidence and mortality of cutaneous melanoma (CM) has increased over the last decades in fair-skinned populations. Incidence and mortality, as well as rates of increase, have been significantly higher in elderly people compared with younger age groups. Lower survival rates from CM among elderly are mainly the result of late diagnosis of tumors with dismal prognostic features. Expansion of current preventive strategies to include older age groups is therefore warranted. Despite differences in clinical presentation and pathological characteristics of CM in the elderly, there is no evidence that primary surgical treatment should differ from that proposed generally for melanoma. However, the rate of positive sentinel node dissection decreases with age, even though overall survival is shorter in older patients, a paradox that remains to be explained. The use of adjuvant treatment with interferon-&agr; in elderly patients requires careful discussion of the risks and benefits, especially when serious illness coexists. For metastatic melanoma, complete metastasectomy is the only treatment associated with benefit for overall survival. However, careful selection of surgical oncogeriatric candidates is necessary, probably with the use of tools to provide a comprehensive geriatric assessment, to identify patients more likely to benefit from this treatment. In the absence of any effective systemic treatment for disseminated CM, new therapeutic agents are urgently needed. Practical means to improve accrual of older patients in clinical trials are necessary to provide better evidence for their treatment.

ePTFE/FEP-Covered Metallic Stents for Palliation of MalignantBiliary Disease: Can Tumor Ingrowth Be Prevented?

AbstractPurposeTo determine the application and clinical effectiveness of ePTFE/FEP-covered metallic stents for palliation of malignant biliary disease, and to evaluate the efficiency of stent coverage in preventing tumor ingrowth.MethodsDuring a 3-year period, 36 patients with malignant obstructive jaundice were treated with ePTFE/FEP-covered stents, with or without proximal side holes. The stricture was located in the lower common bile duct (CBD) in 18 cases, the upper CBD in 9, the lower common hepatic duct (CHD) in 6, and the upper CHD in 3 patients.ResultsThirty-seven covered stents were percutaneously implanted. The technical success rate was 97%. Reintervention was required in 6 cases. The 30-day mortality rate was 40%, not procedure-related. Mean survival was 128 days. Primary patency rates were 100%, 55.5%, and 25% at 3, 6, and 12 months, respectively, while the assisted patency rate was 100% at 12 months. Stents without side holes had higher primary patency rates compared with those with side holes, where occlusion was always due to tumor ingrowth. Tumor ingrowth did not occur in the completely covered stents. No stent dysfunction due to sludge incrustation was found. Complications were 1 case of arterial laceration that occurred during percutaneous transhepatic cholangiography, and a subcapsular hematoma and 1 case of bile peritonitis, that both occurred during primary stenting. No complications followed the secondary stenting technique.ConclusionePTFE/FEP-covered metallic stents are safe and effective for palliation of malignant biliary disease. The presence of the ePTFE/FEP coating is likely to prevent from tumor ingrowth.

Solid Pseudopapillary Neoplasm of the Pancreas: Report of a Case after a 10-Year Follow-Up and Review of the Literature

A solid pseudopapillary neoplasm (SPN) is an extremely rare tumour of the pancreas that frequently occurs in young females and is mostly benign. SPN is a low-grade malignant tumour that may evolve years before symptoms start. However, the pathogenesis of this tumour remains unclear and there are no adequate reports of long-term results to evaluate the management and the long-term surgical control. We describe a new case of SPN with a 10-year follow-up, and review the world literature that accounts for approximately 322 cases. Moreover, a review of the current management and surgical tendencies in the treatment of SPN is considered. An SPN pancreatic tumour occurred in a 24-year-old female who complained of episodic mild abdominal pain sustained by a palpable epigastric mass. The tumour mass was detected by ultrasound and computer tomography and was localised at the tail of the pancreas adherent to the spleen. The preoperative diagnosis was uncertain and en-block distal pancreatectomy and splenectomy were performed. The size of the mass which weighed 300 g was 11 × 12 × 8 cm, and the tumour was strictly adherent and invaded the splenic hilum. Histologic examination confirmed a complete resection of the primary SPN that locally invaded spleen. The postoperative period was uneventful and after a 10-year follow-up the patient is free of symptoms. SPN should be considered in the differential diagnosis of large pancreatic masses, especially in young females. Radical resection, where technically feasible, should be considered the therapy of choice as it is a safe and effective control of the disease.

Hyperglycemia attenuates erythromycin-induced acceleration of liquid-phase gastric emptying of hypertonic liquids in healthy subjects.

Acute hyperglycemia has been associated with delayed gastric emptying in healthy controls. Erythromycin has recently been found to be a gastrointestinal prokinetic agent in both solids and hypertonic liquids. Our aim was to examine whether the acute steady-state hyperglycemia reduces the erythromycin-induced acceleration of gastric emptying of hypertonic liquids after a fasted state of the stomach in healthy subjects. In 12 healthy subjects scintigraphic measurement of gastric emptying of a hypertonic radiolabeled liquid meal, during normoglycemia (5–8.9 mmol/l glucose) or induced hyperglycemia (16–19 mmol/liter glucose) by intravenous glucose infusion after giving either placebo or 200 mg intravenous erythromycin, was performed on four separate days in random order. In the hyperglycemic state compared with normoglycemia, either after placebo administration or erythromycin, the gastric emptying of the hypertonic liquid was reduced. The lag-phase duration was significantly increased (17.5 ± 5.5 min, and 7.2 ± 4.5 min vs 10.5 ± 3.4 min, and 3.5 ± 2.5 min, respectively, P < 0.0001) as were the overall T1/2 (gastric emptying time of the half meal) (52.5 ± 13 min and 24.5 ± 5.5 min vs 42 ± 10.5 min, and 16 ± 6 min, respectively, P < 0.0001) and the percentage of liquid meal retained in the stomach at 60 and 100 min postprandially (P < 0.001). In conclusion, hyperglycaemia attenuates the acceleration effect of erythromycin and decreases the overall gastric emptying rate of hypertonic liquids in healthy subjects.

Use of the LigaSure™ vessel sealer in total abdominal hysterectomy

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Hyperglycemia attenuates erythromycin-induced acceleration of solid-phase gastric emptying in healthy subjects

see front matter D 2005 International Federation of All rights reserved. doi:10.1016/j.ijgo.2004.12.039 T Corresponding author. 114 Akadimias Avenue, GR-71305, Heraklion Crete, Greece. Tel.: +3

Pancreatic Resection for Metastasis to the Pancreas from Colon and Lung Cancer, and Osteosarcoma

AbstractBackground: Acute hyperglycemia has been associated with delayed gastric emptying of solid foods in healthy control subjects. Erythromycin has been found to be a gastrointestinal prokinetic agent in humans. We examined whether acute steady-state hyperglycemia reduces the erythromycin-induced acceleration of gastric emptying of a solid meal after a fasted state in healthy subjects. Methods: Twelve healthy subjects ate standard solid meals that had been radiolabeled. Gastric emptying was measured by scintigraphy during normoglycemia (5–8.9 mmol/L glucose) and hyperglycemia induced by intravenous glucose (16–19 mmol/L glucose) after administration of placebo or 200 mg of erythromycin intravenously. Emptying was measured randomly on 4 different days. Results: Administration of erythromycin during normoglycemia or induced hyperglycemia compared with placebo accelerated the gastric emptying of the solid meal but did not completely normalize the delay caused by hyperglycemia versus normoglycemia (p < 0.001). In both conditions, erythromycin versus placebo significantly reduced the lag-phase duration (9.7 ± 2.3 min and 22.0 ± 3.9 min vs. 38.3 ± 5.7 min and 49.5 ± 6.0 min, respectively; p < 0.001), gastric emptying of the half meal (39.2 ± 4.0 min and 52.0 ± 7.1 min vs. 75.7 ± 11.8 min and 94.0 ± 13.4 min, respectively; p < 0.001), and the percentage of meal retained in the stomach 120 min postprandially (p < 0.001). Conclusion: The erythromycin-induced acceleration effect on gastric emptying was related to the plasma glucose level. Hyperglycemia might have chosen a cholinergic antagonist pathway that delayed gastric emptying of solids. Even though induced hyperglycemia inhibited gastric emptying, erythromycin accelerated the gastric emptying rate through two distinct pathways: cholinergic and noncholinergic.

Video-assisted thoracoscopic surgery in the diagnosis and treatment of chest diseases.

CONTEXT Pancreatic resection for a metastatic colon, lung cancer or an osteosarcoma has rarely been reported in the literature and there is controversy regarding recurrence and the overall survival of these patients. We herein evaluate the outcome of three patients who underwent pancreaticoduodenectomy for the aforementioned metastatic tumors to the pancreas. CASE REPORTS Clinical presentation included pyloric stenosis and acute gastrointestinal bleeding. One patient was asymptomatic and was diagnosed during follow-up for colon cancer. All the pancreatic lesions were located in the head of the pancreas, and the intervals between the diagnosis of the primary cancer and the pancreatic metastases were 6, 14 and 24 months. During exploration of the abdomen, additional metastatic lesions in the small intestine and liver were detected and resected in two patients. One patient died one month after surgery from massive gastrointestinal bleeding. The other two patients experienced relief from their symptoms but died from generalized carcinomatosis 16 and 27 months after pancreaticoduodenectomy. CONCLUSION Pancreatic resection for metastatic disease may be suggested for selected patients, even those with limited extrapancreatic disease. In this setting, it may offer good palliation and may prolong survival. In cases of acute duodenal bleeding resistant to conservative measures, pancreaticoduodenectomy may represent the only alternative for survival; however, significant morbidity and mortality should be expected.