Konstantinos Atmatzidis

Complete dehiscence of the abdominal wound and incriminating factors

OBJECTIVE To find out the causes of abdominal wound dehiscence. DESIGN Retrospective study. SETTING University hospital, Greece. SUBJECTS Abdominal wound dehiscence occurred in 89 cases out of 19,206 major abdominal operations including 4671 emergencies during the past 15 years (0.5%). INTERVENTIONS In the study group 14 local and systemic risk factors were analysed and compared with those in a control group of 89 patients who had similar procedures without dehiscence. MAIN OUTCOME MEASURES Statistical analysis using the chi square test. RESULTS Significant factors (p < 0.05) included age over 65 years, emergency operation, cancer, haemodynamic instability, intra-abdominal sepsis, wound infection, hypoalbuminaemia, ascites, obesity, and steroids. Risk factors that were not significant included sex, anaemia, diabetes mellitus and pulmonary disease. Overall morbidity and mortality were 30% and 16%, respectively. The mortality and the possibility of dehiscence seem to correlate directly with the number of risk factors. CONCLUSION Patients with these risk factors require more attention and special care to minimise the risk of its occurrence.

Splenectomy versus Spleen-Preserving Surgery for Splenic Echinococcosis

Background/Aims: The spleen is the third most common location of hydatid disease after liver and lung. The aim of this study was to analyse the long-term outcome of surgical treatment of patients with splenic echinococcosis comparing splenectomy with spleen-preserving surgery. Methods: During a period of 25 years (1976–2001), 19 (5.4%) patients with splenic echinococcosis were treated in our department out of 349 patients with abdominal hydatid disease. In 16 patients the spleen was the only organ involved, while in 3 patients the liver was also affected. Results: Eleven patients had splenectomy and in the other 8 the spleen was preserved: enucleation (n = 4), partial cystectomy and omentoplasty (n = 2) and cystojejunal Roux-en-Y anastomosis (n = 2). One (6%) patient died in the early postoperative period and 5 (29%) patients had postoperative complications. There was no significant difference between the splenectomy and spleen-preserving groups concerning median hospital stay and postoperative complication rate. The median follow-up in 15 patients was 52 (range 6–300) months. Two patients (13%) developed recurrence of the disease requiring re-operation at 2 and 3 years, respectively. Recurrence occurred in 1 (12%) patient in the splenectomy group and in 1 (14%) out of 7 patients in the spleen-preserving group. Conclusion: In the present series it was possible to preserve the spleen in 8 (42%) of 19 patients, without significant increase of recurrent echinococcosis.

Primary malignant melanoma of the small intestine: report of a case.

Abstract.The small intestine is the most common site of gastrointestinal (GI) metastases from cutaneous malignant melanoma; however, primary malignant melanoma originating in the small intestine is extremely rare. We report the case of a 72-year-old man found to have a primary malignant melanoma in the ileum. The patient presented with anorexia, weight loss, diffuse colicky abdominal pain, and episodic rectal bleeding. A preoperative diagnosis of a small intestinal tumor was based on the findings of enteroclysis and computed tomography scanning. This diagnosis was confirmed at laparotomy and an enterectomy was performed. Histopathological examination of the resected specimen clarified the exact nature of the lesion, confirming the diagnosis of melanoma. A thorough postoperative investigation did not reveal a primary lesion in the skin, anus, oculus, or any other location. Thus, we diagnosed this tumor as a primary lesion. One year after his operation, the patient remains well without any evidence of recurrence. Primary malignant melanoma of the small intestine is an extremely rare lesion, which must be differentiated from other intestinal tumors.

CO2 Pneumoperitoneum Prolongs Survival in an Animal Model of Peritonitis Compared to Laparotomy

BACKGROUND The advantages of laparoscopic surgery have been well documented. However, the impact of pneumoperitoneum on sepsis sequelae is still equivocal. This study aimed to evaluate the effect of CO(2) pneumoperitoneum, applied under different pressures and exposure times, on sepsis cascade and mortality. MATERIAL AND METHODS In 42 New Zealand rabbits, peritonitis was induced by the cecum ligation and puncture model. After 12 h, the animals were randomized in seven groups: a control group, four groups with pneumoperitoneum (10-15 mmHg for 60-180 min), and two groups with laparotomy (for 60 and 180 min). Blood samples were collected before cecum ligation and puncture, 12 h later and 1, 3, and 6 h after pneumoperitoneum desufflation or abdominal trauma closure to evaluate bacteremia, endotoxemia, white blood cells count, C-reactive protein, and procalcitonin levels. Furthermore, the mortality time was recorded in all animals. RESULTS Bacteremia and endotoxemia were induced in all groups. Endotoxemia levels were significantly more elevated in the group where pneumoperitoneum was performed under 15 mmHg for 180 min compared with all other groups at 1 and 3 h after pneumoperitoneum desufflation (P < 0.05), except when compared with the group where pneumoperitoneum was performed under 10 mmHg for 180 min. White blood cell and C-reactive protein levels showed similar trends for all groups. However, serum procalcitonin reached statistically higher levels (P < 0.05) in groups with laparotomy compared with groups with pneumoperitoneum and with the control group at 6 h. Survival was lower in the laparotomy groups compared with the pneumoperitoneum groups and with the control group (P < 0.05). CONCLUSIONS In the presence of peritonitis, CO(2) pneumoperitoneum applied in clinically standard pressures, even for extended time intervals, reduces the severity of sepsis and prolongs survival.

Effect of Time on Risk of Perforation in Acute Appendicitis

Abstract Introduction: The aim of this study was to quantify the role of time between symptom onset and surgery on the changing risk of perforation, and to evaluate the possible factors leading to delay to the operation. Patients and methods: The files of 169 patients who underwent appendectomy in our clinic over a two-year period (May 2004-June 2006) were reviewed. The relative risk of perforation was calculated according to the “time-table” method. Time was divided into intervals, initially of 12 hours and, later on, of 24 hours. Results: 18 patients were found to have perforated appendicitis. The time from symptom-onset to first examination (“symptom onset to presentation” time, “SOP” time) was longer for patients with perforation than for those without (p = 0.047). On the other hand, the time from initial examination in the emergency department to the operating room (“ER to OR” time) was shorter for patients with perforation than for those without (p = 0.027). Overall time from symptom onset to operating room, showed no statistical difference between patients with rupture and those without. The risk of perforation was negligible within the first twelve hours of untreated symptoms, but then increased to 8% within the first twenty-four hours. It then decreased to approximately 1.3% to 2% during 36 to 48 hours, and subsequently rose again to approximately 6% (7.6% to 5.8%) for each ensuing 24-hour period. In multivariate analysis, neither the “SOP” nor the “ER to OR” time remained significant contributors to the probability of an individual to suffer from appendiceal perforation. Conclusion: When time matters and the risk of adverse outcomes can be reduced, we should change our current approach to care. Surgeons should be mindful of delaying surgery beyond 24 hours of symptom onset in patients with assumed appendicitis.

Recurrence and long-term outcome after open cystectomy with omentoplasty for hepatic hydatid disease in an endemic area.

Abstract Background/Purpose: Surgery is the cornerstone in the treatment of echinococcosis. The purpose of this study is to report the long-term results of partial cystectomy and omentoplasty in the management of hepatic hydatid disease. Material and methods: In a retrospective survey over the past 20 years (1982-2001) there were 36 patients (13 men and 23 women, with a mean age of 50 years) with hepatic echinococcosis, treated by partial cystectomy and omentoplasty. All patient data were carefully studied and short-term as well as long-term results were assessed. The cystic lesion was single in all but two cases (5.6%), located in the right lobe of the liver (69.4%), the left lobe (25%) or both lobes (5.6%). The mean size of the cyst was 12 cm in diameter (range 3 to 25 cm). The follow-up was achieved at regular intervals and recently in all, including computed tomography and specific immunological test ELIZA. It has completed a mean 12-year period (range 2 to 21 years) and in 75% of cases up to 10 years. Results: The mean hospital stay was 23 days (range 9 to 51 days). The morbitity was 8/36 (22%) due mainly to septic complications. The 30-day mortality was 1/36 (2.7%). The residual cavity remained for a mean of 8 months (range 4 to 18 months), while fistula formation was seen in 1/36 (2.7%). There was cure in 29 cases (80.6%) without any serological or imaging evidence of residual disease. However, recurrence was documented in 7 cases (19.4%) requiring further treatment. Conclusions: Following the experience of the authors, partial cystectomy and omentoplasty may be an acceptable alternative to more radical procedures, especially in high risk cases and in developing countries.

Carcinoma developing in ectopic pancreatic tissue in the stomach: a case report

The development of pancreatic tissue outside the confines of the main gland, without anatomic or vascular connections between them, is a congenital abnormality referred to as heterotopic pancreas. A heterotopic pancreas in the gastrointestinal tract is usually discovered incidentally and the risk of its malignant transformation is extremely low. In this study, we describe the first case of endoepithelial carcinoma arising in a gastric heterotopic pancreas of a 56-year old woman in Greece. She presented with epigastric pain, periodic nausea and vomiting. Esophagogastroduodenoscopy revealed an ulcerated lesion in the gastric antrum, biopsies of which showed intense epithelial dysplasia with incipient malignant degeneration. The pathology report of the distal gastrectomy specimen demonstrated a 2 cm in diameter ulcerative mass in the gastric antrum. Microscopically, an endoepithelial (in situ) carcinoma of the gastric antrum was determined, which in places turned into an microinvasive endomucosal adenocarcinoma. It also incidentally demonstrated heterotopic pancreatic ducts, detected within the mucosa to the muscularis propria of the same region of the stomach, in which an endoepithelial (in situ) carcinoma was evolving. The follow-up course was uneventful 6 months postoperatively.

Malignant Fibrous Histiocytoma of the Abdominal Cavity: Report of a Case

Malignant fibrous histiocytoma (MFH) is a soft-tissue sarcoma originating from fibroblast cells, characterized by a high rate of metastasis or recurrence. This tumor rarely develops in the gastrointestinal tract, with no more than 30 cases described in the literature. We report a case of MFH of the abdominal cavity in a 45-year-old woman who presented with epigastric pain, anorexia, and weight loss. A computed tomography (CT) scan of the abdomen revealed multiple solid tumors in the peritoneal cavity. We performed exploratory laparotomy and found at least 15 solid whitish tumors attached to the wall of the small intestine, as well as to the parietal peritoneum. There were three metastases in the liver. All of the tumors were excised, most of which were about 10 cm in diameter. Histopathological findings indicated a stromal tumor consisting of spindle cells, and immunohistochemical examination of the resected specimens established the definite diagnosis of a pleomorphic MFH. The patient had an uneventful postoperative course and was given adjuvant chemotherapy. She is currently well 2 years after her operation. We review the clinical picture of this tumor in the abdominal cavity, and discuss its diagnosis, pathogenesis, and treatment.

Repair of a giant inguinoscrotal hernia

Giant inguinoscrotal herniae are infrequent in developed countries nowadays, nonetheless they may still typically present after years of neglect. The morbidity associated with them can be significant. Surgical management, although challenging even for the experienced surgeon, enables the patient to return to a reasonable level of function and quality of life. We present a case of a giant right inguinoscrotal hernia, which was treated with a multi-stage extensive operation, following adequate pre-operative respiratory preparation. The operation included reduction of the hernial contents in the abdominal cavity following omentectomy, right hemicolectomy and splenectomy, hernioplasty and reconstruction of the abdominal wall with the preperitoneal use of a Composix mesh and finally reductive reconstruction of the scrotum. The technique described represents a successful combination of various techniques described for the management of these patients.

The role of prosthetic repair in the treatment of an incarcerated recurrent inguinal hernia with acute appendicitis (inflamed Amyand's hernia).

Dear Sir, We read with considerable interest the paper by Kueper et al. [1], which was referred to the extreme case report of an incarcerated recurrent inguinal hernia with covered and perforated appendicitis which was managed with appendectomy and Bassini operation. The authors concluded that, in a septic environment, the implantation of a prosthetic material should be avoided due to the danger of infection. We report the second case of an incarcerated recurrent Amyand’s hernia with acute appendicitis, but the Wrst to be successfully treated with appendectomy and polypropylene plug placement at the same time. A 63-year-old man was admitted to our surgical emergency department with a 12-h history of right lower quadrant pain. Past medical history was unremarkable, with the exception of a right inguinal hernia, repaired with the Shouldice technique 7 years ago. Physical examination showed mild pressure pain in the right lower quadrant of the abdomen without peritoneal irritation. Moreover, there was a palpable, painful, non-reducible mass in the groin and localized tenderness over the inguinal region. Laboratory tests revealed mild leucocytosis (12,400/mm) and an elevated C-reactive protein level (CRP; 4.5 mg/dl). Abdominal X-ray showed air–Xuid levels suggesting small bowel obstruction. Abdominal computed tomography (CT) scan demonstrated distended small bowel loops being in contact with the right internal inguinal ring. However, the inguinal canal seemed to be intact. Based on his clinical condition and the CT Wndings, the patient was taken to the operating room. Through a median lower laparotomy, the terminal ileum was revealed to be tumescent and distended, and the cecum closely adherent to the anterior abdominal wall. Further exploration demonstrated an incarcerated inXamed appendix inside the sac of a recurrent indirect inguinal hernia. Appendectomy was performed and the hernia was repaired with the placement of a polypropylene plug in the internal inguinal ring. The patient received broadband antibiotics (cefoxitin sodium + metronidazole) preoperatively and for the next 5 days. He was discharged on the 6th postoperative day, after an uncomplicated recovery. Currently, 6 months after the operation, the patient’s condition is excellent. The proper management of an Amyand’s hernia remains a challenging issue. Most authors agree that normal appendix within the hernia sac does not require appendectomy and that every eVort should be made to preserve the organ for an uneventful postoperative course [2]. However, in cases of inXamed appendix, appendectomy is obligatory and, in these cases, the decision for a mesh hernia repair may seem very hazardous [1, 3]. On the other hand, the recommended primary suture using Shouldice or Bassini techniques could be technically very challenging in an inXamed and edematous area, thus, increasing the risk of recurrence. Torino et al. [4] believe that the use of a synthetic mesh could be feasible and safe if the inguinal area is previously irrigated with antibiotics, a drain is placed under the aponeurosis, and the patient is treated postoperatively with intravenous antibiotics. Based on our experience [5, 6], we believe that a septic environment (presence of strangulated or incarcerated inguinal or femoral hernia, inXamed Amyand’s hernia) is not an absolute contraindication for G. Chatzimavroudis (&) · B. Papaziogas · I. Koutelidakis · P. Tsiaousis · T. Kalogirou · S. Atmatzidis · K. Atmatzidis 2nd Department of Surgery, Medical School, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Ethnikis Aminis 41, 54635 Thessaloniki, Greece e-mail: gchatzimav@yahoo.gr