Konstantinos Bramis

Surgery via natural orifices in human beings: yesterday, today, tomorrow

BACKGROUND We performed an evaluation of models, techniques, and applicability to the clinical setting of natural orifice surgery (mainly natural orifice transluminal endoscopic surgery [NOTES]) primarily in general surgery procedures. NOTES has attracted much attention recently for its potential to establish a completely alternative approach to the traditional surgical procedures performed entirely through a natural orifice. Beyond the potentially scar-free surgery and abolishment of dermal incision-related complications, the safety and efficacy of this new surgical technology must be evaluated. METHODS Studies were identified by searching MEDLINE, EMBASE, Cochrane Library, and Entrez PubMed from 2007 to February 2011. Most of the references were identified from 2009 to 2010. There were limitations as far as the population that was evaluated (only human beings, no cadavers or animals) was concerned, but there were no limitations concerning the level of evidence of the studies that were evaluated. RESULTS The studies that were deemed applicable for our review were published mainly from 2007 to 2010 (see Methods section). All the evaluated studies were conducted only in human beings. We studied the most common referred in the literature orifices such as vaginal, oral, gastric, esophageal, anal, or urethral. The optimal access route and method could not be established because of the different nature of each procedure. We mainly studied procedures in the field of general surgery such as cholecystectomy, intestinal cancers, renal cancers, appendectomy, mediastinoscopy, and peritoneoscopy. All procedures were feasible and most of them had an uneventful postoperative course. A number of technical problems were encountered, especially as far as pure NOTES procedures are concerned, which makes the need of developing new endoscopic instruments, to facilitate each approach, undeniable. CONCLUSIONS NOTES is still in the early stages of development and more robust technologies will be needed to achieve reliable closure and overcome technical challenges. Well-designed studies in human beings need to be conducted to determine the safety and efficacy of NOTES in a clinical setting. Among these NOTES approaches, the transvaginal route seems less complicated because it virtually eliminates concerns for leakage and fistulas. The transvaginal approach further favors upper-abdominal surgeries because it provides better maneuverability to upper-abdominal organs (eg, liver, gallbladder, spleen, abdominal esophagus, and stomach). The stomach is considered one of the most promising targets because this large organ, once adequately mobilized, can be transected easily with a stapler. The majority of the approaches seem to be feasible even with the equipment used nowadays, but to achieve better results and wider applications to human beings, the need to develop new endoscopic instruments to facilitate each approach is necessary.

Inflammatory pseudotumor associated with Mycobacterium tuberculosis infection

BACKGROUND Inflammatory pseudotumor is a relatively rare entity; originally identified in the lung, it has been described in multiple extrapulmonary anatomic locations. CASE REPORT We report on the unusual case of an inflammatory pseudotumor associated with Mycobacterium tuberculosis infection, which was initially mistaken for a renal malignancy both in clinical and radiological settings. We additionally present three brief reviews concerning: (1) infectious agents postulated to induce morphological changes of an inflammatory pseudotumor; (2) mycobacterial pseudotumors; and (3) distinction from inflammatory myofibroblastic tumors of the renal pelvis. CONCLUSIONS The present case highlights the diagnostic importance of PCR-based detection of mycobacterial DNA in granulomatous tissue responses. It is of crucial importance that clinicians are aware of this unusual manifestation of mycobacterial infection to ensure that pertinent laboratory evaluation is employed and appropriate treatment is administered in order to avoid potential clinical implications.

Association of the clock genes polymorphisms with colorectal cancer susceptibility.

The circadian rhythm regulates the cell cycle progression and DNA damage response. The aim of our study was to investigate the association between polymorphisms in the CLOCK1, PER2, and PER3 genes with the colorectal cancer (CRC) susceptibility and clinicopathological variables.

Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patients demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Primary appendiceal mucinous adenocarcinoma alongside with situs inversus totalis: a unique clinical case

IntroductionMucinous adenocarcinoma is a rare neoplasm of the gastrointestinal tract and one of the three major histological subtypes of the primary appendiceal adenocarcinoma. The most common type of presentation is that of acute appendicitis and the diagnosis is usually occurred after appendectomy. The accurate preoperative diagnosis and management of the above condition represents a real challenge when uncommon anatomic anomalies such intestinal malrotation and situs inversus take place. Situs inversus totalis with an incidence of 0.01% is an uncommon condition caused by a single autosomal recessive gene of incomplete penetration in which the major visceral organs are mirrored from their normal positions.Case presentationWe present an unusual case of a 59 years old, previously healthy man presented with a left lower quadrant abdominal pain, accompanied with low fever, leukocytosis, anorexia and constipation. A chest radiograph demonstrated dextrocardia with a right side positioned stomach bubble. Both preoperative US and CT scan of the abdomen and pelvis declared situs inversus, with a characteristic thickening in its wall, appendix situated in the left lower quadrant of the abdomen. These findings reached to the diagnosis of acute appendicitis with situs inversus and a standard appendicectomy was performed. Pathologic evaluation established primary mucinous adenocarcinoma of the appendix and three months afterwards the patient underwent a subsequent extended left hemicolectomy.ConclusionIn conclusion, the occurrence of primary appendiceal mucinous adenocarcinoma along with situs inversus, definitely accounts as a unique clinical case. Even synchronous manifestation of primary mucinous adenocarcinoma of the appendix and situs inversus totalis represents an unusual anatomo-pathological entity, all physicians should be familiar having the knowledge to make an appropriate and accurate diagnosis that will lead to prompt and correct treatment.

Acute Recurrent Pancreatitis: A Possible Clinical Manifestation of Ampullary Cancer

CONTEXT Acute recurrent pancreatitis still poses diagnostic difficulties. The coexistence or moreover the causative relationship of carcinoma of the ampulla of Vater and acute recurrent pancreatitis is fairly rare. CASE REPORT We present a case of carcinoma of the ampulla of Vater that presented with acute recurrent necrotizing pancreatitis complicated with pseudocysts. A diagnosis of malignancy in the ampulla was only made after several ERCP attempts due to residual inflammation at the periampullary area. CONCLUSION Malignancy at the ampulla of Vater causing recurrent episodes of pancreatitis represents a realistic risk and attempts to diagnose the underlying cause should always take into account the possibility of cancer.

A prospective longitudinal evaluation and affecting factors of health related quality of life after appendectomy.

BACKGROUND The aim of the present study was to longitudinally evaluate the pattern of Health-Related Quality of Life (HRQoL) alterations, as an indirect convalescence index after appendectomy, to assess the timing of its restoration to the healthy population levels and to attempt a profound investigation into factors determining HRQoL outcomes. METHODS Uncomplicated cases of histologically verified acute appendicitis (AA) were enrolled in a prospective cohort study. HRQoL indices were collected at baseline, 15 days, 1 and 3 months using EQ-5D, SF-36 and, GIQLI questionnaires. Data were processed with non-parametric tests and logistic regression analysis. RESULTS For the 147 patients eventually included, significant improvements compared to baseline at EQ-5D and SF-36 general health and physical function domains were noted at 15 days, while bodily pain was worse. The majority HRQoL parameters were significantly better at the 1st and the 3rd-month compared to baseline and the 15th-day assessments. General health, physical and emotional function were restored at the general population levels between 15 days and 1 month, while bodily pain, social function and EQ-5D indices between the 1st and 3rd month. Logistic regression analysis indicated that high Alvarado score was the most powerful predictor of HRQoL impairment with older age coming second. CONCLUSIONS Post-appendectomy HRQoL disturbances predominate and the burden of AA should not be underestimated. Convalescence period as translated by HRQoL restoration may be extended beyond the second week and up to the first month. Degree of inflammation and patients age emerged as key mediators of HRQoL outcomes.

Complete abdominal aortic aneurysm thrombosis and obstruction of both common iliac arteries with intrathrombotic pressures demonstrating a continuing risk of rupture: a case report and review of the literature

IntroductionAlthough mural thrombus in an abdominal aortic aneurysm is frequent and its role has been studied extensively, complete thrombosis of an abdominal aneurysm is extremely rare and its natural history in relation to the risk of rupture is not known. The case of a patient with a completely thrombosed infrarenal aneurysm is presented along with a literature review.Case presentationWe report the case of a 56-year-old Caucasian man with an infrarenal abdominal aortic aneurysm, presenting at our hospital due to critical ischemia of his right lower limb. Computed tomography and angiography demonstrated complete aneurysm thrombosis and obstruction of both common iliac arteries.ConclusionDuring the operation, systolic and mean intrathrombotic pressures, measured in different levels, constituted 74.5-90.2% and 77.5-92.5% of systolic and mean intraluminal pressure and 73-88.4% and 76.5-91.3% of systemic pressure, respectively. Our findings show that there may be a continuing risk of rupture in cases of a thrombosed abdominal aortic aneurysm.