M. G. Pramateftakis

The failed intraperitoneal colon anastomosis after colon resection

BackgroundThe purpose of this study is to present the incidence of anastomotic leakage after colon resection and intraperitoneal anastomosis for colorectal cancer.Patients and methodsIn the last ten years, 205 patients underwent colonic resection with intraperitoneal anastomosis for colon cancer. The surgical management of colorectal cancer consisted of 66 right hemicolectomies, 3 transverse colectomies, 17 left hemicolectomies, 98 sigmoid colectomies and 21 high anterior resections of the rectum. Diagnosis of leakage was made by clinical features, blood vessel examinations and abdominal CT-scans.ResultsAnastomotic leakage occurred in 5 out of 205 patients (2.4%). One of these patients underwent emergency surgery and the other 4 elective surgery; 3 by manual, 2 by mechanical suture. Three patients with anastomotic leakage were reoperated on days 4, 5 and 7, and 2 patients were treated conservatively. Two of the patients (20%) with anastomotic leakage died due to sepsis.ConclusionsEven though the rate of anastomotic leakage in patients with intraperitoneal anastomosis after colon resection for colorectal cancer is low, it remains a significant complication and a major cause of postoperative morbidity and mortality.

Effects of steroid on the healing of colonic anastomoses in the rat

BackgroundThe aim of this experimental study was to evaluate the effects of steroid on colonic anastomosis in a rat model.MethodsForty female Wistar rats were randomised into two groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. In the rats of the control group 2 ml of solution 0.9% NaCl was injected once daily intraperitoneally perioperatively. Rats of the steroid group received intraperitoneally once daily, and on the same perioperative days, hydrocortisone (5 mg/kg body weight in 2 ml solution NaCl). All the rats were sacrificed on the 8th postoperative day and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded and anastomoses were graded histologically.ResultsDehiscence rate was significantly higher in the steroid group than in the control group (p<0.001). Mean bursting pressure was significantly lower in the steroid group compared to the control group (p<0.001). Colonic healing process assessed as inflammatory cell infiltration and collagen deposition was significantly lower in the steroid group than in the control group (p<0.001, p=0.03 respectively).ConclusionsPerioperative steroid treatment adversely affects healing of colonic anastomoses in the rat.

Effect of 5-Fluorouracil plus Interferon on the Integrity of Colonic Anastomoses Covering with Fibrin Glue

BackgroundIt has been well established that the immediate postoperative intraperitoneal administration of chemotherapeutic agents such as 5-fluorouracil (5-FU) after curative colon resection for colon cancer destroys disseminated cancer cells and inhibits micrometastases but also inhibits anastomotic healing. On the other hand, the application of fibrin glue constitutes a physical barrier around the anastomosis and may prevent anastomotic leakage. The purpose of this experimental study was to determine the effect of 5-FU plus interferon (IFN)-α-2a on the integrity of colonic anastomoses covered with fibrin glue when injected intraperitoneally immediately after colon resection.Materials and MethodsSixty rats were randomized to one of four groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. Rats of the control and the fibrin glue groups were injected with 6 ml of 0.9% sodium chloride (NaCl) solution intraperitoneally. Rats in the 5-FUxa0+xa0IFN and the 5-FUxa0+xa0IFNxa0+xa0fibrin glue groups received 5-FU plus IFN intraperitoneally. The colonic anastomoses of the rats in the fibrin glue and in the 5-FUxa0+xa0IFNxa0+xa0fibrin glue groups were covered with fibrin glue. All rats were sacrificed on the 8th postoperative day, and the anastomoses were examined macroscopically. The bursting pressure measurements were recorded, and the anastomoses were graded histologically.ResultsOnly the 5-FUxa0+xa0IFN group had anastomoses rupture, and the rupture rate (33%) in this group was significantly greater than in the other groups, where there were no ruptures (P = 0.015). The adhesion formations score was, on average, significantly higher in rats of the 5-FUxa0+xa0IFN group compared with the control group (P = 0.006) and the 5-FUxa0+xa0IFNxa0+xa0fibrin glue group (P = 0.010). Bursting pressures were significantly lower in the control group when compared to the fibrin glue and 5-FUxa0+xa0IFNxa0+xa0fibrin glue group (P < 0.001). Rats in the 5-FUxa0+xa0IFNxa0+xa0fibrin glue group developed significantly more marked neoangiogenesis than rats in the other groups. Inflammatory cell infiltration, collagen deposition, and fibroblast activity did not differ significantly among the four groups (P = 0.856, P = 0.192 and P = 0.243, respectively).ConclusionThe immediate postoperative intraperitoneal administration of 5-FU plus IFN impairs colonic healing. However, when the colonic anastomoses were covered with fibrin glue, the injection of 5-FU plus IFN had no adverse effects on the integrity of the anastomoses.

The healing of colon anastomosis covered with fibrin glue after early postoperative intraperitoneal chemotherapy.

AbstractBackgroundAfter colon resection for colonicncancer, the administration of antineoplastic agents maynprolong survival by killing residual cancer calls and preventingnmetastasis, but may also slow anastomotic healing.nThis study was designed to determine the effects of 5-fluorouraciln(5-FU) and leucovorin (LEV), injected intraperitoneally,non the healing of colonic anastomoses with ornwithout fibrin glue (FG) covering.MethodsSixty ratsnwere randomized to one of four groups. After resection ofna transverse colon segment, an end-to-end sutured anastomosisnwas performed. Rats in the 5-FU+LEV and the 5-nFU+LEV+FG groups received 5-FU+LEV intraperitoneally.nThe colonic anastomoses of the rats in the FG group andnin the 5-FU+LEV+FG group were covered with fibrinnglue. All rats were killed on postoperative day 8. Burstingnpressure measurements were recorded and the anastomosesnwere examined macroscopically and histologically.ResultsThe leakage rate of the anastomoses was significantlyndifferent among groups. Specifically, the leakagenrate was significantly higher in the 5-FU+LEV groupn(40%) than in the FG and in the 5-FU+LEV+FG groupsnwhere there were no leakages (p=0.017). The mean adhesionnformation score was significantly higher in rats of then5-FU+LEV group, compared to the control (p=0.023), thenFG (p=0.006) and the 5-FU+LEV+FG (p=0.006) groups.nBursting pressures were significantly lower in the 5-FU+LEV group than in the other groups (p<0.001). Also,nbursting pressures were significantly lower in the controlngroup compared to the FG and 5-FU+LEV+FG groupsn(p<0.001). Rats in the 5-FU+LEV+FG group had significantlyngreater neoangiogenesis and fibroblast activity thannthose in the 5-FU+LEV group (p=0.025).ConclusionThenearly intraperitoneal postoperative administration of 5-fluorouracilnplus leucovorin impaired colonic wound healing.nHowever, the application of fibrin glue prevented the deleteriousneffect of chemotherapy.

Prognostic significance of CEA levels and positive cytology in peritoneal washings in patients with colorectal cancer

Objectiveu2002 The aims of this prospective study were to determine carcinoembryonic antigen (CEA) levels and incidence of cytology in peritoneal washings of patients with colorectal cancer, correlate the results with various histopathological factors and determine their significance as prognostic factors of the disease.

Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids.

BackgroundStapled haemorrhoidopexy (SH) is associated with low postoperative pain but, when performed for advanced piles, carries high recurrence rates. The aim of our study was to assess our long–term results after SH for third–degree haemorrhoids.MethodsA total of 126 consecutive patients (67 men and 59 women) with third–degree haemorrhoids underwent SH in our unit between 1998 and 2002. Of these, 120 (95.2%) were followed up in the outpatient department after a median interval of 61.5 months (range, 38–84 months).ResultsDuring the postoperative period, 7 patients (5.8%) experienced pain for 5–12 days, which was treated with oral analgesia. Seven patients (5.8%) experienced gas incontinence and one of them also reported soiling; the incontinence subsided within 2–8 weeks. Recurrence of the haemorrhoidal disease occurred in 8 patients (6.6%).ConclusionsSH is a safe, low–pain and, in the long–term, effective technique for the treatment of third–degree haemorrhoids.

Retained Gallbladder Remnant After Laparoscopic Cholecystectomy

BACKGROUNDnUpper abdominal pain and other symptoms may recur after cholecystectomy, often presenting a diagnostic challenge. We will analyze 3 cases of gallbladder remnants, containing stones that presented with recurrent biliary symptoms.nnnPATIENTS AND METHODSnThree patients have presented to our clinic with recurrent biliary symptoms, after laparoscopic cholecystectomy, over the last 5 years. All 3 had biliary pain similar to the symptoms that precede cholecystectomy; 1 of them also had associated mild jaundice.nnnRESULTSnA cystic lesion containing stones was identified on transabdominal ultrasound in all 3 patients, suggesting the possibility of a gallbladder remnant. Magnetic resonance cholangiopancreatography confirmed the diagnosis of a gallbladder remnant in 2 of them. The 3 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) owing to jaundice. This revealed a dilated gallbladder remnant and sludge into the bile duct and was treated by sphincterotomy and cleansing of the duct. All 3 patients were treated successfully via laparoscopic recholecystectomy.nnnCONCLUSIONnGallbladder remnant, containing stones, can be the cause of otherwise unexplained postcholecystectomy pain. Recholecystectomy constitutes the definite treatment for any residual gallbladder remnant and can be performed laparoscopically.

Pneumomediastinum after dilatation of anal stricture following stapled hemorrhoidopexy

Stapling procedure is a new technique for the surgical management of prolapsing haemorrhoids. Some articles have reported severe adverse effects of this operation. We describe a case of an excessive staple-line stenosis followed stapled haemorrhoidopexy. Proctoscopic dilatation resulted in complications of retropneumoperitoneum, pneumomediastinum, subcutaneous emphysema and perianal abscess. Drainage of the abscess was performed, allowing quick recovery. After discharge from the hospital, the patient continued to perform periodic dilatation. Simple proctoscopic dilatation was conducted in an outpatient setting.

Effect of Iloprost on Impaired Anastomotic Healing Caused by 5-Fluorouracil plus Leucovorin

PurposeThis experimental study was designed to investigate whether iloprost can reverse impaired colonic healing caused by immediate postoperative intraperitoneal administration of 5-fluorouracil plus leucovorin.MethodsEighty Wistar rats were randomized into four groups. After resection of a 1-cm segment of transverse colon, an end-to-end sutured anastomosis was generated. Rats received saline solution (Group 1), 5-fluorouracil plus leucovorin (Group 2), iloprost (Group 3), and 5-fluorouracil plus leucovorin plus iloprost (Group 4) intraperitoneally from the day of operation and once daily until killing. Each group was further randomized into two subgroups. Subjects were killed on the fifth (Subgroup a) and eighth (Subgroup b) postoperative days. After killing, anastomoses were examined macroscopically and graded histologically. Rats were measured for anastomotic bursting pressures and tissue hydroxyproline levels.ResultsThe leakage rate of the anastomoses was significantly higher in the 5-fluorouracil plus leucovorin group compared with the other groups (Pu2009=u20090.049). Bursting pressure was significantly lower in 2a subgroup (5-fluorouracil plus leucovorin, postoperative Day 5) than in 4a (5-fluorouracil plus leucovorin plus iloprost, postoperative Day 5; Pu2009<u20090.001). Adhesion formation was significantly higher in all b subgroups compared with the Control b subgroup. Neoangiogenesis was significantly higher in iloprost and iloprost plus 5-fluorouracil plus leucovorin subgroups compared with the 5-fluorouracil plus leucovorin subgroups. Hydroxyproline levels, collagen deposition, fibroblasts, and white cell count were significantly higher in the iloprost plus 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8) compared with the 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8).ConclusionsThe immediate postoperative, intraperitoneal administration of iloprost counteracts and reverses the negative effects of 5-fluorouracil plus leucovorin chemotherapy and protects colonic healing in rats.

The effects of tacrolimus on colonic anastomotic healing in rats

AimThe aim of this experimental study is to investigate the effects of tacrolimus on colonic anastomotic healing after subcutaneous administration.Materials and methodsForty Albino–Wistar male rats were divided into two groups, with two equal subgroups each. They all underwent colonic resection followed by a single-layer, inverted colon anastomosis and were injected subcutaneously with either 1xa0ml of 0.9% NaCl solution or tacrolimus (0.1xa0mg/kg body weight) depending on their group. Half of the rats were sacrificed on the fourth postoperative day, while the remaining half were sacrificed on the eighth postoperative day. Macroscopical and histological assessment was performed, while anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were evaluated.ResultsOn the fourth postoperative day, the bursting pressures (217.00u2009±u200911.12, pu2009<u20090.001), the fibroblast activity (2.80u2009±u20090.42, pu2009=u20090.022), the neoangiogenesis (2.10u2009±u20090.32, pu2009=u20090.007) and the tissue hydroxyproline concentration (254.23u2009±u200967.10, pu2009=u20090.001) were significantly higher in the tacrolimus-treated animals. Furthermore, tacrolimus significantly decreased the inflammatory cell infiltration (1.50u2009±u20090.53, pu2009<u20090.001) and the tissue collagenase I concentration (4.16u2009±u20090.76, pu2009=u20090.002).On the eighth day, the bursting pressure (264.00u2009±u200932.61, pu2009<u20090.001) and the hydroxyproline tissue concentration (331.04u2009±u200955.56, pu2009=u20090.002) were significantly higher in the tacrolimus subgroups. The inflammatory cell infiltration (1.20u2009±u20090.42, pu2009<u20090.001) and the collagenase I concentration (1.61u2009±u20090.83, pu2009<u20090.001) were significantly lower. In addition, the adhesion formation score was significantly lower (1.20u2009±u20090.92, pu2009=u20090.065).ConclusionTacrolimus, when injected subcutaneously, promotes healing of colonic anastomoses in rats. It impairs not only inflammatory response but also collagen degradation, resulting to increased anastomotic strength on the fourth as well as on the eighth postoperative day.