Michael Genetzakis

Modified Radical Mastectomy With Axillary Dissection Using the Electrothermal Bipolar Vessel Sealing System

HYPOTHESIS The use of the electrothermal bipolar vessel sealing system is feasible, safe, and effective in modified radical mastectomy with axillary dissection in terms of lymph vessel sealing, hemostasis, and perioperative complications. DESIGN Prospective study. SETTING University surgical department. PATIENTS Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system. MAIN OUTCOME MEASURES Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis). RESULTS The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days. CONCLUSIONS In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications.

Unintentional parathyroidectomy during total thyroidectomy

Unintentional parathyroidectomy during thyroidectomy has been evaluated in a few studies. Moreover, the impact of the surgeons experience and operative technique has not been evaluated. Our aim was to identify the incidence of unintentional parathyroidectomy during total thyroidectomy, its clinical consequences, and factors affecting its occurrence.

Endoscopic Management of a Relapsing Hepatic Hydatid Cyst with Intrabiliary Rupture: A Case Report and Review of the Literature

Hydatid disease, although endemic mostly in sheep-farming countries, remains a public health issue worldwide, involving mainly the liver. Intrabiliary rupture is the most frequent complication of the hepatic hydatid cyst. Endoscopy is advocated, preoperatively, to alleviate obstructive jaundice caused by intracystic materials after a frank rupture and is also a useful and well-established adjunct in locating postoperative biliary fistulas. Endoscopic retrograde cholangiography with sphincterotomy has been successful as the sole and definitive means of treatment of intrabiliary ruptured hydatid cysts. A case of an elderly woman with frank rupture is presented, where the rupture was definitively managed endoscopically in conjunction with sphincterotomy to remove the intrabiliary obstructive daughter cysts and to achieve decontamination of the biliary tree. Endoscopic retrograde cholangiography provided an excellent diagnostic and therapeutic modality in the present case and, thus, it should be considered as definitive treatment in similar cases especially if surgical risk is anticipated to be high.

Undifferentiated giant cell type carcinoma of the gallbladder with sarcomatoid dedifferentiation: a case report and review of the literature

IntroductionUndifferentiated gallbladder carcinoma is a rare entity. Among unusual types of undifferentiated gallbladder carcinoma, giant cell type carcinoma is infrequent and, moreover, very few cases of such neoplasms with osteoclast-like giant cells have been documented. We report a case of undifferentiated gallbladder carcinoma presenting an unusual immunophenotype that was shown to be of giant cell type with sarcomatoid dedifferentiation infiltrated by osteoclast-like multinucleated cells.Case presentationAn 84-year-old Greek man presented with right upper quadrant pain, high fever, rigors, anorexia and weight loss during the past month. Clinical examination revealed tenderness in the right upper abdominal quadrant and a palpable gallbladder. Blood tests showed elevated white blood-cell count and transaminases. Abdominal ultrasound and computed tomography demonstrated a markedly distended gallbladder, measuring 16 cm x 8 cm, with oedema and pericholecystic fluid, consistent with gallbladder empyema. After an open cholecystectomy and an uneventful recovery, the patient was discharged on the 4th postoperative day. On cut surface, a 2cm solid mass was identified, obstructing the lumen in the neck of the gallbladder. Histopathology and immunohistochemistry offered the diagnosis of an undifferentiated, giant cell type carcinoma of the gallbladder with sarcomatoid dedifferentiation infiltrated with osteoclast-like giant cells.ConclusionsUndifferentiated, giant cell type carcinoma of the gallbladder with sarcomatoid dedifferentiation infiltrated with osteoclast-like giant cells is a very infrequent neoplasm. Controversy exists over its nature, as related knowledge remains incomplete. Thorough histopathological and immunohistochemical evaluation is imperative for diagnosis. Due to their rarity, the biological behaviour and prognosis of these tumours remain unclear.

Heparin-Induced Thrombocytopenia and Phlegmasia Cerulea Dolens of the Upper Limb Successfully Treated with Fondaparinux

cause of left upper extremity edema. Doppler ultrasound revealed extensive thrombosis of the axillary, cephalic and basilic veins. The diagnosis of phlegmasia cerulea dolens of the upper limb was made, for which intravenous heparinization was initiated. The following day blood sample analyses revealed a marked decrease of platelet counts (50 ! 10 9 /l) thus giving rise to the clinical suspicion of the HIT syndrome. In view of these data heparin was discontinued and 2 ! 2.5 mg/day fondaparinux (Arixtra inj. sol 2.5 mg/0.5 ml, GlaxoSmithKline, Athens, Greece) was subcutaneously administered. A few days later a strongly positive anti-PF4/ polyanion enzyme immunoassay confirmed our diagnosis. The platelet count recovered after 3 days and phlegmasia cerulea dolens gradually improved. HIT is strongly associated with UEDVT in patients with current or recent CVC use [1] . The insertion of a CVC can serve both as a potential source of heparin exposure, through heparin flushes, and as a local prothrombotic factor. Moreover the prothrombotic effect of the CVC appears to persist even after its removal. Our patient developed UEDVT 6 days after the removal of his CVC. Heparin-induced thrombocytopenia (HIT) is a clinicopathologic syndrome that results in acquired hypercoagulability. Upper extremity deep vein thrombosis (UEDVT) is relatively rare and more frequently occurs in HIT patients with central venous catheters (CVC) [1] . Fondaparinux, a selective inhibitor of factor Xa, has shown in recent studies some rather promising results concerning the thromboembolic treatment or prophylaxis of patients with the HIT syndrome [2, 3] . We report on a 55-year-old male who underwent an elective resection of abdominal aortic aneurysm with graft application. Perioperatively a non-heparin-coated, central catheter was inserted in the left jugular vein and was removed on the 5th postoperative day. He had received a single dose of 2,500 IU of unfractionated heparin during the clamping of the aorta. During the postoperative period the patient received low-molecular-weight heparin 0.3 ml every 12 h by subcutaneous injection (Fraxiparine inj. sol 2,850 anti-Xa IU/0.3 ml, GlaxoSmithKline, Athens, Greece) that was discontinued on the 7th day. The patient recovered uneventfully and was discharged on the 8th day. On the 11th postoperative day he was readmitted beAccepted after revision: October 20, 2008 Published online: January 5, 200

Collision tumour of the stomach with a cancer to cancer metastasis: a case report

IntroductionCoexistence of a primary gastric lymphoma and a gastric adenocarcinoma is a rare event. The diagnosis is suspected after the pathologic examination of the endoscopic biopsies and definitely documented with the examination of the surgical specimen.Case presentationWe are presenting a rare case of a 77-year-old Greek man with epigastric pain of one and a half month duration, nausea, anorexia and weight loss. The pathologic examination of the endoscopic biopsies and a lymph node biopsy excised at laparotomy, presented the interpenetration of synchronous occurring primary gastric lymphoma and a gastric adenocarcinoma with a documented cancer to cancer metastasis.ConclusionPrognosis of these rare tumours is largely dependent on the stage of the adenocarcinoma at presentation but due to lack of large series there are no data on the biological behavior of these tumours in comparison to adenocarcinoma.

Schwannoma of Thigh Mimicking Pseudoaneurysm of the Profunda femoral artery

Femoral and popliteal artery aneurysms constitute the majority of peripheral arterial aneurysms. However, aneurysm of the profunda femoral artery is highly uncommon, being mainly of traumatic and mycotic origin. Diagnosis is usually straightforward with clinical and radiological examination, and such aneurysms are only rarely misdiagnosed as tumors. We herein report a case of preoperatively diagnosed pseudoaneurysm of the profunda femoral artery that was intraoperatively found to be a soft tissue tumor and finally revealed to be a schwannoma, by pathology. Our cases unusual presentation considerably confounded both diagnosis and management, thus providing a salutary clinical lesson.

746 INTRAPERITONEAL LEVOBUPIVACAINE REDUCES PAIN AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Methods: This study was designed as a double blind prospective controlled clinical trial on children with minor surgical problems undergoing day care surgery at our Pediatric day care surgical unit. 100 patients in two groups [A = caudal anesthesia (51 patients); B = ordinary anesthesia (49 patients)] were studied, all 12 years old or younger, ASA I and ASA II, in longitudinal fashion, as they were scheduled electively or urgently for surgery. Results: 69.33% of patients were male and 30.67% were female. We want to highlight the case of pyloric stenosis correction and anoplasty cases using caudal anesthesia. The commonest operation was herniotomy for children for both groups A and B. The number of patients received analgesics during 24 hours after surgery in group B (80%) was higher than group A (18%)(P< 0.001). Mean time for first request or need for administration of analgesics in group B (25 min) was less than group A (320 min) (p< 0.0001). Also FLACC scoring was significantly lower in group A (mean = 1) than group B (mean = 8) (p< 0.05). Conclusion: In the present study we demonstrated that caudal anesthesia with bupivacaine at 3mg/kg produce adequate anesthesia for lower abdominal surgery, for surgery at epigastric level, and postoperative analgesia.