Panagiotis Drimousis

The Effects of Vasopressors on Perfusion of Gastric Graft after Esophagectomy. An Experimental Study

AimsTo evaluate the impact of the perioperative administration of norepinephrine on the perfusion of the esophageal graft.MethodsThis is an experimental study. Six swine underwent transhiatal esophagectomy; the stomach was used to replace the resected esophagus. We provoked hemorrhagic shock to the animals and then we administered noradrenaline to restore the blood pressure. We monitored the graft perfusion perioperatively using the technique of microdialysis.ResultsIn all animals, the graft experienced severe hypoperfusion after the administration of noradrenaline that was statistically significant.ConclusionsOur data support the hypothesis that norepinephrine should be used with extreme caution in the perioperative setting after esophagectomy. Further studies, however, will be required to evaluate the clinical significance of this finding.

Advanced Trauma Life Support certified physicians in a non trauma system setting: is it enough?

OBJECTIVE The purpose of this study was to evaluate the impact of ATLS(®) on trauma mortality in a non-trauma system setting. ATLS represents a fundamental element of trauma training in every trauma curriculum. Nevertheless, there are limited studies in the literature as for the impact of ATLS training in trauma mortality, especially outside the US. DESIGN This is a prospective observational study. The primary end point was to investigate factors that affect mortality of trauma patients in our health care system. We performed a multivariate analysis for this purpose and we identified ATLS certification as a predictor of overall mortality. Following this finding we stratified patients according to the severity of injury as expressed by the ISS score and we compared outcome between those treated by an ATLS certified physician and those treated by non-certified ones. MAIN OUTCOME MEASURES Trauma volume and demographics of trauma patients, factors that affect mortality of traumatized patients and mortality between patients treated by ATLS(®) certified and non-certified physicians. RESULTS In total, 8862 trauma patients were included in the analysis. The majority of trauma patients (5988, 67.6%) were treated by a general surgeon, followed by those treated by an orthopedic surgeon (2194, 24.8%). There were 446 deaths in the registry but, 260 arrived dead in the Emergency Department and were excluded from the analysis. Multivariate analysis of the 186 deaths that occurred in the hospital revealed age, high ISS score, low GCS score, urban location of injury, neck injury and ATLS(®) certification as factors predisposing to mortality. Cross tabulation of ATLS(®) certification and ISS of the trauma patients shows that those treated by certified physicians died more often in all subcategories of ISS score (p<0.05). CONCLUSIONS In Greece, with no formal trauma system implementation, ATLS(®) certified physicians achieve worse outcomes than their non-certified colleagues when managing trauma patients. We believe that these findings must be interpreted in the context of the National health care system. There is considerable room for improvement in our country, and further analysis is required.

The implementation of a national trauma registry in Greece. Methodology and preliminary results.

BACKGROUND Trauma is a leading cause of death worldwide and a major health problem of the modern society. Trauma systems are considered the gold standard of managing patients with trauma. An integral part of any trauma system is a trauma registry. In Europe, and particularly in Greece, trauma registries and systems are in an embryonic stage. In this study, we present an attempt to record trauma in Greece. METHODS The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. In succeeding meetings of the representatives, the reporting form was developed and the inclusion criteria were defined meticulously. Inclusion criteria were defined as patients with trauma requiring admission, transfer to a higher level center, or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic database, and analyzed. RESULTS Thirty-two hospitals receiving patients with trauma participated in the country, representing 40% of the countrys healthcare facilities and serving 40% of the countrys population. In 12 months time, (October 2005 to September 2006), 8,862 patients were included in the study. Of them, 66.9% were men and 31.3% were women. The compilation rate of the reporting forms was surprisingly high, considering that the final reporting form included 150 data points and that there were no independent personnel in charge of filling the forms. CONCLUSIONS Trauma registries are feasible even in health care systems where funding of medical research is sparse.

Paraganglioma of the greater omentum: Case report and review of the literature

BackgroundExtra-adrenal, intra-abdominal paraganglioma constitutes a rare neoplasm and, moreover, its location in the greater omentum is extremely infrequent.Case presentationA 46-year-old woman with an unremarkable medical history presented with an asymptomatic greater omentum mass that was discovered incidentally during ultrasonographic evaluation due to menstrual disturbances. Clinical examination revealed a mobile, non-tender, well-circumscribed mass in the right upper and lower abdominal quadrant. Blood tests were normal. Contrast-enhanced abdominal computed tomography (CT) scan confirmed a huge (15 × 15 cm), well-demarcated, solid and cystic, heterogeneously enhanced mass between the right liver lobe and right kidney. Exploratory laparotomy revealed a large mass in the greater omentum. The tumor was completely excised along with the greater omentum. Histopathology offered the diagnosis of benign greater omentum paraganglioma. After an uneventful postoperative course, the patient was discharged on the 4th postoperative day. She remains free of disease for 2 years as appears on repeated CT scans as well as magnetic resonance imaging (MRI) and scintigraphy performed with radiotracer-labeled metaiodobenzyl-guanidine (MIBG) scans.ConclusionThis is the second reported case of greater omentum paraganglioma. Clinical and imaging data of patients with extra-adrenal, intra-abdominal paragangliomas are variable while many of them may be asymptomatic even when the lesion is quite large. Thorough histopathologic evaluation is imperative for diagnosis and radical excision is the treatment of choice. Since there are no definite microscopic criteria for the distinction between benign and malignant tumors, prolonged follow-up is necessary.

Emergency room management of trauma patients in Greece: preliminary report of a national study.

AIM OF THE STUDY The aim of this study was to record and to evaluate the epidemiology of trauma in Greece and to assess the quality of management provided for trauma patients in the emergency department in Greek hospitals. METHODS The Hellenic Society of Trauma and Emergency Surgery invited all the official representatives of the society throughout the country to participate in the study. The representatives that responded positively, met with the Board of the society in succeeding meetings to establish the reporting form and the inclusion criteria. Inclusion criteria were defined as trauma patients requiring admission, transfer to a higher level center or arrived dead or died in the emergency department of the reporting hospital. All reports were accumulated by the Hellenic Trauma society, imported in an electronic data base and analyzed. The design of the study was prospective and observational. RESULTS In total 8862 patients were included in the study in 12 months time. Of them 68.7% (n=6084) were male, aged 41.8+/-20.6 (mean+/-S.D.) and 31.3% were female (n=2778), aged 52.7+/-24.1 (mean+/-S.D.). The mean duration of treatment in the emergency room department was 1h and 28min. Of the total number of patients, 2312 (26.1%) were initially assessed and managed by a specialist and 6249 (70.5%) were initially assessed and managed by a resident. CONCLUSIONS Data from this study show that there is substantial room for improvement in the patient care in the emergency department following trauma. Further evaluation will be required to identify particular management patterns that can be readily altered.

Traumatic brain injury in Greece: Report of a countrywide registry

Introduction: The purpose of this study was to evaluate the incidence of TBI in Greece and to provide evidence on the epidemiologic characteristics of the disease. Patients and methods: This is a prospective observational study initiated by the Hellenic Society of Trauma and Emergency Surgery. Thirty hospitals participated in the registry. All trauma patients requiring admission transfer to a higher level centre and those who arrived dead were included in the study. This report evaluated the epidemiologic characteristics of patients with brain trauma, the cause and the severity of the injury and the final outcome. Results: Eight thousand eight hundred and sixty-two patients were included in the registry. Of them, 3383 had at least one brain injury. There were 2451 males and 932 females. Traffic accidents were the leading cause of TBI (54.1%), followed by falls (27.7%). The most affected age group was the 15–44 year olds (48.0%), but TBIs were more lethal in the 45–64 age group (17.8%). Interestingly, a 3.4% mortality was recorded if a TBI was present, even if ISS was relatively low (0–9 ISS group). Conclusion: TBI is a major element of trauma. Knowledge of the epidemiologic characteristics of the disease is imperative for adequate planning and future quality assessment.

Porcine model of hemorrhagic shock with microdialysis monitoring.

BACKGROUND A number of experimental protocols have been used to try to reproduce the clinical scenarios of hemorrhagic shock. The present study reports on an experimental swine model of controlled hemorrhagic shock that incorporates microdialysis monitoring for the evaluation of tissue perfusion and oxygenation. The aim of our study was to provide a reproducible, accurate, and reliable model for the testing and evaluation of therapeutic interventions in the area of hemorrhagic shock. METHODS Landrace swine (n = 8) were subjected to controlled hemorrhagic shock, with a mean arterial pressure of 35 ± 5 as the endpoint. Six more pigs were used as the control group. Microdialysis monitoring of the tissue lactate/pyruvate ratio was used. The mean arterial pressure, heart rate, hematocrit, hemoglobin, and lactate/pyruvate ratio measurements were obtained just before (phase A) and 30 min after (phase B) hemorrhage in the study group; the control group underwent the same measurements at the corresponding points. RESULTS The mean arterial pressure, hematocrit, and hemoglobin were lower (P < 0.05) in the study group than in the control group at phase B and compared with the values for the study group at phase A. Also, the lactate/pyruvate ratio and heart rate were greater (P < 0.05) in the study group than in control group at phase B and compared with the values for the study group at phase A. CONCLUSIONS This model of hemorrhagic shock is effective and correlates with the clinical parameters of tissue oxygenation, as documented by microdialysis.

Intramuscular myxoma associated with an increased carbohydrate antigen 19.9 level in a woman: a case report

IntroductionIntramuscular myxoma is a rare benign soft tissue tumor. The lack of specific symptoms and widely used laboratory tests makes the diagnosis quite difficult. We present a case of an Intramuscular myxoma associated with an increased carbohydrate antigen 19.9 level. To the best of our knowledge, there have not been any reported cases of an association of Intramuscular myxoma with tumor markers in the literature.Case presentationA 45-year-old Caucasian woman presented to our department for resection of a mass in her left groin area, discovered incidentally on a triplex ultrasonography of her lower extremities. The diagnosis of Intramuscular myxoma was confirmed on histopathology after the complete surgical excision of the tumor. On laboratory examination, the serum level of carbohydrate antigen 19.9 was found to be elevated, but it returned to normal six months after resection of the mass.ConclusionCarbohydrate antigen 19.9 is a tumor marker that increases in a variety of malignant and benign conditions. After the exclusion of all other possible reasons for carbohydrate antigen 19.9 elevation, we assumed a possible connection of carbohydrate antigen 19.9 elevation and Intramuscular myxoma, an issue that requires needs further investigation.

Vacuum-assisted closure device in intensive care unit patients and dissemination of Gram-negative bacteria.

We read with interest the study by Batacchi and colleagues in a recent issue of Critical Care [1]. Vacuum-assisted closure (VAC) decompression is promising for the management of open abdomen, but our limited experience with this system suggests that dissemination of bacteria may occur. Recently, two patients were treated with VAC in our intensive care unit (ICU). Patient 1 was a 62-year-old man who was originally operated on for paraganglioma and underwent left nephrectomy and gastrojejunal anastomosis. Patient 2 was a 54-year-old woman who was admitted to the ICU two months after a complicated laparoscopic sleeve gastrectomy for morbid obesity. In both patients, at a certain point during their course, intra-abdominal sepsis developed, and they were both managed with extensive debridement, drainage, and VAC placement. Both patients developed fistulas, and although dressings and VAC pump containers were meticulously changed, leaks were repeatedly observed around the dressings. Furthermore, 2 to 4 weeks after the placement of VAC, a rise of positive cultures for Gram-negative bacteria was observed in all patients in our ICU (Figure ​(Figure1).1). As depicted in Figure ​Figure2,2, Klebsiella pneumoniae species became prevalent in our flora despite barrier measures and the isolation of both patients in a separate ward. In 12 out of 34 cases, KPC K. pneumoniae was isolated, whereas in one case it was resistant to all antibiotics. Figure 1 Number of positive Gram-negative and Gram-positive cultures in our intensive care unit during the stay of patients 1 (left) and 2 (right). The arrows represent the time of vacuum-assisted closure placement for each patient. Figure 2 Number of Klebsiella pneumoniae-positive cultures during the stay of patients 1 and 2. The solid arrow represents vacuum-assisted closure (VAC) placement in patient 1. The dotted arrow represents VAC placement in patient 2. Recent literature is inconclusive on this subject. We believe that further studies are needed to confirm the dissemination of bacteria from patients with VAC devices and abdominal leaks.

Anastomotic leak management after a low anterior resection leading to recurrent abdominal compartment syndrome: a case report and review of the literature

IntroductionLow anterior resection is usually the procedure of choice for rectal cancer, but a series of complications often accompany this procedure. This case report describes successful management of an intricate anastomotic leak after a low anterior resection.Case presentationA 66-year-old Caucasian man was admitted to our hospital and diagnosed with a low rectal adenocarcinoma. He underwent a low anterior resection but subsequently developed fecal peritonitis due to an anastomotic leak. He was operated on again but developed abdominal compartment syndrome, multi-organ failure and sepsis. He was aggressively treated in the intensive care unit and in the operating room. Overall, the patient underwent four laparotomies and stayed in the intensive care unit for 75 days. He was discharged after 3 months of hospitalization.ConclusionAbdominal compartment syndrome may present as a devastating complication of damage control laparotomy. Prompt recognition and goal-directed management are the cornerstones of treatment.