Petros Zezos

Peroral transgastric endoscopic procedures in pigs: feasibility, survival, questionings, and pitfalls.

BackgroundMultiple studies have demonstrated the feasibility of peroral transgastric endoscopic procedures in porcine models. We present our experience with these procedures in a porcine survival model and expose the technical difficulties and worries about their application in humans.MethodsWe performed the following transgastric procedures in nine small pigs (20–30xa0kg) under general anesthesia using a double-channel therapeutic endoscope: peritoneoscopy (nine pigs), cholecystectomy (six pigs), gastrojejunal anastomosis (two pigs), and fallopian tube excision (one pig). Postsurgical complications and survival of the pigs were recorded during a 3-week follow-up.ResultsIn six pigs, the gallbladder was successfully resected. The time of the procedure ranged from 2.5 to 3.5xa0hours. In one case, severe bleeding occurred from the cystic artery during dissection and was successfully managed by placement of endoscopic clips. Five pigs survived for 3xa0weeks after cholecystectomy. In one pig, severe peritonitis developed because of gastric contents leakage due to failure of gastric closure and the animal was euthanized 3xa0days after the procedure. Endoscopic transgastric gastrojejunostomy was successfully performed in two pigs without major complications. The time required for the procedure averaged about 50xa0min. Fallopian tube excision was also successful in one pig without any complications. The entire procedure was performed within 60xa0min.ConclusionsThis study reports the feasibility of natural orifice transluminal endoscopic surgery (NOTES) procedures in a porcine survival model and impresses the efficacy, the safety, the complications, and some technical difficulties of transgastric NOTES procedures, which merit further evaluation in future studies.

Basal ganglia hyperintensity on T1-weighted MRI in Rendu-Osler-Weber disease.

The purpose of this study was to evaluate possible central nervous system (CNS) involvement in Rendu–Osler–Weber (ROW) disease in magnetic resonance imaging (MRI). Three patients with symptomatic ROW disease underwent brain MRI. Brain MRI depicted in all three of them increased signal intensity on T1‐weighted images involving the globus pallidus and cerebral crura bilaterally. Laboratory studies of the two men showed iron deficiency anemia, while all three of them had normal liver function tests and increased manganese blood concentration. Gastroscopy and colonoscopy revealed a gastric and a cecal arteriovenous malformation (AVM) in the first one, while pulmonary and hepatic computed tomography (CT) angiography did not detect any intrahepatic shunts. Liver ultrasound in the second one revealed dilatation of intrahepatic artery branches consistent with intrahepatic shunts, while it was normal in the third patient. Chest radiographs were normal in all three patients. Pallidal T1 hyperintensity on T1‐weighted imaging may be a biomarker of manganese overload in ROW disease. J. Magn. Reson. Imaging 2012;426‐430.

Spontaneous bowel perforation complicating ventriculoperitoneal shunt: a case report.

Ventriculoperitoneal shunt placement is an effective treatment of hydrocephalus diverting the cerebrospinal fluid into the peritoneal cavity. Unfortunately, the shunt devices have a high incidence of malfunction mainly due to catheter obstruction or infection and are associated with various complications, 25% of which are abdominal. Spontaneous bowel perforation is a rare potentially fatal complication of ventriculoperitoneal shunt occurring anytime, few weeks to several years, after the placement of the ventriculoperitoneal shunt device. A 54-year-old Greek man with spontaneous perforation of sigmoid colon as a complication of distal ventriculoperitoneal shunt migration was treated successfully by antibiotic prophylaxis and abdominal surgery. Clinicians managing patients with ventriculoperitoneal shunt must be familiar with its possible complications and be aware for early recognition of them.

Simultaneous occurrence of hyperthyroidism and fistulizing Crohn’s disease complicated with intra-abdominal fistulas and abscess: a case report and review of the literature

IntroductionFistula formation in patients with Crohns disease is a common complication during the course of the disease. Perianal and enteroenteric are the most common forms of fistulas, whereas the involvement of the upper gastrointestinal tract with gastrocolic and duodenocolic fistulas represents an extremely unusual condition. Moreover, hyperthyroidism in association with Crohns disease has been rarely described.Case presentationWe present here a rare case of a 25-year-old male with simultaneous onset of hyperthyroidism and fistulizing Crohns disease. Crohns disease was complicated with intra-abdominal fistulas involving the upper gastrointestinal tract (duodenocolic, gastrocolic) and an intra-peritoneal abscess formation in the lesser sac. We describe the clinical presentation and therapeutic management of the patient including both medical treatment and surgical intervention. Despite intense medical treatment with total parenteral nutrition, antibiotics, aminosalicylates and corticosteroids the clinical course of the disease was suboptimal. Finally, the patient underwent laparotomy and right hemi-colectomy with ileo-transverse anastomosis performed, with simultaneous drainage of the abdominal abscess and primary closure of the upper gastrointestinal tract openings (gastric, duodenal and jejunal) at one stage operation. Although the surgical approach definitively cured the perforating complications of the disease (fistulas and abscess), the luminal disease in the colon remnant was still active and steroid-refractory. The subsequent successful treatment with infliximab, azathioprine and mesalazine resulted in the induction and maintenance of the disease remission. Thyrotoxicosis was successfully treated with methimazole and the hyperthyroidism has definitely subsided.ConclusionThe management of intra-abdominal fistulas in Crohns disease is a complex issue, requiring a multi-disciplinary approach and tailoring of the treatment to the individual patients needs. Probably, a sensible approach involves early surgical intervention with prior optimization of the patients general condition when feasible. Common autoimmune mechanisms are probably involved in thyroid dysfunction associated with Crohns disease. Moreover, diagnosis and treatment of coexisting thyroid disorder in patients with Crohns disease has a favorable impact in disease prognosis.

Single-incision assisted laparoscopic surgery (SILS) in the treatment of an intussusception induced by a solitary hamartomatous polyp: a case report and review of the literature

IntroductionIn this case report, we describe the successful treatment of a small-bowel intussusception, which was caused by a 3cm solitary hamartomatous polyp, with single-incision laparoscopic surgery. Single-incision laparoscopic surgery is a minimally invasive surgical procedure with important advantages that allows the reduction of the intussusception and the resection of the polyp. This case report contributes to the medical literature by describing the advantages of this surgical technique that warrant its consideration as a treatment of choice in similar cases.Case presentationWe report a case of a 19-year-old Greek woman who complained about intermittent, non-specific abdominal pain in her left lateral abdomen. She had been admitted to the hospital because of incomplete obstructive ileus. Ultrasound and computed tomography were carried out, which revealed an intussusception of the small bowel. This pathogenic situation was treated by single-incision laparoscopic surgery. Her pathology report revealed a benign, hamartomatous excised polyp of the Peutz-Jeghers type. The patient had a quick recovery without any post-operative complications.ConclusionWe recommend single-incision laparoscopic surgery for the safe excision of solitary hamartomatous polyps and the management of their complications, as it represents a potential advance in minimally invasive approaches.

Does prophylactic administration of somatostatin decrease the rates of complications after pancreatic resection?: A clinical and electron microscopy study.

Objectives The postoperative morbidity after pancreatectomy remains high. The role of somatostatin and its analogs in reducing complications after pancreatic resection is controversial. The aim of the study was to evaluate the ability of somatostatin to influence pancreatic cell’s function with consequence the decrease of postoperative complications. Methods Between January 2006 and December 2009, 67 patients for which pancreatectomy was indicated were randomized into 2 groups. At surgery, biopsies of the pancreas were taken to be studied by electron microscopy and analyzed for ultrastructural morphometry. Results The total mortality was 4.4% (n = 3/67; 2 patients from the control group and 1 patient from the treatment group). The overall morbidity was 35.8% (n = 24/67). Eighteen patients in the control group (n = 18/32; 56.25%) and 6 patients in the treatment group (n = 6/35; 17.14%) developed postoperative complications (2-tailed Fisher exact test; P = 0.001). The most common complication was the presence of fistula (n = 6/67; 8.95%). Conclusions Perioperative administration of intravenous somatostatin at rates applied in this study was able to inhibit the exocrine pancreatic function. This finding supports the prophylactic effect of somatostatin on the early postoperative complications of pancreatic surgery shown in this study.

Quality training in laparoscopic colorectal surgery: does it improve clinical outcome?

Laparoscopic colorectal surgery (LCRS) is a safe, effective and cost-efficient option for the treatment of various benign and malignant conditions. However, its implementation to surgical practice is still limited. That is mainly due to its association with a steep learning curve. We performed a review of the literature to determine whether quality training in LCRS can reduce that learning curve and lead to better clinical outcomes. We concluded that a structured training program with pre-clinical phase focused on basic skill acquisition and a clinical phase focused on mentoring from experts can shorten the learning curve and improve clinical outcomes.

Endoscopically Assisted Transumbilical Single-Incision Laparoscopic Gastric Resection for GIST Treatment

ABSTRACT Purpose: Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs <5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection. Methods: Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy. Results: The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed. Conclusion: The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.

Coagulation and fibrinolysis activation after single-incision versus standard laparoscopic cholecystectomy: a single-center prospective case-controlled pilot study.

Laparoscopic cholecystectomy is associated with attenuated acute-phase response and hypercoagulable state compared with the open procedure. Single-incision laparoscopic cholecystectomy is a new technique aiming to minimize the invasiveness of the procedure. By comparing the degree of coagulation and fibrinolysis activation after conventional multiport (CLC) and single-incision (SILC) laparoscopic cholecystectomy, we aimed to determine whether the reduced incision size induces a lower thrombophilic tendency. Thirty-two adult patients with noncomplicated symptomatic cholelithiasis were nonrandomly assigned to CLC or SILC. Prothrombin fragment 1 + 2 (F1 + 2), thrombin–antithrombin complexes (TAT), D-dimers, fibrinogen, and von Willebrand factor levels were measured at baseline, at 1st, and 24th hour, postoperatively. Twenty-six patients were finally included in the study. Fifteen patients underwent CLC (male/female: 5/10) and 11 underwent SILC (male/female: 1/10). There were no perioperative complications. An almost similar postoperative pattern and degree of activation of coagulation and fibrinolysis pathways was noted in both groups. No statistically significant differences were found between SILC and CLC for F1 + 2, TAT, D-dimers, fibrinogen, and von Willebrand factor levels, duration of surgery, length of hospital stay, and postoperative morbidity. A similar pattern and extent of coagulation and fibrinolysis activation is present in SILC and CLC, and therefore there is no difference in tendency for thrombosis. Thromboembolic prophylaxis should be considered in SILC as recommended for CLC, pharmacologic or mechanical, considering the hemorrhagic risk and the presence of additional thromboembolism risk factors. SILC appears to be a safe, feasible technique that can be recommended for its potential advantages in cosmesis and reduced incisional pain.

Alterations in colonic transit time after laparoscopic versus open cholecystectomy: a clinical study

PurposePostoperative enteral paresis constitutes a common problem for surgeons around the world. Evidence by many authors suggests that colonic inertia constitutes a major component of postoperative enteral paresis. This study aims at comparing the effect of laparoscopic versus open cholecystectomy on colonic transit time in humans.Materials and methodsIn this study, were included a total of 29 patients suffering from cholelithiasis, divided into two groups, a laparoscopic cholecystectomy and an open cholecystectomy group. All patients ingested one capsule containing 24 radiopaque markers on the day of the operation, and plain abdominal films were obtained on the 3rd postoperative day. The number of remaining markers was counted, and the percentage of rejected markers was calculated. For the statistical analysis, SPSS for windows version 12 was used.Results and discussionThe study’s results show a significant difference in postoperative colonic motility, in favor of the laparoscopic cholecystectomy group (Pxa0=xa00,001). Causative interpretation of these results is difficult, mainly due to the multifactorial nature of postoperative colonic hypomotility.ConclusionThe present study suggests an advantage of laparoscopic cholecystectomy, as far as the duration of postoperative colonic paresis is concerned.