S. Rafailidis

Safety of bowel resection for colorectal surgical emergency in the elderly

Objective  Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long‐time experience is presented in this study.

Does Emergency Surgery Affect Resectability of Colorectal Cancer

Abstract Objective: Emergency surgery for colorectal cancer is common in daily practice, and is mainly implied by bowel obstruction. It is related to increased morbidity and mortality. Its relation with the stage and respectability of the disease is uncertain. This study aims to further clarify these parameters. Patients and methods: Over the past 24-year period 121 patients had an emergency operation (12%) from a total of 1009 patients with colorectal carcinoma. There were 59 men (48.8%) and 62 women (51.2%) with a mean age of 68 years (range 21–93); 61 patients (50.4%) were > 70 years old. The data of all these patients were studied retrospectively in comparison with those who underwent elective surgery. Emergency cases were further divided into two age groups (> 70 and < 70 years) and compared. The tumour location was mainly in the left colon, whereas obstruction was the predominant reason for acute presentation. Results: On operation, absence of macroscopic spread was noted in 57.8% of emergency cases and 72% of elective cases (p < 0.05). The resectability rates were 75% and 90% respectively (p < 0.05), and were not significantly affected by the age factor. There were no differences in the grade of malignant cell differentiation or in the depth of microscopic invasion (p > 0.05) in either group. For emergency operations, the morbidity was 20% (24 patients) and the 30-day mortality rate was 5.8% (7 patients). Both parameters were higher in patients > 70 years old. Conclusion: Emergency surgery for colorectal carcinoma is related to lower resectability and to higher-but acceptable-postoperative morbidity and mortality rates, when compared with elective surgical management.

Primary Ewing Sarcoma of the Stomach – A Newly Described Entity

The Ewing sarcoma family of tumors (ESFT) includes classic Ewing sarcoma of the bone, extraosseous or soft tissue Ewing sarcoma, Askin tumors of the chest wall, and peripheral primitive neuroectodermal tumors of the bone and soft tissues. They share a common neural histogenesis, tumor genetics and biology. The genetic hallmark of the ESFT is the presence of t(11;22)(q24;q12), which creates the EWS/FLI1 fusion gene and results in the expression of a chimeric protein. Although Ewing tumors can occur at any age, the great majority are found in individuals less than 20 years of age. We herein report a case of gastric Ewing sarcoma in a 68-year-old male. This patient illustrates the second reported occurrence of primary Ewing sarcoma in the stomach and the first reported with the t(11;22)(q24;q12) gene translocation.

Intraperitoneal ePTFE mesh repair of parastomal hernias

Parastomal hernia represents a common complication of colostomy formation. Surgical techniques such as facial repair and stoma relocation have almost been abandoned because of high recurrence rates. Extraperitoneal prosthetic mesh repair had better results but was accompanied by high rates of mesh contamination. A new technique, with intraperitoneal onlay position of expanded polytetrafluoroethylene (ePTFE) was therefore established. We report herein two cases of symptomatic large parastomal hernias treated in our department.

Effect of Experimentally Induced Liver Cirrhosis on Wound Healing of the Post-Extraction Tooth Socket in Rats

Background: Wound healing in liver cirrhosis is known to be impaired possibly due to liver insufficiency and subsequent malnutrition status; however, there is no study to examine healing effectiveness of the tooth socket following an extraction in such patients. Materials and Methods: Irreversible cirrhosiswas induced in 30 Wistar rats by repetitive weekly doses of CCl4 and continuous administration of phenobarbital in a 12-week course was monitored by body weight measurement and ascites development, and was proved histologically. One week later, cirrhotic and control rats were subjected to extractions of two maxillary grinders on each side, one side by simple method, the other by surgical method. Half of the animals of each subgroup were sacrificed on the 10th post-extraction day, whereas the other half on the 30th post-extraction day, and histological sections were examined from all tooth sockets for wound-healing activity. Results: A malnutrition status was detected in cirrhotic rats with significant difference in their body weight. Several histological parameters of socket healing were not statistically different between cirrhotic and control animals. However, a significant delay on epithelialization and cancellous bone formation was detected on the 10th post-extraction day for either simple or surgical extractions in cirrhotic animals. Conclusions: Liver cirrhosis in rats provokes a significant delay on epithelialization and mature cancellous bone formation and consecutively on early socket wound healing after a tooth extraction.

Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients.

Background: Elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years. Methods: From January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were ≥ 65 years old. Results: Elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged ≥ 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged ≥ 65 years. Conclusions: Open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization.

Laparoscopic cholecystectomy in adult patients with beta-thalassemia or sickle cell disease.

Sickle cell disease is a hereditary hemolytic anemia in which the sickle hemoglobin (HbS) substitutes for the normal adult hemoglobin (HbA). Beta-thalassemia is another hereditary hemolytic anemia in which the reduction of beta chain synthesis produces a marked decrease in normal HbA, with a compensatory increase in fetal hemoglobin (HbF). It is well-known that cholelithiasis, which is due to pigmented stones from increased hemoglobinolysis and bilirubin release, is more common in patients with sickle cell disease or thalassemia than in the general population; it occurs at younger age and is often symptomatic, requiring cholecystectomy. In addition, the modern appropriate management of patients with homozygous beta-thalassemia dealing mainly with secondary hemosiderosis and its consequences has increased survival time, prolonging life. Therefore, more patients may suffer from pigmented gallstone disease [5]. Laparoscopic cholecystectomy with its undoubted advantages of minimally invasive surgery has been advocated in such patients. However, the safety and outcome depend largely on some disease-related factors, which should be managed effectively. It has been performed safely and proven superior to open cholecystectomy in patients with sickle cell disease [6]. A standard protocol of operative preparation and postoperative care, including blood transfusion if hemoglobulin is less than 9 or 10 g/dl, adequate rehydration, analgesia, and oxygen therapy, has been proposed [1, 3, 9]. This care is essential to minimize the risk of complications. Cholecystectomy, either open or laparoscopic, in a patient with sickle cell disease predisposes to specific complications (i.e., acute chest or thoracic syndrome and painful vasoocclusive limb, abdominal, or neurological crisis) [1, 3]. Increased monitoring and peroperative care should be employed to reduce morbidity and possibly mortality from this vasoocclusive crisis by sickled erythrocytes [7, 10]. Hematologists must refer well-prepared patients with symptomatic cholelithiasis, and also those with acute cholecystitis [1], for elective laparoscopic cholecystectomy early [2]. Nevertheless, a rare but potentially lethal complication of portal vein thrombosis has been reported after prolonged laparoscopic surgery combined with cholecystectomy, splenectomy, and appendectomy in a patient with sickle cell disease [8]. In patients with beta-thalassemia, care must be taken during laparoscopic cholecystectomy to prevent liver injury; hepatomegaly and pigmented cirrhosis may cause some operative difficulty, but this will be overcome with increased experience [4, 5]. Likewise, systemic complications of iron overload such as myocardial hemosiderosis may occur, making appropriate preparation necessary. Our laparoscopic experience in such patients with hereditary hematological disorders is based on 28 adult patients with a mean age of 23 years (range, 14–32). All patients suffered from symptomatic cholelithiasis and were referred by hematologists for elective laparoscopic cholecystectomy during a 6-year period (1999– 2004). Thirteen patients had homozygous or major beta-thalassemia, and 15 patients had homozygous or major sickle cell disease. Diagnosis of gallstone disease was based on clinical presentation and ultrasound scanning. All laparoscopic procedures were completed successfully. In all thalassemic patients, pigment cirrhosis and fibrosis in the Calot s triangle were noted and liver biopsy was taken. During the same period, a total of 922 laparoscopic cholecystectomies were performed in our department. Laparoscopic cholecystectomy was performed in the same way in all patients using the four-trocar technique according to the ‘‘American’’ variable and at a stable intraabdominal pressure of 12 mmHg of carbon dioxide pneumoperitoneum. The mean duration of the operation was 65 min (range, 45–80). All patients recovered well without any disease-related complications or death. Postoperatively, one thalassemic patient experienced a transient liver dysfunction due to local ischemia from inadvertent right artery ligation presenting with fever, leukocytosis, and liver function test abnormality; another patient with sickle cell disease had mild amylasemia without clinical or imaging evidence of acute pancreatitis. The morbidity rate was 7%. The mean hospital stay was 3.8 days (range, 2–13). Per-operatively in cooperation with hematologists, our patients were hyperhydrated, transfused if necessary, well oxygenated, and monitored closely for arterial blood gases and pH for 24 h in the intensive care unit. Surg Endosc (2005) 19: 1668–1669 DOI: 10.1007/s00464-005-0373-5

Early Propranolol Administration Does Not Prevent Development of Esophageal Varices in Cirrhotic Rats

Background and Aims: Variceal bleeding is the most serious complication of portal hypertension associated with high mortality. This study was conducted to investigate any protective effect of early propranolol administration in the development and degree of esophageal varices in cirrhotic rats with portal hypertension. This topic is controversial in the literature. Methods: For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl4) administration. This operation enhances the development of cephalad collaterals, responsible for the induction of esophageal varices. After 2 weeks of CCl4 administration, the rats were randomly separated into 2 groups. In group I, propranolol was continuously administered intragastrically throughout the study, whereas in group II normal saline (placebo) was administered instead. Cirrhosis was detected clinically by ascites development. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis, measuring the following parameters: portal pressure, total number of submucosal veins, total submucosal vessel area, mean cross-sectional submucosal vessel area, relative submucosal area (percentage) occupied by vessels and area of the single most dilated submucosal vein. Results: The statistical analysis revealed no statistically important difference between the 2 groups for the morphometrically studied parameters. However, portal venous pressure was lower in group I. Conclusion: Early propranolol administration did not protect rats from developing esophageal varices, despite the fact that a significant decrease in portal pressure was detected.

Acute afferent loop syndrome: a true emergency. A case report.

Abstract Afferent loop syndrome is a relatively rare complication after subtotal gastrectomy. We present a late onset of afferent loop obstruction, in a patient who underwent Billroth II gastrectomy with Roux-Y reconstruction for a gastric ulcer 27 years ago. A 60-year-old male was admitted to the hospital with an 8-hour history of acute epigastric pain, associated with vomiting, fever and signs of sepsis. Laboratory tests revealed leukocytosis, elevated liver function tests and high serum amylase. An obstructed afferent loop appeared on CT as a fluid filled tubular mass, crossing the middle line between the aorta and the mesenteric vessels. Advanced sepsis was also seen in the peripancreatic and retroperitoneal region. Although the patient was operated on immediately after diagnosis with reconstruction of Roux-Y anastomosis, he died 12 hours later. Afferent loop syndrome is quite uncommon, and must be suspected in patients who have undergone subtotal gastrecto-my. Clinical manifestations of the syndrome are usually non-specific. CT is the examination of choice and surgery the first choice treatment.

Gastrosplenic fistula: A rare complication of splenic abscess

Gastrosplenic fistulas are rare complications of malignant gastric or splenic diseases and, less frequently, are the result of benign diseases such as gastric ulcers and Crohns disease. Spontaneous gastrosplenic fistula as a result of splenic abcess has not been reported in the literature so far. A 70‐year‐old man presented with a splenic abscess which had spontaneously developed a gastrosplenic fistula. The fistula was diagnosed by computed tomography scan and upper gastrointestinal endoscopy and was successfully managed by splenectomy with en bloc resection of part of the greater curvature of the stomach. Although gastrosplenic fistulas are a relatively rare complication of gastric or splenic diseases, an awareness might lead the clinician to early recognition and surgery can be offered earlier as the treatment of choice.