Stylianos Kykalos

Small intestine diverticula: Is there anything new?

AIM To globally approach the clinical entity of small bowel diverticulosis and, at the same time, set out the treatment options. METHODS We analysed 77 cases of diverticula located in the duodenum, jejunum and ileum that were treated in our department, evaluating the symptoms, diagnostic approach and offered treatment. RESULTS Almost half of the diverticula (46.7%) were incidentally discovered and Meckels diverticula represented the majority (43%) that were actually the only true diverticula. A high complication rate (53%) which included inflammation with or without perforation (22%), bleeding (10%) or obstructive ileus (12%) due to small bowel diverticulosis was reported. The preoperative diagnosis was often impossible (44% of complicated cases). CONCLUSION Although small bowel diverticulosis has a low incidence, it should be in the clinicians mind in order to avoid misdiagnosis.

From diagnosis to treatment of hepatocellular carcinoma: An epidemic problem for both developed and developing world

Hepatocellular carcinoma (HCC) is the most frequent primary liver malignancy and the third cause of cancer-related death in the Western Countries. The well-established causes of HCC are chronic liver infections such as hepatitis B virus or chronic hepatitis C virus, nonalcoholic fatty liver disease, consumption of aflatoxins and tobacco smocking. Clinical presentation varies widely; patients can be asymptomatic while symptomatology extends from right upper abdominal quadrant paint and weight loss to obstructive jaundice and lethargy. Imaging is the first key and one of the most important aspects at all stages of diagnosis, therapy and follow-up of patients with HCC. The Barcelona Clinic Liver Cancer Staging System remains the most widely classification system used for HCC management guidelines. Up until now, HCC remains a challenge to early diagnose, and treat effectively; treating management is focused on hepatic resection, orthotopic liver transplantation, ablative therapies, chemoembolization and systemic therapies with cytotocix drugs, and targeted agents. This review article describes the current evidence on epidemiology, symptomatology, diagnosis and treatment of hepatocellular carcinoma.

Impact of CYP2D*6 in the adjuvant treatment of breast cancer patients with tamoxifen

Biotransformation of tamoxifen to the potent antiestrogen endoxifen is performed by cytochrome P450 (CYP) enzymes, in particular the CYP2D6 isoform. CYP2D6*4 is one of the most frequent alleles associated with loss of enzymatic activity. The incidence of CYP2D6*4 among Caucasians is estimated up to 27%, while it is present in up to 90% of all poor metabolizers within the Caucasian population. The hypothesis under question is whether the presence of one or two non-functioning (null) alleles predicts an inferior outcome in postmenopausal women with breast cancer receiving adjuvant treatment with tamoxifen. The numerous existing studies investigating the association of CYP2D6 with treatment failure in breast cancer are inconsistent and give rather conflicting results. Currently, routine CYP2D6 testing among women with breast cancer is not recommended and the significance of CYP2D6 phenotype in decision making regarding the administration of tamoxifen is unclear. The present study summarizes current literature regarding clinical studies on CYP2D6*4, particularly in terms of response to tamoxifen therapy and breast cancer outcome.

High MELD score and extended operating time predict prolonged initial ICU stay after liver transplantation and influence the outcome

Background The aim of the present study is to determine the incidence of a prolonged (>3 days) initial ICU-stay after liver transplantation (LT) and to identify risk factors for it. Patients and methods We retrospectively analyzed data of adult recipients who underwent deceased donor first-LT at the University Hospital Essen between 11/2003 and 07/2012 and showed a primary graft function. Results Of the 374 recipients, 225 (60.16%) had prolonged ICU-stay. On univariate analysis, donor INR, high doses of vasopressors, “rescue-offer” grafts, being hospitalized at transplant, high urgency cases, labMELD, alcoholic cirrhosis, being on renal dialysis and length of surgery were associated with prolonged ICU-stay. After multivariate analysis, only the labMELD and the operation’s length were independently correlated with prolonged ICU-stay. Cut-off values for these variables were 19 and 293.5 min, respectively. Hospital stay was longer for patients with a prolonged initial ICU-stay (p<0.001). Survival rates differed significantly between the two groups at 3 months, 1-year and 5-years after LT (p<0.001). Conclusions LabMELD and duration of LT were identified as independent predictors for prolonged ICU-stay after LT. Identification of recipients in need of longer ICU-stay could contribute to a more evidenced-based and cost-effective use of ICU facilities in transplant centers.

Intraluminal rectal cancer metastasis to the small bowel: An extremely rare case report

Prolonged survival in patients suffering from colorectal cancer (CRC) may lead to the emergence of rare metastatic sites that are not well-documented in the literature. We herein describe a very rare case of an intraluminal small intestinal metastasis in a patient with previously resected CRC. A 71-year-old Caucasian male patient with a history of rectosigmoid junction cancer was initially treated with anterior resection. The tumor was classified as pT3pN0 (0/26) M0, stage II. Eighteen months after the primary surgery, local recurrence was detected in the presacral region, and the patient received combined image-guided radiotherapy and chemotherapy. Two months later, due to residual disease at the level of the anastomosis, the patient underwent additional low anterior resection with a diverting stoma. During extensive adhesiolysis, a small palpable intraluminal mass was identified in the jejunum, and segmental small bowel resection was performed. Pathological examination of the resected specimen confirmed that the lesion was a metastasis from the CRC primary. The precise mechanism and clinical significance of CRC metastasis to the small bowel remain unclear. There is limited clinical experience with this condition, as <20 cases have been reported in the literature to date. The main symptoms leading to evaluation, diagnosis and surgical resection are bowel obstruction and bleeding. The present case highlights the possibility of uncomplicated presence of metastatic CRC in the small bowel. Therefore, dilligent inspection of the peritoneal cavity, including the entire length of the gastrointestinal canal, is of paramount importance, particularly in cases of recurrent CRC.

Giant pedunculated hepatocellular carcinoma with hemangioma mimicking intestinal obstruction

BackgroundPedunculated hepatocellular carcinoma (P-HCC) has rarely been reported and is characteristically large and encapsulated. Only sporadic cases have been published, in which P-HCC was combined with other liver tumors (mostly benign), making the diagnosis difficult.Case presentationWe report a patient who was admitted to our hospital with clinical features of intestinal obstruction and a palpable mass in the right iliac fossa. Ultrasound, computed tomography and magnetic resonance imaging demonstrated an encapsulated mass of unclear origin and characteristics of liver hemangioma. Laboratory tests revealed elevated α-fetoprotein (> 800 ng/ml) and cancer antigen 125 (> 51.2 U/ml). With a possible diagnosis of giant liver hemangioma, we proceeded to surgery. During surgery, a giant pedunculated tumor was discovered on the inferior surface of the right lobe of the liver, hanging free in the right abdominal cavity towards the right iliac fossa. The macroscopic appearance of the tumor was compatible with liver hemangioma. Tumor resection was performed at a safe distance, including the pedicle. The rest of the liver appeared normal. Histopathological examination revealed grade II and III HCC (according to Edmondson-Steiners classification) with nodular configuration, central necrosis, and infiltration of the capsule. Underneath the tumor capsule, residual tissue of a cavernous hemangioma was recognized. The resection margins were free of neoplastic tissue.ConclusionThis rare presentation of a giant P-HCC combined with a hemangioma with features of intestinal obstruction confirmed the diagnostic difficulties of similar cases, and required prompt surgical treatment. Therefore, patients benefit from surgical resection because both the capsule and the pedicle prevent vascular invasion, therefore improving prognosis.

Unnecessary histologic examination of stapler doughnuts at low anterior resection for rectal cancer: Is it just a blame game?

To the Editors: We read with interest the article by Sugrue et al titled “No clinical benefit from routine histologic examination of stapler doughnuts at low anterior resection for rectal cancer.” The aim of this study was to evaluate the clinical utility and cost-effectiveness of routine histologic examination of the doughnuts from stapled anastomoses in patients undergoing a low anterior resection for rectal cancer. After a thorough search of the literature, we confirm that the authors verify the results of a long series of studies on this subject. But since when have we been noticing these clinically insignificant results regarding the histology of stapler rings? And why is the use of recommended guidelines still inconsistent? Sixteen years ago, Pullyblank et al examined the then current practice among pathologists throughout the United Kingdom to determine the incidence of clinically important pathology within the colonic doughnuts. They concluded that histology of the doughnuts did not change clinical management in any patient, despite the fact that the guidelines of the Royal College of Pathologists stated that this examination was not necessary. Practice varied between hospitals, with only 15% following the guidelines for examination of doughnuts. Two years later, Speake et al stated that routine histologic examination of doughnuts was nonbeneficial, costly, and labor intensive. In 2006, Morgan et al reported that none of their findings after doughnut examination had any influence on subsequent management, but there was only considerable impact in terms of time and the use of resources. So, why do surgeons keep on sending the doughnuts for pathologic evaluation? And who is to blame: the pathologist or the surgeon? Inspection of the doughnuts in the intraoperative setting serves as an indication of a satisfactory anastomosis, but routine histologic examination of colorectal rings when performing colorectal resections and anastomoses using a stapler is not clinically justified. In contrast and to muddy the waters, we are fully aware that the situation in upper gastrointestinal cancer is different. The guidelines of the Royal College of Pathologists state that the distal and proximal resection margins of esophagectomies, gastrectomies, and esophagogastrectomies, removed for neoplasia should be examined histologically, yet the guidelines are not clear when it comes to the inspection of the doughnuts after a stapled anastomosis. Sillah et al found that doughnut involvement by cancer cells was an independent predictor of overall survival. These differences may be explained by the differing tumor biology of upper and lower gastrointestinal cancers. Esophageal cancers have a propensity for longitudinal submucosal spread, and in the study by Sillah et al, the statis of the doughnut status was more important prognostically than microscopic involvement of the proximal resection margin. Doughnut involvement with cancer and its prognostic implications deserves further investigation in some malignancies. Until then, the well-researched, cost-efficient guidelines for colorectal doughnuts can be applied safely without detriment to patient care.

The clinical significance of apoptosis and M30 expression in colonic cancer progression

Abstract Background/aim: The aim of this study is to identify the significance of M30, an early apoptosis indicator, in colorectal cancer and its liver metastasis. Patients and methods: The expression of M30 was immunohistochemically estimated at colonic and liver metastatic tissues of 66 patients. The results were correlated to clinical and pathological features of the tumors. Results: High expression of M30 was observed in 15.5% of cases. No metastatic tissue showed expression of M30, while stage D tumors (metastasis included) showed a statistic significant lower expression of M30, when compared to earlier tumor stages. Conclusion: Low expression of M30 implies the development of resistance mechanisms against apoptosis, facilitating the progression of colon cancer.

Three-Dimensional Imaging of Pectus Excavatum Mesh Repair 7 Years After Performing Robicsek Technique

The most popular surgical procedure for pectus excavatum repair is the Ravitch technique, with a wide variety of different materials applied to provide posterior support to the sternum. We present the late results of a 17-year-old patient who underwent a modified Robicsek technique [1], based on Ravitch’s stages, with the use of DualMesh 2-mm GoreTex (W.L. Gore & Assoc, Flagstaff, AZ). There were no postoperative complications and excellent cosmetic results were achieved. Seven years postoperatively, a high resolution threedimensional reconstructed computed tomographic scan confirmed that the mesh supports the sternum posteriorly in its corrected position (Fig 1A). The mesh was placed under the sternum and was anchored to the lateral tips of all divided costal cartilages to stabilize the chest wall. We can easily identify the transverse V-shaped osteotomy that was subsequently carried out on the anterior wedge of the depressed section of the sternum. The xyphoid process was intact. The inset in Figure 1A shows the orientation of the body (chest computed tomography horizontal section).

A rare retroperitoneal tumor.

Figure 1: Retroperitoneal lesion in MRI Figure 2: The same lesion in CT A 68 year old man was hospitalized for pulmonary embolism. A month ago, he had a myocardial infarction and 10 days ago he was treated surgically by triple coronary artery bypass grafting. His personal medical and surgical history includes hypertension, appendectomy for appendicitis 50 years ago and exploratory laparotomy for obstructive ileus due to adhesions 5 years ago. He has no family history for malignancy. Abdominal CT and MRI performed for causative evaluation of the pulmonary embolism, revealed a 5 cm large solid mass of the mesenteric root with clear smooth margins and inhomogeneous density. The mesenteric vessels were not infiltrated. The patient did not mention any gastroenterologic disorders (vomiting, blood loss and defacation problems) and had no abnormal signs on physical examination. The performed coloscopy was negative. The surgical specimen was a solid, hard, well defined retroperitoneal tumor lying in front of the superior mesenteric artery and the left renal vein [Figures 1 and 2].