Theodoros Diamantis

Clinical significance of serum levels of E-selectin, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 in gastric cancer patients.

OBJECTIVES:This study evaluated serum concentrations of soluble cell adhesion molecules in patients with gastric cancer and in healthy control subjects. Our objectives were to correlate these levels with clinicopathological features, established tumor markers, and patient survival, and to assess changes in serum levels of cell adhesion molecules after tumor surgery.METHODS:The serum concentrations of the adhesion molecules E-selectin, intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) were investigated by ELISA in 57 gastric cancer patients, both before and 7 days after surgery, and in 47 healthy control subjects.RESULTS:Preoperative serum concentrations of ICAM-1 and VCAM-1 in gastric cancer patients were significantly higher when compared with those of healthy controls, whereas there were no differences regarding serum E-selectin levels. Serum levels of E-selectin, ICAM-1, and VCAM-1 correlated significantly with each other. There was a significant association between preoperative levels of all three adhesion molecules and disease stage, gastric wall invasion, lymph node involvement, and presence of distant metastases. Their concentrations decreased significantly after radical resection of the tumor, whereas they remained almost unchanged in patients with unresectable disease. Elevated preoperative serum levels of E-selectin, ICAM-1, and VCAM-1 levels were found in 24.6%, 33.3%, and 28.1% of patients, respectively. Elevated levels of all three molecules were significant prognostic factors for patient survival but not independent of disease stage.CONCLUSIONS:These findings suggest that serum concentrations of E-selectin, ICAM-1, and VCAM-1 may reflect tumor progression and metastasis, and may be clinically useful.

Cross-sectional long-term micronutrient deficiencies after sleeve gastrectomy versus Roux-en-Y gastric bypass: A pilot study

BACKGROUND Nutritional deficiencies are highly prevalent in obese patients. Bariatric surgery has been associated with adverse effects on homeostasis of significant vitamins and micronutrients, mainly after gastric bypass. The aim of the present study was to compare the extent of long-term postsurgical nutritional deficiencies between Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). METHODS This cross-sectional, pilot study included 95 patients who underwent RYGB or SG surgery with a mean follow-up of 4 years. Demographic, anthropometric, and biochemical parameters were compared according to the type of surgery. RESULTS Both types of surgery were associated with significant nutritional deficiencies. Vitamin B12 deficiency was significantly higher in patients with RYGB compared with SG (42.1% versus 5%, P = .003). The type of surgery was associated neither with anemia nor with iron or folate deficiency (SG versus RYGB: anemia, 54.2% versus 64.3%, P = .418; folate deficiency, 20% versus 18.4%, P = .884; iron deficiency, 30% versus 36.4%, P = .635). CONCLUSION During a mean follow up period of 4 years postRYGB or SG, patients were identified with several micronutrient deficiencies, including vitamin D, folate, and vitamin B12. SG may have a more favorable effect on the metabolism of vitamin B12 compared with RYGB, being associated with less malabsorption. Adherence to supplemental iron and vitamin intake is of primary significance in all cases of bariatric surgery.

Efficacy and safety of laparoscopic mini gastric bypass. A systematic review

BACKGROUND Laparoscopic mini-gastric bypass (LMGB) is a relatively new bariatric procedure; published studies are accumulating in various settings. The objective of this study was to summarize the available evidence about the efficacy and safety of LMGB. METHODS A systematic search in the literature was performed , and PubMed and reference lists were scrutinized (end-of-search date: July 15, 2013). For the assessment of the eligible articles, the Newcastle-Ottawa quality assessment scale was used. RESULTS Ten eligible studies were included in this study, reporting data on 4,899 patients. According to all included studies, LMGB induced substantial weight and body mass index reduction, as well as substantial excess weight loss. Moreover, resolution or improvement in all major associated medical illnesses and improvement in overall Gastrointestinal Quality of Life Index score were recorded. Major bleeding and anastomotic ulcer were the most commonly reported complications. Readmission rate ranged from 0%- 11%, whereas the rate of revision operations ranged from .3%- 6%. The latter were conducted due to a variety of medical reasons such as inadequate or excessive weight loss, malnutrition, and upper gastrointestinal bleeding. Finally, the mortality rate ranged between 0% and .5% among primary LMGB procedures. CONCLUSION LMGB represents an effective bariatric procedure; its safety and minimal postoperative morbidity seem remarkable. Randomized comparative studies seem mandatory for the further evaluation of LMGB.

Bile Duct Injuries Associated with Laparoscopic and Open Cholecystectomy: An 11-Year Experience in One Institute

PurposeBile duct injury (BDI) represents the most serious complication of laparoscopic cholecystectomy (LC). The aim of this retrospective single-institution study was to evaluate the real incidence of BDI during laparoscopic and open cholecystectomy (OC) in a tertiary academic center in Athens, Greece.MethodsBetween January 1991 and December 2001, 3 637 patients underwent cholecystectomy in our department; as LC in 2 079 patients (LC group) and as OC in 1 558 patients (OC group). All the LCs were performed or supervised by five staff surgeons and all the OCs were performed or supervised by another five staff surgeons.ResultsThere were 13 BDIs associated with LC (0.62%) and 6 associated with OC (0.38%) (P = 0.317). There was one death associated with BDI after LC. Only two (15.4%) of the BDIs associated with LC occurred within the proposed learning curve limit of 50 LCs per individual surgeon.ConclusionLaparoscopic cholecystectomy is safe and is not associated with a higher incidence of BDI than OC. Moreover, we did not find that the learning curve for LC affected BDI occurrence.

Comparison of safety and efficacy of ultrasonic and bipolar thermal energy: an experimental study.

The safety and efficacy of the Ligasure-8 Generator with the new Ligasure V 5-mm forceps (Valleylab, Tyco Healthcare) (LS) and the Ultracision Harmonic Scalpel Generator 300 with the new 5 mm 36p Harmonic Ace forceps (Ethicon Endo-Surgery ING) (UC) are compared. Twenty New Zealand rabbits were randomly allocated into 2 groups and the short gastric vessels were divided with either LS or UC. The speed of each method, the number of the times it had to be applied, gastric perforation rates and histopathologic findings were recorded. Approximately the same number of applications was necessary for the 2 groups. UC was significantly faster but resulted in contained perforation in 3 cases against 1 for LS (difference statistically not significant). A tendency for deeper and more severe histopathologic damages was seen with UC. For routine fast dissection, UC is satisfactory, but where prevention of thermal injury is important, LS may be more appropriate.

Clinical significance of serum and urinary c-erbB-2 levels in colorectal cancer

In this study we measured serum and urinary c-erbB-2 levels in 63 patients with colorectal cancer and 29 healthy controls, assessing their role in cancer-specific survival and the effects of resectional surgery. Serum and urinary c-erbB-2 levels were measured by an enzyme-linked immunosorbent assay, preoperatively and 7 days following tumor resection. Preoperative serum c-erbB-2 concentrations were significantly higher in the cancer patients and correlated with disease stage and the presence of liver metastases. Urinary c-erbB-2 was detected more often in cancer patients, although levels did not differ from controls and there was no association with any clinicopathological variable. Serum c-erbB-2 levels decreased significantly in those patients resected for cure and were an independent prognostic factor for cancer-specific survival with higher preoperative concentrations correlating with worse overall survival. These findings suggest that serum assessment of c-erbB-2 concentration may be valuable in defining colorectal cancer prognosis.

Acute Appendicitis: The Reliability of Diagnosis by Clinical Assessment Alone

Background and Aims: This prospective study aimed to review the trustworthiness of the initial clinical assessment in acute appendicitis without employment of imaging modalities, laparoscopy or any other adjunct diagnostic test. Patients and Methods: 717 patients were operated on for appendicitis by six different surgeons. Initial clinical and laboratory examination were evaluated in relation to the intraoperative and the pathological appreciation of the appendiceal inflammation. Results: 598 patients were found to have appendicitis, 34 a different condition, 41 had both appendicitis and an additional condition and 44 no pathology. 6% of the laparotomies and 11 % of the appendectomies were unnecessary. The severity of the inflammation correlated significantly with periumbilical pain, pain migrating to right lower quadrant, loss of appetite, fever, rebound tenderness, local rigidity, polymorphonuclear predominance on deferential, polymorhonucleosis and leukocytosis. Leukocytosis was less frequent in aged patients. All the six surgeons were found to be equally reliable, although they all underestimated the setting compared to the pathologists. Patients with a long duration of symptoms had milder forms of inflammation and increased percentage of unanticipated abdominal conditions. Conclusions: Appendicitis can be reliably diagnosed clinically without employment of adjunct tests. These can be reserved for equivocal cases.

Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patients demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Early Experience with Totally Robotic Roux-en-Y Gastric Bypass for Morbid Obesity

BACKGROUND Laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity is a challenging operation. The application of robotic techniques has been shown to ease the technical difficulties and reduce perioperative morbidity, mainly because it facilitates the construction of the gastrojejunal anastomosis (GJ). Robotic laparoscopic RYGBP (LRYGBP) has been reported either as totally robotic with manual suturing of the GJ or as robotically assisted with the use of the robot only for the construction of the GJ. A totally robotic LRYGBP with a combined stapled and manual GJ has never been reported. PATIENTS AND METHODS Nine consecutive patients underwent totally robotic LRYGBP. The GJ was fashioned with a combination of the linear stapler and manual suturing. RESULTS Mean preoperative body mass index was 45.3 ± 4.7 kg/m(2). In 1 case, we had to undock the Da Vinci Surgical System at the time of the jejunojejunostomy due to unfavorable ergonomics. Mean time to dock the robot was 16.3 ± 3.3 minutes, whereas mean total operative time was 197.2 ± 12.3 minutes. Immediate postoperative morbidity and mortality equaled zero. One patient developed a stenosis of the GJ amenable to endoscopic dilatation. The mean excess weight loss rate 1-year postoperative was 79% ± 15%. CONCLUSION Totally robotic LRYGBP can duplicate precisely any conventional technique without any compromise in operative time, short- or long-term results.

Comparison Between Minimally Invasive and Open Gastrectomy for Gastric Cancer in Europe: A Systematic Review and Meta-analysis:

Aims: We compared laparoscopic and robotic gastrectomies with open gastrectomies and with each other that were held for gastric cancer in Europe. Methods: We searched for studies conducted in Europe and published up to 20 February 2015 in the PubMed database that compared laparoscopic or robotic with open gastrectomies for gastric cancer and with each other. Results: We found 18 original studies (laparoscopic vs open: 13; robotic vs open: 3; laparoscopic vs robotic: 2). Of these, 17 were non-randomized trials and only 1 was a randomized controlled trial. Only four studies had more than 50 patients in each arm. No significant differences were detected between minimally invasive and open approaches regarding the number of retrieved lymph nodes, anastomotic leakage, duodenal stump leakage, anastomotic stenosis, postoperative bleeding, reoperation rates, and intraoperative/postoperative mortality. Nevertheless, laparoscopic procedures provided higher overall morbidity rates when compared with open ones, but robotic approaches did not differ from open ones. On the contrary, blood loss was less and hospital stay was shorter in minimally invasive than in open approaches. However, the results were controversial concerning the duration of operations when comparing minimally invasive with open gastrectomies. Additionally, laparoscopic and robotic procedures provided equivalent results regarding resection margins, duodenal stump leakage, postoperative bleeding, intraoperative/postoperative mortality, and length of hospital stay. On the contrary, robotic operations had less blood loss, but lasted longer than laparoscopic ones. Finally, there were relatively low conversion rates in laparoscopic (0%–6.7%) and robotic gastrectomies (0%–5.6%) in most studies. Conclusion: Laparoscopic and robotic gastrectomies may be considered alternative approaches to open gastrectomies for treating gastric cancer. Minimally invasive operations are characterized by less blood loss and shorter hospital stay than open ones. In addition, robotic procedures have less blood loss, but last longer than laparoscopic ones.