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.

The incidence of HPV infection in anal cancer patients in Greece.

BACKGROUND AND AIM OF THE STUDY: Although anal cancer represents a relatively uncommon malignancy, its incidence over the last five decades, has been reported as increased for both sexes, worldwide. Human papillomavirus (HPV) infection has been shown to be a major cause for its development. The aim of the present study is to report on clinical, epidemiological and virological data of squamous anal cancer in Greek patients. PATIENTS AND METHOD: Between January 2002 and December 2010, 11 Greek patients (6 females) who were diagnosed as suffering from squamous cell anal or perianal cancer, were treated in our Hospital. Formalin fixed paraffin embedded tissue samples, obtained at the time of the anal biopsy or surgery, were analyzed by PCR in order to identify the presence as well as the type of HPV infection. RESULTS: Overall, the presence of HPV DNA was detected in 6 out of the 11 patients (54.5%). The "high risk" HPV DNA was detected in 3 of them (2 women and 1 man), while the "low risk" HPV DNA was detected in the remaining three (2 women and 1 man). CONCLUSION: The incidence of HPV infection in squamous cell anal cancer Greek patients, is lower than other Western countries, probably reflecting differences in sexual habits in the Greek population.

The effect of revascularization procedures on healing of mixed arterial and venous leg ulcers.

AIM: The optimal management of venous leg ulcers in patients with concomitant peripheral artery disease (PAD) remains unclear. The aim of the present study was to evaluate the effectiveness of revascularization procedures in healing of the ulcers of mixed etiology. METHODS: During a 6-year period a total of 20 patients with evidence of chronic venous insufficiency, impaired arterial perfusion (ABI<0.75) and active leg ulcer were treated. Patients with moderate PAD (0.5

Common carotid artery occlusion treatment: revealing a gap in the current guidelines.

OBJECTIVE: To review the literature on the management of common carotid artery occlusion (CCAO). METHODS: A review of English-language medical literature from 1965 to 2012 was conducted using the PubMed and EMBASE databases to find all studies involving management of CCAO. The search identified 21 articles encompassing 146 patients/arteries (73.2% men; mean age 65 ± 6.9 years). RESULTS: The majority of the patients (93.8%) were symptomatic. Most of the patients (61.5%) had ipsilateral internal carotid artery (ICA) and external carotid artery (ECA) patent, while an occluded ICA and a patent ECA were found in 26.6% of the patients. Eighty per cent of the patients treated underwent a surgical bypass procedure, with the subclavian artery as the most common inflow vessel (64.1%). During the first 30 days of the procedure two strokes (1.5%) were reported. During a follow-up period spanning an average of 25.6 ± 11.2 months nine patients (6.6%) experienced a clinical cerebrovascular event. Seven restenoses (5.1%) and two reocclusions (1.5%) also occurred-eight after open surgical and one after endovascular repair. CONCLUSION: The necessity to intervene to a CCAO remains controversial. This review shows that open surgical management of symptomatic CCA occlusive disease is a safe, durable, and effective therapeutic strategy with low perioperative cerebrovascular morbidity.

What is the actual fate of super-morbid-obese patients who undergo laparoscopic sleeve gastrectomy as the first step of a two-stage weight-reduction operative strategy?

The overall success-rate of the two-stage treatment plan for the treatment of super-morbid obesity has not yet been assessed. We reviewed the long-term results of 41 treated super-morbid-obese patients. Mean initial BMI was 59.5 ± 3.5 kg/m(2). Twelve patients (29.3 %) achieved after only LSG a BMI <35 kg/m(2) (mean 31.9 ± 2). They have lost 78.7 ± 11.8 % of excess body weight (EBW). The remaining 28 patients lost 48.1 ± 11.9 % of EBW and achieved a mean BMI of 44.2 ± 4.3 kg/m(2), thus requiring the second stage. Ten of them (24.4 % of the total or 35.7 % of those in need), were submitted to laparoscopic Roux-en-Y gastric bypass (LRYGBP). They lost 71.9 ± 4.3 % of EBW and have a mean BMI of 33.6 ± 2.7 kg/m(2). The 18 remaining patients have a BMI of 42 ± 3.6 kg/m(2) and they still suffer from morbid obesity. They have lost 48.5 ± 8.7 % of EBW. The mean rate of EBW loss for all the available 39 patients after either LSG or both LSG and LRYGBP has been 63.2 ± 16.5 % after a mean follow-up of 42.8 ± 19.5 months. Out of 41 patients, 1 died, 1 was lost to follow-up, 21 (51.2 %) achieved "healthy" BMIs and 18 (44 %) still require LRYGBP. The rate of cure of morbid obesity was 51.2 %. A remaining 44 % of super-morbid obese patients still need the completion LRYGBP but have not undergone it. Half of these patients have lost >50 % of their EBW. The two-stage strategy is an effective treatment plan for super-morbid obesity. A less patient-dependent strategy may be needed for a subset of patients.

[Sexual mutilations through ages]. / Les mutilations sexuelles à travers les âges.

Among the ethnic mutilations (volunteer mutilations performed for religious, aesthetic, moral or hygienic purposes), genital mutilation (circumcision, castration, total emasculation, infibulation, excision, etc.) have always fascinated the human mind and are the subject of our historical overview.

Improvement of skin-graft survival after autologous transplantation of adipose-derived stem cells in rats.

BACKGROUND: Skin grafts are frequently used for a variety of indications in plastic and reconstructive surgery. Their necrosis is a common complication, while different therapies have been proposed. Currently, adipose-derived stem cells (ASCs) hold great promise for their angiogenic potential and role during tissue repair. In this study, autologous transplantation of ASCs was used in skin grafts in rats to determine if it increases angiogenesis, skin-graft survival and wound healing. METHODS: ASCs were isolated, cultured, labelled with fluorescent dye and injected under full-thickness skin grafts in 10 rats (group 1), while 10 others served as controls (group 2). Skin grafts were analysed after 1 week. Collagen's framework was assessed with Masson's trichrome stain and angiogenesis with von Willebrand factor (vWF) immunohistochemistry. In addition, immunohistochemical staining intensity of vascular endothelial growth factor (VEGF) and transforming growth factor b3 (TGFb3) was assessed in all grafts. RESULTS: Mean area of graft necrosis was significantly less in group 1 than in group 2 (6.12% vs. 32.62%, p<0.01). Statistically significant increase of microvessel density, collagen density, VEGF and TGFb3 expression was noted in group 1 compared with group 2 (all: p<0.01). CONCLUSIONS: These findings suggest that autologous ASCs transplantation increases full-thickness skin-graft survival and shows promise for use in skin-graft surgery. This might be both due to in situ differentiation of ASCs into endothelial cells and increased secretion by ASCs of growth factors, such as VEGF and TGFb3 that enhance angiogenesis and wound healing.

Clinical value of right hemicolectomy for appendiceal carcinoids using pathologic criteria.

BACKGROUND: Appendiceal carcinoids (AC) are usually adequately treated by appendectomy. The European Neuroendocrine Tumours Society (ENETS) has recently reconsidered the previous pathologic criteria to identify patients at high risk of extra-appendiceal disease, who are thought to require right hemicolectomy (RHC). AIM: The aim of this retrospective, observational study was to evaluate previous and currently introduced criteria, in identifying patients with AC in whom RHC is justified. SUBJECTS AND METHODS: Twelve patients who underwent RHC for AC were retrospectively identified. Demographic and follow-up data were collected and appendectomy specimens were reviewed for the presence of indications leading to RHC defined as: tumor diameter ≥2 cm, tumor location at the base, mesoappendiceal extension, mitotic index Ki-67≥2%. RHC specimens were examined to identify evidence of extra-appendiceal disease, remaining and/or metastatic disease. RESULTS: Four patients fulfilled two criteria and 8 one criterion for RHC. Two patients had tumors ≥2.0 cm, 5 located at the base, 8 invading the mesoappendix and periappendiceal fat; Ki-67 PI was 1% in all cases measured except one, in which it was 3%. Post-RHC, 3 patients (25%) had extra-appendiceal disease (no residual disease was identified in surgical margins); 1 had tumor at the colon specimen and 2 had lymph node metastasis. All 3 patients fulfilled only one pathologic criterion; 1 had tumor mesoappendiceal extension and 2 tumor location at the base of the appendix. CONCLUSIONS: Applying previous and currently introduced pathologic criteria, 25% of high-risk patients with AC had identifiable extra-appendiceal disease following RHC that might be not detected following the recently introduced ENETS criteria.

Transradial access for carotid artery stenting: a single-center experience.

AIM: The aim of this study was to report our initial experience using the radial artery as access for carotid artery stenting (CAS) and review the existing literature. METHODS: From January to June 2008, nine high-risk consecutive patients were treated with carotid stents by using the radial artery as an access point. Major complications (perioperative myocardial infarction, stroke, transient ischemic attack [TIAs] and death) and minor complications (radial artery occlusion or hematomas) were evaluated during this procedure. RESULTS: Seven of these patients had a right (77.8%) and two had a left (22.2%) sided carotid artery stenosis. Patients were symptomatic (TIAs or strokes or both) and had a >60% stenosis of the internal carotid artery. The technical success rate was 100% and all patients mobilized two hours after the procedure and were discharged home on the first postoperative day. No major or minor complications were reported. CONCLUSION: Patients with vessel pathology or unfavorable anatomy in the iliofemoral arteries or/and the aorta, can be candidates for CAS through the radial artery. Refinement of the technique and improvement in endovascular devices may lead to the replacement of the conventional femoral access by the transradial route in the near future.

Guided remote endarterectomy for superficial femoral artery occlusions: a technical note.

The aim of this paper was to describe a new modification of the remote endarterectomy for the treatment of long superficial femoral artery (SFA) occlusions and to present our preliminary results. Through a subinguinal incision and arteriotomy over the SFA origin, a hydrophilic guidewire was introduced into the subintimal plane of the SFA and advanced distally until reentry into the distal patent popliteal artery. The hydrophilic guidewire is exchanged for an Ablatz wire to provide support for the advancement of the single endarterectomy ring. The MollRing Cutter was introduced in the SFA after the removal of the single endarterectomy ring and it was advanced until the re-entry point. The atherosclerotic core was removed and a nitinol self-expanding stent was placed at the peripheral end of the endarterectomy. Arteriotomy was closed with a patch. Guided subintimally-assisted remote endarterectomy seems to be a successful and safe modification of the traditional technique in the treatment of SFA occlusion, in patients with critical limb ischemia.

Laparoscopic bowel injury: role of the site and the instrument type: study with an animal model.

BACKGROUND: Unrecognized laparoscopic bowel injuries are complications that can occur during any laparoscopic procedure. These complications have variable morbidity and mortality rates, and their early clinical signs of inflammation are not typical. Therefore, a study was planned to predict the mechanical behavior of the injured bowel, taking into consideration two parameters: the size of the instrument and the site of the injury. METHODS: For this study, 78 Wistar rats were divided into eight study groups and one control group with two subgroups. Bowel injury was created using different sizes of needles and electrocautery on two different bowel sites: the jejunum and the terminal ileum. The animals were killed 48 h after surgery, followed by harvesting of the injured part of the bowel and measurement of the intraluminal pressure at which the bowel ruptured. RESULTS: The mean jejunum and terminal ileum rupture pressures on the injured bowel were significantly lower than on the intact bowel. The mean terminal ileum rupture pressures were significantly lower than those of the jejunum. CONCLUSIONS: The terminal ileum appears to be more fragile than the jejunum regardless of the size of the instrument that caused the injury. However, wider instrument tips cause more serious consequences.

Preclinical studies of steroid-linked nitrosoureas in murine pancreatic adenocarcinoma PANO2.

PURPOSE: In earlier studies, this laboratory carried out research on the synthesis and anticancer evaluation of hybrid compounds, which combine two molecules in one such as homo-aza-steroidal esters (HASE) of carboxylic derivatives of N, N-bis (2-chloroethyl) aniline. In this combination, steroidal hormones are employed as carriers for transporting the alkylating agents to specific targeted tissues. Aiming to continue our research, we used alkylating agents, as nitrosoureas, instead of nitrogen mustards. In this work the N-[N- (2-chloroethyl)-N-nitroso-carbomoyl]-L-alanine (CNC-ala) has been used and was bound to 7 newly synthesized modified steroidal esters (carrier molecule) of nitrosourea and the hybrid molecules were tested for antitumor activity against PANO2 murine pancreatic adenocarcinoma. MATERIALS AND METHODS: PANO2 adenocarcinoma was used in this study. C57Bl mice were used for chemotherapy evaluation. The activity was assessed from the inhibition of tumor growth and the oncostatic parameter T/C %. RESULTS: The antitumor activity displayed by 7 hybrid steroidal esters of nitrosourea was quite interesting. It was able to discern 4 of 7 compounds that exhibited considerable antitumor activity, increasing the lifespan of the tumor-bearing mice by inhibiting the tumor growth. CONCLUSION: The comparative study of 7 newly synthesized hybrid steroidal esters of nitrosourea shows that the antitumor effects of compound 7, which has an enlarged (7 carbon atoms) A-lactamic ring and nitrosourea esterified at the position 17, which seems to be the most appropriate for the connection of a DNA cross-linking amino acid derivative is superior.

Can the diameter of endoluminal shunt influence the risk of hyperperfusion syndrome after carotid endarterectomy?

AIM: The aim of this study was to evaluate if there is a possible relation between the size of endoluminal shunt, in carotid endarterectomy (CEA), and the risk of postoperative hyperperfusion syndrome. METHODS: We retrospectively studied prospectively collected data from 156 patients, who were subjected to CEA using shunting and vein patch angioplasty. One hundred and thirty-eight of the patients had bilateral, high grade (> or = 90%) internal carotid lesions and the remaining 18 had a high-grade stenosis (> or = 90%) and a contralateral internal carotid artery (ICA) occlusion. In 81 patients varying diameters of shunts were used (8-14 Fr) according to the diameter of ICA (group A) and in the other 75 patients (group B) only the smallest shunt was used (8 Fr). Development of hyperperfusion syndrome was evaluated both clinically and radiologically with magnetic resonance imaging. RESULTS: Fifteen patients developed hyperperfusion syndrome (9.6%), between 0 to 6 days postoperatively. Thirteen belonged to group A (86.6%), and 2 (13.3%) belonged to group B (P<0.05). One had an intracerebral hemorrhage (0.6% of the study group) the 3rd postsurgical day. CONCLUSIONS: During CEA in patients with high-grade bilateral lesions, we recommend the use of a shunt with small diameter: this aims at reducing the risk of hyperperfusion syndrome.

Pressure dressing in breast surgery: is this the solution for seroma formation?

PURPOSE: Pressure dressing (PD) after modified radical mastectomy (MRM) for breast cancer is investigated here as an easy-to-apply method to reduce seroma formation and subsequent need for clinical care. PATIENTS AND METHODS: Two hundred mastectomized patients who were treated with PD on the skin flaps and the axilla immediately postoperatively (group A) were compared with a similar non-PD group (B). Surgical technique and perioperative care were the same. Drains were removed when drain output was reduced to 30 ml per day, or on postoperative day 8 regardless of output. RESULTS: Mean time with drains kept in situ was 4.9 and 5.5 days in group A and B, respectively. Five (2.5%) patients in group A and 16 (8%) in group B developed seromas after the removal of the drains. In total, 9 seroma needle aspirations were performed in group A and 26 in group B. Differences were statistically significant. CONCLUSION: Our findings are supportive of PD as an effective, cheap and easy-to-apply method for the reduction (a) of the time with drains in situ after MRM, (b) of the number of patients developing seromas and (c) of the seroma aspirations. This can potentially reduce further complications, needed medical care and cut expenditure.

Use of fogarty catheter to limit hemorrhage and hematoma after vacuum-assisted breast biopsy.

A 42-year-old woman underwent vacuum-assisted breast biopsy (VABB, 11G) due to a nonpalpable, BI-RADS 4A lesion without microcalcifications. During the procedure, an extraordinarily large amount of blood was lost. In an attempt to stop the hemorrhage and limit the imminent hematoma, a thin intravascular Fogarty catheter was inserted adjacent to the VABB probe (through the same incision). The catheter was maintained in its position for 2 days. At clinical examination 9 days after VABB, no hematoma was present. The use of a Fogarty catheter seems capable of limiting any severe bleeding after VABB and may also possibly prevent subsequent hematoma formation.

A metalloproteinase-9 polymorphism which affects its expression is associated with increased risk for oral squamous cell carcinoma.

AIM: In light to recently found contribution of factors associated with angiogenesis, thrombosis and inflammation to carcinogenesis, we investigated the possible association of metalloproteinase-9 (MMP-9) with increased risk of oral cancer. METHODS: In DNA samples of 152 patients with oral squamous cell carcinoma and 162 healthy controls of comparable ethnicity, age and sex, we studied the -1562 C/T polymorphism in the MMP-9 gene promoter, which affects its transcription. RESULTS: The detected frequency for the high expression T allele in the patients' group was significantly increased in comparison to that of the control group (22% versus 15%, respectively; P<0.05). This difference was due to the relative increase of C/T heterozygotes in the group of patients, in comparison to controls (P<0.05, 95% OR 1.92, CI 1.21-3.06). The same pattern of significance was observed between controls and the subgroups of patients with initial (I & II) stages of cancer, without positive family history of cancer or thrombophilia, with smoking and alcohol abuse habits. CONCLUSIONS: The investigated MMP-9 polymorphism has a strong association with increased risk for developing oral cancer in a subset of the general population. These results are in accordance to previous studies of constitutive expression and secretion of MMP-9 in invasive oral carcinoma cell lines. The observation that T allele carriers have an increased risk for developing oral cancer only in initial stages, but not in advanced ones, may be due to the role of MMP-9 in the inhibition of angiogenesis by generating angiostatin from plasminogen.

sRANKL/osteoprotegerin complex and biochemical markers in a cohort of male and female hemodialysis patients.

OBJECTIVE: The processes involved in bone remodeling are under the control of a multitude of systemic and local factors. Receptor activator of nuclear factor-kappaB ligand (RANKL)/osteoprotegerin (OPG) complex seems to be one of the major modulators of bone remodeling. In chronic renal failure, the cytokine systems involved in the regulation of bone turnover may be influenced, and are therefore likely to contribute to the pathogenesis of renal bone disease. The aim of the present study was the evaluation of RANKL/OPG complex in concert with other biochemical parameters in hemodialysis (HD) patients and the investigation of possible correlations between the serum levels of its components and several clinical parameters of these patients. METHODS: We measured serum levels of intact PTH (iPTH), total serum RANKL (sRANKL), osteoprotegerin (OPG), alkaline phosphatase, osteocalcin (OC), and tartrate-resistant acid phosphatase (TRAP) in 104 HD patients and in 40 healthy controls. RESULTS: The average serum OPG level was significantly higher, whereas the average serum concentration of RANKL was nonsignificantly lower in patients on HD therapy than in age-matched healthy controls. Consequently, the mean sRANKL/OPG ratio was significantly lower in patients. Among HD patients, serum level of OPG increased significantly with aging and with a longer duration of hemodialysis. RANKL levels were inversely correlated with age nonsignificantly in the whole group of patients and significantly in the female subgroup (r=-0.322, p=0.035), whereas RANKL/OPG ratio declined significantly with age in the entire cohort of patients (r=-0.259, p=0.008). In addition, iPTH, OC, TRAP were significantly higher in female, whereas RANKL/OPG ratio was significantly higher in male than female patients. CONCLUSIONS: Lower values of sRANKL/OPG ratio in HD patients, as well as the age and duration of HD dependent increase of serum OPG and the age-dependent decrease of sRANKL concentration especially in women cannot be explained by the elimination of renal clearance only. Alterations in sRANKL/OPG ratio might reflect a compensatory mechanism to modulate bone remodeling in these patients.

Strong association of interleukin-6 -174 G>C promoter polymorphism with increased risk of oral cancer.

In view of the recently found contribution of factors associated with thrombosis and inflammation to carcinogenesis, we investigated the possible association of interleukin-6 (IL-6) with an increased risk of oral cancer. In DNA samples of 162 patients with oral squamous cell carcinoma and 156 healthy controls of comparable ethnicity, age and sex, we studied the -174 G>C polymorphism in the IL-6 gene, which affects its transcription. C allele frequencies were significantly increased in patients compared to controls, 42.6% versus 23.1% (p<0.001). The CC homozygotes had a 7-fold greater risk of developing oral cancer (odds ratio 7.39, 95% CI 2.61-20.92), while the GC heterozygotes had a 4-fold greater risk (odds ratio 3.74, 95% CI 2.29-6.11). A significant increase in C alleles was observed in patients regardless of their smoking or alcohol consumption habits, early or advanced stage of cancer, and presence or absence of a family history for cancer or thrombophilia (p<0.001; Fisher's exact test). These findings suggest that the -174 G>C polymorphism, by affecting IL-6 gene expression, is strongly associated with oral oncogenesis.