Development and internal validation of a clinical prediction model for serious complications after emergency laparotomy.

PURPOSE: Emergency laparotomy (EL) is a common operation with high risk for postoperative complications, thereby requiring accurate risk stratification to manage vulnerable patients optimally. We developed and internally validated a predictive model of serious complications after EL. METHODS: Data for eleven carefully selected candidate predictors of 30-day postoperative complications (Clavien-Dindo grade > = 3) were extracted from the HELAS cohort of EL patients in 11 centres in Greece and Cyprus. Logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) was applied for model development. Discrimination and calibration measures were estimated and clinical utility was explored with decision curve analysis (DCA). Reproducibility and heterogeneity were examined with Bootstrap-based internal validation and Internal-External Cross-Validation. The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) model was applied to the same cohort to establish a benchmark for the new model. RESULTS: From data on 633 eligible patients (175 complication events), the SErious complications After Laparotomy (SEAL) model was developed with 6 predictors (preoperative albumin, blood urea nitrogen, American Society of Anaesthesiology score, sepsis or septic shock, dependent functional status, and ascites). SEAL had good discriminative ability (optimism-corrected c-statistic: 0.80, 95% confidence interval [CI] 0.79-0.81), calibration (optimism-corrected calibration slope: 1.01, 95% CI 0.99-1.03) and overall fit (scaled Brier score: 25.1%, 95% CI 24.1-26.1%). SEAL compared favourably with ACS-NSQIP in all metrics, including DCA across multiple risk thresholds. CONCLUSION: SEAL is a simple and promising model for individualized risk predictions of serious complications after EL. Future external validations should appraise SEAL's transportability across diverse settings.

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy.

BACKGROUND: Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS: A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS: A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION: The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level II.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece.

BACKGROUND: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Trauma laparotomy for the usual reasons, but for unusual causes.

The impact of synchronous diseases or conditions on operative management of Trauma patients is not well established. In trauma patients, secondary diagnoses may complicate the treatment strategy and lead to changes in management and potentially outcomes. We present 5 unusual trauma cases and we discuss the difficulties and the outcomes we experienced in managing these patients.

Extensive Bilateral Adrenal Rest Testicular Tumors in a Patient With 3ß-Hydroxysteroid Dehydrogenase Type 2 Deficiency.

Testicular adrenal rest tumors (TARTs) are presumably derived from ectopic adrenocortical tissue in the testis, affecting up to 49% to 94% of males with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Few reports have described TARTs in rarer forms of CAH such as 3ß-hydroxysteroid dehydrogenase type 2 deficiency (3ßHSD2D). A man with 3ßHSD2D presented with massive bilateral testicular tumors. He had been treated with glucocorticoids and mineralocorticoids since infancy, with difficulties in suppressing dehydroepiandrosterone sulfate. At the age of 13 years, bilateral testicular lumps were found, and a radiologic diagnosis of TARTs was proposed. Subsequent sonographic examinations showed progression, despite intensifying his glucocorticoid therapy with metabolic complications. Following an open testicular biopsy, concerns of a Leydig cell tumor and risk of malignant transformation were raised, and because the patient also had local symptoms and azoospermia, he underwent bilateral orchiectomy at age 33 years. Histopathology was consistent with bilateral TARTs, exhibiting widespread immunoreactivity for adrenocortical markers, whereas no histological features of Leydig cell tumors were seen. The distinction between TARTs and Leydig cell tumors is important but can be challenging, and in our case, orchiectomy was needed to rule out the latter diagnosis. TART should be considered a differential diagnosis also in patients with 3ßHSD2D who have testicular lumps.

The effects of antioxidants on a porcine model of liver hemorrhage.

PURPOSE: The aim of this study is to assess the efficacy of the combination of N-acetylcysteine (NAC) and deferoxamine (DFO) in the resuscitation from hemorrhagic shock in a porcine model of bleeding during hepatectomy. METHODS: Twenty-one pigs were divided randomly to three groups: Sham (S) group, n = 5; fluid (F) resuscitation group, n = 8; and fluid plus NAC plus DFO (NAC&DFO) resuscitation group, n = 8. The animals of groups F and NAC&DFO were subjected to left hepatectomy and controlled hemorrhage from the traumatic liver surface. Shock was established within 10 minutes and maintained for 30 minutes at mean arterial pressure (MAP) of 30 to 40 mm Hg. Resuscitation followed the shock period with crystalloids and colloids. Group NAC&DFO received additionally NAC and DFO in doses of 200 mg/kg and 65 mg/kg, respectively. The total time of the experiment was 6 hours. RESULTS: Animal weight, blood loss, excised liver mass, and MAP at the end of the shock period were comparable between experimental groups. Group NAC&DFO received significantly lower volume of both crystalloids and colloids (35% and 42% less, respectively) compared to group F. Hepatocellular proliferation (proliferating cell nuclear antigen) was higher in the antioxidant group. Apoptosis, measured by caspase-3, was restored to sham group levels when NAC and DFO were administered. CONCLUSIONS: Our experimental study showed that coadministration of NAC and DFO during liver hemorrhage can decrease the amounts of fluids needed for resuscitation. Moreover, the antioxidant combination restores the energy dependent apoptosis and proliferation of the hepatocytes.

Injury to Azygos Venous System: A Co-Existing Injury in High-Impact Lethal Trauma.

BACKGROUND: About 50 cases of azygos venous system injuries following civilian trauma have been published in current literature. The purpose of our study was to investigate the incidence of these injuries, the causative mechanism and type of trauma, the co-existing injuries, and the mortality rate in our institution. METHODS: We performed a retrospective review of all trauma patients who were admitted to the surgical department of the General Hospital of Rethymno during an 11-year period. Our study included patients arriving at our institution dead or alive with an azygos venous system injury following blunt or penetrating civilian trauma. RESULTS: Seven patients-five men and two women-were identified with azygos venous system injuries. Five had an azygos vein laceration, one suffered from both azygos and hemiazygos vein lacerations, and the last one had sustained hemiazygos and accessory hemiazygos vein injuries. All of them suffered from a blunt trauma. Three arrived at our hospital in extremis, and all died within 24 h despite our resuscitation attempts. All of our patients were polytrauma patients. All of them had co-existing torso injuries which were severe in all but one case, three of them suffered also from serious head injuries, and all but one had at least serious extremity's injuries. CONCLUSION: Azygos venous system injuries are rare, although it seems that they are more frequent than current literature would indicate. Blunt trauma mechanism seems to be predominant in civilian trauma setting, and the patients have usually sustained a lot of serious and severe co-existing injuries with high resultant lethality.

The effects of hemorrhagic shock secondary to hepatectomy in a swine model.

BACKGROUND: Ischemia-reperfusion injury caused by severe hemorrhagic shock and subsequent resuscitation leads to deterioration of hepatic homeostasis and possibly to liver failure. The present study focuses on determining whether there is a different biological response to hemorrhagic shock by different sources of hemorrhage, hepatic hemorrhage (HH) versus peripheral hemorrhage. METHODS: Twenty-one male swine (Sus scrofa domesticus) were randomly allocated in three groups as follows: sham group (S, n = 5), central venous hemorrhage group, (CVH) (n = 8), and HH group (n = 8). Hepatectomy of the left liver lobe was carried out in groups CVH and HH, and the animals were subjected to controlled bleeding from the internal jugular vein and the traumatic liver surface, respectively. After 10 min of hemorrhage, shock was maintained for 30 min at mean arterial pressure levels of 30 mm Hg-40 mm Hg and resuscitation was initiated with crystalloids and colloids. Hemodynamic parameters and fluid balance were monitored throughout the 6 h of total duration of the experiment. Blood samples were collected at 0-, 40-, and 360-min time points for transaminases, albumin, and interleukin-6 measurement. Hepatic tissue was harvested at the end of the experiment for oxidative marker and proliferation analysis. RESULTS: Although blood loss was comparable between the two groups, the amount of fluids needed for resuscitation was higher for the HH group. Inflammatory response, measured by interleukin-6, was found higher in HH group. Oxidative stress markers did not reveal statistically significant difference between the two groups. Liver hemorrhage decreased hepatocellular proliferation measured by proliferating cell nuclear antigen. CONCLUSIONS: Our study provides evidence that HH entails worse consequences for the hepatocytes than systemic hemorrhage. Higher needs for resuscitation fluids, decreased proliferation, and augmented inflammatory response when HH takes place are findings with possible clinical importance in liver surgery and trauma.

The safety of primary repair or anastomosis in high-risk trauma patients.

PURPOSE: There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries. METHOD: In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded. RESULTS: Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation. CONCLUSION: Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.

A morphometric study of multiple renal arteries in Greek population and a systematic review.

The aim of the study was to determine the distribution patterns of multiple renal arteries, evaluate how they are affected by gender and bilateral asymmetry and proceed on a systematic review. Two hundred and six kidneys from 103 Greek cadavers (53 males and 50 females) were investigated. The number and pattern of multiple renal arteries were determined according to side, gender and level of origin. The distances between the main renal and first multiple renal arteries were also measured. Multiple renal arteries were present in 11.2% of the kidneys. No statistically significant difference was found between side and gender (p>0.05). The incidence of multiple renal arteries was 87% unilaterally and 13% bilaterally. As regards the multiple renal arteries, a single artery was detected in 83%, two in 13% and three in 4.3%. In 30.4% (7/23) of the kidneys, there was a short common trunk (<1.5 cm), early dividing into the main renal artery and a thinner artery. Multiple renal arteries on the left side seemed to emerge lower than the right ones and displayed a greater variability at their origin. In the systematic review, we detected the patterns of multiple renal arteries which were classified according to population, gender, side and specimen (cadaveric, radiological or transplant). The awareness of morphology and topography of the multiple renal arteries is important in order to achieve a safe pre and intraoperative management of the renal vascular supply.

Variations in the anatomy of the celiac trunk: A systematic review and clinical implications.

The normal pattern of the celiac trunk (CT) implies its bifurcation to three branches, the common hepatic, the splenic and the left gastric artery. According to the available literature the CT presents several anatomical variations. The purpose of our study is to investigate the different types of these variations, the corresponding incidences and the probable influence of genetic factors, as they are presented in the existing literature. Four databases were searched for eligible articles for the period up to January 2013 and a total of 36 studies were collected. The CT was trifurcated into the three basic branches in the 89.42% (10,906/12,196) of the cases. Bifurcation of the CT occurred in the 7.40% of the pooled samples (903/12,196). Absence of the CT was the rarest variation with a percentage of 0.38% (46/12,196), hepatosplenomesenteric trunk was found in 49 out of the 12,196 cases (0.40%) and the celiacomesenteric trunk presented an incidence of 0.76% (93/12,196). Other variations of the CT were detected in the 1.64% of the pooled cases (199/12,196). The 14.9% of the cases in the cadaveric series (489/3278 specimens), the 10.5% in the imaging series (675/6501 specimens) and the 4.6% (104/2261) in the liver transplantation series presented variations. These differences are statistically significant (p<0.001). The Japanese and Korean populations presented more variations in the CT than Caucasians (p<0.05 and p<0.001). Negro, colored and black populations presented more variations of the CT than Indian ones (p>0.05). Using those data, a novel classification of CT variations is proposed.

A morphometric study of the celiac trunk and review of the literature.

The anatomy of the celiac trunk and its branches was examined in 77 adult human cadavers of Caucasian (Hellenic) origin. The celiac trunk followed the normal pattern, namely trifurcation to the common hepatic, splenic, and left gastric arteries, in 90.9% of the dissections (70/77). Two different types of trifurcation were observed: (a) a true tripod when the celiac trunk ended in a complete trifurcation (74.0%, 57/77) and (b) a false tripod when the three arteries did not have a common origin (16.9%, 13/77). Such a clear predominance of the true tripod is not reported elsewhere. Anatomic variations were found in 9.1% (7/77). Bifurcation of the celiac trunk into splenic and left gastric artery (splenogastric trunk) was observed in one specimen (1.3%), whereas the common hepatic artery emerged directly from the aorta. Absence of the celiac trunk was also found in two individuals (2.6%). The celiac trunk presented additional branches (lumbar and inferior phrenic arteries) in 5.2% (4/77). The median level of origin of the celiac trunk was at the upper third of L1 (22.7% to 17/75). The total length of the celiac trunk ranged from 1.1 to 5.0 cm, whereas the mean length was 2.8 cm (standard deviation = 0.80 cm, standard error of mean = 0.09 cm) irrespective of the existence of variations. The mean length of the celiac arteries which formed a false tripod was found to be larger than those of the arteries which formed a true tripod but only a weak statistically significant difference was established (P = 0.073).

Bilateral Origin of the Testicular Arteries from the Lower Polar Accessory Renal Arteries / Origen Bilateral de las Arterias Testiculares desde las Arterias Renales Polares Inferiores Accesorias

The gonadal arteries (testicular or ovarian arteries) emerge normally from the lateral aspect of the abdominal aorta, a little inferior to the renal arteries. Several other sites of origin of these arteries have been recorded with the renal and accessory renal arteries being the most common. In the present case report, the testicular arteries originated from the lower polar accessory renal arteries in both sides. The testicular veins followed had the usual origin and course, while an accessory renal vein was observed only in the right side. These anomalies were combined with an abnormal left ureter exiting from the lower pole of the kidney. Only one male cadaver among 77 adult human cadavers of Caucasian origin presented this set of variations (frequency: 1.3%). Variations of renal and gonadal vessels are important, as their presence could result in vascular injury of any accessory or aberrant vessel if the surgeon does not identify them.

Las arterias gonadales (testiculares o ováricas) se originan normalmente de la parte lateral de la parte abdominal de la aorta, distal a las arterias renales. Se han registrado otros lugares de origen de estas arterias, entre ellos, los más comunes en las arterias renales y renales accesorias. En el presente caso, las arterias testiculares se originaron bilateralmente desde las arterias renales polares inferiores accesorias. Las venas testiculares siguieron el origen y curso habitual, mientras que una vena renal accesoria sólo se observó en el lado derecho. Estas anomalías se combinaron con un uréter izquierdo anormal que salía desde el polo inferior del riñón. Sólo un cadáver de sexo masculino, de origen caucásico, entre los 77 cadáveres humanos adultos, presentaba este conjunto de variaciones (frecuencia: 1,3%). Las variaciones de los vasos renales y gonadales son importantes. Su presencia, si el cirujano no los identifica, puede resultar en lesiones vasculares de algún vaso accesorio o aberrante.

The effect of warm liver ischaemia & reperfusion injury on circulating plasma lipid levels & lipolytic enzyme activity in rat & the impact of ischaemic preconditioning.

BACKGROUND & OBJECTIVES: Ischaemia/reperfusion (I/R) associated with major liver surgery compromises liver function. Ischaemic preconditioning (IPC) may be effective in minimizing hepatic I/R injury. This study aimed to investigate the impact of liver ischaemic manipulations on lipid metabolism in rat during the process of liver recovery after liver surgery. METHODS: Sixty three male Wistar rats were assigned to three groups: the sham group, the I/R group which underwent warm ischaemia and reperfusion (I/R), and the IPC group. The animals were subdivided in 3 groups [1 st , 3 rd and 7 th postoperative day (PO)]. Hepatic lipase (HL) and total lipase (TL) activity and the levels of aspartate and alanine transaminases (AST, ALT), triglycerides, HDL and cholesterol were measured in plasma. RESULTS: There was no significant difference in the activity of HL and TL between the groups. Significant higher levels of HDL (P<0.0001) were observed in the IPC group when compared to the other groups on the 3 rd PO day. Triglycerides (P<0.0001) and HDL (P=0.003) in the IPC group were higher than the sham group on the 7 th PO day while HDL was also higher in the I/R group. Significantly higher cholesterol levels were found in the I/R and IPC groups on the 7 th PO day, which were not observed in the sham group. There was a similar curve for triglycerides in the sham and IPC groups while there were significantly higher levels of triglycerides on day 7 for the I/R group. The levels of HDL in the IPC group were higher on the 3 rd and 7 th PO day, compared to day 1. INTERPRETATION & CONCLUSION: Warm ischaemia and I/R injury do not seem to affect lipolytic enzyme activity after the 1 st PO day despite the effects on plasma lipids. IPC seems to prevent accumulation of triglycerides and cholesterol in plasma.

Variations of the iliac and pelvic venous systems with special attention to the drainage patterns of the ascending lumbar and iliolumbar veins.

The anatomy of the inferior vena cava (IVC) and common, external and internal iliac veins (CIV, EIV, IIV respectively) was examined in 59 embalmed adult human cadavers of Caucasian origin. In the present study, we focus our attention on the drainage patterns of the ascending lumbar and iliolumbar veins (ALV, ILV) when there are variations in the major pelvic veins by highlighting and describing the variations themselves. The above patterns, when no variations exist, have already been reported. Among the 59 cadavers, nine (9/59, 15.3%) presented anomalies of the major pelvic veins, as follows: anomalous drainage of both EIV and IIV in 8.5% of the specimens (5/59, Type I); variations of the IVC in 3.4% (2/59, Type II); duplication of the IIV (1/59=1.7%, Type III); anastomotic branch between the right IIV and the left CIV (1/59=1.7%, Type IV). ALV drained either into the CIV (8/18 sides, 44.4%) or in EIV (5/18 sides, 27.8%), while absence of ILV was the most frequent pattern (8/18 sides, 44.4%). A common trunk, joining the two veins, was observed in 5/18 sides (27.8%). Those drainage patterns were in accordance with the ones discovered in our previous study. In Type I the two veins always drained into the EIV. Knowledge of the surgical anatomy of all studied veins may prevent injury to these veins during operations in the retroperitoneal space and pelvis or malposition of venous catheters placed from the groin.

Study of the ascending lumbar and iliolumbar veins: surgical anatomy, clinical implications and review of the literature.

The surgical anatomy (geometrical features, metric relations, and drainage pattern) of the ascending lumbar vein (ALV) and iliolumbar vein (ILV) is clinically important. Notwithstanding, the available literature comprises but a small number of studies and a limited number of specimens involved. The present study constitutes a detailed description and classification of the drainage pattern of both these veins. The detailed anatomy of ALV and ILV was examined in both sides in 59 embalmed adult human cadavers of Caucasian origin. Cases with anatomical variations (9 cadavers) of the inferior vena cava (IVC), common iliac vein (CIV), external iliac vein (EIV) and internal iliac vein (IIV) were excluded from subsequent study and analysis. In the remaining 50 cadavers (100 sides) two main drainage types of the lower end of ALV were found. In Type I (54%, 54/100) the ALV presented the same pattern in both sides. In Type II, the ALV differed in pattern from one side to the other (46%, 46/100). Four subtypes were recorded for each Type. An ALV-ILV common trunk occurred in 15% (15/100). The percentage of variations of ALV was 34% and ILV 91%. The number of variations of the two veins differed significantly (p<0.001). No statistically significant difference was found relating to side or gender. Thorough knowledge of the surgical anatomy of ALV and ILV prevents injury, bleeding and further complication of many operations in the retroperitoneal space and pelvis. Awareness of the geometrical features of ALV and ILV helps avoiding or aids early recognition of a misplacement of a vascular catheter into the ALV during femoral vein catheterizations.

The effect of hepatectomy on plasma lipolytic enzyme activity and circulating lipid levels: an experimental study on Wistar rat.

BACKGROUND/AIMS: The aim of this experimental study was to investigate the effect of liver resection and resulting transient hepatic steatosis on circulating lipid levels and plasma lipolytic enzyme activity. METHODOLOGY: Forty-eight male Wistar rats were assigned to the sham (Group A=21) or the hepatectomy group (Group B=27) and were further subdivided according to the day they were sacrificed (POD 1, 3 and 7). We measured hepatic lipase (HL) and total lipase (TL) activity and plasma levels of AST, ALT, triglycerides, HDL and cholesterol. RESULTS: There were no significant differences in the activities of HL and TL between the groups. Nevertheless, significant differences were observed in the levels of HDL (p=0.001) and cholesterol (p=0.001) on the 1st POD, and in triglycerides (p=0.045) on the 7th POD. A significant drop in the levels of HDL and cholesterol on the 1st POD was followed by a rapid recovery (3rd POD) and maintenance of these levels in group B until the 7th POD, while high levels of triglycerides (TG) were observed only on POD 7. CONCLUSIONS: After hepatectomy the activities of the lipolytic enzymes recover early and remain stable during regeneration. HDL and cholesterol levels are reversely proportional to the liver stress.

Imaging features of a huge spermatic cord leiomyosarcoma: Review of the literature.

Spermatic cord leiomyosarcomas (LMSs) are rare tumors which may cause significant morbidity and mortality if inadequately diagnosed or treated. We report a case of a paratesticular LMS in a 60-year-old man who presented with a right scrotal mass. The patient was evaluated by scrotal ultrasound and computed tomography of the abdomen and pelvis (including scans of the scrotum), which revealed a large extratesticular mass. The lesion proved to be malignant and the patient underwent radical orchiectomy with high cord ligation. To improve the assignment of this lesion, we further analyze the imaging features of LMS and correlate them with pathologic findings.

Massive intraperitoneal bleeding due to hemorrhagic cholecystitis and gallbladder rupture: CT findings.

Hemorrhagic cholecystitis with subsequent gallbladder rupture and torrential bleeding is a very rare but life-threatening complication of acute biliary tract diseases. Its clinical presentation may be dubious and therefore Computed Tomography (CT) imaging plays a crucial role in a prompt and accurate diagnosis. We present a case of a 64 year-old male who was admitted to the emergency department with clinical findings of acute cholecystitis. During the following hours the patient became hemodynamically unstable and an emergency abdominal CT scan was performed. CT revealed massive hemoperitoneum containing free gallstones. In addition, active extravasation of iv contrast material inside the gallbladder lumen was demonstrated. Based on these findings hemorrhagic cholecystitis with gallbladder rupture was suspected and the patient underwent urgent laparotomy. We describe specific CT findings of this rare condition, thus emphasizing the role of imaging in facilitating urgent surgical treatment.

A morphometric study concerning the branching points of the main arteries in humans: relationships and correlations.

An adequate quantity of data on the branching points and important arterial segments of the main arteries in humans is missing. Moreover, a suitable data collection and thereby observed correlations might provide some important clues relating to angiogenesis issues. Thus, we chose to examine in sixty-two embalmed human cadavers of Hellenic origin: The level and angles of the branching points did not differ substantially from similar data, mentioned in the literature. Our results revealed that symmetry exists between the limbs and the aortic length and the branching positions of the abdominal aorta. The aortic length is negatively related to the length of both common iliac arteries. The lengths of the celiac and the brachiocephalic artery (correlated weakly with one another) presented fewer correlations, while the segment between the inferior mesenteric and the celiac artery was correlated with other segments from different locations mainly on the right side. This last distance, the aortic length, the distance between the celiac and inferior mesenteric arteries, the length of both common femoral arteries differed significantly according to gender, independently of body length and height. Our data support the view that the final position and length of the arteries might be due to the location of the corresponding viscera during angiogenesis, to the body length and height and to some (hypothetical) elongation angiogenetic factors.