Publications by authors named "Konstantinos Tsalis"

53 Publications

Variations of plasma levels of insulin, glucagon, amylase and glucose and histopathological lesions of pancreatic tissue after complete elimination of exocrine pancreatic function with surgical ligation versus prolamine occlusion.

Ann Ital Chir 2021 ;92:441-451

Objective: Pancreaticoduodenectomy has been established as the treatment of choice for the management of benign and malignant lesions of the pancreatic head, and pancreaticojejunal or pancreaticogastric anastomosis seems to be the safer choice for the management of the pancreatic duct. However, in certain seldom, but still existing circumstances, pancreatic duct ligation or occlusion with a chemical substance is a valuable and viable alternative. The aim of the current study is to compare these two methods of occlusion of the pancreatic duct regarding the endocrine and exocrine function of the pancreas and its histopathology.

Materials And Methods: 18 health mixed breed dog of both sexes were randomized in two groups: group A, in which the pancreatic duct was ligated and group B, in which the pancreatic duct was occluded with prolamine.

Results: None of the animals presented postoperatively steatorrhea and significant body weight changes. Peripancreatic inflammation at sacrifice, inflammatory cell infiltration and edema of the pancreas on the 15th postoperative day and 30th postoperative day were milder after occlusion with prolamine than after ligation. Ligation of pancreatic duct lead to significantly greater hyperamylasemia than prolamine occlusion every day until the 15th. Mild hyperglycemia presented from the first to the fourth day in both groups, which was associated with a significant drop in insulin. Glucagon remained within the normal values at all times during the experiment. None of glucose, insulin and glucagon differed between groups.

Conclusion: Prolamine occlusion of the pancreatic duct causes milder hyperamylasemia and less extensive inflammation both macroscopically and microscopically than ligation.

Key Words: Pancreas, Pancreaticoduodenectomy, Hyperamylasemia.
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September 2021

The effects of growth hormone on the healing of colonic anastomoses in rats.

Ann Ital Chir 2021 ;92:424-434

Aim: Growth hormone is known to affect healing on the postoperative patient. The aim of the present experimental study was to evaluate the effect of systematic infusion of growth hormone on the healing of colonic anastomoses in rats.

Methods: Fourty Albino-Wistar male rats were randomly divided into two groups, a control group (CONTROL) and a growth hormone (GH) group. In both groups, an end-to-end colonic anastomosis was performed after segmental resection. In the CONTROL group, 1 cc saline was administered subcutaneously in the experimental animals' necks in two equal doses daily until the sixth postoperative day. In the GH group, rats were administered a growth hormone solution (2 mg/kg b.w.) in an amount of 1 cc subcutaneously in their necks in two equal doses daily until the sixth postoperative day. Rats were sacrificed on the seventh postoperative day. Anastomoses were resected and macroscopically examined. Bursting pressures were calculated and histological features were graded and hydroxyproline was evaluated.

Results: No deaths or wound infections were observed until the sacrifice. Bodyweight was significantly increased in the GH group until the seventh postoperative day (p = 0.005). Bursting pressures (p = 0.0025), adhesion formation (p=0.0019), hydroxyproline concentrations (p = 0.007) were significantly higher in the GH group than in the control group. Also GH lead to decreased inflammation (p < 0.001), but increased neoangiogenesis (p < 0.001), fibroblast activity (p = 0.001) and collagen deposition (p < 0.001).

Conclusion: Growth hormone, when applied systematically in rats with colonic anastomoses, promotes their healing in rats. Therefore, the application of growth hormone in colonic anastomoses leads to better outcomes.

Key Words: Adhesion, Bursting pressure, Collagen, Hydroxyproline, Inflammation, Neoangiogenesis.
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September 2021

The impact of EAES Fellowship Programme: a five-year review and evaluation.

Surg Endosc 2021 Jun 8. Epub 2021 Jun 8.

Department of General Surgery, Linköping University Hospital, 581 85, Linköping, Sweden.

Background: The European Association of Endoscopic Surgery (EAES) fellowship programme was established in 2014, allowing nine surgeons annually to obtain experience and skills in minimally invasive surgery (MIS) from specialist centres across the Europe and United States. It aligns with the strategic focus of EAES Education and Training Committee on enabling Learning Mobility opportunities. To assess the impact of the programme, a survey was conducted aiming to evaluate the experience and impact of the programme and receive feedback for improvements.

Methods: A survey using a 5-point Likert scale was used to evaluate clinical, education and research experience. The impact on acquisition of new technical skills, change in clinical practice and ongoing collaboration with the host institute was assessed. The fellows selected between 2014 and 2018 were included. Ratings were analysed in percentage; thematic analysis was applied to the free-text feedbacks using qualitative analysis.

Results: All the fellows had good access to observing in operating theatres and 70.6% were able to assist. 91.2% participated in educational activities and 23.5% were able to contribute through teaching. 44.1% participated in research activities and 41.2% became an author/co-author of a publication from the host. 97.1% of fellows stated that their operative competency had increased, 94.3% gained new surgical skills and 85.7% was able to introduce new techniques in their hospitals. 74.29% agreed that the clinical experience led to a change in their practices. The most commonly suggested improvements were setting realistic target in clinical and research areas, increasing fellowship duration, and maximising theatre assisting opportunities. Nevertheless, 100% of fellows would recommend the fellowship to their peers.

Conclusion: EAES fellowship programme has shown a positive impact on acquiring and adopting new MIS techniques. To further refine the programme, an individualised approach should be adopted to set achievable learning objectives in clinical skills, education and research.
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http://dx.doi.org/10.1007/s00464-021-08525-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8186018PMC
June 2021

Metalloproteinase expression after desflurane preconditioning in hepatectomies: A randomized clinical trial.

World J Hepatol 2020 Nov;12(11):1098-1114

Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece.

Background: Hepatectomy with inflow occlusion results in ischemia-reperfusion injury; however, pharmacological preconditioning can prevent such injury and optimize the postoperative recovery of hepatectomized patients. The normal inflammatory response after a hepatectomy involves increased expression of metalloproteinases, which may signal pathologic hepatic tissue reformation.

Aim: To investigate the effect of desflurane preconditioning on these inflammatory indices in patients with inflow occlusion undergoing hepatectomy.

Methods: This is a single-center, prospective, randomized controlled trial conducted at the 4 Department of Surgery of the Medical School of Aristotle University of Thessaloniki, between August 2016 and December 2017. Forty-six patients were randomized to either the desflurane treatment group for pharmacological preconditioning (by replacement of propofol with desflurane, administered 30 min before induction of ischemia) or the control group for standard intravenous propofol. The primary endpoint of expression levels of matrix metalloproteinases and their inhibitors was determined preoperatively and at 30 min posthepatic reperfusion. The secondary endpoints of neutrophil infiltration, coagulation profile, activity of antithrombin III (AT III), protein C (PC), protein S and biochemical markers of liver function were determined for 5 d postoperatively and compared between the groups.

Results: The desflurane treatment group showed significantly increased levels of tissue inhibitor of metalloproteinases 1 and 2, significantly decreased levels of matrix metalloproteinases 2 and 9, decreased neutrophil infiltration, and less profound changes in the coagulation profile.  During the 5-d postoperative period, all patients showed significantly decreased activity of AT III, PC and protein S ( baseline values, < 0.05). The activity of AT III and PC differed significantly between the two groups from postoperative day 1 to postoperative day 5 ( < 0.05), showing a moderate drop in activity of AT III and PC in the desflurane treatment group and a dramatic drop in the control group. Compared to the control group, the desflurane treatment group also had significantly lower international normalized ratio values on all postoperative days ( < 0.005) and lower serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase values on postoperative days 2 and 3 ( < 0.05).   Total length of stay was significantly less in the desflurane group ( = 0.009).

Conclusion: Desflurane preconditioning can lessen the inflammatory response related to ischemia-reperfusion injury and may shorten length of hospitalization.
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http://dx.doi.org/10.4254/wjh.v12.i11.1098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7701968PMC
November 2020

The effect of chemotherapy with 5-fluorouracil, bleomycin and cisplatin in the healing of colonic anastomoses in rats.

Ann Ital Chir 2020 ;91:552-562

Purpose: Chemotherapeutic factors are known to affect healing on the postoperative patient. The aim of the present experimental study was to evaluate the effect of intraperitoneal infusion of 5-fluorouracil, bleomycin and cisplatin on the healing of colonic anastomoses in rats.

Methods: Forty Albino-Wistar male rats were randomly divided into two groups, a control and a chemotherapy (CT) group. In both, an end-to-end colonic anastomosis was performed. collagen, In the control group, 2cc saline was administered intraperitoneally during the operation and daily postoperatively until the sacrifice. In the CT group, rats were administered a solution of 5-fluorouracil (20mg/kg b.w.), bleomycin (4mg/kg b.w.) and cisplatin (0.7 mg/kg b.w.) in an amount of 2cc intraperitoneal intraoperatively and afterwards daily postoperatively until the seventh postoperative day when they were sacrificed. At sacrifice, adhesion presence was calculated and the anastomoses were resected and macroscopically examined. Bursting pressures were calculated and histological features were graded. Hydroxyproline concentrations were evaluated.

Results: No deaths or wound infections were observed until sacrifice. Bodyweight was significantly decreased in the CT group (p=0.005). Bursting pressures (p=0.001) were significantly lower in the chemotherapy group, whereas adhesions were significantly increased (p=0.001). Hydroxyproline concentrations were not significantly different (p=0.401). All histological parameters appeared significantly decreased in the CT group: inflammation (p<0.008), neoangiogenesis (p<0.001), and fibroblast activity (p=0.001) and collagen deposition (p<0.001).

Conclusion: The use of chemotherapeutic agents had negative effects on the healing process of colonic anastomosis in rats. The decreased inflammatory response depicts in more frequent anastomotic dehiscence, ruptures and bodyweight loss postoperatively.

Key Words: Adhesion, Bursting pressure, Collagen, Hydroxyproline, Inflammation, Neoangiogenesis.
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August 2021

The effect of hepatic ischemia in the liver of rats with obstructive jaundice.

Ann Ital Chir 2020 ;91:334-344

Objective: The aim of the current study was to evaluate the effect of ischemia-reperfusion injury on the liver's function and morphology during the establishment and progress of obstructive jaundice.

Material And Methods: 80 Wistar rats were used for the purposes of the study and were allocated in four groups: JAUNDICE (obstructive jaundice), JAUN-ISC (obstructive jaundice and ischemia reperfusion), CONTROL (laparotomy) and ISCHEMIA (ischemia reperfusion).

Results: Obstructive jaundice, and ischemia-reperfusion injury following obstructive jaundice led to increased mortality, while no mortality was noticed in the control and ischemia groups. In the JAUN-ISC group, SGOT was significantly increased on the 10th day and SGPT was significantly increased on the 1st day compared to JAUNDICE group. Moreover, in the JAUN-ISC group, sinusoid dilation was significantly increased on the 5th and 10th days and neutrophil infiltration was significantly increased on the 10th day compared to the JAUNDICE group.

Conclusions: A mild ischemia-reperfusion injury that in the normal liver led only to slight increase of hepatic neutrophil infiltration in the presence of obstructive jaundice led to increased hepatic biochemical markers (SGOT, SGPT) and increased hepatic sinusoid dilatation and enhanced neutrophil infiltration.

Key Words: Dilatation of sinusoids, Granulocytes infiltration, Oxaloxate, Pyruvate transaminase, Transaminase reperfusion.
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August 2021

Synbiotics administration leads to attenuated mucosal inflammatory neutrophil infiltration and increased hematocrit in experimental ulcerative colitis.

Cir Cir 2020 ;88(4):410-419

Medical School, Aristotle University of Thessaloniki, Thessaloniki. Greece.

Objective: The objective of the study was to estimate the effects of synbiotics on laboratory, macroscopic, and histopathologic features in dextran sulfate sodium (DSS) experimental colitis.

Materials And Methods: A total of 40 Wistar rats received 5% of DSS in their drinking water for 8 days to induce ulcerative colitis (UC). Eight rats were sacrificed to confirm the presence of UC. The remaining rats were randomly assigned to two groups: the synbiotics group, which received synbiotics once per day and the control group, which received tap water for another 8 days.

Results: On the 8 day of DSS administration animals developed UC with bloody diarrhea. In the majority of the hematologic variables studied (hemoglobin [HB], red blood cells, platelets, mean corpuscular volume, and mean corpuscular HB), in bodyweight and histopathologic colitis score there was no significant difference between groups. However, the synbiotics group, compared to control, presented a significantly greater colon length on the 4 day, significantly increased hematocrit (HT) on the 8 day, and a significantly decreased number of myeloperoxidase positive cells on the 8 day. Furthermore, there was a trend toward histopathological and clinical improvement.

Conclusions: Administration of synbiotics in the experimental UC results in an attenuation of mucosal inflammatory neutrophil infiltration and an increase in HT.
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http://dx.doi.org/10.24875/CIRU.20000084DOI Listing
May 2021

Duodenal Injuries During Laparoscopic Cholecystectomy: An Unusual But Serious Complication of a Routine Surgical Procedure.

Chirurgia (Bucur) 2019 Jul-Aug;114(4):518-521

Duodenal injury is an unusual complication of laparoscopic cholecystectomy, mostly caused by direct injury of the duodenum by laparoscopic instruments, either mechanical or thermal. The management is usually surgical, with satisfactory results, as long as the complication is detected early. We report two cases of duodenal perforations during laparoscopic cholecystectomy. One was treated with primary closure of the defect, while the other was managed conservatively with abdominal drainage and food deprivation. Both techniques proved successful in the management of that complication.
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http://dx.doi.org/10.21614/chirurgia.114.4.520DOI Listing
October 2019

An incidental intracranial lesion in a young woman with head trauma: The key role of CT bone reconstruction in the diagnosis of an osteoma of the anterior cranial fossa.

Clin Case Rep 2019 Mar 11;7(3):595-596. Epub 2019 Feb 11.

Fourth Surgical Department, Medical School Aristotle University of Thessaloniki Thessaloniki Greece.

A young female was subjected to brain CT due to head trauma after a car accident. A lesion was found in the area of the right frontal lobe raising concern. After reconstruction of the CT slices, the radiologic features indicated a skull base osteoma, without the need for further intervention.
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http://dx.doi.org/10.1002/ccr3.2049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6406142PMC
March 2019

A 20-year single center experience in the surgical treatment of colorectal liver metastasis.

J BUON 2018 Nov-Dec;23(6):1640-1647

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Purpose: To present our experience in the treatment of patients with liver metastases from colorectal cancer.

Methods: The surgical and histopathological records of our department dating from 1st January 1997 to 31 December 2016 were examined, searching for patients who have undergone surgical treatment of colorectal liver metastasis.

Results: A total of 90 patients with colorectal liver metastases were treated in the last 20 years in our department. Their mean age was 65.28 years and 54 (60%) were male. The primary tumor was in the colon in 71 patients (78.9%) and in 19 (21.1%) patients in the rectum. Thirty-six (40%) patients presented with synchronous metastatic liver disease, from which 27 were subjected to simultaneous resection, 2 underwent a liver-first approach and 7 were subjected to resection of primary tumor first. Regarding the number of metastases 67 (74.4%) patients had single metastasis, 12 (13.3%) had 2 lesions, 4 (4.4%) had 3 lesions and 7 (7.8%) had 4-8 lesions. In-hospital and 30-day mortality was 3.85%. Median survival was 41 months.

Conclusion: Surgical resection is the treatment of choice for the management of liver metastasis from colorectal cancer and can be safely performed. Follow up of patients with colorectal cancer is imperative as metachronous metastasis presents in a significant percentage of patients with negative locoregional lymph nodes of the primary tumor. The order of resection doesn't seem to alter outcome in synchronous metastasis. Recurrence is common and re-resection if feasible is the only chance of cure.
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August 2019

Klatskin tumors and "Klatskin-mimicking lesions": our 22-year experience.

Rev Esp Enferm Dig 2019 Feb;111(2):121-128

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki , Gre.

Background and study purpose: Hilar cholangiocarcinoma, also known as Altemeier-Klatskin tumor, is a rare malignancy that arises in the confluence of the hepatic ducts of the porta hepatis. The prognosis is rather poor. Several lesions mimic these tumors and lead to a misdiagnosis, resulting in radical hepatic resections. These lesions are known as Klatskin-mimicking lesions. We present our experience with the diagnosis and treatment of pathological lesions that can mimic a perihilar cholangiocarcinoma and establish an algorithm of treatment Methods: For the current retrospective study, a prospectively established bile-duct tumor database was analyzed by selecting patients with a preoperative diagnosis of perihilar cholangiocarcinoma. Results: In the last 22 years (from January 1, 1996, to December 31, 2017), 73 patients who were referred to our tertiary center with a primary diagnosis of a Klatskin tumor were treated. All patients underwent a thorough evaluation before deciding upon the treatment. However, only 58 cases had a confirmed preoperative diagnosis of hilar cholangiocarcinoma in the final histopathological examination. The final diagnosis in 15 patients differed from the primary cause for referral and the lesions were regarded as Klatskin-mimicking lesions. Conclusions: Clinicians should always highly suspect Klatskin-mimicking lesions when they evaluate a patient for a possible hilar cholangiocarcinoma in order to avoid a misdiagnosis and propose a proper treatment.
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http://dx.doi.org/10.17235/reed.2018.5749/2018DOI Listing
February 2019

A Rare Case of Primary Hyperparathyroidism Caused by a Giant Solitary Parathyroid Adenoma.

Am J Case Rep 2018 Nov 8;19:1334-1337. Epub 2018 Nov 8.

Fourth Surgical Department, Aristotle University of Thessaloniki, General Hospital "G. Papanikolaou", Thessaloniki, Greece.

BACKGROUND Solitary parathyroid adenomas are the leading cause of primary hyperparathyroidism in 0% to 85% of cases. Diagnosis of parathyroid adenoma is based on typical clinical presentation of hypercalcemia, biochemical profile, and modern imaging studies. The purpose of this article is to present the diagnostic and therapeutic approach used for a 73-year-old female patient with a giant parathyroid adenoma measuring 5×2.5×2.5 cm and weighing 30 grams. CASE REPORT A 73-year-old female was referred to the outpatient clinic of our Surgical Department with the diagnosis of primary hyperparathyroidism. The patient suffered from typical symptoms of hypercalcemia such as weakness, bone disease, and recurrent nephrolithiasis; she had a painless cervical mass for 5 months. Primary hyperparathyroidism was confirmed based on the patient's biochemical profile, which showed increased levels of serum calcium and parathyroid hormone. SestaMIBI scintigraphy with 99mTechnetium and cervical ultrasonography revealed a large nodule at the inferior pole of the right lobe of the thyroid gland. Intraoperatively, a giant parathyroid adenoma was found and excised. Additionally, levels of intact parathyroid hormone (IOiPTH) were determined intraoperatively and a 95% reduction was found, 20 minutes after the removal of the adenoma. CONCLUSIONS This is an extremely rare case of a giant solitary parathyroid adenoma. Diagnosis of a giant hyperfunctioning solitary parathyroid adenomas was based on clinical presentation, biochemical profile, and imaging studies. Selective treatment was based on surgical excision combined with IOiPTH levels measurement.
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http://dx.doi.org/10.12659/AJCR.911452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238585PMC
November 2018

Laparoscopic resection of large pelvic lipoma causing obstructive uropathy in a 66 year old female - A case report from Greece.

J Pak Med Assoc 2018 Sep;68(9):1400-1402

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Lipomas are benign, usually asymptomatic, tumours and pelvic lipomas are extremely rare. We describe the case of a giant pelvic lipoma causing obstructive uropathy to a 66-year-old morbidly obese female treated in the 4th Surgical Department of the Medical School of Aristotle University of Thessaloniki in General Hospital "G. Papanikolaou" in March 2016. The patient presented with a history of nocturia and frequent daytime urination for 1 year. Her medical history included diffuse lipomatosis. Computer tomography revealed a giant pelvic mass which lead to left side hydronephrosis, hydrouterer and a pear-shaped bladder, with the differential diagnosis including pelvic lipoma or liposarcoma. An ultrasound guided biopsy excluded the diagnosis of liposarcoma. The patient was submitted to laparoscopic resection of the pelvic lipoma, with complete remission of urinary symptoms. The key-point is to consider the possibility that the pelvic mass is a well-differentiated liposarcoma and to manage it adequately and thus, we recommend intact excision of the mass through a wound protector, and extreme caution to avoid any rupture of the capsule.
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September 2018

Meckel's Diverticulum in Adults: Surgical Concerns.

Front Surg 2018 3;5:55. Epub 2018 Sep 3.

Department of General Surgery, General Hospital of Drama, Drama, Greece.

Since Meckel's diverticulum (MD) is rarely diagnosed in adults, there is no consensus on what type of procedure to be performed for symptomatic MD and whether to resect or not an accidentally discovered MD. Treatment of symptomatic MD is definitive surgery, including diverticulectomy, wedge, and segmental resection. The type of procedure depends on: (a) the integrity of diverticulum base and adjacent ileum; (b) the presence and location of ectopic tissue within MD. The presence of ectopic tissue cannot be accurately predicted intraoperatively by palpation and macroscopic appearance. When present, its location can be predicted based on height-to-diameter ratio. Long diverticula (height-to-diameter ratio >2) have ectopic tissue located at the body and tip, whereas short diverticula have wide distribution of ectopic tissue including the base. When indication of surgery is simple diverticulitis, diverticulectomy should be performed for long and wedge resection for short MD. When indication of surgery is complicated diverticulitis with perforated base, complicated intestinal obstruction and tumor, wedge, or segmental resection should be performed. When the indication of surgery is bleeding, wedge and segmental resection are the preferred methods for resection. Regarding management of incidentally discovered MD, routine resection is not indicated. The decision making should be based on risk factors for developing future complications, such as: (1) patient age younger than 50 years; (2) male sex; (3) diverticulum length >2 cm; and (4) ectopic or abnormal features within a diverticulum. In this case, diverticulectomy should be performed for long and wedge resection for short MD.
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http://dx.doi.org/10.3389/fsurg.2018.00055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129587PMC
September 2018

[Polymetastatic highly aggressive Small Cell Undifferentiated Neuroendocrine Carcinoma of Ascending Colon].

Cir Cir 2018 ;86(5):446-449

Fourth Surgical Department. Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Neuroendocrine carcinoma (NEC) of the colon is a rare and very aggressive tumor with poor prognosis. The current case report presents a 53-year-old male with a 6 cm × 10 cm ascending colon carcinoma, causing large intestine obstruction, with simultaneous multiple hepatic metastases and peritoneal carcinomatosis. Surgical resection of the primary tumor was performed, because of the bowel obstruction, to ameliorate the symptoms before the onset of chemotherapy. Histopathology revealed that the tumor was a small-cell undifferentiated NEC. During the post0operative period, the patient presented pulmonary metastases, and on the 36th post-operative day, death occurred due to respiratory failure.
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http://dx.doi.org/10.24875/CIRU.18000058DOI Listing
February 2019

Laparoscopic Resection of Desmoid Type Fibromatosis of the Splenic Hilum Mimicking a Greater Curvature Gastric GIST.

J Coll Physicians Surg Pak 2018 Sep;28(9):714-716

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Desmoid tumor, recently renamed as desmoid type fibromatosis, is an uncommon neoplasm. The mesentery is the usual origin of intra-abdominal desmoid-type fibromatosis and despite the fact there is no metastatic potential, it can infiltrate adjacent organs. There etiology remains unknown, preoperative diagnosis is difficult and differential diagnosis includes among other gastrointestinal stromal tumor (GIST). In resectable tumors, the mainstay of treatment is surgical resection with at least clean microscopic margins. We present a case of a 51-year lady who presented with a 6.2 x 4.5 x 3.3 cm neoplasm in the anatomic area of the greater gastric curvature, the splenic hilum and the tail of the pancreas that was diagnosed as GIST on the CT scan. The patient was submitted to laparoscopic excision of the tumor and histopathological examination revealed desmoid type fibromatosis of the splenic hilum infiltrating the spleen, pancreatic tale and greater gastric curvature. According to the authors' knowledge, this is the first reported case of a sporadic splenic desmoid tumor, which has been treated successfully by laparoscopic en block resection.
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http://dx.doi.org/10.29271/jcpsp.2018.09.714DOI Listing
September 2018

Atypical anastomotic malignancies of small bowel after subtotal gastrectomy with Billorth II gastroenterostomy for peptic ulcer: Report of three cases and review of the literature.

World J Gastrointest Oncol 2018 Jul;10(7):194-201

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece.

Aim: To present patients who developed small-bowel malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy for ulcer, to review relevant literature, and to attempt to interpret the reasons those cancers developed to these postsurgical non-gastric sights.

Methods: For the current retrospective study and review of literature, the surgical and histopathological records dated from January 1, 1993 to December 31, 2017 of our department were examined, searching for patients who have undergone surgical treatment of small-bowel malignancy to identify those who have undergone subtotal gastrectomy for benign peptic ulcer. A systematic literature search was also conducted using PubMed, EMBASE, and Cochrane Library to identify similar cases.

Results: We identified three patients who had developed small-intestine malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy with Billroth II gastroenterostomy for benign peptic ulcer-two patients with adenocarcinoma originated in the Braun anastomosis and one patient with lymphoma of the efferent loop. All three patients were submitted to surgical resection of the tumor with Roux-en-Y reconstruction of the digestive tract. In the literature review, we only found one case of primary small-intestinal cancer that originated in the efferent loop after Billroth II gastrectomy because of duodenal ulcer but none reporting Braun anastomosis adenocarcinoma following partial gastrectomy for benign disease. We also did not find any case of efferent loop lymphoma following gastrectomy.

Conclusion: Anastomotic gastric cancer following distal gastrectomy for peptic ulcer is a well-established clinical entity. However, malignancies of the afferent or efferent loop of the gastrointestinal anastomosis are extremely uncommon. The substantial diversion of the potent carcinogenic pancreaticobiliary secretions through the Braun anastomosis and the stomach hypochlorhydria, allowing the formation of carcinogenic factors from food, are the two most prominent pathogenetic mechanisms for those tumors.
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http://dx.doi.org/10.4251/wjgo.v10.i7.194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6068855PMC
July 2018

White oesophagus.

Lancet Gastroenterol Hepatol 2018 06;3(6):444

Department of General Surgery, General Hospital of Drama, Drama, Greece.

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http://dx.doi.org/10.1016/S2468-1253(18)30083-9DOI Listing
June 2018

Editorial: Surgical Infections.

Front Surg 2018 21;5:13. Epub 2018 Feb 21.

4th Surgical Department, Medical School, Aristotle University of Thessaloniki, General Hospital "G. Papanikolaou", Thessaloniki, Greece.

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http://dx.doi.org/10.3389/fsurg.2018.00013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850774PMC
February 2018

Midgut neuroendocrine tumor presenting with acute intestinal ischemia.

World J Gastroenterol 2017 Dec;23(45):8090-8096

Fourth Surgical Department, Faculty of Health Science, School of Medicine, Aristotle University of Thessaloniki, "G. Papanikolaou" General Hospital, Thessaloniki 57010, Greece.

Neuroendocrine tumors represent a heterogeneous group of neoplasms that arise from neuroendocrine cells and secrete various peptides and bioamines. While gastrointestinal neuroendocrine tumors, commonly called carcinoids, account for about 2/3 of all neuroendocrine tumors, they are relatively rare. Small intestine neuroendocrine tumors originate from intestinal enterochromaffin cells and represent about 1/4 of small intestine neoplasms. They can be asymptomatic or cause nonspecific symptoms, which usually leads to a delayed diagnosis. Imaging modalities can aid diagnosis and surgery remains the mainstay of treatment. We present a case of a jejunal neuroendocrine tumor that caused nonspecific symptoms for about 1 year before manifesting with acute mesenteric ischemia. Abdominal X-rays revealed pneumatosis intestinalis and an abdominal ultrasound and computed tomography confirmed the diagnosis. The patient was submitted to segmental enterectomy. Histopathological study demonstrated a neuroendocrine tumor with perineural and arterial infiltration and lymph node metastasis. The postoperative course was uneventful and the patient denied any adjuvant treatment.
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http://dx.doi.org/10.3748/wjg.v23.i45.8090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725304PMC
December 2017

Effects of albumin/glutaraldehyde glue on healing of colonic anastomosis in rats.

World J Gastroenterol 2017 Aug;23(31):5680-5691

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, 57010 Thessaloniki, Greece.

Aim: To evaluate the effect of local surgical adhesive glue (albumin/glutaraldehyde-Bioglue) on the healing of colonic anastomoses in rats.

Methods: Forty Albino-Wistar male rats were randomly divided into two groups, with two subgroups of ten animals each. In the control group, an end-to-end colonic anastomosis was performed after segmental resection. In the Bioglue group, the anastomosis was protected with extraluminar application of adhesive glue containing albumin and glutaraldehyde. Half of the rats were sacrificed on the fourth and the rest on the eighth postoperative day. Anastomoses were resected and macroscopically examined. Bursting pressures were calculated and histological features were graded. Other parameters of healing, such as hydroxyproline and collagenase concentrations, were evaluated. The experimental data were summarized and computed from the results of a one-way ANOVA. Fisher's exact test was applied to compare percentages.

Results: Bursting pressures, adhesion formation, inflammatory cell infiltration, and collagen deposition were significantly higher on the fourth postoperative day in the albumin/glutaraldehyde group than in the control group. Furthermore, albumin/glutaraldehyde significantly increased adhesion formation, inflammatory cell infiltration, neoangiogenesis, and collagen deposition on the eighth postoperative day. There was no difference in fibroblast activity or hydroxyproline and collagenase concentrations.

Conclusion: Albumin/glutaraldehyde, when applied on colonic anastomoses, promotes their healing in rats. Therefore, the application of protective local agents in colonic anastomoses leads to better outcomes.
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http://dx.doi.org/10.3748/wjg.v23.i31.5680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569282PMC
August 2017

Fournier's Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis.

Front Surg 2017 10;4:36. Epub 2017 Jul 10.

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Background: Fournier's gangrene (FG) is a rapidly evolving necrotizing fasciitis of the perineum and the genital area, the scrotum as it most commonly affects man in the vast majority of cases. It is polymicrobial in origin, due to the synergistic action of anaerobes and aerobes and has a very high mortality. There are many predisposing factors including diabetes mellitus, alcoholism, immunosuppression, renal, and hepatic disease. The prognosis of the disease depends on a lot of factors including but not limited to patient age, disease extent, and comorbidities. The purpose of the study is to describe the experience of a general surgery department in the management of FG, to present the multimodal and multidisciplinary treatment of the disease, to identify predictors of mortality, and to make general surgeons familiar with the disease.

Methods: The current retrospective study is presenting the experience of our general surgery department in the management of FG during the last 20 years. The clinical presentation and demographics of the patients were recorded. Also we recorded the laboratory data, the comorbidities, the etiology, and microbiology and the therapeutic interventions performed, and we calculated the various severity indexes. Patients were divided to survivors and non-survivors, and all the collected data were statistically analyzed to assess mortality factors using univariate and then multivariate analysis.

Results: In our series, we treated a total of 24 patients with a mean age 58.9 years including 20 males (83.4%) and 4 females (16.6%). In most patients, a delay between disease onset and seeking of medical help was noted. Comorbidities were present in almost all patients (87.5%). All patients were submitted to extensive surgical debridements and received broad-spectrum antibiotics until microbiological culture results were received. Regarding all the collected data, there was no statistically significant difference between survivors and non-survivors except the presence of malignancy in non-survivors ( = 0.036) and the lower hemoglobin ( < 0.001) and hematocrit ( = 0.002) in non-survivors. However, multivariate analysis did not reveal any predictor of mortality.

Conclusion: Early diagnosis, aggressive thorough surgical treatment, and administration of the proper antibiotic treatment comprise the cornerstone for the outcome of this disease. In small populations like in the present study, it is difficult to recognize any predictors of mortality and even the severity indexes, which take into account a lot of data cannot predict mortality.
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http://dx.doi.org/10.3389/fsurg.2017.00036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5502266PMC
July 2017

Synergistic Effect of Ischemic Preconditioning and Antithrombin in Ischemia-Reperfusion Injury.

Exp Clin Transplant 2017 Jun 18;15(3):320-328. Epub 2017 Apr 18.

From the the Fourth Surgical Department, Aristotle University of Thessaloniki, 57010 Thessaloniki, Greece; and the Oxford Transplant Centre, Oxford OX3 7LE, United Kingdom.

Objectives: Our study aimed to determine whether antithrombin plays a synergistic role in accentuating the effects of intestinal ischemic preconditioning.

Materials And Methods: Fifty rats were randomly allocated to 5 groups (10 rats/group) as follows: sham treatment (group 1); ischemia-reperfusion (group 2); ischemic preconditioning followed by ischemia-reperfusion (group 3); antithrombin + ischemia-reperfusion, similar to group 2 but including antithrombin administration (group 4); and antithrombin + ischemic preconditioning, similar to group 3 but including antithrombin administration (group 5). Blood samples and liver specimens were obtained for measurement of cytokines, myeloperoxidase, and malondialdehyde. Liver biopsies were examined by electron microscopy.

Results: Intestinal ischemia-reperfusion induced a remote hepatic inflammatory response as evidenced by the striking increase of proinflammatory cytokines, myeloperoxidase, and malondialdehyde. Tumor necrosis factor-α levels in group 5 (12.48 ± 0.7 pg/mL) were significantly lower than in group 3 (13.64 ± 0.78 pg/mL; P = .014). Mean interleukin 1β was lower in group 5 (9.52 ± 0.67pg/mL) than in group 3 (11.05 ± 1.9 pg/mL; P > .99). Mean interleukin 6 was also significantly lower in group 5 (17.13 ± 0.54 pg/mL) than in group 3 (23.82 ± 1 pg/mL; P ≤ .001). Myeloperoxidase levels were significantly higher in group 3 (20.52 ± 2.26 U/g) than in group 5 (18.59 ± 1.03 U/g; P = .025). However, malondialdehyde levels did not significantly improve in group 5 (4.55 ± 0.46 μmol) versus group 3 (5.17 ± 0.61 μmol; P = .286). Tumor necrosis factor-α, interleukin 6, and myeloperoxidase findings show that antithrombin administration further attenuated the inflammatory response caused by ischemia-reperfusion, suggesting a synergistic effect with ischemic preconditioning. These findings were confirmed by electron microscopy.

Conclusions: The addition of antithrombin to ischemic preconditioning may act to attenuate or prevent damage from ischemia-reperfusion injury by inhibiting the release of cytokines and neutrophil infiltration.
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http://dx.doi.org/10.6002/ect.2015.0331DOI Listing
June 2017

Variations of renal tissue oxygenation during abdominal compartment syndrome and sepsis.

Adv Med Sci 2017 Mar 7;62(1):177-185. Epub 2017 Mar 7.

Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Purpose: This experimental study was designed to evaluate the renal tissue oxygenation under the coexistence of abdominal compartment syndrome and sepsis.

Material And Methods: Fourteen non-breed dogs were divided into two groups: the control group (8) and the study group (6). Sepsis was established with intravenous endotoxin infusion at 100μg/kg for over 30min. Insufflation of CO in the peritoneal cavity was used for the increase in intra-abdominal pressure (IAP). A special catheter placed and fixed in the renal cortex at a depth of 3mm from the renal capsule was used for the measurement of renal tissue oxygenation.

Results: Study parameters were recorded at the starting phase, at IAP of 15mmHg and 30mmHg and after decompression of the abdomen in the control group, and at the same intervals plus the induction of sepsis, prior to increasing abdominal pressure, in the study group. With the elevation of the IAP a reduction of renal tissue oxygenation presents itself, which is more pronounced in the presence of sepsis, especially for IAP over 15mmHg. Like other parameters, after abdominal decompression the renal tissue oxygenation returns to the initial levels, independently of sepsis.

Conclusions: The afferent arterioles vasoconstriction, which takes place during sepsis, and the intra-renal shunt, which occurs and leads to blood diversion to the medulla from the renal cortex due to the combination of intra-abdominal hypertension (IAH) and sepsis, seem to explain this finding.
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http://dx.doi.org/10.1016/j.advms.2016.08.004DOI Listing
March 2017

Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions?

World J Gastrointest Surg 2015 Sep;7(9):190-5

Konstantinos Blouhos, Konstantinos Andreas Boulas, Anestis Hatzigeorgiadis, Department of General Surgery, General Hospital of Drama, 66100 Drama, Greece.

Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions; (2) internal herniation, volvulus and intussusception; (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop; (4) cancer recurrence; and (5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluid-filled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes: (1) adhesiolysis and reconstruction for benign causes; and (2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.
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http://dx.doi.org/10.4240/wjgs.v7.i9.190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4582236PMC
September 2015

Cecal diverticulitis is a challenging diagnosis: a report of 3 cases.

Am J Case Rep 2015 Apr 8;16:206-10. Epub 2015 Apr 8.

4th Department of Surgery, G. Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Background: Cecal diverticulitis is an uncommon cause of acute abdominal pain and presents clinically similar to acute appendicitis. There are many perspectives concerning the management of this condition, ranging from different types of surgical resections to conservative treatment with antibiotics.

Case Report: We present 3 cases of cecal diverticulitis. One of the patients was treated conservatively with intravenous antibiotics and the other 2 were treated with surgical resection.

Conclusions: Conservative treatment with intravenous antibiotics can be used in uncomplicated cecal diverticulitis. Complicated cecal diverticulitis is managed surgically and the type of resection depends mainly on the extent of inflammation.
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http://dx.doi.org/10.12659/AJCR.892848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395017PMC
April 2015

Is histological examination necessary when excising a pilonidal cyst?

Am J Case Rep 2015 Mar 21;16:164-8. Epub 2015 Mar 21.

4th Department of General Surgery, General Hospital "G. Papanikolaou", Aristotle University of Thessaloniki, Thessaloniki, Greece.

Background: Pilonidal disease is a common inflammatory condition mostly affecting young males. Malignant degeneration of a pilonidal cyst is rare, with incidence estimated at 0.1%. The most common type is squamous cell carcinoma and the treatment of choice remains en block resection of the lesion.

Case Report: We present the case of a patient with locally advanced squamous cell carcinoma arising in a pilonidal cyst, due to misdiagnosis of the disease during his first treatment.

Conclusions: Detailed histological examination of all excised pilonidal cyst lesions is essential and any histological suspicion should prompt a wider excision.
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http://dx.doi.org/10.12659/AJCR.892843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4370644PMC
March 2015
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