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Research Interests: Radiology, Medicine, Germany, Complication, Humans, and 15 moreFemale, Feasibility Studies, Hemodialysis, Male, Aged, Middle Aged, Adult, Retrospective Studies, Internal medicine Doppler ultrasonography, Aneurysm, Anastomosis, Renal Dialysis, Reoperation, Reconstructive Surgical Procedures, and Arteriovenous Fistula
Context: Chronic inflammatory vasculitis, namely Wegener's granulomatosis, is an autoimmune disease predominantly affecting the respiratory tract and rarely the mucosa of the upper or lower gastrointestinal tract. We report two cases of... more
Context: Chronic inflammatory vasculitis, namely Wegener's granulomatosis, is an autoimmune disease predominantly affecting the respiratory tract and rarely the mucosa of the upper or lower gastrointestinal tract. We report two cases of isolated pancreatic manifestation of Wegener's granulomatosis, mimicking a tumor. Case reports: Two patients, a 57-year-old man and a 68-year-old woman, presented with isolated lesions thought to be pancreatic adenocarcinoma and both underwent surgical resection. On pathology, the lesions were found to be a granulomatous vasculitis and were considered to represent isolated pancreatic Wegener's granulomatosis, in the absence of other clinical features of the disease. Conclusions: Benign diseases such as Tuberculosis may mimic pancreatic tumours diagnosed on cross-sectional imaging. Wegener's granulomatosis should be included in the differential diagnosis of an isolated pancreatic mass, in the absence of other cardinal symptoms for malignancy, due to the extensive surgery and risks involved in resection of pancreas.
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Leiomyosarcomas (LMS) are mesenchymal tumors of smooth muscle origin. Approximately 20% of leiomyosarcomas are found in the GI tract, and account for 1–2% of GI malignancies. Within the gastrointestinal tract, the small intestine is the... more
Leiomyosarcomas (LMS) are mesenchymal tumors of smooth muscle origin. Approximately 20% of leiomyosarcomas are found in the GI tract, and account for 1–2% of GI malignancies. Within the gastrointestinal tract, the small intestine is the most common site of presentation followed by the colon. They are often diagnosed incidentally during abdominal pain investigation, and they usually present in the fifth decade of life. In the past, the diagnostic differentiation between leiomyosarcomas of gastrointestinal tract and gastrointestinal stromal tumors (GISTs) was very challenging as they share common microscopic appearance. Nowadays, these tumors are diagnosed by immunohistochemical methods as they are positive for smooth muscle markers actin (SMA) and desmin, negative for GIST markers such as receptor tyrosine kinase (KIT), CD34, DOG1, and negative for the schwannoma marker S100 protein. In the current literature, most cases of intestinal leiomyosarcomas are localized in the small intestine, and there are no reports of synchronous liver metastases at the time of presentation of the primary tumor. Herein, we present a patient who was admitted in our department, with the diagnosis of primary leiomyosarcoma of the colon and synchronous liver metastasis.
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Cystic lymphangiomas are uncommon congenital benign tumors originating from the lymph vessels. Most cystic lymphangiomas occur in childhood, in the head, neck or axilla. Abdominal retroperitoneal cystic lymphangioma in adulthood is very... more
Cystic lymphangiomas are uncommon congenital benign tumors originating from the lymph vessels. Most cystic lymphangiomas occur in childhood, in the head, neck or axilla. Abdominal retroperitoneal cystic lymphangioma in adulthood is very rare and accounts for 1% of all lymphangiomas and may present a polymorphic clinical presentation when increases in size. Differential diagnosis accounts for a variety of neoplastic or no neoplastic tumors making a puzzling preoperative diagnostic evaluation. A 39-year-old Caucasian woman was referred to our hospital after an exploratory laparotomy two weeks ago on behalf of an abdominal cystic tumor that was misdiagnosed as an ovarian cyst preoperatively. Physical examination revealed an abdominal large palpable mass extending from the pelvis through the upper abdomen. An MRI of the upper and lower abdomen showed a large retroperitoneal multiseptate cystic lesion measuring 14 x 8 x 12 cm that encased the right common iliac vessels. The cystic tumor was successfully dissected during laparotomy and the pathology report revealed a cystic lymphangioma. Cystic lymphangiomas are rare benign tumors seen rarely in adults and should be considered in the differential diagnosis between the varieties of retroperitoneal cystic masses. Surgical excision is the treatment of choice since the diagnosis is only possible following to the histological examination.
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Background: Hepatobiliary surgery is a high-end surgery comprising of complex operations associated with high economic burden to a healthcare system. The aim of this study was to evaluate the cost-effectiveness of a hepatobiliary surgery... more
Background: Hepatobiliary surgery is a high-end surgery comprising of complex operations associated with high economic burden to a healthcare system. The aim of this study was to evaluate the cost-effectiveness of a hepatobiliary surgery highly standardized operative protocol, that minimizes intraoperative and postoperative costs, implemented by the same surgical team, in a Greek university hospital for a five-year period (2012-2016). Method and Material: The digital medical records of all patients undergoing liver resection at a tertiary university hospital from January 2012 to December 2016 by a single surgical team were retrospectively reviewed. The financial cost of the patients’ treatment was calculated in collaboration with the hospital’s logistics department, and it involved all preoperative, intraoperative, and postoperative expenses from admission to discharge, excluding physician fees and salary cost of the hospital’s nurses. Results: In this study, 127 patients underwent ...
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Aim of the study: Both pre- and postconditioning have been shown to protect the liver parenchyma from ischemia/reperfusion injury by altering the production of NO. However, to date there is no study to directly compare the effect of... more
Aim of the study: Both pre- and postconditioning have been shown to protect the liver parenchyma from ischemia/reperfusion injury by altering the production of NO. However, to date there is no study to directly compare the effect of pre-and postconditioning in the expression of iNOS and eNOS, during the acute phase of ischemia reperfusion liver injury.Material and Methods: A prospective experimental cohort comprising of 3 groups (Sham operated, Preconditioning and Postconditioning group) consisting of 10 animals each. All animals underwent an extended hepatectomy with prolonged warm ischemia either after preconditioning or followed by postconditioning or without any protective manoeuvre (sham). Subsequently blood and liver biopsies were obtained at the start of reperfusion, 6 hours post reperfusion and 12 hours post reperfusion. iNOS and eNOS gene expression was assessed as well as the extend of hepatocellular injury.Results: At the start of reperfusion iNOS expression was significa...
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Morel-Lavallée lesions are cystic lesions occurring between the... more
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Morel-Lavallée lesions are cystic lesions occurring between the subcutaneous tissue and the underlying layer of a fascia. The most frequent mechanism of occurrence is posttraumatic, usually after degloving injuries. The chain of events leading to the occurrence of this lesion is the formation of a potential space between the subcutaneous tissue and the firmly attached deep fascia, which in turn fills with blood and/or lymph and/or necrotic fat, secondary to disruption of the capillaries. We present a case of a 74-year-old male patient with a cystic lesion of the lateral surface of his left thigh increasing in size over a period of six months. Despite the meticulous history acquisition, we were unable to reveal any alleged mechanism of injury of the area. The patient underwent an MRI which revealed an ovoid cyst. The patien...
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Immune checkpoint inhibition therapy using targeted monoclonal antibodies is a new therapeutic approach with significant survival benefit for patients with several cancer types. However, their use can be associated with unique... more
Immune checkpoint inhibition therapy using targeted monoclonal antibodies is a new therapeutic approach with significant survival benefit for patients with several cancer types. However, their use can be associated with unique immune-related adverse effects as a consequence of impaired self-tolerance due to loss of T-cell inhibition via a nonselective activation of the immune system. Nivolumab is an anti-PD-1 immune checkpoint inhibitor that was recently developed for cancer immunotherapy with remarkable responses in nonsmall cell lung cancer patients. We present a 62-year-old Caucasian male with recurrent lung adenocarcinoma and currently under third-line therapy with nivolumab, who was admitted in our hospital with abdominal distension. Radiologic findings were consistent with small bowel ileus. After four days of conservative treatment, the patient underwent exploratory laparotomy where no cause of ileus was discovered. Postoperative the ileus persisted and considering that an ad...
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Background and Aim: Fistula-in-ano is a common problem among patients with Crohn’s disease and carries significant morbidity. We aimed to study the outcomes of surgical treatment of fistula-in-ano after fistulotomy or seton placement in... more
Background and Aim: Fistula-in-ano is a common problem among patients with Crohn’s disease and carries significant morbidity. We aimed to study the outcomes of surgical treatment of fistula-in-ano after fistulotomy or seton placement in patients with perianal fistulizing Crohn’s disease. Material and Methods: A retrospective observational study of 59 patients diagnosed with Crohn’s disease, who were treated surgically for fistula-in-ano between 2010 and 2014 in our department. The assessment of disease complexity included a detailed physical examination, magnetic resonance imaging of the rectum, and examination under anesthesia. Outcomes for analysis included wound healing rate and postoperative incontinence. Results: High transsphincteric fistula was found in 44% of the patients, while mid or low transsphincteric fistulas were found in 51%. Three women (5%) had a rectovaginal fistula. All patients with high transsphincteric fistulas were treated with loose seton placement. Patients...
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Research Interests: Trauma Studies, Medicine, Humans, Female, Caustics, and 6 moreAged, Middle Aged, Adult, Ingestion, Stomach, and Esophageal Stenosis
Introduction and Aim. With the implementation of multimodal analgesia regimens, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are often administered for optimal pain control and reduction of opioid use. The aim of the study was to examine... more
Introduction and Aim. With the implementation of multimodal analgesia regimens, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are often administered for optimal pain control and reduction of opioid use. The aim of the study was to examine the effects of lornoxicam, a NSAID, on anastomotic healing employing an animal model.Materials and Methods. A total of 28 Wistar rats were randomly assigned in two groups. All animals underwent ascending colonic transection followed by an end-to-end hand sewn anastomosis. Group 1 received intraperitoneally lornoxicam before and daily after surgery. Group 2 received intraperitoneally an equal volume of placebo. Half of the animals in each group were euthanized on the 3rd pod and the remaining on the 7th pod. Macro- and microscopic indicators of anastomotic healing were compared using a two-tailed Fisher exact test.Results. The lornoxicam group significantly decreased fibroblast in growth and reepithelization of the mucosa at the anastomotic site on ...
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When confronting a biliary stricture, both benign and malignant etiologies must be carefully considered as a variety of benign biliary strictures can masquerade as hilar cholangiocarcinoma (CCA). Therefore, patients could undergo a major... more
When confronting a biliary stricture, both benign and malignant etiologies must be carefully considered as a variety of benign biliary strictures can masquerade as hilar cholangiocarcinoma (CCA). Therefore, patients could undergo a major surgery despite the possibility of a benign biliary disease. Approximately 15% to 24% of patients undergoing surgical resection for suspected biliary malignancy will have benign pathology. Eosinophilic cholangitis (EC) is a rare benign disorder of the biliary tract, which can cause obstructive jaundice and can pose a difficult diagnostic task.We present a rare case of a young woman who was referred to our hospital with obstructive painless jaundice due to a biliary stricture at the confluence of the hepatic bile ducts, with a provisional diagnosis of cholangiocarcinoma.Though, during her work up she was found to have EC, an extremely rare benign cause of biliary stricture, which is characterized by a dense eosinophilic infiltration of the biliary tr...
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The scope of the present study is to review the topics of initial assessment, diagnosis and clinical management of an isolated abdominal trauma. Progress in the management of trauma patients increasing survival includes a... more
The scope of the present study is to review the topics of initial assessment, diagnosis and clinical management of an isolated abdominal trauma. Progress in the management of trauma patients increasing survival includes a multidisciplinary approach involving multiple specialties at presentation. If immediate surgical intervention is needed, 'damage control' is the best option; if not, it has been proven that conservative management is superior to operative, in terms of survival for the majority of intraabdominal injury. 'Open abdomen' should be performed in major abdominal traumas when indicated. Early enteral feeding is beneficial, even in the presence of 'open abdomen'. Abdominal trauma is a complex injury; the multidisciplinary approach has made nonoperative management feasible and effective. When surgical intervention is needed, it should be performed in an orderly fashion, within the context of the overall management.
Research Interests: Computed Tomography, Medicine, Humans, Female, Diagnosis, and 15 moreMale, Physical examination, Guidance and Counseling Intervention Programs, Multidisciplinary Approach, Damage Control, Clinical management, X ray Computed Tomography, Blunt Trauma, Abdomen, Enteral Nutrition, Abdominal trauma, Injury Severity Score, Open Abdomen, Multiple trauma, and abdominal Injuries
Morel-Lavallée lesions are cystic lesions occurring between the subcutaneous tissue and the underlying layer of a fascia. The most frequent mechanism of occurrence is posttraumatic, usually after degloving injuries. The chain of events... more
Morel-Lavallée lesions are cystic lesions occurring between the subcutaneous tissue and the underlying layer of a fascia. The most frequent mechanism of occurrence is posttraumatic, usually after degloving injuries. The chain of events leading to the occurrence of this lesion is the formation of a potential space between the subcutaneous tissue and the firmly attached deep fascia, which in turn fills with blood and/or lymph and/or necrotic fat, secondary to disruption of the capillaries. We present a case of a 74-year-old male patient with a cystic lesion of the lateral surface of his left thigh increasing in size over a period of six months. Despite the meticulous history acquisition, we were unable to reveal any alleged mechanism of injury of the area. The patient underwent an MRI which revealed an ovoid cyst. The patient underwent surgical excision of the cyst. The pathology examination revealed a simple cyst, lined by a fibrous capsule and filled with serosanguineous fluid, thus...
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Pancreatic cancer is a malignancy with overall poor prognosis. Surgery is the only treatment modality, which could provide cure. Therefore every effort possible should be made for pancreatectomy to achieve R0 resection. However, even... more
Pancreatic cancer is a malignancy with overall poor prognosis. Surgery is the only treatment modality, which could provide cure. Therefore every effort possible should be made for pancreatectomy to achieve R0 resection. However, even after R0 resection, the survival outcomes are still far behind from other solid intrabdominal tumors. Extended lymphadenectomy and “mesopancreas” excision are the two main factors where focus has been given, in order to improve the outcomes of pancreatectomy for pancreatic head cancer. We present an up to date comprehensive review of the current evidence on the topics of extended lymphadenectomy and “mesopancreas” excision during pancreatoduodenectomy for cancer.
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Background Both pre- and postconditioning have been shown to protect the liver parenchyma from ischemia/reperfusion (I/R) injury during hepatectomy by altering the production of NO. However, to date there is no study to compare their... more
Background Both pre- and postconditioning have been shown to protect the liver parenchyma from ischemia/reperfusion (I/R) injury during hepatectomy by altering the production of NO. However, to date there is no study to compare their effect on the inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) gene expression, who are the main modulators in the pathway of NO during the acute phase of I/R injury. Methods We designed a prospective experimental cohort comprising of three groups (sham group-SG, preconditioning-PrG and postconditioning group-PoG) and consisting of 10 animals per group. All animals underwent extended hepatectomy (70%) under prolonged warm ischemia either after preconditioning or followed by postconditioning or without any protective maneuver (SG). Following reperfusion blood samples and liver biopsies were obtained at the start of reperfusion (0 hours), at 6 and 12 hours post reperfusion. iNOS and eNOS gene expression was assessed on liver tissue by polymerase chain reaction (PCR); in addition, the extent of hepatocellular injury was histologically assessed. Results At the beginning of reperfusion iNOS expression was significantly reduced in the PoG in comparison to the SG (Kruskal-Wallis test, P=0.012; Mann-Whitney U test, P<0.0005 Bonferroni correction) and continued to remain at low levels until 6 hours post reperfusion (Kruskal-Wallis test, P=0.01; Mann-Whitney U test, P<0.0005-Bonferroni correction) This difference was eliminated by 12 hours. No significant differences were found in the expression of eNOS between groups and within time measurements. Aspartate aminotransferase (AST) and Alkaline phosphatase (ALP) were found increased at the start of reperfusion; their levels continued to increase by 6 hours in all groups, however only in the PoG the increase attended statistical significance at 12 hours after reperfusion. ALT levels presented only minor alterations during the course of reperfusion. The PrG was found to have more intense hepatocellular injury at the start of reperfusion than the PoG however, that appeared to gradually settle by 12 hours in contrast to PoG where the hepatocellular injury continued to deteriorate. Conclusions PoG appeared to decrease iNOS overexpression more effectively than PrG in comparison to animals who have undergone no protective maneuver (SG). However, PrG was more effective than PoG in ameliorating the hepatocellular injury observed at 12 hours after the ischemic insult.
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Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is... more
Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, compa...
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Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a... more
Gallbladder duplication can present a clinical challenge primarily due to difficulties with diagnosis and identification. Recognition of this anomaly and its various types is important since it can complicate a gallbladder disease or a simple hepatobiliary surgical procedure. The case report of a 63-year-old woman who presented with cholangitis and underwent a successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Using ERCP, MRCP and 3D reconstructions the two cystic ducts with one common bile duct were identified. A review of the literature in referral of this variant, its anatomical classifications and significance to clinical and surgical practice is included. In conclusion, gallbladder anomalies should be anticipated in the presence of a cystic lesion reported around the gallbladder when evaluating radiologic studies. In case of surgery, preoperative diagnosis is essential to prevent possible biliary injuries or reoperation if accessory gallbladder has been overlooked during initial surgery. Laparoscopic cholecystectomy remains feasible for intervention can be safely done and awareness is necessary to avoid complications or multiple procedures.
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Duodenal neuroendocrine tumours (D-NETS) are rare tumours. The management of D-NETs is complex due to the lack of understanding of the natural course of the disease. We present a single centre experience in the surgical management of... more
Duodenal neuroendocrine tumours (D-NETS) are rare tumours. The management of D-NETs is complex due to the lack of understanding of the natural course of the disease. We present a single centre experience in the surgical management of these tumours with long-term follow up