Biomedical subjects

Evangelos Karvounis

Publications and source records attributed to Evangelos Karvounis.

6 recordsLinked to original sources

PubMed2006

Pancreaticoduodenectomy for periampullary malignancies: the effect of bile colonization on the postoperative outcome.

OBJECTIVES: The presence of bacteria in the bile of patients undergoing biliary tract surgery has been proposed as associated to an increased incidence of postoperative complications. The present study was designed to determine whether colonization of the bile has an adverse effect in terms of postoperative infectious or noninfectious complications and mortality in a homogenous population of patients suffering from periampullary region malignancies, who all underwent resectional (curative) procedures. MATERIALS AND METHODS: Between January 1997 and December 2002, 115 patients (n = 115) suffering from periampullary region malignancies underwent resectional procedures. Fifty-two of the above patients were referred having undergone preoperative internal biliary drainage. During the operation, bile was routinely isolated from the common bile duct and was sent for culture and sensitivity. Based on the bile culture results, the patients were divided in sterile and colonized group and were retrospectively compared in terms of postoperative outcome and mortality. RESULTS: Of the 115 bile cultures, 67 were colonized with bacteria and 48 were sterile. Postoperatively, 40 patients developed 35 noninfectious and 21 infectious complications. Univariate analysis did not disclose statistically significant differences in overall, noninfectious or infectious morbidity and mortality between the two groups of patients. Although not statistically significant, a higher incidence (22 vs 10%) of postoperative leaks in the colonized group of patients was noticed. Multiple regression analysis disclosed that colonized bile was independently related to the advanced age, preoperative biliary drainage presence, elevated preoperative serum bilirubin levels and low preoperative serum albumin levels but did not predispose to an increased postoperative morbidity, mortality, or reoperation rate. CONCLUSION: The present study did not conclude in any statistically significant differences in the postoperative infectious and noninfectious morbidity as well as mortality, between colonized and sterile groups of patients who underwent resectional procedures for malignancies of the periampullary region. Although internal biliary drainage introduces microorganisms into the biliary tree, this colonization does not increase the risk of either infectious or noninfectious complications or postoperative death. Thus, the likelihood of bacterobilia should not contraindicate the procedure in selected cases.

Adult↗

PubMed2005

Limitations of fluoroscopic intraoperative cholangiography in cases suggestive of choledocholithiasis.

BACKGROUND: Fluoroscopic intraoperative cholangiography (IOC) has been proposed as a safe and accurate screening method for choledocholithiasis, with a sensitivity and specificity of nearly 100% in selected cases. In the present study we retrospectively reviewed the diagnostic accuracy of IOC in cases highly suggestive of choledocholithiasis. MATERIALS AND METHODS: Between January 1999 and December 2002, 103 patients underwent IOC as an imaging method for common bile duct (CBD) stone detection. We did not routinely perform IOC in all patients who were submitted to laparoscopic cholecystectomy, reserving the method for patients with a high probability of choledocholithiasis, namely patients with a history or the presence of painful obstructive jaundice at the time of referral, patients with a history of mild acute pancreatitis of biliary origin, and patients with abnormalities in their liver biochemistry profile as measured by liver function tests (LFT). RESULTS: The mean rates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for IOC were 98%, 94%, 94.5%, and 98% for the whole series, respectively. The diagnostic accuracy was 100% in patients with a history of obstructive jaundice or liver biochemical derangement, but was less in patients with a history of biliary pancreatitis. There were 3 false positive cases and 1 case of false negative results, all of which occurred in the subgroup of patients with a history of pancreatitis. CONCLUSION: Selective fluoroscopic IOC is generally feasible and safe, as well as highly accurate (100%) for CBD stone detection in patients with obstructive jaundice or abnormal LFT. The PPV of the method decreases in patients with a history of pancreatitis (75%), while a negative result is highly suggestive of the absence of CBD stones (NPV = 98%). The present study concluded in a higher incidence of false results in patients with a normal size CBD, suggesting that the diagnostic accuracy of IOC is probably related to the size of the CBD rather than the indication for its performance.

Aged↗

PubMed2005

Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis.

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

Acute Disease↗

PubMedDate not supplied

Cost-effective method for laparoscopic choledochotomy.

BACKGROUND: Recent reports have noted that postoperative complications following open or laparoscopic choledochotomy for common bile duct (CBD) exploration are mainly related to the T-tube presence, and that there has been no trend of decrease in the laparoscopic era. Laparoscopic endobiliary stent placement with primary closure of the CBD has been proposed as a safe and effective alternative to T-tube placement. METHODS: Between January 1999 and January 2003, 53 consecutive patients suffering from proven choledocholithiasis underwent laparoscopic common bile exploration (LCBDE) via choledochotomy. In the early period, a T-tube was placed at the end of the procedure (group A, n = 32) while, from June 2001 onwards, laparoscopic biliary stent placement and primary CBD closure were chosen as the drainage method (group B, n = 21). RESULTS: Six patients developed T-tube-related complications postoperatively. Univariate analysis revealed statistically significant lower morbidity rate and shorter postoperative hospital stay for the stent group. Although not statistically significant, a median saving of 780 UK pounds per patient was observed in the stent group. CONCLUSION: Biliary endoprosthesis placement following laparoscopic choledochotomy avoids the well-known complications of a T-tube, leading to a shorter postoperative hospital stay. The method is safe and effective and it should also be considered as cost-effective compared to T-tube placement. Further studies are required in order to document cost-effectiveness of the method.

Aged↗

PubMedDate not supplied

Diffuse oesophageal spasm masking achalasia.

Several reports have suggested that esophageal motility disorders may progress from one type to another. A 41-year-old female patient underwent thoracoscopic esophagomyotomy for diffuse esophageal spasm (DOS) with normal resting pressure and complete relaxation of the LOS; findings were confirmed in two preoperative esophageal manometries. Postoperatively, she developed severe dysphagia, and a new esophageal manometry concluded achalasia. She underwent a laparoscopic Heller's myotomy and a posterior (180 degrees) Toupet's fundoplication. Since the second operation, she remains asymptomatic and does not experience any difficulty in swallowing. We concluded that DOS and achalasia might coexist in this case. Through multiple synapses and several nervous roots in the esophageal wall, the inhibitory neurons at the level of LOS were effective before esophagomyotomy and did not show symptoms and manometric findings suggestive for achalasia. Esophagomyotomy, causing disruption of these synapses and lost of inhibitory innervation, finally resulted in symptoms and manometric findings of achalasia.

Adult↗

PubMedDate not supplied

Why does laparoscopic common bile duct exploration fail?

Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis carries an overall ductal clearance rate of between 85% and 95%. We present our single institute experience with LCBDE. Between July 1999 and July 2003, 60 patients (42 females, 18 males; median age, 59.5 years) with proven choledocholithiasis underwent LCBDE for common bile duct (CBD) clearance. The method failed to clear the CBD in six patients, resulting in a 90% overall success rate. Conversion to a conventional open approach (n = 1), hand-assisted LCBDE (n = 1), T-tube placement followed by multiple postoperative endoscopic retrograde cholangiopancreatography (ERCP; n = 2), and endobiliary stent placement followed by single successful postoperative ERCP in each case (n = 2) were chosen as treatment options when the laparoscopic method failed to clear the CBD. LCBDE is a feasible and safe method of managing CBD stones. Impacted stones at the lower end of the CBD or in the ampulla of Vater represent the most likely factors leading to failure of LCBDE. Laparoscopic endobiliary stent placement followed by postoperative ERCP represents the most attractive alternative in these difficult cases of impacted stones.

Cholangiopancreatography, Endoscopic Retrograde↗