Biomedical subjects

John Griniatsos

Publications and source records attributed to John Griniatsos.

13 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↗

PubMed2006

Circadian variation in expression of G1 phase cyclins D1 and E and cyclin-dependent kinase inhibitors p16 and p21 in human bowel mucosa.

AIM: To evaluate whether the cellular proliferation rate in the large bowel epithelial cells is characterized by circadian rhythm. METHODS: Between January 2003 and December 2004, twenty patients who were diagnosed as suffering from primary, resectable, non-metastatic adenocarcinoma of the lower rectum, infiltrating the sphincter mechanism, underwent abdominoperineal resection, total mesorectal excision and permanent left iliac colostomy. In formalin-fixed and paraffin-embedded biopsy specimens obtained from the colostomy mucosa every six hours (00:00, 06:00, 12:00, 18:00 and 24:00), we studied the expression of G(1) phase cyclins (D(1) and E) as well as the expression of the G(1) phase cyclin-dependent kinase (CDK) inhibitors p16 and p21 as indicators of cell cycle progression in colonic epithelial cells using immunohistochemical methods. RESULTS: The expression of both cyclins showed a similar circadian fashion obtaining their lowest and highest values at 00:00 and 18:00, respectively (P<0.001). A circadian rhythm in the expression of CDK inhibitor proteins p16 and p21 was also observed, with the lowest levels obtained at 12:00 and 18:00 (P<0.001), respectively. When the complexes cyclins D(1) -p21 and E-p21 were examined, the expression of the cyclins was adversely correlated to the p21 expression throughout the day. When the complexes the cyclins D(1) -p16 and E-p16 were examined, high levels of p16 expression were correlated to low levels of cyclin expression at 00:00, 06:00 and 24:00. Meanwhile, the highest expression levels of both cyclins were correlated to high levels of p16 expression at 18:00. CONCLUSION: Colonic epithelial cells seem to enter the G(1) phase of the cell cycle during afternoon (between 12:00 and 18:00) with the highest rates obtained at 18:00. From a clinical point of view, the present results suggest that G(1) -phase specific anticancer therapies in afternoon might maximize their anti-tumor effect while minimizing toxicity.

Aged↗

PubMed2006

Emergency helical CT scan in acute abdomen: a case of intestinal intussusception.

Surgeons are familiar to the nosological entity "partial intestinal obstruction". Intussusception constitutes a rare etiologic factor for this entity but usually remains undiagnosed preoperatively. Several imaging techniques have been proposed as useful in the diagnosis of intussusception but none of these has a remarkable sensitivity and specificity. In the following case of partial intestinal obstruction, we performed an helical CT scan of the abdomen. The method revealed with an excellent accuracy the nature (intussusception) and the location (ascending colon) of the partial intestinal obstruction. Having the extra advantage of the shorter examination time than the classical CT scan, we propose the helical CT as an alternative diagnostic modality for preoperative evaluation of patients with partial intestinal obstruction.

Abdominal Pain↗

PubMed2005

Bile duct injuries associated with laparoscopic and open cholecystectomy: an 11-year experience in one institute.

PURPOSE: Bile duct injury (BDI) represents the most serious complication of laparoscopic cholecystectomy (LC). The aim of this retrospective single-institution study was to evaluate the real incidence of BDI during laparoscopic and open cholecystectomy (OC) in a tertiary academic center in Athens, Greece. METHODS: Between January 1991 and December 2001, 3637 patients underwent cholecystectomy in our department; as LC in 2079 patients (LC group) and as OC in 1558 patients (OC group). All the LCs were performed or supervised by five staff surgeons and all the OCs were performed or supervised by another five staff surgeons. RESULTS: There were 13 BDIs associated with LC (0.62%) and 6 associated with OC (0.38%) (P = 0.317). There was one death associated with BDI after LC. Only two (15.4%) of the BDIs associated with LC occurred within the proposed learning curve limit of 50 LCs per individual surgeon. CONCLUSION: Laparoscopic cholecystectomy is safe and is not associated with a higher incidence of BDI than OC. Moreover, we did not find that the learning curve for LC affected BDI occurrence.

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

True giant common hepatic artery aneurysm associated with obstructive jaundice: a case report.

The appropriate treatment for extrahepatic hepatic artery aneurysms remains controversial, with arguments for and against embolization. We describe a case of a giant true aneurysm of the common hepatic artery associated with obstructive jaundice of nonhemobilia origin. The patient, a 49-year-old previously healthy man, presented with upper midepigastric pain, jaundice, and low-grade fever. The diagnosis of the aneurysm was mainly based on computed tomography scan findings. The aneurysm was successfully embolized using wire coils, and the patient was operated on for acute abdomen. Necrotizing acalculus cholecystitis was found, and cholecystectomy followed by aneurysmectomy without hepatic artery reconstruction was performed. The jaundice subsided spontaneously, and the patient was discharged in good condition. Giant common hepatic artery aneurysms can be managed by either surgery or embolization. In the absence of liver ischemia there is no need for common hepatic artery reconstruction unless a bilioenteric bypass has to be performed to resolve the issue of jaundice. If the latter is required, reconstruction of the hepatic artery might be justifiable to maximize the blood supply to the bile duct.

Aneurysm↗

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

Pancreaticojejunostomy versus alternative treatment of the pancreatic stump after pancreaticoduodenectomy: a comparative analysis of early postoperative outcome.

The operative management of the pancreatic stump after pancreaticoduodenectomy has been shown to be an important factor influencing the postoperative development of pancreatic fistula. Thus far, there is no ideal technique for reconstruction, and end-to-end pancreaticojejunostomy (PJS) represents the preferable method. Comparative analysis of early postoperative outcome was done between two groups of patients who underwent either end-to-end PJS or pancreatic remnant ligation (PRL) after pancreaticoduodenectomy. Between January 1997 and December 2001, 39 consecutive patients underwent pancreaticoduodenectomy at the 1st Department of Surgery, University of Athens Medical School. All operations were performed or supervised by two senior surgeons, and all patients underwent a Whipple's procedure. After pancreaticoduodenectomy, 23 patients underwent end-to-end PJS (PJS group), whereas the remaining 16 patients underwent PRL without pancreatic reconstruction (PRL group). We compared the two groups in terms of patients' characteristics, clinical presentation, serum laboratory values on admission, operative details, and postoperative course. The morbidity and mortality rates were 15.4% and 5.1%, respectively, for the whole series. In the PJS group, the morbidity rate was 8.7%, the pancreatic fistula formation rate was 4.3%, and the mortality rate was 4.3%. In the PRL group, the morbidity rate was 25%, the pancreatic fistula formation rate was 12.5%, and the mortality rate was 6.25%. These differences were not statistically significant. There were two deaths in the whole series (one in each group); however, none of the deaths were related to pancreatic fistula formation. Hospital stay was similar in both groups. Both PJS and PRL are valid surgical options that correlate with acceptable postoperative incidence of pancreatic fistula formation, morbidity, and mortality rates. Although PRL avoids the construction of the most risky anastomosis, the results of this study show that early postoperative results after PRL are not superior to PJS; therefore, the method should not be considered as the treatment of choice for the pancreatic stump after a Whipple's procedure. Meticulous surgical technique, surgical experience, and close postoperative care are essential for a successful outcome after this major abdominal operation.

Aged↗

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↗

PubMedDate not supplied

Pancreatic tuberculosis: a medical disease posing surgical dilemmas.

Pancreatic tuberculosis is a rare clinical setting manifesting in various ways. Most often, enlarged peripancreatic lymph nodes or growing tuberculomas compress adjacent organs, leading to biliary tract or gastrointestinal obstruction. Clinical examination, laboratory data, and imaging are all unspecific. Diagnosis is frequently misguided toward neoplasia requiring surgical intervention. However, the role of surgery in pancreatic tuberculosis ends in tissue sampling, abscess drainage, and bypassing obstruction. We present three cases of pancreatic tuberculosis: two caused by obstructive jaundice and the third caused by gastric outlet obstruction. All patients were operated on. Whipple's procedure was performed in one patient, and biliary and duodenal bypassing in the remaining patients. Diagnosis was decided by histopathology in all three cases. Medical treatment was effective in all patients. Although pancreatic tuberculosis is a medical disease, surgery is frequently used. Maintaining a high level of suspicion can assist in avoiding unnecessary laparotomies and solving this medical dilemma.

Adult↗

PubMedDate not supplied

Subsets of patients with advanced gastric cancer responding to second-line chemotherapy with docetaxel-cisplatin.

The role of docetaxel in combination with cisplatin in the management of gastric cancer resistant to first-line chemotherapy has not yet been defined. This multicenter prospective phase II study evaluated the activity and toxicity of the docetaxel-cisplatin combination in gastric cancer patients, whose tumors were primarily resistant to first-line chemotherapy or had tumor recurrence after chemotherapy. Treatment consisted of docetaxel 70 mg/m2 i.v. followed by cisplatin 70 mg/m2 both administered on day one, every three weeks. Thirty-two patients were enrolled in the study. The median age was 60 years and the median performance status (ECOG) was 1. Six (19%) patients had tumor progression during adjuvant chemotherapy, 19 (59%) had tumor recurrence after primary chemotherapy and 7 (22%) had tumor progressing while on first-line chemotherapy. Twenty (62%) patients had received non-platinum agents as first-line chemotherapy, while the rest had received the so-called "new generation" regimen that contained cisplatin. Among 32 patients evaluable for response, there were 5 (16%) (CI 95%-8%-35%) partial responses, all in patients that had received non-platinum agents as first-line chemotherapy. Stable disease was recorded in 8 (25%) and progressive disease in 19 (59%) patients. The median response duration was 4 (range 3-6) months, the median time to progression was 5 (range 3-6) months, the median survival after second-line chemotherapy was 6 (range 2-24) months and the median survival after first-line chemotherapy was 12 (range 4-36) months. Myelotoxicity was the main toxicity with grade 3-4 neutropenia occurring in 19 (59%) of the patients and febrile neutropenia in 4 (12%) patients. G-CSF support was given to 25 (78%) patients. Grade 3-4 thrombocytopenia was recorded in 4 (12%) patients. In conclusion, the combination of docetaxel plus cisplatin appears to be a moderately effective regimen with acceptable toxicity when G-CSF support is provided. According to our results, it seems that patients, whose tumors were not exposed to cisplatin during first-line chemotherapy, were more likely to respond to this regimen.

Adult↗