Cancer is stable heritable cellular alteration. Hepatocarcinogenesis, the pathogenesis of neoplasia in the liver as modelled in rats exhibits three distinct quantifiable stages: initiation, promotion, and progression. Simple mutations and/or epigenetic alterations may occur in the stage of initiation. The stage of promotion results from selective enhancement of cell replication and selective inactivation of apoptosis of initiated cells. The irreversible stage of progression results from initial karyotypic alterations that evolve into greater degrees of genomic instability. Each step is the net result of breakdown of a natural barrier by the unbal-anced oncogene/tumour suppressor gene activities.

Η αιμορραγία κατώτερου πεπτικού συστήματος (ΑΚΠΣ) αποτελεί διαγνωστική και θεραπευτική πρόκληση που θέτει σε δοκιμασία τη γνώση και την ικανότητα του χειρουργού, προβάλλει τη δυνατότητα της αρμονικής συνεργασίας διαφόρων ιατρικών ειδικοτήτων και αξιολογεί την ορθή χρήση του διαθέσιμου τεχνολογικού εξοπλισμού. Η παρούσα μελέτη ανασκοπεί τα πρόσφατα δεδομένα που αφορούν στην αιτιολογία, τη διάγνωση και τη θεραπεία της νόσου, ανιχνεύοντας ιδιαιτερότητες και πιθανά προβλήματα που συναντά ο ιατρός-χειρουργός στην καθημέρα κλινική πράξη. Μέθοδοι: Η συλλογή των δεδομένων έγινε μέσω των ιστότοπων Pubmed και Medline και του ελληνικού IATΡOTEK, με χρήση των λέξεων ευρετηριασμού gastrointestinal hemorrhage, gastrointestinal bleeding, lower peptic bleeding, diverticula, melena, hematochesia της αγγλοσαξωνικής βιβλιογραφίας και αιμορραγία, πεπτικό, και γαστρεντερικό της ελληνικής. Αποτελέσματα: Συμπεριλήφθηκαν 66 μελέτες από το 1982-2012 με τη πλειοψηφία να προέρχεται από την τελευταία 10ετία. Η ακριβής εντόπιση της πηγής της αιμορραγίας αποτελεί συχνά ένα δυσεπίλυτο πρόβλημα και η κολοσκόπηση φαίνεται να είναι η πιο αξιόπιστη μέθοδος. Η εκκολπωμάτωση και οι όγκοι του παχέος εντέρου αποτελούν τα κύρια αίτια ΑΚΠΣ με αυξητική τάση καθώς η νόσος προσβάλλει συχνότερα ηλικιωμένους. Η αιμορραγία παρουσιάζει αυτόματη επίσχεση σε ποσοστό ως 80%, ωστόσο υποτροπιάζει ως και στο 25% των ασθενών. Η θνητότητα δυνατόν να φτάσει το 25%, ιδιαίτερα σε ασθενείς που θα υποστούν επείγουσα χειρουργική επέμβαση. Συμπεράσματα: Οι σύγχρονες τεχνολογικές εξελίξεις στην ιατρική έχουν αυξήσει τις επιλογές του ιατρού στην αντιμετώπιση της ΑΚΠΣ, αλλά η καθεμιά παρουσιάζει πλεονεκτήματα και μειονεκτήματα. Νεότερες κλινικές έρευνες είναι απαραίτητες για να αποσαφηνίσουν την καλύτερη διαγνωστική και θεραπευτική προσέγγιση καθενός από τα ποικίλα αίτια της νόσου.

Background. Groin hernia repair is one of the most frequent procedure in general surgery. Many different techniques of inguinal hernia repair have been described. The successful results of transinguinal preperitoneal (TIPP) repair technique using a memory ring patch have been reported. We have prefered monofilament polypropylene flat mesh instead of memory ring patch which has higher cost to perform TIPP repair technique. The purpose of this retrospective study was to evaluate our primary results more than 3 years after surgery. Methods. This study included consecutive adult patients who were treated with surgery for inguinal hernia by the same surgeon using the same technique between February 2007 and February 2008. A retrospective review of a prospectively maintained databese was performed. Data were reviewed for all patients undergoing TIPP hernia repair. Results. Thirty-three patients (31 men and 2 women) with a mean age of 48.4 years (range 19-67 years) underwent anterior transinguinal preperitoneal mesh hernioplasty. The mean operation time was 26 min (range 17-38 min). The mean follow-up was more than 36 months in all patients (range 37-46 months). There were no recurrences during follow-up. One patient (3%) described chronic groin pain. Conclusion. Groin hernias are a significant health problem and economic burden for developing countries because of high cost of surgery and loss of workforce. TIPP repair technique can be performed using the monofilament polypropylene flat mesh with acceptable long term complication rate. The use of the monofilament polypropylene flat mesh can be feasible and cost effective alternative to memory ring patch, when performing TIPP technique.

Εισαγωγή: Η γαστρο-οισοφαγική παλινδρομική νόσος [ΓΟΠΝ] είναι μια χρόνια παθολογική κατάσταση, συχνή στο δυτικό κό-σμο, με κύρια κλινική εκδήλωση το αίσθημα του οπισθοστερνικού καύσου, η οποία, παρά την επιτυχία της φαρμακευτικής α-γωγής, όχι λίγες φορές πρέπει να αντιμετωπισθεί χειρουργικά. Την τελευταία δεκαετία η τεχνολογία επέτρεψε την εφαρμογή διαφόρων ελάχιστα επεμβατικών ενδοσκοπικών τεχνικών. Μια από αυτές είναι η εφαρμογή ραδιοσυχνοτήτων [Stretta] στον κατώτερο οισοφαγικό σφιγκτήρα. Σκοπός: Η αξιολόγηση της αποτελεσματικότητος της τεχνικής με κριτήριο τη βαρύτητα των συμπτωμάτων της ΓΟΠΝ [ερωτημα-τολόγιο GERD-HRQL] και την ποιότητα ζωής σε συσχετισμό με τη νόσο [ερωτηματολόγιο MOS-SF-36]. Aσθενείς: Περιλαμβάνονται 77 ασθενείς οι οποίοι υποβλήθηκαν σε αντιμετώπιση της ΓΟΠΝ με την τεχνική STRETTA στο Τμήμα Ενδοσκοπήσεων της Α? Προπαιδευτικής Χειρουργικής Κλινικής του ΑΠΘ την τελευταία 5ετία. Αξιολογήθηκαν πριν από την εκτέ-λεση της Stretta, καθώς και 6 και 12 μήνες μετά με τα ερωτηματολόγια GERD-HRQL και MOS-SF-36. Αποτελέσματα: Η βαρύτητα των συμπτωμάτων της ΓΟΠΝ βελτιώθηκε στατιστικά πολύ σημαντικά, με τη βαθμολογία να μετα-βάλλεται από το 38/50 στο χρόνο 0 στο 5/50 στους 6 και 12 μήνες. Όμοια, η ποιότητα ζωής βελτιώθηκε στατιστικά πολύ σημα-ντικά [κατά 18 ως 25 μονάδες σε 100βάθμια κλίμακα] όσον αφορά της παραμέτρους της «λειτουργικής ποιότητας ζωής», δη-λαδή γενική κατάσταση υγείας, σωματικός πόνος, ζωτικότητα, φυσική και κοινωνική δραστηριότητα, ενώ και λιγότερο, αλλά επίσης στατιστικά σημαντικά [κατά 9 ως 13 μονάδες] ως προς τις παραμέτρους της «συναισθηματικής/ψυχικής υγείας», οι ο-ποίες δεν ήταν εξαρχής σημαντικά μειωμένες. Συμπέρασμα: Η τεχνική Stretta φαίνεται ότι είναι μια αποτελεσματική μέθοδος αντιμετώπισης της ΓΟΠΝ αφού μειώνει σημα-ντικά την βαρύτητα των συμπτωμάτων της παλινδρόμησης και συμβάλλει θετικά στη βελτίωση της ποιότητας ζωής των ασθε-νών, όπως οι παράμετροι αυτές εκτιμήθηκαν με αξιόπιστα ερωτηματολόγια ελέγχου.

Objectives: Comparison between bilaterally thoracoscopic sympathectomy-T2/T3 and bilaterally thoracoscopic sympathectomy-T2 in our experience of treatment of primitive hyperhidrosis. Methods: From March 2007 to March 2009, 18 patients affected by focal palmar hyperhidrosis or associated palmar and axillary hyperhidrosis underwent bilateral thoracoscopic sympathectomy in our clinic. Of those, 7 patients underwent a bilateral thora-coscopic sympathectomy with excision of ganglia T2 and T3 (TS-T2/T3) while 11 patients underwent a bilateral thoracoscopic sympathectomy with excision of ganglion T2 alone (TS-T2). We evaluated the following endpoints: the resolution of the main problem, the onset of compensatory hyperidrosis (CH) and its grade (absent, hyper-perspiration, wet, dripping), the CH impact on postoperative quality of life (absent, noise, debilitation, re-lationship problems) and the patients? satisfaction about intervention (excellent, good, sufficient, poor). Results: We found the statistical evidence of a worse postoperative quality of life (QOL) among those who underwent TS-T2/T3 than among those underwent TS-T2 (Fisher exact test p-value= 0.045). Conclusions: We maintain that TS-T2 is more suitable than TS-T2/T3 for the treatment of primitive palmar hyperhidrosis or asso-ciated palmar and axillary hyperhidrosis because it may favourite a better patient?s postoperative QOL and it is a safer interven-tion with shorter duration.

Background: In the era of laparoscopic cholecystectomy (LC), accurate preoperative diagnosis of common bile duct (CBD) stones is necessary as the intraoperative diagnosis is difficult unlike in open cholecystectomy when the manual palpation is possible. Objective: construction and evaluation of an equation to anticipate the presence of common bile duct stones in patients with chole-lithiasis before laparoscopic cholecystectomy. Design: Retrospective analysis, construction of equation and prospective evaluation. Patients: The retrospective analysis involved 428 cases presented with picture suggesting choledocholithiasis and underwent ERCP, in order to develop a predictive equation for presence of CBD stones. 50 patients with symptomatic cholelithiasis were prospectively studied to evaluate the equation. Interventions: Preoperative ERCP, laparoscopic cholecystectomy. Results: In retrospective group, among the studied 15 potentially predictive variables, only four were found to be statistically signifi-cant. An equation was obtained, then it was evaluated prospectively on 50 patients having gall stone disease. For all patients, pre-operative scores were obtained using the predictive equation and ERCP results were compared to confirm presence or absence of CBD stones. No false positive and 2 false negative results. The sensitivity and the specificity of the model were 89% and 100%, re-spectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 100% and 94.1 respectively. Conclusions: This model can be effectively used into the clinical setting to rationalize the use of preoperative ERCP or to identify pa-tients indicated for non-invasive imaging techniques such as magnetic resonance cholangio-pancreatography (MRCP).

Groin hernia repair is one of the most frequently performed operations in general surgery. From the original Bassini's procedure to the Lichtenstein's tension-free procedure, a variety of open techniques have been described to manage groin hernias. With the introduction of laparoscopy in hernia surgery in 1990s, laparoscopic repair has emerged as the procedure of choice orldwide. Since June 1993, our approach for inguinal hernia repair has been laparoscopic TEP. The purpose of this study is to present the results of a large patient cohort operated on by a single surgeon using the TEP procedure. Emphasis is made on the surgical technique, intraoperative and postoperative complications and follow-up outcome.

Background. The use of a mesh in transabdominal preperitoneal laparoscopic hernia repair (TAPP) caries the risk of nerve injury, hematom, adhesions, infectious complications or late mesh rejection. The aim of this article is to report for the first time an early mesh rejection. Results A 54 year old man was indicated to TAPP because of the right side groin hernia. He had no previous abdominal surgery. We performed the laparoscopy with mesh composed of multifilaments of polypropylene and polyglycolic acid, without complications. But since the second day he complained about the pain. Firstly we considered it as a common postoperative pain. But the pain was worsening. The patient had normal temperature.The third day, the white blood cell count was normal, C reactive protein was increased, procalcitonin was normal. Ultrasonographic examination revealed small amount of hypoechogenic fluid around the mash. We thought about a hematom with possible nerve irritation. We went on with conservative therapy. But on the 9. day, despite groin without sign of inflamatory irritation, normal inflammation markers , we indicated laparoscopic revision because of increasing pain. We found mesh without dislocation but it was surrouned by turbid liquid, the underlaying tissue was irritated, the hernia site distinguished. Culturing of the fluid, including anaerobics, did not reveal any bacterial growth. After mesh removal the patient made an uneventful recovery. Conclusion. This is the report of early mesh rejection which is rare but potential complication of TAPP. It should be considered by patients in pain immediately after surgery which is not decreasing.

Giant Hepatocellular Adenomas (HCAs) are rare benign hepatic tumors. Definitive treatment can only be achieved through surgical resection. However, patients with giant lesions may face morbidity and mortality risks during surgery. The authors present a 33 year-old patient with a HCA and we performed a two stage procedure consisting of lesional arterial embolization followed by surgical resection, permiting an easier and safer resection, as the lesion was both smaller in size and less hemmorrhagic that antecipated based on the pre-embolization imaging. The authors propose it to be a safer therapeutic option for large HCA than surgery alone.

Background. Clinical features of endometriosis are various with several onset and often mimic symptoms of obstructed defeca-tion syndrome. Case Presentation. We report our experience about Defecating MRI Proctogram in a 41 years old nulliparous woman studied for obstructed defecation syndrome while she was affected by recurrent pelvic endometriosis. Conclusion. Pelvic diseases such as deep endometriosis could be a hard challenge in diagnosis for proctologist and a mutual col-laboration with gynecologist is mandatory. In order to achieve a correct pathological analysis other imaging tools such as mag-netic resonance and ultrasonography are now available in the hand of the modern proctologist and are useful to avoid potential diagnostic and surgical mistakes in patients complaining chronic constipation.

Background. Seroma formation is the most common complication following modified radical mastectomy. It results in patient?s discomfort and prolongation of hospital stay. Treatment options vary from conservative measures to consecutive evacuating procedures through percutaneous needle aspiration or even re-insertion of a new drain tube. Case presentation. We report a case of a 78-year-old female patient who developed a persistent seroma after mastectomy for breast cancer. Attempts to treat this complication by applying all the aforementioned methods proved ineffective and she was taken back to the operating room for exploration of the axilla. A fibrous cyst containing the serous collection was discovered and was carefully excised. Conclusion. This procedure, which is rarely described in the literature, offered our patient definite treatment. We recommend it in all cases of refractory seroma after axillary dissection.

Introduction: Gastrointestinal Stromal Tumors (GISTs) are the most frequent tumors of mesenchymal origin and can be found throughout the alimentary truck, from the lower portion of the esophagus to the anal canal. GISTs usually appear during the 5th and 6th decade of life, equally in both genders. These tumors vary in size and may be presented with a broad spectrum of symptoms. The smaller ones are often diagnosed accidentally, while the differential diagnosis is often challenging. Case presentation: A 67 year old male patient with a palpable mass extending from the epigastrium to the left iliac fossa is present-ed. The patient referred early satiety feeling and nausea, resulting in great weight loss. The Computed Tomography (CT) and Magnet-ic Resonance Imaging (MRI) revealed a large mass measuring 28x21x15 cm, repelling the stomach and the left hepatic lobe, as well as two hypodence lesions in the right hepatic lobe. A case of sarcoma was suspected. A CT guided biopsy was performed and pathol-ogy examination revealed a GIST. The patient refused the proposed neoadjuvant therapy with Tyrosine Kinase Inhibitor (TKI) and an operation was scheduled, due to persistent and continuous aggravation of the symptoms and patient?s strong will. Laparotomy re-vealed a large mass adhering to left hepatic lobe, originating from the lesser curvature of the stomach. The tumor was resected en block with the left segment of the liver (segments II and III) and the distal stomach while a gastroenterostomy was performed for GI continuinity. Postoperative period was uneventful and the patient was discharged on the 10th postoperative day. The pathology con-firmed a high risk GIST and imatinib adjuvant therapy was administered. Conclusion: Surgical treatment remains the golden standard for non metastatic and resectable GISTs. In patients with advanced or metastatic disease, TKI administration, as neoadjuvant therapy, is a well established management. However, in such cases, surgery, without neoadjuvant TKI therapy, may be used, in well selected cases, as an alternative method when clinical manifestations force to it, or there is increased risk of tumor complications where threatens patient?s life.

Cavernous hemangiomas are the most common benign tumors of the liver. Most of them are asymptomatic and may be man-aged with observation, but in some situations they can reach large dimensions and may produce a great variety of symptoms that normally requires surgical treatment. Although enucleation is the technical of choice because offers greater preservation of hepatic parenchyma and fewer complications; in cases of giant hemangioma, an extended hepatectomy is often recommended. We report a case of a 44 year old man with a symptomatic cavernous giant hepatic hemangioma that was treated by a right extended hepatectomy after two arterial embolization procedures unsuccessful.