Περιεχομενα


Τόμος 19, Τεύχος 1
Ιανουάριος-Μάρτιος 2014


Ανασκοπήσεις
1Κόλλες ινικής: Αποτελεσματικές χωρίς ? αποδείξεις
Κ. Κοτζάμπαση
Πλήρες Κείμενο | Περίληψη
Ο κόλλες ινικής είναι σύνθετα παράγωγα του πλάσματος, βιοσυμβατές και βιολογικά διασπώμενες, οι οποίες χρησιμοποιού-νται με αυξανόμενη συχνότητα σε πολλούς τομείς της χειρουργικής εξ αιτίας των μοναδικών αιμοστατικών και συγκολλητικών τους ιδιοτήτων. Για τη δράση τους μιμούνται τον καταρράκτη του μηχανισμού της πήξης του αίματος και δρουν ανεξάρτητα από την κατάσταση του πηκτικού μηχανισμού του ασθενούς. Το άρθρο αυτό παρουσιάζει περιληπτικά τη σύνθεση της κόλλας και το μηχανισμό δράσης της και την κλινική αποτελεσματικότητά της στη σύγχρονη χειρουργική, με έμφαση στην έκβαση του ασθενούς: Μειώνει τις περι- και μετεγχειρητικές επιπλοκές επιτυγχάνοντας ταχεία αιμόσταση. Μειώνει τη διαρροή αέρα, υ-γρών ή αίματος από τη γραμμή συρραφής ή από μια αναστόμωση και προλαμβάνει τη διάσπαση και τη δημιουργία συριγγίου σε αναστομώσεις του πεπτικού ή επί ρήξεως τις στεγανοποιεί ενδοσκοπικά. Τέλος, με την ταχύτατη εξέλιξη της μηχανικής των ιστών οι δυνητικές εφαρμογές της αυξάνονται ταχύτατα, είτε ως φορέας βλαστοκυττάρων σε περιοχές με ιστικά ελλείμματα είτε ως σύστημα μεταφοράς φαρμάκων σε διαφορετικούς ιστούς, επιλεκτικά.
10Χειρουργικές τεχνικές προσπέλασης της άνω μεσεντερίου αρτηρίας και ριζική εξαίρεση του περιληκυθικού καρκίνου
K. Βασιλειάδης , X. Παπαβασιλείου , Π. Δεληβοριάς , Χ. Μακρίδης
Πλήρες Κείμενο | Περίληψη
Η μη-εξαιρεσιμότητα του τοπικά εκτεταμένου περιληκυθικού καρκίνου καθορίζονταν έως και το πρόσφατο παρελθόν από τη διήθηση της άνω μεσεντερίου και/ή της πυλαίας φλέβας (ΑΜΦ-ΠΦ) από τον όγκο. Ωστόσο, το τελευταίο χρονικό διάστημα, η συνοδός εκτομή και αποκατάσταση του διηθημένου τμήματος της ΑΜΦ-ΠΦ διενεργείται με ασφάλεια, χωρίς αύξηση της με-τεγχειρητικής νοσηρότητας και θνητότητας επιτυγχάνοντας ριζική εκτομή του όγκου. Αντίθετα, η διήθηση της άνω μεσεντερίου αρτηρίας (ΑΜΑ) εξακολουθεί να αποτελεί αντένδειξη διενέργειας παγκρεατοδωδεκαδακτυλεκτομής (ΠΔ). Όμως, στην περί-πτωση που η ΠΔ διενεργηθεί με τη συνήθη κλασική τεχνική, η διήθηση της ΑΜΑ από τον όγκο διαπιστώνεται προς το τέλος της φάσης εκτομής, όταν δηλαδή η επέμβαση έχει ήδη υπερβεί το σημείο «μη επιστροφής». Έτσι, στην περίπτωση διήθησης της ΑΜΑ, το τελικό αποτέλεσμα είναι τα διηθημένα όρια εκτομής. Επιπλέον, η πλήρης εκτομή του οπισθοπεριτοναϊκού περιπα-γκρεατικού ιστού, που αποτελεί έναν από τους καθοριστικότερους προγνωστικούς παράγοντες στους ασθενείς που υποβάλλο-νται σε ΠΔ για την αντιμετώπιση περιληκυθικού καρκίνου, συνιστά το δυσκολότερο χειρουργικό χρόνο της επέμβασης. Προκει-μένου να επιλυθούν αυτά τα προβλήματα, έχουν περιγραφεί στην πρόσφατη διεθνή βιβλιογραφία πέντε διαφορετικές χει-ρουργικές τεχνικές οι οποίες αφενός εξασφαλίζουν την πρώιμη προσπέλαση της ΑΜΑ και αφετέρου διευκολύνουν την πλήρη εκτομή του οπισθοπεριτοναϊκού περιπαγκρεατικού ιστού κατά τη διενέργεια ΠΔ. Αυτές οι τεχνικές είναι: 1) η ανώτερη (superior) δια του ελάσσονος επιπλοϊκού θυλάκου, 2) η οπίσθια (posterior), 3) η αριστερή οπίσθια (left posterior), 4) η μέση- αγκιστροειδούς απόφυσης (medial uncinate) και 5) η κατώτερη υποκολική ή μεσεντέρια (infracolic or mesenteric). Σκοπός αυ-τής της μελέτης είναι η αναλυτική περιγραφή της χειρουργικής τεχνικής των διαθέσιμων σύγχρονων μεθόδων προσπέλασης της ΑΜΑ κατά τη διενέργεια ΠΔ, που εξασφαλίζουν αφενός την πρώιμη διάγνωση της διήθησης της ΑΜΑ από τον όγκο και αφετέ-ρου τη ριζική και ασφαλή εξαίρεση του παρασκευάσματος κατά μήκος του οπισθοπλάγιου ορίου εκτομής

Ερευνητικές εργασίες
21Effects of smoking on the incidence of postoperative complications in colorectal cancer surgery
Z. Adamova , R. Slovacek
Πλήρες Κείμενο
24Predictive factors for reliably preoperative diagnosis of strangulation in a series of 198 patients with adhesive small bowel obstruction nesseciting surgery
A. Hatzigeorgiadis , K. Boulas , K. Ioannidis , K. Zoi
Πλήρες Κείμενο | Περίληψη
Background/aims. The diagnosis of strangulation in case of adhesive small bowel obstruction can frequently be a diagnostic di-lemma. The objective of this study was to determine which indicators can preoperatively predict strangulation. Patients and methods. From 2001-2010, the medical records of 198 patients who were hospitalized due to adhesive small bow-el obstruction and received surgical treatment were retrospectively reviewed. Epidemiological, clinical, laboratory and imaging features were evaluated as probable predictive factors for strangulation. Results. 46 patients had the operative diagnosis of strangulated adhesive obstruction and underwent adhesiolysis and enterec-tomy. 152 patients had the operative diagnosis of non-strangulated adhesive obstruction and underwent only adhesiolysis. In univariate analysis, leukocytosis, localized involuntary guarding, low attenuation of bowel wall on intravenous-CT, persisting air-fluid levels in serial abdominal radiographs and closed-loop obstruction were found to be significantly associated with strangula-tion. In multiple logistic analysis, leukocytosis (p<0.0001, OR 1.001, 95% CI 1.0005-1.0011), localized involuntary guarding (p<0.0001, OR 16.091, 95% CI 3.612-71.764) and low attenuation of bowel wall on intravenous-CT (p=0.006, OR 55.197, 95% CI 3.241-940,011) found to be significantly important as predictive factors for strangulation. Conclusions. The presence of leukocytosis, localized involuntary guarding and low attenuation of bowel wall on intravenous-CT should raise high suspicion index for irreversible strangulation in patients with adhesive obstruction.
28Prospective Randomised Study Of Daily Probing In Emergency Laparotomy Incisional Wounds
V.S. Shah , J.R. Patel , A.P.Jain , A.K.Saxena , D.H.Tiwari , H.V.Shah
Πλήρες Κείμενο | Περίληψη
Background: Present study was aimed to evaluate the effect of daily probing in emergency laprotomy incisional wounds. Methods: A total of 100 patients were enrolled in the study, 50 in povidone-iodine probing group and 50 in povidone-iodine swab-bing group. out of which 4 patients were excluded from the study since the patient expired. So a total of 96 patients were included in the study. The total patient population included 20 females and 76 males, in which after exclusion of 3 male in test group and 1 male in control group . The mean age of patients in study group was 34 years and in control group was 38.72 years. The patients were of GI perforation, acute appendicitis, emergency laprotomy. Wound assessment included daily monitoring based on the ASEP-SIS criteria for Surgical Site Infection(SSI) (additional treatment; presence of serous discharge, erythema, purulent exudate, and sep-aration of the deep tissues; isolation of bacteria; and duration of inpatient stay) .Patients with an ASEPSIS score greater than 20 were considered to have Surgical Site Infection. Results: There were no significant difference (p=0.17) in indoor stay in both group but there was significant difference in ASEPSIS score(p=0.01) and time required for ASEPSIS score to reach zero(p<0.05). Conclusion: The present study of patients who were on daily wound probing had significantly lower surgical site infection in com-parison to the patients who were on routine povidone-iodine swabbing and dressing.
32Serum C-Reactive Protein and Fibrinogen levels as early markers of septic complications after sleeve gastrectomy in morbidly obese patients
J. Ruiz-Tovar , J. Luis Munoz , C. Llavero , M. Diez , L. Zubiaga , A. Arroyo , R. Calpena
Πλήρες Κείμενο | Περίληψη
Purpose: The performance of most bariatric procedures by laparoscopic approach has resulted in significant advantages, includ-ing a reduction in the length of hospital stay to 2-3 days. However, some postoperative complications may appear after the pa-tient has been discharged. The aim of this study was to investigate the efficacy of various acute phase parameters determined 24 hours after a sleeve gastrectomy for predicting septic complications in the postoperative course. Methods: A prospective study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric proce-dure between October 2007 and March 2013 was performed. Blood analysis was performed 24 hours after surgery. Acute phase parameters were investigated. Results: 50 patients were included in the study, 44 females and 6 males, with a mean age of 42.7 years and a mean preoperative BMI of 51,2Kg/m2. Complications appeared in 4 patients (8%):2 patients with an intra-abdominal abscess, a iatrogenic perfora-tion of the lower third of the oesophagus when introducing the calibration bougie and a staple line leak. The 2 patients with intra-abdominal abscess were diagnosed after hospital discharge. Mean values of C reactive protein (CRP), fibrinogen and WBC count were increased in the analytical determination 24 hours after surgery. CRP (p=0.002) and fibrinogen (p=0.036) levels were associated with the appearance of complications in the postoperative course. A cutoff value was established as the most dis-criminatory value: CRP >100mg/l (OR:10;p=0.001) and Fibrinogen >600mg/dl (OR:3.7;p=0.003). Conclusion: An elevation of CRP>100mgl and fibrinogen>600mg/dl should alert the surgeon the possibility of occurrence of postoperative septic complications.
37Rib Fractures: Retrospective Analysis of 1428 Cases
E. Metaxas , N. Tzatzadakis , M. Moustardas , M. Gerazounis
Πλήρες Κείμενο | Περίληψη
Aim of the study. Rib fractures are seen with increasing frequency. The tremendous force necessary to cause RF demonstrate remarkable associated injuries and complications. The purpose of this retrospective study was to determine the incidence, mor-bidity and mortality of this entity. Methods. Between 1995 and 2005, 1428 consecutive patients were admitted to the Department of Thoracic Surgery, General Hospital of Nikea-Piraeus, Greece for RF. There were 1071men( 75%) and 357 women( 25%), ranging in age between 15 and 90 years. Results. The majority (1387 patients),developed closed thoracic trauma and only 41 developed penetrate trauma. Conserva-tive treatment ? Observation received 899 patients ( 62,9% ). Chest tube for haemothorax or pneumothorax or both of them, introduced to 529 patients (37,1%) and 32 (2,2%) underwent thoracotomy cause of hemorrhage. Their hospitalization was 2 to 8 days with mean stay 3.14 ± 1.28 days (Mean ± SD). Their management was based upon analgesic, anti-inflammatory, bron-hodiastolic treatment and in time respiratory physiotherapy. Four hundred seventy one (32,9 %) from 1428 patients (334men and 137 women), developed associated injuries. Their hospitalization was 10 to 39 days with mean stay 9.44 ± 6.89 days (Mean ± SD) that was statistically higher to the hospitalization stay of the patients presented with RF isolated lesion (p=0.02). Head injuries (4,1%), elbow fractures (3,1%), femoral fractures (3,9%), emphysema (4,3%), flail chest (12,6%) was associated injuries. One hundred and three patients (7,2%) were transported to the Intensive Care Unit (ICU) cause respiratory insufficiency. Ninety five patients had polytrauma and in 62 patients coexisted flail chest.The mortality rate became 14,56% (15 patients to 103 who admitted to ICU). The age groups 31-35(50%), 71-75(50%), 21-25(40%), 26-30(37,5%), demonstrated highest morbidity. Conclusions. The cause was motor vehicle accidents in 83 %, falls from height in 14% and crashes in 3%. The RF treatment is mostly conservative. Associated injuries may danger patients? lives. Hospitalization, complication and mortality based on associ-ated injuries and in time treatment.

Ενδιαφέρουσες περιπτώσεις
40Accessory hepatic duct injury during laparoscopic cholecystectomy: Ligation as an alternative treatment approach
D. Paramythiotis , S. Panidis , D. Panagiotou , V. Papadopoulos , A. Michalopoulos , G. Basdanis
Πλήρες Κείμενο | Περίληψη
Introduction: Extrahepatic atypical bile duct such as accessory hepatic duct, aberrant hepatic duct and Luschka duct, is a rare finding and its incidence is reported to vary from 1.4 % - 27%. In patients with such biliary tract anatomical variations injuries are related to difficulty in identifying the correct anatomical structures either laparoscopically or in open way. Case report: A 35 years old woman was scheduled for laparoscopic cholecystectomy (LC) due to symptomatic gallbladder lithiasis. During operation, an aberrant hepatic duct was misdiagnosed as the cystic duct and, thus, it was ligated and cut. During cyst detachment, the injury was noticed and, therefore, the LC was transversed into an open cholecystectomy. The cystic duct was recognized to originate from an aberrant duct, proximally 2 mm in diameter. The aberrant duct was intubated and an intraoperative cholangiography was performed; revealing intrahepatic communication between left and right hepatic ducts and aberrant duct. Ligation of the accessory duct was, therefore, accomplished. The patients? recovery was uneventful and she was discharged in the 5th post operative day. No biochemical alterations of the hepatic enzymes were recorded and the patient had no signs of hepatic pathology during follow up. Conclusion: In spite of excellent laparoscopic visualization, extrahepatic accessory bile duct injuries during LC are unavoidable due to rarity and unexpectedly. In our case, although the duct?s diameter was 2 mm, we proceeded in the final ligation after taking into account that both right and left hepatic lobes had good intercommunication with the aberrant duct and the common hepatic duct. We recommend the use of intraoperative cholangiography in cases that anatomical variations are suspected. The safe performance of these operative procedures requires good knowledge of the anatomy, definite identification of the relevant structures and high degree of clinical suspicion.
44Primary neuroendocrine carcinoma of the breast: 2 Cases
T. Acar , E. Tarcan , M. Atahan , Y. Dere , E. Capk?noglu , N. Acar
Πλήρες Κείμενο | Περίληψη
Neuroendocrine tumors (NETs) are a tumors arising from diffusely spread neuroendocrine system. Among all NETs; 1/3 arises in gastrointestinal system, ? arises in lungs and the remaning in other endocrine tissues. Neuroendocrine tumors of the breast are a group of rare and slowly growing tumors consists <0,1% of all tumors and <1% of all NETs. (1)The type of breast tumors in which >50% of tumor cells showed positive immunohistochemical staining of neuroendocrine markers such as chromogranin and synaptophysin is accepted as pure NETs.(2,3) This tumor was firstly described by Cubilla and Woodruff in 1977 (3). Herein, we report 2 cases of breast carcinoma with neuroendocrine differentiation operated for palpable mass in the breast
46Strangulated obturator Richter?s hernia
K. Jayant , R. Agarwal , S. Agrawal
Πλήρες Κείμενο | Περίληψη
Obturator hernia is a rare type of hernia which accounts for only 0.07?1.4% of all intra-abdominal hernias and 0.2?5.8% of small-intestinal obstructions. It develops predominantly in elderly underweight women. It has nonspecific early symptoms, so these herni-as are usually discovered only after they have become incarcerated. Incarcerated obturator hernias are usually discovered on ab-dominal computed tomography scan or emergency surgery due to bowel obstruction. Here we present a case of a 65-year-old fe-male who presented with intermittent abdominal pain, distension and nausea for last 3 days. She was a known case of hypothyroid-ism, taking Levothyroxine in inadequate dose. Her intial abdominal Xray was showing few air-fluid level with air present in rectum. She was initially managed conservatively but later developed features of peritonitis for which she was operated. In laparotomy, Richter type of right-sided incarcerated obturator hernia was discovered with a small necrotic area and perforation of small bowel. Bowel resection was performed and obturator hernia was closed with interrupted sutures. The patient recovered without complica-tions. Obturator hernia, due to its rarity and nonspecific early symptoms, can still be misleading even to the most experienced clini-cians. Delay in diagnosis of obturator hernia can lead to bowel necrosis and perforation with significant postoperative morbidity and mortality.
48Phytobezoar in stomach and small intestine causing small bowel obstruction. Report of a case
I. Koutelidakis , B. Papaziogas , A. Doundis , S. Kalaitzis , S. Kapoulas , P. Christopoulos , I. Makris
Πλήρες Κείμενο | Περίληψη
Phytobezoar is a quite rare cause of small bowel obstruction nowadays since vagotomy has almost been abandoned as a surgical intervention for the management of GI ulcer disease. An 82-year old male, with a history of gastric surgery, presented with symptoms of small bowel obstruction. He digested a great amount of persimmons for three days. The pre-operative abdominal CT scan examination showed masses both in the stomach and the small intestine. The patient underwent an urgent gastrotomy and enterotomy and the histological report revealed the presence of phytobezoar. We report a rare case of intestinal obstruc-tion caused by a phytobezoar in a patient with a previous gastric surgery.

Εικόνες στη χειρουργική
51Primary Splenic Hydatid Cyst
Y. Duzkoylu , O. Koc , Y. Selim Sari , M. Kucukyilmaz
Πλήρες Κείμενο
52Chloronychia in obstetrician?s fingers
C. Iavazzo , P. Iavazzo , F. Ntziora
Πλήρες Κείμενο

Επιστολές προς Εκδότη
53Σύγκριση χειρουργικών αγκτήρων (χειρουργικών συνδετήρων) με διαφορετικές διατομές ως προς την αντοχή σε λυγισμό και κάμψη
Δ. Μιχαηλίδης
Πλήρες Κείμενο