Τόμος 22, Τεύχος 3
Ιούλιος- Σεπτέμβριος 2017

101Laparoscopic Choledochoduodenostomy in the Management of Obstructive Biliary Tract in the ERCP Era
P. Priego
Πλήρες Κείμενο | Περίληψη
Background: With the advent of endoscopic retrograde cholangiopancreatography (ERCP), indications for choledochoduodenostomy have been drastically reduced. Furthermore, and even although laparoscopic common bile duct (CBD) exploration (LCBDE) is being increasingly used for management of CBD stones, due to the technical challenge associated with a laparoscopic biliaryenteric anastomosis, laparoscopic choledochoduodenostomy (LCDD) has not widely adopted. Patients and methods: A review of the literature limited to studies published from 1989 to 2013, reported in English language and performed on humans was conducted on Pubmed using the following key words: ?laparoscopic choledochoduodenostomy?. Operative details, perioperative outcomes and follow-up data were examined. Results: A total of 5 studies reporting the outcomes of 90 patients undergoing LCDD for benign (choledocholithiasis, cholangitis, chronic pancreatitis and distal CBD stricture) and malignant (unresectable pancreatic neoplasm) indications were included. The mean age of patients was 60.34 years. There were 69 female and 21 male patients. Mean operative time was 180.16 minutes. Average hospital stay was 6 days. The overall success rate in achieving a CBD clearance was 100%, with a morbidity rate of 11% and a mortality rate of 3.3%. Recurrence of symptoms was reported in only one patient(1%). Conclusions: Laparoscopic choledochoduodenostomy is a safe and feasible surgical procedure in the management of obstructive biliary duct with a low morbidity and mortality rates. However, the number of cases of LCDD in our review is small and more long-terms and randomized studies in compare with ERCP and open surgery should be done to validate the results
105The Risk Factors for Reamputation in Patients with Diabetic Foot Ulcers
T. Dinc , S. Sahin , H. Pehlevan , S. I. Kayilioglu , U.U. Goktug , A. Polat-Duzgun , F. Coskun
Πλήρες Κείμενο | Περίληψη
In this review, we aimed to classify the risk factors related with reamputation in patients with diabetic ulcers. We searched all the studies with the keywords ?diabetic ulcer?, ?reamputation?, ?risk factors? between 1980 and 2016 in Google Scholar database. Studies related to ischemic amputations due to peripheral artery disease were not included. Age, gender, ethnicity, comorbid diseases, chronic renal failure, diabetes mellitus duration, coronary artery disease, tobacco usage is associated with the risk of reamputation. In physical examination presence of diabetic ulcer, Wagner classification, wound infection, ankle brachial index, and transcutaneous oxygen pressure are found also related with reamputation. Laboratory findings such as low hemoglobin level, leucocytosis, high CRP are related with recurrence of diabetic ulcer. By means of the technological developments, not only conventional radyography and doppler ultrasound but also MRI, CT angiography, and skin thermograrphy are effective techniques to determinate the amputation level correctly and to decrease the reamputation rate. There are several risk factors associated with the risk of reamputation in patients with diabetic ulcer. Insufficent reamputation is significantly related with reamputation rate, and also history of major amputation is an independent risk factor for reamputation. Postoperative wound care, postoperative rehabilitation, use of proper prosthetics, and alternative walking strategies are effective ways to decrease reamputation rates.

Ερευνητικές εργασίες
109Early Postoperative Outcomes for Pancreaticoduodenectomy Before and After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol
Q.Y. Ling , A.C. Ariffin , A. Azman , Z. Zuhdi , H. Othman , R. Jarmin
Πλήρες Κείμενο | Περίληψη
Background: We implemented the Enhanced Recovery After Surgery (ERAS) for our post pancreaticoduodenectomy patients in our institution since 2013. This study aim to to determine the differences between the previous postoperative care and ERAS. Material and Method: We included all patients who underwent pancreaticoduodenectomy UKM Medical Centre (UKMMC) from Jan 2011 to April 2015. Subjects are divided into control group comprise pre-ERAS patient and study group comprise post ERAS implementation. Recorded data include demographics, patients? characteristic, surgery data, complication, outcomes and length of stay. Results: Total subjects were 81 patients. There were no significant differences in the demographics and patients? characteristic between both groups. Post-operative morbidity, re-laparotomy and readmission rate was equivalent. Mortality rate were more in pre-ERAS group but not significant. The length of stay was lower in the post ERAS group (11.7 days versus 15.4 days; p=0.002). Non-PD related complication is high within the pre-ERAS group (27.7% versus 5.9%; p=0,019). Conclusions: ERAS protocol have a lower complication rate and reduce hospital stay. It should be the standard management in post-operative pancreaticoduodenectomy care
114Management of High Grade Corrosive Injuries of the Upper Gastrointestinal Tract in Adults
D. Kostov , G. Kobakov , D. Yankov , V. Kostov
Πλήρες Κείμενο | Περίληψη
Background. The aim of this retrospective study is evaluation and management of patients with Grade 3b corrosive injuries of the upper gastrointestinal tract (GI). Material and Methods. Between January 1996 and April 2017, 23 adult patients were referred to the Clinic of Surgery at the Na-val Hospital, Varna, for treatment of complications after the ingestion of corrosive substances. The focus is on the management of 11 patients with of grade 3b corrosive injuries of the upper GI. Results. Upper GI endoscopy was the most important investigation in all cases. The corrosive injury is classified as Grade 3 in 11 patients with simultaneous involvement of the stomach and esophagus. In 1 case (9.1%), the duodenum and a part of proximal jejunum were also injured. All cases underwent emergency surgery for the initial management. There were 5 (45%) postoperative deaths within 30 days of surgery. Conclusion. The ingestion of corrosive substances has devastating effects on the upper GI and present major problems in their management. Early upper GI endoscopy is considered crucial and usually recommended in the first 12-48 h after caustic inges-tion, but in our opinion, in the case of ingested large amounts of liquid corrosive substance, the esophagogastroduodenoscopy has to be done within the first 6-12 hours. Surgery plays a key role as both an emergency measure and later also in delayed re-construction. In the acute phase, it is clear that patients with evidence of perforation and high grade (grade 3b) corrosive injuries require immediate surgery. All injured organs must be resected, if possible, during the first operation
119Superficial open lymph node biopsy in a setting with a high burden of HIV infection
A.M. Kgatle , R. Naidoo , B. Singh , Y. Moodley
Πλήρες Κείμενο | Περίληψη
Background: Superficial open lymph node biopsy (SOLNB) remains the ?gold standard? for investigating lymphadenopathy (LN). Literature reporting SOLNB in settings with a high burden of HIV infection are limited. The objective of this study was to contrib-ute to the current understanding of SOLNB in settings with a high burden of HIV infection. Patients and Methods: This was a retrospective audit of 137 adult outpatients who underwent SOLNB at a regional/tertiary South African hospital over a two year period. Data for patient/clinical characteristics and post-SOLNB outcomes (histology re-sults and complications) were collected from each patient?s medical record and analyzed using descriptive statistical methods. Potential statistical associations between patient/clinical characteristics and outcomes were tested using a chi-squared/Fishers Exact test. Results: Localized LN caused by tuberculosis (TB) was common. Incisional biopsy was the preferred surgical approach (72.3% of biopsies). Age and exposure to TB were found to be associated with post-SOLNB histology results (p=0.001 for Age, p=0.040 for exposure to TB). Histology results were found to be associated with complications following SOLNB (p<0.001). Conclusion: Tuberculosis is an important cause of LN in settings with a high burden of HIV infection. We identified associations between certain patient/clinical characteristics and post-SOLNB outcomes in our study
125Extended surgery for Non-Small Cell Lung Cancer (NSCLC)
C. N. Foroulis
Πλήρες Κείμενο | Περίληψη
Extended resections for Non-Small Cell Lung Cancer (NSCLC) are performed for the radical resection of locally advanced T3 and T4 tumors and it is required in less than 5% of all lung resections performed for NSCLC. Extended resections are complex proce-dures which include resection of lung parenchyma en bloc with the neighboring invaded by the tumor structures such as chest wall, diaphragm, spine, main carina or major mediastinal vessels. Exclusion of N2 disease is of paramount importance before any attempt to proceed with extended resection in NSCLC. The expected benefits of surgery are the better local control of the dis-ease, the prolongation of overall survival and the possible cure in 15-35% of the well selected patients for extended resection. The relatively high possibility of occult distant or mediastinal lymph node micrometastases at the time of surgery and the rela-tively high possibility of incomplete resection or open-close thoracotomy are the main drawbacks of extended resections for NSCLC. Induction treatment could result in effective tumor downstaging, indeed restaging of locally advanced tumors after in-duction treatment is a quite difficult process and the available PET criteria should be used for appropriate restaging. Extended resections after induction treatment are associated with increased morbidity and mortality rates. The completeness of resection and the absence of N2 disease are the main determinants of prolonged survival in locally ad-vanced tumors undergoing extended resection. Incomplete resections are associated with survival rates similar to that of no resection, while involvement of mediastinal nodes precludes any chance of cure.

Ενδιαφέρουσες περιπτώσεις
129Giant Fibrovascular Polyp of the Esophagus
H. Bektas , O. Segmen , A.H. Yardimci
Πλήρες Κείμενο | Περίληψη
Ba ckground. Fibrovascular polyps of the esophagus are rare disorders that constitute less than 1% of all gastrointestinal system neoplasms. Despite being universally benign, they can be symptomatic and have serious complications. The definitive treatment is excision of the mass. In this article, we present a rare case of a giant fibrovascular polyp of the esophagus. Case presentation. A 55 year old male patient presented with symptoms of dysphagia and regurgitating mass. Diagnostic tes ts revealed a pedunculated submucosal mass extending through the upper esophageal lumen. Surgical excision of the mass was planned. The pedunculated mass of 10 cm length was resected through a left cervical esophagotomy The patient was discharged without c omplications on the postoperative fifth day. Pathological examination of the specimen revealed a giant fibrovascular polyp measuring 10x2.5x1.7 cm with stroma rich in adipose tissue and prominent vascular components. Conclusion. Benign tumors of the esopha gus are rare, with an incidence of less than one percent. The most common of these tumors are fibrovascular polyps. Although usually asymptomatic, they can present with various symptoms such as dysphagia, pharyngeal or substernal mass and regurgitation. As phyxiation and gastrointestinal bleeding are possible complications. Excision of the polyp is the definitive cure and is recommended for symptomatic patients with large polyps. Endoscopic, cervical or thoracic approach are all possible choices of managemen t among which the decision should be made according to the size and the location of the mass. Patients? symptoms disappear immediately after surgery. Recurrence is rare and complication rates are low
132A rare of inflammatory myofibroblastic tumour (IMT) of the thyroid gland
AG. Suriyana , AR.Nor Faezan , O. Suraya
Πλήρες Κείμενο | Περίληψη
Inflammatory Myofibroblastic Tumour (IMT) of the thyroid is a rare entity with only 19 cases reported in the English literature. Historically it is also known as inflammatory pseudotumour (IPT) or plasma cell granuloma (PCG) that occurs primarily in the vis-cera or soft tissue and it has been reported to occur in any parts of the body, including the thyroid gland. Previously known to be a benign disease, recent evidence has shown that there is a likelihood that this type of tumour may become aggressive. We pre-sent a case of a 50 year-old male who attended our surgical clinic with a complaint of a painless neck lump, occurring 4 years after previous surgery in a euthyroid state. Radiological and cytological assessments showed a benign asymptomatic thyroid nodule. A unilateral hemithyroidectomy was performed and histologically showed an IMT of the thyroid. The literature is re-viewed for management of this disease.
135A rare case of pseudoangiomatous stromal hyperplasia (PASH) ? Tumour forming breast lump
LK. Sim , AR.Nor Faezan , AS. Shahrun Niza , M. Rohaizak , O. Suraya
Πλήρες Κείμενο | Περίληψη
Pseudoangiomatous of the breast is a rare benign stromal proliferation that simulates a vascular lesion. It rarely form a breast lump but more commonly presents as an incidental component coexistent with other breast lesions. Several authors believe in non-surgical intervention with long term follow up if core biopsy is confirmatory of PASH. In our center, we recommend surgical excision with adequate margin for local control. We present a rare case of PASH presenting as a huge, fast growing breast lump with challenging diagnoisis in a young lady. We feel that surgical approach is the definitive treatment for PASH
137Isolated Pancreatic Tuberculosis Mimicking Pancreatic Malignancy
Z. Nur Zawan , SM. Ikhwan , PG.Tan , R. Zubaidah , VM. Leow
Πλήρες Κείμενο | Περίληψη
Tuberculosis (TB) is a common infectious disease in developing countries. Although lung is the most commonly affected site, extra-pulmonary TB accounts for one-fifth of the cases . The patients may present with symptoms mimicking pancreatic malig-nancy such as abdominal pain, jaundice, significant loss of weight or symptoms to suggest on going infection like fever and night sweats. We reported a case of an elderly lady who presented with epigastric pain with significant loss of weight. Computed To-mography (CT) scan of abdomen showed pancreatic body mass. In view of presence of peripancreatic nodes with high ESR, she was subjected for diagnostic laparotomy and biopsy. The histopathological results came back as Tuberculosis and she was treat-ed with anti-TB drugs.
140A rare case of appendico-vesical fistula
AO. Toure , M.L. Gueye , B. Ouedraogo , O.Thiam , P. Ahmet Fall , M. Cisse , C.T. Toure
Πλήρες Κείμενο | Περίληψη
Appendico-vesical fistula is a rare disease for which diagnosis is difficult to make because of unspecific signs. Just a few cases have been described in literature. We report a 42 years-old patient referred in our department 8 days after surgical remo-val of bladder lithiasis. In his history, we noted many recurent urinary infections. He presented urinary and digestive fistula. We suspected an ileal or rectal iatrogenic fistula. After surgical exploration, we discovered an appendico-vesical fistula. We per-formed appendicectomy and bladder closure with uneventfull postoperative course.
142Giant Pleomorphic Adenoma of a Submandibular Gland: A Case Report
B. Nadia Nafasha , AS. Shahrun Niza , A.R. Nor Faezan , O. Othman , M. Rohaizak
Πλήρες Κείμενο | Περίληψη
Benign tumours of the submandibular glands are rare; among those that do occur, pleomorphic adenomas are the most com-mon. Despite having been reported in several publications, giant pleomorphic adenoma of similar origin is extremely uncom-mon. These tumours are known to be painless, slow-growing, and long-standing. These patients tend not to seek out medical treatment, as the condition does no harm to them. We report on a case of giant pleomorphic adenoma of the right submandibu-lar gland, and the management thereof.

Εικόνες στη χειρουργική
145Isolated cutaneous metastases from Esophagus cancer: An unusual presentation
B. Roy , S. Basu , S. Guha , M. Gangopadhaya , P.V. Thambi , V.M. Rewale
Πλήρες Κείμενο | video

Εκπαιδευτικό video
147Laparoscopic Repair of Major Branch of the Middle Hepatic Vein Injury during Laparoscopic Cholecystectomy: A Real Surgical Challenge
G.D. Lianos , N. Hasemaki , K. Athanailidi , S. Gkountas , G. Vangelis , A. Karampa , I. Trikoupis , M. Drakou , E. Lekkas
Πλήρες Κείμενο

Επιστολές προς Εκδότη
148Retropeitoneal cystic lymphagioma
I. Aizat Sabri , S. Lenny Suryani , I. Azim , H Harunarashid
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150Bilateral Giant Hydronephrosis In A Patient With End Stage Renal Failure
A. Jagwani , CKS. Lee
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152A case of Sarcomatoid Renal Cell Carcinoma (RCC) with Lower GI Bleeding
M.S. Siti Salwa , C.A. Mohd Firdaus , EH. Goh , GH. Tan , P. Singam , XI. Fam
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154Local recurrence of breast carcinoma post mastectomy with a different histo-pathology from the initial tumor
MS. Mohamad Fairuz , AS. Shahrun Niza
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