Surgical Tips in Frozen Abdomen Management: Application of Coliseum Technique

Wound dehiscence is a serious postoperative complication, with an incidence of 0.5–3% after primary closure of a laparotomy incision, and represents an acute mechanical failure of wound healing. Relatively recently the concept of “intentional open abdomen” was described and both clinical entities share common pathophysiological and clinical pathways (“postoperative open abdominal wall”). Although early reconstruction is the target, a significant proportion of patients will develop adhesions between abdominal viscera and the anterolateral abdominal wall, a condition widely recognized as “frozen abdomen,” where delayed wound closure appears as the only realistic alternative. We report our experience with a patient who presented with frozen abdomen after wound dehiscence due to surgical site infection and application of the “Coliseum technique” for its definitive surgical management. This novel technique represents an innovative alternative to abdominal exploration, for cases of “malignant” frozen abdomen due to peritoneal carcinomatosis. Lifting the edges of the surgical wound upwards and suspending them under traction by threads from a retractor positioned above the abdomen facilitates approach to the peritoneal cavity, optimizes exposure of intra-abdominal organs, and prevents operative injury to the innervation and blood supply of abdominal wall musculature, a crucial step for subsequent hernia repair.</jats:p

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Expression and prognostic significance of S-100A2 protein in squamous cell carcinoma of the egophagus

The purpose of this study was to evaluate the expression of S100A2 Ca+2-binding protein and its prognostic significance in the management of squamous cell carcinoma of the esophagus.SUMMARYChanges in cytosolic Ca+2 concentration control a wide range of cellular responses including cellular apoptosis. Intracellular S100 Ca+2-binding proteins are key-molecules in transducing Ca+2 signaling. Amonh these, S100A2, has recently attracted major interest due to its stable expression in normal epithelia and down regulation in some tumors. As a candidate tumor suppressor, expression of S100A2 has been proposed as a valuable prognostic marker in different tumors.We examined the clinical significance of S100A2 expression in 116 resected specimens of esophageal squamous cell carcinomas usinh immunohistochemistry. S100A2 was positive in 49 cases (42.2%) and its expression was significantly higher among large (p=0.01) and well differentiated (p=0.013) tumors. Lymph node-positive tumors had a lower expression of S100A2 protein in comparison to the corresponding lymph node-negative equivalents in each of the T stages, but the difference was statistically significant (p=0.041) only for the T1b tumors. S100A2 statusbecame an independent predictor of patient survival (p=0.026) in lymph node-negative cases but not in node-positive cases.Evaluation of S100A2 protein expression may play an important role in the management of esophageal squamous cell carcinoma. The node-negative patients without S100A2 expression might be a high risk group with poor survival and will need further attention to design appropriate adjuvant therapy.Σκοπός της παρούσας μελέτης ήταν να διερευνηθεί η έκφραση και η προγνωστική σημασία της δεσμευτικής το ασβεστίου πρωτεΐνης S100A2 στο πλακώδες καρκίνωμα του οισοφάγου.ΠΕΡΙΛΗΨΗΕίναι γνωστό ότι μεταβολές στην ενδοκυττάρια και κύρια την κυτταροπλασματική συγκέντρωση του ασβεστίου, διαδραματίζουν σημαντικό ρόλο στο μηχανισμό ελέγχου πληθώρας κυτταρικών αντιδράσεων μεταξύ των οποίων και ο κυτταρικός πολλαπλασιασμός και η απόπτωση. Οι ενδοκυττάριες δεσμευτικές του ασβεστίου S100 πρωτεΐνες, έχουν αποδειχθεί μόρια-«κλειδιά» στην προώθηση ενδοκυττάριων μηνυμάτων μέσω του ρυθμιστικού τους ρόλου επί του ασβεστίου.Μεταξύ αυτών, η πρωτεΐνη S100A2, έχει αποτελέσει αντικείμενο αυξημένης έρευνας, λόγω της σταθερής της έκφρασης σε πληθώρα ανθρώπινων επιθηλιακών κυττάρων, καθώς και λόγω της απώλειας της έκφρασής της σε περιπτώσεις ανάπτυξης κακοήθων όγκων. Έχει τοιουτοτρόπως χαρακτηρισθεί σαν «ογκο-κατασταλτική» πρωτείνη και η απώλεια της έκφρασής της έχει αποδειχθεί ότι έχει προγνωστικό χαρακτήρα για την εξέλιξη ασθενών με ποικιλία κακοήθων όγκων, αποδίδοντας της έναν χαρακτήρα προγνωστικού δείκτη.Στην παρούσα μελέτη εξετάσαμε την κλινική αξία της ανοσοϊστοχημικής έκφρασης της πρωτεΐνης S100A2, μεταξύ 116 ασθενών με πλακώδες οισοφαγικό καρκίνωμα που υποβλήθηκαν σε οισοφαγεκτομή. Η έκφραση της πρωτεΐνης αποδείχθηκε ισχυρή και οι αντίστοιχοι όγκοι χαρακτηρίστηκαν ως S100A2-θετικοί σε 49 περιπτώσεις (42,2%). Η έκφραση της πρωτεΐνης ήταν σημαντικά ισχυρότερη μεταξύ ευμεγέθων (p=0.01) και καλά διαφοροποιημένων (p=0.013) όγκων. Όγκοι που συνοδεύονταν από την παρουσία θετικών λεμφαδενικών μεταστάσεων, παρουσίαζαν σταθερά μειωμένη έκφραση της πρωτεΐνης, σε σχέση με τους αντίστοιχους όγκους χωρίς λεμφαδενική διασπορά για κάθε κατηγορία σταδίου Τ, σύμφωνα με το ΤΝΜ σύστημα ταξινόμησης του οισοφαγικού καρκίνου. Παρά ταύτα η διαφορά αυτή απέκτησε στατιστικά σημαντική σημασία (p=0.041) μόνο για τα πρώιμα πλακώδη οισοφαγικά καρκινώματα σταδίου Τ1β.Η έκφραση της πρωτεΐνης S100A2, αποδείχθηκε ανεξάρτητος προγνωστικός παράγοντας για την επιβίωση των ασθενών με αρνητικούς λεμφαδένες όπου η παρουσία της συνδεόταν άμεσα με την επιμήκυνση της επιβίωσης των ασθενών. Αντίθετα δεν αναδείχθηκε καμμία προγνωστική σημασία της έκφρασης της πρωτεΐνης για την επιβίωση των ασθενών με θετικούς λεμφαδένες.Η εκτίμηση της έκφρασης της πρωτεΐνης S100A2 μπορεί ως εκ τούτου να αποδειχθεί σημαντικός παράγοντας στην διαμόρφωση της θεραπευτικής αντιμετώπισης των ασθενών με πλακώδες οισοφαγικό καρκίνωμα. Ιδιαίτερα η κατηγορία των ασθενών με αρνητικούς λεμφαδένες και σύγχρονη απώλεια της κυτταρικής έκφρασης της πρωτεΐνης S100A2, φαίνεται να αντιπροσωπεύει ομάδα ασθενών «υψηλού κινδύνου» για υποτροπή της νόσου και μειωμένη συνολική επιβίωση, επιβάλλοντας την αντιμετώπιση της με την προσθήκη και άλλων επικουρικών θεραπευτικών μέσων καθώς και την παρακολούθηση της με πλέον ενδελεχή μεταθεραπευτικό έλεγχο

Spontaneous rupture of a large non-parasitic liver cyst: a case report

Abstract Introduction Non-parasitic hepatic cysts are benign entities, occur rarely (5% of the population), and in the majority of cases, are asymptomatic. Cysts can cause symptoms when they become large and produce bile duct compression or portal hypertension, and also when complications such as rupture, infection or hemorrhage take place. Case presentation We present the case of a 70-year-old Greek-Caucasian man with a large, asymptomatic and non-parasitic liver cyst that presented as an acute surgical abdominal emergency after spontaneous rupture into the peritoneal cavity. Conclusions We present an extremely rare complication of simple liver cyst, its rupture in the free abdominal cavity, and its presentation as an acute abdomen. Large simple liver cysts should be treated with intervention at early recognition as conservative management usually results in their recurrence.</p

Unusual radiological finding of lethal pneumatosis intestinalis and portomesenteric vein gas

Pneumatosis intestinalis and portomesenteric vein gas are rare and potentially severe radiological findings that occur both in pediatric and adult populations. They actually are radiographic signs of underlying intra-abdominal pathology, abnormality or diagnostic medical interference. If combined with other radiological or clinical signs of intestinal ischemia or sepsis, the prognosis is dismal and urgent laparotomy is mandatory. We report two cases of surgical treatment with ominous outcome in an effort to characterize this finding correctly as an absolute surgical indication or as an additional diagnostic criterion that simply marks a further breakdown of the systems in patients with a long list of severe medical conditions