Adrenal metastasis as first presentation of hepatocellular carcinoma

BACKGROUND: Metastases from hepatocellular carcinoma (HCC) can be found in the lung and adrenal gland. We report case of a patient who presented with adrenal metastasis as the first clinical manifestation of HCC. CASE PRESENTATION: A patient was referred for surgical treatment for a tumor in retro-peritoneal space. The computerized tomography (CT) scan revealed a mass originating from the left adrenal gland. The patient underwent left adrenalectomy and the exploration of abdominal cavity did not reveal any other palpable lesions. Histologically, the resected lesion was a poorly differentiated metastatic tumor from HCC. Seven months later patient was readmitted complaining of cachexia, icterus, and significant weight loss. CT scan revealed hyperdense lesions of the liver CONCLUSION: HCC may have atypical presentations like in present case. Fine needle aspiration/tru-cut(® )biopsy might be useful in the investigation of an accidentally discovered adrenal mass regardless of the size and can lead to the detection of a primary tumor

Our local experience with the surgical treatment of ampullary cancer

BACKGROUND: The aim of this study is to report the outcome after surgical treatment of 32 patients with ampullary cancers from 1990 to 1999. METHODS: Twenty-one of them underwent pancreaticoduodenectomy and 9 local excision of the ampullary lesion. The remaining 2 patients underwent palliative surgery. RESULTS: When the final histological diagnosis was compared with the preoperative histological finding on biopsy, accurate diagnosis was preoperatively established in 24 patients. The hospital morbidity was 18.8% as 9 complications occurred in 6 patients. Following local excision of the ampullary cancer, the survival rate at 3 and 5 years was 77.7% and 33.3% respectively. Among the patients that underwent Whipple's procedure, the 3-year survival rate was 76.2% and the 5-year survival rate 62%. CONCLUSION: In this series, local resection was a safe option in patients with significant co-morbidity or small ampullary tumors less than 2 cm in size, and was associated with satisfactory long-term survival rates

Integrated Reverse Engineering Strategy for Large-Scale Mechanical Systems: Application to a Steam Turbine Rotor

An integrated reverse engineering methodology is proposed for a large-scale fully operational steam turbine rotor, considering issues that include developing the CAD and FE model of the structure, as well as the applicability of model updating techniques based on experimental modal analysis procedures. First, using an integrated reverse engineering strategy, the digital shape of the three sections of a steam turbine rotor was designed and the final parametric CAD model was developed. The finite element model of the turbine was developed using tetrahedral solid elements resulting in fifty-five million DOFs. Imposing impulsive loading in a free-free state, measured acceleration time histories were used to obtain the dynamic responses and identify the modal characteristics of each section of the complete steam turbine. Experimentally identified modal modes and modal frequencies compared to the FE model predicted ones constitute the actual measure of fit. CMA-ES optimization algorithm is then implemented in order to finely tune material parameters, such as modulus of elasticity and density, in order to best match experimental and numerical data. Comparing numerical and experimental results verified the reliability and accuracy of the applied methodology. The identified finite element model is representative of the initial structural condition of the turbine and is used to develop a simplified finite element model, which then used for the turbine rotordynamic analysis. Accumulated knowledge of the dynamic behavior of the specific steam turbine system, could be implemented in order to evaluate stability or instability states, fatigue growth in the turbine blades, changes in the damping of the bearing system and perform necessary scheduled optimal and cost-effective maintenance strategies. Additionally, upon a series of scheduled experimental data collection, a permanent output-only vibration SHM system could be installed and even a proper dynamic balancing could be investigated and designed

Local excision as a treatment for tumors of ampulla of Vater

BACKGROUND: Although local excision (ampullectomy) was first described by Halsted in 1899, its adequacy as an alternative surgical treatment for the ampullary tumors is still a matter of debate. The aim of this study was to evaluate the results of ampullectomy as a curative treatment for benign and malignant tumors arising from the ampulla, in a 14-year single-institution experience. METHODS: From 1990 to 2004, a total of 20 patients of adenocarcinoma (12) or adenoma (8) of the ampulla of Vater underwent local excision. Clinical data were collected and morbidity, mortality, as well as long-term survival were evaluated. The usefulness of several pre or intraoperative diagnostic methods was also recorded. Median follow-up was 85 (range 6–180) months. RESULTS: The combination of endoscopic preoperative biopsies and intraoperative frozen section examination adequately diagnosed ampullary tumors in all cases. The postoperative morbidity and mortality were 0%, whereas the 3 and 5-year survival rates for the patients with adenocarcinoma was 75 % and 33.3 % respectively. All the patients with adenoma are still alive without any sign of recurrence. CONCLUSION: In our series, local excision was a safe option, associated with satisfactory long-term survival rates in patients with benign lesions and in those with small(<2 cm), pT1, well differentiated ampullary tumours without nodal involvement

Non-blood medical care in gynecologic oncology: a review and update of blood conservation management schemes

This review attempts to outline the alternative measures and interventions used in bloodless surgery in the field of gynecologic oncology and demonstrate their effectiveness. Nowadays, as increasingly more patients are expressing their fears concerning the potential risks accompanying allogenic transfusion of blood products, putting the theory of bloodless surgery into practice seems to gaining greater acceptance. An increasing number of institutions appear to be successfully adopting approaches that minimize blood usage for all patients treated for gynecologic malignancies. Preoperative, intraoperative and postoperative measures are required, such as optimization of red blood cell mass, adequate preoperative plan and invasive hemostatic procedures, assisting anesthetic techniques, individualization of anemia tolerance, autologous blood donation, normovolemic hemodilution, intraoperative cell salvage and pharmacologic agents for controlling blood loss. An individualised management plan of experienced personnel adopting a multidisciplinary team approach should be available to establish non-blood management strategies, and not only on demand of the patient, in the field of gynecologic oncology with the use of drugs, devices and surgical-medical techniques

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Vibration-Based Damage Detection Using Finite Element Modeling and the Metaheuristic Particle Swarm Optimization Algorithm

The continuous development of new materials and larger and/or more complex structures drives the need for the development of more robust, accurate, and sensitive Structural Health Monitoring (SHM) techniques. In the present work, a novel vibration-based damage-detection method that contributes into the SHM field is presented using Metaheuristic algorithms coupled with optimal Finite Element Models that can effectively localize damage. The proposed damage-detection framework can be applied in any kind of detailed structural FE model, while requiring only the output information of the dynamic response of the structure. It can effectively localize damage in a structure by highlighting not only the affected part of the structure but also the specific damaged area inside the part. First, the optimal FE model of the healthy structure is developed using appropriate FE model updating techniques and experimental vibration measurements, simulating the undamaged condition. Next, the main goal of the proposed method is to create a damaged FE model that approximates the dynamic response of the damaged structure. To achieve this, a parametric area is inserted into the FE model, changing stiffness and mass to simulate the effect of the physical damage. This area is controlled by the metaheuristic optimization algorithm, which is embedded in the proposed damage-detection framework. On this specific implementation of the framework, the Particle Swarm Optimization (PSO) algorithm is selected which has been used for a wide variety of optimization problems in the past. On the PSO&rsquo;s search space, two parameters control the stiffness and mass of the damaged area while additional location parameters control the exact position of the damaged area through the FE model. For effective damage localization, the Transmittance Functions from acceleration measurements are used which have been shown to be sensitive to structural damage while requiring output-only information. Finally, with proper selection of the objective function, the error that arises from modeling a physical damage with a linear damaged FE model can be minimized, thus creating a more accurate prediction for the damaged location. The effectiveness of the proposed SHM method is demonstrated via two illustrative examples: a simulated small-scale model of a laboratory-tested vehicle-like structure and a real experimental CFRP composite beam structure. In order to check the robustness of the proposed method, two small damage scenarios are examined for each validation model and combined with random excitations

Optimal Sensor Placement for Vibration-Based Damage Localization Using the Transmittance Function

A methodology for optimal sensor placement is presented in the current work. This methodology incorporates a damage detection framework with simulated damage scenarios and can efficiently provide the optimal combination of sensor locations for vibration-based damage localization purposes. A classic approach in vibration-based methods is to decide the sensor locations based, either directly or indirectly, on the modal information of the structure. While these methodologies perform very well, they are designed to predict the optimal locations of single sensors. The presented methodology relies on the Transmittance Function. This metric requires only output information from the testing procedure and is calculated between two acceleration signals from the structure. As such, the outcome of the presented method is a list of optimal combinations of sensor locations. This is achieved by incorporating a damage detection framework that has been developed and tested in the past. On top of this framework, a new layer is added that evaluates the sensitivity and effectiveness of all possible sensor location combinations with simulated damage scenarios. The effectiveness of each sensor combination is evaluated by calling the damage detection framework and feeding as inputs only a specific combination of acceleration signals each time. The final output is a list of sensor combinations sorted by their sensitivity

Definition of the levels of interferon-γ interleukin-2 and tumor necrosis factor-α as prognostic indicators in patients with unstable angina

The aim of this study was the evaluation of the kinetics of the three cytokines: tumor necrosis factor-α (TNF-α), interferon-gamma (IFN-γ) and interleukin-2 (IL-2) by measuring their values on days 1st, 3rd, 7th of the hospitalization of patients suffering from unstable angina, as well as by counting their values on the 30th day, during their first follow-up. At the same time, we tried to correlate possible complications of our patients, like recurrence of angina, with the cytokine values at the above days of blood sampling. We also tried to find the probable prognostic value of these three cytokines for the future well being of these patients up to 18 months after their first, under study, episode of unstable angina pectoris. We enrolled in our study 90 consecutive patients (60 men and 30 women) of ages ranging from 37 to 75 years, that entered the coronary unit due to severe unstable angina (Braunwald class IIIb). All the patients of the study had negative, at repeated measurements, all the enzymes that show myocardial damage including troponin-T. Patients with renal or liver deficiency, or patients with a history of chronic inflammatory disease or cancer, or those with acute myocardial infarction or by-pass surgery in the 6 months prior of the study were excluded from the study, as well as those that had ECG with alterations that did not permit the evaluation of the ST segment deviation. At the same time we drew blood for the measurement of the above-mentioned cytokines from 32 healthy volunteers age and sex matched with the patients of our study. During their stay in the hospital (1st to 7th day of the study) 42 remained uncomplicated, while 48 had recurrence of the angina (without rise of the CPK) or suffered an arrhythmia calling for medical treatment. After their discharge from the hospital and till the 30th day of their observation, only 26 out of 90 showed complications, while from the 30th day till the 18th month of observation only 18 had a complicated clinical course.Ο σκοπός της παρούσας μελέτης ήταν η εκτίμηση της κινητικής των τριών κυτταροκινών: του παράγοντα νεκρώσεως του όγκου-α (TNF-α), της ιντερφερόνης-γ (IFN-γ) και της ιντερλευκίνης-2 (IL-2), μέσα από μετρήσεις των τιμών αυτών την 1η, 3η, 7η ημέρα νοσηλείας καθώς και την 30η ημέρα μετά την ένταξη τους στη μελέτη, ασθενών με ασταθή στηθάγχη. Ταυτόχρονα, έγινε προσπάθεια να συσχετισθούν πιθανές επιπλοκές στην πορεία των ασθενών, όπως η υποτροπή της στηθάγχης, με τις τιμές των κυτταροκινών στα ανωτέρω χρονικά διαστήματα., ενώ παράλληλα ερευνήθηκε η προγνωστική αξία των τριών αυτών κυτοκινών για την πορεία των ασθενών της μελέτης έως και 18 μήνες περίπου μετά το αρχικό επεισόδιο της ασταθούς στηθάγχης. Μελετήθηκαν συνολικά διαδοχικούς 90 ασθενείς (60 άνδρες και 30 γυναίκες) με εύρος ηλικίας από 37 έως 75 έτη που εισήχθησαν στην στεφανιαία μονάδα συνεπεία σοβαρής ασταθούς στηθάγχης (κλάση ΙΙΙb κατά Braunwald). Όλοι οι ασθενείς της μελέτης είχαν σε επανειλημμένες μετρήσεις αρνητικά όλα τα ένζυμα μυοκαρδιακής βλάβης συμπεριλαμβανομένης και της τροπονίνης-Τ. Αποκλείστηκαν επίσης από τη μελέτη ασθενείς με νεφρική ή ηπατική ανεπάρκεια, ιστορικό νεοπλασίας ή χρόνιας φλεγμονώδους νόσου, ασθενείς που υπέστησαν έμφραγμα του μυοκαρδίου ή υποβλήθηκαν σε αορτοστεφανιαία παράκαμψη τους προηγούμενους 6 μήνες προ της εισαγωγής τους καθώς και όσοι παρουσίαζαν ΗΚΓ με διαταραχές που δεν επέτρεπαν την ερμηνεία των μεταβολών του διαστήματος ST. Παράλληλα ελήφθησαν δείγματα ορού για τον προσδιορισμό των τριών κυτταροκινών από 32 υγιής μάρτυρες σε αντιστοιχία, όσον αφορά το φύλο και την ηλικία, με τους ασθενείς της μελέτης. Το διάστημα παραμονής τους στο νοσοκομείο (1η έως 7η ημέρα της μελέτης) 42 παρέμειναν ασυμπτωματικοί, ενώ 48 εμφάνισαν υποτροπή της στηθάγχης (χωρίς συνοδό αύξηση της CPK) ή αρρυθμία χρήζουσα φαρμακευτική αντιμετώπιση. Από την έξοδο τους από το νοσοκομείο έως και την 30η ημέρα παρακολούθησης 26 μόνο σε σύνολο 90 ασθενών υπήρξανε συμπτωματικοί, ενώ από την 30η ημέρα έως και τον 18ο μήνα της παρακολούθησης μόνο 18 είχαν επιπλεγμένη κλινική πορεία