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Postoperative jaundice after cardiac surgery

Hepatobiliary & Pancreatic Diseases International 2007年第4期6卷 383-387页

作者： aikaterini mastoraki Emmanouil Karatzis Sotiria mastoraki Ioannis Kriaras Petros Sfirakis Stefanos Geroulanos Department of Surgical Intensive Care Unit Onassis Cardiac Surgery Center356 Sygrou Ave17674 AthensGreece

BACKGROUND:The frequency and pattern of hyperbili-rubinemia after open-heart surgery and its severe perioperative complications are not well clarified. The purpose of this study was to investigate the incidence and nature of postoperative jaundice in patients undergoing cardiac operation,to analyze the determinants,and to identify the clinical significance of this complication with regard to the associated morbidity and mortality. METHODS:A prospective observational study was made during the period of 2003-2004 in a Surgical Intensive Care Unit of a Cardiac Surgery Center,Athens. One hundred twenty-eight adult patients for open heart surgery were divided into three groups. Group A included 50 patients who underwent coronary artery bypass crafting(CABG),group B 31 patients who were subjected to aortic valve replacement(AVR)+CABG and group C 47 patients who underwent mitral valve replacement(MVR)+CABG. Aminotransferases,alkaline phosphatase,gamma-glutamyl-transpeptidase and both types of bilirubin were determined at admission,24 hours after the operation and thereafter according to clinical evolution. The presence of jaundice was associated with elevated serum bilirubin above 3 mg/dl. RESULTS:Hyperbilirubinemia developed in 34 patients(26.5%). The incidence of postoperative jaundice was higher in patients who were subjected to MVR+CABG than to CABG and AVR+CABG. Hyperbilirubinemia was correlated with prolonged cardiopulmonary by-passtime(P<0.001),aortic cross-clamping time(P<0.001),the use of intra aortic balloon pumping(P<0.001),the administration of inotrops and the number of blood and plasma transfusions. Postoperative jaundice resulted mainly from an increase in conjugated bilirubin. CONCLUSIONS:Although hyperbilirubinemia seems to be multifactorial,the type of operation,the preoperative hepatic dysfunction due to advanced heart failure(NYHA Ⅱ-Ⅲ) and the decreased hepatic flow during the operation seem to determine the incidence of jaundice.

关键词： jaundice conjugated bilirubin cardiac surgery prognosis

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Combined hepatocellular-cholangiocarcinoma:An update on epidemiology,classification,diagnosis and management

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Hepatobiliary & Pancreatic Diseases International 2020年第6期19卷 515-523页

作者： Dimitrios Schizas aikaterini mastoraki Eleni Routsi Michail Papapanou Dimitrios Tsapralis Pantelis Vassiliu Konstantinos Toutouzas Evangelos Felekouras First Department of Surgery National and Kapodistrian University of AthensLaikon General HospitalAthensGreece Fourth Department of Surgery National and Kapodistrian University of AthensAttikon University HospitalAthensGreece Surgical Department General Hospital of IerapetraIerapetraGreece First Department of Propaedeutic Surgery National and Kapodistrian University of AthensHippocration HospitalAthensGreece

Background:Combined hepatocellular-cholangiocarcinoma(CHC)is a rare subtype of primary hepatic malignancies,with variably reported incidence between 0.4%–14.2%of primary liver cancer cases.This study aimed to systematically review the epidemiological,clinicopathological,diagnostic and therapeutic data for this rare entity.Data sources:We reviewed the literature of diagnostic approach of CHC with special reference to its clinical,molecular and histopathological characteristics.Additional analysis of the recent literature in order to evaluate the results of surgical and systemic treatment of this entity has been accomplished.Results:The median age at CHC’s diagnosis appears to be between 50 and 75 years.Evaluation of tumor markers[alpha fetoprotein(AFP),carbohydrate antigen 19–9(CA19–9)and carcinoembryonic antigen(CEA)]along with imaging patterns provides better opportunities for CHC’s preoperative diagnosis.Reported clinicopathologic prognostic parameters possibly correlated with increased tumor recurrence and grimmer survival odds include advanced age,tumor size,nodal and distal metastases,vascular and regional organ invasion,multifocality,decreased capsule formation,stem-cell features verification and increased GGT as well as CA19–9 and CEA levels.In case of inoperable or recurrent disease,combinations of cholangiocarcinoma-directed systemic agents display superior results over sorafenib.Liver-directed methods,such as transarterial chemoembolization(TACE),percutaneous ethanol injection(PEI),hepatic arterial infusion chemotherapy(HAIC),radioembolization and ablative therapies,demonstrate inferior efficacy than in cases of hepatocellular carcinoma(HCC)due to CHC’s common hypovascularity.Conclusions:CHC demonstrates an overlapping clinical and biological pattern between its malignant ingredients.Natural history of the disease seems to be determined by the predominant tumor element.Gold standard for diagnosis is histology of surgical specimens.Regarding therapeutic interventions,major hepatectomy is acknowledged as

关键词： Combined hepatocellular-cholangiocarcinoma Classification Diagnostic approach Therapeutic management

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Facing the challenge of venous thromboembolism prevention in patients undergoing major abdominal surgical procedures for gastrointestinal cancer

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World Journal of Gastrointestinal Oncology 2018年第10期10卷 328-335页

作者： aikaterini mastoraki Sotiria mastoraki Dimitrios Schizas Raphael Patras Nikolaos Krinos Ioannis S Papanikolaou Andreas Lazaris Theodore Liakakos Nikolaos Arkadopoulos 4th Department of Surgery National and Kapodistrian University of AthensAttikon University HospitalAthens 12462Greece Department of Vascular Surgery National and Kapodistrian University of AthensAttikon University HospitalAthens 12462Greece 1st Department of Surgery National and Kapodistrian University of AthensLaikon HospitalAthens 11527Greece

Venous thromboembolism(VTE)refers to a hypercoa-gulable state that remains an important and preven-table factor in the surgical treatment of malignancies.VTE includes two identical entities with regards to deep vein thrombosis and pulmonary embolism.The incidence of VTE after major abdominal interventions for gastro-intestinal,hepato-biliary and pancreatic neoplastic disor-ders is as high as 25%without prophylaxis.Prophylactic use of classic or low-molecular-weight heparin,anti-Xa factors,antithrombotic stocking,intermittent pneumatic compression devices and early mobilization have been described.Nevertheless,thromboprophylaxis is often dis-continued after discharge,although a serious risk may persist long after the initial triggering event,as the coagu-lation system remains active for at least 14 d post-opera-tively.The aim of this review is to evaluate the results of the current practice of VTE prevention in cancer patients undergoing major abdominal surgical operations,with special attention to adequately elucidated guidelinesand widely accepted protocols.In addition,the recent literature is presented in order to provide an update on the current concepts concerning the surgical manage-ment of the disease.

关键词： Deep vein thrombosis Pulmonary embolism Gastro-intestinal cancer Thromboprophylaxis Venous thromboembolism

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Concept of histone deacetylases in cancer:Reflections on esophageal carcinogenesis and treatment

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World Journal of Gastroenterology 2018年第41期24卷 4635-4642页

作者： Dimitrios Schizas aikaterini mastoraki Leon Naar Eleftherios Spartalis Diamantis I Tsilimigras Georgia-Sofia Karachaliou George Bagias Dimitrios Moris 1^st Department of Surgery Laikon General HospitalNational and Kapodistrian University of AthensAthens 11527Greece 4^th Department of Surgery Attikon University HospitalNational and Kapodistrian University of AthensAthens 12462Greece Laboratory of Experimental Surgery and Surgical Research National and Kapodistrian University of AthensAthens 11527Greece Department of General Visceral and Transplant SurgeryUniversity Hospital EssenEssen 45141Germany Department of Surgery Duke University Medical CenterDurhamNC 27710United States

Esophageal cancer (EC) presents a high mortality rate, mainly due to its aggressive nature. Squamous cell carcinoma is the most common histological type world-wide, though, a continuous increase in esophageal adenocarcinomas has been noted in the past decades. Common risk factors associated with EC include smoking, alcohol consumption, gastroesophageal reflux disease, Barrett's esophagus and obesity. In an effort to overcome chemotherapy resistance in oncology, it was discovered that histone acetylation/deacetylation equilibrium is altered in carcinogenesis, leading to changes in chromatin structure and altering expression of genes important in the cell cycle, differentiation and apoptosis. Based on this knowledge, histone acetylation was addressed as a potential novel chemotherapy drug target to repress cancer cell proliferation. There are four classes of histone deacetylases (HDACs) inhibitors with a variety of different mechanisms of actions that render them possible anticancer drugs. They arrest the cell cycle, inhibit differentiation and angiogenesis and induce apoptosis. They do not necessarily act on histone proteins, since they can also exert indirect anti-cancer effects, by modifying various cellular proteins.In addition,HDACs have also been associated with increased chemotherapy resistance.Based on the literature,HDACs have been associated with EC,with surveys revealing that increased expression of certain HDACs correlates with advanced TNM stages,tumor grade,metastatic potential and decreased 5-year overall and disease-free survival.The aim of this survey is to elucidate the molecular identity and mechanism of action of HDAC inhibitors as well as verify their potential utility as anti-cancer agents in esophageal cancer.

关键词： Esophageal cancer Histone deacatylases Inhibitors Drugs

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Management of primary retroperitoneal synovial sarcoma: A case report and review of literature

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World Journal of Gastrointestinal Surgery 2019年第1期11卷 27-33页

作者： aikaterini mastoraki Dimitrios Schizas Ioannis S Papanikolaou George Bagias Nikolaos Machairas George Agrogiannis Theodore Liakakos Nikolaos Arkadopoulos 4th Department of Surgery National and Kapodistrian University of Athens Attikon University Hospital 1st Department of Surgery National and Kapodistrian University of Athens Laikon Hospital Hannover Medical School Clinic for General Visceral and Transplant Surgery 3rd Department of Surgery National and Kapodistrian University of Athens Attikon University Hospital 1st Department of Pathology National and Kapodistrian University of Athens

BACKGROUND Synovial sarcoma(SS) is a rare type of soft tissue sarcoma that is usually developed from areas where synovial tissue exists, especially at the extremities.Nevertheless, several cases of retroperitoneal SS(RSS) have been described. We herein report a case of RSS presented in our institution.CASE SUMMARY A 69-year-old female patient was admitted with a large, palpable, firm mass in the right abdominal space SS. Computerized tomography scan depicted a concentric, sharply marinated retro-peritoneal lesion which was displacing the right kidney and the lower edge of the liver. Subsequently, the patient underwent surgical excision of the mass with additional right nephrectomy and resection of the right adrenal gland and a part of the diaphragm. The final histological diagnosis of the tumour was grade II monophasic RSS.CONCLUSION RSS is encountered in the biphasic type, the monophasic fibrous, and the monophasic epithelial category as well. Relevant clinical manifestations are not always documented at early stages. Therefore, the final diagnosis is posed after complete histological examination taking into consideration the results of immunochemistry and genetic analysis. Therapeutic approach happens often late when metastases at the lungs and the liver are apparent. Thus, 5-year survival rates remain low.

关键词： Retroperitoneal tumours Synovial sarcoma Case report Clinical presentation Diagnostic modalities Therapeutic management

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Synchronous resection of esophageal cancer and other organ malignancies: A systematic review

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World Journal of Gastroenterology 2019年第26期25卷 3438-3449页

作者： Dimitrios Papaconstantinou Diamantis I Tsilimigras Dimitrios Moris Adamantios Michalinos aikaterini mastoraki Efstratia Mpaili Natasha Hasemaki Anargyros Bakopoulos Dimitrios Filippou Dimitrios Schizas Third Department of Surgery National and Kapodistrian University of AthensAttikon University HospitalAthens 12462Greece Department of Surgery Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbusOH 43210United States Department of Surgery Duke University Medical CenterDurhamNC 27710United States Department of Anatomy European University of CyprusNicosia 2404Cyprus First Department of Surgery National and Kapodistrian University of AthensLaikon General HospitalAthens 11527Greece Department of Anatomy and Surgical Anatomy National and Kapodistrian University of AthensMedical SchoolAthens 11527Greece

BACKGROUND Neoplasms arising in the esophagus may coexist with other solid organ or gastrointestinal tract neoplasms in 6%to 15%of patients.Resection of both tumors synchronously or in a staged procedure provides the best chances for long-term survival.Synchronous resection of both esophageal and second primary malignancy may be feasible in a subset of patients;however,literature on this topic remains rather scarce.AIM To analyze the operative techniques employed in esophageal resections combined with gastric,pancreatic,lung,colorectal,kidney and liver resections and define postoperative outcomes in each case.METHODS We conducted a systematic review according to PRISMA guidelines.We searched the Medline database for cases of patients with esophageal tumors coexisting with a second primary tumor located in another organ that underwent synchronous resection of both neoplasms.All English language articles deemed eligible for inclusion were accessed in full text.Exclusion criteria included:(1)Hematological malignancies;(2)Head/neck/pharyngeal neoplasms;(3)Second primary neoplasms in the esophagus or the gastroesophageal junction;(4)Second primary neoplasms not surgically excised;and(5)Preclinical studies.Data regarding the operative strategy employed,perioperative outcomes and longterm outcomes were extracted and analyzed using descriptive statistics.RESULTS The systematic literature search yielded 23 eligible studies incorporating a total of 117 patients.Of these patients,71%had a second primary neoplasm in the stomach.Those who underwent total gastrectomy had a reconstruction using either a colonic(n=23)or a jejunal(n=3)conduit while for those who underwent gastric preserving resections(i.e.,non-anatomic/wedge/distal gastrectomies)a conventional gastric pull-up was employed.Likewise,in cases of patients who underwent esophagectomy combined with pancreaticoduodenectomy(15%of the cohort),the decision to preserve part of the stomach or not dictated the reconstruction method(whether by a gastric pullup or a colonic/jej

关键词： Esophagectomy Esophageal neoplasm Second primary Multiple primary Concurrent neoplasms Management

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Successful management of adhesion related small bowel ischemia without intestinal resection: A case report and review of literature

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World Journal of Gastrointestinal Pathophysiology 2019年第2期10卷 29-35页

作者： Pantelis Vassiliu Vasiliki Ntella George Theodoroleas Zisis Mantanis Ioanna Pentara Eleni Papoutsi aikaterini mastoraki Nikolaos Arkadopoulos 4th Department of Surgery National and Kapodistrian University of Athens Attikon University Hospital

BACKGROUND Intraabdominal adhesions develop spontaneously or after an inflammatory process or surgical procedure in the abdomen.They are the most common cause of small bowel obstruction(SBO).SBO occasionally leads to intestinal ischemia(In Is)which can be a life-threatening condition that requires management as soon as possible.We herein report a case of SBO with In Is presented in our institution and treated without intestinal resection.CASE SUMMARY A 34-year-old man presented at the emergency department after a 12-h-onset diffuse abdominal pain,bloating and nausea.He had a history of traumatic right hepatectomy 11 years ago as well as adhesiolysis and resection of a long part of small bowel 2 years ago.An abdominal computed tomography(CT)showed dilated loops that led to the diagnosis of SBO.Due to deteriorating lactic acidosis,the patient was operated.Torsion of the small bowel around an adhesion led to2.30 m of ischemic ileum.After the application of N/S 40°C for 20 min,the intestine showed signs of improvement and it was decided to avoid resection and instead temporary close the abdomen with vacuum-pack technique.At the second-look laparotomy 48 h later,the intestine appeared normal.The patient was discharged on the 8 th post-op day in excellent condition.CONCLUSION In case of SBO caused by adhesions,extreme caution is needed if In Is is present,as the clinical signs are mild and you should rely for diagnosis in CT findings and lactate levels.Conservative surgical approach could reverse the effects of In Is,if performed quickly,so that intestinal resection is avoided and should be used even when minimum signs of viability are present.

关键词： Intraabdominal adhesions Intestinal ischemia Small bowel obstruction Vacuum-pack technique Case report Conservative surgical approach

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Recurrent aggressive mesenteric desmoid tumor successfully treated with sorafenib: A case report and literature review

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World Journal of Clinical Oncology 2019年第4期10卷 183-191页

作者： aikaterini mastoraki Dimitrios Schizas Chrysovalantis Vergadis Leon Naar Alexios Strimpakos Michail G Vailas Natasha Hasemaki George Agrogiannis Theodore Liakakos Nikolaos Arkadopoulos 4th Department of Surgery National and Kapodistrian University of Athens Attikon University Hospital 1st Department ofSurgery National and Kapodistrian University of Athens Laikon Hospital Department of Radiology National and Kapodistrian University of Athens Laikon Hospital 1st Department of Pathology National and Kapodistrian University of Athens

BACKGROUND Desmoid tumors(DT) are locally advanced but histologically benign monoclonal neoplasms that can occur from any musculoaponeurotic structure. The aim of this report is to analyze a rare clinical case of an aggressive intra-abdominal DT successfully treated with sorafenib.CASE SUMMARY A 36-year-old man presented with increasing colicky abdominal pain and a selfpalpable mass in his left abdomen. Fourteen years earlier he was diagnosed with a large intra-abdominal tumor, which adhered to the left colonic flexure, part of the major gastric curvature and the spleen. Subsequent exploratory laparotomy revealed a voluminous mass in the epigastrium, arising from the posterior surface of the stomach and invading the superior mesenteric vessels, transverse mesocolon and the small bowel mesentery. As the tumor was unresectable, a jejunojejunal bypass was performed. Traditional therapeutic interventions proved insufficient, and the patient was started on sorafenib with a subsequent fulldisease response.CONCLUSIONDT's pathogenesis has been associated with mutations in the adenomatous polyposis coli(APC) gene or beta-catenin gene CTNNB1, sex steroids or previous surgical trauma. Local treatment modalities, such as surgery or radiotherapy, are implemented in aggressively progressing or symptomatic patients. Sorafenib is a hopeful therapeutic option against DTs, while several pharmacological agents have been successfully used.

关键词： Desmoid tumor Aggressive fibromatosis Case report Pathogenesis Therapeutic approach Sorafenib treatment

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LINX^(■) reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies

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World Journal of Clinical Cases 2020年第2期8卷 294-305页

作者： Dimitrios Schizas aikaterini mastoraki Eleni Papoutsi Vassilis G Giannakoulis Prodromos Kanavidis Diamantis Tsilimigras Dimitrios Ntourakis Orestis Lyros Theodore Liakakos Dimitrios Moris 1^(st) Department of Surgery National and Kapodistrian University of AthensLaikon HospitalAthens 11527Greece 4^(th） Department of Surgery National and Kapodistrian University of AthensAttikon University HospitalChaidariAthens 11527Greece Department of Surgery Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research InstituteColumbusOH 45830United States Department of Surgery School of MedicineEuropean University CyprusNicosia 2404Cyprus Department of Visceral TransplantThoracic and Vascular SurgeryUniversity Hospital LeipzigLeipzig 04103Germany Department of Surgery Duke University Medical CenterDuke UniversityDurhamNC 27705United States

BACKGROUND Gastroesophageal reflux disease(GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication(LF) constitutes the gold-standard method. However, magnetic sphincter augmentation(MSA) using the LINX^® Reflux Management System has recently emerged and disputes the standard therapeutic approach.AIM To investigate the device’s safety and efficacy in resolving GERD symptoms.METHODS This is a systematic review conducted in accordance to the PRISMA guidelines.We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019.RESULTS Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor(PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups(e.g., bariatric or large hiatal-hernias)had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD.CONCLUSION The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.

关键词： LINX^(■) reflux management system Magnetic sphincter augmentation Gastroesophageal reflux disease Gastroesophageal reflux disease-health-related quality of life

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Mesenteric ischemia:Pathogenesis and challengingdiagnostic and therapeutic modalities

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World Journal of Gastrointestinal Pathophysiology 2016年第1期7卷 125-130页

作者： aikaterini mastoraki Sotiria mastoraki Evgenia Tziava Stavroula Touloumi Nikolaos Krinos Nikolaos Danias Andreas Lazaris Nikolaos Arkadopoulos 4th Department of Surgery Athens UniversityMedical SchoolATTIKON University Hospital12462 ChaidariAthensGreece Department of Vascular Surgery Athens UniversityMedical SchoolATTIKON University Hospital12462 ChaidariAthensGreece

Mesenteric ischemia(MI) is an uncommon medical condition with high mortality rates. ΜΙ includes inadequate blood supply, inflammatory injury and eventually necrosis of the bowel wall. The disease can be divided into acute and chronic MI(CMI), with the first being subdivided into four categories. Therefore, acute MI(AMI) can occur as a result of arterial embolism, arterial thrombosis, mesenteric venous thrombosis and nonocclusive causes. Bowel damage is in proportion to the mesenteric blood flow decrease and may vary from minimum lesions, due to reversible ischemia, to transmural injury, with subsequent necrosis and perforation. CMI is associated to diffuse atherosclerotic disease in more than 95% of cases, with all major mesenteric arteries presenting stenosis or occlusion. Because of a lack of specific signs or due to its sometime quiet presentation, this condition is frequently diagnosed only at an advanced stage. Computed tomography(CT) imaging and CT angiography contribute to differential diagnosis and management of AMI. Angiography is also the criterion standard for CMI, with mesenteric duplex ultrasonography and magnetic resonance angiography also being of great importance. Therapeutic approach of MI includes both medical and surgical treatment. Surgical procedures include restoration of the blood flow with arteriotomy, endarterectomy or anterograde bypass, while resection of necrotic bowel is always implemented. The aim of this review was to evaluate the results of surgical treatment for MI and to present the recent literature in order to provide an update on the current concepts of surgical management of the disease. Mesh words selected include MI, diagnostic approach and therapeutic management.

关键词： Acute mesenteric ischemia Mesentericischemia Chronic diagnostic approach Therapeuticmanagement Surgical strategy

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