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This prospective randomized study was conducted in order to define the contribution of the generated oxygen and nitrogen reactive species on postlobectomy morbidity and mortality.Between 2001 and 2003, 132 patients with non-small cell lung cancer (NSCLC) were prospectively studied. The patients were grouped according to one-lung ventilation (OLV) use or not and to the duration of lung's atelectasis. Group A included 50 patients with confirmed non-small cell lung cancer who were subjected to lobectomy without one-lung ventilation. Group B included 30 patients subjected to 60 min OLV. Group C included 30 patients subjected to 90 min OLV. Group D included 22 patients subjected to 120 min OLV. Preoperative, intraoperative and postoperative strict blood sampling protocol was followed. Malondialdehyde (MDA) plasma levels were measured. The groups were statistically compared for the occurrence of postoperative complications. OLV (groups B-D) along with other clinical parameters were entered in multivariate analysis as risk factors for complication development.Comparison of group A with groups B-D (OLV) documented significant increase (p0.001) of MDA levels during lung reexpansion. The magnitude of oxidative stress was related to OLV duration (group Dgroup Cgroup B, all p0.001). Univariate analysis disclosed a higher incidence of acute respiratory failure, cardiac arrhythmias and pulmonary hypertension in group D. Multivariate analysis revealed OLV as an independent risk factor for postoperative development of cardiac arrhythmias and pulmonary hypertension.Protracted (1h) OLV should be considered a potential cause for cardiovascular complications through the generation of severe oxidative stress due to lung reexpansion.

Complex thoracic injuries significantly alter the lung mechanics. There appears to be severe ventilation-perfusion inequality that is enhanced by the asymmetrical compliance of the injured areas. In cases of unilateral massive air leaks large tidal volumes are needed to deliver adequate air volume to the injured lung. In such cases, mechanical ventilation via a standard tracheal tube will direct a large fraction of the tidal volume to the less affected areas. An alternative means of ventilating these patients is the application of independent lung ventilation through a double lumen tracheal tube and the use of two separate ventilators. Two such cases are presented with emphasis given on the ventilatory and haemodynamic changes that were recorded.

About 1.7% of all abdominal wall hernias are incisional hernias and they have an expected incidence of 2–5% in uncomplicated abdominal operations which rises to 10%–15% in operations complicated by infection. It is estimated that incisional hernias will complicate 9% of all major abdominal operations and 30% of these hernias show thenselves within the rst 30 postoperative months (1, 5). Risk factors for hernia occurrence are infection and wound dehisence, length of the primary incision, and the use of corticoids during primary operation; in addition, obesity, postoperative cough or high intra-abdominal pressure, and technical errors all predispose to the development of a postoperative incisional hernia (3, 6). Large incisional hernias, apart from physical discomfort and deformity, are the cause of “Eventration Disease” according to Rives (8), which induces multiple symptoms from different systems. Important symptoms derive from pulmonary dysfunction, but symptoms from the gastrointestinal tract, skeletal pain and abdominal skin atrophy are not to be underestimated. Patients operated on for a large abdominal wall hernia face a high incidence of postoperative morbidity, mainly from pulmonary dysfunction, wound infection and the sudden rise in intra-abdominal pressure (10), despite the use of “progressive pneumoperitoneum”, which is a useful technique for preparing patients with large abdominal hernias. Many techniques have been used for repairing these large hernias but recurrence rates remain high, reaching 50% for the Mayo procedure (2, 7). The use of synthetic materials improved the recurrence rates but the results are not yet wholly satisfactory (4). Large incisional hernias pose a challenge in their repair technique and demand a thorough preoperative evaluation of the patient as regards respiratory function, prophylaxis of deep venous thrombosis and infection. Any postoperative complication might jeopardise the outcome. METHODS

Background and Objectives: Pancreaticoduodenectomy is still associated with high morbidity and mortality even though there has been significant progress in the field of pancreatic surgery and postoperative follow-up. The pancreatoenteric anastomosis, regardless of the technique used, is a major cause for both morbidity and mortality after Whipple procedure. To overcome all problems resulting from anastomotic leakage, we used external drainage of the pancreatic duct. Methods: In 24 patients who underwent pancreaticoduodenectomy in our Department from 1986 to 1995, a modification to the standard Whipple procedure was performed. Instead of pancreaticoenteric anastomosis, external drainage of the pancreatic duct remnant was performed. The pancreatic duct was intubated with a silastic tube, the external end of which was sutured to the skin. All patients received substitution therapy with pancreatic enzymes. Results: Mortality in our group of patients was 4%. No complications due to the external drainage of the pancreatic duct were reported, while no patient developed diabetes mellitus after surgery. Conclusions: External drainage of the pancreatic duct remnant can be used alternatively to pancreatoenteric anastomosis after pancreatoduodenectomy. The technique is safe and simple to perform and appears to reduce overall operative time. It may be an option for patients with significant comorbidity and/or intraoperative hemodynamic instability which mandates expeditious completion of the operation. J. Surg. Oncol. 2001; 77:26–29. © 2001 Wiley-Liss, Inc.

OBJECTIVE: To identify preventable prehospital deaths, caused by trauma. DESIGN: Analysis of 82 trauma victims who were dead on arrival (DOA) into our hospital. SETTING: General Hospital of Piraeus, Greece. MATERIALS AND METHODS: Evaluation of the autopsy findings of 82 DOAs. MEASUREMENTS: Demographic, autopsy, and toxicology data, ICD9 codes, Abbreviated Injury Score (AIS)-90, Injury Severity Score (ISS)-body regions, central nervous system (CNS) deaths, non-CNS deaths, p values, and opinion of a clinical assessor. MAIN RESULTS: The 29 (35.36%) DOAs had at least one AIS6 injury. Extracranial hemorrhage, airway, and breathing dysfunction were contributing factors of death of 27 "possibly preventable" CNS deaths, and the causes of death for the 20 non-CNS deaths. p value (0.5) indicated that 24 (29.26%) of the DOAs expected to survive. The clinical assessor characterized four (4.87%) as "definitely preventable" and 35 (42.65%) as "possibly preventable" deaths. CONCLUSIONS: Upgrading of the emergency medical care service is required. Language: en

Cancer Center to general hospitals and homes. In many cases cancer patients need to undergo a long-term systemic treatment or supportive therapies (for example a total parenteral nutrition). A vascular access port (VAP) is often used in such a treatment nowadays, which explains the growth in the number of nurses involved in the management of VAPs. These nurses often lack formal training in managing VAPs. The knowledge needs to be passed on not only to nurses specialized in vascular access, but also to nurses working at secondary or primary level of the healthcare system. Based on everything mentioned above, the priority of the Division of Nursing and Care for Patients in the Cancer Centre was to provide a specialized education and training for nurses to gain the knowledge, skills and technical expertise that were required for managing the care of patients with VAP and recognizing the complications that these patients might experience. Material and Method: In 2009 and 2010 several workshops were organized for nurses who provided care for patients with VAP outside of the Cancer Center. Altogether 99 nurses from tertiary, secondary and primary level and other institutions were educated. In September 2011 the workshop staff sent a questionnaire to all participating nurses in order to receive their workshop evaluation. Nurse coordinators collected the data via an 11-item questionnaire. 51 questionnaires were filled out and returned back. Results: The most important aim of this evaluation was to explore the reasons for attending the workshop in order to find the benefits nurses gained through the education and to identify nurses’ knowledge gaps regarding the management of VAPs. Findings showed that most of the nurses who attended the workshop had a positive attitude towards the lifelong learning. They highly appreciated the education about VAP management and related problems. Nurses were satisfied with the workshop and wished to continue with the professional education; however, they received no financial reimbursement from their organizations or any other advancement. Conclusion: Based on the evaluation results, the Division of Nursing and Care for Patients in the Cancer Centre has decided to compose written guidelines about VAP management for nurses working at secondary or primary level of the healthcare system. This handbook will be published in spring 2012.

Sexuality is something which is intimately combined with the human life and behavior. But in cases in which the human body is severely ill, the sexual instincts are sidelined and subsided. Conversely, fears are raised about survival and condition of health. In intensive care units (ICU), sexuality is most of the times absent. But there are some cases where sexual desire is present and is intense (Kotronoulas, Papadopoulou, & Patiraki, 2009 ;W ilmoth,2007). We report two cases of patients who demonstrated intense sexual desire by masturbating in the area of an ICU. The first patient was a 26-year-old male, who after eight gunshots and two surgical interventions for massive bleeding from liver parenchyma was stabilized and withdrawn from mechanical ventilation. The patient about 3 days before leaving ICU performed masturbation, even if a urinary catheter was present. The overall stay of the patient in the ICU was approximately 3 months. The second patient was a 55-year-old female patient. This woman was a morbidly obese patient who underwent a sleeve gastrectomy. At the third postoperative day, sepsis was developed since a leak from the stapling line near the cardia of the stomach was present. The patient underwent surgical drainage of the region and cervical esophagostomy was performed. During the monitoring of the patient in the ICU, she underwent masturbation. The overall stay of the patient in the ICU was 40 days and the incident was performed 35 days approximately after the transfer of the patient at the ICU. This phenomenon is rare in patients who are critically ill and are hospitalized in an ICU. Nevertheless, both of these patients were in relatively good overall condition near their export from the unit. Thus, both of these patients had a long stay with nonexistent sexual activity. Their medication in the ICU had not diminished sexual desire as an adverse effect. Maybe this act and the return of the sexual desire were indicative of the good clinical condition of the patients and the overtaking of their medical problems. It is very interesting the fact that this instinct was greater than awkwardness which the patients may felt by the presence of the personnel of ICU.

Dear Editor, We appreciate the comments of Dr. Buise and his team that have extensively studied and published on the effects of several pharmacological agents on splanchnic perfusion. In our hospital, we use epidural analgesia but especially avoid the use of local anesthetics perioperatively in order to avoid the hypotension that these agents provoke. Regarding the effects of epinephrine on splanchnic perfusion, we have to bear in mind that epinephrine is not only a pure vasoconstrictor but also has a positive inotropic cardiac effect, which increases the cardiac output. As epinephrine is rarely used in the perioperative period, due to several side effects that it has (i.e., tachycardia, coronary artery vasoconstriction), we elected not to study this medication. It is known that the left gastroepiploic artery is the main vessel in the pigs’ gastric greater curvature anatomy. We did preserve the vascular arcade, we used the same technique in all animals, and finally, we had baseline measurements in order to maintain the comparability of our results. Further measurements and details of the protocol are available but were not found necessary to be included in the presented data. Yours sincerely J Gastrointest Surg (2009) 13:1020 DOI 10.1007/s11605-009-0850-6

Introduction One of the most lethal mechanisms of injury is shotgun wound and particularly the abdominal one. Case presentation We report a case of a 45 years old male suffering abdominal shotgun trauma, who survived his injuries. Conclusion The management of the abdominal shotgun wounds is mainly dependent on clinical examination and clinical judgment, while requires advanced surgical skills.

Hypothesis Splenectomy is recognized as a cause of portal, mesenteric, and splenic vein thrombosis. The exact incidence of the complication and its predisposing factors are not known. Design Prospective observational cohort study. The median follow-up time of the patients was 22.6 months. Setting University surgical clinic in a teaching hospital. Patients A total of 147 consecutive patients who underwent splenectomy in a 4-year period were enrolled in the study. Interventions Preoperative and postoperative evaluation included ultrasonography with color Doppler flow imaging of the portal system, results of blood coagulation tests, fibrinogen levels, D-dimer levels, and complete blood counts. Operative sheets were recorded and reviewed. When portal system thrombosis (PST) was diagnosed, a complete control for acquired and congenital thrombophilia disorders was obtained. Main Outcome Measures Primary end points of the study were the assessment of the incidence of postsplenectomy PST and the identification of risk factors for its occurrence. Results Portal system thrombosis occurred in 7 (4.79%) of 146 patients who underwent splenectomy. The age, sex, type or length of the operation, and use of preoperative and postoperative thromboprophylaxis with low molecular weight heparin did not prove to be significant factors in the occurrence of PST. Platelet count of more than 650 × 10 3 /μL and greater spleen weight (>650 g) was associated with the development of PST ( P = .01, P = .03). Normal D-dimer levels on diagnosis of the complication showed a negative predictive value of 98%. Two of the affected patients were diagnosed with thrombophilia disorders. In a median follow-up period of 22.6 months, no other case of PST was recorded. Conclusions Postsplenectomy PST occurs in approximately 5% of patients. Possible risk factors are thrombocytosis, splenomegaly, and congenital thrombophilia disorders.

A 60-years old male was admitted to our department for investigation of constipation and hypogastric discomfort intensified during defecation of a few weeks duration. The cause proved to be a rectal carcinosarcoma that was treated by abdominoperineal resection and postoperative chemo-radiotherapy. The patient died 6 months later due to hepatic failure, showing evidence of disseminated disease. In general colonic carcinosarcomas constitute a rare category of malignant neoplasms whose nature is still incompletely understood. No specific treatment guidelines exist. Surgery is the mainstay of treatment and regardless of the addition of adjuvant therapy the prognosis is very poor. Systematic genetic analysis may be the clue for understanding the pathogenesis of these mysterious tumors.

The aim of this study was to evaluate the safety, efficacy, and effects of administration of very high doses of norepinephrine (4 microg kg(-1) min(-1)) in catecholamine-resistant septic shock. We reviewed the charts of all patients with nonresponding to commonly used norepinephrine doses (or = 4 microg kg(-1) min(-1)) septic shock from January 1999 to December 2002 in our Surgical Intensive Care Unit. All patients were treated with high norepinephrine doses (4 microg kg(-1) min(-1)), after initial resuscitation, so as to achieve a mean arterial pressure higher than or equal to 65 mmHg. During this 4-year period, 12 consecutive patients with catecholamine-resistant septic shock were included in our study. When compared with the values obtained prior to the administration of very high norepinephrine doses, the values of mean arterial pressure (p = 0.003) and systemic vascular resistance (p = 0.002) significantly increased after the administration of such doses, and additionally, lactate concentrations (p = 0.003) decreased. In contrast, no significant changes were observed regarding mean central venous pressure, pulmonary capillary wedge pressure, and pulmonary arterial pressure. Administration of high norepinephrine doses in our patients resulted in a survival rate of 33.4%. Management of catecholamine-resistant septic shock patients poses a challenging problem. Administration of very high norepinephrine doses is safe and effective and may improve survival of these patients with otherwise extremely high mortality rates.

Reintubation following failed extubation is an independent predictor of prolonged ICU stay, morbidity and mortality. Extubation criteria at the end of surgical procedures are similar to those applied to critically ill patients in mechanical ventilation.

Hyperdynamic circulation of septic shock is characterized in the hyperdynamic phase by increased cardiac output and decreased peripheral vascular resistance, and consequently low pressure. The use of norepinephrine as a pure vasoconstrictor aims to increase vascular resistance and blood pressure. There is a subgroup of patients with septic shock that does not respond to usual or high doses of norepinephrine. Usually in these patients different therapeutic approaches are used. In this study, we try to evaluate the role of very high doses of norepinephrine (≥ 2 μg/kg/min) in the treatment of septic shock.

Forty-two patients with necrotizing soft tissue infection are reviewed. Bacterial culture revealed between two and seven types of micro-organism in each patient. All patients were treated with radical surgical debridement and a combination of antibiotics. In 30 patients, early diagnosis and treatment resulted in only two deaths. Delayed surgical intervention in 12 patients transferred from outside hospitals was followed by nine deaths. Predisposing factors and site of infection did not affect outcome. Of 26 patients with systemic manifestations of sepsis, 16 survivors responded well to initial surgical debridement.

Introduction Low anterior resection is usually the procedure of choice for rectal cancer, but a series of complications often accompany this procedure. This case report describes successful management of an intricate anastomotic leak after a low anterior resection. Case presentation A 66-year-old Caucasian man was admitted to our hospital and diagnosed with a low rectal adenocarcinoma. He underwent a low anterior resection but subsequently developed fecal peritonitis due to an anastomotic leak. He was operated on again but developed abdominal compartment syndrome, multi-organ failure and sepsis. He was aggressively treated in the intensive care unit and in the operating room. Overall, the patient underwent four laparotomies and stayed in the intensive care unit for 75 days. He was discharged after 3 months of hospitalization. Conclusion Abdominal compartment syndrome may present as a devastating complication of damage control laparotomy. Prompt recognition and goal-directed management are the cornerstones of treatment.

Background An umbilical metastatic lesion is called 'Sister Mary Joseph's nodule'. It is an uncommon clinical or radiographic finding, and it is rare as the first sign of a malignant disease. Case presentation We report three cases of Sister Mary Joseph's nodule. In the three cases presented, the primary tumor was an adenocarcinona of the sigmoid colon, a carcinoma of the bladder, and an adenocarcinoma of the gallbladder, respectively. Conclusion The differential diagnosis of an umbilical lesion should always include metastatic disease apart from benign lesions and primary neoplasms.

Background Quality assessment of any trauma system involves the evaluation of the transferring patterns. This study aims to assess interfacility transfers in the absence of a formal trauma system setting and to estimate the benefits from implementing a more organized structure. Methods The 'Report of the Epidemiology and Management of Trauma in Greece' is a one year project of trauma patient reporting throughout the country. It provided data concerning the patterns of interfacility transfers. We compared the transferred patient group to the non transferred patient group. Information reviewed included patient and injury characteristics, need for an operation, Intensive Care Unit (ICU) admittance and mortality. Analysis employed descriptive statistics and Chi-square test. Interfacility transfers were then assessed according to each health care facility's availability of five requirements; Computed Tomography scanner, ICU, neurosurgeon, orthopedic and vascular surgeon. Results Data on 8,524 patients were analyzed; 86.3% were treated at the same facility, whereas 13.7% were transferred. Transferred patients tended to be younger, male, and more severely injured than non transferred patients. Moreover, they were admitted to ICU more often, had a higher mortality rate but were less operated on compared to non transferred patients. The 34.3% of transfers was from facilities with none of the five requirements, whereas the 12.4% was from those with one requirement. Low level facilities, with up to three requirements transferred 43.2% of their transfer volume to units of equal resources. Conclusion Trauma management in Greece results in a high number of transfers. Patients are frequently transferred between low level facilities. Better coordination could lead to improved outcomes and less cost.