Papers by Dionisios Vrochides
International Journal of Surgery, 2013
International Anesthesiology Clinics, 2017
Introduction to Value in Health Care“Value” is a frequently mentioned buzzword in health care, an... more Introduction to Value in Health Care“Value” is a frequently mentioned buzzword in health care, and the quest to deliver value now commands the attention of the anesthesiology community. Value is generally defined as a ratio of care quality to total cost of that care. There are a variety of professio
Clinical nutrition ESPEN, Jun 1, 2023
Journal of surgical case reports, Oct 1, 2022
Anatomic variations of the hepatic artery do not usually cause biliary obstruction. We present a ... more Anatomic variations of the hepatic artery do not usually cause biliary obstruction. We present a 51-year-old male who developed biliary obstruction and hepatolithiasis due to extrinsic compression of the common hepatic duct (CHD) by an arterial ring formed by the anterior and posterior branches of the right hepatic artery. We performed a surgical bile duct exploration and used intraoperative direct cholangioscopy to guide clearance of hepatolithiasis. Herein, we review the existing literature on CHD compression caused by topographical variants of the hepatic artery and discuss diagnostic and treatment strategies.
Hpb, Apr 1, 2016
= 0.571) and rate of patients with newonset diabetes at postoperative 12 months (24.3% vs. 12.5%,... more = 0.571) and rate of patients with newonset diabetes at postoperative 12 months (24.3% vs. 12.5%, P = 0.179) were also comparable. Conclusion: External and internal stent showed comparable clinical outcomes in long-term follow-up as well as short-term results. The type of pancreatic stent can be selected by the operator according to their preference.
Hpb, Apr 1, 2016
Introduction: Bile duct injury is associated with morbidity, even mortality and costs to the pati... more Introduction: Bile duct injury is associated with morbidity, even mortality and costs to the patient and society. Controversy exists regarding optimal timing of surgical repair. Method: All patients who underwent bile duct reconstruction from July 2003 to March 2014 were included. Demographics, clinical data, complications rates and outcomes were recorded. Results: A total of 80 bile duct reconstructions were perfomed. Early repair was performed in all patients, 78.7% in less than 14 days, 21.3% in more than 14 days but less than 3 months. Median operation time was 150 min Rq 120-180, median postoperative hospital stay was 5 days Rq 4-7. Bismuth classification distribution was as follows: I. 7.7%, II. 24.4%, III. 30.8%, IV. 37.2%. Right hepatic artery injury was detected in 19.2% of patients. Complications ocurred in 26.9% of patients, SSI 16.7 %, Bile leak 12.8%, remote infection 2.6%. No patient was reoperated after bile duct reconstruction. There were 2 postoperative deaths (90 days). Biliary stricture after bile duct reconstruction occured in 14.1% of patients. There were no statistically significant risk factors for bile leak in bivariate analysis (e.g. time of reconstruction, vasculobiliary injury, Bismuth classification). Bile leak was the only risk factor statistically significant for biliary stricture after reconstruction both in bivariate (p 0.03) and multivariate analysis (RR 9.39, CI 1.73e51.059). Conclusions: Early surgical repair after bile duct injury appears to have good outcome in our series.
Hepatobiliary & Pancreatic Diseases International, Aug 1, 2020
Surgical Endoscopy and Other Interventional Techniques, Jun 25, 2020
Background Hepatectomy or transplantation can serve as curative treatment for early-stage hepatoc... more Background Hepatectomy or transplantation can serve as curative treatment for early-stage hepatocellular carcinoma (HCC). Unfortunately, as progression remains a reality, locoregional therapies (LRT) for curative or bridging intent have become common. Efficacy on viability, outcomes, and accuracy of imaging should be defined to guide treatment. Methods Patients with HCC who underwent minimally invasive (MIS) microwave ablation (MWA), transarterial chemoembolization (TACE), or both (MIS-MWA-TACE) prior to hepatectomy or transplantation were identified. Tumor response and preoperative computed tomography (CT) accuracy were assessed and compared to pathology. Clinical and oncologic outcomes were compared between MIS-MWA, TACE, and MIS-MWA-TACE. Results Ninety-one patients, with tumors from all stages of the Barcelona Clinic Liver Cancer (BCLC) staging, were identified who underwent LRT prior to resection or transplant. Fourteen patients underwent MIS-MWA, 46 underwent TACE, and 31 underwent both neoadjuvantly. TACE population was older; otherwise, there were no differences in demographics. Fifty-seven percent of MIS-MWA patients had no viable tumor on pathology whereas only 13% of TACE patients and 29% of MIS-MWA-TACE patients had complete destruction (p = 0.004). The amount of remaining viable tumor in the explant was also significantly different between groups (MIS-MWA: 17.2%, TACE: 48.7%, MIS-MWA-TACE: 18.6%; p ≤ 0.0001). Compared with TACE, the MIS-MWA and MIS-MWA-TACE groups had significantly improved overall survival (MIS-MWA: 99.94 months, TACE: 75.35 months, MIS-MWA-TACE: 140 months; p = 0.017). This survival remained significant with stratification by tumor size. CT accuracy was found to be 50% sensitive and 86% specific for MIS-MWA. For TACE, CT had an 82% sensitivity and 33% specificity and for MIS-MWA-TACE, there was a 42% sensitivity and 78% specificity. Conclusion The impact of locoregional treatments on tumor viability is distinct and superior with MIS-MWA alone and MIS-MWA-TACE offering significant advantage over TACE alone. The extent of this effect may be implicated in the improved overall survival.
PubMed, Apr 19, 2017
Background: Treatment of ruptured hepatocellular carcinoma (HCC) focuses on hemorrhage control an... more Background: Treatment of ruptured hepatocellular carcinoma (HCC) focuses on hemorrhage control and utilizes tumor vascular anatomy to palliate or temporize selected patients with hepatic artery embolization (HAE). Radiofrequency ablation (RFA) and microwave ablation (MWA) are feasible alternatives or adjunct modalities to resection of HCC; the method of energy delivery in MWA allows uniform coagulative necrosis in shorter time compared with RFA. Case description: We present the case of an 82-year-old man who presented with a ruptured liver tumor with active intraperitoneal bleeding on angiography. The patient remained hemodynamically stable with evidence of ongoing bleeding following HAE. Tumor destruction and definitive hemostasis were obtained with minimally invasive MWA. Conclusion: Tumor rupture remains a negative prognostic factor in the course of HCC. In select patients, MWA allows definitive hemorrhage control with minimal surgical morbidity. Hippokratia 2016, 20(2): 169-171.
International Journal of Hepatobiliary and Pancreatic Diseases, 2021
evaluate the possible benefit of early drain removal, after adjustment for several confounding fa... more evaluate the possible benefit of early drain removal, after adjustment for several confounding factors. Results: 1066 patient were eligible for this analysis. Patients with early drain removal had lower rates of serious postoperative complications (p < 0.001), overall morbidity (p < 0.001), pancreatic fistula (p < 0.001), organ space infection (p = 0.007), delayed gastric emptying (DGE) (p = 0.026) and shorter in-hospital stay (p < 0.001). After adjustment for several confounding factors, with multivariable regression models, the early drain removal group continued to have a significantly lower risk of all those complications, except the postoperative DGE. Conclusion: Early drain removal (3 days) after a Whipple procedure is associated with lower rates of postoperative adverse outcomes, like pancreatic fistula and shorter in-hospital stay.
Journal of The American College of Surgeons, Oct 1, 2016
molecules play a key role in the interactions of malignant cells with host's immune system. This ... more molecules play a key role in the interactions of malignant cells with host's immune system. This rationale has prompted us to investigate HLA class I APM component expression in intraductal papillary mucinous neoplasms (IPMN) and to correlate the immunohistochemical results with the histopathological characteristics of the lesions. METHODS: Clinicopathologic data was collected for 75 IPMN patients from a single academic center between 2006-2013. Formalin fixed, paraffin-embedded tissue was stained with HLA class I APM component-specific mAbs and were evaluated using the intensity and percentage scoring system. Results were correlated with the histology and grade of dysplasia. RESULTS: Histologically, IPMN samples were gastric type (n¼49), intestinal type (n¼30), pancreatobiliary type (n¼6), oncocytic type (n¼1), and invasive carcinoma (n¼12). Invasive carcinoma (n¼13); high grade (n¼22), intermediate grade (n¼45) and low grade (n¼19) were all included. HLA-A, HLA-B, C and Tapasin were not detected in 35, 9, and 19 IPMN lesions. Furthermore, a significant positive correlation was found between HLA-B, C antigen expression level and degree of lesions in IPMN. CONCLUSIONS: The association between high HLA class I antigen expression and degree of dysplasia in IPMN suggests that NK cells play a role in disease progression in IPMN since high HLA class I antigen expression inhibits their cytolytic activity. If so, the high HLA-B, C antigen expression is likely to reflect the outgrowth of IPMN cells which escape the selective pressure imposed by NK cells on IPMN cell populations.
Hpb, Apr 1, 2016
Introduction: The reported actual 10-year survival rate of hepatocellular carcinoma (HCC) after h... more Introduction: The reported actual 10-year survival rate of hepatocellular carcinoma (HCC) after hepatectomy was 7.2% only. Our study was conducted to compare the characteristics of HCC patients who survived >10 years after hepatectomy. Method: This was a retrospective study in a university affiliated hospital. All patients who had hepatectomy for HCC from 1990 to 2004 were analyzed. Data was retrieved from a prospective collected database. Baseline, operative, pathological and survival data between 10-year survivors were compared to non 10-year survivors. Results: There were 727 HCC patients who had hepatectomy and 247 (34.0%) patients survived 10 years after hepatectomy. Among these 10 year survivors, 150 (60.6%) patients were disease free. 10-year survivors were younger (52 vs. 55 year old, p = 0.04), more likely to have screen detected HCC (54.3 vs. 33.5%, p < 0.001) and had better liver function (indocyanine green retention at 15 mins: 9 vs. 10.9%, p = 0.003). The use of major hepatectomy (61.1 vs. 62.1%, p = 0.80), anterior approach (20.6 vs. 20.8%, p = 0.95) and Pringle manoeuver (32.4 vs. 33.8%, p = 0.71) were not different. There was no difference in postoperative complication and hospital mortality. Non 10-year survivors were more likely to have tumors with marco-or microscopic vascular invasion, microsatellite nodule and multiple tumors (>3). In multivariable analysis, tumor recurrence was associated with inferior survival. Conclusion: We have demonstrated 34% of HCC patients can survive at least 10-years after hepatectomy. Timing and pattern of tumor recurrence predicted long-term survivals.
Journal of Laparoendoscopic & Advanced Surgical Techniques, Aug 1, 2021
Background and Purpose: Operative microwave ablation (MWA) is a safe modality for treating hepati... more Background and Purpose: Operative microwave ablation (MWA) is a safe modality for treating hepatic tumors. The aim of this study is to present our 10-year, single-center experience of operative MWA for neuroendocrine liver metastases (NLM). Methods: A single-institution retrospective review of patients who underwent operative MWA for NLM was performed (2008-2018). Demographics, primary tumor site, operative approach, combined surgical operations, and carcinoid symptoms were recorded. Clinical outcomes for major complications, readmission, and mortality were analyzed 30 days postoperatively. Postablation imaging was evaluated for incomplete ablation/missed lesions, and surveillance imaging reviewed for local, regional, and metastatic recurrence. Results: Of the 50 patients (166 targeted lesions) who received MWA for NLM, 41 (82%) were treated with a minimally invasive approach, and 22 (44%) underwent MWA concomitant with hepatectomy and/or primary tumor resection. Within the study cohort 70% of patients were treated with curative intent with a 77% (27/35) success rate. Carcinoid symptoms were reported in 40% (20/50) of patients preoperatively, and MWA treatment improved symptoms in 19/20 patients. Incomplete ablation occurred in 1/166 treated lesions. Recurrence-free survival at 1 and 5 years was 86% and 28%, respectively. Overall survival at 1 and 5 years was 94% and 70%, respectively (median follow-up 32 months, range 0-116 months). Conclusion: Operative MWA is a versatile modality, which can be safe and effectively performed alone or combined with hepatectomy for NLM, preferably using a minimally invasive approach, to achieve symptom control and possibly improve survival.
American Surgeon, Feb 1, 2018
Afferent loop syndrome (ALS) is a mechanical obstruction causing an accumulation of biliary, panc... more Afferent loop syndrome (ALS) is a mechanical obstruction causing an accumulation of biliary, pancreatic, and intestinal secretions leading to blockage and dilation of the jejunal portion of the afferent limb. ALS most commonly presents acutely in patients who have had a Billroth II gastroenterostomy reconstruction after gastrectomy. This may result in ischemia and gangrene, requiring prompt surgical intervention.1 The greatest contribution to ischemic changes is due to jejunal obstruction and subsequent fluid accumulation causing increased wall tension.2 Diagnosis is best made by CT as presenting symptoms can be nonspecific.3 Chronic presentations of ALS are far less common, especially cases following Roux-en-Y reconstruction that are non-mechanical in nature, with few cases reported in the literature.4 We describe a case of chronic ALS occurring years after a Roux-en-Y reconstruction that became distended and significantly erythematous warranting prompt intervention. A 34-year-old woman presented to the emergency department with a 3-day history of worsening abdominal pain complicated by a recurrent abdominal hernia. She reported nausea and constipation, but denied any recent trauma, vomiting, melena, or hematochezia. Her nausea and pain were mildly relieved by venting of her jejunostomy tube (J-tube) as well as manually reducing her hernia. She had a history of gastroparesis, GERD, hyperinsulinemia, hyperparathoidism, hypothyroidism, irritable bowel syndrome, systemic scleroderma, depressive disorder, and anxiety. Her surgical history was notable for multiple gastrointestinal surgeries, including a laparoscopic Roux-en-Y gastric bypass prior 10 years. It was complicated by abdominal hernias, mesh removal, and intestinal dismotility requiring placement of both colonic and small intestinal pacemakers. She also had a related obstructive episode for which she underwent exploratory laparotomy and J-tube placement in 2014. Her complex medical conditions have been complicated by multiple hospitalizations and unremitting symptoms of nausea and vomiting. On examination, she had normal vital signs, multiple abdominal scars, and a prominent 3-cm reducible periumbilical hernia. Initial laboratory studies showed no leukocytosis, slightly elevated liver enzymes but were otherwise normal. Her small bowel obstruction was medically managed at this time. After observation and pain control, she was discharged home with follow-up surgical consultation in the outpatient clinic. The plan was to repair her hernia and place a larger J-tube to facilitate better ventilation. Approximately two weeks later, the patient represented as a transfer from an outside community hospital complaining of a 1-day history of worsening sharp left upper quadrant abdominal pain. Associated symptoms included nausea and bilious vomiting that began shortly after a J-tube feeding. Disconnecting the tube did not result in improvement of her symptoms, and she was unable to flush the J-tube. She again denied any recent trauma, melena, or hematochezia. Abdominal CT performed at the outside hospital showed a recurrent small bowel obstruction, which prompted transfer to our tertiary-care hospital. On examination, she had normal vital signs, multiple abdominal scars with noted erythema, and discharge surrounding the J-tube site, and tenderness to palpation in the left upper abdominal quadrant. Laboratory studies showed a hemoglobin level of 9 g/ dL, white blood cell count of 19,200 cells/mL, and platelet count of 408,000 cells/mL. Repeat CT displayed small bowel obstruction and proximal small bowel dilation consistent with findings from the outside hospital, but were grossly unchanged from previous imaging studies. Initially, she was admitted for paralytic ileus secondary to gastroparesis. She was made nothing by mouth and treated medically. She was still having intermittent flatus and episodically passing small stools. On the 7th day of Address correspondence and reprint requests to Erica Sutton, M.D., Department of Surgery, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40202. E-mail: [email protected].
Clinical nutrition ESPEN, Jun 1, 2018
premalignant lesions. Of those 45, R0 resection was achieved in 34 (75.6%). Median estimated bloo... more premalignant lesions. Of those 45, R0 resection was achieved in 34 (75.6%). Median estimated blood loss was 300cc. Median OR time was 419 minutes. Median length of stay was 8 days. Grade B or C pancreatic fistula occurred in 7.2% of cases. The overall operative time, rate of conversion to open procedure, and overall complication rate were lower in the post-ERASⓇ group, when compared to the pre-ERASⓇ group. Conclusion: This study demonstrates that approaching PD with a robotic platform is a viable strategy in the setting of either benign or malignant disease. Conversion rates can be expected to decline as surgeons progress along the learning curve and gain familiarity with the robotic technique, however the overall decrease in post op complications appears to coincide with the initiation of an ERASⓇ protocol, and may be explained by a tight compliance to that initiative. The complication profile and safety metrics of cases completed robotically are in line with the standards of open PD. Disclosure of Interest: None declared.
Hpb, Apr 1, 2017
Objective: Severe pancreatitis can lead to walled off pancreatic necrosis (WOPN). This has been t... more Objective: Severe pancreatitis can lead to walled off pancreatic necrosis (WOPN). This has been traditionally managed by open surgery. Recently, endoscopic and minimally invasive techniques (MIS) {laparoscopy and robotics} are being used to perform these complex procedures. We hypothesize that MIS has improved outcomes as compared to endoscopy in the management of WOPN. Methods: We performed a retrospective analysis of patients who underwent cystgastrostomy for WOPN from 2009 to 2015 using minimally invasive surgery (laparoscopic and robotic) and endoscopy. We compared demographics, etiology, preoperative cyst characteristics and time to drainage. We also looked at outcomes including failure rates, complications, length of stay, necessity of repeat procedures and cross over to alternative modality. Results: There were 39 and 42 patients in the surgical and endoscopic groups respectively. Demographics, ASA, comorbidities and size of WOPN were similar. In the endoscopy arm, 35% had true pseudocysts. Median time to intervention was similar (72 days) as well as post-operative (Clavien III and IV) complications were similar (5.6 vs 4. 2%). Median length of stay was greater in the surgical arm Vvs. endoscopic arm (p < 0.05). Treatment failure was 2.5% vs. 11.9% (p = 0.2) and recurrence was 2.5 % vs. 9.5% respectively (p = 0.3) (surgery vs. endoscopy). Secondary procedures were required in 5.1% in surgical arm vs. 16.6% in the endoscopic arm (p = 0.08). Conclusion: Minimally invasive cystgastrostomy as compared to endoscopic approach in the management of WOPN has fewer failures and recurrences and repeat interventions.
Hpb, Apr 1, 2016
analysis I were 1.00 (day 1), 0.93 (day 2), 0.81 (day 3) and 0.86 (day 4). Highest sensitivity (7... more analysis I were 1.00 (day 1), 0.93 (day 2), 0.81 (day 3) and 0.86 (day 4). Highest sensitivity (77%) and specificity (90%) were obtained for drainage/serum bilirubin ratio of 2.4 on day 4 after hepatic resection. Areas under the curve for analysis II were similar than for analysis I: 0.95, 0.91, 0.82 and 0.79. Highest sensitivity (89%) and specificity (87%) was detected for a drainage/serum bilirubin ratio of 2.6 on post-operative day 2 with positive likelihood-ratio of 6.7 and a negative likelihood ratio of 0.13. Conclusion: Based on our statistical investigations we carefully suggest amending the current definition of biliary leakages as defined by the ISGLS. Biliary leakages should be defined in case the drainage/serum bilirubin ratio >2.6 on postoperative day 2.
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Papers by Dionisios Vrochides