[Learning curve in laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity]

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently considered the gold standard treatment for morbid obesity. The learning curve for this procedure is about 100 cases, and it is considered the most important factor in decreasing complications and mortality. We present our experience and learning curve with LRYGB.

METHODS

The data was collected prospectively. All patients with primary LRYGB between March 2006 and April 2014 were included. Only patients with full data on demographics, length of stay, operating time, and complications were included in the study.

RESULTS

Five hundred and eleven patients underwent a LRYGB. Ninety five of them underwent a redo RYGB (conversion), and were excluded. Of the remaining 416 patients, full data was available for 326 and the statistical analysis refers to this group. The complication rate was available for all patients who were included in the study. The mean age and body mass index were 43 years (14-76 years) and 42.8 kg/m2 (34-76) respectively. The mean duration of surgery was 86 minutes (40-420). In the first 100 patients, operating time was 148 min, while in the last 125 patients it was 75 min. The major perioperative complication rate was 7.7%. Of 4 leaks (0.95%, 3 were encountered in the first 100 operations, and one in the following 316 (3% and 0.3% respectively). The mean length of stay was 2.2 days (1-46). None of the patients stayed in the intensive care unit. There was no mortality.

CONCLUSIONS

LRYGB is very safe. We confirm that the learning curve for this procedure is more than 100 cases. Appropriate training is crucial.

Sphincter preservation in distal CT2N0 rectal cancer after preoperative chemoradiotherapy

BACKGROUND

Preoperative chemoradiotherapy is usually not indicated for cT2N0 rectal cancer. Abdominoperineal resection is the standard treatment for distal rectal tumors. The aim of the study was to evaluate the actual sphincter-preservation rate in patients with distal cT2N0 rectal cancer given neoadjuvant chemoradiotherapy.

METHODS

Data were retrospectively collected for all patients who were diagnosed with distal cT2N0 rectal cancer at a tertiary medical center in 2000-2008 and received chemoradiotherapy followed by surgery (5-7 weeks later).

RESULTS

Thirty-three patients (22 male) of median age 65 years (range, 32-88) were identified. Tumor distance from the anal verge ranged from 0 to 5 cm. R0 resection with sphincter preservation was accomplished in 22 patients (66%), with a 22% pathological complete response rate. Median follow-up time was 62 months (range 7-120). There were no local failures. Crude disease-free and overall survival were 82% and 86%, respectively. Factors associated with sphincter preservation were tumor location (OR=0.58, p=0.02, 95% CI=0.37-0.91) and pathological downstaging (OR=7.8, p=0.02, 95% CI=1.35-45.85). Chemoradiotherapy was well tolerated.

CONCLUSION

High rates of sphincter preservation can be achieved after preoperative chemoradiotherapy for distal cT2N0 rectal cancer, with tolerable toxicity, without compromising oncological outcome.

The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease

BACKGROUND

Bariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients.

METHODS

The prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed.

RESULTS

One male and 9 female morbidly obese IBD patients (8 with Crohn's disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9-67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation.

CONCLUSION

Bariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients.

Torsion of a huge accessory spleen in a 20-year-old patient

INTRODUCTION

Accessory spleen is a rare condition. Torsion of accessory spleen can lead to acute abdomen.

PRESENTATION OF CASE

We describe a young woman with an acute abdomen caused by torsion of accessory spleen. Abdominal computed tomography angiography (CTA) demonstrated an ischemic giant accessory spleen with a twisted vascular pedicle. An emergency laparotomy was performed with resection of the infarcted accessory spleen.

DISCUSSION

Accessory spleen is a rare and asymptomatic condition. Torsion of accessory spleen is also uncommon. Abdominal pain is the main symptom. CTA is effective in reaching a diagnosis. Definitive treatment of an acute abdomen due to accessory splenic torsion is emergency accessory splenectomy.

CONCLUSION

Elective accessory splenectomy should be recommended for known giant accessory spleen to prevent complications in future.

Prospective phase II study of neoadjuvant therapy with cisplatin, 5-fluorouracil, and bevacizumab for locally advanced resectable esophageal cancer

BACKGROUND

We investigated the efficacy and tolerability of cisplatin and 5-fluorouracil (5-FU) plus bevacizumab as neoadjuvant therapy for patients with locally advanced resectable esophageal cancer.

PATIENTS AND METHODS

In this prospective phase II study, 22 patients with adenocarcinoma and 6 with squamous cell carcinoma received 2 4-day cycles of bevacizumab 7.5 mg/kg followed by cisplatin 80 mg/m(2) infusion on day 1 followed by 5-FU 1,000 mg/m(2) as a 96-h continuous infusion on days 1-4, separated by a 3-week interval.

RESULTS

The response rate was 39%, the R0 resection rate was 43%, and the median overall survival (OS) was 17 months. The regimen was well tolerated, with the most common severe toxicities being venous thromboembolism (10%), nausea, and gastrointestinal bleeding (7% each). In 37 patients previously treated with cisplatin and 5-FU alone at our institution and thus serving as historical controls, the response rate was 30%, the R0 resection rate was 44%, and the median OS was 23 months. There was no statistically significant difference between the 2 groups of patients.

CONCLUSION

Adding bevacizumab to cisplatin and 5-FU neoadjuvant chemotherapy was active and well tolerated but did not seem to improve the resection rate or OS compared with prior regimens, including the historical controls at our institution.

Preoperative chemoradiation and cetuximab for resectable, locally advanced esophageal cancer: Preliminary results of a prospective phase Ib/II trial

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Background: This prospective phase IB/II study evaluated the safety and efficacy of the addition of cetuximab to standard preoperative chemoradiation (CRT) in locally advanced esophageal cancer (LAEC). We hereby report its preliminary results. Methods: Patients (pts) with potentially resectable LAEC, defined as T2-4N0-1M0, T1-4N1M0 or T1-4N0-1M1A tumors, received an induction cycle of cisplatin 100 mg/m2, day 1, and 5-FU 1000 mg/m2/day as a continuous infusion (CI), days 1–5, followed 4 weeks later by 50.4 Gy radiotherapy (RT) given concurrently with 2 cycles of cisplatin 75 mg/m2 and escalating doses of CI 5-FU, days 1–4 and 29-32. Pts received also 10 weekly infusions of cetuximab, 250 mg/m2, with a loading dose of 400 mg/m2, starting from the induction. The phase II part of the study started when the 5-FU dose during CRT was defined. Surgery was planned 6-8 weeks after CRT. Results: Thirty-six pts have been enrolled to date and 32 completed CRT. The median age was 65 years and 60% were males. The ratio of squamous/adeno histologies was 53%/47%. Pts had very advanced tumors: 95% T3-T4, 63% N1 and 28% M1A. In the absence of dose limiting toxicity, 31 pts received the phase II dose of 5-FU, defined as 1000 mg/m2/day. The most common grade >3 toxicities were leucopenia (51% of pts) and neutropenia (48%). There was one toxic death, due to neutropenic sepsis. Among the 27 operated pts, R0 resection was achieved in 24 (89%). There were 4 cases (15%) of postoperative mortality, due to infection (3 pts) or respiratory failure (1). Downstaging was noted in 83% of pts and pathological complete response (pCR) in 32%. Pts with squamous histology had a higher pCR rate (53% vs 7%, p=0.007). At the time of the analysis, 14 pts (40%) remain free of disease and the local control rate is 92%. Updated results will be presented at the meeting. Conclusions: Preliminary results from this prospective study suggest that the addition of cetuximab to standard CRT is safe. The R0, pCR and local control rates are encouraging. Squamous cell tumors may gain more benefit from the addition of cetuximab.

One hundred transhiatal esophagectomies: a single-institution experience

BACKGROUND

Surgery is considered the mainstay of treatment for esophageal carcinoma. Transhiatal esophagectomy with cervical esophagogastric anastomosis is considered relatively safe with an oncological outcome comparable to that using the transthoracic approach.

OBJECTIVES

To review the results of the first 100 transhiatal esophagectomies performed in a single Israeli center.

METHODS

The records of all patients who had undergone transhiatal esophagectomy during the period 2003-2009 were reviewed. The study group comprised the first 100 patients. All patients who had undergone colon or small bowel transposition were excluded. Indications for surgery included esophageal cancer, caustic injury and achalasia.

RESULTS

The median follow-up period was 19.5 months. The anastomotic leakage rate was 15% and all were managed successfully with local wound care. The benign stricture rate was 10% and all were managed successfully with endoscopic balloon dilation. Anastomotic leakage was found to be a risk factor for stricture formation. Overall survival was 54%. Response to neoadjuvant therapy was associated with a favorable prognosis.

CONCLUSIONS

Transhiatal esophagectomy is a relatively safe approach with adequate oncological results, as long as it is performed in a high volume center.

Evaluation of the NiTi Shape Memory BioDynamix ColonRing™ in colorectal anastomosis: first in human multi-center study

BACKGROUND

Shape-memory compression bowel anastomosis using a nickel and titanium alloy may reduce leak rates and eliminate foreign anastomotic material. Its safety and efficacy had been demonstrated by animal studies. We conducted the first prospective multi-center clinical evaluation of the safety and effectiveness of BioDynamix anastomosis with ColonRing™ for large-bowel end-to-end or side-to-end anastomosis.

MATERIALS AND METHODS

The ColonRing™ was compared to the standard double-stapled colorectal/colocolonic anastomosis. Intraoperative and immediate postoperative and 1- and 3-month postoperative follow-up data were recorded.

RESULTS

Ten study patients (four males, median age 62 years, range 35-75) were compared to 13 demographically matched controls (six males, median age 62 years, range 47-82). Colorectal neoplasia was the most frequent indication for surgery (21/23 patients, 91%). The median anastomotic distance from the anal verge for both groups was 10 cm (6-20 cm). The first postoperative bowel movement was on day 5 ±2.2 (study group) and on day 4 ±1.8 (controls), and the median hospital stay was 8 days (6-14 days) and 7 days (6-13 days), respectively. There were no anastomotic leaks. There were three minor complications in each group, unrelated to the device in the study group. Two patients required transanal digital extraction of the ring which was detached but not expelled (one had a soft anastomotic stricture).

CONCLUSIONS

Our preliminary results in this first study on humans indicate that the safety and efficacy of BioDynamix anastomosis with ColonRing™ in colorectal anastomosis in human is comparable to standard staples technology and warrant larger studies for further validation.

The use of circular stapler for cervical esophagogastric anastomosis after esophagectomy: surgical technique and early postoperative outcome

Stapled esophagogastric anastomosis after esophagectomy is considered to be superior to traditional handsewn techniques. Linear staplers are usually used. The aim of this study is to evaluate early postoperative results of circular stapler in cervical esophagogastric anastomosis. Records of all patients who underwent esophagectomy during the years 2003-2008 were reviewed. Patients that underwent transthoracic esophagectomy, colon transposition, or linear stapler anastomosis were excluded. Esophagogastric anastomosis was done either handsewn or using circular stapler. Patients underwent either pyloromyotomy, pyloroplasty, or no pyloric intervention. Postoperative leakage was diagnosed either clinically or radiologically. The end-point of this study was the incidence of anastomotic leak in the immediate postoperative period. Eighty-two patients (average age 66 years, male/female, 52/30) met the inclusion criteria. In 30 patients, the anastomosis was handsewn, and in 52 patients, it was done using a circular stapler. Overall operative mortality rate was 4.8% (four patients because of pulmonary or cardiac complications). Anastomotic leak occurred in five (n = 5, 16.6%) patients in the handsewn group and eight (n = 7, 13.4%) patients in the circular stapler group. Pyloric manipulation had no significant effect over the leakage rate. Routine upper-gastrointestinal (GI) series done on the fifth or sixth postoperative day did not reveal any of the leaks. Cervical esophagogastric anastomosis using an end-to-side circular stapler is feasible and safe, and has comparable outcomes to handsewn anastomosis in regard of leakage rates or other major surgical or general complications. Postoperative GI series seems to be a poor diagnostic tool for anastomotic leakage and could be omitted as a routine study for occult anastomotic leak.

Endoscopic ultrasound: doubtful accuracy for restaging esophageal cancer after preoperative chemotherapy

BACKGROUND

The role of endoscopic ultrasound in evaluating the response of esophageal cancer to neoadjuvant chemotherapy is controversial.

OBJECTIVES

To evaluate the accuracy of EUS in restaging patients who underwent NAC.

METHODS

The disease stage of patients with esophageal cancer was established by means of the TNM classification system. The initial staging was determined by chest and abdominal computed tomography and EUS. Patients who needed NAC underwent a preoperative regimen consisting of cisplatin and fluouracil. Upon completion of the chemotherapy, patients were restaged and then underwent esophagectomy. The results of the EUS staging were compared with the results of the surgical pathology staging. This comparison was done in two groups of patients: the study group (all patients who received NAC) and the control group (all patients who underwent primary esophagectomy without NAC).

RESULTS

NAC was conducted in 20 patients with initial stage IIB and III carcinoma of the esophagus (study group). Post-chemotherapy EUS accurately predicted the surgical pathology stage in 6 patients (30%). Pathological down-staging was noted in 8 patients (40%). However, the EUS was able to observe it in only 2 patients (25%). The accuracy of EUS in determining the T status alone was 80%. The accuracy for N status alone was 35%. In 65% of examinations the EUS either overestimated (35%) or underestimated (30%) the N status. Thirteen patients with initial stage I-IIA underwent primary esophagectomy after the initial staging (control group). EUS accurately predicted the surgical pathology disease stage in 11 patients (85%).

CONCLUSIONS

EUS is an accurate modality for initial staging of esophageal carcinoma. However, it is not a reliable tool for restaging esophageal cancer after NAC and it cannot predict response to chemotherapy.

Outcome of right colectomy for cancer in octogenarians

BACKGROUND

Colorectal cancer is one of the commonest malignancies in the elderly and, as such, is a major cause of morbidity and mortality. There is no consensus yet if age itself is a risk factor for adverse outcome after colectomy. The aims of the study were to evaluate the impact of age on operative results of right colectomy for cancer and to define factors that influence the postoperative mortality in octogenarians.

METHODS

Data of all patients who underwent right colectomy for colon cancer between January 2001 and December 2006 were collected retrospectively. Patients were divided into two groups: those who were 80 years and older and those who were less than 80 years old. Analysis included patients' demographics, comorbidities, American Society of Anesthesiologists class, functional status, mode of presentation, stage of disease, length of hospital stay, postoperative morbidity, and mortality.

RESULTS

A total of 124 consecutive patients with right colon cancer were operated. Control group included 84 patients less than 80 year old. Study group included 40 patients 80 years or older. In Cox multivariate regression analysis, poor functional status and emergent surgery were independent factors for postoperative mortality.

CONCLUSIONS

There was no significant difference in the outcome of elective right colectomy between elderly patients and their younger counterparts. Operative mortality of emergency surgery was significantly higher in octogenarians. Emergent setting and poor functional status are major risk factors for postoperative mortality.

Postoperative Management after Pneumonectomy for Blunt Thoracic Trauma

Pneumonectomy for blunt thoracic injury carries a high mortality rate. We present a case of severe bilateral blunt thoracic injury in which left pneumonectomy was done. The immediate postoperative measures were directed to maintain right heart performance by minimizing hypoxia, avoiding fluid overload and limiting pulmonary hypertension. We believe that this approach contributed to the favorable outcome of this patient.

Small bowel obstruction caused by secondary tumors

Small bowel obstruction in an oncology patient is a common and serious medical problem which is associated with diagnostic as well as therapeutic dilemmas. While the condition is most commonly caused by postoperative adhesions and peritoneal carcinomatosis, other causes have been reported [Cormier WJ, Gaffey TA, Welch JM, et al. Linitis plastica caused by metastatic lobular carcinoma of the breast. Mayo Clinical Proceedings 1980;55:747-53; Clavien P-A, Laffer U, Torhos J, et al. Gastrointestinal metastases as first clinical manifestation of the dissemination of a breast cancer. European Journal of Surgical Oncology 1990;16:121-6; Bender GN, Maglinte DD, McLarney JH, et al. Malignant melanoma: patterns of metastasis to the small bowel, reliability of imaging studies, and clinical relevance. American Journal of Gastroenterology 2001;96:2392-400; Gatsoulis N, Roukounakis N, Kafetzis I, et al. Small bowel intussusception due to metastatic malignant melanoma. A case report. Technical Coloproctology 2004;8:141-3; Hung GY, Chiou T, Hsieh YL, et al. Intestinal metastasis causing intussusception in a patient treated for osteosarcoma with history of multiple metastases: a case report. Japanese Journal of Clinical Oncology 2001;31(4):165-7; Chen TF, Eardley I, Doyle PT, Bullock KN. Rectal obstruction secondary to carcinoma of the prostate treated by transanal resection of the prostate. British Journal of Urology 1992;70(6):643-7; Kamal HS, Farah RE, Hamzi HA, et al. Unusual presentation of rectal adenocarcinoma. Roman Journal of Gastroenterology 2003;12(1):47-50; Hofflander R, Beckes D, Kapre S, et al. A case of jejunal intussusception with gastrointestinal bleeding caused by metastatic testicular germ cell cancer. Digestive Surgery 1999;16(5):439-40]. One of these, reported thus far in only very few patients, is obstruction caused by secondary tumors, i.e. metastases from other organs to the small bowel wall. As cancer patients live longer with improved therapy, physicians are more likely to cope with rare phenomena of neoplasms, such as small bowel obstruction caused by secondary tumors. We hereby present a review of the relevant medical literature. The goal of this article is to define current knowledge on this phenomenon, with emphasis on its epidemiology and clinical characteristics, and to increase the awareness of the clinician treating cancer patients of such possibility.

Treatment of pilonidal sinus disease using fibrin glue as a sealant

BACKGROUND

Complete excision is the preferred treatment for pilonidal sinus disease. We describe a new technique of excision and tension-free primary closure of pilonidal sinus disease, combined with application of fibrin glue in order to obliterate the dead space and to promote wound healing.

METHODS

A curved incision of the carried out, 2-3 cm lateral to the opening of the sinus, done under general or spinal anesthesia, and a thick flap was created by undercutting the medial edge and advancing it across the midline. The sinus was completely excised with all of its extensions. The flap was then sutured back to its original place by several interrupted monofilament mattress sutures. Then, 2-4 ml of fibrin glue was injected through the original pilonidal sinus opening to the sinus bed in order to obliterate the dead space.

RESULTS

Thirty patients with pilonidal sinus disease were treated by this technique. In four patients, there was a temporary purulent discharge through the opening of the sinus, and there were no other complications. The mean period for returning to daily activities and to work for patients was 11 days (SD=6 days). No infection or recurrent disease was noticed during the follow-up period (23+/-3 months).

CONCLUSIONS

Complete excision with tension free closure with fibrin glue application may be a useful technique for the treatment of pilonidal sinus disease.

Detection of cancer cells in the axillary drainage using RT-PCR after operations for breast cancer

The object of this study was to examine whether MUC-1 can be detected in the axillary lymphatic drainage of patients who have undergone conservative surgery for breast cancer and to assess the correlations between the presence of MUC-1 and prognostic factors in breast cancer. Sixty-eight women with invasive ductal carcinoma of the breast underwent wide local excision and axillary lymph node dissection. Axillary drains were inserted in all these cases, and the presence of MUC-1 and beta-actin was evaluated by RT-PCR in the lymphatic fluid collected after the operation. Prognostic factors included tumour size and grade, vascular and lymphatic invasion, clearance margins of the resected specimens and status of the axillary lymph nodes. RT-PCR assays for MUC-1 in the axillary fluid were positive in 17 patients (25%). The presence of MUC-1 was associated with increased tumour size and showed a positive correlation with axillary lymph node metastases and incomplete resection of the tumour. RT-PCR can disclose cancer cells in the axillary fluid after conservative surgery for breast cancer. The presence of MUC-1 in the axillary drainage may be associated with poor prognostic features, and its detection may have implications for therapy as it suggests that re-excision should be considered.