Achieving a Textbook Outcome in Colon Cancer Surgery Is Associated with Improved Long-Term Survival

Background: Colon cancer surgery is a complex clinical pathway and traditional quality metrics may exhibit significant variability between hospitals and healthcare providers. The Textbook Outcome (TO) is a composite quality marker capturing the fraction of patients, in whom all desired short-term outcomes of care are realised. The aim of the present study was to assess the TO in a series of non-metastatic colon cancer patients treated with curative intent, with emphasis on long-term survival. Methods: Stage I–III colon cancer patients, who underwent curative colectomy following the Complete Mesocolic Excision principles, were retrospectively identified from the institutional database. TO was defined as (i) hospital survival, (ii) radical resection, (iii) no major complications, (iv) no reintervention, (v) no unplanned stoma and (vi) no prolonged hospital stay or readmission. Results: In total, 128 patients (male 61%, female 39%, mean age 70.7 ± 11.4 years) were included in the final analysis. Overall, 60.2% achieved a TO. The highest rates were observed for “hospital survival” and “no unplanned stoma” (96.9% and 97.7%), while the lowest rates were for “no major complications” and “no prolonged hospital stay” (69.5% and 75%). Older age, left-sided resections and pT4 tumours were factors limiting the chances of a TO. The 5-year overall and 5-year cancer-specific survival were significantly better in the TO versus non-TO subgroup (81% vs. 59%, p = 0.009, and 86% vs. 65%, p = 0.02, respectively). Conclusions: Outcomes in colon cancer surgery may be affected by patient-, doctor- and hospital-related factors. TO represents those patients who achieve the optimal perioperative results, and is furthermore associated with improved long-term cancer survival.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management

Management of obstructed defaecation is challenging and remains controversial. No international guidelines have been published.

Detailed and applied anatomy for improved rectal cancer treatment

Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.

Primary curative surgery and preemptive or adjuvant hyperthermic peritoneal chemotherapy in colorectal cancer patients at high risk to develop peritoneal carcinomatosis. A systematic review

PURPOSE

Τo evaluate all available data on the effect of preemptive intervention in patients who have curative surgery for colorectal cancer (CRC) and are at high risk to develop peritoneal carcinomatosis (PC).

METHODS

The authors conducted a systematic review of all published studies from January 2000 to July 2016. Twelve studies were eventually considered for analysis, and were divided in four categories, according to different approaches for adjuvant intra-peritoneal chemotherapy: a) hyperthermic intraperitoneal chemotherapy (HIPEC), during primary surgery for CRC; b) early postoperative intraperitoneal chemotherapy (EPIC), after primary surgery for CRC; c) early re-intervention (laparotomy or laparoscopy) and HIPEC; and d) as second look laparotomy and HIPEC + cytoreductive surgery (CRS), several months after primary surgery.

RESULTS

Considering prophylactic HIPEC during primary surgery, the studies that were analysed showed a peritoneal recurrence rate of 0-12.9%, a 3- and 5-year disease free survival (DFS) of 67-97.5% and 54.8-84% respectively, and a 3- and 5-year overall survival (OS) of 67-100% and 84%, respectively. These oncological results are probably better than what is expected in patients at high risk to develop PC and have only adjuvant systemic chemotherapy. Because of the great heterogeneity in inclusion criteria (risk factors for PC) and methodology of intra-peritoneal chemotherapy (different timing, different techniques, different agents), a meta-analysis was not performed.

CONCLUSIONS

At present and because of the insufficient available evidence, preemptive intervention at the immediate postoperative adjuvant setting is recommended only in the setting of a registered clinical trial.

Gastrointestinal motility following thoracic surgery: the effect of thoracic epidural analgesia. A randomised controlled trial

Backgrounds

Impairment of gastrointestinal (GI) motility is an undesirable but inevitable consequence of surgery. This prospective randomised controlled study tested the hypothesis that postoperative thoracic epidural analgesia (TEA) with ropivacaine or a combination of ropivacaine and morphine accelerates postoperative GI function and shortens the duration of postoperative ileus following major thoracic surgery compared to intravenous (IV) morphine.

Methods

Thirty patients scheduled for major thoracic surgery were randomised to three groups. All patients had bowel motility assessments 1 week preoperatively. All patients received general anaesthesia. Group Ep-R received TEA with ropivacaine; group Ep-RM received TEA with ropivacaine and morphine and group IV-M received IV morphine via patient controlled analgesia pump (PCA). Bowel motility was assessed by clinical examination in addition to oro-ceacal transit time (OCTT) on the first and third postoperative days and colonic transit time (CTT).

Results

Overall the OCTT demonstrated a 2.5-fold decrease in bowel motility on the first postoperative day. The OCTT test revealed statistically significant differences between all groups (Ep-R vs Ep-RM, p = 0.43/Ep-R vs IV-M, p = 0.039 / Ep-RM vs IV-M, p < 0.001). Also, very significant differences were found in the OCCT test between days (Ep-R vs Ep-RM, p < 0.001/Ep-R vs IV-M, p < 0.001 / Ep-RM vs IV-M, p = 0.014). There were no significant differences in the CTT test or the clinical signs between groups. However, 70% of the patients in the Ep-R group and 80% in the Ep-RM group defecated by the third day compared to only 10% in the IV-M group, (p = 0.004).

Conclusions

Objective tests demonstrated the delayed motility of the whole GI system postoperatively following thoracic surgery. They also demonstrated that continuous epidural analgesia with or without morphine improved GI motility in comparison to intravenous morphine. These differences were more pronounced on the third postoperative day.

Trial registration

ISRCTN number: 11953159, retrospectively registered on 20/03/2017.

Is complete mesocolic excision oncologically superior to conventional surgery for colon cancer? A retrospective comparative study

Background:

During the last decade, many efforts have been made in order to improve the oncologic outcomes following colonic resection. Complete mesocolic excision (CME) has proved to provide high rates of disease-free and overall survival rates in patients undergoing resection for colonic malignancies. The aim of our study was to further investigate the role of CME in colonic surgery through comparison with a series of conventional resections.

Methods:

All data regarding resections for colonic cancer since 2006 were obtained prospectively from two surgical departments. Retrieved data from 290 patients were analyzed and compared between those who underwent CME and those who had conventional surgery.

Results:

The CME group presented a higher rate of postoperative morbidity and readmissions. Histopathological features were in favor of CME surgery compared with the conventional group, in terms of both resected bowel length (33 vs. 20 cm) and lymph node harvest (27 vs. 18). Although CME was associated with better disease-free and overall survival times, only tumor differentiation, adjuvant chemotherapy and age had a statistically significant affect on those outcome values (P<0.05).

Conclusion:

CME improves histopathologic features, but without presenting oncologic superiority. Larger prospective studies following adequate surgical training are needed to prove the technique’s advantages in oncologic outcomes.

Clinical practice guidelines for the management of metastatic colorectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO)

There is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus. The aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines. Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed. Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC. Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus. One hundred and nine statements were developed. Ninety experts voted for those statements. The median rate of abstain per statement was 18.5% (range: 0-54%). In the end of the process, all statements achieved a large consensus. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized. R0 resection is the only intervention that may offer substantial improvement in the oncological outcomes.

Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO)

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.

Adjuvant chemotherapy for colon cancer: a consensus statement of the Hellenic and Cypriot Colorectal Cancer Study Group by the HeSMO

Colorectal cancer remains a major cause of cancer mortality in the Western world both in men and women. In this manuscript a concise overview and recommendations on adjuvant chemotherapy in colon cancer are presented. An executive team from the Hellenic Society of Medical Oncology was assigned to develop a consensus statement and guidelines on the adjuvant treatment of colon cancer. Fourteen statements on adjuvant treatment were subjected to the Delphi methodology. Voting experts were 68. All statements achieved a rate of consensus above than 80% (>87%) and none revised and entered to a second round of voting. Three and 8 of them achieved a 100 and an over than 90% consensus, respectively. These statements describe evaluations of therapies in clinical practice. They could be considered as general guidelines based on best available evidence for assistance in treatment decision-making. Furthermore, they serve to identify questions and targets for further research and the settings in which investigational therapy could be considered.

Clinical practice guidelines for the surgical management of colon cancer: a consensus statement of the Hellenic and Cypriot Colorectal Cancer Study Group by the HeSMO

Despite considerable improvement in the management of colon cancer, there is a great deal of variation in the outcomes among European countries, and in particular among different hospital centers in Greece and Cyprus. Discrepancy in the approach strategies and lack of adherence to guidelines for the management of colon cancer may explain the situation. The aim was to elaborate a consensus on the multidisciplinary management of colon cancer, based on European guidelines (ESMO and EURECCA), and also taking into account local special characteristics of our healthcare system. Following discussion and online communication among members of an executive team, a consensus was developed. Statements entered the Delphi voting system on two rounds to achieve consensus by multidisciplinary international experts. Statements with an agreement rate of ≥80% achieved a large consensus, while those with an agreement rate of 60-80% a moderate consensus. Statements achieving an agreement of <60% after both rounds were rejected and not presented. Sixty statements on the management of colon cancer were subjected to the Delphi methodology. Voting experts were 109. The median rate of abstain per statement was 10% (range: 0-41%). In the end of the voting process, all statements achieved a consensus by more than 80% of the experts. A consensus on the management of colon cancer was developed by applying the Delphi methodology. Guidelines are proposed along with algorithms of diagnosis and treatment. The importance of centralization, care by a multidisciplinary team, and adherence to guidelines is emphasized.

Ventral colporectopexy for overt rectal prolapse and obstructed defaecation syndrome: a systematic review

AIM

Laparoscopic ventral rectopexy (VR) with the use of prosthesis has been advocated for both overt rectal prolapse (ORP) and obstructed defaecation syndrome (ODS). The present study reviews the short-term and functional results of laparoscopic VR.

METHOD

A search was performed of MEDLINE, EMBASE, Ovid and Cochrane databases on all studies reporting on VR for ORP, ODS and other anatomical abnormalities of the pelvic floor from 2004 until February 2013. No language restrictions were made. All studies on VR were reviewed systematically. The main outcomes were intra-operative complications, conversion, procedure duration, short-term mortality and morbidity, length of stay, recurrence of ORP, recurrence of anatomical disorder, faecal incontinence and constipation, quality of life (QoL) score and patient satisfaction. Quality assessment and data extraction were performed independently by three observers.

RESULTS

Twenty-three studies including 1460 patients were eligible for analysis. The conversion rate ranged from 0 to 14.3%. No mortality was reported. The immediate postoperative morbidity rate was 8.6%. Length of stay ranged from 1 to 7 days. A significant improvement in constipation and incontinence symptoms was observed in the postoperative period for both ORP and ODS (chi-square test, P < 0.0001).

CONCLUSION

Laparoscopic VR is a safe and effective procedure for ORP and ODS. Longer follow-up is required, and studies comparing VR with standard rectopexy and stapled transanal rectal resection are not yet available.

Complete mesocolic excision in colon cancer surgery: a comparison between open and laparoscopic approach

BACKGROUND

Complete mesocolic excision (CME) with central vessel ligation (CVL) as performed in Erlangen offers the best long-term outcome for colon cancer. The aim of this study was to assess specimens after laparoscopic vs open CME-CVL macroscopically and morphometrically in patients with left and right colon cancers.

METHOD

All specimens were freshly photographed. Precise tumour morphometry and grading of the surgical plane were performed as described by pathologists in Leeds, UK.

RESULTS

Thirty-four specimens from right-sided cancers were divided into 18 transverse colon cancers (nine laparoscopic vs nine open) and 16 caecum-ascending colon cancers (seven laparoscopic vs nine open) and 56 specimens from left-sided cancers (33 laparoscopic vs 23 open). There was no difference between laparoscopically and open acquired left- and right-sided specimens. Specimens of transverse colon displayed differences in length of central ligation to tumour (open 11.67 cm vs laparoscopic 8.72 cm, P = 0.049), length of central ligation to bowel wall (open 9.11 cm vs laparoscopic 6.5 cm, P = 0.015) and lymph node clearance (open 46.33 vs laparoscopic 39.33, P = 0.033).

CONCLUSION

Laparoscopy seems to offer specimens of similar quality after CME-CVL surgery for colon cancer to the open approach. Issues of completeness of excision from laparoscopy are raised for tumours located in the transverse colon.

Implementation of fast-track protocols in open and laparoscopic sphincter-preserving rectal cancer surgery: a multicenter, comparative, prospective, non-randomized study

BACKGROUND

Data on the role of laparoscopy within an enhanced recovery protocol for rectal cancer patients is rather limited. The aim of the study was to investigate the role of laparoscopy within a 'fast-track' protocol in patients who underwent sphincter-preserving surgery for rectal cancer.

PATIENTS/METHODS

156 consecutive patients with low rectal cancer from three centers were assigned in four groups: the open fast track (OPEN-FT), the laparoscopic fast track (LAP-FT), the open (OPEN), and the laparoscopic (LAP). The fast-track protocol was applied in one center and traditional care in the other two. All patients underwent sphincter-preserving surgery and were followed-up for 30 days.

RESULTS

Overall morbidity was less in the fast-track groups (p = 0.007). On the other hand, no statistical significance could be identified in mortality, readmission or reoperations rates among the groups (p = 0.562, p = 0.896, p = 0.238). Fast-track patients required significantly less intramuscular opioids for postoperative analgesia (p < 0.001). Primary (p < 0.001) and total hospital stays (p < 0.001) were significantly shorter in the fast-track groups.

CONCLUSION

The implementation of a fast-track protocol is feasible and safe in low rectal cancer patients. Laparoscopy seems to be a basic element of such protocol as it further enhances recovery and reduces morbidity.

Specific esophagogram to assess functional outcomes after Heller's myotomy and Dor's fundoplication for esophageal achalasia

Esophageal emptying assessed at the 'timed barium' esophagogram correlates well with symptomatic outcomes after pneumatic dilation for esophageal achalasia, although 30% of patients with satisfactory outcome exhibit partial improvement in emptying. The aim of the study was to investigate any correlation of esophageal emptying to symptomatic response after laparoscopic Heller's myotomy and Dor's fundoplication. 'Bread and barium' (transit time of a barium opaque bread bolus) and 'timed barium' (height of esophageal barium column 5 minutes after ingestion of 200-250 mL of barium suspension) esophagogram was used to assess esophageal emptying in 73 patients with esophageal achalasia before 1 and 5 years (31 cases) after laparoscopic myotomy and anterior fundoplication. Symptoms assessment was based to a specific score. At 1-year follow-up, excellent and good symptomatic results were obtained in 95% of the cases. Esophageal maximum diameter, esophageal transit time, and esophageal barium column were significantly correlated to each other and to symptom score postoperatively (P < 0.001). Complete and partial (<90% and 50-90% postoperative reduction in barium column, respectively) emptying was seen in 55% and 31% of patients with excellent result. Patients with a pseudodiverticulum postoperatively had a more delayed esophageal emptying than those without. Symptomatic outcome and esophageal emptying did not deteriorate at 5-year follow-up. Esophageal emptying assessed by 'barium and bread' and 'timed barium' esophagogram correlated well with symptomatic outcome after laparoscopic myotomy for esophageal achalasia. Complete symptomatic relief does not necessarily reflect complete esophageal emptying. Outcomes do not deteriorate by time. Because of wide availability, esophagogram can be applied in follow-up of postmyotomy patients in conjunction with symptomatic evaluation.

Simple suture or prosthesis hiatal closure in laparoscopic repair of paraesophageal hernia: a retrospective cohort study

Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1-year postoperative follow-up, were included in the study. Pre- and postoperative testing included symptom questionnaires, barium esophagogram, pH-monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty-eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.

Laparoscopic or open surgery for the cancer of the middle and lower rectum short-term outcomes of a comparative non-randomised study

INTRODUCTION

The study compares the short-term results of the laparoscopic and open approach for the surgical treatment of rectal cancer. Consecutive cases with rectal cancer operated upon with laparoscopy from 2004 to 2007 were compared to open rectal cancer cases. Total mesorectal excision (TME) was attempted in all cases.

PATIENTS AND METHODS

Forty-two cases were included in the OPEN and 45 in the LAP group and were matched for age, gender, disease stage and operation type.

SURGICAL PROCEDURE

Duration of surgery was longer and blood transfusion requirements were less in the LAP group. Higher blood loss was observed in patients with neoadjuvant treatment in both groups. Patients with neoadjuvant treatment in the OPEN group had higher operation time, but that was not the case in the LAP group. There were three conversions (7%).

RESULTS

Overall morbidity was higher in the OPEN group. LAP group patients were found to recover faster. R0 resection was achieved in 88% in the OPEN and 94% in the LAP group.

DISCUSSION

Less morbidity and faster recovery is offered after laparoscopic TME. Quality of surgery assessed by histopathology is similar between the approaches. Neoadjuvant chemoradiation seems to have significant impact on blood loss but results in longer operation times of the OPEN group.

Diagnostic precision of carcinoembryonic antigen in the detection of recurrence of colorectal cancer

INTRODUCTION

The aim of the study was to evaluate the diagnostic precision of serum carcinoembryonic antigen (CEA) in the detection of local or distant recurrence following resectional surgery for colon and rectal cancer.

METHODS

Quantitative meta-analysis was performed on 20 studies, comparing serum CEA with radiological imaging and/or pathology in detecting colorectal cancer (CRC) recurrence in 4285 patients. The cut-off for a 'positive' CEA ranged from 3 to 15 ng/ml between the various studies. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic curves (SROC) and sub-group analysis were undertaken.

RESULTS

The overall sensitivity and specificity of CEA for detecting CRC recurrence was 0.64 (95% CI: 0.61-0.67) and 0.90 (95% CI: 0.89-0.91), respectively. The area under the SROC curve was 0.75 (SE=0.04) and the diagnostic odds ratio was 18.44 (95% CI: 11.94-28.49). A CEA cut-off of 5 ng/ml yielded a higher diagnostic odds ratio than a cut-off of 3 ng/ml (15.5 vs. 11.1). Using meta-regression analysis the optimum CEA cut-off point for the best combination of sensitivity and specificity was 2.2 ng/ml. On sub-group analysis high quality studies, and those involving > or =100 patients yielded a marginal improvement in the sensitivity and specificity with minimal change to the SROC.

CONCLUSION

Serum CEA is a test with high specificity but insufficient sensitivity for detecting CRC recurrence in isolation. A cut-off of 2.2 ng/ml may provide an ideal balance of sensitivity and specificity. It may be useful as a first-line surveillance investigation in patients during surgical follow-up based on serial CEA measurements using temporal trends in conjunction with clinical, radiological and/or histological confirmation.

Patterns of esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication for esophageal achalasia

BACKGROUND

Heller's myotomy for esophageal achalasia is associated with less esophageal acid gastroesophageal reflux when combined a Dor's fundoplication. The Aim of the study was to assess the incidence of postoperative esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication (HM-DF).

METHODS

Seventy six patients (37 males) with esophageal achalasia were prospectively followed-up by clinical interview and laboratory tests before and after laparoscopic HM-DF. A symptom score was used for clinical assessment. Laboratory assessment included esophageal standard manometry, esophagogram and esophageal pH 24-hour monitoring before and 1- and 5-years after surgery.

RESULTS

Symptom score improved at 1-year after surgery (P < 0.001). Heartburn was only reported by 5 patients, dysphagia or/and regurgitation by 28 and substernal pain by 12. 91% of patients had satisfactory functional results. Pathological esophageal exposure to acid was seen in 21% of the cases. Pathological acid events showed the features of pseudoreflux in 66%t and those of true GER in 34%. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum (P = 0.001) and was related to the diameter of distal esophagus and symptom score (P < 0.001). There was no reduction in esophageal acid exposure after treatment with proton pump inhibitors in 16 patients. Neither the symptom score nor esophageal acid exposure at esophageal pH monitoring changed significantly at the 5-year follow-up in 35 patients. Esophageal configuration remained unchanged.

CONCLUSIONS

Increased esophageal exposure to acid after laparoscopic HM-DF for esophageal achalasia i) is detected in 21% of patients, and is rather the result of food stagnation than of true GER, ii) is more commonly seen in cases with pseudodiverticulum, iii) is related to the diameter of distal esophagus, iv) does not respond to antisecretory treatment and v) does not deteriorate by time.

Patterns of esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication for esophageal achalasia

BACKGROUND

Heller's myotomy for esophageal achalasia is associated with less esophageal acid gastroesophageal reflux when combined a Dor's fundoplication. The Aim of the study was to assess the incidence of postoperative esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication (HM-DF).

METHODS

Seventy six patients (37 males) with esophageal achalasia were prospectively followed-up by clinical interview and laboratory tests before and after laparoscopic HM-DF. A symptom score was used for clinical assessment. Laboratory assessment included esophageal standard manometry, esophagogram and esophageal pH 24-hour monitoring before and 1- and 5-years after surgery.

RESULTS

Symptom score improved at 1-year after surgery (P < 0.001). Heartburn was only reported by 5 patients, dysphagia or/and regurgitation by 28 and substernal pain by 12. 91% of patients had satisfactory functional results. Pathological esophageal exposure to acid was seen in 21% of the cases. Pathological acid events showed the features of pseudoreflux in 66%t and those of true GER in 34%. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum (P = 0.001) and was related to the diameter of distal esophagus and symptom score (P < 0.001). There was no reduction in esophageal acid exposure after treatment with proton pump inhibitors in 16 patients. Neither the symptom score nor esophageal acid exposure at esophageal pH monitoring changed significantly at the 5-year follow-up in 35 patients. Esophageal configuration remained unchanged.

CONCLUSIONS

Increased esophageal exposure to acid after laparoscopic HM-DF for esophageal achalasia i) is detected in 21% of patients, and is rather the result of food stagnation than of true GER, ii) is more commonly seen in cases with pseudodiverticulum, iii) is related to the diameter of distal esophagus, iv) does not respond to antisecretory treatment and v) does not deteriorate by time.

Stapled transanal rectal resection (STARR) to reverse the anatomic disorders of pelvic floor dyssynergia

Anterior rectocele and rectoanal intussusception are anatomic disorders related to excessive straining during defecation that usually manifest with symptoms of obstructive defecation. Stapled transanal rectal resection (STARR), a newly described surgical method for correcting these disorders, is considered a good alternative to the traditional transrectal approaches. The aim of the present study was to assess the early postoperative functional results of STARR. A total of 16 patients (13 female) were subjected to the STARR procedure during a period of 12 months. The presence of anatomic disorders of the anorectum was verified by dynamic defecography. Preoperative assessment also included colonic transit time, anal sphincter ultrasonography, and anorectal stationary manometry. Postoperative assessment included the same battery of tests. Altogether, 12 patients had rectoanal intussusception of > 2 cm and rectocele. In eight of them the anterior component of the rectocele was 2 to 4 cm, and in four it was > 4 cm. Four patients had a 1- to 2-cm internal intussusception and a rectocele of < 2 cm. All of them reported evacuation difficulties, but none had significant incontinence. Preoperative endoscopy did not reveal the presence of a solitary ulcer in any of the patients. All females had had normal vaginal deliveries, and four of them were multiparous. No complications were encountered postoperatively, and the need for analgesics was minimal. At defecography, rectoanal anatomy was seen to be restored in all patients. Obstructive defecation symptoms remained rather unaffected in seven, disappeared in three, and improved significantly in the remaining six patients. The seven failures showed anismus at manometry and had biofeedback treatment with satisfactory results in five of them. Failure of the operation and biofeedback sessions to treat symptoms in those two cases was attributed to coexisting enterocele, which had been missed preoperatively. Immediately after surgery, most of the patients complained of urgency and frequent small motions that resolved spontaneously within 3 to 5 weeks in all but two cases. STARR is a safe, well tolerated surgical procedure that effectively restores anatomy and function of the anorectum in patients with anterior mucosal prolapse and rectoanal intussusception. Additional biofeedback treatment is usually necessary for further functional improvement. Failure may be the result of other coexisting anatomic and functional abnormalities of the pelvic floor.

Long-term functional results after laparoscopic surgery for esophageal achalasia

BACKGROUND

Evidence on the long-term outcome of laparoscopic Heller-Dor surgery is limited. The aim of this study was to assess the long-term outcome of achalasic patients after surgery, particularly in relation to the radiologic preoperative stage of the disease.

METHODS

Sixty-eight patients with achalasia were assessed clinically and by esophageal radiology, manometry, and 24-hour ambulatory esophageal pH monitoring before and at 3 months, 1, 1 to 3, 3 to 5, and 5 to 8 years after a laparoscopic Heller-Dor procedure.

RESULTS

At 1 year after surgery the symptom score was significantly lower than the preoperative score (P < .001), and a satisfactory clinical outcome was seen in more than 90% of the patients with stage I, II, and III disease at the preoperative radiologic assessment. Only 50% of stage IV patients reported satisfactory results. An adequate opening of the lower esophageal sphincter (LES) and LES resting pressure of less than 8 mm Hg was achieved in all patients, and esophageal emptying was accelerated significantly (P < .001). At the consecutive follow-up evaluation (1-8 y), a satisfactory outcome was maintained in all stage I, II, and III responders. Stage IV patients with initially unsatisfactory results reported a worsening of symptoms (P < .02). Patients with pseudodiverticulum had a higher symptom score (P < .01). LES opening and resting pressure remained at levels of the 1-year follow-up evaluation. Esophageal emptying remained satisfactory in stage I, II, and III responders, but deteriorated in stage IV nonresponders and in 6 of the 10 patients with a pseudodiverticulum.

CONCLUSIONS

A satisfactory outcome of the laparoscopic Heller-Dor procedure in stage I, II, and III achalasic patients seems to last. Stage IV nonresponders tend to deteriorate over time. The development of pseudodiverticulum is associated with an increased symptom score.

Lymph node clearance after total mesorectal excision for rectal cancer: laparoscopic versus open approach

BACKGROUND

Laparoscopic resection of the rectum is still under scrutiny for its adequacy of oncological clearance.

AIM

To assess lymph node yield after laparoscopic total mesorectal excision (TME) for rectal cancer as compared to the open approach.

METHODS

74 patients with middle and low rectal cancer were prospectively randomized in two groups. Group A included 39 patients who had an open TME (35 with low anterior resection of the rectum (LARR) and 4 with abdominoperineal resection of the rectum (APR)). In group B, there were 34 patients who had a laparoscopic TME (27 with LARR and 7 with APR). 10 of the LARR patients in group A and 14 of the LARR patients in group B had a defunctioning ileostomy. All operations were performed by one surgeon or under his supervision.

RESULTS

Gender and age distribution were similar for both groups (group A: 23 males; mean age 69 (41-85); group B: 20 males; mean age 72 (31-84)). The mean distance of the tumor from the dentate line was 7.6 cm (1-12 cm) for group A and 6.1 cm (1-12 cm) for group B. Anastomosis was formed at a mean distance of 5.5 cm (1.5-8.5 cm) from the dentate line in group A and 3.5 cm (1-4.5 cm) in group B. At histology, in group A there were 5 T4 tumors, 9 T3, 10 T3+ (<1 mm distance from the circumferential resection margin), 13 T2 and 2 T1. In group B, there were 3 T4 tumors, 14 T3, 8 T3+, 7 T2 and 2 T1. Differences between groups were not significant. The mean number of lymph nodes retrieved in group A specimens was 19.2 (5-45) and in group B 19.2 (8-41) (p = 0.2). In group A, 3.9 (1-9) regional, 13.9 (3-34) intermediate and 1.5 (1-3) apical lymph nodes were retrieved. The respective values in group B were 3.7 (3-7), 14.4 (4-33) and 1.3 (1-3). Differences between groups were not significant. Also, the incidence of lymph node involvement by the tumor was not significantly different between groups (group A: 23; group B: 19).

CONCLUSIONS

Laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach. Also, distribution of the lymph nodes along the resected specimens is similar between the two approaches.

Abdominal and pelvic stop-flow chemotherapy. Effect of chemotherapeutic agents and tissue ischemia on rectoanal pressures

In hypoxic stop-flow chemoperfusion high doses of chemotherapeutic agents are almost directly administered to locally advanced tumors without risking significant systemic toxicity, although chemotherapy-induced neurotoxicity is still a problem. The aim of the study was to assess rectoanal motility and sensation before, during and after abdominal and pelvic stop-flow chemotherapy using the methods of stationary and ambulatory manometry. Stationary rectoanal manometry was performed within 24 hrs before and repeated 48 hrs after stop-flow chemotherapy in 7 consecutive patients with a history of locally advanced or recurrent abdominal and pelvic tumors. Anal sphincter resting and squeeze pressures, rectal sensitivity, rectoanal inhibitory reflex and rectal volumes at which temporary and permanent urge to defecate were reported were examined. Rectal volume associated with leak of rectal contents and rectal compliance were also assessed. Intraoperatively, changes in rectal and anal resting pressures before, during and after occlusion of the vessels and after administration of chemotherapeutic agent were as well recorded, analyzed and interpreted using ambulatory manometry. Induction of anesthesia reduced distal and proximal anal resting pressures. Vascular occlusion further and dramatically decreased resting pressures at all levels, which were fully recovered after re-establishing local blood circulation and for the rest of the recording period. Intraoperative administration of chemotherapy did not further affect anal resting pressures during or after hypoxia. No significant changes in rectoanal motility and sensation were detected on the 48 hrs postoperative assessment as compared to the preoperative state. Tissue hypoxia induced by vascular occlusion during stop-flow chemotherapy procedure, seems to be the only factor leading to a dramatic drop of anal pressures. Anal pressures fully recover after reperfusion of the isolated area. Furthermore, anorectal motility and sensation are not affected by any direct or indirect toxic action of the chemotherapeutic agents.

A Prospective Study Comparing Diathermy and Scalpel Incisions in Tension-Free Inguinal Hernioplasty

Although still controversial, the use of diathermy instead of scalpel for skin incision and underlying tissue dissection is gradually gaining wide acceptance. This is due to the observation that no change in wound complication rates or postoperative pain are reported with the use of electrocautery. However, these studies include operations without the use of prosthetic materials during abdominal wall closure. The purpose of this study was to investigate the hypothesis that a) application of extreme heat may result in significant postoperative pain and poor wound healing because of excessive tissue damage and scarring respectively, and b) skin incision with the use of diathermy entails increased risk of wound infection in the presence of an underlying prosthetic material. One hundred twenty-five consecutive patients submitted to inguinal hernioplasty using the tension-free technique and fulfilling the inclusion criteria for the study were allocated alternately to either scalpel (n = 60), or diathermy (n = 57) groups. Eight patients had bilateral hernias. Five of them were allocated to the scalpel group and three to the diathermy group. According to the study protocol, they received both approaches for skin and underlying tissues incision, thus resulting in a total of 68 scalpel and 65 diathermy individual hernioplasties. Parameters measured included blood loss during the skin incision and underlying tissue dissection, postoperative pain and requirements for analgesics, the presence of wound dehiscence in the absence of infection, and postoperative wound infection on the day of discharge, on the day staples were removed, and 1 month after surgery. The two groups of patients were similar in relation to patient demographics, type of hernias, and operation details. Blood loss was minimal, and the amount of blood lost did not differ between the two groups. Diathermy group patients required less parenteral analgesics on the first postoperative day. A higher proportion of patients in the scalpel group continued to need oral analgesics on the second postoperative day compared to patients in the diathermy group. There was no difference between the two groups in terms of wound strength. Infectious complications were totally absent. The use of diathermy for skin incision during inguinal hernioplasty is as safe as the use of scalpel in terms of wound healing and reduces the analgesics requirements in the postoperative period.

Rectoanal intussusception: presentation of the disorder and late results of resection rectopexy

BACKGROUND

Rectoanal intussusception may cause symptoms of obstructed defecation, and functional results of prosthesis rectopexy are usually not satisfactory. The aim of this study was to assess several parameters of the disorder and to evaluate the outcome of resection rectopexy.

METHODS

During a 10-year period, 27 female patients with symptomatic large rectoanal intussusception had resection rectopexy (23 laparoscopy; 4 laparotomy). Conservative treatment, including biofeedback treatment in 22 patients, had failed in all cases. Preoperative and postoperative evaluation included clinical assessment, anorectal manometry, evacuation defecography, and colon transit studies. Follow-up ranged between one and five years.

RESULTS

Length of intussusception was 2 to 4.9 cm and was significantly related to pelvic floor descent (P = 0.003) and inversely related to resting anal pressures (P < 0.001). Eleven patients had undergone a previous hysterectomy, 9 had enterocele-sigmoidocele, 7 had incontinence of varying severity, and 8 had a solitary rectal ulcer. Colon transit was abnormal in all but five cases. Immediate functional results were bad in two-thirds of the cases; tenesmus, urge to defecate, and frequent stools were the main complaints. By the time these symptoms had subsided, and one year after surgery, all but two patients were satisfied with the outcome. Intussusception was reduced in all cases, anal sphincter tone recovered (P = 0.002), perineal descent decreased (P < 0.001), and colonic transit was accelerated (P < 0.001). Patients available at five-year follow-up had no or only minor defecatory problems.

CONCLUSION

Resection rectopexy improves symptoms of obstructed defecation attributed to large rectoanal intussusception.

Is there any mediterranean diet not affecting bilitec assessment of bile reflux?

BACKGROUND

Colored food substances may interfere with Bilitec system that uses bilirubin as a marker for the detection of duodeno-gastro-esophageal reflux, causing false positive results. Therefore, diets have been suggested for consumption during Bilitec studies that contain minimal amounts of pigments.

AIM

To enrich the list of suitable foods for Bilitec measurements with dishes common in Mediterranean diets, and improve subject's compliance.

METHODS

Ninety substances were in vivo tested for 'bilirubin absorbance'. 'Dry' substances were blended after being diluted in water, while 'floppy' substances and cooked foods were blended undiluted. Blended mixtures and 'liquids' were tested for bilirubin without further dilution and after being mixed with hydrochloric acid. The procedure was repeated to assess reproducibility of the measurements.

RESULTS

Measurements are highly reproducible. Thirty five foods exhibited 'bilirubin absorbance' values safely below the threshold, and are considered to be suitable for Bilitec studies. On the contrary some vegetables and fruits, legumes, tomato sauce preparations, red wine, coffee, tea and jams showed high absorbance values, and are not recommended.

CONCLUSION

Menus containing part of the variety of Mediterranean food preparations are safely recommended for consumption during Bilitec studies, enriching food lists available at present.

The effect of total and anterior partial fundoplication on antireflux mechanisms of the gastroesophageal junction

BACKGROUND

The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication.

METHODS

Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension.

RESULTS

Both types of fundoplication resulted in significant increases in LES resting (P <0.001) and postdeglutition relaxation pressure (P <0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04).

CONCLUSIONS

Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.

First-line intra-arterial chemotherapy (IAC) with epirubicin and mitoxantrone in locally advanced breast cancer

BACKGROUND

Approximately 20% of patients with breast cancer present with locally advanced disease without distant metastases. This phase II double-center trial aimed at investigating the activity of epirubicin (Farmorubicin)--mitoxantrone (Onkotrone/Novantrone) combination as first-line intra-arterial chemotherapy (IAC) in locally advanced breast cancer patients.

PATIENTS AND METHODS

Thirty-six patients with locally advanced disease and no prior exposure to anthracyclines received the following regimen: epirubicin (Farmorubicin) 30 mg/mq and mitoxantrone (Onkotrone/Novantrone) 10 mg/mq by IAC short infusion on day 1, every 3 weeks for up to six cycles. Prior to IAC an arteriogram of subclavian, internal mammary and lateral thoracic arteries was obtained in all patients, followed by infusion of a blue dye solution into the arteries to determine the most appropriate vessel that supplies the tumor area.

RESULTS

Objective responses, confirmed at least 4 weeks after the first documentation, were observed in 25 patients (70%; 95%CI, 62% to 80%): 3 CR, 22 PR. Although three of the patients showed complete tumor regression, operative removal or toilet mastectomy became feasible in 25 patients since tumor shrinkage ranged over 75%. A total of 25 mastectomies were carried out for 36 patients. Four patients had bulky tumors (> 13 cm tumor diameter), while 8 patients had ulcerated tumors, two of which presented with complete infiltration of normal breast tissue. The median time to progression and median overall survival were 11 and 27 months, respectively. The time to local response was 3 weeks and time to mastectomy was 9 weeks. Transient neurological disorders developed in six patients and skin chemical burns with painful inflammatory reactions were encountered in ten patients. No systemic toxicity was observed in terms of bone marrow depression and hair loss. No cardiotoxicity was observed. In all specimens necrosis was reported (complete 3 cases, partial 16 and minimal 6).

CONCLUSION

A combination of epirubicin (Farmorubicin) and mitoxantrone (Onkotrone/Novantrone) as IAC appears to be a safe and well tolerated treatment for locally advanced breast cancer without clinical evidence of distant metastases. When combined with surgery it offers interesting results in terms of local control and allows a high rate of mastectomies in otherwise inoperable cases.

Laparoscopic surgery for gastroesophageal reflux disease patients with impaired esophageal peristalsis: total or partial fundoplication?

BACKGROUND

It has been proposed that partial fundoplication is associated with less incidence of postoperative dysphagia and consequently is more suitable for patients with gastroesophageal reflux disease (GERD) and impaired esophageal body motility. The aim of this study was to assess whether outcomes of Toupet fundoplication (TF) are better than those of Nissen-Rossetti fundoplication (NF) in patients with GERD and low-amplitude esophageal peristalsis.

STUDY DESIGN

Thirty-three consecutive patients with proved GERD and amplitude of peristalsis at 5 cm proximal to lower esophageal sphincter (LES) less than 30 mmHg were randomly allocated to undergo either TF (19 patients: 11 men, 8 women; mean age: 61.7 +/- 8.7 SD years) or NF (14 patients: 7 men, 7 women; mean age: 59.2 +/- 11.5 years), both by the laparoscopic approach. Pre- and postoperative assessment included clinical questionnaires, esophageal radiology, esophageal transit time study, endoscopy, stationary manometry, and 24-hour ambulatory esophageal pH testing.

RESULTS

Duration of operation was significantly prolonged in the TF arm (TF: 90 +/- 12 minutes versus NF: 67 +/- 15 minutes; p < 0.001). At 3 months postoperatively, the incidences of dysphagia (grades I, II, III) and gas-bloat syndrome were higher after NF than after TF (NF: 57% versus TF: 16%; p < 0.01 and NF: 50% versus TF: 21%; p = 0.02, respectively), but decreased to the same level in both groups at the 1-year followup (NF: 14% versus TF: 16% and NF: 21% versus TF: 16%, respectively). At 3 months postoperatively, patients with NF presented with significantly increased LES pressure than those with TF (p = 0.02), although LES pressure significantly increased after surgery in both groups, as compared with preoperative values. Amplitude of esophageal peristalsis at 5 cm proximal to LES increased postoperatively to the same extent in both groups (TF, preoperatively: 21 +/- 6 mmHg versus postoperatively: 39 +/- 12 mmHg; p < 0.001, and NF, preoperatively: 20 +/- 8 mmHg versus postoperatively: 38 +/- 12 mmHg; p < 0.001). Reflux was abolished in all patients of both groups.

CONCLUSIONS

Both TF and NF efficiently control reflux in patients with GERD and low amplitude of esophageal peristalsis. Early in the postoperative period, TF is associated with fewer functional symptoms, although at 1 year after surgery those symptoms are reported at similar frequencies after either procedure.

Duodenogastric reflux after biliary surgery: scintigraphic quantification and improvement with erythromycin

BACKGROUND

Persistence of dyspeptic symptoms after cholecystectomy or choledochoduodenostomy is common. There is -evidence that at least some of these symptoms may be attributed to duodenogastric reflux (DGR). The aim of the study was to quantify DGR before and after cholecystectomy, with or without choledochoduodenostomy, and endoscopic sphincterotomy for common bile duct stones, and to assess the effect of erythromycin on the increased DGR.

METHODS

Forty-seven patients before and after cholecystectomy, 26 after cholecystectomy and choledochoduodenostomy and nine after sphincterotomy had postprandial (300 mL of fresh milk, 4% fat) duodenogastric reflux measured by 99mTc-hepatic imino diacetic acid scintigraphy. Patients with a DGR index (DGRi) >20% were considered as having pathological DGR that justifies symptoms, and their DGRi was reassessed after administration of 200 mg of erythromycin intravenously.

RESULTS

Twenty-seven patients before cholecystectomy (57%) showed a normal DGRi <7%. In five cases DGRi was greater than 20%. After cholecystectomy, duodenogastric refluxes increased, so that only 16 patients (32%) showed a normal DGRi, while a DGRi >20% was observed in 10 cases. Only eight patients after cholecystectomy and choledochoduodenostomy (23%) presented with a DGRi within the normal range. The remaining 18 had a DGRi >7%. Five of them exhibited a DGRi >20%. Of the nine patients with sphincterotomy, three showed a DGRi >20%. Erythromycin almost completely normalized DGRi in all 18 patients with pathological DGR (P < 0.0001).

CONCLUSIONS

Duodenogastric reflux is common after biliary surgery, including endoscopic sphincterotomy. Erythromycin appears to decrease duodenogastric reflux to normal levels.

Twenty-four-hour ambulatory versus stationary esophageal manometry in the evaluation of esophageal motility in patients with gastroesophageal reflux disease

BACKGROUND

Although stationary manometry commonly reveals esophageal body motility disorders in patients with gastroesophageal reflux disease (GERD), esophageal function cannot be fully and precisely assessed during normal daily activities by this investigatory modality.

AIM

To compare the results of 24-hour ambulatory manometry with those of stationary manometry and to determine the specificity and accuracy of the former to detect motility disorders in patients with GERD.

PATIENTS AND METHODS

15 patients with documented GERD were included in the study. Clinical assessment, upper alimentary endoscopy and stationary manometry as well as 24-hour ambulatory manometry with concomitant 24-hour monitoring of the esophageal pH were performed in each patient.

RESULTS

24-hour ambulatory manometry revealed a significant number of dropped or interrupted esophageal contractions in patients who were found to have only complete peristalsis on stationary manometry. Furthermore, in certain patients, ambulatory manometry detected an increased incidence of dropped or interrupted contractions as compared to those recorded during stationary manometry. Ineffective contractions, suggestive of poor esophageal motility, although absent on stationary manometry, were detected in a large number of patients during a 24-hour period of recording. Also, the amplitude of esophageal contractions was clearly overestimated when evaluated by stationary manometry.

CONCLUSIONS

24-hour ambulatory esophageal manometry reveals esophageal motor abnormalities to a greater extent than those demonstrated at stationary manometry, in patients with GERD. This might be of significance in designing the treatment and predicting possible outcome.

Factors affecting esophageal motility in gastroesophageal reflux disease

BACKGROUND

There are conflicting data concerning the effect of gastroesophageal reflux disease (GERD) on esophageal motor function.

HYPOTHESIS

Duration of GERD might affect severity of symptoms, grade of esophageal mucosal injury, and esophageal motor behavior.

DESIGN

Retrospective study of a defined cohort.

SETTINGS

Two referral centers, one of them academic, for esophageal gastrointestinal motility disorders.

PATIENTS

One hundred forty-seven patients with documented GERD.

MAIN OUTCOME MEASURES

Symptoms, grade of mucosal injury on esophagoscopy, esophageal manometry, ambulatory esophageal pH monitoring, and esophagogram.

RESULTS

Patients with GERD had significantly decreased lower esophageal sphincter resting pressure (P =.02), lower amplitude of esophageal peristalsis at all levels of measurement (P<.001), and more delayed esophageal transit (P =.007) compared with control subjects. Patients with dysphagia, severe esophagitis, and Barrett esophagus presented with a longer history of the disease, significantly worse esophageal motor function (P<.01), and more prolonged esophageal transit than patients without the above features of the disease. Impairment of esophageal peristalsis and lower esophageal sphincter resting pressure were significantly inversely related to the duration of the disease (P<.001). Also, delay of esophageal transit was significantly related to the duration of the disease (P =.002) and inversely related to the amplitude of esophageal peristalsis (P<.001). Unlike the manometric variables, the extent of reflux, as assessed by ambulatory 24-hour esophageal pH monitoring, was not related to the duration of the disease.

CONCLUSION

A long history of GERD is more commonly associated with presence of dysphagia, delayed esophageal transit, severe esophagitis, presence of Barrett esophagus, and impaired esophageal motility.

Pancreatic trauma in the adult: current knowledge in diagnosis and management

BACKGROUND/AIMS

Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment.

METHODS

The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience.

RESULTS

The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple's procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory.

CONCLUSION

Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.

Laparoscopic vs open approach for Nissen fundoplication. A comparative study

BACKGROUND

Several studies, most of them nonrandomized, have shown similar functional results for both laparoscopic and open Nissen fundoplication, the operation of choice for the treatment of gastroesophageal reflux disease (GERD).

METHODS

A total of 106 patients with documented GERD were randomized to receive either a laparoscopic or an open Nissen fundoplication. Preoperative and postoperative investigations included clinical assessment, esophagogram, upper gastrointestinal endoscopy, esophageal manometry, and 24-h ambulatory pHmetry.

RESULTS

Both approaches were successful in controlling reflux. There was an overall improvement in esophageal peristalsis and an increase in lower esophageal sphincter (LES) pressure in both groups. Open Nissen fundoplication was associated with a significantly increased rate of wound (p <0.001) and respiratory (p <0.05) complications. Hospitalization was also longer after the open technique (p <0.001). At 3-month follow-up, although the rate of postoperative dysphagia was similar for the two approaches, the open approach was associated with a significantly higher incidence of postprandial epigastric fullness (p <0.05) and bloating syndrome (p <0.01).

CONCLUSIONS

The open and laparoscopic approaches for the Nissen fundoplication are equally effective in controlling GERD. The open approach is associated with a significantly higher rate of wound and respiratory complications and, at early stages, an increased rate of postprandial epigastric fullness and abdominal bloating. The dysphagia rate is similar with both methods.

Octreotide enhances the accelerating effect of erythromycin on gastric emptying in healthy subjects

BACKGROUND

Erythromycin exhibits gastrokinetic properties through cholinergic pathways. Reports regarding the action of octreotide on gastric emptying are conflicting.

AIM

: To assess: (i) the hypothesis that serotonin receptors are involved in the accelerating effect of erythromycin on gastric emptying; and (ii) any modification of the gastrokinetic action of erythromycin induced by octreotide.

SUBJECTS AND METHODS

Gastric emptying of a standard meal was estimated in 20 healthy subjects by scintigraphy on three different occasions in a double-blind, placebo-controlled manner and in random order: (i) after placebo; (ii) after 200 mg of intravenous erythromycin; and (iii) after 200 mg of intravenous erythromycin following pre-treatment with either 4 mg of intravenous ondansetron (10 subjects) or 50 micro g octreotide.

RESULTS

Erythromycin significantly accelerated gastric emptying in all subjects by abolishing the lag phase. Pre-treatment with ondansetron abolished the accelerating effect of erythromycin by restoring the emptying times to placebo levels. Octreotide significantly enhanced the accelerating effect of erythromycin by reducing both the lag and post-lag phases of gastric emptying.

CONCLUSIONS

Serotonin receptors are involved in the accelerating effect of erythromycin on gastric emptying. This effect seems to be enhanced by pre-treatment with octreotide, possibly as a result of the modification of the gastrointestinal hormonal environment.

Total colectomy and J-pouch ileorectal anastomosis for obstructed tumours of the rectosigmoid junction

BACKGROUND

Subtotal colectomy with ileosigmoid or ileorectal anastomosis is one of the standard procedures for obstructed tumours of the left colon. The lower the level of the anastomosis, the greater the number of bowel motions per day. The aim of the present study was to assess whether an ileal pouch-rectal anastomosis is associated with fewer bowel motions per day.

METHODS

In four patients with obstructed carcinoma of the rectosigmoid junction and upper rectum, a total colectomy with removal of the upper rectum for adequate tumour clearance was used, followed by construction of a 10 cm ileal J-pouch that was subsequently anastomosed to the distal rectal stump.

RESULTS

Postoperative recovery was uneventful in all patients. At 3 months postoperatively, anorectal manometry showed anal resting and squeeze pressures at lower normal limits and a neorectal capacity ranging from 160 to 310 mL. One year postoperatively, all patients experienced one to three normal bowel motions daily and no episodes of incontinence.

CONCLUSIONS

Total colectomy with ileal J-pouch-rectal anastomosis is a reasonable operative alternative in cases with obstructed tumours of the rectosigmoid junction, which necessitate removal of the upper rectum.

New perspectives in the management of sigmoid diverticulitis

The sigmoid colon is the part of the large intestine, which most commonly involved in diverticular disease due to its anatomical properties. Diverticular disease of the colon is being seen with increasing frequency mostly in western countries. Diverticulitis results from inflammation and subsequent perforation of a colonic diverticulum. Mild forms of diverticulitis usually present with gradually increasing symptoms from the lower left quadrant of the abdomen, whereas acute complicated disease is characterised by dramatic onset of abdominal pain, followed by fever within a few hours. The standard treatment for uncomplicated diverticulitis is bowel rest, with liquid diet or intravenous fluids in combination with antibiotics. Prophylactic resection is not to be recommended for patients with diverticular disease, but a high-fibre diet may afford protection by preventing further complications. Patients not responding to conservative treatment within the first 24 hours require further evaluation by computed tomography or ultrasonography. Fistula formation and intestinal obstruction are indications for surgical intervention, although the frequent recurrent attacks, which commonly afflict these patients, are seldom associated with severe complications. Laparoscopic approach has been introduced in the diagnosis and definitive treatment of uncomplicated diverticulitis, with less morbidity and mortality rates, and hospitalisation of the patients and in these terms could be promising in the future.

Laparoscopic Heller cardiomyotomy and Dor fundoplication for esophageal achalasia: possible factors predicting outcome

HYPOTHESIS

Laparoscopic Heller myotomy with anterior hemifundoplication is the surgical procedure of choice for the treatment of esophageal achalasia. Specific factors, eg, severity of esophageal body deformity, might affect postoperative outcome.

DESIGN

Prospective case-control study.

SETTING

Academic referral center for gastrointestinal tract motility disorders.

PATIENTS

Twenty-nine patients with esophageal achalasia who underwent 1 to 3 sessions of failed pneumatic dilation each.

INTERVENTION

Laparoscopic Heller myotomy with anterior (Dor) hemifundoplication.

MAIN OUTCOME MEASURES

Preoperative and postoperative symptomatic evaluation, esophagoscopy, esophagography, stationary and ambulatory esophageal manometry, and pH monitoring.

RESULTS

Three patients had stage I disease, 10 had stage II, 12 had stage III, and 4 had stage IV at preoperative radiologic examination. At surgery, there were no conversions to open procedures, and 2 mucosal perforations were immediately identified and sutured. Good or excellent results were seen in 26 patients. All patients with stage I or II disease had excellent functional results. Of patients with stage III disease, results were excellent in 7, good in 4, and bad in 1. Of patients with stage IV disease, 2 had good results and 2 had bad results. After surgery, lower esophageal sphincter pressure was reduced significantly (from 46.1 +/- 12.1 to 5.4 +/- 1.8 mm Hg; P<.001), as was esophageal diameter (from 61 +/- 17 to 35 +/- 19 mm; P<.001) (data are given as mean +/- SD). However, an excellent result occurred only in patients with a postoperative esophageal diameter less than 40 mm.

CONCLUSION

Functional outcome of laparoscopic Heller-Dor procedure for achalasia is related to the preoperative stage of the disease on the esophagogram and to the extent of reduction in esophageal width after surgery.

Laparoscopically assisted subtotal colectomy for slow-transit constipation

BACKGROUND

When medical therapy fails, slow-transit constipation (STC), a condition seen almost exclusively in women, can be treated surgically. The aim of this study was to describe our results with laparoscopically assisted subtotal colectomy (LASC) for STC.

METHODS

Over a 22-month period, four female patients underwent LASC with ileorectal anastomosis for STC at our hospital. The preoperative workup included clinical assessment, evacuation proctography, rectoanal manometry, and colonic transit measurement. Mobilization of the whole colon and ligation and division of colonic mesenteric vessels with preservation of the omentum were achieved laparoscopically. Through a small Pfannenstiel incision, the colon was removed from the abdomen, leaving a 15-cm rectal stump in situ. The rectal stump was fully mobilized posteriorly, a side-to-end ileorectal anastomosis was fashioned, and the rectal stump was fixed onto the presacral fascia with sutures.

RESULTS

The operating time ranged from 150 to 260 min and blood loss was minimal. There were no conversions to open surgery. The postoperative course was uneventful in all patients but one, a 47-year old woman who had transient severe abdominal distension, pain, and frequent small-volume bowel movements. All patients were discharged by the 4th to 10th postoperative day. At 9-month follow-up, all of our patients had normal anorectal function with two to four solid bowel movements per day.

CONCLUSION

Although it is a technically demanding procedure, laparoscopically assisted colectomy for slow-transit constipation, can be achieved safely.

Rectoanal motility in Crohn's disease patients

PURPOSE

It has been documented that Crohn's disease affects anorectal function when anorectal manifestations of the disease are present. The aim of this study was to investigate whether the presence of histologic lesions in rectal biopsy affected anorectal motility in patients with Crohn's disease but no evidence of macroscopic anorectal involvement.

METHODS

Forty-one patients with documented Crohn's disease were included in the study. Twenty-one of them had no endoscopic or histologic lesions in the rectum, and 20 patients had a positive histology for Crohn's disease on rectal biopsy, with or without macroscopic or endoscopic involvement of the anorectum. All patients underwent a standard anorectal manometry, with an eight-channel, water-perfused catheter.

RESULTS

Patients with positive rectal biopsy but no evidence of endoscopic rectal involvement had lower anal resting and squeeze pressures (76 +/- 16 standard deviation vs. 86 +/- 19 standard deviation P = 0.002; 152 +/- 56 standard deviation vs. 192 +/- 52 standard deviation P < 0.001, respectively), and a lower sphincter and high-pressure zone length (2.8 +/- 0.8 standard deviation vs. 3.2 +/- 0.8 standard deviation P = 0.006; 1.7 +/- 0.6 standard deviation vs. 2 +/- 0.6 standard deviation P = 0.005, respectively) compared with patients with negative rectal histology. Also, slow and ultra slow wave amplitude and ultra slow wave frequency were significantly lower (10 +/- 6 standard deviation vs. 13 +/- 7 standard deviation P = 0.04; 17 +/- 16 standard deviation vs. 34 +/- 24 SD P = 0.004; 0.9 +/- 0.8 standard deviation vs. 1.3 +/- 0.6 standard deviation P = 0.05, respectively), rectal sensation more affected, and rectal compliance significantly reduced (7.4 +/- 1 standard deviation vs. 11.1 +/- 2.2 standard deviation P<0.001) in the former group of patients. Simultaneous presence of endoscopic and histologic lesions in the rectum was associated with further impairment of the anorectal function.

CONCLUSION

Microscopic presence alone of Crohn's disease in the rectum appears to induce anorectal motility disorders. The synchronous presence of endoscopic rectal and macroscopic anal involvement is associated with further deterioration of anorectal function.

Prospective randomized trial comparing Nissen to Nissen-Rossetti technique for laparoscopic fundoplication

BACKGROUND

It has been suggested that division of the short gastric vessels (SGV) provides a more floppy Nissen fundoplication, for the treatment of reflux disease. The aim of the study was to assess whether Nissen fundoplication with division of SGV is associated with improved clinical outcome and laboratory findings.

METHODS

Fifty-six consecutive patients with gastroesophageal reflux disease (GERD) were randomly assigned to have a laparoscopic Nissen fundoplication either with division (24 patients; 15 men; mean age 51 +/- 15 years) or without division (32 patients; 23 men, mean age 47 +/- 14 years) of the SGV. Preoperative and postoperative investigation included clinical assessment, esophagoscopy, esophagogram, esophageal manometry, and 24-hour ambulatory esophageal pH monitoring.

RESULTS

Division of the SGV resulted in a significant increase of the operating time (P <0.0001). The operation abolished reflux in both groups. Also, both types of Nissen fundoplication significantly increased the amplitude of peristalsis at distal esophagus (division group: from 56 +/- 20 mm Hg to 64 +/- 25 mm Hg, P = 0.01; nondivision group: from 65 +/- 27 mm Hg to 75 +/- 26 mm Hg, P <0.001) and the lower esophageal sphincter pressure (division group: from 16 +/- 10 mm Hg to 24 +/- 7 mm Hg, P <0.001; nondivision group: from 22 +/- 8 mm Hg to 28 +/- 5 mm Hg, P <0.001). No differences in the incidence of postoperative severe dysphagia (division group: 5 of 24; nondivision group: 3 of 32) and overall esophageal transit were accounted between groups. However, division of the SGV was associated with a significant increased incidence of gas-bloating syndrome (division group, 13 of 24, versus nondivision group, 9 of 32, P = 0.02).

CONCLUSIONS

Division of the SGV at laparoscopic Nissen fundoplication for GERD does not improve clinical outcome and laboratory findings, while it is associated with prolongation of the operating time and increased incidence of gas-bloating syndrome.

Laparoscopic repair of paraesophageal hernia

BACKGROUND AND STUDY AIMS

Surgical repair of paraesophageal hernia is mandatory, due to the risk of severe complications, and it can be accomplished via the laparoscopic route. This study presents the results of laparoscopic repair of paraesophageal hernia combined with anterior hemifundoplication.

PATIENTS AND METHODS

During a two-year period, ten consecutive patients with paraesophageal hernia (six men, four women; mean age 73, range 55-82) underwent laparoscopic treatment. Five patients presented with symptoms of gastroesophageal reflux, while another four reported lower chest pain. There was one patient in whom the paraesophageal hernia was manifested with upper gastrointestinal bleeding. Six patients had type III hiatal hernia. They all underwent esophagography, upper gastrointestinal endoscopy, stationary manometry, and 24-hour ambulatory pH-metry, preoperatively and within three months postoperatively. At laparoscopy, the hernia content was completely reduced, the sac excised, and the diaphragmatic crura approximated. The operation was completed with an anterior hemifundoplication. In three cases, a prosthetic mesh was applied to close the hiatal defect securely.

RESULTS

Operating times ranged from 75 min to 125 min (mean 90 min). There were no postoperative deaths. One patient developed atelectasis, and another had empyema of the left pleura, treated with drainage and antibiotics. All patients but one were discharged on the second or third postoperative day. At the three-month follow-up examination, none of the patients had symptoms related to the paraesophageal hernia, gastroesophageal reflux, or fundoplication. Esophagography demonstrated restoration of normal anatomy at the gastroesophageal region, while esophageal motility was improved, and esophageal pH-metry showed no gastroesophageal reflux.

CONCLUSION

Laparoscopic repair of paraesophageal hernias is a safe, technically feasible, and well tolerated procedure, which offers rapid and total relief of symptoms. The addition of an anterior hemifundoplication not only cures preexisting gastroesophageal reflux, but also prevents the development of postoperative gastroesophageal reflux.

Erythromycin enhances oesophageal motility in patients with gastro-oesophageal reflux

BACKGROUND

Intravenous (i.v.) erythromycin enhances gastric emptying and oesophageal motility in both healthy and disease situations, acting either as a motilin or acetylcholine agonist. The purpose of the present paper was to investigate any possible effect of i.v. erythromycin on oesophageal motility in patients with gastro-oesophageal reflux (GOR).

METHODS

In 15 patients with GOR (proven on 24-h ambulatory oesophageal pH measurement), standard oesophageal manometry was performed after i.v. injection of placebo and 200 mg erythromycin, in a random blind fashion.

RESULTS

Erythromycin significantly increased lower oesophageal sphincter (LOS) pressure from 17 +/- 5 to 41 +/- 10 mmHg (P < 0.001), without affecting the postdeglutition relaxation of LOS. Erythromycin also increased the amplitude (from 79 +/- 34 to 97 +/- 40 mmHg; P < 0.001), duration (from 3.4 +/- 0.6 to 3.8 +/- 0.6 s; P = 0.005), velocity (from 3.1 +/- 0.8 to 3.5 +/- 1.15 cm/s; P = 0.0047) and strength (from 149 +/- 84 to 201 +/- 103 mmHg.s; P < 0.001) of peristalsis at 5 cm proximal to the LOS. Similarly, the drug increased the amplitude of peristalsis at 10 and 15 cm proximal to the LOS (from 70 +/- 39 to 77.4 +/- 37 mmHg; P = 0.049 and from 36 +/- 20 to 49 +/- 36 mmHg; P = 0.004, respectively) and the duration of peristalsis at the same levels (from 3.1 +/- 0.6 to 3.3 +/- 0.5 s; P = 0.011, and from 2.7 +/- 0.6 to 3 +/- 0.5 s; P = 0.003, respectively).

CONCLUSION

Intravenously administered erythromycin improves impaired oesophageal motility in patients with GOR. This observation might be of clinical use.

The effect of erythromycin on human esophageal motility is mediated by serotonin receptors

OBJECTIVE

Erythromycin exhibits prokinetic properties. The drug enhances esophageal and gastric motility by acting as a motilin agonist and promoting acetylocholine release. 5-HT3 receptors are involved in the spontaneously occurring migrating motor complex and the effect of erythromycin on antral motility in dogs. The aim of the study was to investigate the hypothesis that 5-HT3 receptors are also involved in the action of erythromycin on the human esophagus.

METHODS

A total of 18 healthy volunteers underwent standard esophageal manometry on three different occasions in a double-blind, placebo-controlled, randomized manner, as follows: 1) after placebo, 2) after 200 mg of erythromycin i.v., and 3) after 200 mg of i.v. erythromycin subsequent to pretreatment with either 4 mg of i. v. ondansetron (serotonin receptor antagonist) (10 subjects) or 12 microg/kg of i.v. atropine (8 subjects).

RESULTS

Erythromycin significantly increased a) the amplitude of peristalsis at 5 cm (from 87 +/- 19 mm Hg to 108 +/- 26 mm Hg; p = 0.0007), 10 cm (from 72 +/- 24 mm Hg to 81 +/- 26 mm Hg; p = 0.016), and 15 cm (from 47 +/- 15 mm Hg to 55 +/- 17 mm Hg; p = 0.014) proximal to LES, b) the duration of peristalsis at 5 cm (from 4.5 +/- 0.9 s to 5.7 +/- 1.2 s; p < 0.0001) and 10 cm (from 4.1 +/- 1 s to 4.9 +/- 1 s; p < 0.0001) proximal to the LES and c) the strength of peristalsis at 5 cm proximal to the LES (from 180 +/- 49 mm Hg x s to 276 +/- 100 mm Hg x s; p < 0.0001), and decreased the velocity of peristalsis at distal esophagus (from 4.1 +/- 1 cm/s to 3.8 +/- 0.9 cm/s; p = 0.03). In addition, erythromycin significantly increased the resting pressure of the LES (from 36 +/- 10 mm Hg to 44 +/- 12 mm Hg; p = 0.002). Pretreatment with ondansetron totally reversed all of the effects of erythromycin to the placebo state. Pretreatment with atropine not only prevented the effects of erythromycin, but it reduced the amplitude and strength of peristalsis at the distal esophagus at significantly lower levels than after placebo.

CONCLUSIONS

Erythromycin exerts its prokinetic action on the lower esophagus by stimulating cholinergic pathways. This action includes not only an increase in LES pressure, but significant increases in the amplitude and duration of esophageal peristalsis, as well. 5-HT3 receptors are also involved in this process.