Long-term outcome after segmental colonic resection for slow transit constipation.

PURPOSE: Colectomy with ileorectal anastomosis (IRA) is the most common surgical procedure for slow transit constipation (STC). A hemicolectomy has been suggested as an alternative to IRA with good short-term results. However, long-term results are unknown. The aim of this study was to evaluate the long-term results after hemicolectomy as a treatment for STC. METHODS: Fifty patients with STC were selected for right- or left-sided hemicolectomy after evaluation with colonic scintigraphy from 1993 to 2008. Living patients (n = 43) received a bowel function questionnaire and a questionnaire about patient-reported outcome. RESULTS: After a median follow-up of 19.8 years, 13 patients had undergone rescue surgery (n = 12) or used irrigation (n = 1) and were classified as failures. In all, 30 were evaluable for functional outcome and questionnaire data for 19 patients (due to 11 non-responding) could be analysed. Two reported deterioration after several years and were also classified as failures. Median stool frequency remained increased from 1 per week at baseline to 5 per week at long-term follow-up (p = 0.001). Preoperatively, all patients used laxatives, whereas 12 managed without laxatives at long-term follow-up (p = 0.002). There was some reduction in other constipation symptoms but not statically significant. In the patients' global assessment, 10 stated a very good result, seven a good result and two a poor result. CONCLUSIONS: Hemicolectomy for STC increases stool frequency and reduces laxative use. Long-term success rate could range between 17/50 (34%) and 35/50 (70%) depending on outcome among non-responders.

Laparoscopic versus open approach to neurolytic celiac plexus block in inoperable pancreatic cancer.

BACKGROUND: Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control. The purpose of this study was to evaluate the feasibility and effectiveness of the laparoscopic NCPB versus open approach. METHODS: Eight patients (Group A) underwent diagnostic laparoscopy which revealed an inoperable pancreatic cancer. Forty millilitres of solution (20 mL of 95% ethanol mixed with 20 mL of xylocaine) was injected into either side of para-aortic soft tissue. The same solution was injected in 10 patients (Group B), with inoperable pancreatic body cancer diagnosed during laparotomy. RESULTS: There were no intraoperative or post-operative, NCPB related, complications. Patients in both groups, reported significant pain relief in the early post-operative period. Using the visual analogue scale preoperatively, in second post-operative day, first and third post-operative month, no significant different was observed between the two groups. The mean hospital stay in both groups was 2.1 versus 5.2 (P = 0.0005) and the mean survival 8.1 versus 7.9 months (ns). CONCLUSIONS: The NCPB is feasible method for palliation in inoperable pancreatic cancer. Laparoscopic NCPB gives excellent results and could still be considered in selected cases, as an effective alternative during staging laparoscopy.

Oxidative stress in multi-port and single-port cholecystectomy.

BACKGROUND: This study was designed to analyze and compare plasma levels of 8-isoprostane (8-epiPGF2α), a biomarker of lipid peroxidation, and uric acid (UA), a marker of the antioxidant status, in standard laparoscopic (LC) and laparoendoscopic single-site cholecystectomy (LSSC). MATERIALS AND METHODS: Forty patients with noncomplicated cholelithiasis were randomized to undergo either LSSC (n = 20) or LC (n = 20). The patients had body mass index <30, American Society of Anesthesiologists score I or II, and no previous upper gastrointestinal surgery. Blood samples were taken preoperatively and 6 h and 24 h postoperatively. Levels of 8-epiPGF2α were determined using enzyme-linked immunosorbent assay, whereas levels of UA were calculated using automated analyzer. RESULTS: No significant differences were observed in operative data among the groups. Levels of 8-epiPGF2α were significantly higher in LSSC compared with LC at 6 h (P = 0.003) and 24 h (P < 0.001). 8-epiPGF2α levels showed significant changes over time in LC (LSSC: P = 0.720, LC: P < 0.001). UA levels were significantly higher in LC compared with LSSC, 24 h postoperatively (P = 0.021). No significant changes over time in the UA levels in both groups (LSSC: P = 0.056, LC: P = 0.205). CONCLUSIONS: LSSC is associated with increased oxidative stress compared with LC. Further studies are needed to confirm these results.

Predictive role of thymidine phosphorylase expression in patients with colorectal cancer and its association with angiogenesis-related proteins and extracellular matrix components.

BACKGROUND: Thymidine phosphorylase (TYMP) is an angiogenic factor that has potent chemotactic activity for endothelial cells and is involved in 5-fluorouracil (5-FU) metabolism. In colorectal cancer (CRC), previous studies evaluating the relationship between TYMP expression and clinicopathological features have yielded inconsistent results. The aim of this study was to investigate the prognostic value of TYMP, its association with other angiogenic factors, proliferation markers and, to our knowledge, for the first time its relationship with extracellular matrix components. MATERIALS AND METHODS: Formalin-fixed, paraffin-embedded specimens from 97 patients with CRC were immunostained for TYMP, vascular endothelial growth factor (VEGF), microvascular density (CD34), proliferation marker (Ki-67), proliferating cell nuclear antigen (PCNA), p53 oncoprotein and extracellular matrix components (collagen type IV, fibronectin, tenascin and laminin). Survival curves were calculated with the Kaplan-Meier method. RESULTS: Immunoreactivity was observed in the cytoplasm (cyt) and nucleus (n) of the tumor cells, as well in the stroma (st), endothelium and tumor-associated macrophages. High TYMPcyt expression was observed in 7.2% of the cases, moderate in 22.7% and weak in 59.9%, while 10.3% were negative. High TYMPst expression was observed in 58.8% of the cases. TYMPcyt expression was correlated with the VEGF expression of tumor cells and VEGF expression of vessels (p=0.014 and p=0.022, respectively). TYMPst expression was correlated with VEGF expression and tenascin (p=0.014 and p=0.011, respectively). Patients with higher TYMPcyt expression had a more favorable overall survival (p=0.041) in univariate analysis compared to patients without TYMP expression. CONCLUSION: These findings suggest that TYMP plays an important role in angiogenesis, extracellular matrix remodeling and in the prognosis of patients with CRC, but further studies are needed to clearly define its role in CRC.

Association of syndecan-1 with angiogenesis-related markers, extracellular matrix components, and clinicopathological features in colorectal carcinoma.

Syndecan-1 is a transmembrane heparansulfate proteoglycan, which regulates cell proliferation, migration, angiogenesis, cell-to-cell and cell-to-extracellular matrix adhesion and may influence malignant cell behavior. We investigated the alterations of syndecan-1 expression in colorectal cancer and analyzed the relationship between clinicopathological parameters, proliferation indices, angiogenic markers, and extracellular matrix components. Syndecan-1 protein expression observed in the tumorous epithelium was high in 52/97 (53.6%) of the studied cases, moderate in 20/97 (20.6%), and weak in 5/97 (5.22%) of the cases, and there was strong stromal expression in 34.02% of the tumors. Syndecan-1 expression was statistically correlated to VEGF expression in tumor (p=0.001) and vessels (p=0.007). In addition, there was a borderline correlation between syndecan-1 expression and tenascin (p=0.053). Patients with weak staining reaction had a more unfavorable prognosis (p=0.032) in univariate analysis. These results indicate the implication of syndecan-1 in the remodeling and angiogenesis of colorectal cancer tissue, through interaction with other extracellular matrix components and VEGF, probably influencing the tumor progression and aggressiveness.

α-Defensins and hsCRP levels in inflammatory response of standard and laparoendoscopic single-site cholecystectomy.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery is an evolution of laparoscopic surgery aiming at decreasing the patient's parietal trauma associated with abdominal operations. LESS has been found so far to be efficient and have the same good results as the standard four-port laparoscopic cholecystectomy. α-Defensins are antimicrobial peptides of the organism. They are the first cell components against pathogens. Cytokines are also mediators in the response to trauma. The aim of this study was to compare the inflammatory reaction in LESS and four-port laparoscopic cholecystectomy. METHODS: Forty patients with noncomplicated cholelithiasis were randomly assigned into one of two groups. Group A included the patients who would undergo four-port laparoscopic cholecystectomy and group B included the patients who would undergo LESS cholecystectomy. These patients had a BMI < 30, were ASA I or II, and had no previous upper-GI surgery. Blood was taken preoperatively and 6 and 24 h postoperatively. hsCRP (with automated analyzer) and α-defensins (using ELISA) were calculated for each sample. The same postoperative protocol was followed for both groups. Mann-Whitney U test was used to analyze the results. Pain was calculated with a visual analog scale (VAS) for shoulder and abdomen at 6 and 24 h. Hospital stay, nausea, and pain medication needed was noted. RESULTS: The α-defensins value was statistically significantly higher in the 24-h samples (P < 0.001) for LESS cholecystectomy. No statistically significant difference was shown for hsCRP, even though P = 0.05 for the 24-h samples with the values of LESS higher. No LESS was converted to a classical laparoscopic cholecystectomy, and none of the patients of either group needed conversion to open cholecystectomy. Pain was statistically significantly less for the LESS group at the 24-h interval (P < 0.0001). Less medication was needed for LESS patients after the 6th postoperative hour (P = 0.007). CONCLUSION: Higher inflammatory reaction in LESS cholecystectomy could be the result of greater tension on the tissues. More studies are needed to conclude if this has a significant clinical expression.

Toll-like receptors in the inflammatory response during open and laparoscopic colectomy for colorectal cancer.

BACKGROUND: Surgical interventions activate a cascade of reactions that result in an aseptic inflammatory reaction. This inflammatory response initiates the organism's innate immunity. Laparoscopic surgery reduces the trauma, and patients benefit from diminished surgical trauma and maintained immune function. Cytokine levels and C-reactive protein (CRP) are related to the magnitude of surgical trauma and surgical stress. Toll-like receptors (TLRs) 2 and 4 are the first sensor-recognition receptors of the invading pathogens for the innate immune response. This study aimed to compare the inflammatory response and then the stress response during laparoscopic and open colectomy for cancer by calculating TLR-2 and TLR-4 as the first sensor-recognition receptors together with interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity CRP (hsCRP). METHODS: A total 40 patients with colorectal cancer were randomized in two groups: group A (open colectomy, n = 20) and group B (laparoscopic colectomy, n = 20). An epidural catheter was placed in all patients 1 h preoperatively. Rupivocaine was administered perioperatively and 48 h postoperatively. Blood samples were taken for calculation of IL-6, TNF-α, hsCRP, TLR-2, and TLR-4 preoperatively and 5 min after deflation of pneumoperitoneum (group B) or 5 min after division of the colon (group A), then 6 and 24 h postoperatively. RESULTS: The mean operative time was 115 for group A and 142 min for group B. The mean blood loss was respectively 240 and 105 ml (P < 0.001), and the mean hospital stay was respectively 8 and 5 days (P < 0.05). The IL-6 level was significant higher in group A than in group B at 6 and 24 h postoperatively (P < 0.0001), and the hsCRP level was significant higher in group A than in group B at 24 h postoperatively (P < 0.001). The TNF-α values did not differ between the two groups. The TLR-2 level was significantly higher in group A than in group B at 5 min (P = 0.013) and 24 h (P = 0.007) postoperatively. The TLR-4 level was significant higher in group A than in group B at 5 min postoperatively (P = 0.03). CONCLUSION: The inflammatory response and the resultant stress response are significantly less during laparoscopic colectomy than during open colectomy for colorectal cancer. This is an obvious short-term clinical benefit for the patient, providing tinder for further study to investigate the long-term results of laparoscopic colectomy versus open colectomy for colorectal cancer.

Α-defensin expression of inflammatory response in open and laparoscopic colectomy for colorectal cancer.

BACKGROUND: Surgical procedures are related to the activation of the inflammatory reaction. This is called surgical stress. It is believed that diminished surgical trauma reduces surgical stress. The laparoscopic approach reduces trauma, but the systemic immune responses are still invariably activated. Cytokines and C-reactive protein (CRP) are the main markers in the study of inflammatory or stress response. α-Defensins play an important role in host defense, acting early in phagocytosis. α-Defensins, as early markers-earlier than cytokines-of the inflammatory response, have been used, together with high-sensitivity CRP (hs-CRP) and interleukin-6 (IL-6), to determine the inflammatory response in laparoscopic and open colectomy for cancer. MATERIALS AND METHODS: A total of 40 patients with colorectal cancer were randomized to two groups: group A (n = 20), open colectomy; group B (n = 20), laparoscopic colectomy. One hour preoperatively an epidural catheter was placed in all patients and rupivacaine was administered perioperatively and again 48 h postoperatively. Blood samples were taken for calculating α-defensins, IL-6, and hs-CRP levels preoperatively, 5 min after division of the colon (group A), or 5 min after deflation of pneumoperitoneum (group B), 6 h and 24 h postoperatively. RESULTS: The mean operative time was 115 min for group A and 142 min for group B (p < 0.05). The mean blood loss was 240 ml and 105 ml, respectively (p < 0.001). The mean hospital stay was 8 days and 5 days, respectively (p < 0.05). α-Defensin levels were statistically significantly lower in group B than in group A, 5 min and 24 h postoperatively (p < 0.002 and p < 0.007, respectively). The IL-6 levels were statistically significantly lower in group B than in group A, 6 h and 24 h postoperatively (p < 0.0001 at both time intervals), whereas the levels of hs-CRP were significantly lower in group B than in group A 24 h postoperatively (p < 0.001). CONCLUSIONS: The present study confirms the results of previous studies, that the inflammatory immune response and surgical stress are significantly less after laparoscopic colectomy versus open colectomy for colorectal cancer. More investigation is needed to study if surgical stress has any influence on survival of these patients.

Current surgical status of thyroid diseases.

Thyroid nodules are a common clinical problem for surgeons. The clinical importance of nodules is the need to exclude thyroid cancer, which occurs in 5%-15% of patients. If fine needle aspiration cytology is positive, or suspicious for malignancy, surgery is recommended. During the past decade, with the tendency to develop smaller incisions, an endoscopic approach has been applied to thyroid surgery, called minimally invasive video-assisted thyroidectomy. This approach was immediately followed by other minimally invasive or scarless neck techniques, such as the breast approach, axillary-breast approach, and robot-assisted method. All these techniques follow the same principles of surgery and oncology. This review presents the current surgical management of the thyroid gland, including the surgical techniques and compares them by describing benefits and drawbacks of each one.

Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial.

BACKGROUND: The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS). These new techniques are considered to be painless procedures, but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy. In this randomized control study, we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy. PATIENTS AND METHODS: Forty patients (34 women and 6 men) were randomly assigned to two groups. In group A (n = 20) four-port classic laparoscopic cholecystectomy was performed. Patients in group B (n = 20) underwent SILS cholecystectomy. In all patients, preincisional local infiltration of ropivacaine around the trocar wounds was performed. Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well. Shoulder tip and abdominal pain were registered at 2, 6, 12, 24, 48, and 72 h postoperatively using visual analog scale (VAS). RESULTS: Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain, and after the first 6 h for shoulder pain. Total pain after the first 24 h was nonexistent in the SILS group. Also, requests for analgesics were significantly less in the SILS group, while no difference was observed in incidence of nausea and vomiting between the two groups. CONCLUSION: SILS cholecystectomy, as well as the invisible scar, has significantly lower abdominal and shoulder pain scores, especially after the first 24 h postoperatively, when this pain is nonexistent. (Registration Clinical Trial number: NTC00872287, www.clinicaltrials.gov ).

Laparoscopic Nissen fundoplication combined with posterior gastropexy in surgical treatment of GERD.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) has become established as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). Postoperative paraesophageal herniation has an incidence range up to 7% in the immediate postoperative period. AIM: A prospective randomized trial was scheduled to study the role of posterior gastropexy, in combination with LNF, in prevention of paraesophageal herniation and improvement of postoperative results in surgical treatment of GERD. PATIENTS AND METHODS: Eighty-two patients with GERD were randomized to LNF combined with (group A, n = 40) or without (group B, n = 42) posterior gastropexy. Subjective evaluation using disease-specific and generic questionnaires and structured interviews, and objective evaluation by endoscopy, esophageal manometry, and 24-h pH monitoring, were performed before operation, at 2 and 12 months after surgery, and then every year. Crura approximation was performed by stitches if the diameter was less than 6 cm, or with a patch to reinforce the conventional crural closure or by tension-free technique to close the hiatus. Posterior gastropexy (group A) was performed with one stitch between the posterior wall of the wrap and the crura near the arcuate ligament. RESULTS: Sixteen patients of group A and 15 patients of group B with concomitant abdominal diseases had simultaneous procedures [cholecystectomy 25, vagotomy 2, ventral hernia repair 1, gastric polypectomy 1, gastric fundus diverticulectomy 1, gastrointestinal stromal tumor (GIST) wedge resection 1]. In mean follow-up of 48 +/- 26 months (range 7-94 months), one patient of group B presented with paraesophageal herniation in the first postoperative month (reoperation), while recurrent gastroesophageal reflux (Visick III or IV), successfully treated by medication, was noted in three patients of group B and in one patient of group A. Only mild dysphagia, during the first two postoperative months, was noted in nine patients of group A and eight patients of group B. Six patients of each group with Barrett's esophagus had endoscopic improvement after the second postoperative month. Visick score in groups A/B was I in 26/11 (P < 0.0001), II in 13/27 (P = 0.037), III in 1/2 (not significant, NS), and IV in 0/2. Generally, Visick score was I or II in 39/38 in groups A/B (97.5%/90.5%, NS) and III or IV in 1/4 (2.5%/9.5%, P < 0.0001). CONCLUSIONS: LNF combined with posterior gastropexy may prevent postoperative paraesophageal or sliding herniation in surgical treatment of GERD, providing better early and long-term postoperative results. (Registered Clinical Trial number: NCT00872755. www.clinicaltrials.gov .).

Evaluations of laparoscopic proctocolectomy versus traditional technique in patients with rectal cancer.

BACKGROUND: This was a retrospective study that evaluated the surgical outcomes of laparoscopic surgery (LS) for rectal cancer, in comparison with a case control series of open surgery (OS), during an 8-year period. METHODOLOGY: Between October 1998 and December 2006, 203 patients with rectal malignancies underwent colectomy; 146 of them had colectomy with the traditional technique (OS), while 57 underwent resection of rectal cancer laparoscopically (LS). The LS group was compared with 60 patients from the OS group (selected from the 146 OS group patients), matched by size, sex, age, anatomical location of the tumor, type, extent of resection, and pathological stage. Data were obtained from patients' medical records. Statistical analysis was performed with the t test and chi-square test. All data are expressed as mean +/- standard error of the mean (SEM). RESULTS: Mean age of the LS group was 63.7+/-12 years versus 69+/-12 years in the OS group. There were more men than women in both the laparoscopic (33 males, 24 females) and OS groups (35 men, 25 women). The mean follow-up period was 38 months and 78 months for LS and OS groups, respectively. The procedure included low anterior resection (43 in LS and 45 in OS), and 13 patients in both groups underwent abdominoperineal resection and 3 transanal resections (2 in OS and 1 in LS). Mean tumor size was 4.2+/-2.12cm in the LS versus 5.2+/-2.02cm in the OS group. Conversion to an open procedure occurred in 4 patients (6.7%), all in the first 20 cases. Postoperative complications developed in 28 patients (11.7%), 13 in the LS group and 15 in the OS group. Median operative time was longer, but median blood loss was significantly lower in the LS group. The length of hospital stay was significantly shorter for the LS group. CONCLUSION: Laparoscopic surgery is feasible and safe for patients with rectal cancer and provides benefits during the postoperative period without increased morbidity or mortality.

Seroma and recurrence in laparoscopic ventral hernioplasty.

BACKGROUND: Recurrence after laparoscopic ventral hernioplasty is a severe problem despite surgeons' increased experience in recent years. It is well known that the main reasons for recurrences are lack of experience, bad technique, infection, and seroma. The aim of this study was to investigate the events, what caused recurrences, and the technique to prevent recurrence in laparoscopic ventral hernioplasty. METHODS: From May 1996 through December 2005, 78 patients who underwent 80 laparoscopic ventral hernioplasties (67 incisional hernias, 8 large epigastric, 5 large umbilical) were separated into 2 groups. Group A (n=28): ePTFE dual mesh patch secured intraperitoneally by full-thickness stitches and endoscopic tacks to cover the hernia defect and to overlap healthy margins by at least 2.5 cm (n=17, subgroup A1) or 4 cm (n=11, subgroup A2). In subgroup A2, a full-thickness suture was placed in the center of the hernia defect to reduce the "dead space." Group B (n=52): The same technique as in group A, but the hernia sac was cauterized by monopolar cautery (n=5) or Harmonic scalpel (n=47). The overlapping healthy margins were at least 2.5 cm (n=16, subgroup B1) or 4 cm (n=36, subgroup B2). In subgroup B2, a full-thickness suture was placed in the center of the hernia defect to reduce the dead space. Postoperatively, CT-scans were used to confirm complications or recurrences. RESULTS: In group A, 7 seromas [4 clinical (A1) and 3 subclinical (A1=1, A2=2)], 3 hematomas (A1=2, A2=1), 2 infections (A1), and 3 recurrences (10.7%) were observed (A1=2 or 11.8%, A2=1 or 9%). Two recurrences were observed in symptomatic seromas (subgroup A1) and 1 in a patient without seroma (subgroup A2). In group B, 1 subclinical seroma, 1 hematoma, and 1 recurrence (6.2%) were noted in subgroup B1. In subgroup B2, no recurrence was observed. Significantly fewer total seromas occurred in group B compared with group A (P=0.004). The total recurrence rate in group B was 1.95% (NS vs group A), but a significant difference was observed between subgroups A1 and B2 (P=0.036). CONCLUSION: Cauterization of the hernia sac and a central full-thickness suture to reduce dead space seems to prevent seroma. This technique combined with a large patch to cover at least 4 cm of healthy margins and the surgeon's experience may be sufficient to prevent recurrences in laparoscopic ventral hernioplasty.

Two-stage surgical treatment of unresectable obstructive rectal cancer with synchronous hepatic metastases.

Unresectable obstructing rectal cancer with synchronous hepatic metastases is usually a fatal disease. This prospective study was scheduled to treat this difficult condition using a multimodal curative strategy combined with a two-stage surgical treatment. Patients with T4N2 or N3M1 rectal cancer and hepatic metastases underwent a two-stage surgical treatment; in the first stage, a decompressing colostomy plus radiofrequency ablation (RFA) in liver metastases. In the second stage, a colectomy was done with stoma closing and resection of superficial necrotic hepatic tumors, plus repetition of RFA in recurrent or new hepatic tumors. Four patients were included, with 1 to 8 (total 20) hepatic metastases, each <5 cm in diameter. In the first stage, two patients were operated on by open approach and two laparoscopically. All hepatic tumors were treated by RFA to produce at least a 1-cm tumor-free margin. After chemoradiation of the rectal tumor, the second stage of surgical treatment was successful in colectomies and stoma closing. Three had complete necrosis of hepatic tumors and one a recurrent tumor plus two new metastases treated by RFA. Two patients died 14 and 42 months after the first stage of surgical treatment, and the other two patients are alive. One of them is disease-free 54 months after the first stage and the other with new recurrence 52 months after the first stage of the procedure. The multimodal curative strategy for the treatment of unresectable obstructing rectal cancer with synchronous hepatic metastases, containing a two-stage surgical treatment with RFA of hepatic metastases and chemoradiation of the rectal tumor between the two stages of the procedure, is a promising method. A larger number of patients with long-term follow-up is necessary to confirm these findings.