Long-term outcomes of sacral nerve stimulation for fecal incontinence.

BACKGROUND AND OBJECTIVE: In patients with fecal incontinence who do not benefit from medical or behavioral treatments sacral nerve stimulation is now considered a first-line procedure. Although the efficacy of treatment appears to be sustained in the short and medium term, the long-term results of therapy are relatively unknown. OBJECTIVE: We report the results of chronic sacral nerve stimulation in patients who have had more than 8 years of therapy. DESIGN AND SETTINGS: All patients who underwent sacral nerve stimulation for fecal incontinence from 1996 to 2002 were followed up prospectively. Data were collected prospectively by the use of bowel habit diaries and St Mark's continence scores. Treatment success was defined as >50% reduction in episodes of fecal incontinence with sacral nerve stimulation in comparison with baseline symptoms. RESULTS: Between January 1996 and December 2002, 25 patients (male/female 2:23; median age, 54 years (range, 35-68 years) underwent temporary sacral nerve stimulation. Twenty-three (92%) patients had a greater than 50% improvement in their ability to defer defecation during the trial phase and were considered suitable for chronic stimulation. Over a median follow-up of 114 months (range, 96-164 months), full continence was maintained in 12 (48%) of the 23 patients who received a neurostimulator implant. Two patients lost efficacy at 48 and 60 months after permanent implant for unknown reasons and had the device removed. Three patients died at 3, 8, and 9 years after permanent implant because of unrelated comorbidities. Nine patients required a change of battery at a mean (SD) of 87 (13.5) months. CONCLUSIONS: Sacral nerve stimulation can maintain a persistent clinical benefit in the long term for the majority of patients. Some patients will experience deterioration in their symptoms over time, for reasons yet unknown.

[Functional proctology at the University of Pécs]. / Funkcionális proktológia a Pécsi Tudományegyetemen.

INTRODUCTION: Functional proctological investigations have been introduced at Pécs University of Sciences 15 years ago. The Pelvic Floor Multidisciplinary Team has been re-launched after many years of pause in 2010. Experience of the team in the treatment of faecal incontinence and obstructed defecation syndrome is discussed. PATIENTS: In the past 3 years 9 patients underwent sphincter reconstruction for faecal incontinence. The Pelvic Floor Team in the past 1.5 year consulted 31 patients with constipation, who were considered by the referee for surgical intervention. Following investigations 10 patients underwent surgery, the rest of them were treated conservatively. Seven patients underwent perineal reconstruction with mesh, three patients had ventral rectopexy with additional levatoro-pexy. RESULTS: 78% of patients operated on for faecal incontinence reported full continence, 88% improvement. We invented a new symptom score with a maximum of 20 points to evaluate results of treatment of patients with Obstructed Defecation Syndrome. Patients who underwent perineal repair were interviewed pre and postoperatively. They scored 14 ± 2.83 and 5.4 ± 4.62 points, respectively (p = 0.0075). CONCLUSION: Functional proctological patients require a specialist approach from history taking through investigation to treatment. Majority of patients benefit from conservative treatment. Adequate patient selection is essential for successful surgical treatment. Symptom scores applied pre and postoperatively facilitate proper patient selection for various surgical methods.

[Postgastrectomy symptoms following total gastrectomy with or without preservation of the duodenal passage]. / Postgastrectomiás tünetek totális gastrectomia után a duodenalis passage-t megorzo és kizáró rekonstrukciók mellett.

INTRODUCTION: Total gastrectomy leads to decreased quality of life, which is characterized by different symptoms of the postgastrectomy syndrome. Aim of this study was to investigate the correlation of different alimentary symptoms and habits in correlation with the reconstruction type after total gastrectomy. PATIENTS AND METHODS: Between 2005-2009 34 patients after total gastrectomy for gastric cancer were evaluated with questionnaires. Twenty two had a standard Roux-en-Y reconstruction, while 12 Longmire type jejunal interposition. Early dumping syndrome was investigated with the Sigstad score. RESULTS: Most of the investigated parameters were similar in Roux-en-Y and Jejunal Interposition patients. Early dumping syndrome however occurred significantly less frequantly after jejunal interposition. CONCLUSION: Preservation of the duodenal passage after total gastrectomy reduces the prevalence of early dumping.

[Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure, mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case]. / TTP-HUS klinikai képét utánzó és heveny veseelégtelenséggel szövodo krónikus DIC hátterében álló metasztatikus prosztatarák: patomechanizmus, differenciáldiagnózis és kezelés egy eset kapcsán.

Disseminated intravascular coagulopathy (DIC) is characterized as activation of the clotting system resulting in fibrin thrombi, gradually diminishing levels of clotting factors with increased risk of bleeding. Basically two types of DIC are distinguished: (1) chronic (compensated) - with alteration of laboratory values and (2) acute (non-compensated) - with severe clinical manifestations: bleeding, shock, acute renal failure (ARF), transient focal neurologic deficit, delirium or coma. Chronic DIC related to metastatic neoplasia is caused by pancreatic, gastric or prostatic carcinoma in most of the cases. Incidence rate of DIC is 13-30% in prostate cancer, among those only 0.4-1.65% of patients had clinical signs and symptoms of DIC. In other words, chronic DIC is developed in one of eight patients with prostate cancer. DIC is considered as a poor prognostic factor in prostatic carcinoma. The similar clinical and laboratory findings of TTP-HUS (thrombotic thrombocytopenic purpura - hemolytic uremic syndrome) and DIC makes it difficult to differentiate between them. A 71 years old male patient with known chronic obstructive pulmonary disease, benign prostatic hyperplasia, significant carotid artery stenosis, gastric ulcer and alcoholic liver disease was admitted to another hospital with melena. Gastroscopy revealed intact gastric mucosa and actually non-bleeding duodenal ulcer covered by clots. Laboratory results showed hyperkalemia, elevated kidney function tests, indirect hyperbilirubinemia, increased liver function tests, leukocytosis, anemia, thrombocytopenia and elevated international normalized ratio (INR). He was treated with saline infusions, four units of red blood cells and one unit of fresh frozen plasma transfusions. Four days later he was transported to our Institution with ARF. Physical examination revealed dyspnoe, petechiae, hemoptoe, oliguria, chest-wall pain and aggressive behavior. Thrombocytopenia, signs of MAHA (fragmentocytes and helmet cells in the peripheral blood), normal INR, elevated lactate dehydrogenase (LDH) and ARF suggested TTP-HUS. Hemodialysis and six plasmaferesis (PF) were carried out. After the fifth PF, skin manifestations of thrombotic microangiopathy occurred on the feet. Clotting analysis revealed elevated D-dimer (>5 µg/mL), normal fibrinogen (3.2 g/L), a slightly raised INR (1.36) and activated partial prothrombin time (APTT) (45.8 sec), normal reticulocyte (57 G/L) and a slightly low platelet count (123 G/L), which proved to be chronic DIC. Therapeutic dose of low-molecular-weight heparin (LMWH) was started. Elevated prostate-specific antigen (PSA) (109.6 ng/mL) suggested prostatic carcinoma. Prostate biopsy revealed adenocarcinoma (Gleason: 4+4 for left lobe and 3+3 for right lobe). Elevated alkaline phosphatase suggested metastases in the bone, which were confirmed by bone scintigraphy. Combined androgen blockade (CAB) was started. After three months follow-up our patient's status is satisfactory. PSA is in the normal range (4.6 ng/mL). Thrombocytopenia of uncertain origin with normal or raised INR, APTT, elevated D-dimer, normal fibrinogen and reticulocyte count prove the diagnosis of chronic DIC. This process warrants searching for metastatic neoplasia. Due to the relatively low serum levels of circulating procoagulant factors (e.g. tissue factor), therapeutic dose of LMWH can be used with good efficiency in chronic DIC with low risk of bleeding. Severe DIC as a complication of metastatic prostate cancer can be treated by androgen deprivation therapy (ADT) or CAB in combination with ketokonazole and concomitant use of supportive treatment. Deme D, Ragán M, Kovács L, Kalmár K, Varga E, Varga T, Rakonczai E. Metastatic prostate cancer complicated with chronic disseminated intravascular coagulopathy causing acute renal failure mimicking thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: pathomechanism, differential diagnosis and therapy related to a case.

Early-stage adenocarcinoma in Barrett's esophagus: aspects of surgical therapies.

Adenocarcinomas in Barrett's esophagus are increasingly diagnosed at early stages thanks to effective surveillance programs. Subtotal esophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the esophagus. However, such treatment is associated with substantial morbidity and compromised quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment-associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumor penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity of tumor, length of the underlying Barrett's mucosa and risk factors of the affected patient. Surgical resection (radical or limited) remains the treatment of choice for tumors invading the submucosa, multicentric tumor growth and recurrence after endoscopic mucosectomy.

Effect of laparoscopic fundoplication on hypertensive lower esophageal sphincter associated with gastroesophageal reflux.

For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently, the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50-61). Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7-86). Average LES pressure before the operation was 50.5 mmHg (range 35.6-81.3). Six weeks after operation, all patients were symptom free. DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure (24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure may be an etiologic factor in the development of hypertensive lower esophageal sphincter.

[Searching for the optimal reconstructive methods following total gastrectomy]. / Az optimális rekonstrukciós típus keresése totális gastrectomia után.

Three prospective randomised studies and a clinical experiment were performed to study postoperative weight, body mass index, nutritional and immunological laboratory parameters, gut motility, lipid and carbohydrate absorption, quality of life and gastrointestinal hormone production after total gastrectomy with different reconstructions. The first trial compared Roux-en-Y to a newly introduced aboral pouch construction, while the second study compared these two methods and the aboral pouch reconstruction with a preserved duodenal passage version. Improved lipid absorption and quality of life was detected for the aboral pouch reconstruction. In addition to these, the duodenal passage preserving version resulted in a better iron metabolism, too. The third study compared the aboral pouch to conventional oral pouch, both with duodenal passage preserving versions. No significant difference was detected between these two groups. In the fourth study, a clinical experiment was performed examining pre- and postprandial glucose, insulin, cholecystokinin and somatostatin levels in patients recruited from the first two randomised trials. Significant differences were demonstrated between the various reconstruction types: the duodenal passage preserving reconstruction provided close to physiological cholecystokinin and somatostatin productions, while with duodenal exclusion these levels were abnormally raised.

[Surgical treatment of duodeno-gastro-esophageal reflux disease: duodenal switch]. / A duodeno-gastrooesophagealis refluxbetegség sebészi kezelése: duodenal switch mutét.

AIMS: To evaluate the efficacy of duodenal switch operation for patients with duodeno-gastroesophageal reflux disease. METHODS: Four female patients with therapy resistant epigastric pain and biliary regurgitation were enrolled in the study. In all cases, abnormal duodeno-gastric reflux was confirmed by 24-hour Bilitec monitoring. The average age of the patients was 41.75 years (range 32-53) and three of them had a cholecystectomy in the past. Importantly, all patients had previously undergone fundoplication, which had to be repeated in one of them due to recurrent symptoms. More recently, a duodenal switch procedure was performed in these four patients. Their mean follow-up time was 24.25 months (range 21-30). RESULTS: Duodenal switch was performed without any perioperative complications. A good clinical outcome was found in all patients on their follow up; however, an abnormal acidic exposure was found in one case on 24-hour oesophageal pH monitoring. CONCLUSION: Recurrent epigastric complaints developing after anti-reflux surgery in patients with a previous diagnosis of gastroesophageal reflux disease might be due to an abnormal duodeno-gastric reflux. Previous cholecystectomy may increase the risk of biliary reflux. Duodenal switch procedure can be applied with good results in patients with therapy resistant abnormal duodeno-gastric reflux confirmed with Bilitec monitoring.

Prognostic factors in the surgical treatment of gastric cancer--10 years experience.

BACKGROUND: In spite of the increase in radicality and extended resections, the prognosis of gastric cancer is very poor. Surgical resection is the only effective therapy. The morbidity and mortality of surgical interventions decreased during the last years. METHOD: The aim of this study was to evaluate the prognostic effect of different factors on survival of gastric cancer. A retrospective study of 483 patients with gastric cancer was performed. Data were collected from January 1993 to December 2002. There were 380 resections, 267 (70,2%) total gastrectomies, 93 (24.8%) distal resections and 20 (5.2%) proximal resections. Epidemiological factors, tumour and treatment related parameters were analysed. Kaplan-Meier method was used to assess survival and Cox regression analysis to evaluate the effect of prognostic factors on survival. RESULTS: The rate of R0 resections was 73.4% for total gastrectomy, and 73% for distal gastrectomy. The five-year overall survival of the entire population was 26.08%, 36.2% of the resected patients and 69.05% of curative resections. In concordance with literature findings, radicality of resection, depth of tumour invasion and lymph node metastases proved to be the most powerful independent prognostic factors. CONCLUSION: Prognosis of gastric cancer can be remarkably improved by a complete resection of the tumour and its lymphatic drainage, even if extension of the resection is needed.

[Peritonectomy and intraperitoneal chemotherapy in the treatment of peritoneal carcinosis]. / A peritonectomia és az intraperitonealis kemoterápia alkalmazása carcinosis peritoneiben.

The surgery of metastatic gastrointestinal malignancies comes into prominence nowadays. Positive observations inspire the increase of surgical radicality. Occurrence of peritoneal carcinosis means a very bad prognosis. However, on the base of the literature and our experiences the prognosis can be improved in some well-defined groups of patients. We present the method and opportunity of using peritonectomy and intraperitoneal chemotherapy in connection with two cases. We review the method developed and improved by Sugarbaker and his workgroup. Good results can be achieved by this combined technique in the cases of less invasive tumours, for example pseudomyxoma peritonei and peritoneal mesothelioma. Good result can also be achieved in the cases of more aggressive tumours if they are in resectable stage with not so extensive peritoneal seeding. Surveying the literature we can find encouraging results concerning ovarian cancer, gastric and colo-rectal cancer accompanied by peritoneal seeding.

[Progress in the treatment of gastrointestinal cancers due to introduction of neoadjuvant concept]. / A neoadjuváns kezelés eredmenyezte fejlodés a gasztrointesztinális daganatok sebészetében.

Formerly the treatment of gastrointestinal cancers was exclusively surgical. Though the results were improved by increased radicality, the real progress was achieved by the introduction of multimodal therapy, particularly by the neoadjuvant concept. The basic prerequisite for neoadjuvant treatment is precise staging and risk assessment. According to staging patients can be divided into three categories: (1) Early cancers, confined to the mucosal and submucosal layers, are approached with primary surgery. (2) Systemically metastasized tumors receive merely palliative treatment. (3) Locally advanced cancers are treated by neoadjuvant therapy. Due to neoadjuvant treatment the tumor can be downsized (or downstaged) in some patients. These are the responders benefiting from the therapy, because of the increased RO-resection rate, decreased recurrence rate and improved survival. The non-responders, by contrast have poor prognosis. Neoadjuvant treatment considerably improved the chance for cure for patients with gastrointestinal cancers, thus this method became an evidence based treatment for locally advanced gastrointestinal cancers.

[Complete regression after neoadjuvant chemotherapy in locally advanced gastric cancer causing peritonitis carcinomatosa--a case report]. / Neoadjuváns kezelés hatására teljes tumorregresszió peritonitis carcinomatosát okozó gyomorrákban -- esetismertetés.

Gastric cancer is one of the most frequent cause of mortality, survival data are insufficient. Several chemotherapeutic combinations were applied successfully in advanced gastric cancer, following total tumor regression and radical resection, but there are very few cases with total regression after a disease forming carcinosis and causing ascites. In our report, a middle age patient suffering from locally advanced gastric cancer with peritonitis carcinomatosa and ascites was treated with neoadjuvant chemotherapy (DCF: docetaxel, cisplatin, fluorouracil protocol) successfully, as at the restaging examination total tumor regression was found. Ascites and carcinosis disappeared, so we performed radical distal surgical resection. The histological preparation resulted in 100% tumor regression of the specimen. Postoperatively the patient was given adjuvant DCF chemotherapy. The therapeutic modality of cases with advanced gastric cancer, especially with carcinosis must be reassessed, because according to our and some international reports, these patients are also candidates for effective neoadjuvant therapy and curative resection. In our own and in the experience of some others the combinations with taxanes and its derivatives are one of the most effective.

[New laparoscopic procedure for the treatment of large hiatal hernias: the first 20 cases]. / Uj laparoszkópos módszer a nagyméretu hiatus herniák kezelésében: az elso 20 eset.

AIMS: To evaluate the effect of a new laparoscopic procedure, which was developed in our institute for reinforcement of posterior hiatoplasty. METHODS: The results of our first 20 patients of this ongoing prospective study are presented. All patients had gastro-oesophageal reflux disease and a hiatus defect greater than 6 cm. The reinforcement of the posterior hiatoplasty was carried out with ligamentum teres hepatis. The ligamentum was dissected with from the abdominal wall, brought behind the oesophagus and stitched to the right and left crura, with two non-absorbable sutures. In all patients a loose Nissen-DeMeester fundoplication was also performed. Patients were followed up with oesophagograms. The mean follow-up time was 12.4 months (range 3-24). RESULTS: The mean operation time was 115 minutes (range 95-135). Conversion to open procedure was necessary in five patients due to adhesions caused by previous operation. No intraoperative complications were observed. One reoperation was necessary because of a subphrenic haematoma. There was no perioperative mortality. At follow-up two patients had atypical reflux symptoms, but functional tests showed no abnormal gastroesophageal reflux. Oesophagograms showed one recurrence, but the patients was symptom free. CONCLUSION: On the basis of these preliminary results it seems that laparoscopic reinforcement for the closure of large hiatus hernias with ligamentum teres is a safe, feasible and effective technique.

[Neoadjuvant chemotherapy in advanced stomach cancer--a case of complete response]. / Elórehaladott gyomorrák neoadjuvans kemoterápiás kezelése--komplett válaszreakció esete.

In the treatment of gastric cancer R0 surgical resection is the only hope for cure. Unfortunately most patients are first seen when they are in an advanced stage, when the possibility of R0 resection is very poor. In these cases administration of other therapies is justified. In the last decade neoadjuvant combination chemotherapy had been introduced with promising results. ECF neoadjuvant chemotherapy has 60% response rate in irresectable cases. We report about a patient with locally advanced gastric cancer treated with neoadjuvant ECF chemotherapy. The patient reacted with complete response, so following chemotherapy R0 resection could be carried out. We describe different therapies used for patients with locally advanced gastric cancer. Neoadjuvant chemotherapy is a recommended therapeutic modality in locally advanced gastric cancer, because it may have the effect of irresectable disease becoming resectable.

[Neoadjuvant chemotherapy for locally advanced gastric cancer]. / Neoadjuváns kemoterápia lokálisan elórehaladott gyomorrákban.

UNLABELLED: Only surgical resection offers cure in gastric cancer. Curative resection unfortunately is possible only in about every second patient diagnosed with gastric cancer. Neoadjuvant chemotherapy may help to reach R0 resection in patients with locally advanced gastric cancer. AIM: To evaluate the ability of ECF neoadjuvant chemotherapy in locally advanced gastric cancer. PATIENTS AND METHODS: Between December 1998 and April 2003 twenty-four patients with locally advanced gastric cancer were given neoadjuvant chemotherapy according to the ECF scheme. Before treatment, staging examinations were carried out: endoscopy, barium swallow, chest X-ray, computer-tomography and laparotomy or diagnostic laparoscopy. We treated patients with four three-weeks-long courses of chemotherapy with bolus injection of epirubicin and cisplatin on day 1, and continuous infusion of 5-fluorouracil on day 1 to 21. Twelve weeks long treatment was followed by 4 weeks free of treatment, than staging was repeated to determine response. RESULTS: 45.83% response rate was achieved. One complete response was observed. Ten patients showed partial response, 3 stable diseases and 10 progressive disease were detected. Twenty-one patients were operated on. Sixteen resections were carried out, ten with curative intent. Overall survival and disease free survival in the whole group were 12.19 and 8.66 months, while in patients with R0 resection 20.66 and 18.33 months. CONCLUSION: Neoadjuvant chemotherapy provides a hope for cure for patient with locally advanced gastric cancer.

Gastrointestinal stromal tumours in a single institute: is there an association to other gastrointestinal malignancies?

Our knowledge of Gastrointestinal Stromal Tumours (GIST) has been broadened in the last few years by the discovery of the key function of c-kit tyrosine kinase mutation in their pathogenesis. A single institution database is presented and a hypothesis is examined regarding probable connection between GIST and other gastrointestinal malignancies. Between 2000 and 2004 20 patients were admitted to our department with GIS tumour. With the addition of three cases detected between 1991 and 2000, and proved to be GIST retrospectively, 23 cases are followed. Mean age was 64.52 years, male to female ratio 11:12. Ten tumours originated from the stomach, ten from small bowel, one from rectum and two from mesenterium. All patients underwent surgery, 16 operations were completed with R0 radicality, one R1 and four R2 resections were performed. Follow-up ranged from 1 to 157 months. Five out of 23 patients died (21.7%), six patients live with metastatic disease, twelve are disease free. Amongst patient-, tumour- and treatment-related factors the prognostic significance of Fletcher's risk and radicality of resection was demonstrated (p<0.05). Significantly more synchronous or metachronous gastrointestinal malignancies were found is this population of GIST patients, when compared to the prevalence of malignancies in normal Hungarian population (p<0.001).

[Dual tumours in the GI tract: synchronous and metachronous stromal (GIST) and epithelial/neuroendocrine neoplasms]. / Kettôs tumorok a gasztrointesztinális traktusban: szinkron és metakron stromális (GIST) és epiteliális/neuroendokrin daganatok.

Gastrointestinal stromal tumours (GIST) constitute the most frequent group of mesenchymal tumours in the gastrointestinal tract (GI). During the last several decades major advances have been taken in the diagnostics, treatment, and understanding of its pathogenesis. However, much less is known about the either metachronous or synchronous concurrence of GIST and other tumours of different histogenesis. In the present study clinicopathological data of 43 patients with histologically proved gastrointestinal stromal tumour were studied mainly in regard of the occurrence of a secondary neoplasm. Among the 43, 7 cases were found with secondary tumour mainly of epithelial origin. In three cases (cases 3, 5, and 7) GIST concurred with colorectal adenocarcinoma, in one case (case 1) GIST occurred in a patient with a 3-years-history of chronic lymphocytic leukaemia (CLL), in other two (cases 2 and 4) the stromal tumour was combined with in situ adenocarcinoma of the stomach and carcinoid of the pancreas, respectively. In case 6, GIST concurred with a duodenal Brunner gland adenoma. In five cases the stromal tumour and the other neoplasm occurred synchronously, and in four of them, being the stromal tumour clinically silent, GISTs were intraoperative findings. This confirms the importance of surgical intraabdominal control before closure. In one hand the repeated concurrence of GIST and colorectal adenocarcinoma in our series, and on the other hand, that of GIST and adenocarcinoma of the stomach in the literature, may indicate an at least partly common factor, which may be involved in the pathogenesis of these neoplasms.

Chemo-radiotherapy in locally advanced squamous cell oesophageal cancer--are upper third tumours more responsive?

Before neoadjuvant therapy was widely applied, the prognosis of oesophageal cancer had been considered dependent on the location of the tumor, i.e. upper third cancers had had the worst prognosis. The aim of this retrolective study was to prove the efficiency of the neoadjuvant treatment, and to compare the response of esophageal cancer in different locations. Between January 1998 and September 2005, 102 patients with locally advanced squamous cell oesophageal cancer received preoperative chemo-radiotherapy. In 40 cases the tumor was located in the upper third and in 62 cases in the middle third of the oesophagus. After a four-week-long treatment free period restaging was carried out and patients considered resectable were submitted to surgery. From 40 patients with upper third oesophageal cancer 28 underwent oesophageal resection or pharyngo-laryngectomy. Thiry-five percent a complete histopathological remission was observed. From 62 patients with middle third oesophageal cancer 43 underwent oesophageal resection. Histological examination of the resected specimens documented complete response only in three patients. The median survival and the R0 resection rate were similar in the two groups. Although the resection rate, perioperative morbidity, mortality and the median survival were similar in the two groups, a significantly higher rate of complete response (p < 0,05) was observed in patients with upper third oesophageal cancer compared to patients with middle third oesophageal cancer. It seems that upper third oesophageal cancer has superior sensitivity to multimodal treatment therefore our results may support that upper third location is not an unfavorable prognostic factor any more.

Comparing aboral versus oral pouch with preserved duodenal passage after total gastrectomy: does the position of the gastric substitute reservoir count?

BACKGROUND: Total gastrectomy results in a significant weight loss, different postgastrectomy symptoms, and a reduction in quality of life. Elaborate surgical reconstruction methods are evaluated to improve results. The present study compares two types of reconstructions--an aboral pouch with preserved duodenal passage and an oral pouch with preserved duodenal passage--differing only in the site of the pouch. METHODS: Twenty-eight patients entered the study. Primary outcome measures--body weight, body mass index, and quality of life, and secondary outcome measures--serum nutritional parameters, scintigraphic small-intestinal passage, and lipid and carbohydrate absorption were measured 6, 12, and 24 months after surgery. RESULTS: No significant differences were found in anthropometric parameters or in quality of life between the groups. Regarding the secondary outcome measures, albumin levels were higher in the oral pouch group, while protein and immunoglobulin-A levels were higher in the aboral pouch group. CONCLUSION: The site of the reservoir does not significantly influence the outcome after total gastrectomy and reconstruction with a preserved duodenal passage.

Postprandial gastrointestinal hormone production is different, depending on the type of reconstruction following total gastrectomy.

OBJECTIVES: The present study examines the differences in gastrointestinal hormone production at 3 different reconstruction types after total gastrectomy. BACKGROUND DATA: Total gastrectomy causes significant weight loss, mainly due to a reduced caloric intake probably because of a lack of initiative to eat or early satiety during meals. Behind this phenomenon a disturbed gastrointestinal hormone production can be presumed. METHODS: Patients participating in a randomized study were recruited for the clinical experiment. Seven patients with simple Roux-en-Y reconstruction, 11 with aboral pouch (AP) construction, and 10 with aboral pouch with preserved duodenal passage (APwPDP) reconstruction, as well as 6 healthy volunteers were examined. Blood samples were taken 5 minutes before and 15, 30, and 60 minutes after ingestion of a liquid test meal. Plasma concentrations for insulin, cholecystokinin, and somatostatin were determined by radioimmunoassay analysis. RESULTS: Postprandial hyperglycemia was observed in patients after total gastrectomy most prominently in groups with duodenal exclusion (Roux-en-Y and AP) compared with healthy controls. Postprandial insulin curves reached significantly higher levels in all operated groups compared with controls, however, with no difference according to reconstruction type. Significantly higher cholecystokinin levels and higher integrated production of cholecystokinin were observed in Roux-en-Y and AP groups compared with APwPDP and control. Postprandial somatostatin levels were significantly different between the 4 groups, and highest levels and integrated secretions were reached in AP group, lowest in APwPDP and normal groups. CONCLUSION: A disturbed glucose homeostasis was observed in gastrectomized patients most prominently in the Roux-en-Y group. Also, cholecystokinin and somatostatin response differed significantly in favor of duodenal passage preservation after total gastrectomy. Cholecystokinin levels close to physiologic found at APwPDP reconstruction may contribute to a physiologic satiation in reconstructions with preserved duodenal passage after total gastrectomy.