A pilot randomised controlled trial evaluating postoperative packing of the perianal abscess.

PURPOSE: Traditional management of a perianal abscess involves incision and drainage followed by packing of the cavity until healing by secondary intention is complete. The evidence supporting this is lacking however, and regular postoperative packing is time-consuming, painful and costly. This pilot study aimed to assess whether healing could be achieved safely without packing and to obtain preliminary results to enable sample size calculation in order to facilitate the implementation of a large multicentre randomised controlled trial. ClinicalTrials.gov Identifier: NCT01853267. METHODS: Fourteen patients with perianal abscesses were randomised to packing or non-packing of the abscess cavity postoperatively. Outcome measures were time to healing, abscess recurrence, fistula formation and postoperative pain. RESULTS: Healing in the non-packing group was faster compared to the packing group: mean 26.8 days (95 % confidence interval 22.7 to 30.7) vs 19.5 days (13.6 to 25.4); P = 0.047. There were no differences in recurrence rates between the groups (37.5 % packing group vs 33.3 % non-packing group; P = 0.580) at a median follow-up of 90.0 weeks (interquartile range (IQR) 26.0). In patients presenting with recurrence, one fistula was found in the packing group with no fistulas in the non-packing group. The non-packing group reported less pain 2 weeks postoperatively: median (IQR) 2.00 (3.00) vs 0.00 (1.00); (P = 0.030). CONCLUSION: Within the limitations of a small sample population, the results of this pilot study suggest that not packing the perianal abscess cavity after incision and drainage is safe. Our results show not packing confers less pain with a faster healing time compared with the conventional packing method, and this is a novel finding. These results need to be corroborated in the setting of a larger multicentre randomised controlled trial.

Neoadjuvant chemotherapy and primary-first approach for rectal cancer with synchronous liver metastases.

AIM: Up to a quarter of patients with rectal cancer have synchronous liver metastases at the time of diagnosis. This is a predictor of poor outcome. There are no standardized guidelines for treatment. We reviewed the outcomes of our patients with synchronous rectal liver metastases treated with a curative intent by neoadjuvant chemotherapy with or without chemoradiotherapy followed by resection of the primary tumour and then liver metastases. METHOD: Between 2004 and 2012, patients who presented with rectal cancer and synchronous liver metastasis were treated with curative intent with peri-operative systemic chemotherapy as the first line of treatment. Responders to chemotherapy underwent resection of the primary tumour with or without preoperative chemoradiotherapy followed by hepatic resection. RESULTS: Fifty-three rectal cancer patients with 152 synchronous liver lesions were identified. After a median follow-up of 29.6 months, the median survival was 41.4 months. Overall survival was 59.0% at 3 years and 39.0% at 5 years. CONCLUSION: Rectal resection before hepatic resection combined with neoadjuvant chemotherapy is associated with promising clinical outcome. It allows downstaging of liver lesions and removal of the primary tumour before the progression of further micrometastases. Furthermore, patients who do not respond to chemotherapy can be identified and may avoid major surgical intervention.

Surgical treatment of a giant mesenteric fibromatosis mimicking a gastrointestinal stromal tumor: a case report and current treatment aspects.

Intra-abdominal fibromatosis (IAF), usually located at the mesenteric level, is a locally invasive tumor of fibrous origin. Although lacking the ability to metastasize, it has the tendency to recur. The case described here is a case of mesenteric fibromatosis with involvement of the bowel wall, which had the appearance of a gastrointestinal stromal tumor (GIST), a tumor with malignant behavior. This report outlines the fact that certain non-typical cases of IAF with involvement of the bowel wall can be misdiagnosed as GIST. It is of outmost importance to make an early and correct diagnosis in such equivocal cases, so that the appropriate treatment can be closed.

How can we treat a patient with liver cirrhosis (hepatitis C virus), hepatocellular carcinoma, and synchronous colon cancer?

INTRODUCTION: The coexistence of liver cirrhosis with hepatocellular carcinoma (HCC) and colon cancer (Ca), which is a rare clinical condition, was treated in a liver transplant recipient. PATIENTS AND METHODS: A 46-year-old man, diagnosed incidentally during an ultrasound (US) examination with a 3.5-cm HCC in segment VII related to chronic hepatitis C virus (HCV), was referred for liver resection. He underwent a laparoscopic protocol evaluation for liver cirrhosis. Liver appearance and biopsy of the left lobe showed Child B/C liver cirrhosis. Because he fulfilled the Milan criteria, we suggested an orthotopic liver transplantation (OLT). During protocol colonoscopy, we discovered an ulcerative sigmoid colon Ca. Three weeks after completing the pre-OLT assessment he underwent an OLT and was discharged home on day 9 on an immunosuppressive regimen of Everolimus, Myfortic, and Prezolone. Two months after transplantation, the patient underwent a sigmoidectomy and for nearly 1 month thereafter received chemotherapy for colon Ca (6 cycles of FOLFOX:Folinic Acid+Fluorouracil+Oxaliplatin). One and a half years after OLT, patient was in good condition but presented with an increased alpha fetoprotein (a-FP) without other findings. A couple of months later we discovered a colon Ca recurrence and 3 small liver metastases. Patient underwent a bowel resection with Hartmann's procedure. Almost immediately after the last operation, he was found to suffer multiple myeloma. He underwent chemotherapy for both malignancies with good responses, but a few months later died of severe sepsis. DISCUSSION: The relevant literature regarding treatment of liver cirrhosis complicated with HCC and synchronous colon Ca reveals poor and controversial outcomes. Our patient underwent chemotherapy immediately after colon resection in the presence of with a good functioning liver. Although his condition was satisfactory after OLT, the optimal treatment of such complicated patients is as yet uncertain.

The effect of intraocular pressure on visual field after trabeculectomy in patients with primary open angle glaucoma.

PURPOSE: To compare the mean intraocular pressure (IOP), peak IOP and percentage reduction in IOP in the first five years following trabeculectomy between the patients with progressed visual field loss and the patients with stable visual fields. MATERIAL AND METHODS: Thirty-six eyes of 36 patients were followed for five years after their first trabeculectomy with tonometry and automated perimetry (Octopus 500EZ, program G1). The rate of change of the visual field was measured by linear regression analysis of the mean sensitivity value (dB) of each field test versus time (month). Based on the statistical significance of the slope of the regression line (Spearman p value of the correlation coefficient less than 0.05), patients were divided into two groups: with significant negative slope of the regression line (group with progressed visual field loss) and with non-significant slope of the regression line (group with stable visual field). The mean IOP values and percentage of IOP reduction at the end of each of the first five years after surgery were compared between the group with progressed field loss and group with stable fields by using Mann-Whitney U test. RESULTS: Patients with progressed visual field loss had higher mean IOP, higher peak IOP and less reduction in pressure after the operation than patients with stable visual field. The mean IOP at end of the two year postoperative period was significantly higher in patients with progressed visual field loss (21.98 +/- 3.38 mmHg) than in those with stable fields (17.48 +/- 4.80 mmHg). The mean percentage reduction in IOP at the end of two year postoperative period was significantly less in patients that showed progression of field loss (21.84%) than in those with stable fields (41.0%). CONCLUSION: Prognosis for further field loss seems to be better if postoperative pressure is at lower levels and greater percent reduction of IOP is obtained after surgery. The data that predict better prognosis is the mean postoperative IOP value of approximately 18 mmHg or less resulting from at least 35% of IOP reduction.

Single-incision laparoscopic surgery (SILS) vs. conventional multiport cholecystectomy: systematic review and meta-analysis.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has gained increasing attention due to the potential to maximize the benefits of laparoscopic surgery. The aim of this systematic review and pooled analysis was to compare clinical outcome following SILS and standard multiport laparoscopic cholecystectomy for the treatment of gallstone-related disease. METHODS: An electronic search of Embase and Medline databases for articles from 1966 to 2011 was performed. Publications were included if they were randomised controlled studies in which patients underwent either single-incision or multiport cholecystectomy. The primary outcome measures for the meta-analysis were postoperative complications and postoperative pain score [visual analogue scale (VAS) on the day of surgery]. Secondary outcome measures were operating time and length of hospital stay. Weighted mean difference was calculated for the effect size of SILS on continuous variables, and pooled odds ratios were calculated for discrete variables. RESULTS: In total, 375 cholecystectomy operations from 7 randomised controlled trials were included, 195 by single-incision (SILS) and 180 by conventional multiport. Operating time was significantly longer in the SILS group compared to the standard multiport laparoscopic cholecystectomy group (weighted mean difference = 2.13; P = 0.0001). There was no significant difference in the incidence of postoperative complications, postoperative pain score (VAS), or the length of hospital stay between the two groups. CONCLUSION: The results of this meta-analysis demonstrate that single-incision laparoscopic cholecystectomy is a safe procedure for the treatment of uncomplicated gallstone disease, with postoperative outcome similar to that of standard multiport laparoscopic cholecystectomy. Future high-powered randomized studies should be focused on elucidating subtle differences in postoperative complications, reported postoperative pain, and cosmesis following SILS cholecystectomy in more severe biliary disease.

Safety and diagnostic yield of laparoscopically assisted full-thickness bowel biospy.

Advances in minimally invasive surgery have made laparoscopy and full-thickness bowel biopsy possible in the investigation of patients with suspected gastrointestinal neuromuscular disorders. The safety and diagnostic yield of this investigation have not been formally reported. A prospective study was undertaken of 124 patients with clinico-physiological diagnoses of chronic intestinal pseudo-obstruction, enteric dysmotility and severe irritable bowel syndrome undergoing LFTB in three European teaching centres with expertise in the management of gastrointestinal neuromuscular disorders. Perioperative data were collected including complications. Diagnostic yield was expressed as proportion with well-established specific neuromuscular abnormalities based on a protocol of routine and immunohistochemical techniques. The majority of patients underwent a laparoscopically assisted procedure with extracorporeal biopsy. Median operating time was 50 min, conversion rate 2% and length of stay 1 day. There was an 8% readmission rate for obstructive symptoms but minimal other morbidity and no mortality. Overall specific diagnostic yield was 81%, being high for jejunal biopsies (89%) but low for a small number of ileal and colonic biopsies. Laparoscopy and full-thickness biopsy of the bowel appears acceptable in terms of safety. It should be performed in a jejunal site to achieve a high diagnostic yield.

Surgical trauma, minimal residual disease and locoregional cancer recurrence.

The persistence of residual tumour is associated with the histology and stage of the primary cancer, the completeness and quality of surgery, and postoperative events such as anastomotic leakage or entrapment of cells in exudating wound surfaces. At present, there is no clinical evidence that the use of laparoscopic techniques adversely influences the risk of residual disease. The inflammatory process associated with surgery shares a number of central mediators and pathways with tumour growth and invasiveness. Both cellular components (mainly macrophages and fibroblasts) and humoral factors associated with inflammation have been shown to enhance tumour growth in numerous preclinical studies. Tumour foci at a distance from the main cancer are kept in a dormant state by a range of anti-angiogenic mediators produced by the main cancer. Preclinical studies have shown that removal of the primary cancer reactivates proliferative and metastatic pathways in the residual tumour. Clinically, this phenomenon has been proposed as underlying the observed rapid systemic relapse after surgery in young node positive breast cancer patients. Strategies proposed to prevent residual disease encompass avoidance of tumour spill and minimization of surgical trauma and related inflammation. Efforts to remove or kill free intraperitoneal cells by local antiseptic or cytotoxic regimens have met only limited clinical success. Specific targeted therapy aimed at inhibiting the inflammatory response, tumour cell adhesion, or the metastatic phenotype of dormant cells appears promising in preclinical models and needs to be addressed in future clinical trials.

A surgically induced hypoxic environment causes changes in the metastatic behaviour of tumours in vitro.

The use of laparoscopic techniques for curative resections of malignant tumours has been under scrutiny. The potential benefits to the patient in the form of earlier recovery and less immune paresis are countered by the reports of increased tumour recurrence. The biological sequelae of the hypoxic laparoscopic environment on tumour cells is unknown. Components of the metastatic cascade were evaluated under in vitro laparoscopic conditions using a human colonic adenocarcinoma cell line (SW1222). Exposure to the laparoscopic gases carbon dioxide and helium for 4 h, comparable to the duration of a laparoscopic colorectal resection, had no effect on cell viability. A cellular hypoxic insult was demonstrated by the induction of hypoxia inducible factor 1alpha (HIF-1alpha). Exposure also resulted in significant reduction in homotypic adhesion as well as to a variety of extracellular matrix components. These effects were recoverable under re-oxygenation. The changes were reflected at the molecular level by significant down regulation of adhesion molecules known to be involved in tumour progression (E-cadherin, CD44 and beta1 sub-unit). Modulation of adherence has significant implications for laparoscopic oncological surgery, demonstrating that tumours become potentially more friable and easier to disseminate in surgeons who are less experienced or where instrumentation is sub-optimal.

Laparoscopic environmental changes during surgery enhance the invasive potential of tumours.

OBJECTIVE: The use of laparoscopic techniques in resection of malignant tumours has been proposed to offer potential benefit to the patient in the form of earlier recovery and less immune paresis; however, reported tumour seeding, both peritoneal and at port site, has put this approach into question. The biological effects of the introduction of carbon dioxide or helium to form a pneumoperitoneum on tumour invasion and dissemination are unknown. METHODS: A human colonic adenocarcinoma cell line (SW1222) was exposed to in vitro laparoscopic environment of either carbon dioxide or helium for 4 h, mimicking the duration of a laparoscopic colorectal resection. Alteration in production of matrix metalloproteinase (MMP)-2, MMP-9 and urokinase-type plasminogen activator (uPA) due to exposure to a laparoscopic environment was determined by zymography and correlated to invasive capacity by a standard Matrigel-based invasion assay. Incorporation of specific gelatinase inhibitors or antibodies directed at the uPA receptor was utilized to determine the relative importance of proteases. RESULTS: Exposure to the laparoscopic environment significantly enhanced production of the proteases MMP-2, MMP-9 and uPA. A concomitant enhancement of invasive capacity was also observed, being blocked by specific protease inhibitors. Changes in both protease production and aggression were observable for at least 24 h following the removal of the operative environment, indicating the possible long-term effects of the initial insult. CONCLUSION: Exposure to the laparoscopic environment enhances the invasive capacity of colonic adenocarcinomas via a well-defined protease-determined pathway. It therefore appears likely that tumour cells released into the operative field can be made increasingly aggressive by a laparoscopic operative environment and can thus contribute to disease dissemination.

Laparoscopic surgery for colon cancer.

Acceptance of laparoscopy for the management of oncological disease has been slow due to the increased complexity of the technique, requirement of technological advances, and fears for the oncological safety of the approach. Laparoscopic oncological surgery has a role in the management of oncological patients at all stages of disease. Good evidence exists for the laparoscopic approach being a viable option for colon cancer patients. Current large multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and how it compares with open surgery. This article examines some of the parameters by which laparoscopic colectomy will be judged.

Laparoscopy for malignancy: current status.

The acceptance of laparoscopy for the management of oncologic disease has been slow because of initial fears regarding the effect of this new approach on the interaction between the patient and the tumor. Since the initial attempts at laparoscopic resection, experience and technology have improved in parallel, facilitating improvements in this area. Laparoscopic oncologic surgery has a role in the management of oncologic patients at all stages of disease. Good evidence exists that laparoscopy has become an invaluable staging tool in many upper gastrointestinal cancers as well as lymphomas. The specter of port-site recurrence has loomed over the use of a laparoscopic approach for curative resections. However, it is clear from many reported trials that the initial prevalence of port-site metastases was more a technical issue rather than a problem with laparoscopy. Current large, multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and its comparison with open surgery. It does appear that laparoscopic cancer surgery is feasible, safe, and oncologically sound. We fully believe that laparoscopic cancer surgery will play an increasingly major role in the management of gastrointestinal malignancies.

Laparoscopic staging of pancreatic tumors induces increased invasive capacity in vitro.

INTRODUCTION: Laparoscopy and laparoscopic ultrasound have a well-defined role in staging patients with pancreatic malignancy. The effect of the hypoxic pneumoperitoneum induction on tumor biology is unknown. The authors investigated whether an in vitro pneumoperitoneum augments the invasive capacity of pancreatic tumors and elucidate a mechanism by which this may occur. METHODS: A pancreatic (PSN-1) adenocarcinoma cell line was exposed to an in vitro pneumoperitoneum (carbon dioxide (CO2) or helium) for a maximum of 2 h or left in normal growth conditions (control). Cells were nonenzymatically harvested and placed in invasion assays. These were performed over 72 h using Matrigel coated 8-mm Transwell filters and analyzed using MTS colorimetric assay. Gelatin zymography was employed to assess the level of matrix metalloproteases (MMP) 2 and 9 (gelatinase A and B) secretion. Expression of tissue inhibitor of metalloproteases 1 (TIMP-1) was assessed using ELISA (Biotrak). Inhibition of invasion assays was performed using a specific gelatinase inhibitor (MMPI; Calbiochem). RESULTS: The invasive capacity of pancreatic tumour cells is augmented versus control in both helium (p <0.05) and CO2 (p <0.001) groups. Concomitant significant upregulation of the gelatinase activity was demonstrated with both insufflants (p <0.05; 0.001, respectively). Enhanced invasion was attenuated by the addition of a specific gelatinase inhibitor (p <0.05). CONCLUSIONS: These results indicate the invasive capacity of pancreatic tumor cells is augmented by laparoscopic staging in vitro. This is in part mediated by increased gelatinase activity and may be attenuated by the addition of specific inhibitors.

Oncologic implications of laparoscopic and open surgery.

Although instrumental manipulation and mechanical tumor cell spillage seem to play the major role in port-site metastases from laparoscopic cancer surgery, minimally invasive procedures are used more and more in the resection of malignancies. However, port-site metastases also have been reported after resection of colon cancer in International Union Against Cancer (UICC) stage I [2, 14]. Therefore, changes in the peritoneal environment during laparoscopy also might influence intra- and extraperitoneal tumor growth during laparoscopy and pneumoperitoneum. Different results of experimental studies presented at the Third International Conference for Laparoscopic Surgery are analyzed and discussed.

Pneumoperitoneum augmented tumor invasiveness is abolished by matrix metalloproteinase blockade.

BACKGROUND: Certain surgical strategies, including Helium (He) and carbon dioxide (CO2) insufflation in laparoscopy, have been shown to induce a hypoxic environment. This may have a significant effect on the invasive capacity of tumor cells and may be a factor in the incidence of port-site metastases seen in patients following laparoscopic resection for malignancy. METHODS: A colon adenocarcinoma cell line (SW1222) was exposed to an in vitro pneumoperitoneum of CO2 or He at 3 mmHg or left in normal growth conditions (control). After a 4-hour exposure to an in vitro pneumoperitoneum, the ability of the cells to invade through 8.0-microm Transwell filters coated with Matrigel was analyzed by colorimetric MTS assay and by direct staining of the filters. The effect of the addition of a known blocker of matrix metalloproteinases (MMPs), 1,10-phenanthroline (1,10-P), was investigated. RESULTS: Cells exposed to an in vitro pneumoperitoneum demonstrate significantly increased invasive capacity compared to the control set, without loss of viability (He vs control, p <0.001; CO2 vs control, p <0.001). This augmented capacity is abolished by the addition of 1,10-P (p <0.01). CONCLUSION: Exposure of a colonic adenocarcinoma cell line to either a CO2 or He pneumoperitoneum causes an increase in tumor cell invasiveness, which is abolished by the presence of a known inhibitor of MMPs. This suggests that MMPs have an important role in the metastatic potential of tumors exposed to a hypoxic operative environment.

Laparoscopic herniorrhaphy: initial experience in 126 patients.

The initial experience in laparoscopic transabdominal preperitoneal mesh (TAPP) repairs is reviewed. In this study, consecutive TAPP repairs were performed in 126 patients. There were no intraoperative complications, and only 1 procedure had to be converted to open surgery. Forty-six patients had direct inguinal hernias, 56 had indirect inguinal hernias, and 24 had both, of which 21 were recurrent. Fifty-one hernias were right sided, 46 were left sided, and 29 were bilaterals. The male/female ratio was 116:10, and the mean age of the patients was 49.8 (range 17-76). Minor complications included parasthesia over the distribution of the lateral cutaneous nerve of the thigh in 2 patients, hydrocoeles in 2 patients, hematomata in 6 patients, and testicular pain in 4 patients, all of which resolved on conservative management. Incomplete bowel obstruction has been the only major postoperative complication to date, where an area of bowel herniated between two staples in the peritoneum. This was further complicated by an aspiration pneumonia and death of the patient. The mean hospital stay was 1.2 days (range 1-3), and the mean return to unrestricted activity was 8 days (range 3-12). There have been 2 true recurrences to date. One patient had a tender swelling after the repair, which was thought to be a recurrent strangulated hernia. On investigation, it was found to be a hematoma. The mean follow-up has been 7 months (range 1-18). Although early results of the TAPP repair are encouraging, we have had 1 significant complication that may have been avoided if an endoscopic extraperitoneal approach was employed.