Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

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.

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.

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.

Reproducibility of gallbladder emptying scintigraphic studies.

UNLABELLED: This study was designed to investigate the reproducibility of the results obtained from 99mTc-dimethyliminodiacetic acid (99mTc-EHIDA) cholescintigraphy, when used as a method of estimating gallbladder emptying. METHODS: In a random controlled fashion, the reproducibility of scintigraphic gallbladder emptying studies was assessed in 30 subjects, of whom six were normal, four had duodenal ulcers and the remaining 20 had undergone antiulcer gastric surgery. In fasting subjects, who 30 min later drank 250 ml of fresh milk, 2 mCi of 99mTc-EHIDA was intravenously injected. Liver and gallbladder areas were scanned for 60 sec and then every 5 min for 1 hr. The study was repeated in all subjects within 2-5 wk. From the gallbladder emptying curves, the duration of the lag phase (time from milk ingestion to actual start of emptying), the ejection fraction of emptying (peak to least activity in the gallbladder), the time by which maximal emptying was achieved and the pattern of gallbladder emptying were calculated. RESULTS: Two subjects were excluded from the study because their gallbladders did not fill. Lag phase duration was well reproduced in duplicate studies (r = 0.87), as was ejection fraction (r = 0.84). The time by which maximal emptying was achieved was not sufficiently reproduced. The normal pattern of emptying (exponential function) was reproduced in all controls, subjects with duodenal ulcers and patients after antiulcer surgery that did not involve duodenal exclusion. The abnormal pattern of emptying, characterized by refilling, was reproduced in five of the seven patients with gastric surgery that mainly involved duodenal exclusion. CONCLUSION: Scintigraphy with 99mTc-EHIDA to assess gallbladder motility is a method with satisfactory reproducibility of both parametric variables and patterns of emptying.

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.

Effect of the menstrual cycle on gallbladder fasting volume and postprandial emptying in nulliparous young females.

RATIONALE AND OBJECTIVES: Reports on the effect of the ovulatory cycle on gallbladder motility are inconsistent. The authors investigated the gallbladder motor function at both phases of the menstrual cycle in humans. METHODS: Seventeen young, healthy, nulliparous women participated in the study. Gallbladder fasting volume and postprandial emptying were measured twice in each subject using real-time ultrasonography: one at the follicular (12th-13th day) and another at the luteal (21st-22nd day) phases. From the emptying curves, the duration of the lag phase and the ejection fraction of emptying were calculated. RESULTS: Fasting volume was significantly greater (P = 0.025) at the luteal (14.8 +/- 8 mL standard deviation [SD]) than at the follicular (11.2 +/- 4.7 mL SD) phase. Although the lag phase duration was longer (P = 0.009) at the follicular (5.2 +/- 6.4 SD minutes) than the luteal (1.6 +/- 3.6 minutes SD) phase, the ejection fraction was significantly greater at the latter one (follicular phase: 62 +/- 13.2% SD; luteal phase: 73.4 +/- 14% SD; P = 0.0085). CONCLUSIONS: Female sex hormones seem to biologically affect the gallbladder motor function.

Enhancement of gastric emptying of solids by erythromycin in patients with Roux-en-Y gastrojejunostomy.

BACKGROUND: Roux-en-Y reconstruction is sometimes associated with symptoms that suggest food stasis, as a result of dysmotility of either the gastric remnant and/or the efferent jejunal limb. OBJECTIVE: To study the possible effect of intravenous erythromycin lactobionate on gastric emptying of solids in patients who have undergone a Roux-en-Y procedure. PATIENTS: Twenty-four patients with a Roux-en-Y procedure participated in the study. Ten of them had undergone truncal vagotomy with pyloroplasty; the remaining 14 had undergone a Billroth II subtotal gastrectomy as the initial antiulcer procedure. Sixteen healthy subjects served as controls. METHODS: All healthy subjects and patients underwent assessment of gastric emptying of a standard radiolabeled solid meal after administration of placebo or 200 mg of erythromycin lactobionate intravenously. Scanning was done with a gamma camera, and emptying curves were constructed. From these curves the half-time of gastric emptying was calculated. RESULTS: Patients with severe symptoms of gastric stasis had a significantly longer half-time than did patients with mild or no symptoms (P=.002). Patients with a Billroth II subtotal gastrectomy as the initial antiulcer procedure had a significantly worse grade of symptoms (P=.01) and a significantly prolonged half-time (P=.02) compared with patients with a truncal vagotomy with pyloroplasty as the initial antiulcer procedure. Erythromycin significantly reduced the half-time in the controls (P<.001) and all patients after Roux-en-Y procedure (P<.001). CONCLUSION: Erythromycin could be a useful prokinetic drug in patients with Roux stasis syndrome.

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.

Roux-en-Y gastroenterostomy severely disturbs emptying of the gallbladder.

BACKGROUND: It is documented that truncal vagotomy and Billroth II gastroenterostomy disturbs the emptying of the gallbladder. The aim of the present prospective study was to assess the emptying of the gallbladder after Roux-en-Y gastroenterostomy. STUDY DESIGN: There were 34 patients, who had undergone either truncal vagotomy with pyloroplasty (TVP, 14 instances) or Billroth II gastrectomy (20 instances), and were subsequently subjected to Roux-en-Y gastroenterostomy. The emptying of the gallbladder was assessed before and after the Roux-en-Y procedure, by milk-technetium-99m labeled hepatoiminodiacetic acid (milk-99mTc-HIDA) scintigraphy. Milk-99mTc-HIDA scintigraphy was also performed on twenty-eight healthy subjects, who served as the control group. RESULTS: After excluding the subjects having spontaneous gallbladder evacuation before milk ingestion, there remained 26 subjects in the control group, 12 patients with TVP, and 19 with Billroth II gastrectomy. Truncal vagotomy with pyloroplasty was associated with delayed onset (p < 0.001) and decreased rate (p < 0.01) of emptying of the gallbladder compared with the control group. Truncal vagotomy with pyloroplasty also changed the normal pattern of emptying in two patients (sequential emptying and refilling events). Billroth II gastrectomy was associated with decreased extent and abnormal pattern of emptying compared with subjects in the control group (p < 0.0001) and patients having TVP. Roux-en-Y gastroenterostomy, performed upon patients with TVP, significantly increased lag phase duration (p < 0.001), decreased ejection fraction (p < 0.01), and changed the pattern of emptying of the gallbladder (p < 0.01). Roux-en-Y procedure performed upon patients with Billroth II gastrectomy significantly increased lag phase duration (p < 0.0001). CONCLUSIONS: Roux-en-Y gastroenterostomy severely disturbs all parameters of the emptying of the gallbladder.

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.

The effect of intravenous erythromycin on esophageal motility in healthy subjects.

BACKGROUND: It has been confirmed that erythromycin has gastrokinetic properties of enhancing gastric emptying both in health and disease. The objective of the present study was to investigate any possible effect of erythromycin on esophageal motility. METHODS: In 14 healthy subjects, standard esophageal manometry was performed before and after the intravenous administration of 200 mg of erythromycin. The calculated manometric parameters of esophageal motility were the lower esophageal sphincter (LES) pressure; the amplitude and duration of peristalsis at 5, 10, and 15 cm proximal to the LES; and the velocity and strength of peristalsis at 5 cm proximal to the LES. RESULTS: Erythromycin significantly increased the LES pressure (P<0.001), and the amplitude (P=0.002), duration (P=0.003), strength (P=0.014) and velocity (P=0.008) of peristalsis at 5 cm proximal to LES. Erythromycin also increased the amplitude of peristalsis at 10 cm proximal to the LES (P=0.035). CONCLUSION: Erythromycin affects the motility of the distal esophagus.

Roux-Y choledochojejunostomy and duodenojejunostomy for the complicated duodenal diverticulum.

BACKGROUND: Exclusion of the duodenum by means of transection and Roux-Y duodenojejunostomy has been practiced for the treatment of complicated duodenal diverticulum. However, this method does not divert bile away from the diverticulum, hence the possibility of pancreaticobiliary complications is not eliminated. METHODS: Roux-Y choledochojejunostomy and duodenojejunostomy, for the diversion of bile and food, has been applied for the treatment of pancreaticobiliary complications of duodenal diverticulum in 4 patients. Postoperatively, all patients had endoscopy, HIDA-scintigraphy for the measurement of enterogastric reflux, and assessment of gastric emptying. RESULTS: One year postoperatively, there were no recurrent symptoms of cholangitis or pancreatitis, no anastomotic ulceration was found on endoscopy, there were no complaints of gastric stasis, and enterogastric reflux was not significant. CONCLUSIONS: Roux-Y choledochojejunostomy and duodenojejunostomy for the treatment of the complicated duodenal diverticulum is associated with satisfactory results. Postoperative symptoms attributed to anastomotic ulceration, bile reflux, or gastric stasis are also absent.

Gallbladder emptying after antiulcer gastric surgery.

It has been shown that truncal vagotomy with pyloroplasty (TVP), but not highly selective vagotomy (HSV), delays the onset, decreases the extent, and changes the pattern of gallbladder emptying. The aim of the present study was to investigate any alterations in gallbladder emptying after a variety of antiulcer gastric surgery, by milk-technetium 99m (99mTc)-dimethyl iminodiacetic acid (HIDA) scintigraphy. After excluding the cases with spontaneous gallbladder evacuation before milk ingestion, there were 26 controls, 41 duodenal ulcer (DU) patients, 22 after HSV (15 prospective cases), 50 after TVP (23 prospective cases), 8 after TV with gastrojejunostomy (TV-GJ), 10 after Billroth I gastrectomy, and 29 after Billroth II gastrectomy. None of the patients with gastrectomy had additional vagotomy. TVP significantly delayed the onset and decreased the rate of gallbladder emptying as compared with the control, DU, HSV, and Billroth I groups. TVP also changed the pattern of emptying in 20% of the cases (sequential emptying and refilling events). Antiulcer operations excluding the duodenum (TV-GJ and Billroth II) further reduced the rate of gallbladder emptying as compared with (1) control, DU, HSV, and Billroth I groups (P < 0.0001) and (2) TVP (P < 0.001). Onset of gallbladder emptying was not affected by Billroth II gastrectomy, but was significantly delayed by TV-GJ (P < 0.001). The latter two operations also significantly changed the pattern of gallbladder emptying, exhibiting sequential emptying and refilling events, in most cases (P < 0.01 versus TVP). In conclusion, all antiulcer procedures, except HSV, greatly disturb the pattern, the onset, and the rate of gallbladder emptying. Truncal vagotomy seems to disrupt vagally mediated preduodenal mechanism, resulting in delayed onset and reduced rate, whereas duodenal exclusion by gastrojejunostomy results in severely decreased rate of gallbladder emptying.

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.

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.

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.

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.