Lymph node ratio as a prognostic factor in gastric cancer patients following D1 resection. Comparison with the current TNM staging system.

INTRODUCTION: Nodal ratio (NR) has been demonstrated to be an independent prognostic factor in patients with gastric cancer. We evaluated the prognostic role of NR comparing it with the current TNM (2010) classification in gastric cancer patients treated with curative (R0) D1 resection. MATERIALS AND METHODS: We retrospectively reviewed 110 patients who underwent R0 resection for gastric cancer at University Hospital of Larissa between 2002 and 2011. All patients had a D1 lymphadenectomy plus the nodes along the left gastric artery. Factors affecting survival as well as correlations between the N status, NR status and resected nodes were investigated. RESULTS: In univariate analysis the N and NR status but not the numbers of retrieved nodes were significant prognostic factors. Inside N1 and N2 categories, patients with different NR groups were present and survival of some of these subpopulations was statistically different at long-rank test. There was a correlation between the nodes retrieved and N status but not with the NR category. In multivariate analysis both N status (HR=1.45; 95% C.I. = 1.19-1.89) and NR (HR=4.53; 95% C.I. = 1.86-11.03) found to be independent prognostic factors of survival. CONCLUSION: Prognostic significance of N status and NR status was comparable. Unlike N status, NR is independent by the number of resected nodes, and therefore it is particularly useful in case of conventional lymphadenectomy.

Colorectal cancer surgery in the elderly: limitations and drawbacks.

PURPOSE: The purpose of this study was to evaluate the outcomes of colorectal cancer surgery among the elderly. METHODS: From March 2002 until February 2010, 434 patients who presented to our institution with the initial diagnosis of colorectal cancer and were submitted to open curative colorectal cancer resections or some kind of palliative procedure either elective or emergencies were retrospectively reviewed. A total of 286 of these patients (65.8%) were below 75 years (group A) and 148 (34.2%) above 75 years (group B). RESULTS: A procedure with curative intent was undertaken in 386 patients (88.9%), while forty-eight patients (11.1%) were submitted to a palliative procedure. Regarding the incidence of emergency operations, forty-five patients (15.7%) from group A and forty-four patients (29.7%) from group B were operated due to an emergency (obstructing, perforating or bleeding tumors; P < 0.001). Mean ASA score was 1.74 ± 0.84 and 2.32 ± 0.94 for groups A and B, respectively (P < 0.001). Mean TNM stage was 2.28 ± 1.00 and 2.74 ± 0.98 for groups A and B, respectively (P = 0.0001). Elderly patients exhibited increased incidence of post-operative complications and increased post-operative mortality compared with their younger counterparts (P = 0.002 and 0.001, respectively). CONCLUSION: Colorectal cancer surgery in the elderly is a challenging clinical scenario. Treatment decision adjusted to each individual case is the ideal practice in order to maintain an acceptable balance between curative cancer resections and palliative procedures.

Side-to-side anastomosis fashioned as stoma after sigmoid resection for sigmoid volvulus: a case report.

PURPOSE: Colonic volvulus is one of the causes of large bowel obstruction with sigmoid colon being the most usually affected part. Surgery is the gold standard when signs of peritonitis are present or endoscopic decompression fails. MATERIALS AND METHODS: We report the case of 65-year-old man with acute large bowel obstruction due to sigmoid volvulus who underwent a laparoscopic-assisted sigmoid resection on an emergency basis. The condition of the bowel wall precluded a primary anastomosis. But instead, a side-to-side anastomosis that its common blind stump was brought out as an end stoma was performed. RESULTS: The postoperative period was eventless. The patient was discharged on the 6th postoperative day. Eight weeks after the initial operation, the patient was readmitted for the secondary closure of the anastomotic stoma. Local anesthesia and minor sedation were enough in order to perform the stoma take down. CONCLUSION: Laparoscopic-assisted sigmoid resection is a useful adjunct to the surgical armamentarium when facing the problem of sigmoid volvulus. When a safe restoration of the alimentary tract continuity cannot be achieved safely with a primary anastomosis, the proposed anastomotic stoma technique is a useful and practical alternative.

Clinicopathological differences between right- and left-sided colonic tumors and impact upon survival.

AIM: This study is to analyze the clinicopathological differences between right- and left-sided colonic tumors and to evaluate the impact upon the patient's survival. METHODS: In a period of 5 years (2004-2009), 453 patients were diagnosed with colorectal cancer. RESULTS: From a total of 453 patients diagnosed with colon cancer, 56.5% of them were men, while 43.5% of them were women. Right-sided colonic tumors were diagnosed in 54.53% of the patients compared to the 45.47% of patients with left-sided colonic tumors. The size of colonic tumors is statistically significant greater in right-sided colonic tumors compared to left ones (P < 0.001). Left-sided colon cancer patients identified to have a statistically significant better overall 5-year survival rate compared to right-sided ones (P < 0.001). CONCLUSION: Based upon our results, there is a different biological profile between right- and left-sided colonic tumors.

Pudendal nerve block versus local anesthesia for harmonic scalpel hemorrhoidectomy: a prospective randomized study.

BACKGROUND: This prospective randomized trial was used to compare two different local anesthetic techniques, local perianal anesthesia and pudendal nerve block, used for harmonic scalpel hemorrhoidectomy (HSH). METHODS: A total of 120 patients with grade III or IV hemorrhoids were randomly chosen to perform HSH (60 patients under local anesthesia--Group A and 60 patients under pudendal nerve block--Group B). RESULTS: Additional perioperative analgesia during the procedure was needed in 37 patients of group A and 18 patients of group B (P < 0.001). A total of 27 patients from group A and 8 patients from group B (P < 0.001) required additional postoperative analgesia apart from the standard administered analgesics. A statistical significant difference in favor of the second group (B)--(P < 0.003) was found regarding the discharge point from the hospital when the number of patients that were able to be discharged from the hospital on the day of the operation and the first postoperative day was the comparison parameter. Group B (P < 0.001) was superior to local group regarding VAS pain score at discharge for the patient group that were discharge on the day of surgery (5.1 vs. 2.2). CONCLUSION: These data suggest that HSH performed under pudendal nerve block is a safe and efficient technique.

Prevention of postoperative adhesion formation by individual and combined administration of 4 per cent icodextrin and dimetindene maleate.

BACKGROUND: To date, no single method has been successful in eliminating peritoneal adhesion formation after major abdominal surgery. This study evaluated the individual and possible synergistic effect of a local intraperitoneal barrier, 4 per cent icodextrin, and an intravenously administered antihistamine drug, dimetindene maleate, in the prevention of adhesion development following surgical trauma. METHODS: De novo experimental adhesions were induced by standardized trauma of the peritoneum and large bowel in 120 New Zealand White rabbits. The animals were randomized into four groups receiving intraperitoneal saline, intraperitoneal 4 per cent icodextrin (60 ml), intravenous dimetindene maleate (0.1 mg/kg) and 4 per cent icodextrin-dimetindene in combination (n = 30 per group). Ten days later, adhesion scores and incidence were assessed by two independent surgeons. and surface area by computer-aided planimetry. RESULTS: Treatment with either icodextrin or dimetindene maleate significantly reduced adhesion scores and increased the incidence of adhesion-free animals in an equipotent manner. The effect of combined treatment on severity, incidence and surface area of adhesions was more pronounced than that of each drug administered separately. CONCLUSION: Combined administration of 4 per cent icodextrin and dimetindene maleate may be used safely and efficaciously to prevent surgically induced adhesions.

Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh.

OBJECTIVES: Mild pain lasting for a few days is common following mesh inguinal hernia repair. In some patients however, severe groin pain may appear months or even years postoperatively. The aim of this study was to report our experience of late-onset persisting severe postoperative groin pain occurring years after mesh hernioplasty. METHODS: In a 9-year period, 1,633 patients (1,073 men), median age 63 years (range 19-88), underwent mesh groin hernia repair. Between 1.5 and 4 years postoperatively, six patients (0.35%) presented with severe chronic groin pain unrelieved by conservative measures and surgical exploration was essential. The patients' records were retrospectively reviewed for the purpose of this study. RESULTS: Ilioinguinal nerve entrapment was detected in four patients. The meshes appeared to be indistinguishable from the nerve and were removed along with the stuck nerve. New meshes were properly inserted. Mesh fixation on the periostium of the pubic tubercle by a staple was found in the other two patients. The staples were removed from the periostium in both patients. Neither hernia recurrence nor chronic groin pain was persisting in all six patients during a follow-up of 6-44 months postoperatively. CONCLUSION: From the results of this study, it appears that ilioinguinal nerve entrapment and/or mesh fixation on the periostium of the pubic tubercle are the causes of late-onset severe chronic pain after inguinal mesh hernioplasty. Mesh removal, along with the stuck ilioinguinal nerve and staple detachment from the periostium, are the gold-standard techniques if conservative measures fail to reduce pain.