Integrated Approaches for the Management of Staple Line Leaks following Sleeve Gastrectomy.

Introduction. Aim of the study was trying to draw a final flow chart for the management of gastric leaks after laparoscopic sleeve gastrectomy, based on the review of our cases over 10 years' experience. Material and Methods. We retrospectively reviewed all patients who underwent LSG as a primary operation at the Bariatric Unit of Tor Vergata University Hospital in Rome from 2007 to 2015. Results. Patients included in the study were 418. There were 6 staple line leaks (1.44%). All patients with diagnosis of a leak were initially discharged home in good clinical conditions and then returned to A&E because of the complication. The mean interval between surgery and readmission for leak was 13,4 days (range 6-34 days, SD ± 11.85). We recorded one death (16.67%) due to sepsis. The remaining five cases were successfully treated with a mean healing time of the gastric leak of 55,5 days (range 26-83 days; SD ± 25.44). Conclusion. Choosing the proper treatment depends on clinical stability and on the presence or not of collected abscess. Our treatment protocol showed being associated with low complication rate and minor discomfort to the patients, reducing the need for more invasive procedures.

Corrigendum: Correction of the First Author's Affiliation. Outcome of Colorectal Surgery in Elderly Populations.

[This corrects the article on p. 139 in vol. 32, PMID: 27626024.].

Erratum: Author Name Correction: Outcome of Colorectal Surgery in Elderly Populations.

[This corrects the article on p. 139 in vol. 32, PMID: 27626024.].

Outcome of Colorectal Surgery in Elderly Populations.

PURPOSE: The aim of this study is to investigate the impact of age on short-term outcomes after colorectal surgery in terms of the 30-day postoperative morbidity and mortality rates. METHODS: The subjects for the study were patients who had undergone colorectal surgery. Patients were divided into 2 groups according to age; groups A and B patients were ≥80 and <80 years old of age, respectively. Both groups were manually matched for body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index and procedure performed. RESULTS: A total of 200 patients, 91 men (45.5%) and 109 women (54.5%), were included in this retrospective study. These patients were equally divided into 2 groups. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). The overall 30-day postoperative mortality rate was 1% of total 200 patients; both of these 2 patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The overall 30-day postoperative morbidity rate was 27% (54 of 200) for both groups. The 30-day postoperative morbidity rates in groups A and B were 28% (28 of 100) and 26% (26 of 100), respectively. However, these differences between the groups had no statistical significance importance. CONCLUSION: Age alone should not be considered to be more of a contraindication or a worse predictor than other factors for the outcome after colorectal surgery on elderly patients.

Gender Influence on Long-Term Weight Loss and Comorbidities After Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: a Prospective Study With a 5-Year Follow-up.

BACKGROUND: Gender might be important in predicting outcomes after bariatric surgery. The aim of the study was to investigate the influence of gender on long-term weight loss and comorbidity improvement after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: A cohort of 304 consecutive patients underwent surgery in 2006-2009: 162 (98 women, 64 men) underwent LSG and 142 (112 women, 30 men) underwent LRYGB. The mean follow-up time was 75.8 ± 8.4 months (range, 60-96 months). RESULTS: Overall mean (95% CI) reduction in BMI was 23.5 (24.3-22.7) kg/m(2) after 5 years, with no statistical difference between LSG and LRYGB groups (P = 0.94). The overall means ± standard deviations of %EBMIL after 5 years were 78.8 ± 23.5 and 81.6 ± 21.4 in the LSG and LRYGB groups, respectively. Only for LSG group %EBMIL after 24-36 and 60 months differed significantly between male and female patients (P = 0.003 versus P = 0.06 in LRYGB), and 89 versus 90% of patients showed improvements in comorbidities in the LSG and LRYGB groups, respectively. Only two patients (women) were lost to follow-up: 1/162 (0.6%) for LSG at the 4th year and 1/142 (0.7%) for LRYGB to the 5th year. CONCLUSIONS: LSG was more effective in obese male than in female patients in terms of %EBMIL, with no difference in comorbidities. LRYGB elicited similar results in both genders in terms of %EBMIL and comorbidities.

Objective Surgical Skill Assessment: An Initial Experience by Means of a Sensory Glove Paving the Way to Open Surgery Simulation?

INTRODUCTION: Simulation and training in surgery are very promising tools for enhancing a surgeon's skill base. Accurate tracking of hand movements can be a strategy for objectively gauging a surgeon's dexterity, although "open" work is much more difficult to evaluate than are laparoscopic tasks. To the authors' knowledge, a system taking into account the movements of each finger joint has never been applied to open surgery simulation. This work intends to make up for this shortcoming and to perform a data analysis of the surgeon's entire gesture. MATERIALS AND METHODS: The authors developed a sensory glove to measure flexion/extension of each finger joint and wrist movement. Totally 9 experts and 9 novices performed a basic suturing task and their manual performances were recorded within 2 days of measurements. Intraclass correlation coefficients were calculated to assess the ability of the executors to repeat and reproduce the proposed exercise. Wilcoxon signed-rank tests and Mann-Whitney U-tests were used to determine whether the 2 groups differ significantly in terms of execution time, repeatability, and reproducibility. Finally, a questionnaire was used to gather operators' subjective opinions. RESULTS: The experts needed a similar reduced execution time comparing the 2 recording sessions (p = 0.09), whereas novices spent more time during the first day (p = 0.01). Repeatability did not differ between the 2 days, either for experts (p = 0.26) or for novices (p = 0.86). The 2 groups performed differently in terms of time (p < 0.001), repeatability (p = 0.01), and reproducibility (p < 0.001) of the same gesture. The system showed an overall moderate repeatability (intraclass correlation coefficient: experts = 0.64; novices = 0.53) and an overall high reproducibility. The questionnaire revealed performers' positive feedback with the glove. CONCLUSIONS: This initial experience confirmed the validity and reliability of the proposed system in objectively assessing surgeons' technical skill, thus paving the way to a more complex project involving open surgery simulation.

Peritoneal expression of Matrilysin helps identify early post-operative recurrence of colorectal cancer.

Recurrence of colorectal cancer (CRC) following a potentially curative resection is a challenging clinical problem. Matrix metalloproteinase-7 (MMP-7) is over-expressed by CRC cells and supposed to play a major role in CRC cell diffusion and metastasis. MMP-7 RNA expression was assessed by real-time PCR using specific primers in peritoneal washing fluid obtained during surgical procedure. After surgery, patients underwent a regular follow up for assessing recurrence. transcripts for MMP-7 were detected in 31/57 samples (54%). Patients were followed-up (range 20-48 months) for recurrence prevention. Recurrence was diagnosed in 6 out of 55 patients (11%) and two patients eventually died because of this. Notably, all the six patients who had relapsed were positive for MMP-7. Sensitivity and specificity of the test were 100% and 49% respectively. Data from patients have also been corroborated by computational approaches. Public available coloncarcinoma datasets have been employed to confirm MMP7 clinical impact on the disease. Interestingly, MMP-7 expression appeared correlated to Tgfb-1, and correlation of the two factors represented a poor prognostic factor. This study proposes positivity of MMP-7 in peritoneal cavity as a novel biomarker for predicting disease recurrence in patients with CRC.

Laparoscopic ileocolic resection for Crohn's disease associated with midgut malrotation.

Midgut malrotation is an anomaly of fetal intestinal rotation. Its incidence in adults is rare. A case of midgut malrotation in a 51-year-old man with complicated Crohn's disease of the terminal ileum is presented. Symptoms, diagnosis, and treatment are reviewed. Preoperative workup led to correct surgical planning that ultimately allowed a successful laparoscopic resection.

Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal.

BACKGROUND: The principle to avoid surgery for haemorrhoids and/or anal fissure in Crohn's disease (CD) patients is still currently valid despite advances in medical and surgical treatments. In this study we report our prospectively recorded data on medical and surgical treatment of haemorrhoids and anal fissures in CD patients over a period of 8 years. METHODS: Clinical data of patients affected by perianal disease were routinely and prospectively inserted in a database between October 2003 and October 2011 at the Department of Surgery, Tor Vergata University Hospital, Rome. We reviewed and divided in two groups records on CD patients treated either medically or surgically according to the diagnosis of haemorrhoids or anal fissures. Moreover, we compared in each group the outcome in patients with prior diagnosis of CD and in patients diagnosed with CD only after perianal main treatment. RESULTS: Eighty-six CD patients were included in the study; 45 were treated for haemorrhoids and 41 presented with anal fissure. Conservative approach was initially adopted for all patients; in case of medical treatment failure, the presence of stable intestinal disease made them eligible for surgery. Fifteen patients underwent haemorrhoidectomy (open 11; closed 3; stapled 1), and two rubber band ligation. Fourteen patients required surgery for anal fissure (Botox ± fissurectomy 8; LIS 6). In both groups we observed high complication rate, 41.2% for haemorrhoids and 57.1% for anal fissure. Patients who underwent haemorrhoidectomy without certain diagnosis of CD had significantly higher risk of complications. CONCLUSIONS: Conservative treatment of proctologic diseases in CD patients has been advocated given the high risk of complications and the evidence that spontaneous healing may also occur. From these preliminary results a role of surgery is conceivable in high selected patients, but definitve conclusions can't be made. Further randomized trials are needed to establish the efficacy of the surgical approach, giving therapeutic recommendations and guidelines.

Role of 0.4% glyceryl trinitrate ointment after haemorrhoidectomy: results of a prospective randomised study.

INTRODUCTION: Conventional haemorrhoidectomy (CH) is well known to cause significant post-operative pain and delayed return to daily activities. Both surgical wounds and sphincterial apparatus spasms are likely responsible for the pain. In this study, we evaluated the role of glyceryl trinitrate ointment (GTN) in reducing post-operative pain, ameliorating wound healing and recovery after CH. PATIENTS AND METHODS: Between 01/08 and 12/11, 203 patients with symptomatic haemorrhoids were enrolled in the study and received (103 patients) or not (100 patients) 0.4 % GTN ointment for 6 weeks after surgery. Pain was assessed using a 10-cm linear visual analogue scale (VAS). Data on post-operative pain, wound secretion and bleeding, return to normal activities and complications were recorded. Data were analysed using Fisher's exact and Mann-Whitney tests. RESULTS: GTN-treated group experienced significantly less pain during the first week after surgery (p < 0.0001). This difference was more evident starting from post-operative day 4 (p < 0.0001). A significant higher percentage of untreated patients experienced severe pain (mean VAS score > 7) (10 % vs 31 %). There were significant differences in terms of secretion time (p = 0.0052) and bleeding time (p = 0.02) in favor of GTN. In addition, the duration of itching was less in the GTN group (p = 0.0145). Patients treated with GTN were able to an early return to daily activities compared to untreated (p < 0.0001). Fifteen GTN-treated patients (14.6 %) discontinued the application because of local discomfort and headache. CONCLUSIONS: GTN ointment enhances significantly post-operative recovery, reducing pain in terms of duration and intensity. This effect might be secondary to a faster wound healing expressed by reduced secretion, bleeding and itching time.

Solitary metachronous gastric metastasis from pulmonary adenocarcinoma: Report of a case.

INTRODUCTION: Gastric metastases from lung adenocarcinoma are rare and usually associated with disseminated disease. The great majority is asymptomatic and in few cases discovered during autopsy studies. Reports of single metachronous metastases during the lifetime are anecdotal. We describe a case of solitary gastric metastasis 5 years after lung surgery. PRESENTATION OF CASE: A 68-year-old male submitted in 2006 to right lobectomy for lung adenocarcinoma was referred at Emergency Room department in 01/2011 because of chronic epigastric pain. Radiologic and endoscopic evaluation showed a bulky lesion inside the stomach, originating from the muscular layer, suspected for GIST. He underwent a subtotal gastrectomy and the pathologic examination revealed an undifferentiated adenocarcinoma, positive for Thyroid Transcriptional Factor-1, Cytokeratin 7, AE 1/3 and CEA, confirming the pulmonary origin. DISCUSSION: At the time of diagnosis about 50% of lung cancer are metastatic, with survival rates of 1% at 5-year. Gastric metastasis is very rare; autopsy studies report an incidence of 0.2-0.5%. They develop in the submucosa, usually without any symptom and the diagnosis is incidental during the staging of primary cancer or the follow-up. There are no guidelines about surgical treatment; however few cases of long-term survival following the operation were reported. Pathologic diagnosis is difficult, but the immunohistochemical staining helps to recognize the primary origin. CONCLUSION: Solitary metachronous gastric metastasis from pulmonary adenocarcinoma is an exceptional event, but it could happen during the follow-up. It seems that a radical resection, in absence of systemic implants, might provide survival benefits in selected patients.

Radiofrequency versus ultrasonic energy in laparoscopic colorectal surgery: a metaanalysis of operative time and blood loss.

BACKGROUND: Various energy sources are available for tissue dissection and vessel sealing in laparoscopic colorectal surgery. The electrothermal bipolar vessel sealing system (EBVS) and ultrasonic energy (UE) devices are widely used to provide hemostatic dissection in laparoscopic procedures. Nevertheless, available evidenced-based data comparing their operative results still are scarce. This study conducted a metaanalysis of controlled clinical trials comparing EBVS and UE in terms of operative time and intraoperative blood losses in laparoscopic colorectal surgery. METHODS: The MEDLINE and Embase databases were searched using medical subject headings and free text words. All randomized controlled trials (RCTs) and controlled clinical trials using EBVS and UE in laparoscopic colorectal surgery were considered for inclusion in the study. Random effects models were used in case of heterogeneity to obtain summary statistics for the overall difference in operating time and blood loss between instruments. RESULTS: Four studies comparing EBVS with UE for 397 patients (200 EBVS vs. 197 UE patients) were included in the study. The findings showed that EBVS was associated with a significantly shorter operative time and less intraoperative blood loss than UE (p < 0.05). CONCLUSIONS: The metaanalysis indicated that EBVS is associated with a shorter operative time and less blood loss than UE in laparoscopic colorectal surgery. However, these results should be interpreted with caution due to the high heterogeneity of the included trials and the limited number of studies with a high level of evidence. More adequately designed RCTs with a larger number of patients are required to confirm the results of this metaanalysis.

2-Methoxy-5-amino-N-hydroxybenzamide, a derivative of mesalamine, inhibits colon cancer cell growth through cyclo-oxygenase-2-dependent and -independent mechanisms.

COX-2 (cyclo-oxygenase-2) and PGE2 (prostaglandin E2) play a key role in sustaining CRC (colorectal cancer) cell growth and survival. Indeed, the use of agents targeting the COX-2/PGE2 axis has been associated with a reduction in the development of CRC in both humans and murine models of colon carcinogenesis. In the present study, we investigated whether 2-methoxy-5-amino-N-hydroxybenzamide (herein termed 2-14), a derivative of mesalamine that inhibits CRC cell growth both in vitro and in vivo, negatively regulates COX-2/PGE2 expression in CRC cells and assessed whether the 2-14-mediated anti-neoplastic effect is strictly dependent on the inhibition of this pathway. Our results show that 2-14 blocks the growth and enhances the death of HT-115, a CRC cell line overexpressing COX-2, and that these effects associate with inhibition of COX-2 but not COX-1. 2-14 also down-regulates TNFα (tumour necrosis factor α)-induced COX-2 in HT-29 cells as well as COX-2/PGE2 expression in ex vivo cultures of human CRC explants. Similarly, 2-14 reduces COX-2, but not COX-1, in tumoural areas developing in a mouse model of CAC (colitis-associated colon cancer). Finally, we show that 2-14 exhibits in vitro and in vivo anti-mitogenic effects in DLD-1, a COX-deficient CRC cell line. Taken together, these results suggest that 2-14 inhibits CRC cell growth through COX-2-dependent and -independent mechanisms.

Staple-line reinforcement during laparoscopic sleeve gastrectomy using three different techniques: a randomized trial.

BACKGROUND: The main drawback of laparoscopic sleeve gastrectomy (LSG) is the severity of postoperative complications. Staple line reinforcement (SLR) is strongly advocated. The purpose of this study was to compare prospectively and randomly three different techniques of SLR during LSG. METHODS: From April 2010 to April 2011, patients submitted to LSG were randomly selected for the following three different techniques of SLR: oversewing (group A); buttressed transection with a polyglycolide acid and trimethylene carbonate (group B); and staple-line roofing with a gelatin fibrin matrix (group C). Primary endpoints were reinforcement operative time, incidence of postoperative staple-line bleeding, and leaks. Operative time was calculated as follows: oversewing time in group A; positioning of polyglycolide acid and trimethylene carbonate over the stapler in group B; and roofing of the entire staple line in group C. RESULTS: A total of 120 patients were enrolled in the study (82 women and 38 men). Mean age was 44.6 ± 9.2 (range, 28-64) years. Mean preoperative body mass index was 47.2 ± 6.6 (range, 40-66) kg/m². Mean time for SLR was longer in group A (14.2 ± 4.2 (range, 8-18) minutes) compared with group B (2.4 ± 1.8 (range, 1-4) minutes) and group C (4.4 ± 1.6 (range, 3-6) minutes; P < 0.01). Four major complications were observed (3.3 %): one leak and one bleeding in group A; one bleeding in group B; and one leak in group C, with no significant differences between the groups. No mortality was observed. CONCLUSIONS: SLR with either polyglycolide acid with trimethylene carbonate or gelatin fibrin matrix is faster compared with oversewing. No significant differences were observed regarding postoperative staple-line complications.

Staple-line reinforcement with a thrombin matrix during laparoscopic sleeve gastrectomy for morbid obesity: a case series.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) represents a valid option for morbidly obese patients, either as a primary or as a staged procedure. Staple-line reinforcement (SLR) is strongly advocated to decrease the chance of bleeding. The aim of this article is to report our experience with a new technique of SLR using a thrombin-gelatin matrix in a series of morbidly obese patients subjected to LSG. SUBJECTS AND METHODS: Patients subjected to LSG using a thrombin-gelatin matrix for SLR from April 2010 to April 2011 were included in the study. Each patient's record was registered and prospectively collected for the analysis. RESULTS: Seventy-four patients were subjected to LSG using a thrombin matrix for SLR. There were 56 female and 18 male subjects with a mean age of 44.8 years (range, 16-64 years). Mean preoperative body mass index was 46.2 kg/m(2) (range, 40-72 kg/m(2)). Mean operative time was 74.4 minutes (range, 58-96 minutes). Mean time for application of the thrombin matrix was 4.8 minutes (range, 3.2-6.6 minutes). Mean postoperative hospital stay was 3.4 days (range, 2-62 days). Mean follow-up was 8.2 months (range, 3-12 months). Mean postoperative body mass index was 36.2 kg/m(2) (range, 30-42 kg/m(2)), and mean percentage excess weight loss was 34.2% (range, 28.4%-42.8%). We observed two major postoperative complications (2.7%): One gastric stump leak (1.3%) and one major bleeding from the trocar site (1.3%), both successfully treated by laparoscopic re-exploration. CONCLUSION: LSG with a thrombin matrix for SLR is a safe operation and a valid alternative to other well-established techniques.

Laparoscopic ventral rectopexy for internal rectal prolapse using biological mesh: postoperative and short-term functional results.

BACKGROUND: Laparoscopic ventral mesh rectopexy is a novel procedure to correct internal and external rectal prolapse. Several authors have shown that this approach is safe and improves obstructive defaecation symptoms and faecal incontinence, without inducing new-onset constipation, possible after posterior rectopexy. Over the last decade, as for other procedures, biological meshes are used to correct pelvic floor disorders. Literature data are scant. In this study, we present our experience with this procedure using biological mesh. PATIENTS AND METHODS: Prospectively collected data on laparoscopic ventral mesh rectopexy for internal rectal prolapse were analysed. All patients underwent preoperative evaluation with defaecating proctography and/or pelvic dynamic MRI, full colonoscopy, anal physiology studies and endo-anal ultrasound. End-points were to evaluate surgical complications and functional results of this technique such as changes in bowel function (Wexner Constipation Score and Faecal Incontinence Severity Index) at 3 and 6 months. Analysis was performed using Mann-Whitney U test for unpaired data and Wilcoxon signed rank test for paired data (two-sided p test). RESULTS: Thirty-four consecutive patients underwent laparoscopic ventral mesh rectopexy (median age 59, range 25-78 years, mean follow-up was 12 months). Twenty-eight patients (82%) had a constipation score ≥ 5, while 14 (41%) a FISI score ≥ 10. Nine patients (26%) had mixed obstructed defaecation and faecal incontinence. One patient required conversion to open (3%). Median length of stay was 2 days. Overall complication rate was 23.5%. Preoperative constipation (median Wexner score 15) and faecal incontinence (median FISI score 12) improved significantly at 3 months (Wexner 5, FISI 5, both p < 0.001). Two patients experienced prolapse persistence or recurrence. No patients had function worsening or complained of sexual dysfunction. CONCLUSIONS: Laparoscopic ventral mesh rectopexy using biological mesh for internal rectal prolapse is safe and effective in ameliorating symptoms of obstructed defaecation and faecal incontinence.

Prevalence of defaecatory disorders in morbidly obese patients before and after bariatric surgery.

BACKGROUND: The prevalence of obesity is increasing worldwide and has lately reached epidemic proportions in western countries. Several epidemiological studies have consistently shown that both overweight and obesity are important risk factors for the development of various functional defaecatory disorders (DDs), including faecal incontinence and constipation. However, data on their prevalence as well as effectiveness of bariatric surgery on their correction are scant. The primary objective of this study was to estimate the effect of morbid obesity on DDs in a cohort of patients listed for bariatric surgery. We also evaluated preliminary results of the effects of sleeve gastrectomy on these disorders. PATIENTS AND METHODS: A questionnaire-based study was proposed to morbidly obese patients having bariatric surgery. Data included demographics, past medical, surgical and obstetrics histories, as well as obesity related co-morbidities. Wexner Constipation Score (WCS) and the Faecal Incontinence Severity Index (FISI) questionnaires were used to evaluate constipation and incontinence. For the purpose of this study, we considered clinically relevant a WCS ≥5 and a FISI score ≥10. The same questionnaires were completed at 3 and 6 months follow-up after surgery. RESULTS: A total of 139 patients accepted the study and 68 underwent sleeve gastrectomy and fully satisfied our inclusion criteria with a minimum follow-up of 6 months. Overall, mean body mass index (BMI) at listing was 47 ± 7 kg/m(2) (range 35-67 kg/m(2)). Mean WCS was 4.1 ± 4 (range 0-17), while mean FISI score (expressed as mean±standard deviation) was 9.5 ± 9 (range 0-38). Overall, 58.9% of the patients reported DDs according to the above-mentioned scores. Twenty-eight patients (20%) had WCS ≥5. Thirty-five patients (25%) had a FISI ≥10 while 19 patients (13.7%) reported combined abnormal scores. Overall, DDs were more evident with the increase of obesity grade: Mean BMI decreased significantly from 47 ± 7 to 36 ± 6 and to 29 ± 4 kg/m(2) respectively at 3 and 6 months after surgery (p < 0.0001). According to the BMI decrease, the mean WCS decreased from 3.7 ± 3 to 3.1 ± 4 and to 1.6 ± 3 respectively at 3 and 6 months (p = 0.02). Similarly, the FISI score decreased from 10 ± 8 to 3 ± 4 and to 1 ± 2 respectively at 3 and 6 months (p = 0.0001). CONCLUSIONS: Defaecatory disorders are common in morbidly obese patients. The risk of DDs increases with BMI. Bariatric surgery reduces DDs, mainly faecal incontinence, and these findings correlated with BMI reduction.

Comparative study of laparoscopic vs open gastrectomy in gastric cancer management.

AIM: To compare long-term results of gastric cancer patients undergoing laparoscopic and open gastrectomy in a single unit. METHODS: From February 2000 to September 2004, all patients with adenocarcinoma of the stomach were assessed to entry in this longitudinal prospective non-randomized trial. Primary endpoint was cancer-related survival and secondary endpoints were overall survival, evaluation of surgical complications and mortality. RESULTS: Fifty-eight patients were enrolled. Forty-seven patients were followed-up (range 11-103, median 38 mo). Four patients were lost at follow up. Twenty-two patients underwent a laparoscopic gastric surgery (LGS) and 25 had a standard open procedure (OGS). No statistical difference was found between the two groups in terms of 5 years cancer-related mortality rate (50% vs 52%, P = 1), and 5 years overall mortality rate (54.5% vs 56%, P = 1). Accordingly, cancer-related and overall survival probability by Kaplan-Meier method showed comparable results (P = 0.81 and P = 0.83, respectively). We found no differences in surgical complications in the 2 groups. There was no conversion to open surgery in this series. CONCLUSION: LGS is as effective as OGS in the management of advanced gastric cancer. However LGS cannot be recommended routinely over OGS for the treatment of advanced gastric cancer.

Intestinal duplication in adulthood: A rare entity, difficult to diagnose.

Duplications of the alimentary tract (ATD) are rare congenital anomalies often found early in life. They may occur anywhere in the intestinal tract but the ileum is the most frequently affected site. Clinical presentation of ATD in adults is variable and because these lesions occur so infrequently they are rarely suspected. In the present report we describe a case of ileal duplication in a 61-year-old patient with Crohn's disease. Despite various radiological investigations and medical consultations, the diagnosis was only made on the surgical specimen.