Elective bypass surgery for chronic mesenteric ischemic disease: report of 3 cases and review of the literature.

Chronic mesenteric ischemic disease is an unusual cause of chronic abdominal pain. We present our experience from open surgical treatment of patients with this rare disease followed by a short review of the literature. During the period 2006-2008, three patients were referred to our department with clinical and radiological findings of chronic mesenteric ischemic disease. In all patients, at least 2 out of 3 splachnic vessels (celiac artery, superior and inferior mesenteric artery) were occluded, with severe stenosis of the third. Open surgical revasculation was performed in all patients, using autologous or synthetic (Dacron) bypass grafts. Graft patency was examined with triplex ultrasound studies at 3, 6 and 12 months postoperatively and/or follow up CT angiography. All patients had patent grafts during the follow up period and have regained their normal body weight. Immediate and late results, technical details and controversies in open surgical revasculation for chronic mesenteric ischemic disease are reviewed. In conclusion open surgical revasculation for chronic mesenteric ischemic disease is a technically challenging procedure with good results in patients younger than 70 years old , with long occlusions of the splachnic vessels and severe calcification of the vessel wall.

Oxidative stress during abdominal aortic aneurysm repair--biomarkers and antioxidant's protective effect: a review.

BACKGROUND AND OBJECTIVES: Oxidative stress during abdominal aortic aneurysm (AAA) repair is likely to result as a response to an ischemia-reperfusion injury (IRI) to the lower limbs and gastrointestinal tract. This paper reviews the oxidative stress during AAA repair, with specific reference to biological markers and the potential antioxidant's protective effect. EVIDENCE AND INFORMATION SOURCES: The current literature (1966 to July 2010) was reviewed specifically for all articles describing human studies relevant with the particular subject: oxidative stress in patients with AAA repair. Key-words used as single or combined searches included "abdominal aortic aneurysm", "open repair", "EVAR", "oxidative stress", "oxidation" and "antioxidant". RESULTS: A total of 14 relevant human studies were identified. In the majority of studies all samples (blood samples or/and muscle biopsies) were obtained from the patients using regional sampling techniques before or after anaesthesia, during aortic clamping or balloon occlusion (ischemic time) and after aortic clamp removal (reperfusion time) in different time intervals up to 24 or 48 hours. The oxidative status during AAA repair operation was evaluated by measuring quantitative changes of different substances including mainly vascular endothelial adhesion molecules, lipid peroxidation by-products or reactive oxygen species (ROS) and their metabolites. Two studies compared two groups of patients with AAA treated either by open or endovascular repair (EVAR), while four studies used different types of antioxidant supplementation in order to correlate it with a reduction in oxidative stress and damage in the antioxidant group of patients. PERSPECTIVES AND CONCLUSIONS: Current evidence suggests that there is a high-grade oxidative stress during AAA repair operation. This was higher in cases of open repair beside EVAR and in cases with ruptured AAAs beside elective cases. The beneficial effect of an antioxidant supplementation in reducing the oxidative stress during AAA repair was also demonstrated. The use of a biological marker as a predictor of the development of systemic complications could also give a therapeutic advantage.

Palliative gastrectomy and other factors affecting overall survival in stage IV gastric adenocarcinoma patients receiving chemotherapy: a retrospective analysis.

OBJECTIVE: Most patients with gastric cancer present with locally advanced or metastatic disease and usually receive palliative therapy. We sought to identify factors influencing overall survival in patients with stage IV gastric cancer receiving palliative chemotherapy. PATIENTS AND METHODS: The records of 311 patients with histological diagnosis of gastric adenocarcinoma were retrospectively reviewed and 17 clinicopathological and therapeutic parameters were evaluated for their influence on overall survival. RESULTS: In multivariate analysis nine factors were found to independently influence survival: no previous palliative gastrectomy [Hazard ratio (HR, 12; CI 7.969-18.099)], single agent chemotherapy instead of combination chemotherapy (HR, 1.35; CI 1.068-1.721), histological grade III (HR, 1.39; 95% CI 1.098-1.782), the presence of hepatic (HR, 1.6; 95% CI 1.246-2.073) and abdominal metastasis (HR, 1.33; 95% CI 1.039-1.715), CA 72-4 > 7 U/L (HR, 1.39; 95% CI 1.026-1.887), LDH > 225 U/L (HR, 1.72; 95% CI 1.336-2.236], need for blood transfusions (HR, 1.58; 95% CI 1.213-2.082), and weight loss > 5% (HR, 1.96; 95% CI 1.352-2.853) at the time of initial diagnosis. Patients were stratified as low (0-2 factors), intermediate (3-6 factors) and high (7-9 factors) risk and the median survival was 76, 40 and 11 weeks, respectively. CONCLUSION: Nine clinical and laboratory factors that adversely affect survival in patients with stage IV gastric cancer who receive chemotherapy were identified. Their concurrent presence seems to have an additive effect as patients with seven to nine factors have the worse prognosis. Palliative gastrectomy and combination chemotherapy appear to be associated with improved survival.

ICU transfer after elective abdominal aortic aneurysm repair can be succesfully reduced with a modified protocol. A fourteen year experience from a University Hospital.

AIM: To compare different selective criteria for Internal Care Unit (ICU) admission in two different timeframes, after abdominal aortic aneurysm (AAA) repair. A retrospective audit of acquired data was performed. METHODS: During a period of fourteen years (1994-2008), 1152 patients underwent an elective open operation for infrarenal abdominal aortic aneurysm, in our department. Six hundred and two patients (Group A) were treated in the period January 1994-January 2003, and 550 patients (Group B) between January 2003 and August 2008. Postoperatively, all patients were transferred to postanesthesia unit (PAU). After a 2 hours period of close observation, they were transferred either to the ICU or to the surgical ward, according to certain selective criteria (SC). In group A we used SC-A, for admission to an ICU, and in group B we used new, stricter, criteria (SC-B). Thirty-day mortality and morbidity, elective admissions to ICU, rate of subsequent ICU admission, from ward to ICU, and the mean hospital and ICU length of stay, were compared between the two groups. RESULTS: The use of SC-B resulted in a significant reduction of elective admissions to ICU (3.1% vs 8.5%, P<0.001). Nevertheless, the portion of patients, which were transferred with a severe postoperative complication from the ward to ICU, remained similar between the two groups (1.1% vs 0,9%, in group A and B, respectively). All other endpoints were similar in both groups. CONCLUSION: Modifying the protocol of ICU transfer, after elective abdominal aortic aneurysm repair, we can reduce the number of patients requiring ICU, without compromising patients' safety.

Carotid endarterectomy versus carotid angioplasty with or without stenting for treatment of carotid artery stenosis: an updated meta-analysis of randomized controlled trials.

Carotid angioplasty with or without stent placement (CAS) has been proposed as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. We performed a systematic review and meta-analysis of randomized controlled trials to compare the safety and efficacy of endovascular techniques with surgery for carotid stenosis. We searched MEDLINE, PubMed and Cochrane databases to identify randomized controlled trials comparing CAS with CEA. Both random and fixed effects models were used to calculate the pooled odds ratios (OR) and their confidence intervals, with values lower than one indicating a benefit from the endovascular approach. Continuity correction was used for studies with zero events in one arm. We identified 11 trials randomizing a total of 3 258 patients; 1 623 to CEA and 1 635 to CAS. By random effects model, there was no significant difference between the treatments for any stroke (OR, 1.28; 95% CI, 0.82-2.02), or death or any stroke at 30-day (OR, 1.30; 95% CI, 0.92-1.84) and death or any stroke at 6 months (OR, 1.34; 95% CI, 0.86-2.09) or 1 year (OR, 1.41; 95% CI, 0.24-8.27). However there was a significantly higher risk of 30-day death or any stroke (OR, 1.33; 95% CI, 1.01-1.75) after CAS by fixed effects model. Endovascular treatment significantly reduced the risk of 30-day cranial nerve injury (OR, 0.13; 95% CI, 0.04-0.44). In conclusion treating carotid artery stenosis with CAS offers lower rates of cranial nerve injury compared with CEA. CAS could not be proved to be as safe as CEA in treating carotid artery stenosis. The results of ongoing randomized trials comparing CAS with CEA are easily awaited because they may provide sufficient evidence for a change in clinical practice.

Laparoscopic sleeve gastrectomy for morbid obesity with intra-operative endoscopic guidance. Immediate peri-operative and 1-year results after 25 patients.

Laparoscopic sleeve gastrectomy (LSG) represents a promising alternative option for the surgical treatment of morbid obesity. Its standard technique includes the longitudinal division of the stomach along a bougie of varying diameter. We report in this retrospective study our experience with LSG being performed with the use of intra-operative endoscopy instead of the bougie. Twenty-five consecutive patients (18 women, seven men) with a mean age of 40.2 years and mean body weight of 152.1 kg were submitted to LSG with intra-operative endoscopy in our hospital. The mean preoperative BMI was 53.5 kg/m(2). There were no conversions. Mean operative time was 117.5 min. There was no morbidity or mortality. The mean loss of excess body weight (EBW) at 3 months post-op was 19 +/- 1.8 kg, at 6 months was 28.6 +/- 4.5 kg, and at 1 year post-op was 48.9 +/- 3.7 kg (min 11-max 92). In other words the patients had lost 30 +/- 5%, 45 +/- 7.7%, and 60.8 +/- 4.3% of their EBW, respectively. The mean excess body weight loss at the day of the last visit to our outpatient clinic was 52.3 +/- 4.3 kg which corresponded to 66.4 +/- 4.3% of the total excess weight. LSG with intra-operative endoscopic guidance is a safe and efficient alternative method to treat morbid obesity and is a viable option for surgical units familiar with endoscopic techniques.

Irinotecan plus capecitabine as first-line chemotherapy in advanced colorectal cancer.

UNLABELLED: Capecitabine, an oral 5-fluorouracil (5-FU) prodrug, is increasingly replacing intravenous i.v. 5-FU/leucovorin in colorectal cancer treatment. THE AIM of this study was to evaluate efficacy and safety of the combination chemotherapy of irinotecan plus capecitabine (XELIRI), in patients with advanced colorectal adenocarcinoma. PATIENTS AND METHODS: Forty patients received first-line chemotherapy with capecitabine (1.000 mg/m2 twice daily) on days 1-14 and irinotecan (240 mg/m2) on day 1 of a 21-day cycle. Baseline characteristics: 24 men, 16 women; median age 64.5 years. Most common metastatic sites were the liver (55%), lymph nodes (45%), lung (22.5%) and bones (17.5%). RESULTS: There were 12 partial responses (30%), 11 cases of stable disease (27.5%), and 17 cases of disease progression (42.5%). The median survival was 16 months (range, 6-26 months) and median progression-free survival was 7 months (range, 3-14 months). Frequently encountered therapy-related events were leukopenia and gastrointestinal side effects including diarrhea. CONCLUSION: XELIRI is a well-tolerated regimen, with an activity comparable to, but more convenient than, irinotecan-5-FU i.v. combinations in patients with previously untreated advanced colorectal cancer.

Poorly differentiated carcinoma of the rectum with aberrant immunophenotype: a case report.

We report a case of a poorly differentiated epithelial tumour of the rectum with a highly pleomorphic morphology and an aberrant immunophenotype, including the expression of epithelial markers, the focal parameter of neuroendocrine differentiation, and the unexpected detection of CD-117 overexpression. A 69-year-old man was admitted to our clinic complaining of rectal bleeding and weight loss. Colonoscopy showed an ulcerative bleeding mass located about 8 cm from the anal verge. Abdominal and pelvis CT scans demonstrated a large low-density lesion with extracanalicular growth from the middle rectum, with local lymph-node spread, and without tumour infiltration of other pelvic organs, or evidence of distant intra-abdominal spread. The patient underwent a low anterior resection for rectal cancer together with wide resection of lymph nodes. In immunohistochemical analysis, pankeratin and Epithelial Membrane Antigen (EMA) immunolabeling proved the epithelial nature of the tumor cells. Chromogranin A and Leukocyte Common Antigen (LCA) were negative, whereas CD-56 expression was scanty and Neuron Specific Enolase (NSA) was heavily and diffusely expressed. Ki67 immunoexpression was particularly increased. Interestingly, the intense c-kit immunoreactivity (100%) was a common feature. The above phenotypic and immunohistochemical profile was consistent with an anaplastic carcinoma of the large intestine, with focal neuroendocrine differentiation and diffuse immunoreactivity to c-kit protein. Given the resistance of this tumor to conventional chemotherapy and radiation, the incidence of the c-kit alteration may represent a novel approach to a gene-directed treatment using a c-kit inhibitor (STI571) similar to that which has been proposed in GISTs.

Highly conserved sequence of exon 15 BRAF gene and KRAS codon 12 mutation among Greek patients with colorectal cancer.

BACKGROUND: The RAS/RAF/MEK/MAP kinase pathway is essential to intracellular signaling transduction regulating cell proliferation, differentiation and death. We investigated the occurrence of exon 15 BRAF and KRAS codon 12 mutations among Greek patients with colorectal cancer. METHODS: Sixty-one samples from patients with sporadic colorectal adenocarcinomas were studied for exon 15 BRAF mutations. DNA from surgically resected specimens was analyzed by a combination of polymerase chain reaction and direct sequencing. KRAS codon 12 mutational analysis was technically possible in 58 samples (58/61) by a combination of polymerase chain reaction and restriction fragment length polymorphism. RESULTS: No exon 15 BRAF mutations were detected in any of the colon cancer specimens. The frequency of KRAS codon 12 mutations was 29.3% (17/58). Patients aged < or = 70 years more frequently presented carcinomas harboring KRAS codon 12 mutations than patients aged >70 years (p=0.028). Patients between 61 and 70 years of age were more likely to be carriers of this mutation (p=0.040). CONCLUSIONS: Despite the limited study sample, our data suggest that BRAF mutations might be present less frequently than KRAS mutations in Greek patients with colorectal carcinomas. Further research involving larger patient series will be necessary to confirm these findings and to assess possible ethnic, environmental and lifestyle influences on BRAF and KRAS mutagenesis.

Femoral anastomotic aneurysms in the modern era: a reappraisal of a continuing challenge.

AIM: Despite improvement in the operative technique and graft and suture material, femoral anastomotic aneurysms (FAAs) represent a continuing problem for patients undergoing lower extremity revascularization. The present retrospective study investigates the clinical presentation, the infection as a cause of FAAs, the interval between the original operation and the development of FAAs. It also evaluates the mortality and amputation rate of patients with FAAs. METHODS: We reviewed the records of 124 patients (thrombendarterectomy in 9, femoro-femoral bypass in 3 and axillofemoral bypass in 1). RESULTS: There were 13 infected and 14 recurrent FAAs. The overall mean time elapsing between the initial operation and the development of FAAs was 56.9 months (range 1-219). This interval was 62 months for the noninfected FAAs, while it was only 8 months for the infected FAAs. The mean time interval in which a recurrence of FAAs occurred was 39 months. The most common type of repair was an interposition prosthetic graft from the proximal prosthesis to the profunda femoral artery (100 cases). In the postoperative period local complications occurred in 21 (15.4%) cases and systemic in 7 (5.1%). The postoperative mortality was 3.7%. The overall survival at 1 year was 91.3% (standard error: +/-2.5%) and at 2 years 85.4% (standard error: +/-3.3%). Kaplan-Meier analysis showed a cumulative limb salvage of 94.2%, 93.3 % and 89.2% after 6 months, 1 and 2 years, respectively. A significant relationship was demonstrated between amputation and the following parameters: infected FAAs (Log rank test: 26.1, P-value <0.001), diabetes (Log-rank test: 12.9, P-value <0.01), peripheral arterial occlusive disease (Log-rank test: 3.1, P-value =0.08), and prior limb amputation (Log-rank test: 9.9, P-value <0.01). The mean time to amputation for the infected FAAs was 49.6 months (95% CI: 24.3-74.8), while for the noninfected it was 98.8 months (95% CI: 93.4-104.2). CONCLUSIONS: Complicated FAAs are still responsible for significant morbidity and mortality. Elective treatment produce the maximum benefit.

Heregulin, cysteine rich-61 and matrix metalloproteinase 9 expression in human carotid atherosclerotic plaques: relationship with clinical data.

OBJECTIVES: Heregulins (HRGs) are known to induce expression of angiogenic factors such as cysteine rich-61 (CYR61) and collectively to promote neoangiogenesis. Along with extracellular matrix remodelling, mediated by matrix metalloproteinases (MMPs), these factors are important in atherogenesis. The aim of the present study was to investigate HRG, CYR61 and MMP-9 expression and their relationship with clinical and histopathological findings in carotid occlusive disease. MATERIALS AND METHODS: Specimens of human carotid atherosclerotic plaque (n=90) were obtained by endarterectomy. Expression of HRG, CYR61 and MMP-9 was assessed by immunohistochemical and Western blot analysis. Associations between protein expression and degree of carotid stenosis, presence of symptoms, presence of an infarct in CT scan and carotid plaque histopathology were investigated. RESULTS: An increase in HRG, CYR61 and MMP-9 expression was found, particularly in neovascularized regions of the plaques. High HRG expression was associated with the degree of carotid stenosis (p=0.028) and plaque histopathology (p=0.002). More than half of specimens from plaques with >90% stenosis had intense expression of CYR61 (p=0.047). Increased expression of MMP-9 was associated with degree of stenosis and presence of cerebral infarct on CT scan (p=0.05). CONCLUSION: HRG, CYR61 and MMP-9 are highly expressed in human atherosclerotic carotid plaques. The association with the degree of stenosis and/or plaque histopathology implies an involvement in lesion progression.

Surgical treatment of carotid body tumors without embolization.

AIM: Carotid body (CB) paragangliomas are rare neoplasms, usually benign. This study deals with our 10-year experience in their surgical treatment and the evaluation of its effectiveness, without preoperative embolization. METHODS: During a 10-year period, from 1995 to 2004, we studied the medical records of 11 patients with CB tumors, 8 males and 3 females, whom only one had bilateral tumors. Their age ranged from 23 to 65 years (mean 35 years) and all had a palpable neck mass. Only two of the patients were asymptomatic on admission to our department. Twelve tumors were surgically resected and no patient underwent preoperative selective embolism of his tumor. Two patients had carotid endarterectomies with venous patch angioplasty. No one of the patients underwent radiotherapy or chemotherapy. RESULTS: Perioperative mortality was zero. No stroke or any other cerebral event was observed. One patient, with a grade III tumor, had an injury of the internal carotid artery that was repaired with a vein patch. Three patients had temporal cranial nerve lesions that resolved within 3 months. No malignancy was found even in a 10-year follow-up. CONCLUSIONS: Early surgical treatment is strongly recommended in almost all patients. Their resection is a very challenging operation with good postoperative results. Preoperative embolism of the tumor does not need to be a routine procedure. To exclude malignancy, long term follow-up is necessary.

[Angioplasty of the distal anastomosis und runoff arteries of occluded infrainguinal bypasses]. / Die Angioplastie der distalen Anastomose und Run-off-Arterien bei verschlossenen infrainguinalen Bypässen.

BACKGROUND: We investigated the clinical results of transluminal angioplasty performed through infrainguinal bypass grafts for stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries in high risk patients and the influence of different parameters on limb salvage, primary and secondary patency rate. PATIENTS AND METHODS: Between January 2001 and March 2005 we performed 49 transluminal angioplasties on stenotic or occlusive lesions at the distal anastomosis and/or in the runoff arteries in 49 (16 female, 23 male, mean age 71.1 years) patients with occluded infrainguinal bypass. 20 angioplasties occurred in the runoff arteries, 5 at the distal anastomosis and 24 at both locations at a median of 11.3 months (range 2-85 months) after infrainguinal bypass grafting). 20 procedures were on popliteal artery above the knee, 21 below the knee and 8 on crural arteries. RESULTS: Kaplan-Meier analysis showed a cumulative limb salvage of 87.6 and 76.4 % after 6 months and two years, respectively. Patients with gangrenous lesions had a 5 times higher risk of amputation (Cox-regression model). Primary and secondary patency rates were at 6 months 85.1 and 91.1 % respectively and were at one year 73.3 and 78.8 % respectively. Patients with end stage renal disease were in 4 times hazard to primary occlusion and patients with gangrenous lesions 5 times to secondary occlusion (Cox-regression model). CONCLUSION: Even if the long-term results of angioplasty on stenotic or occluded lesions at the distal anastomosis and/or in the runoff arteries are inferior to the results of surgical revisions reported in literature, angioplasty in high risk patients with absence af a vein may be the first line alternative intervention for limb salvage.

A novel spleen-preserving laparoscopic technique using radiofrequency ablation in a porcine model.

BACKGROUND: Partial splenectomy is considered to be the optimal management for a variety of diseases. At the same time, laparoscopic procedures are increasingly used because they present certain advantages against their open counterparts. In this study, the safety and efficacy of radiofrequency ablation (RFA) were evaluated in laparoscopic partial splenectomy performed in a pig model. METHODS: Eight domestic pigs were used. Four abdominal trocars were inserted under general anesthesia and the spleen was stabilized with laparoscopic clamps. A RFA needle electrode was inserted transcutaneously, and coagulative necrosis of a zone of the splenic parenchyma between the body and the lower pole was performed. Bloodless sharp division and removal of the lower pole followed. After 0, 7, 30, or 120 days, the animals were killed and examined. RESULTS: Blood loss and operation time were minimal. Mortality and morbidity were zero. No abnormal findings were encountered during the postmortem abdominal exploration. CONCLUSION: This study demonstrates the feasibility, safety, and efficacy of laparoscopic RFA-assisted partial splenectomy. The RFA-assisted laparoscopic partial splenectomy adds a novel technique to the surgeon's armamentarium for the preservation of a part of the spleen.

Transluminal angioplasty of isolated crural arterial lesions in diabetics with critical limb ischemia.

BACKGROUND: We investigated the long-term clinical results of transluminal angioplasty of isolated infrapopliteal arteries in diabetic patients with severe ischaemic foot lesions and the influence of different parameters on primary success, the long-term outcome and the survival rate. PATIENTS AND METHODS: Between January 2001 and May 2004 we performed 50 transluminal angioplasties in 52 (10 female, 42 male, mean age 69.3 years) diabetics with isolated lesions of crural arteries (tibio-peroneal trunk 41, anterior tibial 13, posterior tibial 5, peroneal artery 14) and limb threatening ischaemia (rest pain 12, tissue loss 40). In two patients the dilatation could not be performed due to vessel perforation and impossibility to catheter localization. The morphological classification of infrapopliteal lesions was determined according to guidelines provided by TransAtlantic Inter-Society Consensus (TASC) (17 type A, 16 type B, 13 type C, 4 type D). RESULTS: Initial technical success after angioplasty of crural arteries could be obtained in 96%. Kaplan-Meier analysis showed a cumulative limb salvage of 92%, 85% and 68,9% after 6 months, one and two years, respectively. Patients falling in TASC group C had significantly higher risk of amputation. Overall survival at I year was calculated at 85% and at 2 years at 65%. CONCLUSION: Our results suggest that depending on the extent of lesions transluminal angioplasty of infrapopliteal artery stenoses and occlusions is considered as an effective and save therapy modality to avoid limb loss in diabetics with critical ischemia.

Laparoscopic liver resection using radio frequency ablation in a porcine model.

BACKGROUND: The aim of this study was to assess the feasibility, efficacy, and safety of laparoscopic left lateral lobe resection, using radiofrequency ablation (RFA) with internally cooled tip electrodes, in a porcine model. METHODS: Eight domestic pigs underwent left lateral hepatic lobectomy. RFA was the sole hemostatic method applied throughout the entire operation. After 0, 7, 30, or 120 days the animals were killed in order to study the macroscopic and microscopic findings on the liver edge. RESULTS: An average of 90 min was enough for the entire operation. No signs of blood loss or infection were observed up to 4 months postoperatively. There was no mortality either during or after surgery. The pathology of the liver revealed the three zone lesions. CONCLUSION: Our study demonstrates that laparoscopic left lateral lobectomy using RFA is technically feasible hi the porcine model and is proved to be highly effective and safe hemostatic method.

Presternal gastric bypass for late postpneumonectomy esophagopleural fistula.

SUMMARY: A 71-year-old diabetic patient underwent right pneumonectomy with wide mediastinal lymph node dissection for lung cancer (right upper lobe). Postoperatively he developed pleura empyema that was successfully treated - drainage and Eloesser window, followed by adjuvant radiotherapy. Two months later he developed an esophagopleural fistula. Due to the patient's physical condition primary repair of the esophageal rupture was considered a high-risk operation. Stenting was also considered as inappropriate due to the existing contamination. Bypassing with the use of the stomach as conduit was preferred due to its simplicity compared to the colon. In order to avoid mediastinum after the postradiation alterations and because of the Eloesser window we adopted a presternal subcutaneous position. Twenty-eight months after the by pass procedure the patient is in good health being able to eat and drink, has gained weight and shows no evidence of malignancy. Presternal gastric esophageal bypass has never been reported as a treatment for esophagopleural fistula. This case report indicates its possible successful use in this debilitating setting, although more experience is needed.

Management of massive presacral bleeding during low pelvic surgery -- an alternative technique.

Although massive presacral bleeding during rectal mobilization is uncommon, it can rapidly destabilize a patient. So, effective hemostasis is critical in severe presacral hemorrhage due to the fatal course of this complication. Among the reported methods are packing, thumbtacks, inflatable devices, muscle tamponade, muscle fragment welding and application of endoscopic staplers. Local hemostatic agents in conjunction with other methods such as diathermy, cyanoacrylate tissue adhesives and application of bone wax are among other alternatives which may help to treat this serious complication. The aim of this study is to describe the anatomic and physiologic basis of our mode of treatment, which is new in the literature approach, treating two patients with presacral bleeding during low anterior resection for rectal cancer. The technique is the early clamping of the infrarenal aorta and suture ligation of the bleeding points from the presacral plexus.

Retroperitoneal perforation of a duodenal diverticulum with colonic necrosis -- report of a case.

Primary duodenal diverticula are usually asymptomatic. About 115 perforations have been reported, but none with right colon necrosis. We report a 45-year-old woman, with a five days history of high fever along with epigastric and periumbilical pain. Physical examination revealed right upper and lower quadrant tenderness with peritoneal signs. White blood cell count was 11 500/mm (3) while biochemical and hepatic biology tests were normal. Abdominal radiographs showed no pathologic findings. Ultrasound disclosed fluid in the lower pelvis. Computerized tomography revealed fluid collection in the right hepatorenal space. Intraoperative findings included purulent fluid in the lower pelvis, segmental necrotic changes of the right colon, and a perforated diverticulum on the antimesenteric border of the third part of the duodenum. Surgery consisted of right hemicolectomy and ileo-transverse anastomosis, diverticulectomy, and decompressive lateral duodenostomy at the second duodenal portion. The patient had an uneventful postoperative course. A contrast study from the duodenostomy tube on the 6 (th) postoperative day showed no leakage or obstruction. Duodenostomy tube was removed on the 14 (th) postoperative day. Histology confirmed the diagnosis of a primary duodenal diverticulum.