Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature.

BACKGROUND: The incidence of perineal hernia after abdominoperineal excision and extralevator abdominoperineal excision ranges from 1 to 26%. In this systematic review, we compared surgical options and postoperative outcomes of perineal hernia repair in this setting from 2012 to 2016 with findings in a review of publications 1944-2011. METHODS: We searched the PubMed database using the keywords "hernia" AND "perineum" identified 392 papers published from 1946 to 2016. Two hundred and ninety-six papers published before 2012 were excluded and 96 were found to be potentially relevant. RESULTS: Twenty-one studies with a total of 108 patients were included in the final analysis. Perineal hernia repair was performed using the perineal approach in 75 patients (69.44%), the laparoscopic approach in 25 patients (23.14%), the open abdominal approach in three patients (2.77%) and the laparoscopic perineal approach in three patients (2.77%) and the open abdominoperineal approach in two patients (1.8%). Non-absorbable mesh was used in 41 (37.96%) of cases, composite mesh in 20 (18.51%) and biological mesh in 19 (17.59%). Flap reconstruction was used in 25 patients (23.14%). First and second recurrences were observed in 26 (24.07%) and 7 (26.92%) cases, respectively. CONCLUSIONS: Comparison of perineal hernia repair from 1944 to 2011 and from 2012 to 2016 showed that perineal and laparoscopic approaches are currently the most commonly used techniques. Primary defect closure was abandoned in favor of synthetic or composite mesh placement. Use of flap reconstruction spread rapidly and the recurrence rate was low. Randomized control trials and a larger sample size are needed to confirm these data and to develop a gold standard treatment for secondary hernia repair after abdominoperineal excision or extralevator abdominoperineal excision.

Late-onset achalasia after esophageal atresia repair.

The development of achalasia in a patient with a history of esophageal atresia (EA) is rare. Here, we report a patient who had undergone surgery for EA at birth and presented achalasia at 30 years of age. He was successfully treated with laparoscopic surgery.

European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations.

INTRODUCTION: Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. METHODS: Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique. RESULTS: These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. CONCLUSION: These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.

Laparoscopic low rectal anastomosis using a new stapling device: early experience with the Contour stapler.

Rectal cancer was initially considered a contraindication for the laparoscopic approach to low rectal resection due to the greater difficulty of deep pelvic dissection, but several studies have demonstrated its potential clinical advantages. The currently accepted technique for this intervention includes total mesorectal excision, which entails complete dissection of the mesorectum followed by low transection of the rectum. The laparoscopic approach provides good visualization and magnification of the operative field, but transection of the rectum may be more difficult. This is illustrated by the conversion rate of around 15% in most series, mainly due to technical difficulties. Contour placement may overcome these difficulties. Two key points support the interest in the use of devices with the features of the Contour. First, the current feeling and evidence indicate that with presently available laparoscopic devices, the section of the low rectum in selected patients (males and mid-third rectal tumors) is often difficult. Secondly, although the Contour device was designed for open surgery, surgeons have the intuitive perception that it perfectly accomplishes the functions an ideal laparoscopic stapler should include. There is clearly a need for more appropriate laparoscopic instruments for low rectal transection. The Contour device could be considered a prototype because it meets the surgeon's requirements when operating on the low rectum, providing one shot, simultaneous sewing and cutting function and a symmetric rectum section. However, a number of technical modifications would enhance the utility of the instrument in this setting.

Imaging-Guided Preoperative Localization of Intra-Abdominal Local Recurrences of Colorectal Cancer Using the Harpoon Technique.

BACKGROUND AND AIMS: Intra-abdominal local recurrences of colorectal cancer can be difficult to localize and excise because they are not easily visible or palpable. MATERIALS AND METHODS: We report on our experience using the computed tomography-guided harpoon technique to locate and resect these nodules in seven patients. RESULTS: No complications were recorded during the procedures. Six nodes were malignant and all margins were tumor free. CONCLUSIONS: Harpoon placement for intra-abdominal local recurrences of colorectal cancer is a feasible and useful technique that provides direct localization and complete excision of lesions.

Immediate peritoneal response to bacterial contamination during laparoscopic surgery.

BACKGROUND: Several studies have shown that laparoscopic surgery (LS) minimizes surgical trauma and the immune function is better preserved. Another major advantage of LS is the lower incidence of septic complications. However, several in vitro studies have shown that CO(2) severely impairs macrophage physiology. In theory, this would reduce the ability to respond to peritoneal contamination. However, there is some controversy in view of the evidence of a better preserved peritoneal response to sepsis. This study analyzed the early response of the peritoneum to contamination in a CO(2) ambience. METHODS: A total of 192 CD-1 mice were distributed in three groups: group 1, laparotomy (LAP, n = 64); group 2, CO(2) laparoscopy (CO(2)-LC, n = 64); and group 3, wall lift laparoscopy (WL-LC, n = 64). Mice in each group were randomized to receive 1 ml of Escherichia coli suspension (1 x 10(4) colony-forming units/ml) or saline. Peritoneal fluid was obtained at 1.5, 3, 6, and 12 h after surgery. Monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), and prostaglandin E(2) (PGE(2)) were measured. RESULTS: MCP-1 levels were significantly greater and higher earlier in group 2 (CO(2)-LC) than in group 1 (LAP) (p < 0.007). Simultaneously, the increment in the traction group (WL-LC, group 3) was significantly higher (p < 0.002) than after laparotomy, with no differences in group 2 (CO(2)-LC). When a contamination was added to the laparotomy subgroup, there was a significant increase compared to the group without contamination (p < 0.5). MCP-1 modifications after contamination in the LAP group were statistically significant and appeared later than in the WL-LC (p < 0.002) and CO(2)-LC groups (p < 0.02). For IL-6, the three models presented a significant increase in the noncontaminated groups. This occurred significantly later in the LAP group. Simultaneously, the increase in IL-6 occurred earlier and was significantly higher in the WL-LC group compared to the LAP group (p < 0.003), without differences between CO(2)-LC and wall lift groups. Significant differences between contaminated and noncontaminated subgroups were only observed in the LC-CO(2) groups. When contaminated, the traction model sustained a higher and earlier rise in IL-6 levels compared to the LAP and LC-CO(2) groups (p < 0.001). For PGE(2), The three models showed a significant increase in PGE(2) levels in the noncontaminated groups. However, there were no significant differences between them. In the contaminated groups, there was no statistical difference between the groups. CONCLUSION: Despite a transient impairment of the immediate peritoneal response to a septic challenge, the degree of injury with LS is lower than that with open surgery, and abdominal infection can therefore be better controlled.

Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura: study of clinical and laboratory data.

BACKGROUND: Laparoscopic splenectomy (LS) offers better short-term results than open surgery for the treatment of immune thrombocytopenic purpura (ITP), but long-term follow-up is required to ensure its efficacy. The remission rate after splenectomy ranges from 49 to 86% and the factors that predict a successful response to surgical management have not been clearly defined. The goal of this study was to determine the preoperative factors that predict a successful outcome following LS. METHODS: From February 1993 to December 2003, LS was consecutively performed in a series of 119 nonselected patients diagnosed with ITP (34 men and 85 women; mean age, 41 years), and clinical results were prospectively recorded. Postoperative follow-up was based on clinical records, follow-up data provided by the referring hematologist, and a phone interview with the patient and/or relative. Univariate and multivariate analyses were performed for clinical preoperative variables to identify predictive factors of success following LS. RESULTS: Over a mean period of 33 months, 103 patients (84%) were available for follow-up with a remission rate of 89% (92 patients, 77 with complete remission with platelet count > 150,000). Eleven patients did not respond to surgery (platelet count < 50,000). Mortality during follow-up was 2.5% (two cases not related to hematological pathology and one case without response to splenectomy). Preoperative clinical variables evaluated to identify predictive factors of response to surgery were sex, age, treatment (corticoids alone or associated with Ig or chemotherapy), other immune pathology, duration of disease, and preoperative platelet count. In a subgroup of 52 patients, we also evaluated the type of autoantibodies and corticoid doses required to maintain a platelet count > 50,000. Multivariate analysis showed that none of the variables evaluated could be considered as predictive factors of response to LS due to the high standard error. CONCLUSION: Long-term clinical results show that LS is a safe and effective therapy for ITP. However, a higher number of nonresponders is needed to determine which variables predict response to LS for ITP.

Multimedia article. Laparoscopic treatment of chronic sigmoid volvulus in a young adult.

INTRODUCTION: Sigmoid volvulus is responsible for 8% of all intestinal obstructions. The most frequent presentation is in the elderly, with it occurring exceptionally in young people. Surgical resection is mandatory to prevent recurrence. Laparoscopic maneuvers in the long and distended bowel are difficult, and not much experience with these procedures has been reported. MATERIALS AND METHODS, AND RESULTS: A 21-year-old man with antecedents of constipation had two episodes of rectal prolapse, and one episode of acute volvulation treated with decompressive endoscopy. A laparoscopic exploration was performed for definitive treatment. Transanal intubation with a large-bore tube permitted deflation of the bowel. A deep Douglas's pouch was observed with a mobile sigmoid loop that intussuscepted the rectum. A proctosigmoidectomy including the 5 cm of the upper rectum was performed without incident. CONCLUSION: Laparoscopic management of suboclusive colonic volvulus is feasible. Intraopertive transanal intubation permits deflation the loop and facilitates manipulation.

Single-dose antibiotic prophylaxis in patients at high risk for infection in biliary surgery: a prospective and randomized study comparing cefonicid with mezlocillin.

The usefulness of antibiotic prophylaxis in biliary surgery is well established. When antibiotic prophylaxis is not used, wound infection rates after biliary surgery range from 10% to 25%. With antibiotic prophylaxis, the rates can be reduced to less than 5%. Three questions are still controversial: Do all patients undergoing biliary surgery require antibiotic prophylaxis? What is the ideal antibiotic for use in biliary surgery? What should be the duration of antibiotic prophylaxis? In this study we prospectively evaluated the efficacy of a single dose of antibiotic prophylaxis in biliary surgery, administered to patients at high risk for infection, in a trial comparing cefonicid (a cephalosporin with a long half-life) with mezlocillin (a broad-spectrum ureidopenicillin).

Surgery in Spain.

The Iberian Peninsula-the southwestern point of Europe, between the Mediterranean Sea and the Atlantic Ocean-was visited and settled in ancient times by a variety of peoples. Phoenicians, Carthaginians, Celts, Greeks, Romans, Visigoths, and Arabs all left their mark on the peninsula, and their cultures blended together to found, among other things, a rich tradition in medicine and surgery. During the Renaissance, the fluid exchange of technical skills and knowledge with the rest of Europe and the emergence of universities ensured the development of a high level of medical expertise. Today, surgery in Spain is at the forefront of innovations in the field.

Complications of laparoscopic splenectomy.

HYPOTHESIS: Analysis of the type and characteristics of complications after laparoscopic splenectomy may permit the identification of clinical factors with predictive value for the development of complications. DESIGN: Univariate and multivariate analysis of factors related to complications in a prospective series of laparoscopic splenectomies. SETTING: A large tertiary referral university-teaching general hospital. PATIENTS: One hundred twenty-two nonselected consecutive patients, in whom laparoscopic splenectomy was attempted between February 1993 and July 1999. INTERVENTION: Laparoscopic splenectomy. MAIN OUTCOME MEASURES: Immediate complications classified according to the Clavien score. Univariate and multivariate analyses were performed of complications related to age, sex, body mass index, and malignant nature of the hematologic disease; preoperative hematocrit and platelet count; operative time; operative position; need of accessory incision; transfusion status; learning curve; and existence of comorbid diseases. RESULTS: One hundred thirteen laparoscopic splenectomies were completed (conversion rate, 7.4%). Twenty patients (18%) developed 23 complications. All were Clavien type I or II, without mortality. One complication was intraoperative (diaphragmatic perforation), and 22 were postoperative: 6 pulmonary (26%), 3 fever (13%), 8 hemorrhagic (35%) (5 episodes of postoperative bleeding and 3 abdominal wall hematomas), and 6 others (26%). Ten (43%) of the 23 were technically related. Univariate analysis showed that complications were only related to age (mean +/- SD, 55 +/- 15 vs 39 +/- 17 years; P<.008) or transfusion (50% vs 11%; P<.001). Multivariate analysis showed that the learning curve (P<.005; 95% confidence interval, 2.46), age (P<.001; 95% confidence interval, 1. 04), spleen weight (P<.009; 95% confidence interval, 1.00), and malignant neoplasm diagnosis (P<.007; 95% confidence interval, 3.82) were independent predictors of complications. CONCLUSIONS: Laparoscopic splenectomy is feasible, and the incidence of severe complications is reduced. However, a high proportion of these complications are technique related. Laparoscopic splenectomy requires great technical care but offers major clinical advantages, even in less favorable situations, such as in patients with splenomegaly or with malignant neoplasms.

Residual splenic function after laparoscopic splenectomy: a clinical concern.

OBJECTIVE: To document the existence of residual splenic function after laparoscopic splenectomy in a series of 48 patients. DESIGN: A noncomparative descriptive case series. SETTING: A tertiary care center. PATIENTS: A series of 9 patients without clinical improvement after laparoscopic splenectomy of 48 consecutive patients undergoing laparoscopic splenectomy for several hematologic disorders after a mean follow-up of 16 months (range, 1-40 months). INTERVENTIONS: A computed tomographic scan and technetium Tc 99m sodium pertechnetate heat-damaged red blood cell scintigraphy were performed for patients with partial (platelet count <100x10(9)/L) or total (platelet count <50x10(9)/L) failure of improvement. MAIN OUTCOME MEASURE: Evidence of residual splenic tissue by image diagnosis. RESULTS: The condition of 9 of the 48 patients failed to improve after laparoscopic splenectomy. Six patients experienced a total failure of improvement and 3 experienced a partial failure of improvement (1 patient had human immunodeficiency virus-related thrombocytopenia and 8 had idiopathic thrombocytopenic purpura). Three patients had residual splenic function, which was revealed by scintigraphy. The results of a computed tomographic scan showed an accessory spleen in one patient and splenic implants in splenic fossa in another patient. CONCLUSION: Laparoscopic splenectomy has a promising role in the management of hematologic diseases requiring splenectomy, but it requires exquisite care to avoid parenchymal rupture and cell spillage and to avoid leaving accessory spleens, which can lead to the failure of surgical treatment.

Extraperitoneal laparoscopically assisted ilioinguinal lymphadenectomy for treatment of malignant melanoma.

BACKGROUND: Current treatment of malignant melanoma of the leg includes ilioinguinal lymphadenectomy (IIL). Standard open IIL (open IIL) includes sectioning of the inguinal ligament to gain access to the iliac nodes. Extraperitoneal laparoscopic IIL (lap IIL) is a feasible, less aggressive approach. It can be combined with standard superficial lymphadenectomy for treatment of malignant melanoma. DESIGN: Comparative, prospective, nonrandomized series. SETTING: Tertiary care center. PATIENTS: Twelve consecutive, unselected patients with malignant melanoma treated with lap IIL (group 1) were compared with 10 consecutive, unselected patients with malignant melanoma on whom open IIL was performed (group 2). INTERVENTIONS: Standard open IIL and laparoscopic extraperitoneal iliac lymphadenectomy (lap IIL) plus superficial groin lymphadenectomy. MAIN OUTCOME MEASURES: Operative time, intraoperative complications, requirements of analgesia, total volume of lymphatic drainage, number of lymph nodes retrieved, immediate morbidity, hospital stay, and long-term morbidity were evaluated. RESULTS: Operative time was significantly longer for the lap IIL group (group 1) than for the open IIL group (group 2) (177+/-44 vs 140+/-18 minutes, respectively; P<.05), but no patients in group 1 needed conversion to open surgery or developed related complications. Overall lymphatic drainage was significantly lower in group 1 than in group 2 (615+/-518 mL vs 1393+/-793 mL, repectively; P<.01). The number of doses of analgesics (13+/-8 vs 31+/-22, P<.03) and length of postoperative stay (7.3+/-3.3 vs 13+/-5 days, P<.006) were also significantly lower in the laparoscopic group. The overall number of lymph nodes retrieved was similar in both groups (10.2+/-4.6 vs 10+/-3, P=.9). One patient developed a groin hernia of 6 m after open IIL. CONCLUSIONS: Laparoscopically assisted IIL offers a less aggressive approach than open IIL and entails less pain and a shorter hospital stay, as we observed in 2 groups with similar oncological results (mainly, a similar number of lymph nodes retrieved) who were treated with one procedure or the other. Further research should be done to confirm these preliminary advantages in a prospective randomized trial with long-term follow-up.

Laparoscopic surgery for treatment of splenic disorders: an update.

Laparoscopic splenectomy is a feasible and safe technique in the hands of skilled laparoscopic surgeons. The special characteristics of the spleen, a fragile solid organ with a rich vascularization, pose a number of technical questions (patient position, organ mobilization and retrieval) which have been successfully resolved during the last few years and permit the advantages of laparoscopic surgery to become available to patients that need splenectomy.

Hand-assisted laparoscopic splenectomy (HALS) in cases of splenomegaly: a comparison analysis with conventional laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) is considerably more difficult to perform when the spleen is enlarged. The new technique of hand-assisted designed technique aimed to assist laparoscopic surgery allows the surgeon to insert his or her hand into the abdomen while maintaining the pneumoperitoneum, thus recovering the tactile sensation lost in conventional laparoscopic surgery. OBJECT: In this study, we compared the immediate results of conventional LS and hand-assisted LS (HALS) in cases of splenomegaly. METHODS: Between February 1993 and August 2001, 200 LS were attempted at two university hospitals. In 56 cases, splenomegaly (final spleen weight >700 g) was observed clinically or detected on radiological examination. We compared the first 36 patients operated on by conventional LS (group I) with the last consecutive 20 patients, who underwent HALS (group II). The study parameters were operative time, conversion rate, transfusion rate, morbidity and length of hospital stay. RESULTS: The groups were comparable in terms of age (58 +/- 13 [ranges, l9-82] vs 58 +/- 16 years [range, 44-84] (ns), diagnosis, and spleen weight (1425 +/- 884 [range, 700-3400]) vs 1753 +/- 1124 g [range, 720-4500] (ns). HALS was associated with less morbidity (36% vs 10%) (ns), a shorter operative time (177 +/- 52 [range, 95-300]) vs 135 +/- 53 min [range, 85-270] (p <0.009), and a shorter hospital stay (6.3 +/- 3.3 [range, 3-14]) vs 4 +/- 1.2 [range, 2-7] days (p <0.05). CONCLUSION: In cases of splenomegaly, HALS assisted laparoscopic surgery significantly facilitates the surgical maneuvers during LS while maintaining the advantages of a purely laparoscopic approach.

Prospective randomized trial comparing conventional laparoscopic colectomy with hand-assisted laparoscopic colectomy: applicability, immediate clinical outcome, inflammatory response, and cost.

BACKGROUND: Hand-assisted laparoscopic surgery (HALS) represents a useful alternative to conventional laparoscopic surgery (LS). Its potential advantages--(a quicker, safer procedure and less need to convert to open surgery) are due to the recovery of tactile feedback. However, HALS requires the performance of a mini-laparotomy when surgery commences, and the wound is stretched and compressed throughout the procedure. In addition, it is associated with a more intense manipulation of the intraabdominal viscera. All of these factors increase the surgical trauma, it is not known whether HALS maintains the minimally invasive characteristics of conventional LS. Therefore, we set out to study the applicability, immediate clinical outcome, inflammatory response, and cost of HALS compared with conventional LS using colectomy as a model. METHODS: We performed a prospective randomized trial comparing laparoscopic-assisted colectomy with HAL colectomy. The aims of the study were to assess (a) perioperative features, including time, advantages, and conversion; (b) the patient's immediate clinical response, including recovery of bowel sounds, refeeding time, postoperative pain, local and general morbidity, and hospital stay; (c) the effect on the inflammatory response, using interleukin-6 (ILG) and C-reactive protein (CRP) measurements; (d) oncological issues, including intraoperative cytology and features of the specimen; and (d) the relative costs of the two procedures. RESULTS: A total of 54 patients were enrolled in the study, 27 laparoscopic and 27 HALS. The operative times were similar, but HALS was associated with a far lower conversion rate--7% vs 23%. Immediate clinical outcomes, oncological features, and costs were similar for the two procedures, but HALS was associated with a significantly greater increase in IL6 and CRP than the conventional laparoscopic procedure. CONCLUSION: This comparative study shows that HALS simplifies difficult intraoperative situations, reducing the need for conversion. Although it is a more aggressive procedure, HALS preserves the features of a minimally invasive approach, maintains all of the oncological features of conventional laparoscopic surgery, and does not increase the cost. HALS should therefore be considered as a useful adjunct when difficult situations arise during conventional laparoscopic colectomy.

Long-term outcome after laparoscopic splenectomy related to hematologic diagnosis.

BACKGROUND: Laparoscopic splenectomy (LS) has been demonstrated as an effective and safe treatment for hematological disorders requiring spleen removal, especially in cases of normal-sized spleens. However, although results are promising, long-term outcome data are lacking. We reviewed our clinical experience with LS in a series of 255 cases, with particular attention to the long-term outcome related to the disease process requiring LS. METHODS: From February 1993 to October 2003, LS was attempted in 255 patients (100 males and 155 females with a mean age of 45 +/- 19 years) and clinical information was recorded in a prospective database. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) (n = 115), HIV-ITP (n = 9), Evans syndrome (n = 6), autoimmune hemolytic anemia (AIHA) (n = 13), hereditary spherocytosis (HS) (n = 19), hematologic malignancy (n = 66), thrombotic thrombocytopenic purpura (n = 1), and others (n = 26). Long-term postoperative follow-up evaluation was obtained through clinical notes, follow-up visits by the referring hematologist, and by phone interviews both with patients and with the referring hematologist. RESULTS: A total of 186 patients (73%) were available for a mean follow-up of 35 months (range, 1-104). Of the ITP patients, 87 (76%) were followed up, with a remission rate of 89% (complete remission in 75%). A similar remission rate was observed in ITP-HIV; in patients available for follow-up (78%), complete remission was achieved in 83%. In Evans, complete remission was achieved in all patients available for follow-up (67%). Clinical response for hemolytic disease ranged between 70% for AIHA and 100% for HS. In the malignant group, the late mortality rate was 22%. The mortality rate in the miscellaneous group was 5%. No cases of splenectomy-related sepsis occurred during follow-up. CONCLUSIONS: LS offers advantages for all types of splenic diseases requiring surgery. It provides not only good clinical short-term outcome but also satisfactory long-term hematological results.

Mid term analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia.

BACKGROUND: Initial experience with the laparoscopic repair of paraesophageal and type III mixed hiatal hernias showed that it is safe and feasible, with excellent immediate and short-term results. However, after a longer follow-up, a recurrence rate of < or =40% has been demonstrated. Data related to the outcome of paraesophageal hernia repair and the recurrence rate are still lacking. Quality-of-life scores may offer a better means of assessing the impact of surgical treatment on the overall health status of patients. Therefore, we performed prospective evaluation of anatomic and/or symptomatic recurrences after paraesophageal or large hiatal hernia repair. In addition, we investigated the correlation between recurrence and the patient's quality of life. METHODS: All patients after who had undergone repair of paraesophageal of mixed hiatal hernia were identified prospectively from a database consisting of all patients who had had laparoscopic operations for gastroesophageal pathology at our hospital between February 1998 and December 2002. The preoperative symptoms were taken from patients' clinical files. In March 2003, all patients with > or =6 months of follow-up had a barium swallow and were examined for radiological and clinical signs of recurrence. Thereafter, the patients' quality of life after surgery was evaluated using three standard questionnaires (Short Form 36 [SF-36], Glasgow Dyspepsia Severity Score [GDSS], and Gastrointestinal Quality of Life Index [GIQLI]. RESULT: During the study period, 46 patients had been operated on. The mean age was 63 years (range, 28-93). Thirty seven of them had a follow-up of > or =6 months. Eight patients (21%) had postoperative gastrointestinal symptoms. Barium swallow was performed in 30 patients (81%) and showed a recurrence in six of them (20%). According to SF-36 and GDSS, the patients' postoperative quality of life reached normal values and did not differ significantly from the standard values for the Spanish population of similar age and with similar comorbidities. Successfully operated patients reached a GIQLI value comparable to the standard population. However, symptomatic patients had significantly lower GIQLI scores than the asymptomatic or the Rx-recurrent group. CONCLUSION: The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.

Is exocrine pancreatic cancer a hormone-dependent tumor? A study of the existence of sex hormone receptors in normal and neoplastic pancreas.

The 5-year survival rate of patients with exocrine pancreatic cancer after surgery is less than 5%, in patients treated with radical surgery, with or without adjuvant therapy. It has been well documented clinically and experimentally that sex hormones influence the physiology of the exocrine pancreas. Hormone manipulation inhibits the growth of human pancreatic cancer in nude mice. Several nonrandomized studies have suggested the efficacy of antihormone therapy in the treatment of advanced pancreatic cancer. However, the existence of sex hormone receptors in exocrine pancreatic cancer has been a matter of controversy. This study was designed to investigate the presence of sex hormone receptors (estrogens, progesterone and androgens in normal pancreas and exocrine pancreatic cancer, using two different methods: immunohistochemistry and enzyme immunoassay. Twenty-eight biopsies of normal pancreas and 15 biopsies of exocrine pancreatic cancer were studied. Estrogen receptors and progesterone receptors were measured by enzyme immunoassay, using specific monoclonal antibodies. Androgen receptors were determined by radioligand assay. Sixteen biopsies of normal pancreas and 12 biopsies of exocrine pancreatic cancer were studied by immunohistochemistry. In exocrine pancreatic cancer we could not detect estrogen receptors or progesterone receptors, either by enzyme immunoassay or immunohistochemistry. Androgen receptors were always negative (less than 2 fm/mg). In the normal pancreas, 5 out of 28 cases showed increased levels of progesterone receptors (greater than 10 fm/mg) as measured by enzyme immunoassay. Immunohistochemistry revealed progesterone receptors in the pancreatic islets of 16 normal pancreases studied. Nuclear staining was observed in more than 70% of the cells. Estrogen receptors were always negative by immunohistochemistry and enzyme immunoassay in the normal pancreas.2+n