Laparoscopic Gastrectomy for Cancer: Cut Down Complications to Unveil Positive Results of Minimally Invasive Approach.

Several randomized controlled trials and meta-analyses have confirmed the advantages of laparoscopic surgery in early gastric cancer, and there are indications that this may also apply in advanced distal gastric cancer. The study objective was to evaluate the safety and effectiveness of laparoscopic gastrectomy (LG), in comparison to open gastrectomy (OG), in the management of locally advanced gastric cancer. The single-center, case-control study included 204 patients, in conveyance sampling, who underwent radical gastrectomy for locally advanced gastric cancer. Out of 204 patients, 102 underwent LG, and 102 patients underwent OG. The primary endpoints were safety endpoints, i.e., complication rates, reoperation rates, and 30-day mortality rates. The secondary endpoints were efficacy endpoints, including perioperative characteristics and oncological outcomes. Even though the overall complication rate was higher in the OG group compared to the LG group (30.4% and 19.6%, respectively), the difference between groups did not reach statistical significance (p = 0.075). No significant difference was identified in reoperation rates and 30-day mortality rates. Time spent in the intensive care unit (ICU) and overall hospital stay were shorter in the LG group compared to the OG group (p < 0.001). Although the number of retrieved lymph nodes is oncologically adequate in both groups, the median number is higher in the OG group (35 vs. 29; p = 0.024). Resection margins came out to be negative in 92% of patients in the LG group and 73.1% in the OG group (p < 0.001). The study demonstrated statistically longer survival rates for the patients in the laparoscopic group, which particularly applies to patients in the most prevalent, third stage of the disease. When patients with the Clavien-Dindo grade ≥II were excluded from the survival analysis, further divergence of survival curves was observed. In conclusion, LG can be safely performed in patients with locally advanced gastric cancer and accomplish the oncological standard with short ICU and overall hospital stay. Since postoperative complications could affect overall treatment results and diminish and blur the positive effect of the minimally invasive approach, further clinical investigations should be focused on the patients with no surgical complications and on clinical practice to cut down the prevalence of complications.

Laparoscopic gastrectomy for stage II and III advanced gastric cancer: long­term follow­up data from a Western multicenter retrospective study.

INTRODUCTION: There has been an increasing interest for the laparoscopic treatment of early gastric cancer, especially among Eastern surgeons. However, the oncological effectiveness of Laparoscopic Gastrectomy (LG) for Advanced Gastric Cancer (AGC) remains a subject of debate, especially in Western countries where limited reports have been published. The aim of this paper is to retrospectively analyze short- and long-term results of LG for AGC in a real-life Western practice. MATERIALS AND METHODS: All consecutive cases of LG with D2 lymphadenectomy for AGC performed from January 2005 to December 2019 at seven different surgical departments were analyzed retrospectively. The primary outcome was diseases-free survival (DFS). Secondary outcomes were overall survival (OS), number of retrieved lymph nodes, postoperative morbidity and conversion rate. RESULTS: A total of 366 patients with stage II and III AGC underwent either total or subtotal LG. The mean number of harvested lymph nodes was 25 ± 14. The mean hospital stay was 13 ± 10 days and overall postoperative morbidity rate 27.32%, with severe complications (grade ≥ III) accounting for 9.29%. The median follow-up was 36 ± 16 months during which 90 deaths occurred, all due to disease progression. The DFS and OS probability was equal to 0.85 (95% CI 0.81-0.89) and 0.94 (95% CI 0.92-0.97) at 1 year, 0.62 (95% CI 0.55-0.69) and 0.63 (95% CI 0.56-0.71) at 5 years, respectively. CONCLUSION: Our study has led us to conclude that LG for AGC is feasible and safe in the general practice of Western institutions when performed by trained surgeons.

The impact of EAES Fellowship Programme: a five-year review and evaluation.

BACKGROUND: The European Association of Endoscopic Surgery (EAES) fellowship programme was established in 2014, allowing nine surgeons annually to obtain experience and skills in minimally invasive surgery (MIS) from specialist centres across the Europe and United States. It aligns with the strategic focus of EAES Education and Training Committee on enabling Learning Mobility opportunities. To assess the impact of the programme, a survey was conducted aiming to evaluate the experience and impact of the programme and receive feedback for improvements. METHODS: A survey using a 5-point Likert scale was used to evaluate clinical, education and research experience. The impact on acquisition of new technical skills, change in clinical practice and ongoing collaboration with the host institute was assessed. The fellows selected between 2014 and 2018 were included. Ratings were analysed in percentage; thematic analysis was applied to the free-text feedbacks using qualitative analysis. RESULTS: All the fellows had good access to observing in operating theatres and 70.6% were able to assist. 91.2% participated in educational activities and 23.5% were able to contribute through teaching. 44.1% participated in research activities and 41.2% became an author/co-author of a publication from the host. 97.1% of fellows stated that their operative competency had increased, 94.3% gained new surgical skills and 85.7% was able to introduce new techniques in their hospitals. 74.29% agreed that the clinical experience led to a change in their practices. The most commonly suggested improvements were setting realistic target in clinical and research areas, increasing fellowship duration, and maximising theatre assisting opportunities. Nevertheless, 100% of fellows would recommend the fellowship to their peers. CONCLUSION: EAES fellowship programme has shown a positive impact on acquiring and adopting new MIS techniques. To further refine the programme, an individualised approach should be adopted to set achievable learning objectives in clinical skills, education and research.

Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: A multi-institutional propensity score-matched study.

BACKGROUND AND OBJECTIVES: In the setting of a minimally invasive approach, we aimed to compare short and long-term postoperative outcomes of patients treated with neoadjuvant therapy (NAT) + surgery or upfront surgery in Western population. METHODS: All consecutive patients from six Italian and one Serbian center with locally advanced gastric cancer who had undergone laparoscopic gastrectomy with D2 lymph node dissection were selected between 2005 and 2019. After propensity score-matching, postoperative morbidity and oncologic outcomes were investigated. RESULTS: After matching, 97 patients were allocated in each cohort with a mean age of 69.4 and 70.5 years. The two groups showed no difference in operative details except for a higher conversion rate in the NAT group (p = 0.038). The overall postoperative complications rate significantly differed between NAT + surgery (38.1%) and US (21.6%) group (p = 0.019). NAT was found to be related to a higher risk of postoperative morbidity in patients older than 60 years old (p = 0.013) but not in patients younger (p = 0.620). Conversely, no difference in overall survival (p = 0.41) and disease-free-survival (p = 0.34) was found between groups. CONCLUSIONS: NAT appears to be related to a higher postoperative complication rate and equivalent oncological outcomes when compared with surgery alone. However, poor short-term outcomes are more evident in patients over 60 years old receiving NAT.

Laparoscopic enucleation of Frantz's tumor of the pancreas: Case report and literature review.

INTRODUCTION: Frantz's tumor of the pancreas is a rare phenomenon, and it accounts for 1-3% of all neoplasms of the pancreas. Its percentage is much higher in younger persons, especially in younger women, as compared to the rest of the population. PRESENTATION OF CASE: The present study describes a 32-year-old female patient in whom a preoperative imaging diagnosis confirmed a mass in the junction of the pancreas' body and tail. Based on the anamnesis, the preoperative diagnosis, and the patient's general status, the decision was made to performed laparoscopic enucleation of the pancreatic tumor. The operation and postoperative recovery passed without complications. Definitive histopathological and immunohistochemical findings confirmed a solid pseudopapillary neoplasm of the pancreas. DISCUSSION: Depending on the localization and the size of the tumor, surgical options range from typical and atypical resections of the pancreas to minimally invasive surgical procedures, such as local excision and enucleation. Laparoscopic procedures have a comparative advantage in cases of enucleation and resection of the pancreas. The low frequency of recidivation and a favorable prognosis, even after repeated surgery, are additional reasons for favoring the laparoscopic approach over the classical surgical approach. CONCLUSION: A minimally invasive surgical approach should be applied whenever the dimensions and the localization of the tumor permit it, bearing in mind all the benefits and advantages that this surgical technique offers.

Preparation and modeling of three-layered PCL/PLGA/PCL fibrous scaffolds for prolonged drug release.

The authors present the preparation procedure and a computational model of a three-layered fibrous scaffold for prolonged drug release. The scaffold, produced by emulsion/sequential electrospinning, consists of a poly(D,L-lactic-co-glycolic acid) (PLGA) fiber layer sandwiched between two poly(ε-caprolactone) (PCL) layers. Experimental results of drug release rates from the scaffold are compared with the results of the recently introduced computational finite element (FE) models for diffusive drug release from nanofibers to the three-dimensional (3D) surrounding medium. Two different FE models are used: (1) a 3D discretized continuum and fibers represented by a simple radial one-dimensional (1D) finite elements, and (2) a 3D continuum discretized by composite smeared finite elements (CSFEs) containing the fiber smeared and surrounding domains. Both models include the effects of polymer degradation and hydrophobicity (as partitioning) of the drug at the fiber/surrounding interface. The CSFE model includes a volumetric fraction of fibers and diameter distribution, and is additionally enhanced by using correction function to improve the accuracy of the model. The computational results are validated on Rhodamine B (fluorescent drug l) and other hydrophilic drugs. Agreement with experimental results proves that numerical models can serve as efficient tools for drug release to the surrounding porous medium or biological tissue. It is demonstrated that the introduced three-layered scaffold delays the drug release process and can be used for the time-controlled release of drugs in postoperative therapy.

Non-active implantable device treating acid reflux with a new dynamic treatment approach: 1-year results : RefluxStop™ device; a new method in acid reflux surgery obtaining CE mark.

BACKGROUND: RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected. METHODS: In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction. RESULTS: There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects. CONCLUSION: The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02759094 . Registered 3 May, 2016.

Laparoscopic Management of Initially Unrecognized Splenic Hydatid Cysts: A Case Report and Review of the Literature.

We present a case report that demonstrates diagnostic and intraoperative challenges in the laparoscopic management of initially unrecognized splenic hydatid disease. A male patient, aged 44, was admitted to our department with a big unilocular splenic cyst, radiologically (ultrasonography, computed tomography) characterized as a simple cyst. Serological tests for anti-Echonococcus antibody were negative, and chests X-ray findings were unremarkable, so laparoscopic cyst fenestration with omentoplasty was planned. The intraoperative finding did not correspond to a simple splenic cyst. Hydatid daughter cysts were recognized after the careful opening of the cyst wall. The operation was completed without shifting to open procedures. Laparoscopic partial pericystectomy with omentoplasty is a safe and effective surgical procedure for the management of splenic hydatid disease.

A Prospective, Randomized, Phase III Study to Evaluate the Efficacy and Safety of Fibrin Sealant Grifols as an Adjunct to Hemostasis as Compared to Cellulose Sheets in Hepatic Surgery Resections.

BACKGROUND: Local hemostatic agents have a role in limiting bleeding complications associated with liver resection. METHODS: In this randomized, phase III study, we compared the efficacy and safety of Fibrin Sealant Grifols (FS Grifols) with oxidized cellulose sheets (Surgicel®) as adjuncts to hemostasis during hepatic resections. The primary efficacy endpoint was the proportion of patients achieving hemostasis at target bleeding sites (TBS) within 4 min (T4) of treatment application. Secondary efficacy variables were time to hemostasis (TTH) at a later time point if re-bleeding occurs and cumulative proportion of patients achieving hemostasis by time points T2, T3, T5, T7, and T10. RESULTS: The rate of hemostasis by T4 was 92.8% in the FS Grifols group (n = 163) and 80.5% in the Surgicel® group (n = 162) (p = 0.01). The mean TTH was significantly shorter (p < 0.001) in the FS Grifols group (2.8 ± 0.14 vs. 3.8 ± 0.24 min). The rate of hemostasis by T2, T5, and T7 was higher and statistically superior in the FS Grifols group compared to Surgicel®. No substantial differences in adverse events (AE) were noted between treatment groups. The most common AEs were procedural pain (36.2 vs. 37.7%), nausea (20.9 vs. 23.5%), and hypotension (14.1 vs 6.2%). CONCLUSIONS: FS Grifols was safe and well tolerated as a local hemostatic agent during liver resection surgeries. Overall, data demonstrate that the hemostatic efficacy of FS Grifols is superior to Surgicel® and support the use of FS Grifols as an effective local hemostatic agent in these surgical procedures.

Open Surgical Treatment of Secondary Aortoesophageal and Aortobronchial Fistula after Thoracic Endovascular Aortic Repair and Esophagocoloplasty in a Second Procedure.

Aortoesophageal (AEF) and aortobronchial fistula (ABF) after thoracic endovascular aortic repair (TEVAR) are rare complications with catastrophic consequences without treatment. In this case report, we presented a patient with AEF and ABF after TEVAR successfully treated with endograft explantation and replaced by Dacron graft followed by esophagectomy and left principal bronchus repairing. We report a patient with AEF and ABF after TEVAR who was evaluated due to dysphagia and chest pain followed by hematemesis and hemoptysis. Endoscopic examination revealed lesion of the esophageal wall with chronic abscess formation and stent-graft protrusion into the cavity. Patient was operated on with extracorporeal circulation. AEF and ABF were confirmed intraoperatively. Endograft was explanted and in situ reconstruction of thoracic aorta was carried out with tubular Dacron 22-mm prosthesis wrapped with omental flap. After aortic reconstruction, esophageal mucosal stripping was performed with cervical esophagostomy, pyloromyotomy, and Stamm-Kader gastrostomy for nutrition. In addition, omentoplasty of the defect in the left principal bronchus was performed. To re-establish peroral food intake esophagocoloplasty was carried out 8 months after previous surgery utilizing transversosplenic segment of the colon and retrosternal route. In very selective cases, stent-graft explantation and in situ reconstruction with Dacron graft covered by omental flap followed by esophagectomy and bronchus repairing permit adequate debridement reducing the risk of mediastinitis and graft infection and allow a safe esophageal reconstruction in a second procedure.

Minimally Invasive Esophagectomy for Cancer: Single Center Experience after 44 Consecutive Cases.

INTRODUCTION: At the Department of Minimally Invasive Upper Digestive Surgery of the Hospital for Digestive Surgery in Belgrade, hybrid minimally invasive esophagectomy (hMIE) has been a standard of care for patients with resectable esophageal cancer since 2009. As a next and final step in the change management, from January 2015 we utilized total minimally invasive esophagectomy (tMIE) as a standard of care. OBJECTIVE: The aim of the study was to report initial experiences in hMIE (laparoscopic approach) for cancer and analyze surgical technique, major morbidity and 30-day mortality. METHODS: A retrospective cohort study included 44 patients who underwent elective hMIE for esophageal cancer at the Department for Minimally Invasive Upper Digestive Surgery, Hospital for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2009 to December 2014. RESULTS: There were 16 (36%) middle thoracic esophagus tumors and 28 (64%) tumors of distal thoracic esophagus. Mean duration of the operation was 319 minutes (approximately five hours and 20 minutes). The average blood loss was 173.6 ml. A total of 12 (27%) of patients had postoperative complications and mean intensive care unit stay was 2.8 days. Mean hospital stay after surgery was 16 days. The average number of harvested lymph nodes during surgery was 31.9. The overall 30-day mortality rate within 30 days after surgery was 2%. CONCLUSION: As long as MIE is an oncological equivalent to open esophagectomy (OE), better relation between cost savings and potentially increased effectiveness will make MIE the preferred approach in high-volume esophageal centers that are experienced in minimally invasive procedures.

Efficacy of long-acting somatostatin analogs in recurrent variceal bleeding in a patient with pre-hepatic portal vein thrombosis.

INTRODUCTION: Bleeding from esophageal varices is a serious medical problem because of the risk of recurrent bleeding and high mortality rate (17-54%). Gastroesophageal varices develop in 50% of cirrhotic patients with portal hypertension, but can also develop in other pre- or post-hepatic causes of portal hypertension. CASE REPORT: We reported a 48-year-old female patient with portal hy- pertension caused by mesenterial vein thrombosis due to congenital thrombophilia. The patient was hospitalized several times be- cause of recurrent gastroesophageal bleeding. Thrombosis of portal, lienal and mesenteric veins was diagnosed using multislice computed tomography (MSCT) angiography. Sclerotherapy and/or variceal ligation could not be used due to variceal size and distribution. Beta blockers were ineffective. Balloon tamponade and octreotide were used in each massive bleeding episode. Carvedilol therapy was introduced but rebleeding occured. Surgical treatment was considered a high risk procedure due to massive thrombosis of mesenterial veins, patient's general condition and high risk of postoperative thrombotic events. Thus, long-acting somatostatin analogue--Sandostatin LAR was initiated at a dose of 30 mg im/month. The patient responded to the therapy well and variceal bleeding did not occur for the following 3 months. After 3 months another episode of gastric variceal hemorrhage occurred and surgical treatment was reconsidered. Total gastrectomy was performed in order to prevent repeated bleeding from large gastric varices and the patient recovered successfully, and after 1 year is symptom-free. Conclusion. Long-lasting somatostatin analogue was used for the first time in treatment of gastroesophageal variceal hemorrhage in the patient with prehepatic portal hypertension. It was effective as temporary therapeutic option allowing the improvement of the patients general condition and adequate planning of elective surgical procedure. Futher reports are needed in order to compare efficacy in treatment of patients with variceal bleeding, where poor outcome is expected.

The use of autologous fascia lata graft in the laparoscopic reinforcement of large hiatal defect: initial observations of the surgical technique.

BACKGROUND: Even though there is no consensus, many authors believe that in the cases of large hiatal defects, structurally altered crura and/or absence of peritoneal lining, a crural reinforcement should be performed. Reinforcement could be performed with different techniques and different type of mesh, either synthetic or biologic. The disadvantages of mesh repair include the possibility of serious complications and increased costs especially in the usage of composite or biologic mesh. METHODS: The study includes 10 cases of reinforced primary suture line of the pillars with autologous fascia lata, in elective laparoscopic repair of the giant PEH with a large hiatal defect and friable crura. After intraopreative confirmation of the large hiatal defect (hiatal surface area of more than 8 cm²) and friable crura, an autologous fascia lata graft was harvested in the usual manner and placed in on-lay fashion to reinforce the pillar suture line. We analyzed surgical technique, complications, and initial follow-up of the patients. RESULTS: Average hiatal surface area (HSA) in our series was 10.6 cm² (range 8.1 to 14.4 cm²). The average duration of operation was 203.9 min/3.4 hours (range 160-250 min). Except for a mild hematoma in the harvesting region that resolved spontaneously, there were no procedure related complications and 30 days mortality rate was zero. The average postoperative length of stay was 6.5 days (5-8 days). Out of 10 patients, 5 completed the annual follow-up visit, while 8 completed a 6- month follow-up visit. So far there is no hernia recurrence and/or problems with swallowing function. However, one patient has felt a mild discomfort in the harvested region that does not influence normal daily activities. CONCLUSIONS: Autologous fascia lata graft hiatal reinforcement represents a technically feasible, easy, and available option for the on-lay reinforcement of large hiatal defects with friable crura in the laparoscopic repair of giant PEHs.

The Burden of Gastroesophageal Reflux Disease on Patients' Daily Lives: A Cross-Sectional Study Conducted in a Primary Care Setting in Serbia.

INTRODUCTION: Recent data from the studies conducted in the Western countries have proved that patients with gastroesophageal reflux disease have significantly impaired health-related quality of life compared to general population. OBJECTIVE: The study is aimed at evaluating the burden of reflux symptoms on patients'health-related quality of life. METHODS: The study involved 1,593 patients with diagnosed gastroesophageal reflux disease.The Serbian version of a generic self-administered Centers for Disease Control and Prevention questionnaire was used. Statistical analyses included descriptive statistics, Pearson chi-square test and a multiple regression model. RESULTS: Among all participants, 43.9% reported fair or poor health. Mean value of unhealthy days during the past 30 days was 10.4 days, physically unhealthy days 6.4 days, mentally unhealthy days 5.3 days and activity limitation days 4.3 days. Furthermore, 24.8% participants reported having ≥ 14 unhealthy days, 14.9% had 14 physically unhealthy days, 11.8% reported 14 mentally unhealthy days, and 9.4% had ≥ 14 activity limitation days. CONCLUSION: This study addressed complex relationships between reflux symptoms and patients'impaired everyday lives.

Laparoscopic repair of hiatal hernias: experience after 200 consecutive cases.

INTRODUCTION: Repair of hiatal hernias has been performed traditionally via open laparotomy or thoracotomy. Since first laparoscopic hiatal hernia repair in 1992, this method had a growing popularity and today it is the standard approach in experienced centers specialized for minimally invasive surgery. OBJECTIVE: In the current study we present our experience after 200 consecutive laparoscopic hiatal hernia repairs. METHODS: A retrospective cohort study included 200 patients who underwent elective laparoscopic hiatal hernia repair at the Department for Minimally Invasive Upper Digestive Surgery, Clinic for Digestive Surgery, Clinical Center of Serbia in Belgrade from April 2004 to December 2013. RESULTS: Hiatal hernia types included 108(54%) patients with type 1, 30 (15%) with type III, 62 (31%) with giant paraesophageal hernia, while 27 (13.5%) patients presented with a chronic gastric volvulus. There were a total of 154 (77%) Nissen fundoplications. In 26 (13%) cases Nissen procedure was combined with esophageal lengthening procedure (Collis-Nissen), and in 17 (8.5%) Toupet fundoplications was performed. Primary retroesophageal crural repair was performed in 164 (82%) cases, Cleveland Clinic Foundation suture modification in 27 (13.5%), 4 (2%) patients underwent synthetic mesh hiatoplasty, 1 (0.5%) primary repair reinforced with pledgets, and 4 (2%) autologous fascia lata graft reinforcement. Poor result with anatomic and symptomatic recurrence (indication for revisional surgery) was detected in 5 patients (2.7%). CONCLUSION: Based on the result analysis, we found that laparoscopic hiatal hernia repair was a technically challenging but feasible technique, associated with good to excellent postoperative outcomes comparable to the best open surgery series.

Does the computed tomography perfusion imaging improve the diagnostic accuracy in the response evaluation of esophageal carcinoma to the neoadjuvant chemoradiotherapy? Preliminary study.

PURPOSE: To estimate whether the computed tomography (CT) perfusion imaging could be useful to predict the pathological complete response (pCR) of esophageal cancer to the neoadjuvant chemoradiotherapy (NACRT). METHODS: Twenty-seven patients with the advanced squamous cell esophageal carcinoma, who were treated with concomitant CRT (CIS/5-FU/LV and 45-50 Gy total radiation dose), were re-evaluated using CT examination, which included the low-dose CT perfusion study. CT perfusion series were analysed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE), and color parametric maps of the blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability surface area product (PS) were displayed. All patients were operated and histopathological analysis of the resected esophagus considered the gold standard for pathologic complete response (pCR). RESULTS: BFpost-NACRT, BVpost-NACRT, and PSpost-NACRT were significantly lower, and MTTpost-NACRT significantly higher in the pCR group. Mean (±SD), or median perfusion parameter values in the pCRs (11 patients) vs non-pCRs (16 patients) were: BFpost-NACRT- 21.4±5.0 vs 86.0±29 ml/min/100 g (p<0.001), BVpost-NACRT- 1.3 vs 3.9 ml/100 g (p<0.001), MTTpost-NACRT- 5.5 vs 3.7 s (p=0.018), and PSpost-NACRT- 5.9 vs 9.8 ml/min/100 g (p=0.006). ROC analysis revealed that BFpost- NACRT (AUC=1.000), BVpost-NACRT (AUC=0.932), MTTpost-NACRT (AUC=0.801), and PSpost-NACRT (AUC=0.844) could predict the pCR (p<0.01), while maximal esophageal wall thickness could not (AUC=0.676, p=0.126). If we set a cut-off value of BFpost-NACRT<30.0 ml/min/100 g, pCR was predicted with sensitivity and specificity of 100%. CONCLUSION: CT perfusion imaging enables accurate prediction of pCR of esophageal carcinoma to neoadjuvant chemoradiotherapy.

[Laparoscopic myotomy in achalasia cardia treatment: experience after 36 operations].

INTRODUCTION: Laparoscopic Heller-Dor operation, a standard method in the treatment of achalasia, has been performed at the Center for Esophageal Surgery of the First Surgical Clinic since April 2006. OBJECTIVE: The aim of this study was to present this surgical procedure and initial experiences after 36 consecutive laparoscopic Heller-Dor operations. METHODS: This partly retrospective, partly prospective study presented our results after laparoscopic Heller-Dor operation (presentation of the treatment method). We performed a standard anterior esophagocardioymiotomy, without releasing the posterior aspect of the cardia, and anterior partial fundoplication. The type and severity of symptoms and their duration were evaluated based on questionnaires fulfilled by patients. The diagnosis was made based on radiological, endoscopic and manometric findings. Laparoscopic surgery as the method of treatment was evaluated based on the duration of surgery, intra- and postoperative complications, time interval until the initiation of oral feeding, length of hospital stay, need for additional therapeutic measures after the operation and effect of surgery on the severity of symptoms. RESULTS: Preopereratively, dysphagia was the predominant symptom in all patients, while regurgitation was much lower (44%). The average duration of operation was 127 minutes. Postoperative hospitalization lasted on the average 5.7 days. From 36 treated patients, 34 (94.4%) considered that the effect of treatment was good or excellent. Postoperative dysphagia was present in two patients (5.6%) and was successfully solved by balloon dilatation. CONCLUSION: Laparoscopic Heller-Dor operation is an effective and safe surgical procedure in resolving symptoms of achalasia and today presents the method of the first choice in the treatment of this disease.

Primary inflammatory myofibroblastic tumor of the stomach in an adult woman: a case report and review of the literature.

Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as "pseudostumor ", denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature.

[Neuroendocrine tumors of gastrointestinal tract: the paradigm that lasts].

Historically, the tumors that were morphologically different and clinically less agressive than the more common gastrointestinal adenocarcinomas were clasified under carcinoid tumors. However, the development of molecular biology tehniques revealed the heterogeneity of these tumors on cellular and subcellular level and ther different biological behaviour. Neuroendocrine tumors of gastrointestinal tract originated from neuroendocrine cells scaterred across the gastrointestinal mucosa. As a result these tumors were capable of secreting many different neurotransmiters, which may or may not be biologically active. The incidence of gastrointestinal NETs has been incresing over the last 2 to 3 decades. Patients often presented with vague, nonspecific symptoms which resulted in delayed diagnosis and adequate treatment. In this article, we discuss the nature of gastrointestinal NETs, clinical presentation, treatment options and prognosis.