Quality of surgery for rectal carcinoma: comparison between open and laparoscopic approaches.

BACKGROUND: Macroscopic evaluation of a tumor specimen is an independent prognostic factor of oncologic outcome after total mesorectal excision (TME) for rectal cancer. This study aimed to assess macroscopic quality of specimens acquired after laparoscopic versus open TME in patients with low rectal cancer. PATIENTS AND METHODS: Seventy-two patients with low rectal cancer underwent TME either by open (n = 39) or laparoscopic (n = 33) approach. In all specimens, the cut edge of the peritoneal reflection at the anterior mid-rectum, the Denonvillier's fascia, the visceral fascia covering the mesorectum both posteriorly and laterally, and the bowel wall below the mesorectum were macroscopically assessed. RESULTS: Colorectal anastomoses were located significantly lower in the laparoscopic than in the open group (P < .001). The Denonvillier's fascia was violated in 7 patients after open surgery (P = .01). A significantly more complete TME with intact visceral pelvic fascia was performed after laparoscopy compared with open surgery (P = .025). CONCLUSIONS: Laparoscopy offers a macroscopically more complete specimen after TME for rectal cancer than the open approach because it offers a better view in the pelvis.

Laparoscopic or open surgery for the cancer of the middle and lower rectum short-term outcomes of a comparative non-randomised study.

INTRODUCTION: The study compares the short-term results of the laparoscopic and open approach for the surgical treatment of rectal cancer. Consecutive cases with rectal cancer operated upon with laparoscopy from 2004 to 2007 were compared to open rectal cancer cases. Total mesorectal excision (TME) was attempted in all cases. PATIENTS AND METHODS: Forty-two cases were included in the OPEN and 45 in the LAP group and were matched for age, gender, disease stage and operation type. SURGICAL PROCEDURE: Duration of surgery was longer and blood transfusion requirements were less in the LAP group. Higher blood loss was observed in patients with neoadjuvant treatment in both groups. Patients with neoadjuvant treatment in the OPEN group had higher operation time, but that was not the case in the LAP group. There were three conversions (7%). RESULTS: Overall morbidity was higher in the OPEN group. LAP group patients were found to recover faster. R0 resection was achieved in 88% in the OPEN and 94% in the LAP group. DISCUSSION: Less morbidity and faster recovery is offered after laparoscopic TME. Quality of surgery assessed by histopathology is similar between the approaches. Neoadjuvant chemoradiation seems to have significant impact on blood loss but results in longer operation times of the OPEN group.

Antecolic gastrointestinal reconstruction with pylorus dilatation. Does it improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy?

OBJECTIVE: The aim of our study focuses upon prevention of delayed gastric emptying (DGE) after pancreaticoduodenectomy using a alternative reconstruction procedure. METHOD: Forty consecutive patients underwent a typical pylorus-preserving pancreaticoduodenectomy (PPPD) with antecolic reconstruction in a two-year period (January 2002 until January 2004), while a similar group of 40 consecutive patients underwent PPPD with application of pyloric dilatation between January 2004 and January 2006. Early and late complications were compared between the two groups. RESULTS: DGE occurred significantly more often in the group of patients treated by the classical PPPD technique (nine patients -22%) compared with those operated on with the addition of pyloric dilatation technique (two patients -5%) (p<0.05). The incidence of other complications did not differ significantly between the two groups. CONCLUSIONS: The application of dilatation may decrease the incidence of DGE after PPPD and facilitates earlier hospital discharge.

Primary hepatic carcinoid; a diagnostic dilemma: a case report.

INTRODUCTION: Primary hepatic carcinoid tumours (PHCTs) are extremely rare neuroendocrine neoplasms. Only 58 cases have been reported in the literature and less than 10 cases were functional. CASE PRESENTATION: We present a case of a 65 years old, Caucasian female with a large unresectable primary hepatic carcinoid tumor secreting 5-hydroxyindoleacetic acid (5-HIAA), presented with flushing and diarrhoea and treated with trans-catheter arterial embolization (TACE) and subsequent administration of lanreotide (long acting somatostatin analogue). CONCLUSION: The diagnosis of PHCTs is difficult due to their common radiologic characteristics with other liver lesions. Their diagnosis is based on the exclusion of other sites of disease and the histologic confirmation. Although the mainstay of treatment when is technically feasible is surgical resection with optimal 5-year survival and low recurrence rate, in cases of unresectable disease palliation with combination of TACE and administration of somatostatin analogues have good results in controlling the disease and the patients symptoms.

Combined liver and lung metastasectomy through an exclusive transthoracic approach.

BACKGROUND: In a very selected group of patients, resection of metachronous liver and lung metastases, prolongs survival despite the aggressive nature of these lesions. We present here our experience with metastasectomy in patients with metachronous liver and lung metastases in whom, an exclusive transthoracic approach was performed. METHODS: Between 2002 and 2005, five patients with metachronous colorectal liver and right-lung metastases, underwent an exclusive transthoracic approach. There were three men and two women, with a median age of 68 years (range, 55-76 years). Liver resections performed included segmentectomy of segments VII, VIII, or both. Previous operations include colon resection, adhesiolysis, or ventral hernia repair were performed in all patients. RESULTS: No mortality was documented. Morbidity included pleural effusion (n = 2) and post-operative pneumonia (n = 1) which responded to conservative management. Median hospital stay was 8 days (range 5-12 days). With a median follow-up of 26 months all patients are alive without recurrent disease. CONCLUSION: An aggressive surgical approach should be undertaken for CRC metastases. An exclusive transthoracic approach is feasible for combined lung and subdiaphragmatic liver metastasectomy in selected cases with previous abdominal surgery.

Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality. METHODS: We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations. RESULTS: A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported. CONCLUSIONS: The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.

Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: a review of the literature and critical reappraisal of the implicated pathomechanism.

Pylorus-preserving pancreaticoduodenectomy (PPPD) is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying (DGE) comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/Medline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy (PD) vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported (but not yet tested in large-scale studies) modification, that is, PPPD with antecolic duodenojejunostomy.

Asymptomatic calcitonin-secreting tumor of the pancreas. A case report.

CONTEXT: Pancreatic endocrine tumors are unusual tumors arising from cells belonging generically to the amine precursor uptake and decarboxylation system. CASE REPORT: We present a case of a calcitonin-secreting pancreatic endocrine tumor in a 59-year-old male who presented at our Center with elevated calcitonin values. The patient was asymptomatic. Further investigation revealed a tumor, 80 mm in diameter, in the pancreatic body and tail along with three metastatic lesions in segments III, V, and VIII of the liver. Following a distal pancreatectomy, splenectomy and wedge resection of segments III and V along with radiofrequency ablation of the segment VIII lesion, his serum calcitonin reached normal values. CONCLUSIONS: Calcitonin-secreting pancreatic endocrine tumors are often malignant and have a poor prognosis. We believe that an aggressive surgical approach may improve survival.

Changing concepts in the management of liver hydatid disease.

Hydatid disease is a rare entity primarily affecting the population of developing countries. The parasite shuttles between the liver and lungs. but almost any organ can be invaded, forming cysts. Septation and calcification of the cysts with a high antibody titre in the patient's serum confirm the diagnosis, although more sophisticated tests have been applied recently. Surgery constitutes the primary treatment, with a variety of techniques based on the principles of eradication and elimination of recurrence by means of spillage avoidance. Minimally invasive techniques and percutaneous drainage of the cysts are now feasible because of progress in the field. The aim of this review is to collect the experience from three different institutions and to provide practical guidelines for diagnostic and therapeutic strategies.

Liver transplantation techniques with preservation of the natural venovenous bypass: effect on surgical resection of renal cell carcinoma invading the inferior vena cava.

Although renal tumors invading the inferior vena cava (IVC) are unusual, they represent a challenge to the surgical team because their accessibility is difficult. Liver transplantation techniques have been developed that preserve the venous collaterals, enhance the exposure, increase the safety of the resection, and avoid cardiopulmonary bypass. We describe our technique for dealing with renal tumors that have invaded the IVC, a combined experience of two centers, and the safety of the procedure and subsequent low morbidity. Between May 1997 and February 2003, a total of 45 patients (mean age 60.7 years) underwent surgical resection of a renal tumor extending into the IVC by techniques developed from liver transplantation, with the intention to avoid sternotomy and cardiopulmonary bypass. In 42 patients (93.3%) surgical resection of the tumor and thrombus was successful using the transabdominal approach while preserving the venous collaterals; 3 patients with a level IV tumor thrombus required cardiopulmonary bypass. The mean operating time was 342 minutes, and the mean estimated blood loss was 1442 cc. Postoperative ileus in one patient required laparoscopic lysis of the adhesions, and 2 patients (4.4%) died owing to multiple system organ failure and massive pulmonary embolism. The median follow-up was 36 months, during which time 6 patients developed metastatic disease and 37 were disease-free. We concluded that liver transplantation techniques enhance the surgical management of complicated urologic tumors. Patients with tumor thrombus extending to the IVC can be treated while avoiding thoracotomy and cardiopulmonary bypass.

Nutritional support in acute pancreatitis.

Acute pancreatitis (AP), mainly the severe necrotizing type, results in extreme energy demands which might lead, if prolonged, to severe malnutrition. Besides that, starving during AP contributes to gut barrier dysfunction, the main cause of bacterial translocation and sepsis. The aim of nutritional support in AP is to prevent malnutrition and protect the gut by maintaining mucosal integrity. Traditionally, nutritional support during the acute phase of the disease has been provided through total parenteral nutrition (TPN) solutions. However, recent animal and human studies have identified new patterns of pancreatic secretion and hormonal stimulation during the course of AP, different from those assumed for years. Thus it has become feasible to use the natural enteral route for nutrition with potential benefits compared with TPN.

Intestinal obstruction and perforation--the role of the surgeon.

Intestinal obstruction and perforation are always a challenge for the surgeon, not only in respect to the surgical option offered to the patient, but also to the ability to accurately diagnose and stage the disease. The understanding of the underlying pathophysiological mechanism is also very important in order to classify each patient in order to receive the more appropriate treatment. Mechanisms of obstruction and perforation, methods of diagnosis as well as prevention and treatment of the disease were reviewed.

Benefits and limitations of enteral nutrition in the early postoperative period.

BACKGROUND: Preexisting malnutrition has been shown to be a major clinical problem in surgical patients. Surgical stress itself increases the energy expenditure and protein loss making necessary the early nutritional support. Although there is strong evidence that "nil by mouth" is not justified, the data are still conflicting over the role of early enteral nutrition compared with the traditional methods of postoperative feeding including total parenteral nutrition support. METHODS AND FOCUS: This paper deals with the various trials related to early enteral feeding. It also compares this with the possible advantages of total parenteral nutrition as a method of perioperative nutritional support in patients undergoing gastrointestinal surgery.