Laparoscopic colectomy for carcinoma of the colon in octogenarians.

BACKGROUND: The incidence of colorectal cancer increases with age; most patients present with resectable disease. Since there is a high morbidity rate in the elderly, the laparoscopic approach, with its lower complication rate, appears to be the ideal choice for treatment of this patient group. In this retrospective study, we aimed to compare the short-term results of laparoscopic (LC) with open (OC) colectomies for carcinoma in patients 80 years of age or older. METHODS: The study comprised 93 patients aged 80 years and over who underwent OC or LC between 2005 and 2008. Demographics and clinical data were compared. RESULTS: The LC group included 47, and the OC included 46 patients. No differences were found between the two groups with regard to mean age, comorbidities, and the extent of the resection. The operative time was shorter in the OC (121 vs. 157 min, P = 0.001). Hospital stay was shorter in the LC (7.6 vs. 8.8 days, P = 0.06). There were more postoperative complications in the OC (35.6%) than in the LC (30.4%), however the difference was not statistically significant (P = 0.6). CONCLUSIONS: LC in the elderly is safe, with a shorter hospital stay, and carries a short-term benefit for selected patients and could be offered to all elderly patients.

Stapled transanal rectal resection: a new surgical treatment for obstructed defecation syndrome.

BACKGROUND: Rectal intussusception, rectocele and rectal prolapse are anatomic disorders in obstructed defecation syndrome. A relatively new surgical approach, Stapled Transanal Rectal Resection, was designed to treat these anomalies. OBJECTIVES: To present our preliminary results with this technique. METHODS: Thirty patients with ODS not responding to medical treatment or biofeedback were operated on with the STARR technique. All the patients underwent a complete workup in the Pelvic Floor Unit. The operation was performed according to the technique described elsewhere. RESULTS: The patients' mean age was 67.1 years, and the median duration of symptoms was 7 years. The mean operating time was 40 minutes (range 35-80 min) and the mean hospital stay was 2 days (range 1-4 days). The mean follow-up was 26 months (range 6-48 months). ODS symptoms were ameliorated in 27 patients (90%), decreased significantly in 18, and in 9 patients the symptoms disappeared. The procedure failed in 3 patients (10%). Complications included minor bleeding that required homeostasis in eight patients during the operation. Three patients had transient tenesmus and five patients had anal pain. There were no cases of mortality or pelvic sepsis. CONCLUSIONS: STARR is an effective and safe procedure for the treatment of obstructed defecation syndrome due to rectal intussusception, rectocele and small rectal prolapse.

Changes in blood lipid levels following silastic ring vertical gastroplasty.

BACKGROUND: The purpose of this study was to evaluate the effect of the Silastic Ring Vertical Gastroplasty (SRVG) operation on blood lipid levels in obese men and women during the first year following surgery. METHODS: 25 patients (11 men and 14 women) age 17-50 (mean 33 years) who suffered from morbid obesity (BMI >40, range 45.9+/-4.7 kg/m2) underwent SRVG. Blood samples were collected before operation and 3, 6 and 12 months following surgery and tested for: triglycerides, total cholesterol, HDL-C, LDL-C, VLDL-C, and Lp(a). RESULTS: Both men and women lost weight significantly. Mean BMI decreased from 48.0 to 32.5 kg/m2 in men and from 44.3 to 29.0 kg/m2 in women (P<0.01). Blood lipid levels 1 year following surgery demonstrated the following changes: In women, triglycerides, total cholesterol, LDL, VLDL cholesterol and Lp(a) decreased from 160.7 mg/dL to 67.7 mg/dL (P<0.01), from 220 mg/dL to 189 mg/dL, from 138.3 mg/dL to 111 mg/dL, from 17 mg/dL to 12 mg/dL, and from 77.5 mg/dL to 18.5 mg/dL (P<0.01), respectively, and HDL increased from 45 mg/dL to 50.5 mg/dL. In men, triglycerides, total cholesterol, LDL, VLDL cholesterol and Lp(a) decreased from 246 mg/dL to 140 mg/dL (P<0.01), from 206 mg/dL to 170 mg/dL (P<0.01), from 134 mg/dL to 112 mg/dL (P<0.05), from 25 mg/dL to 15 mg/dL (P<0.01), and from 30.3 mg/dL to 11.6 mg/dL (P<0.01), respectively, and HDL increased from 31.3 mg/dL to 37.4 mg/dL (P<0.05). CONCLUSION: SRVG improved blood lipid profile in obese patients during the first year following surgery. Reduction in cholesterol and its fractions reaches statistical significance only in men.

Mid-term results of stapled hemorrhoidopexy for third- and fourth-degree hemorrhoids--correlation with the histological features of the resected tissue.

BACKGROUND: Stapled hemorrhoidopexy is used to remove a circumferential strip of mucosa and submucosa about 4 cm above the dentate line, in order to restore the correct anatomical relationships of the anal canal structures. We evaluated the histological features of the resected tissue obtained after stapled hemorrhoidopexy with correlation to the short-term and mid-term results. METHODS: This retrospective study evaluated 234 cases of stapled hemorrhoidopexy. Data concerning postoperative bleeding, anal pain, incontinence, stenosis, and recurrence of hemorrhoids were collected from hospital and outpatient clinic records. Histologic slides were examined for the type of epithelium, presence of muscle fibers, nerve endings, and degree of vascular ectasia. RESULTS: Some 52% of the biopsies revealed on the surface a combination of glandular with squamous epithelium, meaning a stapling line at the level of the transitional zone/dentate line. Smooth muscle fibers were more frequent as the stapling line approached the level of the dentate line/transitional zone (p = 0.0028). Internal sphincter fibers were present in 36% of the cases, yet there were no cases of anal incontinence. Inclusion of merely squamous epithelium in the resected tissue correlated with severe postoperative pain persisting one week after surgery (p < 0.0001), whereas the concurrent presence of squamous and glandular epithelium correlated only with severe pain on the first postoperative day (p = 0.018). Nerve endings were more frequent in patients with anal pain one week after surgery (p = 0.02). The rate of recurrence of symptoms was 3%, which did not correlate with any of the histological parameters tested. CONCLUSIONS: Though stapled hemorrhoidopexy is performed according to well-established technical guidelines, it is too difficult to be standardized.

Impact of gastric banding on plasma adiponectin levels.

BACKGROUND: Several endocrine abnormalities are reported in obesity. In an earlier study, we found that the changes in BMI following laparoscopic adjustable gastric banding (LAGB) were associated with changes in hormone profiles such as insulin and proinsulin. In the current study, we explored the changes in plasma adiponectin levels in morbidly obese subjects who lost abundant weight following LAGB. METHODS: 23 adult morbidly obese patients (15 females), aged 21-56 years, were studied. Blood samples were collected before, and 6 and 14 months after LAGB. The plasma adiponectin levels were determined by commercial kit (B-Bridge International, Inc). Statistical analysis was based on one-way repeated measures ANOVA, followed by Student-Newman-Keuls post-hoc test. Regression model was used to look for predictors of adiponectin change after LAGB. RESULTS: Mean BMI before surgery was 46.04+/-4.44 kg/m2, and decreased significantly by 18% 6 months after surgery to 37.67+/-4.47 kg/m2. BMI further decreased by 32% 14 months after surgery to a mean of 31.30+/-4.65 kg/m2 (P=.000). The mean adiponectin level before surgery was 3997+/-1766 microg/ml, and increased significantly by 16% to 4763+/-1776 microg/ml 6 months after surgery, and to 6336+/-3292 microg/ml (37%) 14 months after surgery. Although BMI persistently decreased, while adiponectin persistently increased, BMI did not correlate with adiponectin. CONCLUSION: In morbidly obese patients who underwent LAGB, adiponectin levels persistently increased, probably due to the reduction of visceral fat mass. Adiponectin plasma increase was correlated with proinsulin levels prior to the surgery. The interaction between adiponectin, proinsulin and BMI change in morbid obesity merits further investigation.

Preoperative chemoradiation in rectal cancer: Retrospective comparison between capecitabine and continuous infusion of 5-fluorouracil.

BACKGROUND: We compared the efficacy and toxicity of oral capecitabine and continuous infusion of 5-fluorouracil (5-FU) in the preoperative chemoradiation treatment of patients with rectal cancer. PATIENTS AND METHODS: The files of 89 patients with rectal cancer, 43 treated preoperatively with oral capecitabine and 46 with intravenous 5-FU, were reviewed, and the outcome of the groups was compared. RESULTS: There was no statistically significant difference in the complete pathological response rate between the capecitabine and the 5-FU groups (30% vs. 17%, P = 0.15). The downstaging rate was higher in the capecitabine group (77% vs. 50%, P = 0.009). Toxicity was mild in both groups. The rate of Grade 3 gastrointestinal toxicity was similar in the two groups (diarrhea 2% vs. 4%, proctitis 5% vs. 7%), except for one patient in the 5-FU group (2%) who developed a rectovaginal fistula. In the capecitabine group, one patient (2%) had Grade 3 hand-foot syndrome, and another had an acute myocardial infarction. In the 5-FU group, two patients (4%) had Grade 3 hematological toxicity, and three (6%) had complications from Port-a-Cath insertion. CONCLUSION: Preoperative chemoradiation with oral capecitabine appears to be safe and well tolerated, and at least as good as continuous 5-FU.

Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of single versus double mesh laparoscopic totally extraperitoneal repair.

The aim of this study was to compare the double and the single mesh techniques, both used in the laparoscopic totally extra peritoneal (TEP) repair of bilateral inguinal hernia. Sixty-five patients with bilateral inguinal hernia were enrolled in a prospective, randomized trial comparing the single and the double mesh techniques. The single and the double mesh techniques compared favorably in terms of operating time, long-term morbidity, hospital stay, time for return to work, postoperative quality of life and recurrence rate. However, the cost of a single, large prosthesis was 38% to 40% lower than that of 2 small ones. The laparoscopic TEP repair of bilateral inguinal hernia with a large, single prosthetic mesh is a technically simple and safe procedure, which offers clear cost savings and a potentially shorter operating time over the double mesh repair. It is strongly recommended for the routine, laparoscopic TEP repair of bilateral inguinal hernias.

The relationship between BMI, plasma leptin, insulin and proinsulin before and after laparoscopic adjustable gastric banding.

BACKGROUND: Morbid obesity is associated with over-secretion of leptin and insulin, and predisposes to development of carbohydrate intolerance. In the current study, we explored the impact of BMI after laparoscopic adjustable gastric banding (LAGB) on leptin, insulin and proinsulin levels. METHODS: 23 obese patients (8 males, 15 females) were included in the study. Their mean age was 36+/-6 yrs (range 21-56 yrs). Blood samples were collected for measurement of plasma leptin, insulin and proinsulin before and 6 and 14 months after LAGB. RESULTS: Mean BMI before surgery was 46.04 +/- 4.44 kg/m2, with significant and equal reduction of 18% in each of the follow-up periods, with total BMI reduction of 33% (P <.0001). The levels of circulating leptin, insulin and proinsulin before intervention were 119.3 +/- 53.1 ng/ml, 159 +/- 13 pmol/l, and 36.36 +/- 23.06 pmol/l respectively. Despite an equal BMI reduction in the 2 follow-up periods, the most significant decrease in hormone levels was observed in the immediate postoperative period (54, 53, and 45%, respectively), when compared to the second follow-up period (15, 30, 10%, respectively). The highest total decline in hormone level of 70% was obtained with insulin, compared to 52% in leptin, and 50% in proinsulin. Despite the significant decrease in proinsulin and insulin levels, their ratio increased from 0.22, to 0.28 and 0.36 after LAGB. Unlike insulin and proinsulin, leptin levels strongly and persistently correlated with BMI during the study. CONCLUSION: Following LAGB, weight loss was associated with decreased levels of circulating leptin, insulin and proinsulin, most prominent in the first follow-up period. Unlike insulin and proinsulin, leptin showed the most significant and persistent correlation with BMI, suggesting that morbid obesity acts through different feedback hormonal mechanisms which are probably not regulated only by absolute weight loss. Longer follow-up and larger numbers of patients are needed to clarify long-term hormonal profile, as well as the beneficial lasting effects of such interventions.

Resting anal pressure following hemorrhoidectomy and lateral sphincterotomy.

PURPOSE: The role of high anal pressure in the pathophysiology of hemorrhoids and anal fissures is debated. We compared resting anal pressures following left lateral sphincterotomy and hemorrhoidectomy in a prospective manometric study with emphasis on the recovery of the internal anal sphincter activity. METHODS: Included in the study were 38 patients with third-degree or fourth-degree symptomatic hemorrhoids who underwent hemorrhoidectomy, 50 patients with anal fissure who underwent sphincterotomy, and 12 healthy patients who served as controls. All patients with anal fissure or hemorrhoids underwent periodic manometric evaluation: 1 month before surgery and 1, 3, 6, and 12 months after surgery. The control group had three manometric evaluations 6 months apart. RESULTS: Baseline pressure measurement in the fissure group was significantly higher than in the hemorrhoid group, which was significantly higher than in the control group (138 +/- 28.4 mmHg vs. 108.4 +/- 23 mmHg vs. 73 +/- 5.9 mmHg, P < 0.0001). Twelve months after surgery, anal resting pressure remained significantly lower than the baseline measurements in both the fissure (110 +/- 18.2 vs. 138 +/- 28.4, P < 0.0001) and hemorrhoid groups (103.6 +/- 21.5 vs. 108 +/- 23, P < 0.0001), but both remained higher than the control group (103.6 +/- 21.5 mmHg vs. 73 +/- 5.9 mmHg, P < 0.0001). CONCLUSIONS: Resting pressure is elevated in hemorrhoid and anal fissure patients. After surgery the anal resting pressure is reduced but is still higher than in the control group. Further studies are required to investigate the protective effect of postsurgical reduction of anal resting pressure against recurrence.

Impact of gastric banding on plasma ghrelin, growth hormone, cortisol, DHEA and DHEA-S levels.

BACKGROUND: Several endocrine abnormalities are reported in obesity. Some are considered as causative factors, whereas others are considered to be secondary effects of obesity. In the current study, we explored the changes in cortisol, growth hormone (GH), DHEA, DHEA-S and GH releasing hormone (ghrelin) plasma levels in morbidly obese subjects who lost abundant weight following laparoscopic adjustable gastric banding (LAGB). METHODS: 12 morbidly obese adult patients (15 females), age 21-56 years with BMI 46.0+/-4.4 kg/cm(2), were studied. Blood samples were collected before, 6 and 14 months after LAGB. The levels of DHEA, DHEA-S, cortisol, GH, and ghrelin were determined by commercial kits. Statistical analysis was based on one-way repeated measures ANOVA, followed by Student-Newman-Keuls post-hoc test. RESULTS: Mean BMI reduced significantly along the study course (P=.000). Cortisol plasma levels significantly decreased 6 months after surgery (from 541.4+/-242.4 nM to 382.4+/-142.1 nM, P=.004), but did not change further after 14 months (460.2+/-244.9 nM), despite further reduction in BMI (P=.050). GH constantly increased throughout the study from 0.076+/-0.149 ng/ml, to 0.410+/-0.509 ng/ml at 6 months (NS), to 1.224+/-1.738 ng/ml at 14 months after surgery (P=.001). DHEA, DHEA-S and ghrelin plasma levels remained stable throughout the study. CONCLUSIONS: GH levels showed a persistent increase during the 14 months following LAGB in association with the weight loss, while a transient decrease in cortisol levels occurred at the 6-months time-point. In contrast, ghrelin, DHEA and DHEA-S were not altered after surgery. The association between GH and cortisol secretion and surgical- and nonsurgical-induced weight reduction merits further investigation.

Internal anal sphincter function following lateral internal sphincterotomy for anal fissure: a long-term manometric study.

BACKGROUND: Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy. OBJECTIVE: The aim of this study was to evaluate long-term manometric results of sphincter healing following lateral internal sphincterotomy. PATIENTS AND METHODS: Between 2000 and 2003, 50 patients with anal fissure were included in this study and underwent sphincterotomy; 12 healthy patients served as controls. All patients with anal fissure underwent manometric evaluation using a 6-channel perfusion catheter. All patients were examined 1 month before surgery and 1, 3, 6, and 12 months following surgery. The control group had 3 manometric evaluations 6 months apart. RESULTS: The mean basal resting pressure before surgery was 138 +/- 28 mm Hg. One month after surgery, the pressure dropped to 86 +/- 15 mm Hg (P < 0.0001) and gradually rose to a plateau at 12 months (110 +/- 18 mm Hg, P < 0.0001). At 12 months, the manometric pressure was significantly lower than the baseline (P < 0.0001). However, manometric measurements in the fissure group were still significantly higher than in the control group (110 +/- 18 versus 73 +/- 4.8 mm Hg, P < 0.0001). All patients were free of symptoms at the 12-month follow-up. CONCLUSION: Lateral internal sphincterotomy caused a significant decline in the resting anal pressure. During the first year following surgery, the tone of the internal anal sphincter gradually increased, indicating recovery, but still remained significantly lower than before surgery. However, postoperative resting pressures were higher than those in the control, and no patient suffered any permanent problems with incontinence, so this decrease may not be clinically significant.

General anesthesia for surgery influences melatonin and cortisol levels.

The purpose of this study was to investigate the effect of general anesthesia and surgery on melatonin production, and to assess the relationship between melatonin secretion and cortisol levels. Twenty (9 males and 11 females) consecutive otherwise healthy patients aged 27 to 52 years were included in this study. The patients underwent laparoscopic cholecystectomy or laparoscopic hernioplasty. All patients had general anesthesia with the same anesthetic drugs. Serum cortisol levels were measured at several time periods. Urine collections for melatonin were performed from 18:00 to 7:00 the day prior to surgery, on the operation day, and on the first postoperative day. Baseline melatonin metabolites were measured the night prior to surgery, and the level was found to be 1979 +/- 1.76 ng. The value decreased to 1802 +/- 1.82 ng (NS) on the night of surgery, and it became a significantly higher, reaching 2981 +/- 1.55 ng the night after surgery (p = .003). The baseline daytime cortisol level was significantly lower than the baseline night cortisol level (6.87 +/- 1.51 microg/dl, 14.89 +/- 1.66 micrograms/dl, respectively, p < 0.0001). Surgery induced a significant increase in both day and night cortisol levels. Daytime cortisol levels increased from 6.89 +/- 1.51 microg/dl to 16.90 +/- 1.27microg/dl (p < 0.0001), whereas right levels increased from 14.89 +/- 1.66 microg/dl to 29.20 +/- 1.24 microg/ dl (p <0.0001). The morning after surgery, cortisol levels decreased to 10.16 +/- 1.40 microg/dl, lower than the value obtained on the day of surgery (p < 0.0001). As was true of melatonin, cortisol levels did not reach the pre operative level (p < 0.005). The finding of the current study is that melatonin and cortisol levels show an inverse correlation after surgery.

Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study.

BACKGROUND: Bowel preparation prior to colonic surgery usually includes antibiotic therapy together with mechanical bowel preparation (MBP). Mechanical bowel preparation may cause discomfort to the patient, prolonged hospitalization, and water and electrolyte imbalance. It was assumed that with the improvement in surgical technique together with the use of more effective prophylactic antibiotics, it was possible that MBP would no longer be necessary. HYPOTHESIS: There is no statistical difference in the postoperative results of patients who undergo elective colon resection with MBP as compared with those who have no MBP. DESIGN AND PATIENTS: The study includes all patients who had elective large bowel resection at Campus Golda between April 1, 1999, and March 31, 2002. Emergency operations were not included. The patients were randomly assigned to the 2 study groups (with or without MBP) according to identification numbers. All patients were treated with intravenous and oral antibiotics prior to surgery. The patients in the MBP group received Soffodex for bowel preparation. RESULTS: A total of 329 patients participated in the study, 165 without MBP and 164 with MBP. The 2 groups were similar in age, sex, and type of surgical procedure. Two hundred sixty-eight patients (81.5%) underwent surgery owing to colorectal cancer and 61 patients (18.5%) owing to benign disease. The hospitalization period was longer in the bowel-prepared group (mean +/- SD, 8.2 +/- 5.1 days) as compared with the nonprepared group (mean +/- SD, 8.0 +/- 2.7 days). However, this difference was not statistically significant. The time until the first bowel movement was similar between the 2 groups: a mean +/- SD of 4.2 +/- 1.3 days in the nonprepared group as compared with a mean +/- SD of 4.3 +/- 1.1 days in the prepared group (P = NS). Four patients (1.2%) died in the postoperative course owing to acute myocardial infarction and pulmonary embolism. Sixty-two patients (37.6%) of the non-MBP group suffered from postoperative complications as compared with 77 patients (46.9%) of the MBP group. CONCLUSION: Our results suggest that no advantage is gained by preoperative MBP in elective colorectal surgery.

Prognostic value of Topoisomerase II in female breast cancer.

Topoisomerase II-alpha (Topo II-alpha) is a nuclear enzyme. Its expression rises rapidly at the end of the S to G2/M phase and falls after the mitotic process ends. We have studied the immunohistochemical expression of Topo II-alpha in breast cancer and its correlation with the menopausal state, tumor type, size, lymph node metastases, stage, and estrogen and progesterone positivity. Histological sections from 50 breast cancers were immunohistochemically stained for Topo II-alpha. The percent of positive cells at the area of highest staining was recorded as Topo index. The correlation between the course of disease, survival and Topo II-alpha index was statistically significant, p<0.001. High-grade tumors showed higher Topo II-alpha levels, than those of intermediate and low-grade, p<0.01. A significant association was found between estrogen receptors positivity and Topo II-alpha, p<0.05. A higher Topo II-alpha index indicates higher probability for recurrence of the disease and overall survival. Therefore, Topo II-alpha expression has a prognostic value in breast carcinoma.

Rectal cancer: the impact of a colorectal unit on the preservation of the anal sphincter.

BACKGROUND: Mid- and lower rectum cancer is a technical challenge to the surgeon aiming to preserve the anal sphincter. The choice between abdominoperineal resection and anterior resection is often related to surgical skills. OBJECTIVES: To evaluate the role of a specialized colorectal unit in preserving the anal sphincter mechanism in the treatment of rectal cancer. METHODS: Between 1991 and 1996, 75 patients with rectal cancer up to 12 cm from the anal verge were operated at the Sheba Medical Center. Among them, 21 patients (group 1) underwent surgery in the colorectal unit and 54 patients (group 2) in the other two surgical departments. All patients had a complete preoperative investigation and were followed for 12-90 months. RESULTS: Background and tumor parameters were similar for both groups. In group 1, 20 patients (95%) had low anterior resection and 1 patient (5%) had abdominoperineal resection as compared to 20 patients (37%) and 34 patients (63%), respectively, in group 2 (P < 0.005). There was no statistical difference in the systemic recurrence rate. Local recurrence was more frequent in group 2 (P < 0.05). CONCLUSIONS: Special training in colorectal surgery enables the surgeon, in keeping with the principles of oncologic surgery, to preserve the anal sphincter mechanism in most patients with adenocarcinoma located in the mid- and lower third of the rectum.

Long-term follow-up and factors influencing success of silastic ring vertical gastroplasty.

BACKGROUND: Careful selection of patients for the operation plays a major role in long-term results of silastic ring vertical gastroplasty. The objective of the current study is to identify predictive factors for the objective (excess weight loss) and subjective (satisfaction) success of silastic ring vertical gastroplasty (SRVG) for morbid obesity. DESIGN: Retrospective cohort study. SETTING: University hospital. SUBJECTS: 300 patients of 450 who were operated on between 1984 and 1997. Follow-up time was 4.4 +/- 2.3 years. INTERVENTION: SRVG. STATISTICAL METHODS: Correlations, multi-linear regression model. RESULTS: Average BMI (body mass index) loss: 13.6 +/- 7.4 kg/m(2), average excess weight loss was 67.4 +/- 33.0%. Satisfaction rate: 81.3%. Correlation was found between objective parameters of successes and the satisfaction of the patient (p < 0.001). Excess weight loss was correlated to younger age (p < 0.005), pre-operative weight and BMI (p < 0.005, p < 0.01, respectively), and shorter follow-up (p < 0.001). Multiple linear regression model revealed that age and preoperative weight were independent variables and correlated to the excess weight loss after SRVG (R(2) = 0.303, p < 0.01; R(2) = 0.026, p < 0.05). Social support was correlated to satisfaction (p < 0.05). CONCLUSIONS: SRVG is an operation with high rates of objective and subjective success rate. Younger and heavier subjects will mostly enjoy SRVG in terms of excess weight loss. Patients who have social support have the most satisfactory emotional outcome.

Inguinal hernia: challenging the traditional indication for surgery in asymptomatic patients.

BACKGROUND: It is generally accepted that most inguinal hernias should be operated on electively in order to avoid the high morbidity and mortality associated with incarceration and small bowel obstruction. The present study reassesses the indication for surgery in asymptomatic inguinal hernia patients. METHODS: We analyzed profiles, separately, for elective and emergency inguinal herniorrhaphies and compared the morbidity and mortality rates. RESULTS: Two hundred randomly selected elective hernia repairs were compared with 67 incarcerated cases. Postoperative complications were more common following emergency (23.9%) than elective repair (10.5%); however, in both groups, minor complications predominated. The mortality rate in the incarcerated group (6%) was clearly linked with a high preoperative American Society of Anesthesiologists (ASA) score. A bowel resection rate of 4.5% was found in the incarcerated cases, which was not correlated with mortality. CONCLUSIONS: Patients with asymptomatic inguinal hernia and unfavorable medical conditions should be recommended an elective repair, preferably under local anesthesia, to avoid the high mortality associated with an emergency operation.

The expression of DCC protein in female breast cancer.

BACKGROUND: The deleted in colorectal cancer (DCC) gene has been shown to be frequently deleted or its expression reduced or absent in glioblastomas, colorectal, gastro-intestinal, pancreatic and prostatic tumors. In the present study, we investigated the expression of DCC in surgical specimen from 75 patients with primary breast cancer. METHODS: The expression of the DCC, estrogen receptors (ER), and progesterone receptors (PR) was studied in 75 surgical specimens of primary breast cancer using an immunohistochemical method. To evaluate the outcomes of the breast cancer patients, we followed up the patients during minimum of 10 years. RESULTS: Reduced or loss of expression of DCC was identified in 45 out of 75 samples. There were significant differences between cases without metastasis or local recurrences versus these with metastasis or local recurrences (p = 0.006), and between patients alive with no evidence of malignancy versus those with recurrence or dead of disease (p = 0.005). There were no significant differences between the DCC status and age, sex, tumor location, stage, grade, or proportion of patients who received adjuvant therapy. CONCLUSIONS: These findings suggest that a decrease in DCC expression may influence the prognosis of breast carcinoma patients.

In vitro and in vivo treatment of colon cancer by VIP antagonists.

Vasoactive intestinal peptide (VIP) is secreted from many cancer lines and VIP binding was observed in many tumors. We have shown before that VIP antagonists are potent inhibitors of neoplastic growth of neuroblastoma, lung and breast cancer cells in vitro. Here, the cultured colon cancer cell line HCT-15 that exhibited VIP receptor expression was treated with the VIP hybrid antagonist neurotensin(6-11)VIP(7-28). The antineoplastic activity was assessed by thymidine incorporation. Neurotensin(6-11)VIP(7-28) efficiently inhibited cancer growth with a maximal effect at nanomolar concentrations. Once the inhibitory properties of the VIP antagonist on colon cancer cells were established, the in vivo curative effects were analyzed. Sprague-Dawley rats were injected with azoxymethane (AOM) (15 mg/kg/week) for 2 weeks, providing artificial induction of colon tumors. The rats were then allocated into four experimental groups: (1) receiving no treatment; (2) receiving treatment with saline; (3, 4) receiving treatment with 10 or 20 microg of neurotensin(6-11)VIP(7-28), respectively. After 10 weeks of daily injections, rats were sacrificed and tumors assessed for stage, volume, location, differentiation and lymphocytic infiltrate. Embedded mucosa was assessed for dysplastic crypts. Results showed that the antagonist treatment reduced the tumor volume, staging, lymphocyte infiltrate and the number of dysplastic crypts. Thus, neurotensin(6-11)VIP(7-28) could serve as an effective cancer treatment and a preventing agent.

Periappendiceal actinomycosis mimicking malignancy report of a case.

A case of a periappendiceal actinomycosis, seen in an 83-year-old woman, clinically mimicking a right ovarian neoplasm penetrating the right colon, is presented. The patient's complaints led to the discovery of a right abdominal mass. Explorative laparotomy and right hemicolectomy were done. Histological examination revealed periappendiceal actinomycotic abscesses. We discuss a possible pathogenesis and the therapeutic modalities.