Long-term survival after pancreatic resection for renal cell carcinoma metastasis.

BACKGROUND: Surgical resection of pancreatic metastasis (PM) is the only reported curative treatment for renal cell carcinoma. However, there is currently little information regarding very long-term survival. The primary objective of this study was to determine the 10-year survival of this condition using the largest surgical series reported to date. METHODS: Between May 1987 and June 2003, we conducted a retrospective study of 62 patients surgically treated for PM from renal cell carcinoma at 12 Franco-Belgian surgical centers. Follow-up ended on May 31, 2012. RESULTS: There were 27 male (44 %) and 35 female (56 %) patients with a median age of 54 years [31-75]. Mean disease-free interval from resection of primary tumor to reoperation for pancreatic recurrence was 9.8 years (median 10 years [0-25]). During a median follow-up of 91 months [12-250], 37 recurrences (60 %) were observed. After surgical resection of repeated recurrences, overall median survival time was 52.6 months versus 11.2 months after nonoperative management (p = 0.019). Cumulative 3-, 5-, and 10-year overall survival (OS) rates were 72, 63, and 32 %, respectively. The corresponding disease-free survival rates were 54, 35, and 27 %, respectively. Lymph node involvement and existence of extrapancreatic metastases before PM were associated with poor overall survival. CONCLUSIONS: Aggressive surgical management of single or multiple PM, even in cases of extrapancreatic disease, should be considered in selected patients to allow a chance of long-term survival.

Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation?

AIM: Function, morbidity and recurrence of symptoms after robotic-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for pelvic floor disorders (PFDs) were compared. METHOD: Forty-four patients operated on for PFD with RVMR were compared with 74 of 144 patients who had had LVMR performed between 2008 and 2011. The groups were matched for age, body mass index, American Society of Anesthesiologists status and previous hysterectomy. The same surgical technique and type of mesh were used. Early postoperative morbidity and function [obstructed defaecation syndrome (ODS), incontinence scores (CCF) and sexual activity] were compared. RESULTS: Operation time was longer in RVMR compared with LVMR (191 ± 26 vs 163 ± 39 min; P = 0.0002). RVMR showed less blood loss (8 ± 34 vs 42 ± 88 ml; P = 0.012) and fewer early complications (2% vs 11%; P = 0.019). ODS and CCF scores improved in both groups. Patients after RVMR reported a better improvement in digitation, straining and satisfaction after defaecation. There was a statistically significant difference in the postoperative ODS score in favour of RVMR (P = 0.004). Sexually active patients in both groups reported a similar improvement. There was no difference in early recurrence (P = 0.692). CONCLUSION: Although not a randomized comparison, this study shows that ventral mesh rectopexy performed by the robot was followed by better function then LVMR.

Anatomical and functional results after stapled transanal rectal resection (STARR) for obstructed defaecation syndrome.

AIM: The STARR procedure is a surgical option for the treatment of rectocoele associated with obstructed defaecation syndrome (ODS). The aim of the study was to assess the efficacy of this technique in restoring anatomy and the long-term sustainability of symptom control and quality of life. METHODS: Of 48 patients operated on from 2003 to 2007, 30 were enrolled for this prospective assessment of anatomical correction and functional improvement of ODS. Results from a standardised questionnaire concerning functional results (ODS score), faecal incontinence (Cleveland Clinic score) and Patient Assessment of Constipation Quality of Life (PAC-QoL) were prospectively collected. Systematic dynamic defaecography, together with anorectal physiology testing, were performed before surgery and 6 months after. 25 patients were available for long-term assessment of functional outcome (more than 4 years). RESULTS: The mean age of the population was 57 +/- 7 years. STARR produced significant improvements in the PAC QoL (p < 0.05) and ODS score (p < .0001), but not in the incontinence score. At defaecography, correction was significant with respect to the depth (p = 0.007), perimeter (p < 0.0001) and neck (p = 0.001) of rectocoele. Anorectal physiology revealed a lower maximal tolerated rectal volume (p<.0001). After 58 months, the 25 patients showed sustained functional results and QoL. Four patients (16%) underwent further surgical procedure for pelvic floor disorders and 8 patients (32%) still required laxatives. CONCLUSION: Our study confirms the efficacy of the STARR procedure, with sustained improvement in function and QoL. However, a substantial number of patients remain symptomatic.

Role and limitations of 18F-FDG positron emission tomography (PET) in the management of patients with pancreatic lesions.

The 18-fluorine-18-fluoro-2-deoxyglucose Positron Emission Tomography coupled with computed tomography is a non invasive exploration. Several studies have shown that PET-CT has superior efficacy over conventional imaging techniques in distinguishing a benign pancreatic tumor from a malignant one. It contributes to the diagnosis of cancer in patients with a doubtful mass, much more in case of chronic pancreatitis. PET-CT is also an important help for the diagnosis of cystic tumors of the pancreas; the results can affect the management strategy. It is interesting for the endocrine tumors, particularly since the emergence of new markers. The aim of this paper is to summarize the role and limitations of 18-F-FDG PET-CT in the management of patients with pancreatic lesions (adenocarcinoma, cystic tumors, endocrine tumors, etc…) concerning the malignancy diagnosis, the detection of metastases, the monitoring after non surgical treatments and to evaluate interpretation difficulties, particularly in case of diabetes or chronic pancreatitis.

Long-term results of Malone's procedure with antegrade irrigation for severe chronic constipation.

AIM: The Malone antegrade colonic enema (MACE) procedure is a minimally invasive treatment for severe constipation, and the objective of the present study was to assess the long-term results and quality of life in patients undergoing such colonic irrigation. METHOD: Twenty-five adult patients underwent MACE between 1995 and 2002 for chronic constipation. After a mean follow-up duration of 55+/-36 months, the patients answered questionnaires to assess stoma usage, constipation score (KESS) and quality of life (GIQLI). RESULTS: The mean quality-of-life scores for these patients was 83+/-28 (normal: 125), while their mean constipation score was 19+/-9 (normal: <7). Twelve patients stopped the irrigations, and eight underwent further surgical procedures, specifically, total colectomy with ileostomy (n=2), ileorectal anastomosis (n=3) or segmental colectomy (n=3). Finally, five patients had permanent stoma. The 13 remaining patients continued to perform irrigations (4.6 per week). The patients' mean KESS score was 18.3+/-8 (normal: <7), and the mean GIQLI score was 98+/-20 (normal: 125). Continence status had no influence on success. CONCLUSION: In our series, MACE was successful in half the patients who were, thus, able to avoid more aggressive approaches. However, when MACE failed, other surgical procedures were often required.

Hypotonic Low Esophageal Sphincter Is Not Predictive of Gastroesophageal Reflux Disease After Sleeve Gastrectomy.

BACKGROUND: Sleeve gastrectomy is the most commonly performed bariatric surgery these days but is associated with de novo reflux. OBJECTIVE: We aimed to study the influence of hypotonic lower esophageal sphincter (LES) on postoperative gastroesophageal reflux disease (GERD). METHODS: Patients with pre- and postoperative esophageal high-resolution manometry (HRM) and 24-h pH monitoring (pHM) were included retrospectively in our study. Preoperative hypotonic LES was defined by a mean residual pressure of the lower esophageal sphincter < 4 mmHg. Postoperative GERD was defined by a DeMeester's score > 14.72. We also evaluated postoperative manometric changes at the esophageal-gastric junction. RESULTS: Sixty-nine patients (54 females and 15 males) had pre- and postoperative HRM and pHM. The mean age was 45.9 ± 9.8 years. The mean body mass index (BMI) was 47.5 ± 7.5 kg/m2. Hypotonic LES concerned 21 patients (30.4%) before sleeve gastrectomy. The mean time between the two esophageal monitorings was 32.1 ± 24.1 months. The sensitivity, specificity, positive predictive value, and negative predictive value of hypotonic LES to predict GERD were 31, 70, 52, and 48% respectively. The LES minimal residual pressure was not statistically decreased after sleeve gastrectomy (p = 0.24). Only the wave speed, esophageal length, and LES length were significantly reduced after SG (p = 0.029, 3.8 × 10-7 and 0.00032). CONCLUSION: Hypotonic LES has a poor predictive value on postoperative GERD. The LES's length is significantly reduced after SG and this could be a factor explaining de novo reflux.

The value of 18F-FDG positron emission tomography to differentiate benign from malignant intraductal papillary mucinous neoplasms: A prospective multicenter study.

OBJECTIVE: To assess the value of 18F-FDG PET/CT in differentiating between benign and malignant intraductal papillary mucinous neoplasms (IPMN) of the pancreas. SUMMARY BACKGROUND DATA: Malignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy. 18F-FDG PET has been studied mostly in small, single center, retrospective series. METHODS: Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen. RESULTS: Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. The 18F-FDG PET/CT was positive in 44 and 31 patients in the overall and IPMN populations respectively. In the 99 IPMN patients, PET/CT showed 13 true positive, 18 false positive, 57 true negative and 11 false negative results. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for the diagnosis of malignancy were 54.2%, 76.0%, 83.8% and 41.9% respectively, versus 64.9%, 75.9%, 82.9% and 54.5% in the overall population. We could not identify a cut-off value for SUVmax to distinguish benign from malignant lesions. Conventional imaging included computed tomography, magnetic resonance cholangiopancreatography and endoscopic ultrasound. In IPMN patients who underwent the 3 techniques, sensitivity, specificity, NPV and PPV were 66.7%, 84.4%, 84.4% and 66.7% respectively. CONCLUSIONS: In this study, 18F-FDG PET/CT did not perform better than conventional imaging to differentiate malignant from benign IPMN.

Value of sacral nerve stimulation in the treatment of severe faecal incontinence: a comparison to the artificial bowel sphincter.

OBJECTIVE: Sacral nerve stimulation (SNS) is a recent treatment option in the management of severe faecal incontinence (FI) that offers promising results. The aim of this study was to compare SNS to artificial bowel sphincter (ABS) implanted patients to assess the rationale of this approach in achieving satisfying functional results and improved quality of life (QoL). METHOD: Among 27 patients tested (December 2001 and April 2004), 15 patients were successfully managed with SNS. They were compared to 15 matched patients implanted with ABS in a previous period (control group). Assessment of continence level (Cleveland Clinic score), constipation score (Knowles, Eccersley, Scott Score) and QoL (Short-Form 36) were prospectively collected. RESULTS: Both groups were comparable for clinical parameters (age, gender, anal testing and aetiology of incontinence) and anal physiology. The mean postoperative continence score was significantly higher in the SNS group [9.4 (+/-3.3) vs 5.7 (+/-3.9), P < 0.01]; however, the mean constipation score was higher in the ABS group (6.3 +/- 6.3 vs 12.8 +/- 5.7, P < 0.01). The mean QoL score was similar in both groups. The mean follow-up after implantation was 15 (+/-9) months in the SNS group, and 43 (+/-33) months in the ABS group. CONCLUSION: In this study, SNS offers satisfying results in terms of QoL, similar to that of ABS. Although it seems to be less effective in restoring continence level, symptoms of outlet obstruction are more frequent after ABS. This SNS approach should be proposed as a first-line treatment of FI in selected patients. ABS should remain an option that can improve function.

Risk factors of exocrine and endocrine pancreatic insufficiency after pancreatic resection: A multi-center prospective study.

Management of functional consequences after pancreatic resection has become a new therapeutic challenge. The goal of our study is to evaluate the risk factors for exocrine (ExoPI) and endocrine (EndoPI) pancreatic insufficiency after pancreatic surgery and to establish a predictive model for their onset. PATIENTS AND METHODS: Between January 1, 2014 and June 19, 2015, 91 consecutive patients undergoing pancreatoduodenectomy (PD) or left pancreatectomy (LP) (72% and 28%, respectively) were followed prospectively. ExoPI was defined as fecal elastase content<200µg per gram of feces while EndoPI was defined as fasting glucose>126mg/dL or aggravation of preexisting diabetes. The volume of residual pancreas was measured according to the same principles as liver volumetry. RESULTS: The ExoPI and EndoPI rates at 6 months were 75.9% and 30.8%, respectively. The rate of ExoPI after PD was statistically significantly higher than after LP (98% vs. 21%; P<0.001), while the rate of EndoPI was lower after PD vs. LP, but this difference did not reach statistical significance (28% vs. 38.5%; P=0.412). There was no statistically significant difference in ExoPI found between pancreatico-gastrostomy (PG) and pancreatico-jejunostomy (PJ) (100% vs. 98%; P=1.000). Remnant pancreatic volume less than 39.5% was predictive of ExoPI. CONCLUSION: ExoPI occurs quasi-systematically after PD irrespective of the reconstruction scheme. The rate of EndoPI did not differ between PD and LP.

Management of acute malignant large-bowel obstruction with self-expanding metal stent.

BACKGROUND: Colorectal stents are being used for palliation and as a "bridge to surgery" in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction. METHODS: Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum. RESULTS: In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication. CONCLUSIONS: Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.

Resectable invasive IPMN versus sporadic pancreatic adenocarcinoma of the head of the pancreas: Should these two different diseases receive the same treatment? A matched comparison study of the French Surgical Association (AFC).

PURPOSE: To compare survival and impact of adjuvant chemotherapy in patients who underwent pancreaticoduodenectomy (PD) for invasive intraductal papillary mucinous neoplasm (IIPMN) and sporadic pancreatic ductal adenocarcinoma (PDAC). METHODS: From 2005 to 2012, 240 patients underwent pancreatectomy for IIPMN and 1327 for PDAC. Exclusion criteria included neoadjuvant treatment, pancreatic resection other than PD, vascular resection, carcinoma in situ, or <11 examined lymph nodes. Thus, 82 IIPMN and 506 PDAC were eligible for the present study. Finally, The IIPMN group was matched 1:2 to compose the PDAC group according to TNM disease stage, perineural invasion, lymph node ratio, and margin status. RESULTS: There was no difference in patient's characteristics, intraoperative parameters, postoperative outcomes, and histologic parameters. Overall survival and disease-free survival times were comparable between the 2 groups. In each group, overall survival time was significantly poorer in patients who did not achieve adjuvant chemotherapy (p = 0.03 for the IIPMN group; p = 0.03 for the PDAC group). In lymph-node negative patients of the IIPMN group, adjuvant chemotherapy did not have any significant impact on overall survival time (OR = 0.57; 95% CI [0.24-1.33]). Considering the whole population (i.e. patients with IIPMN and PDAC; n = 246), patients who did not achieve adjuvant chemotherapy had poorer survival (p < 0.01). CONCLUSIONS: The courses of IIPMN and PDAC were similar after an optimized stage-to-stage comparison. Adjuvant chemotherapy was efficient in both groups. However, in lymph node negative patients, adjuvant chemotherapy seemed not to have a significant impact.

Pancreatic carcinoma: Key-points from diagnosis to treatment.

Pancreatic ductal carcinoma is one of the deadliest cancers in the world. The only hope for prolonged survival still remains surgery with complete R0 resection even if most patients will promptly develop metastases and/or local relapses. Due to the silent nature of the disease, fewer than 20% of patients are eligible for a curative-intent resection. As no gain in survival is expected in case of residual tumor, imaging plays a major role for diagnosis and staging to select patients who will undergo surgery. Multidetector-row computed tomography and magnetic resonance imaging are the key stones and radiologists must be aware of imaging protocols, standardized terms and critical points for structured reporting to assess the tumor staging, minimize potential the morbidity associated with surgery and offer patients the best therapeutic strategy.

French intensive training course in laparoscopic surgery (HUGOFirst) on live porcine models: Validation of a performance assessment scale and residents' satisfaction in a prospective study.

INTRODUCTION: Simulation as a method for practical teaching of surgical residents requires objective evaluation in order to measure the student's acquisition of knowledge and skills. The objectives of this article are to publish our evaluation and validation grids and also the measure of student satisfaction. METHOD: A teaching platform based on practical exercises with a porcine model was created in 2009 at seven French University Hospitals. Three times a year, 31 Diplôme d'Études Spécialisées Complémentaires (DESC) surgical residents underwent timed assessment of the performance of five surgical tasks: trocar insertion (trocars) testing the convergence of instruments (convergence), intra-corporeal knot tying (knots), running of the small intestine to find a lesion (exploration), and performance of a running suture closure of the peritoneum (closure). Two experts evaluated performances prospectively on grid score sheets specifically designed and validated for these exercises. We measured time, scores on a rating scale, and the interest and satisfaction of the residents. RESULTS: Data for 31 residents between May 2011 and March 2012 were analyzed. Rating scales were statistically validated and correlated (Kappa correlation coefficient K>0.69) for each task. The performance times of the most experienced residents decreased significantly for all tasks except for small bowel exploration (P=0.2). After four sessions, times were significantly improved with better quality (fewer errors and higher average scores [>88%]), regardless of the residents' experience. Of the participants, 92% were satisfied, 86% thought that the sessions improved their technical skills and 74% thought it had a favorable impact on their clinical practice. CONCLUSION: This study shows that the performance of surgical techniques can be improved through simulation, that HUFEG grids are valid, and that this teaching program is popular with surgical residents.

[Gallbladder volvulus: two cases report]. / Volvulus de la vésicule biliaire : à propos de deux cas.

The authors report two cases of gallbladder volvulus. The diagnosis of this rare pathology is mainly identified preoperatively. Ultrasonographic findings include a "floating gallbladder" with thickened hypoechoic walls. The treatment is emergency cholecystectomy.

Toward a standard technique for laparoscopic distal pancreatectomy? Synthesis of the 2013 ACHBT Spring workshop.

Laparoscopic distal pancreatectomy is currently a commonly performed procedure. Twenty-five retrospective studies comparing laparotomy and laparoscopy have dealt with the feasibility of this approach for localized benign and malignant tumors. However, these studies report several different techniques. The aim of this review was to determine if a standardized procedure could be proposed. Based on the literature and the experience of surgeons in the French Association of Hepatobiliary Surgery and Liver Transplantation (ACBHT-Association française de chirurgie hépato-biliaire et de transplantation hépatique), we recommend primary control of the splenic artery, use of linear staplers for pancreatic transection, splenic vein control either at its end or its origin, and, depending on local conditions, preservation of the splenic vessels when splenic preservation is envisioned. Current data do not allow establishment of any definitive recommendations as to the ideal site of pancreatic transection, operative patient position, or the direction of dissection, which mainly depends on local practices. Control of the splenic vein remains the critical point of this procedure, and impacts the intra-operative strategy.

Sentinel lymph node mapping in colon cancer.

BACKGROUND: By systematically reviewing the literature on sentinel lymph node mapping of colon cancers, this study aimed to evaluate this technique as it applies to colon cancers. METHODS: Human studies on lymphatic mapping for colon cancers were reviewed. Multiple publications of the same studies, abstracts, and case reports were excluded. Current Contents, MEDLINE, EMBASE, and Cochrane Library databases were investigated. RESULTS: Lymphatic mapping appears to be readily applicable to colon cancers, identifying lymph nodes most likely to harbor metastases. Identification of sentinel lymph nodes varied from 58% to 100% and carried a false-negative rate of approximately 10% in larger studies, but potentially rose 4% to 25% among patients representing a range from node-negative to node-positive (micrometastases) conditions. The prognostic implication of these micrometastases requires further evaluation. Lymphatic mapping in 6% to 29% of cases identified aberrant lymphatic drainage that altered the extent of the lymphadenectomy. CONCLUSIONS: Further follow-up evaluation to assess the prognostic significance of micrometastases for colon cancers is required before the staging benefits of sentinel node mapping can have therapeutic implications. Lymphatic mapping offers the possibility of improving staging by identifying patients with early disseminated disease who should be considered for adjuvant treatment or included in trials of adjuvant treatment to speed up the breakthrough of more effective adjuvant regimens. Large studies are needed to determine whether the sentinel node concept is as valid for colon cancers as studies so far have shown it is for malignant melanoma and breast cancer.

Laparoscopic vs open colectomy for sigmoid diverticulitis: a prospective comparative study in the elderly.

BACKGROUND: The aim of this prospective comparative study was to assess the outcome of laparoscopic and open colectomy for sigmoid diverticulitis in patients aged >/=75 years. METHODS: From January 1993 to December 1998, all patients 75 years of age and older undergoing an elective colectomy for sigmoid diverticulitis were included in the study. The patients were divided into the following two groups: group 1 (n = 22) consisted of patients who underwent a laparoscopic procedure; group 2 (n = 24) consisted of patients who underwent an open procedure. RESULTS: In group 1, there were 12 women and 10 men with a mean age of 77.2 years (range, 75-82); in group 2, there were 14 women and 10 men with a mean age of 78 years (range, 76-84) (p = 0.37). There was no difference between the groups in ASA classification. The operative time was shorter in group 2 (136 vs 234 mins). The postoperative period during which parenteral analgesics were required (5.4 vs 8.2 days, p = 0.001), postoperative morbidity (18% vs 50%, p = 0.02), postoperative length of hospital stay (13.1 vs 20.2 days, p = 0.003), and the inpatient rehabilitation (6 vs 15 patients, p = 0.01) were significantly shorter for group 1 than for group 2. There were no perioperative deaths. The conversion rate was 9% in group 1. CONCLUSION: The data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to older patients with fewer complication, less pain, shorter hospital stay, and a more rapid return to preoperative activity levels than that seen with open colorectal resection.

Laparoscopic cholecystectomy in the elderly: a prospective study.

BACKGROUND: The aim of this prospective study was to determine the feasibility and the complications or benefits of laparoscopic cholecystectomy (LC) in the patients older than 75 years. METHODS: From January 1992 to July 1998, a total of 863 patients underwent LC, of these patients, 102 patients older than 75 years (group 1) were compared with 761 younger patients (group 2). RESULTS: In the elderly, 35.3% were at high surgical risk (American Society of Anesthesiology [ASA] III and ASA IV). The conversion rate to open cholecystectomy (OC) was 21.6%. The mean length of hospital stay was 6.9 days for both laparoscopy and conversion. Morbidity and mortality rates were 13.7% and 1%, respectively. No patient suffered intraoperative cardiopulmonary complication, and there was no reoperation in the elderly. CONCLUSIONS: Elderly patients experience more complications and longer duration of hospital stay than younger patients. However, our results compare favorably with other OC studies in elderly patients.

Laparoscopic colectomy for sigmoid diverticulitis in obese and nonobese patients: a prospective comparative study.

BACKGROUND: The aim of this prospective comparative study was to assess the outcome of laparoscopic colectomy for sigmoid diverticulitis in normal-weight, overweight, and obese patients. METHODS: From January 1995 to December 2000, all patients (n = 77) undergoing an elective colectomy for sigmoid diverticulitis were enrolled in the study. The patients were divided into three groups: Group 1 (n = 29) consisted of healthy, normal-weight patients (BMI, 18-24.9); group 2 (n = 27) consisted of overweight patients (BMI, 25.0-29.9); group 3 (n = 21) consisted of obese patients (BMI, 30.0-39.9). Groups 2 and 3 were compared with group 1. RESULTS: Group 1 was comprised of 13 women and 16 men with a mean age of 58.4 years (range, 37-78); group 2, was comprised of 13 women and 14 men with a mean age of 55.2 years (range, 31-83); group 3, was comprised of 13 women and 14 men with a mean age of 54.1 years (range, 33-86). There was no difference among the three groups in ASA classification, postoperative length of hospital stay, or inpatient rehabilitation. The operating time did not differ for groups 1 and 2 (187 vs 210 min, p = 0.6), but it was shorter in group 1 than in group 3 (187 vs 247 min, p = 0.003). The conversion rate was similar for all three groups: 17.2% in group 1, 14.8% in group 2, and 19% in group 3. The postoperative period during which parenteral analgesics were required did not differ between groups 1 and 2 (5.7 vs 7.7 days, p = 0.1), but it was longer for group 3 (8.5 days, p = 0.03). The morbidity rate was similar for all three groups: 17.2% in group 7, 14.8% in group 2, and 19% in group 3. There were no perioperative deaths. CONCLUSIONS: Data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely in overweight and obese patients

Palliation of carcinoma of the rectum using the urologic resectoscope.

BACKGROUND: Thirty percent to 40% of patients with rectal cancer are not candidates for aggressive surgery because of distant metastases, extensive local tumor infiltration, poor general condition, or refusal of the patient. The aim of this study was to report the results of endoscopic transanal resection (ETAR) using a urologic resectoscope for the palliative treatment of rectal carcinoma. METHODS: This study included 46 consecutive patients who underwent ETAR for rectal adenocarcinoma between October 1992 and October 2000. All patients had histologically confirmed adenocarcinoma. None of the patients were candidates for curative surgery. A retrospective evaluation of the outcome of ETAR was performed. RESULTS: Forty-six consecutive patients (25 men and 21 women), with a median age of 84 years (range, 57-92 years), underwent 76 ETARs. Twenty-four patients (52%) had locally advanced rectal cancer with a tumor length of more than 5 cm. The tumor involved the anterior rectal wall in 52 ETARs. Seventeen patients (37%) required more than one procedure. Median operating time was 49 min (range, 15-120 min). The morbidity rate was 8% (n = 6); perforation of the rectum occurred in 1 patient (2%) during an iterative ETAR. The mortality rate was 2%. The median postoperative stay was 5.5 days (range, 3-16 days). Symptomatic relief was achieved in 87% of patients. Colostomy was performed in 8 cases, with a median interval of 7 months (range, 3-12 months) after the first ETAR and after a median of 2 ETARs (range, 1-3). The median survival time was 14 months (range, 0-62 months); 40 patients died. The survival rate at 1, 2, and 5 years was 54%, 31.6%, and 5%, respectively. CONCLUSION: ETAR is a simple, minimally invasive, and economic method that should be part of palliative treatment for patients with rectal carcinoma. ETAR is a useful addition to the surgeon's armamentarium in the multidisciplinary approach of advanced rectal cancer together with laser destruction, stent implantation, and external beam radiotherapy. All these treatments must be evaluated not only in term of lumen patency or stoma rate, but also from the quality of life standpoint.