Societal importance of Antarctic negative feedbacks on climate change: blue carbon gains from sea ice, ice shelf and glacier losses.

Diminishing prospects for environmental preservation under climate change are intensifying efforts to boost capture, storage and sequestration (long-term burial) of carbon. However, as Earth's biological carbon sinks also shrink, remediation has become a key part of the narrative for terrestrial ecosystems. In contrast, blue carbon on polar continental shelves have stronger pathways to sequestration and have increased with climate-forced marine ice losses-becoming the largest known natural negative feedback on climate change. Here we explore the size and complex dynamics of blue carbon gains with spatiotemporal changes in sea ice (60-100 MtCyear-1), ice shelves (4-40 MtCyear-1 = giant iceberg generation) and glacier retreat (< 1 MtCyear-1). Estimates suggest that, amongst these, reduced duration of seasonal sea ice is most important. Decreasing sea ice extent drives longer (not necessarily larger biomass) smaller cell-sized phytoplankton blooms, increasing growth of many primary consumers and benthic carbon storage-where sequestration chances are maximal. However, sea ice losses also create positive feedbacks in shallow waters through increased iceberg movement and scouring of benthos. Unlike loss of sea ice, which enhances existing sinks, ice shelf losses generate brand new carbon sinks both where giant icebergs were, and in their wake. These also generate small positive feedbacks from scouring, minimised by repeat scouring at biodiversity hotspots. Blue carbon change from glacier retreat has been least well quantified, and although emerging fjords are small areas, they have high storage-sequestration conversion efficiencies, whilst blue carbon in polar waters faces many diverse and complex stressors. The identity of these are known (e.g. fishing, warming, ocean acidification, non-indigenous species and plastic pollution) but not their magnitude of impact. In order to mediate multiple stressors, research should focus on wider verification of blue carbon gains, projecting future change, and the broader environmental and economic benefits to safeguard blue carbon ecosystems through law.

Guidelines for the management of gastroenteropancreatic neuroendocrine (including carcinoid) tumours (NETs).

These guidelines update previous guidance published in 2005. They have been revised by a group who are members of the UK and Ireland Neuroendocrine Tumour Society with endorsement from the clinical committees of the British Society of Gastroenterology, the Society for Endocrinology, the Association of Surgeons of Great Britain and Ireland (and its Surgical Specialty Associations), the British Society of Gastrointestinal and Abdominal Radiology and others. The authorship represents leaders of the various groups in the UK and Ireland Neuroendocrine Tumour Society, but a large amount of work has been carried out by other specialists, many of whom attended a guidelines conference in May 2009. We have attempted to represent this work in the acknowledgements section. Over the past few years, there have been advances in the management of neuroendocrine tumours, which have included clearer characterisation, more specific and therapeutically relevant diagnosis, and improved treatments. However, there remain few randomised trials in the field and the disease is uncommon, hence all evidence must be considered weak in comparison with other more common cancers.

Pre- and postnatal diagnosis and outcome of fetuses and neonates with esophageal atresia and tracheoesophageal fistula.

OBJECTIVES: Clinical symptoms and ultrasound signs during pregnancy could suggest the presence of esophageal atresia (EA). However, most often EA is diagnosed postnatally. The aim of our study is to evaluate the course and outcome for prenatally and postnatally diagnosed EA. In addition, we studied the outcome of isolated versus nonisolated EA. METHODS: In a retrospective data analysis, ultrasound characteristics, maternal and neonatal variables as well as clinical outcome were compared for fetuses/neonates with prenatal (n = 30) or postnatal (n = 49) diagnosis of EA. Clinical outcome in terms of morbidity and mortality of isolated EA was compared with that of EA complicated by chromosomal or structural anomalies. RESULTS: Prenatally diagnosed children were born 2 weeks earlier than postnatally diagnosed children (36.4 weeks vs 38.2 weeks; P = 0.02). The former had higher mortality rates (30 vs 12%; P = 0.05) and more associated anomalies (80 vs 59%; P = 0.04). In both subsets, there was a high morbidity rate in the survivors (not significant). Nonisolated EA was associated with greater occurrence of polyhydramnios (53 vs 27%; P = 0.04) and higher mortality rate (28 vs 0%; P = 0.002). CONCLUSIONS: Mortality was significantly higher in prenatally diagnosed infants and in infants with additional congenital anomalies. Isolated EA is associated with good outcome.

Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident's training.

BACKGROUND: In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training. METHODS: A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005. RESULTS: The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates. CONCLUSIONS: Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.

Thoracoscopic tracheoaortopexia for the treatment of life-threatening events in tracheomalacia.

BACKGROUND: Life-threatening events resulting from tracheomalacia are a well-known complication of infants with esophageal atresia. Aortopexy is accepted as the most effective method for managing severe life-threatening and localized tracheomalacia with a success rate of 85% to 90%. Since the advent of minimally invasive surgery (MIS), the procedure also can be performed using thoracoscopic MIS. METHODS: Between January 2002 and November 2005, six children with esophageal atresia were treated using MIS for life-threatening events attributable to tracheomalacia. RESULTS: The patients tolerated the thoracoscopic procedure well, and all tracheoaortopexies could be performed thoracoscopically. There were two recurrences, which could be treated using thoracoscopy. After a follow-up period of 27 months (range, 10-45 months), all the patients are doing well and have had no more life-threatening events. CONCLUSIONS: Although this is the largest thoracoscopic series to date, the series is too small for any conclusions yet to be drawn. Thoracoscopic tracheoaortopexia is feasible and offers the advantages of MIS.

Duhamel procedure: a comparative retrospective study between an open and a laparoscopic technique.

BACKGROUND: Few studies are available comparing open with laparoscopic treatment of Hirschsprung's disease. This study compares a laparoscopic series of 30 patients with a historical open series of 25 patients. METHODS: The charts of all patients having had a Duhamel procedure in the period from June 1987 through July 2003 were retrospectively reviewed. Open procedures were performed until March 1994. Patients with extended aganglionosis, pre-Duhamel ostomy, or syndrome were excluded from the study. End points were intraoperative complications, postoperative complications, time to first feeding, hospital stay, and outcome at follow-up such as stenosis, enterocolitis, constipation, fecal incontinence, and enuresis. RESULTS: Twenty-five patients had an open Duhamel (OD) and 30 had a laparoscopic one (LD). There were no differences in patient characteristics and there were no intraoperative complications in either group. Time to first oral feeds was significantly longer in the OD group as was the duration of hospital stay. No significant differences at follow-up were observed but there was a tendency for a higher enterocolitis rate in the LD group. In contrast, the adhesive obstruction and enuresis rates were higher in the OD group. Cosmetic results were superior in the LD group. CONCLUSIONS: Except for a significantly shorter hospital stay and shorter time to first oral feeds in favor of LD, no significant differences could be observed. The cosmetic result was not an end point but there was no doubt that it was better in the LD group. Although not statistically significant different, there were no adhesive bowel obstructions in the LD group compared with 3 of 25 in the OD group. Fecal incontinence was not encountered in either group.

Supramolecular surface functionalization via catechols for the improvement of cell-material interactions.

Optimization of cell-material interactions is crucial for the success of synthetic biomaterials in guiding tissue regeneration. To do so, catechol chemistry is often used to introduce adhesiveness into biomaterials. Here, a supramolecular approach based on ureido-pyrimidinone (UPy) modified polymers is combined with catechol chemistry in order to achieve improved cellular adhesion onto supramolecular biomaterials. UPy-modified hydrophobic polymers with non-cell adhesive properties are developed that can be bioactivated via a modular approach using UPy-modified catechols. It is shown that successful formulation of the UPy-catechol additive with the UPy-polymer results in surfaces that induce cardiomyocyte progenitor cell adhesion, cell spreading, and preservation of cardiac specific extracellular matrix production. Hence, by functionalizing supramolecular surfaces with catechol functionalities, an adhesive supramolecular biomaterial is developed that allows for the possibility to contribute to biomaterial-based regeneration.

Laparoscopically assisted liver biopsy with a hemostatic plug.

BACKGROUND: Percutaneous and open liver biopsies are routine procedures for diagnosing liver pathology. However, the procedure can carry significant morbidity and even mortality, especially in the event of an uncorrectable coagulopathy or a highly vascular tumor. METHODS: A technique described for use in such circumstances involves laparoscopy for identification of the lesion to be biopsied, enables placement of a gelatin hemostatic plug in the core biopsy tract, and confirms hemostasis after percutaneous plugging of the biopsy site. RESULTS: The technique was successfully used for seven patients: six patients with hepatic coagulopathy and one with a highly vascular liver tumor. There were no complications during either the intra- or postoperative period. The patients experienced minimal postoperative discomfort and returned to baseline activity on the first postoperative day. CONCLUSION: The authors believe that the described technique of biopsy site plugging offers a safe alternative for liver biopsy among patients with an uncorrectable coagulopathy and those requiring a biopsy before correction of the bleeding disorder.

Long-term outcome of laparoscopic Nissen, Toupet, and Thal antireflux procedures for neurologically normal children with gastroesophageal reflux disease.

BACKGROUND: Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures. METHODS: This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created. RESULTS: The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann-Whitney U test are not statistically significant. CONCLUSIONS: For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon's experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.

Carbon dioxide differentially affects the cytokine release of macrophage subpopulations exclusively via alteration of extracellular pH.

BACKGROUND: The improved outcome after endoscopic surgery has been attributed to less surgical trauma. However, the underlying mechanisms are not fully understood, and direct effects of CO2 used for pneumoperitoneum, cellular acidification, and/or the lack of air contamination have been postulated to additionally modulate immune functions during endoscopic surgery. We investigated the effects of CO2 incubation, extracellular acidification, and air contamination on the inflammatory response of two distinct macrophage populations. METHODS: R2 and NR 8383 rat macrophage cell lines were used. Interleukin-6 (IL-6) and nitric oxide after lipopolysaccharide (LPS) stimulation were determined in these sets of experiments: incubation in 100% CO2, 5% CO2, and room air for 2h; incubation at pH 7.4, 6.5, and 5.5 for 2 h in 5% CO2; and incubation in 100% CO2, 5% CO2 and room air in fixed pH 6.3. The extracellular pH was monitored during incubation. We determined the alteration of intracellular pH in cells subjected to extracellular acidification by fluorescence microscopy. RESULTS: Extracellular pH decreased to 6.3 during 100% CO2 incubation. IL-6 release was reduced after CO2 incubation in NR 8383 cells and increased in R2 cells (p < 0.05). It was not altered by air incubation. Decreasing the extracellular pH to 6.5 mimicked the effects of CO2 and a decrease to 5.5 suppressed IL-6 release in both cell lines. In fixed pH at 6.3, CO2 and air incubation had no effect. CO2 and pH had no impact on nitric oxide release and vitality. Intracellular pH decreased with extracellular acidification without significant difference between the two cell lines. CONCLUSIONS: A decrease in extracellular pH during incubation in CO2 differentially affects IL-6 release in macrophage subpopulations. This may explain contradictory results in the literature. Moreover, we demonstrated that air contamination does not affect macrophage cytokine release. The decrease in extracellular pH is the primary underlying mechanism of the alteration of macrophage cytokine release after CO2 incubation, and it appears that the ability to maintain intracellular pH is not determined by the effects of CO2 or extracellular acidification.

Laparoscopic surgery in infants and children.

Almost all operations that are classically performed as open surgery have now an endoscopic surgical variant. The reason for performing this form of surgery obeys the Hippocratic principle: The less invasive the better. Moreover there is scientific evidence that the less trauma, the less stress response and the less immunosuppression. There are few well conducted studies in children comparing open with endoscopic surgery, but evidence is piling up, especially from studies in adults, that endoscopic surgery results in a faster recovery, better cosmesis and fewer adhesions. The complication rate seems, however, slightly higher. Endoscopic surgery takes more time but hospital stay is shorter so that the same output can be achieved with fewer beds. Endoscopic surgery has changed the mentality of pediatric surgeons. Nowadays pediatric surgeons think more in terms of invasiveness which means that even in open surgery incisions are not as large anymore as they have been in the past. Endoscopic surgery has also changed the mentality in nursing. The wounds do not anymore reflect the magnitude of the surgery that has been performed internally, which may lead to an underestimation of pain. As the turnover of patients is much higher, there is less patient and parent binding. Lastly some parents may be overwhelmed by the rapid discharge and nurses have to guide them. Some nurses feel that the ward has become less surgical, which may have an impact on recruitment.

Prevalence of phylogroups and O25/ST131 in susceptible and extended-spectrum ß-lactamase-producing Escherichia coli isolates, the Netherlands.

To assess the distribution of phylogroups and O25/ST131 in the Netherlands, we performed a real-time polymerase chain reaction (PCR) on a collection of 108 wild-type Escherichia coli (WT-EC) and 134 extended-spectrum ß-lactamase-producing E. coli (ESBL-EC). Phylogroup B2 was predominant, but ESBL-EC were less likely to belong to this phylogroup (48.5%) than were WT-EC (66.7%; p = 0.005). In WT-EC, phylogroups B2 and D seem to be more virulent, having a higher prevalence among midstream urine isolates and blood culture isolates, than in catheter-related urine isolates (83.3% and 87.9% vs. 61.9%; p 0.048). O25/ST131 is associated with ESBL production, being almost absent among phylogroup B2 WT-EC (61.5% vs. 5.6%; p < 0.001).

Designing environmental research for impact.

Transdisciplinary research, involving close collaboration between researchers and the users of research, has been a feature of environmental problem solving for several decades, often spurred by the need to find negotiated outcomes to intractable problems. In 2005, the Australian government allocated funding to its environment portfolio for public good research, which resulted in consecutive four-year programmes (Commonwealth Environmental Research Facilities, National Environmental Research Program). In April 2014, representatives of the funders, researchers and research users associated with these programmes met to reflect on eight years of experience with these collaborative research models. This structured reflection concluded that successful multi-institutional transdisciplinary research is necessarily a joint enterprise between funding agencies, researchers and the end users of research. The design and governance of research programmes need to explicitly recognise shared accountabilities among the participants, while respecting the different perspectives of each group. Experience shows that traditional incentive systems for academic researchers, current trends in public sector management, and loose organisation of many end users, work against sustained transdisciplinary research on intractable problems, which require continuity and adaptive learning by all three parties. The likelihood of research influencing and improving environmental policy and management is maximised when researchers, funders and research users have shared goals; there is sufficient continuity of personnel to build trust and sustain dialogue throughout the research process from issue scoping to application of findings; and there is sufficient flexibility in the funding, structure and operation of transdisciplinary research initiatives to enable the enterprise to assimilate and respond to new knowledge and situations.

Irreversible binding and metabolism of propranolol by human liver microsomes--relationship to polymorphic oxidation.

Studies were performed to investigate the irreversible binding and oxidative metabolism of propranolol in human liver microsomes and the relationship of binding and metabolism to the polymorphic oxidation of debrisoquine. Incubation of microsomes with 14C-labelled propranolol in the presence of a NADPH-generating system gave rise to irreversible binding which increased linearly with time and became saturated at high substrate concentrations. The extent of binding was decreased by the exclusion of cofactors, boiling, anaerobic conditions, and the addition of reduced glutathione and SKF-525A. Trichloropropene oxide had a negligible effect on cofactor-dependent binding. However, debrisoquine, antipyrine and phenacetin decreased binding to a considerable extent. The latter compound abolished cofactor-dependent binding completely at the concentration used (1 mM). Electrophoresis of microsomes which had been incubated with tritiated propranolol revealed that binding was probably occurring to a large number of proteins particularly in the 40,000-90,000 molecular weight range. Glutathione, debrisoquine and antipyrine did not inhibit the 4'-hydroxylation and N-deisopropylation of propranolol. In contrast, phenacetin exerted a very potent inhibitory action on both routes of metabolism. It is concluded that a product or products of propranolol oxidation bind irreversibly but non-selectively to human liver microsomal protein, the enzyme system responsible for the activation of propranolol appears to be related more closely to the cytochrome P-450 system which metabolizes phenacetin than to that metabolising debrisoquine, and radiolabelled propranolol is not a sufficiently specific probe for studying these cytochrome P-450 systems.

Pervenous hepatic transplant angiography using a new low osmolar contrast medium: an experimental study in dogs.

The patency of the vascular anastomoses in a canine liver transplantation model was imaged by serial pervenous angiography using ioxaglate, which is a new ionic low osmolar contrast medium. No premedication or general anesthesia was administered. No major adverse reaction was noted, not even after repeated angiography. Except for the occurrence of one hematoma formation and one paravenous injection, which resolved without leaving sequellae, no local complications occurred. Sufficient information regarding the patency of the hepatic artery anastomosis was obtained in 94% of the angiographic studies, while in 70% the patency of the caval anastomoses could be determined. In addition, portal vein patency was imaged in 21% of the angiograms. Even better visualization results can be expected when combining this method with video subtraction techniques, although patient cooperation or general anesthesia would then be mandatory.

A method for sonographic counting of the lower vertebral bodies in newborns and infants.

PURPOSE: To determine whether the lumbosacral junction of the vertebral column can be identified with sonography in newborns and infants and thus serve as a method for counting the lumbar and sacral vertebral bodies. METHODS: In 32 newborns and infants, the number of ossified vertebral bodies distal to the lumbosacral junction was counted with sonography and radiography. RESULTS: Sonographic and radiographic findings agreed in 29 of 32 examinations (91%). CONCLUSIONS: The lordotic transition at the lumbosacral junction can be identified with sonography in the majority of newborns and infants, allowing intraspinal structures to be related to a specific vertebral level.

Evaluation of whole blood serotonin and plasma and urine 5-hydroxyindole acetic acid in diagnosis of carcinoid disease.

BACKGROUND: Carcinoid disease is an uncommon disorder resulting from tumours of the enterochromaffin cells. Current biochemical investigation usually involves the measurement of 5-hydroxyindole-3-acetic acid (5-HIAA) in 24-h urine collections. Because of the problems associated with urine collections (i.e. inconvenience, accuracy of collection and requirement for preservatives) two alternative markers, fasting plasma 5-HIAA and whole blood serotonin (5-hydroxytryptamine), have been studied. METHODS AND RESULTS: Whole blood serotonin concentration and plasma and urine 5-HIAA concentrations were measured by high-performance liquid chromatography in 31 patients suspected of having carcinoid and 26 known carcinoid patients. Receiver operator characteristic curve analysis of the data showed no statistical difference between the three markers (P>0.01) with regard to their discriminating function. However, fasting plasma 5-HIAA assay showed greater stability than whole blood serotonin assay and is more convenient for the patient than a 24-h urine collection. At a cut-off value of 118 nmol/L plasma 5-HIAA assay showed a sensitivity of 89%, a specificity of 97% and a test efficiency of 93%. Whole blood serotonin assay was further limited by its saturation in platelets at 40 nmol/10(9) platelets which made it less suitable for monitoring the treatment of carcinoid disease. CONCLUSION: Fasting plasma 5-HIAA concentration provides a more convenient screening test for carcinoid and overcomes the problems associated with 24-h urine collections, without any loss of diagnostic precision.

Thoracoscopic repair of esophageal atresia with distal fistula.

BACKGROUND: Esophageal atresia (EA) has always been considered the hallmark of pediatric surgery. In the past decade, mortality was primarily the result of associated diseases, and operative morbidity had greatly improved. Yet the consequences of opening the thoracic cavity remained unchanged. In the era of endoscopic surgery, a thoracic approach to EA has become feasible, but is it of benefit for the patient? METHODS: Between May 2000 and June 2002, 13 neonates underwent thoracoscopic repair of EA. There were 12 boys and 1 girl. Mean gestational age was 36.9 weeks. Mean weight was 3093 g. Eleven children had associated anomalies. RESULTS: All of the procedures were performed thoracoscopically. There were no intraoperative complications, although anastomosis was difficult in one patient due to an extensive distance between the two stumps. Mean operating time was 2.6 h (range, 1.45-3.5). Five short-term postoperative complications occurred. Four of the early patients had stenosis due to a too-small incision in the proximal pouch, which needed one or more dilatations. One of these children, as well together as one other child, had anastomotic leakage, which was treated conservatively. Late complications consisted of gastroesophageal reflux ( n = 5) and tracheomalacia ( n = 1); these conditions required endoscopic correction in, respectively, two and one cases. Feeding by nasogastric tube was started after 3.5 days (mean), and total oral feeding was possible after 8.6 days (mean). Mean hospitalization was 12.2 days. Mean follow-up was 15.2 months. Scar formation was minimal, and the thoracic cage was preserved. CONCLUSION: The feasibility of thoracoscopic repair of EA has already been demonstrated. Today, its results in terms of operating time, feeding, hospital stay, and postoperative complications are equal to open procedures. Its advantages include better cosmesis and preservation of the thorax.

The laparoscopic approach to sacrococcygeal teratomas.

BACKGROUND: Sacrococcygeal teratomas (SCT) are classically approached posteriorly through an inverted chevron incision. In large, external, mainly solid SCT, prior interruption of the arterial supply is warranted because of impending heart failure and life-threatening hemorrhagic diathesis. Hitherto, this has required prior laparotomy. A laparotomy is also added when the tumor extends presacrally into the pelvis. The presacral region is, however, difficult to access. A laparoscopic-assisted approach seems to offer a solution for both problems. METHODS: A laparoscopic-assisted approach was used in five patients with SCT. In one neonate, it was used to interrupt the arterial blood supply only; in the other four patients, it was used to dissect the internal extension of the tumor. RESULTS: Laparoscopic interruption of the median sacral artery proved to be simple in the neonate with a large, external, mainly solid SCT. In three of the remaining four patients with presacral extension of the tumor, good visualization and dissection of the intrapelvic portion of the tumor was obtained. In one patient, the procedure had to be converted because of a lack of working space due to extensive intraabdominal growth of the tumor. CONCLUSION: A laparoscopic-assisted approach seems to be ideal for SCT. It provides the opportunity to interrupt the median sacral artery before the dissection. Moreover, it enables far better access to the presacral area than the conventional surgical approach when the SCT extends presacrally into the pelvis. Such a meticulous laparoscopic dissection may improve the functional results.