Related Articles

Postprandial Proximal Gastric Acid Pocket in Patients after Roux-En-Y Gastric Bypass.

J Gastrointest Surg. 2010 Aug 18;

Authors: Herbella FA, Vicentine FP, Del Grande JC, Patti MG, Arasaki CH

INTRODUCTION: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in normal individuals and patients with gastroesophageal reflux disease (GERD). The role of gastric anatomy in the physiology of the PPGAP remains unclear. It is also unclear whether operations that control GERD, such as Roux-en-Y gastric bypass (RYGB) and Nissen fundoplication, change the PPGAP. AIMS: This study aims to analyze the presence of PPGAP in patients submitted to RYGB. METHODS: Fifteen patients who had a RYGB for morbid obesity (mean age 53 years, 14 females, mean time from operation 3 years) were studied. All patients were free of foregut symptoms. Patients underwent a high-resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES). A station pull-through pH monitoring was performed from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal (40 g of chocolate, 50% fat). RESULTS: Acidity was not detected in the stomach of four patients before meal. After meal, PPGAP was not found in eight patients. In three patients, a PPGAP was noted with an extension of 1 to 3 cm. CONCLUSION: PPGAP is present in a minority of patients after RYGB; this finding may explain part of the GERD control after RYGB and that the gastric fundus may play a role in the genesis of the PPGAP.

PMID: 20717738 [PubMed - as supplied by publisher]

Related Articles

Single-Incision Laparoscopic Endorectal Pull-Through (SILEP) for Hirschsprung Disease.

J Gastrointest Surg. 2010 Aug 18;

Authors: Muensterer OJ, Chong A, Hansen EN, Georgeson KE

BACKGROUND: Over the last 15 years, the laparoscopic-assisted endorectal pull-through procedure first described by Georgeson has become the standard treatment for Hirschsprung disease in many centers around the world. We report the first six patients who were operated using a single-incision endosurgical approach. METHODS: Six infants (one female) diagnosed with Hirschsprung disease underwent laparoscopic endorectal pull-through via a single 1 cm horizontal skin incision in the umbilicus. Firstly, laparoscopic seromuscular leveling biopsies of the rectum and sigmoid were obtained. The affected rectosigmoid colon and rectum was then mobilized distally beyond the peritoneal reflection, facilitating the subsequent perineal dissection, pull-through, and coloanal anastomosis. Operative variables were compared between single-incision and conventional laparoscopic endorectal pull-through. RESULTS: The patients’ average age and weight was 28 days and 3.8 kg, respectively. Operative time ranged from 90 to 220 min, with a mean estimated blood loss of 3.7 ml. There were no intraoperative complications. Postoperatively, all six patients recovered uneventfully and were discharged home on full feeds after a median of 7 days. On follow-up, the patients had virtually no appreciable scar, were feeding well, stooling, and gaining weight appropriately. The results were similar to those of conventional laparoscopic endorectal pull-through. CONCLUSION: Although technically challenging, laparoscopic-assisted endorectal pull-through in infants with Hirschsprung disease can be performed safely through a single umbilical incision with good postoperative results and excellent cosmesis.

PMID: 20717739 [PubMed - as supplied by publisher]

Related Articles

Tumors Arising at Previous Anastomotic Site may have Poor Prognosis in Patients with Gastric Stump Cancer Following Gastrectomy.

J Gastrointest Surg. 2010 Aug 18;

Authors: Namikawa T, Kitagawa H, Iwabu J, Okabayashi T, Kobayashi M, Hanazaki K

INTRODUCTION: We analyzed the clinicopathological characteristics and outcomes of patients with gastric stump cancer (GSC) to identify important prognostic factors. PATIENTS AND METHODS: We retrospectively reviewed clinical reports of 34 patients with GSC treated at Kochi Medical School from 1982 to 2008 to analyze the clinical and pathological factors that influenced patient survival. RESULTS: The median interval between initial and second operation was 15.8 years; this interval was significantly longer in patients diagnosed originally with benign disease than in those with previous malignant disease. Histologically, the incidence of diffuse-type cancer was significantly prominent in patients with previous benign gastric disease than in those with previous malignant gastric disease. The overall 5-year survival rate was 53.3%, with presence of lymph node metastasis and pathological serosal invasion of the tumor associated with poor survival. The final analysis revealed tumor located at anastomosis, tumor size greater than 5 cm, serosal invasion, the presence of lymph node metastasis, and stage III or higher to be significantly associated with poor survival. CONCLUSIONS: Follow-up programs after gastrectomy should account for long latency periods of disease. Early detection, attentive observation of anastomotic site, and sufficient surgical resection were important influences on outcome for patients with GSC after Billroth I or Billroth II reconstruction.

PMID: 20717740 [PubMed - as supplied by publisher]

Related Articles

Laparoscopic Versus Open Appendectomy: An Analysis of Outcomes in 17,199 Patients Using ACS/NSQIP.

J Gastrointest Surg. 2010 Aug 19;

Authors: Page AJ, Pollock JD, Perez S, Davis SS, Lin E, Sweeney JF

BACKGROUND: The current study was undertaken to evaluate the outcomes for open and laparoscopic appendectomy using the 2008 American College of Surgeons: National Surgical Quality Improvement Program (ACS/NSQIP) Participant Use File (PUF). We hypothesized that laparoscopic appendectomy would have fewer infectious complications, superior perioperative outcomes, and decreased morbidity and mortality when compared to open appendectomy. STUDY DESIGN: Using the Current Procedural Technology (CPT) codes for open (44950) and laparoscopic (44970) appendectomy, 17, 199 patients were identified from the ACS/NSQIP PUF file that underwent appendectomy in 2008. Univariate analysis with chi-squared tests for categorical data and t tests or ANOVA tests for continuous data was used. Binary logistic regression models were used to evaluate outcomes for independent association by multivariable analysis. RESULTS: Of the patients, 3,025 underwent open appendectomy and 14,174 underwent laparoscopic appendectomy. Patients undergoing laparoscopic appendectomy had significantly shorter operative times and hospital length of stay. They also had a significantly lower incidence of superficial and deep surgical site infections, wound disruptions, fewer complications, and lower perioperative mortality when compared to patients undergoing open appendectomy. CONCLUSIONS: Using the ACS/NSQIP PUF file, we demonstrate that laparoscopic appendectomy has better outcomes than open appendectomy for the treatment of appendicitis. While the operative treatment of appendicitis is surgeon specific, this study lends support to the laparoscopic approach for patients requiring appendectomy.

PMID: 20721634 [PubMed - as supplied by publisher]

Related Articles

Transcervical Heller Myotomy Using Flexible Endoscopy.

J Gastrointest Surg. 2010 Aug 19;

Authors: Spaun GO, Dunst CM, Arnold BN, Martinec DV, Cassera MA, Swanström LL

INTRODUCTION: Esophageal achalasia is most commonly treated by laparoscopic myotomy. Transesophageal approaches using flexible endoscopy have recently been described. We hypothesized that using techniques and flexible instruments from our NOTES experience through a small cervical incision would be a safer and less traumatic route for esophageal myotomy. The purpose of this study was to evaluate the feasibility, safety, and success rate of using flexible endoscopes to perform anterior or posterior Heller myotomy via a transcervical approach. METHODS: This animal (porcine) and human cadaver study was conducted at the Legacy Research and Technology Center. Mediastinal operations on ten live, anesthetized pigs and two human cadavers were performed using standard flexible endoscopes through a small incision at the supra-sternal notch. The esophagus was dissected to the phreno-esophageal junction using balloon dilatation in the peri-esophageal space followed by either anterior or posterior distal esophageal myotomy. Success rate was recorded of esophageal dissection to the diaphragm and proximal stomach, anterior and posterior myotomy, perforation, and complication rates. RESULTS: Dissection of the esophagus to the diaphragm and performing esophageal myotomy was achieved in 100% of attempts. Posterior Heller myotomy was always extendable onto the gastric wall, while anterior gastric extension of the myotomy was found to be more difficult (4/4 and 2/8, respectively; P = 0.061). CONCLUSION: Heller myotomy through a small cervical incision using flexible endoscopes is feasible. A complete Heller myotomy was performed with a higher success rate posteriorly possibly due to less anatomic interference.

PMID: 20721635 [PubMed - as supplied by publisher]

Related Articles

Intra-abdominal Fat Predicts Survival in Pancreatic Cancer.

J Gastrointest Surg. 2010 Aug 20;

Authors: Balentine CJ, Enriquez J, Fisher W, Hodges S, Bansal V, Sansgiry S, Petersen NJ, Berger DH

BACKGROUND: Body mass index (BMI) has proven unreliable in predicting survival following pancreaticoduodenectomy for cancer. While measures of intra-abdominal fat correlate with medical and postoperative complications of obesity, the impact of intra-abdominal fat on pancreatic cancer survival is uncertain. We hypothesized that the quantity of intra-abdominal fat would predict survival following resection of pancreatic cancer. METHODS: Preoperative CT imaging was used to measure intra-abdominal fat. Cox regression analyses were used to identify independent predictors of survival. RESULTS: Sixty-one patients from 2000-2009 underwent pancreaticoduodenectomy for exocrine pancreatic adenocarcinoma. After adjusting for age and perineural invasion status, preoperative BMI did not predict overall survival (p < 0.827). Unlike BMI, quartile of intra-abdominal fat predicted survival. Relative to patients with the least intra-abdominal fat (lowest quartile), those with more intra-abdominal fat demonstrated worse overall survival, but in a non-linear fashion. Individuals in the second quartile showed a fourfold increase in likelihood of death (HR 4.018, 95% CI 1.099-14.687, p < 0.035) relative to the lowest quartile. Patients in the third (HR 2.124, 95% CI 0.278-16.222, p < 0.468) and fourth quartile (HR 1.354, 95% CI 0.296-6.190, p < 0.696) also showed greater risk of death. CONCLUSIONS: Measuring intra-abdominal fat identifies a subset of patients with worse prognosis in pancreatic cancer.

PMID: 20725799 [PubMed - as supplied by publisher]

Related Articles

From Longitudinal Gastric Resection to Sleeve Gastrectomy-Revival of a Previously Established Surgical Procedure.

J Gastrointest Surg. 2010 Aug 20;

Authors: Spiegel HU, Skawran S

INTRODUCTION: Sleeve gastrectomy is becoming increasingly popular within bariatric surgery. Initially introduced as a component of complex interventions and later as part of a two-stage operation in high-risk patients, the procedure is now more common as one-stage operation and subject of avid scientific discussion. However, the concept of longitudinal gastric resection is not new. The procedure was already established in ulcer surgery but soon faded into insignificance. This article aims to trace the historical development of resection of the greater curvature with particular reference to its origin in ulcer and bariatric surgery. The contribution of ulcer surgery to modern sleeve gastrectomy is highlighted. Furthermore, the current value of sleeve gastrectomy within the spectrum of bariatric surgical procedures will be discussed. Relevant medical literature from PubMed to April 2010 was reviewed. DISCUSSION: Besides bariatric surgery modern sleeve gastrectomy has one more so far largely neglected origin: segmental and later longitudinal gastric resection used in ulcer surgery. Experience and achievements from ulcer surgery simplified and facilitated development of sleeve gastrectomy which is not the desired universal procedure for bariatric surgery but certainly an attractive treatment option. It should be performed in a more standardized manner and with due regard to future long-term results.

PMID: 20725800 [PubMed - as supplied by publisher]

Related Articles

Response to Reader’s Queries.

J Gastrointest Surg. 2010 Aug 21;

Authors: Dudeja V, Gupta P, Al-Refaie WB

PMID: 20730504 [PubMed - as supplied by publisher]

Related Articles

Intestinal Lengthening in Adult Patients with Short Bowel Syndrome.

J Gastrointest Surg. 2010 Aug 24;

Authors: Yannam GR, Sudan DL, Grant W, Botha J, Langnas A, Thompson JS

INTRODUCTION: Limited information regarding the usefulness of bowel lengthening in adult patients with short bowel syndrome is available. METHODS: Retrospective review of a single center series of intestinal lengthening over 15-year period in patients >/=18 years old. RESULTS: Twenty adult patients underwent Bianchi (n = 6) or serial transverse enteroplasty (STEP) (n = 15). Median age was 38 (18-66) years and 11 were female. Indications were (a) to increase the enteral caloric intake thereby reduce or wean parenteral nutrition (PN) (n = 14) or (b) for bacterial overgrowth (n = 6). Twelve patients required additional procedures to relieve the anatomical blockade. Median remnant bowel length prior to surgery, length gained and final bowel length was 60, 20, and 80 cm, respectively. Survival was 90% with mean follow-up of 4.1 years (range = 1-7.9 years). Two patients died during follow-up. Intestinal transplant salvage was required in one patient 4.8 years after STEP. Overall, of 17 patients, ten (59%) patients achieved enteral autonomy and were off PN. Of seven patients who are on PN, three patients showed significant improvement in enteral caloric intake. All except one showed significant improvement in symptoms of bacterial overgrowth. CONCLUSIONS: Bowel lengthening is technically feasible and effectively leads to weaning from PN in more than half of the adult patients. Lengthening procedures may be an underutilized treatment for adults with short bowel syndrome.

PMID: 20734155 [PubMed - as supplied by publisher]

Related Articles

Erratum to: The Long-Term Results of Distal Gastrectomy by Mini-laparotomy in Early Gastric Cancer Patients.

J Gastrointest Surg. 2010 Aug 24;

Authors: Jung H, Jeon HM, Lee HH, Song KY, Park CH

PMID: 20734156 [PubMed - as supplied by publisher]

Emergence of Secondary Resistance to Imatinib in Recurrent Gastric GIST.

J Gastrointest Surg. 2010 Aug 17;

Authors: Jayanthi NV

PMID: 20714935 [PubMed - as supplied by publisher]

Ethnicity Influences Lymph Node Resection in Colon Cancer.

J Gastrointest Surg. 2010 Aug 17;

Authors: Cone MM, Shoop KM, Rea JD, Lu KC, Herzig DO

The purpose of this study is to determine the association between ethnicity and lymph node retrieval after colon cancer resection. Using the Surveillance Epidemiology and End Results (SEER)-Medicare database, patients who underwent colon cancer resection from 2000-2003 were evaluated. Subjects were classified as having <12 (N = 20,605) or >/=12 (N = 12,358) lymph nodes examined. Multivariate models were used to analyze the relationship between lymph nodes resected and independent variables. Out of a total of 32,936 patients, 62.5% had fewer than 12 lymph nodes resected. In multivariate analysis, Hispanic ethnicity was associated with a significantly lower chance of having >/=12 lymph nodes than the Caucasian population (OR = 0.61; CI, 0.50-0.74). Despite this, there was no understaging: the proportion of stage II and III diagnoses was the same. Both groups received the same rate of cancer-directed surgery and survival was equivalent. During this study period, a majority of colon cancer resections were inadequate based on the current standard of >/=12 nodes. Hispanic patients were less likely to have an adequate node resection when compared to Caucasians. Despite fewer lymph nodes harvested, they had equivalent staging and survival. These results suggest that ethnicity influences the lymph node count.

PMID: 20714936 [PubMed - as supplied by publisher]

Pancreatoduodenectomy for Ductal Adenocarcinoma in the Very Elderly; Is It Safe and Justified?

J Gastrointest Surg. 2010 Aug 17;

Authors: Khan S, Sclabas G, Lombardo KR, Sarr MG, Nagorney D, Kendrick ML, Donohue JH, Que FG, Farnell MB

BACKGROUND: The outcomes of complex major surgery in the elderly are being scrutinized because of the demands on surgical services by an aging population and the concern whether such endeavors are justified. Pancreatoduodenectomy (PD) for pancreatic adenocarcinoma presents special challenges because of the high morbidity of the procedure, dismal prognosis of the disease, and the increasing incidence of pancreatic cancer with age. METHODS: All patients who underwent PD for pancreatic adenocarcinoma from 1981 to 2007 were analyzed for perioperative outcomes, tumor-related parameters, use of adjuvant therapy, and long-term survival. Specifically those aged >/=80 years were compared with a control group aged </=80 years. Continuous variables are displayed as median and interquartile range (IQR); log-rank test and Cox’s proportional hazards were used to determine survival and effect of age as an independent marker against other covariates. RESULTS: Fifty-three patients aged >/=80 years underwent PD. Twenty-six (51%) developed complications, including delayed gastric emptying (nine, 17%), pancreatic leak (six, 11%), and postoperative bleeding (five, 9%). There was one in-hospital death (2%). The hospital stay was 13.5 days (IQR 9-19). Forty-one (79%) patients were discharged home; of the 11 (21%) patients who went to an outside health care facility (pancreatic leak/drains and feeding issues-five, delayed gastric emptying/nutritional-four, no home support-one), one died in a nursing home at 5 months while the other ten patients returned to their previous abode (median 4 weeks). The median disease-free and overall survivals were 11.8 (IQR 7.8-18.4) and 13.5 months (IQR 12-21.3). Compared to the non-octogenarians (n = 567), the older population had more poor risk patients with respect to ASA status (P < 0.0004), stayed longer as in-patients (P < 0.04), were more likely to develop complications (P < 0.001), and were less likely to receive adjuvant therapy (P < 0.0001). There was no difference in long-term disease-free or overall survival (log-rank P < 0.30 and P < 0.14), and age did not appear to be an independent marker of prognosis when analyzed (Cox’s proportional hazards P < 0.26; chi-square, 1.25). CONCLUSIONS: In experienced institutions, PD for ductal adenocarcinoma is a viable option in the ambulatory octogenarian population who are deemed operative candidates for a PD. The trade off is a greater complication rate and the prospect of discharge (one in five) to a chronic care facility. The majority, however, can be discharged home with a reasonable functional status, and those discharged to temporary health care rehabilitation facilities are likely to make a recovery over a few weeks.

PMID: 20714937 [PubMed - as supplied by publisher]

Damage Control Principles for Pancreatic Surgery.

J Gastrointest Surg. 2010 Aug 17;

Authors: Ball CG, Correa-Gallego C, Howard TJ, Zyromski NJ, Lillemoe KD

PMID: 20714938 [PubMed - as supplied by publisher]

Preservation of Replaced or Accessory Right Hepatic Artery During Pancreaticoduodenectomy for Adenocarcinoma: Impact on Margin Status and Survival.

J Gastrointest Surg. 2010 Aug 10;

Authors: Turrini O, Wiebke EA, Delpero JR, Viret F, Lillemoe KD, Schmidt CM

AIM: The aim of the study was to determine the impact of replaced or accessory right hepatic artery (RARHA) during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). METHODS: Four hundred seventy-one consecutive patients underwent PD for PA at the two institutions; 47 patients (10%) had RARHA: 16 patients (neoRARHA group) received neoadjuvant chemoradiation, and 31 patients did not receive preoperative treatment (RARHA group). Thirty-one matched patients without RARHA comprised our control group. RESULTS: RARHA was preserved in 44 patients; three patients with involved RARHA had reconstruction (n = 2) or ligation (n = 1). Patients with R1 resection (n = 8) had tumor size >/=3 cm. Patients in the neoRARHA group had identical positive margin rate when compared with patients in RARHA group (p = 0.6). No difference was noted in median or 3-year overall survival times between RARHA group and control group. Two patients in RARHA group with involved RARHA died of disease progression after 6 and 12 months of follow-up. One patient in neoRARHA group with involved RARHA was still alive without recurrence after 28 months’ follow-up. CONCLUSIONS: Pathologic findings did not show increased positive margins despite preservation of RARHA. In contrast, patients with frank RARHA involvement seemed to have poor survival. Thus, patients with suspicion of involved RARHA should be considered for neoadjuvant chemoradiation.

PMID: 20697832 [PubMed - as supplied by publisher]

Evaluating Causes of Death in Familial Adenomatous Polyposis.

J Gastrointest Surg. 2010 Jul 30;

Authors: de Campos FG, Perez RO, Imperiale AR, Seid VE, Nahas SC, Cecconello I

BACKGROUND: Familial adenomatous polyposis is a genetic syndrome associated with an increased risk of colorectal cancer (CRC) and different extracolonic manifestations. GOALS: The goal of this study is to evaluate the frequency of death causes. MATERIAL AND METHODS: Charts from 97 patients treated from 1977 to 2008 were reviewed. Retrieved data and family information allowed us to classify causes of death in those related to CCR to other malignancies or other causes. RESULTS: There were analyzed data from 46 men (47.4%) and 51 women (52.6%) with an average age of 35.1 years (14 to 82). At diagnosis, 57 patients (58.7%) already had CRC-associated polyposis. There were performed 93 colectomies, one internal diversion, and one partial resection. Two patients were not operated on. Results from 19 deceased patients (19.5%) were analyzed. CRC, other tumors (desmoid tumors, lymphoma, and gastric cancer), and other causes (complication of duodenal cancer surgery, complication after ileorectal anastomosis (IRA), and coronary disease) were responsible for 12 (63.1%), four (21.1%), and three (15.8%) of all deaths, respectively. Death from CRC occurred in the context of either systemic, rectal, or pouch recurrence. Desmoid disease was the second cause of death (10.5% of all causes), leading to a fatal outcome 22% of all patients who developed DT during the study period. Upper digestive carcinomas were responsible for other two death cases. CONCLUSIONS: (1) CRC is still the most prevalent cause of death; (2) even after curative resections, CRC can cause death through rectal or pouch malignization; (3) long-term survival was also strongly related to the development of extracolonic neoplasia, especially desmoid tumors and gastroduodenal carcinoma; (4) our results raise the need for local improvement in familiar screening and help us to define follow-up strategies and patient-information standards.

PMID: 20676788 [PubMed - as supplied by publisher]

Not Just for Trauma Patients: Damage Control Laparotomy in Pancreatic Surgery (Response to Letter to the Editor).

J Gastrointest Surg. 2010 Jul 30;

Authors: Morgan K, Adams DB

PMID: 20676789 [PubMed - as supplied by publisher]

Does Body Mass Index/Morbid Obesity Influence Outcome in Patients Who Undergo Pancreatoduodenectomy for Pancreatic Adenocarcinoma?

J Gastrointest Surg. 2010 Jul 30;

Authors: Khan S, Sclabas G, Reid-Lombardo K, Sarr MG, Nagorney D, Kendrick ML, Que FG, Donohue JH, Huebner M, Lohse C, Farnell MB

INTRODUCTION: The obesity epidemic coupled with epidemiologic evidence of the link between pancreatic cancer and obesity has raised the interest in the impact of body mass index (BMI) on outcomes for resected pancreatic cancer. METHODS: All patients who underwent pancreatoduodenectomy (PD) for pancreatic adenocarcinoma from 1981 to 2007 were categorized into four groups according to their BMI (<25, 25 to <30, 30 to <35, and >/=35). Associations of these BMI groups with perioperative (operating time, blood loss, complications, in-hospital mortality), pathologic (tumor diameter, tumor stage, differentiation, lymph node status, R0 status) features and long-term patient outcome were evaluated using Kruskal-Wallis and chi-square tests, logistic regression, and Cox proportional hazards regression. A second set of analyses were performed by dichotomizing patients into morbidly obese (BMI >/= 35) in comparison to the rest. RESULTS: Of the 586 consecutive patients studied, there were 232 (39.6%) with BMI <25, 232 (39.6%) with BMI 25 to <30, 89 (15.2%) with BMI 30 to <35, and 33 (5.6%) with BMI >/= 35. Operating time (P = 0.003) and intraoperative blood loss (P < 0.001) increased with BMI, although none of the remaining perioperative features differed significantly among the BMI groups. Similarly, there were no significant associations between BMI group and the pathological features studied, particularly lymph node status (P = 0.98). BMI was not associated with lymph node status even after adjusting for tumor diameter. All analyses were repeated for the morbidly obese. Cox regression did not demonstrate an impact of BMI or morbid obesity on overall or disease-free survival. CONCLUSIONS: BMI (and morbid obesity) does not appear to influence long-term outcomes for patients undergoing PD. Surgeons should be vigilant of the greater risk of perioperative blood loss with increasing BMI.

PMID: 20676790 [PubMed - as supplied by publisher]

Simultaneous Liver and Colorectal Resections Are Safe for Synchronous Colorectal Liver Metastases.

J Gastrointest Surg. 2010 Jul 30;

Authors: Luo Y, Wang L, Chen C, Chen D, Huang M, Huang Y, Peng J, Lan P, Cui J, Cai S, Wang J

BACKGROUND: Hepatic resection (HR) is the only option offering a potential cure for patients with synchronous colorectal cancer liver metastases (SCRLM). The optimal timing of HR for SCRLM is still controversial. This study aimed to determine whether simultaneous HR is similar to staged resection regarding the morbidity and mortality rates in patients with SCRLM. METHODS: Four hundred and five consecutive patients with SCRLM were treated with either simultaneous (n = 129) or staged (n = 276) HR. The postoperative complications were analyzed retrospectively according to the documented records and hepatectomy databases at the Gastrointestinal Institute. RESULTS: Perioperative morbidity and mortality did not differ between simultaneous resections and staged resections for selected patients with SCRLM (morbidity, 47.3% versus 54.3%; mortality, 1.5% versus 2.0%, respectively; both p > 0.05). Simultaneous liver resections of three or more segments would not increase the rate of complications compared to staged resections (56.8% and 42.4%, respectively; p = 0.119). Meanwhile, patients with simultaneous resections experienced shorter duration of surgery and postoperative hospitalization time as well as less blood loss during surgery (all p < 0.05). CONCLUSIONS: Simultaneous resections of colorectal cancer primary lesions and hepatic metastases were safe and could serve as a primary option for selected SCRLM patients.

PMID: 20676791 [PubMed - as supplied by publisher]

Alternative Port Site Selection (APSS) for Improved Cosmesis in Laparoscopic Surgery.

J Gastrointest Surg. 2010 Jul 30;

Authors: de la Cruz-Munoz N, Koniaris L

The use of laparoscopy can be associated with improved cosmesis following a variety of gastrointestinal procedures versus standard open surgery. The placement of laparoscopic ports in less visible areas of the body such as the bikini line, termed alternative port site selection (APSS), may result in further improved cosmesis. Performance of laparoscopic procedures from such alternative port placement areas may be associated with increased technical challenge. This manuscript discusses APSS approaches for two common laparoscopic procedures, cholecystectomy and gastric banding. Familiarity and implementation of these techniques can allow select patients to undergo procedures with less visible scarring and is less challenging than laparoscopic single site approaches.

PMID: 20676792 [PubMed - as supplied by publisher]

Surgeon Volume Versus Morbidity and Cost in Patients Undergoing Pancreaticoduodenectomy in an Academic Community Medical Center.

J Gastrointest Surg. 2010 Jul 30;

Authors: Kennedy TJ, Cassera MA, Wolf R, Swanstrom LL, Hansen PD

BACKGROUND: Despite trends toward regionalization of care, the majority of pancreaticoduodenectomies (PD) are performed in community hospitals by surgeons with varying degrees of experience. We analyzed the impact of several variables, including surgeon volume, on outcomes following PD within a high-volume community-based teaching hospital system. METHODS: Patients who underwent PD from 2005 to 2008 were reviewed retrospectively. Perioperative data, complications, and hospital financial data was queried. A high-volume (HV) surgeon was defined as an average of 10 or more PD per year. RESULTS: Ninety-four patients underwent PD with an overall operative mortality rate of 9.6% (HV 2.2%, LV 16.0%), major complication rate of 32% (HV 18%, LV 44%), and median cost of $30,860 (HV $27,185, LV $33,007). Factors predictive of death were age (p < 0.02), body mass index (p < 0.01), and surgeon volume (p < 0.05). Factors predictive of major complication were surgeon volume (p < 0.01) and body mass index (p < 0.01). Factors predictive for increased length of stay for patients discharged from the hospital were surgeon volume (p < 0.02) and preoperative ASA classification (p < 0.05). CONCLUSIONS: Surgeon volume and patient body mass index have a significant impact on perioperative morbidity following PD in a community teaching hospital.

PMID: 20676793 [PubMed - as supplied by publisher]

Large Volume Hepatic Microwave Ablation Elicits Fewer Pulmonary Changes than Radiofrequency or Cryotherapy.

J Gastrointest Surg. 2010 Jul 30;

Authors: Ahmad F, Gravante G, Bhardwaj N, Strickland A, Basit R, West K, Sorge R, Dennison AR, Lloyd DM

BACKGROUND: Lung changes after microwave tissue ablation (MTA) of different volumes of liver were compared with hepatic resection, cryotherapy (CRYO) and radiofrequency ablation (RFA). METHODS: Live rats underwent MTA, surgical resection, CRYO or RFA of 15%, 33% and 66% of total hepatic volume and lung samples were collected at the time of death. Lung impairment was assessed directly by examining the tissue specimens for the degree of interstitial pneumonia and by comparing the alveolar thickness in the different groups. RESULTS: All RFA and CRYO rats undergoing 66% of ablations died, but the MTA group had no fatalities. Following 66% RFA or CRYO ablations, the animals had a significantly increased thickness of the alveolar septa compared to 15% or 33% ablations and to 66% ablations in the MTA group. CONCLUSIONS: Large volume MTA is associated with a significant reduction in consequent lung damage and is well tolerated compared to RFA and CRYO.

PMID: 20676794 [PubMed - as supplied by publisher]

Related Articles

Development of a Multimodal Tumor Model for Porcine Liver.

J Gastrointest Surg. 2010 Jul 24;

Authors: Rethy A, Langø T, Aasland J, Mårvik R

In our efforts to develop a guidance system for laparoscopic liver surgery, we are working towards a live animal tumor model. The objective of this study was to establish the tumor model for live porcine liver, visible on both computed tomography (CT) and ultrasound images. The tumor model was created by injecting a mixture of agarose, sephadex, and glycerol. Together with water, the mixture was heated to bring its components into solution. Once heating was complete, methylthionine chloride and CT contrast were added. Using laparoscopic ultrasound guidance, the tumor model mixture was injected into in vivo porcine liver. The resulting model tumors were radiolucent, visible on both CT and conventional X-ray. They appeared as hyperechoic lesions on ultrasound images. Compared to the CT images, the model tumors in the ultrasound images showed good correspondence in size. We conclude that our tumor model, due to its clearly identifiable nature on multiple imaging modalities, is a valuable tool for further studies on laparoscopic ultrasound (2D and 3D) and navigated ultrasound in laparoscopic surgery of the liver and other organs in a pre-clinical set-up.

PMID: 20658203 [PubMed - as supplied by publisher]

Related Articles

Evaluation of Cyst Fluid CEA Analysis in the Diagnosis of Mucinous Cysts of the Pancreas.

J Gastrointest Surg. 2010 Jul 24;

Authors: Nagula S, Kennedy T, Schattner MA, Brennan MF, Gerdes H, Markowitz AJ, Tang L, Allen PJ

BACKGROUND: Although cyst fluid carcinoembryonic antigen (CEA; >192 ng/ml) is the preferred test for identifying mucinous pancreatic cysts, the data are more robust for mucinous cystic neoplasms (MCN) than for intraductal papillary mucinous neoplasms (IPMN). The role of cyst fluid CEA as a marker for either malignancy or malignant progression is uncertain. METHODS: All patients with pancreatic cysts who had undergone endoscopic ultrasound with cyst fluid CEA measurement between 2001 and 2009 were identified. Patient outcomes and pathology from operative resections were recorded. RESULTS: Two hundred sixty-seven patients were identified; pathological diagnosis was obtained in 97. Mucinous cysts were identified in 66 of 97 (68%): benign IPMN, n = 42; malignant IPMN, n = 10; benign MCN, n = 12; malignant MCN, n = 2. CEA > 192 ng/mL had a sensitivity and specificity of 73% and 65% for identifying mucinous cysts; cyst fluid CEA was not associated with malignancy (p = 0.85). One hundred seventy-eight patients were managed with an initial non-operative strategy. Eight (4%) developed radiographic changes necessitating surgery; pathology demonstrated seven benign mucinous cysts and one retention cyst. CEA was not associated with radiographic progression (p = 0.37). CONCLUSIONS: Cyst fluid CEA is a useful test for identifying mucinous cysts, including MCN and IPMN. In mucinous cysts, cyst fluid CEA is not associated with malignancy or radiographic progression.

PMID: 20658204 [PubMed - as supplied by publisher]

Related Articles

Emergency Portacaval Shunt Versus Rescue Portacaval Shunt in a Randomized Controlled Trial of Emergency Treatment of Acutely Bleeding Esophageal Varices in Cirrhosis-Part 3.

J Gastrointest Surg. 2010 Jul 24;

Authors: Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ

BACKGROUND: Emergency treatment of bleeding esophageal varices in cirrhosis is of singular importance because of the high mortality rate. Emergency portacaval shunt is rarely used today because of the belief, unsubstantiated by long-term randomized trials, that it causes frequent portal-systemic encephalopathy and liver failure. Consequently, portacaval shunt has been relegated solely to salvage therapy when endoscopic and pharmacologic therapies have failed. Question: Is the regimen of endoscopic sclerotherapy with rescue portacaval shunt for failure to control bleeding varices superior to emergency portacaval shunt? A unique opportunity to answer this question was provided by a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt conducted from 1988 to 2005. METHODS: Unselected consecutive cirrhotic patients with acute bleeding esophageal varices were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup was completed and treatment was initiated within 8 h. Failure of endoscopic sclerotherapy was defined by strict criteria and treated by rescue portacaval shunt (n = 50) whenever possible. Ninety-six percent of patients had more than 10 years of follow-up or until death. RESULTS: Comparison of emergency portacaval shunt and endoscopic sclerotherapy followed by rescue portacaval shunt showed the following differences in measurements of outcomes: (1) survival after 5 years (72% versus 22%), 10 years (46% versus 16%), and 15 years (46% versus 0%); (2) median post-shunt survival (6.18 versus 1.99 years); (3) mean requirements of packed red blood cell units (17.85 versus 27.80); (4) incidence of recurrent portal-systemic encephalopathy (15% versus 43%); (5) 5-year change in Child’s class showing improvement (59% versus 19%) or worsening (8% versus 44%); (6) mean quality of life points in which lower is better (13.89 versus 27.89); and (7) mean cost of care per year ($39,200 versus $216,700). These differences were highly significant in favor of emergency portacaval shunt (all p < 0.001). CONCLUSIONS: Emergency portacaval shunt was strikingly superior to endoscopic sclerotherapy as well as to the combination of endoscopic sclerotherapy and rescue portacaval shunt in regard to all outcome measures, specifically bleeding control, survival, incidence of portal-systemic encephalopathy, improvement in liver function, quality of life, and cost of care. These results strongly support the use of emergency portacaval shunt as the first line of emergency treatment of bleeding esophageal varices in cirrhosis.

PMID: 20658205 [PubMed - as supplied by publisher]

Comments of Prof. Pedrazzoli “Impact of Postoperative Pancreatic Fistula on Surgical Outcome-the Need for a Classification-Driven Risk Management”

J Gastrointest Surg. 2010 Jul 22;

Authors: Moussavian MR, Schilling MK

PMID: 20652437 [PubMed - as supplied by publisher]

An Unusual Complication Encountered Incidentally at Laparoscopic Cholecystectomy: A Case Series.

J Gastrointest Surg. 2010 Jul 21;

Authors: Uzzaman MM, Nair MS, Myint F

INTRODUCTION: This is a case series of erosion of the common bile duct by an in situ stent found incidentally during laparoscopic cholecystectomy (LC). To the best of our knowledge, this is one of the first reported incidences of this nature. METHOD: Four individual case reports. RESULTS: Thirty nine patients with an in situ CBD stent underwent LC for symptomatic gallstones in our institution over a 4-year time period (2005 to 2009). Four patients were found to have the stent eroding through the wall of the CBD. In these four patients, endoscopic retrograde cholangiopancreatography (ERCP) had previously been performed – extracting stone(s) – followed by sphincterotomy and insertion of a 7 Fr pigtail stent (measuring 4 cm). The operation was converted to open in two patients, and the procedure was abandoned in one of these cases. In the other two patients, the anatomy of Calots triangle was delineated well, and the operator was able to complete LC. The duration between initial pigtail stent insertion and LC ranged from 32 to 400 days. None of our patients required a definitive surgical repair of the CBD or T-tube placement. The stent was removed during surgery in one case, removed endoscopically at a later date in two patients, and passed spontaneously in one patient. All four patients made a good postoperative recovery. CONCLUSION: CBD erosion is a complication of plastic biliary stent insertion. CBD stent erosion will make surgery more hazardous especially if it remains in situ for a significant period of time. CBD erosion can generally be managed conservatively without the need for surgical repair. Awareness of this complication should prompt earlier surgery or earlier removal of plastic pigtail stents.

PMID: 20652438 [PubMed - as supplied by publisher]

Related Articles

Clinical Presentation and Diagnosis of Intestinal Adenocarcinoma in Crohn’s Disease: Analysis of Clinical Predictors and of the Life-Time Risk.

J Gastrointest Surg. 2010 Jul 14;

Authors: Ruffolo C, Scarpa M, Polese L, D’Amico FE, Boetto R, Pozza A, D’Incà R, Checchin D, Sturniolo GC, Bassi N, Angriman I

BACKGROUND: Late diagnosis of cancer in CD often occurs, and the prognosis is poor. The primary aim of this study was to assess the relationship between clinical presentation and diagnosis of intestinal adenocarcinoma in CD; the secondary aim was to evaluate the timing of cancer occurrence in CD patients. PATIENTS AND METHODS: Medical records of 12 consecutive patients with intestinal adenocarcinoma in CD and of 79 consecutive CD patients undergoing bowel surgery were reviewed. Presentation symptoms were analyzed as possible predictors. Timing of intestinal adenocarcinoma occurrence in patients with CD was analyzed including all the 347 consecutive patients that had undergone surgery for CD in our institute from January 1984 to June 2008. Life table analysis and uni/multivariate analyses were performed. RESULTS: Ten men and two women underwent surgery for intestinal cancer in CD with a median age of 50 years (31-68). Carcinomas were localized in the terminal ileum in four cases, right colon in three, transverse colon in one, sigmoid colon in one, rectum in two, and an anorectal fistula in one. Only three patients were pre-operatively diagnosed with cancer. At multivariate analysis only age (OR 1.057 (95% CI 0.999-1.107), p = 0.05) and obstruction (OR 6.530 (95% CI 1.533-27.806), p = 0.01) significantly predicted cancer diagnosis. The risk rate (RR) for cancer occurrence started to rise at the end of the third decade of life (RR = 0.005). The analysis of risk rate for cancer occurrence during overt CD showed that it is initially high at onset (RR = 0.001) and after two other peaks at 150 months from onset, it began to rise again. The presence of Crohn’s colitis was associated to a significant risk of cancer (HR = 4.790, p = 0.009) while the use of 5-ASA resulted to be a protective factor against cancer occurrence (HR = 0.122, p = 0.013). DISCUSSION: In CD, rectal bleeding, the most common alarm symptom for intestinal cancer, is not useful for an early diagnosis. CD patients presenting with an older age and obstruction should be thoroughly investigated to rule out neoplastic lesions. There is probably no safe interval of CD where surveillance for intestinal cancer can be omitted. In the meantime, even in absence of active disease, all CD patients should undergo therapy with 5-ASA.

PMID: 20628906 [PubMed - as supplied by publisher]

Living Donor and Deceased Donor Liver Transplantation for Autoimmune and Cholestatic Liver Diseases-An Analysis of the UNOS Database.

J Gastrointest Surg. 2010 Jul 9;

Authors: Kashyap R, Safadjou S, Chen R, Mantry P, Sharma R, Patil V, Maloo M, Ryan C, Marroquin C, Barry C, Ramaraju G, Maliakkal B, Orloff M

INTRODUCTION: Autoimmune hepatitis and cholestatic liver diseases have more favorable outcomes after liver transplantation as compared to viral hepatitis and alcoholic liver diseases. However, there are only few reports comparing outcomes of both living donor liver transplants (LDLT) and deceased donor liver transplants (DDLT) for these conditions. AIM: We aim to study the survival outcomes of patients undergoing LT for autoimmune and cholestatic diseases and to identify possible risk factors influencing survival. Survival outcomes for LDLT vs. DDLT are also to be compared for these diseases. PATIENTS AND METHODS: A retrospective analysis of the UNOS database for patients transplanted between February 2002 until October 2006 for AIH, PSC, and PBC was performed. Survival outcomes for LDLT and DDLT patients were analyzed and factors influencing survival were identified. RESULTS: Among all recipients the estimated patient survival at 1, 3, and 5 years for LDLT was 95.5%, 93.6%,and 92.5% and for DDLT was 90.9%, 86.5%, and 84.9%, respectively (p = 0.002). The estimated graft survival at 1, 3, and 5 years for LDLT was 87.9%, 85.4%, and 84.3% and for DDLT 85.9%, 80.3%, and 78.6%, respectively (p = 0.123). On multivariate proportional hazard regression analysis after adjusting for age and MELD score, the effect of donor type was not found to be significant. CONCLUSION: The overall survival outcomes of LDLT were similar to DDLT in our patients with autoimmune and cholestatic liver diseases. It appears from our study that after adjusting for age and MELD score donor type does not significantly affect the outcome.

PMID: 20617395 [PubMed - as supplied by publisher]

Fertility Preservation for Young Women with Rectal Cancer-A Combined Approach from One Referral Center.

J Gastrointest Surg. 2010 Jul 7;

Authors: Spanos CP, Mamopoulos A

PMID: 20607436 [PubMed - as supplied by publisher]

Hemostasis after Liver Resection Improves after Single Application of Albumin and Argon Beam Coagulation.

J Gastrointest Surg. 2010 Jul 7;

Authors: Mueller GR, Wolf RF, Hansen PD, Gregory KW, Prahl SA

BACKGROUND: Bleeding from the liver surface is common after hepatic resection. Animal studies have demonstrated superiority of argon beam coagulation (ABC) and 38% human serum albumin when applied together after partial liver resection when compared to ABC alone. There are no data addressing the combination of albumin and argon beam coagulation (ABCA) applied to the bleeding liver after resection in humans. The aim of this study was to evaluate the safety and efficacy of ABCA on hemostasis when applied to the surface of the liver remnant post-hepatic resection. METHODS: Ten patients underwent liver resection and were treated with ABCA immediately after the liver was divided. The liver surface was coated with albumin and ABC applied simultaneously, the liver was covered with gauze for 3 min, and ABCA was repeated if necessary. Number of rebleeding episodes requiring re-application of ABCA, time of ABCA application, overall blood loss, and liver functions were monitored. Patients were followed for at least 6 months. RESULTS: Nine of 10 patients required a single application of ABCA, and one patient required two treatments. Average time of ABC use was 5 +/- 3 min. Median blood loss was 230 ml. Liver functions returned to near normal within 4 days of resection. CONCLUSIONS: ABCA performed well with respect to hemostatic properties, much like previous observations in animal studies. Further clinical trials are justified using this technique.

PMID: 20607437 [PubMed - as supplied by publisher]

Needlescopic Splenectomy: A Safer Alternative to Single Incision Laparoscopic Splenectomy (SILS).

J Gastrointest Surg. 2010 Jul 2;

Authors: Gagner M

PMID: 20596787 [PubMed - as supplied by publisher]

Quo Vadis STARR? A Prospective Long-Term Follow-Up of Stapled Transanal Rectal Resection for Obstructed Defecation Syndrome.

J Gastrointest Surg. 2010 Jul 2;

Authors: Zehler O, Vashist YK, Bogoevski D, Bockhorn M, Yekebas EF, Izbicki JR, Kutup A

INTRODUCTION: Functional and clinical long-term outcome after stapled transanal rectal resection (STARR) in patients with an isolated symptomatic rectocele are investigated. Short-term results after 1 year are comparable with the functional outcome even after 5 years. Eighty per cent of the patients were still satisfied. STARR is an alternative procedure to the conventional surgical approaches for patients with an obstructed defecation syndrome and rectocele. Several studies have reported short-term outcome after STARR, but long-term results are still missing. The objective of this study was to evaluate long-term clinical outcome after STARR with a follow-up of 5 years. MATERIALS AND METHODS: Twenty patients with only an isolated symptomatic rectocele due to obstructed defecation syndrome were subjected to STARR. Functional and clinical outcome was assessed by Outlet Obstruction Syndrome score (OOS score), Wexner score (WS), and Symptome Severity score (SSS score). Data were prospectively collected over 7 years. RESULTS: The perioperative morbidity after STARR accounted for 20% (n = 4). One patient was subjected to reoperation due to perforation, two postoperative bleedings occurred, and one patient developed an increasing local granulomatous reaction at the stapler line. The median follow-up accounted for 66 months (range 60-84). Sixteen patients (80%) were satisfied with the functional outcome. The median OOS, SSS and WS score improved significantly already after 1 year in these patients and remained stable at 5-year follow-up. In contrast, four patients were classified as treatment failures since the OOS score and the SSS score showed no improvement. At 5-year follow-up, these patients remained symptomatic without improvement in OOS and SSS scores. CONCLUSIONS: The STARR procedure is an effective operation in isolated symptomatic rectoceles with regard to relief of the obstructed defecation syndrome. The short-term improvement after STARR predicts long-term outcome in obstructed defecation syndrome caused by a rectocele.

PMID: 20596788 [PubMed - as supplied by publisher]

Clinicopathological Determinants of Survival After Hepatic Resection of Hepatocellular Carcinoma in 97 Patients-Experience From an Australian Hepatobiliary Unit.

J Gastrointest Surg. 2010 Jun 29;

Authors: Chua TC, Saxena A, Chu F, Liauw W, Zhao J, Morris DL

BACKGROUND: Identification of clinicopathological determinants that predict for risk of recurrence and overall survival after undergoing potentially curative hepatic resection for hepatocellular carcinoma is a strategy towards personalizing therapy to improve outcome. Through evaluation of a center’s experience with treatment of a disease, determinants unique to the treated patient cohort may be identified. METHODS: Ninety-seven patients with hepatocellular carcinoma underwent liver resection. Clinical, treatment, and histopathological variables were collected and evaluated using univariate and multivariate analyses with disease-free survival (DFS) and overall survival (OS) as the endpoints. RESULTS: The median follow-up period of 19 (range, 1 to 188) months from the time of hepatic resection. The median DFS and OS after resection of HCC were 17 and 41 months, respectively. Five-year overall survival rate was 45%. Eight independent factors associated with disease-free and overall survival were identified through a multivariate analysis. Three factors: Child-Pugh score (DFS p = 0.045, OS p = 0.001), histopathological grade (DFS p < 0.001, OS p < 0.001), and histological diagnosis of cirrhosis (DFS p < 0.001, OS p < 0.001) predicted for both disease-free and overall survival. CONCLUSION: Integrating the knowledge of identified prognostic factors into clinical decision making may provide a clinicopathological signature that could identify patients at greatest risk of treatment failure such that novel interventions may be applied to improve the survival outcome.

PMID: 20585991 [PubMed - as supplied by publisher]

Node Yield and Node Involvement in Young Colon Cancer Patients: Is There a Difference in Cancer Survival Based on Age?

J Gastrointest Surg. 2010 Jun 29;

Authors: Wang L, Hollenbeak CS, Stewart DB

BACKGROUND: The effect on cancer-specific survival (CSS) from the number of resected nodes (node yield) and the number of nodes involved with colon cancer has not been studied with respect to age. PATIENT AND METHODS: Data from 1992 to 2006 from the Surveillance, Epidemiology and End Results (SEER) registry were analyzed for colon cancer patients undergoing curative resection, comparing younger (<40; n = 2,642) and older (>/=40; n = 138,769) patients. RESULTS: The mean number of positive nodes and mean node yield was higher for the younger group. Younger patients were more likely to have metastatic disease and to have a nodal yield of >/=12 nodes, and were less likely to have node-negative colon cancers (all p < 0.0001). Younger age was associated with a lower risk of death from colon cancer (HR = 0.65; p < 0.0001). No CSS effect was noted with the interaction of age with either node yield or node involvement. Node yield <12 created a higher risk of cancer-specific death (HR = 1.22; p < 0.0001) regardless of stage. KM plots by stage demonstrated a CSS advantage (p < 0.0001) for younger patients. CONCLUSIONS: Younger patients with colon cancers do not have a worse CSS simply because of their young age, so long as proper oncologic surgical principles are adhered to.

PMID: 20585992 [PubMed - as supplied by publisher]

Revising the Atlanta Classification of Acute Pancreatitis: Festina Lente.

J Gastrointest Surg. 2010 Jun 29;

Authors: Petrov MS

PMID: 20585993 [PubMed - as supplied by publisher]

Are We Moving Towards a New Era in Minimally Invasive Thoracic Surgery?

J Gastrointest Surg. 2010 Jun 29;

Authors: Assouad J, Grunenwald D

PMID: 20585994 [PubMed - as supplied by publisher]

True Aneurysm of the Pancreaticoduodenal Arteries: A Single Institution Experience.

J Gastrointest Surg. 2010 Jun 29;

Authors: Katsura M, Gushimiyagi M, Takara H, Mototake H

BACKGROUND: True pancreaticoduodenal artery (PDA) aneurysm is a rare but potentially fatal disease. The aim of this study was to make recommendations for management of true PDA aneurysm. METHODS: True aneurysms of the PDA were diagnosed at our institution between 1996 and 2007 and analyzed retrospectively, for clinical presentation, management, and outcome. RESULTS: Eight patients were admitted to our institution for true aneurysms of the PDA. Five patients had aneurysmal rupture, and three were asymptomatic. In the rupture group, computed tomography (CT) showed the retroperitoneal hematoma around the pancreas and aneurysm, ranging from 5 to 25 mm (median, 12 mm). In the non-rupture group, CT revealed saccular aneurysm, ranging from 10 to 20 mm (median, 16 mm). The celiac axis was occluded in two patients, stenotic in four, and normal in two. Two patients underwent laparotomy, and we finally performed transcatheter arterial embolization in seven. All patients are alive, and there is no evidence of recurrence after median follow-up of 6 years. CONCLUSIONS: We recommend treatment of all true PDA aneurysms at the time of diagnosis. True PDA aneurysm with celiac artery stenosis or occlusion requires precise techniques for embolization to preserve blood flow in the celiac artery territory.

PMID: 20585995 [PubMed - as supplied by publisher]

The Long-Term Results of Distal Gastrectomy by Mini-laparotomy in Early Gastric Cancer Patients.

J Gastrointest Surg. 2010 Jun 30;

Authors: Jung H, Jeon HM, Lee HH, Song KY, Park CH

INTRODUCTION: Radical distal gastrectomy by mini-laparotomy is an alternative surgical treatment modality with technical feasibility in early gastric cancer (EGC) patients. The aim of this study is to assess the oncologic feasibility of distal gastrectomy by mini-laparotomy in EGC patients through a long-term survival analysis based on the prospectively collected data. PATIENTS AND METHODS: From January 2003 to November 2003, a total of 53 EGC patients who received distal gastrectomy by laparotomy were enrolled in this study. These patients were divided into two groups, that is, the mini-laparotomy group (ML, n = 22) and the conventional laparotomy group (CL, n = 31). A comparative long-term survival analysis was performed. RESULTS: The hospital stay was significantly shorter in mini-laparotomy group (P = 0.002). However, there were no significant differences in the pathologic results such as the resection margin and the number of harvested lymph nodes. In long-term survival results, there were no significant differences in disease-free and overall survival rate of the patients according to the method of laparotomy. CONCLUSIONS: Radical distal gastrectomy by mini-laparotomy in EGC patients would be also one of the minimally invasive surgical modality in oncologic aspect.

PMID: 20589443 [PubMed - as supplied by publisher]

The Need of a Severity Scoring System for Postoperative Pancreatic Fistulas.

J Gastrointest Surg. 2010 Jun 30;

Authors: Pedrazzoli S, Canton AS, Sperti C

PMID: 20589444 [PubMed - as supplied by publisher]

Re: High-Resolution Manometry and Lower Esophageal Sphincter Length.

J Gastrointest Surg. 2010 Jun 30;

Authors: Ayazi S, Hagen JA, Zehetner J, Demeester SR, Lipham JC, Demeester TR

PMID: 20589445 [PubMed - as supplied by publisher]

Laparoscopic Distal Pancreatectomy Offers Shorter Hospital Stays with Fewer Complications.

J Gastrointest Surg. 2010 Jun 30;

Authors: Dinorcia J, Schrope BA, Lee MK, Reavey PL, Rosen SJ, Lee JA, Chabot JA, Allendorf JD

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. The aim of this study was to investigate short-term outcomes after LDP compared to open distal pancreatectomy (ODP) at a single, high-volume institution. METHODS: We reviewed records of patients who underwent distal pancreatectomy (DP) and compared perioperative data between LDP and ODP. Continuous variables were compared using Student’s t or Wilcoxon rank-sum tests. Categorical variables were compared using chi-square or Fisher’s exact test. RESULTS: A total of 360 patients underwent DP. Beginning in 2001, 95 were attempted, and 71 were completed laparoscopically with a 25.3% conversion rate. Compared to ODP, LDP had similar rates of splenic preservation, pancreatic fistula, and mortality. LDP had lower blood loss (150 vs. 900 mL, p < 0.01), smaller tumor size (2.5 vs. 3.6 cm, p < 0.01), and shorter length of resected pancreas (7.7 vs. 10.0 cm, p < 0.01). LDP had fewer complications (28.2% vs. 43.8%, p = 0.02) as well as shorter hospital stays (5 vs. 6 days, p < 0.01). CONCLUSIONS: LDP can be performed safely and effectively in patients with benign or low-grade malignant neoplasms of the distal pancreas. When feasible in selected patients, LDP offers fewer complications and shorter hospital stays.

PMID: 20589446 [PubMed - as supplied by publisher]

Factors Predicting Failure Following High Bilio-enteric Anastomosis for Post-cholecystectomy Benign Biliary Strictures.

J Gastrointest Surg. 2010 Jun 30;

Authors: Pottakkat B, Vijayahari R, Prakash A, Singh RK, Behari A, Kumar A, Kapoor VK, Saxena R

INTRODUCTION: Failures following Roux-en-Y hepatico-jejunostomy (HJ) for post-cholecystectomy benign bile duct strictures (BBS) pose significant challenge. This study was aimed to find out the factors predicting failure after surgical repair in patients with BBS. METHODS: Between January 1989 and May 2007, 364 patients underwent Roux-en-Y HJ to the hilum for BBS. With a median follow-up of 61 (6-212) months, 334 (92%) patients had successful outcome and 30 (8%) had failure. A multivariate analysis was performed to find out the factors predicting failure. RESULTS: Thirty patients who had failure became symptomatic after a median of 35 months (3 days-190 months) after surgical repair. Out of 30 patients, 11 (37%) were experiencing occasional episodes of cholangitis responding to antibiotics. All have patent anastomosis on nuclear scintigraphy and/or cholangiography. Cholangiogram demonstrated anastomotic stricture in 19/30 (63%) patients. Eighteen patients underwent re-intervention for re-strictures (nine – percutaneous balloon dilatation of the stricture, five – revision HJ, one – right hepatectomy, three – a combination of interventions). One patient refused to undergo a planned percutaneous balloon dilatation. Out of 18 patients, 12 (67%) had successful outcome following re-interventions. One patient who underwent revision HJ after a failed percutaneous balloon dilatation died in the immediate postoperative period. Preoperative bilirubin (p = 0.001), attempted bilio-enteric anastomosis before referral (0.004), cirrhosis (0.006), portal hypertension (p = 0.056), repair in the presence of external biliary fistula (0.000), and spontaneous bilio-enteric fistula (p = 0.011) were the factors found to be predicting failure of surgical repair on multivariate analysis. CONCLUSIONS: Previous attempts of repair and delay in repair which predispose cirrhosis and portal hypertension may cause failure of surgical management in patients with BBS. In patients presenting with external biliary fistula, for a better outcome, surgical repair may be delayed till the fistula resolves.

PMID: 20589447 [PubMed - as supplied by publisher]

High-Resolution and Conventional Manometry in the Assessment of the Lower Esophageal Sphincter Length.

J Gastrointest Surg. 2010 Jul 1;

Authors: Herbella FA, Vicentine FP, Del Grande JC

PMID: 20593307 [PubMed - as supplied by publisher]

Obstetric and Cryptoglandular Rectovaginal Fistulas: Long-term Surgical Outcome; Quality of Life; and Sexual Function.

J Gastrointest Surg. 2010 Jul 1;

Authors: El-Gazzaz G, Hull TL, Mignanelli E, Hammel J, Gurland B, Zutshi M

PURPOSE: Rectovaginal fistula (RVF) repair can be challenging. Additionally, women may experience sexual dysfunction and psychosocial ramifications even after a successful repair. The aim of this study was to investigate variables looking for predictors of healing/failure and examine long-term quality-of-life (QOL) and sexual function in women with low RVF from obstetrical or cryptoglandular etiology METHODS: From June 1997-2009, 268 women underwent RVF repair. Of those, 100 with obstetric or cryptoglandular etiology agreed to participate in this study. Healing, type of procedure, use of seton or stoma, number of previous procedures, smoking, age, body mass index (BMI), dyspareunia, QOL using SF-12, FIQL, IBS-QOL, and female sexual function index was obtained from our prospective database and telephone contact. Fisher’s exact test, chi-square test, and multivariable-logistic-regression model were used to identify the variables associated with healing/failure. RESULTS: Mean follow-up was 45.8 +/- 39.2 months; mean age 42.8 +/- 10.5 years; and BMI was 28.8 +/- 7.6. Sixty (60%) fistulas were obstetric and 40 (40%) cryptoglandular and 68/100 patients (68%) healed. On multivariate analysis, treatment failure was related to a heavier BMI (p = 0.001) and number of repairs (p = 0.02). Looking at each type of repair, episioproctotomy had significant healing compared to the other choices (but was not significant on multivariate analysis). Forty-seven women were sexually active at follow-up and 12/47 (25.5%) reported dyspareunia. Fecal incontinence was reported preoperatively in 42 women, more often in those with obstetric-related RVF (76% vs. 24% p < 0.05). Healing was not affected by age, smoking, co-morbidities, preoperative seton, or stoma use. Fecal and sexual function and QOL were comparable between women with healed and unhealed RVF. CONCLUSION: Patients with higher BMI and more repairs had a decreased healing rate following RVF repair. Despite surgical outcome, QOL and sexual function were surprisingly similar regardless of fistula healing.

PMID: 20593308 [PubMed - as supplied by publisher]

Binding Versus Conventional Pancreaticojejunostomy After Pancreaticoduodenectomy: A Case-Matched Study.

J Gastrointest Surg. 2010 Jun 25;

Authors: Maggiori L, Sauvanet A, Nagarajan G, Dokmak S, Aussilhou B, Belghiti J

BACKGROUND: Postoperative morbidity of pancreaticoduodenectomy remains high and is mainly related to postoperative pancreatic fistula. Peng et al. (J Gastrointest Surg 2003;7:898-900; Am J Surg 2002;183:283-285; Ann Surg 2007;245:692-298) recently described binding pancreaticojejunostomy and reported a zero percent rate of pancreatic fistula. The aim of this study was to compare postoperative outcome of binding pancreaticojejunostomy and conventional pancreaticojejunostomy after pancreaticoduodenectomy. METHODS: Between June 2006 and June 2008, a case-control study was conducted, including all patients with binding pancreaticojejunostomy after pancreaticoduodenectomy. These patients were matched with similar patients with conventional pancreaticojejunostomy. Matching criteria were as follows: age, body mass index, pancreatic texture, and pancreatic main duct size. Postoperative mortality and morbidity were analyzed. Postoperative pancreatic fistula was defined according to the International Study Group of Pancreatic Surgery. RESULTS: Twenty-two patients with binding pancreaticojejunostomy and 25 with conventional pancreaticojejunostomy were included. There was no difference concerning the rate of postoperative pancreatic fistula, but median delay for healing of postoperative pancreatic fistula was longer in the binding pancreaticojejunostomy group (29 vs. 9 days, p = 0.003). Postpancreatectomy hemorrhage was more frequent in the binding pancreaticojejunostomy group (6/22 vs. 0/25, p = 0.023). CONCLUSION: Results of this study showed that binding pancreaticojejunostomy after pancreaticoduodenectomy was not associated with lower postoperative pancreatic fistula and moreover seems to increase postpancreatectomy hemorrhage.

PMID: 20577828 [PubMed - as supplied by publisher]

Related Articles

Sociodemographics and Comorbidities Influence Decisions to Undergo Pancreatic Resection for Neoplastic Lesions.

J Gastrointest Surg. 2010 Jun 23;

Authors: Sandroussi C, Brace C, Kennedy ED, Baxter NN, Gallinger S, Wei AC

INTRODUCTION: Pancreatic resection is being performed with increasing frequency and safety. Technical outcomes and long-term survival for neoplastic lesions are well reported; however, reasons why patients do not undergo surgery for potentially resectable lesions are not well understood. The aim of this study was to determine the factors contributing to the decision not to operate for resectable pancreatic neoplasms. METHODS: From 2004 to 2008, all patients with resectable pancreatic neoplasms at a single high-volume hepatopancreaticobiliary center were evaluated. The impact of patient factors, sociodemographics, medical comorbidities (Charlson combined comorbidity index (CCI) and ACCI), disease factors (tumor characteristics), and surgical factors (type of resection required) on the decision to undergo pancreatectomy were analyzed using univariate and multivariate binary logistic regression analysis. RESULTS: Three hundred seventy-five patients with resectable pancreatic lesions were identified. The median age was 62 years (21-93); 203 out of 375 (54.1%) were males. Fifty-five (14.7%) did not undergo resection. On univariate analysis, age (odds ratio (OR) 1.116, p < 0.001), non-English speaking background (NESB; OR 4.276, p = 0.001), tumor type (p = 0.001 increased for cystic neoplasms including intraductal papillary mucinous neoplasm), CCI score (OR 1.239, p = 0.001), and ACCI score (OR 1.433, p < 0.001) were associated with an increased risk of not undergoing resection. Gender, age, marital status, and urban residence were not predictive. On multivariate analysis, NESB (p = 0.018) and the ACCI (p = 0.002) remained predictive of not undergoing resection. The majority of patients did not undergo surgery because the patient declined in 25 out of 55 (45.5%), and resection was not offered in 15 out of 55 (27.3%). In the remainder, medical contraindications precluded surgery. Advanced age, tumor type, comorbidities (27.3%), age (21.8%), surgical risk (29.1%), frailty (18.2%), and uncertain diagnosis (5.5%) were cited as reasons for not proceeding with surgery. CONCLUSION: Patients with a higher ACCI and those from a NESB are less likely to undergo surgery for resectable neoplastic lesions of the pancreas. These factors must be taken into consideration in the decision-making process when considering surgery for patients with pancreatic neoplasms. Novel strategies should be employed to optimize access to surgery for patients with resectable pancreatic neoplasms.

PMID: 20571928 [PubMed - as supplied by publisher]

Impact of Obesity on Perioperative Outcomes and Survival Following Pancreaticoduodenectomy for Pancreatic Cancer: A Large Single-Institution Study.

J Gastrointest Surg. 2010 Apr 30;

Authors: Tsai S, Choti MA, Assumpcao L, Cameron JL, Gleisner AL, Herman JM, Eckhauser F, Edil BH, Schulick RD, Wolfgang CL, Pawlik TM

BACKGROUND: To examine the effect of body mass index (BMI) on clinicopathologic factors and long-term survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. METHODS: Data on BMI, weight loss, operative details, surgical pathology, and long-term survival were collected on 795 patients who underwent pancreaticoduodenectomy. Patients were categorized as obese (BMI > 30 kg/m(2)), overweight (BMI 25 to <30 kg/m(2)), or normal weight (BMI < 25 kg/m(2)) and compared using univariate and multivariate analyses. RESULTS: At the time of surgery, 14% of patients were obese, 33% overweight, and 53% normal weight. Overall, 32% of patients had preoperative weight loss of >10%. There were no differences in operative times among the groups; however, higher BMI was associated with increased risk of blood loss (P < 0.001) and pancreatic fistula (P = 0.01). On pathologic analysis, BMI was not associated with tumor stage or number of lymph nodes harvested (both P > 0.05). Higher BMI patients had a lower incidence of a positive retroperitoneal/uncinate margin versus normal weight patients (P = 0.03). Perioperative morbidity and mortality were similar among the groups. Obese and overweight patients had better 5-year survival (22% and 22%, respectively) versus normal weight patients (15%; P = 0.02). After adjusting for other prognostic factors, as well as preoperative weight loss, higher BMI remained independently associated with improved cancer-specific survival (overweight: hazard ratio, 0.68; obese: hazard ratio, 0.72; both P < 0.05). CONCLUSION: Obese patients had similar tumor-specific characteristics, as well as perioperative outcomes, compared with normal weight patients. However, obese patients undergoing pancreaticoduodenectomy for pancreatic cancer had an improved long-term survival independent of known clinicopathologic factors.

PMID: 20431978 [PubMed - as supplied by publisher]

Related Articles

Surgical Outcomes Associated with Oesophagectomy in New South Wales: An Investigation of Hospital Volume.

J Gastrointest Surg. 2010 Apr 23;

Authors: P Stavrou E, S Smith G, Baker DF

INTRODUCTION: Resection remains the standard treatment for curable oesophageal cancer. By linking the NSW Central Cancer Registry (CCR) and the NSW Admitted Patient Data Collection (APDC) databases, mortality, post-resection complication and survival associated with oesophagectomy were investigated. METHODS: All patients diagnosed with oesophageal cancer from 2000 to 2005 as recorded in the CCR (n = 2,082) were linked with records in the APDC, giving a total of 17,205 episodes of care. Over 15% (n = 321) of all patients underwent an oesophagectomy. RESULTS AND DISCUSSION: The overall 30-day mortality rate following resection was 3.7%, ranging from 2.6% in high volume hospitals to 6.4% in low volume hospitals. Three-year absolute survival for localised-regional disease following oesophagectomy was 64% (95%CI 54-73%) in high-volume hospitals, 58% (95%CI 46-68%) in mid-volume and 45% (95%CI 23-65%) in low-volume hospitals. The post-resection complication rate was 19% (95%CI 13-26%) for high-volume hospital, 24% (95%CI 13-40%) in low-volume and 31% (95%CI 22-41%) in mid-volume hospitals. CONCLUSION: Oesophagectomy in NSW is performed with satisfactory results. However, there is a suggestion that higher- rather than lower-volume hospitals have better post-resection outcomes.

PMID: 20414814 [PubMed - as supplied by publisher]

Related Articles

Benefit of Post-operative Surveillance for Recurrence after Curative Resection for Gastric Cancer.

J Gastrointest Surg. 2010 Apr 22;

Authors: Kim JH, Jang YJ, Park SS, Park SH, Mok YJ

BACKGROUND: Although most clinicians perform surveillance after gastrectomy, there is no consensus on the optimal follow-up schedule. This study aimed to evaluate the benefit of postoperative surveillance for recurrence after curative resection for gastric cancer. METHOD: We retrospectively studied 110 patients who had recurrences after undergoing curative gastrectomies between 2000 and 2004 at Korea University Hospital. We analyzed the clinico-pathologic factors and oncologic results according to the presence of recurrence symptoms. RESULTS: Fifty-five (50%) patients had symptomatic recurrences. There were significant differences in recurrence patterns; locoregional (29.1%) and peritoneal recurrences (27.3%) were dominant in asymptomatic group; peritoneal (47.3%) and hematogenous recurrences (25.5%) were dominant in symptomatic group. The median recurrence-free survival was not different for both groups (p = 0.054). However, median overall and post-recurrence survival was poor in the symptomatic group (p = 0.004, p < 0.001). The presence of symptoms and short disease-free survival were independent poor prognostic factors for post-recurrence survival. CONCLUSION: Patients with asymptomatic recurrences could have increased survival compared to symptomatic patients. Although our post-operative surveillance could not be any benefit to improve outcomes for recurrent gastric cancer, it is important to discriminate the nature of recurrent gastric cancer by the presence of symptoms for planning further treatment.

PMID: 20411347 [PubMed - as supplied by publisher]

Related Articles

Single-Incision Pediatric Endosurgical (SIPES) Versus Conventional Laparoscopic Pyloromyotomy: A Single-Surgeon Experience.

J Gastrointest Surg. 2010 Apr 20;

Authors: Muensterer OJ

BACKGROUND: Pyloromyotomy by single-incision pediatric endosurgery (SIPES) is a new technique that leaves virtually no appreciable scar. So far, it has not been compared to conventional laparoscopic (CL) pyloromyotomy. This study compares the results of the first 15 SIPES pyloromyotomies of a surgeon to his last 15 CL cases. METHODS: Data were collected on all SIPES pyloromyotomies. Age, gender, operative time, estimated blood loss, conversion/complication rate, and outcome in the SIPES patients were compared to the CL cohort. RESULTS: There was no difference in age, weight, gender, blood loss, or hospital stay. A trend toward shorter operating time was found in the CL group (21.7 +/- 9.9 versus 30.3 +/- 15.8, p = 0.08, 95%CI 20.9-39.7 min). Two mucosal perforations occurred in the SIPES cohort. Both cases were converted to conventional laparoscopy, the defect was repaired, and both patients had an uncomplicated postoperative course. There were no wound infections or conversions to open surgery. Parents were uniformly pleased with the cosmetic results of SIPES. CONCLUSION: SIPES pyloromyotomy may have a higher perforation rate than the CL approach. If recognized, a laparoscopic repair is feasible. Improved cosmesis must be carefully weighed against the potentially increased risks of SIPES versus conventional laparoscopic pyloromyotomy.

PMID: 20405233 [PubMed - as supplied by publisher]

Related Articles

Ileal Pouch Prolapse: Prevalence, Management, and Outcomes.

J Gastrointest Surg. 2010 Apr 15;

Authors: Joyce MR, Fazio VW, Hull TT, Church J, Kiran RP, Mor I, Lian L, Shen B, Remzi FH

AIM: The study aim is to review the prevalence, management, and outcomes for patients diagnosed with ileal pouch prolapse after restorative proctocolectomy. MATERIALS AND METHODS: Patients were identified retrospectively from a prospectively maintained pouch database. Parameters analyzed included presenting symptoms, indications for pouch surgery, type of ileal pouch-anal anastomosis, treatment modalities, and outcomes. RESULTS: Of 3,176 patients who underwent ileal pouch surgery, 11 were diagnosed with pouch prolapse (0.3%). Seven had full-thickness prolapse and four mucosal prolapse. Six were male, and five were female. Indication for index surgery was ulcerative colitis (nine patients), familial adenomatous polyposis (one patient), and colonic inertia (one patient). Median age at pouch prolapse was 34 years. Median time from index surgery to prolapse diagnosis was 2 years. Two patients with mucosal prolapse responded to conservative management; two required mucosal excisions. An abdominal approach was successful in four out of seven patients with full thickness prolapse. The three failures subsequently underwent continent ileostomy formation and prompted us to add biological mesh to future pouchpexy repairs. CONCLUSIONS: Pouch prolapse is rare, and there are no obvious predisposing factors. Mucosal prolapse may be treated by stool bulking or a local perineal procedure. Full thickness prolapse requires definitive surgery and is associated with risk of pouch loss.

PMID: 20393806 [PubMed - as supplied by publisher]

Related Articles

An Alternative Surgical Technique for Caval Preservation in Liver Transplantation.

J Gastrointest Surg. 2010 Apr 13;

Authors: Doria C, Bodzin AS, Frank AM, Maley WR, Ramirez CB

INTRODUCTION: The results of orthotopic liver transplantation in patients with end-stage liver disease continue to improve. Refinements in surgical techniques represent an important part of this improvement. MATERIALS AND METHODS: With the advent of split-liver and living-donor liver transplantation, inferior vena cava (IVC) preservation transitioned from being a potential option to being mandatory for many cases. Preserving the IVC can be a demanding technical maneuver in many liver transplants and several different approaches have been developed. When utilizing IVC preservation, there are several options for implantation of the graft. The piggyback technique, when feasible, is considered safe and provides hemodynamic stability for the recipient. RESULTS AND DISCUSSION: In some cases it may be difficult to perform the piggyback technique if intense inflammatory adhesions and severe significant collateral circulation exist between the IVC and the posterior segments of the liver. In these cases, the retro-hepatic dissection can be carried out with a different approach: the infrahepatic vena cava and the confluence of the three hepatic veins can be cross-clamped en-bloc without dissection. CONCLUSION: This technique broadens the transplant surgeons’ armamentarium and can be used in the setting of a very difficult retro-hepatic dissection. It is safe, and allows a shorter anhepatic phase with caval preservation.

PMID: 20387127 [PubMed - as supplied by publisher]

Related Articles

Gastric Venous Reconstruction After Radical Pancreatic Surgery: Case Report and Review of the Literature.

J Gastrointest Surg. 2010 Apr 13;

Authors: Sandroussi C, McGilvray ID

Vascular resection during surgery for adenocarcinoma of the pancreas is being performed with increasing frequency in order to achieve an R0 resection. With increasingly radical operations come challenges for reconstruction. Generally, these are related to reconstruction of the portal vein; this is particularly true of long-segment vein involvement by the tumor, in which venous outflow from dependent organs can become compromised. We report the first case of left gastric vein to inferior mesenteric vein bypass during a radical total pancreatectomy with long-segment portal vein resection for pancreatic adenocarcinoma, performed to relieve severe gastric venous congestion.

PMID: 20387128 [PubMed - as supplied by publisher]

Related Articles

Pancreatic Exocrine Function Is Preserved After Distal Pancreatectomy.

J Gastrointest Surg. 2010 Apr 13;

Authors: Speicher JE, Traverso LW

INTRODUCTION: Our objective was to measure human stool elastase-1 to determine the effect of distal pancreatectomy on exocrine function. METHODS: During a 72-month period, 115 patients underwent resection. Stool elastase values were measured preoperatively in 83 patients and repeated at 3, 12, and 24 months. The amount of pancreas resected was divided into two categories-limited to the left of the portal vein and those resections over or extended to the right of the vein. RESULTS: Elastase values were normal in 84% (n = 70) of cases prior to resection (33% if chronic pancreatitis, 70% if pancreatic adenocarcinoma). In the 70 patients with normal preoperative values, exocrine function was maintained in those with resection that was limited to the left of the portal vein at 3, 12, and, 24 months. If the resection was over or extended to right of the portal vein, then 88% maintained normal exocrine function at 3 months, 92% at 12 months, and 100% were normal at 24 months. CONCLUSION: Of patients undergoing distal pancreatectomy, one sixth will have preoperative pancreatic insufficiency, most commonly those with pancreatic adenocarcinoma or chronic pancreatitis. Postoperative pancreatic insufficiency was seen transiently in those with resection that extended to the portal vein or beyond.

PMID: 20387129 [PubMed - as supplied by publisher]

Related Articles

Extended Pancreaticoduodenectomy with Vascular Resection for Pancreatic Cancer: A Systematic Review.

J Gastrointest Surg. 2010 Apr 9;

Authors: Chua TC, Saxena A

OBJECTIVES: This systematic review objectively evaluates the safety and outcomes of extended pancreaticoduodenectomy with vascular resection for pancreatic cancer involving critical adjacent vessels namely the superior mesenteric-portal veins, hepatic artery, superior mesenteric artery, and celiac axis. METHODS: Electronic searches were performed on two databases from January 1995 to August 2009. The end points were: firstly, to evaluate the safety through reporting the mortality rate and associated complications and, secondly, the outcome by reporting the survival after surgery. This was synthesized through a narrative review with full tabulation of results of all included studies. RESULTS: Twenty-eight retrospective studies comprising of 1,458 patients were reviewed. Vein thrombosis and arterial involvement were reported as contraindications to surgery in 62% and 71% of studies, respectively. The median mortality rate was 4% (range, 0% to 17%). The median R0 and R1 rates were 75% (range, 14% to 100%) and 25% (range, 0% to 86%), respectively. In high volume centers, the median survival was 15 months (range, 9 to 23 months). Nine of 10 (90%) studies comparing the survival after extended pancreaticoduodenectomy with vascular resection versus standard pancreaticoduodenectomy reported statistically similar (p > 0.05) survival outcomes. Undertaking vascular resection was not associated with a poorer survival. CONCLUSIONS: The morbidity, mortality, and survival outcome after undertaking extended pancreaticoduodenectomy with vascular resection for pancreatic cancer with venous involvement and/or limited arterial involvement is acceptable in the setting of an expert referral center and should not be a contraindication to a curative surgery.

PMID: 20379794 [PubMed - as supplied by publisher]

Ultimate Fate of the Leaking Intestinal Anastomosis: Does Leak Mean Permanent Stoma?

J Gastrointest Surg. 2010 Apr 7;

Authors: Francone TD, Saleem A, Read TA, Roberts PL, Marcello PW, Schoetz DJ, Ricciardi R

BACKGROUND: The ultimate fate of the leaking intestinal anastomosis is unknown. We sought to analyze long-term outcomes of anastomotic leak with an emphasis on identifying the likelihood of re-establishing intestinal continuity and the potential for releak with corrective surgery. METHODS: All consecutive subjects treated for clinical anastomotic leak from January 2001 through December 2007 were retrospectively reviewed. Patients were stratified by management of leak: (1) drainage alone, (2) proximal loop diversion, (3) repair/revision without diversion, (4) end stoma, or (5) tube enterostomy. We then determined management of anastomotic leak, mortality, corrective procedures, releak, and re-establishment of intestinal continuity. RESULTS: In a database of 2,627 intestinal procedures, 79 patients had 88 anastomotic leaks with a final overall mortality of 10.1%. The aggregate rate of re-establishment of intestinal continuity was lowest for the patients treated by end stoma (44.4%) as compared to other initial management options (p < 0.01). Of the patients who survived their initial anastomotic leak, 20.5% had another leak (releak). CONCLUSIONS: Patients who underwent resection of the leaking anastomosis and end stoma or proximal loop diversion have a high rate of long-term fecal diversion. The proportion of patients who experience an anastomotic releak is substantial following further corrective surgery to re-establish intestinal continuity.

PMID: 20373046 [PubMed - as supplied by publisher]

Related Articles

Minimally Invasive Esophagectomy for Barrett’s with High-grade Dysplasia and Early Adenocarcinoma of the Esophagus.

J Gastrointest Surg. 2010 Apr 1;

Authors: Pennathur A, Awais O, Luketich JD

PMID: 20358407 [PubMed - as supplied by publisher]

Related Articles

A Meta-Analysis of Randomized Controlled Trials that Compared Laparoscopy-Assisted and Open Distal Gastrectomy for Early Gastric Cancer.

J Gastrointest Surg. 2010 Mar 31;

Authors: Ohtani H, Tamamori Y, Noguchi K, Azuma T, Fujimoto S, Oba H, Aoki T, Minami M, Hirakawa K

BACKGROUND: We conducted a meta-analysis to evaluate and compare the advantages of laparoscopy-assisted distal gastrectomy (LADG) over open distal gastrectomy (ODG) for treating early gastric cancer (EGC). METHODS: We searched MEDLINE, EMBASE, Science Citation Index, and Cochrane Controlled Trial Register for relevant papers published between January 1990 and January 2010 by using the following search terms: laparoscopy-assisted gastrectomy, laparoscopic gastrectomy, and early gastric cancer. The following data were analyzed: operative time, estimated blood loss, number of harvested lymph nodes, time required for resumption of oral intake, duration of hospital stay, frequency of analgesic administration, complications, tumor recurrence, and mortality. RESULTS: We selected four papers reporting randomized control studies (RCTs) that compared LADG with ODG for EGC. Our meta-analysis included 267 patients with EGC; of these, 134 and 133 had undergone LADG and ODG, respectively. The volume of intraoperative blood loss, frequency of analgesic administration, and rate of complications were significantly lesser for LADG than for ODG. However, the time required for resumption of oral intake and duration of hospital stay did not significantly differ between LADG and ODG. The operative time for LADG was significantly longer than that for ODG; further, the number of harvested lymph nodes was significantly lesser in the LADG group than in the ODG group. CONCLUSION: LADG is advantageous over ODG because it results in lesser blood loss, is less painful, and is associated with a low risk of complications. Additional RCTs that compare LADG and ODG and investigate the long-term oncological outcomes of LADG are required to determine the advantages of LADG over ODG.

PMID: 20354807 [PubMed - as supplied by publisher]

Related Articles

Anastomotic Sealing by Extracellular Matrices (ECM) Improves Healing of Colonic Anastomoses in the Critical Early Phase.

J Gastrointest Surg. 2010 Mar 31;

Authors: Hoeppner J, Wassmuth B, Marjanovic G, Timme S, Hopt UT, Keck T

BACKGROUND: Extracellular matrices have proven potential for in vivo tissue regeneration at gastrointestinal luminal organs. In this study, small intestinal submucosa (SIS) was tested as a sealant for colonic anastomoses in a rodent model. METHODS: In the rodent model, standard colonic anastomoses in the control group (CG; n = 30) and anastomoses sealed by omentum (n = 30) were compared to SIS-sealed anastomoses in the study group (SG; n = 30). After 4-, 30-, and 90-day macroscopic and microscopic healing, bursting pressure and anastomotic stricture rate were evaluated. RESULTS: The rate of anastomotic dehiscence was 1/10 after 4 days and 0/10 after 30 and 90 days in all groups. In the SG, the bursting pressure was significantly increased after 4 days compared to CG (148 +/- 9 vs. 108 +/- 8 mmHg; p > 0.05). Histologically, after 4 days of neovascularization, fibroblast ingrowth and collagen deposition were significantly increased in SG compared to CG. After 30 days, nonsignificant differences were noted in all three parameters. Adhesion rate and anastomotic stricture rate were not significantly affected by SIS sealing after 4, 30, and 90 days. CONCLUSION: Especially in the critical phase of anastomotic healing up to day 4, anastomotic healing was improved by SIS sealing. SIS sealing did not cause long-term complications.

PMID: 20354808 [PubMed - as supplied by publisher]

Related Articles

Infection Rates in a Large Investigational Trial of Sacral Nerve Stimulation for Fecal Incontinence.

J Gastrointest Surg. 2010 Mar 31;

Authors: Wexner SD, Hull T, Edden Y, Coller JA, Devroede G, McCallum R, Chan M, Ayscue JM, Shobeiri AS, Margolin D, England M, Kaufman H, Snape WJ, Mutlu E, Chua H, Pettit P, Nagle D, Madoff RD, Lerew DR, Mellgren A

INTRODUCTION: Treatment options for patients with fecal incontinence (FI) are limited, and surgical treatments can be associated with high rates of infection and other complications. One treatment, sacral nerve stimulation (SNS), is approved for FI in Europe. A large multicenter trial was conducted in North America and Australia to assess the efficacy of SNS in patients with chronic fecal incontinence. The aim of this report was to analyze the infectious complication rates in that trial. METHODS: Adult patients with a history of chronic fecal incontinence were enrolled into this study. Those patients who fulfilled study inclusion/exclusion criteria and demonstrated greater than two FI episodes per week underwent a 2-week test phase of SNS. Patients who showed a >/=50% reduction in incontinent episodes and/or days per week underwent chronic stimulator implantation. Adverse events were reported to the sponsor by investigators at each study site and then coded. All events coded as implant site infection were included in this analysis. RESULTS: One hundred twenty subjects (92% female, 60.5 +/- 12.5 years old) received a chronically implanted InterStim(R) Therapy device (Medtronic, Minneapolis, MN, USA). Patients were followed for an average of 28 months (range 2.2-69.5). Thirteen of the 120 implanted subjects (10.8%) reported infection after the chronic system implant. One infection spontaneously resolved and five were successfully treated with antibiotics. Seven infections (5.8%) required surgical intervention, with infections in six patients requiring full permanent device explantation. The duration of the test stimulation implant procedure was similar between the infected group (74 min) and the non-infected group (74 min). The average duration of the chronic neurostimulator implant procedure was also similar between the infected (39 min) and non-infected group (37 min). Nine infections occurred within a month of chronic system implant and the remaining four infections occurred more than once a year from implantation. While the majority (7/9) of the early infections was successfully treated with observation, antibiotics, or system replacement, all four of the late infections resulted in permanent system explantation. CONCLUSION: SNS for FI resulted in a relatively low infection rate. This finding is especially important because the only other Food and Drug Administration-approved treatment for end-stage FI, the artificial bowel sphincter, reports a much higher rate. Combined with its published high therapeutic success rate, this treatment has a positive risk/benefit profile.

PMID: 20354809 [PubMed - as supplied by publisher]

Related Articles

The Incidence and Risk Factors of Post-Laparotomy Adhesive Small Bowel Obstruction.

J Gastrointest Surg. 2010 Mar 30;

Authors: Barmparas G, Branco BC, Schnüriger B, Lam L, Inaba K, Demetriades D

INTRODUCTION: The purpose of this review was to assess the incidence and risk factors for adhesive small bowel obstruction (SBO) following laparotomy. METHODS: The PubMed database was systematically reviewed to identify studies in the English literature delineating the incidence of adhesive SBO and reporting risk factors for the development of this morbidity. RESULTS: A total of 446,331 abdominal operations were eligible for inclusion in this analysis. The overall incidence of SBO was 4.6%. The risk of SBO was highly influenced by the type of procedure, with ileal pouch-anal anastomosis being associated with the highest incidence of SBO (1,018 out of 5,268 cases or 19.3%), followed by open colectomy (11,491 out of 121,085 cases or 9.5%). Gynecological procedures were associated with an overall incidence of 11.1% (4,297 out of 38,751 cases) and ranged from 23.9% in open adnexal surgery, to 0.1% after cesarean section. The technique of the procedure (open vs. laparoscopic) also played a major role in the development of adhesive SBO. The incidence was 7.1% in open cholecystectomies vs. 0.2% in laparoscopic; 15.6% in open total abdominal hysterectomies vs. 0.0% in laparoscopic; and 23.9% in open adnexal operations vs. 0.0% in laparoscopic. There was no difference in SBO following laparoscopic or open appendectomies (1.4% vs. 1.3%). Separate closure of the peritoneum, spillage and retention of gallstones during cholecystectomy, and the use of starched gloves all increase the risk for adhesion formation. There is not enough evidence regarding the role of age, gender, and presence of cancer in adhesion formation. CONCLUSION: Adhesion-related morbidity comprises a significant burden on healthcare resources and prevention is of major importance, especially in high-risk patients. Preventive techniques and special barriers should be considered in high-risk cases.

PMID: 20352368 [PubMed - as supplied by publisher]

Impact of Splenectomy on Thrombocytopenia, Chemotherapy, and Survival in Patients with Unresectable Pancreatic Cancer.

J Gastrointest Surg. 2010 Mar 23;

Authors: Donahue TR, Kazanjian KK, Isacoff WH, Reber HA, Hines OJ

BACKGROUND: Patients with unresectable pancreatic cancer (PDAC) or endocrine tumors (PET) often develop splenic vein thrombosis, hypersplenism, and thrombocytopenia which limits the administration of chemotherapy. METHODS: From 2001 to 2009, 15 patients with recurrent or unresectable PDAC or PET underwent splenectomy for hypersplenism and thrombocytopenia. The clinical variables of this group of patients were analyzed. The overall survival of patients with PDAC was compared to historical controls. RESULTS: Of the 15 total patients, 13 (87%) had PDAC and 2 (13%) had PET. All tumors were either locally advanced (n = 6, 40%) or metastatic (n = 9, 60%). The platelet counts significantly increased after splenectomy (p < 0.01). All patients were able to resume chemotherapy within a median of 11.5 days (range 6-27). The patients with PDAC had a median survival of 20 months (range 4-67) from the time of diagnosis and 10.6 months (range 0.6-39.8) from the time of splenectomy. CONCLUSIONS: Splenectomy for patients with unresectable PDAC or PET who developed hypersplenism and thrombocytopenia that limited the administration of chemotherapy, significantly increased platelet counts, and led to resumption of treatment in all patients. Patients with PDAC had better disease-specific survival as compared to historical controls.

PMID: 20309646 [PubMed - as supplied by publisher]

‘Slowing Down When You Should’: Initiators and Influences of the Transition from the Routine to the Effortful.

J Gastrointest Surg. 2010 Mar 23;

Authors: Moulton CA, Regehr G, Lingard L, Merritt C, Macrae H

BACKGROUND: ‘Slowing down when you should’ has been described as marking the transition from ‘automatic’ to ‘effortful’ functioning in professional practice. The ability to ‘slow down’ is hypothesized as an important factor in expert judgment. This study explored the nature of the ‘slowing down’ phenomenon intraoperatively and its link to surgical judgment. METHODS: Twenty-eight surgeons across different surgical specialties were interviewed from four hospitals affiliated with a large urban university. In grounded theory tradition, data were collected and analyzed in an iterative design, using a constant comparative approach. Emergent themes were identified and a conceptual framework was developed. RESULTS: Surgeons recognized the ‘slowing down’ phenomenon acknowledging its link to judgment and described two main initiators. Proactively planned ‘slowing down’ moments were anticipated preoperatively from operation-specific (tying superior thyroid vessels) or patient-specific (imaging abnormality) factors. Surgeons also described situationally responsive ‘slowing down’ moments to unexpected events (encountering an adherent tumor). Surgeons described several influencing factors on the slowing down phenomenon (fatigue, confidence). CONCLUSIONS: This framework for ‘slowing down’ assists in making tangible the previously elusive construct of surgical judgment, providing a vocabulary for considering the events surrounding these critical moments in surgery, essential for teaching, self-reflection, and patient safety.

PMID: 20309647 [PubMed - as supplied by publisher]

Optimal Technical Management of Stump Closure Following Distal Pancreatectomy: A Retrospective Review of 215 Cases.

J Gastrointest Surg. 2010 Mar 20;

Authors: Harris LJ, Abdollahi H, Newhook T, Sauter PK, Crawford AG, Chojnacki KA, Rosato EL, Kennedy EP, Yeo CJ, Berger AC

BACKGROUND: Pancreatic fistula (PF) is a major source of morbidity following distal pancreatectomy (DP). Our aim was to identify risk factors related to PF following DP and to determine the impact of technique of transection and stump closure. METHODS: We performed a retrospective review of 215 consecutive patients who underwent DP. Perioperative and postoperative data were collected and analyzed with attention to PF as defined by the International Study Group of Pancreatic Fistula. RESULTS: PF developed in 36 patients (16.7%); fistulas were classified as Grade A (44.4%), B (44.4%), or C (11.1%). The pancreas was transected with stapler (n = 139), cautery (n = 70), and scalpel (n = 3). PF developed in 19.8% of remnants which were stapled/oversewn and 27.7% that were stapled alone (p = 0.4). Of the 69 pancreatic remnants transected with cautery and oversewn, a fistula developed in 4.3% (p = 0.004 compared to stapled/oversewn; p = 0.006 compared to stapled/not sewn). The median length of postoperative hospital stay was significantly increased in patients who developed PF (10 vs. 6 days, p = 0.002) CONCLUSION: The method of transection and management of the pancreatic remnant plays a critical role in the formation of PF following DP. This series suggests that transection using electrocautery followed by oversewing of the pancreatic remnant has the lowest risk of PF.

PMID: 20306151 [PubMed - as supplied by publisher]

Transumbilical Totally Laparoscopic Single-Port Nissen Fundoplication: A New Method of Liver Retraction: The Istanbul Technique.

J Gastrointest Surg. 2010 Mar 20;

Authors: Hamzaoglu I, Karahasanoglu T, Aytac E, Karatas A, Baca B

INTRODUCTION: Mustafa Kemal Atatürk, founder of the Turkish Republic, had guarded many German scientists of a Jewish descent before the Second World War. Dr. Rudolf Nissen was one of the outstanding surgeons who had served in the Turkish university hospitals. He had created an antireflux procedure which is named after his own name while he was working in our clinic, the Cerrahpaşa Hospital. From a laparoscopic approach, the Nissen fundoplication was the gold standard intervention for the surgical treatment of gastroesophageal reflux disease (GERD). Currently, video laparoscopic surgery is evolving quickly with the guidance of new technology. Single-port (SP) laparoscopic transumbilical surgery is one of the newest branches of advanced laparoscopy. DISCUSSION: Simple or complex manipulations may be performed with SP laparoscopic transumbilical surgery. The advantages, which are gained from conventional laparoscopy, can be invigorated by an SP laparoscopic approach. The retraction technique of the liver and the optical system were the most important factors, which made the Nissen fundoplication possible via single port. Here, we report that totally laparoscopic transumbilical SP Nissen fundoplication procedure was performed in three patients for sliding hiatal hernia with GERD. CONCLUSION: Totally laparoscopic transumbilical SP Nissen fundoplication is a safe and feasible technique for the surgical treatment of GERD.

PMID: 20306152 [PubMed - as supplied by publisher]

Related Articles

Clarification.

J Gastrointest Surg. 2010 Mar 17;

Authors: Malik AA, Ul Bari S

PMID: 20237860 [PubMed - as supplied by publisher]

Related Articles

Fundoplication After Laparoscopic Heller Myotomy for Esophageal Achalasia: What Type?

J Gastrointest Surg. 2010 Mar 19;

Authors: Patti MG, Herbella FA

Because of the high success rate of minimally invasive surgery, a radical shift in the treatment algorithm of esophageal achalasia has occurred. Today, a laparoscopic Heller myotomy is the preferred treatment modality for achalasia. This remarkable change is due to the recognition by gastroenterologists and patients that a laparoscopic Heller myotomy gives better and more durable results than pneumatic dilatation and intrasphincteric injection of botulinum toxin injection, while it is associated to a short hospital stay and a fast recovery time. While there is agreement about the need of a fundoplication in conjunction to the myotomy, some questions still remain about the type of fundoplication: Should the fundoplication be total or partial, and in case a partial fundoplication is chosen, should it be anterior or posterior? The following review describes the data present in the literature in order to identify the best procedure that can achieve prevention or control of gastroesophageal reflux after a myotomy without impairing esophageal emptying.

PMID: 20300876 [PubMed - as supplied by publisher]

Related Articles

Periampullary and Duodenal Neoplasms in Neurofibromatosis Type 1: Two Cases and an Updated 20-Year Review of the Literature Yielding 76 Cases.

J Gastrointest Surg. 2010 Mar 19;

Authors: Relles D, Baek J, Witkiewicz A, Yeo CJ

BACKGROUND: Patients with neurofibromatosis type 1 (NF1) are at increased risk to develop tumors throughout the gastrointestinal tract, including neuromas, gastrointestinal stromal tumors (GIST), and periampullary somatostatin-rich carcinoids. Here, we briefly describe two male patients with NF1 and review the recent literature on this topic. METHODS: Databases for PubMed and MEDLINE were searched for English-language articles since 1989 using a list of keywords, as well as references from review articles. RESULTS: The results generated by the search yielded 50 articles and 74 cases. Patients most commonly presented with jaundice, weight loss, GI bleeding, or anemia. The mean age at presentation was 47.9 years, with 59% of patients being female. Mean tumor size was 3.8 cm (range 0.9-27 cm). Tumor location was the duodenum (60%), ampulla (31%), pancreas (5%), or bile duct/gallbladder (4%). Tumor type was reported as somatostatinoma (40%), GIST (34%), adenocarcinoma (8%), carcinoid (6%), neurofibroma (5%), schwannoma (4%), or gangliocytic paraganglioma (3%). Treatment included classic Whipple procedure (42%), local excision (25%), pylorus-preserving pancreaticoduodenectomy (17%), and other resection (6%). Mean follow-up was 31 months postresection (range 0-99 months): 75% of patients were alive with no evidence of disease. CONCLUSIONS: These results underscore the importance of a thorough evaluation for tumors in NF1 patients with gastrointestinal symptoms, as well as subsequent surgical management when findings suggest a tumor in the periampullary region, as resection remains the mainstay of treatment.

PMID: 20300877 [PubMed - as supplied by publisher]

4-Dimensional Intravital Microscopy: A New Model for Studies of Leukocyte Recruitment and Migration in Hepatocellular Cancer in Mice.

J Gastrointest Surg. 2010 Mar 6;

Authors: Takeichi T, Engelmann G, Mocevicius P, Schmidt J, Ryschich E

INTRODUCTION: Although it is accepted that the immune system plays a role in the prognosis of hepatocellular carcinoma (HCC), the exact mechanisms of leukocyte recruitment into HCC are poorly understood. Progress in the study of this aspect has been hindered by technical limitations. MATERIALS AND METHODS: In the present study, we describe the use of 4D intravital microscopy which represents an advantageous technology for the investigation of the microvascular system and leukocyte migration in HCC. To establish 4D intravital microscopy, we used a HCC tumor model in transgenic mice expressing enhanced green fluorescent protein in specific leukocyte subpopulations and combined digital time-lapse recording, laser scanning confocal microscopy, and 3D reconstruction. Using this technology, we studied the intra- and extravascular leukocyte adhesion and migration in HCC in vivo at the single-cell level. RESULTS: We showed that although vessel density in HCC was lower than in normal liver, tumor tissue was moderately infiltrated with leukocytes of lymphoid and myeloid origin. Most tumor-infiltrating leukocytes migrated in a random manner frequently changing direction of migration in the tumor tissue. The migration velocity of myeloid and lymphoid leukocytes in HCC tissue was not different. DISCUSSION: These results demonstrated that 4D intravital microscopy has potential to be a powerful tool in the study of mechanisms of leukocyte recruitment and intratumoral migration in HCC.

PMID: 20229071 [PubMed - as supplied by publisher]

Analysis of Function and Predictors of Failure in Women Undergoing Repair of Crohn’s Related Rectovaginal Fistula.

J Gastrointest Surg. 2010 Mar 16;

Authors: El-Gazzaz G, Hull T, Mignanelli E, Hammel J, Gurland B, Zutshi M

PURPOSE: Crohn’s-related rectovaginal fistulae have significant impact on quality of life including sexual function. The aim of this study was to obtain long-term follow-up of Crohn’s related rectovaginal fistulae to assess variables that influence surgical success and determine its effects on quality of life and sexual function. METHODS: All women with Crohn’s-related rectovaginal fistulas who underwent surgical repair from 1997 to 2007 were contacted for long-term follow-up. Variables assessed were age, body mass index, smoking, presence of active Crohn’s disease, type of surgical procedure performed, use of perioperative seton or stoma, number of previous procedures, time interval between last repair and current repair, use of immunomodulators, and steroids. SF-12, Fecal Incontinence Quality-of-Life Scale, and Female Sexual Function Index were used to assess quality of life and sexual function. Multivariable logistic regression model was used to identify variables associated with surgical failure. RESULTS: Sixty-five women were identified at median follow-up of 44.6 months (interquartiles, 13.1-79.1) of which 30 patients (46.2%) were successfully healed. Methods of repair included advancement flap (n = 47), episioproctotomy (n = 8), colo-anal anastomosis (n = 7), and fibrin glue or plug (n = 3). Twenty-eight women (43.1%) were sexually active at follow-up, and of those, nine complained of dyspareunia, all within the unhealed group of patients. On multivariate analysis, only immunomodulators were associated with successful healing (p = 0.009). Smoking and steroids were associated with failure (p = 0.04). Sexual function and quality-of-life scores were comparable between healed and unhealed groups. CONCLUSIONS: Crohn’s-related rectovaginal fistulae are difficult to treat. Healing increased with use of immunomodulators; however, smoking and steroids were predictors of failure. Dyspareunia was higher in unhealed women.

PMID: 20232172 [PubMed - as supplied by publisher]

Not Just for Trauma Patients: Damage Control Laparotomy in Pancreatic Surgery.

J Gastrointest Surg. 2010 Mar 12;

Authors: Morgan K, Mansker D, Adams DB

BACKGROUND: Damage control laparotomy (DCL) has been a major advance in modern trauma care. The principles of damage control which include truncation of operation to correct acidosis, hypothermia, and coagulopathy with subsequent planned definitive repair are applicable in managing patients undergoing abdominal operations. In order to define indications, technique, and outcome, we undertook a retrospective review and analysis of pancreatic surgery patients in whom DCL was utilized. METHODS: In a cohort of 835 patients who underwent elective pancreatic operations at the Medical University of South Carolina from 2001 to 2007, eight patients were identified who required DCL. Under Institutional Review Board approval, records were reviewed to define intraoperative blood loss, acidosis, hypothermia, coagulopathy, operative techniques, timing of definitive operation, and hospital outcome. RESULTS: There were five men and three women with a mean age of 51 years. The diagnosis was chronic pancreatitis in seven patients and cancer in one. The index operation was pancreatoduodenectomy in four patients, distal pancreatectomy in three, and total pancreatectomy in one. In four patients undergoing elective pancreatic resection intraoperative portal vein hemorrhage initiated damage control laparotomy. Four patients had damage control utilized at reoperation for abdominal sepsis (two) and hemorrhage (two). DCL techniques included external tube drainage (eight), abdominal packing (seven), staple closure of open bowel (four), and rapid abdominal closure (four). Operative blood loss ranged from 300 to 12,000 cc. Operative transfusions ranged from 0 to 44 U of packed red cells. Intraoperative INR was greater than 1.5 in four patients, pH ranged from 7.08 to 7.45, and temperature ranged from 34.8 to 38.8 degrees C. Laparotomy for pack removal and intestinal reconstruction was undertaken 1 to 7 days after DCL. Length of hospital stay ranged from 7 to 80 days. Hospital mortality was zero. CONCLUSIONS: Patients with exsanguinating hemorrhage and severe sepsis related to pancreatic surgery can be successfully managed with principles of DCL. Truncation of operation with abdominal packing, bowel closure, external drainage of bile and pancreatic ducts, and rapid abdominal closure with planned subsequent completion laparotomy should be considered in pancreatic operations when patients risk intraoperative acidosis, hypothermia, and coagulopathy due to sepsis or hemorrhage.

PMID: 20224981 [PubMed - as supplied by publisher]

Short-Term Outcomes of Laparoscopic Colectomy for Transverse Colon Cancer.

J Gastrointest Surg. 2010 Mar 12;

Authors: Akiyoshi T, Kuroyanagi H, Fujimoto Y, Konishi T, Ueno M, Oya M, Yamaguchi T

BACKGROUND: The role of laparoscopic surgery for transverse colon cancer (TCC) remains controversial. This study aimed to evaluate the safety of laparoscopic resection of TCC. METHODS: Fifty-three patients undergoing laparoscopic resection of TCC (group A) were compared with 39 patients undergoing open resection of TCC (group B) and 200 patients undergoing laparoscopic resection of ascending or descending colon cancer (group C). RESULTS: Mean operating time was longer (224 vs. 157 min), and mean estimated blood loss was lower (40 vs. 79 ml) in group A than in group B, but these were similar in groups A and C. The rates of conversion to open surgery were similar in groups A and C (1.9% vs. 1.0%). Tumor stage was more advanced in group B than in group A. All patients in groups A and B underwent pathologic R0 resection. The rates of postoperative complications did not differ significantly between groups (9.4% vs. 7.7% vs. 5.0%). Time to flatus (1.7 vs. 2.5 days), time to liquid diet (2.4 vs. 5.3 days), and hospital stay (12 vs. 15 days) were significantly shorter in group A than in group B, but similar in groups A and C. CONCLUSIONS: Laparoscopic resection for TCC can be performed safely with similar short-term postoperative outcomes seen for colon cancer at other sites. Laparoscopic resection may be associated with faster gastrointestinal recovery and shorter length of hospital stay, compared with open surgery.

PMID: 20224982 [PubMed - as supplied by publisher]

Dose Delivery Estimated by Bremsstrahlung Imaging and Partition Model Correlated with Response Following Intra-arterial Radioembolization with (32)P-Glass Microspheres for the Treatment of Hepatocellular Carcinoma.

J Gastrointest Surg. 2010 Mar 12;

Authors: Wang XD, Yang RJ, Cao XC, Tan J, Li B

RATIONALE: The objective of this study was to retrospectively evaluate the efficacy of a combination of (32)P-glass microsphere-mediated intra-arterial internal radiation and chemoembolization for the treatment of hepatocellular carcinoma. METHODS: Twenty-five consecutive patients with primary hepatocellular carcinoma referred for radiation therapy were treated with intra-arterial infusion of (32)P-glass microspheres followed by chemoembolization. beta-bremsstrahlung imaging was performed to monitor microsphere distribution. A partition model and a radiation dose equation were used for determination of radiation exposure in various tissues. Clinical response was evaluated using computed axial tomography scans. RESULTS: The mean estimated absorption dose in tumor tissue was 137.42 +/- 56.69 Gy. A receiver operating characteristic curve was used to establish 90.65 Gy as the cutoff absorption dose with the best sensitivity and specificity for predicting response. The overall tumor response rate was 92%, while response in patients with radiation doses >90.65 Gy was 100%. Overall median patient survival was 15 months. CONCLUSION: beta-bremsstrahlung imaging following intra-arterial infusion of (32)P-glass microspheres and chemoembolization incorporates effective treatment with convenient dosimetry monitoring and manageable adverse events using a single surgical procedure. This approach is a safe and effective method for ameliorating hepatocellular carcinoma.

PMID: 20224983 [PubMed - as supplied by publisher]

Surgery and Staging of Pancreatic Neuroendocrine Tumors: A 14-Year Experience.

J Gastrointest Surg. 2010 Mar 12;

Authors: Ito H, Abramson M, Ito K, Swanson E, Cho N, Ruan DT, Swanson RS, Whang EE

BACKGROUND: The aims of this study were to evaluate contemporary outcomes associated with the surgical management of pancreatic neuroendocrine tumors (PNETs) and to assess the prognostic value of the World Health Organization (WHO) classification and TNM staging for PNETs. METHODS: The medical records of 73 consecutive patients with PNETs treated at a single institution from January 1992 through September 2006 were reviewed. Survival was analyzed with the Kaplan-Meier method (median follow-up: 43 months). RESULTS: Median patient age was 52 years (range, 19-83 years), and 36 (49%) patients were male. Thirty-three patients had a well-differentiated neuroendocrine tumor (WDT), 26 had a well-differentiated neuroendocrine carcinoma (WDCa), and 14 had a poorly differentiated neuroendocrine carcinoma (PDCa). Fifty (68%) patients underwent potentially curative resection, and the 5-year disease-specific survival (DSS) rate for the entire cohort was 62%. WHO classification and TNM staging system provided good prognostic stratification of patients; 5-year DSS rates were 100% for WDT, 57% for WDCa, 8% for PDCa, respectively, by WHO classification (p < 0.001), and 100% for stage 1, 90% for stage 2, 57% for stage 3, and 8% for stage 4, respectively, by TNM stage (p < 0.001). Among the patients who underwent potentially curative resection, nodal status, distant metastasis, and tumor grade were significant prognostic factors. CONCLUSION: WHO classification and TNM staging are useful for prognostic stratification among patients with PNETs.

PMID: 20224984 [PubMed - as supplied by publisher]

Cystic Lymphangioma of the Mesocolon.

J Gastrointest Surg. 2010 Mar 11;

Authors: Limdi JK, Mehdi S, Sapundzieski M, Manu M, Abbasi AM

A 46-year-old gentleman presented to our hospital with a short story of abdominal pain and distension. On examination, gross ascites was noted and confirmed on subsequent imaging with no other notable features. CT scan after ascitic drainage showed a cystic mass extending from the lower pole of the spleen to the left iliac fossa in keeping with an intraperitoneal cyst. At laparatomy, a cystic lymphangioma was resected. Lymphangiomas are rare benign tumours and are reported to occur preferentially in the neck of axilla in children. Abdominal lymphangiomas are extremely rare particularly in adults but important to recognise due to a potential for serious consequences.

PMID: 20221854 [PubMed - as supplied by publisher]

Influence of Lys656asn Polymorphism of Leptin Receptor Gene on Surgical Results of Biliopancreatic Diversion.

J Gastrointest Surg. 2010 Mar 6;

Authors: de Luis DA, Aller R, Sagrado MG, Izaola O, Terroba MC, Cuellar L, Conde R, Martin T

BACKGROUND: Bariatric surgery is the most effective long-term treatment for morbid obesity, reducing obesity-associated comorbidities. The purpose of the present study was to evaluate Lys656Asn polymorphism of leptin receptor gene on outcomes 1 year after biliopancreatic diversion. METHODS: A sample of 41 morbidly obese patients (body mass index (BMI) > 40 kg/m(2)) were operated on. Biochemical and anthropometric evaluation were realized at basal visit and at each visit. The frequency of patients with diabetes mellitus, hypertension, and hyperlipidemia was recorded at each visit. RESULTS: Thirty-two patients (78%) had genotype Lys656/Lys656, eight patients (19.5%) Lys656/Asn656 genotype, and one patient (2.4%) Asn656/Asn656 genotype. In the wild-type group, body mass index, weight, glucose, total cholesterol, LDL cholesterol, triacylglycerol, and systolic blood pressure decreased. In the mutant group, the same parameters improved. Initial weight percent loss at 1 year of follow-up was higher in mutant group than in wild-type group (38.9% vs 29.9%; p < 0.05). Total weight loss was higher in mutant group than wild-type group (50.7 vs 37.2 kg; p < 0.05). Basal weight and BMI were higher in mutant group than wild type. CONCLUSION: Weight loss was higher in mutant group (Lys656Asn and Asn656Asn) than wild-type group (Lys656Lys) after bariatric surgery. Carriers of the allelic variant (Asn) had higher basal weight.

PMID: 20213209 [PubMed - as supplied by publisher]

Evidence-Based Surgical Practice in Academic Medical Centers: Consistently Anecdotal?

J Gastrointest Surg. 2010 Mar 6;

Authors: Melis M, Karl RC, Wong SL, Brennan MF, Matthews JB, Roggin KK

INTRODUCTION: Randomized trials, meta-analyses, and guidelines form the basis of clinical decision making. We queried a small sample of surgeons at three academic medical centers to determine whether key elements of surgical practice were concordant with available evidence. MATERIALS AND METHODS: A French Society of Digestive Surgery (FSDS) questionnaire was submitted to general surgery trainees and faculty at the University of South Florida and University of Chicago and to surgical oncology fellows at the Memorial Sloan-Kettering Cancer Center. Participants were asked to respond “never,” “rarely,” “often,” or “always” to 13 questions involving different aspects of gastrointestinal surgery. For each question, a correct evidence-based answer was available from published studies. RESULTS AND DISCUSSION: One hundred ten surgeons (79% of eligible participants) completed the survey. Only 60% of the answers were concordant with existing data. The percentages of correct answers did not differ significantly according to institution or level of experience of participants. The low frequency of correct responses in our subjects paralleled the findings from the 2004 FSDS study. Variability in the quality of evidence and ambiguity in the survey questions may have influenced the responses, but evidence-based medicine does not appear to uniformly influence clinical decision making.

PMID: 20213210 [PubMed - as supplied by publisher]

Related Articles

Future applications of flexible endoscopy in esophageal surgery.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S127-32

Authors: Swanstrom LL, Dunst CM, Spaun GO

INTRODUCTION: Flexible endoscopy has long played a role in esophageal surgery, and procedures like perforation closure, stenting of occluding malignancies, antireflux procedures, and removal of Barretts are increasingly replacing open and laparoscopic procedures. We present early results of a series of acute animal experiments studying the feasibility of using flexible endoscopes for complex esophageal surgery such as Heller myotomy and esophagectomy. METHODS: A total of six animals and one human cadaver have been operated on in a series of three protocols. The first study involves extraluminal flexible endoscopy through a cervical incision. The esophagus is dissected to the phrenoesophageal junction and a Heller myotomy performed. The second study involves labeling specific mediastinal node areas using EUS and transesophageal tattooing. Transcervical access is once again obtained, and wide esophageal dissection is performed; sequential identification of the marked nodes is performed. The final study involves full thoracic esophageal mobilization and laparoscopic gastric mobilization for an esophagogastrectomy. RESULTS: Heller myotomy in five animals was performed via flexible endoscopy. Total operative time was 49 min with mean time for myotomy being 22 min. One animal had hemodynamic compromise from over insufflating the mediastinum with air. The second study involved three animals and one human cadaver. An average of four nodes was marked by EUS, and there was 100% success in identifying all nodes with flexible medistinoscopy. Operative times had a mean of 187 min (147-227) for the animal model and 198 min for the cadaver model. CONCLUSION: There is a move to increase the role of flexible endoscopy in GI surgery. This is facilitated by the introduction of novel scopes and instrumentation designed for NOTES. We outline early favorable results from animal studies looking at the use of flexible endoscopy as a surgical tool for Heller myotomy and esophagectomy.

PMID: 19756877 [PubMed - in process]

Related Articles

Genetics in the pathogenesis of esophageal cancer: possible predictive and prognostic factors.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S75-80

Authors: Vallböhmer D, Brabender J, Metzger R, Hölscher AH

INTRODUCTION: Esophageal adenocarcinoma is the most rapidly increasing cancer in Western countries. Like esophageal squamous-cell carcinoma, these tumors are often detected at an advanced stage, requiring a multimodal concept. Despite improvements in detection, surgical resection, and (neo-) adjuvant therapy, the overall survival of esophageal cancer remains lower than other solid tumors. In fact, just 30-40% of the patients with advanced esophageal cancer benefit from a neoadjuvant therapy. Therefore, predictive/prognostic markers are needed to allow tailored multimodality therapy with increased efficacy. DISCUSSION: In recent years, there has been an exponential growth in our understanding of the cellular and molecular events associated with cell cycle regulation, programmed cell death, angiogenesis, and tumor growth. In this review, the classification of Hanahan and Weinberg is used concerning the six essential changes in carcinogenesis, i.e., the six hallmarks of cancer: (1) self-sufficiency in growth signals; (2) insensitivity to antigrowth signals; (3) avoidance of apoptosis; (4) limitless replicative potential; (5) sustained angiogenesis; and (6) tissue invasion and metastasis. CONCLUSIONS: According to these six steps, this review provides an update of the most recent data about predictive/prognostic molecular markers in patients with esophageal cancer.

PMID: 19756878 [PubMed - in process]

Related Articles

Non-acid gastroesophageal reflux measured using multichannel intraluminal impedance in older patients.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S17-23

Authors: Schneider JH, Küper MA, Königsrainer A, Brücher BL

BACKGROUND: Diagnosing gastroesophageal reflux disease is challenging in the older population, as comorbid conditions can obscure the disease. METHODS: This prospective study included 97 participants: 25 healthy controls (group 1), 46 reflux patients aged 26-64 (group 2), and 26 patients over 65 (group 3). Esophageal motility was assessed using conventional esophageal manometry, and 24-h pH-metry and non-acid reflux episodes were assessed using multichannel intraluminal impedance. RESULTS: Among the older patients (group 3), 34% had reflux disease. The rate of lower esophageal sphincter insufficiency in group 3 was comparable with that in group 2 and significantly different from group 1. Gastric 24-h pH-metry showed no significant differences between the groups. Esophageal pH-metry results for groups 1 and 3 differed significantly from those in group 2. Impedance assessment showed that older patients have non-acid reflux episodes in the recumbent position significantly more often in comparison with controls and reflux patients. Reflux patients and older patients had proximal reflux episodes significantly more often than healthy volunteers. CONCLUSIONS: Patients aged over 65 have non-acid reflux, particularly in the recumbent position, significantly more often than normal individuals and patients with reflux disease. Non-acid reflux may mimic a negative DeMeester score in older patients with severe reflux disease.

PMID: 19756879 [PubMed - in process]

Related Articles

Emerging concepts of bile reflux in the constellation of gastroesophageal reflux disease.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S9-16

Authors: Kauer WK, Stein HJ

RATIONALE: Reflux of gastric and duodenal contents in patients with gastroesophageal reflux disease (GERD) has been postulated as a major cause of complications, such as Barrett’s esophagus or malignant degeneration. FINDINGS: We present a summary of experimental, clinical, and immunohistochemical studies that show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett’s esophagus, and are possibly related to the development of esophageal adenocarcinoma.

PMID: 19756880 [PubMed - in process]

Related Articles

Evaluation and treatment of superficial esophageal cancer.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S94-100

Authors: DeMeester SR

INTRODUCTION: Adenocarcinoma of the esophagus is the fastest increasing cancer in the USA, and an increasing number of patients are identified with early-stage disease. The evaluation and treatment of these superficial cancers differs from local and regionally advanced lesions. METHODS: This paper is a review of the current methods to diagnose, stage, and treat superficial esophageal adenocarcinoma. RESULTS: Intramucosal adenocarcinoma can be effectively treated with endoscopic resection techniques and with less morbid surgical options including a vagal-sparing esophagectomy. However, submucosal lesions are associated with a significant risk for lymph node metastases and are best treated with esophagectomy and lymphadenectomy. DISCUSSION: There has been a major shift in the treatment for Barrett’s high-grade dysplasia and superficial esophageal adenocarcinoma in the past 10 years. New therapies minimize the morbidity and mortality of traditional forms of esophagectomy and in some cases allow esophageal preservation. Individualization of therapy will allow maximization of successful outcome and quality of life with minimization of complications and recurrence of Barrett’s or cancer.

PMID: 19760303 [PubMed - in process]

Related Articles

The molecular pathogenesis of Barrett’s esophagus: common signaling pathways in embryogenesis metaplasia and neoplasia.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S81-7

Authors: Peters JH, Avisar N

Although Barrett’s esophagus has been recognized for over 50 years, the cellular and molecular mechanisms leading to the replacement of squamous esophageal epithelium with a columnar type are largely unknown. Barrett’s is known to be an acquired process secondary to chronic gastroesophageal reflux disease and occurs in the presence of severe disruption of the gastroesophageal barrier and reflux of a mixture of gastric and duodenal content. Current hypothesis suggest that epithelial change occurs due to stimulation of esophageal stem cells present in the basal layers of the epithelium or submucosal glands, toward a columnar epithelial differentiation pathway. The transcription factor CDX2 seems to play a key role in promoting the cellular biology necessary for columnar differentiation, and can be induced by bile salt and acid stimulation. Several cellular signaling pathways responsible for modulation of intestinal differentiation have also been identified and include WNT, Notch, BMP, Sonic HH and TGFB. These also have been shown to respond to stimulation by bile acids, acid or both and may influence CDX2 expression. Their relative activity within the stem cell population is almost certainly responsible for the development of the esophageal columnar epithelial phenotype we know as Barrett’s esophagus.

PMID: 19760304 [PubMed - in process]

Related Articles

Rudolf Nissen (1896-1981)-perspective.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S58-61

Authors: Liebermann-Meffert D

INTRODUCTION: Rudolf Nissen was one of the outstanding general surgeons of the last century. Between the years 1921 and 1933, he was the pupil and protégé of the famous surgeon Ferdinand Sauerbruch. He was nominated professor of surgery in 1930. Forced by the Nazi-Regime to resign his position, Nissen emigrated in 1933 first to Turkey and then in 1939 to the USA. Here, he held positions in hospitals at New York. Having been appointed to the Chair of Surgery at the University of Basle, Switzerland, he returned to Europe in 1952. Nissen was a critical prolific writer and excellent researcher, surgeon, and teacher. CONCLUSION: The first successful pneumectomy and lung lobectomy in man, as well as the description of surgical pathophysiology and treatment of gastroesophageal reflux disease, including hiatus hernia, are considered to be his most important pioneer work.

PMID: 19760372 [PubMed - in process]

Related Articles

A controversy that has been tough to swallow: is the treatment of achalasia now digested?

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S33-45

Authors: Roll GR, Rabl C, Ciovica R, Peeva S, Campos GM

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.

PMID: 19760373 [PubMed - in process]

Related Articles

High-resolution esophageal manometry: using technical advances for clinical advantages.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S24-32

Authors: Ayazi S, Crookes PF

BACKGROUND: High-resolution manometry (HRM) is a new technique to investigate the motor function of the esophagus. It differs from conventional manometry in recording pressures by solid state microtransducers at 12 points around the circumference at every centimeter of esophageal length, and displaying the data in pseudo-three-dimensional format using a topographic plot, where esophageal pressures within a given range are represented by different colors. RATIONALE: The large amount of data and the capacity to analyze and display it intuitively has afforded many new insights into esophageal dysfunction. Among these insights are the ability to distinguish three different subtypes of achalasia and predict their response to therapy, better understanding of the relationship between the lower esophageal sphincter (LES) and the crural diaphragm, the development of novel quantitative parameters to understand the nature of the dysfunction in non-specific esophageal motor disorders, and the elucidation of a newly described motility disorder characterized by failure of peristalsis at the transitional zone between the upper skeletal muscle and the more distal smooth muscle portion of the esophagus. It is also ideally suited to analysis of the effect of prokinetic medications. The method is quicker and less uncomfortable for patients and the analysis is visually appealing and intuitively comprehensible. CONCLUSION: Despite these potential advantages, there are currently no data to demonstrate a clinical advantage in treatment. The results of such studies will be crucial to the acceptance of this novel technology.

PMID: 19763703 [PubMed - in process]

Related Articles

Personalized treatment-the promise of molecular genetics diagnostics.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S2-5

Authors: Wajed SA

PMID: 19768512 [PubMed - in process]

Related Articles

Esophagectomy without mortality: what can surgeons do?

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S101-7

Authors: Law S

INTRODUCTION: Surgical resection remains the mainstay treatment for patients with localized esophageal cancer. It is, however, a complex procedure. Mortality rate used to be high, but in recent years, death rate has been reduced to below 5% in specialized centers. METHODS: Outcome of esophagectomy can be improved by paying attention to (1) appropriate patient section, (2) choice of surgical techniques and their execution, and (3) optimizing perioperative care. A volume-outcome relationship is also evident. Surgeons can perform esophagectomy without mortality, but a multi-disciplinary team management is essential to achieve this goal.

PMID: 19774427 [PubMed - in process]

Related Articles

Bile in the esophagus-model for a bile acid biosensor.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S6-8

Authors: Nehra D

Acid and bile acids form important constituents of the refluxed substances in patients who suffer from gastroesophageal reflux disease. Whilst 24h ambulatory pH monitoring using antimony or glass pH electrodes measures acid levels 5 cm above the gastroesophageal junction, there are no reliable methods of measuring other constituents of duodenal juices such as bile acids. Past studies in detection of bile acids have included esophageal aspiration studies with detection of bile acids with HPLC or indirect methods using fiber-optic bile sensor “Bilitec” to detect bilirubin in the bile. These methods have either been impracticable or unreliable for routine and accurate measurement of bile acid. More recently, impedance technology has been used to define “weakly” acid or alkaline reflux. There are many potential applications of biosensors of various types, and it is envisaged that a biosensor specific for bile acid would be a more practical tool for routine measurement. This paper looks at a model for development of a biosensor for bile acid based on molecular imprinted polymers.

PMID: 19774428 [PubMed - in process]

Related Articles

Is esophagectomy the paradigm for volume-outcome relationships?

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S115-20

Authors: Louie BE

INTRODUCTION: Esophagectomy is considered one of the most complicated, difficult to perform, and physiologically altering operations performed by surgeons. DISCUSSION: Outcome, not only depends upon surgeon and hospital volume but also involves a “supporting cast” of health professionals, such as physical therapy and ICU. The complementary skill set of the surgeon may also influence esophagectomy outcomes. CONCLUSIONS: Young surgeons can perform esophagectomy with low mortality while their volume increases if they engage and involve all of the components in this paradigm.

PMID: 19777313 [PubMed - in process]

Related Articles

Initial experience with new intraluminal devices for GERD Barrett’s esophagus and obesity.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S121-6

Authors: Filipi CJ, Stadlhuber RJ

BACKGROUND: Transoral intraluminal surgery is less painful. However, endoscopic antireflux procedures have been unsuccessful, endoscopic foregut mucosal excision procedures are often difficult to perform, and endoscopic intra-luminal suturing is both imprecise and too shallow. We have endeavored to correct these deficiencies and report here new devices for GERD, obesity, and Barrett’s mucosal excision. METHOD: A retrospective review of ex vivo and in vivo animal experiments using sharp blade mucosal excision for esophageal and gastric mucosa and a suturing device with transverse needles designed to full thickness penetrate the gastric wall were completed. A total of 338 excisions were performed in 134 ex vivo tissue experiments and in 119 in vivo attempts. Suture needle testing was performed in ex vivo human stomachs and porcine stomachs and in in vivo canine and baboon stomachs. RESULTS: One excision perforation (0.9%) occurred in a live animal. Satisfactory mucosal excision depth for the Barrett’s device was reproducible. Progressive suture actuation reliability improved from 83% during ex vivo testing to 96.7% in in vivo experiments. CONCLUSION: The results demonstrate feasibility, reliability, and safety for gastric and esophageal mucosal excision. Suturing reliability improved and further studies will be performed to finalize the instrument designs, the operative techniques, and the other device applications.

PMID: 19777314 [PubMed - in process]

Related Articles

Minimally invasive esophagectomy.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S108-14

Authors: Dunst CM, Swanström LL

INTRODUCTION: Minimally invasive esophagectomy has gained popularity over the past two decades. The procedural goal is to decrease the high overall morbidity of a traditional open esophageal resection. The entire spectrum of open esophagectomy techniques has been successfully replicated in a minimally invasive fashion. DISCUSSION: Esophagectomy remains one of the most technically challenging operations, and developing the skills necessary for minimal invasive esophagectomy is associated with a steep learning curve. Minimally invasive approaches show most promise for benign disease and select early esophageal cancers, but their role in more advanced cancer remains controversial due to lack of long-term results. CONCLUSION: As minimally invasive esophagectomy matures, its true value in both benign and malignant disorders will become better defined.

PMID: 19789930 [PubMed - in process]

Related Articles

Radiofrequency ablation of Barrett’s esophagus.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S88-93

Authors: Watson TJ

INTRODUCTION: Barrett’s esophagus (BE) is known to be due to chronic gastroesophageal reflux disease and is a precursor of esophageal adenocarcinoma. DISCUSSION: The ability to eliminate BE is appealing, given the neoplastic potential of this condition and the continued increase in incidence of adenocarcinoma involving the esophagus and esophagogastric junction, a highly lethal disease. While a number of endoscopic technologies targeting metaplastic or neoplastic esophageal mucosa have been introduced into the clinical marketplace, most have not been widely adopted. Radiofrequency ablation recently was developed and holds appeal as a reliable, minimally invasive, inexpensive, and well-tolerated technique to destroy pathologic esophageal epithelium. CONCLUSION: The available data show its efficacy and safety in the short-term, though more mature follow-up is needed to demonstrate its durability in the long-term and its cost-effectiveness in ultimately saving lives.

PMID: 19816748 [PubMed - in process]

Related Articles

Achalasia–if surgical treatment fails: analysis of remedial surgery.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S46-57

Authors: Gockel I, Timm S, Sgourakis GG, Musholt TJ, Rink AD, Lang H

INTRODUCTION: Heller myotomy leads to good-excellent long-term results in 90% of patients with achalasia and thereby has evolved to the “first-line” therapy. Failure of surgical treatment, however, remains an urgent problem which has been discussed controversially recently. MATERIALS AND METHODS: A systematic review of the literature was performed to analyze the long-term results of failures after Heller’s operation with emphasis on treatment by remedial myotomy. DISCUSSION: Other reinterventions and their causes after failure of surgical treatment in patients with achalasia are discussed.

PMID: 19856034 [PubMed - in process]

Related Articles

Introduction to Festschrift for Tom R DeMeester.

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S1

Authors: Peters J

PMID: 19953337 [PubMed - in process]

Related Articles

Is there a role for anything other than a Nissen’s operation?

J Gastrointest Surg. 2010 Feb;14 Suppl 1:S67-74

Authors: Fein M, Seyfried F

BACKGROUND: The Nissen fundoplication is the most frequently applied antireflux operation worldwide. The aim of this review was to compare laparoscopic Nissen with partial fundoplication. METHODS: Nine randomized trials comparing several types of wraps were analyzed, four for the comparison Nissen vs. Toupet and five for the comparison Toupet or Nissen vs. anterior fundoplication. Similar comparisons in nonrandomized studies were also included. RESULTS: Dysphagia rates and reflux recurrence were not related to preoperative esophageal persistalsis independent of the selected procedure. Overall, Nissen fundoplication revealed slightly better reflux control, but was associated with more side effects, such as early dysphagia and gas bloat. Advantages of an anterior approach were only reported by one group. A significantly higher reflux recurrence rate for anterior fundoplication was observed in all other comparisons. CONCLUSION: Tailoring antireflux surgery according to esophageal motility is not indicated. At present, the relevant factor for selection of a Nissen or Toupet fundoplication is personal experience. Anterior fundoplication offers less effective long-term reflux control.

PMID: 20012380 [PubMed - in process]

Related Articles

Autoimmune Esophagitis: IgG4-related Tumors of the Esophagus.

J Gastrointest Surg. 2010 Mar 2;

Authors: Lopes J, Hochwald SN, Lancia N, Dixon LR, Ben-David K

We present a case of a 23-year-old gentleman who presented with dysphagia, weight loss, and recurrent esophageal strictures requiring multiple dilatations. An endoscopic ultrasound with esophagogastroduodenoscopy revealed a mass present in the distal esophagus. Fine needle aspiration suggested that the mass in the lower esophagus resembled a gastrointestinal stromal tumor. After surgical resection, final pathologic analysis revealed that the tumor was comprised of benign-appearing fibroinflammatory cells with an increase and predominance of IgG4-positive plasma cells. The microscopic appearance was consistent with a benign condition as a result of an IgG4-related process. He did not, however, have any other symptoms indicative of systemic autoimmune disease or connective tissue disorders. We present the pre-operative imaging, operative management, pathologic diagnosis, and literature review of this rare condition and the first known report of autoimmune esophagitis as part of the IgG4 spectrum of diseases.

PMID: 20195914 [PubMed - as supplied by publisher]

Related Articles

Conservative and Surgical Treatment of Chronic Anal Fissure: Prospective Longer Term Results.

J Gastrointest Surg. 2010 Mar 2;

Authors: Sileri P, Stolfi VM, Franceschilli L, Grande M, Di Giorgio A, D’Ugo S, Attina’ G, D’Eletto M, Gaspari AL

INTRODUCTION: The aim of this prospective study was to assess the efficacy of different medical treatments and surgery in the treatment of chronic anal fissure (CAF). PATIENTS AND METHODS: From January 2004 to March 2009, 311 patients with typical CAF completed the study. All patients were initially treated with 0.2% nitroglycerin ointment (GTN) or anal dilators (DIL) for 8 weeks. If no improvement was observed after 8 weeks, the patients were assigned to the other treatment or a combination of the two. Persisting symptoms after 12 weeks or recurrence were indications for either botulinum toxin injection into the internal sphincter and fissurectomy or lateral internal sphincterotomy (LIS). During the follow-up (29 +/- 16 months), healing rates, symptoms, incontinence scores, and therapy adverse effects were prospectively recorded. RESULTS: Overall healing rates were 64.6% and 94% after GTN/DIL or BTX/LIS. Healing rate after GTN or DIL after 12 weeks course were 54.5% and 61.5%, respectively. Fifty-four patients (17.4%) responded to further medical therapy. One hundred two patients (32.8%) underwent BTX or LIS. Healing rate after BTX was 83.3% and overall healing after LIS group was 98.7% with no definitive incontinence. CONCLUSION: In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence.

PMID: 20195915 [PubMed - as supplied by publisher]

Microscopic Findings in Sigmoid Diverticulitis-Changes after Conservative Therapy.

J Gastrointest Surg. 2010 Feb 25;

Authors: Holmer C, Lehmann KS, Engelmann S, Frericks B, Loddenkemper C, Buhr HJ, Ritz JP

INTRODUCTION: The indications for prophylactic surgery for phlegmonous and covered perforated type of acute sigmoid diverticulitis (SD) are currently matters of debate, and a more conservative approach has been advocated. However, it has not yet been clarified to what extent CT findings indicative of acute SD correlate with histological findings, and it is still uncertain how these findings change in the time interval between initial antibiotic treatment and late elective surgery. The aim of this study was to record time-course changes of inflammation in phlegmonous and abscess-forming diverticulitis after conservative treatment in order to check the indication for surgery. MATERIAL AND METHODS: This study included all patients who underwent surgery for CT morphologically phlegmonous and covered perforated SD from January 2002 to June 2007. Two groups were formed to record time-course changes: early elective surgery (7-10 days after antibiotic treatment) and late elective surgery (4-6 weeks after conservative treatment). Exclusion criteria were emergency interventions, free perforations (Hinchey III and IV), recurrent inflammations, and contrast allergy. The extent of the inflammation recorded preoperatively by CT scan was compared with histological findings. RESULTS: A total of 257 patients (142 male and 115 female; mean age, 56.6 years) underwent surgery (116 early elective and 141 late elective) for phlegmonous and covered perforated SD. Phlegmonous SD was seen in 127 cases and covered perforated SD in 130 cases. In the phlegmonous type of SD, early surgery led to conformity with the preoperative stage in 56%, to more extensive findings in 11%, and to subsided inflammation in 33%. Late surgery led to conformity in 0% and to signs of subsided inflammation in 100%. In the covered perforated type of SD, early surgery led to conformity in 90%, to subsided inflammation in 10%, and to milder manifestation in 0%. In contrast, late surgery here led to conformity in 26% of the cases and to subsided inflammation in 74%. Considerable histological changes can be detected under conservative therapy. The acute inflammation subsides under antibiotic therapy as awaited. It must be clarified whether the phlegmonous form of SD should, in principal, be regarded as an indication for surgery, since it shows early and nearly complete regression of the inflammation. Otherwise, the covered perforated type of SD still shows marked inflammatory changes after conservative therapy in a high percentage of patients and should thus preferably be treated by surgery. However, the clinical appearance of the patient with sigmoid diverticulitis still remains the most important part of decision making.

PMID: 20186500 [PubMed - as supplied by publisher]