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

BACKGROUND Macroscopic evaluation of a tumor specimen is an independent prognostic factor of oncologic outcome after total mesorectal excision (TME) for rectal cancer. This study aimed to assess macroscopic quality of specimens acquired after laparoscopic versus open TME in patients with low rectal cancer.PATIENTS AND METHODS Seventy-two patients with low rectal cancer underwent TME either by open (n = 39) or laparoscopic (n = 33) approach. In all specimens, the cut edge of the peritoneal reflection at the anterior mid-rectum, the Denonvillier's fascia, the visceral fascia covering the mesorectum both posteriorly and laterally, and the bowel wall below the mesorectum were macroscopically assessed.RESULTS Colorectal anastomoses were located significantly lower in the laparoscopic than in the open group (P < .001). The Denonvillier's fascia was violated in 7 patients after open surgery (P = .01). A significantly more complete TME with intact visceral pelvic fascia was performed after laparoscopy compared with open surgery (P = .025).CONCLUSIONS Laparoscopy offers a macroscopically more complete specimen after TME for rectal cancer than the open approach because it offers a better view in the pelvis. (C) 2009 Elsevier Inc. All rights reserved.

Background: Laparoscopic resection of the rectum is still under scrutiny for its adequacy of oncological clearance. Aim: To assess lymph node yield after laparoscopic total mesorectal excision (TME) for rectal cancer as compared to the open approach. Methods: 74 patients with middle and low rectal cancer were prospectively randomized in two groups. Group A included 39 patients who had an open TME (35 with low anterior resection of the rectum (LARR) and 4 with abdominoperineal resection of the rectum (APR)). In group B, there were 34 patients who had a laparoscopic TME (27 with LARR and 7 with APR). 10 of the LARR patients in group A and 14 of the LARR patients in group B had a defunctioning ileostomy. All operations were performed by one surgeon or under his supervision. Results: Gender and age distribution were similar for both groups (group A: 23 males; mean age 69 (41–85); group B: 20 males; mean age 72 (31–84)). The mean distance of the tumor from the dentate line was 7.6 cm (1–12 cm) for group A and 6.1 cm (1–12 cm) for group B. Anastomosis was formed at a mean distance of 5.5 cm (1.5–8.5 cm) from the dentate line in group A and 3.5 cm (1–4.5 cm) in group B. At histology, in group A there were 5 T4 tumors, 9 T3, 10 T3+ (<1 mm distance from the circumferential resection margin), 13 T2 and 2 T1. In group B, there were 3 T4 tumors, 14 T3, 8 T3+, 7 T2 and 2 T1. Differences between groups were not significant.The mean number of lymph nodes retrieved in group A specimens was 19.2 (5–45) and in group B 19.2 (8–41) (p = 0.2). In group A, 3.9 (1–9) regional, 13.9 (3–34) intermediate and 1.5 (1–3) apical lymph nodes were retrieved. The respective values in group B were 3.7 (3–7), 14.4 (4–33) and 1.3 (1–3). Differences between groups were not significant. Also, the incidence of lymph node involvement by the tumor was not significantly different between groups (group A: 23; group B: 19). Conclusions: Laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach. Also, distribution of the lymph nodes along the resected specimens is similar between the two approaches.

Background: Evidence on the long-term outcome of laparoscopic Heller-Dor surgery is limited. The aim of this study was to assess the long-term outcome of achalasic patients after surgery, particularly in relation to the radiologic preoperative stage of the disease.Methods: Sixty-eight patients with achalasia were assessed clinically and by esophageal radiology, manometry, and 24-hour ambulatory esophageal pH monitoring before and at 3 months, 1, 1 to 3, 3 to 5, and 5 to 8 years after a laparoscopic Heller-Dor procedure. Results: At I year after surgery the symptom score was significantly lower than the preoperative score (P <.001), and a satisfactory clinical outcome was seen in more than 90% of the patients with stage 1, 11, and III disease at the preoperative radiologic assessment. Only 50% of stage IV patients reported satisfactory results. An adequate opening of the lower esophageal sphincter (LES) and LES resting pressure of less than 8 mm Hg was achieved in all patients, and esophageal emptying was accelerated significantly (P <.001). At the consecutive follow-up evaluation (1-8 y), a satisfactory outcome was maintained in all stage I, II, and III responders. Stage IV patients with initially unsatisfactory results reported a worsening of symptoms (P <.02). Patients with pseudodiverticulum had a higher symptom score (P <.01). LES opening and resting pressure remained at levels of the 1-year follow-up evaluation. Esophageal emptying remained satisfactory in stage 1, 11, and III responders, but deteriorated in stage IV nonresponders and in 6 of the 10 patients with a pseudodiverticulum.Conclusions: A satisfactory outcome of the laparoscopic Heller-Dor procedure in stage 1, 11, and III achalasic patients seems to last. Stage IV nonresponders tend to deteriorate over time. The development of pseudodiverticulum is associated with an increased symptom score. (c) 2007 Excerpta Medica Inc. All rights reserved.

BACKGROUND:Rectoanal intussusception may cause symptoms of obstructed defecation, and functional results of prosthesis rectopexy are usually not satisfactory. The aim of this study was to assess several parameters of the disorder and to evaluate the outcome of resection rectopexy.METHODS:During a 10-year period, 27 female patients with symptomatic large rectoanal intussusception had resection rectopexy (23 laparoscopy; 4 laparotomy). Conservative treatment, including biofeedback treatment in 22 patients, had failed in all cases. Preoperative and postoperative evaluation included clinical assessment, anorectal manometry, evacuation defecography, and colon transit studies. Follow-up ranged between one and five years.RESULTS:Length of intussusception was 2 to 4.9 cm and was significantly related to pelvic floor descent (P = 0.003) and inversely related to resting anal pressures (P < 0.001). Eleven patients had undergone a previous hysterectomy, 9 had enterocele-sigmoidocele, 7 had incontinence of varying severity, and 8 had a solitary rectal ulcer. Colon transit was abnormal in all but five cases. Immediate functional results were bad in two-thirds of the cases; tenesmus, urge to defecate, and frequent stools were the main complaints. By the time these symptoms had subsided, and one year after surgery, all but two patients were satisfied with the outcome. Intussusception was reduced in all cases, anal sphincter tone recovered (P = 0.002), perineal descent decreased (P < 0.001), and colonic transit was accelerated (P < 0.001). Patients available at five-year follow-up had no or only minor defecatory problems.CONCLUSION:Resection rectopexy improves symptoms of obstructed defecation attributed to large rectoanal intussusception.

Background: The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication.Methods: Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension.Results: Both types of fundoplication resulted in significant increases in LES resting (P < 0.001) and postdeglutition relaxation pressure (P < 0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04).Conclusions: Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery. (C) 2004 Excerpta Medica, Inc. All rights reserved.

Background: It has been suggested that division of the short gastric vessels (SGV) provides a more floppy Nissen fundoplication, for the treatment of reflux disease. The aim of the study was to assess whether Nissen fundoplication with division of SGV is associated with improved clinical outcome and laboratory findings.Methods: Fifty-six consecutive patients with gastroesophageal reflux disease (GERD) were randomly assigned to have a laparoscopic Nissen fundoplication either with division (24 patients; 15 men; mean age 51 +/- 15 years) or without division (32 patients; 23 men, mean age 47 +/- 14 years) of the SGV. Preoperative and postoperative investigation included clinical assessment, esophagoscopy, esophagogram, esophageal manometry, and 24-hour ambulatory esophageal pH monitoring.Results: Division of the SGV resulted in a significant increase of the operating time (P <0.0001). The operation abolished reflux in both groups. Also, both types of Nissen fundoplication significantly increased the amplitude of peristalsis at distal esophagus (division group: from 56 +/- 20 mm Hg to 64 +/- 25 mm Hg, P = 0.01; nondivision group: from 65 +/- 27 mm Hg to 75 +/- 26 min Hg, P <0.001) and the lower esophageal sphincter pressure (division group: from 16 +/- 10 nun Hg to 24 +/- 7 mm Ha, P <0.001; nondivision group: from 22 +/- 8 min Hg to 28 +/- 5 min Hg, P <0.001). No differences in the incidence of postoperative severe dysphagia (division group: 5 of 24; nondivision group: 3 of 32) and overall esophageal transit were accounted between groups, However, division of the SGV was associated with a significant increased incidence of gas-bloating syndrome (division group, 13 of 24, versus nondivision group, 9 of 32, P = 0.02).Conclusion: Division of the SGV at laparoscopic Nissen fundoplication for GERD does not improve clinical outcome and laboratory findings, while it is associated with prolongation of the operating time and increased incidence of gas-bloating syndrome. (C) 2001 Excerpta Medica, Inc. All rights reserved.

The motility pattern of the internal anal sphincter was estimated manometrically in 42 patients with fissure-in-ano before and after left lateral internal sphincterotomy (LAS). Resting anal pressure and anal pressure during straining were significantly higher in patients than in controls (132±21 SD cmH2O vs 81±14SD cmH2O P<0.0002 and 46±16SD cmH2O vs 13±4SD cmH2O P<0.0005), but were normal after LAS. Slow waves were more common in fissure patients (86±6SD% of total recording time vs 68±11SD % of total recording time, P<0.0002), but also became normal after successful treatment. The presence of ultra slow waves was also more common in fissure patients (P<0.0001), and although it was significantly reduced postoperatively (P<0.0001), it did not return to normal. Sampling was less frequent in fissure patients (P<0.0001) and improved significantly after successful treatment (P<0.0002). Rectal distension produced significantly less reduction in anal pressure in fissure patients as compared to controls (P<0.01), but successful treatment returned the response to normal. There were 2 patients with anal fissure who did not heal after left LAS. Those patients and a further 5 patients with non healed fissures after left LAS showed the same pathological manometric features as before surgery. Their fissures were successfully treated by additional right lateral internal sphincterotomy. In conclusion, increased internal sphincter activity is probably an aetiological factor in fissure-in-ano, while successful LAS improves anal sphincter function. Fissures which fail to heal after LAS, can be successfully treated by additional right internal sphincterotomy.

A series of 155 cases of hepatic hydatid disease, occurring in 121 patients, were operated on at the Naval and Veterans Hospital of Athens. Ultrasonography and computerized axial tomography provided the preoperative diagnosis in 89 and 93 percent of the cases respectively in recent years. Thirty one percent of the cases presented with complications, the commonest of these being infection of the cyst (10 percent) and rupture of the cyst into the bile ducts (17 percent). Total cystectomy was performed in three cases and removal of the endocyst with its content in the remaining 152. The remaining cavity was either externally drained (57 cases), or filled with omentum (omentoplasty--95 cases). External fistula and infection of the residual cavity occurred in 32 and 56 percent after simple drainage and in 4 and 2 percent respectively after omentoplasty. Differences are statistically significant (p less than 0.001). Hospitalization was also significantly longer after drainage than after omentoplasty (p less than 0.01). Obstructive jaundice after intrabiliary rupture of the cyst was more successfully managed after additional choledochoduodenostomy than after simple drainage of the common bile duct. Intrapericoneal recurrence of hydatid disease occurred in two cases. The conclusion of the present study is, that ultrasonography and computerized axial tomography provide an acceptable rate in the diagnosis and that omentoplasty offers a very low complication rate in the management of hydatid cystic disease of the liver.

Antral and duodenal G-cells and fundic, antral, duodenal and pancreatic D-cells were demonstrated immunocytochemically and their population size was estimated in guinea pigs of both sexes. The population of antral (210 + 18.03 SD cells/cm) and duodenal (13.20 + 3.12 SD cells/cm) G-cells is lower in guinea pigs than in dogs. Antral and duodenal G/D-cell ratios (1.6/1 and 1.2/1) are also lower in the guinea pig than in man. Antral G- and D-cell populations are greater in male (210 + 18.03 SD cells/cm and 128.2 + 17.63 SD cells/cm) than in female (176 + 13.8 SD cells/cm and 108.4 + 6.9 SD cells/cm) guinea pigs. The percentage of pancreatic D-cells is greater in the guinea pig (20-25%) than in man and rat. It is concluded that the differences in gastric and duodenal G- and D-cells between guinea pigs and other species possibly reflect different gastric secretory functions. Sex related differences in the endogenous sex hormones can explain differences in gastric secretion between the two sexes. Pancreatic D-cells possibly exert their action on neighbouring endocrine cells through different pathways from those seen in man and rat.