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Background: Hypothermia has been associated with an increase in the rate of infectious complications following colectomy. We hypothesized that a substantial fraction of temperature loss in patients undergoing elective colectomy occurs prior to operation.Methods: Temperature data were collected from 105 consecutive patients undergoing elective colectomy at a single institution.Results: The study population consisted of 105 patients; 67(64%) male, median age 59 years (range 17-95 years), median body mass index 27 kg/m2 (range 15-48 kg/m2). Median preoperative temperature was 36.7 °C (range 35.2-39.2 °C), dropping to 35.7 °C (range 34.0-37.3 °C) immediately following intubation and then rising to 36.2 °C (range 34.0-38.0 °C) prior to leaving the operating room. The median first postoperative temperature was 36.3 °C (range 34.4-37.7 °C). Temperatures were significantly different from one another (p < 0.05, ANOVA), except for the last operative and first postoperative temperature. A first postoperative temperature of ≥ 36.0 °C (meeting Surgical Care Improvement criteria Inf-10) was achieved in 78 (74%) of patients. A preoperative temperature of ≥ 36.5 °C was associated with a first postoperative temperature of ≥ 36.0 °C, but operative approach (laparoscopic versus open) was not.Conclusions: Most temperature loss occurs prior to operation in patients undergoing colectomy. Patients are rewarmed during the operative procedure. The time period prior to operation should be the focus of efforts designed to ensure normothermia. [ABSTRACT FROM AUTHOR]

I Dear Editor i Rectal cancer management is discussed within multidisciplinary team meetings with treatment options stratified based on staging, patient choice and local expertise. For T1 or T2 rectal cancer, surgeons more often chose local excision with standard chemoradiotherapy, standard chemoradiotherapy alone or total neoadjuvant therapy. [Extracted from the article]

Background: This study aimed to assess the efficacy of a method for avoiding conversion to laparotomy in patients considered for laparoscopic colectomy. Patients deemed to be at high risk for conversion to laparotomy were initially approached via an 8-cm midline incision ("peek port") with the laparoscopic equipment unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy. If intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. Patients deemed to be at low risk for conversion to laparotomy were approached laparoscopically from the outset.Methods: Data from 241 consecutive patients brought to the operating room for intended laparoscopic colectomy were retrieved from a prospective database.Results: The study population consisted of 132 men and 109 women with a mean age of 62 years and a mean body mass index (BMI) of 28. Prior abdominal surgery had been performed in 49% of these patients. Inflammatory conditions accounted for 38% of the diagnoses, and enteric fistulas were present in 7% of the cases. Of the 25 patients who underwent the initial "peek port," 8 (32%) underwent immediate incision extension to formal laparotomy. Hand-assisted laparoscopic colectomy was performed in 17 (68%) of these 25 patients, with one subsequent conversion to formal laparotomy. Of the 216 patients initially approached laparoscopically, 5 (2%) required conversion to laparotomy. The laparotomy rate for the "peek port" group (9/25, 36%) was higher than for the initial laparoscopy group (5/216, 2%) (p < 0.0001). Of the 233 patients from both groups who underwent laparoscopy, the overall rate for conversion to laparotomy was 3% (6/233).Conclusions: The "peek port" approach to the patient with a potentially hostile abdomen allows for rapid assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy. This technique should reduce overall cost by avoiding the use of laparoscopic equipment as well as potential complications related to trocar placement and laparoscopic dissection in patients who will ultimately require formal laparotomy. [ABSTRACT FROM AUTHOR]

This study aimed to assess the efficacy of a method for avoiding conversion to laparotomy in patients considered for laparoscopic colectomy. Patients deemed to be at high risk for conversion to laparotomy were initially approached via an 8-cm midline incision (“peek port”) with the laparoscopic equipment unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy. If intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. Patients deemed to be at low risk for conversion to laparotomy were approached laparoscopically from the outset. Data from 241 consecutive patients brought to the operating room for intended laparoscopic colectomy were retrieved from a prospective database. The study population consisted of 132 men and 109 women with a mean age of 62 years and a mean body mass index (BMI) of 28. Prior abdominal surgery had been performed in 49% of these patients. Inflammatory conditions accounted for 38% of the diagnoses, and enteric fistulas were present in 7% of the cases. Of the 25 patients who underwent the initial “peek port,” 8 (32%) underwent immediate incision extension to formal laparotomy. Hand-assisted laparoscopic colectomy was performed in 17 (68%) of these 25 patients, with one subsequent conversion to formal laparotomy. Of the 216 patients initially approached laparoscopically, 5 (2%) required conversion to laparotomy. The laparotomy rate for the “peek port” group (9/25, 36%) was higher than for the initial laparoscopy group (5/216, 2%) ( p < 0.0001). Of the 233 patients from both groups who underwent laparoscopy, the overall rate for conversion to laparotomy was 3% (6/233). The “peek port” approach to the patient with a potentially hostile abdomen allows for rapid assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy. This technique should reduce overall cost by avoiding the use of laparoscopic equipment as well as potential complications related to trocar placement and laparoscopic dissection in patients who will ultimately require formal laparotomy. [ABSTRACT FROM AUTHOR]

Selection of candidates for surgical fellowships has traditionally been based on subjective evaluations by the program directors and references from previous positions. The introduction of well-validated objective methods of assessment has allowed us to evaluate candidates’ technical skills and base the selection process on objective, reliable, and transparent criteria. The aim of the study was to assess the applicability of such methods in current practice. Prospective study. Eight surgeons, applying for a fellowship position in minimally invasive surgery (MIS), performed a previously validated assessment curriculum using a Virtual-Reality Laparoscopic Trainer (LapSim® 3.0, Surgical Science, Gothenburgh, Sweden). Technical performance was evaluated using criteria registered by the simulator, i.e., time, error score, and efficiency of movements score. Candidates performed all the tasks in easy end medium level until reaching predefined criteria. If proficiency criteria were not achieved on easy or medium level after nine repetitions the test was considered as failed. Additionally, all applicants underwent an interview by two independent attending surgeons. Each applicant received a grade on a ten-point scale. Five out of the eight candidates failed the technical skills assessment test. One candidate failed to achieve proficiency criteria on easy level, one on medium, and three on difficult level. Evaluation scores, based on the interview of the candidates showed a good interrater reliability (Cronbach’s α = 0.8). There was no significant correlation between the interviewers rating, and the applicants technical skills demonstrated during the test on the VR trainer (Spearman’s ρ = 0.182, p = 0.696). Evaluations by senior surgeons are reproducible and reliable. The introduction of technical skills assessment has the potential to improve the current method of candidate selection, making it more valid, objective, and transparent. [ABSTRACT FROM AUTHOR]

Endoscopically unresectable apparently benign colorectal polyps are considered by some surgeons as ideal for their early laparoscopic colectomy experience. Our hypotheses were: (1) a substantial fraction of patients undergoing laparoscopic colectomy for apparently benign colorectal neoplasia will have adenocarcinoma on final pathology; and (2) in our practice, we perform an adequate laparoscopic oncological resection for apparently benign polyps as evidenced by margin status and nodal retrieval. Data from a consecutive series of patients undergoing laparoscopic colectomy (on an intention-to-treat basis) for endoscopically unresectable neoplasms with benign preoperative histology were retrieved from a prospective database and supplemented by chart review. The study population consisted of 63 patients (mean age 67, mean body mass index 29). Two out of 63 cases (3%) were converted to laparotomy because of extensive adhesions ( n = 1) and equipment failure ( n = 1). Colectomy type: right/transverse ( n = 49, 78%); left/anterior resection ( n = 10, 16%); subtotal ( n = 4, 6%). Invasive adenocarcinoma was found on histological analysis of the colectomy specimen in 14 out of 63 cases (22%), standard error of the proportion 0.052. Staging of the 14 cancers were I ( n = 6, 43%), II ( n = 3, 21%), III ( = 4, 29%), and IV ( n = 1, 7%). The median nodal harvest was 12 and all resection margins were free of neoplasm. Neither dysplasia on endoscopic biopsy nor lesion diameter was predictive of adenocarcinoma. Eight out of 23 (35%) patients with dysplasia on endoscopic biopsy had adenocarcinoma on final pathology versus 6/40 (15%) with no dysplasia ( p = 0.114, Fisher’s exact test). Mean diameter of benign tumors was 3.2 cm (range 0.5–10.0cm) versus 3.9cm (range 1.5–7.5cm) for adenocarcinomas ( p = 0.189, t - test). A substantial fraction of endoscopically unresectable colorectal neoplasms with benign histology on initial biopsy will harbor invasive adenocarcinoma, some of advanced stage. This finding supports the practice of performing oncological resection for all patients with endoscopically unresectable neoplasms of the colorectum. The inexperienced laparoscopic colectomist should approach these cases with caution. [ABSTRACT FROM AUTHOR]

Background: Lumbar peritoneal and ventriculoperitoneal shunts are widely used for the treatment of hydrocephalus. In the past, the abdominal portion of these procedures required laparotomy. With the advent of minimally invasive techniques, laparoscopically assisted placement of the distal catheter has been tried. Materials and Methods: We performed 10 shunt procedures (3 lumbar peritoneal, 6 ventriculoperitoneal, and 1 meningomyelocele-peritoneal) in 10 patients (mean age 56; age range, 30–78 years). Four patients had undergone previous open shunt placement that failed. The abdominal portion of the procedure was performed using a 5-mm trocar and a 10Fr introducer for camera and catheter insertion. In 3 cases, an additional 5-mm port was necessary for lysis of adhesions. These access punctures did not require fascial closure and caused minimal pain and limitation. Results: No intra- or postoperative complications were encountered in this small patient group. At a median follow-up of 50 months (range, 3–56 months) all patients had functioning shunts. Conclusion: Single trocar laparoscopically assisted placement of central nervous system–peritoneal shunts is safe and simple, and should be considered the procedure of choice. This technique is also suitable for repositioning migrated catheters and other catheter-tip manipulations. [ABSTRACT FROM AUTHOR]

PURPOSE: This study was designed to: determine the efficacy of sentinel lymph node mapping in patients with intraperitoneal colon cancer, and create an algorithm to predict potential survival benefit by using best-case estimates in favor of sentinel node mapping and lymph node ultraprocessing techniques. METHODS: Forty-one patients with intraperitoneal colon cancer undergoing colectomy with curative intent were studied prospectively. After mobilization of the colon and mesentery, 1 to 2 ml of isosulfan blue dye was injected subserosally around the tumor. The first several nodes highlighted with blue dye were identified as sentinel nodes. Additional nodes were identified by the pathologist in routine fashion by manual dissection of the mesentery. All nodes were processed in routine fashion by bivalving and hematoxylin and eosin staining. To create an algorithm to predict potential survival benefit of sentinel node mapping and lymph node ultraprocessing techniques, assumptions were made using data from the literature. All bias was directed toward success of the techniques. RE- SULTS: Three of 41 patients (7 percent) did not undergo injection of dye and were excluded from further analysis. Stage of disease in the remaining 38 patients was: I, n = 10 (26 percent): II, n = 15 (39 percent): III, n = 11 (29 percent); IV, n = 2 (5 percent). At least one sentinel node was identified in 30 of 38 patients (79 percent). The median number of sentinel nodes identified was two (range, 1–3). Median total nodal retrieval was 14 (range, 7–45). All nodes were negative in 26 of 38 patients (68 percent). Sentinel nodes and nonsentinel nodes were positive in 2 of 38 pa- tients (5 percent). Sentinel nodes were the only positive nodes in 1 of 38 patients (3 percent). Sentinel nodes were negative and nonsentinel nodes were positive in 9 of 38 patients (24 percent). Thus, sentinel node mapping would have potentially benefited only 3 percent, and failed to ac- curately identify nodal metastases in 24 percent of the patients in our study. To create a survival benefit algorithm. we assumed the following: combined fraction of Stage I and II disease (0.5); fraction understaged by bivalving and hematoxylin and eosin staining that would have occult posi- tive nodes by more sophisticated analysis (0.15), fraction of occult positive nodes detected by sentinel node mapping (0.9); and survival benefit from chemotherapy (0.33). Thus, the fraction of patients benefiting from sentinel lymph node mapping and lymph node ultraprocessing techniques would be 0.02 (2 percent). CONCLUSIONS: Sentinel node mapping with isosulfan blue dye and routine processing of retrieved nodes does not improve staging accuracy in patients with intraperitoneal colon cancer. Even using best- case assumptions, the percentage of patients who would potentially benefit from sentinel lymph node mapping is small. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery in patients >50 years has been controversial. We investigated the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients >55 years of age. Methods: Prospective data on 71 patients (54 females and 17 males) undergoing LRYGBP were reviewed. The patients were followed for a mean of 17 months (range 2-35 months). Results: The mean age was 59 years (range 55-67 years), and the mean preoperative BMI was 50.2 kg/m2 (range 37-65 kg/m2). There were no conversions to open technique. Mean percent of excess weight loss (%EWL) was 20%, 48%, 64% and 67% at 1, 6, 12 and 24 months respectively. 89% of patients had at least a 50% EWL at 1 year postoperatively. There was a significant decrease in the number of patients requiring medical treatment for co-morbidities associated with morbid obesity: diabetes mellitus 87%, hypertension 70% and sleep apnea 86%. There was no inpatient mortality. 1 patient died suddenly 2 weeks postoperatively of possible myocardial infarction or pulmonary embolism. 16 patients developed 22 complications. The median length of hospital stay was 3 days. Conclusion: LRYGBP is a safe and well-tolerated surgical option for the treatment of morbid obesity in patients >55 years old. These patients demonstrate a satisfactory weight loss and resolution of co-morbidities. [ABSTRACT FROM AUTHOR]

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes. [ABSTRACT FROM AUTHOR]

PURPOSE:. This study was designed to compare histologic T and N stages in patients with rectal adenocarcinoma undergoing various neoadjuvant radiotherapy regimens and proctectomy, in an attempt to determine if final histologic stage of the mural tumor predicts nodal status. METHODS:. Data were collected from computerized databases at two institutions on 649 consecutive patients who underwent neoadjuvant radiotherapy or chemoradiotherapy and proctectomy for primary adenocarcinoma of the rectum from 1990 to 2002. RESULTS:. Five patients were excluded because of incomplete pathology data sets, leaving a study population of 644. Patients underwent neoadjuvant radiotherapy alone (2,000 cGy in 5 fractions, n = 191; or 4,500 cGy in 25 fractions, n = 259) or chemoradiation (4,500 cGy in 25 fractions with concurrent 5-fluorouracil, n = 194). Histologic stage of the remaining mural tumor (ypT) correlated with nodal status (ypN). Lymph nodes harboring metastatic tumor were found in 1 of 42 (2 percent) ypT0 patients, 2 of 45 (4 percent) ypT1 patients, 43 of 186 (23 percent) ypT2 patients, 158 of 338 (47 percent) ypT3 patients, and 16 of 33 (48 percent) ypT4 patients (P < 0.001, chi-squared test). The probability of finding ypN+ disease was 3 of 87 (3 percent) in patients with ypT0-1 residual primary tumors vs. 220 of 557 (39 percent) in patients with ypT2-4 residual primary tumors (P < 0.0001; Fisher’s exact test). CONCLUSIONS:. Nodal metastases are rare in patients whose mural tumor burden shrinks to ypT0-1 after neoadjuvant radiotherapy. If transanal excision is offered to select patients with distal rectal cancer, it is reasonable to select those who have an excellent clinical response to neoadjuvant therapy for transanal excision, and then reserve proctectomy for patients proven to have residual ypT2-4 disease. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been very effective in managing a broad range of morbid obesity-related co-morbidities. We report a beneficial effect of LRYGBP that has not been previously observed. Methods: Between December 1999 and September 2002, 224 patients underwent LRYGBP. Preoperative assessment for hypothyroidism and follow-up data were prospectively collected in our database. Improved thyroid function (ITF) or unchanged thyroid function (UTF) was determined by comparison of preoperative and postoperative thyroxine requirements. Results: 23 of 224 patients (10.3%) were treated preoperatively for hypothyroidism. During a median follow-up of 17 months, hypothyroidism was improved in 10/23 patients (43.5%). 2 patients had complete resolution, and the remaining 8 had reduction (14%-50%) of their thyroxine requirements. ITF occurred at a mean follow-up of 8.9 months and at a mean excess weight loss (EWL) of 57%. 6 of the 8 patients (75%) with ITF ≥ 25% had EWL >90% at last follow-up, compared to 1 out of 15 patients (6.6%) with UTF or <25% improvement ( P =0.001). Comparison of patients with ITF and UTF over time during a 20-month follow-up, showed no significant difference in mean body mass index (BMI) and mean percentage of EWL. Conclusion: Improvement of hypothyroidism may be an additional benefit of bariatric surgery that has not been previously reported. Reduction of thyroxine requirements is most likely the result of the decrease in the BMI. [ABSTRACT FROM AUTHOR]

Background: The prevalence of irritable bowel syndrome (IBS) is higher among subjects with gastroesophageal reflux disease (GERD). This study aimed to assess the effect of IBS on the postoperative outcome of antireflux surgery.Methods: For this study, 102 patients who underwent laparoscopic fundoplication were screened preoperatively for IBS with the Rome II criteria. There were 32 patients in the IBS group and 70 patients in the non-IBS group. Most of the patients (97%) (31 of 32 IBS and 68 of 70 non-IBS patients) had both pre- and postoperative IBS evaluation. A visual analog GERD-specific scoring scale was used to evaluate GERD symptoms prospectively.Results: In both groups, GERD symptom scores were statistically improved postoperatively. Of the 31 IBS patients 25 (80.6%) showed a reduction in their symptoms below the Rome II criteria for IBS diagnosis postoperatively.Conclusion: Irritable bowel syndrome does not have a negative effect on the outcome of laparoscopic antireflux surgery. Surgical correction of GERD may improve the severity of irritable bowel symptoms. [ABSTRACT FROM AUTHOR]

The effect of prior nonoperative treatment, type of fundoplication, and surgical approach on quality of life after minimally invasive Heller myotomy (MIHM) for achalasia in not known. MIHM for achalasia was performed in 105 patients (primary 102; redo 3). Sixty-five patients had prior nonoperative treatment (dilations in 41; botulinum toxin injections in 13; dilations and botulinum toxin injections in 11). Primary laparoscopic MIHM with fundoplication (Dor in 32; Toupet in 56) was performed in 88 patients and thoracoscopic MIHM without fundoplication in 14. Achalasia and quality-of-life–related symptoms were evaluated prospectively with a visual analogue scoring scale. Median follow-up was 25 months. There was a trend toward a higher incidence of intraoperative esophageal perforation and recurrent dysphagia in patients with prior nonoperative treatment. Patients with prior nonoperative treatment had significant improvement in achalasia-related symptoms postoperatively. Patients with prior botulinum toxin injections with or without dilations had no improvement in quality of life after MIHM. The operative success of MIHM may be compromised if prior nonoperative treatment is used. Botulinum toxin injections may blunt the beneficial effect of MIHM on quality of life. The outcome of MIHM is good regardless of the type of fundoplication or surgical approach. [Copyright &y& Elsevier]

Steal syndrome is a well-known complication of arteriovenous (AV) access placement. To assess the derangement in hemodynamics of the upper extremity after AV access creation, brachial and digital pressures were performed before and after operation. Thirty-five patients (ages 20-88 years) with end-stage renal disease requiring new upper extremity hemodialysis AV access were prospectively evaluated. Values were obtained preoperatively, on the day of surgery, and 1 month postoperatively. Follow-up at 1 year was obtained on all patients. Of the 35 patients, 19 (54%) were diabetic and 9 (26%) had had a prior AV access. The AV accesses created included the following: autogenous brachial-cephalic (n = 14, 40%), autogenous radialcephalic (n= 10, 29%), brachial-basilic transposition (n = 5, 14%), prosthetic brachial-antecubital forearm loop (n = 3, 9%), autogenous brachial-axillary saphenous vein translocation (n = 2, 6%), and 1 (3%) prosthetic brachial-axillary. After AV access creation the digital brachial index (DBI) dropped in 28 (80%) of the 35 patients. Six patients (17%) developed a symptomatic steal, 3 of which (9%) eventually required revision. In those patients without ischemic steal symptoms (n=29) the mean DBI decreased from 0.9 to 0.7 (p<0.01) immediately and decreased no further at 1 month. For those with a symptomatic steal the DBI decreased from 0.8 to 0.4 (p<0.01) immediately and decreased no further at 1 month. Utilizing a DBI less than 0.6, the sensitivity was 100%, the specificity 76%, the positive predictive value 46%, and the negative predictive value 100%. Hemodynamic steal after AV access creation is very common, with symptomatic steal occurring nearly a fifth of the time. Utilizing digital pressure measurements, a DBI less than 0.6 obtained on the day of surgery can reasonably predict which patients are at risk for the development of a symptomatic steal. [ABSTRACT FROM AUTHOR]

Spilled gallstones have emerged as a new issue in the era of laparoscopic cholecystectomy. We treated a 77-year-old woman who underwent laparoscopic cholecystectomy. Subsequently, a right flank abscess developed. During the cholecystectomy, the gallbladder was perforated and stones were spilled. After a failed attempt to drain the abscess percutaneously, the patient required open drainage, which revealed retained gallstones in the right flank. The abscess resolved, although the patient continued to have intermittent drainage without evidence of sepsis. Review of the literature revealed 127 cases of spilled gallstones, of which 44.1% presented with intraperitoneal abscess, 18.1% with abdominal wall abscess, 11.8% with thoracic abscess, 10.2% with retroperitoneal abscess, and the rest with various clinical pictures. In case of gallstone spillage during laparoscopic cholecystectomy, every effort should be made to locate and retrieve the stones. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a popular operation for morbid obesity.Early complications can be treated successfully with a laparoscopic approach.We reviewed our experience with laparoscopic re-exploration in the early postoperative period. Methods: The initial 85 patients who underwent LRYGBP by two surgeons at a training hospital were reviewed. All patients who required re-exploration within the first 60 days postoperatively were considered. Results: Nine patients underwent ten laparoscopic explorations. Mean BMI was 50 kg/m2. One patient underwent revision for proximal anastomotic obstruction at 58 days postoperatively. Three patients developed obstruction at the level of the transverse mesocolon secondary to cicatrix and required laparoscopic release of the scar tissue.Two patients required revision of the jejuno-jejunostomy. Internal hernia through the mesenteric defect at the level of the transverse mesocolon was the cause of bowel obstruction in two patients. One patient underwent lysis of adhesions between the left colon and the transverse mesocolon at 6 days postoperatively. One out of the ten laparoscopic re-explorations was negative for any findings. Eight patients recovered without further complications and one patient required endoscopic dilatations of the proximal anastomosis. Conclusion: In the course of treating morbid obesity with laparoscopic intervention, complications will arise. Laparoscopic exploration for early complications is a safe and feasible option. [ABSTRACT FROM AUTHOR]

PURPOSE: Preoperative chemoradiotherapy followed by radical surgical resection has been the preferred treatment for patients presenting with locally advanced distal rectal carcinoma at our institutions. We postulated that chemoradiotherapy-induced pathologic response of the primary tumor would identify which patients would be candidates for local excision as definitive surgical therapy. METHODS: A retrospective analysis of 60 patients with palpable, locally advanced, distal rectal adenocarcinomas treated from 1995 to 2000 was performed. All patients received preoperative chemoradiotherapy consisting of 5-fluorouracil (325 mg/ m²) and leucovorin (20 mg/m²) by bolus infusion on Days 1 through 5 and 29 through 33 delivered concurrently with at least 45.0 to 50.4 Gy of pelvic radiation, followed six to eight weeks later by radical surgery and then adjuvant chemotherapy. RESULTS: Among 60 patients (20 females) there was a mean age of 58.7 (28-84) years. Clinical staging was as follows: Stage II, 14 patients (23 percent); Stage III, 35 patients (58 percent): and Stage IV, 11 patients (18 percent). Pathologic examination revealed that negative margins were obtained in 58 patients (97 percent). Down-staging to T0-2N0 was achieved in 17 patients (28 percent), with five (8 percent) achieving a pathologically complete response. Lymph nodes were positive in 24 patients (40 percent) despite chemoradiotherapy. Pathologic node positivity was found in 0 of 5 pT0 patients, 9 (41 percent) of 22 pT1 or pT2, and 15 (45 percent) of 33 pT3. Clinical stage, tumor size, pathologic stage, and adverse histologic features could not reliably predict pN0 status, except pT0 (5 patients only). CONCLUSIONS: Preoperative chemoradiotherapy often downsizes and downstages locally advanced rectal carcinoma. Neither pretreatment clinical characteristics, response to preoperative chemoradiotherapy, or pathologic features reliably predict pN0 status. Therefore, local excision is not recommended as an alternative to radical surgery for locally advanced adenocarcinoma of the distal rectum regardless of the response of the primary tumor to preoperative chemoradiotherapy. [ABSTRACT FROM AUTHOR]

Roux-en-Y gastric bypass (RYGBP) is the most commonly performed operation for the treatment of morbid obesity in the USA. Complications related to the jejuno-jejunal (J-J) anastomosis include postoperative leak, staple-line bleeding and obstruction. We present 3 cases of perforation at the J-J anastomosis occurring more than 30 days after surgery. 3 morbidly obese patients underwent laparoscopic RYGBP. The side-to-side J-J anastomosis was created with a linear stapler, and the anastomotic defect was closed with a running absorbable suture. All 3 patients had uneventful recoveries, but presented 7 to 8 weeks postoperatively with acute abdominal pain and peritoneal signs. Exploratory laparoscopy in these patients revealed a perforation at the J-J anastomosis. No apparent reason for the perforation was found in 2 patients. These perforations were repaired laparoscopically with absorbable suture. The third patient had an obstruction at the J-J anastomosis from an phytobezoar and required conversion to open technique due to limited pneumoperitoneum. All 3 patients recovered uneventfully. Late perforation of the J-J anastomosis is a very rare complication. Primary laparoscopic repair is a feasible and safe choice of treatment. [ABSTRACT FROM AUTHOR]

Access to the bypassed stomach is difficult following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The bypassed stomach is not readily available for endoscopic or radiographic evaluation. Diagnosis and treatment of peptic ulcer disease and its complications in the excluded stomach becomes difficult. We present a case of perforation in the bypassed stomach following LRYGBP secondary to peptic ulcer disease. [ABSTRACT FROM AUTHOR]

A response by James T. McCormick to a letter to the editor about the case report of a 51-year old woman who presented with a solitary parotid mass and no other manifestation of sarcoidosis is presented.

We describe an unusual case of sarcoidosis in which the patient presented with a discrete solitary parotid mass and no other manifestation of the disease. The diagnosis was based on the unexpected pathologic findings during examination of a superficial parotidectomy specimen. To the best of our knowledge, no such presentation has been previously reported in the English-language literature. [ABSTRACT FROM AUTHOR]

A case report of recurrent appendicitis two months after a laparoscopic appendectomy is presented. This complication may become more common if a long appendiceal stump is not recognized and resected during laparoscopic appendectomy. [ABSTRACT FROM AUTHOR]

This case report describes near-obstructing sigmoid colon cancer resected using the laparoscopic-assisted technique. An unrecognized, synchronous cecal cancer caused an early postoperative bowel obstruction. The authors review the incidence of synchronous colon lesions and the need for preoperative and intraoperative evaluation of the entire colon, especially with the use of the laparoscopic technique. [ABSTRACT FROM AUTHOR]

An abstract of the article "A Case of Hematochezia," by Sarfraz Ahmad, Nicholas Bellicini, Peter J. Molloy, Philip F. Caushaj, and Robert J. Kania is presented.

An abstract to the article "Cholecystectomy vs Cholecystostomy in High Risk Surgical Patients," by Gintaras Antanavicius, Michael O'Mara, Pavlos Papasavas, Daniel Gagne, and Philip Caushaj is presented.

An abstract to the article "Analysis of Radiographic Studies Used to Evaluate Complications After Laparoscopic ROUX-EN-Y Gastric Bypass," by James T. McCormick, Pavlos K. Papasavas, Christopher G. Pastor, H. Scott Beasley, Philip F. Caushaj and Daniel J. Gagne is presented.