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Background: Colon cancer surgery is a complex clinical pathway and traditional quality metrics may exhibit significant variability between hospitals and healthcare providers. The Textbook Outcome (TO) is a composite quality marker capturing the fraction of patients, in whom all desired short-term outcomes of care are realised. The aim of the present study was to assess the TO in a series of non-metastatic colon cancer patients treated with curative intent, with emphasis on long-term survival. Methods: Stage I–III colon cancer patients, who underwent curative colectomy following the Complete Mesocolic Excision principles, were retrospectively identified from the institutional database. TO was defined as (i) hospital survival, (ii) radical resection, (iii) no major complications, (iv) no reintervention, (v) no unplanned stoma and (vi) no prolonged hospital stay or readmission. Results: In total, 128 patients (male 61%, female 39%, mean age 70.7 ± 11.4 years) were included in the final analysis. Overall, 60.2% achieved a TO. The highest rates were observed for “hospital survival” and “no unplanned stoma” (96.9% and 97.7%), while the lowest rates were for “no major complications” and “no prolonged hospital stay” (69.5% and 75%). Older age, left-sided resections and pT4 tumours were factors limiting the chances of a TO. The 5-year overall and 5-year cancer-specific survival were significantly better in the TO versus non-TO subgroup (81% vs. 59%, p = 0.009, and 86% vs. 65%, p = 0.02, respectively). Conclusions: Outcomes in colon cancer surgery may be affected by patient-, doctor- and hospital-related factors. TO represents those patients who achieve the optimal perioperative results, and is furthermore associated with improved long-term cancer survival.

Elective surgery has been proposed, after at least two episodes of acute diverticulitis, initially treated conservatively, in order to prevent further episodes or chronic complaints. However, prophylactic surgery has been questioned, due to the associated risks of postoperative mortality and morbidity, as well as the risk of recurrent diverticulitis. This systematic review attempts to assess the role of prophylactic left colonic resection, after episodes of uncomplicated acute diverticulitis treated either conservatively with antibiotics and/or other supportive measures.A systematic search was performed using Medline, Embase, Ovid, and Cochrane databases for studies reporting on the treatment of acute uncomplicated diverticulitis (Hinchey I). The main endpoint was treatment failure, defined as persistent/recurrent symptoms or need for readmission and/or reintervention. Secondary endpoints were the immediate postoperative outcomes.In total, 24 studies with 2855 patients were included in the analysis. Intra- and postoperative complications rate were 5% and 16%, respectively. Anastomotic leak was 1.3% and emergency reoperation was 2.4%. Long-term symptomatic resolve was reported at 91%. Persistent or recurrent symptoms were observed in 5.4% of cases. Meta-analysis showed no significant difference in recurrence rates between surgical and conservative management.Elective surgery to prevent recurrent diverticulitis is not recommended, irrespective of the number of previous episodes. Generally, elective sigmoidectomy should not be recommended to patients with ongoing atypical lower abdominal symptoms after acute diverticulitis, but should aim primarily at improving quality of life. It should be offered to patients with ongoing inflammation, or diverticular complications.

Protrusion of the appendix within an inguinal hernia is termed an Amyand’s hernia. A systematic review of case reports and case series of Amyand’s hernia was performed, with emphasis on surgical decision-making. The English literature (2000–2019) was reviewed, using PubMed and Embase, combining the terms “hernia”, “inguinal”, “appendix”, “appendicitis” and “Amyand”. Overall, 231 studies were included, describing 442 patients. Mean age of patients was 34 ± 32 years (adults 57.5%, children 42.5%). 91% were males, while a left-sided Amyand’s hernia was observed in 9.5%. Of 156 elective hernia repairs, 38.5% underwent appendectomy and 61.5% simple reduction of the appendix. 88% of the adult patients had a mesh repair, without complications. Of 281 acute cases, hernial complications (76%) and acute appendicitis (12%) were the most common preoperative surgical indications. Appendectomy was performed in 79%, more extensive operations in 8% and simple reduction in 13% of cases. A mesh was used in 19% of adult patients following any type of resection and in 81% following reduction of the appendix. Among acute cases, mortality was 1.8% and morbidity 9.2%. Surgical site infections were observed in 3.6%, all of which in patients without mesh implantation. In elective Amyand’s hernia cases, appendectomy may be considered in certain patients, provided faecal spillage is avoided, to prevent mesh infection. In cases of appendicitis, prosthetic mesh may be used, if the surgical field is relatively clean, whereas endogenous tissue repairs are preferred in cases of heavy contamination.

Protrusion of the appendix within an inguinal hernia is termed an Amyand's hernia. A systematic review of case reports and case series of Amyand's hernia was performed, with emphasis on surgical decision-making.The English literature (2000-2019) was reviewed, using PubMed and Embase, combining the terms "hernia", "inguinal", "appendix", "appendicitis" and "Amyand". Overall, 231 studies were included, describing 442 patients.Mean age of patients was 34 ± 32 years (adults 57.5%, children 42.5%). 91% were males, while a left-sided Amyand's hernia was observed in 9.5%. Of 156 elective hernia repairs, 38.5% underwent appendectomy and 61.5% simple reduction of the appendix. 88% of the adult patients had a mesh repair, without complications. Of 281 acute cases, hernial complications (76%) and acute appendicitis (12%) were the most common preoperative surgical indications. Appendectomy was performed in 79%, more extensive operations in 8% and simple reduction in 13% of cases. A mesh was used in 19% of adult patients following any type of resection and in 81% following reduction of the appendix. Among acute cases, mortality was 1.8% and morbidity 9.2%. Surgical site infections were observed in 3.6%, all of which in patients without mesh implantation.In elective Amyand's hernia cases, appendectomy may be considered in certain patients, provided faecal spillage is avoided, to prevent mesh infection. In cases of appendicitis, prosthetic mesh may be used, if the surgical field is relatively clean, whereas endogenous tissue repairs are preferred in cases of heavy contamination.

Mini: A radiological, anatomic distinction between the rectum and sigmoid colon was agreed by consensus of international experts in rectal cancer using the Delphi Technique. Use of this landmark, “the sigmoid take-off,” may harmonize efforts in research and clinical practice to improve patient outcomes. Background: The wide global variation in the definition of the rectum has led to significant inconsistencies in trial recruitment, clinical management, and outcomes. Surgical technique and use of preoperative treatment for a cancer of the rectum and sigmoid colon are radically different and dependent on the local definitions employed by the clinical team. A consensus definition of the rectum is needed to standardise treatment. Methods: The consensus was conducted using the Delphi technique with multidisciplinary colorectal experts from October, 2017 to April, 2018. Results: Eleven different definitions for the rectum were used by participants in the consensus. Magnetic resonance imaging (MRI) was the most frequent modality used to define the rectum (67%), and the preferred modality for 72% of participants. The most agreed consensus landmark (56%) was “the sigmoid take-off,” an anatomic, image-based definition of the junction of the mesorectum and mesocolon. In the second round, 81% of participants agreed that the sigmoid take-off as seen on computed tomography or MRI achieved consensus, and that it could be implemented in their institution. Also, 87% were satisfied with the sigmoid take-off as the consensus landmark. Conclusion: An international consensus definition for the rectum is the point of the sigmoid take-off as visualized on imaging. The sigmoid take-off can be identified as the mesocolon elongates as the ventral and horizontal course of the sigmoid on axial and sagittal views respectively on cross-sectional imaging. Routine application of this landmark during multidisciplinary team discussion for all patients will enable greater consistency in tumour localisation.

Introduction Several studies show that mutational profiles could influence treatment decisions in patients with metastatic CRC (mCRC). KRAS mutational status was the first step in biomarkers development in the era of molecular targeted therapies. Recently, NRAS mutational status was identified as an independent prognostic factor for the response to treatment with anti-EGFR moAbs. The aim of this observational study was to assess the feasibility of the KRAS/NRAS mutational analysis in patients with metastatic colorectal cancer in Greece and to identify any correlations with known clinical characteristics and histopathologic features. Methods From January 2014 until September 2014 all patients registered to the GIC-SG database with newly diagnosed metastatic disease from colon or rectal cancer were included and tumor samples were analyzed for kras/nras mutations in 9 different certified laboratories in Greece. Results Samples from 510 patients were analyzed. Mutations’ distribution was as follows: 173 (33,9%) KRAS exon 2, 10 (2%) KRAS exon 3, 25 (4,9%) KRAS exon 4, 22 (4,3%) NRAS exon 2, 11 (2,2%) NRAS exon 3 and 3 (0,6%) NRAS exon 4. The only factor significantly associated with RAS mutational status was primary tumor location, with right sided tumors exhibiting higher rates of mutations. Discussion The incidence and distribution of KRAS or NRAS exon 2-4 mutations are in accordance with those reported in the literature. The most significant clinical or pathological parameter revealed from the analysis is the location of the primary tumor.

There is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus. The aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines. Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed. Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC. Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus. One hundred and nine statements were developed. Ninety experts voted for those statements. The median rate of abstain per statement was 18.5% (range: 0-54%). In the end of the process, all statements achieved a large consensus. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized. R0 resection is the only intervention that may offer substantial improvement in the oncological outcomes.

Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.

Τo evaluate all available data on the effect of preemptive intervention in patients who have curative surgery for colorectal cancer (CRC) and are at high risk to develop peritoneal carcinomatosis (PC).The authors conducted a systematic review of all published studies from January 2000 to July 2016. Twelve studies were eventually considered for analysis, and were divided in four categories, according to different approaches for adjuvant intra-peritoneal chemotherapy: a) hyperthermic intraperitoneal chemotherapy (HIPEC), during primary surgery for CRC; b) early postoperative intraperitoneal chemotherapy (EPIC), after primary surgery for CRC; c) early re-intervention (laparotomy or laparoscopy) and HIPEC; and d) as second look laparotomy and HIPEC + cytoreductive surgery (CRS), several months after primary surgery.Considering prophylactic HIPEC during primary surgery, the studies that were analysed showed a peritoneal recurrence rate of 0-12.9%, a 3- and 5-year disease free survival (DFS) of 67-97.5% and 54.8-84% respectively, and a 3- and 5-year overall survival (OS) of 67-100% and 84%, respectively. These oncological results are probably better than what is expected in patients at high risk to develop PC and have only adjuvant systemic chemotherapy. Because of the great heterogeneity in inclusion criteria (risk factors for PC) and methodology of intra-peritoneal chemotherapy (different timing, different techniques, different agents), a meta-analysis was not performed.At present and because of the insufficient available evidence, preemptive intervention at the immediate postoperative adjuvant setting is recommended only in the setting of a registered clinical trial.

Laparoscopy for rectal cancer is a challenge as it presents many technical difficulties and requires high level of expertise. That is the reason for the high conversion rate. Reports on outcomes of converted cases after laparoscopic rectal resection for cancer are conflicting.The present meta-analysis compares short- and long-term outcomes between converted rectal cancer cases with both open and laparoscopically completed cases.All studies reporting on outcomes separately for the converted cases were reviewed systematically. Main outcomes were intraoperative complications, procedure duration, short-term mortality and morbidity, length of stay, local recurrence, number of lymph nodes retrieved, and distant metastases. Quality assessment and data extraction were performed independently by 3 reviewers.Fourteen studies were eligible for analysis, including 10,845 patients. Overall conversion rate was 11.9%. Converted cases had significantly longer duration, hospital stay, and higher rates of wound infection compared with laparoscopic cases. All other outcomes had no difference. When compared with open cases, conversions displayed longer operative times, but there was no other significant difference in the short- or long-term outcomes.Converted cases seem to have some short-term unfavorable outcomes. Further retrospective analysis of big registries will be helpful for further investigation of converted cases.

Backgrounds Impairment of gastrointestinal (GI) motility is an undesirable but inevitable consequence of surgery. This prospective randomised controlled study tested the hypothesis that postoperative thoracic epidural analgesia (TEA) with ropivacaine or a combination of ropivacaine and morphine accelerates postoperative GI function and shortens the duration of postoperative ileus following major thoracic surgery compared to intravenous (IV) morphine. Methods Thirty patients scheduled for major thoracic surgery were randomised to three groups. All patients had bowel motility assessments 1 week preoperatively. All patients received general anaesthesia. Group Ep-R received TEA with ropivacaine; group Ep-RM received TEA with ropivacaine and morphine and group IV-M received IV morphine via patient controlled analgesia pump (PCA). Bowel motility was assessed by clinical examination in addition to oro-ceacal transit time (OCTT) on the first and third postoperative days and colonic transit time (CTT). Results Overall the OCTT demonstrated a 2.5-fold decrease in bowel motility on the first postoperative day. The OCTT test revealed statistically significant differences between all groups (Ep-R vs Ep-RM, p = 0.43/Ep-R vs IV-M, p = 0.039 / Ep-RM vs IV-M, p

Depending on the extent of left colon resection, splenic flexure mobilization is sometimes necessary to achieve a tension-free anastomosis. The aim of the study was the assessment of necessity and impact on morbidity of splenic flexure mobilization for laparoscopic colectomy with anastomosis for cancer located distally to the splenic flexure.Patients subjected to laparoscopic colectomy for carcinoma located at any site from the descending colon to the distal rectum from 2004 to 2010 were reviewed. Comparisons were made between cases with and without splenic flexure mobilization.A total of 229 patients were operated for left colon or rectal cancer. There was no difference with regard to the intraoperative bleeding and bowel perforation and no differences concerning the conversion rates. In contrast, stoma formation rates were higher in the mobilized group. Moreover, total operative time was higher for the mobilized group except for the middle rectum cancer cases. Postoperative outcomes as far as mortality and morbidity rates and primary hospital stay are concerned, did not display any difference.Splenic flexure mobilization can provide a tension-free anastomosis and sufficiently vascularized anastomosis in laparoscopic colorectal surgery for distal colon pathology, with no impact on immediate postoperative outcomes, despite longer operative time.

In accordance to the total mesorectal excision concept for rectal cancer, that of the complete mesocolic excision (CME) for colon cancer has been recently developed. CME involves dissection along the embryological planes, ligation and division of the supplying vessels at their origin and removal of a specimen with intact fascia and peritoneum, adequate distal and proximal bowel margin as well as the maximum number of the regional lymph nodes. CME surgery seems to achieve better oncological outcomes, in terms of local recurrence and survival, as compared to standard colectomy. CME has also been attempted by the laparoscopic approach. Provided that the tumour is located at the left or right and not at the transverse, a specimen of high quality can be resected, similar to that obtained by the open approach. There is also evidence that the oncological results of laparoscopic CME are superior to those achieved by the standard laparoscopic surgery, and similar to those achieved by open CME.

Background: Based on sound evidence, traditional mechanical bowel preparation for elective colorectal surgery has mostly been abandoned during the last two decades. However, more recent evidence from USA large databases show that mechanical bowel preparation combined with oral antibiotics, reduces significantly surgical site infections (SSI) after elective colorectal surgery. Hypothesis-Aim: We hypothesise that administration of oral antibiotics only, and not mechanical bowel preparation, is the main factor that prevents SSI. Furthermore, we consider that rectal surgery for cancer differs from colon surgery in that the former is usually associated with defunctioning stoma, which requires an empty colon. Patients-Methods: Patients to be subjected to elective colectomy for colonic neoplasms or diverticular disease will be randomised to two arms; Arm A: no bowel preparation; Arm B: mechanical bowel preparation combined with oral antibiotics (MECCLAND –C Trial). Patients scheduled for elective low anterior resection of the rectum for rectal cancer will be randomised to two arms; Arm A: mechanical bowel preparation only; Arm B: mechanical bowel preparation combined with oral antibiotics (MECCLAND –R Trial). All patients will receive intravenous antibiotics one hour prior to first surgical incision. Enemas at the day prior to surgery are optional. Participating centres are advised to implement enhanced recovery programmes in all patients. Primary End-Points: The primary end point is surgical site infection (SSI), including (i) superficial wound infection, (ii) deep wound infection, and (iii) intrabdominal infection (contaminated fluid or pus collection). Statistical Points: Considering a SSI rate of 0.12 for Arm A vs. a SSI rate of 0.06 for Arm B, a randomization rate of 1:1 and negligible drop-off rate, the sample size of either Arm of either Trial should be 356 patients.

Background During the last decade, many efforts have been made in order to improve the oncologic outcomes following colonic resection. Complete mesocolic excision (CME) has proved to provide high rates of disease-free and overall survival rates in patients undergoing resection for colonic malignancies. The aim of our study was to further investigate the role of CME in colonic surgery through comparison with a series of conventional resections. Methods All data regarding resections for colonic cancer since 2006 were obtained prospectively from two surgical departments. Retrieved data from 290 patients were analyzed and compared between those who underwent CME and those who had conventional surgery. Results The CME group presented a higher rate of postoperative morbidity and readmissions. Histopathological features were in favor of CME surgery compared with the conventional group, in terms of both resected bowel length (33 vs. 20 cm) and lymph node harvest (27 vs. 18). Although CME was associated with better disease-free and overall survival times, only tumor differentiation, adjuvant chemotherapy and age had a statistically significant affect on those outcome values (P

Complete mesocolic excision (CME) for colonic cancer offers a surgical specimen of higher quality, with higher number of lymph nodes compared to conventional colectomy. However, evidence on oncological outcomes is limited. The aim of the present study is to review recent literature and provide more information regarding the effect of CME colectomy on short- and long-term outcomes. PubMed and MEDLINE databases were searched, and articles in English reporting data on CME were reviewed. Intraoperative events; postoperative morbidity and mortality; histopathological characteristics, including macroscopic assessment, number, and status of retrieved lymph nodes; and oncological outcomes were the end-points. Thirty-two studies were analyzed. As regards the macroscopic assessment, a larger specimen (p = 0.02) that contains a higher number of lymph nodes (p

Obstructed defecation (OD) syndrome is associated with several abnormalities of the pelvic organs, namely anterior rectal mucosa prolapse, anterior rectocele, recto-anal intussusception, and a deep Douglas pouch which predisposes to enterocele or rectocele. Surgical repair of the anatomical deformities should be attempted, only after thorough selection of patients and conservative treatment has been exhausted. Transperineal procedures include resection-plication of the anterior rectal wall and stapled transanal rectal resection, and are indicated for the treatment of anterior rectocele and internal rectal prolapse. Functional results are satisfactory in approximately 75 percent of the cases. Transabdominal procedures include posterior prosthesis rectopexy, resection suture-rectopexy and ventral prosthesis colporectopexy. These procedures are indicated in patients with large rectocele and rectal intussusception and enterocele or sigmoidocele. The rate of repair of anatomical deformities is very high and improvement of symptoms is accounted in more than 80 percent of the cases. Ventral prosthesis colporectopexy seems a very promising approach, but further evidence is mandatory.

Data on the role of laparoscopy within an enhanced recovery protocol for rectal cancer patients is rather limited. The aim of the study was to investigate the role of laparoscopy within a 'fast-track' protocol in patients who underwent sphincter-preserving surgery for rectal cancer.156 consecutive patients with low rectal cancer from three centers were assigned in four groups: the open fast track (OPEN-FT), the laparoscopic fast track (LAP-FT), the open (OPEN), and the laparoscopic (LAP). The fast-track protocol was applied in one center and traditional care in the other two. All patients underwent sphincter-preserving surgery and were followed-up for 30 days.Overall morbidity was less in the fast-track groups (p = 0.007). On the other hand, no statistical significance could be identified in mortality, readmission or reoperations rates among the groups (p = 0.562, p = 0.896, p = 0.238). Fast-track patients required significantly less intramuscular opioids for postoperative analgesia (p0.001). Primary (p0.001) and total hospital stays (p0.001) were significantly shorter in the fast-track groups.The implementation of a fast-track protocol is feasible and safe in low rectal cancer patients. Laparoscopy seems to be a basic element of such protocol as it further enhances recovery and reduces morbidity.

Introduction The aim of the study was to evaluate the diagnostic precision of serum carcinoembryonic antigen (CEA) in the detection of local or distant recurrence following resectional surgery for colon and rectal cancer. Methods Quantitative meta-analysis was performed on 20 studies, comparing serum CEA with radiological imaging and/or pathology in detecting colorectal cancer (CRC) recurrence in 4285 patients. The cut-off for a ‘positive’ CEA ranged from 3 to 15 ng/ml between the various studies. Sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each study. Summary receiver operating characteristic curves (SROC) and sub-group analysis were undertaken. Results The overall sensitivity and specificity of CEA for detecting CRC recurrence was 0.64 (95% CI: 0.61–0.67) and 0.90 (95% CI: 0.89–0.91), respectively. The area under the SROC curve was 0.75 (SE = 0.04) and the diagnostic odds ratio was 18.44 (95% CI: 11.94–28.49). A CEA cut-off of 5 ng/ml yielded a higher diagnostic odds ratio than a cut-off of 3 ng/ml (15.5 vs. 11.1). Using meta-regression analysis the optimum CEA cut-off point for the best combination of sensitivity and specificity was 2.2 ng/ml. On sub-group analysis high quality studies, and those involving ≥100 patients yielded a marginal improvement in the sensitivity and specificity with minimal change to the SROC. Conclusion Serum CEA is a test with high specificity but insufficient sensitivity for detecting CRC recurrence in isolation. A cut-off of 2.2 ng/ml may provide an ideal balance of sensitivity and specificity. It may be useful as a first-line surveillance investigation in patients during surgical follow-up based on serial CEA measurements using temporal trends in conjunction with clinical, radiological and/or histological confirmation.

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or

Anterior rectocele and rectoanal intussusception are anatomic disorders related to excessive straining during defecation that usually manifest with symptoms of obstructive defecation. Stapled transanal rectal resection (STARR), a newly described surgical method for correcting these disorders, is considered a good alternative to the traditional transrectal approaches. The aim of the present study was to assess the early postoperative functional results of STARR. A total of 16 patients (13 female) were subjected to the STARR procedure during a period of 12 months. The presence of anatomic disorders of the anorectum was verified by dynamic defecography. Preoperative assessment also included colonic transit time, anal sphincter ultrasonography, and anorectal stationary manometry. Postoperative assessment included the same battery of tests. Altogether, 12 patients had rectoanal intussusception of > 2 cm and rectocele. In eight of them the anterior component of the rectocele was 2 to 4 cm, and in four it was > 4 cm. Four patients had a 1- to 2-cm internal intussusception and a rectocele of < 2 cm. All of them reported evacuation difficulties, but none had significant incontinence. Preoperative endoscopy did not reveal the presence of a solitary ulcer in any of the patients. All females had had normal vaginal deliveries, and four of them were multiparous. No complications were encountered postoperatively, and the need for analgesics was minimal. At defecography, rectoanal anatomy was seen to be restored in all patients. Obstructive defecation symptoms remained rather unaffected in seven, disappeared in three, and improved significantly in the remaining six patients. The seven failures showed anismus at manometry and had biofeedback treatment with satisfactory results in five of them. Failure of the operation and biofeedback sessions to treat symptoms in those two cases was attributed to coexisting enterocele, which had been missed preoperatively. Immediately after surgery, most of the patients complained of urgency and frequent small motions that resolved spontaneously within 3 to 5 weeks in all but two cases. STARR is a safe, well tolerated surgical procedure that effectively restores anatomy and function of the anorectum in patients with anterior mucosal prolapse and rectoanal intussusception. Additional biofeedback treatment is usually necessary for further functional improvement. Failure may be the result of other coexisting anatomic and functional abnormalities of the pelvic floor.

Low anterior resection of the rectum (LARR) with total mesorectal excision (TME) for rectal cancer by laparoscopy is considered very technically demanding, particularly at the stages of dissection around the mesorectal fascia deep into the pelvis and transection of the rectum distally to the tumour. These technical difficulties translate to an increased conversion-to-open rate, higher than that seen after laparoscopic surgery for colon cancer. Conversion-to-open is considered as a technical limitation of the approach rather than a complication. There are reports claiming that converted cases are associated with higher morbidity rates than the laparoscopically completed. However, a review of the published articles indicates that conversion-to-open shows similar overall morbidity and mortality rates to those seen in the laparoscopically completed LARR-TME cases, and only duration of surgery is longer and wound infection rate is higher in the former group. Similarly, the overall oncological outcomes, namely local recurrence, distant metastasis and overall survival rates, are similar between the two groups.

Although still controversial, the use of diathermy instead of scalpel for skin incision and underlying tissue dissection is gradually gaining wide acceptance. This is due to the observation that no change in wound complication rates or postoperative pain are reported with the use of electrocautery. However, these studies include operations without the use of prosthetic materials during abdominal wall closure. The purpose of this study was to investigate the hypothesis that a) application of extreme heat may result in significant postoperative pain and poor wound healing because of excessive tissue damage and scarring respectively, and b) skin incision with the use of diathermy entails increased risk of wound infection in the presence of an underlying prosthetic material. One hundred twenty-five consecutive patients submitted to inguinal hernioplasty using the tension-free technique and fulfilling the inclusion criteria for the study were allocated alternately to either scalpel (n = 60), or diathermy (n = 57) groups. Eight patients had bilateral hernias. Five of them were allocated to the scalpel group and three to the diathermy group. According to the study protocol, they received both approaches for skin and underlying tissues incision, thus resulting in a total of 68 scalpel and 65 diathermy individual hernioplasties. Parameters measured included blood loss during the skin incision and underlying tissue dissection, postoperative pain and requirements for analgesics, the presence of wound dehiscence in the absence of infection, and postoperative wound infection on the day of discharge, on the day staples were removed, and 1 month after surgery. The two groups of patients were similar in relation to patient demographics, type of hernias, and operation details. Blood loss was minimal, and the amount of blood lost did not differ between the two groups. Diathermy group patients required less parenteral analgesics on the first postoperative day. A higher proportion of patients in the scalpel group continued to need oral analgesics on the second postoperative day compared to patients in the diathermy group. There was no difference between the two groups in terms of wound strength. Infectious complications were totally absent. The use of diathermy for skin incision during inguinal hernioplasty is as safe as the use of scalpel in terms of wound healing and reduces the analgesics requirements in the postoperative period.

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. 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. 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. Resection rectopexy improves symptoms of obstructed defecation attributed to large rectoanal intussusception.

Background: Colored food substances may interfere with Bilitec system that uses bilirubin as a marker for the detection of duodeno-gastro-esophageal reflux, causing false positive results. Therefore, diets have been suggested for consumption during Bilitec studies that contain minimal amounts of pigments. Aim: To enrich the list of suitable foods for Bilitec measurements with dishes common in Mediterranean diets, and improve subject’s compliance. Methods: Ninety substances were in vivo tested for ‘bilirubin absorbance’. ‘Dry’ substances were blended after being diluted in water, while ‘floppy’ substances and cooked foods were blended undiluted. Blended mixtures and ‘liquids’ were tested for bilirubin without further dilution and after being mixed with hydrochloric acid. The procedure was repeated to assess reproducibility of the measurements. Results: Measurements are highly reproducible. Thirty five foods exhibited ‘bilirubin absorbance’ values safely below the threshold, and are considered to be suitable for Bilitec studies. On the contrary some vegetables and fruits, legumes, tomato sauce preparations, red wine, coffee, tea and jams showed high absorbance values, and are not recommended. Conclusion: Menus containing part of the variety of Mediterranean food preparations are safely recommended for consumption during Bilitec studies, enriching food lists available at present.

Summary Background : Erythromycin exhibits gastrokinetic properties through cholinergic pathways. Reports regarding the action of octreotide on gastric emptying are conflicting. Aim : To assess: (i) the hypothesis that serotonin receptors are involved in the accelerating effect of erythromycin on gastric emptying; and (ii) any modification of the gastrokinetic action of erythromycin induced by octreotide. Subjects and methods : Gastric emptying of a standard meal was estimated in 20 healthy subjects by scintigraphy on three different occasions in a double-blind, placebo-controlled manner and in random order: (i) after placebo; (ii) after 200 mg of intravenous erythromycin; and (iii) after 200 mg of intravenous erythromycin following pre-treatment with either 4 mg of intravenous ondansetron (10 subjects) or 50 µg octreotide. Results : Erythromycin significantly accelerated gastric emptying in all subjects by abolishing the lag phase. Pre-treatment with ondansetron abolished the accelerating effect of erythromycin by restoring the emptying times to placebo levels. Octreotide significantly enhanced the accelerating effect of erythromycin by reducing both the lag and post-lag phases of gastric emptying. Conclusions : Serotonin receptors are involved in the accelerating effect of erythromycin on gastric emptying. This effect seems to be enhanced by pre-treatment with octreotide, possibly as a result of the modification of the gastrointestinal hormonal environment.

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.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.Division of the SGV resulted in a significant increase of the operating time (P0.0001). 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 mm Hg, P0.001) and the lower esophageal sphincter pressure (division group: from 16 +/- 10 mm Hg to 24 +/- 7 mm Hg, P0.001; nondivision group: from 22 +/- 8 mm Hg to 28 +/- 5 mm Hg, P0.001). 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).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.

BACKGROUND Intravenous (i.v.) erythromycin enhances gastric emptying and oesophageal motility in both healthy and disease situations, acting either as a motilin or acetylcholine agonist. The purpose of the present paper was to investigate any possible effect of i.v. erythromycin on oesophageal motility in patients with gastro-oesophageal reflux (GOR). METHODS In 15 patients with GOR (proven on 24-h ambulatory oesophageal pH measurement), standard oesophageal manometry was performed after i.v. injection of placebo and 200 mg erythromycin, in a random blind fashion. RESULTS Erythromycin significantly increased lower oesophageal sphincter (LOS) pressure from 17 +/- 5 to 41 +/- 10 mmHg (P < 0.001), without affecting the postdeglutition relaxation of LOS. Erythromycin also increased the amplitude (from 79 +/- 34 to 97 +/- 40 mmHg; P < 0.001), duration (from 3.4 +/- 0.6 to 3.8 +/- 0.6 s; P = 0.005), velocity (from 3.1 +/- 0.8 to 3.5 +/- 1.15 cm/s; P = 0.0047) and strength (from 149 +/- 84 to 201 +/- 103 mmHg.s; P < 0.001) of peristalsis at 5 cm proximal to the LOS. Similarly, the drug increased the amplitude of peristalsis at 10 and 15 cm proximal to the LOS (from 70 +/- 39 to 77.4 +/- 37 mmHg; P = 0.049 and from 36 +/- 20 to 49 +/- 36 mmHg; P = 0.004, respectively) and the duration of peristalsis at the same levels (from 3.1 +/- 0.6 to 3.3 +/- 0.5 s; P = 0.011, and from 2.7 +/- 0.6 to 3 +/- 0.5 s; P = 0.003, respectively). CONCLUSION Intravenously administered erythromycin improves impaired oesophageal motility in patients with GOR. This observation might be of clinical use.

Erythromycin exhibits prokinetic properties. The drug enhances esophageal and gastric motility by acting as a motilin agonist and promoting acetylocholine release. 5-HT3 receptors are involved in the spontaneously occurring migrating motor complex and the effect of erythromycin on antral motility in dogs. The aim of the study was to investigate the hypothesis that 5-HT3 receptors are also involved in the action of erythromycin on the human esophagus.A total of 18 healthy volunteers underwent standard esophageal manometry on three different occasions in a double-blind, placebo-controlled, randomized manner, as follows: 1) after placebo, 2) after 200 mg of erythromycin i.v., and 3) after 200 mg of i.v. erythromycin subsequent to pretreatment with either 4 mg of i. v. ondansetron (serotonin receptor antagonist) (10 subjects) or 12 microg/kg of i.v. atropine (8 subjects).Erythromycin significantly increased a) the amplitude of peristalsis at 5 cm (from 87 +/- 19 mm Hg to 108 +/- 26 mm Hg; p = 0.0007), 10 cm (from 72 +/- 24 mm Hg to 81 +/- 26 mm Hg; p = 0.016), and 15 cm (from 47 +/- 15 mm Hg to 55 +/- 17 mm Hg; p = 0.014) proximal to LES, b) the duration of peristalsis at 5 cm (from 4.5 +/- 0.9 s to 5.7 +/- 1.2 s; p0.0001) and 10 cm (from 4.1 +/- 1 s to 4.9 +/- 1 s; p0.0001) proximal to the LES and c) the strength of peristalsis at 5 cm proximal to the LES (from 180 +/- 49 mm Hg x s to 276 +/- 100 mm Hg x s; p0.0001), and decreased the velocity of peristalsis at distal esophagus (from 4.1 +/- 1 cm/s to 3.8 +/- 0.9 cm/s; p = 0.03). In addition, erythromycin significantly increased the resting pressure of the LES (from 36 +/- 10 mm Hg to 44 +/- 12 mm Hg; p = 0.002). Pretreatment with ondansetron totally reversed all of the effects of erythromycin to the placebo state. Pretreatment with atropine not only prevented the effects of erythromycin, but it reduced the amplitude and strength of peristalsis at the distal esophagus at significantly lower levels than after placebo.Erythromycin exerts its prokinetic action on the lower esophagus by stimulating cholinergic pathways. This action includes not only an increase in LES pressure, but significant increases in the amplitude and duration of esophageal peristalsis, as well. 5-HT3 receptors are also involved in this process.

The aim of this study was to investigate any possible relation between the severity of anorectal dysfunction in diabetes mellitus and duration of disease and presence of microangiopathy or neuropathy or both.Standard multiport anorectal manometry was performed in 25 healthy control subjects (10 males; age (mean +/- 1 standard deviation), 62 +/- 14 years) and 38 patients with diabetes mellitus. Patients were divided into two groups according to the duration of the disease: Group A (19 patients) with a duration less than 10 years (7.2 +/- 2.5; 8 males; age, 57 +/- 18) and Group B (19 patients) with a duration longer than 10 years (19.8 +/- 5.6; 6 males; age, 62 +/- 15).Results are reported as mean +/- one standard deviation. Patients showed lower resting and squeeze anal pressures (P0.01), impaired rectoanal inhibitory and anocutaneous reflexes, and reduced sensitivity in rectal distention (P = 0.004) as compared with controls. In addition, Group B showed a significantly increased incidence of microangiopathy (P = 0.04) and autonomic and peripheral neuropathy (P = 0.002), significantly reduced basal and squeeze anal pressures (52 +/- 16 vs. 64 +/- 24 mmHg; P = 0.03 and 98 +/- 39 vs. 124 +/- 54 mmHg; P = 0.04, respectively), reduced amplitude of slow waves (7.3 +/- 3 ts. 9.5 +/- 3.7 mmHg; P = 0.03), anal leak in smaller rectal volumes (P = 0.003), and reduced response of the anal sphincter at the anocutaneous reflexes (29 +/- 14 vs. 39 +/- 14 mmHg; P = 0.05) compared with Group A. The former group of patients exhibited a significantly higher incidence of fecal incontinence (P = 0.008).Patients with long-standing diabetes mellitus have increased incidence of fecal incontinence and severely impaired function of both the anal sphincters and the rectum. These findings could be attributed to the increased incidence of microangiopathy and autonomic and peripheral neuropathy observed in this subset of diabetic patients.

Purpose: To assess the shortest time for catheter removal with regard to the transhepatic or transperitoneal approach in patients undergoing percutaneous cholecystostomy (PC).

It has been recently shown that erythromycin, amacrolide antibiotic, exhibits prokinetic properties, byenhancing gastric emptying in health and disease and byinducing gallbladder contraction. The aim of the study was to further investigate theeffect of intravenous erythromycin on gallbladdermotility during fasting and postprandial states. In 10healthy male subjects gallbladder emptying was assessed by ultrasonography on three differentoccasions, each in a random sequence, as follows: (1)after giving 300 ml of fresh milk and infusing normalsaline as placebo (postprandial emptying), (2) afterinfusing 200 mg of erythromycin during the fastingstate, and (3) after infusing 200 mg of erythromycinalong with ingestion of 300 ml of fresh milk. Infusionof erythromycin and placebo lasted 10 min. From the emptying curves, the duration of the lag phaseof emptying, the ejection fraction of emptying, and thetime by which maximal emptying was achieved werecalculated. Infusion of erythromycin induced animmediate contraction [lag phase (±SD): 1.3± 2.6 SD min] of the gallbladder by 42.1 ±22% of its initial volume. Infusion of erythromycinduring the postprandial state significantly decreasedthe duration of the lag phase (1.3 ± 3.5 min after erythromycinplus test meal versus 3.6 ± 4.2 min after testmeal only, P < 0.04) and significantly increased theejection fraction (78 ± 8.5% after erythromycinplus test meal versus 60.6 ± 8.5% after test meal only, P

background Exclusion of the duodenum by means of transection and Roux-Y duodenojejunostomy has been practiced for the treatment of complicated duodenal diverticulum. However, this method does not divert bile away from the diverticulum, hence the possibility of pancreaticobiliary complications is not eliminated. methods Roux-Y Choledochojejunostomy and duodenojejunostomy, for the diversion of bile and food, has been applied for the treatment of pancreaticobiliary complications of duodenal diverticulum in 4 patients. Postoperatively, all patients had endoscopy, HIDA-scintigraphy for the measurement of enterogastric reflux, and assessment of gastric emptying. results One year postoperatively, there were no recurrent symptoms of cholangitis or pancreatitis, no anastomotic ulceration was found on endoscopy, there were no complaints of gastric stasis, and enterogastric reflux was not significant. conclusions Roux-Y Choledochojejunostomy and duodenojejunostomy for the treatment of the complicated duodenal diverticulum is associated with satisfactory results. Postoperative symptoms attributed to anastomotic ulceration, bile reflux, or gastric stasis are also absent.

Several procedures have been designed and applied to treat overt rectal prolapse (ORP). Transperineal procedures, such Altemeier and Delorme operations, are associated with less morbidity, but higher rate of recurrence and less optimal functional results. Transabdominal procedures include a variety of rectopexies with the use of prosthesis or sutures and with or without resection of the redundant sigmoid colon. Nowadays, they are all approached by laparoscopy. Traditional prosthesis rectopexies repair ORP and improve incontinence, but are associated with increased rate of constipation. Resection sutuere-rectopexy seems to be associated with the best functional results, particular in patients with slow transit constipation and diverticular disease. More recently, prosthesis ventral coloporectopexy seems to be less invasive and to offer very satisfactory results.

The study's aim was to assess the functional results of laparoscopically performed Heller's myotomy and Dor's fundoplication in our first few cases of esophageal achalasia. Four male patients (mean age: 61 years) with long-standing symptoms of achalasia (documented on esophagogram and esophageal manometry) and not responding to several sessions of pneumatic dilatation, had laparoscopic Heller's myotomy and Dor's fundoplication. Myotomy was facilitated by distending the esophagus. The mean duration of the operation was 99 min. The third patient developed a leak from the exposed esophageal mucosa on the 5th postoperative day while at home. The leak was attributed to late desloughing of a mucosal burn, and was sealed spontaneously 15 days later after drainage. The remaining three patients were discharged after resuming diet within the first 2 postoperative days. By 1 year postoperatively, dysphagia was abolished in all cases, and there were no gastroesophageal reflux symptoms. The esophagogram showed no reflux, which was also confirmed on ambulatory 24-h esophageal pH measurement. On manometry, lower esophageal sphincter (LES) pressure dropped significantly postoperatively (preop: 56 +/- 7 SD mm Hg, postop: 5 +/- 1 SD mm Hg, p0.001). In conclusion, laparoscopic Heller's myotomy with Dor's fundoplication for esophageal achalasia is a feasible procedure, offering clinical and laboratory results similar to the open approach, but with better patient tolerance.

Background It has been confirmed that erythromycin has gastrokinetic properties of enhancing gastric emptying both in health and disease. The objective of the present study was to investigate any possible effect of erythromycin on esophageal motility. Methods In 14 healthy subjects, standard esophageal manometry was performed before and after the intravenous administration of 200 mg of erythromycin. The calculated manometric parameters of esophageal motility were the lower esophageal sphincter (LES) pressure; the amplitude and duration of peristalsis at 5, 10, and 15 cm proximal to the LES; and the velocity and strength of peristalsis at 5 cm proximal to the LES. Results Erythromycin significantly increased the LES pressure ( P P = 0.002), duration ( P = 0.003), strength ( P = 0.014) and velocity ( P = 0.008) of peristalsis at 5 cm proximal to LES. Erythromycin also increased the amplitude of peristalsis at 10 cm proximal to the LES ( P = 0.035). Conclusion Erythromycin affects the motility of the distal esophagus.

PURPOSE: Based on the rationale that the calcium channel blocker, nifedipine, decreases lower esophageal sphincter pressure in achalasia, a prospective controlled trial was performed to evaluate the effect of sublingual nifedipine on the anal sphincter of controls and patients with high anal resting pressures. METHODS: Ten age-matched and sex-matched controls without evidence of anal disorder and ten patients with hemorrhoids and/or fissure-in-ano were included in the study. Anorectal manometry, with an eight-channel, water-perfused catheter was performed on all patients before and 30 minutes after administration of 20 mg of sublingual nifedipine. RESULTS: Nifedipine significantly reduced anal resting pressure in both controls and patients by approximately 30 percent (P

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score, P = 0.016; total reflux time, P = 0.008, reflux time in supine position, P = 0.024; reflux time in upright position, P = 0.008), a lower frequency of reflux events (P = 0.005), a more severe esophagitis on endoscopy (P < 0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P = 0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P = 0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P = 0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P = 0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.

BACKGROUND Persistence of dyspeptic symptoms after cholecystectomy or choledochoduodenostomy is common. There is -evidence that at least some of these symptoms may be attributed to duodenogastric reflux (DGR). The aim of the study was to quantify DGR before and after cholecystectomy, with or without choledochoduodenostomy, and endoscopic sphincterotomy for common bile duct stones, and to assess the effect of erythromycin on the increased DGR. METHODS Forty-seven patients before and after cholecystectomy, 26 after cholecystectomy and choledochoduodenostomy and nine after sphincterotomy had postprandial (300 mL of fresh milk, 4% fat) duodenogastric reflux measured by 99mTc-hepatic imino diacetic acid scintigraphy. Patients with a DGR index (DGRi) >20% were considered as having pathological DGR that justifies symptoms, and their DGRi was reassessed after administration of 200 mg of erythromycin intravenously. RESULTS Twenty-seven patients before cholecystectomy (57%) showed a normal DGRi 20% was observed in 10 cases. Only eight patients after cholecystectomy and choledochoduodenostomy (23%) presented with a DGRi within the normal range. The remaining 18 had a DGRi >7%. Five of them exhibited a DGRi >20%. Of the nine patients with sphincterotomy, three showed a DGRi >20%. Erythromycin almost completely normalized DGRi in all 18 patients with pathological DGR (P < 0.0001). CONCLUSIONS Duodenogastric reflux is common after biliary surgery, including endoscopic sphincterotomy. Erythromycin appears to decrease duodenogastric reflux to normal levels.

It has been shown that truncal vagotomy with pyloroplasty (TVP), but not highly selective vagotomy (HSV), delays the onset, decreases the extent, and changes the pattern of gallbladder emptying. The aim of the present study was to investigate any alterations in gallbladder emptying after a variety of antiulcer gastric surgery, by milk-technetium 99m (99mTc)-dimethyl iminodiacetic acid (HIDA) scintigraphy. After excluding the cases with spontaneous gallbladder evacuation before milk ingestion, there were 26 controls, 41 duodenal ulcer (DU) patients, 22 after HSV (15 prospective cases), 50 after TVP (23 prospective cases), 8 after TV with gastrojejunostomy (TV-GJ), 10 after Billroth I gastrectomy, and 29 after Billroth II gastrectomy. None of the patients with gastrectomy had additional vagotomy. TVP significantly delayed the onset and decreased the rate of gallbladder emptying as compared with the control, DU, HSV, and Billroth I groups. TVP also changed the pattern of emptying in 20% of the cases (sequential emptying and refilling events). Antiulcer operations excluding the duodenum (TV-GJ and Billroth II) further reduced the rate of gallbladder emptying as compared with (1) control, DU, HSV, and Billroth I groups (P0.0001) and (2) TVP (P0.001). Onset of gallbladder emptying was not affected by Billroth II gastrectomy, but was significantly delayed by TV-GJ (P0.001). The latter two operations also significantly changed the pattern of gallbladder emptying, exhibiting sequential emptying and refilling events, in most cases (P0.01 versus TVP). In conclusion, all antiulcer procedures, except HSV, greatly disturb the pattern, the onset, and the rate of gallbladder emptying. Truncal vagotomy seems to disrupt vagally mediated preduodenal mechanism, resulting in delayed onset and reduced rate, whereas duodenal exclusion by gastrojejunostomy results in severely decreased rate of gallbladder emptying.

Background: Subtotal colectomy with ileosigmoid or ileorectal anastomosis is one of the standard procedures for obstructed tumours of the left colon. The lower the level of the anastomosis, the greater the number of bowel motions per day. The aim of the present study was to assess whether an ileal pouch–rectal anastomosis is associated with fewer bowel motions per day. Methods: In four patients with obstructed carcinoma of the rectosigmoid junction and upper rectum, a total colectomy with removal of the upper rectum for adequate tumour clearance was used, followed by construction of a 10 cm ileal J-pouch that was subsequently anastomosed to the distal rectal stump. Results: Postoperative recovery was uneventful in all patients. At 3 months postoperatively, anorectal manometry showed anal resting and squeeze pressures at lower normal limits and a neorectal capacity ranging from 160 to 310 mL. One year postoperatively, all patients experienced one to three normal bowel motions daily and no episodes of incontinence. Conclusions: Total colectomy with ileal J-pouch–rectal anastomosis is a reasonable operative alternative in cases with obstructed tumours of the rectosigmoid junction, which necessitate removal of the upper rectum.

Fast-track (FT) protocols accelerate patient's recovery and shorten hospital stay as a result of the optimization of the perioperative care they offer. The aim of this review is to examine the latest evidence for fast-track protocols when compared with standard care in elective colorectal surgery involving segmental colonic and/or rectal resection.All randomized controlled trials and controlled clinical trials on FT colorectal surgery were reviewed systematically. The main end points were short-term morbidity, length of primary postoperative hospital stay, length of total postoperative stay, readmission rate, and mortality. Quality assessment and data extraction were performed independently by two observers.Eleven studies were eligible for analysis (four randomized controlled trials (RCTs) and seven controlled clinical trials (CCT)), including 1,021 patients. Primary hospital stay (weighted mean difference -2.35 days, 95% confidence interval (CI) -3.24 to -1.46 days, P0.00001) and total hospital stay (weighted mean difference -2.46 days, 95% CI -3.43 to -1.48 days, P0.00001) were significantly lower for FT programs. Morbidity was also lower in the FT group. Readmission rates were not significantly different. No increase in mortality was found.FT protocols show high-level evidence on reducing primary and total hospital stay without compromising patients' safety offering lower morbidity and the same readmission rates. Enhanced recovery programs should become a mainstay of elective colorectal surgery.

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.

A case of colonic varices manifesting with rectal bleeding in a young patient is presented. There was no evidence of portal hypertension or any other cause. Familial history was also negative. Diagnosis was established by barium enema, colonoscopy and angiography. On colonoscopy, varices involved the entire colon. At operation, dilatation of the subserosal small veins of the entire small and large bowel was confirmed. The patient underwent a subtotal colectomy with ileorectal anastomosis with satisfactory result.

Heller's myotomy for esophageal achalasia is associated with less esophageal acid gastroesophageal reflux when combined a Dor's fundoplication. The Aim of the study was to assess the incidence of postoperative esophageal acid exposure after laparoscopic Heller's myotomy and Dor's fundoplication (HM-DF).Seventy six patients (37 males) with esophageal achalasia were prospectively followed-up by clinical interview and laboratory tests before and after laparoscopic HM-DF. A symptom score was used for clinical assessment. Laboratory assessment included esophageal standard manometry, esophagogram and esophageal pH 24-hour monitoring before and 1- and 5-years after surgery.Symptom score improved at 1-year after surgery (P0.001). Heartburn was only reported by 5 patients, dysphagia or/and regurgitation by 28 and substernal pain by 12. 91% of patients had satisfactory functional results. Pathological esophageal exposure to acid was seen in 21% of the cases. Pathological acid events showed the features of pseudoreflux in 66%t and those of true GER in 34%. Pathologically increased esophageal exposure to acid was more commonly detected in patients with a pseudodiverticulum (P = 0.001) and was related to the diameter of distal esophagus and symptom score (P0.001). There was no reduction in esophageal acid exposure after treatment with proton pump inhibitors in 16 patients. Neither the symptom score nor esophageal acid exposure at esophageal pH monitoring changed significantly at the 5-year follow-up in 35 patients. Esophageal configuration remained unchanged.Increased esophageal exposure to acid after laparoscopic HM-DF for esophageal achalasia i) is detected in 21% of patients, and is rather the result of food stagnation than of true GER, ii) is more commonly seen in cases with pseudodiverticulum, iii) is related to the diameter of distal esophagus, iv) does not respond to antisecretory treatment and v) does not deteriorate by time.

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+ (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.

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.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.At 1 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 I, II, 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 I, II, and III responders, but deteriorated in stage IV nonresponders and in 6 of the 10 patients with a pseudodiverticulum.A satisfactory outcome of the laparoscopic Heller-Dor procedure in stage I, II, 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.