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PROCARE, a Belgian multidisciplinary project on rectal cancer, started in 2006 with participation on a voluntary basis. Completeness and bias of registration in PROCARE were assessed.Data from 6353 patients with rectal cancer were extracted from the population based Belgian Cancer Registry for the period 2006-2008. Registration bias was studied by comparing patient, tumour and treatment characteristics of cases registered and non-registered in PROCARE. Relative survival (RS) of patient subgroups was analysed.PROCARE included 37% of all Belgian rectal cancer patients. Registration was highly variable between participating centres which recorded on average 56% of their patients. Significant differences in patient, tumour and treatment related characteristics were observed between registered and non-registered patients. The 5-year RS was 77% (95% confidence interval (CI): 74-80%) for registered patients and 56% (95% CI: 53-59%) for non-registered patients. After adjustment for patient, tumour characteristics and volume of centre, the relative excess risk of dying (RER) between registered and non-registered patients was 2.15 (95% CI: 1.85-2.50, p0.001). The 5-year RS of patients treated in centres that never participated in the project was 59% (95% CI: 55-63%) and, after adjustment, the RER was 1.16 (95% CI: 1.00-1.35, p0.050) compared to patients of the participating centres.Registration of PROCARE patient data was incomplete, biased and variable between centres. Participation on a voluntary basis should be avoided for further projects. Quality assurance on a centre level requires compulsory and complete registration with a minimal but relevant data set for all patients treated in all centres.

Background Research on the relationship between hospital volume and quality of care in the treatment of rectal cancer is limited. Methods Process and outcome indicators were assessed in patients with rectal adenocarcinoma who underwent total mesorectal excision, registered on a voluntary basis in the PROCARE clinical database. Volume was derived from an administrative database and analysed as a continuous variable. Sphincter preservation, 30-day mortality and survival rates were cross-checked against population-based data. Results A total of 1469 patients registered in PROCARE between 2006 and 2011 were included in this study. A volume effect was observed regarding neoadjuvant therapy for stage II–III disease, reporting of the circumferential resection margin, R0 resection rate, sphincter preservation rate, and number of nodes examined after chemoradiotherapy. The global estimate of quality of care was highly variable, but surgery was the single domain in which quality correlated with volume. No volume effect was observed for recurrence and overall survival rates. In the population-based data set (5869 patients), volume was associated with 30-day mortality adjusted for age (odds ratio 0·99, 95 per cent confidence interval (c.i.) 0·98 to 1·00; P = 0·014) and adjusted overall survival (HR 0·99 (95 per cent c.i. 0·99 to 1·00) per additional procedure; P = 0·001), but not with the sphincter preservation rate. Because of incomplete and biased registration on a voluntary basis, results from a clinical database could not be extrapolated to the population. Conclusion Some volume effects were observed, but their effect size was limited.

Fast-track programs (ERAS) have been shown to improve postoperative recovery in colorectal surgery, combining newer anesthetic and minimally invasive surgery with evidence-based adjustments to facilitate revalidation. This prospective study evaluated the outcome of an ERAS protocol implementation in a university colorectal unit.Between 2009 and 2010, 94 patients (49 males and 45 females) underwent an elective colorectal resection and were included in this protocol. All data were prospectively gathered in an electronic database. A cohort comparison was performed with 120 patients operated on in 2008 before ERAS implementation.The median age was 58 years [range: 29-76 years] and the median ASA score was 2. All colorectal procedures (85 sigmoid resections, 7 right hemicolectomies and 2 low anterior resections) were performed laparoscopically, with a conversion rate of 9,5%. Complications were noted in 14 patients (14,9%); two patients (2,1%) required a laparoscopic drainage of an infected hematoma during initial hospital stay. A significant (p0,001) reduced median postoperative hospital stay of 4 days [range : 2-11 days] in the ERAS group, compared with 6 days [range : 3-37] in the non fast-track group was noted. Early readmission occurred in five patients (5,3%) because of anastomotic leakage (n = 2), ileus (n = 2) and a wound infection (n = 1).These results of length of stay, morbidity and readmission-rates have important implications for the organization of health care, waiting lists and costs. Therefore the ERAS principles should be more wide-spread implemented.

OBJECTIVES Intestinal metaplasia is associated with gastric carcinomas, in particular intestinal-type carcinomas. According to the literature, intestinal metaplasia, especially the sulphomucin-rich incomplete type (type IIb or III) can be considered as a precancerous lesion. Intestinal metaplasia is not uncommon in gastric lymphomas, and the purpose of this study was to determine its prevalence and extent, its different subtypes and the distribution of sulphomucin and to compare these findings with those in gastric carcinomas. DESIGN The prevalence and grade of intestinal metaplasia were investigated in surgical specimens from 160 patients with gastric carcinoma (102) [intestinal type (69), diffuse type (33)] and gastric lymphoma (58) [marginal zone cell (29), diffuse large cell (29)]. Intestinal metaplasia is analysed by specific mucin stains. METHODS Intestinal metaplasia was described according to the Updated Sydney system. Using periodic acid-Schiff Alcian Blue pH 2.5 and high iron-diamine/Alcian Blue staining, the intestinal metaplasia was classified (Jass classification) and its sulphomucin content was determined. RESULTS The prevalence and extent of intestinal metaplasia are significantly higher in intestinal-type carcinomas than all other gastric malignancies. Subtyping of intestinal metaplasia is independent of the different types of gastric neoplasia. High sulphomucin positivity in the metaplastic epithelium is only seen in intestinal-type carcinomas, although in a small number of cases (21.5%). CONCLUSION Prevalence, extent and sulphomucin content of intestinal metaplasia are significantly higher in intestinal-type gastric carcinoma compared to diffuse-type carcinoma, marginal zone cell and diffuse large cell lymphomas in the stomach.

Laparoscopic ventral recto(colpo)pexy (LVR) is a minimally invasive, autonomic nerve-sparing technique to treat rectal prolapse syndromes. The position of the mesh on the anterior aspect of the rectum in the rectovaginal septum allows correction of concomitant rectocele and enterocele.Demographic, perioperative, and follow-up data of consecutive patients were analyzed in order to audit our 10-years' experience with the technique.From January 1999 to December 2008, 405 patients (93% female) underwent LVR for internal rectal prolapse (45.9%, n = 186), total rectal prolapse (43%, n = 174) and rectocele or enterocele (11.1%, n = 45). Mean age was 54.6 years (SD 15). The median hospital stay was 4 days (range 2-21). Conversion rate was 2%. There was no postoperative mortality. At a mean follow-up of 25.3 months, recurrence was observed in 4.6% (19 patients). Most often detachment of the mesh at the sacral promontory was found. Late complications occurred in 18% of patients. In five patients, LVR combined with perineotomy was complicated by mesh erosion into the vagina. Mesh erosion was not observed after LVR without perineotomy. Symptomatic improvement was observed in 85% of patients with total rectal prolapse and in 70% of patients with internal rectal prolapse (p0.050). The difference was mainly due to a lesser effect on obstructed defecation symptoms.LVR, with or without perineotomy, appears to be safe and feasible, with relatively low morbidity. Functional outcome data support its efficacy. The indication for LVR in patients with internal rectal prolapse could be optimised.

Common problems after rectal resection are loose stools, faecal incontinence, increased frequency and evacuation difficulties, for which there are various therapeutic options. A systematic review was conducted to assess the outcome of treatment options aimed to improve anorectal function after rectal surgery.Publications including a therapeutic approach to improve anorectal function after rectal surgery were searched using the following databases: MEDLINE, PubMed, EMBASE, Pedro, CINAHL, Web of Science, PsychInfo and the Cochrane Library. The focus was on outcome parameters of symptomatic improvement of faecal incontinence, evaluation of defaecation and quality of life.The degree of agreement on eligibility and methodological quality between reviewers calculated with kappa was 0.85. Fifteen studies were included. Treatment options included pelvic floor re-education (n=7), colonic irrigation (n=2) and sacral nerve stimulation (SNS) (n=6). Nine studies reported reduced incontinence scores and a decreased number of incontinent episodes. In 10 studies an improvement in resting and squeeze pressure was observed after treatment with pelvic floor re-education or SNS. Three studies reported improved quality of life after pelvic floor re-education. Significant improvement of the Fecal Incontinence Quality of Life Scale was found in three studies after SNS.Conservative therapies such as pelvic floor re-education and colonic irrigation can improve anorectal function. SNS might be an effective solution in selected patients. However, methodologically qualitative studies are limited and randomized controlled trials are needed to draw evidence-based conclusions.

Single incision laparoscopy aims to reduce access trauma and facilitate specimen extraction. We report our early experience and describe the learning curve for single-port laparoscopic appendectomy and cholecystectomy as a primer for more advanced single-port laparoscopic procedures.From June 2009 to February 2010, all consecutive patients undergoing elective single-port appendectomy and cholecystectomy at the day surgical centre were included. A prospective database with perioperative data was created.Ten appendectomies and 4 cholecystectomies were done in 13 patients, predominantly males (77%), with a mean age of 45 years and a mean BMI of 23 kg/m2. The mean operative time was 31 minutes and 75 minutes for appendectomy and cholecystectomy, respectively. One extra trocar was placed in the first two cholecystectomies, to improve exposure and allow cholangiography. All patients did well at a median follow-up of 5.8 months and no wound infections, nor incisional hernias were detected.Single-port laparoscopic appendectomy and cholecystectomy is safe and feasible with a short learning curve and has good outcome.

There have been initiatives to create a European audit project. This paper addresses the issue of differences in data collected by different registries.Patients with rectal cancer treated in 2008 and recorded in quality registries from Belgium, Germany/Poland, Spain and Sweden were analyzed. The comparison included number of patients, gender, age, American Society of Anesthesiology (ASA) classification, preoperative diagnostic and staging procedures, neoadjuvant therapy, surgical treatment and quality of surgery, postoperative complications and adjuvant treatment.The Belgian database consisted of 622 patients, the German/Polish database consisted of 3,393 patients, the Spanish database consisted of 1,641 patients and the Swedish database consisted of 1,826 patients. The percentage of patients in each ASA stage was highly variable. MRI use was highest in Spain and Sweden and very low in Germany/Poland. The percentage of cT4 stage tumours in Sweden was much higher than in all other countries. Sweden recorded the highest percentage of primary metastatic disease (20.3%) and Belgium recorded the lowest (10.2%). Neoadjuvant therapy in different protocols was administered to 41.2% patients in Germany/Poland, to 50.8% in Spain, to 55.2% in Belgium and to 62% in Sweden. Laparoscopic surgery (conversion rate) was performed for cure in 5% (28%) of patients in Sweden, in 20.8% (20.6%) in Spain, in 28.6% (15.2%) in Belgium and in 14.5% (8.9%) in Germany/Poland. The 30-day mortality for anterior resection, abdominoperineal excision and Hartmann's procedure in Sweden, Belgium and Spain was 2.0%, 2.3% and 3.1%, respectively. The German/Polish database reported an in-hospital mortality of 3.2%.A European quality assurance project in rectal cancer is possible only after data collection is standardized.

Diarrhoea with urgency is a debilitating long-term complication of ileal pouch anal anastomosis (IPAA) after a proctocolectomy. Somatostatin analogues are used to control diarrhoea and high-output ostomies. Hence, we designed a prospective, double-blind, crossover trial to explore the efficacy and tolerability of octreotide to reduce diarrhoea in adult patients with IPAA.Patients were randomized to octreotide subcutaneously (SC), 500 μg three times daily (t.i.d.), or matching placebo SC for 7 days. Responders (a reduction in stool frequency of three or more stools per 24-h period and with a reduction in stool frequency of at least 30% after 7 days of treatment compared with baseline; the primary end-point) remained in the same group and nonresponders could cross over to the alternative treatment for 7 days. Open-label octeotide LAR 30 mg was offered to all responders on day 14. Flexible pouchoscopy with biopsies was performed at baseline in all patients and was repeated on days 7 and 14 in patients with pouchitis.Fifteen patients (11 men, median age 52 years), all with ulcerative colitis, were randomized. Three patients were withdrawn for side effects during the blinded phase. Response was achieved by two of 12 and two of 11 patients treated with octreotide or placebo, respectively (including crossover, P = 0.9). The median stool frequency remained stable in both groups [Δoctreotide: 0 (IQR, -4 to 0), Δplacebo: -1 (IQR, -1 to 1), P = 0.45]. Octreotide had no effect on the modified pouch disease activity index (mPDAI), and pouchitis persisted in five of six subjects with pouchitis at onset. One subject received open-label octreotide LAR.Octreotide has no clear beneficial effect on the stool pattern or on pouchitis severity in patients with high stool frequency after IPAA.

With the introduction of single-port surgery, expected advantages are improved cosmesis, decrease of pain and shorter length of stay. The aim of this study was to compare early outcomes of single-port colectomy with those of conventional laparoscopic colectomy.All consecutive patients undergoing single-port colectomy between January and June 2010 were identified from a prospective database. They were matched for age, sex, body mass index, American Society of Anesthesiology score and type of resection with patients who had conventional laparoscopic colectomy. All perioperative data, analgesic requirement, pain scores and inflammatory response were compared using the Wilcoxon signed-rank and McNemar tests.Fourteen patients [five men, nine women; median age (interquartile range) 56 (30-73) years, body mass index (interquartile range) 22 (20-24) kg/m2] underwent single-port colectomy and were matched with patients who had conventional laparoscopic colectomy. Median operating times, estimated blood loss, pain scores, analgesic requirement, inflammatory response and length of hospital stay were similar. Median increase in incision length was significantly higher in the single-port group (P=0.004), but maximal incision length for specimen extraction was comparable. There were no anastomotic leaks, wound infections or 30-day readmissions.In a case-matched setting with a small sample size, single-port laparoscopic colectomy has comparable outcomes to conventional laparoscopic colectomy.

We present a case of miliary tuberculosis diagnosed 15 months after infliximab treatment despite negative screening for previous exposure to Mycobacteria on skin PPD and chest X-ray. This case shows that--although screening for TB with a skin PPD and a chest X-ray should be performed in all patients--this is not 100% effective and may be a problem in patients on concomitant immunosuppression. The clinical course of this patient further shows that in a patient treated with anti-TNF antibodies who's condition does not improve one should always be aware of the possibility of a tuberculosis infection. Even though tuberculosis is usually not rapidly fatal, the disease may show a fulminant course in immunocompromised patients.

Division of the rectum following total mesorectal excision (TME) using intracorporeal stapling devices is technically difficult due to their width and limited roticulation. More than one cartridge is often required and resultant wedging of the stump may be associated with an appreciable leak rate.Three-dimensional reconstruction was performed of CT and MRI images from the lower abdomen of six patients undergoing laparoscopic TME using the Amira software environment. The stapling device was virtually reconstructed by in-house developed software, superimposed over the point of division of the rectum and the site of skin entry identified.The 45 degrees angulation of available roticulating stapling devices precludes perpendicular division of the rectum following laparoscopic TME. The optimal angulation for transverse rectal stapling varied between 62 degrees and 68 degrees .A roticulating stapler with minimum angulation of 65 degrees would achieve transverse division of the rectum following laparoscopic TME.

To compare the postoperative evolution and the long-term efficacy after stapled haemorrhoidopexy (PPH) and Milligan-Morgan haemorrhoidectomy (MM).In a prospective randomized study, 40 patients requiring surgical treatment for prolapsing haemorrhoids grade II or III were assigned to either MM or PPH (20 each). Postoperative pain, wound healing were evaluated, as well as anal pressures and sphincter anatomy. Mean follow-up is 46 months.Postoperative pain at rest and during defecation was less important after PPH if no resection of external piles or skin tags was associated (P0.0001). Healing time was shorter after PPH (P0.0001). Endoanal ultrasound remained unchanged postoperatively. Resting and squeeze pressures decreased after MM, but not after PPH (P0.01). After a mean follow-up of 46 months (12-56), persistent or recurrent symptoms, mostly mild and temporary, were observed after both MM and PPH, in 7 and 11 patients respectively (NS). After PPH, five patients (25%) complained of recurrent external swelling and/or prolapse (P = 0.047 vs. MM) requiring redo surgery in four of them, after 10, 13, 14 and 21 months. No redo-surgery was required after MM. Long term patient satisfaction after PPH was not better than after MM.Postoperative pain is less important after PPH. This advantage disappears if any resection is associated with the stapling. At medium to long-term follow-up, PPH seems to carry a higher risk of symptomatic external haemorrhoidal disease, needing further surgery.

The optimal treatment for patients with nonparasitic splenic cysts is controversial. This study aimed to evaluate the clinical outcome of patients treated for a symptomatic splenic cyst, and to define a surgical strategy.Spleen-preserving surgery (9 laparotomies and 6 laparoscopies) was performed for a primary cyst in six patients and a secondary cyst in nine patients. The median follow-up time was 37.5 months. Partial splenic resection was performed for eight patients and cyst decapsulation for seven patients.Cyst recurrence was observed in four patients after decapsulation of a primary splenic cyst, as compared with none after resection. Postoperative complications were encountered only after laparotomy (5/9). The median hospital stay was 3.5 days (range, 2-5 days) after laparoscopy, as compared with 9 days (range, 5-14 days) after laparotomy.Symptomatic splenic cysts should be treated laparoscopically. For patients with recurrent or suspected primary splenic cysts, laparoscopic partial splenectomy is preferable. For other cases, a laparoscopic decapsulation is advocated.

Some young and active patients requiring abdominoperineal resection for rectum cancer ask for an alternative of an abdominal colostomy. We analysed the results after a combination of a perineal colostomy and antegrade continence enemas (ACE). Fifteen patients have been operated between 1999 and 2004. Follow-up wassix months in 12 patients with a mean of two years and with a maximum of 55 months. The QLQ-C30 (version 3) and CR 38 questionnaires of the EORTC have been used to evaluate quality of life aspects. Five out of 15 patients presented complications: infection of the caecal conduit (2), small bowel obstruction (1), prolapse of the perineal colostomy (1), eventration (1), urologic complications (2). ACE are still used by all patients. The volume needed was 400 ml and duration of irrigation was 30 minutes (15-45 minutes). The median score for faecal incontinence was 0 ; faecal pseudocontinence was obtained by 7/12 patients. The scores for all aspects of functioning were excellent, as well as the score for body image. The general health status and quality of life were estimated at 75% from normal value. The procedure is simple and can be performed in one operative session. A perineal colostomy with ACE seems to be a valuable and less expensive alternative for an abdominal colostomy, and certainly for total anorectal reconstruction.

Background Dynamic graciloplasty (DGP) is an option in patients with end-stage faecal incontinence. The aim of this retrospective multicentre study was to assess early and late outcome after DGP. Methods Sixty consecutive patients with congenital (14) or acquired (40) faecal incontinence or who had undergone total anorectal reconstruction (six) underwent DGP. Patients were followed up for a median of 48 (range 13–117) months. Results There were no deaths; 75 complications that required 61 reoperations were observed in 44 patients. Loss of muscle stimulation occurred in 22 patients, more frequently after direct nerve stimulation. Evacuation difficulties occurred in 12 patients. Overall, DGP failed in 27 patients, of whom seven had stoma construction. At follow-up, continence to solid stool without stoma was obtained in 47 of 60 patients, although 26 required use of antegrade continence enemas or other measures. Functional outcome was related to the presence of a functioning DGP and a short delay (less than 50 days) of muscle training after transposition. Conclusion DGP is a major operation with a high morbidity rate; it requires experience and early muscle training. The outcome after DGP should be compared prospectively with that after implantation of an artificial sphincter or other less expensive alternatives.

By temporarily suppressing the immune response, the anti-tumour necrosis factor agent, infliximab, may increase the risk of peri-operative complications.To test this hypothesis for intestinal resection in a cohort of 313 Crohn's disease patients treated with infliximab. Forty received one or more infusions prior to intestinal resection (31/40 within 12 weeks).The post-operative events of these patients were compared with those of a control group (infliximab naive) of 39 patients adjusted for age, gender and surgical procedure. Early (10 days) and late (3 months) major or minor complications were identified.The incidence of early minor (15.0% vs. 12.8%) and major (12.5% vs. 7.7%) and late minor (2.5% vs. 5.1%) and major (17.5% vs. 12.8%) complications and the mean hospital stay after surgery (10.3 +/- 4.0 days vs. 9.9 +/- 5.5 days) were similar in both groups. A trend towards an increased early infection rate was found in infliximab pre-treated patients (6 vs. 1; P = 0.10), but more patients in this group received corticosteroids and/or immunosuppressives (29 vs. 16 patients; P0.05).The use of infliximab before intestinal resection does not prolong the hospital stay and does not increase the rate of post-operative complications.

The aim of the study was to evaluate the use of positron emission tomography with [18F]-fluorodeoxyglucose (FDG-PET) in patients with unexplained rising carcinoembryonic antigen (CEA) in the postoperative surveillance of colorectal cancer. 50 consecutive patients with elevated CEA levels and a completely normal (n=31) or equivocal (n=19) conventional diagnostic work-up (CDW) were retrospectively selected. All PET images were reviewed with full knowledge of the CDW. The gold standard consisted of histology, or clinical follow-up of more than 1 year. Recurrent disease was established in 56 lesions in 43 patients. On a patient-based analysis, the sensitivity of FDG-PET was 34/43 (79%), and the positive predictive value 34/38 (89%). In 14/50 patients (28%), the FDG-PET findings led to a surgical resection with curative intent. On a lesion-based analysis, FDG-PET detected 42/56 lesions (sensitivity: 75%), the positive predictive value was 79% (42/53). These results demonstrate that FDG-PET can have a clear impact on patient management in patients with an unexplained elevation in CEA levels.

In order to select a species for drug absorption studies of ester prodrugs and to identify a possible absorption window with low esterase activity and hence increased absorption of the ester prodrug, the esterase activity was investigated in homogenates from various intestinal segments of different species. p-Nitrophenyl acetate and tenofovir disoproxil [bis(POC)-PMPA] were used as substrates for esterases. p-Nitrophenyl acetate is a model substrate for esterase activity, while tenofovir disoproxil (fumarate salt) is an ester prodrug of the potent antiviral nucleoside phosphonate analogue tenofovir. As esterase-mediated degradation during transepithelial transport may be a limiting factor for its oral absorption, targeting the prodrug to a region of the intestine with lower esterase activity may lead to an increase in oral absorption of the prodrug. The results obtained with p-nitrophenyl acetate and tenofovir disoproxil showed both a site-specific (duodenum > or = jejunum > ileum > or = colon) and species-dependent (rat > man > pig) degradation in intestinal homogenates. Degradation of tenofovir disoproxil in homogenates from Caco-2 monolayers (0.016+/-0.003 nmol. s(-1). mg protein(-1)) was low compared to its degradation in homogenates from human ileum (0.177+/-0.052 nmol. s(-1). mg protein(-1)). Rat ileum appears to be a suitable model to evaluate the influence of esterase activity on the oral absorption of the ester prodrug, as the degradation rate for tenofovir disoproxil (0.245+/-0.054 nmol. s(-1). mg protein(-1)) in rat ileum was similar to degradation in human ileum. The results also suggest that colon targeting may be a useful strategy to reduce the esterase-mediated degradation of ester prodrugs, hence resulting in a possible increase in their oral absorption.

Two groups of patients referred for suspicion of acute appendicitis were compared to evaluate the accuracy of preoperative ultrasonography (US) and surgical decision-making. In one retrospective study, US was performed by trainees using a 3.5 MHz probe (219 patients). In the second prospective study, US was performed by a resident radiologist using a 5 MHz probe (144 patients). US accuracy rose from 65% to 90%, especially due to an improved negative predictive value (from 52% to 92%). The positive predictive value of US was 89%. The sonographically adjusted clinical decision to operate was correct in 85%. Thus, all patients with positive US should be operated. In contrast, clinical judgment must prevail in case of negative US findings in order to prevent surgical delay in about 11%. The negative laparotomy rate decreased by 5% only. This is probably due to the limited influence of negative US findings on surgical decision. US is to be recommended in all patients suspected for acute appendicitis when performed with an appropriate probe by an experienced ultrasonographist. However, it may not, on it self, reduce the rate of unnecessary operative procedures.

The authors describe their technique of videoscopic (VS) lumbar sympathectomy (LSE), compared to the open LSE. From 1992 to 1994, 21 open and 19 VS LSE were performed. The indication was reflex sympathetic dystrophy in 17 and arterial insufficiency in 23 patients. In the open LSE the mean duration of anaesthesia was 80 min (55-115) and of surgery 37 min (25-65). The length of the chain removed varied from 1 to 3 ganglia (6-7 cm). Complications were noted in 5 patients: 1 pneumonia, 2 superficial wound problems and 2 cases of postsympathectomy neuralgia. Hospital stay of patients with RSD varied from 2 to 5 days. Of the 19 attempts to perform a VS LSE 4 had to be converted to the open technique. The duration of anesthesia was 150 min (90-280) and of surgery 92 min (45-240). Lengths of chain removed varied from 1 to several ganglia (6-7 cm). A pneumoperitoneum was present in 10 procedures, but a Veress needle was placed in only 4 of these. Complications were present in 9 patients: 1 important subcutaneous emphysema, 1 severe costal pain, 2 neuralgia, 1 temporary psoas dysfunction, 1 haemorrhage from a lumbar vein with conversion to the open technique and 3 minor superficial wound problems. The hospital stay ranged from 2 to 5 days. This study suggests that the VS LSE has no benefit over the open technique as far as the operative and early results are concerned. Whether this technique avoids some of the late disadvantages of a lumbotomy remains to be seen.

It has been suggested that the combination of etoposide, leucovorin and 5-fluorouracil (ELF) is very active in the treatment of advanced gastric cancer in elderly patients. The aim of this study was to confirm the efficacy and to investigate the toxicity of the ELF-regimen in patients of all ages. Thirty patients with advanced gastric adenocarcinoma were treated with leucovorin (300 mg/m2), etoposide (100 mg/m2) and 5-FU (500 mg/m2) for 3 consecutive days every 4 weeks in a phase II study. Reevaluation of measurable disease was done after 3 cycles. A partial response was shown in 8 (27%) patients. An improvement of the Karnofsky Performance Status was observed in 10 (33%) patients. The mean survival amounted to 8 months (range 2-24). Toxicity was mild. No grade 4 toxicity nor chemotherapy-related mortality were observed. It is concluded from this phase II study that the ELF-regimen is an active palliative treatment for advanced gastric cancer, with mild toxicity.

The relationship between symptoms and manometric data was studied in incontinent patients. Conventional anal manometry, the rectal saline infusion test and the balloon-retaining test were performed in 27 control subjects (M:8, F:19; mean age: 47 yr) and in 40 incontinent patients (M:5, F:35; mean age: 49 yr). The correlation coefficient between the clinical degree of continence/incontinence and the maximum anal basal tone, squeeze pressure and the pressure increment during squeeze was -0.74, -0.74 and -0.57, respectively. Discriminatory values of40 mmHg for maximum basal pressure and92 mmHg for squeeze pressure could identify continent patients with 96%, and incontinent patients with 88% accuracy. The uncontrollable evacuation of a balloon, progressively filled with water at 60 ml/min, before the maximum tolerable sensation level was reached, was related to the degree of clinical incontinence. Also the maximum retained volume and the interval between the first sensation volume and the maximum retained volume ("perceived rectal capacity") were related to the clinical symptoms: r = -0.72 and -0.71, respectively. The balloon-retaining test proved to be superior to the rectal saline infusion test for the determination of the severity of incontinence. The saline infusion test, however, was found to be more adequate to identify minor defects of continence. Thus, the manometric assessment of anorectal continence should consist of routine anal manometry, the rectal saline infusion test and the balloon-retaining test. Some important clinical implications are discussed.

Widespread alterations of the gut autonomic nervous system have been described in Crohn's disease. Immunohistochemistry shows that these alterations are associated with the expression of major histocompatibility (MHC) class II antigens (HLA-DR) on enteroglial cells in the ganglia of the submucous and myenteric plexuses and on the enteroglial sheaths of the nerve extensions. Neuronal cell bodies and extensions do not express MHC class II antigens. The class II expression is associated with the presence of UCHL1-positive T lymphocytes. MHC class II expression can also be found on endothelial cells and vascular smooth muscle cells but not on smooth muscle cells of the muscularis mucosae or propria. The intensity of MHC class II expression on the glial cells of the enteric nervous plexus and on endothelial cells correlates well with the intensity of class II expression on epithelial cells.

The role of the distal stomach in gastric emptying was studied. Ten patients with proximal gastric vagotomy (PV) and 10 age-matched patients with Roux-en-Y gastro-jejunostomy (R-Y) were compared with 10 healthy controls. Gastric emptying of solids and liquids was determined by the use of Tc-99m SC scrambled eggs and In-111 DTPA. In PV, gastric emptying of both solids and liquids was delayed; the prolongation with solids was mainly accounted for by an abnormal lag phase. In R-Y patients, no lag phase was observed, and the solid emptying curve pattern was characterized by early rapid emptying followed by very slow emptying. Both the solid and liquid phases were prolonged. The lag phase is affected by proximal vagotomy and is mainly determined by the distal stomach, which appears to be essential for normal emptying.

Patients presenting diffuse, advanced, established peritonitis due to free perforation of the colon, in whom an adequate abdominal debridement cannot be obtained in one operative session were selected. We report results of the planned relaparotomy approach in 44 patients as compared with an historical series of 9 analogous patients treated by on demand exploratory relaparotomies. Planned relaparotomies were performed every 2 days until the abdominal cavity became macroscopically clean. This approach significantly reduced both the incidence of multiple organ failure and the mortality rate (31%) as compared with the regimen of on demand relaparotomy. The mortality rate in the planned relaparotomy group is related to the age of the patient and to the nature of peritonitis. Faecal peritonitis carries a higher mortality rate than purulent peritonitis. The mortality rates of severe postoperative peritonitis and advanced primary peritonitis were not significantly different. Surgery for severe, diffuse peritonitis has to be prompt, moderately aggressive and repeated if necessary. Therefore, planned relaparotomies have a place in the treatment of selected patients presenting diffuse, advanced, established peritonitis.

The recurrence rate after highly selective vagotomy was evaluated in patients with chronic duodenal ulcer disease presenting non-refractory (64 cases) or refractory ulcers (41 cases) followed for 1 to 8 years postoperatively. Refractoriness was considered when an ulcer remained symptomatic and was not healed at endoscopy after 8 weeks (3 cases) or 12 weeks (30 cases) of appropriate treatment with cimetidine, or when it recurred during maintenance therapy and did not heal after adapted treatment (8 cases). The cumulative 5 year-recurrence rate was 28.7% in refractory ulcers, in contrast with 9.3% in non-refractory ulcers (p less than 0.05). The early and constantly increased risk of recurrences in the refractory ulcer group could not be explained by factors related to surgeon or technique, nor by differing patient characteristics, including sex, age at the first ulcer episode, duration of the preoperative ulcer disease, familial ulcer history, prior ulcer complications, use or abuse of anti-inflammatory drugs, caffeine or alcohol, smoking habits and occupational state. It is concluded that highly selective vagotomy can not be considered a surgical procedure of choice in patients with refractory duodenal ulcers as there are valuable alternatives.

The immunohistochemical findings in granulomatous lymphadenitis in patients with Crohn's disease are presented and compared with conventional light microscopic findings. The cellular composition of the granulomas in mesenteric lymph nodes was examined with a broad panel of monoclonal and polyclonal antibodies directed to B-cells, T-cells, monocytes/macrophages, dendritic reticulum cells, HLA-DR antigens and the transferrin receptor. The centre of the granulomas contains OKIa+, OKM1+, OKT9+, DRC-, To5- epithelioid cells and giant cells and OKT3+ lymphocytes. In general, the majority of the small lymphocytes within the granulomas expresses the OKT3+, OKT4+ Leu 3a+ phenotype which points toward T-helper cells. Fewer OKT3+ OKT8+ T suppressor/cytotoxic cells are observed. At the periphery of the granulomas a lymphocytic corona composed of BA1+, B1+ B lymphocytes may be present. From these findings it can be concluded that the granulomas in mesenteric lymph nodes from patients with Crohn's disease are composed of centrally located T-lymphocytes and of epithelioid cells which are of monocyte/macrophage origin and have the characteristics of antigen-presenting cells.

Five Heitz-Boyer-Hovelacque operations in children were reviewed in which particular attention was paid to pre-operative examinations, including electromanometry (EMM) and post-operative evaluation of continence, functional result and renal function. In our limited experience the rectal bladder operation is a good procedure in selected cases; it produces satisfactory continence and maintains renal function.

Benign neoplasms of the stomach lead to atypical symptoms. Radiological and endoscopic investigations are always recommended. Our surgical experience with 11 epithelial and 26 mesenchymal benign neoplasms is discussed. A local excision could be carried out in 24 patients, of whom 4 developed postoperative complications and one deceased. Ten cases required a partial and 3 cases a total gastrectomy. This was mainly due to the localisation or the extent of the lesions. One surgical complication occurred and one patient died. Relapse was never observed in the long-term (i.e. 6 years) follow-up of 29 patients. Nonetheless, a yearly radiological or endoscopical control is advocated since hyperplastic polyps can relapse as exaggerated healing of an ulcer, and because especially leiomyomas, neurilemmomas en lipomas carry a substantial risk of malignant degeneration.

Three patients are described with hepatic involvement by Echinococcus granulosus, complicated by spontaneous rupture into the biliary tract. Clinical features consisted of upper abdominal pain, jaundice, fever, anorexia, and vomiting. Hepatomegaly and marked epigastric tenderness were consistently observed. Laboratory findings included obstructive liver function tests, leucocytosis, eosinophilia, and hyperamylasemia. Abdominal computed tomography, showing the cystic wall, the presence of wall calcifications, daughter cysts and wall enhancement, provided a correct diagnosis of hepatic hydatidosis in all patients. Dilatation of the bile ducts with the presence of intraluminal material was clearly shown by sonography and endoscopic retrograde cholangiography. These abnormalities were most frequently found in the common bile duct and in the left hepatic duct. On sonography, the intraluminal material appeared as amorphous, sludge-like hydatid sand, and as daughter cysts. On ERCP, the intrabiliary parasitic material appeared as non-homogeneous, irregularly shaped and mobile filling defects. Other findings at ERCP were displacement and distortion of intrahepatic bile ducts by the hepatic cysts and a mild dilatation of the pancreatic duct. In one occasion, evacuation of a daughter cyst through the papilla was observed. The therapeutic value of mebendazole and endoscopic sphincterotomy in our patients is discussed.

106 patients had a partial gastrectomy for a benign gastric ulcer. 63 of them got a long-term follow-up. The mean follow-up is 127 months. The mortality rate of the emergency operation is 20%. For the elective operation the mortality rate is 0%. More than 90% of the patients have no complaints after a long time. Following a Billroth I operation most patients feel better initially but later there is no difference at all. The frequency of the ulcer recurrence following a B I is higher than following a B II, but it is lower than after another operation (resp. 5.8% and 2.2%). For these reasons we propose a partial gastrectomy for a benign gastric ulcer in elective circumstances. To prevent alkaline biliary reflux gastritis a 2/3 distal gastrectomy with selective vagotomy and Roux-in-Y anastomosis has to become a routine operation. In emergency circumstances a partial gastrectomy is not indicated because of the high mortality rate.

Some damaging effects that occur during cryopreservation by freezing to -196 degrees C have been evaluated in rabbit taenia coli by analyzing the proportional recovery of acetylcholine- and histamine-induced maximal contractions. Dimethyl sulfoxide (Me2SO) 10 v/v% was used as the cryoprotectant; it reversibly abolishes spontaneous contractility even after incubation at 37 degrees C during 2 hr. Programmed freezing at 0.6 degrees C/min with compensation for the latent heat of fusion and warming at 35 degrees C/min proved to be slightly superior to programmed cooling without compensation and slower warming. The degree of functional recovery was comparable after either abrupt or stepwise removal of Me2SO. Freeze-thawing resulted in a significant reduction of contractile force in each buffer solution tested, and acetylcholine-induced contractility was always better preserved than histamine-induced contractility. The best preservation (approximately 65%) was obtained in a potassium-rich buffer solution. The absence of calcium and magnesium from the incubating medium had no influence, whereas the presence of EDTA significantly affected functional recovery. It is difficult to compare our results with those reported by others because of multiple methodological differences. However, it seems that previous results can be improved by changing the freezing rate and the composition of the incubating and cryoprotecting medium.

Thirteen cases of intestinal atresia are described: 9 jejunal and 4 ileal. The duration of pregnancy was significantly shorter and the birthweight significantly lower in jejunal than in ileal atresia. The proximal intestine was strongly dilated in 8/9 cases with jejunal atresia. This group also contains several complex and extended varieties of atresia. The postoperative mortality was 8%. Gastrointestinal functional disturbances occurred only in the group treated for jejunal atresia. These disturbances were temporary and occurred postoperatively in 2 cases but reoperation was mandatory in another 2 cases, once without functional success. There were no problems in the other cases. Ileal atresia is easy to treat and the result is always good. In contrast, the situation is much more challenging in cases of jejunal atresia: prematurity, higher incidence of complex and extended gastrointestinal malformations, impossibility to resect the dilated proximal segment, presence of a long under-developed distal segment. No problems have been observed after construction of a double stoma and restoration of the intestinal continuity. However a proximal stoma leads to important fluid and electrolyte losses, necessitating total parenteral nutrition. Functional gastrointestinal disturbances are frequently observed after end-to-side anastomosis in Y with mucous fistula. An end-to-end anastomosis can be combined with enteroplasty of the proximal distended bowel segment, eventually including the duodenum. Although the enteroplasty technique is an important progress in the treatment of neonates with extended types of jejunal atresia, transit problems cannot always be prevented by this procedure.