Lower third cancer rectum: situations dictating abdomino-perineal resection

Low anterior resection for lower third rectal cancer is a great objective, however the winds are sometimes stronger and in many situations the surgeon is obliged to do abdomino-perineal resection. The aim of this work was to define different situations of patients with resectable lower third rectal cancer in whom sphincter preservation procedures could not be done and abdomino-perineal resection was the only option. During the period from July 2001 till the end of December 2004, out of 45 patients with lower third rectal cancer 31 patients had a resectable disease with no distant metastasis, out of these, curative low anterior resection was done for 11 patients, the different situation of patients who underwent abdomino-perineal resection [20 patients] represented the material of this study. All patients were evaluated clinically. Laboratory workup, rigid proctosigmoidoscopy, endorectal ultrasonography, colonoscopy and or double contrast enema, plain X ray chest, abdominal U/S and or abdomino-pelvic C.T scan, and I.V.P were all used to assess these patients. In this work, 20 patients with resectable lower third rectal cancer lost their sphincters and the surgeon was obliged to perform abdomino-perineal resection. In these patient the mean tumor height from the anal verge was 3.1 cm ranging between 0.0 - 4.5 cm. Endosonographic invasion of the anal sphincter complex was the finding in 4 patients. In another 4 patients the lower edge of the tumor was seen overlying and invading the dentate line. After full rectal mobilization a distal safety margin could not be achieved in 6 patients. An infiltrated distal resection margin by frozen section was the cause of failure to preserve the sphincter in 4 patients. Tumor seedling on a recently done haemorroidectomy wound led to abdomino-perineal resection in one patient, the last patient developed a low rectal mucoid carcinoma six months after transanal excision of 3 x 4 cm villous adenoma. Abdomino-perineal resection of the rectum is not an endangered operation. It still has its major role in the management of patients with lower third rectal cancer. The height of the tumor from the anal verge is the most important deciding factor in resectable lower third rectal cancer whether to preserve the sphincter or not. The majority of patients with a tumor edge of 4 cm or less from the anal verge may lose their sphincters

Rare gastric tumors: clinical presentations, endoscopic aspects and management challenges

Many challenges will be present on dealing with rare gastric tumors there. The aim of the present work was to study the clinical presentations, endoscopic aspects of some of the uncommon gastric tumors and the different lines of management of such cases. Ten patients, five males and five females, presented with rare gastric tumors were included in the study. Their age ranged between 42 and 73 years. The main presentations were; epigastric pain, vomiting associated with a sizable epigastric and right hypochondrial mass in one patient, upper gastro intestinal tract bleeding in four patients, vague epigastric pain and dyspeptic manifestation not responding to medication in two patients, non specific symptoms [abdominal pain and dyspepsia] which were modified by a known primary malignant disease and the effects of its treatment were the presentation in three patients. Esophago-gastro-duodenoscopy was done for all patients; [the number, site and appearance of the lesions were described], this was repeated twice for the first patient [one year interval] with evidence of GERD grade I and extrinsic antral compression with no definite masses or ulcers, no biopsy was taken. Endoscopic biopsy could not be taken in two patients, inconclusive in two [CT guided core liver biopsy settled the diagnosis in one patient with multiple liver secondaries while surgical resection specimen was the only option in the other three patients] and conclusive in five. Metastatic Gastric Tumors [MGT] were found in three patients, mesenchymal tumors in three, hepatoid adenocarcionoma, gastric carcinoid, and high grade MALT lymphoma one patient each and synchronous tumors in one patient [lower oesophageal adenocarcinoma and antral mesenchymal tumor]. The primary tumor was cutaneous malignant melanoma, breast adenocarcinoma, and pancreatic adenocarcinoma in the three patients with metastatic gastric tumors. Six patients were treated surgically; two by chemotherapy, one by percutaneous biliary drainage followed by chemo-radiotherapy, and one patient received supportive medication. Four patients are still alive during a follow up period of 12 - 32 months, while six patients died within 9 to 28 weeks from the time of diagnosis. The diagnosis of MGTs is often difficult as gastric involvement is usually masked by manifestations of the original tumor. A negative endoscopic biopsy in mesenchymal tumors with intact overlying gastric mucosa is always a diagnostic challenge. Poor response of most gastric tumors to chemo-radiotherapy makes surgery the main line of treatment

Bile duct injury during cholecystectomy diagnostic and surgical aspects

Bile duct injury following cholecystectomy is an uncommon but challenging clinical condition. The aim of this work was to analyze clinical presentations, evaluate different diagnostic procedures and to assess the outcome of surgery. During the period from January 2001 till the end of May 2003, 28 patients with a post cholecystectomy bile duct injury [presented either early 21 patients or late 7 patients] were included in the study. They were 21 females and seven males. Their age ranged between 29 and 66 years. All patients were evaluated clinically and biochemically. To assess the site and extent of injury ultrasonography, direct cholangiography and / or MRCP were done for all patients. Computed tomography was done when needed. In this work, complete bile duct ligation with early onset of progressive jaundice represented the majority of patients who presented early [47.6%]. When the ligation or clipping was distal to the cystic duct insertion a biliary fistula also developed [4.8%]. Injury with subsequent bile leakage [fistula, biloma or diffuse peritonitis] and later stricture formations were the other presentation in this group [47.6%]. Jaundice and cholangitis were the main presentation in patient who presented late. The majority of patients were jaundiced [92.8%] with elevated serum alkaline phosphatase in all of them. Ultrasonography had a 100% success rate to detect; IHBD, localized collection and free intra-peritoneal bile. The success rate to localize the site of the injury was 64.3%, it also evaluated accurately the liver parenchymal pathology. MRCP was the key stone in the diagnosis of the site and the extent of the bile duct injury with a 100% success rate in visualization of the biliary tree below and above the stricture. ERCP failed to opacify the bile ducts proximal to the stricture in 48% of the patients. In this group, low stricture [Bismuth type I and II] was the common finding [84%]. Bilio-enteric anastomosis without preoperative stenting of the bile ducts was done safely for all patients [except one where the procedure could not be completed] with excellent and good results in 82% of our patients