In vivo sentinel lymphatic mapping in rectal cancer

Nearly 30% of patients with stage I, II rectal cancer with no evidence of nodal deposits develop systemic disease despite radical curative surgery. It is postulated that a subset group of patients do harbor nodal micrometastases not detected by the classic Hematoxylin and Eosin [H and E] staining. This prospective study aimed to assess the feasibility of in vivo sentinel lymphatic node [SLN] mapping and biopsy in accurate nodal staging and decision making. This might offer a reasonable clue to whether lateral lymph node metastases can be diagnosed by SLN mapping and so provide benefit to patients with advanced rectal cancer regarding consideration of more extensive resection. The study included 25 patients with mid and low rectal tumours. In mid rectal tumours blue dye was injected circumferentially in the peritumoral area in the subserosal plane. Similarly in low rectal tumours submucosal injection around the tumour through proctoscopy was performed. Immediate labeling and prompt dissection of blue stained nodes were followed by the standard radical resection. The sentinel nodes were separately sent for focused histopathological examination, the surgical specimen including other nodes for routine examination. H and E negative SLN were tested Immunohistochemically [IHC]. Sentinel Lymph Node [SLN] mapping was feasible in 24 out of 25 patients [96%] with a mean number of SLN 2.87 patient [0-3].Positive SLN were found in 9 patients [38%] while negative SLN were found in 15 patients [62%].The incidence of metastasis in SLN was 26%.Lateral positive nodes were found in 3 patients [13%].Upstaging of T2-3NO to T2-3N1 was done in 15% of cases. Skip lesions were present in one patient. Sentinel Lymph Node [SLN] In vivo mapping using blue dye is a promising and feasible technique with a short learning curve. Lateral node dissection was excluded in 87% of patients. Proper nodal Staging by SLN focused analysis leads to identification of a subset group of patients that could benefit from Adjuvant therapy

Distal subtotal gastric resection for prevention of delayed gastric emptying following pancreaticoduodenectomy

Delayed gastric emptying is one of the leading causes of morbidity following pancreatico-dudenectomy occurring in nearly one third of patients. Literature reports indicate that the incidence of delayed gastric emptying [DGE] is higher after Pylorus-preserving pancreaticodudenectomy [PPPD] than after conventional pancreatico-dudenectomy [CPD]. Delayed Gastric emptying is traditionally diagnosed from patient report subjective sensations. In order to improve gastric emptying, distal subtotal gastrectomy with resection of nearly 60% of the stomach converting it from a reservoir into a conduit is undertaken to prevent gastric stasis and shortens transient time. Over a period of five years from 2001-2006, a total of twenty patients with operable pancreatic lesions underwent extended gastric resection in the form of distal subtotal gastric resection concomitant with pancreaticodudenectomy. The male-female ratio was 14/6, the mean age was 55 years with 15.5 standard deviation [SD]. This group was compared prospectively with a matched control group of patients who underwent conventional pancreaticodudenectomy regarding the development of delayed gastric emptying. We sought to quantify the rates of subjective DGE [sDGE] based on patient complaint versus objective DGE [oDGE] based on gastrograffin study in the tenth post operative day post Extended distal subtotal gasric resection with pancreatico-dudenectomy group [EPD] and the control retrospective group post conventional pancreatico-dudenectomy [CPD]. For the 20 patients in the EPD group and the other 20 patients in the CPD control group sDGE and oDGE data were collected on the postoperative day 14, and 6 months postoperatively. The incidence of sDGE was higher for the CPD [42%] than for EPD [15%] at 14 days, [33%] and [6%] at 6 months. The oDGE was higher for CPD [9 1%] than for EPD [67%] at 14 days, with a 6-months incidence of [37%] in CPD and [4.7%] for EPD. The proximal gastric function detected by the Liquid phase gastric emptying test [normal control reference=23 minutes] was prolonged for the CPD group [73 minutes] compared to [38 minutes] for the ECP in the first 14 days. At 6-months interval the LGE was [48 minutes] for CPD and [12.7 minutes] for ECP. 1-The concept of DGE should distinguish between subjective and objective symptoms. 2-The loss of distal stomach mechanoreceptors in EPD reduces patient sensation of oDGE producing silent DGE. 3- The EPD contributed greatly in preventing the early delayed gastric emptying, resulting in short hospital stay and decrease cost with minimal associated surgical morbidity