Effect of length of oesophageal stump on postoperative gastro-oesophageal function after resection of lower oesophageal carcinoma

Oesophageal carcinoma is not uncommon. One common goal of curative and palliative resection of oesophageal carcinoma is to achieve good functional outcome. During the last decade, Ivor Lewis operation with intrathoracic oesophagogastric anastomosis has been rising as the operation of choice for lower oesophageal carcinoma. It is wdl known that no oesophageal substitute is able to function as proper as the original organ, the peristalsis of which is essential to propel food into the gastric reservoir. Many authors think that the greater the length of the remaining oesophageal stump the better the postoperative functional outcome. The aim of this work was to evaluate the functional outcome after Ivor Lewis oesophagectomy and gastric pull-up for oesophageal cancer and to correlate the results with the length of the preserved oesophageal stump. Twenty patients [15 males, mean age 60 ys] were studied at the sixth postoperative month by questionnaire, stationary manometry and upper GI endoscopy. The commonest postoperative unpleasant complaints were early postprandial sensation of fullness [70%], diarrhea [40%] and gastrooesophageal reflux disease [GORD] [40%]. GORD was more profound in the left lateral position. According to the actual site of the oesophago-gastric anastomosis away from the central incisors as seen during endoscopy, patients were classified into 2 groups: High anastomosis group [A] with anastomosis lying less than 25cm from the central incisors [i.e. the anatomical length of the oesophageal stump < 10 cm] and low anastomosis group [B] with anastomosis lying at or below 25cm from the central incisors [ie. the anatomical length of the oesophageal stump >/= 10 cm]. It has been found that in low anastomosis group, there was a significant difference between the anatomical length of oesophageal stump and the functional length [as measured by manometry]. Patients in low anastomosis group had significantly better postoperative oesophageal body functions as revealed by better mean peristaltic pressure amplitudes [37 mmHg in group B versus 20.1 mmHg in group A, P < 0.05], better duration of contractions [2.11 sec. in group B versus 1.62 sec. in group A, P < 0.05] and better propagation velocity of the muscular contractions [2.7 mm/sec, in group B versus 2.01 mm/sec, in group A, P < 0.05]. This was reflected clinically by significant increase in body weight and significantly higher proportion of patients regaining their normal preoperative body weight in the low anastomosis group. It has been concluded that, provided oncological rules are not breached, Ivor Lewis operation with low intrathoracic anastomosis gives better functional outcome than high anastomosis in patients with lower oesophageal carcinoma

Differences between colorectal cancer in Egypt and the Western prototype

This study aimed to review patients with colorectal cancer presented to a general surgery unit with special interest in coloproctology in Ain-Shams University concentrating on the differences between the pattern of the disease in Egypt and western countries. The study is a six-year retrospective review of one hundred and fifty-five patients with colorectal cancer. The results showed that 38% of the tumors occurred in patients less than 40 years and only 15% of patients were above 60 years of age. 3% of the tumors were Dukes A and 58% were Dukes C. 6% of the tumors were irresectable, 36% of the resections were palliative and 29% of curative operations entailed massive resection of nearby organ or tissue. Synchronous adenomas were present in 5.2% of patients and bilharziasis in 3.2%. At a mean follow up of 52 months, 58% of curative resection patients had recurrence, 38% died of their disease or secondary to its treatment and 42% were alive and disease free

Effect of gastro-esophageal devascularization and esophageal transection on the prevention of variceal rebleeding

Nineteen patients [Child's A or B grade] with previous variceal bleeding underwent an elective gastro-esophageal devascularization and esophageal transection over two years period. Eight of them [42%] had recurrent bleeding despite medical therapy. There were neither operative death nor intraoperative complications. No anastomotic leakage was observed from the transection line. Nine patients [47%] had 16 postoperative complications. Routine ultrasonography following surgery showed portal vein thrombosis in three patients [16%]. In one patient, this has resulted in a late postoperative death due to mesenteric vein thrombosis. Follow-up endoscopy on the third postoperative month, showed that 42% of the patients had no visible varices and all patients except one showed marked reduction in the grade of esophageal varices. The study suggests that gastro-esophageal devascularization and esophageal transection carries a low operative risk and results in good prevention of recurrent variceal bleeding. The authors believe that this procedure deserves greater attention and can be used for the management of Egyptian patients with esophageal varices who may require surgery. A longer period of evaluation in a larger series of patients is required

Management of cholelithiasis during pregnancy

Twenty-seven pregnant women, with symptomatic gallstone disease, were admitted to this prospective study. All patients received initial medical therapy, and surgical intervention was performed in cases with frequent relapses or no response to medical treatment. Twelve patients underwent surgery during pregnancy, 2 in the first and 10 in the second trimester. Eight patients underwent laparoscopic cholecystectomy, while 4 had open cholecystectomy [one had exploration of the common bile duct]. While no maternal or fetal deaths occurred secondary to medical treatment, one spontaneous abortion occurred following open cholecystectomy in the first trimester. Patients, after receiving primary medical treatment, had 74.1% rate of relapse and additional days in hospital, compared to no relapse and less hospital stays after surgery. Patients acute cholecystitis had increased incidence of medical treatment failure and need of surgery. It is concluded that management of biliary tract disease during pregnancy should follow a protocol, with clear indications for the role of surgical intervention during the second trimester of pregnancy does not increase maternal or fetal morbidity. It may in fact reduce the number of relapses during pregnancy, hence reduces the consequent complications and additional hospital stay. Laparoscopic cholecystectomy is feasible in the great majority of patients, except those with large uteri in the late second trimester and the presence of common bile duct stones

Problems encountered in diagnosis and management of retroperitoneal cystic swellings

This study included 7 patients with retroperitoneal cysts who were diagnosed and managed between 1989 and 1992. All cases presented with intra-abdominal masses and 5 patients had pressure symptoms of either the gastrointestinal or the urinary tract. The initial diagnosis of an intra-abdominal cyst was made by ultrasound in 6 cases. CT scan was reliable in the diagnosis of a retroperitoneal cyst in all the cases as well as demonstrating its anatomic relations. Diagnostic aspiration of the cyst is a potentially hazardous procedure and should not be done. Five patients had complete excision of the cyst and 2 patients had excision by marsupialization. Complete excision of the cyst remains the treatment of choice. Marsupialization can be undertaken in cases of developmental cysts when complete excision can not be safely done if frozen section histology proves benign nature of the cyst