Functional evaluation after laparoscopic Heller-Dor surgery for esophageal achalasia

Evidence of long-term outcome of laparoscopic Heller-Dor surgery is limited. The aim of this study was to assess the long-term outcome of achalasia patients after surgery, particularly in relation to the preoperative stage of the disease. Sixty eight patient with esophageal achalasia, undergoing laparoscopic Heller-Dor surgery were assessed clinically and by esophageal radiology, manometry and 24-hour ambulatory pH monitoring before and at 3 months, 1 year, 1 to 3 years, 3 to 5 years and more than 5 years after surgery. The study included 68 patients, 36 were males [52.9%] and 32 were female [47.1%] with median age of 41 years [range 19-79y]. At 1 year after surgery the symptom score was significantly lower than the preoperative score [p<0.001], 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 8mm Hg was achieved in all patients and esophageal emptying was accelerated significantly [p<0.001]. At the consecutive follow-up evaluation [1-5y], the satisfactory outcome was maintained in all stage I, II and III responders. Those with initially unsatisfactory results [stage IV patients] reported a worsening of symptoms [p<0.02]. LES opening and resting pressure remained at the level of the 1-y follow-up evaluation. Esophageal emptying remained satisfactory in stage I, II and III responders, but deteriorated in stage IV non-responders. A satisfactory outcome has been achieved after laparoscopic Heller-Dor procedure in stage I, II and III achalasic patients and seems to last. Stage IV nonresporders tend to deteriorate over time

Factors affecting survival after pancreaticoduodenectomy

Pancreatic cancer is the fourth most common cause of cancer related mortality in the western world. Most patients with pancreatic cancer present late in the course of the disease and have locally extensive with or without metastatic disease. Overall only up to 20% are candidates for resection and have potential for curative surgery. In the management of periampulary tumors resection is the only likelihood for cure and pancreaticoduodenectomy continues to be the surgical procedure of choice. The aim of this study was to evaluate different prognostic factors that may influence the overall survival after pancreaticoduodenectomy in patients with periampulary tumors. This retrospective study was conducted at the Gastroenterology Center, Mansowa University. The study group included 154 patients with periampulary tumor underwent pancreaticoduodenectomy in the period between September 2001 and April 2004. All patients were subjected to thorough clinical evaluation, complete laboratory work up, abdominal ultrasonography and computed tomography. Pancreaticoduodenal resection was performed as classic Whipple. All surgical specimens were histologically examined. Follow up was carried out at monthly interval during the first year then every 3 months thereafter. The study group included 154 patients, 97 [62.9%] were males and 57 [37.1%] were females with mean age of 52 +/- 11 years. Jaundice was the commonest presentation occurring in 150 patients [97.4%] .followed by abdominal pain in 118 patients [76.6%] and weight loss in 45 patients [29.2%]. Many parameters were evaluated by unvaried analysis to determine their impact on survival. The 3- year survival was 62.2% for patients below 50 year and 43.3%for those above 60 years [P= 0.02]. The 3- year survival was 46.8%for males and 48.4% for females [P=0.32]. As regard the site of origin of the tumor survival was 44.1% in pancreatic, 57.5% in ampulary, 70% in distal CBD and 60% in duodenal tumors [P = 0.02]. The survival rate was 75%for tumors less than 2 cm and 36.8% for tumors more than 3 cm [P = 0.02]. Well differentiated tumors showed a survival rate of 55.5%, whereas moderately and poorly differentiated tumors showed survival rate of 43.4% and 25% respectively [P=0.02]. Patients with stage I disease had a 3- year survival rate of 59.3% while those with stage II and III disease had a survival of 42.1% and 30% respectively [p=0.001]. The 3-year survival for patients with negative lymph nodes was 53.8% compared to 15.2% for those with positive lymph nodes [P = 0.011]. The 3- year survival was 52.8% for those with negative safety margin and as low as 10% for those with positive safety margin [P = 0.009]. Patients who received 3 units of blood transfusion or less showed a better [49.2%] survival compared to those who received more than 3 units [36.3%], a result which was statistically significant [P=0.029]. Periampulary carcinoma represents a major therapeutic challenge to surgeons. Despite recent improvement in hospital mortality and morbidity, the long-term survival after pancreaticoduodenectomy is still disappointing and many factors should be considered to improve the outcome. We believe that, the age of the patient, the site of origin of the tumor, the cellular differentiation, the pathological tumor stage, the resection margin and the amount of blood transfusion all are important prognostic factors and should be considered in selecting patients eligible to surgical resection

Coangiocarcinoma; a major therapeutic challenge

Cholangiocarcinoma represent a major therapeutic challenge because of different histologies, tumor location and difficult surgical approach .The aim of this work was to evaluate the long-term outcome after surgical resection of bile duct cancer .An effort was also made to determine factors affecting survival. This study was conducted at the Gastroenterology Center, Mansoura University in the period between January 2001 and December 2006. The study group included 60 patients with Cholangiocarcinoma subjected to surgery. These patients were classified according to the site of origin of the tumor into 2 groups; group [A] hilar Cholangiocarcinoma [28 patients];and group [B] distal Cholangiocarcinoma [32 patients]. In group[A],20 patients[71.5%] had surgical resection done with added hepatectomy when the tumor was found extended to the corresponding branch either right or left. Eight patients [28.5%] were found advanced at the time of exploration .In group [B], 30 patients [93.8%] underwent pancreaticoduodenectomy, 1 palliative bypass and the last one no surgical intervention due to advanced disease. All patients were followed closely at 1 month, 6 months, one year and every year. Data regarding quality of life, survival mortality and recurrence were thoroughly collected evaluated and analyzed. This study included 60 patients with cholangiocarcinoma,41 males [68.4%] and 19 females [31.6%] with mean age of 50.3 +/- 12 years [range 23-76 years]. Jaundice was the main presenting symptom in all patients, whereas pain was encountered in 38 patients [63.4%]. Microscopic examination of the resected surgical specimens revealed the presence of adenocarcinoma in 47 patients [94%], squamous cell carcinoma in 2 [4%] and high grade dysplasia in one patient [2%]. Postoperative biliary leakage occurred in 6 patients [12%], abdominal collection in 4 [8%] and bleeding in 4 patients [8%], from the gastrojejunal anastomotic site in 2, pancreatic stamp in 1 and from the operative field in the last one. Hospital mortality occurred in 5 patients [10%], 4 due to liver cell failure and one due to cardiopulmonary factor. Late mortality occurred in 20 patients [40% of the surgically treated group], 13 [26%] due to disease recurrence, 5 [10%] due to liver cell failure and 2 patients [4%] missed follow up but reported by their relatives. Disease recurrence occurred in 13 patients [26%], this was in the form of local recurrence in 7 patients [14%] and liver metastasis in 6 [12%].In this study, 50 patients were surgically treated and followed for 2-25 months [mean 14 +/- 9.2 months]. Acturarial 6, 12, 18 and 24 months survival rates were 92.1%, 63.2%, 36.8% and 13.2% respectively. Radical resection for cholangiocarcinoma provides the best survival rates, moreover, preoperative biliary drainage to decrease jaundice together with a curative resection and adequate safety margins are recommended if longer survival is to be anticipated