Genito-urinary function after lateral node dissection with concomitant pelvic autonomic nerve preservation [PANP] for rectal cancer

Lateral node dissection for advanced rectal cancer, in which perirectal tissues are widely removed and superior as well as lateral nodes are dissected has contributed to improve the local failure and survival. Nevertheless urinary and sexual dysfunction frequently occur after lateral node dissection because of the damage of the intrapelvic nerves. A total of 31 male patients underwent lateral node dissection, 15 patients were eligible for the technique while 16 patients did not receive [PANP]. All the patients responded to standardized questionnaire regarding the current and preoperative urinary sexual function as well as follow-up examination six months after surgery. Regarding the bladder function, 10 patients out of 15 [67%] who were offered [PANP] maintained good urinary control p<0.04, compared to 5 patients out of 16 [19%] in the group that was not submitted to [PANP]. Regarding the sexual function, 9 patients out of 15 [60%] with [PANP] maintained satisfactory erection p<0.04, compared to 4 patients out of 16 [25%] who were not submitted to PANP]. Ejaculation was achieved in 2 patients out of 15 [13%] with [PANP], compared to 0% in the group without [PANP]. Lateral node dissection with either partial or complete [PANP] combines the curative benefit of enhanced perirectal tissue excision with a minium of voiding and sexual dysfunction in the majority of advanced rectal cancer patients

outcome of sphincter-saving resection and abdomino-perineal resection for distal rectal cancer

The advent of surgical techniques has enabled more patients with mid and low rectal cancer to have sphincter saving resections [SSR]. This procedure, however has provoked doubts regarding the adequacy of resection and fear of increased rates of recurrence compared with Abdomino-perineal resection [APR]. The introduction of Total Mesorectal Excision [TME] has much lowered the recurrence rate to nearly 4%. This study was performed to compare the oncological results of SSR for low and mid rectal cancer patients with those obtained APR before that period. A total of one hundred and fifteen patients [115] were enrolled in this study. The tumours were located between 3-12cm from anal verge. Fifty one patients [45%] underwent SSR between the years 2002-2007. The incidence of recurrence after radical SSR was compared with the historical control group of sixty patients [52%] which underwent APR. The two groups being matched for Duke's stage and tumour location. Four patients had local treatment. The mean follow-up period of patients was 2.3 years, range [1-5] years. After 2 years follow-up, the local recurrence cumulative rate was 10.3% after SSR and 16.5% after APR. Distant recurrence rates were 15% and 20% respectively. Six patients [12%] died of their disease within 2 years of radical SSR, nine patients [15%] after radical APR. The overall 5 years actuarial survival in the SSR group was 70.2% compared to 64% in the retrospective matched control group who underwent APR. SSR for mid and low rectal tumours appears to have a superior outcome over APR since there is no risk of increased recurrent disease compared to APR after an equivalent follow-up period

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

Is gastric pull-up reconcstruction still the versatile method in the surgical treatment for hypopharyngeal carcinoma

The objective of this cross sectional study was to assess the best option for reconstruction after pharyngolaryngectomy for hypopharyngeal carcinoma. The study was done in surgical oncology department. National Cancer Institute, Cairo University. The study included 131 patients with carcinoma of the hypopharynx. The results of this study showed that gastric pull-up was the suitable reconstructive option in 67.1% of cases with free jujenal flap reconstruction in 9.2%. No reconstruction teas done in 9.2% of advanced patients leaving the patient with a pharyngostome, an orostome and a tracheostomy. Pectoralis major myocutaneous flaps were used primarily for repair in 3.8% of patients, and free antrolateral thigh flap in 2.3% while primary closure was done in 8.4% of cases when conservative surgery was feasible. Postoperative morbidity was encountered in 47% of patients. The most common morbidities were pharyngeal fistula and chest infection. Local and nodal recurrence occurred in 19.1% of cases. Postoperative mortality occurred in 33% of cases. Of 81 cases there was an extrahypopharyngeal spread in 60% of them. Extension to the larynx occurred in 22% of cases, thyroid gland in 11% of cases, esophagus also in 11% of cases [all from postcricoid area], soft tissue extension in 11% of cases and oropharynx in 5% of cases. Pathological examination of nodes in cases subjected to lymph node dissection [53 cases,] revealed metastatic lymph nodes in 52.8%. Most of the cases were at advanced stage [48% of cases were stage IV and 35% of cases were stage III. Lack of sufficient safety margin was found in 15 cases [11.5%. All positive margins were less than 2 cm. According to the advanced stage of the disease at presentation, reconstruction by gastric pull-up after pharyngolaryng- esophagectomy for hypopharyngeal carcinoma is the optimal option

Extended lymphadenectomy to the lower paraortic nodes during radical cystectomy

Evaluation of the diagnostic, prognostic and possible therapeutic role of extended lymphadenectomy to lower para-aortic area in operable bladder cancer patients. One hundred and nine patients were subjected to the procedure in the National Cancer Institute, Cairo University, and in Minea Oncology Center, Ministry of Health by the same group of surgeons, during the period from September 2000 to March 2003. The lymph nodes dissected were labeled to the following groups: perivesical, lymph node of Cloquet, external iliac, internal iliac and obturator, common iliac and paraortic groups both right and left. These nodes were subjected with the primary tumor to serial sectioning for histopathologic examination. Preoperatively, all patients were subjected to routine laboratory investigations. In addition to cystoscopy, biopsy and histopathologic examination, bone scan, chest X-Ray and computerized tomography with IV. contrast examination for the abdomen and pelvis were done for clinical staging of the disease. 34.4% of the node positive patients have been found to harbor the disease in the para-aortic lymph nodes above the common iliac bifurcation. Obturator, external iliac, internal iliac, para-aortic, common iliac, perivesical and lymph node of Cloquet are the higher incidence groups of positive lymph nodes sequentially. The clinical and C.T. staging are inaccurate methods of diagnosis due to high overall error in up to 70.6% of patients. There is no higher incidence of morbidity, mortality, operative time or intraoperative blood loss related to the addition of lower para-aortic dissection to the routine radical cystectomy. Extension of lymphadenectomy to include the lower para-aortic area in addition to the standard pelvic lymphadenectomy during radical cystectomy for bladder cancer is a more accurate technique for diagnosis and staging of bladder cancer patients and it may help in determining the benefit of adjuvant chemotherapy +/- radiotherapy. By itself, it gives a better recurrence-free survival rate without adding higher morbidity or mortality than the standard pelvic lymphadenectomy