High incidence of non-upper aerodigestive primary tumors in patients with esophageal cancer.

Earlier reports have described an association between esophageal cancer (EC) and high incidence of other primary tumors (OPTs) of the upper aerodigestive tract and breast cancer. We evaluated the incidence of non-upper aerodigestive OPTs among Israeli EC patients; 2328 EC patients were retrieved from the Israeli National Cancer Registry between 1980 and 2004. The relative risk of OPTs for EC patients was measured using standardized incidence ratio (SIR). Two cohorts, Israeli National Cancer Registry registered colorectal cancer (CRC) patients and the general Israeli population, were used for reference; 297 EC patients (12.7%) had OPTs, including breast (18.9%), CRC (16.2%), prostate (8.8%), and bladder (8.4%) cancers. Upper aerodigestive OPTs were less common. Most OPTs were identified before (74.4%) or simultaneously with (13.8%) EC diagnosis. The median time interval between OPTs diagnoses and EC development was 6.0 years. The incidence of OPTs was significantly higher among EC patients compared with CRC patients (SIR: 2.05, P < 0.01) or the general Israeli population (SIR: 3.90, 95% CI: 3.46-4.34, P < 0.01) regardless of gender or tumor histology. Patients with EC have high incidence of non-upper aerodigestive malignancies. Unlike previous reports, the distribution of OPTs in EC seems to represent the relative incidences of these cancers in the western populations.

A nickel-titanium memory-shape device for colonic anastomosis in laparoscopic surgery.

BACKGROUND: Minimally invasive surgery is used increasingly for colonic resection. With this procedure, the involved colon is dissected laparoscopically and exteriorized through a small incision, and the segment containing the tumor is resected. The anastomosis is performed extraperitoneally either by hand suture or with a stapler. This study was designed to evaluate the feasibility of using a memory-shape compression anastomosis clip (CAC) to perform laparoscopically assisted colonic anastomosis. The study was prompted by the authors' successful experience with the CAC in an animal model and in 10 patients with diverse colonic cancers. METHODS: The sample consisted of 10 patients who underwent laparoscopic colonic surgery at the authors' center. The anastomosis was performed with the CAC for five patients and with a stapler for five patients. To perform anastomosis with the CAC, the two edges of the resected colon are aligned. Two 5-mm incisions are made near the edges, through which the CAC, after cooling in ice water, is introduced in an open position using a special applier. In response to body temperature, the clip resumes its original (closed) position, thereby clamping the two bowel loops together. At the same time, the small scalpel incorporated in the applier makes a small incision through the clamped walls for the passage of gas and feces, and the clip is released into the intestine. The two 5-mm incisions are sutured. The clip is expelled with the stool within 5 to 7 days, creating a perfect uniform anastomosis. RESULTS: Neither group had complications, except one patient from the control group who experienced a small bowel obstruction attributable to a wound suture problem, which required laparotomy. His recovery was uneventful. CONCLUSIONS: The use of the CAC for colonic laparoscopic surgery is simple and very efficient, shortening operation time. It creates a uniform anastomosis, approximating the no-touch concept in surgery, and may prevent infection. It also is lower in cost than the stapler.

Laparoscopic gastric banding with Lap-Band for morbid obesity: two-step technique may improve outcome.

BACKGROUND: Laparoscopic placement of an adjustable gastric band is an attractive alternative for patients who can benefit from a restrictive bariatric procedure. Creation of the retrogastric tunnel (RGT) may, however, be a considerable challenge early in the surgeon's learning curve. Recent reports described up to 10% band slippage and occasional gastric perforation associated with RGT. The two-step (TS) technique involves a crural dissection towards the angle of His through a gastrohepatic ligament approach. It facilitates passage of the band's tubing posteriorly with no wide posterior gastric wall dissection. PATIENTS AND METHODS: Prospective data were registered for the 109 patients (92 females, 17 males) who underwent laparoscopic adjustable gastric banding from December 1998 to May 2000. In 11 patients the standard RGT approach was used, and in 98, the TS technique. The two groups were demographically similar. Mean age was 37 years (18-59); mean preoperative weight was 120 kg (90-165). RESULTS: All procedures were completed laparoscopically. The mean operative time was 59 minutes (31-150) and the mean hospital stay 1.2 days (1-5). Complications in the TS group were gastric wall hematoma in one patient, 3 days of intubation postoperatively in one patient, damage to a band demonstrated in a postoperative contrast study in one patient, and a port-site hernia in one patient. There was no band slippage in the TS group. Among the 11 patients undergoing RGT, there was band slippage in three (27%), immediately postoperatively in one and after 3 and 11 months in the other two. In a mean follow-up of 7 months (1-18), similar weight loss was found in both groups. The mean BMI decreased from 44 kg/m2 (36-61) preoperatively to 40, 38, 36, 34 kg/m2 at 1, 3, 6 and 9 months respectively. 52 patients required band adjustment; of these, 12 required two adjustments. CONCLUSION: Our experience with both the RGT and TS techniques indicates that the latter may offer better results, particularly in the early experience period. It is recommended that in their initial experience with the adjustable band, surgeons should become familiar with this approach.

Pathogenesis and current management of gastrooesophageal-reflux-related asthma.

In the past decade the use of proton pump inhibitors on the one hand, and an aggressive surgical approach on the other hand have revolutionised the treatment of gastro-oesophageal reflux disease (GORD). Many studies have suggested that the successful management of GORD results in improvement of the symptoms of asthma which coexist in many of these patients. In this paper we review the pathogenesis and the medical and surgical treatment of GOR-related asthma. Both anti-reflux operations and anti-acid medications improve GORD and GOR-related asthma. Although anti-reflux surgery is superior to H2 blockers, there are not sufficient data to evaluate proton pump inhibitors compared with operation in controlling the symptoms of asthma.

The influence of aprotinin on myocardial function after liver ischemia-reperfusion.

BACKGROUND: The beneficial effect of aprotinin, a naturally occurring protease inhibitor, on preservation of organs such as the liver, kidney and lung has been documented. OBJECTIVE: To explore the effects of hepatic ischemia and reperfusion on both liver and myocardial function, using a dual isolated perfused organ model with and without aprotinin. METHODS: Isolated rat livers were stabilized for 30 minutes with oxygenated modified Krebs-Henseleit solution at 37 degrees C. Livers were then perfused continuously with KH or KH + aprotinin 10(6) KIU/L for an additional 135 min. Livers of two other groups were made globally ischemic for 120 min, then perfused for 15 min with KH or with KH + aprotinin. Isolated hearts (Langendorff preparation) were stabilized for 30 min and then reperfused with KH or KH + aprotinin exiting the liver for 15 min. The liver's circuit was disconnected, and hearts were re-circulated with the accumulated liver + heart effluent for an additional 50 min. RESULTS: In the ischemia and ischemia + aprotinin groups, portal vein pressure (1 and 15 min reperfusion) was 331 +/- 99% and 339 +/- 61% vs. 308 +/- 81% and 193 +/- 35% of baseline, respectively (P < 0.03 vs. ischemia). There were no other differences in the enzyme leakage between aprotinin-treated or untreated ischemic livers. Left ventricular pressure was stable in the controls. However, LV pressure in groups perfused with ischemic liver effluent declined within 65 min reperfusion, whether aprotinin treated or not (84 +/- 8% and 73 +/- 5% of baseline, respectively, P < 0.004 only for ischemia vs. control). CONCLUSION: When aprotinin was used, LV pressure was inclined to be higher while liver portal vein pressure was lower, thus providing protection against liver and heart reperfusion injury.

Gastrointestinal anastomosis with the nickel-titanium double ring.

We used a dog model to test the safety and effectiveness of sutureless gastrointestinal anastomoses (n = 23) (end-to-end, end-to-side, or side-to-side) with the nickel-titanium double ring with temperature-dependent shape memory. Results were compared to conventional hand-sutured anastomoses (n = 5). Examination performed after 2 weeks' follow-up showed no leaks and no difference in return of bowel function between the experimental groups and the control group. Microscopic studies showed a complete epithelial lining and perfectly functioning anastomoses. We conclude that the nickel-titanium double-ring device may have an important place in the armamentarium of the gastrointestinal surgeon.

Structured triacylglycerol emulsion, containing both medium- and long-chain fatty acids, in long-term home parenteral nutrition: a double-blind randomized cross-over study.

Structured lipid emulsion, an innovative approach in which both medium-chain and long-chain fatty acids are esterified to the same glycerol backbone, has been recently shown to be a safe and efficient way of providing energy to patients requiring parenteral nutrition. As yet, no assessment has been made of its safety and effect on liver functions during long-term treatment. Twenty-two home parenteral nutrition patients with Crohn's disease or short bowel syndrome were enrolled in a double-blind randomized, cross-over study. Twenty patients who completed the study were treated for 4 wk with a structured lipid emulsion and for 4 wk with long-chain triacylglycerol emulsion. Determined every 1 or 2 wk were blood pressure, body weight, respiratory rate, blood count, liver functions, albumin, transferrin, plasma lipids, free fatty acids (FFAs), and, at the end of each treatment period (weeks 4 and 8), plasma dicarboxylic acids and 3-OH-fatty acids. No differences were observed between the groups or within the groups between the two treatments with respect to either clinical safety and adverse event occurrence or laboratory assessments. Plasma dicarboxylic acids and 3-OH-fatty acids were similar and within normal range. No alteration of liver function occurred in any of the patients treated with the structured lipid emulsion, whereas two of the patients receiving long-chain triaclyglycerol emulsion developed abnormal liver function, which resolved after switching to the structured lipid emulsion. In conclusion, structured triacylyglycerols containing both medium- and long-chain fatty acids appear to be safe and well tolerated on a long-term basis in patients on home parenteral nutrition, and it may be associated with possible reduction in liver dysfunction.

Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation.

BACKGROUND: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. METHODS: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. RESULTS: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 +/- 7 min for unilateral hernia and 65 +/- 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. CONCLUSIONS: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia.

Laparoscopic surgery of the gastroesophageal junction.

Incompetence of the lower esophageal sphincter mechanism leads to gastroesophageal reflux (GER), which is the most common indication for surgery of the gastroesophageal junction. Evaluation, diagnosis, and the modern surgical treatment of GER are discussed. Evaluation of patients with severe heartburn include upper endoscopy to evaluate the general condition of the esophagus, stomach, and duodenum; an upper gastrointestinal contrast study for a complete anatomic view of the esophagus and stomach; esophageal manometry to evaluate the function of the esophagus; 24-hour pH monitoring to determine esophageal acid exposure; and a gastric emptying study selectively to determine the presence of a motility disorder. These studies most often prove the diagnosis of gastroesophageal reflux, hiatal hernia, Barrett's esophagus, peptic esophageal stricture, paraesophageal hernia, or achalasia. The laparoscopic approach to treatments for these include Nissen fundoplication, Toupet fundoplication, Collis gastroplasty with fundoplication, modified Heller myotomy, esophageal diverticulectomy, and revisional operations. These procedures are described in detail. The results of these operations indicate that they are safe and effective and should be considered the new gold standard for correction of gastroesophageal pathology. Laparoscopic surgery has revolutionized many procedures traditionally performed through a laparotomy. Although they are technically more difficult and require a significant amount of time and practice for the surgeon to become proficient, it is becoming apparent that for functional surgery of the gastroesophageal junction laparoscopy is the access of choice.

[129 liver surgeries--five years of experience in a surgery department].

Major hepatic resections have been associated with significant morbidity and mortality. In the past decade or so this has changed and such procedures are now done in increasing numbers. In the past 5 years we operated on 129 patients with benign or malignant hepatic lesions (75 females, 54 males; age-range 14-84). The reason for surgery was malignancy in 94 (72.9%) and benign lesions in 35 (27.1%). The most common indication for surgery was liver metastases secondary to colorectal cancer in 45% of all patients or 61.7% of those operated for malignancy. Primary liver cancer was the cause for liver resection in 13.2% of all patients or 18.1% for those with malignancy. Of the 35 patients with benign lesions the leading causes for surgery included: giant cavernous hemangioma, simple liver cysts, echinococcus cysts and focal nodular hyperplasia (11%, 22.8%, 20% and 14.3%, respectively). 76 patients underwent anatomical resection and 63 had either a nonanatomical resection or a different operation. Among the former the most common procedure was right hepatectomy (36) and among the later a nonanatomical resection equal to 1-3 Couinod segments (44). Operating time ranged from 55 min. to 8:41 hours with a mean of 3:31 +/- 1:37. Mean hospital stay was 8.7 +/- 5.8 days and 86.8% received between 0-2 units of blood. Overall mortality was 6.2% and 31.2% of the fatalities had cirrhosis. Overall mortality in noncirrhotic patients was 2.6%. The complication rate was 16.3% and only 7 patients (4.4%) were hospitalized in the intensive care unit. This indicates that major liver resections can be done safely, with morbidity and mortality similar to that of other major abdominal operations.

Percutaneous drainage of subcapsular splenic hematoma: an experimental model in dogs.

Preservation of the spleen in patients with posttraumatic subcapsular hematoma is still controversial. To determine the best therapeutic approach for this type of splenic injury, we designed an experimental model of subcapsular hematoma of the spleen in dogs. A total of 23 subcapsular hematomas were caused in 19 dogs, which were followed both clinically and ultrasonographically for 12 weeks. Fifty-seven per cent of the hematomas resolved spontaneously; those that persisted (43%) were aspirated percutaneously with ultrasound guidance, after which they were all resolved. Our results support a conservative approach. When the hematoma does not resolve spontaneously, percutaneous ultrasound-guided aspiration may be considered.

Phytobezoar: a rare cause of intestinal obstruction.

Phytobezoar is a well-known although uncommon cause of mechanical alimentary tract obstruction, mainly in patients who have undergone previous gastric operation. Between January 1988 and March 1995, we operated on 14 patients with gastrointestinal obstruction due to phytobezoar. Eleven patients (78.6%) had undergone previous gastric operation and in all of them the diagnosis was made at the time of surgery. All admissions were during winter: supposedly because of the seasonal increase in intake of citrus fruits and persimmons. During the 7-year study period, we observed an unexpected increase in the incidence of this disorder. During the first 4 years we treated 2 patients (14.3%), an average of 0.5 patients a year, whereas during the last 3 years we operated on 12 patients (87.7%), an average of 4 patients a year. The recent increase in small-bowel obstruction secondary to phytobezoars may at least in part be explained by a major immigration wave from the former USSR. These immigrants have become exposed to an abundance of cheap fruits such as citrus and persimmons that were not available in their home country. The large consumption and the failure of information regarding the risks of consuming these fruits in association with previous gastric surgery may have played a major role in the recent increase of the incidence. Since phytobezoars may play increasingly an important role in the future due to the ingestion of great quantities of different fruits containing great amounts of cellulose, these findings call for restriction of citrus fruit and persimmons in patients who have undergone gastric surgery.

Major rectal perforations caused by enema: is surgery mandatory?

BACKGROUND: Current methods of large bowel preparation prior to colonoscopy, barium enema and surgery are extremely effective in cleaning the bowel of feces. We rationalize, therefore, that under these conditions rectal perforations secondary to barium and cleansing enema could be treated expectantly, namely either defer or completely avoid immediate surgery. PATIENTS: Two female patients with major rectal perforations secondary to barium and cleansing enema who had thoroughly prepared large bowel were treated conservatively. RESULTS: Both patients did well without surgery and were discharged without any long-term sequela. CONCLUSION: Since a large number of iatrogenic perforations of the rectum occur in patients with well-prepared and clean bowel immediate surgery can be deferred or avoided all together without compromising them.

Thromboxane A2 in postischemic acute compartmental syndrome.

OBJECTIVE: To evaluate whether thromboxane A2 participates in the ischemia-reperfusion injury associated with acute compartmental syndrome (ACS) and if by using a cyclooxygenase inhibitor this can be either reduced or abolished. DESIGN: To assess the role of thromboxane A2 in ACS, a tourniquet was applied for 2 hours to the hind limb of 12 dogs. Group 1 (n = 6) served as controls while group 2 (n = 6) was pretreated with lysine-acetyl-salicylate (Lysoprim). Blood thromboxane B2 levels and intracompartmental pressures were assayed prior to inflation of the tourniquet and at 5 minutes, 90 minutes, and 24, 72, and 144 hours after deflation. RESULTS: Five minutes after deflation, the compartmental pressure increased from 11.2 +/- 2.2 mm Hg to 16.1 +/- 3.3 mm Hg and 17 +/- 2.2 mm Hg (mean +/- SD) in groups 2 and 1, respectively. At 90 minutes and 24 hours, pressures were 17.1 +/- 3.3 mm Hg and 23.2 +/- 3.3 mm Hg (P<.01) and 15.3 +/- 2.6 mm Hg and 25.2 +/- 1.8 mm Hg (mean +/- SD) (P<.001), respectively, in groups 2 and 1. A similar effect, although of a lesser magnitude, was observed in the counterlateral limb. Thromboxane B2 levels increased from a mean (+/- SD) of 46 +/- 5.5 pg/0.1 mL to 132 +/- 7.5 pg/0.1 mL at 90 minutes in group 1, while remaining unchanged in group 2. CONCLUSIONS: Thromboxane A2 plays a major role in the ischemia-reperfusion injury of acute compartmental syndrome. By using a cyclooxygenase inhibitor both the levels of thromboxane and the compartmental pressures can be reduced.

Technetium-99m-MIBI scintimammography in palpable and nonpalpable breast lesions.

UNLABELLED: The aim of this study was to determine the diagnostic accuracy of 99mTc-MIBI scintimammography in patients with palpable and nonpalpable breast cancer. METHODS: One hundred and forty patients with a clinically palpable breast mass and/or suspicious mammographic finding had prone scintimammography after the intravenous injection of 740 MBq 99Tc-MIBI within 5 days before open biopsy or surgery. All patients had mammography within 2 mo before the scintimammography. The mammography was read as probably benign, probably malignant or indeterminate. The scintimammography was read as positive or negative for breast cancer. The scintigraphic studies were correlated with mammographic findings and with histopathology. RESULTS: Histopathological studies showed that the mean tumor size for 61 palpable tumors was 2.57 cm with a range of 1-6 cm, and for 24 nonpalpable tumors the mean size was 1.34 cm with a range of 0.5-3 cm. Mammography had an overall sensitivity of 91.58% and a specificity of 42.87%; the sensitivity was 90.16% and 95.45% and specificity was 57.14% and 32.14% for palpable and nonpalpable tumors, respectively. Eight cases were considered indeterminate. Scintimammography was true-positive for 71 breast cancers, true-negative for 47, false-positive for 8 and false-negative for 14. The overall sensitivity was 83.5% and the specificity 85.4%. In the patients with palpable masses, sensitivity was 95.1% and specificity 75%; in those with nonpalpable lesions, sensitivity was only 54.2% and specificity, 93.5%. Among 18 cases of palpable abnormalities with probably benign mammography, six had true-positive scintimammography. Of eight patients with indeterminate mammography, one was true-positive on scintimammography. CONCLUSION: Scintimammography is an accurate and clinically useful tool for evaluating patients with palpable breast abnormalities when mammography is negative and in the cases of indeterminate mammography. A significant improvement in lesion detectability is necessary in nonpalpable breast abnormalities.

Acute bacterial peritonitis: permeability of cephalosporins in the peritoneal cavity.

Acute bacterial peritonitis is a common surgical disease treated with fluid resuscitation, surgery and antibiotics. The choice and use of antibiotics is an important supplement of therapy. Cephalosporins are among the most frequently used drugs for this condition. Although there is evidence that these agents reach the peritoneal cavity under normal conditions, no data are available regarding their delivery and concentration during acute secondary bacterial peritonitis. In order to determine the effectiveness of these agents in such cases, we studied the diffusion of three generations of cephalosporins--cefazolin, cefonicid and cefotaxime--into the peritoneal cavity during controlled bacterial peritonitis in rats. Our results show that all three drugs reached therapeutic concentrations in the peritoneal fluid; the highest concentration was obtained by the third-generation cefotaxime.

[Giant cavernous hemangioma of the liver].

Hemangioma, the most common benign tumor of the liver, is found in 2% of all autopsies. Giant cavernous hemangiomas are those larger than 4 cm, and the only ones of clinical importance. During 1991-95 we saw 69 patients with cavernous hemangiomas of the liver ranging from 2 to 25 cm in diameter. In 62% (30 women and 13 men) they ranged from 4 to 15 cm (mean 6.3). Only 11 patients, in whom the hemangioma was symptomatic, were referred for surgery. The others were either asymptomatic or their symptoms were considered mild, and they were only followed. 4 refused surgery, but in 7 the hemangioma (ranging from 4.8 to 15.0 cm, mean 10.2) was removed; 1 required 4 units of blood. There was no mortality; complications consisted of single cases of slipped tie requiring reoperation for intraabdominal bleeding, a bile leak treated by percutaneous drainage, and delayed wound healing. After 6 months all patients were symptom-free. Our data are consistent with the present trend to operate only when a giant, cavernous hemangioma of the liver produces symptoms.

[Transanal endoscopic microsurgery for local excision of rectal neoplasms].

We removed 30 benign, sessile, rectal polyps by the transanal approach between January 1990 and April 1994. In 16 patients we used transanal endoscopic microsurgery (TEM), while in 14 the adenoma was removed by submucosal excision (SE). There were 3 local recurrences in the SE group, but none as yet in the TEM group. There was no operative mortality. Early complications included myocardial infarction in 1 patient and persistent postoperative fever which responded to antibiotic treatment in another. Late complications included temporary, anal mucous leakage in 10% and 5% of the TEM and SE groups, respectively. TEM was found to be efficient for the removal of polyps in the upper and middle thirds of the rectum, and SE for those in the lower third. This enables safe removal of rectal polyps, avoiding the need for complex operations involving greater risks.

Traumatic rupture of the intestine in patients with inflammatory bowel disease.

Three young patients suffering from inflammatory bowel disease were admitted to our hospital during the past year for extensive intestinal rupture caused by disproportionately minor trauma. There was almost no concomitant intra-abdominal injury. We believe that a minimal direct or acceleration/deceleration trauma to a preexisting diseased intestine might have caused extensive damage that was not apparent on admission. It was concluded that these patients should be carefully monitored and that their relative intestinal vulnerability should be borne in mind during diagnosis of and therapeutic planning for their condition.

[Primary and metastatic hepatic cancer: the surgical option].

Major hepatic resection is the treatment of choice in patients with primary and secondary liver cancer. During a 22-month period 31 men and 27 women (mean age 63 years, range 14-84) with space-occupying hepatic lesions were admitted. All 15 patients with benign lesions were operated, except for 3 in whom a liver abscess was drained percutaneously. Of the 43 with malignant liver lesions, 30 had liver metastasis secondary to colorectal cancer, 15 of whom underwent major, anatomical and nonanatomical, liver resection and 1 had cryoablation of the tumor. 9 had hepatocellular carcinoma, 1 of whom had a 4-segment non-anatomical resection and 1 tumor cryoablation. 2 with metastasis from a neuroendocrine tumor had anatomical resection of liver lobes. Of 2 with liver metastasis secondary to breast cancer, 1 underwent resection. CT portography, intraoperative ultrasonography and intraarterial injection of Lipiodol were found to be very useful in selecting patients for liver resection.