The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour.

AIM: The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib. METHOD: The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment. RESULTS: Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant. CONCLUSION: Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

Simple clinical examination predicts complexity of perianal fistula.

OBJECTIVE: To investigate the diagnostic value of the distance between external opening of perianal fistula and anal verge and to evaluate its relation to the type of fistula. Preoperative identification of complex fistulae is important for proper planning of treatment. PATIENTS AND METHODS: One hundred and fifteen consecutive patients operated for perianal fistula were studied prospectively. The distance between the external opening and the anal verge was measured. Location of the external opening, demographic and medical history data were correlated with characteristics of the fistulae. Data analysis was performed using the SPSS statistical package. The association between categorical variables was examined using the chi(2)-test or Fisher's exact test for small sample. Comparison of continuous variables between two groups was analysed by t-test. RESULTS: The mean distance between external opening and anal verge in simple fistulae was 2.8 cm (range 1.5-4.3, SD 0.689) and in complex fistulae it was 4.4 cm (range 3.5-6.0, SD 0.526). This difference was statistically significant -P < 0.0001. Age and previous operations (particularly attempted definitive operations) were also significantly related to the complexity of the fistula. Data concerning location and direction of the fistulous tracts confirm the validity of Goodsall's rule. CONCLUSION: Simple preoperative clinical examination may reliably predict the complexity of a perianal fistula. Identification of these patients permits to select the cases that should have specific sophisticated preoperative work-up. The first definitive operation is most important to assure a successful outcome, thus such preoperative triage may also permit selective referral to a specialized colorectal team.

Duodenal necrosis as the presenting manifestation of polyarteritis nodosa.

Polyarteritis nodosa involves necrotising vasculitis of small and medium-sized arteries. Multiple organ systems are involved. A non-specific and slow course of disease is common. Gastrointestinal involvement is characterised by abdominal pain, nausea and vomiting. Bowel infarction and perforation, cholecystitis and hepatic infarction are well known complications. However, bowel infarction as the presenting symptom of the disease is rare. The case of a 20-year-old male with necrosis of the duodenum heralding polyarteritis nodosa is reported. The patient made a slow recovery after extensive abdominal surgery and a stormy course. The postoperative management and treatment of polyarteritis nodosa are discussed. A high index of suspicion and prompt multidisciplinary approach are needed in order to improve survival in these rare but potentially fatal conditions.

Sutureless closed hemorrhoidectomy: a new technique.

OBJECTIVE: To compare a new technique of radical hemorrhoidectomy using an electrothermal device originally devised to seal vessels in abdominal operations, with the conventional open Milligan-Morgan procedure performed with diathermy. SUMMARY BACKGROUND DATA: Hemorrhoidectomy is one of the most commonly performed anorectal operations. Two well-established methods, the "open" Milligan-Morgan excision and the "closed" Ferguson technique, both carry risks of postoperative bleeding, urinary retention, and late anal stenosis. The convalescence is similarly long and difficult after both operations. The quest for an improved technique of radical excision of hemorrhoids is justified. METHODS: In this case-control study, two groups of patients were alternatively allocated into study and control groups. In the study group (n = 40), an electrothermal system was used. The tissue fusion produced by this device consists of melting of collagen and elastin. This technique essentially achieves a sutureless closed hemorrhoidectomy. The operative time, postoperative complications, and time off work were compared with the group undergoing conventional Milligan-Morgan hemorrhoidectomy (control group, n = 40). RESULTS: The operative time and time off work were significantly shorter in the study group. There were also fewer postoperative complications in this group. CONCLUSIONS: The "tissue-welding" properties of this device and the shape of the electrode handpiece may be successfully applied to the performance of an operation most appropriately described as a "modified sutureless closed hemorrhoidectomy." This pilot study shows that this new technique is simple and safe, significantly shortens the operation, and is followed by a significantly easier and shorter recovery.

Complications of Milligan-Morgan hemorrhoidectomy.

Based on a retrospective review of a personal experience with 500 modified Milligan-Morgan hemorrhoidectomies, technical suggestions for avoiding early and late complications are presented. The problems of early and delayed bleeding, anal verge and mucosal stenosis, pain and prolonged healing due to persistent anal ulcer are discussed

Surgical treatment of leiomyosarcoma of the distal duodenum.

Malignant tumors of the small intestine are rare. An uncommon finding of leiomyosarcoma located in the fourth part of the duodenum was diagnosed by gastrointestinal contrast studies, CT and angiography. Although malignant lesions of the small bowel are usually diagnosed late and thus are far advanced, curative resection was possible in our case. The location and histology of the tumor permitted a 'pancreas-preserving segmental duodenectomy'. The operative approach and exposure using the Cattell maneuver is described. It is emphasized that the more extensive pancreatoduodenectomy should be reserved for adenocarcinomas or lesions situated in the proximal part of the duodenum. Thirteen years following the operation, the patient is asymptomatic while CT and gastrointestinal contrast studies reveal no evidence of disease.

Abdominal stoma fashioned by a used circular stapler.

A method of application of a used circular stapler in abdominal stoma formation is described. The procedure is rapid, simple, carries less tissue trauma than the conventional methods and does not involve any additional cost. It allows for a precise circular aperture in the abdominal wall which may be optimally adjusted to the bowel diameter. This method seems to minimize the occurrence of stomal complications and particularly the incidence of troublesome parastomal hernias.

Effect of rectal stump washout on the presence of free malignant cells in the rectum during anterior resection for rectal cancer.

PURPOSE: It is possible that implantation of viable malignant cells is one of the mechanisms of anastomotic recurrence in rectosigmoid cancer. The viability of shed intraluminal cells was previously established and malignant cells were retrieved on circular staplers in unwashed rectal stumps. The aim of this study is to evaluate the effectiveness of a defined and uniform washout protocol in eradication of intraluminal malignant cells during anterior resection. METHODS: In 14 consecutive patients the closed rectal stump was washed before insertion of the circular stapler. The washout was performed uniformly by instillation of ten increments of 50 ml of saline through a rectal tube. Samples from the first, fifth, and tenth washings were collected for cytologic examination. The presence or absence of malignant cells was then correlated with rectal stump length, length of the tumor-free distal margin, and differentiation and Dukes staging of the tumor. RESULTS: In 11 patients the first washing was positive for free malignant cells, and the fifth washing was still positive in 7 patients; however, the last (tenth) samples were clear in 10 patients, and malignant cells were recovered in only 4 patients. The rectal stump and the tumor-free distal margin were shorter in patients who still had positive cytology for free intraluminal malignant cells after stump irrigation with 500 ml of saline. No correlation was found with tumor differentiation or staging. CONCLUSIONS: Free malignant cells are shed into the rectal stump during anterior resection. Mechanical lavage with saline effectively eradicates these cells; however, the completeness of cleansing is volume related. Incomplete cleansing with 500 ml of saline correlates with lower tumors. Technically more difficult surgery involves traumatic handling of the tumor and possibly induces shedding of more malignant cells. We suggest that rectal stump washout during anterior resection for carcinoma should be routine, and the volume of the lavage fluid should be larger than 500 ml.

Previous trauma as a risk factor for recurrent trauma in rural northern Israel.

BACKGROUND: Recently, a few urban trauma centers reported on repetitiveness of injury in some population groups. The aim of this study is to evaluate the concept of "trauma recidivism" by measurement of the association of previous trauma events with acute trauma in a rural region of northern Israel with a specific sociocultural population mixture, low drug and alcohol abuse, and low levels of criminal activity. METHODS: A case-control study was conducted comparing 100 consecutive trauma cases with selected controls. The main predictor variable evaluated in this study was a history of previous significant traumatic events. Cases were defined as patients > 14 years of age hospitalized for acute trauma. Controls were selected from hospitalized patients with nontraumatic conditions. Logistic regression analysis was performed to adjust for potential sociodemographic confounding factors. RESULTS: The trauma group was significantly younger (p < 0.001) and predominantly male (p < 0.03). The incidence of "recurrent trauma" was highly significant in this group (p < 0.00001), and "injury-free intervals" were significantly shorter (p < 0.002). A history of previous significant traumatic events was a strong predictor for recurrent trauma (adjusted odds ratio, 10.36; 95% confidence interval, 3.10-34.58). Injury types and patterns differed in subgroups, although the demographic structure of the trauma recidivists group conformed to that of the general population. CONCLUSIONS: In this limited population study from rural northern Israel, a previous history of significant trauma is associated with recurrent trauma. Sociodemographic and cultural factors do not appear to be strong predictors for recurrent trauma. Further research investigating trauma recidivism is needed to clarify these relationships.

Varicocele treatment in pubertal boys prevents testicular growth arrest.

PURPOSE: There is evidence that varicocele damage, as reflected by loss of testicular mass, is most striking in the pubertal age group. We attempted to evaluate the long-term effect of early varicocele treatment on testicular growth and sperm count and, thus, determine its prophylactic value. MATERIALS AND METHODS: We compared testicular mass and sperm count in 32 men (mean age 28 years) who underwent surgery for varicocele at 11 to 15 years old (mean age 13) to those in 26 untreated, age matched men (mean age 30 years) with varicocele and 27 male controls (mean age 25 years). Mean followup in the treated group was 14.5 years (range 12 to 20). Testicular volumes were measured by ultrasonography. RESULTS: There was no significant difference between left and right testicular volumes in the treated or control group, in contrast to the untreated group, in which the left testicles were significantly smaller. Comparison of testicular mass showed a striking similarity between the treated and control groups, while there was a significant difference when the untreated group was compared to the control and operated groups. Total sperm counts were significantly less in the untreated than the treated and control groups. CONCLUSIONS: These data support the notion that testicular hypotrophy related to varicocele may be reversed by early intervention and they further strengthen the indication for varicocelectomy in children.

Richter's hernia--a surgical pitfall.

BACKGROUND: Although Richter's hernia was first described in 1598, little attention has been given to this topic in recent literature. The diagnosis of Richter's hernia is difficult because of the innocuous development of signs and symptoms and it is associated with a high mortality rate. Awareness of this relatively rare surgical entity is important. STUDY DESIGN: Of 350 patients with incarcerated hernias who underwent operation between 1977 and 1994 at the Department of Surgery "A," Assaf Harofeh Medical Center, 14 had strangulated Richter's hernia. A retrospective study was carried out in order to characterize the clinical manifestations of Richter's hernia and to assess preoperative delay, hospital stay, and complication and mortality rates. A comparison study was made with matched patients with strangulated hernias of non-Richter's type. Differences in morbidity and mortality rates, preoperative delay, and hospital stay of patients with Richter's hernias and the comparison group were evaluated. RESULTS: Of 14 patients with Richter's hernia, seven underwent intestinal resection. The hernia most commonly occurred at the femoral and inguinal sites. Compared with patients with other hernias, patients with Richter's hernias had greater preoperative delay, rate of bowel resection, length of hospital stay, and postoperative morbidity and mortality rates. CONCLUSIONS: Early operative intervention is the mainstay of successful management of Richter's hernia and awareness of this disease and its misleading clinical presentation is of utmost importance.

Laparoscopic simultaneous ligation of internal and external spermatic veins for varicocele.

The conventional treatment of varicocele consists of interruption of reflux in the internal spermatic vein either by open retroperitoneal high ligation, an open inguinal approach or percutaneous embolization. Recently, high ligation of the internal spermatic vein has been performed via laparoscopy. We previously suggested that ligation of the internal spermatic vein alone is not adequate, and a comparative study has shown that our method of trans-inguinal ligation of the internal and external spermatic (cremasteric) veins yields better surgical results. A laparoscopic version of this operation is described, which was performed in 25 patients for 31 ligations (6 bilateral cases). Short-term results (followup at 3 months) have shown that the procedure is safe and effective (no complications, 24-hour hospitalization and 1 case of persistence due to a technical error). This procedure seems to be an attractive alternative to our trans-inguinal combined approach especially if bilateral ligation is necessary.

Routine laparoscopic ultrasonography in biliary surgery. A preliminary experience.

A new technique of intraoperative imaging of the biliary tract in laparoscopic cholecystectomy is described. A specifically designed laparoscopic ultrasonographic probe is used to obtain both transverse and longitudinal views of the entire extrahepatic biliary tract. This technique was successfully used in 28 patients. The ultrasonographic imaging quality achieved equals our experience with intraoperative ultrasonography in open biliary surgery. It may be assumed, therefore, that the advantages of ultrasonography over cholangiography as documented in conventional open surgery will also apply to laparoscopic operations.