Ileoileal intussusception in unspecific recurrent abdominal pain in adult: A case report.

Primary small bowel tumours are very uncommon accounting about 1% of all gastrointestinal tumours. Intestinal lipomas are a rare entity of benign tumours with an incidence at autopsy ranging from 0.04% to 4.5%, most being asymptomatic. Complications such as obstruction, haemorrhage, intussusception and perforation might demand invasive management. Among these, intussusception is the most rare complication of intestinal lipomas. Here, we present a case of intussusception in a 52-year-old female with a large intramural lipoma of the ileum.

Does hyperthermic intraoperative chemotherapy lead to improved outcomes in patients with ovarian cancer? A single center cohort study in 111 consecutive patients.

BACKGROUND: For recurrent disease or primary therapy of advanced ovarian cancer, cytoreductive surgery (CRS) followed by adjuvant chemotherapy is a therapeutic option. The aim of this study was to evaluate the outcome for patients with epithelial ovarian cancer treated with hyperthermic intraoperative chemotherapy (HIPEC) and completeness of cytoreduction (CC). METHODS: Data were retrospectively collected from 111 patients with recurrent or primary ovarian cancer operated with the contribution of visceral surgical oncologists between 1991 and 2006 in a tertiary referral hospital. RESULTS: Ninety patients received CRS and 21 patients CRS plus HIPEC with cisplatin. Patients with complete cytoreduction (CC0) were more likely to receive HIPEC. Overall, 19 of 21 patients (90.5 %) with HIPEC and 33 of 90 patients (36.7 %) with CRS had a complete cytoreduction (P < 0.001). Incomplete cytoreduction was associated with worse survival rates with a hazard ratio (HR) of 4.4 (95%CI: 2.3-8.4) for CC1/2 and 6.0 (95%CI: 2.9-12.3) for CC3 (P < 0.001). In a Cox-regression limited to 52 patients with CC0 a systemic concomitant chemotherapy (HR 0.3, 95%CI: 0.1-0.96, P = 0.046) but not HIPEC (HR 0.98 with 95 % CI 0.32 to 2.97, P = 0.967) improved survival. Two patients (9.5 %) developed severe renal failure after HIPEC with absolute cisplatin dosages of 90 and 95 mg. CONCLUSIONS: Completeness of cytoreduction was proved to be crucial for long-term outcome. HIPEC procedures in ovarian cancer should be performed in clinical trials to compare CRS, HIPEC and systemic chemotherapy against CRS with systemic chemotherapy. Concerning the safety of HIPEC with cisplatin, the risk of persistent renal failure must be considered when dosage is based on body surface.

Selective decontamination of the gastrointestinal tract in patients undergoing esophageal resection.

BACKGROUND: Selective decontamination of the digestive tract (SDD) to eliminate gram-negative bacteria is still not widely accepted, although it reduces the incidence of nosocomial infections. In a previous retrospective study, a clear benefit to perioperative morbidity, and a reduction in nosocomial infections were found in patients who underwent an esophageal anastomosis. Thus, SDD was applied routinely for esophageal anastomoses. We report the outcome of a cohort of 81 patients who underwent this treatment. METHODS: From 2002, patients who underwent an esophageal anastomosis (esophagojejunostomy) were prospectively recorded. Perioperatively, patients received polymyxin, tobramycin, vancomycin and nystatin by mouth four times a day. Outcome was compared to a control group that was treated before 2002 (68 patients without SDD and 53 patients with SDD). Postoperative morbidity and mortality were assessed. RESULTS: Between 2002 and 2007, 81 patients who underwent an esophageal anastomosis received SDD. Compared to a retrospective control group, patients with SDD had significantly less pneumonia (OR 0.06 (0.01-0.46), p < 0.001) and lower morbidity (OR 0.16 (0.05-0.49), p < 0.001). Furthermore, fewer anastomotic insufficiencies and complications were found. Similar results were found in the analysis of the patients treated before 2002. CONCLUSIONS: SDD significantly reduces perioperative morbidity and mortality in patients who undergo a distal esophageal anastomosis compared to a historical control group. In patients with an anastomotic leakage, there was a strong tendency of SDD to reduce postoperative mortality.

Limited predictive value of FDG-PET for response assessment in the preoperative treatment of esophageal cancer: results of a prospective multi-center trial (SAKK 75/02).

BACKGROUND: Only responding patients benefit from preoperative therapy for locally advanced esophageal carcinoma. Early detection of non-responders may avoid futile treatment and delayed surgery. PATIENTS AND METHODS: In a multi-center phase ll trial, patients with resectable, locally advanced esophageal carcinoma were treated with 2 cycles of induction chemotherapy followed by chemoradiotherapy (CRT) and surgery. Positron emission tomography with 2[fluorine-18]fluoro-2-deoxy-d-glucose (FDG-PET) was performed at baseline and after induction chemotherapy. The metabolic response was correlated with tumor regression grade (TRG). A decrease in FDG tumor uptake of less than 40% was prospectively hypothesized as a predictor for histopathological non-response (TRG > 2) after CRT. RESULTS: 45 patients were included. The median decrease in FDG tumor uptake after chemotherapy correlated well with TRG after completion of CRT (p = 0.021). For an individual patient, less than 40% decrease in FDG tumor uptake after induction chemotherapy predicted histopathological non-response after completion of CRT, with a sensitivity of 68% and a specificity of 52% (positive predictive value 58%, negative predictive value 63%). CONCLUSIONS: Metabolic response correlated with histopathology after preoperative therapy. However, FDG-PET did not predict non-response after induction chemotherapy with sufficient clinical accuracy to justify withdrawal of subsequent CRT and selection of patients to proceed directly to surgery.

Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction.

BACKGROUND AND AIMS: Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage. MATERIALS AND METHODS: Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3-4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively. RESULTS/FINDINGS: No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023). INTERPRETATION/CONCLUSION: Patient's safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.

Altered esophageal motility and gastroesophageal barrier in patients with jejunal interposition after distal esophageal resection for early stage adenocarcinoma.

INTRODUCTION: Limited resection of the esophagogastric junction has been proven to be safe and oncologically radical in patients with early esophageal cancer. Reconstruction with interposition of isoperistaltic jejunal loop (Merendino procedure) is supposed to prevent gastroesophageal reflux and therefore the recurrence of intestinal metaplasia at the anastomosis. The aim of this study was to assess the frequency of acid and nonacid refluxes after Merendino procedure using multichannel intraluminal impedance-pH (MII-pH) monitoring. PATIENTS AND METHODS: Between 2002 and 2005, 12 patients with esophageal adenocarcinoma underwent limited resection and jejunal interposition. Ten patients agreed to undergo a Gastrointestinal Symptom Rating Scale assessment, upper gastrointestinal (GI) endoscopy, esophageal manometry, and combined 24-h MII-pH monitoring more than 10 months postoperatively. RESULTS: Postoperatively, 4 (40%) patients reported belching without heartburn or acid regurgitation, 3 of them having a positive symptom index during 24-h MII-pH monitoring. Upper GI endoscopy revealed no inflammation, metaplasia, or stenosis at the esophagojejunal anastomosis. Esophageal manometry showed ineffective esophageal motility in four of ten patients. Combined 24-h MII-pH monitoring revealed normal distal esophageal acid exposure (% time pH < 4: 0.1% [0-1.5]), normal number of acid reflux episodes (3 [0-11]) but a high number of nonacid reflux episodes (82 [33-184]). Overall, eight patients revealed an abnormal number of nonacid reflux episodes. CONCLUSION: The limited resection with jejunal interposition for early esophageal cancer is efficient in controlling acid but not nonacid reflux. While the clinical relevance of nonacid reflux in the recurrence of Barrett's esophagus is currently unknown, endoscopic surveillance should be considered in these patients.