A pilot study on disturbed gastric myoelectric activity in obstructed defecation syndrome.

BACKGROUND: Electrogastrography (EGG) is a noninvasive technique for recording gastric myoelectric activity. The aim of this study was to measure and record gastric myoelectric activity in patients with obstructed defecation syndrome (ODS) and to compare their results with those of normal individuals. METHODS: Forty-two patients (22 male) with ODS and a mean age of 41.02 y were enrolled in this prospective study after thorough clinical and physiologic assessment. Eleven normal subjects (six female) with a mean age of 39.2 ± 8.4 y were assigned to the control group. Both patients and controls were subjected to surface EGG in fasting and postprandial states. Data were recorded and analyzed via a computer system to reveal the EGG pattern in both groups. RESULTS: Abnormalities in the EGG were found in 24 (57.1%) of the 42 patients with ODS. EGG in ODS patients showed alterations in the fasting state in the form of a significant decrease of the normal gastric slow wave (P = 0.03) and a nonsignificant increase in gastric dysrhythmias. The EGG alterations of ODS patients were significantly improved in the postprandial state as the normal gastric slow waves significantly (P = 0.006) increased and the gastric bradycardia declined significantly (P = 0.02). No significant differences were observed in the power distribution between the ODS patients and the healthy controls. CONCLUSIONS: Patients with ODS showed an altered EGG pattern compared with that of healthy control subjects. The alterations in ODS patients were more clearly observed during the fasting state and improved significantly after eating.

Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases.

AIM: To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors. METHODS: This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017). RESULTS: The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods. CONCLUSION: Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Comparative Study Between Laparoscopic Heller Myotomy Versus Pneumatic Dilatation for Treatment of Early Achalasia: A Prospective Randomized Study.

INTRODUCTION: Achalasia is an incurable primary motor disorder of the esophagus. The best treatment modality for achalasia is still controversial. This study compared the short- and intermediate-term outcome between endoscopic pneumatic dilatation (EPD) versus laparoscopic esophageal myotomy (LEM) for the management of adult patients with early-stage achalasia. PATIENTS AND METHODS: This was a prospective randomized controlled study of adult patients (20-50 years old) who presented with early-stage achalasia (esophageal diameter of <3.5 cm on contrast esophagography). Patients were classified into two groups according to the method of management: Group A patients were treated with LEM, whereas Group B patients were treated with EPD. Follow-up evaluations were conducted at 1 week, 3 months, 6 months, and then 1 year. RESULTS: In total, 50 patients were managed for a manometrically confirmed diagnosis of achalasia. The median age of presentation was 31.5 years, with a male-to-female ratio of 0.4:1. Both groups were comparable regarding patient demographics and preoperative severity of the condition. The rate of symptoms relief was 76% in EPD compared with 96% in LEM (P=.04). There was a significant lowering of lower esophageal sphincter in the LEM group (P=.0001). Perforation of the esophagus occurred in 8% of the patients during EPD, whereas mucosal tears occurred in 4% of the patients during LEM. Reflux symptoms developed in 28% and 16% of the patients in the EPD and LEM groups, respectively. CONCLUSIONS: LEM was more effective clinically and manometrically for patients with early-stage achalasia than EPD. There was no significant difference between the two procedures regarding complications.

Laparoscopic Heller myotomy for achalasia: analysis of successes and failures.

BACKGROUND/AIMS: The outcome of laparoscopic myotomy for achalasia is dictated by many factors. METHODOLOGY: A retrospective study was conducted between 1997-2007, 58 patients who fulfilled all criteria for the diagnosis of achalasia underwent laparoscopic Heller myotomy and 45 (77.6%) were included. Mean follow-up period was 36±15 months; 56 patients had Dor fundoplication; 17 patients had been previously treated by pneumatic dilatation. All steps of the procedure, esophageal manometric findings and radiological records were analyzed to determine factors contributing to the clinical success or failure of the operation. The main outcome measure was swallowing status. RESULTS: Median hospital stay was 3±1 days and mean operative time was 75±20min. There were 7 intra-operative mucosal injuries; all sutured laparoscopically (5 had previous pneumatic dilatation). Good or excellent relief of dysphagia was obtained in 41 patients and was persistent among 2 patients (both had pneumatic dilatation preoperatively). The remaining 2 patients developed gastroesophageal reflux symptoms. These 41 patients had a preoperative smaller diameter of the esophagus (stage I, II and III), while those with guarding results (4) had stages III and IV. There was a decrease in LES pressure from 45±7mmHg to 10±2mmHg without evidence of restoration of esophageal peristalsis in any patient. CONCLUSIONS: Laparoscopic Heller myotomy with Dor fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. A good postoperative result is expected when the length of myotomy is adequate, LES pressure declines substantially, preoperative esophageal dilation is not excessive and distortion of the distal esophagus is absent.

Surgical management of gastric gastrointestinal stromal tumor: a single center experience.

BACKGROUND/AIM: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgery remains the mainstay of curative treatment. Our objective is to evaluate the outcome of surgical treatment of primary gastric GIST. MATERIALS AND METHODS: Between January 1997 and April 2008, thirty seven consecutive patients underwent resection for GISTs (35 patients with primary gastric GISTs and two patients with intestinal GISTs who were excluded from the study). These patients underwent upper endoscopy ± biopsy, barium meal and abdominal CT scan. Patients' demographics and clinical presentations were analyzed. Perioperative parameters measured included operative times, estimated blood loss, intraoperative finding, surgical techniques, morbidity and length of hospitalization. Recurrence and survival were also analyzed. RESULTS: Of the 35 patients with gastric GISTs included in the study, 63% were female. The median age was 59 ± 14 years (range, 23 to 75 years). The primary presenting symptoms were bleeding and dyspepsia; 43% of these tumors were located mainly in the body of the stomach. Tumor size was < 10 cm in 80% of the patients. The average tumor size was 6.3 ± 3.2 cm (range from 3 to 13 cm). Regarding the surgical management, 20 patients (57%) underwent gastric wedge resection, eight patients (23%) underwent partial gastrectomy and the remaining seven patients (20%) underwent total gastrectomy. Radical resections were found in 32 patients (91.5%) while palliative resections were found in three patients (8.5%). The resected lymph nodes were negative in 32 patients (91.5%). Recurrence was noted in three patients, with a median time to recurrence of 14.3 months (range, 7 to 28 months). The three- and five-years survival in patients who underwent wedge resection was 92% and 81%, respectively, where it was 95% and 87%, respectively, in patients who underwent gastrectomy (either partial or total). There were no major intraoperative complications or mortalities. CONCLUSION: Complete surgical resection either through wedge resection or gastrectomy with negative margins remains the gold standard treatment in the management of patients with primary resectable gastric GISTs.

Implications of CEA and p53 overexpression in the poor prognosis of colorectal cancer.

Colorectal cancer (CRC) is one of the most frequent and aggressive types of cancer. Several clinicopathologic features have been studied to identify the prognostic factors that can provide information concerning the favorable or the poor outcome of colorectal cancer. In the present study, the relationship between serum CEA, p53 expression, and DNA index to the different clinicopathological characteristics of colorectal cancer patients was sought. Fifty patients with CRC were included in this study. p53 protein was detected immunohistochemically using specific monoclonal antibodies. Samples were investigated for DNA index using flow cytometry. In addition, the serum CEA was determined using ELISA. The results showed that 27/50 (54%) were positive for p53. Concerning CEA reactivity, it was found that 35/50 (70%) were reactive for CEA. These results indicate that CEA is more sensitive than p53 to detect colorectal cancer. There was a statistically significant difference between the recurrent and nonrecurrent groups in the CRC Duke's stages, survival time, serum CEA (p = 0.001, 0.016, < 0.001, respectively). Kaplan-Meier method and log-rank test showed that the mean survival time for cases positive for both p53 and CEA is significantly different from cases positive for CEA only, positive for p53 only, and negative for both p53 and CEA (p = 0.0002). Survival time was statistically significant with respect to sex, p53, CEA, and Duke's stages (p = 0.006, 0.024, 0.001, 0.017, respectively). Cox regression model showed that the prognosis of colorectal cancer is influenced by sex, p53, CEA reactivity, and CRC Duke's stages (p = 0.014, 0.006, 0.019, 0.014, respectively). In conclusion, the use of more than one tumor marker may successfully aid in the prediction of colorectal cancer prognosis.

p53, Bcl-2 and C-Myc expressions in colorectal carcinoma associated with schistosomiasis in Egypt.

BACKGROUND AND AIMS: Oncogenes and tumor suppressor genes expression are well described in bladder cancer associated with schistosomiasis especially in Egypt. Scarce studies were directed to colorectal cancer (CRC) associated with Schistosoma mansoni (S. mansoni). Apoptosis (programmed cell death) and the genes regulating this process (e.g., Bcl-2) have recently become a focus of interest in the study of cancer development and progression. In the present study, we aimed to investigate the expression pattern of p53, Bcl-2 and C-Myc in CRC tissues obtained from Egyptian colorectal cancer patients divided in two different groups, one associated with Schistosoma mansoni (CRC-Sm) and the other without Schistosoma mansoni (CRC-NSm). METHODS: Seventy-five CRC tumors containing 36 draining lymph node metastatic tumors were immunohistochemically stained using specific monoclonal antibodies for p53, Bcl-2 and C-Myc, in addition the apoptotic activity of these tumors were analyzed. RESULTS AND CONCLUSIONS: Regardless of the S. mansoni infection, the obtained results showed that the apoptotic activity was more evident in p53 diffuse positive tumors (P = 0.021). There was a significant correlation between p53 diffuse positive staining and Bcl-2 positive immunostaining (P = 0.011). Signet ring cell carcinoma and mucinous adenocarcinoma exhibited both intense C-Myc expression than non-mucinous carcinoma (P = 0.001). When adjusting for S. mansoni infection, 58.3% of CRC-Sm cases were Bcl-2 positive compared to only (33.3%) of CRC-NSm (P = 0.046). Apoptotic activity was more evident in the latter group than of CRC-Sm tumors (P = 0.009). p53 and C-Myc expressions were found insignificantly different in CRC-Sm compared with CRC-NSm (P > 0.05). These observations suggest that the genotoxic agents produced endogenously through the course of schistosomiasis mansoni may play a role in CRC-Sm pathogenesis through the dysregulation of apoptosis by alteration the expression pattern of Bcl-2 protein differently from CRC-NSm suggesting a different biological behavior.

Nissen fundoplication in infants and children: a long-term clinical study.

BACKGROUND/AIMS: Infants and children who underwent open Nissen fundoplication for gastroesophageal reflux disease were retrospectively evaluated to assess the success and complications of this operation. METHODOLOGY: Twenty-six neurologically normal children (16 boys and 10 girls between 6 months and 11 years old) underwent Nissen fundoplication for intractable or complicated gastroesophageal reflux between October 1982 and February 2002. Before surgery and at follow-up visits, all children were subjected to thorough history, barium meal study and gastroscopy with multiple esophageal biopsies. The median follow-up period was 28 months (range: 11 months-19 years). RESULTS: Persistent vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%), chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth were found in 4 patients (15.4%), hematemesis and/or melena occurred in 2 patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients (15.4%). There was no mortality. The mean hospital stay was 4.1 days. Twenty-two patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases (15.4%). One of these cases had no evidence of recurrent pathological reflux, 2 cases with preoperative stricture developed wrap disruption, recurrent reflux and re-stricture. Both refused a second operation. The fourth case developed melena and reflux esophagitis due to wrap herniation through the hiatus and was successfully managed by a second operation. CONCLUSIONS: Nissen fundoplication is an effective operation to correct gastroesophageal reflux in infants and children when the drug therapy fails. The operation should be done before occurrence of complications to decrease the recurrence of reflux.