Impact of the Myotomy Extent on Gastric Side on Surgical Outcome After Heller's Cardiomotomy for Achalasia.

BACKGROUND: Laparoscopic Heller cardiomyotomy (LHM) with Dor fundoplication represents the most commonly accepted surgical management for achalasia. The ideal extent of myotomy on the gastric side remains a matter of continuous debate. The aim of this study was to compare the impact of the extent of myotomy on the gastric side on the outcome of LHM. PATIENTS AND METHODS: Patients with achalasia who underwent LHM included in the study. The patients were classified according to the length of the gastric myotomy into 3 groups (group I: <1.5 cm, group II: 1.5 to 2.5 cm, and group III: >2.5 cm). RESULTS: In total, 212 patients (94 males and 118 females) with achalasia treated by LHM and Dor fundoplication included in the study. No statistically significant differences were found among the 3 groups as regards preoperative data, intraoperative mucosal perforation, operative time, blood loss, and hospital stay. The incidence of persistent dysphagia was significantly higher in the group I. Postoperative GERD symptoms were significantly higher in group III (23.3%, P<0.0001). Recurrent achalasia was significantly higher in group I with 11 patients (15.9%), 8 patients in group II (7.1%), and nil in group III (P<0.02). CONCLUSIONS: Longer myotomy on the gastric side (>2.5 cm) ensures complete division of the LES with better outcomes in term of resolution of dysphagia but may be associated with higher postoperative GERD. Therefore, a myotomy length of 1.5 to 2.5 cm on the gastric side provides a balance between relieve of dysphagia and development of postoperative GERD.

Laparoscopic gastric plication: technical report.

BACKGROUND: Laparoscopic gastric plication is an emerging restrictive bariatric procedure but still lacks standardization of the technique. The aim of this study was to apply a standardized, modified 3-port approach to laparoscopic gastric plication to improve outcomes. METHODS: The modified laparoscopic gastric plication technique was applied for 63 morbidly obese patients between March 2010 and January 2013. There were 9 men and 54 women, with a mean age of 34.2 years (range 20-48 years) and a mean body mass index of 38.9 kg/m(2) (range 32-65 kg/m(2)). RESULTS: There were no deaths, no conversion to laparotomy, no reoperation, and no readmission. Percent excess weight loss was 41%, 52%, and 60% at 3, 6, and 12 months, respectively. There were no major complications reported in our study, but prolonged early postoperative nausea and vomiting occurred in 3 of 63 (4.8%) patients who had been successfully treated with proton pump inhibitors and antiemetics. CONCLUSIONS: Our initial experience showed that the 4-bite technique starting 2 cm below the angle of His with tight calibration of the gastric tube for obese patients is feasible, effective, and well tolerated, with a low frequency of major problems.

Functional outcome after Swenson's operation for Hirshsprung's disease.

BACKGROUND/AIM: Hirschsprung's disease (HD) is one of the most common causes resulting in lower intestinal obstruction in children with atypical clinical symptoms and inconspicuous morphological findings by barium enema X-ray. Recently, this situation has been largely ameliorated by improvement of instrument for measurement of anorectal pressure. By now, anorectal manometry has been regarded as a routine means for functional assessment and diagnosis of HD. It is accurate in nearly all cases of HD with characteristic absence of rectoanal inhibitory reflex. Different surgical modalities of treatment are available and Swenson's operation is one of the surgical procedures done for HD. Anorectal manometric findings may change after Swenson's operation with improvement of rectoanal inhibitory reflex in some cases. We aimed to evaluate functional results after Swenson's operation for HD using anorectal manometry. PATIENTS AND METHODS: Between 1996 and 2005, 52 patients were diagnosed with HD and operated upon by Swenson's operation in Gastroenterology Center, Mansoura University. There were 33 males (63.46%) and 19 females (36.54%) with a mean age of 3.29 +/- 1.6, (range 2-17 years). Anorectal manometry and rectal muscle biopsy were done preoperatively for diagnosis but after operation anorectal manometry was done after every six months and then yearly. RESULTS: All of the 52 patients showed absent rectoanal inhibitory reflex on manometric study with relatively higher resting anal canal pressure and within normal squeeze pressure. Postoperatively, there were 35 continent patients (67.31%) with 11 patients (21.15%) showing minor incontinence and six (11.54%) with major incontinence. On the other side, there were five patients (9.62%) with persistent constipation after operation (three due to anal stricture and two due to residual aganglionosis). Postoperative manometric study showed some improvement in anal sensation with the rectoanal inhibitory reflex becoming intact in six patients (11.54%) four years after operation. CONCLUSION: Anorectal manometry is a more reliable method for diagnosis of HD than barium enema X-ray but for final diagnosis, it is reasonable to combine anorectal manometry with tissue biopsy. Functional outcome after Swenson's operation for HD may improve in some patients complaining of incontinence or constipation. Anorectal manometry may show improvement of the parameters after Swenson's operation.

p53 expression and DNA ploidy pattern in Egyptian colorectal carcinoma.

BACKGROUND/AIMS: p53 gene mutation occurs in about 50-60% of colorectal carcinoma cases. This mostly occurs as a late event in the adenoma-carcinoma sequence. These late stages are associated with more aneuploidy compared to adenomas and early carcinomas. However there is a controversy regarding the relation between p53 overexpression and DNA index. This study was designed to investigate the relationship between p53 status and DNA ploidy pattern. METHODOLOGY: Nuclear DNA content of paraffin-embedded material from 83 colectomy specimens for colorectal carcinoma was measured by flow cytometry. Also, p53 was detected by immunohistochemistry in 73 out of the 83 tumor cases using a monoclonal antibody that detects both wild and mutant p53 proteins (Biogenex 1801). RESULTS: Aneuploidy was identified in 37 cases (46.25%). Tumors with rectal location were significantly more aneuploid in comparison to other sites (P = 0.009), p53 staining showed three patterns: diffuse staining (29 cases), focal (13 cases), and negative (31 cases). Diffuse p53 staining was associated with aneuploidy (P = 0.04). The majority of DNA indices fell within the range 1.1-2.2 (32 out of 37). Twenty-one of these had DNA index = 1.1-1.8 (aneuploidy short of tetraploidy) significantly associated with diffuse p53 staining compared with peritetraploid cases (DNA index 1.8-2.2) (P = 0.034). CONCLUSIONS: p53 immunohistochemistry demonstrates two distinct patterns in colorectal carcinoma. Diffuse p53 staining, which is associated with aneuploidy short of tetraploidy (DNA index 1.1-1.8), a finding which is different from previously published work. Focal p53 staining pattern, in contrast, is related to high G2M and more abnormal tetraploid peaks but less aneuploidy.