Laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer: initial Egyptian experience at the National Cancer Institute.

BACKGROUND: Laparoscopic gastrectomy has been used as a superior alternative to open gastrectomy for the treatment of early gastric cancer. However, the application of laparoscopic D2 lymphadenectomy remains controversial. This study aimed to evaluate the feasibility and outcomes of laparoscopic gastrectomy with D2 lymphadenectomy for gastric cancer. RESULTS: Between May 2016 and May 2018, twenty-five consecutive patients with gastric cancer underwent laparoscopic D2 gastrectomy: eighteen patients (72%) underwent distal gastrectomy, four patients (16%) underwent total gastrectomy, and three patients (12%) underwent proximal gastrectomy. The median number of lymph nodes retrieved was 18 (5-35). A positive proximal margin was detected in 2 patients (8%). The median operative time and amount of blood loss were 240 min (200-330) and 250 ml (200-450), respectively. Conversion to an open procedure was performed in seven patients (28%). The median hospital stay period was 8 days (6-30), and the median time to start oral fluids was 4 days (3-30). Postoperative complications were detected in 4 patients (16%). There were two cases of mortality (8%) in the postoperative period, and two patients required reoperation (8%). CONCLUSIONS: Laparoscopic gastrectomy with D2 lymphadenectomy can be carried out safely and in accordance with oncologic principles.

TRAM flap for immediate post mastectomy reconstruction: comparison between pedicled and free transfer.

UNLABELLED: Breast reconstruction after mastectomy is primarily carried out to improve the patients' quality of life. The most commonly used autologous tissue for reconstruction is the transverse rectus abdominis musculocutaneous flap (TRAM). The TRAM flap could be transferred either as pedicled or a free flap with microvascular anastomosis. The following work was carried out to evaluate the two techniques. PATIENTS AND METHODS: Thirty-one female patients with operable breast cancer consented to immediate breast reconstruction during the period from June 1998 to December 2000. Fifteen patients had a free TRAM flap reconstruction. In sixteen patients, a pedicled TRAM flap was used. Three patients in the pedicled group underwent bilateral breast reconstruction, thus there were 19 pedicled flaps available for evaluation. Four patients in the pedicled flap group underwent reduction mammoplasty of the normal breast and in five other patients a bipedicled flap was used to achieve size matching with the reconstructed breast. Criteria for analysis included operative data, hospital stay, donor site morbidity, abdominal wall integrity, flap related complications, fat necrosis and final aesthetic result. RESULTS: There was no difference between the two groups as regards age and, operative time. The pedicled flap group had shorter hospital stay and less blood loss than the free flap group, which was statistically significant (p=0.007 and p=0.001, respectively). In the pedicled flap group, two patients (10.5%) experienced partial flap loss and fat necrosis was detected in two other patients. For the free flap group, two patients (13.3%) developed complete flap loss, but none suffered fat necrosis. Donor site morbidity was equal in both groups. The total number of complications was higher in the pedicled group (7/19) (36.8.8%) than in the free flap group (5/15) (33.3 degrees k) but this was not statistically significant (p=0.27). None of the patients in both groups developed abdominal wall hernia, but abdominal wall weakness was evident in eight patients in the pedicled flap group that gradually improved over 2-3 months. Aesthetic results were comparable in both groups with a slightly better figure for the free flap group, but this was not statistically significant (p=0.23). IN CONCLUSION: Although free TRAM flap seems to provide several advantages over the pedicled group, namely skin volume available for harvesting, preservation of abdominal wall integrity, and better flap contouring, yet the pedicled TRAM flap is a reliable and easy technique that will produce matching aesthetic results.

Near total laryngectomy: a versatile approach for voice restoration in advanced T3 and T4 laryngeal cancer: functional results and survival.

PURPOSE: Creation of a tunneled mucosal shunt between the trachea and pharynx that is controlled by remaining intrinsic laryngeal musculature with its nerve supply is an acceptable voice restoration procedure for advanced T3 and T4 laryngeal cancer. Such a tunnel will allow unilateral direction of air from lung to pharynx during phonation and will prevent aspiration since deglutition is a vagal mediated response which will induce contraction of tubed laryngeal musculature preventing aspiration. We previously reported our preliminary experience with the technique and we adopted the voice restoration approach based on the concept of the near total laryngectomy thereafter. METHODS: Forty five patients with histologically proven squamous cell carcinoma of the larynx were included in this study (between January 1998 and February 2001). They were 42 males and 3 females with a mean age of 52.6 years. Criteria for selection were a normal vocal process and arytenoid cartilage on the opposite side of the lesion as evidenced by endoscopy and CT scan with no major subglottic extension. In two patients supraglottic laryngectomy was carried out and in four other patients, complete tumor extirpation necessitated total laryngectomy. Accordingly, near total laryngectomy was carried out in the remaining 39 patients. Following a near total laryngectomy, where all laryngeal mucosa and cartilages are resected sparing the contralateral arytenoid cartilage with the overlying mucosa and surrounding musculature, the shunt was created by tubing the remaining mucosa with augmentation by pyriform sinus mucosa if necessary. The resulting tube was fashioned over 14 FG catheter for diameter control only and the remaining muscles were sutured over the tube. A permanent tracheostomy was established. Voice training was started postoperatively following resumption of oral feeding. RESULTS: Only one patient died in the immediate postoperative period due to massive myocardial infarction. One patient developed reactionary hemorrhage that was explored and controlled. Minor salivary fistula developed in nine patients (23.1%) and all were managed conservatively, none required intervention. Two patients (7.6%) had a retracted tracheostomy that required refashioning. Thirteen patients (33.3%) suffered transient aspiration that resolved spontaneously, non required intervention. Six patients developed recurrent disease (15.8%). The overall two year disease free survival was 76%. None of the cases developed laryngeal mucosal recurrences. Intelligible speech was achieved in 31 patients (81.6%). In the seven patients with shunt failure, insertion of a one way valve was successful in five patients in restoring a good quality voice. CONCLUSION: Near total laryngectomy is an oncologically safe procedure with acceptable complications that are well tolerated. It represents an ideal solution for patients with advanced T3 and T4 laryngeal cancer. Voice quality is very good and it does not require further management as is the case with prosthetic voice shunt valves.