[Results and prognostic factors in rectal cancer surgically treated with curative intent--experience of a single tertiary center]

BACKGROUND

Rectal cancer has a paradoxal prognosis in about 25% of patients, although intraoperative parameters and tumor stage are known as major determinants of prognosis.

AIM

This study assessed the prognostic factors in patients with rectal cancer treated without total mesorectal excision in long-term follow-up.

MATERIAL AND METHODS

A single center tertiary population included retrospectively 87 patients with rectal cancer operated between 1992 and 2002 using conventional resection. Some 90.5 per cent of the patients had surgery alone and 9.5 per cent had postoperative radiochemotherapy. Patients who did not have adenocarcinoma, those in whom the curative operation was not done, and those who received preoperative radiotherapy were excluded. Median follow-up was 7 years.

RESULTS

Seven-year cancer specific survival was 52% (95% CI:3.21) and only pT, pN and lymphatic invasion were significant as prognostic factors on multivariate analysis. Disease free cancer survival was 56% and only lymphatic invasion was significant for prognosis. The risk of death was higher for abdomino-perineal resection (APR) than for anterior resection (AR), advanced pT stage, vascular and perineural invasion. Local recurrence and distant metastasis were 12.6 and 26.43 per cent respectively for patients. The risk for local reccurence was higher for advanced pT stage, perineural and lymphatic invasion and distal margin invasion. The risk for metastasis was higher for advanced pT stage and vascular invasion.

CONCLUSION

Advanced tumor stage and lymphatic invasion represent prognostic factors in rectal cancer, suggesting the necessity of adjuvant therapy in cases with lymphatic invasion.

Evaluation of the combined laparoscopic and mediastinoscopic esophagectomy technique

BACKGROUND

Laparoscopic esophagectomy is technically difficult especially during dissection in the upper mediastinum. This limitation may be surpassed with the help of mediastinoscopy or of the recently introduced robotic surgical systems. The aim of the present study was to evaluate in an experimental porcine model the feasibility of the combined laparoscopic and mediastinoscopic transhiatal esophagectomy technique and to compare it with the robotic-assisted transhiatal and conventional approaches.

MATERIALS AND METHODS

Transhiatal esophagectomy was performed in Landrace pigs under general anesthesia using three different techniques: Group A (n = 9): combined laparoscopic and mediastinoscopic, group B (n = 4): robotic-assisted and group C (n = 8): conventional "open". The feasibility, difficulty and accuracy of the procedure along with operative time, blood loss, intraoperative incidents and overall satisfaction of the surgical team were assessed for each technique.

RESULTS

Operations in group A were feasible and reproducible. Although the procedure was technically difficult, the constant view on the operative field was highly appreciated by the operative team and facilitated an accurate and safe dissection. The main intraoperative complications were related to the side-effects of tension pneumothorax accompanying pleural injuries. In group B the features of the robotic system reduced the difficulty of dissection and obviated the need for mediastinoscopy. Operations in group C were quick and almost incident-free, facilitated also by the particularities of the animal model that could not reproduce identically the clinical situation.

CONCLUSIONS

The combined laparoscopic and mediastinoscopic esophagectomy technique is feasible and offers certain advantages over the open approach while the robotic-assisted approach is an emerging less difficult alternative. Further studies are required to establish whether the advantages of minimally-invasive approach compensate for the increased technical difficulty and prolonged operative time.

Gas-chamber mediastinoscopy for dissection of the upper esophagus

AIM

Mediastinoscopy has the potential to bring under view the upper mediastinum, the area most difficult to dissect during transhiatal esophagectomy. The aim of the present study was to evaluate in an animal model the feasibility of the gas-chamber mediastinoscopy technique for dissection of the upper esophagus.

METHODS

Operations were performed in nine Landrace pigs using a 30 degrees laparoscope and conventional 35-cm laparoscopic instruments. Through a left collar incision a virtual space was created with sharp and blunt dissection around the cervical esophagus and insufflated with CO2 at a pressure of 5 mmHg. Using one 10-mm optical trocar and two 5-mm working trocars dissection advanced in the periesophageal space with the aim to reach at least to the tracheal bifurcation.

RESULTS

Performed under visual control, the procedure was accurate and safe, the level of tracheal bifurcation being reached in all cases. Anatomical structures such as trachea and its bifurcation, pleura, pericardium, arch of the azygos vein and periesophageal lymph nodes were visible during the operation. There were no major intraoperative incidents and blood loss was minimal.

CONCLUSIONS

The technique of gas-chamber mediastinoscopy is feasible. It allows a fair amount of freedom of movement for the working instruments and offers a good view on the operative field for a controlled and accurate dissection. Further evaluation in experimental and clinical studies is required to establish the role of this procedure in esophageal surgery.

Surgical treatment of severe acute pancreatitis

Surgical treatment of severe necrotizing pancreatitis (SNP) is still controversial, inadequate indications and timing of operations being associated with high rates of mortality and morbidity. The aim of the present study is to analyze the indications and results of surgery in patients with SNP. Between 1989 and 2005, necrosectomy followed by open packing drainage (OPD) was performed in 80 patients with SNP. Timing of operations was individualized according to presence of pancreatic necrosis infection. Major postoperative complications were present in 34 patients (42.5%), pancreatic, enteric and biliary fistula, sepsis, iatrogenic bleeding and stress-ulcers being among the most frequently encountered. Secondary contamination of sterile pancreatic necrosis after OPD occurred in 13 patients (35.1%). The overall mortality rate was 32.5%, aggravation of MOF and septic shock being the main causes of death. Late surgical cure for OPD-related incisional hernia was required in 10% of the patients. Infection of pancreatic necrosis is an indication for urgent surgical necrosectomy and repeated re-debridements. Due to technical impossibility to perform adequate necrosectomy and the risk of MOF aggravation, early surgery is not recommended in patients with sterile necrosis. It should be postponed beyond the third week, when the biological condition of the patient is improved and delimitation of necrosis is complete. OPD is an adequate and efficient drainage procedure following necrosectomy. "Prophylactic" OPD for sterile necrosis is not recommended because it is associated with high morbidity rates and secondary infection of necrosis.

[Conservative management in blunt splenic trauma]

We reviewed for analysis the charts of two groups of adults patients with blunt splenic injuries issued from two University Hospital Centers; the group 1 (G1) of 22 patients and the group 2 (G2) of 20 patients. The results of actually therapeutic procedures concerning blunt splenic injuries and subsequently the effectiveness of non operative treatment were evaluated. Splenectomy was performed in G1 for 11 patients, instead of 19 patients in G2 (p = 0.0003), whereas, the non surgical treatment was done in 9 patients and 1 patient, respectively (p = 0.02). The mean Splenic Injury Score (SIS) was 2,95 in G1 and 3.47 in G2 (p = 0.03). The spleen was preserved in G1 for 8 patients, instead 1 patient in G2 (p = 0.04). In G1, the non operative treatment was successfully accomplished in 66% of patients. It was obtained with lack of mortality, with a lower overall morbidity and a lower length of hospital stay than in splenectomized patients, but the latter group accounted higher values of Injury Severity Scores (p < 0.05). If proper selection criteria for non operative management are used, more than a third of patients with blunt splenic injury can be treated by splenic preservation at least as safely as splenectomized patients.

[Stapled anastomoses in colorectal surgery]

The purpose of this paper was to analyze the advantages, indications and results of stapled circular anastomoses in colorectal surgery. In the last four years (1995-1998), fifteen patients underwent stapled anastomoses after Dixon's anterior rectal resection for cancers of upper and midrectum (11 patients), total colectomy with ileorectal anastomosis for malignant familial polyposis (1 patient), segmental colectomy of transverse and descending colon (1 patient with synchronous colic and rectal cancers, having concomitant rectal resection for cancer), previous Hartmann's resection for perforated upper rectal cancer (1 patient) or distal sigmoid diverticulitis (1 patient). The anastomoses have been performed in end-to-end fashion (11 patients), according to the Knight's technique (2 cases) or in side-to-end fashion (2 patients). As most frequent associated technique with stapled anastomoses, anterior rectal resection for cancer was performed with 2 cm of clearance beyond the macroscopic margin of tumor. Distal margin of resection was histologically verified and it proved to be free of tumor cells. There was no operative mortality. Anastomotic leakage occurred in three patients because of imperfection of stapled anastomosis (2 cases) or after local irradiation (1 case). Spontaneous closure was seen in one patients. The other two patients needed reoperation for suture or colostomy. Late clinical, endoscopic and X-ray controls did not discover local recurrences. Functional results were good in terms of stool frequency and continence. In conclusion, stapled fashioned anastomoses have the main indication in sphincter saving Dixon's and Hartmann's procedures. In these cases, stapled anastomoses are easier than manual technique, reduce operative time and improve suture reliability.

[The indications for celiostomy in acute necrotizing pancreatitis]

The aim of this study was to analyze the indication and results of open pancreatic drainage by celiostomy in severe necrotizing pancreatitis (SNP). 44 patients with SNP were treated surgically by open lesser-omental sac drainage (celiostomy) in the last nine years (1989-1997). They were classified into three groups according to date (timing) of celiostomy: a group of 23 patients with early celiostomy (in the first week after the onset of pancreatitis); second group of 11 patients with celiostomy in the second and third week after SNP; the third group of 10 patients with late celiostomy (4-12 weeks after pancreatitis). Drainage procedure consisted in marsupialization of lesser omental sac by suturing open gastrocolic ligament to anterior peritoneum, with drains inserted via celiostomy. The indications of celiostomy in the first group were: diagnostic laparotomy for unknown acute abdomen (18 patients), severe acute cholecystitis (1 patient), common bile duct stones (2 patients), persistent MOSF (1 patient). The necrosectomy was technically possible only in eight patients (34.7%) at date of laparotomy. Postoperative infection of necrosis occurred in seven patients (30.4%) and nine patients died postoperatively (39.1%) because of aggravated MOSF. In the second group, celiostomy was carried out for extensive sterile (2 patients) or infected necrosis (9 patients). Good results were obtained in 9 patients and two patients with infected necrosis died postoperatively. In the third group late celiostomy was performed for treatment of the pancreatic abscess, with good results in all patients (0% mortality). In conclusion, celiostomy is drainage procedure of choice for patients with extensive infected pancreatic necrosis or pancreatic abscesses and stable biologic condition. It facilitates intermittent debridements of residual necrosis and purulent foci, without relaparotomies. Early celiostomy is not recommended as it is proved ineffective (nondemarcated necrosis) and may cause aggravation of SNP or exogenous infections of necrosis.

[Total gastrectomy with mechanical sutures]

Between 1994-1996, nine consecutive patients underwent total gastrectomy with stapled sutures for II, III or IV TNM stage carcinoma (8 patients) or lymphoma (1 patient) of the middle or upper stomach. Digestive continuity was established by stapled end-to-side "ended", end-to-side and end-to-end Roux-en-Y (7 patients) and omega loop (2 patients) esophagojejunal anastomoses using circular staplers (EEA or ILS). The duodenal stump and the end of the Roux loop were closed with TA 55 or TA 30 linear stapler. Interjejunal anastomoses were hand sewn. Nasojejunal feeding catheter was placed for ten days in all patients. No postoperative mortality non anastomotic fistula occurred. One patient had duodenal stump leakage which closed spontaneously. In three patients postoperative chemotherapy with 5-FU and Leucovorian was associated. At late follow-up, there were two patients with reflux esophagitis cured by medical treatment and one patient with peritoneal and hepatic metastases at relaparotomy. In conclusion, the use of stapled sutures in total gastrectomy facilitates esophagojejunal anastomosis and improves suture reliability.

[Sclerosing cholangitis in the evolution of a surgical hepatic hydatid cyst]

The retrospective analysis of 3 clinical observations points out the etiopathogenetic, clinical and therapeutical aspects of the diffuse stenotic cholangitis, which can occur after the surgical treatment of the hepatic hydatid cyst. Although rare (2.9% of hydatid cysts, 13% of those which communicate with the bile ducts), the diffuse stenotic posthydatid cholangitis represents a severe postoperative complication in cases of median cysts, exerting a compression upon the convergence of hepatic ducts and communicating with the biliary tract. Its presence should be clinically suspected if a mechanical icterus with septic angiocholitis, sometimes associated with an external biliary fistula (from the residual cavity), occurs in the postoperative course of these patients, especially if the primary operation has excluded the remanance of an obstacle at the level of the main bile duct. The lesional substrate is comparable with that of the primitive sclerosing cholangitis, from which it differs through its clear relation with the primary treatment of the hepatic hydatid cyst, through the rapid course of stenotic lesions which, although diffuse, may become more marked in certain segments, as well as through the constant suprastenotic dilatation of the bile ducts. In the pathogenesis are involved the caustic action of some scolicide solutions (2 per cent formaldehyde solution, hypertonic salt solution) on the wall of the bile duct and the cystobiliary communication which predisposes to the peroperative occurrence o-a migration syndrome and of angiocholitis. It requires an early surgical reintervention in order to solve the cholestasis and angiocholitis: according to the morphological situation, we have the choice between disobstruction and trans-stenotic calibration drainage, on the one hand, and biliodigestive derivations in the hilum, which are more efficient, on the other. The prognosis is burdened with the vital risk of septic angiocholitis and with the early occurrence of a secondary biliary cirrhosis or of stenotic recurrences. Prophylaxis consists in the performance of a primary surgical treatment, adequate in median and communicating hydatid cysts, avoiding the "blind" intracystic administration of scolicide solutions, which exert a caustic action on the bile ducts.

[Late reinterventions after the surgical treatment of gastric and duodenal ulcer]

A number of 87 reinterventions performed during a 5-year-period for late complications of the gastric and duodenal ulcer surgery are analysed. In most of them (64 cases), the cause of the reintervention was a postoperative ulcer. A long afferent loop (6 cases), the dumping syndrome (4 cases), the stenosis of the anastomosis opening (6 cases) and the primitive neoplasm of the gastric stump (7 cases) represented other causes of reintervention. The immediate postoperative results were very good and good in 69 cases. The risks related to the specific character of this surgery materialized themselves in 14 postoperative complications (anastomotic fistulas, haemorrhages from the anastomosis, stress ulcers etc.), which required iterative operations; the postoperative death rate attained 3.4%. The analysis of these postgastrectomy syndromes is an opportunity to discuss about the failure factors in the surgery of the gastric and duodenal ulcer, the possibilities of exploration and the principles which should guide the reparative therapy.

[The reinsertion of the duodenum into the digestive circuit. The indications and surgical technics in operated stomach syndromes]

The authors analyse, retrospectively, the experience of the Clinic of Surgery III. Cluj-Napoca, in the indications and surgical methods for reintroducing the duodenum in the digestive circuit in the syndromes of the stomach operated for benign affections. Between 1974 and 1987, the duodenum was reinstated in the digestive circuit in 37 patients, operated previously for duodenal ulcer (32 cases), gastric ulcer (3 cases), syndrome of mesenteric clip (2 cases). The primary surgeries that led to the exclusions of the duodenum from the digestive tract were gastroenteroanastomosis in 4 cases, and the gastric resections with gastrojejunal anastomoses of the Billroth II type in 33 cases (Reichel-Polya in 28 cases. Hoffmeister-Finsterer in 3 cases, Roux in 2 cases). The reintroduction of the duodenum in the digestive circuit, based on clinical and paraclinical criteria, was indicated in anastomotic ulcer (in 17 cases), gastric ulcer following gastroenteroanastomoses (in 1 case), syndrome of afferent loop (in 11 cases), persistent "dumping" syndrome (in 8 cases), association of plurideficiency syndrome (in 54% of the cases). The way of reconstructing the duodenum was adapted to the type and correctness of the primary operation, to the dominant clinical syndrome and associated lesions to the biological background and possibilities offered by the intrasurgical situation: reconversion by direct gastroduodenal anastomosis after degastrogastrectomy was used in 31 cases, the indirect methods by transposition of the afferent loop (Soupault--Bucaille) in 4 cases, or of the afferent one (Henley)--1 case gastrography and segmentary enterectomy in 1 case. The postoperative complications appeared in 35.1% of case, with a mortality of 8.1%. The therapeutic results were good and very good in 89.3% of the cases. The authors insist on the importance of maintaining the duodenum in the digestive circuit, during the primary surgeries for preventing some severe postsurgical syndromes.

[The malignant degeneration of colorectal polyps]

The authors make a retrospective analysis of problems related to diagnosis and therapy raised by malignization of adenomatous rectocolic polyps representing 38.7% of the total number of adenomatous polyps (98 cases), and 5% of cancers of the large bowel (759 cases in all). It is stressed that the rate of malignization increases in direct proportion with the number of polyps, and it is higher in segmentary or diffuse polyposis, predominantly in the sigmoidorectal segment. The clinical, endoscopic and radiologic signs have an orientational value in the diagnosis of malignant polyps, but they are truly important for the detection of the polyps (the site, the number, the extent, and the morphology), and for certain indices of malignancy (density, bleeding, ulceration), which are not constantly found, and which occur at the later stage of the disease. The diagnosis is made by polypectomy and histologic examination of multiple sections, the major diagnostic condition being the identification of the malignancy in the initial stage. Directed partial endobiopsies is frequently followed by diagnostic errors (in 32.2% of the cases), and should be reserved for those cases where polypectomy is technically unfeasible. With regard to therapeutic problems the necessity for oncologic interventions is stressed, characterized by wide exeresis with ablation of all polyps, the type and the extension of the resections depending on the site of the malignancy, and the extent of the polyps. It is stressed that polypectomy, as a definitive therapeutic procedure, does not represent a radical type of surgery, and has exceptional indications for patients with major operatory risks and incipient malignancies. Detection and treatment of polyps in the benign stage is one of the preventive methods that can be applied in rectocolic cancers.

[Emergency operations in colorectal cancer]

In a group of 161 patients subjected to emergency surgery of rectocolonic cancers with occlusive (111 cases), hemorrhagic (39 cases) or perforating (11 cases) complications, the authors analyze the immediate therapeutic results, as a function of the complication form and the surgical method used in emergency (primary colectomy, serial surgeries, palliative surgeries). Emergency colectomy (55 cases) performed deliberately in strictly selected cases or as the unique possible choice, was followed by immediate good results (the lowest rate of surgical morbidity and mortality) in comparison with the serial surgeries (cumulative morbidity and mortality). The paper discusses the indications of the proximal colectomy and of Hartman's surgery in primary emergency colectomies. Serial surgeries (secondary colectomy--30 cases) are mainly indicated in the complicated cancers of the left colon, in the patients with resectable tumours, but with critical biological state or with insufficiently prepared colon. Palliative surgeries (colostomies, internal derivations) used in patients with nonresectable tumours were followed by the highest surgical mortality, a consequence of the biological substrate weakened by disease and complications. The data reported show the necessity of a selective tactical behaviour in the emergency surgery of rectocolonic cancer and plead for the primary urgent colectomy in the patients meeting certain general and local conditions. Likewise, they point to the importance of discovering rectocolonic cancer in an early stage, before the appearance of complications requiring the emergency surgery.

[Hemorrhagic juxtapapillary duodenal ulcer with choledochal and Wirsung's duct stenosis and duodenojejunal fistula following biliojejunal en-Y diversion. The surgical solution]

The paper reports on the clinical observation of a patient with bulbar duodenal ulcer placed in a juxtapapillary position due to a short bile duct, complicated with choledochal and Wirsung's stenosis and, finally haemorrhage and duodenojejunal fistula favoured by a gallbladder-jejunum diversion assembly. Three major surgeries, during 17 years, were required: cholecystectomy and choledochoduodenostomy for the choledochal stenosis induced by penetrating posterior bulbar ulcer; after 8 years, choledocholithotomy and gallbladder-jejunum derivation the loop in Y, (Roux) for the choledochoduodenostomy stenosis with the local lithiasis of the CBP; after 9 years, the resection of the proximal segment of the anastomosed jejunal loop with CBP and gastric resection with ulcer exeresis, followed by restoration of the gallbladder-jejunum anastomosis, gastrojejunal anastomosis and reimplantation of Wirsung's duct in the duodenal stump for juxtapapillary duodenal ulcer complicated with haemorrhage, penetration into pancreas, perforation in the jejunal loop anastomosed preduodenally and stenosis of Wirsung's duct. The final therapeutic result is good and lasts in time. The paper discusses the duodenum-gallbladder-pancreas interrelationships in the juxtapapillary ulcers, drawing the attention on the possibility of forming a duodenojejunal fistula in the patients with gallbladder-jejunum derivations.