Aras Emre Canda

Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients

PurposeDeterioration of anorectal function after long-course preoperative chemoradiotherapy combined with surgery for rectal cancer is poorly defined. We conducted a prospective study to evaluate the acute and long term effects of preoperative chemoradiotherapy on anorectal function and quality of life of the patients.MethodsThere were 26 patients in surgery group and 31 patients in preoperative chemoradiotherapy group. Anorectal function and quality of life of the patients were assessed by anorectal manometry, incontinence score, quality of life questionnaire.ResultsSignificant lower resting pressures in both groups and lower maximal squeeze pressures in the preoperative chemoradiotherapy group were observed after postsurgical evaluations compared with the paired pretreatment ones. In the surgery group, both the Wexner continence score, FIQL score, and the rectoscopy score were comparable before and after surgery, whereas significant worsening in the Wexner score was observed in the preoperative chemoradiotherapy group postoperatively (P < 0.01). Significant reduction in anal canal resting pressures and squeeze pressures, Wexner score, and FIQL score were observed immediately after the completion of preoperative chemoradiotherapy. Significant lower maximal squeeze pressures and worsening of the Wexner scores were observed in the preoperative chemoradiotherapy group compared to the surgery group during the postoperative assessments (P < 0.05 and P < 0.01, respectively).ConclusionsBoth total mesorectal excision and preoperative chemoradiotherapy may adversely affect the anorectal function. Careful selection of the patients who will benefit from neoadjuvant therapy and identifying the patients with a high risk of developing functional problems may help to improve functional outcomes for the treatment of rectal cancer.

Survivin, p53, and Ki-67 as predictors of histopathologic response in locally advanced rectal cancer treated with preoperative chemoradiotherapy

PurposeThe ability to predict response to chemoradiotherapy before the treatment may allow protecting poorly responding patients from the side effects of neoadjuvant treatment. Several molecular markers have been proposed to radio and chemosensitivity of rectal cancer. In this study, from pre-irradiation tumor biopsies, a novel and promising candidate factor survivin, and p53 and Ki-67 were assessed as predictors of response to preoperative chemoradiotherapy.Materials and methodsExpression of each marker was evaluated by immunohistochemistry on pretreatment biopsies from 37 patients having rectal cancer treated with preoperative chemoradiotherapy and curative surgery. Treatment response was assessed histopathologically in the resected surgical specimen.ResultsThere was no correlation between expression of p53, Ki-67, and survivin with response to preoperative chemoradiotherapy and prognosis.ConclusionsOur data suggest that these molecular markers are not helpful to identify patients who would have benefit from neoadjuvant treatment of rectal cancer. Further investigations are necessary to select patients for preoperative treatment based on analysis of the preoperative biopsies.

The prognostic impact of the log odds of positive lymph nodes in colon cancer.

This study aimed to investigate the prognostic impact of the log odds of positive lymph nodes (LODDS) in colon cancer.

Gastrointestinal stromal tumor of the stomach with lymph node metastasis

BackgroundLymph node (LN) metastasis of gastrointestinal stromal tumors (GIST) is unusual. Unlike gastric adenocarcinomas, routine lymphadenectomy is not recommended unless there is no suspicion for LN metastasis. Herein, we report a case of GIST of the stomach with LN metastasis treated with distal gastrectomy with perigastric LN dissection followed by adjuvant imatinib therapy.Case presentationA 32-year-old female presented with anemia. Diagnostic investigations including thoracoabdominopelvic computed tomography (CT) scan and gastroscopy revealed a 8 cm gastric antral submucosal tumor without any metastasis. Enlarged periantral LNs were detected during laparotomy and patient underwent distal gastrectomy with en bloc perigastric LN dissection. Pathologic investigation revealed antral stromal tumor with high mitotic and Ki-67 index. Lymph node metastasis was observed in 7 of 12 resected perigastirc nodes. Immunohistochemically, tumor cells were positive for CD117. She was diagnosed as high grade gastric GIST due to the presence of LN metastasis, large tumor size and unfavorable histopathologic features thus underwent adjuvant imatinib treatment (400 mg, daily). No recurrence or metastasis has been detected during a 12-month of postoperative follow-up.ConclusionSurgery remains the mainstay of treatment in patients with localized, resectable GISTs. Although lymphatic metastasis rarely occurs in patients with GIST, LN dissection should be considered for patients with any suspicion of nodal metastasis. Adjuvant imatinib treatment is recommended according to the well defined prognostic factors.

Body image and cosmesis after laparoscopic or open appendectomy.

Introduction Minimally invasive techniques, such as laparoscopic appendectomy (LA), are thought to produce better cosmetic results. The aim of this study was to evaluate the body image and cosmesis of patients after both LA and open appendectomy (OA). Patients and Methods Between August 2007 and June 2008, patients who underwent LA or OA with the diagnosis of acute appendicitis were invited to participate in the study by filling out the body image questionnaire. Patients with OA who had the Rockey-Davis incision and LA patients who had the operation by 3 trocars (10-mm infraumbilical, 5-mm suprapubic and additional 10 mm left lower quadrant), were included in the study. Results A total of 38 patients (20 LA, 18 OA) participated in the study. The mean incision size for OA was 3.2 cm (range, 2 to 6 cm), and the mean scores from the body image questionnaire (both body image scale and cosmetic scale) were similar for both groups (P>0.05). No significant complications or changes in self-confidence (preoperative vs. postoperative) were observed in either group (P>0.05). Conclusions To our knowledge, there is no study in the literature that evaluates body image and cosmesis using objective methods for LA. Our results showed that LA has no advantage for body image and cosmesis over OA. Furthermore, prospective studies using different tools with a larger sample size are needed to rationalize the use of laparoscopy for appendectomy.

Management of enteroatmospheric fistulae

A small‐bowel enteroatmospheric fistula (EAF) is an especially challenging complication for patients with open abdomens (OAs) and their surgeons. Manipulation of the bowel during treatment (e.g. dressing changes) is one of the risk factors for developing these openings between the atmosphere and the gastrointestinal tract. Unlike enterocutaneous fistulae, EAFs have neither overlying soft tissue nor a real fistula tract, which reduces the likelihood of their spontaneous closure. Surgical closure is necessary but not always easy to do in the OA environment. Negative pressure wound therapy (NPWT) has been used successfully as an adjunct therapy to heal the wound around EAFs. This review discusses many aspects of managing EAFs in patients with OAs, and presents techniques that have been developed to isolate the fistula and divert effluent while applying NPWT to the surrounding wound bed.

Hospital Experience, Body Image, and Cosmesis After Laparoscopic or Open Splenectomy

Background Laparoscopic splenectomy (LS) is becoming the “gold standard” technique for splenectomy. The aim of this study was to evaluate the hospital experience, body image, and cosmesis after LS or open splenectomy (OS). Methods Patients who underwent LS or OS were invited to fill out questionnaires evaluating their hospital experience, body image, and cosmetic results. A total of 72 patients (34 LS and 38 OS) agreed to participate in the study. Results No significant difference was observed between the groups in terms of age, sex, body mass index, or indication for splenectomy. Mean spleen weight and postoperative complications were slightly higher (P>0.05) and the postoperative hospital stay was significantly longer (P<0.05) in the OS group compared with the LS group. Scores from the modified Body Image, Hospital Experience, and Photo Series Questionnaires were higher (favorable) in the LS group compared with the OS group (P<0.01, P<0.001, and P<0.001, respectively). Conclusions LS is the procedure of choice for most indications of splenectomy, which has comparable or better perioperative outcomes and complication rate as well as the advantages of better body image, cosmesis, and hospital experience compared with OS. Our results presenting improved outcomes with LS will contribute to the widespread application of laparoscopy for splenectomy.

Laparoscopic splenectomy using LigaSure in benign hematologic diseases.

Today laparoscopic splenectomy (LS) is considered the gold standard for the treatment of hematologic disorders of the spleen with the aid of advancements in laparoscopy technique and modern electrosurgical devices. LigaSure vessel sealing system permanently fuses vessels up to 7 mm in diameter by applying a precise amount of pressure and bipolar energy to the tissue. We performed 14 LSs (7 has autoimmune hemolytic anemia, 6 has idiopathic thrombocytopenic purpura, and 1 has hereditary spherocytosis) using LigaSure. The mean spleen weight was 247 g (range, 147 to 620) and the largest diameter of the spleen was 12.1 cm (range, 10 to 23). The average operative time was 84.7 minutes (range, 30 to 190) including combined laparoscopic cholecystectomy in 2 patients and transabdominal preperitoneal inguinal hernia repair in 1 patient. Conversion to open procedure was unnecessary in our series. Minor morbidity occurred in 2 patients; no perioperative hemorrhage or mortality was observed. The average postoperative hospital stay was 3.1 days (range, 2 to 8). LS is a safe and feasible procedure for patients with previous abdominal surgery; gallstones in association with hemolytic anemia can also be treated during LS. LigaSure vessel sealing system during LS is safe and cost-effective method and reduces operating time.

Peritoneal carcinomatosis of gastrointestinal tumors: where are we now?

The peritoneal stromal tissue which provides a rich source of growth factors and chemokines is a favorable environment for tumor proliferation. The pathophysiological mechanism of peritoneal carcinomatosis is an individual sequence consisting of genetic and environmental factors and remains controversial. The natural history of the disease reveals a poor median prognosis of approximately 6 mo; however aggressive surgery and multimodal treatment options can improve oncologic outcomes. Considering peritoneal carcinomatosis as though it is a locoregional disease but not a metastatic process, cytoreductive surgery and and intraperitoneal chemotherapy has been a curative option during recent years. Cytoreductive surgery implies a series of visceral resections and peritonectomy procedures. Although the aim of cytoreductive surgery is to eliminate all macroscopic disease, viable tumor cells may remain in the peritoneal cavity. At that point, intraperitoneal chemotherapy can extend the macroscopic disease elimination to microscopic disease elimination. The successful treatment of peritoneal carcinomatosis requires a comprehensive management plan including proper patient selection, complete resection of all visible disease, perioperative intraperitoneal chemotherapy and postoperative systemic chemotherapy. Surgical and oncologic outcomes are strictly associated with extent of the tumor, completeness of cytoreduction and patient-related factors as well as multidisciplinary management and experience of the surgical team. In this review, pathophysiology and current management of peritoneal carcinomatosis originating from gastrointestinal tumors are discussed according to the latest literature.

Role of gelatinases (matrix metalloproteinases 2 and 9), vascular endothelial growth factor and endostatin on clinicopathological behaviour of rectal cancer.

Aim  The aim of this study was to evaluate the role of matrix metalloproteinases (MMPs), their tissue inhibitors [tissue inhibitors of metalloproteinases (TIMPs)] and activators [membrane‐type MMPs (MT1‐MMPs)], vascular endothelial growth factor (VEGF) and endostatin on clinicopathological variables and prognosis in patients with rectal cancer.