Christos Dervenis

Lymph Node Clearance after Total Mesorectal Excision for Rectal Cancer: Laparoscopic versus Open Approach

Background: Laparoscopic resection of the rectum is still under scrutiny for its adequacy of oncological clearance. Aim: To assess lymph node yield after laparoscopic total mesorectal excision (TME) for rectal cancer as compared to the open approach. Methods: 74 patients with middle and low rectal cancer were prospectively randomized in two groups. Group A included 39 patients who had an open TME (35 with low anterior resection of the rectum (LARR) and 4 with abdominoperineal resection of the rectum (APR)). In group B, there were 34 patients who had a laparoscopic TME (27 with LARR and 7 with APR). 10 of the LARR patients in group A and 14 of the LARR patients in group B had a defunctioning ileostomy. All operations were performed by one surgeon or under his supervision. Results: Gender and age distribution were similar for both groups (group A: 23 males; mean age 69 (41–85); group B: 20 males; mean age 72 (31–84)). The mean distance of the tumor from the dentate line was 7.6 cm (1–12 cm) for group A and 6.1 cm (1–12 cm) for group B. Anastomosis was formed at a mean distance of 5.5 cm (1.5–8.5 cm) from the dentate line in group A and 3.5 cm (1–4.5 cm) in group B. At histology, in group A there were 5 T4 tumors, 9 T3, 10 T3+ (<1 mm distance from the circumferential resection margin), 13 T2 and 2 T1. In group B, there were 3 T4 tumors, 14 T3, 8 T3+, 7 T2 and 2 T1. Differences between groups were not significant.The mean number of lymph nodes retrieved in group A specimens was 19.2 (5–45) and in group B 19.2 (8–41) (p = 0.2). In group A, 3.9 (1–9) regional, 13.9 (3–34) intermediate and 1.5 (1–3) apical lymph nodes were retrieved. The respective values in group B were 3.7 (3–7), 14.4 (4–33) and 1.3 (1–3). Differences between groups were not significant. Also, the incidence of lymph node involvement by the tumor was not significantly different between groups (group A: 23; group B: 19). Conclusions: Laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach. Also, distribution of the lymph nodes along the resected specimens is similar between the two approaches.

Malnutrition – The Ignored Risk Factor

Accessible online at: www.karger.com/ddi Nutritional therapy, once a cornerstone of medical treatment, has lost its attractivity in favor of drug treatment, molecular genetic interventions or other high-tech therapies. As a consequence, data about nutritional status or dietary habits are missing in many patient charts. This development reflects the opinion of many doctors that nutrition does not greatly affect the course of diseases, and that nutritional intervention is laborious but much less effective than other forms of therapy. In view of this trend, it seems interesting to analyze the importance of nutrition in different dieseases. Of course, it is well accepted that nutrition is an important factor for the therapy and prognosis in several diseases, such as diabetes mellitus, hyperlipidemia, obesity or hemochromatosis. However, the most basic nutritional disturbance – malnutrition – is frequently ignored since it is considered as a complication of the disease process, with little bearing on the prognosis and little possibility for therapeutic intervention. However, an analysis of the literature reveals that malnutrition is an independent risk factor in many disease processes and that treatment of malnutrition can indeed improve the patients’ prognosis. Such an analysis has to address several questions, mainly the prevalence and diagnosis of malnutrition and its impact on the patients’ prognosis. It should set the stage for the papers in this issue of Digestive Diseases, which deals with nutritional questions.

Liver Transplantation Techniques with Preservation of the Natural Venovenous Bypass: Effect on Surgical Resection of Renal Cell Carcinoma Invading the Inferior Vena Cava

Although renal tumors invading the inferior vena cava (IVC) are unusual, they represent a challenge to the surgical team because their accessibility is difficult. Liver transplantation techniques have been developed that preserve the venous collaterals, enhance the exposure, increase the safety of the resection, and avoid cardiopulmonary bypass. We describe our technique for dealing with renal tumors that have invaded the IVC, a combined experience of two centers, and the safety of the procedure and subsequent low morbidity. Between May 1997 and February 2003, a total of 45 patients (mean age 60.7 years) underwent surgical resection of a renal tumor extending into the IVC by techniques developed from liver transplantation, with the intention to avoid sternotomy and cardiopulmonary bypass. In 42 patients (93.3%) surgical resection of the tumor and thrombus was successful using the transabdominal approach while preserving the venous collaterals; 3 patients with a level IV tumor thrombus required cardiopulmonary bypass. The mean operating time was 342 minutes, and the mean estimated blood loss was 1442 cc. Postoperative ileus in one patient required laparoscopic lysis of the adhesions, and 2 patients (4.4%) died owing to multiple system organ failure and massive pulmonary embolism. The median follow-up was 36 months, during which time 6 patients developed metastatic disease and 37 were disease-free. We concluded that liver transplantation techniques enhance the surgical management of complicated urologic tumors. Patients with tumor thrombus extending to the IVC can be treated while avoiding thoracotomy and cardiopulmonary bypass.

Restructuring the Finances of the Greek Health Care System in the Era of Economic Crisis

The Greek health system has recently faced problems because of the measures taken to resolve our state fiscal deficit and debt caused mainly by Greece’s conservative administration during 2007–2009 and the world crisis. Financial regulations and structural reforms were needed in many governmental sectors, among them health, under the socialist administration (2010–2011), which made mistakes when planning how to correct the situation. Based on comparisons for the years 2009 and 2011, when efforts had begun to address the situation, there were several obvious improvements. Hospital budgets were found to be 20 % less in 2011 than in 2009 as a result of more efficient financial management (e.g., procurement, logistics, accounting systems, costing, pricing). Before 2009, it had not been fully recognized that prices of medical supplies were overpriced by approximately 20 %. The National Health Service (NHS) witnessed a more than 20 % increase in admissions to its hospitals in 2011 compared with 2009, mainly because patients could no longer afford care from the private sector. According to the Hellenic Statistical Authority, the mortality rate was the same for the two years in question [1]. Furthermore, data envelopment analysis based on the esy.net (web page of the Greek Ministry of Health, or MoH) annual data (2010–2011) showed an increase in hospital efficiency, implying that the crisis has not had a short-term effect on NHS services [2]. It should be noted that the NHS doctors adapted their practices to the above changes. Also, NHS hospitals’ chief executive officers were directed to redistribute resources from noneffective services to others that were more effective in an effort to offer citizens a better quality of service through NHS professionals. In 2010, the MoH reestablished a Health Procurement Committee (EPY) and set up a different system for providing medical supplies. The new system combined the individual annual tenders usually put out by hospitals into a single tender, thereby reducing procurement costs, improving payment time, making uniform medical requests, transferring redundant materials from one hospital to another, and improving management of expired products. Under the new centralized procurement system, a request is initiated at the lowest level of hospital management (e.g., a medical department). The request then goes to the hospital CEO, who sends it to the respective regional health system (DYPE), which conveys the demands of all of the hospitals under its jurisdiction, and sends it to the EPY. The EPY, before organizing the tender, explores the possibility of standardizing similar requests, which could involve going back to each hospital for appropriate alterations. Previously, public hospitals purchased goods directly from suppliers at massively inflated prices through contracts/agreements established after the tenders had gone out. These products included cardiovascular implants (intracoronary prostheses, pacemakers, defibrillators), hemodialysis filters and needles, peritoneal This letter refers to the article available at doi: 10.1007/s00268-011-1228-y

Intestinal Obstruction and Perforation – The Role of the Surgeon

Intestinal obstruction and perforation are always a challenge for the surgeon, not only in respect to the surgical option offered to the patient, but also to the ability to accurately diagnose and stage the disease. The understanding of the underlying pathophysiological mechanism is also very important in order to classify each patient in order to receive the more appropriate treatment. Mechanisms of obstruction and perforation, methods of diagnosis as well as prevention and treatment of the disease were reviewed.

Nutritional Support in Acute Pancreatitis

Acute pancreatitis (AP), mainly the severe necrotizing type, results in extreme energy demands which might lead, if prolonged, to severe malnutrition. Besides that, starving during AP contributes to gut barrier dysfunction, the main cause of bacterial translocation and sepsis. The aim of nutritional support in AP is to prevent malnutrition and protect the gut by maintaining mucosal integrity. Traditionally, nutritional support during the acute phase of the disease has been provided through total parenteral nutrition (TPN) solutions. However, recent animal and human studies have identified new patterns of pancreatic secretion and hormonal stimulation during the course of AP, different from those assumed for years. Thus it has become feasible to use the natural enteral route for nutrition with potential benefits compared with TPN.

Rectal cancer - towards establishing a new strategy of treatment.

and the pathologist evaluate macroscopically and classify the completeness of the rectal cancer resection specimen. Quality control of surgery provides the first prognostic information concerning local and distant recurrence [4, 5] . With such impressive results of local control and survival after TME, adjuvant radiotherapy and chemotherapy seem to offer no additional benefit. However, there are always patients at risk to develop local recurrence and distant metastases. These subsets include patients with lymph node metastases, venous or lymphatic vessels invasion, distally located tumors most likely requiring an abdominoperineal resection (APR) and, most importantly, a threatened by tumor extension circumferential margin of resection (CRM). It is established beyond any doubt that the status of the CRM is possibly the strongest predictive factor of local recurrence or even survival. A positive CRM, namely presence of tumor at a distance

Kidney transplantation with two donor ureters in patient with previous ileogastric conduit

The purpose of our publication is to focus upon the technical aspects of a rare combination of kidney transplant with two donor ureters in a patient with neurogenic bladder and previous reconstruction of a continent ileogastric conduit.