D. L. van der Peet

Feasibility study of transanal total mesorectal excision.

Laparoscopic resection of colorectal cancers is a safe alternative to open surgery. The conversion rate to open surgery remains fairly constant but is associated with increased morbidity. A new approach to the surgical excision of rectal cancer is transanal total mesorectal excision (TME), in which the rectum is mobilized peranally using endoscopic instruments. This feasibility study describes initial results with transanal TME.

Mild colonic diverticulitis can be treated without antibiotics. a case–control study

Aimu2002 Conservative treatment of mild colonic diverticulitis usually consists of observation, restriction of oral intake, intravenous fluids and antibiotics. The beneficiary effect of antibiotics remains unclear. The aim of this study is to evaluate the need for antibiotics in mild colonic diverticulitis.

Laparoscopic treatment of large paraesophageal hernias : Both excision of the sac and gastropexy are imperative for adequate surgical treatment

AbstractBackground: We set out to evaluate the results of the laparoscopic treatment of large paraesophageal hernias in 22 patients.nnMethods: Between 1993 and 1998, we operated on 22 consecutive patients. Preoperative assessment consisted of endoscopy, barium esophagogram, 24-h pH testing, manometry, and gastric emptying times.nnResults: In the first three patients, the sac was not excised and gastropexy was not performed. Because of recurrences, we decided to change the technique in an attempt to avoid further complications. During middle- to long-term follow-up, only three recurrences were seen in the subsequent 19 patients. There were no deaths in this series.nnConclusions: Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic treatment, both resection of the sac and some form of gastropexy are imperative.n

Influence of circumferential resection margin on prognosis in distal esophageal and gastroesophageal cancer approached through the transhiatal route

We studied the influence of circumferential resection margin (CRM) involvement on survival in patients with malignancies of the distal esophagus and gastroesophageal junction. One hundred ten consecutive patients undergoing a laparoscopic or open transhiatal esophagectomy for malignancy of the distal 5 cm of the esophagus, or a Siewert I gastroesophageal junction tumor were analyzed, retrospectively. Only patients with potentially resectable tumors were included. CRM status was defined as clear or involved (microscopic tumor within 1 mm of the resection margin). Statistical analysis was done by means of univariate and multivariate analysis using the Kaplan-Meier method and Cox proportional hazard model. One hundred ten patients were analyzed. Sixty patients underwent open transhiatal esophagectomy, and 50 patients underwent laparoscopic transhiatal esophagectomy. There were 6 (5%) T(1), 18 (16%) T(2), and 86 (89%) T(3) tumors. CRM was clear in 68 (62%) patients and involved in 42 (38%) patients. Median survival in these groups was 50 vs. 20 months (P = 0.000). Since CRM involvement was only seen in T(3) tumors, this group was analyzed in detail. Median survival in the T(3)CRM(-) and T(3)CRM(+) group was 33 vs. 19 months (P = 0.004). For T(3)N(0) tumors, median survival in CRM(-) and CRM(+) was 40 and 22 months, respectively (P = 0.036). Median survival for T(3)N(1) tumors in CRM(-) and CRM(+) was 22 and 13 months, respectively (P = 0.049). Involvement of the circumferential resection margin was found to be an independent prognostic factor on survival in our study. It predicts a poor prognosis in patients with potentially resectable malignancies of the distal 5 cm of the esophagus and Siewert I adenocarcinomas of the gastro esophageal junction.

Technical difficulty grade score for the laparoscopic approach of rectal cancer: A single institution pilot study

IntroductionWe aimed to categorize laparoscopic rectal resections according to technical difficulty to standardize learning purposes and stratify results, making future studies more comparable.Materials and methodsFifty patients undergoing a laparoscopic total mesorectal excision were prospectively followed. Four preoperatively known facts (gender, body mass index (BMI), tumor localization, and preoperative radiation therapy) were compared to four operative outcomes (operation time, blood loss, a visual analogue score (VAS) for difficulty rewarded by the surgeon, and oncological radicality of the procedure).ResultsOperating time for male and female patients was 257 vs. 245xa0min (Pu2009=u20090.229), blood loss was 300 vs. 300xa0ml (Pu2009=u20090.309), the VAS was 8 vs. 6 (Pu2009<u20090.001), and radicality was 93% vs. 91% (Pu2009=u20090.806). Operating time was 215, 250, and 305xa0min for high, mid, and low tumors (Spearman −0.44; Pu2009=u20090.02), respectively. Blood loss was 105, 300, and 600xa0ml (Spearman −0.38; Pu2009=u20090.01). Lower tumors were rewarded a higher VAS (Spearman −0.57; Pu2009<u20090.001) and were less often radically resected (Spearman 0.32; Pu2009=u20090.026). Operating time for irradiated and nonirradiated patients was 277 vs. 225xa0min (Pu2009=u20090.008), blood loss was 500 vs. 150xa0ml (Pu2009=u20090.006), the VAS was 7 vs. 5 (Pu2009<u20090.001), and radicality was 79% vs. 100% (Pu2009=u20090.046). Operating time was 240xa0min for BMI 25–30 and 253xa0min for BMIu2009>u200930 (Spearman 0.13; Pu2009=u20090.391). Blood loss was 150xa0ml for BMI 25–30 and 500xa0ml for BMIu2009>u200930 (Spearman 0.38; Pu2009=u20090.01). Higher BMIs were rewarded a higher VAS (Spearman 0.06; Pu2009=u20090.704). BMI had no correlation to radicality of the procedure (Spearman −0.12; Pu2009=u20090.402). There was an association between technical difficulty score and operation time (Pu2009=u20090.007), blood loss (Pu2009<u20090.001), VAS (Pu2009<u20090.001), and radicality of surgery (Pu2009=u20090.043).ConclusionLaparoscopic surgery in male, irradiated, and obese patients with lower tumors seemed more difficult. A categorization according to technical difficulty, to preoperatively predict difficulty of the procedure, was found feasible.

Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease (GERD). Surgery after extensive conservative treatment.

AbstractBackground: A prospective study was conducted to evaluate the physiologic and clinical consequences of laparoscopic Nissen fundoplication (LNF), using strict indications for surgery.n Methods: From 1992 to 1997, 50 patients underwent LNF. Indications for operative treatment were either failure of conservative treatment or foresight to see long-term use of strong acid suppressive therapy. Patients were evaluated by barium esophagogastric study (BES), esophagoscopy, 24-h pH monitoring (pHM), stationary esophageal manometry, gastric-emptying studies (GES), pancreatic polypeptide stimulation test (PPT) and clinical evaluation using questionnaires.n Results: Perioperative complications necessitated conversion to laparatomy in two cases, and there was no mortality. Severe dysphagia resulted in reoperation in two patients. The average maximum lower esophageal sphincter pressure (MLESP) increased from 6.1 mmHg to 12.7 mmHg. Endoscopy showed improved grading of the esophagitis, and the total percentage of pH less than 4 during 24 h decreased from a mean of 9.2 to 0.95. Three patients demonstrated impaired PPTs postoperatively; two had (mild) diarrhea. The overall success rate after the operation was 90%.n Conclusions: The results of LNF in a limited number of patients with severe and/or resistant gastroesophageal reflux disease (GERD) receiving continuous medical treatment with proton pump inhibitors (PPIs) on a maintenance base are comparable with LNF results in centers with a more liberal policy concerning indications for LNF surgery.

Early enforced mobilisation following surgery for gastrointestinal cancer: feasibility and outcomes

OBJECTIVESnTo evaluate the feasibility and outcomes of early enforced mobilisation following surgery for gastrointestinal cancer.nnnDESIGNnFeasibility study with a separate-sample pre-post-test design.nnnSETTINGnSurgical gastrointestinal ward.nnnPARTICIPANTSnPatients with various types of gastrointestinal cancer, before and after implementation of postoperative enforced mobilisation (n=55 and n=61, respectively).nnnINTERVENTIONnThe enforced mobilisation protocol included structured mobilisation by a nurse and walking supervised by a physiotherapist, starting within 24hours of surgery.nnnMAIN OUTCOME MEASURESnThe enforced mobilisation protocol was deemed to be feasible if at least 50% of patients were able to walk the scheduled distance on postoperative day 1. Pre- and postimplementation differences in postoperative pulmonary complications (PPCs), length of hospital stay (LOS) and re-admission rate were analysed using regression analyses, adjusting for relevant co-variables.nnnRESULTSnIn the various surgical groups, between 48% and 56% of patients were able to walk the scheduled distance on postoperative day 1, which was regarded as feasible. However, none of the patients who had undergone oesophageal resection were able to walk on postoperative day 1. Excluding these patients from the analyses, a significant decrease in PPCs was found (odds ratio 0.08, 95% confidence interval 0.010 to 0.71, P=0.023) following implementation of enforced mobilisation. Differences in LOS and re-admission rate were not significant.nnnCONCLUSIONSnEarly enforced mobilisation seems to be feasible in patients following surgery for gastrointestinal cancer, except for those undergoing oesophageal resection. The occurrence of PPCs was reduced after implementation of enforced mobilisation. Further research is needed to confirm these results.

Risk Factors and Management of Presacral Abscess following Total Mesorectal Excision for Rectal Cancer

Introduction:There is scant information regarding the incidence, risk factors and management of presacral abscesses following total mesorectal excision (TME) for rectal cancer. Methods:Gender, age, body mass index (BMI), neoadjuvant radiation therapy, ASA classification, tumor size, tumor localization and fecal diversion were investigated as independent risk factors for the development of a presacral abscess. Results: 261 patients were included, 26 patients (10%) developed a presacral abscess. Twenty-two patients (14.8%) with and 4 patients (3.6%) without neoadjuvant radiation therapy developed a presacral abscess (p = 0.003), respectively. Nine ASA 1 patients (5.7%), 8 ASA 2 patients (8.5%) and 3 ASA 3 patients (70%) developed a presacral abscess (p = 0.001). More presacral abscesses were observed after resection of larger tumors: 38 versus 30 mm (p = 0.041). No correlation between gender, age, BMI, tumor localization and the development of a prescaral abscess was found. Management of the presacral abscess, without overt leakage, was initially performed by drainage through the anastomosis following anterior resections and through the perineal suture line following abdominoperineal resections. Conclusion: Presacral abscess is a frequent (10%) complication following TME for rectal cancer. Patients in poor general condition, neoadjuvant radiation therapy and large tumors are at risks for developing a presacral abscess. Management, without overt leakage, is in our experience best executed by drainage through the anastomosis or perineal suture line.

Multicentre randomized clinical trial of inspiratory muscle training versus usual care before surgery for oesophageal cancer

Up to 40 per cent of patients undergoing oesophagectomy develop pneumonia. The aim of this study was to assess whether preoperative inspiratory muscle training (IMT) reduces the rate of pneumonia after oesophagectomy.

Endoscopic closure of transmural esophageal perforation after balloon dilation for achalasia

A 56-year old woman was transferred to our hospital 1 day after balloon dilation for recently diagnosed achalasia that had been complicated by transmural esophageal perforation. Physical examination revealed tachycardia and fever, as well as left-sided pleural fluid. Emergency surgery was performed, which involved transhiatal primary closure of a 4-cm long transmural perforation, debridement of the left pleural cavity, and placement of a thoracic drain. Despite the patient making an initial recovery, signs of inflammation recurred 1 week after surgery, with production of increased fluid via the drain. Esophagogastroduodenoscopy revealed the surgical sutures just proximal to the esophagogastric junction and at least two locations where these sutures had given way resulting in recurrent perforation (● Fig.1). Clipping was considered unlikely to be helpful because of the size of the perforation. Stent placement was not considered to be a useful option because of the wide diameter of the esophagus. Therefore, an over-the-scope clip (OTSC, Ovesco Endoscopy GmbH, Tübingen, Germany) was deployed to close the perforation (● Fig.2). Subsequent application of methylene blue did not result in staining of the drainage fluid, which suggested immediate complete closure had been achieved. The thoracic drain was able to be removed 1 week after the endoscopic procedure, and oral intake was reinstated after a barium swallow showed no leakage of contrast medium. The patient was discharged in a good clinical condition 10 days after the procedure. Esophageal perforation occurs in approximately 2% of balloon dilations being performed for achalasia [1]. Nonsurgical management is feasible, with favorable short-term and long-term outcomes, but in our patient severe systemic inflammation required closure of the perforation and debridement of the pleural space [2]. The OTSC system has been developed for treatment of gastrointestinal bleeding and colonic perforations [3]. Recently, its use in postoperative esophageal leaks has been described as well [4,5]. This clipping device is relatively easy to use and may play an important role in primary closure of (iatrogenic) gastrointestinal perforations, as well as being a second-line treatment after failed surgical therapy.