Khaled M. Madbouly

Endogenous morphine levels after laparoscopic versus open colectomy.

Endogenous morphine may be a component of the acute‐phase response to surgical trauma that affects both hospital stay and gastrointestinal motility. The purpose of this study was to assess the responses of endogenous morphine, stress hormones and cytokines following laparoscopic and open colectomy.

Metastatic lymph node ratio in stage III rectal carcinoma is a valuable prognostic factor even with less than 12 lymph nodes retrieved: a prospective study

BACKGROUND The aim of this study was to assess the prognostic value of metastatic lymph node (LN) ratio (MLNR) in stage III rectal cancer and whether this prognostic value remains significant when <12 LNs are retrieved. METHODS This prospective study included 115 patients with stage III rectal cancer from 2006 to 2010. All patients underwent neoadjuvant long-course chemoradiation, curative resection, and postoperative adjuvant therapy (5-fluorouracil and leucovorin). Data collected included demographics, tumor pathology, tumor-node-metastasis staging, number of LNs retrieved, MLNR, recurrence, and mortality. RESULTS The mean number of examined LNs was 12.1, and the mean number of metastatic LNs was 3.5 (range, 1 to 19). The mean MLNR was .37 (range, 0 to 1.00). The mean duration of follow-up was 37 months (range, 24 to 63). Forty patients died during the follow-up period (overall mortality, 34.8%), only 31 because of cancer (cancer-specific mortality, 27%). Univariate analysis revealed that ypN stage, lymphovascular invasion, and follow-up duration were significantly associated with increased recurrence and decreased survival. Number of positive nodes and ypT stage significantly affected recurrence, with no effect on overall survival. Multivariate analysis proved that MLNR was the only independent risk factor for both mortality and recurrence. Prognostic capability was not affected by having <12 nodes retrieved. The best sensitivity and specificity of MLNR as a prognostic factor for both tumor recurrence and overall survival were achieved at a cutoff value of .375. CONCLUSIONS MLNR is an independent prognostic factor for recurrence and survival after the resection of stage III rectal cancer, with high sensitivity and specificity in patients who received neoadjuvant chemoradiation and postoperative chemotherapy. The total number of LN retrieved did not affect the prognostic value of MLNR even if <12.

Temporary sacral nerve stimulation in patients with fecal incontinence owing to rectal hyposensitivity: A prospective, double-blind study

BACKGROUND Rectal hyposensitivity (RH) can lead to fecal incontinence (FI). Sacral nerve stimulation (SNS) is known to modulate rectal sensation, but no data about affecting FI owing to RH are available. This prospective study aimed to assess the therapeutic effect of temporary SNS on patients with FI owing to RH. METHODS Twenty-four patients with FI owing to RH had temporary SNS (4 weeks on followed by 1 week off). Before SNS (baseline), after 4 weeks of stimulation (on), and at the end of the off week we recorded first constant sensation (FCS), defecatory desire volume (DDV), maximum tolerated volume (MTV), anal pressures, bowel diaries, Wexner incontinence score, and FI quality-of-life score (FIQOL). RESULTS There were significant decreases in DDV and MTV during the on-treatment period (P < .0001); this decrease was not significant during the off period. FCS was not significantly affected by SNS. FI episodes significantly improved during the on period in 22 patients (from 5.3 to 1.1 per week; P < .0001) and mean Wexner incontinence score improved from 13.3 to 1.7 (P < .0001). Anal pressures (resting and squeeze) significantly increased during the on period but not during the off period. There was significant improvement in FIQOL during the on period only. CONCLUSION SNS can be effective in restoring continence and improving QOL in patients with FI owing to RH. Improved continence might be related to improvement of rectal sensation and/or increased anal pressure. The washout effect of SNS on the continence score, DDV, and MTV after cessation of stimulation needs to be explained.

Is it safe to omit neoadjuvant chemo-radiation in mucinous rectal carcinoma?

BACKGROUND Purpose was to compare the oncologic outcome of neoadjuvant chemoradiotherapy (nCXRT) versus postoperative chemoradiotherapy (pCXRT) for locally advanced mucinous rectal carcinoma (MRC) having curative total mesorectal excision (TME). METHODS One hundred and two patients with MRC (T3-4 and/or N1-2) of middle and lower third rectum were included. Patients were non-randomly divided into 2 groups: Group A (N = 61) had nCXRT followed by total mesorectal excision (TME) after 8-11 weeks and Group B (N = 41) had TME followed by pCXRT. Primary end points were disease free survival (DFS) and overall survival (OS). Secondary endpoints were tumor regression grade (TRG) and morbidity. RESULTS In group A, 29 patients had partial response after nCXRT, 26 patients showed no change and 6 patients had progression. TME was done in 55 patients in group A and 41 patients in group B. Six patients in group A turned to be unresectable after nCXRT due to progressive disease. Mean follow-up was 53 months. In patients received TME, Four-year DFS was higher in group A compared to group B yet not statistically significant (DFS 0.69 [95% CI 0.54-0.85] vs. 0.67 [95% CI 0.47-0.87]; P = 0.39). However, actuarial 4 years OS was comparable in both groups (0.72 [95% CI 0.59-0.91] vs. 0.70 [95% CI 0.55-0.88]; P = 0.46 in groups A and B respectively). Multivariate analysis revealed that age <40, and N2 were risk factors of recurrence. CONCLUSION Whilst accepting that the numbers are small, there was no statistical difference in outcome (DFS and OS) between patients receiving pre- or post-operative chemo-radiotherapy. In most MRC patients, tumor regression is not significant after nCXRT and there is considerable possibility of tumor progression during nCXRT treatment. So, nCXRT should be used with close follow-up in MRC for early detection of possible tumor progression. If the patient cannot tolerate nCXRT, it is possibly safe to do surgery followed by pCXRT. Prospective study is needed to study the value of nCXRT in MRC.

Erratum: Endogenous morphine levels after laparoscopic versus open colectomy

British Journal of Surgery 2010; 97: 759–764 DOI: 10.1002/bjs.7220 The results section of the abstract incorrectly stated that ‘‘Levels remained significantly higher in the laparoscopic group at 3 h (10·36 versus 0·52 ng/ml; P < 0·001) and 24 h, but were similar in both groups after 48 h’’. However, this should have read ‘‘Levels remained significantly higher than in the laparoscopic group at 3 h (10·36 versus 0·52 ng/ml; P < 0·001) and 24 h, but were similar in both groups after 48 h’’. The publisher apologizes for any confusion caused.