Manousos-Georgios Pramateftakis

Anastomotic leakage following anterior resection for rectal cancer.

BackgroundThe aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.Patients and methodsDuring the last ten years, 93 patients underwent anterior resection of the rectum for rectal cancer. Low anterior resection with total mesorectal excision (TME) was performed in 72, and high anterior resection in 21 patients. The definition of the anastomotic leakage was based on clinical features, peripheral blood investigations and abdominal CT scan.ResultsClinically apparent anastomotic leakage developed in 9 patients (9.7%). Four patients were managed conservatively and five operatively. Postoperative mortality among the patients with anastomotic leakage was not recorded.ConclusionsThe incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low. It remains however the most serious complication following rectal resection for cancer.

Usefulness of Lateral Internal Sphincterotomy in Reducing Postoperative Pain after Open Hemorrhoidectomy

The aim of the present study was to evaluate the effect of lateral internal sphincterotomy on pain after open hemorrhoidectomy. From 1998 to 2003, seventy-eight (78) patients with fourth-degree hemorrhoids were included in this prospective randomized trial. The patients were randomized into two equal groups of 39 patients. Patients from group I underwent Milligan-Morgan hemorrhoidectomy. Patients from group II, quite apart from Milligan-Morgan hemorrhoidectomy, underwent lateral internal sphincterotomy up to the dentate line, in the left hemorrhoidectomy wound. One surgeon from the Department, who did not know to which group the patients belonged, evaluated the postoperative course in all the patients. After the first bowel movement, there were three (7.7%) patients who did not experience any pain in the internal sphincterotomy group, while in the non-internal sphincterotomy group all patients experienced mild or moderate pain. There were also more patients who experienced excruciating pain in the non-internal sphincterotomy group than in the internal sphincterotomy group (25 vs. 18); these differences were statistically significant (p = 0.034). There was no significant difference in the Wexner Incontinence Scale between the groups (p = 0.228). The addition of lateral internal sphincterotomy to open hemorrhoidectomy seems to have a positive effect on reducing postoperative pain in a few patients, without affecting the postoperative complications rate.

Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years

BackgroundThe aim of our study was to assess our early and long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids.MethodsOur study covers the time period from 1998 to 2002 and consists of 56 consecutive patients (33 men) with fourthdegree haemorrhoids who underwent stapled haemorrhoidopexy.ResultsDuring the postoperative period, 6 patients (10.7%) experienced pain for 7–14 days, which was treated with oral analgesia. Ten patients (17.8%) experienced gas incontinence and two of them also reported soiling. The incontinence subsided within 3–4 weeks. Median follow-up was 72.1 months (range, 55–56 months). Recurrence of the haemorrhoidal disease occurred in 33 patients (58.9%). The overall reintervention rate was 42.8%, as 24 patients required excisional haemorrhoidectomy by the Milligan-Morgan technique at a later stage.ConclusionsStapled haemorrhoidopexy seems to be a safe, low-pain but ineffective technique for the treatment of fourth-degree haemorrhoids, as it is accompanied by high recurrence and reintervention rates in the long term.

Optimizing colonic cancer surgery: high ligation and complete mesocolic excision during right hemicolectomy

IntroductionWhen performing a colonic resection for cancerous lesions, a complete mesocolic excision (CME) can lead to improved oncologic results. The CME along with the high vessel ligation, meaning the ligation of the supplying vessels close to their origin, can ensure maximal lymph node harvest. The principles of CME and high ligation have been applied by us during colonic resections for cancer. We present our experience with tumors of the proximal colon, for which a radical right hemicolectomy has been performed.Patients and methodsBetween 1989 and 2008, we performed a right hemicolectomy in 115 patients. The mean age was 65.6 years (range 35–86). The tumor was located in the cecum in 37% of patients, the ascending colon in 58% of the patients and the hepatic flexure in 5% of the patients. All patients underwent complete mesocolic excision and high ligation of the supplying vessels. A total of 93% (107/115) of these operations were performed on an elective basis. Out of all patients, 48 (42%) received adjuvant chemotherapy.ResultsNo patient died during the immediate postoperative period. The postoperative morbidity was 13.9% (16/115). One patient developed a metachronous rectal carcinoma 28 months after his surgery, for which he underwent an abdoperineal resection. The 5-year survival rate lies at 72.4% (55/76). Twenty patients (26.3%) died due to metastatic disease before completing 5 years of follow-up. The remaining 39 patients have been operated after the end of 2004 and have therefore not completed 5 years from the day of their operation yet.ConclusionsThere is no doubt that standardized oncologic surgery shows particular importance by reducing the rate of local recurrence and achieving increased survival. It is important to remember that colon cancer treatment today is multimodal and that the improvement in patients’ survival in the last decades is surely linked with the improvement in chemotherapy and the advances in the agents used. However, optimal surgery is with no doubt an important element of good oncological outcome, as the experience with rectal cancer treatment has taught us.

Local excision as a treatment for tumors of ampulla of Vater

BackgroundAlthough local excision (ampullectomy) was first described by Halsted in 1899, its adequacy as an alternative surgical treatment for the ampullary tumors is still a matter of debate. The aim of this study was to evaluate the results of ampullectomy as a curative treatment for benign and malignant tumors arising from the ampulla, in a 14-year single-institution experience.MethodsFrom 1990 to 2004, a total of 20 patients of adenocarcinoma (12) or adenoma (8) of the ampulla of Vater underwent local excision. Clinical data were collected and morbidity, mortality, as well as long-term survival were evaluated. The usefulness of several pre or intraoperative diagnostic methods was also recorded. Median follow-up was 85 (range 6–180) months.ResultsThe combination of endoscopic preoperative biopsies and intraoperative frozen section examination adequately diagnosed ampullary tumors in all cases. The postoperative morbidity and mortality were 0%, whereas the 3 and 5-year survival rates for the patients with adenocarcinoma was 75 % and 33.3 % respectively. All the patients with adenoma are still alive without any sign of recurrence.ConclusionIn our series, local excision was a safe option, associated with satisfactory long-term survival rates in patients with benign lesions and in those with small(<2 cm), pT1, well differentiated ampullary tumours without nodal involvement.

Endoscopic application of n-butyl-2-cyanoacrylate on esophagojejunal anastomotic leak: a case report

IntroductionThis case report describes an esophagojejunal anastomotic leak following total gastrectomy for gastric cancer. The leak was treated successfully with endoscopic application of n-butyl-2-cyanoacrylate. This is the first case report on the endoscopic application of cyanoacrylate alone for the treatment of an anastomotic leak.Case presentationThis report describes a case of a 68-year-old Caucasian man who underwent surgery for gastric cancer. He underwent total gastrectomy and esophagojejunal anastomosis with Roux-en-Y anastomosis plus transverse colectomy. An anastomotic leak was treated conservatively at first for a total of three weeks. However, the leak persisted; therefore, the decision was made to apply topical endoscopic n-butyl-2-cyanoacrylate.ConclusionThe endoscopic application of n-butyl-2-cyanoacrylate alone can be used successfully to treat esophagojejunal anastomotic leakage.

Surgical treatment of hepatic metastases from colorectal cancer

Colorectal carcinoma is one of the most frequent cancers in Western societies with an incidence of around 700 per million people. About half of the patients develop metastases from the primary tumor and liver is the primary metastatic site. Improved survival rates after hepatectomy for metastatic colorectal cancer have been reported in the last few years and these may be the result of a variety of factors, such as advances in systemic chemotherapy, radiographic imaging techniques that permit more accurate determination of the extent and location of the metastatic burden, local ablation methods, and in surgical techniques of hepatic resection. These have led to a more aggressive approach towards liver metastatic disease, resulting in longer survival. The goal of this paper is to review the role of various forms of surgery in the treatment of hepatic metastases from colorectal cancer.

Value of Carcinoembryonic Antigen Assay in Predicting Hepatic Metastases, Local Recurrence, and Survival After Curative Resection of Colorectal Cancer

PurposeWe measured carcinoembryonic antigen (CEA) levels in peripheral and portal venous blood, and bile from patients with colorectal cancer, to determine its role in predicting hepatic metastases, local recurrence, and survival.MethodsThe subjects were 73 patients who underwent curative surgery for colorectal cancer.ResultsThe median serum, bile, and portal CEA levels were significantly lower in 5-year survivors than in patients in whom hepatic metastases or recurrent disease subsequently developed. The CEA level in portal blood and bile was a good indicator of hepatic metastases, with sensitivity of 92% and 100%, respectively. However, the accuracy of any CEA measurement for predicting hepatic metastases, local recurrence, or 5-year survival did not exceed 70%.ConclusionsNone of these CEA measurements is accurate enough to be the basis of a management decision. Thus, we suggest that CEA measurement be used to assist in the prediction of a high risk of the development of hepatic secondaries and that these patients are followed up closely after curative resection.

Anastomotic leakage following low anterior resection for rectal cancer

AimAim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.Patients and methodsBetween 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME).ResultsA total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy.ConclusionThe incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

The Effects of Irinotecan on the Healing of Colonic Anastomoses in Rats

Aim: The aim of this experimental study was to investigate the effects of intraperitoneally injected irinotecan on the healing of colonic anastomoses after colon resection. Methods: Thirty male Wistar rats were used. The rats were randomized into two groups of 15 rats each. Immediately after colonic anastomoses were performed, the rats were injected intraperitoneally with either 3 ml of 0.9% NaCl solution or ir- inotecan (3 mg/kg body weight) depending on their group. All rats were sacrificed on the eighth postoperative day. The anastomoses were examined macroscopically and histologically. The anastomotic bursting pressures were recorded. Results: Anastomotic dehiscence was noted in 3 rats of the irinotecan group. All anastomoses of the control group re- mained intact until sacrifice. The adhesion formation at the anastomotic sites and the average inflammatory cell infiltra- tion scores were significantly higher in the irinotecan group compared to the control group. The bursting pressures, the hydroxyproline tissue content, the fibroblast activity and the collagen deposition were significantly lower in the irinotecan group. Neoangiogenesis did not differ significantly between the groups. Conclusion: Irinotecan, when injected intraperitoneally, affects the healing of colonic anastomoses in rats.