T. Tsachalis

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.

Long-term results after stapled haemorrhoidopexy for third-degree haemorrhoids.

BackgroundStapled haemorrhoidopexy (SH) is associated with low postoperative pain but, when performed for advanced piles, carries high recurrence rates. The aim of our study was to assess our long–term results after SH for third–degree haemorrhoids.MethodsA total of 126 consecutive patients (67 men and 59 women) with third–degree haemorrhoids underwent SH in our unit between 1998 and 2002. Of these, 120 (95.2%) were followed up in the outpatient department after a median interval of 61.5 months (range, 38–84 months).ResultsDuring the postoperative period, 7 patients (5.8%) experienced pain for 5–12 days, which was treated with oral analgesia. Seven patients (5.8%) experienced gas incontinence and one of them also reported soiling; the incontinence subsided within 2–8 weeks. Recurrence of the haemorrhoidal disease occurred in 8 patients (6.6%).ConclusionsSH is a safe, low–pain and, in the long–term, effective technique for the treatment of third–degree haemorrhoids.

Synchronous polyps in patients with colorectal cancer

BackgroundThe aim of this study is to underscore the incidence of synchronous polyps in patients with colorectal cancer and to emphasise the importance of their perioperative detection and management.Patients and methodsThree hundred and seven patients underwent a potentially curative resection for colorectal cancer during the last ten years. A total of 129 synchronous polyps were detected in 72 of the patients (23.5%). Complete preoperative colonoscopy was performed in 62 of the patients. Forty-three polyps (33.4%) in 37 patients were removed preoperatively, while 69 polyps (53.4%) in 25 patients were included in the surgical specimen. In 10 patients the colon was evaluated postoperatively and 17 polyps (13.1%) were removed via endoscopy.ResultsA total of 81 polyps were detected in different surgical segments than the index cancer. Furthermore, 15 polyps were detected in the right colon of 55 patients with left colon cancer.ConclusionsSynchronous polyps in patients with colorectal cancer are a frequent event. Thus, all patients should undergo a perioperative colonoscopy and endoscopic polypectomy, if feasible. The planned surgical procedure may alter as a consequence of the colonoscopic findings in some of the patients.

Sebaceous gland tumors and internal malignancy in the context of Muir-Torre syndrome. A case report and review of the literature

BackgroundThe Muir-Torre syndrome is a rare autosomal dominant condition and is currently considered a subtype of the more common hereditary nonpolyposis colorectal cancer syndrome, in which multiple primary malignancies occur together with sebaceous gland tumors.Case presentationWe describe a case of a 62-year-old woman with three primary colorectal tumors, genital tumor, and sebaceous adenomas and present her family history of three generations. Our case represents the first case reported from Greece in the international literature.ConclusionRecognition of the syndrome in patients with sebaceous gland tumors should facilitate early detection of subsequent malignancies if the patient is entered into appropriate screening programs.

Reliability of selective surveillance colonoscopy in the early diagnosis of colonic ischemia after successful ruptured abdominal aortic aneurysm repair.

Purpose To evaluate the reliability of selective surveillance colonoscopy based on 6 specific perioperative risk factors in the early diagnosis of colonic ischemia (CI) after successful ruptured abdominal aortic aneurysm (rAAA) repair. Patients and Methods From 1999 to 2005, 62 consecutive patients underwent rAAA repair. In 59 of them, routine aggressive surveillance colonoscopy was offered every 12 hours within the first 48 hours, and CI was graded consistently. Patients with stage I or stage II CI were treated conservatively and were followed up with repeat colonoscopy, whereas patients with stage III CI underwent immediate laparotomy and colectomy. In parallel, 6 specific perioperative risk factors (PRFs) were retrospectively analyzed. Results Overall mortality was 33.9%. Nineteen patients (32.2%) developed CI and 12 (63.2%) of them survived. Thirteen (22%) had grade III CI and among these 6 survived. In patients with CI the mortality rate was 36.2%. Patients with less than 3 PRFs had no CI whereas all instances of CI could be diagnosed if colonoscopy was offered selectively in patients with more than 3 PRFs. The positive predictive value of CI increased with the number of PRFs. Patients with 5 or 6 PRFs were about 101 times more likely to develop CI compared with patients with 0 to 4 PRFs (P < .001). Conclusion Our study showed that CI is a frequent complication after successful rAAA repair and could reliably be early diagnosed if surveillance colonoscopy was offered selectively in patients with more than three PRFs.

Locally recurrent rectal cancer after curative resection

BackgroundTo determine the incidence of local recurrence, after curative resection for rectal cancer, with the application of total mesorectal excision (TME).Patients and methodsDuring the last ten years, 120 patients underwent curative resection for rectal cancer. As a rule, except for the cases that underwent high anterior resection, TME was applied. In terms of local relapse, routine TME, preoperative radiotherapy, tumour’s stage, differentiation grade and number of positive nodes were taken into account.ResultsEight patients (6.7%) presented with local relapse. At 5 years, 91.9% of patients were free of local recurrence and the actuarial disease-free survival was 81%. A significant association between routine TME, tumour’s stage, differentiation grade, lymph node invasion and local recurrence was observed. Conversely, preoperative radiotherapy appeared to play no protective role.ConclusionsThe curative resection of rectal cancer, with the application of TME, has led to a very low incidence of local relapse during the last few years.

Five-year survival after curative resection for adenocarcinoma of the colon

BackgroundThe purpose of this study was to evaluate the 5-year survival of patients with colon adenocarcinoma that underwent elective or emergency curative surgical treatment.Patients and methodsBetween 1993 and 1998, 80 patients underwent a potentially curative colonic resection based on mobilisation along anatomic planes. Among the patients, 26 underwent right colectomy, 3 transverse colectomy, 13 left colectomy and 38 sigmoidectomy. All patients classified as TNM stage III underwent adjuvant chemotherapy. The Kaplan–Meier method was used to analyse survival.ResultsOverall 5-year survival was 69.5%. Patient’s sex and age, mucinous characteristics of the tumour and tumour location did not significantly affect survival. Patients with higher Duke’s classification and TNM stage had significantly worse 5-year survival (p=0.025 and p=0.007, respectively). Although patients with good tumour differentiation had the highest 5-year survival, this difference was not statistically significant (p=0.211).ConclusionsThe treatment of colon adenocarcinoma with curative resection by the end of the 20th century is accompanied with acceptable rates of overall 5-year survival.

Is TNM classification related to early postoperative morbidity and mortality after colorectal cancer resections

BackgroundTo examine the role of TNM staging system as a predictive factor for postoperative morbidity and mortality, after colorectal cancer resections.Patients and methodsDuring the last ten years, 368 patients with colorectal cancer were referred to our institution. All patients, who underwent primary treatment elsewhere or defunctioning colostomy only, or who did not undergo surgical therapy were excluded from the analysis. The early postoperative outcomes registration of the remaining 351 patients (197 men, median age 66.2 years) was retrospectively linked to TNM stage.ResultsTNM stage had a poor prognostic value for the early postoperative morbidity rate. In addition, according to the statistical analysis, the proportion of early postoperative mortality proved to be higher in patients with TNM stage III or IV colorectal cancer.ConclusionsTNM classification could be considered as a reliable predictor of early postoperative mortality, but has no role in the prediction of early postoperative morbidity after colorectal resections.

Radio-frequency ablation of hepatic metastases from colorectal cancer

BackgroundThe aim of our study is to present the preliminary results of an ongoing radio-frequency (RF) ablation study in patients with hepatic metastases from colorectal cancer.Patients and methodsFrom November 2003, two patients affected with metachronous liver metastases from colorectal cancer were treated with RF ablation. The mean age of the patients was 66 years (58 and 74 years). Tumours were unifocal right-lobe lesions in one patient and bifocal in the second patient. Under general anaesthesia, a Radionics 200-W RF generator was used to ablate lesions with H2O-cooled electrodes via laparotomy. Patients’ follow-up ranged from two to five months including evaluation of salient clinical, radiological and laboratory parameters.ResultsThe patients experienced moderate-to-severe pain in the right abdomen lasting for 2–3 days and mild fever for 3–6 days after treatment. During the follow-up period no local recurrence was observed.ConclusionsRF ablation emerges to be a promising method for the treatment of hepatic metastases from colorectal cancer.

Abstracts Colorectal Games, Rethymnom, Crete, Greece, May 2008

268 Tech Coloproctol (2008) 12:267–271 shows that mobilization of the low rectum after a long course of preoperative chemo-radiotherapy might sometimes carry a major surgical difficulty. Extreme fibrosis of the surrounding tissues can happen as an overreaction to radiation therapy in some patients. This fibrosis may force to a loss of the TME plan and may subsequently lead either to intra-operative or late complications. Conclusions Pre-operative radiotherapy, though it is a mandatory element in the modern treatment of low rectal cancer, is associated with early postoperative complications and long-term side effects. Difficulties during operation may be significant and can lead to serious complications in inexperienced surgeons. This negative effect of preoperative chemo-radiotherapy in the surgical outcome must always be considered in the clinical practice. The role of dynamic functional imaging for the assessment of radio sensitivity in patients with locally advanced low rectal cancer 1K. Kopanakis, 2N. Oikonomopoulos, 1G. Martikos, 1P. Patapis, 1E. Misiakos, 1D. Tsapralis, 1A. Azas, 1A. Charalobopoulos, 1L. Liakakos 11st Department of Radiology, “ATTIKON” Hospital, University of Athens, Greece; 23rd Academic Department of Surgery, “ATTIKON” Hospital, University of Athens, Greece Background The management of low rectal cancer, requires a detailed preoperative staging in order to plan the appropriate treatment. We tried to evaluate the response to neo-adjuvant radiotherapy in four of our patients with low rectal cancer, based on the information taken from the preoperative Dynamic Contrast Enhanced Magnetic Resonance Imaging (DCE-MRI). Methods High resolution MRI, is a mode of great sensitivity and specificity in clinical staging of the low rectal cancer and it can predict with accuracy the likelihood of achieving a clear circumferential surgical margin. The DCE-MRI, refers to tissue signal augmentation, during time, caused by the presence of contrast medium in the extravascularextracellular space. This in fact can determine parameters such as tumor blood flow, angiogenesis and capillary permeability on tumor surface and can be used as a radiological marker of tumor radio-sensitivity to neo-adjuvant radiotherapy. Results Four patients suffering of locally advanced low rectal cancer, underwent a preoperative DCE-MRI, in order to assess the response to neoadjuvant radiotherapy. Patients were classified according to the findings of DCE-MRI as: (a) Positive responders (+) and (b) Unidentifiable responders (Und). The classic long-term regimen consisted of 40 Gy radiation with a daily dose of 5-FU over a three weeks period was given to all patients. Four -six weeks after completion of chemo-radiotherapy, they were restaged according to pelvic MRI findings, as (a) complete responders, (b) good responders, (c) poor responders. Soon after MRI, they were operated on. Four TME low anterior resections (3 open and 1 laparoscopic) with a diverting loop ileostomy were successfully carried out. The DCEMRI prediction was compared with post chemo-radiotherapy MRI and pathology findings. Results are shown in Table 1. In our study we have tried to use the DCE-MRI as a prediction tool, of the efficacy of preoperative radiotherapy in down-staging or significantly reducing the tumor bulk in the locally advanced low rectal cancer. We have noticed a strong correlation between the positive prediction with the findings of the postoperative pelvic MRI and of the pathology report (patients 1 and 4). It seems that no correlation can be established in the unidentifiable patients. Conclusions We believe that patients with a positive DCE-MRI prediction of response, will benefit from a long course of preoperative chemoradiotherapy, despite the higher complication rates, as they have a high probability of real clinical remission. Laparoscopic anterior resection of the rectum in situs viscerum inversus. A case report P. Millo, R. Allieta, M. Nardi Jr, R. Brachet Contul, G. Scozzari “U. Parini” Regional Hospital. Department of Surgery, Aosta, Italy Situs viscerum inversus (S.V.I.) is a rare congenital anatomical abnormality caused by an autosomic recessive or X-linked mutation. The abnormality is characterised by an inversion of endoabdominal and endo-thoracic organs. There are two types of S.V.I.: totalis, with associated destro-cardia (prevalence: 1/10000) and incomplete, without destro-cardia (prevalence 1/22000). We present a case report of a 59 year-old male patient with a situs viscerum inversus who was admitted in the Division of General Surgery of Aosta’s Valley (“U. Parini” Regional Hospital of Aosta’s Valley) with cancer of the upper rectum: this clinical association is extremely rare with major intra-operative technical difficulties, especially when abnormal anatomical position of mesenteric vessels exists. We performed a laparoscopic anterior rectal resection with a transanal Knight-Griffen anastomosis. No intra-operative complications were observed; the length of hospital stay was 6 days. Anorectal malformations and the posterior sagittal approach I. Alexandrou, N. Lainakis, E. Efstathiou, D. Demetriadis, Th. Dolatzas, S. Antypas 1st Surgery Department, Children’ Hospital “Aghia Sophia” Athens, Greece Background Aim of this presentation is to show the technique of anorectal malformations’ repair via the posterior sagittal approach. Methods A wide spectrum of anorectal diseases were treated in 79 patients, aged from 1 day to 12 months, in our clinic during the last 15 years. Results There were 42 males and 37 females. Among the males 30 suffered from rectal agenesis and anal atresia with a recto-urethral fistula, 3 from recto-vesical fistula, 5 from imperforate anus without fistula, 1 from rectal stenosis and 3 from recto-perineal fistula and covered anus. Among the females, 12 suffered from rectal agenesis and anal atresia with a recto-vestibular fistula, 10 from recto-vaginal fistula, 3 Table 1 Complications Presacral Impaired Injury Colo-vaginal Colo-vesical plexus TME of inferior fistula fistula haemorrhage margins hypo-gastric 6–8 months 6–8 months plexus postoperative postoperative n 3 4 2 2 3 Table 1 Results Patients DCE-MRI Postradiotherapy Pathology prediction MRI response response 1 + Complete response Complete response 2 Und Poor response No response 3 Und Good response Good response 4 + Good response Good response from imperforate anus without fistula, 1 from rectal atresia, 3 from persisted cloaca and 8 from recto-perineal fistula and covered anus. All of them, excluding the 3 males with recto-vesical fistula and the 2 females with persisted cloaca, were treated only via the posterior sagittal approach without an abdominal approach. Conclusions Anorectal malformations comprise a wide spectrum of diseases, which can affect boys and girls, and involve the distal anus and rectum as well as the urinary and genital tracts. The surgical approach for repairing these defects changed dramatically in 1980 with the introduction of the posterior sagittal approach, which allowed surgeons to view the anatomy of these defects clearly, to repair them under direct vision, and to learn about the complex anatomic arrangement of the junction of rectum and genitourinary tract. It has become the predominant surgical method for anorectal anomalies. When the rectum or the vagina are very high and an abdominal approach is also needed, laparoscopy can be used in combination with the posterior sagittal approach. Laparoscopic left colectomy with preservation of mesenteric artery for diverticular disease U. Parini, P. Millo, R. Allieta, R. Brachet Contul, F. Persico, A. Loffredo, E. Lale Murix, M. Fabozzi, M. Roveroni, A. Usai, J. Da Broi, M.J. Nardi “U. Parini” Regional Hospital, Department of Surgery, Aosta, Italy Respecting the plane of Toldt-Gerota during left colon resection makes it possible to preserve the nerves of the hypogastric plexus. Anatomical plane alteration caused by inflammation during the diverticulitis often makes it difficult to perform the operation. In particular, inferior mesenteric artery (AMI) ligation involves a risk of hypogastric plexus injury leading to genitourinary disorders. The technique of AMI preservation for non-malignant pathology described by the authors makes it possible to perform left colectomy without damaging the plexus and also results in better vascularized intestinal stumps. The authors perform this technique with the help of the 10 mm Ligasure Atlas ® (TYCO Health care), which allows more efficient and quicker tissue and vessels dissection and coagulation. Complications in laparoscopic versus open colectomies for colorectal cancer E. Roustanis, N. Benetatos, G. Pappas-Gogos, K.E. Tsimogiannis,