TME quality in rectal cancer surgery

Background

The concept of total mesorectal excision has revolutionised rectal cancer surgery. TME reduces the rate of local recurrence and tumour associated mortality. However, in clinical trials only 50% of the removed rectal tumours have an optimal TME quality. Patients: During a period of 36 months we performed 103 rectal resections. The majority of patients (76%; 78/103) received an anterior resection. The remaining patients underwent either abdominoperineal resection (16%; 17/103), Hartmann''s procedure (6%; 6/103) or colectomy (2%; 2/103).

Results

In 90% (93/103) TME quality control could be performed. 99% (92/93) of resected tumours had optimal TME quality. In 1% (1/93) the mesorectum was nearly complete. None of the removed tumours had an incomplete mesorectum. In 98% (91/93) the circumferential resection margin was negative. Major surgical complications occurred in 17% (18/103). 5% (4/78) of patients with anterior resection had anastomotic leakage. 17% (17/103) developed wound infections. Mortality after elective surgery was 4% (4/95).

Conclusion

Optimal TME quality results can be achieved in all stages of rectal cancer with a rate of morbidity and mortality comparable to the results from the literature. Future studies should evaluate outcome and local recurrence in accordance to the degree of TME quality.     

Satisfactory long-term results after simultaneous resection of the esophagus, stomach and pancreas

Purpose  Surgical procedures for esophageal cancer and chronic pancreatitis are demanding and still characterized by high morbidity and mortality. Cases of one-stage combined operations on the pancreas and esophagus with a long-term follow-up are rarely reported. Materials and methods  We present the case of a 54-year-old woman with a Barrett’s carcinoma and an 8-year history of severe chronic pancreatitis complicated with multiple episodes of cholangitis and resistant to conservative treatment. Results  After a successful one-stage operation consisting of esophagogastrectomy and pancreaticoduodenectomy, a 30-month disease-free follow-up with a good quality of life has been observed. Conclusion  Complicated surgical procedures such as one-stage multiple organ resections may offer, in selected cases, satisfactory long-term results, provided that patients are treated at a high-volume center by a multidisciplinary team.     

Double sigmoid colon perforation by a migrated biliary stent

The case of a female patient with a covered double perforation of the sigmoid colon is described. The perforation was due to a migrated plastic biliary stent inserted 3 weeks earlier for benign biliary obstruction and was facilitated by the presence of expressed diverticulosis of the colon. The lack of peritonitis and the early surgical procedure allowed a successful primary reconstruction after the colonic resection. Since the use of biliary stents is constantly increasing, such complications as stent migration and perforation should always be kept in mind by surgeons.     

Corticosteroid-binding globulin: a possible early predictor of infection in acute necrotizing pancreatitis

OBJECTIVE: Infected pancreatic necrosis is the main cause of death in patients with acute pancreatitis, and therefore its early prediction is of utmost importance. Endogenous cortisol metabolism plays a basic role both in the course of acute pancreatitis and in the process of infection. The purpose of this study was to analyze corticosteroid-binding globulin (CBG), total cortisol, calculated free cortisol and adrenocorticotropic hormone as potential early predictors in order to differentiate between infected pancreatic necrosis and sterile pancreatic necrosis in patients with acute pancreatitis. MATERIAL AND METHODS: Serum levels of CBG, total cortisol, calculated free cortisol, and plasma levels of adrenocorticotropic hormone were determined in 109 consecutive patients with acute pancreatitis. C-reactive protein was measured as the control parameter. Thirty-five patients developed necrotizing pancreatitis and 10 developed infection of the necrosis. Blood was monitored for 6 days after the onset of pain; 30 healthy individuals served as controls. RESULTS: Of all parameters only CBG showed a significant difference (p = 0.0318) in its peak levels measured in the first 48 h in patients with sterile (26.5 microg/ml, range 21.3-34.7) and infected (16.0 microg/ml, range 15.2-25.0) necrosis at a cut-off level of 16.8 microg/ml. That difference was further preserved for the first 6 days after onset of pain. CONCLUSIONS: In our group of patients, a decreased CBG level below 16.8 g/ml within the initial 48 h of acute pancreatitis was an early predictor of later infected pancreatic necrosis, with a positive predictive value of 100% and a negative predictive value of 87.5%.