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Amphipods are among the most abundant macroinvertebrates in freshwater ecosystems of the Palaearctic and crucial for ecosystem functioning. Furthermore, their high sensitivity to environmental change and pollutants makes them widely used model organisms in environmental sciences and ecotoxicology. In field studies and surveys across Eurasia, species of the genus Gammarus are commonly used, yet laboratory-based studies and ecotoxicological tests are often restricted to the in most parts of the world non-native Hyalella azteca, as Gammarus is much harder to breed and maintain under laboratory conditions. However, for direct comparisons and extrapolations of results of field- vs. laboratory-based studies, the use of the same species would be desirable. Here, we investigated different settings with respect to feeding, shelter and day length to successfully increase survival, juvenile production and their respective growth and survival, and ultimately multi-generation breeding of the amphipod Gammarus fossarum. Amphipod populations persisted and reproduced successfully under optimized husbandry conditions for 12 months and were partially maintained for another year in populations up to a few hundred individuals. Specifically, supplementing diet with protein-rich food sources as well as the provisioning of shelters improved survival rate of G. fossarum significantly. However, we found no significant effect of different day length treatments on the overall relative reproductive activity or on the total amphipod abundance maintained. We conclude that G. fossarum can be kept and reared under standardized conditions. Despite the longer generation times of G. fossarum and higher effort required for maintenance compared to H. azteca, direct ecological relevance and comparability of results to natural systems may justify its future use and development as a study organism for environmental sciences and ecotoxicology., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

In male elite gymnastics, lately, eccentric training is often used to improve the maximum specific strength of static elements on rings. Therefore, in this study, we aimed to investigate the effects of a three-week, gymnastic-specific, eccentric-isokinetic (0.1 m/s) cluster training with a change of stimulus after three of six training sessions (eccentric-isokinetic with additional load) on a computer-controlled training device on the improvement of the elements swallow and support scale on rings. Maximum strength and strength endurance in maintaining the static positions of ten international elite male gymnasts were determined on a weekly basis. After three weeks of training, specific maximum strength and strength endurance increased significantly (strength: swallow: +8.72%, p < 0.001; support scale: 8.32%, p < 0.0001; strength endurance: swallow: +122.36%; p = 0.02; Support Scale: +93.30%; p = 0.03). Consequently, top gymnasts can considerably improve ring-specific strength and strength endurance in only three weeks. The separate analysis of the effects of both eccentric-isokinetic training modalities showed that efficiency might even be increased in future training interventions. We suggest using this type of training in phases in which the technical training load is low and monitoring the adaptations in order to compile an individually optimized training after an intervention.

On rings, in men's artistic gymnastics, the general strength requirements for important static elements remain elusive. Therefore, the aim was to describe the relationship between a new conditioning strength test and a maximum strength test of static elements on rings in order to determine the minimal strength level (benchmarks) required to maintain these elements with one's own body weight. Nineteen elite gymnasts performed a concentric (1RM isoinertial) and eccentric (isokinetic: 0.1 m/s) conditioning strength test for swallow/support scale (supine position) and inverted cross (seated position) on a computer-controlled device and a maximum strength test maintaining these elements for 5 s on rings with counterweight or additional weight. High correlation coefficients were found between the conditioning maximum strength for swallow/support scale (r: 0.65 to 0.92; p < 0.05) and inverted cross (r: 0.62 to 0.69; p > 0.05) and the maximum strength of the elements on rings. Strength benchmarks varied between 56.66% (inverted cross concentric) and 94.10% (swallow eccentric) of body weight. Differences in biomechanical characteristics and technical requirements of strength elements on rings may (inter alia) explain the differences between correlations. Benchmarks of conditioning strength may help coaches and athletes systematize the training of strength elements on rings.

Background: Enhanced recovery program is a multimodal, multidisciplinary-team, evidence-based care approach to reduce perioperative surgical stress, decrease morbidity and hospital stay, and improve recovery after surgery. This program may be most beneficial for elderly (≥70 y), but sparse series have investigated this question., Objective: Feasibility and efficiency of a dedicated enhanced recovery program in the elderly as compared with standard care were studied., Design: This was a nonblinded, randomized controlled study., Settings: This study was conducted in a single high-volume university hospital., Patients: A total of 150 eligible elderly patients undergoing elective colorectal surgery were included., Interventions: Enhanced recovery after colorectal elective surgery in elderly patients was studied., Main Outcome Measures: The primary outcome was 30-day postoperative morbidity. Additional outcomes included hospital stay, readmission, postoperative pain, opioid consumption, independence preservation, and protocol compliance., Results: An enhanced recovery program reduces postoperative morbidity according to Clavien-Dindo classification by 47% as compared with standard care (35% vs 65%; p = 0.0003), total number of complications (54 vs 118; p = 0.0003), and infectious complications (13 vs 29; p = 0.001). No anastomotic leak was recorded in the enhanced recovery group versus 5 for the standard group (p = 0.01). The enhanced recovery program resulted in shorter hospital stay (7 vs 12 d; p = 0.003) and better independence preservation (home discharge, 87% vs 67%; p = 0.005). A high protocol compliance of 77.2% could be achieved in this population. According to multivariate analysis, enhanced recovery program was strongly associated with reduced morbidity (OR = 0.23 (95% CI, 0.09-0.57); p = 0.001), less severe complications (OR = 0.36 (95% CI, 0.15-0.84); p = 0.02), and shorter hospital stay (OR = 2.07 (95% CI, 1.33-3.22); p = 0.001)., Limitations: Limitations were a single-center recruitment and the impossibility of subject or healthcare professional blinding attributed to the nature of this multimodal program., Conclusions: Enhanced recovery program is safe and improves postoperative recovery in elderly patients with decreased morbidity, shorter hospital stay, and better maintenance of independence. It should therefore be considered as a standard of care for elective colorectal surgery in elderly patients. See Video Abstract at http://links.lww.com/DCR/A981., Trial Registration: clinicaltrials.gov identifier: NCT01646190. ENSAYO CONTROLADO ALEATORIZADO DE UN PROGRAMA DE RECUPERACIÓN INTENSIFICADA DEDICADO A PACIENTES DE EDAD AVANZADA DESPUÉS DE CIRUGÍA COLORECTAL: El Programa de Recuperación Intensificada es un enfoque de atención multimodal, multidisciplinaria y basada en evidencia para reducir el estrés quirúrgico perioperatorio, disminuir la morbilidad y la estancia hospitalaria, y mejorar la recuperación después de la cirugía. Este programa puede ser más beneficioso para las personas mayores (≥70 años), pero pocas series han investigado esta pregunta., Objetivo: Viabilidad y eficiencia del Programa de Recuperación Intensificada dedicado en personas de edad avanzada en comparación con la atención estándar. DISEÑO:: Este fue un estudio controlado, aleatorizado, sin método ciego., Escenario: Este estudio se realizó en un único hospital universitario de alto volumen., Pacientes: Un total de 150 pacientes de edad avanzada elegibles sometidos a cirugía colorrectal electiva fueron incluidos., Intervenciones: Recuperación Intensificada después de cirugía electiva colorrectal en pacientes de edad avanzada., Principales Medidas De Resultado: El resultado primario fue la morbilidad postoperatoria a 30 días. Los resultados adicionales incluyeron estancia hospitalaria, reingreso, dolor postoperatorio, consumo de opioides, preservación de la independencia y cumplimiento del protocolo., Resultados: El Programa de Recuperación Intensificada reduce la morbilidad postoperatoria según la clasificación de Clavien-Dindo en un 47% en comparación con la atención estándar (35% vs 65%; p = 0.0003), número total de complicaciones (54 vs 118; p = 0.0003) y complicaciones infecciosas (13 vs 29; p = 0.001). No se registró ninguna fuga anastomótica en el grupo de Recuperación Intensificada frente a 5 para el grupo estándar (p = 0.01). El Programa de Recuperación Intensificada dio como resultado una estancia hospitalaria más corta (7 contra 12 días; p = 0.003) y una mejor conservación de la independencia (alta hospitalaria: 87% vs 67%; p = 0.005). Se pudo lograr un alto cumplimiento del protocolo del 77.2% en esta población. De acuerdo con el análisis multivariable, el Programa de Recuperación Intensificada se asoció fuertemente con la reducción de morbilidad (OR = 0.23; IC 95%: 0.09-0.57; p = 0.001), menos complicaciones graves (OR = 0.36; IC 95%: 0.15-0.84; p = 0.02) y estancia hospitalaria más corta (OR = 2.07; IC 95%: 1.33-3.22; p = 0.001)., Limitaciones: Las limitaciones fueron un centro único de reclutamiento y la imposibilidad de que los pacientes o el profesional de la salud tuvieran cegamiento debido a la naturaleza de este programa multimodal., Conclusiones: El Programa de recuperación Intensificada es seguro y mejora la recuperación postoperatoria en pacientes de edad avanzada, con menor morbilidad, menor estancia hospitalaria y mejor mantenimiento de la independencia. Por lo tanto, debe considerarse como un estándar de atención para la cirugía colorrectal electiva en pacientes de edad avanzada. Vea el Resumen en video en http://links.lww.com/DCR/A981.

Microtubule-targeting agents (MTAs) like taxol and vinblastine are among the most successful chemotherapeutic drugs against cancer. Here, we describe a fluorescence anisotropy-based assay that specifically probes for ligands targeting the recently discovered maytansine site of tubulin. Using this assay, we have determined the dissociation constants of known maytansine site ligands, including the pharmacologically active degradation product of the clinical antibody-drug conjugate trastuzumab emtansine. In addition, we discovered that the two natural products spongistatin-1 and disorazole Z with established cellular potency bind to the maytansine site on β-tubulin. The high-resolution crystal structures of spongistatin-1 and disorazole Z in complex with tubulin allowed the definition of an additional sub-site adjacent to the pocket shared by all maytansine-site ligands, which could be exploitable as a distinct, separate target site for small molecules. Our study provides a basis for the discovery and development of next-generation MTAs for the treatment of cancer.

A new convergent total synthesis of the marine macrolide mandelalide A (1) has been developed that is based on macrocyclic ring closure by a Shiina-type macrolactonization and the construction of the requisite precursor seco acid by a highly efficient Sonogashira cross-coupling reaction between two fragments of comparable complexity. Key steps in the elaboration of the acid building block were the enantioselective, catalytic addition of a protected acetylene to crotonaldehyde and the construction of the tetrahydropyran unit that is embedded in the macrocycle by means of an acid-catalyzed Prins reaction. The synthesis of the alcohol fragment features the formation of the trisubstituted tetrahydrofuran ring through an acetal cleavage/epoxide opening cascade reaction and a rarely used radical alkynylation of a primary alkyl iodide. Intriguingly, the dihydroxylation of a terminal double bond as part of the synthesis of this building block gave the same major product for both the α- and β-AD-mix reagents, albeit with moderate or low selectivity. Synthetic mandelalide A (1) was a potent proliferation inhibitor of A549, HT460, and H1299 human lung cancer cells in vitro, but not of SK-N-SH neuroblastoma cells. However, in no case did we observe complete cell kill even at the highest compound concentration tested (5 μm)., (© 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Superior lumbar triangle hernia, also known as Grynfeltt-Lesshaft hernia, denotes a subtype of abdominal wall hernia, and more specifically of lumbar hernia, occurring between the 12th rib, the internal oblique muscle, and the quadratus lumborum muscle. We report the case of a 92-year-old female patient in which this form of hernia occurred, complicated by incarceration and acute bowel obstruction. The discussion contains a short résumé of the different kinds of abdominal wall hernias.

Background: Lower gastrointestinal bleeding represents 20 % of all gastrointestinal bleedings. Interventional radiology has transformed the treatment of this pathology, but the long-term outcome after selective embolization has been poorly evaluated. The aim of this study is thus to evaluate the short-term and long-term outcomes after selective embolization for colonic bleeding., Methods: From November 1998 to December 2010, all acute colonic embolizations for hemorrhage were retrospectively reviewed and analyzed. The risk factors for post-embolization ischemia were also assessed., Results: Twenty-four patients underwent colonic embolization. There were 6 men and 18 women with a median age of 80 years (range, 42-94 years). The underlying etiologies included diverticular disease (41.9 %), post-polypectomy bleeding (16.7 %), malignancy (8.2 %), hemorrhoid (4.1 %), and angiodysplasia (4.1 %). In 23 patients, bleeding stopped (95.8 %) after selective embolization. One patient presented a recurrence of bleeding with hemorrhagic shock and required urgent hemorrhoidal ligature. Four patients required an emergent surgical procedure because of an ischemic event (16.7 %). One patient died of ileal ischemia (mortality, 4.1 %). The level of embolization and the length of hypoperfused colon after embolization were the only risk factors for emergent operation. Mean hospital stay was 18 days (range, 9-44 days). After a mean follow-up of 28.6 months (range, 4-108 months), no other ischemic events occurred., Conclusion: In our series, selective transarterial embolization for acute colonic bleeding was clinically effective with a 21 % risk of bowel ischemia. The level of embolization and the length of the hypoperfused colon after embolization should be taken into consideration for emergent operation.

Duodenal diverticula (DD) are frequently encountered and are usually asymptomatic, with an incidence at autopsy of 22%. Perforation of DD is a rare complication (around 160 cases reported) with potentially dramatic consequences. However, little evidence regarding its treatment is available in the literature. The aim of this study was to review our experience of perforated DD, with a focus on surgical management. Between January 2001 and June 2011, all perforated DD were retrospectively reviewed at a single centre. Seven cases (5 women and 2 men; median age: 72.4 years old, rang: 48-91 years) were found. The median American Society of Anesthesiologists' score in this population was 3 (range: 3-4). The perforation was located in the second portion of duodenum (D2) in six patients and in the third portion (D3) in one patient. Six of these patients were treated surgically: five patients underwent DD resection with direct closure and one was treated by surgical drainage and laparostomy. One patient was treated conservatively. One patient died and one patient presented a leak that was successfully treated conservatively. The median hospital stay was 21.1 d (range: 15-30 d). Perforated DD is an uncommon presentation of a common pathology. Diverticular excision with direct closure seems to offer the best chance of survival and was associated with a low morbidity, even in fragile patients.

Background and Study Aims: Very recently, robotic single site cholecystectomy (RSSC) has been reported feasible and safe for selected cases. While an intra-operative cholangiography can be performed, data is scarce with respect to its use. Indocyanin green (ICG) has been shown to be a viable option to visualize biliary anatomy. Since the introduction of a new near infrared camera integrated to the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA), the surgeon is able to assess the biliary anatomy by a non-invasive and non-ionizing method. This paper presents the first report of ICG imaging during a RSSC., Patients and Methods: Twelve consecutive patients presenting symptomatic cholelithiasis were prospectively enrolled. They underwent RSSC approximately 45 minutes after intravenous administration of ICG (2.5 mg). The biliary anatomy was analyzed using a near infrared camera integrated to the robot before and after the robotic dissection., Results: Eight women and four men underwent the procedure. There was a port addition in one case and no peri-operative complications. Mean operative time was 85 minutes (range: 57-125). The cystic, common bile and common hepatic ducts were recognized by fluorescence imaging before the dissection in 91.7%, 50%, and 33.3% of patients, respectively. At least one structure was visualized in 100% of patients. After the completion of Calot's triangle dissection, the cystic, common bile, and common hepatic ducts were recognized in 100%, 83.3%, and 66.7% of cases respectively., Conclusions: RSSC using ICG for biliary tree fluorescence imaging can be performed safely. Fluorescent cholangiography enabled real-time identification of the extra-hepatic biliary anatomy using a near infrared camera integrated to the robot. Its routine clinical use merits further investigations., (Copyright © 2012 John Wiley & Sons, Ltd.)

Questions Under Study/principles: In most centers, Upper Gastrointestinal series (UGI) following Roux-en-Y Gastric Bypass (RYGB) is performed to rule out GJ anastomotic leak. According to the introduction of robotic technology associated with a hypothetical decrease of anastomotic complications, we aim to assess the validity and cost effectiveness of early routine UGI following robot-assisted RYGB., Methods: Between July 2006 and December 2010, 167 robot-assisted RYGB were performed at a single institution. All data were collected prospectively in a computerised database and reviewed retrospectively. Patients underwent a gastrografin UGI at postoperative day 2 to exclude anastomotic leak or stenosis., Results: None of the 167 patients who underwent an early UGI experienced leak radiologically and clinically. The only radiological abnormalities were two GJ edema (1.2%) and one jejunojenunostomy stenosis (0.6%), all treated conservatively with success. The total cost for the 167 UGI was CHF 93,520 (= USD 96,886)., Conclusions: In most centres, the risk of anastomotic leak has been the rationale for obtaining an UGI following RYGB. However, provided low leak rates as for our experience with robotic RYGB, the authors show this exam to be expensive and of limited value. A decisional algorithm for on demand UGI has been developed according to patient's characteristics and is now under validation.

Background: Robot-assisted Roux-en-Y gastric bypass (RYGBP) is rapidly evolving as an important surgical approach in the bariatric field. However, the specific learning curve associated with this new approach remains poorly investigated. This study aimed to evaluate the learning curve for robot-assisted RYGBP., Methods: A series of 64 consecutive robot-assisted RYGBP procedures were performed between December 2008 and December 2010 by a single surgeon already experienced in advanced laparoscopic procedures but not in bariatric surgery. All data were collected prospectively in a database and reviewed retrospectively. The learning curve was evaluated using the cumulative sum (CUSUM) method., Results: Women comprised 76.6% and men 23.4% of this series. These patients had a mean age of 43 years and a mean body mass index (BMI) of 44.5 kg/m(2). The mean operative time (OT) was 238.1 min (range, 150-400 min). A total of six complications occurred (9.4%). The CUSUM learning curve consisted of two distinct phases: phase 1 (the initial 14 cases; mean OT, 288.9 min) and phase 2 (the subsequent cases; mean OT, 223.6 min), which represented the mastery phase, with a decrease in OT (P = 0.0001). The two groups were similar in terms of gender, age, and BMI. The two phases did not differ in terms of complications or hospital stay., Conclusions: This series confirms previous study findings concerning the feasibility and the safety of robotic RYGBP even after a limited experience with laparoscopic RYGBP. The data reported in this article suggest that the learning phase for robot-assisted RYGBP can be achieved with 14 cases.

Background: The technique of single-port laparoscopy was developed over the past years in an attempt to reduce the invasiveness of surgery. A reduction of incisions and their overall size might result in enhanced postoperative cosmesis and potentially reduce pain when compared to conventional techniques. While manual single-port laparoscopy is technically challenging, a newly approved robotic platform used with the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA, USA) might overcome some of the difficulties of this technique., Methods: Patients with cholelithiasis were scheduled for robotic single-port cholecystectomy in an initial clinical trial. Demographic data, intra- and short-term postoperative results were assessed prospectively., Results: Twenty-eight patients (22 females/6 males; median age, 48 years) underwent robotic single-port cholecystectomy in our first week of clinical cases. Median OR time was 80 min with a median docking time of 8 min and median robotic console time of 53 min. Two patients underwent intraoperative cholangiography. Eight cases presented with adhesions, tissue alterations, or anatomical abnormalities. No conversions, intra- or postoperative complications occurred., Conclusion: Robotic single-port cholecystectomy appears feasible and safe in our early experience. The robotic approach to single-port surgery seems to overcome some of the technical difficulties of manual single-port surgery. This robotic platform may facilitate completion of more complex cases.

Background: Since the introduction of robotics, relatively few series have been published evaluating its role for right colectomy. The aim of this study was to report our preliminary experience with totally robotic right colectomy (TRRC)., Methods: Between 2009 and 2010 we performed three TRRCs, using a hand-sewn intracorporeal anastomosis. Data were retrospectively reviewed., Results: Two women and one man underwent a TRRC. Mean operative time was 270 min. Mean blood loss was 30 ml. There was no conversion. Mean number of lymph nodes harvested was 18. There were no complications. Median hospital stay was 10 days. After a median follow-up of 10 months, there was no tumoural recurrence., Conclusion: TRRC is not only safe and feasible but also oncologically effective. Although preliminary and small, this experience confirmed the results from previous series using a hand-sewn intracorporeal anastomosis. Larger series are required to draw firm conclusions concerning the possible indications for TRRC., (Copyright © 2011 John Wiley & Sons, Ltd.)

Background: Recent population survey has shown a preference for transumbilical laparoendoscopic single-site surgery (U-LESS) compared with natural orifice transluminal endoscopic surgery (NOTES) for cholecystectomy, assuming similar surgical risk. This study was designed to evaluate the perception and preference of women regarding conventional laparoscopy, U-LESS, and transvaginal NOTES (TV-NOTES) with particular interest to access perception., Methods: An anonymous questionnaire on laparoscopic, U-LESS, and TV-NOTES cholecystectomy, without regards to risks or advantages, was given to female medical/paramedical staff (n=100), patients (n=100), and the general population (n=100). Women participants (median age, 35 (range, 16-79) years) were queried about preference, perception of the different accesses, and personal informations. Of the respondents, 54% had children, 79% had stable relationships, and 96% were sexually active (vaginal intercourse)., Results: With similar operative risk, 87% preferred U-LESS, 4% TV-NOTES and 8% laparoscopy. LESS/NOTES choice was influenced by a desire of improved cosmetics (82%) and lower pain (44%). 96% had worries regarding transvaginal access, among them: dyspareunia (68%), decreased sensibility during intercourse (43%), refuse of short-term sexual abstinence (40%), and infertility (23%). Transumbilical access evocated worries in 35%: umbilical pain (19%), postoperative umbilical sensibility (15%), and incisional hernia (11%). Postoperative intercourse abstinence after TV-NOTES evocated worries in 76% (defined as 3 weeks in survey): feel less attractive (40%), less feminine (32%), tension with their intimate (35%), lover non-acceptation (20%), possible abortion of new relationship (26%), and feel less comfortable socially (16%)., Conclusions: The high acceptation rate for U-LESS approach compared with TV-NOTES may be related to fears regarding postoperative sexuality and fertility. The importance of temporary postoperative sexual abstinence (vaginal intercourse) is high and may be difficult to influence. Future research on TV-NOTES should focus on the access risk to be able to scientifically reassure our patients. For now, U-LESS seems to be favor compared with TV-NOTES for cholecystectomy in female patients.

Background: New technologies can considerably improve preoperative planning, enhance the surgeon's skill and simplify the approach to complex procedures. Augmented reality techniques, robot assisted operations and computer assisted navigation tools will become increasingly important in surgery and in residents' education., Methods: We obtained 3D reconstructions from simple spiral computed tomography (CT) slides using OsiriX, an open source processing software package dedicated to DICOM images. These images were then projected on the patient's body with a beamer fixed to the operating table to enhance spatial perception during surgical intervention (augmented reality)., Results: Changing a window's deepness level allowed the surgeon to navigate through the patient's anatomy, highlighting regions of interest and marked pathologies. We used image overlay navigation for laparoscopic operations such cholecystectomy, abdominal exploration, distal pancreas resection and robotic liver resection., Conclusions: Augmented reality techniques will transform the behaviour of surgeons, making surgical interventions easier, faster and probably safer. These new techniques will also renew methods of surgical teaching, facilitating transmission of knowledge and skill to young surgeons.

Background: Although still under development, single-port access (SPA) approach may be of interest in patients prone to port-side incisional hernia, ensuring absence of increased fascial incision. This forms the basis for evaluating SPA for prosthetic ventral hernia repair. We report a new SPA technique of ventral hernia repair using working-channel endoscope, standard laparoscopic instruments, and 10-mm port., Methods: Prospective experience with SPA prosthetic repair of primary and incisional ventral hernia in 52 patients for 55 ventral hernias is presented. Median (range) patient age was 46 years (26-85 years), and BMI was 28 kg/m2 (20-38 kg/m2). Mean fascial defect was 16.2 cm2 for primary hernia (n=23) and 48.3 cm2 for incisional hernia (n=32). Intraperitoneal composite mesh repair was achieved through single 10-mm flank port using working-channel endoscope. Meshes were fixed using absorbable tackers and transfascial stitches., Results: SPA repair of primary and incisional ventral hernia was completed in all cases without conversion to standard laparoscopy. Median (range) operative time was 54 min (39-95 min). Mesh size ranged from 118 to 500 cm2. No intra- or postoperative complications were recorded, except two seromas. Median (range) hospital stay was 1 day (1-5 days). One patient presented prolonged postoperative pain on mesh fixation that resolved after 3 months. No recurrence or port-site incisional hernias have been recorded at median (range) follow-up of 16 months (3-28 months)., Conclusions: SPA prosthetic repair of primary and incisional ventral hernia is easily feasible according to natural exposition by pneumoperitoneum and gravity. In the present series, SPA ventral hernia repair appears to be safe for experienced SPA surgeons. It may decrease parietal trauma and scarring in patients prone to incisional hernia. SPA repair may be associated with a decrease in rate of port-site incisional hernia compared with multiport laparoscopy, but this has to be verified by randomized trial with standard laparoscopic approach on long-term follow-up.

Background and Aim: Positron Emission Tomography (PET) using (18)F-fluorodeoxyglucose (FDG) associated with computed tomography (CT) is increasingly used for the detection and the staging of pancreatic cancer, but data regarding its clinical added value in pre-surgical planning is still lacking. The aim of this study is to investigate the performance of FDG PET associated with contrast-enhanced CT in detection of pancreatic cancer., Methods: We prospectively evaluated FDG PET/CT studies obtained in patients with suspicion of operable pancreatic cancer between May 2006 and January 2008. Staging was conducted according to a standardized protocol, and findings were confirmed in all patients by surgical resection or biopsy examination., Results: Forty-five patients with a median age of 69 (range 22-82) were included in this study. Thirty-six had malignant tumors and nine had benign lesions (20%). The sensitivity of enhanced versus unenhanced PET/CT in the detection of pancreatic cancer was 96% versus 72% (P=0.076), the specificity 66.6% versus 33.3% (P=0.52), the positive predictive value 92.3% versus 80% (P=0.3), the negative predictive value 80% versus 25% (P=0.2), and the accuracy 90.3% versus 64% (P=0.085)., Conclusions: Our preliminary data obtained in a limited number of patients shows that contrast-enhanced FDG PET/CT offers good sensitivity in the detection and assessment of pancreatic cancer, but at the price of a relatively low specificity. Enhanced PET/CT seems to be superior to unenhanced PET/CT. Further larger prospective studies are needed to establish its value for pre-surgical diagnosis and staging in pancreatic cancer., (© 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.)

Background: Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) are prospected as the future of minimally invasive surgery. While scarless surgery (NOTES and LESS) is gaining increasing popularity, perception of these approaches should be investigated., Methods: An anonymous questionnaire describing laparoscopy, LESS, and NOTES was given to medical staff (n=120), paramedical staff (n=100), surgical patients (n=100), and the general population (n=100). The survey participants (median age, 37 years; range, 18-81 years) were queried about their expectations for surgical treatment and their approach preference., Results: The first concern of the survey responders was the risk of surgical complications (92%). When asked about the respective importance of surgical safety, cure, and cosmetics, cure was placed first by 74%, safety by 33%, and cosmetics by 3%. These results were not influenced by sex, age, prior surgery or endoscopy, or education. When operative risk was similar, 90% of the participants preferred a scarless approach (75% preferred LESS and 15% preferred NOTES) to laparoscopy. The scarless approach preference was significantly higher among the younger participants (age<40 years; p=0.026), whereas sex showed no influence. The LESS preference was significantly higher among patients and the general population (86%) than among medical (67%) and paramedical (70%) staffs (p<0.001). A decreasing trend of preference for LESS and NOTES was observed with increased procedural risks., Conclusion: Although cure and safety remain the main concern, the population has a favorable perception of scarless surgery, even in the case of increased procedural risk, with LESS favored over NOTES. Such a popular adoption of scarless surgery should warrant the promotion of further research, technological innovations, and the establishment of surgeon training to improve its safety.

Despite improvements in minimally invasive techniques over recent decades, kidney implantation into the iliac fossa has remained a domain of open surgery. However, it was hypothesized that it would be feasible to perform robotic transplant kidney implantation as a means of reducing surgical trauma. Two robotic kidney transplantations into the iliac fossa were attempted in human cadavers. In the first cadaver, a 5 cm incision was placed in the right lower abdomen, the peritoneum was mobilized in a cranial direction, the iliac vessels were identified, and the kidney placed in the pre-peritoneal space. The incision was sealed with a gel port through which the Vinci(©) Surgical System was installed. In the second cadaver, a robotic kidney implantation with robotically sutured vascular and ureteric anastomoses was performed trans-abdominally. Open incision, identification, placement of gel port, and robotic docking were feasible. Robotic performance of vascular anastomosis was not possible in the first cadaver because of advanced decay and excess fat in the surgical field. Robotic kidney positioning was feasible and anastomoses were performed successfully in the second cadaver within 35, 25, and 20 min (arterial, venous, and ureteric, respectively). Robotic kidney transplantation seems feasible in human cadavers if tissue condition is suitable, but is very technically challenging. Because of the delicacy of anatomical structures, the cadaveric model with the risk of advanced decay and the absence of circulation sets limits on the exploration of this complex procedure. Hence, further research and animal work in this area is critical to improve understanding of the benefits and limitations of robotic kidney implantation.

Aim: To evaluate the results of segmental duodenectomy (SD) and pancreaticoduodenectomy (PD) for duodenal gastrointestinal stromal tumor (GIST) and help clinicians with surgical management., Methods: All patients who underwent surgery for non-metastatic GIST of the duodenum in a single institution since 2000 were prospectively followed up. Seven patients (median age 51 years, range: 41-73 years) were enrolled: five underwent SD and two underwent PD., Results: All the patients had a complete resection (R0), with no postoperative morbidity and mortality. Among the SD group, GIST was classified as low risk in two patients, intermediate risk in two, and high risk in one, according to the Fletcher scale, (vs two high risk patients in the PD group). With a median follow-up of 41 (18-85) mo, disease-free survival (DFS) rates were 100% after SD and 0% after PD (P < 0.05). The median DFS was 13 mo in the PD group., Conclusion: Whenever associated with clear surgical margins, SD is a reliable and curative option for most duodenal GISTs, and is compatible with long-term DFS.

Background: Laparoscopic resection of gastric gastrointestinal stromal tumor (GIST) has been shown as feasible and safe in terms of oncologic results. However, laparoscopic resection has been demonstrated to be mainly suitable for small, favorably localized GIST. The robotic approach may, by its characteristics, enable the surgeon to perform atypical gastrectomies in an unfavorable location (i.e., close to pylorus or cardia). Its use in oncologic gastric surgery has been poorly defined and has never been reported for GIST., Materials and Methods: All patients who underwent robotic-assisted gastric resection for GIST at a single institution from 2006 to 2009 were prospectively followed-up., Results: There were 5 patients (3 men and 2 women), with a median age of 39 years (range, 32-74), who had a complete resection (R0). Two patients had a cardial GIST and 3 of the antrum. Median tumor sizes were of 5.5 cm (range, 4.2-7). According to Fletcher criteria, 4 tumors (80%) were classified as intermediate or high risk. No postoperative morbidity and mortality were noted. One patient had a conversion to open surgery because of a suspicion of diffuse adenocarcinoma on fresh frozen section and necessitated a total gastrectomy with a radical lymph node dissection. Median operation time was 192 minutes (range, 132-285). With a median follow-up of 18 months (range, 11-27), disease-free survival rate was 100%., Conclusions: The da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA) is a valuable instrument for oncologically safe resection with esogastric or duodenogastric junction preservation for an unfavorably located gastric GIST. Moreover, the three-dimensional, high-definition vision, instrument mobility, and ease of performing a difficult suturing enable a safe, large atypical gastrectomy, close to the pylorus or cardia.

Background: The clinical relevance of phlegmonous colitis (PC), a rare autopsy finding in cirrhotic patients, is poorly documented. We postulated that PC might be a source of sepsis in patients with portal hypertensive colopathy (PHC)., Case Presentation: We report three cirrhotic patients who were admitted with abdominal sepsis and who illustrate, to various degrees, the clinico-pathological sequence of colonic alterations associated with portal hypertension. Two cirrhotic patients with PHC developed gram-negative bacteraemia and quickly responded to intravenous antibiotics. Another cirrhotic patient underwent emergency colectomy for PC, and subsequently died from multiple organ failure. Histological alterations in the operative specimen included: a) mucosal ulcerations; b) disseminated micro-abscesses in the submucosa; and c) a severe vasculopathy leading to complete obliteration of submucosal blood vessels., Conclusions: These data suggest that cirrhotic patients with PHC may progress towards PC, which, in turn, may be the cause for life-threatening sepsis.

Background: Transumbilical single-port access (SPA) surgery is a rapidly evolving field that combines in part the cosmetic advantage of natural orifice transluminal endoscopic surgery (NOTES) with the ability to perform the operation with standard laparoscopic instruments. We report our experience with the first transumbilical single-port access radical left colectomy conforming to surgical oncologic principle and minimally invasive colectomy technique., Methods: Umbilical single-port access (embryonic natural orifice transluminal endoscopic surgery) left colectomy was performed in a patient with sigmoid colon adenocarcinoma in situ. During the same procedure, a single-port access cholecystectomy was performed for chronic cholecystitis., Results: Transumbilical single-port access radical left colectomy was feasible with conventional laparoscopic instruments. A 39-cm pathologic specimen with sufficient surgical margins and lymph nodes (34) was resected. Final diagnosis revealed an adenocarcinoma in situ. Operative time for left colectomy and cholecystectomy was 213 minutes. No intraoperative or postoperative complications were recorded., Conclusion: Single-port access radical left colectomy is feasible when performed by experienced laparoscopic surgeons. Carcinologic surgical principles can be respected using this colectomy technique. Single-port access left colectomy may have a clinical advantage over natural orifice transluminal endoscopic surgery in offering the safety of laparoscopic colectomy. It has yet to be determined whether or not this approach would offer patient benefits, except in cosmesis, compared with standard laparoscopic left colectomy.

Background: Laparoscopic gastrojejunostomy allows effective palliation and rapid recovery for the patient with limited survival due to advanced pancreatic cancer presenting with gastric outlet obstruction. Transumbilical single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. The authors report the first transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy., Methods: Preliminary experience with transumbilical single-incision, intracorporeal anastomosis for gastrojejunostomy for a patient with gastric outlet obstruction caused by advanced pancreatic cancer is reported., Results: Transumbilical single-incision laparoscopic intracorporeal anastomosis for gastrojejunostomy was performed with a linear endoscopic stapler using an omega loop. The operative time was 117 min. No intra- or postoperative complications were recorded., Conclusion: Transumbilical single-incision laparoscopic intracorporeal anastomoses are feasible using the endoscopic linear stapler. Transumbilical single-incision gastrojejunostomy for gastric outlet obstruction may improve cosmetic results and allow accelerated recovery for patients with limited survival. This anastomosis technique of single-incision laparoscopic surgery for other digestive tract procedures needs further evaluation.

Background: Single port access (SPA) surgery is a rapidly evolving field due to the complexity of NOTES (natural orifice translumenal endoscopic surgery). SPA combines the cosmetic advantage of NOTES and possibility to perform surgical procedure with standard laparoscopic instruments. We report a technique of umbilical SPA cholecystectomy using standard laparoscopic instruments and complying with conventional surgical principle and technique of minimally invasive cholecystectomy., Methods: Preliminary, prospective experience of SPA cholecystectomy in 11 patients (median age, 46 (range, 27-63) years) scheduled for cholecystectomy was evaluated. Diagnoses for cholecystectomy were: symptomatic gallbladder lithiasis (n = 7), previous acute cholecystitis (n = 3), and biliary pancreatitis (n = 1)., Results: SPA cholecystectomy was feasible in all patients (median body mass index, 24 (range, 20-34) kg/m(2)) who were scheduled for preliminary experience using conventional laparoscopic instruments. Median operative time was 52 (range, 40-77) minutes. Intraoperative cholangiography was performed in all patients, except one, and was considered normal. No peroperative or postoperative complications were recorded. Median hospital stay was less than 24 h., Conclusions: SPA cholecystectomy is feasible and seems to be safe when performed by experienced laparoscopic surgeons using standard laparoscopic instrumentation. SPA cholecystectomy may be safer than the NOTES approach at this time. It has to be determined whether this approach would benefit patients, other than cosmesis, compared with standard laparoscopic cholecystectomy.

We present a case of an asymptomatic 76-year-old woman treated laparoscopically for an urachal mucocele owing to a nonmetastatic urachal mucinous adenocarcinoma. Since laparoscopic en bloc resection of the urachus and partial cystectomy, the patient has been healthy and disease-free for 12 months. Modern surgical treatment of urachal adenocarcinoma is discussed in the light of this case.

Background: Single port access (SPA) surgery is a rapidly evolving field as it combines some of the cosmetic advantage of the Natural Orifice Translumenal Endoscopic Surgery (NOTES) and allows performing surgical procedure with standard surgical instruments. We report in this paper a new technique of umbilical SPA right hemicolectomy with conventional surgical oncologic principle and technique of minimally invasive colectomy., Methods: Preliminary experience with umbilical SPA right hemicolectomy in a patient with degenerated ascending colon polyp., Results: Umbilical SPA right hemicolectomy was feasible with conventional laparoscopic instruments. Carcinologic surgical principle can be respected using this technique as pathological specimen had sufficient surgical margins (>10 cm) and lymph nodes (33). Operative time was 158 min. No peroperative or postoperative complications were recorded., Conclusion: SPA right hemicolectomy is feasible and safe when performed by experienced laparoscopic surgeons. SPA right hemicolectomy may have the advantage over NOTES approach to offer the safety of laparoscopic colectomy especially for haemostasis and anastomosis. It has to be determined whether or not this approach would offer benefit to patients, except in cosmesis, compared to standard laparoscopic right hemicolectomy.

Background: Up to 15% of colorectal cancer (CRC) patients present with obstructive or perforated tumours, and require emergency surgery. The Hartmann's procedure (HP) provides the opportunity to achieve a potentially curative (R0) resection, while minimizing surgical trauma in poor-risk patients. The aim of this study was to assess the surgical (operative mortality), and oncological (long-term survival after curative resection) results of emergency HP for obstructive or perforated left-sided CRC., Methods: A retrospective review of 50 patients who underwent emergency HP for perforated/obstructive CRC in our institution between 1995 and 2006., Results: Median age of patients was 75 (range 22-95) years and the indications for HP were obstruction (32) and perforation (18 patients). Operative mortality and morbidity were 8% and 26% respectively. 35 patients (70%) were operated with a curative intent; in this group, overall 1-, 3- and 5-year survival rates were 80%, 54% and 40%. In univariate analysis, the presence of lymph node metastases was associated with poor 5-year survival (62% [Stage II] vs. 27% [Stage III], log-rank test, p = 0.02). Eleven patients (22%) had their operation reversed with a median delay of 225 (range 94-390) days. In this subgroup, two patients died from distant metastases, but there were no instances of loco-regional recurrence., Conclusion: Hartmann's operation remains a good option to palliate symptoms in 30% of patients with left-sided CRC who are not candidates to a curative resection. For those who have a curative resection, the oncological outcome is acceptable, especially stage II patients, who appear to benefit the most from this surgical strategy.

Background: A number of surgical techniques for colorectal anastomosis have been described for laparoscopic left-sided colectomies. Due to the complexity of these procedures, open preparation of the proximal bowel for circular stapler anastomosis through a Pfannenstiel incision has become the gold standard. We report a new laparoscopic technique for totally intracorporeal colorectal circular anastomosis (TLCCA) using a circular stapler., Methods: Preliminary experience using TLCCA in three patients scheduled for laparoscopic left colectomies (two) and sigmoidectomy (one)., Results: Side-to-end colorectal anastomosis through TLCCA was feasible in all patients scheduled for preliminary experience. Median time from anvil insertion into abdominal cavity to anastomosis was 14 (11-17) minutes. No postoperative complications were recorded., Conclusion: Side-to-end anastomosis can be easily and safely performed using conventional circular stapler through TLCCA. TLCCA is performed using four laparoscopic ports without additional skin incision (except trocars incision) and allows the retrieval of surgical pieces through a specimen bag.

Objectives: Infected necrotizing pancreatitis represents a serious and therapeutically challenging complication. Percutaneous drainage of infected pancreatic necrosis is often unsuccessful. Alternatively, open necrosectomies are associated with high morbidity. Recently, minimally invasive necrosectomy techniques have been tried with satisfying results; however, they frequently necessitate multiple sessions for definitive necrosectomy. To evaluate results of single large-port laparoscopic necrosectomy for proven infected necrotizing pancreatitis., Methods: Eight patients presenting proven infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological drainage were prospectively offered minimally invasive necrosectomy. Laparoscopic necrosectomy were performed using a single large port placed along the drain tract directly into the infected necrosis. In all patients, drainage was placed during laparoscopic necrosectomy for continuous postoperative lavage., Results: No perioperative complications were recorded with a median operative time of 87 +/- 42 minutes. No blood transfusions were needed. No surgical postoperative morbidity and mortality were recorded. In all cases, except for one patient with multiple abscesses, only one session of necrosectomy was sufficient to completely clear the necrotic abscess. Laparoscopic necrosectomy was successful in all patients, and none required complementary surgical or radiological treatment., Conclusions: Minimally invasive necrosectomy has been safe and highly efficient through single large-port laparoscopy for infected pancreatic necrosis in our series of patients. Minimally invasive necrosectomy is a promising technique for infected necrotizing pancreatitis and should be regarded as a valid therapeutic option for necrotizing pancreatitis.

Background: Anastomotic dehiscence is the most severe surgical complication after large bowel resection. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with anastomotic leakage after colorectal surgery., Materials and Methods: All procedures involving anastomoses of the colon or the rectum, which were performed between November 2002 and February 2006 in a single institution, were prospectively entered into a computerized database., Results: One thousand eighteen colorectal resections and 811 anastomoses were performed over this 40-month period. The most frequent procedures were sigmoid (276) and right colectomies (217). The overall anastomotic leak rate was 3.8%. The mortality rate associated with anastomotic leak was 12.9%. In univariate analysis, the following parameters were associated with an increased risk for anastomotic dehiscence: (1) ASA score >or= 3 (p = 0.004), (2) prolonged (>3 h) operative time (p = 0.02), (3) rectal location of the disease (p < 0.001), (4) and a body mass index > 25 (p = 0.04). In multivariate analysis, ASA score >or= 3 (OR = 2.5; 95% CI 1.5-4.3, p < 0.001), operative time > 3 h [OR = 3.0; 95% CI 1.1-8.0, p = 0.02), and rectal location of the disease (OR = 3.75; 95% CI 1.5-9.0 (vs left colon), p = 0.003; OR = 7.69; 95% CI 2.2-27.3 (vs right colon), p = 0.001] were factors significantly associated with a higher risk of anastomotic dehiscence., Conclusions: Three risk factors for anastomotic leak have been identified, one is patient-related (ASA score), one is disease-related (rectal location), the third being surgery-related (prolonged operative time). These factors should be considered in perioperative decision-making regarding defunctioning stoma formation.

Objective: Abdominoperineal resection (APR) is a disfiguring procedure, frequently associated with significant urogenital dysfunction. The aim of this prospective study was to repeatedly assess quality of life (QoL) 1, 6, and 12 months after APR., Methods: Twenty patients who underwent APR between June 2002 and September 2005 were considered for analysis. QoL was assessed using two self-rating validated questionnaires developed by the European Organization for Research and Treatment of Cancer (EORTC)., Results: All patients were free of recurrence at time of last interview. At 1-year follow-up patients reported significant improvement in global QoL [scores: 53 +/- 23 (1 month) vs. 70 +/- 15 (1 year), P = 0.01], and physical function (74 +/- 16 vs. 91 +/- 12, P = 0.001). Patients also reported significant improvement in symptoms such as fatigue (39 +/- 30 vs. 15 +/- 19, P = 0.01); and pain (33 +/- 31 vs. 10 +/- 14, P = 0.01). By contrast, there was no improvement at 1 year for the following items: body image (75 +/- 33 vs. 75 +/- 30, P = 0.99), sexual dysfunction (10 +/- 21 vs. 21 +/- 27, P = 0.40); and stoma-related problems (19 +/- 14 vs. 11 +/- 28, P = 0.34)., Conclusion: One year after APR, patients demonstrated significant improvement in global QoL and tumor-related symptoms, while body image remained significantly altered. Similarly, treatment-related side effects did not improve over the time period considered., ((c) 2007 Wiley-Liss, Inc.)

Background: Conservative treatment of perforated gastroduodenal ulcer has been shown to be associated with good results in patients whose general condition is good. However, its use in patients not eligible for surgical repair has not been supported. The aim of this study is to evaluate the results of conservative treatment in these patients in the era of proton pump inhibitor., Material and Methods: In the period 1978-2004, 533 patients were admitted for perforated gastroduodenal ulcer. 503 patients underwent surgery, while 30 (median age 79 [42-98] years) were allocated to conservative treatment due to poor general condition. Conservative treatment consisted of nasogastric aspiration, antibiotics and antisecretory therapy (H2-blockers from 1978-1995, 11 patients, and proton pump inhibitors (PPI) from 1996, 19 patients). Endpoints were: hospital morbidity and mortality and hospital stay., Results: Overall morbidity and mortality were 33% and 30%. Median hospital stay was 11 days (range 0-32). General complications developed in 73% versus 16% of patients (p = 0.023) and mortality was 64% versus 11% (p = 0.008) for the H2-blocker and PPI groups respectively. On multivariate analysis mortality correlated with presence of shock at admission and type of antisecretory therapy., Conclusion: In the era of PPI conservative treatment for perforated ulcer is possible with acceptable morbidity and mortality in patients not eligible for surgical repair. However, presence of shock at admission was associated with high mortality and, even in these patients, militates in favour of a surgical approach.

Background/aims: Vater's ampulla neoplasms account for 30% of resected bilio-pancreatic confluent tumors. Study aim was to review long-term results of surgical treatment for ampullary neoplasms., Methodology: A retrospective review from 1993 to 2002 identified 55 patients admitted for Vater's ampulla neoplasm in our institution. Follow-up was complete for all cases with a median follow-up of 24 (range 2-180) months., Results: Among the ampullary neoplasms, 10 were adenomas (median age 71) and 45 adenocarcinomas (median age 69). Of the adenomas 60% were treated surgically with excellent long-term results. The resectability rate of ampullary carcinomas was 84%. 34 patients had pancreaticoduodenectomy and 4 ampullectomy. Importantly, the rate of false-negative preoperative biopsies was 45%. Seven patients were treated by stenting or derivation due to poor condition. Actuarial five-year survival rate after pancreatoduodenectomy was 68% (median follow-up 24 months), compared to 0% for other approaches (p < 0.01). After pancreatoduodenectomy, the lymph node status influenced survival, while disease-free survival at 5 years was 85% for NO and 27% for N1 (p < 0.001). Among the pancreatoduodenectomies, 55% consisted of pylorus-preserving procedure which did not influence prognosis compared to absence of pylorus preservation., Conclusions: Pancreatoduodenectomy remains the gold standard for Vater's ampulla neoplasms resection due to the low sensitivity of diagnostic biopsies for carcinoma detection. Vater's ampulla neoplasms resection by pancreatoduodenectomy is associated with good long-term results; however survival after curative resection is influenced by lymph node status.

Elective colectomies are standard procedures carrying below 1% mortality; by contrast, emergency colonic resections remain surgical challenges in compromised and/or elderly patients and are associated with high complication rates.

Aim: Postoperative ileus is an important factor of complications following gastrointestinal procedures. Its pathophysiology and the parameters, which may impact on its duration, remain unclear. The aim of this study was to measure the role of various clinical determinants on restoration of intestinal function after elective colorectal surgery., Methods: From July 2002 to September 2003, all patients who underwent laparotomy for colectomy (laparoscopic resections excluded) with either an ileotransverse, colocolic, or high colorectal anastomosis were entered in this prospective study. The intervals in hours between the end of the surgical procedure and passing of flatus (PG) and passing of stool (PS) were recorded by an independent investigator. PG and PS were eventually correlated with the following parameters: type of colectomy, early removal of nasogastric tube (NGT), mechanical bowel preparation (MBP), type of underlying disease, systemic administration of opiates, and surgical training (colorectal fellowship or other)., Results: One hundred twenty-four patients were entered in this study. Four patients (3.2%) developed septic complications (3 anastomotic leaks and 1 intraabdominal abscess) and were excluded from the analysis. Median age in this population was 68 (range 30-95) years. Mean duration of postoperative ileus was 70+/-28 h (PG) and 99+/-34 h (PS). The type of colectomy, underlying disease, MBP, and early NGT removal failed, in univariate analysis, to correlate with the duration of postoperative ileus. By contrast, time intervals PG and PS were statistically shorter in the group of patients treated by a colorectal surgeon [56+/-23 vs 74+/-28 h (PG); 82+/-26 vs 103+/-35 h (PS), p=0.004], as well as in patients who received systemic opiates for less than 2 days [64+/-27 vs 75+/-28 h (PG), p=0.04; 88+/-32 vs 108+/-33 h (PS), p=001]., Conclusion: Restoration of normal intestinal function after elective open colectomy takes 3 (PG) to 4 (PS) days. In our series, specialized training in colorectal surgery has a positive impact on the duration of postoperative ileus. Surgical specialization should be considered an important parameter in future clinical trials aiming to minimize postoperative ileus.

Introduction: The aim of this study was to assess the outcome of surgery for rectal cancer in patients 80 years of age or more., Methods: A retrospective study of 29 patients older than 80 years, who presented in our institution between 1997 and 2001 with the diagnosis of rectal adenocarcinoma, was undertaken., Results: Median follow-up was 54 (range 27-78) months, and the median age of patients was 85 (range 80-94) years. Twenty-four out of 29 patients (83%) underwent surgery, 23 being operated electively. Twenty out of 24 patients (83%) underwent resection with curative intent, while four patients (17%) had a palliative procedure. Median hospital stay was 13 (range 10-35) days. Postoperative morbidity and mortality were 46% and 12.5%, respectively. However, when considering only elective procedures with curative intent, operative mortality was 5%. At the time of last follow-up, 13 patients were alive, five of them with no evidence of recurrent disease at 5 years, for an overall 2- and 5-year survival rate of 80% and 67%, respectively. Four out of the 7 deaths, which occurred after surgery, were due to medical causes unrelated to cancer., Conclusion: In our institution, two thirds of patients older than 80 years who presented with rectal cancer underwent surgery with curative intent. In this selected population, good results in terms of short-term survival can be achieved, at the price of an elevated postoperative morbidity. Whenever possible, treatment with curative intent should be considered in patients with rectal cancer, irrespective of the age.

Purpose: The feasibility and safety of left-sided colorectal procedures with avoidance of mechanical bowel preparation has recently been demonstrated. Moreover, mechanical preparation has been associated with an increased risk for abdominal septic complications, including anastomotic leakage. This study was designed to determine whether mechanical bowel preparation is associated with histologic alterations in the colon., Methods: Fifty patients (mean age, 61 (range, 45-78) years) scheduled to undergo elective colorectal surgery were prospectively randomized to receive mechanical preparation (polyethylene glycol; Group 1) or no preparation (Group 2) preoperatively. A macroscopically healthy segment of the bowel was excised at the proximal margin of the colectomy piece. A pathologist, blinded to the patient's group allocation, assessed various morphologic parameters., Results: Indications for colectomy (cancer and complicated diverticulosis) did not differ between groups. Bowel wall alterations were more frequent in patients who received a preparation. The most striking alterations associated with mechanical preparation were loss of superficial mucus (moderate-to-severe in 96 and 52 percent in Groups 1 and 2, respectively; P < 0.001) and epithelial cells (moderate-to-severe in 88 and 40 percent in Groups 1 and 2, respectively; P < 0.01). In addition, inflammatory changes, i.e., lymphocytes (severe in 48 and 12 percent in Groups 1 and 2, respectively; P < 0.02) and polymorphonuclear cells infiltration (severe in 52 and 8 percent in Groups 1 and 2, respectively; P < 0.02), were more prevalent after mechanical preparation., Conclusions: Mechanical bowel preparation is associated with structural alteration and inflammatory changes in the large bowel wall. Although bowel wall inflammation is a known risk factor for anastomotic leak, it remains to be elucidated whether these changes have a direct relation to the deleterious effect of mechanical bowel preparation in terms of abdominal morbidity.

Adenocarcinoid of the appendix is an infrequent tumor with histologic features of both adenocarcinoma and carcinoid tumor. Although its malignant potential remains unclear, adenocarcinoids seem to be biologically more aggressive than conventional carcinoids. The aim of this study was to analyze long-term results of surgical treatment for appendiceal adenocarcinoid. A retrospective review (1991-2003) identified seven patients (median age 72, range 27-81 years) treated for appendiceal adenocarcinoid. The clinical data of these patients were reviewed. Follow-up was complete for all patients (median 60 months, range 24-108 months). Most cases presented with associated acute appendicitis (71%). First intention surgery consisted of appendectomy (m = 6) and right hemicolectomy (m = 1). In three patients, additional surgical procedures were performed (right colectomy). Indications for colectomy were tumor size (three cases) associated with appendectomy margin invasion in one case. One patient with lymph node and peritoneal involvement experienced recurrence 9 months after hemicolectomy and died of the disease at 2 years. One patient subsequently died of colon carcinoma 6 years after adenocarcinoid treatment. Five patients were alive without disease at the time of the last follow-up. Synchronous or metachronous colon carcinomas developed in three patients (43%). Our results suggest that appendectomy alone could be used for appendiceal adenocarcinoid provided that the tumor (1) is less than 1 cm; (2) does not extend beyond the appendix adventitia; (3) has less than 2 mitoses/10 high power fields; and (4) has surgical margins that are tumor free. Otherwise, carcinologic right colectomy seems to be indicated. The risk for developing colorectal adenocarcinoma seems to be extremely high in patients treated for appendiceal adenocarcinoid and warrants close follow-up with colonoscopic screening.