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This study was designed to compare the efficacy of subarachnoid morphine alone or in combination with bupivacaine and fentanyl for combined spinal-epidural analgesia in colorectal surgery. This is a prospective, randomised, double-blind clinical trial. Sixty patients undergoing low anterior resection were assigned to one of three groups: subarachnoid morphine, bupivacaine and fentanyl, subarachnoid morphine and bupivacaine or subarachnoid morphine only. Epidural catheter placement and subarachnoid injection were done via a combined spinal-epidural Epistar needle at L2-3. The epidural catheter was used for scheduled intraoperative bupivacaine and intermittent postoperative bupivacaine and morphine administration. Intraoperative epidural bupivacaine, intraoperative intravenous fentanyl use, time to first analgesia request, postoperative visual analogue scale pain scores, tramadol requirements and side-effects were recorded for 72 hours. Postoperative analgesia was comparable in all groups. Intraoperative fentanyl and bupivacaine consumption was lowest in the morphine, bupivacaine and fentanyl group. Time to first analgesia request was longer in the morphine, bupivacaine and fentanyl compared to the morphine group (P = 0.009). Tramadol use was lower in the morphine and bupivacaine group compared to morphine, bupivacaine and fentanyl (P = 0.017) on postoperative day two. There were no significant adverse effects. All patients ambulated the morning after surgery. The addition of bupivacaine and fentanyl to subarachnoid morphine did not confer any advantage on postoperative visual analogue scale scores and tramadol use, but lowered the need for additional intraoperative intravenous fentanyl and epidural bupivacaine and prolonged the time to first analgesia request. [ABSTRACT FROM AUTHOR]

Objective: Functional outcomes were prospectively compared between the standard Roux-en-Y and Double-tract reconstruction following a total gastrectomy and D2 lymphadenectomy., Methods: One hundred ten patients with gastric cancer were divided into two groups by the type of reconstruction. Age, gender, T stage, AJCC stage, length of operation, BMI (body mass index, kg/m2), time to soft diet, postoperative leakage of the esophagojejunostomy (EJS), stricture of the EJS, meal intake, and quality of life (QOL) were recorded., Results: The mean age in the R-Y group was 61.57, with the SD of 9.53, while in the DT group the mean age was 60.17 with a SD of 9.92. The BMI decline in the R-Y group was 4.09 with a SD of 1.11, while in the DT group it was 2.85 with a SD of 1.27. We found a highly significant statistical difference between the two groups in the rate of the BMI decline (p<0,001). We found no statistically significant difference regarding QOL between the two groups, p>0.05., Conclusions: The Double tract reconstruction is a simple procedure and the rate of the BMI decline is much smaller compared to the Roux-en-Y group.

Background: Psychosocial stressors either acute or more sustained frequently precede the onset and exacerbation of the symptoms of the functional dyspepsia (FD). Depressive mood and quality of life have been already reported for interference in functional dyspepsia suffering patients., Methods: The examination were performed on 60 FD patients (30 females and 30 males), aged 20-79 years, 60 peptic ulcer subjects and 60 healthy volunteers in which we have investigate levels of anxiety and depression, personality traits and quality of life., Result: According to the Hamilton Depression and Anxiety Rating Scales, the population with FD had the average score which classified them into the group of patients with the moderate depression (20.57 ± 4.45). Personality traits estimation based on data obtained by the Eysenck personality questionnaire revealed higher neuroticism scores in the group with functional dyspepsia. Both parameters, level of the neuroticism and anxiety level, expressed highly significant level of mutual concordance. Patients with functional dyspepsia reported a greater adverse impact of symptoms of emotional distress and food and drink problems., Conclusion: Results are indicating that the depression and anxiety level is the highest in patients with functional dyspepsia and that anxiety level corroborates with the neuroticism level from the Eysenck scale. Psychological disturbances are influencing the quality of life mostly in patients with dyspepsia in the form of emotional distress and the problem with the food and beverage intake., (Copyright © 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Background: Various types of reconstructions have been developed to improve the quality of life of patients following total gastrectomy. In addition, to ensure larger food-intake reservoirs and extend meal transit times, different types of pouch reconstructions have been developed and described. Our opinion is that the most important factor in providing better physiologic regulation of ingested food is restoration of the duodenal passage and enlargement of the gastric substituent., Materials and Methods: In the present study, we compared standard a Roux-en-Y reconstruction and a preduodenal pouch (PDP) reconstruction. We evaluated the quality of life (QoL) for 60 patients during the first postoperative year, comparing serum albumin, protein, hemoglobin, iron, body weight, body mass index, and QoL. QoL was defined according to Korenaga's score scale, which has 14 questions, for better understanding of subjective patient perceptions of digestive function., Results: Our study population did not differ in iron and hemoglobin levels at a 1-y follow-up. The difference between total serum albumin level was significant in all observed patients in the follow-up period in favor of the PDP reconstruction group (P = 0.001). The PDP reconstruction group also had a significantly higher serum protein level after 12 mo. The higher score difference between the two groups generally confirm the improved QoL in the PDP group (P = 0.001)., Conclusion: The most important aspects of improved QoL after gastrectomy due to gastric carcinoma are maintenance of the duodenal transit and the addition of a pouch. Jejunal preduodenal pouches provide a better QoL than Roux-en-Y reconstruction. Our study results suggest preduodenal pouch reconstruction should be used as the method of choice., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Total gastrectomy causes numerous disorders, such as reflux esophagitis, dumping syndrome, malabsorption, and malnutrition. To minimize the consequences, different variants of reconstruction are performed. The aim of our study is the comparison of two reconstructive methods: the standard Roux-en-Y and a new modality of pouch interposition, preduodenal-pouch interposition. This study aims to investigate the advantage of bile reflux prevention and to reduce symptoms of dumping syndrome after 3- and 6-mo follow-up., Materials and Methods: A total of 60 patients were divided in two groups: (A) 30 patients with Roux-en-Y reconstruction, and (B) 30 patients with the preduodenal-pouch (PDP) type of reconstruction. Endoscopic examination and endoluminal jejunal limb pressure measurements were performed. Scintigraphic measurements of half-emptying time were performed to evaluate meal elimination in the context of reflux esophagitis and early dumping syndrome. The Japan Society of Gastrointestinal Surgery has provided guidelines with which to classify the symptoms of early dumping syndrome. Patients were followed up for periods of 3 and 6 mo after the surgery., Results: Our study groups did not differ with regard to the level of reflux esophagitis (P = 0.688). Average values of pressure at 10 and 15 cm below the esophago-jejunal junction were significantly lower in the PDP group (P < 0.001). Elimination of the test meal between two groups was not significant (P = 0.222). Evaluation of early dumping syndrome symptoms revealed a significant reduction among PDP patients after 3 and 6 mo., Conclusion: Our study showed significant superiority of the new pouch reconstruction over the standard Roux-en-Y approach in the treatment of early dumping syndrome., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Many different benign and malignant diseases can cause obstruction of the extrahepatic biliary duct. One of the more serious complications of biliary obstruction is cholangitis leading to emergency decompression. Anatomic variations are frequent in this region; however, it has rarely been reported that the extrahepatic bile duct is compressed by the arterial vessels., Case Report: We present the case of a 68-year-old woman who was admitted through the emergency department of our hospital with jaundice, abdominal pain and fever. Biochemical analyses of liver function showed increased value of AST (113 IU/L) and AST (128 IU/L). Total bilirubin was 5.88 mg/dl, conjugated bilirubin was 3.00 mg/dl, and alkaline phosphatase was 393 IU/L. We performed abdominal ultrasound (US), magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) imaging. Multislice CT angiography showed that the arterial ring of the common hepatic artery around the common bile duct (CBD) originated from the superior mesenteric artery. Cholecystectomy and intraoperative cholangiography were performed, as well as decompression and lavage of the biliary tree. Escherichia coli was identified from bile. Dissection of the hepatoduodenal ligament confirmed that the proper hepatic artery made a vascular ring around the CBD. Finally, a T tube was placed into the CBD. During 5 years of follow-up the patient has been without recurrent episodes of jaundice. In such cases dissection of the proper hepatic artery from the common hepatic duct is the treatment of choice., Conclusions: If there are signs of cholangitis decompression and lavage of the biliary tree with "T", drainage should be performed. Vascular malformations should be considered as a possible cause of extrahepatic biliary obstruction. CT angiography may be helpful in identifying these malformations.

Background/aims: Malnutrition appears to be a major and noticeable problem for hospitalized patients and often present in patients with gastrointestinal diseases. This study attempts to evaluate differences in nutritional status parameters and nutritional state differences among hospitalized patients with various gastrointestinal diseases and disorders., Methodology: Our study included 154 males and 146 females, aged 18-84 years old, with various gastrointestinal diseases and disorders. All patients underwent baseline nutritional assessment, including subjective global assessment (SGA), anthropometric measurements, bioelectrical impedance analysis (BIA), and biochemical markers., Results: Prevalence of malnutrition was 45.7%. The highest prevalence was detected among patients suffering from gastrointestinal malignancies and chronic pancreatitis. All parameters decreased with malnourishment levels, except CRP and in-hospital stay which rose with malnourishment grade. SGA and length of hospital stay negatively correlated with all analyzed variables of nutritional assessment, except CRP., Conclusions: Patients suffering from gastrointestinal malignancies, inflammatory bowel disease and peptic ulcer disease have more pronounced level of malnutrition. Body mass index, triceps skin fold thickness, mid-arm circumference, MAMC, wrist circumference, total protein level, albumin, cholesterol, glucose level, lymphocyte count, basal metabolic rate, body fat mass, fat free mass, muscle mass, total body water and resistance appeared to be inversely correlated with malnutrition. However, CRP level correlated positively with the malnutrition severity. SGA malnutrition level is dependent of hospitalization length.

Background: To investigate differences in laboratory markers, nutritional status parameters and eating patterns among newly diagnosed patients with functional dyspepsia., Method: The investigation was performed on 180 newly diagnosed patients with functional dyspepsia, aged 20-79, which were referred to the gastroenterology unit of the Clinical and Hospital Center "Bezanijska Kosa" from April to October 2009. Rome II criteria were used for further classification., Results: ANOVA Bonferroni post hoc correction outlined that concentrations of serum magnesium and calcium were significantly lower in subjects with ulcer-like dyspepsia, while vitamin B12, glucose and immunoglobulin G level was significantly higher in group with dismotility-like dyspepsia. Statistical analysis revealed that the numbers of meal taken per day were significantly different. There was a statistical trend to skipping meals and to eat fast in patients with ulcer-like and dismotility-like functional dyspepsia when compared with non-specific dyspeptic subjects., Conclusion: Patients with ulcer-like functional dyspepsia suffered from epigastric pain and burning and from heartburn, while persons with dismotility-like dyspepsia were complaining about postprandial fullness, bloating and early satiety. They skipped meals more frequently and avoided intake of certain supplies which, together with eating habits, provoked or emphasized the annoying symptoms., (Copyright © 2011 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

The aim of this study is to evaluate influence of allogeneic blood transfusion on prognosis in patients in Dukes B stage of colorectal cancer. All patients with colorectal cancer who were admitted at our Department of Surgery between January 2000 and December 2004 were analyzed. One hundred fifty-one patients who fulfilled inclusion criteria were enrolled in further evaluation. B stage according to Dukes classification and curative resection were inclusion criteria. Exclusion criteria were polyposis syndromes, nonpolyposis syndromes, inflammatory bowel disease, autoimmune disease and previous blood transfusion. Patients were divided into two groups: Group 1 received ≤ 3 units of allogeneic blood transfusion and group 2 received >3 units of allogeneic blood transfusion. "Cutoff" value of 3 units of blood was defined according to our results and literature data. Follow-up was 5 year. There was no statistical difference between these groups in local recurrence (χ(2) = 0.009, P > 0.05) and distant metastasis (χ(2) = 0.44, P > 0.05). Also, the Kaplan-Meier survival curves were calculated, and long-rank test did not show a survival difference between these two groups (log rank = 0.075, P > 0.05). Postoperative complications are significantly more frequent in Group 2 (χ(2) = 4.67, P < 0.05). Multivariate logistic regression analysis confirmed that intraoperative blood transfusion more than three units had independent influence on local recurrence. Postoperative transfusion more than 3 units was statistically independent prognostic factor for metastasis and mortality. Overall transfusion less than 3 units of allogeneic blood does not influence the outcome of patients in Dukes B stage of colorectal cancer.

Composite glandular/exocrine-endocrine carcinoma of the gastrointestinal tract is a special tumor type composed of common adenocarcinoma and the neuroendocrine component comprising at least one-third of the whole tumor area. These tumors are rare in the stomach and mostly published as case reports. We describe a further case of a 36-year-old man being unique in that it was associated with extensive formation of sarcoid-like granulomas. Tumor consisted of, predominantly poorly differentiated, intestinal-type adenocarcinoma and poorly differentiated neuroendocrine, small cell carcinoma. The adenocarcinomatous and neuroendocrine areas were separated, but closely juxtaposed with focal areas showing gradual transition from one to another. Perigastric lymph node metastases corresponded either to neuroendocrine or adenocarcinomatous component. On immunohistochemistry, the exocrine part was positive for cytokeratin 7, whereas superficial well-differentiated parts showed positivity with cytokeratin 20 as well. The neuroendocrine component was negative with those two types of cytokeratin. Both adenocarcinomatous and neuroendocrine tumor portions showed carcinoembryonic antigen (CEA) immunoexpression. Neuroendocrine markers (chromogranin A, synaptophysin and neuron-specific enolase) were diffusely positive in the neuroendocrine component, and found only in the scattered cells within the neoplastic glands of the adenocarcinoma. Entire gastric mucosa and all perigastric lymph nodes were extensively affected by noncaseating, sarcoid-like granulomas. The absence of any clinical manifestations combined with the negative results of chest radiograph and laboratory test for the serum angiotensin converting enzyme argued against the possibility of systemic sarcoidosis.

Carcinosarcomas are rare, malignant, biphasic tumors. We report the case of a 62-year-old man with gastric carcinosarcoma, along with its clinical, macroscopic and histopathological features. Macroscopically, a specimen of deformed stomach was obtained that measured 200 mm x 150 mm x 100 mm. A 150 mm x 100 mm x 50 mm exophytic tumoral mass (Borrmann type I) was found, which involved the posterior wall from the cardia to the antrum. Histopathologically, a mixed type of malignancy was revealed: an adenocarcinoma with intestinal metaplasia, with interposed fascicles of fusiform atypical cells and numerous large, rounded and oval cells. The tumor showed positive histochemistry for cytokeratin 18, epithelial membrane antigen, carcinoembryonic antigen, chromogranin A and vimentin. Liver metastases were diagnosed 8 mo postoperatively, and the patient died 4 mo later. A review of the available literature is also presented.

The incidence of gastric foveolar hyperplasia, a reliable histological marker of bile reflux into the stomach, was evaluated in patients with cancer of the intact stomach. Lesions classified as foveolar hyperplasia were found in 17 of 32 gastric cancer patients and in seven of 30 controls. This difference was statistically significant (p < 0.02). Differences in the incidence of foveolar hyperplasia according to sex, tumor site, attendant chronic atrophic gastritis, and alcohol consumption were not significant, which lends support to the association of gastric cancer with duodenogastric reflux.