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BACKGROUND: Standardization of total mesorectal excision (TME) had a great impact on decreasing local recurrence rates for the treatment of rectal cancer. However, exact numbers and distribution of lymph nodes (LN) along the mesorectum remains controversial with some studies suggesting that few LNs are present in the distal third of the mesorectum. METHODS: Eighteen fresh cadavers without a history of rectal cancer were studied. The rectum was removed by TME and then was divided into right lateral, posterior and left lateral sides, which were further subdivided into 3 levels (upper, middle and lower). A pathologist determined the number and sizes of the LNs in each of the nine areas, b linded to their anatomical origin. RESULTS: Overall, the mesorectum had a mean of 5.7 LNs (SD=3.7) and on average each LN had a maximum diameter of 3.0 mm (SD=2.7). There was no association between the mean number or size of LNs with gender, BMI, or age. There was a significantly higher prevalence of LNs in the posterior location (2.8 per mesorectum) than in the two lateral locations (0.8 and 1.2 per mesorectum; p=0.02). The distribution of LNs in the three levels of the rectum was not significant. CONCLUSIONS: The distribution of LNs reinforces the fact that TME should always include the distal third of the mesorectum. Care must be taken to not violate the posterior aspect of the mesorectum.

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Rectal bleeding following colorectal anastomosis is common but usually self-limited. Continuous hemorrhage is rare, and when it occurs, often requires further treatment. The most frequently used strategies for treatment of stapled anastomotic hemorrhage are clinical observation with or without blood transfusion, rectal packing, angiographic identification of the bleeding site with vasopressin infusion or embolization, and endoscopic eletrocoagulation. We report the case of a 49-year-old man with uncomplicated diverticular disease who was treated by laparoscopic sigmoidectomy, with double-stapled colorectal anastomosis. Six hours later, the patient presented intense rectal bleeding and was taken to the operation room for urgent colonoscopic examination. After complete removal of blood clots inside the rectum, a bleed localized at the anastomotic site was identified and submucosal peri-anastomotic injection of 10 ml adrenaline (1:200 000) in saline was performed with immediate bleeding control.

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Percutaneous liver biopsy is a routine procedure in the diagnosis, management, and follow-up of several liver disorders. Mortality and morbidity rates from percutaneous liver biopsy are low. This report of three cases of serious percutaneous liver biopsy complication and their management highlights the role played by videolaparoscopy as a diagnostic and therapeutic procedure in two different types of PLB complication: hemobilia and bile peritonitis. In two patients, intrahepatic arteriobiliary fistula developed with gastrointestinal hemorrhage (hemobilia). Both were treated with cholecystectomy and ligation of the right branch of the hepatic artery. In the third case, the percutaneous liver biopsy needle punctured the gallbladder, leading to bile peritonitis and acute abdomen, and the patient underwent videolaparoscopic cholecystectomy with aspiration and lavage of the abdominal cavity. Videolaparoscopic procedures are an adequate alternative for the management of serious percutaneous liver biopsy complications such as hemobilia and bile peritonitis. The advantages of a videolaparoscopy include low morbidity rates, quick recovery, good cosmetic result, and ability to resolve the complications of percutaneous liver biopsy.

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Several drugs and their associations are being used for adjuvant or complementary chemotherapy with the aim of improving results of gastric cancer treatment. The objective of this study was to verify the impact of these drugs on nutrition and on survival rate after radical treatment of 53 patients with gastric cancer in stage III of the TNM classification. A control group including 28 patients who had only undergone radical resection was compared to a group of 25 patients who underwent the same operative technique followed by adjuvant polychemotherapy with FAM (5-fluorouracil, Adriamycin, and mitomycin C). In this latter group, chemotherapy toxicity in relation to hepatic, renal, cardiologic, neurological, hematologic, gastrointestinal, and dermatological functions was also studied. There was no significant difference on admission between both groups in relation to gender, race, macroscopic tumoral type of tumor according to the Borrmann classification, location of the tumor in the stomach, length of the gastric resection, or response to cutaneous tests on delayed sensitivity. Chemotherapy was started on average, 2.3 months following surgical treatment. Clinical and laboratory follow-up of all patients continued for 5 years. The following conclusions were reached: 1) The nutritional status and incidence of gastrointestinal manifestation were similar in both groups; 2) There was no occurrence of cardiac, renal, neurological, or hepatic toxicity or death due to the chemotherapeutic method per se; 3) Dermatological alterations and hematological toxicity occurred exclusively in patients who underwent polychemotherapy; 4) There was no significant difference between the rate and site of tumoral recurrence, the disease-free interval, or the survival rate of both study groups; 5) Therefore, we concluded, after a 5-year follow-up, chemotherapy with the FAM regimen did not increase the survival rate.

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Jejunostomy is widely acknowledged in the literature as a means for enteral nutrition. Complication rates range from 16% to 46% for the classical open technique and from 11% to 70% for the several mini-invasive techniques currently in use, including the laparoscopic techniques. The most probable complications are abscess, intestinal obstruction, abdominal wall infection, intraperitoneal leakage, enterocutaneous fistula, and loss, elbowing, or even rupture of the enteral probe. The authors report the case of a patient with severe malnutrition concomitant with advanced gastric cancer who underwent jejunostomy because of an incapacity for normal oral feeding. Previous attempts to pass a nasal enteral probe were not successful, even with the aid of endoscopy. Videolaparoscopy was indicated for adequate staging of the neoplasm and for performance of video-assisted jejunostomy. During the procedure, an extensive carcinomatous process was observed that rendered comprehension of the abdominal anatomy extremely difficult. Consequently, while attempting jejunal catheterization, unintentional catheterization of the terminal ileum took place. The authors discuss this first reported case of unintentional ileostomy and review the literature.

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UNLABELLED: The Peutz-Jeghers syndrome is a hereditary disease that requires frequent endoscopic and surgical intervention, leading to secondary complications such as short bowel syndrome. CASE REPORT: This paper reports on a 15-year-old male patient with a family history of the disease, who underwent surgery for treatment of an intestinal occlusion due to a small intestine intussusception. DISCUSSION: An intra-operative fiberscopic procedure was included for the detection and treatment of numerous polyps distributed along the small intestine. Enterotomy was performed to treat only the larger polyps, therefore limiting the intestinal resection to smaller segments. The postoperative follow-up was uneventful. CONCLUSION: We point out the importance of conservative treatment for patients with this syndrome, especially those who will undergo repeated surgical interventions because of clinical manifestation while they are still young.

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The case of a patient with gastric adenocarcinoma with indication for gastrectomy is reported. The surgery took place without complications. A palliative, subtotal gastrectomy was performed after para-aortic lymph nodes compromised by neoplasm were found, which was confirmed by pathological exam of frozen sections carried out during the intervention. At the end of the gastroenteroanastomosis procedure, the patient began to show intense bradycardia: 38 beats per minute (bpm), arterial hypotension, changes in the electrocardiogram's waveform (upper unlevelling of segment ST), and cardiac arrest. Resuscitation maneuvers were performed with temporary success. Subsequently, the patient had another circulatory breakdown and again was recovered. Finally, the third cardiac arrest proved to be irreversible, and the intra-operative death occurred. Necropsy showed massive pulmonary embolism. The medical literature has recommended heparinization of patients, in an attempt to avoid pulmonary thromboembolism following major surgical interventions. However, in the present case, heparinization would have been insufficient to prevent death. This case indicates that it is necessary to develop preoperative propedeutics for diagnosing the presence of venous thrombi with potential to migrate, causing pulmonary thromboembolism (PTE). If such thrombi could be detected, preventative measures, such as filter installation in the Cava vein could be undertaken.

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A case of cystic dilation isolated from the cystic duct is described. The patient showed symptoms of chronic calculous cholecystitis; the ultrasonographic examination confirmed the clinical hypothesis and showed a 1.3-cm calculus impacted in the infundibulum of the gallbladder. The hepatic and biliary functions were normal. During surgery, the routine cholangiographic study showed a sizable cyst in the cystic canal, as well as an anomalous duct uniting the cyst to the right hepatic duct. As for the rest of the extrahepatic biliary canal, as well as the intrahepatic canal, nothing abnormal was noticed. The videolaparoscopic treatment consisted of a ligature with a clip of the cystic duct and the anomalous duct plus en bloc resection of the cyst and the gallbladder. Histopathologic study showed it to be a benign cyst and chronic calculous cholecystitis. It is important to establish the site of the cyst precisely before surgery, as the procedure should include its resection, since it could be the source of infection or development of lithiasis and even malignant degeneration. There are two hypotheses for the appearance of cysts in the biliary tract: congenital, due to a flaw in the multiplication of the cells that will form the biliary tract during the fetal life, and by aggression by pancreatic juice flowing back to the main biliary canal. The congenital origin seems to be the hypothesis that better explains the appearance of the cyst in the case described here, considering that the backflow of the pancreatic juice could hardly have occurred because of the anatomy as observed: the nonexistence of the common biliary-pancreatic canal and the valvular mechanism, present in the cystic canal, between the cyst itself and the confluence of the cystic canal into the main biliary canal, in addition to the anomalous biliary canal communicating the cyst to the right intrahepatic canal.

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In 190 patients with malignant gastric neoplasia the value of laparoscopy for diagnosing intra-abdominal metastases was investigated. At the laparoscopic examination the presence of tumoral tissue was appraised on the serosal coat of the stomach, epiploons, parietal and visceral peritoneum, and in the liver. On hand of laparoscopic findings (peritoneal or hepatic metastases) the surgical treatment was discarded in 34 patients (70.6%). In the remaining 29.4% of patients a bad general condition or concomitant diseases contra-indicated surgical intervention. A comparison of laparoscopic and surgical findings showed that correct diagnosis was established by laparoscopy in 61.4% of cases with tumoral invasion of gastric serosa, in 21.4% of cases with involvement of epiploon, in 27% of parietal peritoneum, and in 33.3% of the liver. Falsely positive findings were rare (5% of examinations).

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The efficacy and toxicity of a combination of etoposide (100 mg/m2 i.v. on days 1 to 3), Adriamycin (20 mg/m2 i.v. on days 1 and 8) and cisplatinum (40 mg/m2 i.v. on days 2 and 8) repeated every 4 weeks as an outpatient regimen were assessed in 29 consecutive patients with metastatic gastric cancer with measurable disease. Five of these patients were refractory to 5-Fluorouracil, Adriamycin, and Mitomycin C. Three of these previously treated patients responded to the etoposide. Adriamycin, cisplatinum (VAP) therapy. An overall objective response rate of 72.5% was achieved, including 14% that were complete responses. The median duration of response was 6.0 months; median overall survival was 7.2 months, overall one-year survival was 34.4%. Hematologic toxicity was intense, particularly among patients with lower performance status. Three patients died as a consequence of nadir sepsis episodes.

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