54 AJournal of

Gastrointestinal Surgery

KEYNOTE LECTURES

KY001Molecular Therapeutic Targets for GIST: Expanding ClinicalOptionsBarbara Lee BassSurgery, University of Maryland School of Medicine, USA

Gastrointestinal stromal tumors (GIST), the most common mes-enchymal cell tumor type of the GI tract, arise from progenitorcells of the interstitial cells of Cajal. Oncogenic mutations in thetyrosine kinase protein KIT, most resulting in constitutive activa-tion, are the defining molecular feature of GIST and are identifiedin over 95% of tumors. KIT activity influences a variety of impor-tant cellular processes linked to malignant phenotype includingcell proliferation, adhesion and apoptosis. Oncogenic mutationsmay involve the extracellular, juxtamembrane or kinase codingdomains in c-kit providing evidence that signalling pathways forKIT may present targets for development of a variety of specificdeactivating molecular therapeutic agents. The first such clinicallyuseful molecular therapeutic agent for GIST is the tyrosine kinaseinhibitor imatinib mesylate. While complete surgical resection ofGIST is the primary therapeutic modality for these tumors ofwidely variable malignant potential, the value of imatinib in theadjuvant and neoadjuvant setting and as therapy for metastatic dis-ease is being defined by ongoing clinical trials. Molecular mecha-nisms of imatinib resistance and strategies for development ofnovel agents for targeting KIT signalling pathways will bereviewed.

KY002Gastric Cancer- from Minimal Access to MultimodalityTherapyFrank J. BranickiFaculty of Medicine and Health Sciences, United Arab EmiratesUniversity, UAE

Management of gastric neoplasms is largely dependent on stage ofthe disease at presentation. In the absence of lymph node involve-ment early gastric cancer may be managed with endoscopic mucos-al resection. Alternatively, minimal access laparoscopic surgeryeither transperitoneal or via an intragastric approach can be pre-formed. The laparoscopic approach has been shown to be feasiblewith an appropriate lymph node harvest if nodal disease is present.Considerable controversy still exists as to the need for radicallymph node dissection in advanced gastric cancer. It is now evidentthat the procedure does confer a survival advantage in patientswith pNO disease on H& E staining but micrometastases evidenton immunohistochemistry. Meta-analysis of trials of adjuvantchemotherapy have led to disappointment and the focus for treat-ment of advanced cancer has now shifted to multimodality therapyusing newer agents, a neoadjuvant approach is now being favoured.Cisplatin based combinations have proved effective but the resultsof phase III trials of taxanes are awaited. Intraoperative hyperther-mic chemotherapy has not been widely adopted because of associ-ated morbidity. The results of the Intergroup 0116 trail have notsubstantiated a role for chemoirradiation when nodal dissection isundertaken.Intra-arterial chemotherapy may well have a role todownstage advanced disease for salvage surgery.When diffuse gas-

tric cancer occurs in a family member at a young age prophylacticgastrectomy is now advocated for individuals with over expressionof E-cadherin.Newer treatment modalities are eagerly awaited asare parameters which will identify patients who are likely torespond to specific cytotoxic chemotherapeutic agents.

KY003Application of Pelvic Three-dimension Digital Model in theSphincter Saving Resection of the Mid /Lower Rectal CancerJin Gu1, Jing Fang2, Ming Li1, Xuefeng Bo2, Aiwen Wu1, XiaopengZhang1

1Colorectal Department, Beijing Cancer Hospital, 2Peking Univer-sity Department of Mechanics & Engineering Science, China

Objective: To build a pelvic digital model and analyze the role of apelvis in LAR preoperatively. Method: 58 patients with mid/lowerrectal cancer were underwentrt abdominoperitoneal resection(APR) or LAR. They had standard pelvic CT scan preoperatively,then analyzed by 3D DOCTOR to build a pelvic digital model.The three-dimension digital rigorous are measured included:occipitofrontal diameter of pelvic inlet (OPI); bi-ischial tuberositydiameter (BIT); occipitofrontal diameter of pelvic outlet (OPO);upper pubis to coccyx (UPC); inferior pubis to coccyx (IPC); theshortest diameter from upper pubis to the sacrum (SUPS). Alsodescribed the curving extent of the sacrum (CES). Results: Suc-cessful LAR must be content with requirements: BIT>=100mm,OPI >=130mm,OPO >=110mm,which means thesphincter saving resection of lower rectal cancer would be difficultif pelvis is smaller than those. We also discover that the SUPS ismost important. It hardly does LAR when the SUPS is less than124mm in 4cm subgroup and =<132mm in 3cm subgroup.Smoother CES is easier for LAR.Conclusion: LAR is restricted bythe pelvic anatomy structure. The shortest diameter from upperpubis to sacrum is more important to the LAR. The more smoothcurving extent of sacrum is also helpful to the operation. Keywords: three-dimension digital model, pelvis, sphincter savingresection, rectal cancer.

KY004Towards a Simple Guideline for the Treatments of Hepato-cellular CarcinomaAmr Helmy1, Nada Helmy2

1Surgery Department, The National Liver Institute, Egypt,2Surgery Dept. Cairo University School of Medicine, FayoumBranch, Egypt

Surgery-either resection or transplantation-remains the gold stan-dard in treating Hepatocellular Carcinoma (HCC). Many patientsare not fit for surgery upon diagnosis because of the severity of theunderlying liver disease, the location, volume and or number ofHCC lesion (s), vascular invasion or the presence of an extrahepat-ic disorder. Nowadays, other therapeutic options are commonlyused. They aim at local ablation, cytoreduction of the lesion orarrest of its growth. Selective Transarterial Chemoembolization(TACE) has been widely used for the past 2 decades. PercutaneousIntralesional Ethanol Injection (PEI) became in vogue in the early1990s followed by Radiofrequency Thermal Ablation (RFA). Both

55 AVol. 8, No.7S2004 KEYNOTE LECTURES

can be applied during open or laparoscopic surgery. StereotacticRadiotherapy (SRT) appears to achieve good results with lesionsless than 4 cm in diameter without radiation hepatitis and is com-pletely non-invasive. Yet many patients with HCC still do not fitthe inclusion criteria for any modality. For these, supportive, hor-monal or systemic chemotherapy can be offered with still poorresults. Immune modulating therapies, intralesional irradiation andgene therapies are future prospects. This study offers an algorithmto help the practitioner select the proper modality to treat anHCC lesion and helps map the sequence of using each in case ofintegrated therapy. The classification is based mainly on the condi-tion of the liver, the classical Child-Pugh grading, the size of thelesion, the affection of either lobes or both, the location of thelesion, peripheral or central, and the presence or absence of portalvein thrombosis.

KY005Surgical Strategies in the Management of Bile Duct InjuriesSerafin C. HilvanoUniversity of Philippines, Philippines

Records of patients who were noted to have bile duct strictureswere reviewed. It was noted that the most common operation priorto the stricture or injury was cholecystectomy. Prevention and var-ious surgical techniques in the reatment of this problem is present-ed.

KY006Laparoscopic Versus Open Subtotal Gastrectomy for DistalGastric Cance: 5-Year Results of a Randomized ProspectiveTrialCristiano G.S Hüscher1, Cecilia Ponzano1, Massimiliano Di Paola1,Andrea Sansonetti1, Andrea Mingoli2, Giovanna Sgarzini2

1Department of Surgery, Azienda Ospedaliera San Giovanni Addo-lorata, 2Dept, of Surgery P.Valdoni, Policlinico Umberto I, LaSapienza University, Roma, Italy

Objective The aim of this study was to compare technical feasibili-ty and early 5-year clinical outcomes of laparoscopic assisted andopen radical subtotal gastrectomy for distal gastric cancer. Back-ground The role of laparoscopic surgery in the treatment of gastriccancer has not yet been defined and many doubts remain about theability to satisfy all the oncological criteria met during convention-al, open surgery. Method This study was designed as a prospective,randomized clinical study with a total of 59 patients. Twenty-nine(49.1%) patients were randomized to undergo open subtotal gas-trectomy (OG, open group), whilst thirty (50.9%) patients wererandomized to the laparoscopic group (LG, laparoscopic group).Demographics, ASA status, pTNM and stage, histologic type ofthe tumour, number of resected lymph nodes, postoperative com-plications and 5-year overall and disease-free survival rates werestudied to assess outcome differences between the groups.

KY007Pancreaticogastrostomy and Pancreaticojejunostomy afterPancreaticoduodenectomyDaniel JaeckCentre de Chirurgie Viscerale et de Transplantation, Hopital Uni-versitaire de Hautepierre, France

Aim. To discuss the technique and to analyze the results of pan-creaticogastrostomy (PG) method after pancreaticoduodenectomy(PD).Patients and methods. Between 1987 and 2001, among 250 con-secutive patients, 83 underwent pancreaticojejunostomy (PJ) and167 PG after PD. A double layers invaginating PG anastomosiswas performed following the technique of Delcore et al. [1] In-hospital mortality, postoperative morbidity, and rates of pancreaticfistula and of relaparotomy caused by PF were compared in bothgroups.Results. The mortality rate did not differ between PG and PJgroups (2.9 % versus 2.4%). The incidence of PF and the meanhospital stay were significantly lower in the PG group (2.3 % and17·8 days) than in the PJ group (20.4% and 23·12 days, bothp<0.0001). The overall relaparotomy rate was significantly lower inthe PG group (4.7%) than in the PJ group (18%, p=0.0006). Therelaparotomy rate for PF after PD was significantly lower in PGgroup (0%) than in PJ group (10.8%, p<0.0001).Conclusion. PG is a safe method of reconstruction after PD, asso-ciated with lower rate of PF and relaparotomy compared to PJ. [2][1] Delcore R, Thomas JH, Pierce GE, Hermreck AS. Pancreato-gastrostomy ; a safe drainage procedure after pancreatoduodenec-tomy. Surgery 1990 ; 108 : 641-647[2] Oussoultzoglou E, Bachellier P, Bigourdan JM, Weber JC,Nakano H, Jaeck D. Pancreatogatrostomy decreased relaparotomycaused by pancreatic fistula after pancreaticoduodenectomy com-pared to pancreaticojejunostomy. Arch Surg 2004 ; 139 : 327-335.Copyrighted © 2004, American Medical Association. All Rightsreserved.

KY008Japanese Experiences of Laparoscopic Bariatric SurgeryKazunori Kasama1, Nobumi Tagaya2, Norio Suzuki2, Yasuharu Kaki-hara1, Syoujirou Taketsuka1, Kenji Horie1, Masaaki Kodama3, IsaoKawamura3

1Department of Surgery, Horie Hospital, 2Dokkyo UniversitySchool of Medicine, 2nd Department of Surgery, 3ShimostugaGeneral Hospital, Japan

Background: Bariatric Surgery was very rare in Japan But recentlyobesity become a social problem. We performed the first totallyLaparoscopic Roux en Y Gastric Bypass (LRYGB) in Japan in May2003. In this study we present our experiences. Methods: FromFeb.2002 to June 2004, 18patiens underwent LRYGB. There were13 women and 5 men with median age 34.5 (range 25-55), Nation-ality were 6 Japanese, 9 Brazilian 1 Peruvian, 1Bolivian and 1American. Median preoperative BMI was 46 (range 35-54) Results:Our procedures are : Size of pouch:30cc Biliopancreatic tract: 50-100cm Alimentaly tract: 120cm-200cm(depends on BMI), Antecol-ic Antegastric approach, Gastrojejunostomy methods were 1 circu-lar stapler ,7 liner stapler, 10 Hand sewn Double-layer. The FirstPatient needed to be converted because of Gastrojejunostomy fail-ure. Leakage occurred in 1 circular stapler case , 1 linear staplercase and 1 Hand-sewn case. Stenosis occurred in 1 linear staplercase and 1 hand-sewn case. One case was treated with re-opera-

56 AJournal of

Gastrointestinal SurgeryAbstract of 19th WC-ISDS

tion. No motality was occurred. Follow up ranges from 1 to 26months. 84% of Excess body weight loss was achieved two yearafter surgery, 65% one year after surgery. Conclusion: LRYGB ischallenging operation. We have to brush up our technique moreand make bariatric surgery popular in Japan.

KY009Defects in the Internal Anal Sphincter (IAS) Are SignificantlyMore Important in Determining Continence Than Injury tothe External Anal Sphincter (EAS) after Repair of ThirdDegree TearsMichael Keighley1, Tomoo Shatari2, Joanne Hayes3, Samantha Pretlove4, Phillip Toosz-Hobson4, Simon Radley3

1University of Birmingham, Queen Elizabeth Hospital, 2Mito RedCross Hospital, 3Queen Elizabeth Hospital, Birmingham, 4Birm-ingham Women’s Hospital, UK

INTRODUCTION To correlate symptoms, anal ultrasonogra-phy and manometry in women after third degree tears treated byimmediate repair. METHODS 80 women who had repairs forthird degree tears were investigated in the anorectal physiology labwithin two years of delivery. Symptoms were scored using theCleveland Clinic scale (0-25); severe >5, mild. RESULTS 43women were completely continent (54%), 15 had mild inconti-nence (19%) and 12 (15%) had severe incontinence compromisinglifestyle. 51 had an intact IAS, of whom 36 (71%) were completelycontinent, 27 individuals had an IAS defect, of whom 17 (59%)were continent (p=0.06). By contrast, only 21 had an intact EASbut there was no correlation between continence and an EASdefect (15/12 [72%] intact EAS versus 38/59 [64%] EAS defect).IAS defects were associated with a significantly lower maximumresting pressure (MAP); 66.1±39 than an intact IAS; 85.7 ± 66(p<0.03), and a significantly lower maximum squeeze pressure(MSP) 135.3±67 versus 170.9±73 (p<0.04). By contrast, EASdefects had no significant influence on MAP; 74.2±38 versus91.7±35 or MSP; 148.0±69 versus 185.4 ±83 CONCLUSIONSDefects in the IAS have a much greater influence on continenceafter repair of third degree tears than residual defects in the EAS.

KY010Sphincter Preserving Operations-Sutured Coloanal Anasto-mosis for Distal Rectal CancerNamkyu KimDepartment of Surgery, Yonsei University College of Medicine,Korea

PURPOSE: Prevention of local recurrence and preservation ofanal function present important goals in the treatment of distalrectal cancer. With advances in anastomosis techniques, sphincterpreservation have become more popular in middle or distal rectalcancer without compromising oncologic principles. The presentstudy aimed to investigate curability and functional results ofultralow anterior resection and sutured coloanal anastomosis fordistal rectal cancer. METHODS: Forty four patients underwentsutured CAA (Coloanal anastomosis) following ultralow anteriorresection from July 1997 to November 2003. Operative procedureswere performed according to total mesorectal excision. Pelvic dis-section to the levator ani muscle and transected rectum at the levelof anorectal ring. Mobilized colon sutured to the dentate line peranus. Diverting ileostomy was done. RESULTS: Mean age was

54.3± 10.4 years old. The type of anastomosis was straight (N=20),J pouch (N=24). Mean tumor size was 4.1± 1.9 cm and mean distalresection margin was 1.3± 0.9 cm. Mean follow up period was36.3± 22.8 months. The complication were multiple perianal fistu-la (N=4), anal stenosis (N=7). local recurrence with anal stenosis(N=1). Anal incontinence was noted in 16 patients and bowelmovement more than six times per day was observed in 16patients. Overall recurrence occurred in 6 patients and 5 year sur-vival rate was 84.4% and 5 year disease free survival rate was68.9%. CONCLUSION: Acceptable oncologic outcomes andanal function were obtained after ultralow anterior resection andsutured coloanal anastomosis in patients with distal rectal cancer.

KY011Day Case Laparoscopic Cholecystectomy: Keys to SuccessHung LauUniversity of Hong Kong Medical Centre, Hong Kong, China

Objective: Although day case laparoscopic cholecystectomy is acommon practice in the United States, acceptance of day caselaparoscopic cholecystectomy remains poor and skepticism persistsin most Asian countries. The author will present the contemporarypractice and outcomes of day case laparoscopic cholecystectomy, aswell as the keys to its success. Methods: Since the commencementof this service in 2000, more than 150 patients have undergone daycase laparoscopic cholecystectomy in our institutionResults: Our contemporary success rate of day case laparoscopiccholecystectomy exceeded 94%. There was no major complication.Post-operative nausea and vomiting was the commonest reason forunanticipated admission after operation. Significant factors associ-ated with unplanned admission included operative duration oflonger than 60 minutes and thickened gallbladder wall on ultra-sonography. Operative time greater than 60 minutes incurred a 4-fold increased risk of unanticipated admission. Prolonged anesthe-sia will lead to a higher incidence of nausea, vomiting and reten-tion of urine. Adequate analgesia without noticeable side effects ispivotal to attaining a high level of patient satisfaction.Conclusions: Day case laparoscopic cholecystectomy is cost-effec-tive and safe. Success of day case laparoscopic cholecystectomyrelies on appropriate selection of patients, operative time of lessthan an hour, adequate analgesia with multimodal method, as wellas the combined efforts of experienced anesthesiologists, skilledsurgeons and the staff of day surgery centre. The development ofday case laparoscopic cholecystectomy helps to shorten the waitinglist, spares hospital beds for other patients and confers economicbenefits to the hospital.

KY012Ventral Hernia Repair TodayDavede LomantoDepartment of Surgery, National University Hospital, Singapore

There have been few operative challenges more vexing in the his-tory of surgery than the incisional hernia, especially because theoutcome of incisional hernia may have major social and economicimplications. Although 10%to 30%of patients undergoing laparo-tomy will develop an incisional hernia and subsequent convention-al open repair often fails to adequately address this substantialproblem. The recurrence rate for primary tissue repairs mayapproach the 35% range, which is higher than the primary occur-

57 AVol. 8, No.7S2004 KEYNOTE LECTURES

rence rate; when repaired for recurrence, rates have been reportedgreater than 50%. 4 Recently with the use of mesh repair the rateof incisional hernia recurrence is decreased but still remains in theranges of 10% to 24%. Since its introduction in 1992, laparoscopicincisional hernia repair has revolutionized the management of ven-tral hernia. To date, the laparoscopic approach has achieved betteroutcomes than have the historical conventional approach. Patientsgain the routine benefits associated with laparoscopy, such as lesspain, shorter length of hospital stay, and less blood loss. Therecurrence rate is reduced significantly by 2%-9%. Additionally,the infection rate is lower than reported rates of 12%-45%in openrepairs. In our series, a randomized controlled study using meshrepair, we report about 3% recurrence in laparoscopic repair(usingstapler and suture fixation) vs 10.8% of open repair, no infectionrequiring mesh removal and 40%of pts underwent laparoscopicrepair pts are very satistified compared to 6% of open approachLaparoscopic approach provide other than better clinical outcomealso some benefit like a complete exploration of the abdominalcavity, an easier adhesiolysis, which is very important in preventingchronic post-operative abdominal pain linked to the laparotomicprocedures.

KY013Radiofrequency Thermal Ablation of Liver Tumors:Overview, Present and FutureJunji MachiDepartment of Surgery, University of Hawaii, USA

Background: In the last decade, radiofrequency thermal ablation(RFA) has emerged as a new therapy for liver tumors, evolvedtechnologically, and is expected to expand. Methods: A review ofliterature and personal experience on over 300 RFA operations forboth hepatocellular carcinomas (HCC) and metastatic tumors.Results: The uses of RFA vary depending on the countries. Morefrequently, RFA has been performed by surgeons via open surgical,laparoscopic or percutaneous methods for unresectable metastases(mostly colorectal cancer) in the United States and Europe, where-as it has been used by internists percutaneously for resectable aswell as unresectable HCC in Japan and Italy. Various instrumentaland technical advances have improved the effect of RFA. RFA hasdemonstrated advantages over other ablative therapies (cryoabla-tion, ethanol injection) in safety and local control efficacy. Its mor-tality is 1% or less, and major complications including liver failure,biliary leakage and stricture, other organ thermal injury, bleedingand infection occur less than 5 to 10%. Local tumor recurrencedue to incomplete ablation ranges from a few % to 15%, probablyless in HCC as compared to metastases. The long-term outcomeof RFA is not yet documented well, but seemingly encouragingparticularly in treating unresectable tumors. Conclusions: RFA isbecoming one of beneficial modalities for both primary andmetastatic liver tumors. Further studies, including long-term fol-low-up, comparison and combination with other therapies, differ-ent approaches, are warranted to clarify the role of RFA in variousclinical settings. Beyond the liver, RFA of other organs is antici-pated to grow.

KY014Reconstruction of the Thoracic Esophagus with Jejunal Pedi-cled Segments for Cancer of the Thoracic EsophagusTetsuro Nishihira1, Tadanobu Tani1, Nobuo Ubukata1, HiroshiNakaura1, Shinichiro Kanai1, Takafumi Yuba1, YoshikazuHashimoto1, Hidenori Suzuki1, Masakata Ogata1, Morio Kasai2

1Double-Barred Cross Hospital (Fukujuji Hospital), 2TohokuUniversity School of Medicine, Japan

Details of operative procedures of esophageal reconstruction usinglong pedicled jejunal grafts after resection for cancer of the tho-racic esophagus are presented. In addition, functional characteris-tics of three kinds of esophageal substitutes, namely, gastric tubes,pedicled jejunal segments and pedicled colonic segments are ana-lyzed. From 1977-2004, 484 out of 586 cases with cancer of thethoracic esophagus (squamous cell carcinoma) were resected. Therate of resection was 81.2%. Operative deaths (6 cases) within 30days after surgery were below 1.2%. The average age of thepatients was 61.8 years. The organs used for reconstruction duringthis period were the jejunum in 54 cases (11%), the colon in 6cases (1.2%) and the stomach in 424 cases (87.6%). With regardsto the 54 cases in which jejunal segments were employed, anasto-motic sites, reconstructive routes and the status of gastrectomybefore reconstruction of the esophagus are shown for the 25 casesand 29 cases in which cervical and intrathoracic anatomosis wererespectively performed. Typical intraluminal pressures and auto-nomic contraction of the three kinds of organs were found to bediverse. In the patients examined, the frequency of complaints ofpost-operative symptoms such as bloating, diarrhea and stenoticsensation were observed to be various in the early periods aftersurgery but became almost equal 2 years post-operatively, eventhough the reconstructive routes and/or organs for substituteswere different.

KY015Clinical Value of Procalcitonin (PCT) in Predicting Infec-tious Complications and Overall Prognosis in Severe AcutePancreatitis: A Prospective International Multicenter StudyBettina Rau1, E. Kemppainen2, A. Gumb3, W. Uhl4, M. W. Büchler4,K. Wegscheider5, C. Bassi3, P. Puolakkainen2, H. G. Beger6, M. K.Schilling1

1Department of General, Visceral, and Vascular Surgery, Universi-ty of the Saarland, Germany, 2Department of Surgery, HelsinkiUniversity Central Hospital, Helsinki, Finland, 3Department ofSurgery and Gastroenterology, Pancreatic Unit, University ofVerona, Italy, 4Department of Visceral- and TransplantationSurgery, University of Bern, Switzerland, 5Wegscheider Biometryand Statistics, Berlin, Germany, 6Department of General Surgery,University of Ulm, Germany

Early and accurate diagnosis of pancreatic infections is a majorissue in severe acute pancreatitis (SAP). PCT, the 116 amino-acidprecursor of calcitonin is the first biochemical parameter for pre-dicting bacterial infection and sepsis in various inflammatory dis-eases. However, in AP the clinical value of PCT determinationsstill remains controversial.Patients and Methods: A total of 104patients with SAP were included in five European centers. Ninety-four patients (90%) had CT-proven necrosis of whom 17 (16%)developed infection (IN). Multi organ dysfunction syndrome(MODS) was observed in 28 (27%) patients, 8 patients (8%) died.

58 AJournal of

Gastrointestinal SurgeryAbstract of 19th WC-ISDS

CRP was determined routinely, PCT (BRAHMS AG, Berlin, Ger-many) was assessed in a real-time fashion in each center.Results:PCT concentrations were significantly higher in patients whodeveloped IN, which was not observed for CRP. If IN was associ-ated with MODS or patients subsequently died PCT valuesreached highest concentrations already peaking at the third dayafter disease onset, whereas CRP values did not differ. At a cut-offlevel of ≥ 3.5 ng/ml (ROC analysis) for PCT the combined predic-tion of IN with MODS or death was possible with a sensitivity of93%, a specificity, of 88%, and an accuracy of 89%, which was sig-nificantly better than CRP (p<0.0001). Conclusion: Monitoring ofPCT is a non-invasive and reliable method to predict clinically rel-evant IN as well as overall prognosis in SAP. This single test para-meter significantly contributes to an improved stratification ofpatients at risk to develop major complications and deserves rou-tine clinical application.

KY016TEM -Transanal Endoscopic MicrosurgeryJose M SchiappaH.CUF-Infante Santo, Portugal

TEM - Transanal Endoscopic Microsurgery is a technique forresection of lesions located in the rectal area and not suitable forother types of resection (by colonoscopy or recto sigmoidoscopy).For its application is used special equipment including large diam-eter anuscopes, special instruments, stereoscopic optics, insufflatorand other devices which allow the working space to be closed keeping the working area with gas.The technique started long time ago and has been used only at afew specialized centers for some reasons, including the cost ofequipment, the training of surgeons and the availability of patients.Recent new trends in indications - broadening it to T2 malignanttumours - bring a new application for the technique that maybecome more widespread. The details of the equipment, technique, indications, selection andpreparation of patients, as well as the results of our series are pre-sented, discussing also the new ways for this type of treatment ofrectal lesions. The presentation includes video clips demonstratingthe points of equipment and technique.

KY017The Best Treatment of Colorectal CancerFrancis Seow-ChoenSeow-Choen Colorectal Centre Pte Ltd, Singapore

Colorectal cancer is either the commonest or the second common-est cancer in the industrialized countries of the world. The man-agement of this cancer had undergone remarkable changes overthe last twenty years. Whereas in the past the generalist would bemanaging most of such cases; this is no longer the case currently.The reasons are several. Firstly in such a fast evolving field, thetreatment regiments and methods are rapidly evolving. The nonspecialist would be hard put to keep up with all the changes thatare occurring and hence would not be in a good position to offerthe best up to date advice on an often difficult and life threateningdisease. Secondly, many studies have now shown that the results ofsurgery and even radiotherapy are best in the hands of specialistscolorectal compared to the generalist who may treat a range of dis-eases. For example, local recurrences after rectal surgery for can-

cer varies from about 3 to 60 % world wide varying from depart-ment to department even when only potentially curative Dukes Ato C cases are considered. In the best units, the range is muchlower and the range much narrower. In my own experience andthe experience of my previous unit, 5 year local recurrence follow-ing rectal cancer surgery ranged from 3 to 5 % only. Differencesare much wider between units then within units. Good standard-ized surgery gives consistently good results. Inconsistent or lessthan adequate surgery may not result in such superior results.

KY018Combined Chinese-Traditional and Modern-Western Med-ical Treatment for Late Cases of Periampullary CancerWeijin ShiShanghai Second Medical University, Surgical Dept., Ren Ji Hos-pital, China

Background: The morbidity of periampullary cancer in Shanghai,China elevated in recent years. Although the early diagnostic rateand operability were raised and the postoperative complicationswere decreased, still many patients can’t be cured operatively. Sothe key point of palliative treatment is how to relieve jaundice,bowel obstruction and abdominal pain. The insertion of bile stentthrough ERCP, PTCD, bilio-enteric internal drainage and block-ing the celiac plexus are usually used in clinic. But the successfulrate of bile stent insertion and the duration of patency are not sat-isfied; the loss of bile through external drainage may cause dyspep-sia and water-electrolyte imbalance; the effect of blocking the celi-ac plexus is not quite sure, routine bilio-enteric internal drainagemay cause unexpected trauma.

KY019Difficult Laparoscopic Cholecystectomy Single Surgeon/Sin-gle Centre Experience in 5240 CasesKuldip SinghSurgery, Dayanand Medical College & Hospital, Ludhiana Pun-jab, India

Difficult Cholecystectomy like acute cholecystitis, empyema gallbladder, mirizzi syndrome, fistulas, cirrhotic and pancreatitispatients used to be contraindicated for laparoscopic approach inthe beginning of the lap surgery. With the increasing experience ofsurgeons, these cases were taken up laparoscopically in the pastdecade but with higher incidence of biliary complications and con-version rate. We have encountered 958 cases of difficult gall blad-der out of total of 5240 cases that underwent Cholecystectomysince 1992 in a single centre. The technical difficulties which wereencountered were : thick and fibrotic adhesions at the fundus, gallbladder not visible at the first instance due to bad adhesions, diffi-culty to hold the gall bladder, frozen up callot's triangle, impactedstones in hartman's pouch, fistulous track, mirizzi syndrome, diffi-cult gall bladder bed dissection and extraction. All these difficultsituations were managed by using all basic surgical techniques aswe use in conventional surgery like blunt dissection using peanutgauze, water and gauze piece to define anatomy in callotís trian-gle to avoid injury to CBD. We had only 1.7% conversion rate inEmpyema gall bladder and mirizzi syndrome with 3 bile ductinjuries all together, which were managed during the same proce-dure. To conclude, we recommend all cases to be taken up forlaparoscopic approach irrespective of their presentations and the

59 AVol. 8, No.7S2004 KEYNOTE LECTURES

results of Laparoscopic approach are comparable to conventionalsurgery.

KY020International Guideline for the Management of IntraductalPapillary Mucinous Neoplasms (IPMNs) and Mucinous Cys-tic Neoplasms (MCNs)Masao TanakaDepartment of Surgery and Oncology, Graduate School of Med-ical Sciences, Kyushu University, Fukuoka, Japan

IPMNs and MCNs of the pancreas are fascinating entities of cur-rent controversy. Obstruction of the main duct with mucin maycause acute pancreatitis; otherwise IPMNs are diagnosed inciden-tally. IPMNs are classified into main duct type, branch type, andmixed type. Most branch type IPMNs are benign, while the mainduct type are frequently malignant. The presence of mural nodulesindicates a possibility of malignancy. Abundant mucin secretionmay dilate the ampulla of Vater. Branch type IPMNs may form amultilocular cyst reminiscent of MCNs. IPMNs and MCNs actu-ally share some features but have several distinct characteristics.IPMNs are often found in the pancreatic head of elderly men andconnected to the pancreatic ducts. In contrast, MCNs usually forma thick-walled cystic lesion in the pancreatic tail of perimenopausalwomen, showing no communication with the pancreatic ducts, andare characterized by ovarian-type stroma typically expressingestrogen and progesterone receptors. Synchronous or metachro-nous malignancy may develop in various organs including the pan-creas in IPMNs but not in MCNs. Prognosis is excellent afterresection of benign and noninvasive malignant IPMNs andMCNs. Only asymptomatic branch type IPMNs without muralnodules can be followed up until the maximal size reaches 30 mm.Malignant ones with parenchymal invasion require adequatelymph node dissection. Appreciation of the similarities and distin-guishing characteristics of IPMNs and MCNs is important. Theauthor will be presenting a guideline for the management of theseunique diseases proposed by an international team of the Interna-tional Association of Pancreatology.

KY021Management of Fecal IncontinenceJoe Janwar TjandraColorectal Surgery, Royal Melbourne Hospital, University of Mel-bourne, Australia

Faecal incontinence is common, distressing to the patient andsocially incapacitating. The treatment options depend on theseverity and aetiology of incontinence. For mild cases of faecalincontinence, dietary modification, stool bulking agents and pelvicfloor physiotherapy may be adequate. For more severe cases,surgery is often required. Anal sphincter repair is effective if thereis a discrete external anal sphincter defect, although its longtermresults are unpredictable and probably poor. Till now, there hasbeen no effective treatment for internal sphincter dysfunction orpudendal neuropathy New treatment options include injectable silicone biomaterialdirected at the internal anal sphincter and Sacral nerve stimulation.The only injectable silicone biomaterial available is the PTPTM

implant. This is a minimally invasive day-case treatment, directedat the internal anal sphincter and inter-sphincteric space under

endoanal ultrasound guidance. In the world’s largest experiencefrom Melbourne, Australia, the treatment is highly effective forinternal sphincter dysfunction, even if pudendal neuropathy is pre-sent.Sacral nerve stimulation is innovative and has had a medium termsuccess with improvement of quality of life in over 80% of patientstreated for faecal incontinence. The technique is unique becausethere is a screening phase, which has a high predictive value. It isalso associated with minimal complications that are usually minor.The randomized trial in Melbourne is about to complete andwould further clarify the indications, selection criteria and the roleof sacral nerve stimulation in refractory end-stage fecal inconti-nence.

KY022Laparoscopic versus Open Total Mesorectal Excision withAnal Sphincter Preservation for Low Rectal CancerZong Guang Zhou, Yuan Li, Mu HuDepartment of Gastroenterological Surgery & Institute of Diges-tive Surgery, West China Hospital, Sichuan University, China

Purpose To assess the feasibility of laparoscopic total mesorectalexcision (TME) with anal sphincter preservation (ASP), and toanalyze the short term outcome of patients with low rectal cancer.Methods We analyzed open versus laparoscopic low/ultralowanterior resection via a prospective, randomized control trail.From June 2001 to September 2002, 171 patients with low rectalcancer underwent TME with ASP, 82 by the laparoscopic proce-dure and 89 by the open technique. The lowest margin of tumorswas below peritoneal reflection and 1.5 to 8 cm above the dentateline (1.5 to 4.9 cm in 104 cases and 5 to 8 cm in 67 cases). ResultsResults of operation, postoperative recovery, and short-term onco-logical follow up were compared between laparoscopic and opengroup. In laparoscopic group, 30 patients underwent anteriorresection had the anastomosis below peritoneal reflection andmore than 2 cm above the dentate line, 27 patients underwentultralow anterior resection had anastomosis within 2 cm above thedentate line, 25 patients underwent coloanal anastomosis had theanastomosis at or below the dentate line. In open group, the num-bers were 35, 27, and 27 respectively. No statistical difference inoperation time, administration of parenteral analgesics, start offood intake, and mortality rate between the two groups. However,less blood loss, earlier recovered bowel function, and shorter hos-pitalization were in the laparoscopic group. Conclusions As a minimally invasive technique, totally laparoscop-ic TME with ASP is feasible and with benefits of less intraopera-tive blood loss, earlier bowel function return, and shorter hospital-ization.