Govaresh
Volume:15 Issue: 2, 2010

Today the use of laparoscopy before laparotomy is an effective method for decision-making in patients with gastric adenocarcinoma. The reliance on CT scans for decision-making purposes is not only unhelpful, yet also misleading. Nonetheless, indications for laparoscopy and its application are changing daily. The low quality of diagnostic tools and epidemiological situation in our country requires that an independent study should be done in this case. All patients in the interval from the 12th month of 1388 until the 5th month of 1389 who were diagnosed as new cases of gastric adenocarcinoma and admitted to Shahid Sadoghy Hospital, Yazd, Iran were included in this experimental study. At first indication, laparoscopy was defined. All patients with complications who needed palliative surgery such as intolerable dysphagia, obstruction, bleeding or perforation in addition to those with distant metastases were excluded.TNM score and staging were noted for all patients. There were 26 patients who underwent laparoscopies to determine TNM scores and staging. These patients weredivided into three groups:1. Patients eligible for surgery with no neoadjuvant chemotherapy.2. Patients needing neoadjuvant chemotherapy prior to laparatomy.3. Non-operable patients, who only required chemotherapy.Subsequently, surgical pathological staging and TNM were determined for all 37 patients and used as the gold standard for comparison with other methods. A total of 30 (88.9%) patients with the aid of CT scans were classified as stages І and ІІ, where laparoscopy estimated six patients as stages І and ІІ, and surgical pathology diagnosed five (13.5%) cases out of the 37. The 37 patients were divided into the following groups: A-11 patients on clinical evaluation required laparotomy, but no laparoscopy was indicated. B-7 patients were identified as stages І and ІІ who underwent surgery without neoadjuvant chemotherapy.C-8 patients were candidates for neoadjuvant chemotherapy after laparotomy.D-11 patients were estimated as inoperable and were only given chemotherapy.Of these, one patient was assumed to be operable with laparoscopy, yet was unoperable in laparatomy. Another patientdid not receive neoadjuvant chemotherapy due to the lower estimation of laparoscopy. If patient management solely depended on the results of CT scans, therefore a total of 87% of patients were mismanaged. With laparoscopy, however, 30 patients (81%) were correctly managed whereas seven patients (19%) were not. There were five patients with surgical pathological stages І and ІІ who did not benefit fromlaparoscopy and two patients were mismanaged because of incorrect laparoscopic information. No similarities with pathological and CT scan results according to TNM and staging were noted, so there was significant statistical diferrence. The results of TNM and staging scores of 30 patients who had laparoscopies were similar to the surgical TNMand staging scores, so there was no significant statistical diferrence Therefore, conventional CT scans are less sensitive than usuall in our city. Since access to multi-detector CT scans and endosonography is very difficult in our city, therefore we could not use them for better patient management which is a pitfall for this study.Thus, use of laparoscopy before laparotomy not only decrease the un nessessary laparotomies rate,but also help us in selecting the patients who need neoadjuvant chemotherapy before surgery.

Irritable bowel syndrome (IBS) with chronic abdominal pain and changes in bowel habits in the absence of any organic cause is identified as the most common known gastrointestinal disorder. IBS affects both sexes and can occur atany age. Diagnosis of this disease in younger patients and women is more likely. In the pathophysiology of IBS, hereditary, environmental, visceral, psychological factors, emotional stress and to a lesser degree, brain factors and hormones, have been discussed. Cortricotropin releasing factor (CRF) has a strong relationship with stress. This factor plays a role in the production of several steroid hormones, including testosterone. During stress, CRF and its receptors’ activities increase. This may play a role in some digestive system disorders such as IBS. This study was undertaken from December 2009 to June 2010 on 32 men diagnosed with IBS from a GI clinic, Iran as cases and 23 healthy men who were employees of Ali-Ebn-Abitaleb Hospital, as the control group.Serum testosterone levels were measured by ELISA. Demographic data and laboratory results were analyzed by SPSS version 15. The t-test compared serum testosterone levels of the two groups. Testosterone levels of the IBS cases were 5.73 ± 3.5 ng/dl and the control group was 1.84 ± 0.67 ng/dl in this study, which was statistically significant (P < 0.05). Testosterone may play a role in the pathogenesis of IBS. More extensive studies should be done to discover the pathogenesis of IBS and role of this hormone.

Achalasia is a primary motor disorder of the esophagus, in which esophageal emptying is impaired. Diagnosis of achalasia is based on clinical findings and confirmed by radiologic, endoscopic and manometric evaluations. Several treatments for achalasia have been introduced. We searched the Pubmed Database for original articles and meta-analyses about achalasia to summarize the current knowledge regarding this disease, with particular focus on different procedures utilized for treatment. We also report the Iranian experience of treatment of this disease, since it could be considered as a model formedium-resource countries. Laparoscopic myotomy with fundoplication is the best surgical method for treatment of achalasia with its high success rate and therapeutic response. Compared to other treatments, however, the initial cost of myotomy is usually higher and the recovery period is longer.Graded pneumatic dilation with a slow rate of balloon inflation seems to be an effective and safe initial alternative.Injection of botulinum toxin into the lower esophageal sphincter before pneumatic dilation may increase remission rates. However, this needs to be confirmed in further studies. Due to the lack of adequate information regarding the role of expandable stents in the treatment of achalasia, insertion of stents does not currently seem to be a recommended treatment.In summary, laparoscopic myotomy can be considered as the procedure of choice for surgical treatment of achalasia. Graded pneumatic dilation is an effective alternative and can be recommended as a first therapeutic option in the majority of achalasia patients.

Primary intestinal lymphangiectasia (PIL) is a rare disease of intestinal lymphatics presenting with hypoproteinemia, bilateral lower limb edema, ascites and protein-losing enteropathy. We report a case of PIL in a 22 year old patient from Tabriz, Iran who presented with anasarca edema, recurrent diarrhea, hypoproteinemia and confirmatory features of PIL on endoscopy and histopathology. Therefore we advise the consideration of PIL in the differential diagnosis of chylous ascitis.

Ileosigmoid knotting (ISK), also known as compound volvulus or double volvulus, is a rare cause of intestinal obstruction. The incidence of ISK is not well known, but it generally occurs in areas with a high incidence of sigmoid volvulus (SV). Ileosigmoid knotting is predominately seen in males (80.2%) with a mean age of 40 years. In an ileosigmoid knot, closed proximal loops of the ileum become congested and gangrenous within a few hours; therefore, early recognition and surgical treatment of ileosigmoid knots are essential. Despite the critical condition, in less than 20% of patients the diagnosis can be made preoperatively. The mean mortality rate is 6.8-8% in nongangrenous and 20100%-in gangrenous cases. The mortality figures are generally related to the duration of symptoms, the presence or absence of gangrene, and the general status of the patient, including the presence of septicemic shock. A 38-year-old man with a history of IV drug abuse presented with generalized abdominal pain which was severe in the epigaster and hypogaster regions. He had a history of obstipation since four days prior. Upon physical examination, the patient had abdominal tenderness and generalized guarding. Rectal examination was bloody. After adequate hydration, laparatomy was done and ileosigmoid knotting with gangrene of the terminal ileum were seen. A colostomy was performed in proximal end to end anastomosis, in the distal Hartman Poutch. The patient has been followed since three months ago, with no additional complaints at this time.

The use of intravenous sedatives is common in gastrointestinal endoscopy. This study is to evaluate the safety and efficacy of propofol and/or midazolam in induction of proper sedation in esophagogastroduodenoscopy (EGD) compared with a control group, which does not receive sedation for EGD. Four groups (A, B, C and D) of 30 patients each for whom EGD had been indicated were defined. Group A received no sedative, whereas groups B, C and D received midazolam, propofol and midazolam plus propofol intravenously, respectively. The four groups were compared with each other regarding heart rate (HR), oxygen saturation (O2S), systolic blood pressure (SBP), diastolic blood pressure (DBP), duration of endoscopy (DE), patient compliance (CM), retrograde amnesia (RA), antegrade amnesia (AA), patient activity (PA), skin color (SC), patient consciousness (CS), blood flow (BF), respiration state (RS) and pain.Patient compliance, retrograde amnesia, antegrade amnesia, patient activity, patient consciousness and pain were significantly different in our patient groups. On the contrary, no significant difference was found among the four groups regarding heart rate, oxygen saturation, systolic and diastolic blood pressures, duration of endoscopy, skin color, blood flow and respiratory state. Based on our findings, no sedation is necessary for EGD unless the patient feels anxious and therefore can not cooperate appropriately. For this case, the administration of propofol alone is a priority over midazolam alone and propofol plus midazolam.