Laparoscopic surgery for the cure of colorectal cancer: results of a German five-center study.

PURPOSE: The aim of this study was to assess the feasibility and safety of laparoscopic surgery for the cure of colorectal cancer with emphasis on oncologic follow-up in particular. METHODS: A study was performed of patients with colorectal cancer treated by laparoscopy in five German centers between May 1991 and September 1997. Surgical and pathologic data were recorded in an anonymous registry database and analyzed by type of resection. Standard procedures were sigmoid or left colectomy, anterior resection, abdominoperineal resection, and right hemicolectomy. Follow-up information included incidence of local, distant, and port site recurrence and cancer-related death. RESULTS: A total of 399 patients (212 females) with a mean age of 66.6 years underwent laparoscopic curative resections (sigmoid resection, 89; left colectomy, 11; anterior resection, 157; abdominoperineal resection, 102; right hemicolectomy, 40). Conversion was necessary in 6.3 percent (n = 25). Complications requiring reoperation occurred in 9 percent (n = 35). Complications that were treated conservatively occurred in 27.6 percent (n = 110). Thirty-day mortality was 1.8 percent (n = 7). First bowel movements resumed on the third postoperative day; patients did not use analgesics after a mean of five days. Mean postoperative hospitalization was two weeks. According to International Union Against Cancer classification, 147 patients had Stage I cancer, 35 had Stage II cancer, and 217 underwent curative resection for Stage III cancer. Mean number of lymph nodes resected was 12.1. At a mean follow-up of 30 months, one port site recurrence was documented. No local recurrence was observed after curative resection of Stage I colorectal cancer. Of 399 patients, local recurrence occurred in 6 patients (Stage II, 2; Stage III, 4), and distant metastases were documented in 25 patients (Stage I, 3; Stage II, 3; Stage III, 19). The highest incidence of cancer-related death occurred after abdominoperineal resection (4.9 percent). CONCLUSION: To assess the role of laparoscopic colorectal surgery for the cure of cancer objectively, prospective randomized trials are necessary.

In cirrhotic patients variceal bleeding is more frequent in the evening and correlates with severity of liver disease.

BACKGROUND/AIMS: It has been observed that the portal pressure in cirrhotic patients shows circadian variation and is at a maximum at night. Our aims in this study were a) to evaluate the frequency of upper gastrointestinal (UGI) bleeding from esophageal/gastric varices or portal congestive gastropathy during the day, evening or night shift, and b) to correlate the frequency of bleeding during various shifts with severity of liver disease. METHODOLOGY: At our institution, during the period from January 1997 to June 1995, 15,000 gastrointestinal (GI) endoscopic reports and consultations were evaluated. Episodes of bleeding due to portal hypertension (PH), i.e., esophageal varices, gastric varices or congestive gastropathy, were noted. The time of occurrence of bleeding from PH in various shifts, e.g., day shift (DS), evening shift (ES) or night shift (NS) was determined. The severity of liver disease was classified as A, B or C according to Child's classification. RESULTS: There were 221 episodes of UGI bleeding due to PH in 144 patients. 75.5% of patients presented with hematemesis, whereas 24.5% presented with melena (p < 0.025). Bleeding started during the DS in 39/221 (17.6%), during the ES in 122/221 (55.2%), and during the NS in 60/221 (27.1%). There were 29 (13.1%) patients in Child's A, 75 (33.9%) in Child's B, and 117 (52.9%) in Child's C. Among the 122 bleeders during ES, 85 (69.6%) were in category C. It seems that in these patients UGI bleeding is more frequent during the ES compared to DS and NS (p < 0.0001; chi square; 95% CI: 0.52-0.58). Child's C patients are more likely to bleed during ES compared to Child's A or B patients (p < 0.0001; Odds Ratio: 4.8%; 95% CI: 2.7-8.5). CONCLUSIONS: 1) The majority of the cirrhotic patients with PH who develop UGI bleeding present with hematemesis rather than melena. 2) The bleeding in these patients is more likely to occur during the ES. 3) Child's C patients are more likely to bleed during the ES.

Pelvic fractures associated with open perineal wounds: a survivable injury.

Blunt pelviperineal trauma has been associated with mortality rates of 32% to 58% in recent literature. A review of our institution's experience revealed a much lower mortality rate, prompting further investigation. Nine hundred-seventy five patients with pelvic fractures were admitted to our institution from July 1984 through June 1991. The mortality rate for all pelvic fractures was 7.3%. During this interval 21 patients (2.2%) were admitted with open pelvic fractures. Only one patient in this group died. Our low mortality figures were the result of better control of pelvic hemorrhage and sepsis, and a lower incidence of associated injuries to the head and thorax, representing a more favorable mechanism of injury.

The single indication for cystography in blunt trauma.

To define the indications for cystography in blunt trauma, two studies were completed. First, a 15-month retrospective evaluation revealed 26 patients with bladder trauma. All 26 patients presented with gross hematuria. This was followed by a randomized prospective study of all patients with blunt trauma. Patients were randomized to be evaluated with cystography for any degree of hematuria or the diagnosis of pelvic fracture versus those to be evaluated only for the presence of gross hematuria. Eleven patients had pelvic fractures and no hematuria. One hundred nine patients had microscopic hematuria and a 39 per cent incidence of coexistent pelvic fractures. Thirty-one patients had gross hematuria and a 26 per cent incidence of pelvic fracture. Bladder injuries were seen only in this latter group. Cost analysis of the prospective study revealed a potential savings of $26,322 if gross hematuria had been the sole indication for cystography in blunt trauma. This approach has potential cost savings and, more importantly, will not compromise the quality of trauma care.

Blunt laryngeal trauma: classification and management protocol.

Ten patients with the diagnosis of blunt laryngotracheal trauma were admitted to Orlando Regional Medical Center from March 1, 1987 through September 30, 1988. These patients have been studied retrospectively with attention to type of injury, management, treatment, and outcome. The use of a flexible nasopharyngoscope in the Emergency Department, significance of a patient's inability to tolerate the supine position, and tracheotomy as the airway of choice are key points in the laryngotracheal injury classification and management protocol presented herein.

Regulation of granulopoiesis following severe thermal injury.

Neutropenia often accompanies septicemia in burned patients. This paradox suggests a defect in the regulation of granulopoiesis. Colony stimulating factor (CSF) produced by the monocyte-macrophage system is an important regulator of granulocyte production. We followed serial serum CSF levels and peripheral blood leukocyte differential counts in 22 patients with greater than 30% burns. Six patients (mean burn, 58%) developed Gram-negative septicemia and died (Group I). Sixteen patients (mean burn, 38%) had no fatal septicemias (Group II). Nonsurvivors had initially low levels of CSF and developed persistent monocytopenia. Survivors, in contrast, had prompt rises in CSF and developed monocytosis. The presence of monocytopenia and low CSF levels in Group I suggests an abnormality in the stimulatory arm regulating granulopoiesis. Such a defect may play a role in the development of fatal septicemia following severe thermal injury.

Incidence of lobular carcinoma in bilateral breast cancer.

The histology and clinical records of 52 patients with bilateral breast cancer recorded in a community tumor registry were reviewed. Previous studies have demonstrated the propensity of lobular carcinoma to occur bilaterally. This view is supported by the large number of lobular cancers found in our patients. Thirty-six percent of the patients with bilateral disease had lobular cancer in at least one breast. Those with lobular cancer tended to be younger and more likely to have simultaneous cancers than did patients with nonlobular carcinoma. In those patients in whom the occurrence of tumors was not simultaneous, they were smaller in the second breast but had similar rates of axillary metastases. This study raises the question of how best to manage the contralateral breast in patients with breast cancer. Lobular carcinoma is one marker of the likelihood for development of disease in the second breast; but if advantage is to be gained by this finding, investigation of the opposite breast is best done early. Finally, thorough examination of patients with nonlobular carcinoma must not be ignored because they still comprise the majority of bilateral breast cancers.

The anemia of thermal injury: studies of erythropoiesis in vitro.

Anemia is invariably seen in patients who have been severely burned, and a number of factors have been implicated in its etiology. Prior studies have suggested that a depressed rate of erythropoiesis is involved. In order to study this, we evaluated the effect of serum from burned patients on red cell and white cell colony growth in vitro. We found that these sera were capable of inhibiting red cell, but not white cell, colony growth. Additional experiments indicated that this was related to the presence of some substance in the burned serum rather than the absence of a factor required for colony formation. Further studies, including review of clinical data, suggested that this effect was not due to topical medications nor to episodes of bacterial sepsis. Serial studies showed that inhibition was often not present in the immediate postburn period but developed gradually, reaching maximum intensity approximately 20 to 30 days following the burn and then returning toward normal as patients healed their injury. Our studies permit the hypothesis that inhibition of erythropoiesis plays a role in the pathogenesis of the anemia of thermal injury.

The MGM Grand Hotel fire: lessons learned from a major disaster.

Most community disaster plans are formulated to respond to disasters of moderate size. The MGM Grand Hotel fire in Las Vegas, because of its magnitude, had the potential to overwhelm completely the local medical resources. It did not, because of innovative responses to unforeseen problems based on sound disaster planning. Fortunately, disasters on the magnitude of this fire are rare, and few communities have ever faced the problem of dealing with thousands of casualties. The important lessons learned about perimeter control, command functions, helicopter evacuation, crowd control, and transportation priorities will benefit disaster planners in other communities.

Surgical implications of Behçet's disease.

Behcet's disease, though originally described as a triad of oral and genital aphthous ulcers and inflammatory ocular lesions, has had several new elements added to its description. The updated syndrome now includes gastrointestinal (GI) involvement as well as polyarthritis, neuritis, myocarditis, and glomerulonephritis. Of particular importance to the surgeon are the GI manifestations that include hemorrhage and perforation. A review of the literature indicates that the GI manifestations of Behcet's disease are not uncommon and, though usually mild, may necessitate surgical intervention. Our experience with a patient with GI hemorrhage and subsequent perforation underlines the occasional urgent complications of this disease.

Nitrogen balance and electrolyte requirements in intralipid-based hyperalimentation.

The present study was directed at determining whether or not a relatively low-calorie regimen in which 40 to 50% of the calories are provided as fat will produce positive nitrogen balance in most patients, and at establishing the electrolyte requirements for such a regimen. Clearly, the recommended regimen is successful in promoting nitrogen balance and provides adequate electrolytes. Further experience will be necessary to determine the place of intravenous fat emulsions in the clinical practice of total parenteral nutrition.

Major hepatic resection and portal pressure.

Although other reports have stressed the inevitability of portal hypertension and splanchnic pooling following major liver resections, clinical observations during 30 major hepatic resections and measurements of portal pressure in three consecutive trisegmentectomies fail to support this contention. If the remaining liver is normal and careful anatomic dissection is used, major resections can be performed without inducing portal hypertension.

Community experience with small bowel bypass for morbid obesity.

A comparison of small bowel bypass performed at university centers and by private practitioners in a large metropolitan area demonstrates definite stmilarities in terms of patient selection, mortality and morbidity, and weight loss results. The only aspect of small bowel bypass in the private sector that could be criticized would be the adequacy of follow-up. An operation with as many known and probably other unknown long-term complications as jejunoileal bypass necessitates prolonged careful patient follow-up. We belive the person most qualified to provide such follow-up is the surgeon who performed by bypass procedure.

Cholecystectomy with and without surgical drainage.

Thirty-seven patients who met specific criteria had cholecystectomy without drainage, and thirty-seven matched control patients had cholecystectomy with drainage. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and may be unwise. Such drainage may result in an increased incidence of postoperative morbidity and prolonged hospital stay.