Colorectal cancer screening in a low-incidence area: general invitation versus family risk targeting: a comparative study from Montenegro.

OBJECTIVES: Colorectal cancer (CRC) is one of the most common malignancies worldwide. The aim of this study was to compare the outcomes of two different screening approaches in a small country (Montenegro, 650,000 inhabitants) with a CRC incidence lower than the European average. METHODS: Two structured invitation programs were compared with respect to compliance and neoplasia yield: (i) program A focused on first-degree relatives of CRC patients diagnosed in two hospitals (n=206), inviting them for colonoscopy; (ii) program B was an invitation program for fecal occult blood testing, followed by colonoscopy if positive, conducted in University Hospital, Podgorica, Montenegro, on 2760 randomly selected average-risk persons, age 50-74 years, living in a single municipality. RESULTS: Of 710 first-degree relatives of 206 CRC patients approached, 540 presented for colonoscopy (76.05% uptake). Overall, 31 were diagnosed with a cancer, 58 with advanced adenoma, and 151 with adenoma in general. In the general screening program, of 2760 individuals invited, 920 underwent fecal immunochemical test (33.3% uptake) and colonoscopy was performed in all 95 positive cases (10.3%); six cancers was found in five patients (one patient had two cancers), 19 patients were diagnosed with advanced adenoma, and 26 with any adenomas. The risk-targeted screening program had a significantly higher yield for cancers in both per invited (31/710 vs. 5/2760, P<0.001) and per eligible person analysis (31/540 vs. 5/920, P<0.001). CONCLUSION: In a low-incidence country with limited resources, it may be advisable to start with CRC screening targeted to risk groups.

Clinical outcome in patients with hilar malignant strictures type II Bismuth-Corlette treated by minimally invasive unilateral versus bilateral endoscopic biliary drainage.

BACKGROUND: Stenting of malignant hilar strictures remains a standard endoscopic treatment in patients with unresectable tumors. The aim of this two-center prospective study was to compare unilateral versus bilateral drainage in hilar malignant stenosis Bismuth-Corlette type II. METHODS: During a 3-year period, a total of 49 patients with hilar tumors (Bismuth-Corlette type II) were referred for endoscopic treatment, following the criteria of unresectability. Ultrasound, computed tomography scan and magnetic resonance cholangiopancreatography (MRCP) were previously performed in all patients in order to facilitate endoscopic retrograde cholangiopancreatography (ERCP). The stricture was first passed by the hydrophilic guide-wire and then contrast medium was injected. Mechanical bile duct dilation was performed, followed by plastic stent placement only in the liver lobe which was previously opacified. The procedures were performed under conscious sedation. The patients were followed up for the next 12 months with a stent exchange every 3 months. Primary outcome was assessed by patient survival in the first 12 months after the procedure. RESULTS: All 49 patients were treated with ERCP while 39 (79.59%) had successful stent placement. Among these, 32 had hilar cholangiocarcinoma (82%) and 7 (18%) had gallbladder cancer. Two groups of patients had Bismuth II strictures: A, 21 patients (54%) with unilateral contrast injection and drainage, and B, 18 (46%) with bilateral contrast injection and drainage. A total of 57 plastic stents were used (10 Fr, 89%; 11.5 Fr, 11%). Group B showed a lower bilirubin level 7 days after the procedure (P=0.008). Early complications were cholangitis (3 patients, 2 in group A and 1 in group B) and acute pancreatitis (2 patients, 1 each in A and B) with no statistical difference between the groups. Late complications were stent migration (5 patients, 1 in A and 4 in B) and stent clogging (6 patients, 2 in A and 4 in B) showing a significant difference between the groups (P<0.01). The first stent replacement after 3 months was successful in 87% of patients (four died due to disease progression and one due to cardiopulmonary insufficiency) showing no statistical difference between the groups. At 6 months follow-up, 72% patients survived, with no statistical difference between the groups. A final follow-up (12 months) showed the survival rate of 18% (4 patients from group A and 3 from group B) (P>0.05). CONCLUSIONS: A minimally invasive approach, based on the criterion that every bile duct being opacified needs to be drained, is associated with a lower incidence of early complications. Considering that the clinical outcome measured by bilirubin level was lower in patients with bilateral drainage 7 days after the procedure, we assumed that drainage of 50% or more of the liver volume leads to sufficient drainage effectiveness.

Is there any benefit from expanding the criteria for the resection of hepatocellular carcinoma in cirrhotic liver? Experience from a developing country.

BACKGROUND: Patients with large-size (>10 cm) hepatocellular carcinoma (HCC) in Child B cirrhosis are usually excluded from curative treatment, i.e., hepatic resection, because of marginal liver function and poor outcome. This study was designed to evaluate the feasibility of the radiofrequency (RF)-assisted sequential "coagulate-cut liver resection technique" in expanding the criteria for resection of large HCC in cirrhotic livers with impaired liver function. METHODS: Forty patients with Child-Pugh A or B cirrhosis underwent liver resection from December 1, 2001 to December 31, 2008. Of these, 20 patients (13 Child-Pugh A and 7 Child-Pugh B) with advanced stage HCC (stage B and C according to Barcelona-Clinic Liver Cancer Group) underwent major liver resection. The two groups were comparable in terms of patient age, liver cirrhosis etiology, tumor number, and size. RESULTS: All resections were performed without the Pringle maneuver. There was no significant difference found between the two groups regarding resection time, perioperative transfusion, postoperative complications, hospital stay, and day 7 values of hemoglobin and liver enzymes. Likewise, there was no significant difference found in the overall survival between Child A and Child B patients who underwent major liver resection CONCLUSIONS: RF-assisted sequentional "coagulate-cut liver resection technique" may be a viable alternative for management of patients with advanced HCC in cirrhotic liver with impaired function.

Intraoperative cell salvage versus allogeneic transfusion during abdominal aortic surgery: clinical and financial outcomes.

The objective of this study was to assess the clinical and financial outcomes of intraoperative cell salvage (ICS) during abdominal aortic surgery. In this study, 90 patients were operated on with the use of ICS (group 1, prospective) and 90 patients without ICS (group 2, historical control). According to the type of operation, the patients were subdivided into three consecutive 30-patient subgroups (1, aortoiliac occlusive disease [AOD]; 2, elective abdominal aortic aneurysm [AAA]; or 3, ruptured abdominal aortic aneurysm [RAAA]). Transfusion requirements and postoperative complications were recorded. The total amounts of perioperatively transfused allogeneic blood were higher in all patient subgroups that underwent surgery without ICS (p = .0032). In the ICS group, 50% of AOD patients and 60% of elective AAA patients received no allogeneic transfusions. There were no significant differences in the incidence of postoperative complications in any group examined. ICS significantly reduced the necessity for allogeneic transfusions during abdominal aortic surgery. ICS use was most valuable in urgent situations with high blood losses, such as RAAA, for which only small amounts of allogeneic blood were initially available. In patients with more than 3 units of autologous blood reinfused, this method was cost effective.