Prognostic factors for traumatic bowel injuries: killing time.

BACKGROUND: Intestinal rupture/perforation after abdominal trauma is a rare complication, but it is related to significant morbidity and mortality. Our objective is to identify determinants of prognosis in patients surgically treated for a bowel injury (small bowel and colon) after abdominal trauma. METHODS: The present study is a retrospective analysis of 102 patients seen at our hospital during a 10-year period in whom laparotomy for traumatic bowel injury was performed. Predictors for morbidity and mortality were assessed in univariate and multivariate analysis models. RESULTS: Mean age at diagnosis was 40 years, and most patients were male. There was a slight preponderance of blunt abdominal trauma, and the most frequent mechanism of injury was motor vehicle accident. In 75% of patients there was a small bowel lesion, and the colon was affected in 47%. There was no statistical relation between stoma construction and mortality, but an increase in morbidity was ultimately dependent on the severity of the underlying trauma. The univariate determinants of mortality were the new injury severity score (NISS) and American Society of Anesthesiologists (ASA) scores, the presence of blunt trauma and multiple intestinal or extra-abdominal lesions, and the elapsed time to surgery. The occurrence of postoperative complications was related to all these factors, as well as to tachycardia, hypotension, and bleeding. In multivariate analysis ASA score (p = 0.015), NISS (p = 0.002), time to surgery (p = 0.007), and presence of colonic lesions (p = 0.02) were identified as independent prognostic factors for postoperative morbidity. CONCLUSIONS: The only modifiable determinant of morbidity seems to be the time to surgery. Only an expeditious evaluation and diagnosis and prompt surgical intervention can improve the prognosis of these patients.

A brief history of bariatric surgery.

Obesity has been a problem since medieval times, but only in the latter 20 years it has been recognized as a worldwide epidemic. Treating obesity is challenging and difficult, but surgery has led to an increased success and novel insights on the pathophysiology of obesity. Several surgical techniques have been developed during the last 50 years and the advent of laparoscopic surgery has increased its safety, efficacy and demand from the population. Nowadays, the ever increasing and successful use of novel techniques have been responsible for several changes in the established treatment paradigms.

Gastric bypass is a cost-saving procedure: results from a comprehensive Markov model.

BACKGROUND: Obesity is a growing public health problem in industrialized countries and is directly and indirectly responsible for almost 10% of all health expenditures. Bariatric surgery is the best available treatment, however, associated with important economical expenditures. So, cost-effectiveness analysis of the available surgical options is paramount. METHODS: We developed a Markov model for three different strategies: best medical management, gastric band, and gastric bypass. The Markov model was constructed to allow for the evaluation of the impact of several obesity-related comorbidities. The results were derived for a representative population of morbidly obese patients, and subgroup analyses were performed for patients without comorbidities, patients with diabetes mellitus, different age, and body mass index (BMI) groups. Cost-effectiveness analysis was performed accounting for lifetime costs and from a societal perspective. RESULTS: Gastric bypass is a dominant strategy, rendering a significant decrease in lifetime costs and increase in quality-adjusted life years (QALYs). Comparing with the best medical management, in the global population of patients with a BMI of > 35 kg/m2, gastric bypass renders 1.9 extra QALYs and saves on average 13,244€ per patient. Younger patients, patients with a BMI between 40 and 50 kg/m2, and patients without obesity-related diseases are the ones with a bigger benefit in terms of cost effectiveness. CONCLUSIONS: Gastric bypass surgery increases quality-adjusted survival and saves resources to health systems. As such, it can be an important process to control the ever-increasing health expenditure.

Three decades of clinical-pathological trends in gastric cancer: prospective data from a Portuguese hospital.

INTRODUCTION: Gastric cancer is a heterogeneous disease, whose pathological and clinical patterns have changed in the last decades. In most western countries, decreases in incidence and mortality and a proximal migration have been reported. The clinical and pathological trends in an European country with high prevalence of gastric cancer were reviewed, based on the patients treated at a University Hospital. METHODS: Analysis of a prospective database with 1618 patients who underwent surgery for gastric cancer in the last 3 decades. The patients were divided in 3 groups according to decades and the cohorts were analyzed according to demographic, surgical and pathological factors. RESULTS: The mean age increased from 59.8 to 65.6 years. Antral tumors and intestinal cancer were the most frequent. The rate of complete resection increased as well as the percentage of total gastrectomies and D2-type lymphadenectomies. There was an increase both in early stage carcinomas and in surgically treated Stage-IV carcinomas. The median overall crude survival almost doubled from 14 to 22 months (p = 0.003), but once stratified for stage, only in stage II patients could we observe a significant increase in survival time. (29-47 months; p = 0.047). CONCLUSION: The proximal migration described for Western Europe was not observed and the intestinal-type carcinoma is still the most frequent. We are treating older patients, often with more advanced disease. In spite of an increasing surgical aggressiveness, the prognosis has only been significantly improved in Stage-II cancers. The prognosis for advanced cancer is still dismal, hence the need for effective adjuvant treatments.

Open gastrostomy by mini-laparotomy: a comparative study.

BACKGROUND: Gastrostomy tube feeding is the best option for long lasting nutritional support in patients with dysphagia caused by obstructive tumours of the mouth, pharynx, larynx and ooesophagus or neuromuscular diseases. However, these severely compromised patients often present severe respiratory risks, precluding the use of general anesthesia, sedation or even endoscopy. A simplified open gastrostomy (SOG) under local anesthesia has been in practice in our institution, especially for patients with severe neuromuscular diseases and continuous non-invasive ventilatory support. In this study, we try to compare the surgical outcomes of this technique, with the classical Stamm gastrostomy (SG). MATERIAL AND METHODS: This simplified technique uses a minimal vertical midline incision (3 cm), just below the xyphoid process, under local anesthesia. The gastrostomy tube is passed by a left lateral stab wound, inserted in a double purse-string in the gastric wall and pulled to the anterior abdominal wall. No sutures between the stomach and the peritoneum are placed. We retrospectively analyzed the clinical records of 63 consecutive gastrostomies performed upon a 3-year period, 23 of which were by SOG. RESULTS: The SG was performed mainly in oncological patients, and SOG in patients with neuromuscular diseases (p < 0.001). In the SOG group, 95,4% (n = 22) of the patients were ASA IV, compared with 74,4% (n = 29) in SG (p = 0,03). The mean operative time was shorter in the simplified technique (37 vs 60 min; p = 0,01). All the surgeries in the SOG group were performed exclusively with local anesthesia and in the Stamm procedure, 47,5% required invasive ventilatory support (p < 0.001). There were no significant differences regarding in-hospital morbi-mortality (p = 0,18). The patients were able to receive adequate nutritional support, and the overall satisfaction of the patients and family/caregivers is very good. CONCLUSION: The simplified mini-laparotomy gastrostomy is a safe and effective alternative to other approaches. The association of local anesthesia with a minimal surgical offense and a short operative time render its effectiveness, even in high-risk patients.

Acute diverticulitis in younger patients: any rationale for a different approach?

AIM: To compare the natural history and course of acute diverticulitis in a younger age group with an older population and to evaluate whether younger patients should be managed differently. METHODS: This study was a retrospective review of 157 patients treated with acute diverticulitis between January 1, 2004 and December 31, 2007. Diverticulitis was stratified according to the Hinchey classification. Patients were divided into 2 populations: group A ≤ 50 years (n = 31); group B > 50 years (n = 126). Mean patient follow-up was 15 mo. RESULTS: The median age was 60 years. A significantly higher proportion of patients in group B presented with complicated diverticulitis (36.5% vs 12.9%, P = 0.01). Recurrence was more frequent in group A (25.8% vs 11.1%, P = 0.03) and the mean time-to-recurrence was shorter (12 mo vs 28 mo, P = 0.26). The most severe recurrent episodes of acute diverticulitis were classified as Hinchey stage I and none of the patients required emergency surgery. In multivariate analysis, only age (P = 0.024) was identified as an independent prognostic factor for recurrence. CONCLUSION: Based on the results of this study, the authors recommend that diverticulitis management should be based on the severity of the disease and not on the age of the patient.

Primary gastric adenosquamous carcinoma in a Caucasian woman: a case report.

INTRODUCTION: Most gastric tumors are adenocarcinomas. Primary gastric adenosquamous carcinoma is a rare malignancy, mostly associated with Asian populations. It constitutes less than one percent of all gastric carcinomas and its clinical presentation is the same as adenocarcinoma. It occurs more frequently in the proximal stomach, usually presents with muscular layer invasion and tends to be found in advanced stages at diagnosis, with a worse prognosis than adenocarcinoma. CASE PRESENTATION: We report the case of an 84-year-old Caucasian woman with an adenosquamous carcinoma extending to her serosa with lymphatic and venous invasion (T3N1M1). Nodal and hepatic metastasis presented with both cellular types, with dominance of the squamous component. CONCLUSIONS: Adenosquamous gastric cancer is a rare diagnosis in western populations. We present the case of a woman with a very aggressive adenosquamous carcinoma with a preponderance of squamous cell component in the metastasis. Several origins have been proposed for this kind of carcinoma; either evolution from adenocarcinoma de-differentiation or stem cell origin might be possible. The hypothesis that a particular histological type of gastric cancer may arise from stem cells might be a field of research in oncological disease of the stomach.