Clinical significance of macroscopic completeness of mesorectal resection in rectal cancer.

AIM: Local recurrence after resection of rectal cancer is usually regarded as being due to a 'failure' of surgery. The completeness of resection of the mesorectum has been proposed as an indicator of the 'quality' of the resection. We determined the prognostic value of macroscopic evaluation of rectal cancer resection specimens and the circumferential resection margin (CRM) after curative surgery. METHOD: From 1999 to 2006, the macroscopic quality of the mesorectum and the CRM were prospectively assessed in 127 patients who underwent rectal cancer resection with curative intent (R0+R1). Chemoradiotherapy was administered for 61 tumours staged as locally advanced tumours (T3, T4 and N+). Univariate analysis of time to local recurrence and cancer-free survival were tested (Kaplan-Meier) and multivariate analysis calculated with a Cox regression model. RESULTS: The mesorectum was incomplete in 34 (26.8%) patients. At a median follow up of 34 months (range, 9-96 months), in the group with an adequate mesorectal excision, the cumulative risk of local recurrence at 5 years was 10%. This was 25% if the mesorectum was incomplete (P < 0.01). Five-year cancer-free survival was 65% if the mesorectal excision was adequate and 47% if it was not (P < 0.05). Multivariate analysis identified T status, the CRM and the mesorectal score as independent factors for local recurrence, and T and N status and the mesorectal score as independent factors for disease-free survival. CONCLUSION: The outcome of surgical treatment of rectal cancer is related to the completeness of mesorectal excision. It is a more discriminative prognostic factor than the classic tumour-node-metastasis (TNM) system.

Intermittent pringle maneuver and hepatic function: perioperative monitoring by noninvasive ICG-clearance.

BACKGROUND: Intermittent Pringle maneuver or selective portal clamping often are used to control inflow during parenchymal liver transection. This study was designed to determinate whether these maneuvers are associated with adverse hepatic function. METHODS: Resection was performed without portal clamping in 17 patients (group 1). Selective continuous portal clamping was performed in 11 patients (group 2) and the remaining 33 patients (group 3) had intermittent nonselective portal clamping (occlusion of the main portal trunk). The centers' protocol for total portal occlusion is 15-min occlusion alternated with 5-min reperfusion in patients with normal liver parenchyma or 10 min alternated with 5 min in patients with abnormal parenchyma. ICG elimination tests were conducted concurrently using a noninvasive monitor that tracks the plasma disappearance rate (PDR-ICG-%/min) and 15-min retention rate after administration (ICG-R15-%). RESULTS: There was no statistically difference between the three studied groups in terms of sequential changes of ICG-PDR (p < 0.625) or ICG-R15 (p < 0.398). CONCLUSIONS: Our study indicates that 15 min of intermittent Pringle maneuver or selective hemihepatic continuous portal clamping are safe methods of vascular control during liver resection, with no adverse effects on hepatocellular function.

Laparoscopic surgery for duodenal ulcer: first results of a multicenter study applying a personal procedure.

BACKGROUND/AIMS: First results from 14 different centers applying a personal procedure for the treatment of duodenal ulcer by laparoscopic surgery. METHODOLOGY: One hundred and thirty-six patients were operated on in 14 surgical centers between January 1991 and February 1995. All patients underwent posterior truncal vagotomy (PTV) and anterior linear gastrectomy (ALG) for chronic duodenal ulcer. RESULTS: The mean duration of operation was 65 min (range: 25-180) and there were no peroperative complications or deaths. Immediate post-operative morbidity rate was 2-9%, with a mean hospital stay of 3-1 days (range: 2-13). A total of 131 patients were evaluated between 6 and 33 months (mean: 25) after operation. Of these, 126 (96.2%) were graded as Visick I or II. Four (3.0%) were Visick III, and one patient (0.8%) was considered Visick IV. Gastric function studies were performed in 45 patients before and after operation, with a maximum acid output reduction of 83% 3 months after the operation CONCLUSIONS: Laparoscopic PTV with ALG constitutes a simple, efficient, rapid and safe method in the treatment of patients with chronic duodenal ulcer.

Citrullinemia stimulation test in the evaluation of the intestinal function.

BACKGROUND: Citrullinemia is been reported as a quantitative parameter of the enterocyte mass and function. AIM: The objective of this research is to analyse the value of fasting and stimulated citrullinemias in the intestinal function evaluation. METHODS: A case-control study was undertaken, including 11 patients with short bowel syndrome, 13 patients submitted to malabsorptive bariatric surgery and 11 healthy controls. Plasma levels of amino acids were determined, before and after a stimulation test with oral Lglutamine, by ion exchange chromatography. RESULTS: Citrullinemia was inferior in short bowel patients (28,6 ± 11,3 versus 35,5 ± 11 in operated obese versus 32,2 ± 6,6 µmol/L in controls; n.s.) and lower than 25,5 µmol/L in 54,5% of them (versus 16,7%; p = 0,041; accuracy = 74%; odds ratio = 3, 95%CI 1,2-7,6). ΔCitrullinemia80 (relative variation of citrullinemia at the 80th minute of test) was lower in short bowel patients; its diagnostic accuracy was similar to baseline citrullinemia and also not significant. ΔCitrullinemia80 revealed a high predictive capacity of a short bowel inferior or equal to 50 cm (auR.O.C. = 82,3%; 95%CI 61,7-102,8; p = 0,038). CONCLUSIONS: In short bowel syndrome context, citrullinemia stimulation test with oral L-glutamine is feasible and it may improve the predictive capacity of severity. Further investigation is required to determine its clinical relevance and applicability.

Introducción: Citrulinemia sí ha reportado como un parámetro cuantitativo de la masa y la función del enterocito. Objetivo: El objetivo de esta investigación es analizar el valor de las citrulinemias en ayuno y estimulada en la evaluación de la función intestinal. Métodos: Un estudio de casos y controles se llevó a cabo, incluyendo 11 enfermos con síndrome del intestino corto, 13 pacientes sometidos a cirugía bariátrica de malabsorción y 11 controles sanos. Los niveles plasmáticos de aminoácidos se determinaron, antes y después de la prueba de estimulación oral con L-glutamina, por cromatografía de intercambio iónico. Resultados: Citrulinemia fue menor en los pacientes de intestino corto (28,6 ± 11,3 versus 35,5 ± 11 en los obesos operados versus 32,2 ± 6,6 µmol/L en los controles; n.s.) e inferior a 25,5 µmol/L en el 54,5% de ellos (versus 16,7%; p = 0,041, exactitud = 74%, odds ratio = 3, IC95% 1,2 a 7,6). ?Citrullinemia80 (variación relativa de la citrulinemia a los 80 minutos de la prueba) fue menor en enfermos de intestino corto; su precisión diagnóstica fue similar a la citrulinemia en ayuno y también no significativa. ?Citrullinemia80 reveló una elevada capacidad predictiva de intestino corto inferior o igual a 50 cm (abR.O.C. = 82,3%; IC95% 61,7-102,8; p = 0,038). Conclusiones: En el contexto de lo síndrome de intestino corto, la prueba de estimulación de la citrulinemia con L-glutamina oral es factible y puede mejorar la capacidad predictiva de gravedad. Se requieren nuevas investigaciones para determinar su importancia clínica y aplicabilidad.

Perioperative tumor cell dissemination in patients with primary or metastatic colorectal cancer.

INTRODUCTION: Although there is general correlation between the TNM stage of colorectal cancer (CRC) and its prognosis, there is often significant variability of tumor behaviour and individual patient outcome, which is unaccounted for by pathologic factors alone. Our aim was to estimate perioperative tumor cell dissemination in patients with primary or CRC liver metastases as a possible factor influencing the outcome. METHODS: Forty patients were prospectively enrolled in the study from the year 2007 to 2008. Eighteen patients had histologically proven CRC (50% rectal, 44% colonic, 6% colonic and rectal). Sixteen patients (47%) had CRC liver metastases only. The remaining six patients who underwent colon or liver resection for benign conditions, acted as the control group. All patients with malignant pathologies had R0 resections. Blood samples were taken before the surgical incision (T0), immediately after tumor resection (T1) and at the end of the surgical intervention (T2). Data acquisition was performed using a dual-laser FACSCalibur flow cytometer. Circulating malignant cells were identified as being CD45-/cytokeratin+. RESULTS: The analysis of patients overall (CRC resection subgroup and hepatectomy subgroup) revealed that there was no statistically significant difference of the tumoral cell count in the blood per million of hematopoietic cells at T0, T1 and T2. CONCLUSIONS: This study demonstrates no differences in the detected circulating numbers of tumor cells at different stages of surgical intervention.

Is prophylactic colectomy indicated in patients with MYH-associated polyposis?

OBJECTIVES: The MYH gene has recently been associated with multiple colorectal tumours. It participates in the DNA base-excision-repair, avoiding mutations in other genes, namely the APC and Ki-ras. Recently, biallelic MYH mutations have been described in patients with attenuated polyposis and in 7.5% with classic polyposis and no detectable APC mutation. The aim of this study was to analyse the incidence of germ-line MYH mutations in selected Portuguese families recorded in a hereditary tumour registry and to evaluate the risk of colorectal cancer in this syndrome. PATIENTS AND METHODS: Nineteen APC mutation negative patients, 13 presenting attenuated polyposis and 6 with classic familial adenomatous polyposis (> 100 adenomas), were screened for germline biallelic MYH mutations. RESULTS: Biallelic germline mutations in MYH were identified in 9 of the attenuated polyposis and in one of the classic polyposis patients. The mean age at the clinical diagnosis was 50.6 years (from 35 to 69 years); six were men and four women. Five patients belonged to families with affected siblings; three showed evidence for vertical transmission and two had no evidence for familial transmission of the disease. No extra-colonic manifestations were reported. All patients had surgical resections: five total colectomies, four reconstructive proctocolectomies and one left hemicolectomy. Eight patients had associated malignant degeneration: three T3N+, four T3N0 and one T1N+. In the follow-up two patients died due to tumour recurrence. CONCLUSION: A large frequency of biallelic MYH mutations (69%) was found in APC mutation negative patients belonging to families with attenuated polyposis; the highest percentage was observed in families presenting evidence for horizontal transmission of the disease. The high percentage of degeneration found in these patients suggests that colonoscopy with polypectomies is not sufficient and prophylactic colectomy is recommended. The identification of MYH associated polyposis is important to evaluate the level of risk, particularly for the siblings.

[Changes in lung function after cholecystectomy--open versus laparoscopic cholecystectomy]. / Veränderungen der Lungenfunktion nach Cholezystektomie--Offene versus laparoskopische Cholezystektomie.

Impairment of respiratory function after open cholecystectomy may cause atelectasis and hypoxemia. Clinical experience shows evidence for easier recovery after laparoscopic operation. Postoperative respiratory function using spirometric tests was assessed in 50 patients with simple symptomatic cholecystolithiasis submitted either to open or laparoscopic cholecystectomy and revealed less impairment of respiratory function in the laparoscopic group.

Effect of perioperative blood transfusions on survival of patients after radical surgery for colorectal cancer.

The effect of perioperative blood transfusion on the survival of patients with colorectal cancer was evaluated in 128 patients undergoing curative surgery between 1980 and 1988. The following clinical and histopathological variables were also studied: age, sex, duration of symptoms, presence of intestinal obstruction, tumour site, extent of spread through the bowel wall, lymph node involvement, Dukes' stage, grade of differentiation, venous invasion and type of surgical procedure performed. The need for perioperative blood transfusion was unrelated to the stage of disease. In the transfused patients (n = 73) the 5-year recurrence-free survival, calculated by the Kaplan-Meyer technique, was 37% and in the non-transfused (n = 55) was 60% (P = 0.0027, Mantel-Cox). Similar differences were found in the comparison of the groups with (n = 68) and without (n = 60) transfusions on the day of operation. The deleterious effect of transfusion was evident in patients who received only one unit of blood (n = 19)--these had a 5-year survival rate of 45% compared those who had more than one unit of blood (n = 54) (5-year survival rate 35%) (P = 0.0062). With a multivariate analysis, using a Cox proportional hazard model, taking into account all the variables studied, a significant and independent effect on survival was found for lymph node involvement (beta coefficient = 3.97), blood transfusion (beta coefficient = 2.16) and extent of bowel wall spread (beta coefficient = 1.75).(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic surgery for duodenal ulcer: first results of a multicentre study applying a personal procedure.

Between January 1991 and February 1995 data were gathered on 136 patients operated on in 14 surgical centres. All patients underwent posterior truncal vagotomy (PTV) and anterior linear gastrectomy (ALG) for chronic duodenal ulcer. Recurrence and repeated bleeding were the main indications for surgery. An antireflux technique was simultaneously carried out in 17 patients, while 13 underwent cholecystectomy. There were no peroperative complications or deaths, and the mean duration of operation was 65 (range 25-180) min. Immediate postoperative morbidity rate was 2.9 per cent, with a mean hospital stay of 3.1 (range 2-13) days. A total of 131 patients were evaluated between 6 and 33 (mean 25) months after operation. Of these, 126 (96.2 per cent) were graded as Visick I or II. Four (3.0 per cent) were Visick III, and one patient (0.8 per cent) was considered Visick IV. Gastric function studies were performed in 45 patients before and after operation, with a maximum acid output reduction of 83 per cent 3 months after the operation. Laparoscopic PTV with ALG constitutes a simple, efficient, rapid and safe method in the treatment of patients with chronic duodenal ulcer.

Dissociation between vasodilation and Leishmania infection-enhancing effects of sand fly saliva and maxadilan.

In this study, the ability of maxadilan and Lutzomyia longipalpis salivary gland lysate to enhance the infection of CBA mice by Leishmania major and of BALB/c mice by L. braziliensis was tested. No difference was observed between sizes of lesion in CBA mice infected with L. major and treated or not with salivary gland lysate or maxadilan, although they were injected in concentrations that induced cutaneous vasodilation. Although parasites were more frequently observed in foot pads and spleens of animals treated with maxadilan than in the animals treated with salivary gland lysate or saline, the differences were small and not statistically significant. The lesions in BALB/c mice infected with L. braziliensis and treated with maxadilan were slightly larger than in animals that received Leishmania alone. Such differences disappeared 14 weeks after infection, and were statistically significant only in one of two experiments.

Pulmonary function after laparoscopic cholecystectomy in the elderly.

The results of laparoscopic cholecystectomy in a group of 52 patients older than 69 years (group 1) were compared with the results of the same operation in a group of 338 younger patients (group 2). In group 1, 23 per cent of patients had acute cholecystitis and 13 per cent were operated on after an episode of acute pancreatitis. In group 2, 8 per cent of patients had acute cholecystitis and 4 per cent were operated on after acute pancreatitis. Pulmonary function was assessed prospectively before operation, 24 h after surgery and on the seventh day after operation, in 20 patients in group 1 and 30 in group 2. In group 1 there was one death (2 per cent); the morbidity rate was 14 per cent and conversion to laparotomy was required in 15 per cent. In group 2 there were no deaths, the morbidity rate was 11 per cent and the conversion rate 4 per cent. No significant differences were found between the two groups in mortality and morbidity rates. Preoperative values of forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) were significantly lower in group 1 than in group 2 (P < 0.05); the values of FVC, FEV1 and forced expiratory flow at 50 per cent 24 h after surgery were less depressed in group 1 (P < 0.01) and also recovered more quickly in these patients 7 days after operation. Laparoscopic cholecystectomy gives excellent results in geriatric patients and can be recommended as the treatment of choice for symptomatic cholelithiasis in the elderly.