Assessing tumor response to neoadjuvant chemoradiation in rectal cancer with rectoscopy and 18F-FDG PET/CT: results from a prospective series.

INTRODUCTION: rectoscopy and 18F-FDG PET/CT as a diagnostic algorithm for the assessment of tumor response in rectal cancer after neoadjuvant chemoradiation therapy (CRT) is very useful. MATERIAL AND METHODS: this was a prospective longitudinal study in patients with locally advanced rectal cancer treated with neoadjuvant CRT. Patients were assessed after CRT completion with a digital rectal examination, proctoscopy and 18F-FDG PET/CT. Patients were subdivided as clinical (cCR) or radiologic (rCR) responders and non-responders according to tumor response. Clinical and radiological re-assessment was compared with the surgical specimen. Pathological tumor regression (pCR) grade was determined according to Mandard's classification. Of the 68 patients included, 15 (22 %) presented pCR in the surgical specimen and tumor persistence (non-PCR) was detected in the remaining 53 (78 %). Clinical assessment (DRE+ rectoscopy) identified 15 patients as cCR and 53 as non-cCR, two were false positives and two were false negatives. The overall accuracy was 94 %. 18F-FDG PET/CT identified 18 patients as rCR and 50 as non-rCR, one was a false positive and four were false negatives. The overall accuracy was 92 %. A combination of clinical findings and 18F-FDG PET/CT resulted in an accuracy of 96 %. The combination of clinical findings + 18F-FDG PET/CT was able to correctly identify all cases of pCR, with the exception of one case that presented a tumor regression of 80 %. In this series, 18F-PET-CT and clinical assessment had excellent accuracies in differentiating PCR from non-PCR after CRT completion. PET-CT combined with clinical assessment had a better accuracy than both modalities independently. 18F-FDG PET/CT is a valid tool that complements the clinical assessment of tumor response.

Lanthanum carbonate has a radiopaque appearance on the plain abdominal radiography.

An 84-year-old woman presented to her local emergency department for abdominal pain. Her medical history included hemodialysis in the treatment of chronic renal failure, Parkinson's disease, chronic atrial fibrillation, chronic constipation, appendicectomy and cholecystectomy. The patient complained of diffuse abdominal pain for 4 days, associated with nausea and vomiting in the last 24 hours. Physical examination revealed a soft and depressible abdomen, diffusely painful, without signs of peritoneal irritation. A digital rectal exam revealed large amount of stool in the rectal vault without palpable masses. Blood tests showed a creatinine level of 2.7 mg/dl due to chronic renal failure and the plain abdominal radiography revealed a dolichocolon completely contrasted. The patient denied the realization of any medical imaging-proofs with oral or rectal contrast. Reviewing home treatment, the patient was taking lanthanum carbonate (2 tablets of 750 mg per day) since 1 month ago, a drug that contrasts the digestive tract. Appreciating contrast in the colon, intestinal subocclusion was excluded and the clinical picture was attributed to her chronic constipation. In conclusion, it should be noted that lanthanum carbonate contrasts the digestive tract, with radiopaque appearance on the plain abdominal radiography and without any pathological significance.

Prospective randomized controlled study to assess the value of a hemostatic and sealing agent for preventing seroma after axillary lymphadenectomy.

BACKGROUND AND OBJECTIVES: Postoperative seroma after axillary lymphadenectomy leads to an increased use of resources and an impaired quality of life of patients. This randomized clinical trial was designed to assess the value of a hemostatic and sealing agent for decreasing seroma occurrence after axillary lymphadenectomy. METHODS: A prospective, randomized, blind study was conducted on 91 axillary lymphadenectomies distributed into a control group (n = 47) and a test group in which a collagen sponge coated with human coagulation factors was used (n = 44). Primary end-points were number of days before removal of axillary drainage, axillary drainage output, and occurrence of seroma, wound infection, haematoma, or wound dehiscence, within 8 weeks of surgery. Bivariate and multivariate analyses on seroma occurrence were performed. RESULTS: Seroma occurred in 29 patients (31.86%). A significant direct relationship (P = 0.002) was only noted between use of the hemostatic and sealing agent and nonoccurrence of seroma. In the multivariate study, the only variable found to be significantly related to seroma occurrence was use of the above agent (P = 0.046; odds ratio: 3.365 [95%CI: 1.024-11.060]). CONCLUSIONS: Use of a collagen sponge coated with human coagulation factors following axillary lymphadenectomy was associated to a lower incidence of postoperative seroma. J. Surg. Oncol. 2016;114:423-427. © 2016 Wiley Periodicals, Inc.

El carbonato de lantano tiene una apariencia radiopaca en la radiografía de abdomen / Lanthanum carbonate has a radiopaque appearance on the plain abdominal radiography

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Exploración laparoscópica de la vía biliar, lecciones aprendidas tras más de 200 casos / Laparoscopic common bile duct exploration. Lessons learned after 200 cases

INTRODUCCIÓN: El abordaje laparoscópico de la vía biliar (ALVB) es una técnica segura, reproducible y coste-efectiva para el tratamiento de la coledocolitiasis frente a la cirugía abierta. Tras la realización de la coledocotomía han sido propuestas diversas técnicas para el cierre de la vía biliar principal (VBP). OBJETIVO: Presentar nuestra experiencia en el ALVB como técnica rutinaria en el tratamiento de la coledocolitiasis y las lecciones aprendidas tras más de 200 casos. PACIENTES Y MÉTODOS: Entre enero de 1999 y julio de 2012 se realizó el ALVB en 206 pacientes con el diagnóstico de coledocolitiasis. En los inicios de la serie realizamos el cierre de la vía biliar (VB) mediante tubo de Kehr, posteriormente la técnica de elección fue la colocación de un stent anterógrado, pero dada la elevada incidencia de pancreatitis aguda (PA), en los últimos pacientes de la serie realizamos un cierre primario de la VBP sin drenaje de la misma. RESULTADOS: Los grupos fueron homogéneos en cuanto a edad y sexo. La presentación clínica más frecuente fue la ictericia. En 185 pacientes (88,5%) se realizó un abordaje quirúrgico mediante coledocotomía y en 17 pacientes (8,7%), transcístico. En los pacientes a los que se realizó coledocotomía, el tamaño medio de las litiasis fue mayor (9,7 vs. 7,6 mm en el abordaje transcístico). Tras la coledocotomía colocamos un tubo de Kehr para el cierre de la VBP en 36 pacientes, en 133 se colocó un stent anterógrado observando un 11,6% de PA y un 26,1% de hiperamilasemia, por lo que en los últimos pacientes de la serie (16) hemos realizado un cierre primario de la VBP sin drenaje, mejorando la morbilidad y la estancia hospitalaria. Se observó una disminución de la morbimortalidad en pacientes menores de 75 años y en el grupo de pacientes en los que existía una mayor experiencia por parte del cirujano. CONCLUSIONES: Tras la realización del ALVB en el tratamiento de la coledocolitiasis, un cierre primario de la VB sin drenaje de la misma presenta ventajas sobre otras técnicas más clásicas como la colocación de un tubo de Kehr o el stent. Es importante una adecuada curva de aprendizaje para mejorar los resultados en el manejo laparoscópico de esta enfermedad. El ALVB es una técnica segura y reproducible, especialmente en pacientes menores de 75 años

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) is a reliable, reproducible and cost-effective treatment for common bile duct stones. Several techniques have been described for choledochotomy closure. AIMS: To present our experience and the lessons learned from more than 200 cases of LCBDE. Patients and methods Between January 1999 and July 2012, 206 patients with common bile duct stones underwent LCBDE. At the beginning of the series, we performed the closure of the CBD over a T-tube (36 patients), subsequently we favoured closure over an antegrade stent (133 patients), but due to a high incidence of acute pancreatitis in the last 16 patients we have performed primary closure. RESULTS: The 3 closure groups were matched for age and sex. Jaundice was the most frequent presentation. A total of 185 (88.5%) patients underwent choledochotomy, whereas in 17 (8.7%) patients the transcystic route was used. The group that underwent choledochotomy had a larger size of stones compared to the transcystic group (9.7 vs 7.6 mm). In the stented group we found an 11.6% incidence of pancreatitis and a 26.1% incidence of hyperamylasemia. In the primary closure group we found a clear improvement of complications and hospital stay. The increased experience of the surgeon and age (younger than 75) had a positive impact on mortality and morbidity. CONCLUSIONS: Primary closure of the common bile duct after LCBDE seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes, making it a safe and reproducible technique especially for patients aged under 75 years

Laparoscopic common bile duct exploration. Lessons learned after 200 cases.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) is a reliable, reproducible and cost-effective treatment for common bile duct stones. Several techniques have been described for choledochotomy closure. AIMS: To present our experience and the lessons learned in more than 200 cases of LCBDE. PATIENTS AND METHODS: Between January 1999 and July 2012, 206 patients with common bile duct stones underwent LCBDE. At the beginning of the series, we performed the closure of the CBD over a T-tube (36 patients), subsequently we favoured closure over an antegrade stent (133 patients) but due to a high incidence of acute pancreatitis in the last 16 patients we have performed primary closure. RESULTS: The 3 closure groups were matched for age and sex. Jaundice was the most frequent presentation. A total of 185 (88,5%) patients underwent choledochotomy whereas in 17 (8,7%) patients the transcystic route was used. The group that underwent choledochotomy had a larger size of stones compared to the transcystic group (9,7 vs 7,6mm). In the stented group we found an 11,6% incidence of pancreatitis and 26,1% of hyperamylasemia. In the primary closure group we found a clear improvement of complications and hospital stay. The increased experience of the surgeon and age (younger than 75) had a positive impact on mortality and morbidity. CONCLUSIONS: Primary closure of the common bile duct after LCBDE seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes making it a safe and reproducible technique especially for patients aged under 75.