Duodenopancreatectomia e hemicolectomia no tratamento do câncer de cólon avançado / Pancreaticoduodenectomy and hemicolectomy in the treatment of advanced colon cancer

O tratamento das lesões neoplásicas localmente avançadas de cólon permanece um desafio pelo envolvimento e invasão de órgãos como o pâncreas e o duodeno. Apresentamos um caso de câncer de cólon avançado de um paciente submetido a colectomia direita associada a duodenopancreatectomia. No seguimento de cinco anos, o paciente permanecia livre de doença. Apesar da elevada morbidade, a ressecção multivisceral associada a quimioterapia adjuvante apresenta boa sobrevida e até mesmo cura em longo prazo (AU)

The treatment of locally advanced neoplastic lesions of right colon remains a challenge due to the involvement and invasion of organs such as pancreas and duodenum. We report a case of advanced colon cancer of a patient that underwent right hemicolectomy in association with pancreaticoduodenectomy. The 5-year follow-up showed that the patient remained free of disease. Despite the high morbidity rate, multi-visceral resection associated with adjuvant chemotherapy seems to provide an increase in survival or even long-term cure (AU)

Early clinical experience with the POEM procedure for achalasia.

BACKGROUND: Per oral endoscopic myotomy (POEM) is a viable alternative to standard Heller myotomy for surgical treatment of achalasia. Outcomes from the United States, Europe and Asia have been reported. We sought to report data after the initiation of POEM in a Canadian centre. METHODS: We enrolled patients with achalasia in a research ethics board-approved pilot study. Surgeons learned the POEM procedure in a systematic manner that included visiting experts in POEM, practice in an animal laboratory and mentoring from POEM experts. Preoperative evaluation included manometry, 24-hour pH, barium swallow, endoscopy and Eckhardt Symptom Score. All patients underwent gastrograffin swallow on postoperative day 1. Patients were re-evaluated using the Eckhardt score on postoperative day 14. RESULTS: Ten patients underwent POEM. Seven patients had previous endoscopic treatments: 6 had balloon dilatation and 1 had botulinum toxin injection. Mean preoperative Eckhardt score was 8.1 ± 2.4. Mean preoperative lower esophageal sphincter resting and residual pressure was 32.3 ± 9.2 and 20.8 ± 5.3, respectively. Mean duration of surgery was 141.3 ± 43.7 minutes. Mean length of hospital stay was 1 day. No major perioperative complications occurred. On postoperative day 14, the mean Eckhardt score was 1 ± 1.2. CONCLUSION: Our approach to POEM introduction was systematic and deliberate. The procedure is safe, feasible and has good perioperative outcomes. Our early results are consistent with current literature.

CONTEXTE: La myotomie perorale endoscopique (POEM) est une solution de rechange viable à la myotomie de Heller standard pour le traitement chirurgical de l'achalasie. Des rapports ont fait état de résultats enregistrés aux États-Unis, en Europe et en Asie. Nous avons voulu faire le point après l'instauration de la méthode POEM dans un centre canadien. MÉTHODES: Nous avons inscrit des patients atteints d'achalasie à une étude de recherche pilote, approuvée par le comité d'éthique. Les chirurgiens se sont initiés à la technique POEM de façon systématique auprès d'experts de cette technique, en s'exerçant sur des animaux de laboratoire et ensuite auprès d'experts-mentors. L'examen préopératoire incluait : manométrie, pH des 24 heures, repas baryté, endoscopie et score d'Eckardt (pour les symptômes). Tous les patients ont subi un transit du grêle avec Gastrografin au jour 1 postopératoire. Le score d'Eckardt des patients a été réévalué au jour 14 postopératoire. RÉSULTATS: Dix patients ont subi la technique POEM. Sept avaient déjà reçu des traitements endoscopiques : 6 avaient subi une dilatation par ballonnet et 1 avait reçu une injection de toxine botulique. Le score d'Eckardt préopératoire moyen était de 8,1 ± 2,4. La pression préopératoire moyenne du sphincter oesophagien inférieur au repos et résiduelle était de 32,3 ± 9,2 et de 20,8 ± 5,3, respectivement. La durée moyenne de la chirurgie a été de 141,3 ± 43,7 minutes. La durée moyenne du séjour hospitalier a été d'un jour. Aucune complication périopératoire majeure n'est survenue. Au jour 14 postopératoire, le score d'Eckardt moyen était de 1 ± 1,2. CONCLUSION: Notre approche à l'instauration de la technique POEM a été systématique et délibérée. L'intervention s'est révélée sécuritaire, réalisable et a procuré des résultats périopératoires positifs. Nos résultats préliminaires concordent avec ceux de la littérature actuelle.

Laparoscopic versus open surgical management of adhesive small bowel obstruction: a comparison of outcomes.

BACKGROUND: Laparoscopic management of adhesive small bowel obstruction (SBO) has become an established technique within the domain of acute care surgery. As minimally invasive management of SBO becomes more widely accepted, there is increased need for reporting of outcomes. OBJECTIVE: To compare outcomes of laparoscopic versus open surgery for adhesive SBO. METHODS: Patients undergoing surgery for adhesive SBO at our institution between 2005 and 2013 were eligible for inclusion. The primary outcome was overall complication rate, while secondary outcomes included operative time, gastrointestinal (GI) function, and postoperative length of stay (LOS). Univariable analysis compared laparoscopic (including conversions) and open groups with regard to patient baseline and perioperative characteristics as well as outcomes of interest. Multivariable analysis was performed comparing the endpoint of overall complications between groups. Sensitivity analysis excluding patients who underwent bowel resection was performed to assess effect on outcomes. Factors associated with laparoscopic success, as well as impact of conversion to open on postoperative outcomes, are reported. RESULTS: A cohort of 269 patients with adhesive SBO was identified: 186 patients (69.1%) underwent open surgery, 83 (30.9%) were managed laparoscopically. Within the laparoscopy group, 32 (38.6%) underwent conversion to open. Operative time was similar between groups (P = 0.506), while laparoscopy was associated with quicker recovery of GI function indicated by removal of nasogastric tube (P = 0.031) and passage of flatus (P = 0.005). Postoperative LOS was shorter (5 vs. 7 days, P = 0.031) with laparoscopy. The overall complication rate was significantly lower in the laparoscopic group (27.7 vs. 43.6%, P = 0.014), with an adjusted odds ratio (OR) for overall complications of 0.37 (P = 0.002). Following exclusion of bowel resections, secondary outcomes continued to favor laparoscopy, while reduction in overall complications trended toward significance, OR 0.47 (P = 0.050). CONCLUSION: Laparoscopic surgical management of adhesive SBO was associated quicker GI recovery, shorter LOS, and reduced overall complications compared to open surgery.

Perioperative nonselective non-steroidal anti-inflammatory drugs are not associated with anastomotic leakage after colorectal surgery.

INTRODUCTION: Recent evidence raises concern about the use of perioperative non-steroidal anti-inflammatory drug (NSAID) use after colorectal resection. The purpose of this retrospective cohort study was to investigate the relationship between perioperative ketorolac use and anastomotic leakage after colorectal surgery. METHODS: A retrospective review (2004-2011) was performed on patients who underwent elective colorectal surgery. Univariate analysis and multivariate logistic regression were used to evaluate the association between patients who did not receive any NSAIDs and those who received ketorolac within the first 5 days perioperatively and leak rate. RESULTS: A total of 731 patients were identified as having resection with primary anastomosis: 376 (51.4 %) received no NSAIDs and 355 (48.6 %) received ketorolac perioperatively within 5 days after their surgery. There were 24 (3.3 %) leaks, with 12 in both the no NSAIDs (3.2 %) and ketorolac (3.4 %) groups, odds ratio (OR) 1.06 (0.43, 2.62; p = 0.886). Adjusting for smoking, steroid use, and age, there remained no significant difference between ketorolac use and leakage, OR 1.21 (0.52, 2.84; p = 0.660). In our multivariate model, only smoking was a significant predictor of postoperative leak, OR 3.34 (1.30, 8.62; p = 0.021). CONCLUSIONS: There does not appear to be a significant association between perioperative ketorolac use and anastomotic leakage after colorectal surgery. However, further prospective studies are needed to confirm our findings before definitive guidelines on NSAID use perioperatively can be recommended.

Laparoscopic versus open surgical management of small bowel obstruction: an analysis of short-term outcomes.

BACKGROUND: Laparoscopy in acute care surgery continues to expand. While adhesive small bowel obstruction (SBO) has traditionally been managed via an open approach, appropriately selected patients may benefit from laparoscopy. The objective of our study was to compare short-term postoperative outcomes in patients with adhesive SBO treated with laparotomy versus laparoscopy. METHODS: Using the ACS NSQIP participant use files (2005-10), patients with a postoperative diagnosis of adhesive SBO were selected for inclusion in this study. Patients with bowel resections or concomitant procedures were excluded. Both univariate analyses and multivariate logistic regression were performed to compare 30-day outcomes in the open and laparoscopic groups. RESULTS: A total of 4,616 patients with adhesive SBO were identified: 3,697 (80.1%) and 919 (19.3%) in the open and laparoscopic groups, respectively. Mean operative time was similar in both groups. The mortality and overall complications were 84 (2.3%) and 819 (22.2%), respectively, in the open group compared to 7 (0.8%) and 81 (8.8%) in the laparoscopic group, with respective unadjusted odds ratios (ORs) of 0.33 (0.13-0.71, P < 0.01) and 0.39 (0.30-0.49, P < 0.01). The adjusted OR for overall complications was 0.46 (0.37-0.59, P < 0.01) favouring the laparoscopic group. The mean postoperative length of stay (LOS) was 8.4 days compared to 3.8 in the open and laparoscopic groups, respectively (P < 0.01). CONCLUSION: The laparoscopic approach to treating adhesive SBO resulted in significantly fewer complications and shorter LOS.