Prognostic value of the detection of lymph node micrometastases in colon cancer

INTRODUCTION AND OBJECTIVES: A study is made of the clinical repercussions of occult metastases-micrometastases (MMs+)-or isolated tumour cells (ITCs+) in the lymph nodes of patients with stage IIA and IIB colon adenocarcinoma initially considered as corresponding to N0. MATERIAL AND METHODS: A retrospective study of 39 patients with stage IIA and IIB (T3-T4 N0 M0) colon adenocarcinoma, subjected to similar surgical and adjuvant chemotherapy treatment, with long and careful follow-up (minimum: 5 years, mean: 81.7 months) was performed on their previously resected lymph nodes, with the aid of new histological and immunohistochemical (cytokeratin) sections, in order to detect MMs or ITCs. Disease-free survival (DFS) and global survival (GS) in the two groups (patients with MMs+ or ITCs+ vs. patients without MMs or ITCs) were compared at 5 years based on the corresponding Kaplan-Meier survival curves, with the Breslow test. RESULTS: A total of 382 lymph nodes from the 39 patients (mean: 9.8; standard deviation: 6.09) were revised. MMs+ were detected in 2 cases and ITCs+ in 2 more cases on the Cytokeratin study. GS of the whole series at 5 years was 89.74% (35 patients alive) with a DFS at 5 years of 79.49% (31 patients free of disease), but the 2 cases with MMs+ were dead at 5 years, with high statistical differences between both groups (MMs+/MMs-) (p<0.0001). When comparing the group of MMs+/ITCs+ patients and the group of MM-/ITCs- patients, the DFS and GS times at 5 years were higher in the MMs-/ITCs- group (p=0.0692 and p=0.006 respectively). CONCLUSIONS: Although the incidence of MMs+ or ITCs+ in the examined lymph nodes was low, the presence of MMs is related to a dramatic reduction in GS and DFS at 5 years. We encourage a detailed histological study of lymph nodes resected in patients with deep penetrating colon tumours in order to assure a pN0 status (AU)

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Carcinomatosis peritoneal mucinosa tratada con cisplatino (CDDP) intraperitoneal y 5-FU endovenoso / Mucinous peritoneal carcinomatosis treated with intraperitoneal cisplatin (CDDP) and intravenous 5-FU

• Propósito: describir el tratamiento de una entidad clínica poco frecuente de curso clínico variable.• Material y método: se presenta el caso de un paciente con carcinomatosis peritoneal mucinosa, varianteintermedia.• Resultados y conclusiones: una cirugía de citoreducción adecuada, seguida de quimioterapia conCDDP Intraperitoneal (IP) y 5FU ev, puede lograr una larga supervivencia en pacientes afectos de carcinomatosisperitoneal, con buena tolerancia al tratamiento

• Purpose: To describe the treatment of a slightly frequent clinical entity of variable clinical course.• Material and methods: We present the case of a patient with mucinous peritoneal carcinomatosis,intermediate variant.• Results and conclusion: A suitable cytoreductive surgery, followed by chemotherapy withintraperitoneal CDDP and intravenous 5-FU, can achieve a long survival of patients with peritonealcarcinomatosis, with good tolerance for the treatment

Tratamiento del cáncer colorrectal: encuesta de la Sociedad Valenciana de Cirugía / Management of colorectal cancer: a survey by the Surgical Society of Valencia

Introducción. Motivados por conocer la situación actual del tratamiento del cáncer colorrectal en los hospitales de la Comunidad Valenciana, y por encargo de la Sociedad Valenciana de Cirugía, se elaboró una encuesta dirigida a todos los Servicios de Cirugía General y Aparato Digestivo de estos centros, cuyo resultado exponemos. Material y método. Se realizó un análisis retrospectivo mediante encuesta, y se obtuvieron los datos desde el año 1997 hacia atrás, agrupándolos por años naturales. La encuesta abordó siete apartados del tratamiento del cáncer colorrectal (diagnóstico, cirugía programada, cirugía de urgencias, terapéutica adyuvante, enfermedad avanzada, seguimiento y anatomía patológica), y se estudiaron tanto parámetros de estructura como de proceso, así como los resultados de los mismos. Resultados. Se remitieron un total de 20 cuestionarios obteniéndose 17 respuestas (85 por ciento). Sólo 2 hospitales (11,7 por ciento) disponen de ecografía endorrectal. Ninguno realiza por sistema enema de doble contraste. Únicamente en 3 hospitales (17,64 por ciento), el cáncer rectal es tratado por un grupo determinado de cirujanos. Cinco hospitales (29,4 por ciento) realizan con asiduidad el lavado colónico intraoperatorio en la cirugía del cáncer obstructivo. Siete centros (41,1 por ciento) llevan a cabo algún tipo de terapéutica adyuvante preoperatoria en el cáncer rectal, siendo la cifra total de recidivas locales del 11,58 por ciento a los 2 años de seguimiento. No existe ningún protocolo establecido de seguimiento postoperatorio de estos pacientes en 3 hospitales (17,64 por ciento). El número medio de ganglios aislados por pieza quirúrgica es de nueve, y sólo 2 centros (11,7 por ciento) reflejan en sus informes anatomopatológicos la afectación del margen circunferencial. Conclusiones. De los resultados obtenidos en esta encuesta y su posterior comparación con la bibliografía concluimos: a) en el aspecto diagnóstico, se debe mejorar el porcentaje de colonoscopias completas; los enemas opacos, cuando se realicen, deberían llevarse a cabo sistemáticamente mediante la técnica de doble contraste; sería aconsejable implantar la ecografía endorrectal como exploración de rutina para la correcta estadificación del cáncer rectal con el fin de realizar una correcta selección de los pacientes candidatos a terapéutica adyuvante preoperatoria; b) en la cirugía electiva, dado que la cirugía del cáncer rectal depende del cirujano, creemos que debería ser realizada por personal especialmente entrenado; c) respecto a la cirugía del cáncer colorrectal obstructivo, si las condiciones del paciente lo permiten, debería tratarse de aumentar el porcentaje de resecciones con anastomosis primaria, entrenando al equipo quirúrgico en la realización del lavado intraoperatorio; d) se necesitan estudios prospectivos para valorar el régimen terapéutico adyuvante preoperatorio más adecuado; e) es recomendable que los distintos hospitales dispongan de protocolos de seguimiento postoperatorio homogéneos, con la finalidad de uniformizar el control de estos pacientes, además de prestarles un apoyo psicológico y servir de auditoría de sus propios resultados, y f) debe tratarse de que en los informes anatomopatológicos se especifique el margen circunferencial, así como intensificar el aislamiento de ganglios linfáticos a fin de evitar la infraestadificación tumoral (AU)

Laparoscopic reconstruction of intestinal continuity following Hartmann's procedure.

Laparoscopy-guided reversal of Hartmann's procedure was performed in eleven patients who had been treated surgically for inflammatory disease or cancer of the colon. Restoration of intestinal continuity was achieved in ten of them. There were no postoperative complications. The mean surgical time was 144 minutes and the mean duration of postoperative ileus was 48 hours (range: 30 to 60 hours). The mean hospital stay was 7 days. Our results suggest that laparoscopic reversal of Hartmann's procedure is safer than and as effective as open surgery.

Early results of laparoscopic resection of colorectal cancer.

OBJECTIVE: To study the immediate and early postoperative results obtained in patients subjected to laparoscopic resection of colorectal cancer. PATIENTS AND METHOD: A prospective, observational cohort study was initiated in January 1993, involving 50 patients subjected to laparoscopic resection for colorectal adenocarcinoma (rectal amputation in 10 cases, lower rectal resection in 13, recto-sigmoidectomy in 18, and miscellaneous colectomies in 9 cases). Seventy-percent of the tumors were in IUCC stages II and III. Mean follow-up was 21 months. RESULTS: Conversion to open surgery was required in 18 cases (36%). Intraoperative problems were limited to a single urethral lesion, while postoperative complications were recorded in 11 patients (22%), and were managed conservatively: a urinary fistula secondary to the aforementioned urethral lesion; subclinical dehiscence of the anastomosis (2 cases); phlebitis (1 case); infection of the surgical wound (4 cases), and urinary and pulmonary infection (1 case each). There were no differences between converted surgery (i.e., conventional laparotomy) and those operations completed endoscopically (with a final assisted or combined minilaparotomy) in terms of the length of the surgical resection piece, the length of the distal margin of the specimen or the number of lymph nodes. Global hospital stay ranged from 9-12 days, versus 5-7 in the group without complications. Global survival is 78% at 42 months, with a disease-free interval of 53% at this time. CONCLUSIONS: Laparoscopic colorectal resection presents an incidence of intra- and postoperative complications characteristic of major surgery, with no differences in surgical specimen size with respect to those operations converted to laparotomy. Global survival is similar to that reported in the literature for open surgery.

[Venous reservoirs: the late complications according to the route of implantation. The Interhospital Group of Valencia (GIHV)]. / Reservorios venosos: complicaciones tardías según la vía de implantación. Grupo Interhospitalario Valenciano (GIHV).

UNLABELLED: The aim of the study which we present is to analyze the incidence of late complications, clinical and sub-clinical, of venous reservoirs implanted through two access routes, subclavian (group A), and brachial (group B). It is a multi-centric clinical study, initiated in 1992, in which the general surgery departments of three general hospitals of the Valencian Community were involved. It is made up of 87 patients, 48 men and 39 women, with a mean age (SD) of 57.1 (12.6) years, of whom we made a late review of 41 patients (29 from group A and 12 from group B). They were subjected to a physical examination, bacterial cultures of the entrance, and phlebograms of the upper extremities through the dorsal veins of the hands. RESULTS: The incidence of clinical complications was 39% in group A and 77% in group B (p = 0.0507). The main clinical complications were minimally symptomatic venous thrombosis, catheter thrombosis, infection, and miscellaneous (migration, paresthesias, articular movement alterations, etc.). And the prevalence of phlebographic venous thrombosis was 18% in group A and 40% in group B (p = 0.051). CONCLUSIONS: The subclavian access for the implantation of venous reservoirs has a lower incidence (with a tendency towards clinical significance) of clinical complications and subclinical venous thrombosis (Phlebogram) than the brachial access.

[Subcutaneous injection chambers for central venous access: a multicenter clinical trial. The Interhospital Group of Valencia (GIHV)]. / Cámaras de inyección subcutánea para acceso venoso central: un ensayo clínico multicéntrico. Grupo Interhospitalario Valenciano (GIHV).

UNLABELLED: A multicentric clinical trial was performed to evaluate two routes of access for implantable subcutaneous central venous devices: by way of the subclavian vein (group A) and peripheral access by way of the veins of the flexion side of the elbow (group B). The indications for implantation were: antineoplastic treatment of solid tumors, myelo- and lymphoproliferative syndromes, antiviral treatment, and parenteral nutrition at home. The study was composed of 87 patients, 48 men and 39 women, with a mean age of 57.1 years (SD = 12.6). Group A was made up of 48 patients, and group B of 39. RESULTS: Implantation failure was 8.3% in group A and 5.1% in group B (p = n.s.). Complications of implantation were 23.4% in group A and 15.4% in group B (p = n.s.). The complications of permanence were diagnosed at 27.6% in group A and at 15.4% in group B (p = n.s.). CONCLUSIONS: We have not been able to find significant differences between the two groups, probably due to the fact that the series is still short. Nevertheless, the manageability, comfort for the nursing staff and for the patients, appears to be greater with the devices implanted in the infraclavicular region, by means of a subclavian vein puncture.

[The role of glucose-1-phosphate in total parenteral nutrition protocols]. / Aporte de glucosa-1-fosfato en nutrición parenteral total protocolizada.

The results of a clinical study to evaluate the use of glucose-1-phosphate for phosphate supplementation to a group of 8 surgical patients receiving standardized total parenteral nutrition are presented. Average phosphate (p + 0.001), calcium (NS) and magnesium (NS) plasma concentrations increased during total parenteral nutrition. Positive average daily balances were obtained: 8.1 + 14.8, 4.5 + 4.3 and 1.8 + 3.3 mmol/day for phosphate, calcium and magnesium respectively. These findings support the hypothesis of higher bioavailability of glucose-1-phosphate with respect to inorganic phosphate. On the other hand, hyperphosphatemia was a frequent situation (45.8%); this fact suggests the need for reviewing phosphate daily requirements when supplied in the form of glucose-1-phosphate.

[Surgical treatment of cancer of the colon: a review of 175 cases]. / Tratamiento quirúrgico del cáncer de colon: revisión de 175 casos.

We present a review of 175 cases of carcinoma of the colon out of 270 cases of colorectal cancer operated in our service during the period 1980-1986. It is noteworthy that 46.8% of the patients underwent emergency surgery for occlusion and/or diastasic tumoral perforation, and that they presented an advanced average age (48.5% were over 70 years). In emergency surgery there was a predominance of bypass operations (73%) versus tumoral resection (27%). In programmed surgery the index of resectability was 83%. The global operative mortality was 12.5%, but separately it was greater for emergency surgery (18%) than for elective surgery (7.5%). Wound infection occurred in 35% of emergency operations and in 11.8% of programmed operations. An anastomotic fistula appeared in 6.9% of cases, with a similar incidence for mechanical and manual anastomoses. It is concluded that early detection of the disease is necessary to reduce the percentage of urgent operations, and consequently the rates of operative morbi-mortality, and improve long-term survival.