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1.
Anticancer Res ; 39(12): 6781-6786, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31810943

RESUMO

BACKGROUND/AIM: Patients affected with Stage IV colorectal cancer and unresectable metastases represent a heterogeneous group. Resection of the primary tumor or stent positioning followed by chemotherapy and/or targeted therapies still represent a difficult choice for surgeons. PATIENTS AND METHODS: From February 2013 to September 2019, 46 patients were enrolled into a prospective randomized open label parallel trial presenting with Stage IVA and IVB rectal cancer, unresectable metastases and symptoms of subacute large bowel obstruction. Our population was divided into two groups: Group 1 included 20 patients who underwent placement of a self-expandable metal stent and Group 2 included 26 patients in whom primary tumor resection was performed. RESULTS: One-year actuarial survival rate of Group 1 was significantly lower compared to Group 2. Overall 17 patients had survival longer than 1-year (3 in Group 1 and 14 in Group 2). Cox regression analysis showed that endoscopic stent positioning and the suspension of the chemotherapy because of deterioration of liver function tests were the two most important factors negatively influencing survival. CONCLUSION: Patients affected with stage IVA and IVB rectal cancer and symptoms of bowel obstruction had a significant longer survival rate when submitted to surgical rectal resection followed by chemotherapy.


Assuntos
Adenocarcinoma/terapia , Obstrução Intestinal/terapia , Neoplasias Retais/terapia , Stents Metálicos Autoexpansíveis , Adenocarcinoma/complicações , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Camptotecina/administração & dosagem , Camptotecina/análogos & derivados , Terapia Combinada/métodos , Feminino , Fluoruracila/administração & dosagem , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Leucovorina/administração & dosagem , Masculino , Pessoa de Meia-Idade , Terapia de Alvo Molecular , Compostos Organoplatínicos/administração & dosagem , Estudos Prospectivos , Neoplasias Retais/complicações , Neoplasias Retais/mortalidade , Neoplasias Retais/patologia , Taxa de Sobrevida
2.
Khirurgiia (Mosk) ; (9): 73-79, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31532170

RESUMO

Modern surgical and intensive care achievements did not result decrease of mortality in patients with acute small bowel obstruction (ASBO). Direct cause of mortality in ASBO patients is peritonitis followed by multiple organ failure syndrome including acute failure of liver, kidneys, lungs and other organs. Publications devoted to the problem of acute liver failure and its complicationsare reviewed in the article. Mechanisms of pathogenesis and clinical manifestations of multiple organ failure syndrome in patients with acute small bowel obstruction are analyzed.


Assuntos
Obstrução Intestinal/mortalidade , Falência Hepática/mortalidade , Insuficiência de Múltiplos Órgãos/mortalidade , Peritonite/mortalidade , Doença Aguda , Humanos , Obstrução Intestinal/etiologia , Intestino Delgado , Falência Hepática/diagnóstico , Falência Hepática/etiologia , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/etiologia , Peritonite/etiologia
3.
World J Gastroenterol ; 25(33): 4970-4984, 2019 Sep 07.
Artigo em Inglês | MEDLINE | ID: mdl-31543687

RESUMO

BACKGROUND: Obstructive colorectal cancer (OCC) is always accompanied by severe complications, and the optimal strategy for patients with OCC remains undetermined. Different from emergency surgery (ES), self-expandable metal stents (SEMS) as a bridge to surgery (BTS), could increase the likelihood of primary anastomosis. However, the stent failure and related complications might give rise to a high recurrence rate. Few studies have focused on the indications for either method, and the relationship between preoperative inflammation indexes and the prognosis of OCC is still underestimated. AIM: To explore the indications for ES and BTS in OCCs based on preoperative inflammation indexes. METHODS: One hundred and twenty-eight patients who underwent ES or BTS from 2008 to 2015 were enrolled. Receiver operating characteristic (ROC) curve analysis was used to define the optimal preoperative inflammation index and its cutoff point. Kaplan-Meier analyses and Cox proportional hazards models were applied to assess the association between the preoperative inflammation indexes and the survival outcomes [overall survival (OS) and disease-free survival (DFS)]. Stratification analysis was performed to identify the subgroups that would benefit from ES or BTS. RESULTS: OS and DFS were comparable between the ES and BTS groups (P > 0.05). ROC curve analysis showed derived neutrophil-to-lymphocyte ratio (dNLR) as the optimal biomarker for the prediction of DFS in ES (P < 0.05). Lymphocyte-to-monocyte ratio (LMR) was recommended for BTS with regard to OS and DFS (P < 0.05). dNLR was related to stoma construction (P = 0.001), pneumonia (P = 0.054), and DFS (P = 0.009) in ES. LMR was closely related to lymph node invasion (LVI) (P = 0.009), OS (P = 0.020), and DFS (P = 0.046) in the BTS group. dNLR was an independent risk factor for ES in both OS (P = 0.032) and DFS (P = 0.016). LMR affected OS (P = 0.053) and DFS (P = 0.052) in the BTS group. LMR could differentiate the OS between the ES and BTS groups (P < 0.05). CONCLUSION: Preoperative dNLR and LMR could predict OS and DFS in patients undergoing ES and BTS, respectively. For OCC, as the potential benefit group, patients with a low LMR might be preferred for BTS via SEMS insertion.


Assuntos
Neoplasias Colorretais/mortalidade , Obstrução Intestinal/mortalidade , Linfócitos , Monócitos , Seleção de Pacientes , Adulto , Idoso , Neoplasias Colorretais/sangue , Neoplasias Colorretais/complicações , Neoplasias Colorretais/cirurgia , Descompressão Cirúrgica/instrumentação , Descompressão Cirúrgica/métodos , Intervalo Livre de Doença , Procedimentos Cirúrgicos Eletivos/métodos , Tratamento de Emergência/instrumentação , Tratamento de Emergência/métodos , Feminino , Humanos , Obstrução Intestinal/sangue , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Estimativa de Kaplan-Meier , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Prognóstico , Curva ROC , Fatores de Risco , Stents Metálicos Autoexpansíveis
4.
Chirurgia (Bucur) ; 114(3): 343-351, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31264572

RESUMO

Background: Malignant intestinal obstruction is a frequent complication in advanced stages cancer patients. The prognosis is poor, with mean survival rate beneath 3 months. Clinical treatment, endoscopic or surgical procedures are options for malignant intestinal obstruction management. There is no generally accepted management strategy. Objectives: To evaluate prognostic factors of patients with malignant intestinal obstruction who underwent surgical treatment. Methods: A retrospective analysis was performed including patients of a single institution with diagnosis of malignant intestinal obstruction. Demographic data, in-hospital stay, postoperative complications, and overall survival were assessed. Logistic regression was used to evaluate associated prognostic factors. Results: Two hundred thirty-three surgeries were performed due to suspicion for malignant intestinal obstruction over a seven-year period. This diagnosis was confirmed in 210 operations (90.1%). The main causes of malignant obstruction were colorectal (49.5%) and gynecological cancer (21.9%). The rate of severe complications was 11.42%. In-hospital mortality rate was 40.95% (CI 95%: 34.16-47.74%). Functional status impairment,high serum urea, and low albumin levels were associated to higher mortality rate. Conclusion: Malignant intestinal obstruction implies poor prognosis, with high in-hospital mortality rate and severe postoperative complications. The decision regarding management of malignant intestinal obstruction must be multimodal and individualized, according to individual prognostic factors.


Assuntos
Neoplasias Colorretais/cirurgia , Neoplasias dos Genitais Femininos/cirurgia , Obstrução Intestinal/cirurgia , Neoplasias Colorretais/complicações , Feminino , Neoplasias dos Genitais Femininos/complicações , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Neoplasias/complicações , Prognóstico , Estudos Retrospectivos
5.
Clinics (Sao Paulo) ; 74: e787, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31188910

RESUMO

OBJECTIVES: Intestinal obstruction has a high mortality rate when therapeutic treatment is delayed. Resuscitation in intestinal obstruction requires a large volume of fluid, and fluid combinations have been studied. Therefore, we evaluated the effects of hypertonic saline solution (HS) with pentoxifylline (PTX) on apoptosis, oxidative stress and survival rate. METHODS: Wistar rats were subjected to intestinal obstruction and ischemia through a closed loop ligation of the terminal ileum and its vessels. After 24 hours, the necrotic bowel segment was resected, and the animals were randomized into four groups according to the following resuscitation strategies: Ringer's lactate solution (RL) (RL-32 ml/kg); RL+PTX (25 mg/kg); HS+PTX (HS, 7.5%, 4 ml/kg), and no resuscitation (IO-intestinal obstruction and ischemia). Euthanasia was performed 3 hours after resuscitation to obtain kidney and intestine samples. A malondialdehyde (MDA) assay was performed to evaluate oxidative stress, and histochemical analyses (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling [TUNEL], Bcl-2 and Bax) were conducted to evaluate kidney apoptosis. Survival was analyzed with another series of animals that were observed for 15 days. RESULTS: PTX in combination with RL or HS reduced the MDA levels (nmol/mg of protein), as follows: kidney IO=0.42; RL=0.49; RL+PTX=0.31; HS+PTX=0.34 (p<0.05); intestine: IO=0.42; RL=0.48; RL+PTX=0.29; HS+PTX=0.26 (p<0.05). The number of labeled cells for TUNEL and Bax was lower in the HS+PTX group than in the other groups (p<0.05). The Bax/Bcl-2 ratio was lower in the HS+PTX group than in the other groups (p<0.05). The survival rate on the 15th day was higher in the HS+PTX group (77%) than in the RL+PTX group (11%). CONCLUSION: PTX in combination with HS enhanced survival and attenuated oxidative stress and apoptosis. However, when combined with RL, PTX did not reduce apoptosis or mortality.


Assuntos
Apoptose/efeitos dos fármacos , Obstrução Intestinal/metabolismo , Estresse Oxidativo/efeitos dos fármacos , Pentoxifilina/farmacologia , Ressuscitação/métodos , Solução Salina Hipertônica/farmacologia , Animais , Modelos Animais de Doenças , Imuno-Histoquímica , Marcação In Situ das Extremidades Cortadas , Obstrução Intestinal/mortalidade , Obstrução Intestinal/prevenção & controle , Intestino Delgado/efeitos dos fármacos , Intestino Delgado/metabolismo , Estimativa de Kaplan-Meier , Rim/efeitos dos fármacos , Rim/metabolismo , Peroxidação de Lipídeos/efeitos dos fármacos , Masculino , Malondialdeído/análise , Distribuição Aleatória , Ratos Wistar , Reprodutibilidade dos Testes
6.
Ann Surg Oncol ; 26(11): 3611-3617, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31190209

RESUMO

BACKGROUND: Patients with peritoneal metastases from appendiceal cancer are at high risk of malignant bowel obstruction (MBO), which is associated with significant morbidity and mortality. There are no definitive treatment guidelines regarding operative intervention for MBO. We sought to evaluate the efficacy and safety of operative intervention in this population. METHODS: We identified patients with peritoneal metastases from appendiceal cancer who underwent surgery for MBO at our institution between 2011 and 2018. Baseline characteristics, postoperative complications, and follow-up data were collected. The primary endpoint was obstruction-free survival (OFS). Other endpoints were postoperative recovery of bowel function, 60-day Clavien-Dindo (CD) morbidity, and overall survival (OS). RESULTS: Twenty-six patients underwent operative treatment for MBO, of whom 14 had high-grade (HG) histology and 12 had low-grade (LG) histology. Seven (25.9%) patients had severe (CD grade 3 or higher) 60-day complications, including one (3.8%) postoperative death. All remaining patients had return of bowel function and resumed oral intake during hospitalization. Six (23.1%) patients had repeat admissions for MBO after surgery. Median OFS was 17.0 months (95% confidence interval [CI] 2.3-31.8), and median OS was 18.5 months (95% CI 3.6-33.3) following surgery. CONCLUSION: In this carefully selected group of patients with peritoneal metastases from appendiceal cancer, surgery for MBO provided durable palliation with acceptable morbidity.


Assuntos
Neoplasias do Apêndice/mortalidade , Procedimentos Cirúrgicos de Citorredução/mortalidade , Hospitalização/estatística & dados numéricos , Obstrução Intestinal/mortalidade , Laparoscopia/mortalidade , Cuidados Paliativos , Neoplasias Peritoneais/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias do Apêndice/patologia , Neoplasias do Apêndice/cirurgia , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Feminino , Seguimentos , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/prevenção & controle , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Neoplasias Peritoneais/patologia , Neoplasias Peritoneais/cirurgia , Complicações Pós-Operatórias , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
7.
World J Gastroenterol ; 25(16): 1975-1985, 2019 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-31086465

RESUMO

BACKGROUND: Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surgery can be created to obviate the need for emergency surgery, its effects on long-term outcomes and the most practical management strategies for right-sided malignant colonic obstruction remain unclear. AIM: To determine the appropriate management approach for right-sided malignant colonic obstruction. METHODS: Forty patients with right-sided malignant colonic obstruction who underwent curative resection from January 2007 to April 2017 were included in the study. We compared the perioperative and long-term outcomes of patients who received bridges to surgery established using decompression tubes and those created using self-expandable metallic stents (SEMS). The primary outcome was the overall survival duration (OS) and the secondary endpoints were the disease-free survival (DFS) duration and the preoperative and postoperative morbidity rates. Analysis was performed on an intention-to-treat basis. RESULTS: There were 21 patients in the decompression tube group and 19 in the SEMS group. There were no significant differences in the perioperative morbidity rates of the two groups. The OS rate was significantly higher in the decompression tube group than in the SEMS group (5-year OS rate; decompression tube 79.5%, SEMS 32%, P = 0.043). Multivariate analysis revealed that the bridge to surgery using a decompression tube was significantly associated with the OS (hazard ratio, 17.41; P = 0.004). The 3-year DFS rate was significantly higher in the decompression tube group than in the SEMS group (68.9% vs 45.9%; log-rank test, P = 0.032). A propensity score-adjusted analysis also demonstrated that the prognosis was significantly better in the decompression tube group than in the SEMS group. CONCLUSION: The bridge to surgery using trans-nasal and trans-anal decompression tubes for right-sided malignant colonic obstruction is safe and may improve long-term outcomes.


Assuntos
Doenças do Colo/cirurgia , Neoplasias Colorretais/complicações , Descompressão Cirúrgica/instrumentação , Obstrução Intestinal/cirurgia , Cirurgia Endoscópica por Orifício Natural/instrumentação , Idoso , Idoso de 80 Anos ou mais , Canal Anal , Doenças do Colo/etiologia , Doenças do Colo/mortalidade , Neoplasias Colorretais/mortalidade , Descompressão Cirúrgica/efeitos adversos , Descompressão Cirúrgica/métodos , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Análise de Intenção de Tratamento , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/métodos , Nariz , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents Metálicos Autoexpansíveis , Taxa de Sobrevida , Resultado do Tratamento
8.
J Trauma Acute Care Surg ; 87(3): 636-644, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31095068

RESUMO

BACKGROUND: Adhesive small-bowel obstruction (aSBO) is among the most common reasons for admission to a surgical service. While operative intervention for aSBO is associated with a lower risk of recurrence, current guidelines continue to advocate a trial of nonoperative management. The impact of the increased risk for recurrence on long-term survival is unknown. We sought to explore the potential for improved survival with operative management through the prevention of admissions for recurrence of aSBO and the associated risks. METHODS: This is a population-based retrospective cohort study using administrative data. We identified patients admitted to hospital for their first episode of aSBO from 2005 to 2014 and created a propensity-matched cohort to compare survival of patients managed operatively with those managed nonoperatively. To test whether survival differences were mediated by recurrence prevention, a competing risk regression was used to model the subdistribution hazard of death when accounting for the risk of recurrence. An instrumental variable approach was used as a secondary analysis to compare survival while accounting for unmeasured confounding. RESULTS: There were 27,904 patients admitted for their first episode of aSBO between 2005 and 2014. The mean age was 61.2 years (std dev, 13.6), and 51% were female. Operative management was associated with a significantly lower risk of death (hazard ratio, 0.80; 95% confidence interval, 0.75-0.86), which was robust to instrumental variable analyses, and a lower risk of recurrence (hazard ratio, 0.59; 95% confidence interval, 0.54-0.65). When adjusting for the risk of recurrence, operative intervention was not associated with improved survival, suggesting that the survival benefit is mediated through prevention of recurrences of aSBO. CONCLUSION: In patients admitted for their first episode of aSBO, operative intervention is associated with a significant long-term survival benefit. This survival benefit appears to be mediated through the prevention of recurrences of aSBO. STUDY TYPE: Retrospective cohort study. LEVEL OF EVIDENCE: Therapeutic study, Level II.


Assuntos
Obstrução Intestinal/cirurgia , Prevenção Secundária , Feminino , Humanos , Obstrução Intestinal/mortalidade , Obstrução Intestinal/prevenção & controle , Obstrução Intestinal/terapia , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Análise de Sobrevida , Aderências Teciduais/prevenção & controle , Aderências Teciduais/cirurgia
9.
Ulus Travma Acil Cerrahi Derg ; 25(3): 268-280, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31135942

RESUMO

BACKGROUND: Acute mechanical bowel obstruction (AMBO) is still a major surgical problem for emergency departments. The aim of this study was to evaluate AMBO in terms of etiology, management, and survival. METHODS: Data of the age, sex, etiology, management, and survival of patients who were hospitalized for bowel obstruction between January 2014 and December 2018 were evaluated retrospectively. Adhesions, tumors, hernias and peritoneal carcinomatosis were evaluated in detail. RESULTS: A total of 735 patients were included in the study. The obstruction was located in the small bowel (AMSBO) in 60% and in the large bowel (AMLBO) in 40%. The mean patient age was 59.9+-16.02 years and 52.9% of the patients were male. Adhesion, tumor, and hernia were the most common etiologies of the overall AMBO group (43.3%, 26.2%, and 6%, respectively). The most common etiology for AMSBO was an adhesion (69.3%), while it was a tumor for AMLBO cases (61.6%). The most common management of AMBO patients was a conservative approach (53.2%; adhesions: 76.7%). Surgical palliation was performed in 24.9% (peritoneal carcinomatosis: 65.7%), and resection was performed in 21.9% (volvulus: 61.9%). The mortality rate in the group was 8.6%. The most common etiology was colorectal surgery (51.4%) for adhesions, colorectal cancer (93.8%) for tumors, and incisional hernia (47.7%) in cases of hernia-related AMBO. CONCLUSION: Adhesions, tumors, and hernias are the most common etiologies of AMBO. The incidence of femoral/inguinal hernia have decreased while that of incisional hernia has increased, and it was further observed that peritoneal carcinomatosis has now become as common as hernia as a cause.


Assuntos
Obstrução Intestinal , Adulto , Idoso , Feminino , Hérnia Femoral/complicações , Hérnia Inguinal/complicações , Humanos , Neoplasias Intestinais/complicações , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Obstrução Intestinal/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Aderências Teciduais/complicações , Turquia/epidemiologia
10.
Ann Surg Oncol ; 26(9): 2787-2796, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30989498

RESUMO

BACKGROUND: Although self-expandable metal stents (SEMS) are widely used as a bridge to surgery (BTS) in patients with malignant colorectal cancer obstruction, there has been some debate about their effect on long-term oncological outcomes. Furthermore, data on the safety and feasibility of minimally invasive surgery (MIS) combined with stent placement are scarce. We aimed to determine the long-term oncological outcomes of SEMS as a BTS, and the short-term outcomes of SEMS used with minimally invasive colorectal surgery. METHODS: Data from patients who were admitted with malignant obstructing colon cancer between January 2006 and December 2015 were retrospectively reviewed; 71 patients underwent direct surgery and 182 patients underwent SEMS placement as a BTS. Long-term and short-term outcomes of the groups were compared. In a subgroup analysis of the BTS group, the short-term outcomes of conventional open surgery and MIS were compared. RESULTS: There were no differences in long-term oncologic outcomes between groups. The primary anastomosis rate was higher in the stent group than in the direct surgery group. In the stent group, postoperative complication rates were lower in the minimally invasive group than in the open surgery group. Time to flatus and time to soft diet resumption were shorter in the minimally invasive group, as was length of hospital stay. CONCLUSIONS: Elective surgery after stent insertion does not adversely affect long-term oncologic outcomes. Furthermore, MIS combined with stent insertion for malignant colonic obstruction is safe and feasible.


Assuntos
Neoplasias do Colo/mortalidade , Obstrução Intestinal/mortalidade , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Complicações Pós-Operatórias , Stents Metálicos Autoexpansíveis/estatística & dados numéricos , Idoso , Neoplasias do Colo/complicações , Neoplasias do Colo/patologia , Neoplasias do Colo/cirurgia , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Obstrução Intestinal/complicações , Obstrução Intestinal/patologia , Obstrução Intestinal/cirurgia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida
11.
Khirurgiia (Mosk) ; (1): 53-59, 2019.
Artigo em Russo | MEDLINE | ID: mdl-30789609

RESUMO

AIM: To standardize surgical care for malignant colonic obstruction. MATERIAL AND METHODS: There were 572 patients with malignant colonic obstruction: 247 of them were hospitalized in 2011-2013 (I group); 325 - in 2014-2017 (group II). Forty-six patients underwent medication; 302 - acute resection; 141 - stoma construction; 83 - stent deployment. Elective surgery and radiation or chemotherapy was performed after 0.5-6 months in 110 patients of group II. Acute resection was more common in I group, elective resection - in group II. Early and long-term results including Kaplan-Meier 3-year overall survival were compared in both groups. RESULTS: Complications occurred in 46.69% (group I) and 21% (group II). Postoperative mortality was significantly higher in group I compared with II group: 26.11 and 10.33%, respectively. Three-year overall survival was higher in group I compared with group II: 0.82 and 0.69, respectively. CONCLUSION: Advisability of new two-stage surgical standard is confirmed for malignant colonic obstruction. Stoma formation and stenting may be a valid alternative in some patients with malignant colonic obstruction due to significantly lower postoperative mortality.


Assuntos
Neoplasias do Colo/terapia , Procedimentos Cirúrgicos do Sistema Digestório/normas , Obstrução Intestinal/terapia , Antineoplásicos/administração & dosagem , Quimioterapia Adjuvante , Colectomia , Neoplasias do Colo/complicações , Neoplasias do Colo/mortalidade , Colostomia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Estimativa de Kaplan-Meier , Implantação de Prótese , Radioterapia Adjuvante , Stents
12.
Int J Colorectal Dis ; 34(4): 613-619, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30652215

RESUMO

INTRODUCTION: Stenting of obstructing colorectal cancers obviates the need for emergency surgery, reducing initial morbidity and mortality rate associated with emergency surgery and facilitates full staging of the neoplastic process with an opportunity to optimize the patient for surgery. Some recent publications have suggested however that this approach may be associated with higher local recurrence rates. We examined our outcomes following colonic stenting as a bridge to resection. METHODS: A database was reviewed (2006-2018) of patients presenting with acute colorectal obstruction that proceeded to endoscopic stenting. We assessed the bridge to surgery strategy, its success, complication rate, and impact on recurrence and survival. RESULTS: Of a total of 103 patients who presented with acute malignant large bowel obstruction over this time period, 26 patients had potentially curable disease at presentation and underwent stenting as a bridge to surgery. The technical success rate for stenting in those managed as a bridge to surgery was 92% (n = 24/26) with 7.69% (n = 2/26) having a complication. There was one stent-related perforation. Median follow-up of this cohort was 31 months, with a 5-year overall survival of 53.5%. CONCLUSION: Colorectal stenting as a bridge to resection is a successful management strategy for those presenting with obstructing colorectal obstruction. Selective use is associated with lower rates of stoma formation, greater rates of laparoscopic resections with low complication rates, and acceptable oncological outcomes.


Assuntos
Neoplasias Colorretais/cirurgia , Obstrução Intestinal/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Neoplasias Colorretais/mortalidade , Feminino , Humanos , Obstrução Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento
13.
Scand J Surg ; 108(1): 36-41, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29756508

RESUMO

BACKGROUND AND AIMS:: Small-bowel obstruction is a frequent cause of hospitalization. The condition is potentially life-threatening, causing many admission days and is a heavy burden socioeconomically. Patients with small-bowel obstruction may develop abdominal free fluid and the quality of this fluid may be predictive of worse outcomes. Our aim was to examine whether the presence of free fluid and its density, measured on computed tomography scans, was associated with severe complications and mortality postoperatively. MATERIALS AND METHODS:: Patients admitted to the Department of Surgery, Zealand University Hospital with a diagnosis of small-bowel obstruction between January 2010 and December 2015 were included. Medical records were reviewed and preoperative computed tomography scans were examined. A radiologist blinded to the outcomes reviewed all Hounsfield unit values of the free fluid. The primary outcomes evaluated were odds ratios of the severity of complications and hazard ratios of 30- and 90-day mortality postoperatively. RESULTS:: A total of 289 patients were included. Analyses revealed an adjusted odds ratio of 1.03 (95%confidence interval = 0.93-1.15) between the presence of free fluid and postoperative complications and an adjusted hazard ratio of 1.28 (95% confidence interval = 0.80-2.05, p = 0.30) of the 30-day mortality in this patient group. Furthermore, the analyses revealed an adjusted odds ratio of 1.22 (95% confidence interval 0.98-1.52) between the density of the free fluid > 20 Hounsfield unit and postoperative complications and an adjusted hazard ratio of 0.85 (95% confidence interval = 0.28-2.63, p = 0.78) of the 30-day mortality. CONCLUSION:: No significant correlation was found between the presence of free fluid nor its density in regard to postoperative complications or mortality in patients with small-bowel obstruction.


Assuntos
Ascite/mortalidade , Obstrução Intestinal/mortalidade , Intestino Delgado , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Ascite/complicações , Ascite/diagnóstico por imagem , Feminino , Humanos , Obstrução Intestinal/complicações , Obstrução Intestinal/diagnóstico por imagem , Intestino Delgado/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X
14.
Gastroenterol Hepatol ; 42(3): 157-163, 2019 Mar.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30314765

RESUMO

OBJECTIVES: (1) To evaluate the short- and long-term clinical outcomes of patients after colorectal stent placement and (2) to assess the safety and efficacy of the stents for the resolution of colorectal obstruction according to the insertion technique. METHODS: Retrospective cohort study which included 177 patients with colonic obstruction who underwent insertion of a stent. RESULTS: A total of 196 stents were implanted in 177 patients. Overall, the most common cause of obstruction was colorectal cancer (89.3%). Ninety-two stents (47%) were placed by radiologic technique and 104 (53%) by endoscopy under fluoroscopic guidance. Technical success rates were 95% in both groups. Clinical success rates were 77% in the radiological group and 81% in the endoscopic group (p>0.05). The rate of complications was higher in the radiologic group compared with the endoscopic group (38% vs 20%, respectively; p=0.006). Among patients with colorectal cancer (158), 65 stents were placed for palliation but 30% eventually required surgery. The multivariate analysis identified three factors associated with poorer long-term survival: tumor stage IV, comorbidity and onset of complications. CONCLUSIONS: Stents may be an alternative to emergency surgery in colorectal obstruction, but the clinical outcome depends on the tumor stage, comorbidity and stent complications. The rate of definitive palliative stent placement was high; although surgery was eventually required in 30%. Our study suggests that the endoscopic method of stent placement is safer than the radiologic method.


Assuntos
Doenças do Colo/terapia , Obstrução Intestinal/terapia , Implantação de Prótese/métodos , Doenças Retais/terapia , Stents Metálicos Autoexpansíveis , Idoso , Doenças do Colo/etiologia , Doenças do Colo/mortalidade , Colonoscopia , Neoplasias Colorretais/complicações , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/patologia , Constrição Patológica/complicações , Diverticulite/complicações , Feminino , Fluoroscopia , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/estatística & dados numéricos , Implantação de Prótese/estatística & dados numéricos , Radiografia Intervencionista , Doenças Retais/etiologia , Doenças Retais/mortalidade , Estudos Retrospectivos , Stents Metálicos Autoexpansíveis/estatística & dados numéricos , Resultado do Tratamento
15.
J Surg Res ; 233: 345-350, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30502269

RESUMO

BACKGROUND: With the population of octogenarians projected to increase fourfold by 2050, we sought to compare outcomes of laparoscopic versus open approach in octogenarians requiring surgery for adhesive small bowel obstruction (SBO). METHODS/MATERIALS AND METHODS: Using 2006-2015 American College of Surgeons National Surgical Quality Improvement Project, we identified patients aged ≥80 y who underwent emergency surgery within 1 d of admission for SBO. Risk variables of interest included age, sex, race, body mass index, preoperative sepsis, and American Society of Anesthesiologists (ASA) classification. Outcomes included length of stay, mortality, and pneumonia. Univariable and multivariable analyses were performed. RESULTS: Eight hundred fifty-six patients were identified. Six hundred ninety-nine (81.7%) underwent laparotomy; 157 (18.3%) underwent laparoscopy. Twenty-four (15.3%) of laparoscopic cases were converted. There was no difference between the open and laparoscopic groups in age, and race, preoperative albumin, or preoperative sepsis. The open group had higher rates of totally dependent functional status, congestive heart failure, chronic obstructive pulmonary disease, and higher ASA class. There was no difference in operative time. Laparoscopy was associated with shorter length of stay. The open approach showed higher rates of postoperative pneumonia, myocardial infarct, and mortality. Multivariable analysis showed increased age, functional status, preoperative albumin, and ASA class associated with mortality. The operative approach was not associated with mortality. Postoperative pneumonia was associated with male sex and open approach. CONCLUSIONS: Age, preoperative functional status, low preoperative albumin, and ASA classes IV and V were associated with mortality, while the open approach and male sex were associated with postoperative pneumonia. Octogenarians who present with SBO due to adhesive disease may benefit from an initial laparoscopic exploration. Further prospective studies are warranted.


Assuntos
Nível de Saúde , Obstrução Intestinal/cirurgia , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Fatores Etários , Idoso de 80 Anos ou mais , Conversão para Cirurgia Aberta/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Obstrução Intestinal/mortalidade , Intestino Delgado/cirurgia , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Fatores Sexuais , Aderências Teciduais/mortalidade , Aderências Teciduais/cirurgia , Resultado do Tratamento , Estados Unidos/epidemiologia
16.
Surg Endosc ; 33(2): 499-509, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30006840

RESUMO

BACKGROUND: Self-expandable metallic stenting (SEMS) for malignant colorectal obstruction (MCO) as a bridge to elective surgery (BTS) is a widely used procedure. The aim of this study was to assess short-term outcomes of SEMS for MCO as BTS. METHODS: This study analyzed pooled data from BTS patients who were enrolled in two multicenter prospective single-arm observational clinical studies that used different stent types. Both studies were conducted by the Japan Colonic Stent Safe Procedure Research Group (JCSSPRG). The first study evaluated the WallFlex™ colonic stent for BTS or palliative treatment (PAL) from May 2012 to October 2013 and the second evaluated the Niti-S™ colonic stent from October 2013 to May 2014. Fifty-three facilities in Japan participated in the studies. Before each study started, the procedure had been shared with the participating institutions by posting details of the standard methods of SEMS placement on the JCSSPRG website. Patients were followed until discharged after surgery. RESULTS: A total of 723 consecutive patients were enrolled in the two studies. After excluding nine patients, the remaining 714 patients were evaluated as a per-protocol cohort. SEMS placement was performed in 426 patients (312 WallFlex and 114 Niti-S) as BTS and in 288 as PAL. In the 426 BTS patients, the technical success rate was 98.1% (418/426). The clinical success rate was 93.8% (392/418). SEMS-related preoperative complications occurred in 8.5% of patients (36/426), perforations in 1.9% (8/426), and stent migration in 1.2% (5/426). Primary anastomosis was possible in 91.8% of patients (391/426), 3.8% of whom (15/393) had anastomosis leakage. The overall stoma creation rate was 10.6% (45/426). The postoperative complication rate was 16.9% (72/426) and mortality rate was 0.5% (2/426). CONCLUSIONS: SEMS placement for MCO as BTS is safe and effective with respect to peri-procedural outcomes. Further investigations are needed to confirm long-term oncological outcomes.


Assuntos
Neoplasias Colorretais/cirurgia , Obstrução Intestinal/cirurgia , Stents Metálicos Autoexpansíveis , Idoso , Neoplasias Colorretais/complicações , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Estudos de Viabilidade , Feminino , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Japão , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Stents Metálicos Autoexpansíveis/efeitos adversos
17.
Khirurgiia (Mosk) ; (8. Vyp. 2): 24-29, 2018.
Artigo em Russo | MEDLINE | ID: mdl-30199048

RESUMO

AIM: To develop medical algorithms for reduction of morbidity and mortality in rare forms of mechanical intestinal obstruction. MATERIAL AND METHODS: 17 patients with mechanical intestinal obstruction have been operated in Sklifosovsky Research Institute for Emergency Care for the period 2010 - 2016. There were 13 women and 4 men aged 56 (44,5-74,5) years on the average. Phytobezoar was detected in 7 patients (41.2%), tumor in 7 patients (41.2%) and gallstone ileus in 3 patients (17.6%). RESULTS: There were no complications in group 1. In group 2 postoperative complications occurred in 3 patients: gastrocnemius vein thrombosis followed by successful medication (Clavien-Dindo type II), abdominal abscess drained under ultrasonic control (Clavien-Dindo type IIIa) and 1 (8.3%) death (Clavien-Dindo type V). Postoperative mortality in group 2 was 8.3%. CONCLUSION: Despite small sample size and no statistically reliable results the advantages of minimally invasive access are obvious. However, further trials are required to ensure the reliability of the results.


Assuntos
Obstrução Intestinal/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Adulto , Idoso , Algoritmos , Feminino , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Reprodutibilidade dos Testes
18.
World J Gastroenterol ; 24(28): 3101-3111, 2018 Jul 28.
Artigo em Inglês | MEDLINE | ID: mdl-30065556

RESUMO

Encapsulating peritoneal sclerosis (EPS) is a debilitating condition characterized by a fibrocollagenous membrane encasing the small intestine, resulting in recurrent small bowel obstructions. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infection, and systemic inflammatory disorders have been implicated. Many cases remain idiopathic. Diagnosis is often delayed given the rarity of the disorder combined with non-specific symptoms and laboratory findings. Although cross-sectional imaging with computed tomography of the abdomen can be suggestive of the disorder, many patients undergo exploratory laparotomy for diagnosis. Mortality approaches 50% one year after diagnosis. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents (i.e. peritoneal dialysis, medications, infections) and nutritional support, frequently with total parenteral nutrition. EPS-specific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may be beneficial. In practice, distinguishing between stages may be difficult and both may be used. Surgical intervention, consisting of peritonectomy and enterolysis, is time-consuming and high-risk and is reserved for situations in which conservative medical therapy fails in institutions with surgical expertise in this area. Herein we review the available literature of the etiology, pathogenesis, diagnosis, and treatment of this rare, but potentially devastating disease.


Assuntos
Obstrução Intestinal/etiologia , Intestino Delgado/patologia , Fibrose Peritoneal/etiologia , Peritônio/patologia , Glucocorticoides/uso terapêutico , Humanos , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/mortalidade , Obstrução Intestinal/terapia , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/cirurgia , Nutrição Parenteral Total , Diálise Peritoneal/efeitos adversos , Fibrose Peritoneal/diagnóstico , Fibrose Peritoneal/mortalidade , Fibrose Peritoneal/terapia , Peritônio/diagnóstico por imagem , Peritônio/cirurgia , Peritonite/complicações , Peritonite/terapia , Recidiva , Esclerose , Tamoxifeno/uso terapêutico , Tomografia Computadorizada por Raios X , Resultado do Tratamento
19.
Cochrane Database Syst Rev ; 8: CD012812, 2018 08 10.
Artigo em Inglês | MEDLINE | ID: mdl-30095168

RESUMO

BACKGROUND: People with advanced ovarian or gastrointestinal cancer may develop malignant bowel obstruction (MBO). They are able to tolerate limited, if any, oral or enteral (via a tube directly into the gut) nutrition. Parenteral nutrition (PN) is the provision of macronutrients, micronutrients, electrolytes and fluid infused as an intravenous solution and provides a method for these people to receive nutrients. There are clinical and ethical arguments for and against the administration of PN to people receiving palliative care. OBJECTIVES: To assess the effectiveness of home parenteral nutrition (HPN) in improving survival and quality of life in people with inoperable MBO. SEARCH METHODS: We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), MEDLINE (Ovid), Embase (Ovid), BNI, CINAHL, Web of Science and NHS Economic Evaluation and Health Technology Assessment up to January 2018, ClinicalTrials.gov (http://clinicaltrials.gov/) and in the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal (http://apps.who.int/trialsearch/). In addition, we handsearched included studies and used the 'Similar articles' feature on PubMed for included articles. SELECTION CRITERIA: We included any studies with more than five participants investigating HPN in people over 16 years of age with inoperable MBO. DATA COLLECTION AND ANALYSIS: We extracted the data and assessed risk of bias for each study. We entered data into Review Manager 5 and used GRADEpro to assess the quality of the evidence. MAIN RESULTS: We included 13 studies with a total of 721 participants in the review. The studies were observational, 12 studies had only one relevant treatment arm and no control and for the one study with a control arm, very few details were given. The risk of bias was high and the certainty of evidence was graded as very low for all outcomes. Due to heterogeneity of data, meta-analysis was not performed and therefore the data were synthesised via a narrative summary.The evidence for benefit derived from PN was very low for survival and quality of life. All the studies measured overall survival and 636 (88%) of participants were deceased at the end of the study. However there were varying definitions of overall survival that yielded median survival intervals between 15 to 155 days (range three to 1278 days). Three studies used validated measures of quality of life. The results from assessment of quality of life were equivocal; one study reported improvements up until three months and two studies reported approximately similar numbers of participants with improvements and deterioration. Different quality of life scales were used in each of the studies and quality of life was measured at different time points. Due to the very low certainty of the evidence, we are very uncertain about the adverse events related to PN use. Adverse events were measured by nine studies and data for individual participants could be extracted from eight studies. This revealed that 32 of 260 (12%) patients developed a central venous catheter infection or were hospitalised because of complications related to PN. AUTHORS' CONCLUSIONS: We are very uncertain whether HPN improves survival or quality of life in people with MBO as the certainty of evidence was very low for both outcomes. As the evidence base is limited and at high risk of bias, further higher-quality prospective studies are required.


Assuntos
Obstrução Intestinal/terapia , Nutrição Parenteral no Domicílio , Neoplasias Abdominais/complicações , Adulto , Idoso , Feminino , Humanos , Obstrução Intestinal/etiologia , Obstrução Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Nutrição Parenteral no Domicílio/efeitos adversos , Nutrição Parenteral no Domicílio/mortalidade , Qualidade de Vida
20.
Am Surg ; 84(7): 1214-1216, 2018 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-30064591

RESUMO

Emergency general surgery (EGS) is defined as the urgent assessment and treatment of nontrauma, general surgical emergencies involving adults. Acute surgical emergencies often represent the most common reason for hospital admission with diagnoses, including bowel obstruction and appendicitis. EGS is a growing surgical subspecialty that includes both operative and nonoperative management of acutely ill patients. We sought to assess the burden of nonoperative care in EGS patients at our academic medical center. This study was conducted by retrospective analysis of prospectively collected data from patients entered into the Duke EGS Registry between July 1, 2016 and September 10, 2017. Fifty-six per cent (n = 771) of patients in the Duke EGS Registry (n = 1377) were managed nonoperatively as compared with 44 per cent (n = 606) who were managed operatively. Nonoperative management of disease represents a large subset of EGS and, therefore, needs further investigation to improve processes, outcomes, and standardization of care.


Assuntos
Apendicite/cirurgia , Emergências , Cirurgia Geral , Obstrução Intestinal/cirurgia , Centros Médicos Acadêmicos , Adulto , Idoso , Apendicite/mortalidade , Feminino , Humanos , Obstrução Intestinal/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Estados Unidos
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