The effect of ischemic preconditioning on redox status during liver resections--randomized controlled trial.

BACKGROUND AND OBJECTIVES: Portal clamping during liver resection decreases intraoperative blood loss, but causes ischemic-reperfusion (I-R) injury. Intermittent portal clamping (IPC) and ischemic preconditioning (IP) decreased I-R injury in animal models. Most of the human studies about IP excluded cirrhotic patients, whose liver is more vulnerable to I-R injury. The effect of IP and IPC during extended liver resection was investigated in this randomized controlled trial, with special respect to cirrhotic patients. METHODS: One hundred sixty patients (100 normal liver, 60 cirrhotic) undergoing major liver resection were randomized to receive IPC (15 min ischemia, 5 min reperfusion), or IP (10 min ischemia, 10 min reperfusion). Serum oxygen-derived free radicals (ODFR) and antioxidant concentrations (preoperative, after reperfusion and 7th postoperative day), such as "conventional" liver tests (preoperative, 1st, 3rd, and 7th postoperative day) were measured. RESULTS: IP resulted in significantly lower peak ODFR, AST, ALT, and bilirubin levels after liver resection than IPC (P < 0.05). The level of serum antioxidants after reperfusion was significantly higher in IP than in IPC groups (P < 0.05). In cirrhotic patients without IP none of these values normalized until the 7th postoperative day. CONCLUSIONS: Ischemic preconditioning--especially in patients with liver cirrhosis--is a suitable method to decrease the I-R injury of the liver.

[Pathological characteristics of esophago-respiratory fistulas of esophageal tumor origin]. / Nyelocsotumor-eredetu oesophago-respiratoricus fistulák kórtani jellemzoi.

Esophago-respiratory fistulas, evolving as a result of esophageal tumors, are serious and lethal complications on account of the constant respiratory contamination and the inability to swallow. They can develop either as the complication of the end stage disease or sometimes even in the first stage of the malignancy. The objective was to reveal the characteristics of the disease. In a prospective single-center study in the period between 1984 and 2004, 243 fistulas were diagnosed. Their data were analyzed using multivariate analysis. The mean age of patients with fistula was 56.9 years, the male-to-female ratio was 4.3:1. The average time of the complaints was 5.2 months, while the time of manifestation of the fistula was 7.5 months. Dysphagia was diagnosed in 97.5% of the patients, fever in 36.9%, and cachexia in 59.5%, respectively. The average loss of weight was 10.4 kg and the average size of the tumor was 7.7 cm. Endoscopic intubation was performed in 176 cases. The average survival was 3.4 months. Patients with fistula were divided into two groups, where the characteristics of the disease were significantly different. Only in 66.3% was the fistula a late complication. In the other 33.7% of the cases the fistula was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival were shorter.

Experience with stent implantation in malignant esophageal strictures: analysis of 1185 consecutive cases.

PURPOSE: The aim of this retrospective study was to analyze the experience in endoprosthesis implantation in cases of malignant esophageal strictures. METHODS: A total of 1185 consecutive patients underwent endoprosthesis implantation: through open surgery in 42 cases and by endoscopy in 1143 cases. RESULTS: Stent implantation was performed successfully in 61.2% of cases. Dysphagia was resolved temporarily in 6.2% and permanently in 93.5% of cases. The score of dysphagia decreased from 1.93 to 0.38. Complications were detected in 23.7% of patients, and 69.2% of cases were treated by endoscopy. Wound complications were seen in 21.9% of patients intubated through surgery. The mean survival time of patients with esophageal intubation was 5.4 months and that of patients not eligible for stent implantation was 3.3 months. CONCLUSIONS: Stent implantation improves the quality of life and gives an opportunity for adjuvant oncological therapy. Evaluation of morphologic anomalies is of considerable importance for achieving success in treatment through implantation.

Characteristics of esophagorespiratory fistulas resulting from esophageal cancers: a single-center study on 243 cases in a 20-year period.

BACKGROUND: Esophagorespiratory fistulas are serious complications of esophageal tumors. The main goal of this study was to reveal their characteristics. METHODS: In the period between 1984 and 2004, 243 fistulas were diagnosed among the 1993 patients with esophageal cancer. Comparing the characteristic data of patients with and without fistula (demographics, symptoms, duration time of symptoms, morphologic features, histology, metastases, staging), multivariance analysis showed significant differences (P < 0.05). Patients with fistula were divided into two additional groups (I, n = 82; II, n = 161 cases) with cluster analysis. The difference between these two groups was also significant. RESULTS: It was possible to perform a palliative endoscopic intubation in 176 cases, while 62 patients could be treated only supportively. The average survival was 3.4 and 1.2 months, respectively. Fistula was a late complication of tumor in two thirds (66.3%) of the cases, while in 33.7% it was diagnosed in younger patients at the early stage of the disease, with a more aggressive, less differentiated histology. In these patients the weight loss, the grade of dysphagia, and the size of the tumor were smaller, the possibilities of treatment were fewer, and survival time was shorter (2.1 vs. 3.1 months). CONCLUSIONS: These tumors seem to be specific forms of esophageal cancers. For a better quality of life and longer survival time for these patients, there should be earlier diagnosis and endoscopic intubation as the best palliative treatment should be performed.

Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period.

OBJECTIVE: Esophagorespiratory fistulas developing from malignant tumors have serious complications by maintaining continuous airway contamination. The objective was to reveal the incidence, causes and characteristics of fistula formation and to examine the possibilities and efficiency of the treatment. METHODS: In a single-center study between 1984 and 2004, the data of 2113 patients with tumorous esophageal stenosis were analyzed. Esophagorespiratory fistulas were detected in 264 cases (12.5%). Successful esophageal intubation, stent correction or replacement was performed in 188 cases, while there was one lethal complication. Twenty-seven patients had an intervention for nutritional support: 25 gastrostomies, 1 jejunostomy and 1 percutaneous endoscopic gastrostomy. RESULTS: The mean survival period of all patients was 2.8 months; patients with implanted endoprosthesis 3.4 months; with nutritional support 1.1 months and with only supportive therapy 1.3 months, respectively. The differences between the endoprosthesis implanted group and the other two groups were significant (p<0.001). CONCLUSIONS: By sealing the fistula, a successful endoscopic esophageal intubation ends the severe respiratory contamination and the inability to swallow, improving the quality of life and survival period. After the procedure, it is the malignant tumor and not the fistula that determines the future of the patient.