Bernard Detroz

Intravenous lidocaine infusion facilitates acute rehabilitation after laparoscopic colectomy

Background:Intravenous infusion of lidocaine decreases postoperative pain and speeds the return of bowel function. The authors therefore tested the hypothesis that perioperative lidocaine infusion facilitates acute rehabilitation protocol in patients undergoing laparoscopic colectomy. Methods:Forty patients scheduled to undergo laparoscopic colectomy were randomly allocated to receive intravenous lidocaine (bolus injection of 1.5 mg/kg lidocaine at induction of anesthesia, then a continuous infusion of 2 mg · kg−1 · h−1 intraoperatively and 1.33 mg · kg−1 · h−1 for 24 h postoperatively) or an equal volume of saline. All patients received similar intensive postoperative rehabilitation. Postoperative pain scores, opioid consumption, and fatigue scores were measured. Times to first flatus, defecation, and hospital discharge were recorded. Postoperative endocrine (cortisol and catecholamines) and metabolic (leukocytes, C-reactive protein, and glucose) responses were measured for 48 h. Data (presented as median [25–75% interquartile range], lidocaine vs. saline groups) were analyzed using Mann–Whitney tests. P < 0.05 was considered statistically significant. Results:Patient demographics were similar in the two groups. Times to first flatus (17 [11–24] vs. 28 [25–33] h; P < 0.001), defecation (28 [24–37] vs. 51 [41–70] h; P = 0.001), and hospital discharge (2 [2–3] vs. 3 [3–4] days; P = 0.001) were significantly shorter in patients who received lidocaine. Lidocaine significantly reduced opioid consumption (8 [5–18] vs. 22 [14–36] mg; P = 0.005) and postoperative pain and fatigue scores. In contrast, endocrine and metabolic responses were similar in the two groups. Conclusions:Intravenous lidocaine improves postoperative analgesia, fatigue, and bowel function after laparoscopic colectomy. These benefits are associated with a significant reduction in hospital stay.

Misdiagnosed malignancy in transplanted organs

The case reports of three patients who received cancer-bearing organs at this institution are presented. A fourth recipient, who was to be transplanted with a cancerous kidney, was spared this disastrous complication. The relevant data regarding the donors is also alluded to, with special reference to the type and site of the primary malignancy. Following these case reports, the implications of these issues, their possible prevention, and further management are discussed.

Causes of death in patients undergoing liver surgery.

The earliest liver surgery was performed almost exclusively for trauma. In 1888, Langenbuch reported the first liver resection for tumor [1]. At the end of the nineteenth century, Keen related another case of hepatic resection for removal of a neoplasm and reviewed 76 cases of liver resection performed up to that time [2]. Controlled anatomic hepatic resections became more accepted after Couinaud and others reported in the 1950s the precise lobar and segmental anatomy of the liver [3–7]. Since that time major advances in the technique of liver resection, as well as improvement in preoperative and postoperative care, have been associated with a reduction in postoperative mortality and complication rate.

Strictureplasty in Crohn's disease: short- and long-term follow-up.

Abstract Strictureplasty for obstructive Crohn’s disease is still controversial because lesions are left in place and the suture is performed on a diseased bowel. Many surgeons prefer to perform bowel resection, hoping for fewer complications and a lower recurrence rate. In this paper, the authors report their strictureplasty experience. They performed a systematic retrospective review of the patients suffering from Crohn’s disease who underwent strictureplasties during a 10-year period in the abdominal surgery department of the University Hospital of Liège Sart Tilman, and studied the short-and long-term clinical results of 68 strictureplasties performed in 18 patients. Median follow-up was 63 months (range 12 to 144). Mortality was 0% and septic morbidity was 11% (one wound abscess and one leakage). Among the 16 patients available for the latest follow-up, symptomatic stenotic recurrence had to be medically treated in hospital for 4 patients (25%) with a recurrence delay range of 19 to 49 months. Stenosis recurrence needed re-intervention in one patient 48 months after surgery: stenosis occurred at a distance from the corrected site. These results confirmed that strictureplasty is a safe and efficient procedure in selected patients undergoing surgery for obstructive Crohn’s disease.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Carcinomatosis : Higher Complication Rate for Oxaliplatin Compared to Mitomycin C

Abstract Background : Peritoneal carcinomatosis (PC) from colo-rectal cancer carries a very poor prognosis with a mean and median overall survival times of 6.9 and 5.2 months. It has been proved that a locoregional therapeutic approach of this disease with cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) improved survival of these patients. However, this combined treatment presents a high complication rate. Methods : 21 patients with PC of colorectal origin underwent complete cytoreduction followed by HIPEC using Mitomycin-C (13 patients) or oxaliplatin (8 patients) and the open coliseum technique. For each case the medical datas were retrospectively analysed to determine feasibility, morbidity, mortality, survival time and prognostic factors. Results : All patients presented a Sugarbaker’s Peritoneal Cancer index inferior to 15. The mean operating time was 453 minutes. After a median follow-up of 24.9 months, actuarial disease-free survival was 36.6% at 5 years. The median survival time was 34 months. The morbidity rate was 33.3% with a significant higher complication rate in the oxaliplatin group (5/8) than in the Mytomycin-C (MMC) group (2/13). One patient (4.7%) died two months after treatment with MMC (endocarditis). Conclusions : This series confirm positive impact of cytoreduction and HIPEC on PC. We obtained a moderated complications rate thanks to a high degree of selection of the patient. Oxaliplatin scheme is responsible of a higher morbidity than in MMC group. Phase III trial comparing these two drugs is needed.

Adjuvant hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) associated with curative surgery for locally advanced gastric carcinoma. An initial experience.

Abstract Aim of the study : After macroscopic radical (R0) surgery for advanced gastric carcinoma, 40 to 50% of the tumors recur in the abdomen as locoregional or peritoneal disease. We initiated a protocol in which patients with suspicion of macroscopic serosal, lymphatic or peritoneal invasion, treated with R0 resection, underwent adjuvant HIPEC. Methods : Between June 1998 and January 2003, 16 patients with locally advanced adenocarcinoma of the stomach were included in the study. Surgery consisted of a total gastrectomy with a D2 lymphadenectomy. Splenectomy (n = 1), splenopancreatectomy (n = 4), transverse colectomy (n = 3), left hepatectomy (n = 1), localized peritonectomy (n = 3) were associated to obtain a R0 resection. HIPEC protocol consisted of heated (42.5°C) intraperitoneal mitomycin C (15 mg/m2) for a planned duration of 90 minutes. Results : HIPEC median duration was limited to 73(20–90) min because of central hyperthermia recognition in half of the cases. One patient died in the postoperative period of sepsis secondary to a duodenal fistula. Postoperative morbidity included pancreatic fistula (n = 2), pulmonary oedema (n = 1), pulmonary embolus (n = 1) and transient renal failure (n = 1). UICC staging was IB (n = 2), II (n = 2), IIIA (n = 5), IIIB (n = 1), IV (n = 6). Nine of the 16 patients are alive without recurrence with a median follow-up of 52 months. Four patients developed a recurrence, intraperitoneal (n = 2), systemic (n = 1), or combined (n = 1). Two patients were lost to follow-up. Conclusions : Aggressive surgical therapy and HIPEC might represent the standard of care in a selected population with locoregional disease and for whom a r0 resection can be achieved. This protocol was associated in this study with a 75% 5-year survival with a low peritoneal recurrence rate and an acceptable morbidity.

Acute rehabilitation program after laparoscopic colectomy using intravenous lidocaine.

Abstract Background: The concept of postoperative acute rehabilitation was introduced to accelerate postoperative recovery and improve outcome. We investigated whether intravenous lidocaine infusion, which decreases postoperative pain and speeds the return of bowel function, can be used instead of epidural analgesia in an acute rehabilitation protocol for patients undergoing laparoscopic colectomy. Methods: Twenty eight consecutive patients scheduled for laparoscopic colectomy were prospectively included in this case series study. Segmental colectomy was performed only for benign pathology. Intraoperative opioid use was restricted. After a bolus injection of lidocaine 1.5 mgkg-1, an infusion (2 mgkg-1h-1, IV) was started before pneu-moperitoneum. Balanced analgesia was used to reduce postoperative opioid consumption. Patients were allowed to drink 6 h postoperatively. The day after surgery, patients were allowed to eat a normal breakfast. Enforced mobilisation and ambulation were required from the patients. Our goal was to discharge patients within 3 days after surgery. Postoperative pain was measured. Time to first flatus, defecation, and hospital discharge were recorded. Results: Mean postoperative pain at rest and mobilisation remained below 30 mm on a 100 mm visual analogue scale. Time to first flatus, defecation, and hospital discharge were 29 ± 13 h, 38 ± 13 h, and 3.0 ± 1.0 days, respectively. Conclusion: Acute rehabilitation after laparoscopic colectomy using IV lidocaine gives similar outcomes to those reported using epidural analgesia.

Rationale for hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment or prevention of peritoneal carcinomatosis.

Abstract Up to now, the prognosis of peritoneal carcinomatosis from GI tract cancers remains very poor. Intraperitoneal hyperthermic chemotherapy has been proposed in the prevention or treatment of peritoneal carcinomatosis. The rationale for this locoregional approach comes from a better knowledge of the physiopathology of the disease. Intraperitoneal chemotherapy achieves high local drug concentration with limited systemic toxicity. It should be performed during or immediately after surgery to be effective towards microscopic residual tumor cells. A synergistic cytotoxic effect has been demonstrated when heat is combined with antineoplastic drugs. Intraperitoneal hyperthermic chemotherapy might not be regarded as the panacée but as a promising step in the management of peritoneal carcino-matosis. Some randomized studies of gastric cancer with macroscopic serosal invasion have suggested the efficacy of hyper-thermic intraperitoneal chemotherapy for the prevention of peritoneal carcinomatosis. In patients with peritoneal carci-nomatosis, some studies suggest, in selected cases, the positive effect of hyperthermic intraperitoneal chemotherapy on survival, when combined with cytoreductive surgery.

HSV-1 thymidine kinase gene therapy for peritoneal carcinomatosis.

Peritoneal carcinomatosis is a common clinical situation that requires novel therapeutical approaches. Suicide gene therapy consists of the intracellular delivery of a gene coding for an enzyme which transforms a prodrug into a cytotoxic product [1]. Thymidine kinase from the Herpes Simplex Virus type I (HSV-TK) is the most commonly used enzyme [2, 3]. HSV-tk-transduced cells as well as neighboring cells are killed in the presence of ganciclovir, because of the so-called “bystander effect” [4].