E. Balen

Stent or surgery for incurable obstructive colorectal cancer: an individualized decisión

IntroductionIn the setting of stage-IV obstructive colorectal cancer, self-expanding metallic stents (SEMS) placement and palliative surgery may be appropriate options. The aim of the present study is to evaluate the long-term results of surgery compared with stent implantation and to identify patients in whom one of these options can provide more benefit.Materials and methodsFrom November 2000 to November 2008, 98 patients with incurable stage-IV colorectal cancer were treated with palliative surgery (n=53) or SEMS (n=45). Data were recorded with respect to age, gender, tumor location, carcinoembryogenic antigen, ASAclass, presence of metastatic disease in one or multiple organs, volume of liver metastases, urgency of the procedure and treatment with chemotherapy. Comparison between surgery and stent placement was performed for all group and for patients who received and did not receive chemotherapy.ResultsBoth groups were comparable regarding age, ASA-class, chemotherapy treatment, tumor location and presence of metastatic disease in one or multiple organs but not in gender, rate of urgent procedures, abnormal CEA and of volume of liver metastases >25%. Survival in surgical group was significantly higher (11.9 vs 7.3 months; log-rank test, p = 0.002). SEMS group had lower early morbidity, hospital stay and stoma creation. For patients who received chemotherapy, surgery provided benefit in survival (6.8 vs 3.9 months; log-rank test, p = 0.101); in this subgroup, long-term complications from the primary tumour were more common in stented group, and time to chemotherapy was longer in the group of surgery. No differences in survival were shown in patients who did not receive chemotherapy.ConclusionStent placement offers advantages regarding early morbidity, hospital stay and stoma creation. Surgery offers a benefit in survival in patients who receive chemotherapy but not in non-candidates to chemotherapy.

Giant jejunoileal duplication: prenatal diagnosis and complete excision without intestinal resection.

A 7-week-old child presented to the pediatrician after persistent vomiting and abdominal distension developed. Intestinal dilatation had been detected in utero. Emergency ultrasonography showed only small bowel dilatation. There were no signs of intestinal obstruction; however, complete intestinal malrotation was demonstrated by an upper gastrointestinal series and barium enema. Intestinal duplication was also suspected, and emergency laparotomy was performed. A 70-cm-long jejunoileal duplication was found and successfully dissected free from the normal small bowel and excised without intestinal resection-anastomosis. The authors describe this unique case and the surgical technique for the treatment of small bowel duplications.

Pathologic Response of Primary Rectal Cancer to Oxaliplatin-Based Chemotherapy

Management of stage IV rectal cancer is controversial, and different strategies may be useful. Preoperative chemotherapy for liver metastases might cause pathologic changes over the primary rectal tumor. In this study, the authors show the pathologic regression of the primary rectal tumor after neoadjuvant chemotherapy treatment. Patients suffering stage IV rectal cancer underwent surgery after oxaliplatin-based chemotherapy. Age, gender, type of surgery, carcinoembryogenic antigen (CEA) level, presence of metastatic disease in one or multiple organs, ypT, ypN, and circumferential resection margin (CRM) were evaluated. Pathologic response of the primary tumor was estimated by using three conventional grading systems and a semiquantitative system assessed by the amount of viable cells out of the total tumor area macroscopically described. Fibrosis, necrosis, and colloid response were evaluated with a semiquantitative system. A complete pathologic response (ypTO) was found in one patient. A good response was observed in the 41.6% of the cases with all grading systems. Presence of fibrosis in the primary tumor was found in six cases. No patient showed CRM involvement. One patient developed a local recurrence. Oxaliplatin-based chemotherapy for stage IV rectal cancer provides high rates of pathologic regression in the rectal tumor and may allow surgery without CRM involvement.

Experimental model of non–heart-beating donors: oxidative stress metabolism in kidney after cardiac arrest (30 minutes of warm ischemia) and reimplantation 24 hours later

THE procurement of organs from non–heart-beating donors (NHBD) is a new way to increase the number of the grafts available for transplantation. Because of increasing organ demand, it is important to establish a protocol to select optimal donors. Postischemic renal failure is an important problem, especially if the kidney has been harvested from a NHBD, presumably because of the combined injury from warm and cold ischemia. The organs obtained from NHBDs go through potential periods of injury for ischemia reperfusion: warm ischemia (NHBD with cardiopulmonary resuscitation; hyperoxygenated reperfusion (cardiopulmonary resuscitation); cold ischemia (preservation and storage); and reperfusion (graft revasculation). Free radicals generated from oxygen by activated xanthine oxidase at reperfusion have been shown to be a major mediator of renal injury following either warm or cold ischemia. The process in human has not been reproduced in animals totally. The goals of the present study are to develop a NHBD process that reproduces the human one in animals; to study ischemia–reperfusion lesion repercution, determining ATP, reduced glutathione (GSH), malondialdehyde (MDA), and myeloperoxidase (MPO); to evaluate warm ischemia as an indicator of graft viability with 30 minutes of renal ischemia; and to determine the quality and quantity of damage in each phase. MATERIALS AND METHODS

Asociación entre la inestabilidad de microsatélites y las características clínicas y anatomopatológicas en pacientes con cáncer de colon esporádico

Universidad de Navarra. Pamplona. Navarra. Espana. Fundamento y objetivo: La inestabilidad de microsatelites derivada del fallo en la reparacion de los falsos emparejamientos del ADN es la alteracion caracteristica de los tumores de la via mutadora o inestables (MSI). Tales casos parecen presentar diferencias desde el punto de vista clinicopatologico con los tumores de la via supresora o estables (MSS). Los tumores con alto grado de inestabilidad (MSI-H) parecen constituir una nueva entidad de tumores con diferencias en determinadas caracteristicas anatomopatologicas y clinicas con respecto a los tumores estables (MSS) e inestables de bajo grado (MSI-L). En el presente estudio se valora la posible asociacion entre el alto grado de inestabilidad de microsatelites con la localizacion, contenido mucinoso, grado de diferenciacion, estadio, asi como el intervalo libre de enfermedad y supervivencia. Pacientes y metodo: Se clasifica a 117 pacientes con cancer de colon esporadico en las poblaciones MSS/MSI-L y MSI-H (siguiendo las recomendaciones del National Cancer Institute) mediante reaccion en cadena de la polimerasa y electroforesis de 7 microsatelites. Resultados: Los tumores MSI-H tendieron a localizarse en el colon derecho (p = 0,022) y a presentar contenido mucinoso (p = 0,04). El conjunto de pacientes MSI-H de estadios II y III no presento intervalos libres de enfermedad ni periodos de supervivencia mas prolongados (p = 0,54, p = 0,37, respectivamente). Los tumores MSI-H de estadio II presentaron periodos de supervivencia mas prolongados que los tumores MSS/MSI-L (p = 0,027). No observamos diferencias en la respuesta a quimioterapia con 5-fluorouracilo y leucovorin entre los grupos MSS/MSI-L y MSI-H (p = 0,38). Conclusiones: El alto grado de inestabilidad de microsatelites se asocia con determinadas caracteristicas patologicas, asi como con periodos de supervivencia mas prolongados para los tumores de estadios II.

Giant Megalo-ureter and Duplex Kidney in an Asymptomatic Adult

An abdominal mass was palpated in an asymptomatic adult during a routine medical check-up. Ultrasonography and computed tomography scan diagnosed a simple renal cyst, a mesenteric cyst and a seminal vesicle cyst. At laparotomy a complete ureteral duplication and a giant ectopic megalo-ureter were diagnosed. Other complications were ruled out in the follow-up. Ureterectomy without heminephrectomy was performed and the patient remains asymptomatic 5 years after surgery.

The Endo-GIA stapler for the side-to-side colorectal anastomosis in the Duhamel operation

A new technical modification of the Duhamel operation for construction of the side-to-side colorectal anastomosis is reported. A 21/2-year-old boy was duagnosed as having Hirschsprungs disease affecting the rectum and sigmoid colon. A Duhamel operation was performed with three modifications of the technique described by Lester W. Martin: the side-to-side colorectal anastomosis was performed with an Endo-GIA 30 stapler (Auto Suture; United States Surgical Corporation, Norwalk, Conn.) in an inverted V-shaped triangular manner; the remnant of the rectal stump was excited just above the Endo-GIA anastomosis, thus preserving only the rectal ampulla; and the rectal stump was left closed without being anstomosed to the descending colon. The postoperative functional results were excellent 6 months after the operation.

Metabolic and immunohistochemical asessment of endocrine pancreatic function after orthotopic multivisceral transplantation

IT is well known that pancreatic allografts normalize hyperglycemia a few hours after reperfusion. Endocrine function has been intensively studied in pancreas allografts from a biochemical point of view. Outstanding among functional studies is intravenous (IV) glucagon test, which has rarely been used in pancreas transplantation. However, there is little information on early histochemical aspects of pancreas transplantation and endocrine function has not been properly studied in multivisceral transplantation with the pancreas allograft draining into the portal vein of the liver graft. We studied the endocrine function of the orthotopically transplanted pancreas after multiorgan procurement in a multivisceral transplantation model in a previously reported model.

Pancreatic preservation in a multiorgan procurement procedure and transplantation.

U M LTIORGAN harvesting for individual organ transplantation is well defined according to the principles of Starzl. However, some pancreatic transplant surgeons believe the pancreas should not suffer hyperperfusion as occurs in multiorgan harvesting. This is in conflict with the need of all donor organs for transplantation and specially when multivisceral transplantation is planned. We believe that the pancreas is not so sensitive to high-volume flushing: most pancreata are harvested from multiorgan donors with good functional results. Even when flushing to the pan-creas in the adult donor is only 2 L, severe allograft pancreatitis has been reported in multivisceral transplantation. There must be some other etiologic factors of pancreatic preservation injury, namely warm ischemia and preservation time. We studied the quality of pancreas preservation in a multiorgan conventional preservation and orthotopic multivisceral transplantation technique.