E. Cugat

Obstructing colorectal carcinomas: Prospective study

Intestinal obstruction owing to colonic carcinoma is a relatively frequent cause of acute abdominal pain. The aim of this prospective study is to evaluate the prognostic factors that may influence the final outcome of those patients operated upon for an intestinal obstruction (OG) as opposed to those electively operated upon (EG). From September 1984 to March 1988, a total of 188 patients with colorectal cancer have been included in the study. One hundred thirty-five were EG, while 53 (28.1 percent) were OG. The mean ages were similar in both groups. Sex, morbidity, and mortality rates were equally distributed. Curative resection rate was significantly higher in the EG group (P=0.029). Tumor staging tended to be significantly more advanced in OG patients (chi-square = 9.054;df=3;P=0.026). Multivariate analysis (proportional hazards model) showed that the only independent prognostic factor was tumor staging (P=0.0000). Obstruction itself disappears as a predictive variable when tumor staging is introduced in the model. We conclude that obstructing colon carcinomas tend to be more locally advanced, that probably being the only reason for a worse long-term prognosis.

Must ERCP Be Routinely Performed if Choledocholithiasis Is Suspected

Objective: To evaluate the results of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of those patients suspected of harboring bile duct stones before laparoscopic cholecystectomy (LC). Patients and Methods: A total of 1,235 consecutive LCs performed between 1991 and 1997 were studied prospectively. ERCP was performed to explore the common bile duct (CBD) preoperatively when choledocholithiasis was suspected on the basis of clinical, analytical or echographical data. Results: ERCPs were performed in 268 patients: unsuccessful CBD evaluation in 3%; dilated CBD without lithiasis in 13%, and normal exploration in 37% (99 patients). CBD stones were found in 46% (124 patients), and endoscopic sphincterotomy was then performed and stone extraction attempted. Endoscopic therapy achieved 92.8% successful removal of CBD stones (115 patients). There was no ERCP-related mortality and the morbidity rate was 6%. Retained CBD stones have been observed in 7 cases after ERCP-LC; all of them have been successfully treated by ERCP. Conclusions: A combined approach to bile duct stones with selective use of ERCP followed by LC is a good therapeutical alternative. Nevertheless, the usual selection criteria for ERCP may lead to unnecessary exploration. It appears to be necessary to modify the current diagnostic and therapeutic strategy.

Hepatic cytoprotective effect of ischemic and anesthetic preconditioning before liver resection when using intermittent vascular inflow occlusion: a randomized clinical trial.

BACKGROUND Ischemic preconditioning (IPC) and anesthetic preconditioning (APC) have been reported to attenuate ischemia-reperfusion (IR) injury after liver resection under continuous inflow occlusion. This study evaluates whether these strategies enhance hepatic protection of remnant liver against IR after liver resection with intermittent clamping (INT). METHODS A total of 106 patients without underlying liver disease and submitted to liver resection using INT were randomized into 3 groups: IPC (10 minutes of inflow occlusion followed by 10 minutes of reperfusion before liver transection), APC (sevoflurane administration for 20 minutes before liver transection), and INT (no preconditioning). Patients were also stratified according to the extent of the hepatectomy. Cytoprotection was evaluated by comparing hepatocyte and endothelial dysfunction markers, apoptosis, histologic lesions, and postoperative outcome. RESULTS No differences were observed in preoperative chemotherapy and steatosis, total warm ischemia time, operative time, or blood loss. Kinetics of transaminases (aspartate aminotransferase, P = .137; alanine aminotransferase, P = .616), bilirubin (P = .980), and hyaluronic acid increase (P = .514) revealed no differences. Significant apoptosis was present in 40% of patients, mild-to-moderate leukocyte infiltration and steatosis in 45% and 55%, respectively, and mild sinusoidal congestion in 65%, with a similar distribution in the 3 groups. When patients were stratified by major versus minor resections, no differences were observed in any of the variables studied. Postoperative clinical outcomes were also similar. CONCLUSION These results suggest that these protocols of IPC and APC used in this study do not provide better cytoprotection from IR when INT is used.

Gallstone Surgery in Cirrhotic Patients: Morbidity and Mortality in Relation to Risk Groups

Reports on the morbidity and mortality in the surgical treatment of gallstone disease in cirrhotic patients vary markedly depending on the authors. We reviewed our experience over the last 4 years, studying the charts of 36 patients with liver cirrhosis, operated on with the diagnosis of biliary lithiasis. Isolated cholecystectomy was performed in 27 patients and concomitant surgical procedures in 9. Patients were divided according to the Child-Campbell classification: 24 in group A and 12 in group B. Morbidity (33.3%) was related to the degree of liver function impairment: 6 patients in group A (25%), and 6 in group B (50%). Hemorrhage was not a common complication in this series. Only 1 patient died (2.7%) secondary to ascitic fluid infection. We propose a flowchart in the treatment of biliary lithiasis in patients with liver cirrhosis, taking their liver function into account.

Colorectal Carcinoma: Results of a Follow-Up Protocol

We report the results of a prospective study designed to evaluate a follow-up program in patients undergoing curative resection for colorectal carcinoma. From January 1984 to December 1989 a total of