Elena Muñoz

Macroscopic Assessment of Mesorectal Excision in Rectal Cancer: A Useful Tool for Improving Quality Control in a Multidisciplinary Team

High quality of surgical technique and the use of descriptive measures to assess and report surgical proficiency have been shown to influence locoregional tumor control in patients with rectal cancer. In this study, the authors have aimed to audit the implementation of a macroscopic assessment of mesorectal excision (MAME) and to investigate factors that influenced surgical quality and disease recurrence.

Neoplasias de páncreas y periampulares: morbimortalidad, resultados funcionales y supervivencia a largo plazo

AIMS To evaluate postoperative morbidity and mortality, pancreatic function and long-term survival in patients with surgically treated pancreatic or periampullar tumours. PATIENTS AND METHODS Cohort study including 160 patients consecutively operated on: 80 pancreaticoduodenectomies (PD), 30 distal pancreatectomies (DP), 7 total pancreatectomies, 4 central pancreatic resections and 3 ampullectomies. The tumour was not resected in 36 patients. Pancreatic function was evaluated by oral glucose tolerance test, faecal fat excretion and elastase. RESULTS Resectability rate was 77.5%. In resected patients (n = 124), 38.7% had complications with a pancreatic fistula rate of 6.4% and a mortality rate of 4%. In PD, endocrine function worsened in 41% and 58.6% had steatorrhoea; these figures in DP were 53.6% and 21.7% respectively. In the 36 non-resected patients, postoperative morbidity was 27.7% and mortality 8.3%. Two and five-year survival rates in resected patients with pancreatic cancer were 42% and 9% respectively; in malignant ampulloma 71% and 53%; in mucinous adenocarcinomas 83% and 33%; in duodenal adenocarcinoma 100% and 75%; and in distal cholangiocarcinoma 50% and 50%. CONCLUSIONS Morbidity associated with resective pancreatic surgery is still high, but perioperative mortality is low. Endocrine and exocrine disturbances are very common depending on the type of resection. Despite the associated morbidity and functional disorders, surgery provides long-term survival in selected cases.

On the mechanism of the addition of organolithium reagents to cinnamic acids

The regioselectivity of the addition of tert-butyllithium to cinnamic acid is subject to reaction conditions and to substituent electronic effects. Significant effects are observed in the presence of several additives including a radical trap such as α-methylstyrene. Competition experiments by addition of the organolithium reagent to mixtures of substituted cinnamic acids show that the relative rates of both conversion of the starting acids and formation of the 1,3-adducts are subject to electronic effects, whereas rates for 1,4-addition are independent of the substituents. These features are in agreement with a polar addition mechanism, but a fast SET equilibrium followed by slow radical combination would be possible as well.

Addition of organolithium reagents to cinnamic acids

Abstract Reaction of tert -butyllithium with p - and m -substituted cinnamic acids at low temperature affords mixtures of 1,4- and 1,3-addition products, whose composition depend on the nature of the substituents. Electron-donating and electron-withdrawing groups favour 1,4- and 1,3-additions, respectively. Linear correlations are obtained with electronic effect and with radical substituent constants.

Conjugate addition of organolithium reagents to α,β-unsaturated carboxylic acids

Abstract Conjugate addition of primary, secondary, tertiary alkyl and phenyl lithium reagents to 2-alkenoic acids affords good yields of branched saturated carboxylic acids. Methyl groups at the α- and β-carbon of the 2-alkenoic acid decrease reactivity as acceptors, and foster deprotonation, respectively. The lithium enediolate resulting from the conjugate addition can react with electrophiles. PM3 calculations are in agreement with the substituent effects.

Evaluation of mesorectal fascia in mid and low anterior rectal cancer using endorectal ultrasound is feasible and reliable: a comparison with MRI findings.

BACKGROUND: Accuracy of MRI in assessing mesorectal fascia and predicting circumferential resection margin decreases in low anterior rectal tumors. OBJECTIVE: The purpose of this work was to evaluate the accuracy of endorectal ultrasound in predicting the pathologic circumferential resection margin in low rectal anterior tumors and to compare it with MRI findings. DESIGN: This was a prospective series comparing the preoperative circumferential resection margin assessed by endorectal ultrasound and MRI with pathologic examination. SETTINGS: The study was conducted by a specialized colorectal multidisciplinary team at a tertiary teaching hospital. PATIENTS: Between 2002 and 2008, 76 patients with mid to low rectal cancer were preoperatively evaluated by endorectal ultrasound and MRI and underwent total mesorectal excision without neoadjuvant radiochemotherapy. Twenty-seven patients with posterior or postero-lateral tumors were excluded, leaving 49 patients with anterior or antero-lateral tumors for the present subanalysis. We compared preoperative circumferential resection margin status using endorectal ultrasound and MRI with pathologic examination. INTERVENTIONS: We conducted a comparison between preoperative circumferential resection margin status and pathologic examination after total mesorectal excision surgery. MAIN OUTCOME MEASURES: Accuracy in predicting pathologic circumferential resection margin status was measured. RESULTS: Overall accuracy of endorectal ultrasound and MRI in assessing circumferential resection margin status was 83.7% and 91.8%, with negative predictive values of 97.2% and 97.5%. When focusing on low rectal tumors, the overall accuracy of endorectal ultrasound increased to 87.5%, whereas the accuracy of MRI decreased to 87.5%, with a negative predictive value of 95.6% for both diagnostic tests. LIMITATIONS: The sample size is small, and interobserver variability in radiologic assessment was not evaluated. CONCLUSIONS: Endorectal ultrasound can help MRI in predicting circumferential resection margin involvement in mid to low anterior rectal cancer, especially at the low third of the rectum, with a high negative predictive value.

Modified Wong's classification improves the accuracy of rectal cancer staging by endorectal ultrasound and MRI.

BACKGROUND: Douglas Wong proposed a new classification of tumor penetration in the rectal wall (T stage) in an attempt to incorporate the prognostic heterogeneity of T3 rectal cancers into the preoperative staging. OBJECTIVE: This study aimed to evaluate if the accuracy of endorectal ultrasound and MRI in predicting rectal cancer T staging improves when using a modified Wongs classification. DESIGN: This prospective series compares local standard TN staging and a modified Wongs classification. SETTINGS: This study was conducted by a specialized Colorectal Multidisciplinary Team at a tertiary teaching hospital. PATIENTS: Seventy patients underwent surgery for middle or low rectal cancer between 2002 and 2008 without neoadjuvant radiochemotherapy. We compared the preoperative staging with the pathological staging to determine the preoperative accuracy of endorectal ultrasound and MRI when using a modified Wong’s classification vs the standard TN classification. INTERVENTIONS: A modified version of Wong’s classification was used for preoperative and pathological staging. MAIN OUTCOME MEASURES: The primary outcome measured was the accuracy in the preoperative T staging. RESULTS: The overall accuracy of endorectal ultrasound and MRI in assessing T staging was 68.6% and 72.9% (uT1/2, 90%; uT3, 58.3%; and uT4, 100% and rT1/2, 88%; rT3, 63.4%; and rT4, 75%). By using the proposed modified Wongs classification, the overall accuracy of endorectal ultrasound and MRI improved to 82.9% and 90%. LIMITATIONS: The interobserver variability in radiological assessment was not evaluated. CONCLUSION: With use of the modified Wongs classification proposed in this study, the overall accuracy of preoperative imaging in assessing T staging of rectal cancer is substantially improved, especially when endorectal ultrasound and MRI stage match, enhancing the selection of patients for neoadjuvant radiochemotherapy.

The occlusive tourniquet: a simple method for rectal stump washout during open and laparoscopic surgery.

Rectal stump washout with cytolytic agents is recommended and usually performed during anterior rectal or rectosigmoid resection. The use of a linear stapler instrument during ultralow anterior resection makes the placement of pelvic clamps difficult for rectal stump washout prior to resection. The objective of this work is to demonstrate the use of a simple procedure, the occlusive tourniquet for rectal stump washout. Occlusive tourniquet applied to open technique: after complete dissection of the rectum and sigmoid colon according to the usual technique, a simple piece of tubing from an intravenous line is passed behind and around the rectum/sigmoid colon at some point distal to the tumor to form an occlusive tourniquet. Occlusive tourniquet applied to laparoscopic technique: similar to the open technique, tubing is passed through the left iliac fossa trocar and passed behind the sigmoid mesocolon. This simple procedure allows easy exposure and dissection of the mesorectum, without traumatizing the rectum/sigmoid colon or the tumor and lavage can be performed without the need for clamps or other instruments which may traumatize the rectum and provoke anastomotic failure. In conclusion, the occlusive tourniquet is a simple method for rectal stump washout so this step can be done.

Borderline resectable pancreatic cancer. Challenges and controversies

Pancreatic cancer is a dismal disease with an increasing incidence. Despite the majority of patients are not candidates for curative surgery, a subgroup of patients classified as borderline resectable pancreatic cancer can be selected in whom a sequential strategy of neoadjuvant therapy followed by surgery can provide better outcomes. Multidisciplinary approach and surgical pancreatic expertise are essential for successfully treating these patients. However, the lack of consensual definitions and therapies make the results of studies very difficult to interpret and hard to be implemented in some settings. In this article, we review the challenges of borderline resectable pancreatic cancer, the complexity of its management and controversies and point out where further research and international cooperation for a consensus strategy is urgently needed.

Miositis osificante circunscrita en codo simulando un sarcoma de partes blandas: hallazgos clínico-radiológicos similares

We present the case of a 36 year old female, monitored for painful, progressive tumour in the anteromedial surface of the left elbow and functional deficit, of 2-month onset, which was resistant to analgesic treatment. She referred to a previous history of trauma, and had been diagnosed with fibrillar muscle rupture. Due to the persistence of symptoms, an out-patient MRI was performed which resulted in suspicion of soft tissue sarcoma and the patient was admitted to hospital for further study. Laboratory tests and a CT scan of the chest and abdomen were negative. A two phase bone scan (Fig. 1A and B), showed a heterogeneous uptake area in the anterior region of the left elbow with no relevant findings at any other level. Differential diagnosis was suggested as sarcoma of the soft tissue, chondrosarcoma and osteochondroma with malignant degeneration. It was finally decided that ultrasound-guided percutaneous biopsy be performed, the result of which was mesenchymal tumour without signs of malignancy and final diagnosis of myositis ossificans was made. Rest, anti-inflammatory treatment and physiotherapy were recommended as treatment. Three months later the patient showed clinical signs of improvement and a reduction in pain, with complete flexion and extension at 120◦. Plain radiological control (Fig. 2A and B) and noncontrast CT imaging (Fig. 3) revealed a calcified mass, compatible with the anatomopathological diagnosis.