Javier Granell

Modifications to Rives technique for midline incisional hernia repair

Abstract. Between 1990 and 1997, 284 patients were treated in our hospital for abdominal hernias. In the original group, 239 patients (84.15%) had midline hernia, and 45 (15.8%) had lateral hernia. A total of 152 midline hernia patients (63.5%) were treated using our variant of Rives technique. In all these cases, preperitoneal and retromuscular polypropylene mesh was used as a reinforcement and was subsequently attached by means of absorbable sutures to the external border of the rectus muscles. There were no deaths. A total of 42 of all patients operated on (27.6%) suffered from long-term postoperative pain. In seven cases (4.6%) it was necessary to remove the prosthesis because of chronic infection, and there were two recurrences in patients in whom the prosthesis had to be removed. In our experience, the Rives technique is a suitable and safe treatment for the repair of midline incisional hernias. The use of absorbable sutures and fixation of the mesh to the external oblique aponeurosis can reduce the original problems of abdominal pain and unaesthetic skin scars.

Prediction of recurrence in B–C stages of colorectal cancer by p53 nuclear overexpression in comparison with standard pathological features

This study investigated the predictive value of p53 nuclear overexpression on recurrence of colorectal adenocarcinomas compared with established prognostic pathological features. Sixty-one paraffin-embedded sections from primary tumours were examined by immunohistochemistry. Specific nuclear staining was detected in 27 (44.2%) cases. Positivity was more frequent in tumours with venous invasion (76.9%) (P = 0.06) and in rectal cancer (68.4%) (P = 0.06). After a median observation time of 46 months, p53-positive tumours exhibited a higher percentage of recurrence (40.7% vs 11.7%) (P = 0.03), and a higher likelihood of relapse at 5-year follow-up (46% vs 13%) (P = 0.006). Among the pathological variables analysed, only the extent of bowel wall invasion showed a relationship with recurrence. After adjustment for the other covariates in a Coxs regression model, p53 overexpression was the only factor showing independent prognostic significance (hazard ratio: 4.96; 95% Confidence Interval (CI): 1.47-16.71) (P = 0.012). The results of this study show that nuclear p53 protein overexpression has higher predictive value than standard pathological variables.

Prognostic Value of Flow Cytometric DNA Analysis in Non-Small-Cell Lung Cancer: Rationale of Sequential Processing of Frozen and Paraffin-Embedded Tissue

Abstract. The objective of this study was to determine the prognostic information provided by flow cytometric DNA analysis in non-small-cell lung cancer. Lung samples of 132 consecutive patients submitted to surgery were prospectively processed. When no aneuploid populations were detected in fresh frozen samples, the process continued as a second step in paraffin-embedded tissue, consuming all the tumor available. The influence of ploidy on the postoperative outcome was studied by both a univariate and a multivariate analysis. Aneuploidy was found in 81 patients (61.4%). Fourteen patients showed no aneuploidy in fresh frozen samples; and only after further analysis in paraffin-embedded tissue was abnormal DNA detected. Overall, the 36-month survival was 69% for the diploid group and 24% for the aneuploid group (p = 0.0006). Including subjects submitted to complete tumor removal (stages I, II, and IIIA) in a multivariate analysis adjusted for TNM stage and histologic type, bearers of aneuploid tumors exhibited a higher risk of relapse (hazard ratio 2.65; CI 95% 1.5–4.66;p = 0.004) or death (hazard ratio 2.17; CI 95% 1.08–4.39;p = 0.032) than patients with diploid tumors. DNA ploidy resulted an independent prognostic factor of survival and tumor relapse in completely resected non-small-cell lung cancer. Sequential analysis of fresh and paraffin-embedded samples can help avoid the bias due to intratumoral DNA content heterogeneity. DNA ploidy could be an useful parameter in any future multifactorial analysis of outcome in such tumors.

Serum CEA, CA125, and SCC antigens and tumor recurrence in resectable non-small cell lung cancer

Carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), and CA125 were determined pre- and postoperatively in non-small cell lung cancer patients (NSCLC) to assess the relationship between serum levels and postoperative recurrent disease. Ninety-five patients who underwent curative surgical resection were included (TNM stages I, II, IIIa). CEA and CA125 were determined by solid-phase enzyme-immunoassay, SCC by radio-immunoassay. Tumor relapse was detected in 41 patients (43%): 16 (39%) with locoregional disease and 25 (61%) with disseminated disease. The overall 36-month disease-free survival rate was 42%. The sensitivity for recurrence was 58% for CEA, 53.6% for CA125, and 51.2% for SCC; 87.8% of patients showed at least one elevated marker. The sensitivity of CEA and CA125 increased significantly in patients with preoperative serum concentrations above the cut-off: 86.6% versus 42.3% (p < 0.01), and 93% versus 18% (p < 0.01), respectively. Preoperative CA125 above 15 U/ml identified a high-risk group of patients: a lower 36-month disease-free survival rate (0%) versus 56%) (p < 0.001), a 3.02-fold higher risk of recurrence (p < 0.05), and a 6.22-fold higher risk of disseminated failure (p < 0.001). The identification of CEA and CA125 producer-tumors, based on preoperative serum values, enhances the clinical performance of a postoperative surveillance program in surgically treated NSCLC. Preoperative serum CA125 is a prognostic factor to identify patients at high risk of postoperative tumor recurrence.

Evaluation of serum carcinoembryonic antigen monitoring in the follow-up of colorectal cancer patients with metastatic lymph nodes and a normal preoperative serum level.

The value of serial serum carcinoembryonic antigen (CEA) assay in the follow-up of colorectal cancer patients with metastatic lymph nodes and normal (≤ 5 ng/ml) preoperative CEA levels, was examined in this study. Thirty-eight patients were studied and compared with 22 patients with elevated CEA levels. The overall sensitivity of CEA for the diagnosis of recurrence was 36%. Postoperative CEA was strongly influenced by the site of recurrence. CEA monitoring showed the best results in patients who developed hepatic metastases (sensitivity 60%, specificity 94%, positive predictive value 60%, and negative predictive value 94%), and was ineffective for the detection of locoregional or pulmonary metastases. The results indicate that elevation of CEA in the postoperative course of these patients is an indicator of the presence of hepatic metastases. Postoperative CEA monitoring should not be omitted in Dukes C patients with normal preoperative levels, and is more reliable for the detection of liver metastases.

Perioperative chemotherapy for resectable gastroesophageal cancer: A single-center experience

BACKGROUNDS Multimodal treatment for locally advanced gastric cancer has been reported to improve disease-free survival when compared to surgery alone. We aimed to clarify the efficacy and safety of perioperative chemotherapy for locally advanced gastric cancer patients treated in daily clinical practice. METHODS Patients diagnosed with locally advanced gastric cancer were treated with perioperative chemotherapy and surgery. The primary end point was the complete resection (R0) rate. Secondary end points were disease-free survival (DFS), overall survival (OS), toxicity, radiological response rate, pathological response rate and downstaging rate. We also looked for prognostic and predictive factors for DFS, OS, pathological complete response and the R0 rate. RESULTS Forty patients were found eligible for this retrospective analysis. At diagnosis, 52.5% of patients were classified as stage II and 47.5% were stage III. Forty percent of patients completed three preoperative cycles and three postoperative cycles. A tolerable toxicity related to chemotherapy was found. Thirty-nine patients underwent surgery: 80% reached a complete resection (R0), down-staging was detected in 57.5% and 17.5% had a pathologically complete response. The median time of disease-free survival was 34.05 months (95%CI 25.6-42.4), and the median time of overall survival was 39.01 months (95%CI 30.8-47.1). We found that the presence of comorbidities were independent predictive factors for the pathologic response, while the chemotherapy schedule and the clinical response could independently predict a complete resection. CONCLUSIONS Our results support that perioperative chemotherapy for locally advanced gastric cancer can be safely delivered in daily clinical practice, obtaining an improvement of the pathologic response and the complete resection of gastric cancer.

Evaluation of the SENIC risk index in a Spanish university hospital.

OBJECTIVE To assess the performance of the Study of the Efficacy of Nosocomial Infection Control (SENIC) risk index for the evaluation of the risk of surgical-site infection (SSI) in a country other than the United States, having a different health system. SETTING 350-bed university hospital in Spain belonging to the National Health System (Insalud). DESIGN Observational cohort study of 1,019 patients who underwent consecutive surgery from January to December 1992. Surgical-infection risk factors assessed by the traditional wound-classification system (clean, clean-contaminated, contaminated, and dirty-infected wound) and by the SENIC risk index (length of intervention more than 2 hours, more than three discharge diagnoses, abdominal surgery, and contaminated or dirty-infected wound) were compared by forward logistic regression. RESULTS The SENIC risk index showed a greater ability to predict SSI than the traditional wound-classification system. The study carried out in our institution reproduced the estimators provided by the SENIC study in the United States. The SENIC risk index provided a stepwise increase in SSI rates, according to the number of factors present, for every traditional wound-classification group. In the case of clean wounds, the incidence of surgical infection (per 100 interventions) increased (1.5, 2.4, 5.3, and 50; P<.001) for patients having from zero to three risk factors of the SENIC risk index. CONCLUSIONS This study shows that the SENIC risk index results are reproducible, and the index can be used to compare rates of wound infection across countries with different health systems than the United States.

Incisional hernia following appendectomy. Surgical experience

SummaryAppendectomy is a very frequent cause of incisional hernia. In this paper the rate of recurrence after the hernia repair by simple suture and mesh repair was studied. 17 lateral incisional hernias secondary to appendectomy were repaired over a 9 year period. Prosthetic repair was carried out in 9 cases and primary closure in the remaining 8 cases. All the patients were followed over a period that ranged from 1 to 8 years (mean 5.6 years). There was one recurrence, though 2 patients (11.7%) with mesh repair complained about abdominal pain during the first postoperative year. The study concludes that both techniques can be successfully implemented if the correct indications based on the extent of the defect and the clinical characteristics of the patient are respected.

Influencia de la presión atmosférica sobre la incidencia de neumotórax espontáneo

BACKGROUND This study analyses the relationship between the incidence of idiopathic spontaneous pneumothorax (ISP) and atmospheric pressure (AP). METHODS A total of 288 cases of ISP were included, 229 men and 59 women. The AP of the day of diagnosis, of the 3 prior days and the monthly average was registered. The association between the incidence of ISP and AP was analyzed by calculating standardized incidence ratio (SIR) and Poisson regression. RESULTS The AP on the day of admission (mean±standard deviation) (1,017.9±7 hectopascals [hPa]) was higher than the monthly average AP (1,016.9±4.1 hPa) (P=.005). There was a monthly distribution pattern of ISP with the highest incidence in the months of January, February and September and the lowest in April. When AP was less than 1,014 hPa, there were fewer cases registered than what would statistically have been expected (58/72 cases). In contrast, when the pressure was higher than 1,019 hPa, the registered cases were more than expected (109/82 cases) (SIR=1.25; 95% CI: 1.04 to 1.51). The risk of ISP increased 1.15 times (95% CI: 1.05 to 1.25, P=.001) for each hPa of AP, regardless of sex, age and monthly average AP. A dose-response relationship was observed, with progressive increases in risk (IRR=1.06 when the AP was 1,014-1016 hPa; 1.17 hPa when the AP was 1,016-1,019 hPa and 1.69 when AP was superior to 1,019 hPa) (P for trend=.089). CONCLUSION The AP is a risk factor for the onset of idiopathic spontaneous pneumothorax.

Tratamiento quirúrgico del enterocele mediante la resección del saco peritoneal y reparación protésica del espacio rectovaginal. Estudio prospectivo y validación de una nueva técnica quirúrgica

Resumen Introduccion El tratamiento quirurgico del enterocele constituye actualmente un tema de debate, no habiendose conseguido la unificacion de criterios en cuanto a la idoneidad de su via de abordaje y tratamiento. La idea de este estudio prospectivo es evaluar los resultados del tratamiento quirurgico del enterocele, mediante una nueva tecnica disenada personalmente y consistente en la reseccion del saco peritoneal redundante y la reparacion protesica del espacio rectovaginal. Material y metodos Se estudian 13 pacientes diagnosticadas de enterocele entre junio 1997 y diciembre de 2000, mediante exploracion clinica y posterior confirmacion con proctografia de evacuacion. Se realiza en todos los casos la extirpacion del saco peritoneal redundante colocando una protesis de polipropileno anclada en el espacio interrectovaginal. La edad media de las pacientes fue de 64 anos (rango 54-86). Se analiza en todas ellas el grado de enterocele, las alteraciones en la defecacion, la asociacion con otras enfermedades del suelo pelvico, asi como la posible repercusion de las mismas en la clinica del enterocele. Resultados La tolerancia a la malla de polipropileno fue perfecta en todos los casos, no observandose infecciones de la malla que nos obligaran a su extraccion. La obliteracion del espacio rectovaginal fue completa en todos los casos, como se comprobo en las proctografias de evacuacion realizadas en los controles posteriores. Los grados de enterocele mayor tuvieron mejor respuesta clinica a la mayoria delos parametros estudiados, que los grados menores de enterocele, no obstante en todas ellas los sintomas fueron menores que antes de la cirugia. Conclusiones En pacientes con malestar pelvico y alteraciones en la defecacion, el enterocele puede ser considerado como un importante factor. El estudio proctografico y el grado de enterocele es fundamental a la hora de plantearnos un tratamiento quirurgico. La reseccion del saco peritoneal redundante del enterocele y la posterior colocacion de una malla protesica de polipropileno parece ser un tratamiento adecuado para estas pacientes.