L. Burgos

Gallbladder cancer: An analysis of a series of 139 patients with invasion restricted to the subserosal layer

The goal was to study our experience in the management of a series of patients with a potentially curative subserosal gallbladder cancer who were prospectively treated by the authors. Between April 1988 and July 2004, 139 patients were enrolled in our prospective database. Of the above, 120 were operated on with an open procedure and the rest with laparoscopic surgery. In only eight patients was the diagnosis suspected before the cholecystectomy. The majority of tumors were adenocarcinoma. Six patients had an epidermoid tumor, and one had a carcinosarcoma. Of the patients, 74 underwent reoperation, while in 55 (70.2%) it was possible to perform an extended cholecystectomy with a curative aim. Operative mortality was 0%, and operative morbidity was 16%. Lymph node metastases were found in 10 (18.8%), while in 7 (13.2%) the liver was involved. The overall survival rate was 67.7%, while in those who underwent resection, the survival rate was 77%. Through the use of a multivariate analysis, the presence of lymph node metastasis was found to be an independent factor with respect to prognosis. The feasibility of performing an extended cholecystectomy in patients with gallbladder cancer and invasion of the subserosal layer allows for a good survival rate. The presence of lymph node metastases represents the main poor prognosis factor, and some type of adjuvant therapy should be studied in this particular group.

Laparoscopic Cholecystectomy: Its Effect on the Prognosis of Patients with Gallbladder Cancer

Numerous reports suggest more recurrences and a worse prognosis after laparoscopic cholecystectomy (LC) than after open cholecystectomy (OC). The objective of this study was to compare the survival rate of patients undergoing a laparoscopic procedure versus those undergoing an open operation. A series of 24 patients with gallbladder cancer detected after LC were compared with 40 consecutive patients with gallbladder cancer detected after OC. Patients were matched by wall invasion, age, and whether they underwent a reoperation or only cholecystectomy. The series included 2 patients with in situ tumors, 2 with mucosal tumors, 1 with muscular invasion, 13 with subserosal invasion, and 6 with serosal invasion. Recurrences were observed in 4 of the 10 patients with subserosal compromise who underwent reoperation. In contrast, in the OC group of 26 patients with subserosal invasion, 20 of whom were reoperated, only 2 had a recurrence. Of the six patients with serosal infiltration, three in the LC underwent reoperation, all of whom had recurrences that precluded resection. Of the 12 patients in the OC group who presented with serosal invasion, 6 were reoperated and 4 had a recurrence. Overall survival curves did not show differences when patients were compared according to the type of procedure performed. Similarly, the analysis of patients according to the level of wall invasion indicated that there was no significant difference in survival. Although multiple reports have shown a worse prognosis for patients with gallbladder cancer undergoing LC, this study did not show a significant survival difference between the two methods. Although there is a higher but insignificant recurrence rate among the patients who underwent LC, this is not translated into survival.

Calidad metodológica de un artículo de tratamiento de cáncer gástrico adoptado como protocolo por algunos hospitales chilenos

BACKGROUND Surgery is a curative treatment for gastric cancer (GC). As relapse is frequent, adjuvant therapies such as postoperative chemo radiotherapy have been tried. In Chile, some hospitals adopted Macdonalds study as a protocol for the treatment of GC. AIM To determine methodological quality and internal and external validity of the Macdonald study. MATERIAL AND METHOD Three instruments were applied that assess methodological quality. A critical appraisal was done and the internal and external validity of the methodological quality was analyzed with two scales: MINCIR (Methodology and Research in Surgery), valid for therapy studies and CONSORT (Consolidated Standards of Reporting Trials), valid for randomized controlled trials (RCT). Guides and scales were applied by 5 researchers with training in clinical epidemiology. RESULTS The readers guide verified that the Macdonald study was not directed to answer a clearly defined question. There was random assignment, but the method used is not described and the patients were not considered until the end of the study (36% of the group with surgery plus chemo radiotherapy did not complete treatment). MINCIR scale confirmed a multicentric RCT, not blinded, with an unclear randomized sequence, erroneous sample size estimation, vague objectives and no exclusion criteria. CONSORT system proved the lack of working hypothesis and specific objectives as well as an absence of exclusion criteria and identification of the primary variable, an imprecise estimation of sample size, ambiguities in the randomization process, no blinding, an absence of statistical adjustment and the omission of a subgroup analysis. CONCLUSION The instruments applied demonstrated methodological shortcomings that compromise the internal and external validity of the.