Pilar Taura

Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial

BACKGROUND Although early reports on laparoscopy-assisted colectomy (LAC) in patients with colon cancer suggested that it reduces perioperative morbidity, its influence on long-term results is unknown. Our study aimed to compare efficacy of LAC and open colectomy (OC) for treatment of non-metastatic colon cancer in terms of tumour recurrence and survival. METHODS From November, 1993, to July, 1998, all patients with adenocarcinoma of the colon were assessed for entry in this randomised trial. Adjuvant therapy and postoperative follow-up were the same in both groups. The main endpoint was cancer-related survival. Data were analysed according to the intention-to-treat principle. FINDINGS 219 patients took part in the study (111 LAC group, 108 OC group). Patients in the LAC group recovered faster than those in the OC group, with shorter peristalsis-detection (p=0.001) and oral-intake times (p=0.001), and shorter hospital stays (p=0.005). Morbidity was lower in the LAC group (p=0.001), although LAC did not influence perioperative mortality. Probability of cancer-related survival was higher in the LAC group (p=0.02). The Cox model showed that LAC was independently associated with reduced risk of tumour relapse (hazard ratio 0.39, 95% CI 0.19-0.82), death from any cause (0.48, 0.23-1.01), and death from a cancer-related cause (0.38, 0.16-0.91) compared with OC. This superiority of LAC was due to differences in patients with stage III tumours (p=0.04, p=0.02, and p=0.006, respectively). INTERPRETATION LAC is more effective than OC for treatment of colon cancer in terms of morbidity, hospital stay, tumour recurrence, and cancer-related survival.

Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer

The authors examined the impact of the laparoscopic approach on the early outcome of resected colon carcinomas. The role of laparoscopic techniques in the treatment of colon carcinomas is questionable. Previous studies have suggested technical feasibility of surgical resections of these cancers by laparoscopic means and have implied a benefit to laparoscopic technique for patients undergoing colorectal resections. A prospective, randomized study was conducted comparing laparoscopic assisted colectomy (LAC) open colectomy (OC) for colon cancer. We present the preliminary results in relation to the short-term outcome and judge the feasibility of the laparoscopic procedure to as a way of performing accurate oncologic resection and staging. Benefit has been demonstrated with LAC in this setting. Passing flatus, oral intake, and discharge from hospital occurred earlier in LAC- than OC-treated patients The mean operative time was significantly longer in the LAC group than in the OC group. The overall morbidity was significantly lower in the LAC group. No significant differences were observed between both groups in the number of lymph nodes removed or the pathological stage following the Astler-Coller modification of the Dukes classification. The laparoscopic approach improves the short-term outcome of segmental colectomies for colon cancer. However, the further follow-up of these patients will allow us to answer in the near future whether or not the LAC may influence the long-term outcome.

Bacterial translocation of enteric organisms in patients with cirrhosis

BACKGROUND/AIMS The aim of the study was to investigate the prevalence and associated risk factors for bacterial translocation in patients with cirrhosis, a mechanism involved in the pathogenesis of bacterial infections in experimental cirrhosis. METHODS Mesenteric lymph nodes were obtained for microbiological culture from 101 patients with cirrhosis and from 35 non-cirrhotic patients. RESULTS Enteric organisms were grown from mesenteric lymph nodes in 8.6% of non-cirrhotic patients. In the 79 cirrhotic patients without selective intestinal decontamination, the prevalence of bacterial translocation significantly increased according to the Child-Pugh classification: 3.4% in Child A, 8.1% in Child B and 30.8% in Child C patients (chi2 = 6.106, P < 0.05). However, translocation by Enterobacteriaceae, the organisms commonly responsible for spontaneous bacteremia and peritonitis in cirrhosis, was only observed in 25% of the cases. The prevalence of bacterial translocation in the 22 cirrhotic patients undergoing selective intestinal decontamination, all Child-Pugh class B and C, was 4.5%. The Child-Pugh score was the only independent predictive factor for bacterial translocation (odds ratio 2.22, P = 0.02). CONCLUSIONS Translocation of enteric organisms to mesenteric lymph nodes is increased in patients with advanced cirrhosis and is reduced to the level found in non-cirrhotic patients by selective intestinal decontamination.

Hepatocellular carcinoma and cirrhosis. Results of surgical treatment in a European series.

OBJECTIVE The authors analyze the outcomes of patients with hepatocellular carcinoma (HCC) and cirrhosis who underwent liver resections. BACKGROUND Liver resection is the best option for HCC arising from hepatic cirrhosis. The experience of Western centers with these patients is shorter than the Asian series. METHODS Forty-eight consecutive patients with cirrhosis and HCC who underwent liver resections were studied after a similar diagnostic and therapeutic process. Survival and cumulative recurrence were calculated according to pathologic findings. RESULTS Factors influencing survival at 3 years were as follows: type of resection, absence of vascular invasion, size of the tumor, absence of satellite nodules, and the number of nodules. Factors influencing the rate of recurrence at 3 years were the presence of vascular invasion and the presence of satellite nodules. Patients with favorable prognostic factors have a good survival rate with an acceptable recurrence rate. CONCLUSIONS Identification of prognostic factors may help in the selection of the appropriate treatment for these patients with HCC and cirrhosis.

Liver Transplant Using Donors After Unexpected Cardiac Death: Novel Preservation Protocol and Acceptance Criteria

Donors after cardiac death (DCD) suffer irreversible cardiac arrest prior to donation. We describe our liver transplant experience with DCD whose cardiac arrest is unexpected, not following the removal of ventilatory support, whom we maintain with normothermic extracorporeal membrane oxygenation (NECMO). A potential donor goes into cardiac arrest outside the hospital and is brought to the hospital under continuous cardiopulmonary resuscitation (CPR). The donor is declared dead and placed on a cardiocompressor. Femoral vessels are cannulated and connected to cardiopulmonary bypass (CPB) to establish NECMO. Blood parameters and CPB pump flow are monitored throughout NECMO, which is continued until cold preservation. From April 2002 to May 2006, 10 of 40 potential DCD livers were transplanted. Only one graft was lost to primary nonfunction (PNF) and another to hepatic artery thrombosis. Posttransplant hepatic function was good. Certain parameters, such as CPR and NECMO times, hepatic transaminases during NECMO, and donor age, determined the viability of DCD liver grafts and were used to establish criteria for their acceptance. Though considered marginal, unexpected DCD can represent an important source of viable livers for transplant if strict acceptance criteria are employed and they are maintained with NECMO prior to recovery.

Laparoscopic Approach to Pheochromocytoma: Hemodynamic Changes and Catecholamine Secretion

Abstract. This study compares the outcome of laparoscopic adrenalectomy (LpA) in 23 patients using CO 2 insufflation with the outcome of this procedure in another 8 patients with pheochromocytoma (7 unilateral, 1 bilateral) using helium for pneumoperitoneum. The adrenal lesions in the first group included nonfunctional adenoma (n = 3), aldosterone adenoma (n = 11), Cushing’s adenoma (n = 6), and Cushing’s disease (n = 3). The latter patients were compared with a third group of 8 patients with pheochromocytoma undergoing conventional transabdominal adrenalectomy (CTA). With both procedures, intraoperative changes in plasma catecholamine levels were studied during pheochromocytoma removal and the changes correlated with intraoperative cardiovascular derangements. LpA was successfully performed in 95% of patients with adrenal lesions and in 100% of patients with pheochromocytoma. There was no significant difference in laparoscopic adrenalectomy for pheochromocytoma compared to that for other adrenal lesions in terms of operative time, blood loss, hospital stay, analgesic requirements, and return to normal activity. The outcome was less favorable in pheochromocytoma patients undergoing CTA. The largest increase of catecholamine levels in pheochromocytoma patients occurred during tumor manipulation with both LpA (17.4-fold for epinephrine and 8.6-fold for norepinephrine) and CTA (34.2-fold for epinephrine and 13.7-fold for norepinephrine), but cardiovascular instability was associated only with CTA. LpA may become the technique of choice for surgical removal of adrenal lesions and may also become the preferred method for removing pheochromocytoma.

Superior Preservation of DCD Livers With Continuous Normothermic Perfusion

Objective:Unexpected donation after cardiac death (DCD) donors suffer cardiac arrest suddenly and are maintained with normothermic extracorporeal membrane oxygenation (NECMO) while consent for donation is obtained. The objective of this study was to determine whether ex vivo normothermic machine perfusion (NMP) improves upon the benefits of NECMO in a large-animal model of unexpected DCD liver transplant. Methods:Donor pigs underwent 90-minute cardiac arrest and were divided in to 3 groups. In the first, livers were preserved immediately with cold storage (CS, n = 6). In the other 2 groups, donors underwent 60-minute NECMO followed by CS (NECMO+CS, n = 6) or NMP (NECMO+NMP, n = 6). After 4–hour preservation, livers were transplanted into recipient pigs. Results:Five-day survival was 0 in CS, 83% in NECMO+CS, and 100% in NECMO+NMP. After reperfusion, injury, and inflammatory markers rose significantly among CS grafts, all of which developed primary nonfunction. Sixty minutes of NECMO, however, resulted in only 1 death, whereas NECMO followed by NMP led to no deaths and significant improvements in injury, inflammation, and synthetic function in comparison to NECMO and CS. Conclusion:Although 60 minutes recuperative NECMO is better than CS alone, NMP improves further on NECMO and may have a role in preserving DCD livers in the clinical setting.

Applicability and Results of Maastricht Type 2 Donation After Cardiac Death Liver Transplantation

Maastricht type 2 donation after cardiac death (DCD) donors suffer sudden and unexpected cardiac arrest, typically outside the hospital; they have significant potential to expand the donor pool. Herein, we analyze the results of transplanted livers and all potential donors treated under our type 2 DCD protocol. Cardiac arrest was witnessed; potential donors arrived at the hospital after attempts at resuscitation had failed. Death was declared based on the absence of cardiorespiratory activity during a 5‐min no‐touch period. Femoral vessels were cannulated to establish normothermic extracorporeal membrane oxygenation, which was maintained until organ recovery. From April 2002 to December 2010, there were 400 potential donors; 34 liver transplants were performed (9%). Among recipients, median age, model for end‐stage liver disease and cold and reperfusion warm ischemic times were 55 years (49–60), 19 (14–21) and 380 (325–430) and 30 min (26–35), respectively. Overall, 236 (59%) and 130 (32%) livers were turned down due to absolute and relative contraindications to donate, respectively. One‐year recipient and graft survivals were 82% and 70%, respectively (median follow‐up 24 months). The applicability of type 2 DCD liver transplant was <10%; however, with better preservation technology and expanded transplant criteria, we may be able to improve this figure significantly.

laparoscopic Unilateral and Bilateral Adrenalectomy for Cushing's Syndrome : transperitoneal and Retroperitoneal Approaches

OBJECTIVE This prospective randomized study compares the safety and efficacy of transperitoneal laparoscopic adrenalectomy (TLPA) and retroperitoneal approach (RLPA) in obese patients with Cushings syndrome. SUMMARY BACKGROUND DATA Recently, a retroperitoneal laparoscopic approach has been described with benefits of avoiding the respiratory and hemodynamic effects of carbon dioxide (CO2) pneumoperitoneum and giving direct access without the need to mobilize abdominal organs. METHODS Twenty-one adrenalectomies were performed in 9 patients (2 men, 7 women; mean age, 46.33 +/- 19.41 years old; range, 16 to 74 years old) with Cushings adenoma and in 6 women (mean age, 41.83 +/- 9.97 years old; range, 34 to 62 years old) with Cushings disease. Randomization gave 10 TLPA and 11 RLPA. Arterial blood gas samples, mean arterial pressure, heart rate, and clinical parameters were evaluated. RESULTS The partial pressure of carbon dioxide (PaCO2) increased in both retroperitoneal and transperitoneal CO2 insufflation compared with basal values (p < 0.01), and the TLPA showed a greater rise in the PaCO2 level compared with the RLPA at 30 minutes (p < 0.05); simultaneously, a significant increase (p < 0.05) of mean arterial pressure was observed in the TLPA compared with RLPA. No significant changes in heart rate were observed in both groups. The operative time with the TLPA and RLPA in patients with adenoma was 88.75 versus 105 minutes, respectively (p = not significant [NS]), and in patients with bilateral hyperplasia was 271.66 versus 305 minutes, respectively (p = NS). No patients required blood transfusions. The number of doses of analgesic with TLPA and RLPA in patients with adenoma was 3.25 versus 3.5, respectively (p = NS), and in patients with bilateral hyperplasia was 7.66 versus 7.33, respectively (p = NS). The hospital stay with TLPA and RLPA in patients with adenoma was 3.0 versus 2.75 days, respectively (p = NS), and in patients with bilateral hyperplasia was 6.0 versus 6.66 days, respectively (p = NS). The days to return to normal activity with TLPA and RLPA in patients with adenoma were 12.5 versus 12.25, respectively (p = NS), and in patients with bilateral hyperplasia were 19.66 versus 19.33, respectively (p = NS). Two patients with bilateral hyperplasia and TLPA had urinary infection. CONCLUSIONS Transperitoneal laparoscopic adrenalectomy and RLPA may become the techniques of choice for surgical removal of the adrenal lesions in Cushings syndrome. The retroperitoneoscopic approach might be a better option in patients with previous abdominal surgery and in patients with pre-existing cardiorespiratory disease.

The Effect of Normothermic Recirculation is Mediated by Ischemic Preconditioning in NHBD Liver Transplantation

We have evaluated the involvement of hepatic preconditioning mediators (adenosine, adenosine A1 and A2 receptors) during normothermic recirculation (NR) in a model of liver transplantation from non‐heart‐beating donor (NHBD) pigs.