Serge Dubé

Adjuvant chemotherapy in colorectal carcinoma

Despite the National Institutes of Health consensus regarding use of adjuvant chemotherapy in colorectal carcinoma, many general surgeons question the efficacy of this approach when considering costs involved for both the individual patient and society at large. PURPOSE: This study was designed to determine the real impact of adjuvant chemotherapy on five-year survival rates of patients. METHOD: A qualitative and quantitative meta-analysis of results from 39 randomized clinical trials published from 1959 to 1993 is described. RESULTS: Design quality of clinical trials had a mean score of 48.6 percent (±6.2 standard deviation). A small benefit of therapy in terms of overall survival was noted, with a mortality odds ratio (OR) of 0.91 (confidence interval (CI) 95 percent, 0.83–0.99). For the group of colon carcinomas, the OR was 0.81 (CI 95 percent, 0.69–0.94) with an OR of 0.64 (CI 95 percent, 0.48–0.85) for the group of rectal carcinomas. The effect size was 0.09 for the colon group and 0.20 for the rectal group. For those patients who receive chemotherapy, this effect size implies that we can expect an increase of 5 percent in the survival rate in the group with colon carcinoma and a 9 percent increase in the survival rate in the group with rectal carcinoma. CONCLUSION: Given the high incidence of colorectal carcinoma, the small benefit observed for those patients receiving chemotherapy is far from negligible. However, indications for adjuvant chemotherapy warrant further discussion.

Risk factors for mortality following emergency colectomy for fulminant Clostridium difficile infection.

PURPOSE: This study evaluated risk factors for mortality after emergency colectomy for fulminant Clostridium difficile infection. METHODS: Retrospective study of 130 cases of Clostridium difficile infection that required a colectomy between 1994 and 2007 in four hospitals of Quebec, Canada. Primary outcome was 30-day mortality. RESULTS: Twenty-five cases underwent colectomy in 1994 to 2002, 41 in 2003, 40 in 2004, and 24 in 2005 to 2007. Common indications were septic shock (41 percent) and nonresponse to medical treatment (39 percent). Overall, 30-day mortality was 37 percent. Mortality increased with age but was not influenced by comorbidities burden. Mortality correlated with preoperative lactate (≤2.1 mmol/L: 26 percent; 2.2-4.9 mmol/L: 52 percent; ≥5.0 mmol/L: 75 percent, P < 0.001), leukocytosis (<20.0 × 109/L: 32 percent; 20.0-49.9 × 109/L: 33 percent; ≥50.0 × 109/L: 73 percent, P = 0.008), albumin (≥25 g/L: 19 percent; 15-24 g/L: 38 percent; <15 g/L: 52 percent, P = 0.04) and renal failure. In multivariate analysis, risk factors for mortality were age (per year, adjusted odds ratio: 1.03, 95 percent confidence interval: 1.00-1.06), preoperative lactate greater than or equal to 5.0 mmol/L (adjusted odds ratio: 10.32, 95 percent confidence interval: 2.59-41.1), leukocytosis greater than or equal to 50.0 ×109/L (adjusted odds ratio: 3.68, 95 percent confidence interval: 0.92-14.8) and albumin less than 15 g/L (adjusted odds ratio, 6.57, 95 percent confidence interval: 1.31-33.1). CONCLUSIONS: Incidence of Clostridium difficile infection-related emergency colectomies increased 20-fold during the epidemic. Postoperative mortality can be predicted by simple laboratory parameters. Three-fourths of patients with leukocytosis greater or equal to 50.0 ×109/L or lactate greater or equal to 5.0 mmol/L died. When possible, emergency colectomy should be performed earlier.

Determining gastric contents during general anaesthesia: evaluation of two methods

Two methods used to measure the volume of gastric contents were evaluated in 24 supine anaesthetized adults. Methods compared were: (1) aspiration of stomach contents through a large, vented, multi-orificed gastric tube, and (2) indirect determination by a dye dilution method using polyethylene glycol (PEG) as the marker. The volumes determined by these methods (Vasp and Vpag respectively) were compared to the total volume (Vtot) present in the stomach, determined by direct inspection of the gastric pouch by the surgeon at the beginning of surgery. The results show that the volume of aspirated gastric fluid, using this type of tube, is a very good estimate of the total volume of gastric residue. The PEG dilution method yields similar results. However, correlation between Vpeg and Vtot was not as close-fitting as the correlation between Vasp and Vtot. PEG dilution is more complicated, time-consuming and offers no advantage over aspiration.RésuméCette étude avait pour but de valider, chez ľadulte anesthésié en décubitus dorsal, deux méthodes de mesure du volume du résidu gastrique couramment disponibles en clinique. Il s’agit de 1) ľaspiration directe du contenu gastrique avec une sonde de gros calibre, ventilée et pouvue ďorifices multiples, et de 2) la mesure indirecte du volume gastrique par dilution de ľindicateur polyéthylène glycol (PEG). Les volumes mesurés par ces deux méthodes étaient comparés au volume absolu présent dans ľestomac déterminé par inspection directe au début de la laparotomie. Nos résultats démontrent que le volume mesuré par aspiration directe, lorsque ľon utilise ce type de sonde, est une bonne évaluation du volume du contenu liquide de ľestomac, le sous-estimant ďenviron 4 ml. La méthode utilisant la dilution du PEG fournit également des résultats satisfaisants. La technique est cependant plus compliquée, nécessite la collaboration du laboratoire, et n’offre aucun avantage sur ľaspiration directe.

Postoperative myocardial infarction and cardiac death. Predictive value of dipyridamole-thallium imaging and five clinical scoring systems based on multifactorial analysis.

Sixty-six patients unable to complete a standard preoperative exercise test because of physical limitations were studied to determine the predictive value of individual clinical parameters, of clinical scoring systems based on multifactorial analysis, and of dipyridamole-thallium imaging before major general and vascular surgery. Study endpoints were limited to postoperative myocardial infarction or cardiac death before hospital discharge. There were nine postoperative cardiac events (seven deaths and two nonfatal infarctions). There was no statistical correlation between cardiac events and preoperative clinical descriptors, including individual clinical parameters, the Dripps-American Surgical Association score, the Goldman Cardiac Risk Index score, the Detsky Modified Cardiac Risk Index score, Eagles clinical markers of low surgical risk, and the probability of postoperative events as determined by Coopermans equation. There were no cardiac events in 30 patients with normal dipyridamole-thallium scans or in nine patients with fixed myocardial perfusion defects. Of 21 patients with reversible perfusion defects who underwent surgery, nine had a postoperative cardiac event (sensitivity, 100%; specificity, 43%). In the six other patients with reversible defects, preoperative angiography showed severe coronary disease or cardiomyopathy. Thus in patients unable to complete a standard exercise stress test, postoperative outcome cannot be predicted clinically before major general and vascular surgery, whereas dipyridamole-thallium imaging successfully identified all patients who sustained a postoperative cardiac event.

Blunt diaphragmatic rupture

Diaphragmatic injury is often a missed diagnosis in patients with multiple trauma. For this reason, mortality can be high. From 1970 to 1981, 32 patients with diaphragmatic injuries were seen at Maisonneuve-Rosemont Hospital. Twenty-four of the patients (22 men and 2 women aged 18 to 79 years) had blunt abdominal or thoracic trauma causing diaphragmatic disruption. Rupture occurred 20 times on the left side of the diaphragm, and 3 times on the right side. There was one pericardiophrenic rupture. Motor vehicle accident was the most common cause of trauma. On arrival, 21 patients had acute diaphragmatic rupture. Clinical signs and radiography permitted early diagnosis in 15 patients, whereas diagnosis was made later in 3 other patients because of deterioration of vital signs. In two patients, diagnosis was made at laparotomy for another reason. Four patients were operated on for post-traumatic chronic diaphragmatic hernia. The abdominal approach was used in 18 patients, the thoracic approach in 4, and the thoracoabdominal approach in 2. Three patients died, two of whom had a late diagnosis. Fourteen patients had no complications. Diaphragmatic trauma can be easily managed surgically when diagnosis is made early after trauma. It must always be looked for in patients with multiple trauma.

Fatal Clostridium difficile enteritis caused by the BI/NAP1/027 strain: a case series of ileal C. difficile infections.

Clostridium difficile generally causes diarrhoea and colitis. Small-bowel infections are considered to be rare. Twelve cases of ileal C. difficile infections are presented, including the first reported case proven to be caused by the hypervirulent BI/NAP1/027 strain. This case series suggests that small bowel involvement in C. difficile infections may be more frequent than previously thought.

Acute colonic surgery and unrecognized hypothyroidism: A warning

PURPOSE: This study was designed to highlight the significant morbidity related to undetected hypothyroidism in the elderly who are undergoing emergency surgery. METHOD: Case reports of six patients who presented with acute colonic surgical conditions are reviewed. RESULTS: Six cases of undetected hypothyroidism in a group of elderly patients was unmasked at the time of surgery for acute colonic conditions or in the perioperative period. These patients experienced increased morbidity, but once detected and treated, all but one had an uneventful recovery. CONCLUSION: Unrecognized hypothyroidism may lead to unnecessary surgery or even a potentially fatal outcome. A heightened awareness of this not so uncommon entity is mandatory.

Coeliac disease in an adult presenting as intussusception without a lead point

A case of adult intussusception is presented in which previously undiagnosed coeliac disease was the cause. The diagnosis was made following microscopic examination of a resected segment of small intestine containing multiple intussusception sites. Adult intussusception is rare and in most cases associated with a ‘lead point’ lesion, often a tumour. As illustrated here, intussusception without a lead point in the adult patient may be the presenting sign of coeliac disease. Recognition of such may allow correct diagnosis and thus prevent unnecessary surgery.

The Concordance of Judgement Learning Tool

of 50 physicians, postgraduate specialists, senior nurses, medical and nursing students and patients. Participants were asked to narrate critical incidents related to deficiencies in communication skills in physicians in which they had been involved or which they had witnessed first-hand. Eighty-one critical incident narrations were recorded and transcribed. They were analysed and grouped according to themes, categories and sub-categories. Communication skills deficiencies were identified from the themes, categories and sub-categories. In-depth analysis of communication gaps, cultural or contextual influences and their medical consequences were identified. One critical incident referred to the failure of a physician to identify the locus of decision making. An individual in need of surgery for a hernia was also at risk for cardiac complications during surgery. The patient felt that his family needed to make the decision, whereas the physician demanded that he make the decision. Another example referred to the fact that ward rounds are usually conducted in English, a language most patients do not understand. One day during discussions at the bedside, the word ‘surgery’ was mentioned causing much unnecessary anxiety and alarm in an elderly female patient. These are two of the incidents narrated which illustrate poor communication with medical consequences. What lessons were learned? Four categories of communication deficiency were developed from the narrated incidents: (i) content omission (8 sub-categories); (ii) inappropriate responses (6 sub-categories); (iii) inappropriate setting (4 sub-categories), and (iv) non-verbal communication issues (6 subcategories). These categories and sub-categories formed an interrelated framework for the content and learning activities of a new communication skills course for Sri Lankan doctors. Critical incident analysis themes provided the content necessary to design a culturally and contextually relevant solution to a significant problem in physician communication in Sri Lanka. The 81 authentic scenarios will also be useful in the teaching process during this course.