Postoperative Morbidity Following Chemoradiation for Locally Advanced Low Rectal Cancer

Background  Postoperative morbidity remains a significant clinical problem and may alter long-term outcome particularly after neoadjuvant chemoradiation in patients with locally advanced low rectal cancer. The aim of the present study was to identify a potential long-term effect of postoperative morbidity. Methods  Analysis of prospectively collected data of 90 consecutive patients who underwent neoadjuvant chemoradiation and curative mesorectal excision for locally advanced (cT3/4, Nx, M0/1) adenocarcinoma of the mid and lower third of the rectum during a 7-year period (1996–2002). Results  Major postoperative complications occurred in 17.8% and minor complications in 26.6% of patients. Hospital mortality and 30-day mortality was 0%. Infectious complications were seen in 34.5%. The leading causes of infectious complications were anastomotic leakage and perineal wound infection. Postoperative morbidity was statistically significantly associated with gender (P < 0.05), pre-therapeutic haemoglobin level (P < 0.05), ASA score (P < 0.05), hospitalisation (P < 0.001) and clinical long-time course (P < 0.01). Moreover, early postoperative morbidity was proven as an independent prognostic factor concerning disease-free (P < 0.05) and overall survival (P < 0.05). Conclusion  Early postoperative morbidity in patients with preoperative chemoradiation due to locally advanced low rectal cancer is demonstrated as an independent prognosticator. Gender, pre-therapeutic haemoglobin level and ASA score indicate patients at risk for early postoperative complications and may therefore serve as predictive features.     

Usefulness of perioperative blood glucose control in patients undergoing off-pump coronary artery bypass grafting

Objective We investigated the usefulness of perioperative blood glucose control in patients undergoing coronary artery bypass grafting (CABG). Methods DM patients were aggressively treated with intensive insulin therapy to achieve a preoperative fasting blood glucose level of 140 mg/dl and a postoperative level of 200 mg/dl. For comparison, patients were divided as follows: (1) DM group vs. non-DM group, and (2) for mean blood glucose level in the intensive care unit (ICU), lower than 200 mg/dl (IL) vs. 200 mg/dl or higher (IH). Results (1) In the DM group, the amount of insulin (U) used during surgery was greater (P < 0.05), and the duration of ICU stay was longer (P < 0.05). The incidence of all complications was higher in the DM group (P < 0.05). (2) Between the IH group (54) and the IL group (82), the proportion of DM patients was higher in the IH group (75% vs. 38%, P < 0.05). In the IH, the duration of ICU stay (P < 0.01) was longer, and the incidence of all complications was higher (P < 0.05). (3) In the DM group, the incidence of complications tended to be higher in the IH group. The incidence of complications was extremely low in the non-DM group. Conclusion Strict perioperative blood glucose control may help to improve the outcomes of CABG.     

Evaluation of lithogenic elements in urine of healthy newborns

The determination of urinary excretion of lithogenic elements in healthy newborns involves factors ranging from urine collection and data handling to maternal influences, which can cause difficulties in analyzing the results. The objective of this study was to determine normal values of parameters related to lithogenesis, such as calcium, uric acid, citrate, and oxalate, in urine of healthy newborns using isolated samples, focusing on variations according to gender, weight, milk ingestion, and family history of lithiasis. Parameters measured in isolated urine samples from 104 healthy newborns (77 males and 27 females) were corrected by creatinine. The ratios were expressed as milligram/milligram of creatinine: calcium/creatinine of 0.10±0.01 (X±SE), uric acid/ creatinine of 1.10±0.10, citrate/creatinine of 0.56±0.04, and oxalate/creatinine of 0.07±0.01. Differences were observed between males and females, in terms of uric acid (0.80±0.07 vs. 1.10±0.10 mg/mg, P<0.05), citrate (0.05±0.06 vs. 0.17±0.05, P<0.05), sodium (0.17± 0.01 vs. 0.05±0.01, P<0.001), and potassium (0.05± 0.01 vs. 0.20±0.02, P<0.001). Interestingly, the urinary concentration of protector factors such citrate and potassium was higher in females than in males with low sodium excretion. Artificial milk feeding leads to higher calcium (0.10±0.06 vs. 0.06±0.01), uric acid (1.40±0.20 vs. 0.90±0.09, P<0.05), citrate (0.90±0.09 vs. 0.50±0.04, P<0.001), and oxalate (0.17±0.03 vs. 0.05±0.01, P<0.001) excretion when compared with breast feeding. There was higher excretion of calcium and sodium in patients under 3 kg. Children with familial antecedents presented some differences in urinary excretion, with higher uric acid (1.50±0.30 vs. 0.80±0.08, P<0.05) but lower calcium (0.05±0.02 vs. 0.10±0.01, P<0.05) and sodium (0.15±0.02 vs. 0.20±0.02, P<0.05) excretion, respectively. This report provides urinary parameters obtained in healthy newborns and correlates them with factors that could be involved in the genesis of osteopenia, renal stones, and/or nephrocalcinosis. Received: 8 May 2000 / Revised: 7 June 2001 / Accepted: 12 June 2001     

Efficacy of Postoperative Transarterial Chemoembolization and Portal Vein Chemotherapy for Patients with Hepatocellular Carcinoma Complicated by Portal Vein Tumor Thrombosis—a Randomized Study

Objectives The aim of this single, randomized study was to explore the efficacy of postoperative transarterial chemoembolization (TACE) and portal vein chemotherapy (PVC) for patients with hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombosis (PVTT) and to evaluate prognostic factors. Methods The study cohort consisted of 112 patients with HCC and PVTT randomly divided into three groups: Group A (37 patients), operation only; Group B (35 patients), operation plus TACE; Group C (40 patients), operation plus TACE and PVC. Disease-free survival rates and prognostic factors were analyzed. Results Most of the side effects and complications were related to the operation, catheters, and local chemotherapy and included liver decompensation (15.0%), catheter obstruction (11.6%), and nausea and loss of appetite (22.1%). The disease-free survival curve was significantly different among the three groups, as estimated by the Kaplan-Meier method (both P < 0.05). Group C showed a significantly higher disease-free survival rate than Group A (P < 0.05), but no statistical differences were found between group A and group B, and group B and group C (both P > 0.05). Tumor size, tumor number, PVTT location, and treatment modalities were independent prognostic factors (P < 0.05). Conclusion Postoperative TACE combined with PVC may benefit the survival of patients with HCC complicated by PVTT in the short-term (less than 60 months), but long-term efficacy is not yet certain and needs to be confirmed by further studies.     

Most Common Intoxication in Nephrology Ward Organophosphate Poisoning

Objectives. In Taiwan, the widespread use of organophosphates (OPs) in agricultural and household environments results in numerous OP poisoning. To better understand the clinical significance of associated parameters on respiratory failure and patient outcome, we evaluate patients admitted to the Nephrology ward in our hospital with OP intoxication. Patients and Methods. Over a period of 2 years, a total of 42 consecutive patients with OP poisoning admitted to the nephrology ward or the Intensive Care Unit of Chang‐Gung Memorial Hospital were the subjects in the study. The diagnosis of poisoning was based on history of ingestion and characteristic clinical features of anticholinesterase agent poisoning. Prior to treatment, all symptoms recorded at emergency room and blood samples for blood chemistry including plasma amylase and plasma acetyl‐cholinesterase were collected from each patient immediately after the admission. Results. As clinical manifestations of OP show, nausea and vomiting and salivation were the leading manifestations, 45.2% and 33.3%, respectively. Patients who developed respiratory failure were older than those who did not (54.3 ± 6.9 vs. 43.1 ± 5.6, p < 0.05). The dosage of atropine administered for treatment was significantly higher in the patient group with respiratory failure compared to those without respiratory failure (29.7 ± 14.5 vs. 9.1 ± 10.2, p < 0.05). Plasma amylase level of the patient group with respiratory failure was significantly higher than those without respiratory failure (436.1 ± 87.1 vs. 181.3 ± 29.6, p < 0.01). Of course, mean days of hospitalization in the respiratory failure group are significantly longer than the other group (12.1 ± 2.1 vs. 5.4 ± 1.9, p < 0.05). Based on univariant analysis, bradycardia, hypotension, fasciculation and coma were significant factors associated with respiratory failure. The dose of atropine administered for treatment was significantly higher in the oral exposure group compared to nonoral exposure group (23.6 ± 12.6 vs. 10.6 ± 6.4, p < 0.05). The same is true for the pralidoxime treatment (9.6 ± 1.9 vs. 5.3 ± 1.4, p < 0.05). As for mean days of hospitalization (11.6 ± 3.9 vs. 6.4 ± 2.1, p < 0.05) and fatality (2 vs. 0, p < 0.05), those of oral exposure patients were significantly longer and higher than those with nonoral exposure. Conclusions. We demonstrate that elevated plasma amylase concentration was related to the development of respiratory failure in OP intoxication. It also provided us various important risk factors to identify those patients with OP poisoning who would ultimately require ventilatory support.     

Elevated circulating levels of soluble CD-40 ligand in haemodialysis patients with symptomatic coronary heart disease

Aim: The CD40–CD40L system has been implicated in the pathogenesis of atherothrombotic complications in cardiovascular disease. The aim of this study was to determine the relationship between plasma soluble CD40 ligand (sCD40L) and symptomatic coronary heart disease (CHD) in end-stage renal disease (ESRD) patients on maintenance haemodialysis (HD). Methods: This cross-sectional study included 57 HD patients, 31 of whom had symptomatic CHD. Lipid profile, markers of endothelial activation such as sCD40L, and both inflammatory and oxidative stress markers were measured and analyzed. Results: The sCD40L concentration was significantly higher in HD patients than in controls (1.34 ± 0.53 vs 0.86 ± 0.12 ng/mL, P < 0.01). Plasma concentration of sCD40L (P < 0.01), soluble vascular adhesion molecule-1 (sVCAM-1; P < 0.01) and high-sensitivity CRP (hsCRP; P < 0.01) were higher in HD patients with symptomatic CHD than in those without CHD. In addition, we also found that oxidative stress biomarkers such as nitrotyrosine (NT), malonaldehyde (MDA) and protein carbonyl (PC) were significantly elevated in patients with symptomatic CHD compared to those without. There was a strong overall positive relationship between sCD40L concentration and sVCAM-1 (r = 0.54, P < 0.001), MDA (r = 0.365, P < 0.01), NT (r = 0.293, r < 0.05) and log-transformed triglycerides (r = 0.275, P < 0.05). Conclusion: Circulating concentrations of sCD40L were elevated in HD patients with symptomatic CHD. This study suggests that CD40–CD40L may play a potentially important role in the atherosclerotic complications of HD patients.     

Long-Term Safety of Autotransfusion During Hepatectomy for Hepatocellular Carcinoma

Purpose To evaluate the long-term safety of autotransfusion (AT) in hepatectomy for hepatocellular carcinoma (HCC). Methods Between 1988 and 1989, 46 patients with HCC underwent hepatectomy with AT (group 1). For a comparison, we matched 50 patients with HCC who underwent hepatectomy, and received homologous but not autologous blood (group 2). The 10-year cumulative survival curves and cancer-free curves of the two groups were examined, and the pattern of recurrence was compared. Results Group 1 had a significantly higher cumulative 10-year survival rate than group 2, at 20% vs 8%, respectively (P < 0.05). Among the patients who underwent curative resection, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 27% vs 11% (P < 0.05) and 13% vs 0% (P < 0.05), respectively. Among the patients with stage I–II HCC, those in group 1 had significantly better cumulative survival and cancer-free survival rates than those in group 2, at 30% vs 5% (P < 0.01) and 20% vs 5% (P < 0.05), respectively. However, the rates were similar among patients with stage III–IV disease in both groups. The pattern of recurrence in the two groups was similar. Conclusion Autotransfusion promoted survival in patients undergoing hepatectomy for stage I or II HCC.     

Apoptosis as a Prognostic Factor in Colorectal Carcinoma

P < 0.05); in tumors showing evidence of moderate differentiation than in well-differentiated tumors (P < 0.05); and in tumors with venous invasion or lymph node metastasis than in those without these features (P < 0.05). Moreover, the subgroup of patients with a low AI of <4.1 had a significantly poorer survival rate than the subgroup with a high AI in tumors at Dukes stage C, the 5-year survival rates being 33% vs 68% (P < 0.05; Cox-Mantel). Our findings suggest that less apoptosis might result in a greater progression of colorectal carcinoma, and that the rate of apoptosis might be an indicator of the degree of malignancy. Thus it would appear that the frequency of apoptosis in tumor cells could be a useful prognostic factor in colorectal carcinoma. (Received for publication on Sept. 17, 1996; accepted on May 12, 1997)     

A Change in Practice from Epidural to Intrathecal Morphine Analgesia for Hepato-Pancreato-Biliary Surgery

Background  This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery. Methods  All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay. Results  During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3–11) liters vs. 5 (3–11) liters, P < 0.05) and in total (15.5 (5–48.5) liters vs. 9 (3–70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3–36) days vs. 7 (3–55) days, P < 0.01). Conclusions  In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.     

The incidence and outcome of pelvic sepsis following handsewn and stapled ileal pouch anal anastomoses

P < 0.05). The incidence of pelvic sepsis in patients with UC complicated by toxic megacolon and/or fulminant colitis was significantly higher that in those without any preoperative complications, at 36.4% vs 7.4% (P < 0.05). The incidence of pelvic sepsis following handsewn anastomosis was significantly higher than that following stapled anastomosis, at 15.6% vs 5.5% (P < 0.05). The outcome of pelvic sepsis in patients with a stapled anastomosis was better than that in those with a handsewn anastomosis. The prognosis of women who developed pelvic sepsis was better than that of men who developed pelvic sepsis. The risk factors predisposing to pelvic sepsis were UC, especially when complicated by toxic megacolon and/or fulminant colitis, and male sex, while a handsewn anastomosis was more vulnerable than a stapled anastomosis. (Received for publication on Dec. 2, 1998; accepted on Sept. 17, 1999)