The Outcome of Self-Expanding Metal Stents in Elderly Patients

Background and Objectives:

Emergency surgery for large bowel obstruction is associated with high morbidity and mortality rates, especially in elderly patients. Colonic self-expanding metal stents may provide temporary relief of obstructions and enable preoperative evaluation. The aim of this retrospective study was to assess the clinical outcomes of emergency stenting in elderly patients with large bowel obstructions.

Methods:

Between 1997 and 2010, patients presenting with large bowel obstructions were treated predominantly with self-expanding metal stent insertion. Clinical data, including age, site of obstruction, success rate, and surgery and mortality rates, were collected. Patients were divided into 3 groups (I, II, and III) according to age: <69, 70 to 79, or >80 years.

Results:

One hundred thirty-two consecutive patients underwent stent implantation, with a mean age of 72.1 years (range, 28–95 years). Similar diversity of sex, indication, and stricture location was found. There were no significant differences in clinical success (88.7%, 73.8%, and 78.4%, P = .16) and stent-related mortality (2.1%, 3.3%, and 3.6%, P = 1.00). Similar rates of stoma creation were also found (59.3%, 46.7%, and 60.0%, P = .76). In contrast, rates of surgery were lower in older patients (50.9%, 38.1%, and 13.5%, P = .0013), and mortality during the same admission was significantly higher in patients >70 years of age (4.0%, 15.0%, and 22.2%, P = .027). Kaplan-Meier 30-day survival curves for the 3 groups showed a trend toward earlier death among patients >70 years of age.

Conclusions:

This study demonstrates that stenting provides similar success rates in all age groups but is associated with higher mortality rates in older patients.     

Surgery as a Bridge to Palliative Chemotherapy in Patients with Malignant Bowel Obstruction from Colorectal Cancer

Background Malignant bowel obstruction (MBO) is a feature of the clinical course of 10–28% of colorectal cancer (CRC) patients and is associated with a poor prognosis. Recent advancements in palliative chemotherapy regimens have prolonged survival in patients with stage IV CRC. Few reports exist that describe outcomes in patients who have had surgery for MBO and subsequent chemotherapy as part of their treatment. The objective of this study was to review surgical outcomes in patients with MBO for CRC and to evaluate the extent to which surgery can serve as a bridge to palliative chemotherapy. Methods Patients who presented with MBO and had surgical treatment were identified from a prospectively kept database at a single tertiary care center between 09/99 and 08/04. Charts were retrospectively reviewed and clinical and outcomes data were abstracted. Results Forty-seven patients were identified who had surgery as part of the treatment for MBO from CRC. Operations included resections, bypasses and stoma creation. Overall, 80% of patients were able to tolerate solid food post-operatively and return home. The median survival for the entire cohort was 3.5 months. Seven patients died within 30 days of surgery. Of the remainder, 24 patients were palliated with surgery alone and 16 patients ultimately received palliative chemotherapy. Survival in the final cohort was significantly prolonged (P < 0.001). Conclusion Surgery can adequately palliate a substantial proportion of patients with MBO from CRC with acceptable morbidity and mortality. In addition, in a subset of patients it can facilitate palliative chemotherapy that is associated with improved overall survival. Dr. Calvin Law is a Career Scientist of the Ontario Ministry of Health and Long Term Care and is supported through a Health Research Personnel Development—Career Scientist Award.     

Oncologic Outcomes of Self-Expanding Metallic Stent Insertion as a Bridge to Surgery in the Management of Left-Sided Colon Cancer Obstruction: Comparison with Nonobstructing Elective Surgery

Background  Self-expanding metallic stents (SEMS) have been used as a bridge to surgery in patients with obstruction by colorectal cancer, but the oncologic safety of this technique has not yet been established. The aim of the present study was to compare the outcomes of bridge to surgery after SEMS insertion and nonobstructing elective surgery. Methods  Between October 1999 and July 2007, 35 patients who had left-sided colon malignancy obstruction and underwent surgical resection after SEMS insertion (group A) were matched to 350 patients who underwent elective surgery for nonobstructing left-sided colon cancer based on stage II, III, and IV malignancies according to the 2001 American Joint Committee on Cancer (group B). Group B was randomly extracted from the colorectal database of our institute. The two groups were compared for clinicopathologic variables, complications, and survival rate. Results  There were no significant differences in clinicopathologic variables between group A and group B. However, the stoma formation rate was statistically different between the two groups (p = 0.003). Self-expanding metallic stent insertion had an adverse effect on the 5-year overall survival rate (A vs. B, 38.4% vs. 65.6%, respectively; p = 0.025) and the 5-year disease-free survival rate (A vs. B, 48.3% vs. 75.5%, respectively; p = 0.024). Conclusions  These data show that insertion of SEMS as a bridge to surgery in the management of left-sided colon cancer obstruction is possibly associated with adverse oncologic outcomes compared with nonobstructing elective surgery, but it is unclear what magnitude of this effect is related to the underlying obstruction rather than to the SEMS.     

Use of Flexible Endoscopic Scissors to Cut Obstructing Suture Material in Gastric Bypass Patients

With the epidemic increase in obesity in the USA and consequent increased demand for bariatric surgery, new complications of the surgery are being described. The most common surgery practiced is the Roux-en-Y gastric bypass (RYGBP). Unraveling of suture material at the gastrojejunal anastomosis may occur, which may be troublesome if nonabsorbable suture is employed. We describe, for the first time, two patients who developed obstructive symptoms as a consequence of food matter/bezoars entrapped within a mesh of unraveled nonabsorbable suture material at their anastomoses. One of these patients also developed ulceration, presumably as a result of pressure necrosis from the entrapped bezoar. We describe a third patient where the placement of nonabsorbable sutures led to obstructive symptoms by limiting distensibility at an otherwise satisfactory anastomosis. We also describe for the first time, the use of a new endoscopic scissors in cutting luminal suture material with subsequent resolution of the clinical problem.     

保留乳房手术治疗乳腺癌37例

目的：观察Ⅰ-Ⅱa期乳腺癌保留乳房手术加术后放疗及化疗的疗效。方法：有选择地对37例Ⅰ-Ⅱa期乳腺癌病人施行乳腺癌局部广泛切除加腋淋巴结清扫术。乳腺肿块位于1区原发癌灶与腋窝淋巴结清扫尽可能取与皮纹一致的梭形切口；位于2、4区原发癌灶取放射状切口；位于3区取放射状切口或乳腺下方弧形切口。腋窝淋巴结清扫取腋窝皱襞下横形切口，前端至胸大肌外缘，后缘不超过腋后线。术中将距肿瘤2cm边缘送快速病理检查，确保切缘无肿瘤残余。肿块切除后瘤床4个方向各放一金属标志物，以指导放疗。切线照射乳腺及胸壁，依据金属标记瘤床加用电子线照射瘤床，共达60-70cy，并辅以化疗、内分泌治疗。结果：平均随访52．8个月，均无局部复发，无远处转移，乳房无明显萎缩变形，保留乳房美容效果满意。结论：该术式是治疗Ⅰ-Ⅱa期乳腺癌的首选方法之一，并可提高病人的术后生存质量。     

The clinical outcomes of the radiologic method for self-expandable metal-stent placement in patients with colorectal obstruction: A prospective study

ObjectivesTo assess the clinical outcomes of self-expandable metal stent (SEMS) placement for patients with colorectal obstruction.MethodsA total of 61 patients underwent SEMS placement using computerized tomography (CT) to confirm malignancy of intrinsic origin and evaluate the exact location, notch, and extent of the disruptive laceration.ResultsThe overall technical success rate and clinical success rate of SEMS placement using the radiological method were 59 (96.7%) and 57 (93.4%), respectively. The technical success rate and clinical success rate of SEMS placement in the palliative and bridge to elective surgery (BTS) groups were 35 (97.2%), 24 (96.0%), 33 (91.7%), and 24 (96.0%). The median cumulative primary stent patency duration and patients’ survival of SEMS placement was 123 days (95% CI, 65–123 days), and 133 days (95% CI, 72–133 days). The median cumulative primary stent patency duration and patient survival did not differ significantly between the palliative group 119 days; (95% CI, 59–119 days), 128 days; (95% CI, 71–128 days), and the BTS group 120 days; (95% CI, 68–120 days; p = 0.362), 130 days; (95% CI, 78–130 days); p = 0.412).ConclusionsThe colorectal obstruction had convoluted with curved angulation and located mainly at the rectum, sigmoid, descending colon, and the radiologic method of SEMS placement has more efficacious with a high technical and clinical success rate. However, SEMS placement was highly technical, and clinical success with median stent patency and patient survival did not differ significantly between the palliative group and the BTS group.     

Preoperative diagnosis of obstructive colitis in colorectal cancer patients who underwent self-expandable metallic stent insertion as a bridge to surgery

PurposeObstructive colitis (OC) is a risk factor of anastomotic leakage in colorectal cancer resection. We aimed to clarify the relationship between the severity of OC and clinicopathological findings and to detect predictive factors of OC.MethodsWe retrospectively reviewed 43 cases of colectomy after self-expandable metallic stent placement for left-sided colorectal cancer. Preoperative diagnosis of OC was made by multiple modalities (initial computed tomography (CT), presurgical CT, and colonoscopy). We classified OC macroscopically in resected specimens into five groups (Grade 0: none, 1: mild [mild edema], 2: moderate [severe edema, redness, erosion], 3: severe [ulceration, bleeding], 4: very severe [necrosis, perforation]), and investigated the relationship between the preoperative assessment, surgical findings and the severity of OC.ResultsOC of Grade 2 or more (53.5%) was significantly correlated with severe edema in initial CT. There was no significant correlation between OC and anastomosis rate. The creation of covering stoma was significantly higher in the Grade 2 or more OC group. No leakage was observed in either group.ConclusionsInitial CT may be most useful for prediction of OC. It is important to make a preoperative diagnosis of OC by combining multiple modalities, which enables to determine the appropriate location for resection, anastomosis, and construction of a covering stoma.     

妇科腹腔镜手术中转开腹45例临床分析

目的探讨妇科腹腔镜手术中转开腹的原因。方法对我院2002年1月～2007年12月2630例腹腔镜手术中45例中转开腹的临床资料进行回顾性分析。结果中转开腹原因：特殊部位的子宫肌瘤25例（55.6%）,严重盆腹腔粘连10例（22.2%）,宫角妊娠3例（6.7%）,卵巢肿瘤3例（6.7%）,手术损伤3例（6.7%）,子宫腺肌瘤要求保留子宫1例（2.2%）。结论特殊部位的子宫肌瘤手术、盆腹腔粘连是妇科腹腔镜手术中转开腹的常见原因。术前加强评估可以减少手术中转开腹率,及时中转开腹可以减少并发症的发生。     

Sentinel Node Navigation Surgery Using Indocyanine Green in Patients with Lung Cancer

Purpose To investigate the potential use of sentinel node navigation surgery (SNNS) using indocyanine green (ICG) in lung cancer.Methods The subjects were 38 patients with stage cN0 lung cancer. After thoracotomy, we injected 5ml ICG and 400U hyaluronidase around the tumor, and identified the stained lymph nodes (LNs) intraoperatively by inspection. Postoperatively, we measured ICG concentrations in the dissected LNs. Lymph nodes with an ICG concentration of more than 1.5 times the mean were defined as sentinel nodes (SNs).Results There were 30 pN0, 6 pN1, and 2 pN2 cancers. The tumor size ranged from 11 to 75 (mean 31 ± 15) mm. Sentinel nodes were identified by inspection in 7 (18.4%) of the 38 patients. Lymphatic mapping with ICG concentration was successful in 38 (100%) of 38. One SN was found in 18 patients and two SNs were found in 20. The SN predicted the status of metastasis of all LNs in 37 (97%) of 38. Metastases were identified in the SN alone in 5 (62.5%) of 8. There was one false negative, caused by a metastatic LN being occupied by tumor cells.Conclusion These findings support the efficiency of SNNS for clinically node-negative lung cancer.This paper was presented at the 17th Annual Meeting of the Japanese Association for Chest Surgery, Tokyo, May 25–26, 2000     

Self-Expanding Metallic Stents for Palliation and as a Bridge to Minimally Invasive Surgery in Colorectal Obstruction

Background and Objectives:

Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. Emergency procedures had an associated mortality rate of 10% to 30%. This encouraged development of other options, most notably self-expanding metallic stents. The primary endpoint of this study to is to report our group''s experience.

Methods:

We performed a retrospective review of 37 patients who underwent self-expanding metallic stent placement for colorectal obstruction between July 2000 and May 2012. Data collected were age, comorbidities, diagnosis, intent of intervention (palliative vs bridge to surgery), complications, and follow-up.

Results:

The study comprised 21 men (56.76%) and 16 women (43.24%), with a mean age of 67 years. The intent of the procedure was definitive treatment in 22 patients (59.46%) and bridge to surgery in 15 (40.54%). The highest technical success rate was at the rectosigmoid junction (100%). The causes of technical failure were inability of the guidewire to traverse the stricture and bowel perforation related to stenting. The mean follow-up period was 9.67 months. Pain and constipation were the most common postprocedure complications.

Discussion:

The use of a self-expanding metallic stent has been shown to be effective for palliation of malignant obstruction. It is associated with a lower incidence of intensive care unit admission, shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Laparoscopic or robotic surgery can then be performed in an elective setting on a prepared bowel. Therefore the patient benefits from advantages of the combination of 2 minimally invasive procedures in a nonemergent situation. Further large-scale prospective studies are necessary.     

Early Postoperative Intraperitoneal Chemotherapy Following Cytoreductive Surgery in Patients with Very Advanced Gastric Cancer

Background The survival of patients with stage IV gastric cancer is poor due to frequent peritoneal failure. The aim of this study was to investigate the impact of early postoperative intraperitoneal chemotherapy (EPIC) after cytoreductive surgery on the long-term survival of these patients, as determined by residual disease status. Methods A total of 154 patients with stage IV gastric cancer were enrolled in our study. All patients underwent potentially curative or palliative resections. After surgery, the residual disease states of the patients were recorded. All patients received EPIC. Results Of all 154 patients, R0 resection was achieved in 37, R1 in 56, and R2 in 61. All patients received a mean of 4.3 EPIC perfusions. After a mean followup period of 29 months, 14 patients remained alive. The median survival of all 154 patients was 11.4 months. Survival times were analyzed according to the type of residual tumor; the median survival time was 25.5 months in the R0 group, 15.6 months in the R1 group, and 7.2 months in the R2 group (p < .001). Upon multivariate analysis, the residual tumor states and the cycle of EPIC perfusion were found to be independent prognostic predictors (p < .001 and p = .018, respectively). Conclusions The residual tumor status is the most important predictor for the survival of very advanced gastric cancer patients who received cytoreductive surgery and EPIC. Therefore, complete cytoreductive surgery yielding R0 resection is mandatory for achieving the beneficial effects of EPIC. J.-H. Cheong and J. Y. Shen contributed equally to this work.     

完全腹腔镜下进展期远端胃癌根治术的临床体会(附26例报道)

目的总结完全腹腔镜下进展期胃癌根治术的临床体会。方法回顾性分析我科2005年8月至2010年5月期间对26例进展期胃癌患者行完全腹腔镜远端胃癌根治术的临床资料。结果所有患者均成功在腹腔镜下完成整个手术,无中转开腹。手术时间为270~450 min,(283.2±27.6)min;术中出血为80~350 ml,(178.4±67.4)ml。术后患者胃肠功能恢复时间为2~4 d,(2.8±1.2)d;下床活动时间为1~3 d,(1.5±0.4)d;进流质饮食时间为3~4 d,(3.5±1.4)d;术后住院时间为7~13 d,(10.0±2.6)d。清扫淋巴结为11~34枚,(17.8±7.3)枚。所有病例切缘均为阴性,近端切缘与肿瘤距离为5~12 cm,(7.0±2.1)cm;远端切缘与肿瘤距离为4~8 cm,(5.5±1.8)cm。术后所有患者均获随访,时间为3~48个月,平均18.5个月,2例低分化腺癌患者分别于术后13和18个月复发并转移死亡,其余患者未发现复发、转移。结论完全腹腔镜下远端胃癌根治术是安全、可行的,但其优越性相对于开腹手术尚需大量的临床资料来证明。     

加速康复外科护理在直肠癌保肛患者中的应用研究

目的：探讨基于加速康复外科理念的护理措施在直肠癌保肛患者中的应用效果。方法：纳入 119 例直肠癌保肛患者,分为两组,对照组接受常规护理,观察组接受基于加速康复外科理念的护理措施,比较两组患者术前术后焦虑情况、术后恢复质量、术后并发症发生率、术后进食时间和住院时间。结果：观察组患者术后焦虑情况（42.1±5.12）分 vs（49.5±8.21）分、收缩压（125±15.3）mmHg vs（131±9.2）mmHg、疼痛情况（6±2.3）分 vs（4.5±1.7）分、无法接受指令（6.9% vs 21.3%）和恶心呕吐（17.2% vs 34.4%）均明显优于对照组,有统计学差异（P<0.05）。观察组患者的术后并发症发生率（6.9% vs 21.3%）、进食时间（4.8±1.5）天 vs（6.3±1.1）天和住院日（9.1±1.9）天 vs（14.8±2.3）天均明显优于对照组,有统计学差异（P<0.05）。结论：加速康复外科护理措施可以有效减少直肠癌保肛患者的焦虑情况,促进其术后康复。     

Morphologic Risk Factors for Local Recurrence in Patients with Invasive Breast Cancer Treated with Conservative Surgery and Radiation Therapy

Abstract: The combination of conservative surgery and radiation therapy (CS and RT) is now the local treatment of choice for many women with invasive breast cancer. A number of patient factors, treatment factors, and pathologic factors must be taken into consideration in determining the suitability of this approach for an individual patient. The purpose of this article is to review the morphologic features of the tumor that are important to consider in selecting patients for CS and RT and in assessing their risk of local recurrence.     

Determination of the Necessary Total Protein Substitution Requirements in Patients with Advanced Stage Ovarian Cancer and Ascites,Undergoing Debulking Surgery. Correlation with Plasma Proteins

Background Ascites is common in patients with advanced ovarian carcinoma (AOC). Its drainage during surgery affects plasma proteins. We sought to correlate the volume of ascites with the oncological parameters of the disease, calculate its drainage effect on plasma proteins, and determine the necessary substitution requirements and a clinical way of achieving that. Patients and Methods We evaluated 138 patients with AOC and ascites who underwent primary cytoreductive surgery. Intraoperatively found ascites and its postoperative production were evaluated. Its drainage effect on plasma proteins and the substitution requirements were determined using a mathematic formula. Human albumin(HA) and fresh frozen plasma (FFP) were used to cover these requirements. Results The intraoperative ascites was found to correlate only with the stage of the disease, while its postoperative production correlated with the residual disease. Optimally debulked patients had a mean ascites production of 128 mL on postoperative day 1 compared with 668 mL of the suboptimally debulked. This production required 3 and 5–7 days, respectively, to drop <50 mL. Plasma proteins fell on their minimum level (88.9 versus 80.8%) on the second postoperative day. The protein deficit was calculated to be 379 and 691 g/day, respectively. This deficit was substituted by administering 2 HA and 2 FFP for 3–6 days. Conclusions Ascites drainage affects the postoperative homeostasis of plasma proteins. A mean acute drop of 12–20% is monitored on postoperative day 2. This deficit can be managed with HA and FFP for a minimum of 3 days.     

Concomitant Transsphenoidal Approach to the Anterior Skull Base and Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

Objectives To describe outcomes of endoscopic resection of sellar tumors with concomitant endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS).Design Retrospective chart review.Setting Tertiary care medical center.Participants Patients who underwent endoscopic transsphenoidal surgery for excision of anterior skull base lesions and simultaneous functional endoscopic sinus surgery (FESS) for CRS between January 2006 and January 2011 by senior authors (MRR and JJE).Main Outcomes Measured Short- and long-term postoperative complications.Results Fourteen patients were identified. Average follow-up was 27 months. All patients had preoperative symptoms consistent with CRS. No patients were treated with preoperative antibiotics. Surgical pathology revealed chronic sinusitis in all specimens. Pathology of the intracranial lesions included 11 pituitary macroadenomas, one craniopharyngioma, one chondrosarcoma, and one cholesterol granuloma. Short-term postoperative morbidities included a sphenoid polyp, one adhesion, and one case of pharyngitis. Long-term outcomes included one frontoethmoidal mucocele, one recurrence of nasal polyps, and three cases of acute sinusitis. There were no intracranial complications for the entire follow-up period.Conclusions Transsphenoidal surgery can safely be performed in the setting of CRS without increased risk of intracranial complications.