Reassessing the role of surgery in the elderly or chronically sick with proximal extrahepatic cholangiocarcinoma

BackgroundMost data on postoperative outcomes among patients with proximal extrahepatic cholangiocarcinoma are reported by single institutions. The purpose of this study was to analyze postoperative outcomes stratified by age and comorbidities.MethodsPatients with proximal extrahepatic cholangiocarcinoma who underwent a resection were identified in the National Cancer Database. Pathologic, postoperative, and survival outcomes were compared based on age and Charlson-Deyo comorbidity index.ResultsAmong the 1,579 patients, the average age was 66 years, and 9.4% of patients were older than 80 years. Most patients had a Charlson-Deyo score of 0 (72.4%), with the minority having scores of 1 (20.5%) or ≥2 (7.1%). Patients ≥80 years had a higher 90-day mortality rate compared with patients 65 to 79 and <65 years (21.3% vs 12.0% vs 7.4%, P < .001). Patients with a Charlson-Deyo score ≥2 had longer duration of stay, greater likelihood of requiring an unplanned readmission, and a higher 90-day mortality rate compared with patients with a lower comorbidity index. Median survival of patients <65, 65 to 79, and ≥80 years was 31, 24, and 17 months, respectively. A similar trend was seen with increasing Charlson-Deyo score (0: 27 months, 1: 25 months, ≥2: 20 months). On multivariable analysis, age ≥80 years (hazard ratio = 1.52, P = .01) and Charlson-Deyo score ≥2 (hazard ratio = 1.45, P = .01) were associated with poor survival.ConclusionIn patients with proximal extrahepatic cholangiocarcinoma, age ≥80 years and greater comorbidity index are associated with increased risk of 90-day mortality and poor overall survival. This suggests that resections in high-risk patient populations should be approached with caution.     

Adrenergic,purinergic, and endothelial mediators and modulators of norepinephrine-induced mesenteric autoregulatory escape

We evaluated the effects of potential factors in autoregulatory escape from norepinephrine-induced vasoconstriction in rat anterior mesenteric artery. We determined mesenteric artery blood flow velocity with a pulsed Doppler, sonic flowmeter, and systemic arterial blood pressure with a transducer. A 4-min norepinephrine infusion (0.125–1.0 × 10^–8 M/min) intravenously evoked a dose-dependent, initial vasoconstriction that was followed by rapid escape of blood flow toward or above the control value during sustained norepinephrine administration. Neonatal capsaicin treatment enhanced vasoconstrictor responses to norepinephrine but failed to affect escape parameters. Propranolol decreased norepinephrine-induced escape dose dependently. Adenosine deaminase attenuated escape, and the combination of this enzyme plus propranolol nearly abolished escape from norepinephrine-induced vasoconstriction. Methylene blue also diminished autoregulatory escape. These findings suggest that norepinephrine-induced autoregulatory escape involves simultaneous -adrenoceptor, purinergic, and endothelial mediation. Norepinephrine-evoked mesenteric vasoconstriction appears to involve predominantly ₂-adrenoceptors and is modulated by peptidergic sensory nerves and adenosine.NIH grant number supporting these studies: USPHS # DK37050.     

A Novel technique of ureteroneocystostomy (extravesical seromuscular tunnel): An experimental study in dogs. II. Optimization of surgical technique

Objectives

To optimize the surgical technique of the new extravesical seromuscular tunnel ureteroneocystostomy and to study the optimal relation between the length and width of the tunnel and the diameter of the normal and dilated ureters.

Methods

The optimized technique was applied to the left ureters of 20 dogs; 10 with normal ureters and 10 after induction of ureteral dilation. The new technique was performed to maintain a ratio of 3:1 between the width of the tunnel and the diameter of the ureter and a ratio of 1:1 between the length of the tunnel and the ureteral diameter. The results were compared with those for 5 dogs in which unilateral direct ureterovesical reimplantation was performed without an antireflux procedure. All the dogs were evaluated by intravenous urography, radioisotope renography, and ascending cystography before and at 1, 3, and 6 months after ureteroneocystostomy.

Results

All the dogs of the control group showed low-pressure vesicoureteral reflux and 3 demonstrated mild hydronephrosis and significant deterioration of the corresponding kidney. At 6-month follow-up, none of the 20 dogs subjected to the new technique showed deterioration of the function or configuration of the corresponding kidney. Moreover, the new technique was sufficient to prevent reflux in all but two dilated ureters that showed high-pressure vesicoureteral reflux.

Conclusions

For the extravesical seromuscular tunnel to be effective in reflux prevention without obstruction, the width of the tunnel must be triple the diameter of the ureter, and the length of the tunnel covering the intact (nonspatulated) part of the ureter should be equal to its diameter.     

Saline irrigation and wound infection in abdominal gynecologic surgery.

OBJECTIVE: To evaluate whether saline wound irrigation decreases the incidence of wound infection following abdominal gynecologic surgery. METHOD: In this prospective randomized study, 104 patients underwent wound irrigation before wound closure following abdominal gynecologic surgery and 102 patients did not. RESULTS: There were no significant differences between the 2 groups in patient characteristics or in factors influencing the incidence of wound infection after abdominal gynecologic surgery. The incidence of wound infection was 10.6% among women who underwent wound irrigation and 9.8% among those who did not, and the difference was not statistically significant. CONCLUSION: Saline wound irrigation before abdominal wall closure is not helpful in decreasing the incidence of wound infection after abdominal gynecologic surgery.