The Landmark Series: Surgical Treatment of Colorectal Cancer Peritoneal Metastases

Background

Peritoneal metastases (PM) are a form of metastatic spread affecting approximately 5-15% of colon cancer patients. The attitude towards management of peritoneal metastases has evolved from therapeutic nihilism towards a more comprehensive and multidisciplinary approach, in large part due to the development of cytoreductive surgery (CRS), usually coupled with heated intraperitoneal chemotherapy (HIPEC), along with the constant improvement of systemic chemotherapy of colorectal cancer. Several landmark studies, including 5 randomized controlled trials have marked the development and refinement of surgical approaches to treating colorectal cancer peritoneal metastases.

Methods

This review article focuses on these landmark studies and their influence in 4 key areas: the evidence supporting surgical resection of peritoneal metastases, the identification and standardization of important prognostic variables influencing patient selection, the role of surgery and intraperitoneal chemotherapy in prevention of colorectal PM and the role of intraperitoneal chemotherapy as an adjuvant to surgical resection.

Results

These landmark studies indicate that surgical resection of colorectal PM should be considered as a therapeutic option in appropriately selected patients and when adequate surgical expertise is available. Standardized prognostic variables including the Peritoneal Cancer Index and the Completeness of Cytoreduction Score should be used for evaluating both indications and outcomes.

Conclusions

Current evidence does not support the use of second look surgery with oxaliplatin HIPEC or prophylactic oxaliplatin HIPEC in patients with high risk colon cancer nor the use of oxaliplatin HIPEC with CRS of colorectal PM.

     

Epidemiology of neurosensorial deafness in the Foral Community of Navarra

Congenital deafness is a relatively frequent disorder that shows a heterogeneous aetiology. Knowledge and the control of some risk factors have decreased the incidence of acquired deafness and increased the relative importance of genetic cause. In an attempt to investigate the clinical relevance of congenital deafness and the mechanisms of prevention in our population, a clinical and genetic study of cases with neurosensorial deafness born in Navarra between 1975 and 1990 was carried out. A total of eighty-one cases were identified, giving an incidence of 0.8 per thousand. Thirty per cent of the cases showed deafness associated with defects. Cause of deafness was identified in seventy per cent of the cases with whom a detailed clinical and genetic study could be performed (n=50). Genetic factors were responsible for the disorder in more than half of these cases. The most frequent hereditary factor was of the autosomic recessive type. This was associated with a more severe form of hearing loss.     

Abdominal tuberculosis. A report of 3 cases

Three patients admitted to the surgical wards of Johannesburg Hospital in whom abdominal tuberculosis was suspected are presented. In every case difficulties were encountered in diagnosis and treatment. Each case presentation is followed by a short commentary on relevant aspects of abdominal tuberculosis.     

EFFICACY OF SUCRALFATE IN PREVENTING GASTROINTESTINAL SIDE EFFECTS OF NSAIDs

To find out the efficacy of sucralfate in preventing gastrointestinal side effects of non-steroidal anti-inflammatory drugs (NSAIDs) a prospective, randomised single blind study was conducted from 1989 to 1992. Patients with osteoarthritis, rheumatoid arthritis and other long standing painful conditions, who were expected to receive NSAIDs for over three months, were recruited into the study. All medicines were discontinued for a period of 10–15 days prior to initial endoscopic assessment. NSAID therapy was started and the patients were randomised to receive either placebo (group A) or sucralfate (group B) in addition. Patient were reassessed clinically every week and an endoscopic examination was repeated after 6–8 weeks of follow-up. A total of 176 patients were studied in group A (n=91) and group B (n=85). At the end of 8 weeks gastrointestinal symptoms were present in 30.6% and 26.4% patients of group A and B respectively. Endoscopic assessment showed superficial lesions in 36.5% and 18.7% while endoscopic ulcer in 2.4% and 1.1% patients of groups A and B respectively. Thus in patients receiving chronic NSAID therapy, simultaneous administration of sucralfate reduces the incidence of superficial gastric lesions but has no significant effect on symptoms or ulcer formation.KEY WORDS: Gastropathy, Sucralfate, Nonsteroidal anti-inflammatory drugs     

Ceftriaxione associated biliary lithiasis in newborns-report of two cases

The occurrence of biliary calculosis as a complication of the use of ceftriaxone was first described in an 18-year-old patient with chronic granulomatosis. Since then many reports have been published on this type of complication both in children and in adults, but until the present moment, this complication had never been reported in pre-term neonates.The authors describe two cases of biliary calculosis associated with the use of ceftriaxone in preterm-newborns, emphasizing that due to the frequent use of this type of antibiotic in neonatal I.C.U., routine ultrasonographic control exams should be performed to diagnose this possible complication in all neonates receiving ceftriaxone.     

Management of arterial hypertension in patients with acute ischemic stroke

PURPOSE: We aimed with study to assess the current clinical practice about the management of high blood pressure in patients in the acute phase of ischemic stroke. We also comment some topics of ischemic stroke treatment. METHODS: A case report of a patient admitted 8 hours after onset of ischemic stroke and with blood pressure of 186 x 110 mmHg was presented to 120 surgeons and clinician. They were asked to decide the best therapeutic option: to increase, decrease or maintenance blood pressure. RESULTS: Thirty-eight physicians (31.7%) considered decreasing blood pressure the best therapeutics, 82 (68.3%) considered maintenance and none decided to increase it (p < 0.05). There was no difference between the two specialties conduct. The physicians, with more than 10 years of graduation, had a tendency to decrease the blood pressure (p < 0.05). CONCLUSION: The maintenance of blood pressure may present a sufficient blood support to compensate brain flow. A high percentage of the physicians (31.7%) do not know about the current concepts of therapeutics considering hypertension in acute ischemic stroke. The development on special units to treat these patients ("stroke units") may eventually decrease the morbimortality rates of ischemic stroke.     

Syncope-related trauma: rationale and yield of diagnostic studies

BACKGROUND: Syncope occasionally occurs in trauma patients. The most appropriate and cost-effective evaluation for such patients is unknown. METHODS: Trauma patients admitted to a Level I trauma center with a diagnosis of syncope or possible syncope between 1988 and 1994 were reviewed. History, physical examination, and past medical history were noted, as were the results of tests done as part of the syncope evaluation. RESULTS: Eighty-eight patients were reviewed; 45% had been injured in falls. Thirteen patients who remembered their entire injury and denied syncope as a cause had negative evaluations. History, physical examination, and admission laboratory values were helpful in diagnosis 59% of the time. Subsequent evaluation provided useful diagnostic information 30% of the time. No patients with normal admission electrocardiograms (EKGs) had cardiac causes for their syncope. CONCLUSIONS: (1) Patients with possible syncope without loss of consciousness require no further evaluation. (2) A cerebrovascular evaluation should be the initial diagnostic approach in patients with signs and symptoms suggestive of stroke or transient ischemic attack. (3) Possible syncope patients with normal admission EKGs should undergo computed tomography of the head and electroencephalography. Those with abnormal EKGs should undergo echocardiography.