Radical surgery for gallbladder cancer. Results of the French Surgical Association Survey.

BACKGROUND/AIMS: Gallbladder carcinoma is a highly lethal disease. The advantages of radical surgery remain controversial. The authors' objective was to evaluate the effectiveness of an aggressive approach to gallbladder carcinoma on long-term survival. METHODOLOGY: A questionnaire was sent to 73 institutions in France, Europe, and overseas. Data, from 724 patients treated between 1980 and 1989, were analyzed for patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports and survival. Seventy-eight percent of the patients were women, and 22% were men. Gallstones were present in 86% of the cases. Four percent of the patients had Tis lesions, 11% had T1 to T2 lesions, and 85% had T3 to T4 lesions. RESULTS: Twenty-three percent of the patients underwent curative operations, and 77% had a palliative treatment (25% of the patients underwent exploratory laparotomy). Exploratory laparotomy was followed by the highest mortality rate (66%), and older patients (>70 years) had a higher operative risk. The overall median survival was 3 months, and long-term survival correlated with cancer stage: Tis >60 months, T1 to T2 >22 months, and T3 to T4 2 to 8 months. Projected five-year survival for cancers limited to the gallbladder and treated by simple cholecystectomy was 93%, 18% and 10% for Tis, T1 and T2 respectively. For T3 to T4, no difference was observed among the different surgical procedures adopted--hepatic resection, trans-tumoral stenting or biliary-enteric anastomosis. CONCLUSIONS: In conclusion, a simple cholecystectomy is effective only for Tis cancer. An extended cholecystectomy for invasive cancer should be performed, but only if there is limited involvement of the immediately adjacent hepatic parenchyma. There is now a need to evaluate more effective adjuvant therapy in the form of radiotherapy or newer chemotherapeutic agents.     

Three new cases of dysfibrinogenemia: Poissy III, Saint-Germain I and Tahiti.

In order to identify unknown mutations, the FAMA method was used to rapidly screen the fibrinogen chain genes in individuals with dysfibrinogenemias. Chemical cleavage at mismatches on heteroduplexes DNA end-labeled with strand-specific fluorescent dyes reliably detects sequence changes in DNA fragments of up to 1.5 kb and locates them precisely. This method was successfully used for the detection of three new dysfibrinogenemias: Poissy III, Tahiti (heterozygous Aalpha Arg16His) and Saint-Germain I (heterozygous AalphaGly12Val). The mutations were confirmed by dideoxy sequencing.     

Changes in cerebral blood flow and oxygen extraction during post-resuscitation syndrome

INTRODUCTION: Most survivors of out-of-hospital cardiac arrest (OHCA) will die subsequently from post-anoxic encephalopathy. In animals, the severity of brain damage is mainly influenced by the duration of cardiac arrest and also by the cerebral blood flow (CBF) and oxygen extraction (CEO2) abnormalities observed during the post-resuscitation period. The aim of our study was to describe CBF and CEO2 modifications during the first 72 h in OHCA patients treated by induced mild hypothermia. METHODS: Consecutive OHCA patients were studied every 12 h over 72 h. Diastolic flow velocities (dFV), mean flow velocities (mFV) and pulsatility index (PI) were assessed by transcranial doppler (TCD) as an estimate of CBF changes. Simultaneous measurements of CEO2 were obtained using retrograde jugular catheterisation. RESULTS: Eighteen patients (61 [47-74] years) were studied (12 non-survivors and 6 survivors). At admission, mFV values were low (27.3 [21.5-33.6]cm/s) but reached normal values after 72 h (50.5 [36.7-58.1]cm/s). Initial PI values were high (1.6 [1.3-1.9]) but reached normal values after 72 h (1.04 [0.82-1.2]). No differences were found between survivors and non-survivors regarding these CBF estimates. CEO2 values were quite normal at admission (20.4 [11-27%]) but decreased over time in non-survivors until H72 (25.8% [19.3-31.1] versus 5.7% [5.1-11.5], p=0.02). CONCLUSION: Cerebral haemodynamic and oxygenation values are altered considerably but evolve during the first 72 h following resuscitation after cardiac arrest. In particular, these changes may lead to a mismatch between CBF and CEO2 leading to a "luxurous perfusion" in non-survivors.     

Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units: the CIREA1 randomized trial

Purpose

Venous thromboembolism (VTE) is a frequent and serious problem in intensive care units (ICU). Anticoagulant treatments have demonstrated their efficacy in preventing VTE. However, when the bleeding risk is high, they are contraindicated, and mechanical devices are recommended. To date, mechanical prophylaxis has not been rigorously evaluated in any trials in ICU patients.

Methods

In this multicenter, open-label, randomized trial with blinded evaluation of endpoints, we randomly assigned 407 patients with a high risk of bleeding to receive intermittent pneumatic compression (IPC) associated with graduated compression stockings (GCS) or GCS alone for 6 days during their ICU stay. The primary endpoint was the occurrence of a VTE between days 1 and 6, including nonfatal symptomatic documented VTE, or death due to a pulmonary embolism, or asymptomatic deep vein thrombosis detected by ultrasonography systematically performed on day 6.

Results

The primary outcome was assessed in 363 patients (89.2 %). By day 6, the incidence of the primary outcome was 5.6 % (10 of 179 patients) in the IPC + GCS group and 9.2 % (17 of 184 patients) in the GCS group (relative risk 0.60; 95 % confidence interval 0.28–1.28; p = 0.19). Tolerance of IPC was poor in only 12 patients (6.0 %). No intergroup difference in mortality rate was observed.

Conclusions

With the limitation of a low statistical power, our results do not support the superiority of the combination of IPC + GCS compared to GCS alone to prevent VTE in ICU patients at high risk of bleeding.     

Indications and Outcomes of a Cross-Linked Porcine Dermal Collagen Mesh (Permacol) for Complex Abdominal Wall Reconstruction: A Multicenter Audit

World Journal of Surgery - To reduce the occurrence of complications in the setting of high-risk patients with contaminated operative field, a wide range of biologic meshes has been developed. Yet,...     

Role of laparoscopy in blunt perforations of the small bowel

Background: The purpose of this study was to determine whether laparoscopy could improve our ability to diagnose and treat perforations of the small bowel. Methods: From 1985 to 2001, among 250 patients admitted for a blunt abdominal trauma, 195 surgical explorations were performed, comprising 42 laparoscopies. On admission, 108 patients underwent an abdominal ultrasonography (US) and 104 a computed tomography (CT). Thirty-nine patients had a blunt small bowel trauma (BSBT) that was explored and/or treated by laparoscopy (n = 15) or celiotomy (n = 24). We compared the patients who underwent emergency surgery (23) and those who were operated on after a mean delay of 51 h. Results: On admission, for detecting free intraperitoneal fluid with a BSBT, the sensitivity of CT was 93.3% and specificity was 13.6%. Regarding the 23 patients who underwent emergency surgery, 8/20 had positive US and 10/15 had positive CT, whereas the 15 celiotomies and 8 laparoscopies indicated BSBT. Regarding the 16 patients who underwent delayed surgery, 9 patients underwent a celiotomy and 7 a laparoscopy; all BSBTs were diagnosed. In searching for BSBT, the sensitivity and specificity of laparoscopy were both 100%, whereas the sensitivity of CT was 83.3% and specificity was 22.2%. Twenty of 23 patients undergoing emergency surgery had bowel suture repair compared to 3/16 after delayed surgery. In contrast, a resection was necessary in 10/12 patients treated after a delay compared to 2/17 operated in emergency. Five BSBTs were sutured by laparoscopy, whereas 10 required conversion. Laparoscopy avoided celiotomy in 15 cases. There were no deaths and no enterostomy. Conclusion: In hemodynamically stable patients with blunt abdominal trauma, laparoscopy safely and effectively identifies small bowel injuries. Early recognition of these injuries and timely surgical treatment offer the best prognosis.     

Tissue concentrations of platelet-activating factor in colorectal carcinoma: inverse relationships with Dukes' stage of patients

The lipid mediator platelet-activating factor (PAF) plays a role in cancer. We investigated its presence in human colon carcinoma by assessing the levels of tissue phospholipase A(2) (PLA(2), the key enzyme in the generation of the lyso-PAF precursor), lyso-PAF, PAF and acetylhydrolase activity (AHA, the key enzyme in PAF degradation) in colorectal cancer patients and by correlating them with Dukes' classification. The results highlighted that the tumour tissues of Dukes' A and B patients had significantly higher PLA(2), lyso-PAF, PAF and AHA levels as compared with nontumour tissues. Dukes' C patients had higher PLA(2), lyso-PAF and AHA levels but unchanged PAF. Dukes' D patients had higher AHA levels but unchanged PLA(2), lyso-PAF and PAF. A pathophysiological role for PAF is suggested in human colon carcinoma.     

Activated protein C sensitivity ratio in pregnant women at delivery

We studied activated protein C sensitivity ratio (APC-SR), factors V and VIII activity and von Willebrand antigen in control women, women using oral contraceptives, and pregnant women at delivery. The mean APC-SR of 2.4 in pregnant women was significantly lower than the mean APC-SR value of 3.5 for both the other groups and 45% of pregnant women had a ratio below the 5th percentile of the control group. None of them carried the R506→Q mutation. This decreased ratio at delivery appeared to be connected, at least in part, with increased VIII activity. Thus, APC-SR at delivery should not be used to detect APC resistance.