Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer

The authors examined the impact of the laparoscopic approach on the early outcome of resected colon carcinomas. The role of laparoscopic techniques in the treatment of colon carcinomas is questionable. Previous studies have suggested technical feasibility of surgical resections of these cancers by laparoscopic means and have implied a benefit to laparoscopic technique for patients undergoing colorectal resections. A prospective, randomized study was conducted comparing laparoscopic assisted colectomy (LAC) open colectomy (OC) for colon cancer. We present the preliminary results in relation to the short-term outcome and judge the feasibility of the laparoscopic procedure to as a way of performing accurate oncologic resection and staging. Benefit has been demonstrated with LAC in this setting. Passing flatus, oral intake, and discharge from hospital occurred earlier in LAC- than OC-treated patients The mean operative time was significantly longer in the LAC group than in the OC group. The overall morbidity was significantly lower in the LAC group. No significant differences were observed between both groups in the number of lymph nodes removed or the pathological stage following the Astler-Coller modification of the Dukes classification. The laparoscopic approach improves the short-term outcome of segmental colectomies for colon cancer. However, the further follow-up of these patients will allow us to answer in the near future whether or not the LAC may influence the long-term outcome.Presented at the annual meeting of the Society of American Gastrointestinal Surgeons (SAGES), Orlando, FL, USA, 11–14 March 1995     

Preliminary trial of a retroperitoneal approach for modified selective distal splenorenal shunt

A modified selective splenorenal shunt without portal-azygos disconnection through the left retroperitoneal approach was performed in 13 patients with cirrhosis of the liver and acute massive variceal hemorrhage. The anastomosis was end-to-side in 9 patients and end-to-end in 4 patients. All patients survived the operation. The post-operative course was extraordinarily benign; none of the patients developed clinical manifestations or biological evidence of hepatic dysfunction attributable to the operation. The only patient who died had an acute massive hemorrhage in the third postoperative week. None of the 12 surviving patients experienced further gastrointestinal bleeding. Dissection of the splenic and renal veins through the posterior retroperitoneal approach is technically easy. It may be the only alternative approach for portosystemic decompression in patients with dense intra-abdominal adhesions from previous operations involving the biliary tree or the upper gastrointestinal tract.The retroperitoneal approach for modified selective splenorenal portosystemic decompression is an effective method in the treatment and prevention of gastroesophageal bleeding in cirrhotic patients.

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Résumé Chez 13 malades atteints de cirrhose hépatique avec hémorragie massive par varices oeosphagiennes, un shunt spléno-rénal sélectif modifié, sans déconnection azygo-portale, a été réalisé par voie rétropéritonéale gauche. L'anastomose a été termino-latérale dans 9 cas et termino-terminale dans 4. Tous les malades ont survécu à l'opération. Les suites opératoires ont été extraordinairement faciles; aucun malade n'a présenté de symptomes ou d'anomalie biologique d'altération fonctionnelle hépatique. Un seul malade est mort d'hémorragie massive à la troisième semaine postopératoire. Aucun des 12 survivants n'a présenté de récidive d'hémorragie digestive. La dissection des veines splénique et rénale par voie postérieure, rétropéritonéale, est techniquement aisée. Cette voie d'abord peut être la seule utilisable chez les malades opérés antérieurement sur les voies biliaires ou le tube digestif et qui présentent d'importantes adhérences intrapéritonéales.Le shunt splénorénal sélectif par voie rétropéritonéale est une thérapeutique préventive efficace des hémorragies gastro-oesophagiennes chez le malade cirrhotique.

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Presented at the XXVIIth Congress of the Société Internationale de Chirurgie, Kyoto, Japan, September 3–8, 1977.     

Hepatopulmonary syndrome in candidates for liver transplantation

BACKGROUND: Hepatopulmonary syndrome (HPS) has been defined as a clinical triad, including chronic liver disease, gas exchange defects (increased alveolar-arterial PO2 difference irrespective of the presence of arterial hypoxemia), and widespread intrapulmonary vascular dilatations. We determined the incidence and the clinical and pulmonary functional characteristics of HPS in candidates for orthotopic liver transplantation (OLT) and tested their predicted accuracy. METHODS: We studied 80 patients with cirrhosis prospectively, and carried out contrast-enhanced (CE) echocardiography and lung function tests, including ventilation-perfusion (V(A)/Q) distributions. RESULTS: Fourteen patients had HPS (incidence, 17.5%). Patients with HPS (49 +/- 12 (+/-SD) years) had more cutaneous spiders, finger clubbing and dyspnea (P < 0.05 each) and a lower diffusing capacity (DLCO, 56 +/- 18% predicted; P < 0.001) than non-HPS patients (n = 66). Mild to moderate V(A)/Q inequalities and increased intrapulmonary shunt were predominant in HPS patients, but oxygen diffusion impairment was observed in those with hypoxemia (n = 8) only. The DLCO showed a considerable area under the receiver operating characteristic curve (0.89). CONCLUSIONS: HPS in cirrhotic patient candidates for OLT shows a high incidence and these patients present with distinctive clinical and functional features compared with non-HPS individuals. The presence of a low DLCO may be of help for the diagnosis of HPS.     

Erythromycin ototoxicity in liver transplant patients

We reprot on three liver transplant patients who developed erythromycin-related ototoxicity. This complication has been described in renal transplant patients and in patients with liver dysfunction, but to our knowledge it has not yet been reported in liver transplant patients. The influence of hepatic dysfunction, common renal failure, and the interaction between cyclosporin and erythromycin in the development of erythromycin ototoxicity are discussed.     

Port site metastases and recurrence after laparoscopic colectomy

Background: This study was performed to prospectively assess the impact of the laparoscopic approach to the patterns of port site metastases (PSM) and recurrence rate (RR) of resected colon carcinomas as compared with conventional colectomies. Methods: All patients were included in a prospective randomized trial comparing laparoscopic-assisted colectomy (LAC) versus open colectomy (OC) for colon cancer. The randomization was stratified for localization of the lesion. Patients with metastasic disease at the time of the surgery were excluded. Follow-up in the outpatient clinic was done every 3 months for a minimum of 12 months. Endpoints for the study were metastasis at port site and laparotomy incision as well as recurrence rate. Results: Of 91 segmental colectomies performed from November 1993 to January 1996, there were 44 LAC and 47 OC. Patient data were similar in both groups (age, sex, Dukes stage, type of operation). Mean follow-up was 21.4 months, with a range of 13 to 41 months. There were no wounds or PSM in those series. RR was similar for both groups. For LAC, it was five of 31 (16.1%); for OC, it was six of 40 (15%). Conclusions: The laparoscopic approach has a recurrence rate similar to that for open procedures for colon cancer. However, additional follow-up of these patients is needed before we can determine whether or not the laparoscopic approach influences overall survival.     

Evaluation of Reduced Susceptibility to Quaternary Ammonium Compounds and Bisbiguanides in Clinical Isolates and Laboratory-Generated Mutants of Staphylococcus aureus

The MICs and minimum bactericidal concentrations (MBCs) for the biocides benzalkonium chloride and chlorhexidine were determined against 1,602 clinical isolates of Staphylococcus aureus. Both compounds showed unimodal MIC and MBC distributions (2 and 4 or 8 mg/liter, respectively) with no apparent subpopulation with reduced susceptibility. To investigate further, all isolates were screened for qac genes, and 39 of these also had the promoter region of the NorA multidrug-resistant (MDR) efflux pump sequenced. The presence of qacA, qacB, qacC, and qacG genes increased the mode MIC, but not MBC, to benzalkonium chloride, while only qacA and qacB increased the chlorhexidine mode MIC. Isolates with a wild-type norA promoter or mutations in the norA promoter had similar biocide MIC distributions; notably, not all clinical isolates with norA mutations were resistant to fluoroquinolones. In vitro efflux mutants could be readily selected with ethidium bromide and acriflavine. Multiple passages were necessary to select mutants with biocides, but these mutants showed phenotypes comparable to those of mutants selected by dyes. All mutants showed changes in the promoter region of norA, but these were distinct from this region of the clinical isolates. Still, none of the in vitro mutants displayed fitness defects in a killing assay in Galleria mellonella larvae. In conclusion, our data provide an in-depth comparative overview on efflux in S. aureus mutants and clinical isolates, showing also that plasmid-encoded efflux pumps did not affect bactericidal activity of biocides. In addition, current in vitro tests appear not to be suitable for predicting levels of resistance that are clinically relevant.