Laparoscopic versus open surgery for rectal cancer: results of a prospective multicentre analysis of 4,970 patients

OBJECTIVE

To compare laparoscopic versus open surgery for rectal cancer and analyse the results of the multidisciplinary audited project on total mesorectal excision conducted in Spain.

BACKGROUND

The safety and therapeutic efficiency of laparoscopic surgery for rectal cancer are controversial due to the technical difficulties it involves. A deviation from the oncological principles of mesorectal excision would mean a potential increase in local recurrence and shorter survival.

METHODS

This prospective non-randomised multicentre study includes 4,970 patients with rectal cancer. The study compares perioperative, postoperative, anatomicopathological and survival variables.

RESULTS

Five hundred and sixty five patients were excluded. Of the remaining 4,405, 3,018 (68.51%) had open surgery (OS) and 1,387 (31.49%) laparoscopic surgery (LS). The rate of anterior resections was higher in the LS group. The rate of intraoperative tumour perforation, number of red blood cell concentrates transfused and length of hospital stay were greater in the OS group, whereas surgical time was longer in the LS group. The incidence of complications was 45.6% in the OS group and 38.3% in the LS group. Involvement of the circumferential and distal margin, as well as unsatisfactory and partially satisfactory quality of the mesorectum, were greater in the OS group. There were no differences for local recurrence and survival rates.

CONCLUSIONS

According to these results, laparoscopic surgery is the best option for the surgical treatment of rectal cancer, with similar rates of local recurrence and survival, although there are oncological indicators in this study to suggest that these results can be improved with laparoscopic surgery.

Chondrodystrophy in calves associated with manganese deficiency

A severe congenital chondrodystrophy in Charolais calves is described. Thirty-two calves were born on the same farm with shortened limbs and enlarged joints. Histologically, there was poor cartilage maturation with excessive amounts of rarefied cartilage matrix. There were degenerative changes in the chondrocytes and a severe reduction in the mucopolysaccharide content of all body hyaline cartilage. The cartilage matrix, when examined ultrastructurally, showed loose, disorganised fibres in a rarefied matrix, and extensive vacuolation of the chondrocytes. A low level of manganese was found in the liver of an affected calf. The pregnant cows were fed on apple pulp and corn silage, both of which are low in manganese.

Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer

BACKGROUND

The laparoscopic treatment of rectal cancer is controversial. This study compared surgical outcomes after laparoscopic and open approaches for mid and low rectal cancers.

METHODS

Some 204 patients with mid and low rectal adenocarcinomas were allocated randomly to open (103) or laparoscopic (101) surgery. The surgical team was the same for both procedures. Most patients had stage II or III disease, and received neoadjuvant therapy with oral capecitabine and 50-54 Gy external beam radiotherapy.

RESULTS

Sphincter-preserving surgery was performed in 78.6 and 76.2 per cent of patients in the open and laparoscopic groups respectively. Blood loss was significantly greater for open surgery (P < 0.001) and operating time was significantly greater for laparoscopic surgery (P = 0.020), and return to diet and hospital stay were longer for open surgery. Complication rates, and involvement of circumferential and radial margins were similar for both procedures, but the number of isolated lymph nodes was greater in the laparoscopic group (mean 13.63 versus 11.57; P = 0.026). There were no differences in local recurrence, disease-free or overall survival.

CONCLUSION

Laparoscopic surgery for rectal cancer has a similar complication rate to open surgery, with less blood loss, rapid intestinal recovery, shorter hospital stay, and no compromise of oncological outcomes.

[Laparoscopic nephrectomies: initial experience of a community hospital]

We present our initial experience with 34 laparoscopic nephrectomies performed in a 29 months period of time. 32% of the patients with renal tumor (clinical stage T1-T2) and the others for benign pathology. Average surgical time was 131 minutes (70-210). Average bleeding was 330 ml (50-2500). Average time of hospitalization was 2,7 days (1-14). 62% of patients were discharged to home between the first and second day post surgery. One patient with tumor required conversion to open surgery for an hilium bleeding. There were 3 serious complications (9%), included one patient died by septic shock and one lesion of left colon that required segmental colectomy. The results of this initial serie are promissory and a special care should be taken in selection of patients to achieve good results with low surgical morbidity.

Motor threshold in transcranial magnetic stimulation: comparison of three estimation methods

AIMS

Motor threshold (MT) is an important parameter for the practice of transcranial magnetic stimulation. Our goal was to compare three methods to estimate MT in a clinical setting.

METHODS

Comparison of three MT estimation algorithms: 1) the Rossini-Rothwell method consists in lowering stimulus intensity until only five positive responses out of 10 trials are recorded, defining MT; 2) the Mills-Nithi method considers the MT as the mean of an upper threshold (10 positive out of 10 trials) and a lower threshold (0 out of 10 trials); 3) the supervised parametric method estimates the MT by fitting (mathematically and graphically) a sigmoid function on raw data obtained by stimulation at variable intensities. Six MT estimations (two per method) were recorded in a single session in 10 healthy subjects.

RESULTS

The within-subject variation of MT (expressed as % of the mean MT+/-standard deviation) during a single session was of 8.5+/-7.2% for the Rossini-Rothwell method, 8.7+/-5.7% for the Mills-Nithi method and 9.5+/-4.0% for the supervised parametric method. No significant differences in variability of MT estimation were found between the methods, but the Rossini-Rothwell method was significantly shorter (half the number of stimuli compared to the two other methods).

CONCLUSION

In our setting, Rossini-Rothwell method was superior to the two other methods. The variability of MT estimation measured in our study is important, yet acceptable for clinical applications. However, this variability can be a source of considerable errors in excitability studies and should be a focus of future research.

Visual assessment of pneumonic area in ovine lungs

Twelve veterinarians were asked to estimate the percentage of lung surface that appeared consolidated in eleven projected colour transparencies of pneumonic ovine lungs. The estimates were compared to the pneumonic area measured by image analysis. Although all observers had some experience in veterinary pathology there was considerable variation between individuals in the accuracy of their estimates. Large lesions were underestimated and small lesions overestimated by most observers.

Neoadjuvant radiation and chemotherapy in rectal cancer does not increase postoperative complications

BACKGROUND AND AIMS

Neoadjuvant radiation and chemotherapy in rectal cancer reduces local recurrences and increases the rate of conservative sphincter surgery. However, an increase in postoperative morbidity and mortality has also been observed. This study analyzed the operative difficulty and postoperative complications in patients with this treatment.

PATIENTS AND METHODS

Retrospective review of 103 patients with rectal cancer, divided into two groups: group A, 53 patients undergoing preoperative radiotherapy with 45 Gy combined with chemotherapy, and group B, 50 patients with rectal cancer who received surgery after diagnosis. Both groups were homogeneous. The two groups were compared for both technical difficulty, using intraoperative data and rate of complications.

RESULTS

There were no statistically significant differences between the two groups with regard to intraoperative or postoperative data. In group A there were 20 complications in 17 patients (32%) and in group B 22 complications in 19 patients (38%). The rates of perineal wound infection were similar. The percentage of anastomotic leaks was higher in group A. A greater number of anterior resections was performed in group A.

CONCLUSION

Preoperative radiation and chemotherapy in rectal cancer does not increase postoperative complications and increases the rate of sphincter-preserving surgery.

Laparoscopic gastric bypass in the treatment of morbid obesity. Preliminary results of a new technique

INTRODUCTION

Gastric bypass is one of the most commonly used surgical techniques for the management of morbid obesity. It is usually done as an open surgery procedure, and in recent years surgeons have begun to perform it via the laparoscopic approach. The aim of this paper is to describe our surgical technique for laparoscopic gastric bypass (LGBP) and present the short-term results.

MATERIALS AND METHODS

Between January 2000 and January 2002 we operated on 50 patients with morbid obesity who met criteria for bariatric surgery. The patients had a mean age of 34 years and a body mass index (BMI) of 47.

RESULTS

Conversion was necessary in 4 of the 50 patients (8%). Mean operating time was 181 min, with a difference of 60 min between the first 10 and last 10 cases. There was a 26% rate of complications, 14% of which were early (%<% 30 days) and 12% late (%>%30 days). Mean hospital stay was 4.5 days.

CONCLUSION

LGBP is a technique with good short-term results as far as weight loss is concerned, although it has one of the most complex learning curves in laparoscopic surgery. Surgeons who regard gastric bypass as the technique of choice for the surgical management of morbid obesity should consider performing it via the laparoscopic approach.

[Primitive neuroectodermal tumor of the kidney. A case report]

A 27 years old female presented with diffuse abdominal pain, malaise, weight loss and a palpable mass in the left abdomen. Abdominal CAT scan showed a 18 cm heterogeneous tumoral mass that originated in the kidney. The patient was operated on and it was not possible to completely remove the mass. In the postoperative period the patient received chemotherapy with vincristine, cyclophosphamide and adryamicin but the disease progressed and the patient died 16 months later. The pathological study of the surgical specimen disclosed a tumor with monotonous proliferation of small round cells with a basophilic nucleus and scanty cytoplasm with PAS positive granules. Immunohistochemistry was positive for specific neuronal enolase and CD99. Involvement of the urinary system with primary neuroectodermal tumors is very infrequent.

Aneurysm of the pulmonary trunk with patent arterial duct

We present a 14-year-old female with a massive aneurysm of the pulmonary trunk occurring secondary to bacterial endocarditis of the patent arterial duct. Echo Doppler imaging, magnetic resonance and angiography confirmed the diagnosis. On intermediate follow-up after surgical correction, the echo studies and cardiac catheterization disclosed no residual lesions. The patient is now asymptomatic.

Misleading manifestations of Coccidioides immitis in vivo

We describe a case of coccidioidomycosis in which several unusual morphologic forms of Coccidioides immitis occurred in biopsy tissue from the right lower lung of a patient. To our knowledge, this is the first case where so many diverse morphologic forms were manifested in a single patient in the absence of typical endosporulating spherules. Immature spherules demonstrating segmentation mimicked morula forms of Prototheca spp. Certain elements resembled budding cells of Blastomyces dermatitidis. These consisted of juxtaposed immature spherules without endospores, a germinating endospore, or thick-walled hyphal cells. Branched, septate hyphae and moniliform hyphae consisting of chains of thick-walled arthroconidia or immature spherules were also present. Complement fixation and immunodiffusion tests performed on the patient's serum were negative for C. immitis, B. dermatitidis, and Histoplasma capsulatum antibodies. Fluorescent-antibody studies were carried out with a specific C. immitis conjugate. All of the diverse fungal tissue elements stained positive with a moderate to strong (2 to 3+) intensity.

Inflammatory cells and ferruginous bodies in bronchoalveolar lavage in urban dogs

OBJECTIVE

To investigate whether high levels of atmospheric pollution modify the inflammatory cell count of the canine lung and to detect the presence of ferruginous bodies (FB) in the respiratory system.

STUDY DESIGN

Bronchoalveolar lavage (BAL) was performed on dogs from four different areas of Mexico City and a rural area. With the BAL fluid recovered, total and differential cell counts were made, and ferruginous bodies were isolated by sodium hypochlorite digestion. They were counted by light microscopy and evaluated as a marker of exposure to particulate pollutants.

RESULTS

There was no significant difference in the total cell count or in the macrophage number between the five groups. The neutrophil count was statistically higher in dogs from the southwest area as compared to the northeast and rural areas (P < .05). The lymphocyte count was significantly greater in the southwest, also. The northeast part of the city showed the highest number of FB in BAL fluids.

CONCLUSION

The most polluted areas, in terms of particulate matter, were the northeast and the northwest; those are the locations of heavy industry. In contrast, in the southwest, where more inflammation was seen, the highest levels of ozone were registered during the year.

Clinical isolates of Mycobacterium simiae in San Antonio, Texas. An 11-yr review

During a period of 11 yr (1983-1993) 137 clinical isolates of Mycobacterium simiae obtained from 75 patients were identified in a University hospital in San Antonio, Texas. One hundred twenty-eight isolates (93%) were from a pulmonary source, four (3%) from blood, and five from other sites including skin, urine, lymph node, bone marrow, and brain. Of 62 evaluable patients, six (10%) had definite infection, nine (14%) had probable disease, and 48 (76%) were thought to be colonized. During the last 2 yr of the study (1992 and 1993), M. simiae became the second most frequently isolated nontuberculous mycobacterium at this institution surpassed only by Mycobacterium avium complex. There are limited data about effective treatment for this multidrug-resistant organism. New macrolides, quinolones, ethambutol, clofazimine, and aminoglycosides are promising therapeutic agents.

Successful treatment of cryptococcal meningitis with amphotericin B colloidal dispersion: report of four cases

Four patients with cryptococcal meningitis were treated with amphotericin B colloidal dispersion because of nephrotoxicity from prior treatment with conventional amphotericin B. The limited experience presented here suggests that amphotericin B colloidal dispersion is efficacious for the treatment of cryptococcal meningitis, despite being undetectable in cerebrospinal fluid, and offers a potential therapeutic alternative for patients who cannot tolerate conventional amphotericin B.

Control of myocardial reperfusion injury with hypertonic-hyperosmotic solution in isolated rabbit heart

The effects of postischemic reperfusion were investigated in 14 isolated rabbit hearts in Langendorff preparation. Seven were controls and the others were reperfused with a sodium 7.5% and dextran 60 (60,000 MW) solution diluted with Krebs-Henseleit buffer to a sodium concentration of 150 mEq/l. The incidence of arrhythmias was lower in this group (p = 0.034). Coronary flow was higher than in controls (p = 0.035), the levels of isoenzyme MB of creatine kinase were lower than in controls (p = 0.035), myocardial water content was also lower (p = 0.047), and histological damage was reduced (p = 0.018). It was concluded that early reperfusion with 7.5% sodium chloride, 6% dextran 60 solution has a protective effect in the treatment of cardiac reperfusion injury.

Activities of clarithromycin, ofloxacin, and clarithromycin plus ethambutol against Mycobacterium simiae in murine model of disseminated infection

After 2 weeks of intravenous challenge with Mycobacterium simiae, ICR outbred mice were treated with clarithromycin, ofloxacin, or clarithromycin plus ethambutol for 4 weeks. All three therapy groups demonstrated a decrease in the level of infection in both the lungs and the spleen. There were no significant differences among the three treated groups in decreasing mycobacterial counts in the lungs; however, both ofloxacin and clarithromycin plus ethambutol were superior to clarithromycin alone in reducing the level of infection in the spleen. Results of the study suggest a potential role for these agents in the treatment of human M. simiae infection.

Subpleural lymph nodes in goat lungs

Subpleural lymph nodes were found in more than 4% of 3245 goat lungs during a slaughterhouse survey of respiratory disease. Their frequency varied between flocks from 2% to as much as 27%. They were more common in feral goats than in crossbreds or Angoras. Their numbers were positively associated with carcass weight and the number of nodular muellerius lesions on the lung surface. Their distribution and architecture were different from the pulmonary lymphoid nodules described in cattle with dictyocaulus re-infection syndrome.

Group A Streptococcus septicemia and an infected, ruptured abdominal aortic aneurysm associated with pharyngitis

A 65-year-old man had a 3-day history of sore throat, fever, rigors, back pain, abdominal discomfort, nausea, vomiting, and diarrhea. The patient's daughter had group A streptococcus pharyngitis. The patient was found to have a ruptured abdominal aortic aneurysm. He underwent resection of the aneurysm and right axillary femoro-femoral bypass graft. The patient died 40 hours after admission. Gram stain of the aneurysm showed numerous gram-positive cocci. Group A streptococcus grew from cultures of blood, throat, and aneurysm. The group A streptococcus was M type 3, T type 3 and produced streptococcal pyrogenic exotoxin A. This case is a very rare fatal complication of group A streptococcus pharyngitis.

A slaughterhouse survey of lung lesions in goats

A survey of the lungs from 4284 goats killed at a slaughterhouse in the North Island of New Zealand during the winter of 1990 revealed only ten cases of non-parasitic bronchopneumonia. However, 41% of the lungs had lesions consistent with infection by Muellerius capillaris, 33% with Dictyocaulus filaria, and 8% with both species. The prevalence of parasitic lesions increased with age. The carcasses of goats with mild to severe Dictyocaulus filaria lesions were from 0.81 to 1.52 kg lighter than those without the lesions (p<0.001). The carcasses of goats with more than ten nodular (Muellerius capillaris) lesions were 0.75 kg lighter than those without the lesions (p<0.001). Twelve sets of lungs had lesions of chronic bronchiectasis. Nematode larvae were seen in the bronchial lumina of three of them. The microscopic appearance varied from a moderate dilatation of occluded bronchi which retained an intact epithelium, to large foreign-body granulomas where the remaining bronchial outlines were barely discernible. Multiple, very discrete, fibrous pleural plaques were found on the caudal lobes in two cases. Plaques of this morphology have not been described previously in the veterinary literature. Pleural adhesions were found in 350 cases (8.2%). The relatively higher frequency of pleurisy versus non-parasitic pneumonia suggests that pneumonia in goats in the North Island of New Zealand completely resolves in most cases.

[Transluminal coronary angioplasty using ultrasound]

The application of ultrasonic energy for ablation of atherosclerotic plaques was studied. This study was performed in 92 segments obtained from human coronary arteries which belonged to eleven hearts obtained from patients who have died from acute myocardial infarction. An ultrasound generating system (Cavitron 600) was used, and an ultrasonic probe wire (P-150 Endosonic), was attached to it. A stainless steel wire (0.36 mm in width and 145 cm length), was fixed to this probe. Sonic pulsed stimulations 20 sec long and 25 kHz in frequency were performed. The sound transmitting characteristics of the angioplasty guide wire were studied, as well as the ultrasound effects upon atherosclerotic plaques, blood elements, coagulation, and it's lysis effects upon recently formed clots. The anatomic pieces were filmed in cineangiocoronary graphy in two planes, anterior right oblique an anterior left oblique, to be studied later under light microscopy. The results were as following: in the 100% obstructions, a 41% recanalization was obtained; in the 95% obstructions, a 79%, in the 75% obstructions, a 37%. We did not work in the 50% or less obstructions. Under the procedure, no artery suffered perforations. Under Light microscopy, a plaque fragmentation was observed in 24% of the cases; rupture and fragmentation, in 14%, cavitations in 10%; ondulations in 9%; plaque rupture and thermic lesion in 8%; 22% did not present changes. The collected detritus had 110 +/- microns diameter. Erythrocytes exposed to 30 or 60 sec of ultrasound were found to present crenocytosis, central cavitation, hypochromia, and poikilocytosis; these ones exposed less than 22 sec did not show changes. The fibrinogen levels after the application of ultrasound were 19% lower. Coagulation time did not change with exposure 20 sec long at 20 kHs. The angioplasty guide wires attenuation coefficients were: with the guide wire outside the Miller's catheter, 44%; and with the guide wires inside, 65%. Coronary transluminal angiosonoplasty is a new interventionist technic designed to remodel an obstructive lesion of the coronary arteries, in order to diminish or nullify the obstruction. It's clinic use in the acute myocardial infarction, as a mechanical method to achieve clot's lysis, could be an alternative or a co-helper therapeutics to thrombolysis.