Secondary technical resectability of colorectal cancer liver metastases after chemotherapy with or without selective internal radiotherapy in the randomized SIRFLOX trial

Background

Secondary resection of initially unresectable colorectal cancer liver metastases (CRLM) can prolong survival. The added value of selective internal radiotherapy (SIRT) to downsize lesions for resection is not known. This study evaluated the change in technical resectability of CRLM with the addition of SIRT to FOLFOX‐based chemotherapy.

Methods

Baseline and follow‐up hepatic imaging of patients who received modified FOLFOX (mFOLFOX6: fluorouracil, leucovorin, oxaliplatin) chemotherapy with or without bevacizumab (control arm) versus mFOLFOX6 (with or without bevacizumab) plus SIRT using yttrium‐90 resin microspheres (SIRT arm) in the phase III SIRFLOX trial were reviewed by three or five (of 14) expert hepatopancreatobiliary surgeons for resectability. Reviewers were blinded to one another, treatment assignment, extrahepatic disease status, and information on clinical and scanning time points. Technical resectability was defined as at least 60 per cent of reviewers (3 of 5, or 2 of 3) assessing a patient's liver metastases as surgically removable.

Results

Some 472 patients were evaluable (SIRT, 244; control, 228). There was no significant baseline difference in the proportion of technically resectable liver metastases between SIRT (29, 11·9 per cent) and control (25, 11·0 per cent) arms (P = 0·775). At follow‐up, significantly more patients in both arms were deemed technically resectable compared with baseline: 159 of 472 (33·7 per cent) versus 54 of 472 (11·4 per cent) respectively (P = 0·001). More patients were resectable in the SIRT than in the control arm: 93 of 244 (38·1 per cent) versus 66 of 228 (28·9 per cent) respectively (P < 0·001).

Conclusion

Adding SIRT to chemotherapy may improve the resectability of unresectable CRLM.

Guidelines for surgical procedures after liver transplantation

OBJECTIVE

The first purpose of this study is to identify the types and incidences of surgical procedures in patients who have previously undergone liver transplantation, with particular focus on the complication rates and the lengths of hospital stay. The second purpose is to present the management guidelines for patients with liver transplants at the preoperative, intraoperative, and postoperative stages of surgical procedure.

SUMMARY BACKGROUND DATA

The surgical literature on this issue is scant, and with the growing liver transplant patient population it is not unlikey for any surgery specialist to have to operate on a patient who has undergone liver transplantation.

METHODS

A sample of 409 patients with available hospital records, with a minimum of a 2-year follow-up, and with telephone access for interviews was chosen. Type of surgery, time from the liver transplant, hospital stay, immunosuppressive regimen, and complications were recorded.

RESULTS

A large proportion of patients (24.2%) underwent some type of surgical procedure 2 to 10 years after liver transplantation. The authors demonstrate that most of the elective procedures can be safely carried out without an increased incidence of complication and without longer hospital stay than the general population. Conversely, emergent procedures are plagued by a greater incidence of complications that not only affect the function of the liver graft but may risk the life of the patient.

Intermittent peritoneal dialysis. Review of three years' experience

A study has been made of 61 periods of peritoneal dialysis (PD), in 58 patients, Each period lasted 24–36 hours (mean 27.6 hours), using 18–40 litres (mean 27.31) of dialysis fluid per period. Due to technical faults PD was unsuccesful in 5 instances. In the remaining 56 periods of PD mean reduction of blood urea and serum potassium per period were 19.85 mmol/1 and 1.96 mEq/1 respectively. Clinical improvement was observed in 60.6% of patients. Of 11 patients with pulmonary oedema, 9 improved; and one patient with gross generalized oedema responded. Among 17 patients who died in hospital, only one death could be directly attributed to PD. Peritonitis was not encountered following PD. Dialysis for a period not exceeding 36 hours is adequate to avert life-threatening complications of renal failure in most patients. This “short-period” PD will be advantageous in developing countries with limited facilities.

Autonomic function tests in non-insulin dependent diabetic patients and apparently healthy volunteers

Traditionally accepted symptoms suggestive of autonomic neuropathy (ANP) were elicited in 65 non-insulin dependent diabetic patients attending a diabetic clinic and four autonomic function tests (AFTs) were performed in these diabetics and 60 non-diabetic healthy volunteers. Though 18 (27.6%) diabetics had symptoms of ANP, none of these symptoms were severe. AFTs were abnormal in 30 (46.2%) diabetics and 9 (15%) healthy volunteers. AFT abnormalities in diabetics were found more frequently than symptoms would suggest (21, i.e. 70% of the 30 diabetics did not have symptoms of ANP). There was poor correlation between symptoms of ANP and AFT abnormalities (only 9 of the 18 diabetics with symptoms of ANP had abnormal AFTs). Of the four AFTs performed, R-R variation was the commonest abnormality occurring in 17 of the 30 diabetics with abnormal AFTs. The prevalence of AFT abnormalities did not increase significantly with the duration of diabetes (chi 2 = 0.42; p = 0.8392), but increased significantly with the advancing age of the diabetics (chi 2 = 11.14; p less than 0.005). In healthy volunteers, the test values for standard deviation for R-R variation in deep breathing decreased significantly (p less than 0.05) with the advancing age of the subjects.

Russell's viper bite in Sri Lanka. A study of 22 cases

Twenty-two patients who had been bitten by a Russell's viper were studied. Neurological manifestations and generalized myalgia were observed, respectively, in 86.4% and 72.7%. Renal failure did not occur in three patients who received antivenin within 5 hours of the bite, and it is suggested that administration of antivenin within the first few hours following the bite could prevent renal failure. Of 19 patients who were in acute renal failure, seven responded to conservative management while 12 needed peritoneal dialysis. Nine patients developed pulmonary edema and four had grand mal seizures. Five patients died. Autopsy revealed massive pulmonary edema, thought to be the immediate cause of death, in four of them and extensive cortical and tubular necrosis in three.

Tuberculous peritonitis: a review of thirty-five cases

The clinical course of 35 patients with tuberculous peritonitis notified in Kandy (Sri Lanka) over a 6-year period has been reviewed. The maximum incidence occurred in the age group 21 to 40 years and the female/male ratio was 3:2. Clinical features were non-specific and the main presenting features were fever (68.5%), abdominal pain (65.7%), abdominal distension (54.2%), abdominal mass (54.2%) and ascites (45.7%). The symptoms were of insidious onset and 85% had symptoms for more than one month. Chest X-ray revealed abnormality suggestive of tuberculosis in 47%. Intra-abdominal tuberculosis was suspected in 43% of 26 patients before laparotomy. Four of the 32 patients given anti-tuberculous drugs died. Overall mortality was 20%.