Challenge in diagnosis and treatment of colonic carcinoma emergencies

Despite advances in perioperative care and operative techniques, urgent colorectal operations are still associated with higher mortality and morbidity than elective surgery. This study was to identify the challenge in diagnosis and treatment of emergencies caused by colon carcinoma; and to assess its outcome. This included 59 consecutive patients treated with emergency surgical intervention for colonic carcinoma; and other 59 patients of elective colonic surgery. Morbidity rates were 27.1% versus 10.2% after emergency and elective surgery. Rates of 1-, 2- and 3-year survival were 64.4%, 57.6% and 47.5% respectively after emergency surgery; and 71.2%, 62.7% and 50.8% respectively after elective surgery. Challenge included presentation of undiagnosed patients with difficult or impossible colon preparation, colonoscopy, tissue biopsy or tumor staging; in addition to associated diseases and/or old age. Mortality and morbidity rates after emergency surgery were higher than elective surgery. Selection of the surgical procedure was guided by the tumor staging, co-morbidities and intraoperative assessment. Emergency resection, when possible, could approximate survival of elective resection. Total colectomy could obtain good outcome and survival when compared to other emergency procedures

Controversies in surgical intervention and percutaneous biliary drainage for malignant obstructive Jaundice

Management of malignant jaundice is frequently a real challenge. Most patients present in advanced stages of the disease, and usually there are co-morbidities. Some investigations may not be diagnostic or conclusive. There are controversies about the diagnostic and therapeutic procedures for jaundice. Surgical intervention and percutaneous biliary drainage are two lines of treatment with much controversy. Of this work was to assess the controversies in the management of malignant obstructive jaundice as regards benefits, drawbacks and basis of selection of surgical intervention versus percutaneous biliary drainage. 37 patients were included in this study. Detailed medical history, clinical examination and complete y laboratory and imaging investigations for the hepato-biliaiy tract were done. Decision of treatment was guided by the data of the patients, stage and extent of the disease, expected morbidity of the procedure and expected prognosis. 23 males and 14 females with mean age 58.6 +/- 17.4 years were studied. Diagnosis of the studied patients included 17 [45.9%] patients with pancreatic head carcinoma, 12 [32.4%] patients with cholangiocarcinoma, 6 [16.2%] patients with periampullary tumours, one [2.7%] patient with intrahepatic metastatic tumour one [2.7%] patient with hepatocellular carcinoma. Resectable tumours were found in 4 [10.8%] patients, while unresectable tumours were found in 33 [89.2%] patients. The treatment of the patients included surgical intervention for 14 [37.8%] patients and percutaneous biliary drainage for 23 [62.1%] patients. The mean survival duration was 11 +/- 4.8 months after resectional surgery, 6.5 +/- 2.4 months after palliative surgical bypass, while it was 4.7 +/- 1.2 months after percutaneous biliary drainage. Selection of therapeutic procedure was guided and individualized by the data of the patient. Whenever the tumour is operable, resectional surgery is the treatment of choice. However, in the majority of patients, the tumours were inoperable and treatment was palliative. Palliative surgical bypass was associated with less morbidity and longer survival than stenting, and was preferable for lower biliary obstruction. However, precutaneous biliary drainage was more suitable for hilar biliary obstruction. It can be the sole therapeutic procedure for jaundice of patients unfit for surgical intervention. Percutaneous biliary drainage was beneficial for patients with advanced inoperable tumours, with bad general conditions and deteriorated uncorrectable liver functions. It also included diagnostic cholangiography, especially 1 ERCP is not feasible, allowed internal/external drainage and the simultaneous positioning of several protheses