Renal failure in obstructive jaundice.

BACKGROUND/AIMS: The optimal preoperative management of patients with acute obstructive jaundice is still a matter of debate. Reduction in effective plasma volume and systemic endotoxemia are major consequences both in experimental acute bile duct ligation and in patients with acute obstructive jaundice (AOJ). The objective of this study is to show the necessity for adequate preoperative hydration and lactulose administration for the prevention of postoperative renal dysfunction in patients with AOJ. METHODOLOGY: Fifty-five patients (35 male, 20 female) with a mean age of 62 years were entered into the study. There were 23 benign and 32 malignant strictures in this group. All patients received oral lactulose (30-45mL per day) and IV cefazoline (3-4g/day) before surgery. Fluid and electrolyte balance was precisely maintained throughout the hospitalization via daily body weight calculations. High-risk elderly patients with left ventricular systolic dysfunction were assessed by echocardiography and therapeutic measures were undertaken. Renal function was assessed by creatinine clearance (ClCr) measurements and impairment of renal function was defined as a >20% fall in ClCr value post-surgery. RESULTS: Mean preoperative bilirubin level was 11.05mg/dL (range: 3.45-27.0mg/dL). None of the patients developed postoperative renal failure. The difference between pre- and postoperative ClCr value (104.02mL/min vs. 101.0mL/min respectively) was not significant (t=0.698, P=0.489). One patient with mild renal function impairment before surgery (ClCr=45.4mL/min) successfully recovered with 60% rise in creatinine clearance (ClCr=78.1mL/min) after the operation. Three patients with normal functioning kidneys died within 30 days of operation. The principle cause of death was carcinomatosis and pulmonary embolus in two and intraoperative hemorrhagic shock in one patient. CONCLUSIONS: These results further substantiated the importance of adequate preoperative hydration and endotoxin inactivation in terms of acute renal failure prophylaxis in patients with AOJ. This regimen obviates the afferent events in obstructive jaundice and provides prevention of acute renal failure even in high-risk elderly patients.

Adjuvant chemotherapy in a unique population of patients with gastric cancer undergoing surgery.

BACKGROUND/AIMS: Total gastrectomy with D2 dissection theoretically removes the gross primary tumor with its potential route of dissemination, that is locoregional lymph nodes. Complementary therapy for the control of systemic microscopic disease should be taken into consideration in patients whom surgery with curative intent was performed. METHODOLOGY: Twenty-eight patients with moderately differentiated, locally advanced gastric carcinoma underwent total gastrectomy with D2 lymph node dissection. The operative mortality rate was 0% in this series. Fifteen patients received six courses of adjuvant 5-FU + leucovorin in doses of 425 mg/m2/d and 20 mg/m2/d respectively in five-day cycles month ly. The remaining 13 patients constituted the control (surgery only) group. RESULTS: The mean disease-free and overall survival rates were 41 and 48 months (p: 0.78) and 42 and 53 months (p: 0.43) in the control and chemotherapy groups, respectively. The odds ratio for crude mortality was 0.7. CONCLUSIONS: Although statistical significance has not been achieved in this study, a trend toward adjuvant chemotherapy has emerged in that unique group of patients with moderately differentiated (intestinal type) adenocarcinoma of the stomach undergoing curative surgery.