The impact of splenectomy on outcome after resection for colorectal cancer: a multicenter, nested, paired cohort study.

PURPOSE: This study was designed to determine whether incidental splenectomy for iatrogenic injury affects long-term cancer-specific survival in patients having resection of an adenocarcinoma of the sigmoid or rectum. METHODS: A retrospective case-matched review of patients undergoing surgery for colorectal cancer with incidental splenectomy between January 1, 1990 and December 31, 1999 was undertaken. Data were analysed for age, American Society of Anesthesiologists physical status, gender, disease stage, operation type, and outcome. These cases were matched with patients from the same center, of the same age and gender, with the same stage of disease and operation, who did not require a splenectomy at the time of their surgery. RESULTS: Fifty-five patients were identified who had an iatrogenic splenectomy. Matched gender, stage, and American Society of Anesthesiologists-matched controls were identified. Follow-up from time of surgery to death or last follow-up ranged from 2 to 205 (median, 43) months. A Kaplan-Meier survival analysis using the Cox proportional hazards model to define the statistical significance found a significant difference between the groups favoring those without splenectomy (hazard ratio, 1.8; 95 percent confidence interval (CI), 1-3.3; P=0.0399). Cancer-specific survival at five years was 70 vs. 47 percent and at ten years was 55 vs. 38 percent. DISCUSSION: Patients with colorectal cancer who had splenectomy as a result of iatrogenic damage of the spleen while undergoing resection of the sigmoid or rectum for adenocarcinoma had a significantly worse prognosis.

Misconceptions about the colonic J-pouch: what the accumulating data show.

INTRODUCTION: Since 1986 when the colonic J-pouch-anal anastomosis was first described, it has gained increasing acceptance as the operation of choice for low rectal cancer surgery. However, there still exist several misconceptions about its use, namely anastomotic complications, alterations in anorectal physiology, and functional outcome. METHODS: All relevant articles derived from MEDLINE databases from 1986 to the present were reviewed. Emphasis was placed on reviewing the features that are claimed to make the colonic J-pouch-anal anastomosis superior to a straight anastomosis. RESULTS AND CONCLUSIONS: The colonic J-pouch has a role in ultra-low rectal cancer surgery, with an apparent reduction in the incidence of anastomotic leaks and reduced bowel frequency. Continence is unchanged and defecatory difficulties can be reduced by constructing a small pouch (< or =5 cm).

Priority access criteria for elective cholecystectomy: a comparison of three scoring methods.

AIM: To compare two priority access criteria scoring methods for elective cholecystectomy, with a score based on clinical judgement obtained using a linear analogue scale. METHODS: Patients placed on the waiting list for elective laparoscopic cholecystectomy between June and October 1997 were prioritised using the three methods. RESULTS: Data were obtained for 22 patients. The distributions of scores were different but there was a significant correlation between them. However, limits of agreement analysis demonstrated little agreement between them with a difference of +/- 30 points (out of a 100) between scores obtained with each method. CONCLUSION: The proposed methods for establishing priority access to elective cholecystectomy are poor tools, require validation and bear little relation to expert clinical judgement.

Generic surgical priority criteria scoring system: the clinical reality.

AIMS: To assess the 'generic surgical priority criteria' (GSPC) introduced into Auckland Hospital by the Northern Division of the Transitional Health Authority in 1997 and compare it with a score based on clinical judgement obtained using a linear analogue scale (LAS). METHODS: From the time of introduction in June 1997 all patients being placed on the general surgical waiting list have been scored using both the GSPC and the LAS. After two months the scores given to 209 patients were reviewed and compared. Correlation and limits of agreement analysis were performed for grouped data, cancer and benign groups. RESULTS: The data showed wide variation and poor agreement between the surgeons' clinical judgement in assessing priority for surgery and the score patients obtained using the GSPC. CONCLUSION: The GSPC has poor diagnostic discrimination as it failed to identify reliably a cancer diagnosis as high priority, with benign diagnoses scoring consistently higher. This highlights the need for clinical involvement in designing priority criteria and for formal validation of such tools.

Noradrenaline excites neurons in the guinea pig cerebellar vermis in vitro.

Noradrenaline (NA) was applied to the solution bathing the cavy cerebellar vermis in vitro and the responses of 98 neurons were recorded extracellularly. Two thirds (23/35) of the responses were excitations and the remaining third were inhibitions. The lowest concentration of NA with which responses could be obtained was 10(-11) M NA. Responses were generally transient and occurred with a mean latency of 61 +/- 8 sec. The excitation was generally direct as most responses (9/11) survived synaptic blockade. The excitations were thought to be mediated by alpha 1 receptors because they could be mimicked by phenylephrine and antagonised by prazozin.