Primary resection and side-to-end anastomosis next to an end-colostomy in the management of acute malignant obstruction of the left bowel: an alternative in selected patients.

BACKGROUND: Patients presenting with an acute obstructing carcinoma of the left bowel are a surgical challenge. Under more difficult circumstances with gross distension of the proximal colon many surgeons will decide to defer anastomosis. Hartmann's procedure still represents a valid treatment option. We describe our experience with primary resection and side-to-end anastomosis next to an end-colostomy in the management of acute malignant obstruction of the left bowel. METHODS: The surgical procedure involves resection of the tumour and primary stapled side-to-end anastomosis next to a protecting end-colostomy. This type of enterostomy was first described by Santulli and Blanc in 1961. Colostomy closure is possible via a local procedure avoiding relaparotomy. Ten patients (five women) underwent surgery using this technique. Their mean age was 71 years (range 54-88 years). All patients had a massively distended colon. All obstructing lesions were biopsy-proven adenocarcinomas. RESULTS: There was no postoperative mortality and no anastomotic leakage. The colostomy could be closed without a laparotomy in all patients. The only two complications were one superficial necrosis of the stoma and one wound infection after colostomy closure. In all other patients the postoperative course was uneventful. Wound infection after colostomy closure was seen in the very first patient in whom the wound was closed primarily. In subsequent patients the skin was left open. CONCLUSIONS: The concept of an end-colostomy next to the anastomosis is an alternative approach combining the safety of proximal decompression and the advantages of primary anastomosis. This technique may be considered in patients presenting with a massively distended and faeces-loaded colon caused by an obstructing tumour in the descending or sigmoid colon, when the surgeon would otherwise elect to defer anastomosis.

Sentinel lymph node biopsy in breast cancer: results of intradermal periareolar tracer injection and follow-up of sentinel lymph node-negative patients.

Several methods are in use for identification of the sentinel lymph node (SLN) in breast cancer. We set up the hypothesis that intradermal (i.d.) infra-areolar injection of technetium-99m in combination with i.d. injection of patent blue dye lateral to the areola can identify the same lymph node as peritumoral injection, regardless of the location of the tumour. Each of 50 patients with breast cancer (group I) received an i.d. injection of technetium-99m 1cm caudal to the areola. After induction, blue dye was injected intradermally 1cm lateral to the areola. These patients underwent axillary dissection regardless of their lymph node status. The SLN was identified in 96% of these patients. One of them had axillary lymph node metastases even though the SLN was negative (6%). Further 82 patients (group II) underwent SLN identification and removal without further axillary dissection. The duration of mean follow-up for these patients was 28 months (16-39 months). One patient developed axillary recurrence (1%) 24 months after the initial operation. Intradermal periareolar tracer injection is an accurate method of locating the sentinel node. Long-term follow-up of patients who had negative sentinel nodes and did not undergo axillary dissection revealed a low axillary recurrence rate.

Is it necessary to lift the abdominal wall when preparing a pneumoperitoneum? A randomized study.

BACKGROUND: In order to create a pneumoperitoneum with the Veress needle, it is generally advocated that the abdominal wall should be lifted. Lifting is aimed at increasing the distance between the abdominal wall and the intraabdominal structures. This study was conducted to compare lifting (L) and nonlifting (NL) of the abdominal wall. METHODS: All patients scheduled for laparoscopic surgery without previous abdominal surgery or morbid obesity were included in the study group. The number of attempts needed for proper positioning of the needle was assessed. RESULTS: A total of 150 patients were randomized. There were no complications. The number of attempts needed for correct positioning of the Veress needle was significantly higher in the L group than in the NL group (31 of 75 vs nine of 75, p < 0.001). The body mass index (BMI) of patients in whom peritoneal entry needed more than one puncture was significantly higher than the BMI of patients with immediate proper placement (28.3 vs 24.7 kg/m(2), p < 0.05). CONCLUSION: Abdominal wall lifting is not necessary.

Open versus closed establishment of pneumoperitoneum in laparoscopic surgery.

BACKGROUND: Closed laparoscopy, employing a Veress needle and blind insertion of the first trocar, is favoured by most laparoscopic surgeons. The potential danger of this technique is the occurrence of visceral or vascular injury. Establishment of pneumoperitoneum by an open technique using a blunt-tipped trocar may be a safer alternative. METHODS AND RESULTS: Retrospective review of the literature and the authors' experience was used to compare closed and open laparoscopy. Data on closed laparoscopy in 489335 patients and on open laparoscopy in 12444 patients were culled. Rates of visceral and vascular injury were respectively 0.083 and 0.075 per cent after closed laparoscopy, and 0.048 per cent and zero after open laparoscopy. Mortality rates after closed and open laparoscopy were respectively 0.003 per cent and zero. Pearson chi 2 analysis demonstrated a statistically significant difference in terms of visceral and vascular injury between closed and open laparoscopy (P = 0.002); there was no such difference for mortality rates. CONCLUSION: Open establishment of pneumoperitoneum is advocated in laparoscopic surgery because it is safer than the closed method.

Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair.

BACKGROUND: Inguinal hernias can be repaired by laparoscopic techniques, which have had better results than open surgery in several small studies. METHODS: We performed a randomized, multicenter trial in which 487 patients with inguinal hernias were treated by extraperitoneal laparoscopic repair and 507 patients were treated by conventional anterior repair. We recorded information about postoperative recovery and complications and examined the patients for recurrences one and six weeks, six months, and one and two years after surgery. RESULTS: Six patients in the open-surgery group but none in the laparoscopic-surgery group had wound abscesses (P=0.03), and the patients in the laparoscopic-surgery group had a more rapid recovery (median time to the resumption of normal daily activity, 6 vs. 10 days; time to the return to work, 14 vs. 21 days; and time to the resumption of athletic activities, 24 vs. 36 days; P<0.001 for all comparisons). With a median follow-up of 607 days, 31 patients (6 percent) in the open-surgery group had recurrences, as compared with 17 patients (3 percent) in the laparoscopic-surgery group (P=0.05). All but three of the recurrences in the latter group were within one year after surgery and were caused by surgeon-related errors. In the open-surgery group, 15 patients had recurrences during the first year, and 16 during the second year. Follow-up was complete for 97 percent of the patients. CONCLUSIONS: Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair.

The learning curve for totally extraperitoneal laparoscopic inguinal hernia repair.

BACKGROUND: Several laparoscopic techniques have been introduced to re pair inguinal hernia, the newest and most promising being a totally extraperitoneal approach. Nevertheless, the surgeon may encounter several complications and technical difficulties associated with the transition from the conventional anterior operation. METHODS: In late 1993 and 1994, 120 patients were operated on for inguinal hernia using the totally extraperitoneal approach by four laparoscopic surgeons inexperienced in this new technique in a secondary referral setting. Their learning curve was assessed through operation time, perioperative and postoperative complications, and technical difficulties. RESULTS: Median operative time decreased significantly (P = 0.0003) when going through the learning curve. During the initial part of the learning curve, conversion to another technique was necessary in 10 (8%) cases, and in 6 of these cases, conversion was needed for a peritoneal tear (relative risk for conversion if peritoneal tear was present: 4.0; 95% confidence interval 1.2 to 13.1, P = 0.025). The median operative time for Nyhus type IIIb and IVb hernias was significantly longer than for other types (70 versus 55 minutes, P = 0.003). Median postoperative stay was 2 days (range 0 to 7). There were 10 recurrences within 6 months due to technical or judgement errors. CONCLUSIONS: For surgeons, the learning curve for totally extraperitoneal laparoscopic hernia repair can be overcome; however, the presence of an experienced surgeon during the procedure is vital, as this may prevent unnecessary recurrences.

Prophylactic use of cefuroxime in biliary tract surgery: randomized controlled trial of single versus multiple dose in high-risk patients. Galant Trial Study Group.

To assess the efficacy of a single-dose short-acting antibiotic in the prevention of septic complications after biliary surgery, a randomized controlled double-blind multicentre trial was conducted. One dose of cefuroxime before operation (1.5 g intravenously) was compared with a three-dose regimen of the drug as control (1.5 g before and two doses of 0.75 g after operation). The study group comprised 1004 patients with risk factors for infection, who were followed for 4-6 weeks after surgery. The characteristics of both treatment groups were comparable. No significant difference was found between the one- and three-dose antibiotic regimens in preventing postoperative wound infection: 6.6 versus 6.2 per cent for minor wound infection (P = 0.78) and 4.6 versus 3.8 per cent for major wound infection (P = 0.52). The estimated difference in major wound infection rate between the two groups was 0.8 per cent (95 per cent confidence interval -1.7 to 3.3 per cent).

Eicosanoids in breast cancer patients before and after mastectomy.

In 19 patients with a malignant breast tumor, tumor tissue and blood were taken to determine the eicosanoid profile and platelet aggregation. Values were compared with those of patients with benign tumors (n = 4), or undergoing a mammary reduction (n = 7). Postoperatively, blood was taken as well in order to compare pre- and postoperative values. Eicosanoids were measured in peripheral blood monocytes and mammary tissue by means of HPLC; furthermore, TXA2, 6-keto-PGF1 alpha, and PGE2 were determined by RIA. Differences in pre- and postoperative values of cancer patients were seen in plasma RIA values: PGE2 and 6-k-PGF1 alpha were significantly higher preoperatively when compared with postoperatively, however, such differences were seen in the control groups as well. Compared to benign tumor or mammary reduction test material the eicosanoid profile of tissue obtained from malignant mammary tumors showed important differences. Except for PGF2 alpha, HHT and 15-HETE no detectable quantities of eicosanoids were found in the non-tumor material, whereas in the malignant tumor material substantial quantities of a number of eicosanoid metabolites were present. Statistically significant correlations could be established between patient/histopathology data and the results of the platelet aggregation assays, e.g. between menopausal status and ADP aggregation; oestrogen receptor (+/-) and collagen and arachidonic acid aggregation, inflammatory cell infiltration score and arachidonic acid aggregation and fibrosis score and ADP aggregation. The results show that eicosanoid synthesis in material from mammary cancer patients is different from that in benign mammary tissue. The implications, in particular, in relation to future prognosis of the patient, remain obscure.

[Gallbladder extirpation in The Netherlands; frequency, surgical mortality and postoperative complications (1987-1989)]. / Galblaasextirpaties in Nederland; frequentie, operatieve sterfte en postoperatieve complicaties (1987-1989).

In view of the fast-growing popularity of laparoscopic cholecystectomy, a retrospective analysis was made of 'traditional' cholecystectomy in the Netherlands in the period 1987-1989 (data provided by the Health Care Information Centre Foundation), as compared with the period 1979-1981 (data provided by the Medical Registration Foundation). As regards frequency, the number of cholecystectomies had decreased by 25.5% compared with the period 1979-1981. The number of cholecystectomies with exploration of the choledochus had decreased by 43.8%. The surgical mortality in the period 1987-1989 amounted to 1.4%. Postoperative complications, including wound infections, were relatively infrequent, occurring in 4.3% and 1.5%, respectively, of the patients. Acute cholecystitis, age greater than 70 years and choledochus exploration proved to be risk factors with substantially higher surgical mortality and postoperative morbidity.

Postoperative radiation therapy for rectal cancer. An interim analysis of a prospective, randomized multicenter trial in The Netherlands.

The authors assessed the potential benefit of postoperative radiation therapy for rectal cancer in a two-arm, prospective multicenter trial. One hundred seventy-two patients who had undergone surgical resection for rectal adenocarcinoma were randomly assigned to either treatment consisting of external irradiation to a dose of 5000 cGy in 5 weeks or a control group (no adjuvant therapy). It was assumed that the number of cells remaining after radical surgery would be low and that the dose of 5000 cGy would be adequate in eradicating the majority of those cells. The number of local recurrences was lower in the treated group of patients, but the difference was not statistically significant. It was assumed that if a significant reduction in the number of local recurrences could be obtained, improved (disease-free) survival would result. No influence on disease-free or overall survival could be detected. These results were in agreement with those reported in Europe and the US, and it was concluded that postoperative radiation therapy alone cannot be justified as a routine procedure in the primary management of resectable rectal cancer.

Antibiotic prophylaxis in biliary tract surgery--current practice in The Netherlands.

A questionnaire about the current practice of antibiotic prophylaxis in biliary tract surgery was sent to the chairmen of the departments of surgery of 175 hospitals in The Netherlands. The Dutch hospitals are classified into three categories depending on the type of residency in general surgery. Overall, 80 per cent replied. Antibiotic prophylaxis in elective cholecystectomy is given in 76 per cent of the clinics (100/132), and single-dose prophylaxis is employed in 28 per cent of the clinics (28/100). In patients with acute cholecystitis, emergency surgery is the treatment of choice in 108 hospitals (82%). Differences in antibiotic prophylaxis between the three categories of hospitals include the omission of prophylaxis in elective cholecystectomy in 31 per cent of the C-clinics (vs. 10% in A-clinics and 16% in B-clinics), and the use of single-dose prophylaxis in 13 per cent of the B-clinics (vs. 30% of the A-clinics and 31% of the C-clinics). Since prophylaxis for more than 24 hours has no additional effect and peri-operative prophylaxis in acute cholecystitis is mandatory, antibiotic prophylaxis in biliary tract surgery is inappropriate in at least 31 hospitals in The Netherlands (23%).

Meta-analysis of randomized, controlled clinical trials of antibiotic prophylaxis in biliary tract surgery.

In this study all available clinical trials of antibiotic prophylaxis in biliary tract surgery, published from 1965 to 1988, were examined. Results of 42 randomized, controlled trials (4129 patients), in which a group of patients treated with antibiotics was compared with a group of patients not treated with antibiotics, were pooled. Wound infection rates in the control groups range from 3 to 47 per cent and are 15 per cent overall. The overall difference in infection rates is 9 per cent in favour of antibiotic treatment (95 per cent confidence interval 7-11 per cent), while the common odds ratio is 0.30 (95 per cent confidence interval 0.23-0.38). Subgroup meta-analysis showed a significant stronger protective effect in high risk patients, while the timing of wound inspection (i.e. early in hospital or late at follow-up) markedly influenced the treatment effect reported. Comparison of wound infection rates in patients treated with first generation versus second or third generation cephalosporins (11 trials, 1128 patients), as well as single-dose versus multiple-dose regimens (15 trials, 1226 patients) did not reveal any significant effect (P greater than 0.05) in each trial separately as well as in the overall comparison. The results indicate that there is evidence against further use of no-treatment controls and that the choice of treatment regimen can largely be made on the basis of cost.

Adjuvant portal liver infusion in colorectal cancer with 5-fluorouracil/heparin versus urokinase versus control. Results of a prospective randomized clinical trial (colorectal adenocarcinoma trial I).

This prospectively randomized clinical trial was carried out in four Dutch hospitals to reduce the development of metachronous liver metastases and to get a better survival in patients with colorectal malignancies after surgically radical en bloc resection of the primary tumor and the regional lymph nodes. Three hundred seventeen patients were randomized to participate in three trial arms. One group of patients was treated by surgery alone (control group); in the other patients a catheter was placed in the dilated umbilical vein and advanced until the tip was lying in the left branch of the portal vein. Fifty percent of these patients got immediate postoperative portal infusion with 1 g 5-fluorouracil (5-FU) and 5000 U heparin daily for 7 days; the others received portal vein infusion with urokinase 10.000 U/hour for 24 hours only. Three hundred four patients were eligible. Overall hospital mortality was 3.6% (11 patients) and was not influenced by adjuvant treatment. After a median follow-up of 44 months 66 patients have died with relapse and 21 as a result of other causes. The chance of developing liver metastases and other distant metastases after portal infusion with 5-FU/heparin was one third of the chance in the control group (P less than 0.001). Only an insignificant reduction of the average death rate in the 5-FU/heparin group was found. In the urokinase group no significant effect in reducing metastases or in survival was noted. Before recommending cytotoxic portal infusion as an adjuvant treatment in patients with colorectal cancer, detailed analysis of other ongoing portal infusion studies has to be awaited and careful calculations have to be made regarding how many patients really can be saved by this treatment.

Malignant fibrous histiocytoma of the spermatic cord.

We report a case of malignant fibrous histiocytoma of the spermatic cord and review 11 previously reported cases. Radical orchiectomy along with wide local excision is the treatment of choice. The rate of local recurrences and distant metastases is 33 per cent (4 of 12 cases) and the 5-year survival rate is 57 per cent (4 of 7 cases).