[Colorectal surgery in patients over 65 years of age]. / Cirugía colorrectal en pacientes mayores de 65 años.

BACKGROUND: There is a limited functional reserve in patients over 65 years of age which is conducive to more frequent postoperative complications. Disease extension at the time of diagnosis (clinical stage) and complete tumor resection are two independent risk factors that have a direct influence on survival. AIMS: To describe the factors that influence morbidity and mortality in patients over 65 years of age after colorectal surgery. MATERIAL AND METHODS: A retrospective, observational, descriptive study was carried out within the time frame of January 2004 and December 2009 on 105 colon cancer patients after colorectal surgery. They were divided into two groups, one under 65 years of age and the other over 65 years of age, in order to compare preoperative comorbidity, as well as morbidity and mortality 30 days after surgery. RESULTS: Of the 105 patient total (53,3%), 56 were ≤ 65 years of age. There were complications in 42,8% of the patients, and those of early and less severe presentation were the most frequent; late complications were more frequent in patients ≤ 65 vs > 65 years of age (16,0% vs 10,2%). Overweight (BMI > 25 kg/m(2)) was observed in 35,0% of the study population. Patients > 65 years of age had fewer comorbidities. The most common causes of reintervention were anastomosis dehiscence and postoperative hemorrhage. Mortality in the group was 6,6% and sepsis was the most frequent cause of death. CONCLUSIONS: Colorectal surgery in patients over 65 years of age has an acceptable complication frequency and a low mortality rate. Our results suggest that patients older than 65 years of age be treated with the same prospects for cure as younger patients.

Morbidity and mortality of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: national cancer institute, Mexico city, Mexico.

Peritoneal carcinomatosis (PC) is generally considered a lethal disease, with a poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a new approach for peritoneal surface disease. This study investigated the early experience with this combined modality treatment at a single institute. From January 2007 to March 2010, 24 patients were treated After aggressive CS, with HIPEC (cisplatin 25 mg/m(2)/L and mitomycin C 3.3 mg/m(2)/L was administered for 90-minutes at 40.5° C). These data suggest that aggressive CRS with HIPEC for the treatment of PC may result in low mortality and acceptable morbidity. Rigorous patient selection, appropriate and prudent operative procedures were associated with encouraging results in our experience.

[Early gastric carcinoma. Analysis of 21 cases]. / Carcinoma gástrico incipiente. Análisis de 21 casos.

BACKGROUND: Early gastric carcinoma (EGC) is defined as a neoplasm confined to the mucosa and submucosa regardless of the presence of metastasis. This lesion is found in approximately 3% of cases in Mexico. The aim of this study is to describe our experience with EGC, emphasizing early detection as the most useful method to decrease mortality. METHODS: Retrospective review of records of patients with EGC treated at an oncologic referral center over a 12-years period. RESULTS: Twenty-one cases of EGC were retrieved. Mean age was 58.1 years (range, 33 to 84). Twelve were women and nine, men. Lymph node or distant metastasis were not found. Overall 5-year survival was 66.4%. Twenty patients underwent radical gastrectomy and only one underwent wedge resection of the gastric wall. Two patients (9.5%) presented recurrence and cancer-related death. Mean follow-up was 8.3 years. CONCLUSION: The prognosis of EGC in our hospital is lower than in countries other than Mexico and this lesion is found with low frequency. Increasing the detection EGC is the best method to reduce GC-related mortality.

[Laparoscopic partial hepatectomy. Report of the first case in Mexico]. / Hepatectomía parcial por laparoscopia. Informe del primer caso en México.

The authors report the case of a 47-year-old female patient referred to the Instituto Nacional de Cancerología with abdominal pain and a focal liver lesion in the left lateral segment. After a careful tumor work-up, a laparoscopic left lateral segmentectomy was performed. The postoperative course was uneventful and the patient was discharged at the 2nd postoperative day. Histologic examination revealed focal nodular hyperplasia. In a search of the literature we find this to be the first case treated by this approach in Mexico.

[Obstructive esophageal membrane in recessive dystrophic epidermolysis bullosa]. / Membrana esofágica obstructiva en epidermólisis ampollosa distrófica recesiva.

BACKGROUND: Dysphagia is a rare complication of esophageal webs. OBJECTIVE: To describe a patient with dystrophic epidermolysis bullosa who developed dysphagia produced by an esophageal web that simulated carcinoma. CASE REPORT: A 26 year-old male with dystrophic epidermolysis bullosa developed severe dysphagia and subsequently aphagia secondary to an upper third esophageal obstruction. A (CT) scan showed a circumferential esophageal wall thickening of the affected area. The patient was submitted to surgical neck exploration with endoscopic assistance to identify the obstruction and a esophagotomy was carried on detecting a complete esophageal web that was excised. CONCLUSIONS: Esophageal web must be considered a cause of esophageal obstruction in patients with dystrophic epidermolysis bullosa.

Survival benefit of D2 lympadenectomy in patients with gastric adenocarcinoma.

BACKGROUND: A definite resolution to the controversy on the optimal extension of lymph node dissection (LND) in gastric cancer has not been achieved. Surgical morbidity and survival of D1 and D2 LND are compared by multivariate analysis. METHODS: A retrospective cohort study of 219 patients with gastric cancer and curative resection performed according to Japanese rules. D1 dissection was performed in 106 cases and D2 in 113. The logistic regression model was used to define risk factors for surgical morbidity and the Cox model to determine prognostic factors. RESULTS: Surgical morbidity occurs in 16.9% and 19.5% in D1 and D2 LND, respectively (P = .7). The morbidity determinants were operation blood loss, splenectomy, pancreaticosplenectomy, antrum location, low serum albumin, total gastrectomy, and metastatic nodal ratio (P < .0001), but not D2 LND. Five-year survival was 35.1% for D1 and 64% for D2 LND (P < .039). The prognostic factors were T stage, N stage, serum albumin level, total gastrectomy, D2 LND, and comorbidity (P < .0001). CONCLUSIONS: The increment of surgical morbidity and mortality rates attributed to D2 LND is largely caused by the effect of splenectomy and pancreaticosplenectomy. A significant survival benefit because of D2 LND was found. The results support the value of extended LND in the surgical treatment of gastric cancer.

Preoperative multivariate prediction of morbidity after gastrectomy for adenocarcinoma.

BACKGROUND: Gastrectomy remains the only curative treatment for gastric cancer. However, surgical morbidity and mortality remains high. Our aim was to identify the risk factors that determine operative morbidity and mortality and to describe a simple method for preoperative stratification of morbidity outcome. METHODS: Retrospective review of patients who underwent gastrectomy for gastric cancer. Multivariate analysis was used to define risk factors for surgical morbidity and mortality. RESULTS: A total of 208 cases were included. Fifty-one episodes of operative morbidity and 19 surgery-related deaths were found. Operative blood loss (risk ratio [RR], 1.0012), serum albumin (RR, 0.42), extent of gastrectomy (RR, 2.8), lymphocyte count (RR, 0.999), and splenectomy (RR, 1.51) were the most important risk factors for morbidity. However, location of the tumor, serum albumin level, and lymphocyte count were the most important preoperative risk factors that determine the appearance of surgical complications. Receiver operating characteristic analysis of this model allowed definition of three risk groups in terms of surgical morbidity (11.8%, 28.5%, and 52.4%, respectively). CONCLUSIONS: A new method for preoperative calculation of the probability of surgical complications was developed. It must be validated prospectively and in different settings to be used in preoperative interventions designed to reduce that risk.

[Multiorgan resection in T4 colonic adenocarcinoma. Report of a case]. / Resección multiorgánica en adenocarcinoma de colon T4. Informe de un caso.

BACKGROUND: Colorectal cancer is the second among gastrointestinal malignancies in Mexico Locally advanced disease or metastatic lesions are frequently found. To resect or not such a tumor is a difficult decision. OBJECTIVE: To report a case of colon cancer with multivisceral invasion resected and to review the published information. CLINICAL MATERIAL: A 43 year-old Mexican male with rectal bleeding and weight loss with a tumor located in transverse colon with direct invasion to stomach. CT scan demonstrated invasion to spleen and pancreas. En-bloc radical-extended right colectomy, total gastrectomy, distal pancreatectomy, splenectomy and left adrenalectomy was performed. Adjuvant chemotherapy was used. At 12-month follow-up he is asymptomatic, without neoplasic activity and with good quality of life. CONCLUSION: An aggressive multiorganic resection in T4 colorectal tumors is justified in selected cases. The high morbidity and mortality of these procedures must be evaluated individually, and if permissive must be performed.

[Indications and results of hepatic resection in benign and malignant tumors]. / Indicaciones y resultados de la resección hepática en tumores benignos y malignos.

OBJECTIVE: The authors analyze the indications and results in 75 consecutive liver resections. BACKGROUND: In recent years, the morbidity and mortality of this procedure have been reduced at specialized centers due to better control of intraoperative bleeding and improved perioperative management. METHODS: The clinical records of 72 patients who had a liver resection over a 4-year period were reviewed. RESULTS: Fifty-two were females and 23, males. Ages ranged between 15 and 88 years (X: 50 +/- 22 years). The indications for surgery were liver, secondary in 28, gallbladder or bile duct cancer in 17, benign liver tumors in 16, and primary malignant liver tumors in 14. Forty-seven major liver resections were performed and included 25 right hepatectomies, 13 left hepatectomies, five right trisegmentectomies, and four left trisegmentectomies. Additionally, 28 minor resections included 12 resections of the left lateral segment, nine bisegmentectomies, five segmentectomies and two resections of the caudate lobe. Operative time ranged from 60-540 min (X: 260 +/- 97 min); the mean operative bleeding was 1439 +/- 660 mL (range 20-5,000 mL). The pringle maneuver was used in 63 patients and ranged from 20-100 min (X: 42 +/- 25 min). Twenty-five patients presented complications (33%), the most frequent being hepatic failure, postoperative bleeding, ascitis and bilomas. Six patients died (8%) due to hepatic and multiorganic failure in four pneumonia and myocardial infarct in one, and systemic sepsis in the other. CONCLUSIONS: Liver resection is an excellent therapeutic alternative in patients with benign and malignant liver focal lesions.

[Prognostic factors in 793 cases of gastric cancer in an oncologic referral center]. / Factores pronósticos en 793 casos de cáncer gástrico en un centro de referencia oncológico.

OBJECTIVE: To describe the 12-year experience with Gastric Cancer (GC), with special emphasis in prognostic factors. BACKGROUND: GC is the most common gastrointestinal malignancy and is the second cause of cancer-related mortality in Mexico. Poor results have been reported, and new treatments have not improved the life expectancy. The available information regarding GC in our country is limited. METHODS: Retrospective cohort study of 793 patients with gastric adenocarcinoma treated in an oncologic referral center in Mexico City. Demographic and clinical data, and the results of surgical treatment are presented. Survival curves by TNM stage and other prognostic factors are described. RESULTS: Sixty two percent of the patients presented in stage IV, with a median survival of 8.6 months. Only 33% of the whole group underwent surgical resection. One hundred and sixty two subtotal, 86 total and 12 proximal gastrectomies were performed, 74% with curative intention and in 26% for palliation. Operative morbidity and mortality were 23.3% and 10.9%, respectively. The multivariate analysis showed that the independent prognostic factors were TNM stage (Risk ratio 1.49; 95% CI 1.26-1.76; p < 0.0001), operative morbidity (RR 6.05; 95% IC 3.74-9.7; p < 0.0001), seralbumin (RR 1.26; 95% CI 1.03-1.5; p < 0.03), age (RR 1.01; 95% CI 0.9-1.02; p < 0.057), type of lymphadenectomy (RR 1.59; 95% CI 0.97-2.59; p < 0.06) and gastrectomy performed (RR 1.9; IC 95% 0.9-4.2; p < 0.06). CONCLUSION: The TNM staging system was the most important prognostic factor. The high rate of GC in advanced stages affects directly the results. Better survival may be expected if the relative frequency of stages I and II increase. Endoscopy is warranted to patients with dispeptic symptoms who present no response to treatment or recurrence. Our experience reflects the importance of this health problem in México.

Papillary-cystic neoplasm of the pancreas. A sex-steroid dependent tumor.

CONCLUSION: The rate of growth of a papillary-cystic tumor of the pancreas seemed to be enhanced by the concurrence of pregnancy. Progesterone receptors in the tumor were demonstrated by immunohistochemistry and by molecular biology methods. BACKGROUND: Papillary cystic tumor of the pancreas is extremely rare, occurring predominantly young females. Owing to the low frequency of the tumor, there is scarce information about the conditions that promote tumor growth. METHODS: In this report, we present the temporal association between very rapid growth of a papillary-cystic neoplasm and pregnancy. Clinicopathological, immunohistochemical, and molecular biology analyses were performed. RESULTS: A 21-yr-old woman was admitted because of recurrent epigastric abdominal pain associated with episodes of nausea and vomiting, and a history of an abdominal tumor of about 50 mm near the head of the pancreas, detected by ultrasound. On admission the patient had a flat, nontender abdomen without palpable masses. Laboratory analysis including hematologic and hepatic tests were strictly normal; only CA 19-9 (42 U/mL, normal 37 U/mL) was above normal values. One week after admission, an abdominal computerized axial tomography (CAT) scan revealed an 81.6-mm cystic mass localized in the head of the pancreas, and 1 wk later, in a laparotomy, a papillary-cystic neoplasm of 120 mm, limited to the head of the pancreas, was found. Three months later, in a routine follow-up visit, an 18-wk pregnancy was clinically diagnosed and confirmed by ultrasound exploration. The pregnancy continued without complications, and a normal male infant (3.7 kg) was born at 39 wk of gestation, by vaginal delivery. Eighteen months after tumor resection, the patient was asymptomatic and her child was in good health. We propose that progesterone affects tumor growth.

[Management of digestive system carcinoid tumors and carcinoid syndrome]. / Manejo del tumor carcinoide del aparato digestivo y del síndrome carcinoide.

INTRODUCTION: Carcinoid tumors are rare, most of the publications are case reports and the clinical series are uncommon. The quality of life and survival time of these patients depend on the adequate control of tumor growth and good palliation of their symptoms. AIMS: The purpose of this study is to inform epidemiological data and forms of management for these tumors and the Carcinoid Syndrome at the National Institute of Cancerology (INCan) at Mexico City in the last 15 years. METHODS: A retrospective review of the clinical records of patients diagnosed and treated at the INCan with carcinoid tumors from 1982 to 1997 was performed. RESULTS: The most common origin place was the gastrointestinal tract (GI), and the majority involved the right colon and the appendix. The longest survivors were patients with tumors originated in the appendix, tumors smaller than 2 cm or localized. At the time of diagnosis 47% of patients had metastatic disease that was also a poor prognostic factor. The experience in our hospital seem to support the use of interferon alone or in combination with octreotide or debulking surgery for the palliation of carcinoid syndrome. CONCLUSIONS: Carcinoid tumors are rare, and have a slow growth and less aggressive biological nature than noncarcinoid tumors. Treatment should be focused on trying to cure the small or localized lesions or to find the best palliative method for those symptomatic advanced lesions.

[Gastric cancer]. / Cáncer gástrico.

Gastric cancer (GC) is a frequent neoplasm with high mortality. Most patients in occidental countries show advanced stages of the disease, and low resectability rates. In this paper, some epidemiological items are detailed. The morphologic classifications, TNM stages and risk factors for GC are defined. Clinical manifestations are described, focused in the necessity of early diagnosis as it is the only way to reduce mortality. The usefulness of diagnostic methods in preoperative staging are discussed in relation to the role of these methods in the prediction of resectability and the evaluation of new therapeutic regimens. The role of radical surgery and extended lymphadenectomy as definitive treatment is analyzed as well the role of adjuvant and palliative interventions. The experience in Instituto Nacional de Cancerología is briefly described.

[Tumors of the small intestine]. / Tumores de intestino delgado.

Small bowel tumors (SBT) are rare neoplasms and represent less than 10% of all gastrointestinal tumors. The majority of them are benign and discovered at the time of autopsy. However of those who present symptoms the majority belong to the group of malignant tumors and require of treatment. The most common histological variety are the adenocarcinoma and the carcinoid tumors. Abdominal pain, intestinal obstruction or gastrointestinal bleeding are the most common clinical complaints. Endoscopy or contrast X-ray examination are the most common forms of diagnosis and surgery remain the best way of treatment chemotherapy or radiotherapy are used in combination with surgery according to the histological diagnosis, the survival depends to the final histological report. A review of the experience at the National Institute of Cancer in Mexico city was performed and 34 patients were found with the diagnosis of SBT of which the majority presented with abdominal pain, nausea, vomiting and abdominal distension. The most common histological diagnosis were the adenocarcinoma (52%) and the leiomyosarcoma (32%). Surgery was the most common form of treatment (73%) of which in 20% distant metastasis was diagnosed. Only nine are alive at the time of the report without recurrent disease with a mean follow up of 7 months. Our experience shows that SBT are rare neoplasms, the majority are diagnosed late but surgery remain the best way of treatment because it can offer the possibility of cure or adequate palliation with derivative procedures.

[Primary carcinoma of the gallbladder]. / Carcinoma primario de la vesícula biliar.

OBJECTIVE: Determine the general features of primary gallbladder carcinoma (GBC), the diagnostic procedure and the current management as well as to analyze the experience at the National Institute of Cancer in Mexico City (INCan). INTRODUCTION: GBC is a rare and frequently lethal disease. The majority of patients are diagnosed at late clinical stages when the prognosis is poor. However in recent years several investigators have shown that radical procedures increase survival. MATERIAL AND METHODS: A review of relevant articles regarding epidemiological features, laboratory and imaging studies together with the actual form of management according to the stage at diagnosis was made. A review of clinical records of patients with GBC at the INCan in the last 10 years was also made. RESULTS: The prognosis of GBC carcinoma depends of the stage at the time of diagnosis, tumors confined to the gallbladder (Nevin I-III) have better prognosis than those presented with lymphadenopathy or liver invasion. Actually the surgical procedure most accepted is wedge liver resection and lymphadenectomy, because it seems to improve survival. At the INCan one hundred patients were analyzed of which only six were diagnosed with lesion Nevin I all alive with a mean follow up of 33 months, with lesions Nevin II five out of 13 are alive and were treated with wedge liver resection or radiotherapy, lesion Nevin III only 4 alive and received radiotherapy. Patients with lesions Nevin IV and V have the poorest prognosis. CONCLUSION: GBC is a highly lethal disease. Early diagnosis make possible to perform radical resections and improve survival.

[Cancer of the anal canal]. / Cáncer de canal anal.

Anal carcinoma is a rare malignant tumor, It occurs in only 0.02% of all malignant neoplasms. In Mexico, the incidence is of 1.5%, and only 0.18% belong to the anal canal. In recent years it has been reported an increased incidence of this tumor due to the association with the human papilloma virus in HIV positive patients. The most common histological forms are the epidermoid and the cloacogenic carcinomas. The most relevant prognostic factors are the size of the tumor and the presence of lymph node metastasis. Surgery has been the traditional form of treatment but the combined use of chemotherapy and radiotherapy seems to have the best results and surgery is reserved for local recurrences or palliation. A review of our experience at the National Institute of Cancer at Mexico city with the management of this tumor was performed. Thirty-four patients with the diagnosis of carcinoma of the anal canal were included of which none of them received previous treatment or have the diagnosis of AIDS. Patients were divided in four groups according to the form of treatment (surgery, radiation, and chemoradiation either with 5FU-MMC or 5FU and CDDP). The group that received chemotherapy with 5FU and CDDP combined with radiotherapy had the best results in terms of clinical response, survival and toxicity. The size of the tumor and the presence of lymph node metastasis are the prognostic factors that influence in survival: tumor smaller than 5 cm without lymph node metastasis have the best prognosis (p: 0.01 and p: 0.00004). Epidermoid carcinoma have a better prognosis than cloacogenic carcinoma (p: 0.07).

[Laparoscopic cholecystectomy at an oncologic center: a comparative analysis]. / La colecistectomía por laparoscopia en un centro oncológico: un análisis comparativo.

OBJECTIVE: To analyze and compare our results with open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) in patients with cancer. DESIGN: Case-control study. SETTING: An oncologic referral center in Mexico City. PATIENTS: All patients with previous treatment for cancer and indication for cholecystectomy who where referred in a 60-month period. They were divided into two groups. Group OC with operation performed in the former 30 months and group LC with operation performed in the later 30 months. RESULTS: Lower morbidity and mortality rates and less hospital stay were found in group LC (55 cases) as compared with group OC (50 cases). Conversion rate in group LC was 14%. This rate is higher in patients with previous surgeries in upper abdomen. There were no differences in morbidity and mortality in patients with previous abdominal surgeries or with diabetes. Patients with liver cirrhosis in group OC had higher morbidity and mortality. CONCLUSIONS: LC can be performed safely in patients with history of cancer, laparotomy or abdominal radiation therapy and should be considered as first choice for symptomatic gallstones. LC should be considered also in diabetes and liver cirrhosis. When previous surgery in the upper abdomen is found we recommend to insert the first trocar under direct vision of peritoneal cavity. In this case conversion rate is high.

[Hepatocellular carcinoma. Experience at the Instituto Nacional de Cancerología]. / Carcinoma hepatocelular. Experiencia en el Instituto Nacional de Cancerología.

BACKGROUND: Hepatocellular carcinoma (HCC) is a rare tumor in Mexico. Stands in the 21st place, corresponding to 1.4% of all malignant tumors. However in Southeast Asia, Japan and Sub-Sahara Africa, its incidence is very high. Frequently this tumor is diagnosed in late clinical stages and curative surgery is difficult to perform. OBJECTIVES: To analyze the general features of patients with HCC, and its management in our hospital. METHODS: An observational, transversal retrospective study was performed with 63 patients with histological proved HCC. RESULTS: Thirty-two were male (50.7%) and 31 female, the mean age was 56 years, 18 had history of alcohol abuse. Liver enlargement, abdominal pain and weight loss were the most common clinical manifestations. The alpha-fetoprotein (AFP) was positive in 55% of the patients, ultrasonography and computed tomography were the most useful studies. Fifty-six percent had associated chronic liver pathology, of which 51% had alcoholic cirrhosis, 43% had cirrhosis of other undetermined origin, and 6% had chronic hepatitis. Seventy percent were diagnosed in clinical stage II, 17% in stage III. Only 31% were taken to surgery, of which laparotomy and liver biopsy was performed in 70%, liver resection in 15%, liver dearterialization in 15%. Fifty-four percent of all cases did not received any kind of treatment. Postoperative complications occurred in 25% and the operative mortality was 20%, with a mean survival time of 10 months. CONCLUSIONS: HCC is a rare tumor in our country. All cases were diagnosed in late clinical stages. The male-female ratio was 1:1. AFP was positive in only 55% of cases. Due to the late stages at presentation or poor clinical conditions, most tumors were considered irresectable, thereby other forms of management need to be evaluated in order to define its place. It is important to identify patients with higher risk of HCC for an early detection and management.