[Prognostic factors in gallbladder cancer]. / Factores pronósticos del cáncer de vesícula.

BACKGROUND AND AIM: Carcinoma of the gallbladder is the most frequent biliary tract lesion but the 5-year survival is less than 5%. The aim of this study was to analyze the influence of several clinico-pathological variables on survival in a series of 226 carcinomas of the gallbladder. PATIENTS AND METHODS: The results were retrospectively analyzed and prognostic factors were identified by univariate statistical analysis and Cox regression model. All patients underwent surgery and in 67 of these (29.6%), surgery was potentially curative. In 63 patients (27.9%) diagnosis was made when the resected gallbladder was studied for benign disease. Tumor node metastasis (TNM) stage was 0 in 7 patients (3.1%), stage I in 19 patients (8.4%), stage II in 21 patients (9.3%), stage III in 61 patients (27%) and stage IV in 118 patients (52%). RESULTS: Overall 5-year survival was 17.3%. In the univariate analysis, significant variables were the presence of jaundice, weight loss, palpation of abdominal tumors at diagnosis, surgical technique, TNM stage and the three variables of this system (T: size, N: adenopathies; M: distant metastasis). In the multivariate analysis, the three variables of the TNM system and surgical technique were significantly associated with survival. CONCLUSIONS: The most important prognostic factor was TNM stage. Currently, radical cholecystectomy in stages II and III has become another important prognostic factor.

¿Está indicada la derivación gástrica profiláctica en la cirugía paliativa del cáncer de páncreas? / Is prophylactic gastroenterostomy indicated in palliative surgery for pancreating cancer?

Introducción. En la cirugía paliativa del adenocarcinoma pancreático, actualmente existe controversia sobre la necesidad de añadir una gastroenterostomía profiláctica a la derivación biliar. El objetivo es evaluar la morbimortalidad de la cirugía derivativa biliar frente a la cirugía derivativa biliar y gástrica simultáneas. Pacientes y método. Se estudiaron retrospectivamente 123 pacientes sometidos a intervención paliativa debido a ictericia obstructiva por adenocarcinoma pancreático. Se diferenciaron dos grupos: grupo A, formado por 74 pacientes con derivación biliar, y grupo B con 49 pacientes con derivación biliar y gastroentérica simultáneas. Resultados. La morbilidad postoperatoria en el grupo A fue del 13,5 por ciento frente al 30,6 por ciento del grupo B (p < 0,001). Precisó reintervención un paciente (1,3 por ciento) con fístula biliar externa en el grupo A, y cuatro, tres hemorragias digestivas y un absceso intraabdominal, en el grupo B. Los pacientes del grupo B presentaron enlentecimiento en el vaciamiento gástrico durante los primeros días del postoperatorio. La mortalidad postoperatoria fue del 8 por ciento en ambos grupos. Durante su evolución, en el grupo A se presentaron 13 casos (17,5 por ciento) de obstrucción duodenal, de los que 12 precisaron una gastroyeyunostomía transmesocólica (un paciente falleció antes de la intervención por su mala situación clínica). En el grupo B ningún paciente presentó obstrucción digestiva (p < 0,001 respecto al grupo A). La supervivencia fue semejante en ambos grupos. Conclusiones. La gastroenterostomía profiláctica reduce de forma estadísticamente significativa la necesidad de reintervención quirúrgica por obstrucción duodenal en los pacientes con cáncer de páncreas irresecable, aunque conlleva una mayor morbilidad postoperatoria (AU)

Prognostic factors in primary gastrointestinal non-Hodgkin's lymphoma: a multivariate analysis of 76 cases.

OBJECTIVE: To present our experience with the treatment of primary gastrointestinal (GI) non-Hodgkin's lymphoma, evaluate prognostic factors, and give our recommendations for treatment. DESIGN: Retrospective study. SETTING: Teaching hospital, Spain. SUBJECTS: 76 patients (47 men and 29 women, mean age 51 years) treated over the 15 years 1980-1994. INTERVENTIONS: 52 patients had radical resections, 19 palliative resections, and 5 biopsy alone. 42 (55%) also had adjuvant chemotherapy and 20 (26%) radiotherapy. RESULTS: Patients with primary intestinal lymphoma were slightly but not significantly younger than those with gastric lymphoma (43 compared with 56 years). 43 Patients (57%) had tumours in the stomach, 26 (34%) in the small bowel, and 7 (9%) in the colon. At presentation 34 had stage I disease, 25 stage IIE1 disease, and the remaining 17 stage IIE2; 14 were classified as low grade, 41 as intermediate, and 21 as high grade. 60 (79%) had a B-cell phenotype. Overall 5-year survival was 53%. Of the 11 variables tested by univariate analysis for their prognostic effect only abdominal mass (p < 0.001), clinical stage (p < 0.001), type of operation (p < 0.001), tumour size (p < 0.05), and histological grade (p < 0.05) achieved significance, but when Cox's multivariate analysis was applied only clinical stage was significant (p < 0.01). CONCLUSION: Operation is the treatment of choice, but chemotherapy and radiotherapy may have a role though as yet there are no standard guidelines for their use.

Prognostic factors in a series of 297 patients with gastric adenocarcinoma undergoing surgical resection.

BACKGROUND: Gastric cancer has a poor prognosis. The aim of this study was to determine the influence of several clinicopathological variables on outcome in a series of 297 Western patients undergoing surgical resection for gastric adenocarcinoma. METHODS: The results were analysed retrospectively and prognostic factors were identified in a univariate and Cox proportional hazards regression model. Mean patient age at the time of operation was 61.9 years; 65.7 per cent were men. Mean follow-up was 7.8 (range 1-15) years. Of the 297 patients undergoing surgery, 70 per cent had subtotal gastrectomy, 26.3 per cent underwent total gastrectomy and 3.7 per cent had proximal gastrectomy. RESULTS: The overall survival rate was 38.9 per cent at 5 years. In th univariate analysis, survival-related factors were weight loss (P < 0.05), abdominal mass (P < 0.01), dysphagia (P < 0.001), type of gastrectomy (subtotal gastrectomy versus total gastrectomy, P < 0.001), intention of resection (curative versus palliative resection, P < 0.001), tumour site (P < 0.001), histopathological grade (low versus high grade, P < 0.05), tumour diameter less than 3 cm (P < 0.001), degree of gastric wall invasion (P < 0.001), degree of lymph node invasion (P < 0.001) and stage of the neoplasia (P < 0.001). Other variables had no significant influence. In the multivariate analysis, degree of gastric wall invasion, lymph node invasion, tumour size and dysphagia at presentation were the only independent prognostic variables. CONCLUSION: From these data it was possible to derive a prognostic index with which patients could be classified as at low, intermediate or high risk.

Does perioperative blood transfusion influence long-term prognosis of gastric cancer?

We analyzed the influence of packed red blood cell (PRBC) transfusions on the prognosis of 163 patients with gastric adenocarcinoma undergoing subtotal gastrectomy with a curative intention. Over a period of 15 years, our department admitted 505 patients with gastric adenocarcinoma, with curative subtotal gastrectomy being performed in 167 cases. Mean age was 62.2 years (range: 30-87); there was a predominance of males (104 cases; 63.8%). Excluding the four patients who died in the immediate postoperative period (first 30 days), the remaining 163 were reviewed twice yearly in our department until either they died or the study ended. Follow-up averaged 49.5 months, with a median of 36 months. Sixty-nine (42.3%) of the 163 patients received transfusions of PRBC. On correlating the variables with the transfusion, we found a statistical significance only between the rate of transfusion and patient age over 63 years (P < 0.01), with an evolution time of less than three months (P < 0.05) and in tumors of >4 cm (P < 0.05). The five-year survival rate of the nontransfusion patients was 56.9% and of the transfusion patients 40%, with statistically significant differences (P = 0.0132). On studying patients according to tumor stage, we found that blood transfusion had a statistically significant influence on prognosis only in patients with tumor stage III (P = 0.0051). In the univariate analysis of the remaining variables collected, the existence of abdominal tumor (P = 0.0307), tumor size (P = 0.00001), degree of involvement of the gastric wall (P = 0.00001), lymph node involvement (P = 0.00001) and tumor stage (P = 0.00001) revealed a statistically significant influence on prognosis. If we apply Cox's regression model to the variables that in the univariate analysis had a statistically significant influence on prognosis, we found that only tumor size and stage were independent predictors of survival. In our experience, PRBC transfusion does not influence the long-term survival of patients with resected gastric adenocarcinoma.

Primary small bowel malignant tumors.

We reviewed 69 patients who underwent surgery for primary malignant tumors of the small bowel over a 15-year period. Patients with periampullary lesions were excluded, as were those with known adenocarcinomas in other sites. There were 46 males (67%) and 23 females (33%) with an average age at presentation of 52.6 years (range 4-92). Of the 69 patients, four (6%) were asymptomatic. The mean duration of symptoms before diagnosis, in the remaining 65 symptomatic patients, was 3.6 months (range 1 day 1.2 years). The most frequent symptom was abdominal pain (83%), followed by nausea and/or vomiting (54%), and weight loss (43%). Abdominal mass was the most common finding on physical examination (29%), followed by abdominal distension (24%) and abdominal guarding and rigidity (14%). Laboratory examinations were normal in 26 patients (40%). Radiographic study of the duodenum and small bowel was abnormal in 87%. The diagnosis was suspected preoperatively in 51%. Lymphoma was the most common tumor (42%), followed by adenocarcinoma (38%), carcinoid (10%) and leyomiosarcomas (10%). In 41% the neoplasm was located in the jejunum, in 33% in the ileum, in 22% in the duodenum and in 4% multiple sites were found. Lymph node metastases were found in 45% and vascular invasion was found in 19%. Of the 65 symptomatic patients 43% presented as surgical emergencies, the rest had elective surgery. 61% had a curative resection, the rest were palliative or a bypass. The operative mortality rate was 10% and the morbidity rate was 24%. Ten patients underwent emergency surgery, developed a complication, giving a morbidity rate of 32% in this group. The 5-year overall survival was 43.25%. The 5-year survival for carcinoid tumors was 60% while the 5-year survival for small bowel malignant lymphoma and adenocarcinoma was 40 and 34.28% respectively.

[Results of surgical treatment of esophageal cancer (209 cases)]. / Resultados del tratamiento quirúrgico del cáncer de esófago (209 casos).

We present a series of 209 patients with cancer of the esophagus over a 13-year period. Average age was 61.99 years and 87.56% of the patients were male. As for histological type, 59.8% of cases were epidermoid carcinomas and the remaining adenocarcinomas. In 76.55% of cases tumor stage was III or IV. Operability rate was 81.8% and resectability 57.89%. The most frequent resective procedure was oesophagogastrectomy through a right thoracotomy and laparotomy. Reconstruction of digestive continuity was achieved in 86.77% with the stomach; 53.72 of resections were judged to be "radical". Overall postoperative morbidity was 45.61%. Respiratory failure and anastomotic leakage accounted for most of morbidity. Anastomotic leakage was more frequent in patients undergoing bypass, with cervical anastomosis, and when the reconstruction was performed with the colon. Mortality rate was 14.04%, but fell to 7.69% in patients undergoing "radical" resection. Overall 5-year survival was 7.83% and 11.81% in patients undergoing resection. The more relevant prognostic factor was tumour stage; 5-years survival of patients with tumor stage I-II was 27.53%, and 0% for patients with tumour stage II or IV.

[Benign tumors of the small intestine]. / Tumores benignos del intestino delgado.

We reviewed 50 patients with benign tumors of small intestine treated over a period of 15 years. Mean age was 58 years, and 54% of the patients were female. The most frequent location of the tumors was the jejunum (54%). The commonest histological variety was leiomyoma (56%), followed by fibroma (14%). Average size of tumor was 4.8 cm. With regard to clinical data, 20% of the patients were asymptomatic; in the remaining 80% of the patients, abdominal pain, gastrointestinal hemorrhage and abdominal distension were the most frequent symptoms. The mean symptom-diagnosis interval was 2 months. Barium studies, duodenal endoscopy and selective angiography were the most useful diagnostic tools. However, only in 30% of cases the correct diagnosis was reached preoperatively. All patients underwent surgical treatment. The more frequent surgical technique was segmental resection of small bowel (84%). Operative mortality was 4% and morbidity was 10%. Actuarial 5-year survival for all patients was 96%.

Results of surgical treatment of epidermoid carcinoma of the thoracic esophagus.

During 1979 to 1991, 125 patients with epidermoid carcinoma of the thoracic esophagus were admitted to our General Surgery unit. The average age was 60.1 years; 94.4 percent of the patients were male. The mean duration of symptoms was 3.65 months. The most frequent symptom was dysphagia in 97.19 percent, followed by weight loss in 64.48 percent. The most frequent location was the middle one-third in 58.4 percent. The tumor was well differentiated in 27.2 percent, moderately well differentiated in 41.6 percent and poorly differentiated in 31.2 percent. By preoperative staging, 1 patient was stage I, 24 were stage II, 86 were stage III and 14 were stage IV. The operability rate was 76 percent and the resectability rate was 48.8 percent. Resection was "curative" in 42.62 percent and palliative in 57.37 percent. Radiation therapy and chemotherapy were used only in those patients who did not undergo resection. All of the patients in whom resection was possible underwent a single-stage esophagogastrectomy. The postoperative mortality rate was 20 percent, but only 11.54 percent if we only consider those patients who underwent "curative" resection. The most frequent causes of mortality were respiratory complications and anastomotic leakage. The five year overall survival rate was 5.99 percent. In the resected group, the five year survival rate was 8.82 percent and in patients in whom resection was considered "curative," the rate was 20.86 percent.

Long-term results of Nissen fundoplication in reflux esophagitis without strictures. Clinical, endoscopic, and pH-metric evaluation.

The present paper evaluates the efficiency of Nissen fundoplication as an antireflux technique in a series of 51 patients with different grades of esophagitis. Follow-up time averaged 6.6 years. The evaluation includes a clinical assessment, endoscopic study, and 24-hr pH monitoring. The results reveal an acceptable rate of recurrences, with clinical (9.8%) being less frequent than endoscopic (13.7%) or pH-metric (19.6%) recurrences. Side effects appeared in 37.3% of the patients (mainly inability to belch or vomit, and postprandial fullness), which were mild and transitory in most cases. Nissen fundoplication proved effective in controlling long-term gastroesophageal reflux, as over 80% of the patients presented an excellent-to-good clinical situation, without or with minimal digestive consequences.

Surgery improves defective oesophageal peristalsis in patients with gastro-oesophageal reflux.

Postoperative manometry was carried out in 12 patients with gastro-oesophageal reflux associated with hypomotility of the oesophageal body. A Nissen fundoplication was carried out in all patients. After a median follow-up of 3.5 years, patients underwent clinical, endoscopic, radiological, manometric and pH-metric evaluation. Manometric results revealed an overall improvement in oesophageal motor function with an increase in the amplitude of deglutition waves and a decrease in the percentage of deglutitions without response. Six of the patients (one with complete motor failure) recovered normal peristaltic function. Non-specific oesophageal motor disorders may be secondary to gastro-oesophageal reflux and are reversible in nature.

[Barrett's esophagus does not revert after medical or surgical therapy for gastroesophageal reflux]. / El esófago de Barrett no revierte tras el tratamiento médico o quirúrgico del reflujo gastroesofágico.

An evaluation was made of 34 patients having Barrett's oesophagus. Medical therapy consisted of antacids, H2 blockers, orthopramides, and postural measures (20 cases, mean follow-up 2.9 years). A Nissen fundoplication was done in 14 cases (mean follow-up 2.5 years). Clinical, endoscopic and histologic evaluation was done in all patients and pH measurements also done in all operated cases. Clinical results have been excellent in 70% of medically treated patients and in 100% of surgically treated ones, pH measurements were between normal limits in all operated patients. However, recovery of the normal epithelium did not occur in any case, except for some partial improvement in one patient treated surgically.

[Mallory-Weiss syndrome as etiologic factor of upper gastrointestinal hemorrhage. A review of 142 cases]. / El síndrome de Mallory-Weiss como factor etiológico en la hemorragia digestiva alta. Revisión de 142 casos.

The diagnosis of Mallory-Weiss syndrome was made in 142 patients with upper gastrointestinal haemorrhage by early endoscopy. These patients represent 5.16% of all patients with haemorrhage treated in our unit over a period of ten years. Emergency surgery was needed in 13 due to persistent haemorrhage. In the remaining 129, conservative management sufficed to stop the bleeding. All patients receiving medical therapy survived while one of the surgically treated patients died of pulmonary thromboembolism in the early postoperative period.

[Surgical treatment of gastric cancer. Evaluation of results in 313 consecutive cases]. / Tratamiento quirúrgico del cáncer gástrico. Valoración de resultados en 313 casos consecutivos.

The results of 313 gastric adenocarcinomas, treated by the same surgical team during 10 years have been evaluated retrospectively. The pathological characteristics, operability (88.8%) and resectability (69.8%) rates, surgical technique and morbility and mortality rates are analyzed. The causes of late mortality, total five-year survival, depending on the stage of the tumors, and survival in relation to treatment are reported.

[Early cancer of the stomach. Review of 29 cases]. / Cáncer gástrico precoz. Revisión de 29 casos.

A series of 29 patients with early gastric cancer operated on in our department over a period of 10 years is presented; this figure represents 9.10% of total number of gastric cancers. The most common symptom was epigastric pain, present in 51.72% of cases. Diagnosis was established by endoscopy and biopsy in 96.5% patients. Treatment was subtotal gastrectomy in 28 cases; most lesions (24) were located in the distal third of the stomach. Lesion was intramucosal in 44.8% of cases; in 55.17% there was infiltration of the submucosal layer and only 13.8% of tumors presented lymph node metastases. Macroscopically the most common pattern of the lesions was the ulcerated type. All patients have been followed up at least 4 years; of them died: one of carcinoma of the bladder and three of chronic respiratory failure. There were no recurrences of the gastric lesion and the 5 years actuarial survival was 84.32%.

[Barrett esophagus: epidemiologic data and risk of becoming malignant]. / Esófago de Barrett: datos epidemiológicos y riesgo de malignización.

A series is presented of 152 patients diagnosed over a 9-year period by endoscopy and biopsy as Barrett's esophagus. We analyzed epidemiological data and the risk of malignancy, and calculated the prevalence and incidence in our series.