Esophageal cancer surgery in patients older than 75: long term results.

PURPOSE: The purpose of this study was to evaluate short and long term results after esophageal cancer resection in patients older than 75. METHODS: We retrospectively analyzed the database of esophageal cancer surgically treated in our department between January 2003 and December 2009 to identify patients older than 75. The preoperative, operative, postoperative and long term characteristics were analyzed. RESULTS: Among 137 patient, 23 were older than 75. The histological subtype was adenocarcinoma in 100%. The surgical techniques were a "Lewis-Santy" procedure in 43%, a trans-hiatal resection in 22%, a "Sweet" procedure in 13%, a stripping in 13% and a McKeown procedure in 9%. The in-hospital postoperative mortality was 13%. The in-hospital postoperative morbidity (Dindo-Clavien Grade >2, deceased patients included) was 26%. In univariate analysis, no statistically significant risk factor of morbidity was found. A Charlson Comorbidity Index >2 was, in univariate analysis, the sole risk factor of postoperative mortality (p = 0.0362). The mean hospital stay was 22 +/- 12 days. The median survival was 24.2 months. The 5-year overall survival was 39% and the 5-year disease free survival was 26%.57% of long-term deaths were not cancer related. CONCLUSION: Esophageal surgery performed in selected patients older than 75 has an acceptable morbidity and mortality but when a severe complication occurs, it leads to death in half of the cases. Surgery enables a long term survival benefit. This study confirmed our attitude of not considering age as a contra-indication for esophageal surgery but rather considering general status, self-reliance and associated comorbidities for patients' selection.

Surgical management of hepatic metastases of colorectal origin.

Colorectal cancer is the most frequent digestive cancer. Prognosis is greatly depending on the TNM stage at the time of diagnosis. Fifty percent of all patients shall develop, synchronously or metachronously, liver metastases. Different means such as chemotherapy, targeted therapies, radiofrequency ablation, portal vein embolization and two-stage hepatectomy may be used to make these metastases eventually resectable and to increase overall survival. This is a short review of these different methods used to increase resectability but also on the integration of these parameters in a larger approach of colorectal liver metastasis surgery especially insisting on multidisciplinary discussion.

Trends in colorectal cancer survival following the 2-week rule.

OBJECTIVE: The 2-week rule has reduced waiting times for a specialist opinion among patients with a suspected malignancy. We aimed at assessing the effect of this rule on colorectal cancer survival. METHOD: Patients diagnosed with colorectal cancer before (group 1) and after (group 2) the introduction of the 2-week rule were identified from a prospective database. Emergency patients were excluded. Overall 2-year survival for each group was calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: Waiting times fell from 26 to 21 days (P =0.22). There was no significant difference in 2-year survival between the groups (hazard ratio 1.1; P = 0.56). There was a slight divergence between the survival curves at 2 years. CONCLUSION: There has been no improvement in 2-year survival from colorectal cancer following the introduction of the 2-week rule.

Operative delay for fracture of the hip: a two-centre prospective study.

We undertook a simultaneous prospective two-centre study to examine why patients with fractures of the proximal femur experience a delay in undergoing surgery. At centre 1, 23 of 105 patients (22%) suffered an avoidable delay, 18 (78%) because of a lack of theatre capacity while at centre 2, 71 of 130 patients (55%) had an avoidable delay, with 54 (76%) because of this cause. Miscellaneous reasons such as poor ward management, co-existing medical conditions, and lack of equipment were responsible for the remainder of the delays. Without a substantial increase in operating capacity for acute trauma, it will not be possible to comply with guidelines which recommend surgical treatment within 24 hours in elderly and vulnerable patients.

A comparison of adolescent moderate-to-vigorous physical activity participation in relation to a sustained or accumulated criterion.

Contemporary guidelines for young people advocate both a sustained and accumulative approach to moderate-to-vigorous physical activity (MVPA) participation. In order to investigate the behavioural significance of applying these approaches, this study assessed if differences in adolescent MVPA occurred when either a sustained or accumulated criterion was adopted. Using heart rate thresholds indicative of intensity, the physical activity of 25 adolescents was assessed by monitoring heart rate over 3 days. Results indicated that differences in MVPA participation did exist when different approaches were used, in that the majority of adolescents were active with respect to an accumulated criterion yet inactive with respect to a sustained criterion. Such a disparity may be due to accumulative MVPA being more characteristic of young people's natural activity behaviour. Such findings have strong implications for practitioners seeking to counter young people's inactivity, in that the application of an accumulative approach may be more effective at initiating and establishing an habitual activity behaviour than that of a sustained approach.

Beta-adrenoceptors and adenylate cyclase activity in hypertrophied and failing rabbit left ventricle.

Beta-adrenoceptor density and affinity, studied by H3-CGP 12177 binding, and adenylate cyclase activity were measured in 12 left ventricles of rabbits with heart failure and compared to 13 left ventricles of control (C) rabbits. Heart failure (HF) was induced by a double volume (aortic insufficiency) plus pressure (aortic stenosis 14 days later) overload. Left ventricular mass was increased in HF by 67% above C. Saturation curves with CGP 12177 showed a 36% decrease in beta-adrenoceptor density (C = 61.5 +/- 5.4 fmol/mg prot., P less than 0.05) but competition curves with isoproterenol were not different in HF and C. Basal and Gpp(NH)p stimulated adenylate cyclase activity were decreased by 36% and 22% respectively in rabbits with heart failure as compared with control animals and cAMP production was significantly smaller in failing left ventricles than in control left ventricles both after NaF stimulation (C: 161.3 +/- 24.9 pmols/mg/min; HF: 98.8 +/- 7.0 pmols/mg/min; P less than 0.05) and even more after forskolin stimulation (C: 159.1 +/- 23.9 and HF: 60.8 +/- 7.3 pmols/mg/min; P less than 0.01). Although isoproterenol stimulated ACA was smaller in HF than in C, EC50 was similar in both groups (1.6 x 10(-7) M). We conclude that in the early stage of heart failure in the rabbit, although adrenoceptor density is decreased, there are no changes of affinity of beta-adrenoceptors for isoproterenol and the major alteration of cAMP production appears to lie down-stream the receptor level with a markedly impaired stimulation of adenylate cyclase activity by forskolin.

Left ventricular function and beta-adrenoceptors in rabbit failing heart.

Few models of heart failure (HF) are available for physiological and pharmacological studies. We report here a model of pressure plus volume overload induced in rabbits in which left ventricular (LV) function was studied in the conscious state after instrumentation of the animals with LV pressure catheter and ultrasonic crystals measuring LV diameter. Beta-Adrenoceptors were studied on crude membranes obtained from control (C) and HF rabbits using [3H]CGP 12177. LV weights and end-diastolic diameters were significantly increased in the HF group compared with the C group (by 79 and 38%, respectively). The percentage of diameter systolic shortening was decreased, in the control state, in rabbits with HF (15.3 +/- 1.6%) as compared with C rabbits (29.6 +/- 2.5%) and remained lower in the HF group when end-systolic pressures were matched. Chronotropic response to isoproterenol injection was significantly decreased in rabbits with HF compared with that of C rabbits. Beta-Adrenergic receptor density was decreased in rabbits with HF (39.3 +/- 3.7 fmol/mg) compared with C rabbits (56.7 +/- 4.2 fmol/mg) without affinity changes. This model of chronic HF thus produces a marked hypertrophy with ventricular dilatation and a depression of LV function within 2 mo, factors that are associated with a reduced cardiac responsiveness to catecholamines and a decreased ventricular beta-adrenergic receptor density.

Modification of enzyme activities concerned with collagen metabolism in the heart of spontaneously hypertensive and aortic-constricted rats.

The activities of three enzymes concerned with collagen metabolism 4-prolyl hydroxylase, UDP-glucose: collagen glucosyltransferase and glucosyl-galactosyl-hydroxylysine glucohydrolase and 4-hydroxyproline content have been studied in the cardiac ventricles of spontaneously hypertensive rats (SHR) during prehypertensive, hypertensive and sustained hypertensive stages (respectively 4.5, 12 and 19 weeks of age). They were compared with values observed in age-matched normotensive Wistar Kyoto rats (WKY). The same studies have been performed in parallel on aortic-constricted rats (ACR) 8 days after suprarenal constriction of the abdominal aorta. The most striking finding was a significant increase in cardiac prolyl hydroxylase specific activity in the ACR but not in the SHR. No variation in 4-hydroxyproline concentration was found in the hearts of ACR. In contrast, a decrease in 4-hydroxyproline concentration was found in the hearts of SHR at 19 weeks. Cardiac glucosyltransferase specific activity was significantly elevated only in the SHR at 12 weeks. No variation in glucohydrolase specific activity was detected in the hearts of either SHR or ACR. The cardiac enzyme activities all decreased with age. These data show that the alterations in cardiac collagen metabolism are different in SHR and ACR. The patterns of the alterations found in the heart mirror those observed in the aorta in both models under the same experimental conditions.

Left ventricular pressure-diameter relations in the conscious rabbit.

A model for the study of left ventricular (LV) contractility in a small species was developed using conscious rabbits previously instrumented with a LV catheter and ultrasonic crystals measuring LV internal diameter. Afterload increase produced by methoxamine infusion was associated with a reduction in heart rate from 272(SEM18) to 214(20) beats.min-1, p less than 0.01; and an increase in LV end systolic pressure from 76.3(4.1) to 101(6.5) mm Hg, p less than 0.001, and in end systolic diameter from 8.7(0.7) to 9.9(0.7) mm, p less than 0.01. For matched end systolic pressure and heart rate, the increase in inotropic state produced by noradrenaline infusion significantly shifted the pressure-diameter relation to the left. Similarly, end systolic pressure and diameter were significantly lowered by sodium nitroprusside infusion, with a reflex increase of heart rate; and a decrease in inotropic state produced by verapamil infusion was demonstrated by a significantly larger end systolic diameter for matched end systolic pressure and heart rate. The pressure-diameter relation was not modified by volume loading, which increased end diastolic diameter by 9.6(1.1)% with no evidence of a Bainbridge reflex. The mild depressant effect of diltiazem was not detected by peak dP/dt changes but was demonstrated by the analysis of end systolic pressure-diameter relations. The instrumented rabbit thus appears to be a sensitive model for studying LV function and the cardiovascular effects of drugs.

Aorta collagen metabolism in spontaneously hypertensive and aortic-constricted rats: variations in enzyme activities concerned with disaccharide unit synthesis and degradation according to blood pressure and age.

Two enzyme activities concerned with collagen disaccharide unit metabolism (UDP-glucose: collagen glucosyltransferase and glucosyl-galactosyl-hydroxylysine glucohydrolase) have been studied in the thoracic aortic wall together with 4-prolyl hydroxylase activity and 4-hydroxyproline content in spontaneously hypertensive rats (SHR) at the prehypertensive, hypertensive and sustained hypertensive stages (respectively 32 days, 12 weeks and 19 weeks of age). They were compared with values observed in age-matched normotensive Wistar Kyoto rats (WKY). The same studies have been performed in parallel on aortic-constricted rats (ACR) 8 days after suprarenal constriction of the abdominal aorta. Negative regressions of all three specific activities as function of age were observed. The most striking difference observed between the SHR and the WKY was the increase of glucosyltransferase specific activity, already found at the prehypertensive stage and continuing thereafter; the glucohydrolase specific activity was increased only during the establishment of hypertension whereas no modification was found with prolyl hydroxylase at any stage. However, a diminution of hydroxyproline concentration was seen at all ages while total hydroxyproline mass remained unaffected. The alterations of the aortic collagen metabolism observed in the ACR recall those seen in the SHR at the prehypertensive stage: the only significant modification was that of glucosyltransferase activity. Correlation was found between glucosyltransferase activity and blood pressure level in the two animal models.