Endoscopy or surgery for malignant GI outlet obstruction?

BACKGROUND

The treatment of gastroduodenal outflow obstruction (GOO) caused by malignant diseases represents a significant challenge. Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. More recently, endoscopic placement of self-expanding metallic stents (SEMS) has been proposed and the results of small, preliminary studies are encouraging. This study compared technical and clinical success, morbidity, mortality, and hospital stay in patients undergoing endoscopic and surgical treatment of GOO.

METHODS

Medical records of 60 consecutive patients with GOO seen between April 1997 and November 2002 were retrospectively reviewed. Because of extremely short life expectancy, 13 patients were treated by insertion of a double-lumen nasogastric-jejunal tube. The remaining 47 patients (28 men, 19 women; mean age 73.5 years, range 48-92 years) with unresectable pancreatic (33), gastric (7), metastatic lymph nodal (4), papillary (2), and biliary (1) tumors were treated by placement of a SEMS (24) or open surgical GJ (23).

RESULTS

The technical success rates were similar, but clinical success was lower in the GJ group (92% vs. 56%, p = 0.0067). The SEMS group had a shorter length of hospital stay (3.0 [1.4] days vs. 24.1 [10.3], p < 0.001). Thirty-day mortality was 30% in the GJ group, and 0% in the SEMS group ( p = 0.004). Morbidity was higher in the GJ compared with the SEMS group (61% vs. 17%, p = 0.0021). Mean survival was longer in the SEMS group (96.1 [9.6] days vs. 70.2 [36.2] days, p = 0.0165 for a single test of hypothesis; Bonferroni correction for a multiple testing removes this significance), consequently, out-of-hospital survival was longer for the SEMS group (93.2 [9.3] days vs. 46.0 [31.5] days, p < 0.001). None of the endoscopic procedures required the assistance of an anesthesiologist or the use of an operating room.

CONCLUSIONS

The results of this retrospective study suggest that SEMS insertion is better than surgical GJ for palliation of patients with GOO in terms of clinical success, morbidity, and mortality. Technical success rates were similar. SEMS placement should be proposed as the first-line treatment for relief of GOO. However, a randomized, comparative, prospective study of SEMS vs. laparoscopic GJ is needed.

[Characteristics of diagnosis and treatment of patients with an acute intestinal obstruction]

Results of treatment of 1035 patients with an acute intestinal impassability (AII) were analyzed. There were determined advantages of the ultrasonic investigation (USI) in comparison with roentgenological investigation. Diagnostic validity of USI, not depending on the All origin, had constituted 100% and of roentgenological investigation--33-78%. Modern diagnosis and adequate volume of operative intervention had permitted to improve the results of the patients treatment with All. The mortality rate had constituted 3.3% (43 patients died).

Treatment of complicated colorectal cancer. Evaluation of the outcome

A comparison of the outcome of 66 patients with complicated colorectal cancer (CRC) who underwent an emergency operation and 217 electively operated patients in an 11-year period was retrospectively determined. The complications presented on admission were obstruction (13.4%), perforation with peritonitis (6.36%), obstruction and perforation (1.4%) and massive bleeding (2.1%). The majority of the patients electively treated were of stages II and III (45.5% and 29%) and those urgently operated on were stages III and IV (67.7% and 14.1%) respectively. Radical resections were performed in 45 patients and palliative in 21. Only ten patients from the urgently treated are still alive and free of the disease. In conclusion, the treatment of complicated CRC carries a considerable incidence of complications, morbidity and mortality, and the overall 5-year survival rate is disappointing compared to electively treated patients.

Surgical management of large bowel obstruction due to colonic cancer

BACKGROUND

Bowel obstruction represents a common surgical emergency. The purpose of this study is to highlight our principles while managing cases of large bowel obstruction (LBO) due to colonic carcinoma.

METHODS

Twenty-one patients with LBO underwent emergency surgery. Patients with LBO caused by obstructive malignant colonic lesions underwent either with one-stage primary resection and anastomosis (14 patients, 67%) or two-stage operation (7 patients, 33%).

RESULTS

There were no operation-related complications. The average length of hospitalisation was 14 days with a range from 10 to 23 days. Postoperative mortality was 14%.

CONCLUSIONS

One-stage primary resection and anastomosis of the large bowel, is a feasible option in cases of emergency. LBO caused by colonic carcinoma can be performed with acceptable morbidity and mortality whenever comorbidity of the patient is not a contraindication.

Emergency operation in carcinomas of the left colon: value of Hartmann's procedure

BACKGROUND

Colonic resection according to the procedure by Hartmann is considered a fast and safe surgical intervention, which has been used for years, in particular, in emergency situations.

METHODS

Using data of a prospective multicentre study on the operative treatment of colorectal carcinoma over the time period from 1 January 2000 to 31 December 2002, the value of Hartmann's procedure was investigated in carcinoma of the left colon (n=8825) compared with alternative surgical options under emergency circumstances. The significant impact of independent variables on the type of the selected approach was determined by means of logistic regression.

RESULTS

While in total 422 primary Hartmann's procedures (4.8%) were executed under curative intention, 213 (50.5%) of those were carried out in emergency situations. Hartmann's procedure was beneficial in cases with tumour-associated obstruction and perforation of the left colon as it resulted in the lowest mortality (7.5%) of the radical operations. Even under palliative intention, Hartmann's procedure was preferred at the left colon but led to a postoperative mortality (32.7%) very similar to that in creation of a colostoma (33.3%) or segmental colonic resection (38.9%).

CONCLUSIONS

Hartmann's procedure has been widely accepted as a curative intervention in emergency cases (oncosurgically adequate R0 resection) for the carcinoma of the left colon. Because of the high postoperative morbidity and mortality in emergency situations with only palliative options (R0 resection not possible), alternative endoscopic treatment should be considered more frequently.

Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series

BACKGROUND

Self-expandable metal stents (SEMS) are being increasingly used to palliate malignant stenoses of the gastric outlet and proximal small bowel. Accordingly, we reviewed our experience in this setting.

METHODS

Patients with gastric outlet or proximal small bowel stents were identified by reviewing hospital charts. Outcome criteria included survival data, need for reintervention, and clinical improvement.

RESULTS

A total of 52 SEMS were placed in 36 patients with nonesophageal upper GI stenosis. Initial stent placement was successful in 92% and clinical improvement documented in 75%. Mean survival of patients who eventually died was 3.5 months. Seven patients are alive (mean follow-up, 5.0 months). Stent dysfunction occurred in 36% and required subsequent interventions. Biliary obstruction was documented in 50% of patients, 12 of whom had previously undergone biliary stenting and 5 who needed subsequent biliary decompression.

CONCLUSIONS

Enteral stent placement has been reported to be an effective alternative for palliation of high-risk surgical patients with malignant gastric outlet and small bowel obstruction. Considering the short life expectancy of these patients and significant complications including stent migration, perforation, biliary obstruction, and need for subsequent endoscopic, radiologic and surgical interventions, the authors suggest that this procedure be performed in experienced centers on selected patients only and that biliary decompression be ensured early.

Neonatal colonic mucormycosis--a tropical perspective

Neonatal gastrointestinal (GI) mucormycosis is a rare, usually fatal, opportunistic fungal infection, which is difficult to diagnose early or preoperatively. We report three babies, only one of whom survived, with a review of the literature. All three had similar findings of necrosis of colon with multiple perforations. While the first baby was diagnosed as long segment Hirschsprung's, the second was treated as small left colon but went on to show signs of peritonitis. The third presented with pneumonia, which progressed to sepsis and peritonitis. All three were diagnosed by histology postoperatively and two of them succumbed, one in spite of amphotericin and the other as he was too sick to start antifungals and had a rapid downhill course. The one who survived did so even though she did not receive amphotericin, but had clear margins of resection. The only chance of survival in this fatal disease is early diagnosis and rapid institution of aggressive therapy inclusive of adequate surgical debridement and appropriate antifungal medications.

[Treatment of tumoral colonic obstruction]

The work was devoted to problems of treatment of patients with cancer of the colon complicated by tumoral colonic obstruction. The authors propose an improved clinical classification of disturbances of colonic obstruction with colorectal cancer. The questions discussed are: decision on the strategy of treatment of acute colonic obstruction patients, the possible differential approach to choosing methods of treatment depending on localization of tumor and duration of the period of the development of intestinal obstruction. The results of treatment of 148 patients with colorectal cancer complicated by acute colonic obstruction are analyzed. It was shown that in 20% of patients with the initial stage of obstruction with the tumor localized in the left half of the colon it was possible to resolve the obstruction by conservative measures followed by the preparation of the patients to planned operation.

Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

BACKGROUND

Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction.

METHODS

Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures.

RESULTS

Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941).

CONCLUSIONS

Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

Large bowel obstruction: predictive factors for postoperative mortality

PURPOSE

The aims of this study were to assess the prognostic value for mortality of several factors in patients with colonic obstruction and to study the differences between proximal and distal obstruction.

METHODS

Two-hundred and thirty-four consecutive patients who underwent emergency surgery for colonic obstruction were studied. Patients with an obstructive lesion distal to the splenic flexure were assessed as having a distal colonic obstruction. Resection and primary anastomosis was the operation of choice in selected patients. Alternative procedures were Hartmann's procedure in high-risk patients, subtotal colectomy in cases of associated proximal colonic damage, and colostomy or intestinal bypass in the presence of irresectable lesions. Obstruction was considered proximal when the tumor was situated at the splenic flexure or proximally and a right or extended right colectomy was performed. A range of factors were investigated to estimate the probability of death: gender, age, American Society of Anesthesiologists score, nature of obstruction (benign vs. malign), location of the lesion (proximal vs. distal), associated proximal colonic damage and/or peritonitis, preoperative transfusion, preoperative renal failure, and laboratory data (hematocrit < or = 30 percent, hemoglobin < or = 10 g/dl, and leukocyte count >15,000/mm3). Univariate and multivariate forward steptwise logistic regression analysis was used to study the prognostic value of each significant variable in terms of mortality.

RESULTS

One or more complications were detected in 109 patients (46.5 percent). Death occurred in 44 patients (18.8 percent). No differences were observed between proximal and distal obstruction. Age (>70 years), American Society of Anesthesiologists III-IV score, preoperative renal failure, and the presence of proximal colon damage with or without peritonitis were significantly associated with postoperative mortality in the univariate analysis. Only American Society of Anesthesiologists score, presence of proximal colon damage, and preoperative renal failure were significant predictors of outcome in multivariate logistic regression.

CONCLUSION

Large bowel obstruction still has a high of mortality rate. An accurate preoperative evaluation of severity factors might allow stratification of patients in terms of their mortality risk and help in the decision-making process for treatment. Such an evaluation would also enable better comparison between studies performed by different authors. Principles and stratification similar to those of distal lesions should be considered in patients with proximal colonic obstruction.

Surgical management of malignant bowel obstruction

MBO is a common but difficult problem for surgeons caring for cancer patients. Nonsurgical interventions should be considered in all patients with MBO, especially inpatients with limited survival or for whom surgery will have little effect on disease control. Although there is no algorithm for all patients with MBO, decision-making is based on reasonable expectations of survival and treatment-related success. Surgical options can be helpful in the setting of MBO as long as reasonable goals and realistic outcomes are clear.

Jejunal diverticulosis: a potentially dangerous entity

Although jejunal diverticulosis is a rare entity and usually asymptomatic, it may cause chronic symptoms and acute complications. Because of the rarity of the entity, diagnosis is often delayed, resulting in unnecessary morbidity and mortality. The purpose of this study was to draw attention to jejunal diverticula and their complications. The medical records of 8 consecutive patients with complications due to small-bowel diverticula treated at our department during the past 4 years were reviewed. All diverticula were located in the jejunum. Seven patients had acute complications, 3 patients had an intra-abdominal abscess, 2 had free perforation with diffuse peritonitis, 1 had a bowel occlusion and 1 patient had concomitant bleeding and occlusion. One patient presented with chronic symptoms. A preoperative diagnosis of jejunal diverticula, before explorative laparotomy, was not reached in any of the 7 patients with acute symptoms. In the patient with chronic symptoms, multiple jejunal diverticula complicated by a jejuno-colic fistula and foreign body were found at laparotomy. On patient died of multiorgan failure. Small-bowel diverticulosis is a rare entity, but it should not be regarded as a clinically insignificant finding. It may be difficult to make a preoperative diagnosis. Patients with incidentally detected proximal jejunal diverticula, at imaging studies or at laparotomy, warrant close observation and awareness that the diverticula may cause serious complications.

Is there a role for TPN in terminally ill patients with bowel obstruction?

OBJECTIVE

There is controversy regarding the use of total parenteral nutrition (TPN) in individuals with metastatic malignancies. The objective of this study was to determine whether a subgroup of patients with intestinal obstruction would benefit from support with TPN.

METHODS

A retrospective review of patients considered for home TPN by a regionalized home TPN program was conducted

RESULTS

Over a 6-y period, nine patients with primary gastrointestinal malignancy and metastatic intestinal obstruction were identified. There was a variable survival rate of 27 to 433 d. Survival rate longer than 60 d was noted in six of nine patients. Most patients had no direct TPN-related complications, but one patient had significant morbidity related to venous thrombosis and line sepsis. There were no nutritional predictors of prolonged survival rate with TPN. TPN was continued until death in six of nine patients.

CONCLUSION

Patients with small bowel obstruction and metastatic malignancy may benefit from TPN as demonstrated by prolonged survival rate longer than 60 d. There are no clear predictors of who will benefit from TPN, and each case should be considered individually, with the potential risks and benefits discussed with the family and primary caregivers. Future studies should address the effect of TPN on quality of life of the patient and their caregivers.

Long-term prognosis after operation for adhesive small bowel obstruction

AIM OF STUDY

The objective of this study was to determine the pattern of recurrence after one or more episodes of adhesive small bowel obstruction (ASBO) during a follow-up period of up to 40 years. Furthermore, we wanted to analyze possible factors with an influence on the recurrence rate and to study the magnitude of "everyday" abdominal pain among these patients.

PATIENTS AND METHODS

Hospital records of 500 patients operated on for adhesive obstruction at Haukeland University Hospital from 1961 to 1995 were studied. The patients were followed until death, loss to follow-up, or end of study (February 2002), with a median follow-up of 10 years and a maximum follow-up time of 40 years. A questionnaire was sent to all living patients to obtain information on recurrences and abdominal complaints.

RESULTS

The cumulative recurrence rate for patients operated once for ASBO was 18% after 10 years and 29% at 30 years. For patients admitted several times for ASBO, the relative risk of recurrent ASBO increased with increasing number of prior ASBO episodes. The cumulative recurrence rate reached 81% for patients with 4 or more ASBO admissions. Other factors influencing the recurrence rate were the method of treatment of the last previous ASBO episode (conservative versus surgical) and the number of abdominal operations prior to the initial ASBO operation. Compared to results from the general populations, more ASBO patients suffer from abdominal pain at home. Women and patients having matted adhesions have significantly more complaints about abdominal pain than men and patients with band adhesions.

CONCLUSION

The risk of recurrence increased with increasing number of ASBO episodes. Most recurrent ASBO episodes occur within 5 years after the previous one, but a considerable risk is still present 10 to 20 years after an ASBO episode. Surgical treatment decreased the risk of future admissions for ASBO, but the risk of new surgically treated ASBO episodes was the same regardless of the method of treatment. People treated for ASBO seem to be more prone to experiencing abdominal pain than the normal population, especially those having matted adhesions.

Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models

OBJECTIVE

To review two predictive models, based on the American Society of Anaesthesiologists (ASA) and the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (POSSUM)-used for estimating postoperative mortality in patients, undergoing surgery for colorectal disease, in the UK.

METHODS

Data was derived from three multicentre, UK-based studies involving a total of 16,006 patients with malignant or non-malignant bowel pathologies. Data sources were: The Colorectal-POSSUM (CR-POSSUM) Study population, comprising 6883 patients undergoing colorectal surgery in 15 UK hospitals between 1993 and 2001; The Association of Coloproctology of Great Britain and Ireland (ACPGBI) Colorectal Cancer (CRC) Database, encompassing 8077 newly diagnosed CRC patients, undergoing surgical resections in 79 hospitals, between April 2000 and March 2002; The ACPGBI Malignant Bowel Obstruction (MBO) Study, encompassing 1046 patients with MBO in 148 hospitals, treated between April 1998 and March 1999. Multifactorial logistic regression analyses were used to adjust for case-mix, identify risk factors for in-hospital/30-day operative mortality and to accommodate the variability of outcomes between hospitals.

RESULTS

In the ACPGBI CRC study, 7374 patients had surgery, 6622(89.8%) a major bowel resection and 1465(19.9%) emergency surgery. Nine hundred and eighty-nine (94.6%) patients with MBO had surgery and 854(86.3%) underwent bowel resection. In the CR-POSSUM study, of the 6790(98.6%) patients undergoing surgery, 3451(50.8%) had a major colorectal resection, including 2107(31.0%) as an emergency. The operative mortality was 7.5% for the ACPGBI CRC study, 15.7% for patients with MBO and 5.7% for patients in the CR-POSSUM study. When tested, the predictive models showed good discrimination, with an area under the receiver-operator characteristic curve of 77.5% for the ACPGBI CRC, 80.1% for the MBO and 89.8% for the CR-POSSUM.

CONCLUSIONS

Prediction of postoperative death can be made by the clinician using simple, numerical, tables derived from the ACPGBI CRC, MBO and CR-POSSUM models. The models can be used in everyday practice for pre-operative counselling of patients and their carers, as a part of the process of informed consent. They may also be used to compare the outcomes between multidisciplinary CRC teams.

The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer

BACKGROUND

This study was designed to investigate the early outcomes after surgical treatment of malignant large bowel obstruction (MBO) and to identify risk factors affecting operative mortality.

METHODS

Data were prospectively collected from 1046 patients with MBO by 294 surgeons in 148 UK hospitals during a 12-month period from April 1998. A predictive model of in-hospital mortality was developed using a 3-level Bayesian logistic regression analysis.

RESULTS

The median age of patients was 73 years (interquartile range 64-80). Of the 989 patients having surgery, 91.7% underwent bowel resection with an overall mortality of 15.7%. The multilevel model used the following independent risk factors to predict mortality: age (odds ratio [OR] 1.85 per 10 year increase), American Society of Anesthesiologists grade (OR for American Society of Anesthesiologists grade I versus II,III,IV-V = 3.3,11.7,22.2), Dukes' staging (OR for Dukes' A versus B,C,D = 2.0, 2.1, 6.0), and mode of surgery (OR for scheduled versus urgent, emergency = 1.6, 2.3). A significant interhospital variability in operative mortality was evident with increasing age (variance = 0.004, SE = 0.001, P < 0.001). No detectable caseload effect was demonstrated between specialist colorectal and other general surgeons.

CONCLUSIONS

Using prognostic models, it was possible to develop a risk-stratification index that accurately predicted survival in patients presenting with malignant large bowel obstruction. The methodology and model for risk adjusted survival can set the reference point for more accurate and reliable comparative analysis and be used as an adjunct to the process of informed consent.

[Factors affecting morbidity and mortality in mechanical intestinal obstruction]

BACKGROUND

We evaluated the effects of factors related to both the patient and the treatment on morbidity and mortality of patients with mechanical intestinal obstruction.

METHODS

A total of 152 patients (83 males, 69 females; mean age 55.05 years; range 15 to 90 years) who underwent surgery for intestinal obstruction were retrospectively evaluated. The effect of several factors on morbidity and mortality during hospitalization (mean 8.6 days; range 1 to 105 days) was assessed, including age, sex, associated diseases, the presence of intestinal necrosis, previous abdominal operations, the time of the operation, and the level of obstruction. Statistical evaluations were made with the use of a multiple logistic regression analysis.

RESULTS

Complications were encountered in 52 patients (34.2%), the most common being systemic complications (15.8%) followed by wound site infections (11.2%). During hospitalization, mortality occurred in six patients (4%), all of whom had at least one associated disease. Logistic regression analysis showed that age beyond 75 years (p<0.01), male gender (p<0.01), associated disease (p<0.05), non-viable strangulation (p<0.001), previous operations (p<0.05) and malignancies (p<0.05) were significant independent factors affecting the complication rate. On the other hand, only non-viable strangulation (p<0.05) had significant independent effect on mortality.

CONCLUSION

Patient-related factors should be taken into consideration in the evaluation and treatment of mechanical intestinal obstruction.

Kolorektales Karzinom

Over 50,000 new cases of colorectal cancer are diagnosed in Germany every year. About half of these patients will be cured by surgery. The other reoccur or present primarily with advanced disease. Recently, the survival of patients with metastasized disease has been prolonged from about 6 months with best supportive care alone to more than 20 months with combination chemotherapy. Therefore, adequate palliation is reasonable. Irresectable liver metastasis can be treated by locally ablative procedures such as radiofrequency ablation (RFA) or laserinduced thermotherapy (LITT). In the individual case resection of lung or brain metastasis should be discussed. Practitioners have to deal with plenty of supportive opportunities e.g. analgesics, bisphosphonates, central acting drugs, nutrition but also with drug side effects. In centers different endoscopic or interventional radiologic procedures are offered. Considering the variety of therapeutic options, it is prudent to discuss individual treatment plans in an interdisciplinary "tumor board" and involve the practitioners in the decision making.

Use of sedation to relieve refractory symptoms in dying patients

OBJECTIVES

To document the use of sedation for refractory symptoms in patients admitted to an independent palliative care unit.

METHOD

A prospective descriptive study.

SETTING

The 7-bed inpatient unit at Sungardens Hospice, Pretoria.

SUBJECTS

Patients who required sedation for refractory symptoms in addition to normal palliative care treatment between January and June 2002.

FINDINGS

Twenty of 100 consecutive patients admitted required sedation. All had advanced cancer. Their mean age was 68 years. Thirty-six per cent were men and 64% women.

INDICATIONS

Agitated delirium was the most common reason (45%) for using sedation, followed by intractable vomiting due to inoperable malignant intestinal obstruction in 25% of patients. Three patients with persistent convulsions or myoclonic jerking and 2 patients with severe refractory dyspnoea required some sedation. Intractable pain was the main reason for sedation in only 1 patient.

SURVIVAL

Mean survival following the start of sedation was 92 hours/3.8 days (range 6 - 369 hours/0.25 - 19.4 days). The combined mean survival recorded in 9 other studies was 57 hours/2.4 days (range 36 - 93.6 hours/1.5 - 3.9 days).

MEDICATION

The main drugs used for sedation were midazolam and haloperidol. The mean dosage for midazolam was 18.5 mg/24 hours (range 7.5 - 40 mg) and for haloperidol 8 mg/24 hours (range 5 - 10 mg). For pain relief the mean daily dose of parenteral morphine was 76 mg (range 15 - 260 mg).

CONCLUSION

Use of sedation for the relief of refractory symptoms at Sungardens Hospice is in line with several studies reported in the international literature.

Obstructed inguinal hernia: role of technical aid program

AIM

The purpose of the study was to determine the influence of the presence of a surgeon on the outcome of obstructed inguinal hernia at Mongomo, in Equatorial Guinea.

METHODOLOGY

A prospective study of patients with obstructed inguinal hernia seen between June 1997 and May 1999 was carried out. During the same period, all uncomplicated hernias seen at the surgical outpatient clinic were noted.

RESULT

Fifteen patients presented with obstructed inguinal hernia, while 138 were uncomplicated. All the 15 patients were males, and one of them died. Death resulted from lack of treatment as he presented on our arrival on a technical aid program from Nigeria. The others (N = 14) were operated upon, and eight of them had resection of the intestine because of gangrene. The duration of obstruction was more than two days among those that had bowel resection.

COMMENT

Inguinal hernia is a treatable surgical condition. When done electively, the cost and the risk of treatment are very low. Operative treatment can only be offered to patients with inguinal hernia by a surgeon in the community.

CONCLUSION

The study has demonstrated that the presence of a surgeon in a community changes the outcome of obstructed inguinal hernia. Sponsorship of medical aid programs should be encouraged.

Adhesion intestinal obstruction in children in northern Nigeria

In developing countries, reports on adhesion intestinal obstruction in children are scanty. We report 30 children managed for adhesion intestinal obstruction during a 16-year period. The age range was 10 weeks-14 years (median 9 years). There were 24 boys and 6 girls. Postoperative adhesion was the cause in 13 (43%) patients, inflammatory in 11 (37%), and in 5 (17%) no cause could be identified. In one patient, adhesion followed missed ileal perforation from blunt abdominal trauma. Duration of symptoms was 1-21 days (median 4 days). Only four of the 13 patients with postoperative adhesion obstruction were managed conservatively initially, but this failed in all; one was found to have an intestinal perforation at laparotomy. The remaining nine had immediate laparotomy owing to presence of features of strangulation at presentation; two required intestinal resection for gangrene. All other patients had laparotomy soon after resuscitation. The resection rate for gangrene was 13% and 3% required closure of perforations. Postoperatively six (20%) patients developed eight infective complications. There was recurrence in three of 27 (11%) surviving patients within 3 months. Mortality was three (10%). The presentation of adhesion intestinal obstruction in children in northern Nigeria is late and morbidity and mortality are high. Early presentation should improve the outcome.

[Ascaris lumbricoides-caused risk factors for intestinal occlusion and subocclusion]

OBJECTIVES

Our objective was to determine risk factors and mortality for partial and complete bowel obstruction caused by Ascaris lumbricoides as well as diagnostic validity of eosinophilia in peripheral blood.

MATERIAL AND METHODS

We studied 50 patients with partial or complete bowel obstruction and expulsion of Ascaris lumbricoides by mouth or anus, as well as 50 patients as controls; no patient had a negative coproparasitoscopic study. The period of study was from January 1995-December 2001 at the General Hospital of Ciudad Valles, San Luis Potosí State, Mexico.

RESULTS

Cases with partial bowel obstruction had average age of 3.1 years against 10.13 years for those with complete obstruction (p = 0.029). Females accounted for 55% and males 43%, respectively. We do not find a relationship among nutritional status, gestational order in the family, and place of excreta deposition in this study group. In the case of eosinophilia, best point of section found was three or more eosinophils with sensitivity of 34% but specificity of 100%; mortality was 2%.

CONCLUSIONS

We do not find a statistical difference between partial and complete bowel obstruction for different variables studied with the exception of age. To find 3% or more of eosinophils in peripheral blood strongly suggests the etiology of the obstruction as Ascaris lumbricoides at prevalence sites of this parasite.

[Urgent management of obstructing colo-rectal cancer: authors' experience]

PURPOSE

The aim of this retrospective study is to compare the different surgical approaches in obstructing colo-rectal cancer in terms of mortality, morbidity and quality of life.

MATERIALS AND METHODS

We observed 379 patients with colorectal cancer, 354 of which underwent surgical treatment, 189 M (53.4%) and 165 F (46.6%), with a median age of 72.6 years. Complicated tumors were 150 (42.4%), with 126 obstructions (84%). For 95 obstructing left-sided colorectal cancers we performed: 9 defunctioning colostomies; 62 two-stages operations: 55 Hartmann's procedures, 5 primary anastomosis with colostomy; 2 primary anastomosis with on table wash-out and ileostomy; 24 single-stage operations: 17 primary anastomosis with on table wash-out and 7 colectomy.

RESULTS

The overall operative mortality rate was 8.7% (11/126). The overall leak rate was 8% (5/62), 12.9% (4/31) in left colon and 3.2% (1/31) in right colon, all treated conservatively. The wound infection rate was 23.8% (30/126).

DISCUSSION AND CONCLUSIONS

Obstructing colo-rectal cancer is associated with a high operative mortality and a worse prognosis. Defunctioning colostomy can be regarded as a valid option only in extreme circumstances. Hartmann's operation has indicated in case of metastatic disease, unsure anastomosis, simultaneous colonic perforation. The gold-standard is primary anastomosis, as colonic resection with on table wash-out or subtotal/total colectomy, in case of largely distended colon or synchronous lesions.

[The method of choice for surgical treatment of intestinal obstruction in colon cancer]

The authors present the results of surgical treatment of 326 patients with cancer of the colon complicated by occlusive intestinal obstruction. Three degrees of colon passage disorders were distinguished. Surgical policy depended on location of the tumor, degree of the obstruction, severity of general state and concomitant diseases. General postoperative lethality was 13% (43 of 326 operated patients died). Resection of the colon and subtotal colectomy with one-stage intestinal reconstruction may be recommended for patients with compensated stage of intestinal obstruction and stable general state.

Evidence of secondary neuronal intestinal dysplasia in a rat model of chronic intestinal obstruction

The etiology of neuronal intestinal dysplasia remains largely unknown. There is, however, supporting evidence of the existence of Hirschprung's disease or chronic intestinal obstruction associated with neuronal intestinal dysplasia. With the aim of investigating the possible development of neuronal intestinal dysplasia linked to chronic intestinal obstruction, we have examined the enteric nervous system response to long-term obstruction in a rat model. Three different surgical techniques were tested in Wistar male rats. In animals that survived longer than the cutoff chronic intestinal obstruction point (6 weeks), full-thickness biopsies and acetylcholinesterase (AChE), NADH, hematoxylin-eosin, and anti-S100 protein stainings were performed. The results of our model indicate that chronic intestinal obstruction induced different degrees of enteric nervous system dysplasia, including histological features of neuronal intestinal dysplasia. The relationship between chronic intestinal obstruction and anomalies of the enteric nervous system, including neuronal intestinal dysplasia, needs to be further studied.