Acceptable Quality Of Life Research Articles

Wanted, Dead or Alive

Wanted, Dead or Alive Frank Chessa, Thomas I. Cochrane, Joan MacGregor, and Kenneth Leeds To the Editor: In “Rethinking the Ethics of Vital Organ Donation” (Nov-Dec 2008), Franklin Miller and Robert Truog offer a provocative argument for overturning status quo justification for medical decision-making at the end of life. They do this in the name of providing a more “honest” justification for the procurement of vital organs for transplant. They correctly point out that incoherencies and practical difficulties involved in diagnosing death have led to an unsatisfactory justification of current practices in organ donation. But their proposed solution ignores equally troublesome issues in obtaining informed consent from patients and surrogates. Miller and Truog argue that when a patient dies after life-sustaining treatment is withdrawn, the withdrawal is the cause of death, and therefore, the physician who orders it has caused the death. This contrasts with the status quo view that withdrawing life-sustaining treatment allows death to occur, but that death itself is caused by the underlying illness. On Miller and Truog’s view, the key element distinguishing a justified causing of death by removal of life-sustaining treatment from criminal homicide is that the patient or surrogate consents to removing life-sustaining treatment. This allows them to argue that causing death by removing vital organs can also be justified by patient or surrogate consent, freeing organ procurement practices from the need to be justified by suspect neurological or cardiovascular criteria for death. The most important turn in this argument is to make patient or surrogate consent the primary gatekeeper for permitting organ procurement, jettisoning the dead donor rule in the process. Unfortunately, there are many reasons to believe that obtaining valid informed consent is at least as problematic as formulating defensible criteria for death. There are three ways to obtain consent to withdraw life-sustaining treatment: (1) a patient with decisional capacity provides contemporaneous consent; (2) a legally authorized surrogate decision-maker provides consent using either the substituted judgment or best interest standard; or (3) the patient has provided an advance directive stating that she does not wish to have her life prolonged in certain situations. The problems with each have been well discussed. The most common approach to determining patient capacity (see Paul Appelbaum and Thomas Grisso, “Assessing Patients’ Capacities to Consent to Treatment,” New England Journal of Medicine vol. 319 (1988): 1635–38) uses four criteria: ability to communicate choice; understanding; ability to manipulate information rationally; and appreciation of the situation and its consequences. These criteria are open to subjective interpretation in all cases but are especially difficult to evaluate in a critically ill person. When communication is limited, for example, to gestures, mouthing words, or pointing to letters on a board, it is difficult to know in any but the broadest terms what a patient really wants. By contrast, an apnea test and clinical exam for brain death are pleasingly unambiguous. If the bar for meeting the criteria is kept high to avoid relying on the responses of persons with compromised capacity, we move to relying on surrogates or advance directives. In a systematic review, David Shalowitz and colleagues (“The Accuracy of Surrogate Decision Makers: A Systematic Review,” Archives of Internal Medicine vol. 166 (2006): 493–97) show that patient-designated and next-of-kin surrogates incorrectly identify patients’ end-of-life wishes one-third of the time, which calls into serious question whether substituted judgment is ethically appropriate. Advance directives are also notoriously difficult to apply in actual situations, when doctors may be hesitant to predict death and thereby activate them. Studies also suggest that persons tend to change their minds about what they would judge an acceptable quality of life as they become sicker, so advance directives may not reflect current wishes. Of course, these problems with consent will be with us whether or not we accept Miller and Truog’s indictment of the current criteria for death. It is tempting to think that when faced with two or more flawed concepts, it is always good practice to eliminate what we can. But in the current instance, if we jettison the dead donor rule because we are less than clear about...

Do Patients Profit from Third Time CABG?

Introduction It has been shown that in experienced hands repeated CABG is doable procedure. However the quality of life after third time CABG has not been evaluated so far. Patients and Methods The peri-operative data of 25 (22 male, mean age of 65.5 ± 8.0 years) consecutive patients in a single centre undergoing third time-CABG from 4/96 to 11/06 were studied. Quality of life (QoL) was assessed by Short Form (SF)-36 Questionnaire. Results 30 day mortality was 12% (3/25). Seven died during follow-up. In 15 survivors median follow-up was 94 months (2–122 months). 1-, 5-, and 10-year survival were 77.8%, 65.0%, and 53.1%, respectively. Present NYHA status was significantly improved in comparison to preoperative values (2.4 ± 0.8 vs. 3.2 ± 0.56, p = 0.012). QoL was comparable with an age matched general population with heart insufficiency. Conclusion Third time CABG can be performed with acceptable peri-operative mortality. Significant improvement of NYHA status and acceptable quality of life results justifies our surgical approach in this challenging patient cohort.

Recovery: What does this mean to patients with low back pain?

To explore patients' perceptions of recovery from low back pain, about which little is known. A qualitative study was conducted in which 36 participants, either recovered or unrecovered from low back pain, participated in focus groups. Interviews were audiorecorded and transcribed verbatim. Framework analysis was used to identify emergent themes and domains of recovery. Patients' views of recovery encompassed a range of factors that can be broadly classified into the domains of symptom attenuation, improved capacity to perform a broad scope of self-defined functional activities, and achievement of an acceptable quality of life. An interactive model is proposed to describe the relationships between these domains, cognitive appraisal of the pain experience, and self-rated recovery. Pain attenuation alone was not a reliable indicator of recovery. The construct of recovery for typical back pain patients seeking primary care is more complex than previously recognized and is a highly individual construct, determined by appraisal of the impact of symptoms on daily functional activities as well as quality of life factors. These findings will be valuable for reassessing how to optimize measures of recovery from low back pain by addressing the spectrum of factors patients consider meaningful.

Correction of Laminin-5 Deficiency in Human Epidermal Stem Cells by Transcriptionally Targeted Lentiviral Vectors

Deficiency of the basement membrane component laminin-5 (LAM5) causes junctional epidermolysis bullosa (JEB), a severe and often fatal skin adhesion defect. Autologous transplantation of epidermal stem cells genetically corrected with a Moloney leukemia virus (MLV)-derived retroviral vector reconstitutes LAM5 synthesis, and corrects the adhesion defect in JEB patients. However, MLV-derived vectors have genotoxic characteristics, and are unable to reproduce the physiological, basal layer-restricted expression of LAM5 chains. We have developed an alternative gene transfer strategy based on self-inactivating (SIN) or long terminal repeat (LTR)-modified lentiviral vectors, in which transgene expression is under the control of different combinations of promoter-enhancer elements derived from the keratin-14 (K14) gene. Analysis in human keratinocyte cultures and in fully differentiated skin regenerated onto immunodeficient mice showed that gene expression directed by K14 enhancers is tissue-specific and restricted to the basal layer of the epidermis. Transcriptionally targeted lentiviral vectors efficiently transduced clonogenic stem/progenitor cells derived from a skin biopsy of a JEB patient, restored normal synthesis of LAM5 in cultured keratinocytes, and reconstituted normal adhesion properties in human skin equivalents transplanted onto immunodeficient mice. These vectors are therefore an effective, and potentially more safe, alternative to MLV-based retroviral vectors in gene therapy of JEB.Molecular Therapy (2008) 16 12, 1977-1985 doi:10.1038/mt.2008.204.

Titrating Guidance

Over the last century, developments in new medical treatments have led to an exponential increase in longevity, but, as a consequence, patients may be left with chronic illness associated with long-term severe functional and cognitive disability. Patients and their families are often forced to make a difficult and complex choice between death and long-term debility, neither of which is an acceptable outcome. Traditional models of medical decision making, however, do not fully address how clinicians should best assist with these decisions. Herein, we present a new paradigm that demonstrates how the role of the physician changes over time in response to the curved relationship between the predictability of a patient's outcome and the chance of returning to an acceptable quality of life. To translate this model into clinical practice, we propose a 5-step model for physicians with which they can (1) determine at which point the patient is on our model; (2) identify the cognitive factors and preferences for outcomes that affect the decision-making process of the patient and his or her family; (3) reflect on their own reaction to the decision at hand; (4) acknowledge how these factors can be addressed in conversation; and (5) guide the patient and his or her family in creating a plan of care. This model can help improve patient-physician communication and decision making so that complex and difficult decisions can be turned into ones that yield to medical expertise, good communication, and personal caring.

Dialysis or not in the very elderly ESRD patient

Nephrology societies and dialysis registries are reporting a dramatic increase in the number of elderly patients who require dialysis. During the last decade the number of patients starting renal replacement therapy (RRT) has increased for all ages but the increase for patients over the age of 75 years has been particularly dramatic, with a 4.3-fold rise in the USA [1]. In view of this development, it is necessary to examine more closely the quality of the results (survival, selected technique, and morbidity) of kidney replacement therapy in this age group. Despite the fact that very old patients raise the most difficult problems with respect to indication and dialysis therapy management because of their multiple comorbidities and presumed short life expectancy, there are few studies devoted to very old end-stage renal disease (ESRD) patients and their conclusions are rather discordant. Some studies report very poor survival of very old patients on dialysis, whereas others report more favorable outcomes. Moreover, specific predictive factors that could help in deciding whether dialysis would offer pre-ESRD old patients substantial prolongation of life expectancy with an acceptable quality of life are lacking [2]. Below we discuss in more depth the reasons why, in general, dialysis should not be withheld from patients above 75 years of age. Let us first consider the title of this controversy: ‘‘The dilemma of renal replacement therapy in patients over 75 years.’’ Is this actually a dilemma? Basically, a dilemma is characterized by the need to choose between two evils, or in the present case between two possibilities. If the question is posed ‘‘should 75-year-old patients be started on dialysis: yes or no?’’ it is sensible to ask the question the other way round. What could be the reasons for not providing them with dialysis? Is the survival time too short? Is the quality of life that can be achieved unsatisfactory? Are there so many old people above 75 years of age and dialysis facilities are insufficient? Do financial constraints make age a matter of rationing? Good survival on dialysis for the very old is currently well documented. Shaefer and Rohrich showed that survival in very old patients after 12 months from the start of dialysis treatment was 70.5%, and after 24 months 50.3%, and after 60 months 18.5%. These results provide no rationale for withholding dialysis treatment, even when life expectancy of over 75-year-old dialysis patients is compared with that of younger dialysis patients. In fact 75-year-old dialysis patients have a life expectancy of only 36% of age-matched healthy controlled individuals. Therefore, the remaining life time is, M. Busuioc P. Gusbeth-Tatomir A. Covic (&) Nephrology Clinic and Dialysis Center, Parhon University Hospital, ‘‘Gr.T. Popa’’ University of Medicine and Pharmacy, Carol 1st Blvd. Nr. 50, Iasi 700503, Romania e-mail: acovic@xnet.ro

Chronic illness: the process of integration

The aim of this study was to explore how adults with a chronic illness integrate the illness experience into their life context. Adults with chronic illnesses are challenged to learn self-management strategies to prevent complications and achieve an acceptable quality of life. Integration represents the process undertaken by an individual to achieve a sense of balance in self-managing a chronic illness and living a personally meaningful life. A mixed-method descriptive design was employed to recruit English-speaking adults with a chronic illness. A semi-structured interview was completed, transcribed verbatim and content analysed. Descriptive data were collected on demographics, co-morbidity and depressive symptoms. The research was undertaken in Connecticut, USA. The sample (n = 26) was diverse with respect to age (25-80 years), education (8-24 years), duration of illness (1-39 years), gender (63% female) and ethnicity (63% white). Participants reported a mean of four chronic illnesses and 31% of the sample had increased depressive symptoms. The process of integration was complex and multifactorial. Themes of integration included: shifting sands, staying afloat, weathering the storms, rescuing oneself and navigating life. Numerous factors including treatment side effects, a progressive or uncertain illness trajectory, co-morbidity, bad days, financial hardships and interpersonal/environmental challenges contributed to a disruption or difficulty in the integration process. All participants made considerable effort to integrate the illness into their life context and participate in a personally meaningful life. However, it was easy to be consumed with 'living an illness' as the daily tasks, the changing symptoms and the fluctuating emotions could be overwhelming. There was a complex co-existence between 'living a life' and 'living an illness'. There were numerous challenges to the process of integration and ongoing self-management, psychosocial, vocational and existential support appears indicated, particularly with individuals with multiple chronic illnesses, progressive chronic illnesses and limited resources.

Quality of life after liver resection for hepatobiliary malignancies

Few prospective longitudinal studies have used a validated quality of life (QOL) instrument in patients undergoing liver resection for hepatobiliary malignancy. Patients undergoing liver resection for hepatobiliary tumours in a 1-year period were enrolled. The cancer-specific European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) was completed before operation, and at 6, 12 and 36-48 months after surgery. QOL over time was analysed in relation to several clinical factors. A total of 103 patients were enrolled. Patient compliance was at least 75 per cent at all stages. Most functional scales and the global QOL scale showed a non-significant trend towards deterioration at 6 months and a return to preoperative level at 12 months. Physical functioning and dyspnoea deteriorated significantly at 6 months (P = 0.020 and P = 0.004 respectively) and did not recover by 12 months (P = 0.002 and P < 0.001 respectively). Pain and fatigue showed clinically significant deterioration over 12 months, which was not statistically significant. Survivors without recurrence at 36-48 months showed better QOL than those with recurrent disease. Major liver resection is associated with acceptable QOL outcomes, and QOL continues to improve in the long term in those without recurrence.

Intradural Jugular Paragangliomas: Complications and Sequelae

To present the long-term results of a group of patients who underwent surgery for intradural jugular paragangliomas. We discuss the complications, sequelae, and evolution of recurrences and behavior of residual tumors. From 1989 to 2002, 11 patients with intradural jugular paragangliomas underwent surgery using different approaches. The paragangliomas were grouped according to the classification of Fisch. Total removal of the paraganglioma was possible in eight patients, while a subtotal resection was achieved in the other three cases. The tumor remnant remained stable in two patients but continued to grow in one. Recurrence was observed in one patient. There were preoperative deficits in cranial nerves IX to XI in four patients and of XII in two patients. Deficits of cranial nerves IX to XI were acquired as a result of surgery in three cases and of XII in another. Six patients had a pure-tone average of 45 to 75 dB while the others had dead ears. Persistent dysphagia and dysphonia were managed in two patients by injection of the paralyzed cord with fat and subsequent medialization of the vocal cord by thyroplasty. Two patients had a cerebrospinal fluid leak. Surgical results in patients with extensive jugular paragangliomas are consistent and offer an acceptable quality of life even in advanced cases.

Health‐related quality of life after bladder preservation therapy for muscle invasive bladder cancer

To assess health-related quality of life (QOL) of bladder cancer patients following bladder preservation therapy (BPT). Eighty patients with muscle-invasive bladder cancer had been treated between January 1992 and July 2005 at our institutions with BPT consisting of transurethral resection, intra-arterial chemotherapy and radiotherapy. Among them, 48 were alive and free from recurrence at the time of survey and were asked to participate. A total of 168 patients who had been treated for superficial bladder cancer in the same period were used as a control group. Three questionnaires, namely the International Prostate Symptom Score (IPSS), the SF-36, and the Expanded Prostate Cancer Index Composite (EPIC) were used. Thirty-three patients in the BPT group (68.8%) and 128 patients in the control group (76.2%) answered the QOL survey. There was no significant difference in age, gender and other clinical factors among these two groups. No significant difference was found between the groups according to IPSS. The QOL score of BPT was lower than that of the control group in the SF-36, but there was no significant difference without body pain (P = 0.047). There was a tendency toward a diminished physical functioning (P = 0.053) and role-physical (P = 0.064) in BPT. The EPIC scores for urinary function, especially storage and voiding symptoms, and bowel function were significantly lower in the BPT group. At multivariable analysis, body pain and bowel function were associated with the type of treatment. Although some of the QOL outcome parameters after BPT were found to be lower than the control group, these differences were not significant. Overall, patients retaining their bladder had an acceptable health related QOL.

The Summer 2006 Lebanese Food Crisis: A Quality of Life Perspective

ABSTRACT This article explores major predicaments encountered by the four million people of Lebanon have encountered for thirty-four days of war during the summer of 2006. During the war, Lebanon witnessed land, sea, and air blockade barring all food imports. Furthermore, the country's infrastructure, farmlands, seaports, bridges, and airport were all heavily bombarded and shelled. The blockade and the bombardment created a national food crisis and made it difficult for humanitarian agencies to transport food and aid supplies. Local food distributors were not able to transport goods, and warehouses were either selling out or having their products expire due to the absence of power. Being a nation that lacks a food policy and always susceptible to war, the country needs to create a food policy in order to maintain acceptable quality of life during difficult times.

Benign Prostatic Hyperplasia and Sexual Dysfunction

Symptomatic benign prostatic hyperplasia (BPH) as characterized by lower urinary tract symptoms suggestive of obstruction is a common condition in the elderly male population. Although there are some country-specific differences, symptomatic PBH in general occurs in approximately 20 to 30% of men aged 60 years or over. Patients consulting for symptomatic PBH are not only seeking to be relieved from their symptoms but certainly wish to retain an acceptable quality of life. From self-administered questionnaires, the aspects reported to be the more affected and to be the more important in PBH patients were sleep, anxiety and worry about the disease, impact of symptoms on daily activities, but also sexual functions and satisfaction with sexual relationships. Indeed, epidemiological studies revealed that, independently of age, LUTS are strongly associated with sexual dysfunction and a spoilt sex life. Moreover, the prevalence of erectile dysfunction and reduced ejaculation increases with the severity of LUTS, affecting about 2/3 patients with severe LUTS. Both conditions are also highly bothersome: among those patients with severe LUTS, respectively 93% and 78% of patients with reduced erection and reduced ejaculation, consider it to be a problem. On the other hand, assessments of patients with erectile dysfunction revealed that the prevalence of LUTS was very common, up to 72.2%. BPH treatment modalities, either surgical or medical, may also impair sexual function. Transurethral resection of the prostate (TURP), for example, may cause bothersome retrograde ejaculation in more than 70% and impotence in about 5 to 8% of men undergoing the procedure. Plant extracts do not interfere noticeably with sexuality. Direct comparative studies have shown that finasteride, a 5a-reductase inhibitor, is associated with an increased incidence of ED, decreased libido and abnormal ejaculation compared with alpha-blockers as alfuzosin, doxazosin and terazosin. An abnormal ejaculation is reported by 4% to 6% of patients treated with tamsulosin in Europe. These percentages are much more important in US where up to 30% of patients complain of abnormal ejaculation over a mean exposure of 16 months. Conversely, ejaculatory disorders appear to be negligible with alfuzosin and terazosin. Moreover, when analysing alfuzosin results in population trials, a sexual status improvement was noted. With increasing age, men experience significant changes in their sexual function, namely the average frequency of intercourse and the ability in getting or maintaining erection. Nevertheless, regular sexual activity is a normal finding in ageing men and satisfaction with sex life is an important dimension of quality of life which is rarely considered when managing LUTS. Medical treatment of LUTS may also impact on sexual function and side-effects should be discussed with the patient before initiating a therapy.

Modular prostheses in the treatment of proximal humerus metastases: review of 40 cases

BackgroundThe humerus is the second most common site of metastatic bone disease involving long bones. Tumors which have a predilection for dissemination to bone are those of breast, prostate, thyroid, lung and kidney. The rationale for surgical treatment of these lesions is to prevent or treat pathological fractures in order to relieve pain and improve function.Materials and methodsForty patients who had resection of the proximal humerus for metastatic bone disease and reconstruction with a modular prosthesis were retrospectively reviewed.ResultsMean functional outcome was 73.1% (Enneking score) and better results were achieved when a reverse prosthesis was implanted. Overall survival was 70% at 1 year, 42.5% at 2 years and 20% at 5 years. Local recurrence occurred in 4 patients, each of whom had initially been treated for a pathological fracture.ConclusionsIt is important to follow rational guidelines, like those of Capanna and Mirels, in order to prevent pathological fractures and to give the patient a definitive treatment, as the advances in the management of cancer prolong the survival of these patients. In this series, satisfactory results were obtained, giving the patients an acceptable quality of life.

Fibrose cística no adulto: aspectos diagnósticos e terapêuticos

Once considered a childhood disease, cystic fibrosis is now also a disease of adults. Increased longevity has resulted in the aging of the cystic fibrosis population. The consequent age-related medical problems among adults with cystic fibrosis have increased medical care needs. These needs are being met by a growing number of non-pediatric pulmonologists and other non-pediatric specialists. The objective of this review was to summarize the current knowledge about diagnosis and treatment in adult cystic fibrosis. In most cases, the diagnosis is suggested by manifestations of chronic sinopulmonary disease and exocrine pancreatic insufficiency. The diagnosis is confirmed by a positive sweat test result. Adult patients may, however, present pancreatic sufficiency and atypical clinical features, sometimes in combination with normal or borderline sweat test results. In such cases, identifying cystic fibrosis mutations and measuring nasal potential difference can have diagnostic utility. The standard therapeutic approach to pulmonary disease includes the use of antibiotics, airway clearance, exercise, mucolytics, bronchodilators, oxygen therapy, anti-inflammatory agents and nutritional support. Appropriate application of these therapies results in most cystic fibrosis patients surviving into adulthood with an acceptable quality of life.

A call to arms to reduce premature deaths by using inexpensive resuscitation care

Two hundred seventy thousand people in the US and 450,000 people in Europe experience out-of-hospital cardiac arrest each year. Perceived poor prognosis and expense of care of patients resuscitated from cardiac arrest remain barriers to implementation of effective therapies. In this issue of Critical Care, Graf and colleagues have provided a programmatic evaluation of the costs and consequences of intensive care after resuscitation from cardiac arrest. Thirty-one percent of the cohort that survived to be cared for in the intensive care setting were still alive 5 years after hospital discharge. The health-related quality of life of this group of 5-year survivors was similar to that of matched healthy controls, and the cost per quality-adjusted life year gained was similar to or less than the cost of other commonly used medical interventions. We need to change the culture of resuscitation and recognize that cardiac arrest is a treatable condition that is associated with acceptable quality of life and costs of care after resuscitation.

Urologic surgical procedures in patients with uterus neoplasm and colon-rectal cancer

Introduction. During the last 30 years, the multidisciplinary treatments of colon and uterus neoplasm have yielded an increase in total survival rates, fostering therefore the increase of cases with regional relapse involving the urinary tract. In these cases the iterative surgery can be performed, if no disease secondary to pelvic pain, haemostatic or debulking procedure is present, and must be considered and discussed with the patient, according to his/her general status. Materials and Methods. From 1997 to August 2007 we performed altogether 43 pelvic iterative surgeries, with simultaneous urologic surgical procedure because of pelvic tumor relapse in patients with uterus neoplasm and colon and rectal cancer. In 4 cases of anal cancer, the urological procedure were: one radical prostatectomy with continent vesicostomy in the first case, while in the other 3 cases radical pelvectomy with double-barrelled uretero-cutaneostomy In 23 cases of colon cancer, the urologic procedures were: 9 cases of radical cystectomy with double-barrelled uretero-cutaneostomy, 4 cases of radical cystectomy with uretero-ileo-cutaneostomy according to Bricker-Wallace II procedure, and 9 cases of partial cystectomy with pelvic ureterectomy and ureterocystoneostomy according to Lich-Gregoire technique (7 cases) and Lembo-Boari (2 cases) procedure. In 16 cases of uterus cancer, the urological procedure were: 7 cases of partial cystectomy with pelvic ureterectomy and uretero-cystoneostomy according to Lich-Gregoire procedure; in 3 cases, a radical cystectomy with urinary continent cutaneous diversion according to the Ileal T-pouch procedure; 2 cases of total pelvectomy and double uretero-cutaneostomy, and 4 cases of bilateral uretero-cutaneostomy. Results. No patients died in the perioperative time; early systemic complications were: 2 esophageal candidiasis, 1 case of venous thrombosis. Conclusions. The iterative pelvic surgery in the case of oncological relapse involving the urinary tract aims to achieve the best quality of life with the utmost oncological radicality. The equation: eradication of pelvic neoplasm and urinary tract reconstruction, with acceptable quality of life, will be the future target; nevertheless, it is not possible to establish guidelines beforehand, and the therapy must be adapted to each single case.

Laparoscopic intersphincteric resection for low rectal cancer

The goal of this review is to outline some of the important surgical issues surrounding the management of patients with low rectal cancer submitted to laparoscopic intersphincteric resection (ISR). Surgery for rectal cancer continues to develop towards the ultimate goals of improved local control and overall survival, maintaining quality of life, and preserving sphincter, genitourinary, and sexual function. Nevertheless, all progress in the development of oncologic therapy (i.e., radiation and chemotherapy), radical surgical removal of the tumour is the only chance for permanent cure of rectal cancer. Beside this main objective, the preservation of faecal continence is the second-most important goal to reach an acceptable quality of life with preservation of sphincter function. Information concerning the depth of tumour penetration through the rectal wall, lymph node involvement, and presence of distant metastatic disease is of crucial importance when planning a curative rectal cancer resection. Preoperative staging is used to determine the indication for neoadjuvant therapy as well as the indication for local excision versus radical cancer resection. In appropriate patients, minimally invasive procedures, such as local excision, TEM, and laparoscopic resection with ISR allow for improved patient comfort, shorter hospital stays, and earlier return to preoperative activity level. Data from small, non-randomized studies evaluating laparoscopic ISR suggest that this procedure is feasible by experienced surgeons. A literature search identified five studies [Uchikoshi F, Nishida T, Ueshima S, Nakahara M, Matsuda H. Laparoscope-assisted anal sphincter-preserving operation preceded by transanal procedure. Tech Coloprocto 2006;10:5-9; Bretagnol F, Rullier E, Couderc P, Rullier A, Saric J. Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer. Colorectal Disease 2003;5:451-3; Rullier E, Sa Cunha A, Couderc P, Rullier A, Gontier R, Saric J. Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer. British Journal of Surgery 2003;90:445-51; Watanabe M, Teramoto T, Hasegawa H, Kitajima M. Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer. Diseases of the Colon and Rectum 2000;43(Suppl. 10):S94-7; Miyajima N, Yamakawa T. Laparoscopic surgery for early rectal carcinoma. Nippon Geka Gakkai Zasshi 1999;100:801-5]. The aim was to find those studies that documented potential clinical application of laparoscopic ISR. These studies concluded that a laparoscopic approach can be considered in most patients with low rectal cancer in which laparoscopic ISR represents a feasible alternative to conventional open surgery. Hopefully, randomized controlled trials, which utilize these alternative procedures, will in future determine the results of laparoscopic ISR in terms of sphincter function, faecal continence, disease free and overall survival. The reviewed studies concluded that high quality and less invasive surgery could be achieved if ISR and laparoscopic surgery were combined.

An assessment of burn care professionals’ attitudes to major burn

The resuscitation of severe burn remains a controversial area within the burn care profession. There is ongoing debate as to what percentage burn is associated with a sufficient quality of life to support initial resuscitation efforts. We conducted a survey of delegates at the 39th Annual Meeting of the British Burns Association (2005), regarding attitudes towards resuscitation following major burns. Respondents were asked the maximum percentage total body surface area (TBSA) burn beyond which they would not wish to be resuscitated. They were also asked what maximum TBSA they perceived to be commensurate with an acceptable quality of life (QOL). One hundred and forty three of 300 delegates responded to the questionnaire. Thirty three percent of respondents would not wish to be resuscitated with 50–75% TBSA burns or greater. A further 35% would not wish to have life-sustaining intervention with 75–95% TBSA burns or greater. The remaining 32% indicated that they would not want resuscitation with TBSA burns > 95%. Regardless of TBSA affected, 16% would not wish resuscitation if they had full thickness facial burns, a further 10% did not want resuscitation if both their hands and faces were affected. Our survey demonstrates the diversity of personal preference amongst burn care professionals. This would suggest that a unifying philosophy regarding the resuscitation of extensive burns will remain elusive.

Combined Surgical and Endovascular Repair of a Ruptured Bilateral Aortoiliac Aneurysm

Aortoiliac aneurysms are frequent entities that have very important clinical implications, especially in the younger patients. We are asked not only to save lives by preventing the rupture or repairing those that are already ruptured but also to provide an acceptable quality of life in the postoperative period. Endovascular approaches certainly give us such an expectative but are not clearly indicated in our younger patients and cannot be used routinely in those aneurysms with a yuxtarrenal origin. This is the case report of a young man with a yuxtarrenal aortoiliac inflammatory aneurysm that was treated by the interposition of an aortobifemoral bypass with the addition of endovascular devices in the hypogastric vessels to preserve the pelvic blood flow; they contribute to seal the common iliac aneurysms. This approach was useful to avoid complications during a difficult iliac dissection and was permeable within 1 year of the operation. Durability must be assessed.

Laparoscopic Radiofrequency Ablation Combined With Laparoscopic Liver Resection for More Than One HCC on Cirrhosis

The management of patients affected by more than one hepatocellular carcinoma (HCC) is still controversial but nowadays a multimodal approach to this pathology seems to be the most effective and versatile therapeutic option. When orthotopic liver transplantation is not indicated, survival-time and quality of life improvement is the goal for patients who will have a long metabolic and oncologic disease history. Combined use of minimally invasive nonsurgical treatments [percutaneous ethanol injection, radiofrequency ablation, transcutaneous arterial chemioembolization (TACE)] allows to offer to the patients the advantages of each therapeutic procedure reducing their individual side effects and complications. We consider laparoscopy as a minimally invasive procedure, which can offer the benefits of surgical treatment, by tumor removing, but with an improved postoperative course. If recurrence risk factors are present, the costs/benefits rapport can be decreased by the laparoscopic approach which offers, in addition to a radical resection, a decreased postoperative pain, reduced trauma to the abdominal wall, smaller incisions, reduced peritoneal adhesions and, in selected cases, an earlier beginning of chemiotherapy. We report the case of a patient affected by more than one HCC with a bigger lesion of 50 mm protruding from hepatic segment III, one subcapsular lesion located at segment V, and one deep lesion located at segment VII-VIII. The patient was submitted to a double laparoscopic liver resection in association with laparoscopic radiofrequency ablation. Five months later, the patient presented an early recurrence of malignancy that was treated by TACE. At 8 months from the treatment, the patient presented another multifocal recurrence and was submitted to another TACE. At 2 years from the laparoscopic procedure, the patient is in apparent good conditions with an acceptable quality of life. We think that laparoscopic resection could gain a considerable place in the multimodal treatment of cirrhotic liver with more than one HCC because, by tumor removing, it offers the benefits of surgical treatment with a lower complications rate.