Francis T. McDermott

CONTEXT: Prehospital hypertonic saline (HTS) resuscitation of patients with traumatic brain injury (TBI) may increase survival but whether HTS improves neurological outcomes is unknown. OBJECTIVE: To determine whether prehospital resuscitation with intravenous HTS improves long-term neurological outcome in patients with severe TBI compared with resuscitation with conventional fluids. DESIGN, SETTING, AND PATIENTS: Double-blind, randomized controlled trial of 229 patients with TBI who were comatose (Glasgow Coma Scale score, <9) and hypotensive (systolic blood pressure, <100 mm Hg). The patients were enrolled between December 14, 1998, and April 9, 2002, in Melbourne, Australia. INTERVENTIONS: Patients were randomly assigned to receive a rapid intravenous infusion of either 250 mL of 7.5% saline (n = 114) or 250 mL of Ringer's lactate solution (n = 115; controls) in addition to conventional intravenous fluid and resuscitation protocols administered by paramedics. Treatment allocation was concealed. MAIN OUTCOME MEASURE: Neurological function at 6 months, measured by the extended Glasgow Outcome Score (GOSE). RESULTS: Primary outcomes were obtained in 226 (99%) of 229 patients enrolled. Baseline characteristics of the groups were equivalent. At hospital admission, the mean serum sodium level was 149 mEq/L for HTS patients vs 141 mEq/L for controls (P<.001). The proportion of patients surviving to hospital discharge was similar in both groups (n = 63 [55%] for HTS group and n = 57 [50%] for controls; P =.32); at 6 months, survival rates were n = 62 (55%) in the HTS group and n = 53 (47%) in the control group (P =.23). At 6 months, the median (interquartile range) GOSE was 5 (3-6) in the HTS group vs 5 (5-6) in the control group (P =.45). There was no significant difference between the groups in favorable outcomes (moderate disability and good outcome survivors [GOSE of 5-8]) (risk ratio, 0.99; 95% confidence interval, 0.76-1.30; P =.96) or in any other measure of postinjury neurological function. CONCLUSION: In this study, patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.

Local recurrence and its related mortality after potentially curative resection for rectal cancer have been analysed in a series of 1008 patients managed by one of the authors. Nine hundred and thirty-four were available for analysis of recurrence. One hundred and seven (11 per cent) patients developed local recurrence without evidence of systemic spread and 84 (9 per cent) both local and systemic recurrence. Local recurrence was less common (14 per cent) after resection of tumours of the upper third of the rectum compared with the middle (21 per cent) (P = 0.02) or lower thirds (26 per cent) (P less than 0.001). Local recurrence was related to both tumour stage and differentiation (P less than 0.001). There was no significant relationship between local recurrence and tumour size or the type of curative resection performed, restorative or non-restorative. The distal margin of clearance after restorative resection did not influence the local recurrence rate. Of patients who developed metastases recurrence was evident within 2 years in 60 per cent. Three hundred and thirty-two patients died from recurrence, 91 (27 per cent) with evidence of local recurrence only, 80 (24 per cent) with combined local and systemic recurrence and 161 (48 per cent) with evidence of systemic spread only. The corresponding median survivals were 35, 34 and 39 months.

In the Melbourne (Monash) series reviewed here the development of apparently isolated incisional scar tissue recurrences after curative excisions for large-bowel cancer proved unusual. Eleven patients with such a recurrence all died of disseminated disease within four years, and most within 12 months, of its development. This suggests that an incisional recurrence is a manifestation of disseminated cancer rather than isolated implantation.

A series of 908 cases of colonic carcinoma has been analysed to elucidate reasons for the poor prognosis in obstructing colonic cancer. Complete obstruction was present in 148 cases (16.3 per cent), 280 cases (30.8 per cent) had partial obstruction and 480 (52.8 per cent) presented without obstruction. There were fewer Dukes' A tumours in those with complete obstruction (P less than 0.005) and greater numbers of advanced tumours (P less than 0.0005) compared with those without obstruction. This is reflected in a lower curative resection rate of 50.7 per cent in those with obstruction compared with 70.6 per cent in those without obstruction (P less than 0.001). However, after curative resection there was no significant difference in the distribution of tumour stage. Patients with complete obstruction showed a higher incidence of recurrence (P less than 0.01) after curative resection, consequent to an increased incidence of local recurrence (P less than 0.02). Five-year cancer-specific survival for the total series was decreased from 59.1 per cent in patients without obstruction to 31.8 per cent in those with complete obstruction (P less than 0.001). After curative resection there was also a significant reduction in survival (P less than 0.001). It is concluded that completely obstructing colonic cancers are more aggressive than other colonic cancers.

A total of 1578 patients were treated with potentially curative surgical resection for colon and rectal cancer by one surgeon from 1950 to 1982. Follow-up revealed that 117 (11.5 percent) of 1013 patients with rectal carcinoma eventually presented with clinical evidence of pulmonary recurrence, with or without evidence of spread elsewhere; the corresponding figures for the colon were 20 (3.5 percent) of 565 (P less than 0.001). An analysis of the times to recurrence revealed that half of the lung recurrences were clinically obvious within 32 months for rectal tumors and 34 months for colonic, compared to 22 and 21 months, respectively, for liver recurrences, excluding those with other distant metastases. The slower recurrence rate and the longer survival in patients with recurrences in the lung compared to the liver were statistically significant only for rectal primaries (P less than 0.02 and P = 0.001, respectively). Sixteen patients underwent surgery with curative intention for lung recurrences; four of these remain alive at two, six, 11, and 15 years, and one patient was free of recurrence when he died from other causes 15 months after surgery. The conditional probability survival rate for the 16 patients was 38 +/- 13 percent at five years after recurrence operation.