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PubMed2001

The analysis of resectability and survival in pancreatic cancer patients with vascular invasion.

One of the major limitations of curative resection in patients with pancreatic cancer is local tumor extension to the mesenteric vessels. Thus, the purposes of our study were to assess the clinical value of contrast-enhanced spiral computed tomography (CT) in predicting the resectability and survival of patients with pancreatic cancer with suspicious vascular invasion and to assess the influence of curative resection on the survival of these patients. We enrolled 40 patients with pancreatic cancer who were suspected of having an involvement of the adjacent large vessels and who subsequently underwent operation with curative intent in the study. Resectability and survival were correlated with CT findings such as segment length, degree of encasement, and type and number of vessels involved. The survival rate was compared between the curative and palliative resection groups, and survival rate was compared between the resected and unresected groups. Of the 40 patients with adenocarcinoma of the pancreas, 14 had curative resections and 26 had palliative resections. The probability of curative resection was higher in patients with segment lengths less than 2 cm, as compared with segment lengths more than 2 cm. However, there was no difference in survival between the two groups. There were no differences in resectability and survival according to the degree of encasement and type and number of vessels involved. There was no difference in survival between the curative and palliative resection groups. There was no difference in survival between the resected and unresected groups. A survival benefit was not achieved by curative resection in patients with pancreatic cancer with vascular invasion. Therefore, it would be better to avoid aggressive surgery in patients with pancreatic cancer with vascular invasion.

Humans↗
PubMed2002

Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade.

OBJECTIVE: To assess the nature of changes in the field of hepatic resectional surgery and their impact on perioperative outcome. METHODS: Demographics, extent of resection, concomitant major procedures, operative and transfusion data, complications, and hospital stay were analyzed for 1,803 consecutive patients undergoing hepatic resection from December 1991 to September 2001 at Memorial Sloan-Kettering Cancer Center. Factors associated with morbidity and mortality and trends in operative and perioperative variables over the period of study were analyzed. RESULTS: Malignant disease was the most common diagnosis (1,642 patients, 91%); of these cases, metastatic colorectal cancer accounted for 62% (n = 1,021). Three hundred seventy-five resections (21%) were performed for primary hepatic or biliary cancers and 161 (9%) for benign disease. Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies, and 526 segmental resections. Sixty-two percent of patients had three or more segments resected, 42% had bilobar resections, and 37% had concomitant additional major procedures. The median blood loss was 600 mL and 49% of patients were transfused at any time during the index admission. Median hospital stay was 8 days, morbidity was 45%, and operative mortality was 3.1%. Over the study period, there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this, there was a significant decline in blood loss, the use of blood products, and hospital stay. Despite an increase in concomitant major procedures, operative mortality decreased from approximately 4% in the first 5 years of the study to 1.3% in the last 2 years, with 0 operative deaths in the last 184 consecutive cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both perioperative morbidity and mortality. CONCLUSIONS: Over the past decade, the use of parenchymal-sparing segmental resections has increased significantly. The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality, and reductions in both are largely responsible for the decrease in perioperative mortality, which has occurred despite an increase in concomitant major procedures.

Adolescent↗
PubMed1993

Preoperative determination of the resectability of hepatic tumors: efficacy of CT during arterial portography.

OBJECTIVE: A multiinstitutional study was performed to evaluate the efficacy of CT during arterial portography for determining the resectability of hepatic tumors. The impact of findings from CT during arterial portography on patients' treatment (i.e., surgical vs nonsurgical) was assessed. In patients considered to have resectable tumors, the accuracy of CT during arterial portography for predicting surgical findings was also evaluated. MATERIALS AND METHODS: A retrospective study was done of 404 patients from three institutions who had CT during arterial portography during the period 1985-1991 as part of preoperative staging to determine the resectability of hepatic tumors. The tumors included metastases from colorectal carcinoma in 197 patients (49%); other hepatic metastases, mostly from adenocarcinoma of the stomach, pancreas, and biliary tree in 123 (30%); and primary hepatocellular carcinoma in 84 (21%). Imaging results were correlated with results of percutaneous biopsy of at least one hepatic lesion in patients whose tumors were considered unresectable. In patients whose tumors were considered resectable, results were correlated with preoperative percutaneous biopsy (obtained in almost all cases) and pathologic examination of a surgical specimen (all cases). Although each case was considered individually, four criteria were used for resectability: (1) accessibility of all lesions to lobar or wedge resection that would yield clear margins, (2) anticipation that residual liver tissue after resection would provide sufficient function, (3) the absence of invasion of central hepatic vascular or biliary structures, and (4) the absence of extrahepatic disease. No specific restriction was made with respect to the number of hepatic lesions present. The accuracy of findings by CT during arterial portography for predicting resectability was assessed in the 146 patients who had tumors that were considered resectable on the basis of imaging findings and had surgery. RESULTS: Of 404 patients, only 146 (36%) were thought to be candidates for resection on the basis of findings from CT during arterial portography. Of these, 122 (84%) actually had resection. The 24 patients who did not have resection included 22 patients with disease understaged or overstaged by CT during arterial portography, one with true-negative findings by CT during arterial portography, and one who died during surgery. The accuracy of findings by CT during arterial portography for predicting results at surgery was 85% for all patients and 91% for the subset of patients who had primary colorectal tumors with hepatic metastases. CONCLUSION: Our experience shows that CT during arterial portography is a useful procedure for assessing the resectability of hepatic tumors. In our study, 64% of patients were spared unnecessary surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Carcinoma↗
PubMedDate not supplied

Surgical resection of liver metastases from colo-rectal cancers.

Surgical resection is currently the only potentially curative treatment in some selected patients with colo-rectal liver metastases (LM). Unfortunately only a minority of patients are candidates for resection. Only solitary or unilobar LM that can be removed by partial liver resection, are considered to be resectable. The second condition for the resection of LM is that the primary cancer must be resected. The third condition for resection is that the patient must be able to undergo a major liver resection if it is necessary. Small metastases which do not exceed 5 cm, and appear on the surface of the liver can be removed by a simple wedge resection. If the tumor is larger than 5 cm, or if multiple unilobar nodules are discovered, a major liver resection becomes necessary. Hospital mortality does not exceed 5% in most published series. Five year survivals are very rare when histologically proven colo-rectal LM are left in place. After surgical resection of LM, five year survival rates are close to 25% and range from 18% to 52%. Surgical resection is of benefit to approximately one fourth of the patients, who survive five years or more, but three fourths of the patients have early recurrences. None of the studied criteria can predict which patients will benefit from surgical resection of LM. In order to try to reduce the rate of early recurrences adjuvant chemotherapy has been proposed. No positive data have yet been obtained.

Colonic Neoplasms↗
PubMed1985

[Resection with preservation of the lower limb in chondrosarcoma of the pelvis].

Twenty-seven chondrosarcomata of the pelvis were treated by local resection with preservation of the limb. Twenty-two were grade I or II, and 5 were grade III or IV. Attention is drawn to the importance of tomodensitometry in assessing the extent of the tumor before operation. An en bloc resection was well wide of the tumour in 16 cases, close to the tumour in 10 cases and involved the tumour in one case. Post-operative complications were varied. There were 6 nerve paralyses after iliac resection, 3 cases of sepsis after resection of the anterior part of the pelvic ring, and 3 cases of sepsis and 2 vascular complications after peri-acetabular resections. The average follow-up was 5 years. Three had metastases and three had local recurrences, one of whom died later from pulmonary metastases. No local recuRrence was seen in cases with wide resection. The functional results were satisfactory in 6 out of 7 partial resections of the ilium and in 4 out of 5 resections of the anterior part of the pelvic ring. They were only fair after peri-acetabular resections and complete resections of the ilium. After peri-acetabular resections, the results were about the same after ilio-femoral arthrodesis or Girdlestone operations. It is not appropriate to reconstruct the pelvic ring after resection limited to the anterior part of the pelvis but it is indicated after resections of the whole of the ilium, particularly in children to avoid shortening of the limb with pelvic shift.

Adult↗
PubMed1997

Gastrectomy with combined resection of other organs for carcinoma of the stomach with invasion to adjacent organs: clinical efficacy in a retrospective study.

BACKGROUND: Carcinoma of the stomach invading one or more adjacent organs raises serious concerns over en bloc dissection because en bloc resection has an associated high risk and such advanced carcinoma is frequently associated with incurable factors. Thus, it is important to understand the efficacy of gastrectomy combined with other organ resection and to refine the indications for en bloc dissection. STUDY DESIGN: Seventy-seven patients with carcinoma of the stomach directly invading adjacent organs or structures were analyzed retrospectively to investigate the efficacy of en bloc resection. Forty-one patients underwent gastrectomy combined with resection of one or more invaded organs (combined resection group), while the other 36 patients underwent gastrectomy with palliative abrasion between the primary tumor and the invasion site (noncombined resection group). RESULTS: The five-year survival rate was 23 percent in the combined resection group and 0 percent in the noncombined resection group (p < .05). The 23 curative cases and 18 noncurative cases in the combined resection group had a survival rate of 41 percent and 0 percent, respectively (p < .05). The survival rate after a single organ resection was 29 percent, and after a multiple organ resection, 0 percent (p < .05). Cases of carcinoma invading either the pancreas or mesocolon had a slightly but not significantly better prognosis. In Borrmann type IV carcinoma there was no difference in survival between the curative and noncurative operation. Cases with P1 dissemination had a better prognosis than those of P2 and P3 dissemination. CONCLUSIONS: The best indication for an en bloc combined organ resection was an invasion limited to only one other organ, not more than N2, no incurable factor, and any type except Borrmann type IV. Additionally, an en bloc combined resection would be worth trying for any type of gastric carcinoma with not more than P1 dissemination and with no other incurable factor.

Carcinoma↗
PubMed1998

Anatomically based patellar resection criteria for total knee arthroplasty.

Thirty-six patellae were used to geometrically assess anatomically based patellar resection criteria for total knee arthroplasty. The plane of resection was defined in the coronal plane by three distinct anatomic landmarks on the undersurface of the patella: the medial and lateral edges of the quadriceps tendon insertion and the lateral edge of the patellar ligament insertion. The depth of the resection plane is defined by the anatomic landmark points approximately 1 mm posterior to the posterior aspect of the superior and inferior ligament insertions. Following resection, the resected patellae were geometrically characterized using two dimensional rectangular Cartesian coordinate system. The anatomically based patellar resection yielded a simple, consistent, and reliable method for patellar resection for total knee arthroplasty. The proportionate geometric characteristics of both the remaining anterior piece and the resected posterior piece were remarkably uniform. Following resection, the remaining patellar thickness was 65.6+/-5.3% (mean+/-SD) of the original thickness. The maximum width to height ratio of the resected surface was approximately 1:1. The thickness to diameter ratio of the resected portion of the patella was approximately 1:5. The apex of the patella was slightly off to the medial-distal quadrant from the geometric center of the resected surface. The results of this study indicate that anatomically based patellar resection criteria may help reduce the surgical variations associated with patellar resurfacing in total knee arthroplasties with dome-shaped prostheses.

Anthropometry↗
PubMed1998

Resection of hepatic and pulmonary metastases in patients with colorectal carcinoma.

BACKGROUND: Surgical resection of hepatic or pulmonary metastases has been accepted as appropriate therapy. However, whether aggressive surgery of both hepatic and pulmonary metastases from colorectal carcinoma is of value has not been verified in detail. METHODS: The authors identified 156 patients who had undergone hepatic resection for colorectal carcinoma metastases. This study reviewed six of these patients who underwent resection of both hepatic and pulmonary metastases from colorectal carcinoma. RESULTS: Five of the patients included four who underwent pulmonary resection for pulmonary metastases after initial hepatic resection for hepatic metastases and one patient who underwent hepatic metastasis resection after initial pulmonary metastasis resection. One additional patient underwent a simultaneous resection of hepatic and pulmonary metastases. The median interval between the 2 resections was 23 months. The median follow-up was 32 months after the second resection. At the time of last follow-up, 4 patients were alive and free of recurrent disease at 6, 7, 38, and 64 months, respectively, after their second resection. The remaining 2 patients died of disease at 17 and 32 months, respectively, after the second surgery. CONCLUSIONS: The results of the current study suggest that hepatic and pulmonary resection can result in long term survival in select patients with hepatic and pulmonary metastases from colorectal carcinoma because surgery remains the only potentially curative treatment.

Adult↗
PubMed2001

Combined colon and hepatic resection for synchronous colorectal liver metastases.

BACKGROUND AND OBJECTIVES: The surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer remains controversial. This study was performed to assess the outcome of combined resection of colorectal cancer and liver metastases. METHODS: The perioperative data, morbidity, and survival of the patients who underwent combined colon and liver resections for synchronous colorectal liver metastases from 1988 to 1999 were compared to the parameters of the patients who underwent colon resection followed by resection of liver metastases in a staged setting. RESULTS: 198 hepatic resections were performed, of which 112 procedures in 103 patients were done for metastatic colorectal carcinoma. Twenty six patients (25%) had combined hepatic and colon resection and were compared to 86 patients with metachronous metastases who underwent colon and hepatic resection in the staging setting. Postoperative morbidity was 27 and 35%, respectively. There was no hospital mortality in the combined group vs. 2.3% in the staged group. Blood loss, intensive care unit (ICU) stay and length of postoperative stay (LOS) were similar in both groups. The 5 years cumulative survival of the group after combined surgery was 28% vs. 27% of the group after isolated hepatic resections (P = 0.21). CONCLUSION: Combined colon and hepatic resection is a safe and efficient procedure for the treatment of synchronous colorectal liver metastases. It can be performed with acceptable morbidity and no perioperative mortality. The survival after combined procedure is comparable to the one achieved after staged procedure of colon resection followed by liver resection.

Adult↗
PubMed1996

Effect of extent of resection on intestinal muscle adaptation.

The response of intestinal muscle to resection has received less attention than mucosal adaptation but may be important in relation to altered motility and improved intestinal absorption. Our aim was to determine the effect of extent of resection on intestinal muscle adaptation. Distal resections of 25% (n = 5), 50% (n = 5), and 75% (n = 5) of the intestine were performed. Transverse intestinal sections were taken at resection and 12 weeks later to evaluate changes in mucosa and circular and longitudinal muscle thickness. Muscle cell number and size and muscle length were also measured. Mucosal thickness increased (P < 0.05) after all resections, (1007 +/- 253 microns vs 1259 +/- 181 microns, 25%; 1019 +/- 191 microns vs 1366 +/- 293 microns, 50%; and 927 +/- 88 microns vs 1432 +/- 213 microns, 75%). Longitudinal muscle thickness (169 +/- 35 microns vs 254 +/- 45 microns, 50%; 207 +/- 71 microns vs 353 +/- 103 microns, 75%) and length (180 +/- 10 cm vs 203 +/- 16 cm, 50%; 90 +/- 16 cm vs 110 +/- 21 cm, 75%) increased (P < 0.05) following 50% and 75% resections but not after a 25% resection. Circular muscle length increased after 75% resection alone (4.4 +/- 0.2 cm vs 5.8 +/- 0.4 cm, P < 0.05). There was no significant change in circular muscle thickness after any resection. Muscle cell size and number per unit area were unchanged in all groups. We concluded that: (1) Intestinal muscle adapts after intestinal resection and this response is related to the extent of resection; in contrast, mucosal adaptation was evident following even the least extensive resection. (2) Increased thickness and length of the longitudinal muscle layer are the most prominent changes. (3) This increased muscle thickness results from hyperplasia rather than hypertrophy.

Adaptation, Physiological↗
PubMedDate not supplied

Resection of synchronous liver metastases from colorectal cancer.

Whereas resection for metachronous liver metastases from colorectal cancer is considered to be a potentially curative approach, little is known about the prognosis after resection of synchronous liver metastases. In the past, these patients usually underwent only palliative therapy. Therefore, we have analyzed the data of 36 patients who underwent curative hepatic resection of synchronous liver metastases from colorectal carcinomas from 1977 to 1987 at the Department of Surgery, Hannover Medical School. In 19 patients, liver resection was combined with colonic resection; in the other 17 patients, hepatic resection was performed after a median interval of 2 months following resection of the primary tumor. No operative mortality was observed in either of the approaches. The median survival time was 28 months for all patients with a median recurrence-free interval of 13.5 months. Overall 5-year survival probability for all patients was 20%. There were no significant differences observed between immediate or delayed liver resection (median survival 18 months versus 31 months). Survival rates were not different after resection of solitary versus multiple liver metastases (26 versus 28 months). Twenty-one of the 36 patients had a recurrence of their liver metastases. In 7 of them, curative liver resection could be performed again. These 7 patients had a significantly improved survival (p less than 0.05) compared to the residual 14 patients. It is concluded that patients with synchronous liver metastases from colorectal cancer may profit from resection of the primary tumor and liver metastases. Timing of liver resection--immediate versus delayed--obviously has no impact on survival rates.

Adult↗
PubMed1999

Pelvic resection of recurrent rectal cancer: technical considerations and outcomes.

PURPOSE: Pelvic recurrence of rectal cancer is an ominous event for the patient and a formidable challenge to the managing surgeon. We reviewed the results of abdominosacral resection to manage these patients and correlated outcome (survival and recurrence) with known prognostic factors. METHODS: An abdominosacral resection was performed on 61 patients with pelvic recurrence (53 with curative intent and 6 for palliation; 2 had extended pelvic resection). Of the 53 patients (32 males; average age, 59 years) previous resection included abdominoperineal resection in 27 patients, abdominoperineal resection plus hepatic lobectomy in 2 patients, low anterior resection in 19 patients, plus trisegmentectomy in 1 patient, and advanced primary cancers in 4 patients. Initial primary stage was Dukes B (64 percent) and Dukes C (36 percent). All had been irradiated (3,000-6,500 in 50 patients, 8,300 and 11,000 in 2 patients, and unknown dose in 3 patients). Preoperative carcinoembryonic antigen was elevated (>5 ng/ml) in 54 percent. Extent of resection: high sacral resection S-1-S2 was done in 32 patients, midsacrum in 14 patients, and low S-4-S-5 in 6 patients. Twenty-eight patients (60 percent) required partial or complete bladder resection with or without adjacent viscera, and all had internal iliac and obturator node dissection. RESULTS: There were four postoperative (within 60 days) deaths, 8 percent in curative groups (5.4 percent overall). Major complications included prolonged intubation (20 percent), sepsis (34 percent), posterior wound infection or flap separation (38 percent). The survival rate in the curative group (49 postoperative survivors) was 31 percent at five years, with 13 patients surviving beyond five years. Seven of these patients survived from 5 to 21 years, whereas six patients recurred again and died within 5.5 to 7.5 years after abdominosacral resection. Disease-free survival rate at five years was 23 percent. Recent reconstruction with large composite myocutaneous gluteal flaps in 5 patients permitted complete sacral wound coverage, resulting in earlier ambulation and reduced hospital stay. CONCLUSIONS: Abdominosacral resection permits removal of pelvic recurrence of rectal cancer that is fixed to the sacrum and is associated with long-term survival in 31 percent of patients. Recent technical advances have improved the short-term outcome and have made the procedure more feasible for surgical teams familiar with these techniques.

Abdomen↗
PubMed1998

Prospective multicenter study of the quality of oncologic resections in patients undergoing laparoscopic colorectal surgery for cancer. The Laparoscopic Colorectal Surgery Study Group.

PURPOSE: Laparoscopic colorectal surgery for cancer is currently under discussion. Results of large, randomized studies will not be available for a number of years yet. This study analyses the results of such resections in consecutive patients operated on by unselected surgeons. METHODS: A prospective, observational, multicenter study was initiated on August 1, 1995, in the German-speaking countries of Europe. One year after initiation of the study, findings are presented with respect to the quality of oncologic resections. RESULTS: Of 500 operations, 231 (46 percent) were performed for cancer, 167 (33 percent) with a curative intent. The most common curative resections were as follows: 63 anterior rectum resections (38 percent), 51 sigmoid resections (30 percent), and 27 abdominoperineal resections (16 percent). Segmental resections were performed in 20 patients (12 percent). Intraoperative tumor spillage was reported in 2 percent. Mean number of lymph nodes harvested was 13 (confidence interval, 5-95 percent; range, 11.5-14.6) and positive lymph nodes harvested was 2.2 (confidence interval, 5-95 percent; range, 0.9-3.4). Significant differences were noted between participating centers in terms of number of lymph nodes resected (P < 0.0001). Distal and proximal resection margins were tumor-free in every case. Lateral margins were tumor free when examined. In the case of 63 curative anterior resections, the mean distal resection margin was 39 (confidence interval, 5-95 percent; range, 33-45) mm, and in 8 of these resections, it was less than 20 min. Mean blood loss was 344 (confidence interval, 5-95 percent; 292-396) ml, and 21 percent of patients received blood transfusion. CONCLUSIONS: These data document that the average quality of laparoscopic colorectal procedures for cancer is satisfactory but differs among surgeons.

Aged↗
PubMed1988

Resection of the liver for colorectal carcinoma metastases. A multi-institutional study of long-term survivors.

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to 1-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primary carcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

Adult↗
PubMed1998

Hepatic resection in the elderly.

From 1986 to 1995 a total of 97 patients > 65 years of age underwent hepatic resections at the Department of General Surgery, Hospital Lainz, Vienna, Austria. The population consisted of 39 men and 58 women with a mean age of 74.0 +/- 5.5 years. Primary neoplasia of the liver was the cause of resection in 35 patients, gallbladder cancer in 16 patients, and metastatic disease to the liver (due to colorectal cancer in 70%) in 40 patients. The rate of major resections (> or = 3 liver segments) was 96% for primary neoplasia of the liver, 70% for metastatic disease to the liver, and 50% for gallbladder cancer; the associated mortality rates were 23%, 2.5%, and 25%, respectively. The magnitude of the resection had a significant influence on survival for gallbladder cancer (p = 0.02) and for primary neoplasia of the liver (p = 0.002) but not for metastatic disease to the liver. This reflects the high rate of cirrhosis in hepatocellular and cholangiocellular carcinoma (88%) and gallbladder cancer (37.5%). Both pre- and postoperative severe liver dysfunction had a significantly higher risk for postoperative mortality and morbidity, which showed an incremental risk with age. Another organ system able to predict outcome at the beginning of treatment by its moderate severe dysfunction were the lungs. Overall, only right and extended right lobectomies carried a significantly higher risk for postoperative mortality and morbidity. Postoperative complications were recorded in 43% of our patients, with infection the most frequent problem in nearly all of these patients (95%). Pneumonia was the leading complication associated patient survival. All patients who developed pneumonia as a late complication during a complicated postoperative course died postoperatively. The postoperative Goris score of the patients who died was 6.9 +/- 2.9 (range 3-11), whereas the surviving patients' score averaged 2.2 +/- 1.9 (range 0-9), which was significantly different (p = 0.0003). None of the 54 patients with a GORIS score < or = 2 died postoperatively, whereas 5 of 6 patients with a score > or = 9 died (p = 0.0001). Severe liver dysfunction rather than the extent of resection influences clinical mortality. Patients > 80 years of age with a preoperative severe liver dysfunction showed a postoperative mortality of 57%, and all of these patients developed postoperative complications. Therefore resection cannot be recommended for those patients. Cirrhosis led to an unacceptable mortality of 44% after hepatic resection of > or = 5 liver segments for primary neoplasia of the liver. Major resections cannot be recommended in the aged with gallbladder cancer because 50% of the patients died after such operations. Overall, only resection of > or = 5 liver segments with segments I to III or less remaining were found to pose a major risk for clinical mortality and morbidity, but the cause of death was preexisting liver dysfunction and cirrhosis in all of these patients. Major resections of large neoplasia of the liver can be recommended even in the aged, but a preoperative preselection of patients with respect to liver function and pulmonary function preoperatively may help lower the postoperative morbidity and mortality, especially in patients who will undergo resection of > or = 5 liver segments. Major hepatic resection for metastatic disease to the liver in the elderly carries no additional survival risk. Patients > 65 years of age and especially those > 80 years of age are more liable to succumb to postoperative organ failure and complications, especially infections.

Aged↗
PubMed2003

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients.

BACKGROUND: Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer. METHODS: A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient's choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l-9 years). RESULTS: We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group ( p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group ( p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group ( p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery ( n = 10) and patients who had undergone surgery in the past year ( n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection ( p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group ( p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection ( p = 0.162), whereas for Dukes' stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 ( p = 0.392), 0.722 vs 0.584 ( p = 0.199), and 0.500 vs 0.417 ( p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free ( p = 0.623). CONCLUSIONS: Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international randomized controlled trials.

Adult↗
PubMed1993

Extended resection of pulmonary metastases: is the risk justified?

Extended resection of pulmonary metastases by pneumonectomy or by pulmonary resection en bloc with chest wall or other thoracic structures (diaphragm, pericardium, superior vena cava) is infrequently performed as survival benefit is presumed low. Between 1981 and 1992, 38 patients underwent extended resection for pulmonary metastases (24 men, 14 women; average age, 48 years) from various primary neoplasms. Thirty-three patients (33/38, 87%) had complete resection. Five-year actuarial survival was 25.4%. Mortality was 5.3% (2/38) and occurred in patients undergoing pneumonectomy (2/19, 10.5%). Nineteen patients underwent pneumonectomy, and 19 patients had other assorted resections: pulmonary resection en bloc with chest wall in 11 and pulmonary resection en bloc with other thoracic structures in 8. Actuarial median survival (median, 27 months) did not differ between patients having pneumonectomy and those having pulmonary resection en bloc with chest wall or other thoracic structures. Initial disease-free interval (median) was no different between those patients undergoing pneumonectomy (32 months) or other type resection (35 months; p = 0.16). Median survival for extended resection as the initial operation for pulmonary metastases was 28 months compared with 14 months for all others (p = 0.095). Pneumonectomy for pulmonary metastases may be performed with operative risk equivalent to pneumonectomy for primary bronchogenic carcinoma. Patients may safely undergo extended resection of pulmonary metastases by pneumonectomy or in continuity with chest wall or other thoracic structures. Despite advanced localized metastatic disease, some patients achieve long-term survival after pneumonectomy and extended resection for pulmonary metastases.

Actuarial Analysis↗
PubMed2003

Survival benefits of portal vein resection for pancreatic cancer.

BACKGROUND: The efficacy of portal vein resection for pancreatic cancer is controversial. METHODS: Eighty-one consecutive patients with pancreatic cancer undergoing surgical resection were retrospectively analyzed. The clinicopathological findings and relationship between portal vein resection and survival were investigated. RESULTS: Thirty-three patients with pancreatic cancer underwent pancreatic resection with portal vein resection. Histological examination revealed that 17 patients had definite invasion to the portal vein (group 1) and 16 patients had no invasion (group 2). Forty-eight patients with pancreatic cancer underwent pancreatic resection without portal vein resection (group 3). There were no significant differences in survival rates (P = 0.437) between patients with portal vein resection and patients without portal vein resection. However, patients in group 1 had a significantly (P = 0.021) worse prognosis as compared with those in group 2. Despite aggressive surgical resection, the surgical margin was positive in 35% of patients in group 1 as compared with 13% of patients in group 2 and 21% of patients in group 3. CONCLUSIONS: Patients undergoing portal vein resection for pancreatic cancer had a prognosis similar to patients without portal vein resection. Negative microscopic invasion to the portal vein was significantly associated with improved survival.

Adenocarcinoma↗