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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↗
PubMed2003

Perioperative and long-term outcome of major hepatic resection for small solitary hepatocellular carcinoma in patients with cirrhosis.

HYPOTHESIS: Major hepatic resection is safe and provides favorable long-term survival for cirrhotic patients with a small solitary hepatocellular carcinoma. DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: From January 1, 1989, to December 31, 2001, 218 cirrhotic patients with a solitary hepatocellular carcinoma 5 cm or less in diameter underwent either a major hepatic resection (n = 84) or a minor hepatic resection (n = 134). MAJOR OUTCOME MEASURES: Perioperative morbidity and mortality, and long-term survival rates. RESULTS: The major resection group had significantly larger tumors (median, 3.5 vs 2.5 cm; P<.001) and better liver function (median indocyanine green retention at 15 minutes, 9.3% vs 12.9%; P<.001) than the minor resection group. Postoperative morbidity (46.4% vs 39.6%) and mortality (8.3% vs 3.0%) were higher in the major resection group than in the minor resection group, but the differences did not reach statistical significance (P =.32 and P =.11, respectively). The median overall survival did not differ significantly between the 2 groups (102.0 vs 72.3 months; P =.25). However, the median disease-free survival in the major resection group was significantly better than that in the minor resection group (59.0 vs 29.5 months; P =.03). On further subgroup analysis, both disease-free and overall survival rates were significantly better in the major hepatic resection group for tumors of 3 to 5 cm. CONCLUSION: In well-selected cirrhotic patients with a small, solitary hepatocellular carcinoma, major hepatic resection is safe and may offer a better long-term survival over minor hepatic resection for patients with tumors of 3 to 5 cm.

Adolescent↗
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↗
PubMed2002

Long-term outcome after endoscopic mucosal resection in patients with esophageal squamous cell carcinoma invading the muscularis mucosae or deeper.

BACKGROUND: Endoscopic mucosal resection is recommended for squamous cell carcinoma of the esophagus confined to the lamina propria. However, endoscopic mucosal resection is often performed in patients with tumors that invade the muscularis mucosa or upper submucosa to minimize surgical invasiveness, despite the increased risk of lymph node metastasis. This study prospectively evaluated long-term outcome in such patients. METHODS: Twenty-six consecutive patients with squamous cell esophageal carcinoma invading the muscularis mucosa or submucosa who underwent endoscopic mucosal resection from June 1992 through March 2000 (extended endoscopic mucosal resection group) were studied. As control group, 44 consecutive patients with esophageal carcinoma invading the muscularis mucosae or upper third of the submucosa and no preoperative evidence of lymph node metastasis who underwent esophagectomy during the same period (surgical resection group) were studied. RESULTS: Overall survival rates at 5 years in the extended endoscopic mucosal resection group and surgical resection group were, respectively, 77.4% and 84.5%. There was no significant difference between survival distributions. Cause-specific survival rates at 5 years in extended endoscopic mucosal resection and surgical resection groups were, respectively, 95.0% and 93.5%. Survival curves for the groups were similar. CONCLUSION: Although patients were not randomized to extended endoscopic mucosal resection or surgical resection in this study, the results suggest that endoscopic mucosal resection may be safe and effective for management of squamous cell esophageal carcinoma invading the muscularis mucosae or upper submucosa.

Adult↗
PubMed1997

Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer.

BACKGROUND: The role of nonanatomic wedge resection in the management of stage I (T1 N0 M0) non-small-cell lung cancer continues to be debated against the present gold standard of care--anatomic lobectomy. METHODS: We analyzed the results of 219 consecutive patients with pathologic stage I (T1 N0 M0) non-small-cell lung cancer who underwent open wedge resection (n = 42), video-assisted wedge resection (n = 60), and lobectomy (n = 117) to assess morbidity, recurrence, and survival differences between these approaches. RESULTS: There were no differences among the three groups with regard to histologic tumor type. Analysis demonstrated the wedge resection groups to be significantly older and to have reduced pulmonary function despite a higher incidence of treatment for chronic obstructive pulmonary disease when compared with patients having lobectomy. The mean hospital stay was significantly less in the wedge resection groups. There were no operative deaths among patients having wedge resection; however, a 3% operative mortality occurred among patients having lobectomy (p = 0.20). Kaplan-Meier survival curves were nearly identical at 1 year (open wedge resection, 94%; video-assisted wedge resection, 95%; lobectomy, 91%). At 5 years survival was 58% for patients having open wedge resection, 65% for those having video-assisted wedge resection, and 70% for those having lobectomy. Log rank testing demonstrated significant differences between the survival curves during the 5-year period of study (p = 0.02). This difference was a result of a significantly greater non-cancer-related death rate by 5 years among patients having wedge resection (38% vs 18% for those having lobectomy; p = 0.014). CONCLUSION: Wedge resection, done by open thoracotomy or video-assisted techniques, appears to be a viable "compromise" surgical treatment of stage I (T1 N0 M0) non-small-cell lung cancer for patients with cardiopulmonary physiologic impairment. Because of the increased risk for local recurrence, anatomic lobectomy remains the surgical treatment of choice for patients with stage I non-small-cell lung cancer who have adequate physiologic reserve.

Aged↗
PubMed1999

Elimination of Na+-dependent bile acid transporter from small intestine by ileum resection increases [correction of increase] colonic tumorigenesis in the rat fed deoxycholic acid.

Ileal Na+-dependent bile acid transporter (ISBT) constituting a gateway to enterohepatic circulation of bile acids occurs exclusively at the distal site of the small intestine. In the present study, we examined colonic tumorigenesis promoted by deoxycholic acid in relation to the expression of the ISBT. For this purpose, the small intestine of a Fischer-344 rat was resected a length of 20 cm above the ileo-cecal valve (ileal resection) or below the duodenum (jejunal resection). Then, rats were treated with an intraperitoneal injection of azoxymethane (15 mg/kg body wt.) once a week for 3 weeks and fed a 20% casein diet supplemented with 0.2% deoxycholate for 39 weeks. Northern blot analysis demonstrated that the ISBT mRNA was hardly detectable in ileum-resected rats. The excretion of fecal bile acids was 1.5-fold higher in the ileum-resected group than in the jejunum-resected group (P < 0.05). On the contrary, the serum bile acids concentration of ileal-resected rats was about one-half of that of jejunum-resected animals (P < 0.05). The tumor incidence and the total tumor number were significantly higher in the ileum-resected group than in the jejunum-resected one (P < 0.05). Interestingly, no tumor was found at the proximal colon in the jejunum-resected group while tumors developed frequently at the proximal site as well as mid and distal colon in the ileum-resected group. These observations demonstrate that malabsorption of bile acids owing to the lack of ISBT enhanced colon tumorigenesis.

Animal Feed↗
PubMed2000

Repeat resection of pulmonary metastases in patients with soft-tissue sarcoma.

BACKGROUND: Even after an apparent complete resection of sarcomatous pulmonary metastases, 40% to 80% of patients will re-recur in the lung. The benefit of subsequent re-resection is poorly defined. This study examines patient survival after repeat pulmonary exploration for re-recurrent metastatic sarcoma at a single institution. STUDY DESIGN: Between July 1982 and December 1997, data on 3,149 adult in-patients with soft tissue sarcoma were prospectively gathered. Of these, pulmonary metastases were present or developed in 719 patients and 248 underwent at least one resection. Of the patients relapsing in the lung after an apparently complete resection, 86 underwent reexploration. Disease-specific survival (DSS) after re-resection was the end point of the study. Time to death was modeled using the method of Kaplan and Meier. The association of factors to time-to-event end points was analyzed using the log-rank test for univariate analysis and the Cox proportional hazards model for multivariate analysis. Clinicopathologic factors were analyzed with the Pearson chi-square or Fisher's exact test when appropriate. RESULTS: The median DSS after re-resection for all patients undergoing at least two pulmonary resections was 42.8 months with an estimated 5-year survival of 36%. The median DSS in patients with complete reresection was 51 months (n = 68) compared with 6 months in patients with an incomplete re-resection (n = 16, p<0.0001). Patients with one or two nodules at re-resection (n = 39) had a median DSS of 51 months compared with 20 months in patients with three or more nodules (n = 40, p = 0.003). Patients in whom the largest metastasis re-resected was less than or equal to 2 cm (n = 33) had a median DSS of 44 months compared with 20 months in patients with metastasis greater than 2 cm (n = 43, p = 0.033). Patients with primary tumor high-grade histology (n = 75) had a median DSS of 32 months and patients with low-grade histology (n = 11) had a median DSS that was not reached (p = 0.041). Three independent prognostic factors associated with poor outcomes may be determined preoperatively: > or =3 nodules, largest metastases > 2 cm, and high-grade primary tumor histology. Patients with either zero or one poor prognostic factor had a median DSS > 65 months and patients with three poor prognostic factors had a median DSS of 10 months. CONCLUSIONS: Reexploration for recurrent sarcomatous pulmonary metastases appears beneficial for patients who can be completely re-resected. Outcomes are described by factors that may be determined preoperatively, including metastasis size, metastasis number, and primary tumor histologic grade. Patients who cannot be completely re-resected or those with numerous, large metastasis and high-grade primary tumor pathology have poor outcomes and should be considered for investigational therapy.

Adolescent↗
PubMed1998

Isolated liver metastases from neuroendocrine tumors: does resection prolong survival?

BACKGROUND: Neuroendocrine tumors commonly metastasize to the liver. Although surgical resection is considered a treatment option for patients with localized metastases confined to the liver, the longterm survival benefit of liver resection has not been clearly demonstrated. We examined the survival of patients undergoing liver resection for this disease. STUDY DESIGN: Between 1984 and 1995, we evaluated 38 patients with liver-only metastases from neuroendocrine tumors, including 21 carcinoid, 13 islet cell, and 4 atypical neuroendocrine neoplasms. Data from a combined prospective and retrospective database and a tumor registry were analyzed. Of these patients, 15 underwent complete resection of all known disease. The remaining 23 patients, who also had disease confined to the liver, had comparable tumor burden but were believed to be unresectable. The longterm survival rates of these two groups were compared. RESULTS: Patients who underwent liver resection did not differ from those who were unresectable with regard to age, pathology, primary tumor site, serum alkaline phosphatase levels, or percentage of the liver involved. All resections were complete, leaving no residual disease, and consisted of lobectomy (n = 3), segmentectomy (n = 1), and wedge resections (n = 11). There were no operative deaths. Patients who underwent hepatic resection had a significantly longer survival than unresected patients. Although median survival had not been reached in resected patients, the median survival in the unresectable group was 27 months. Patients who underwent liver resection had a higher 5-year actuarial survival (73% versus 29%). CONCLUSIONS: Hepatic resection in selected patients with isolated liver metastases from neuroendocrine tumors may prolong survival. This conclusion was reached by comparing our resected group with an unresectable group with similar tumor burden.

Female↗