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PubMed2003

Simultaneous resection of colorectal primary tumour and synchronous liver metastases.

BACKGROUND: The surgical strategy for treatment of synchronous colorectal liver metastases remains controversial. The outcome and overall survival of patients presenting with such metastases, treated either by simultaneous resection or by delayed resection, were evaluated. METHODS: From 1987 to 2000, 97 patients presented with synchronous colorectal liver metastases, of whom 35 (36 per cent) underwent a simultaneous resection and 62 patients (64 per cent) a delayed resection. Simultaneous resection was considered prospectively for patients with fewer than four unilobar metastases. RESULTS: Age, blood transfusion requirements, operating time, duration of inflow occlusion, hospital stay and mortality rate were similar in the two groups. The morbidity rate did not differ significantly (23 per cent after simultaneous resection and 32 per cent after delayed resection). The location of the primary tumour and extent of liver resection did not influence the morbidity rate significantly in the simultaneous resection group. The overall survival rate was 94, 45 and 21 per cent at 1, 3 and 5 years respectively after simultaneous resection, and 92, 45 and 22 per cent after delayed resection. CONCLUSION: In selected patients, simultaneous resection of the colorectal primary tumour and liver metastases does not increase mortality or morbidity rates compared with delayed resection, even if a left colectomy and/or a major hepatectomy are required.

Colorectal Neoplasms↗
PubMed1996

Smooth muscle adaptation after intestinal transection and resection.

Changes in motor function occur in the intestinal remnant after intestinal resection. Smooth muscle adaptation also occurs, particularly after extensive resection. The time course of these changes and their interrelationship are unclear. Our aim was to evaluate changes in canine smooth muscle structure and function during intestinal adaptation after transection and resection. Twenty-five dogs underwent either transection (N = 10), 50% distal resection (N = 10), or 50% proximal resection (N = 5). Thickness and length of the circular (CM) and longitudinal (LM) muscle layers were measured four and 12 weeks after resection. In vitro length-tension properties and response to a cholinergic agonist were studied in mid-jejunum and mid-ileum. Transection alone caused increased CM length in the jejunum proximal to the transection but did not affect LM length or muscle thickness. A 50% resection resulted in increased length of CM throughout the intestine and thickening of CM and LM near the anastomosis. Active tension of jejunal CM increased transiently four weeks after resection. Active tension in jejunal LM was decreased 12 weeks after transection and resection. Sensitivity of CM to carbachol was similar after transection and resection. It is concluded that: (1) Structural adaptation of both circular and longitudinal muscle occurs after intestinal resection. (2) This process is influenced by the site of the intestinal remnant. (3) Only minor and transient changes occur in smooth muscle function after resection. (4) Factors other than muscle adaptation are likely involved in the changes in motor function seen following massive bowel resection.

Adaptation, Physiological↗
PubMed2001

Local recurrence after curative anterior resection with principally blunt dissection for carcinoma of the rectum and rectosigmoid.

PURPOSE: The aim of this study was to determine the incidence of local pelvic recurrence of carcinoma of the rectum and rectosigmoid (tumors where the lower edge is 18 cm or less from the anal verge) in a consecutive series of patients operated on by a single surgeon. All patients underwent curative anterior resection and a formal anatomic dissection of the rectum where mobilization was achieved through a principally careful blunt manual technique along fascial planes, preserving an oncologic package. METHOD: During the period April 1986 to December 1997, 157 consecutive anterior resections for carcinoma of the rectum and rectosigmoid were performed by one surgeon (ALP). One hundred thirty-eight (87.9 percent) were curative, and 19 (12.1 percent) were palliative. The mean follow-up period was 46 +/- 31.6 (range, 2-140) months. Data were retrospectively collated and computer coded by an independent contracted medical research team. Follow-up data were available on all patients. RESULTS: Four (3.1 percent) of the 131 patients undergoing curative anterior resection had local recurrence. Local recurrences occurred between 16 and 38 months from the time of resection, and the cumulative risk of developing local recurrence at five years was 5.2 percent. All tumors in which pelvic recurrence occurred were high grade, and the probability of developing local recurrence at five years for this group was 13.9 percent, which is significantly higher compared with patients who had average or low-grade tumors (P = 0.01). The probability of developing local recurrence at five years for Stage I tumors was 0, Stage II was 5.9 percent, and Stage III was 8.9 percent. In addition, there was a significantly higher incidence of local recurrence in the group of patients undergoing ultralow anterior resection (between 3 and 6 cm from the anal verge) as compared with patients undergoing low or high anterior resection (P = 0.03). Local recurrence developed in 3 of 28 (10.7 percent) patients having ultralow anterior resection, 1 of 57 (1.8 percent) patients having low anterior resection (between 6 and 10 cm from the anal verge), and no patients having high anterior resection (above 10 cm from the anal verge). The clinical anastomotic leak rate for curative anterior resection was 7 of 131 patients (5.3 percent). Thirty-seven of the 131 (28.2 percent) required a proximal defunctioning stoma; 35 (41.2 percent) of these were established for low or ultralow anterior resections and 2 for high anterior resection. The overall five-year cancer-specific survival rate of the entire group of 131 patients was 81.8 percent, and the overall probability of being disease free at five years including both local and distal recurrence was 72.9 percent. Three local recurrences occurred in the 101 patients (77 percent) who did not receive any form of adjuvant therapy. One local recurrence occurred in the 18 patients (13.7 percent) who had adjuvant chemoradiation. No recurrence occurred in the 12 patients (9.2 percent) who had adjuvant chemotherapy alone. CONCLUSION: Curative anterior resection for carcinoma of the rectum and rectosigmoid with principally blunt dissection of the rectum in this study is associated with a 3.1 percent incidence and a 5.2 percent probability at five years of developing local recurrence. Evidence from this study indicates that, as with sharp pelvic dissection, a low incidence and probability of local recurrence can be achieved by a principally blunt mobilization technique through careful attention to preservation of fascial planes in the pelvis and removal of an oncologic package with selective rather than routine adjuvant or neoadjuvant chemoradiation.

Aged↗
PubMed1999

Laparoscopic vs. open abdominoperineal resection for cancer.

PURPOSE: The aim of this study was to compare the safety and efficacy of laparoscopic abdominoperineal resection and open abdominoperineal resection for cancer. METHODS: Records of 194 patients who underwent laparoscopic abdominoperineal resection (42 patients) or open abdominoperineal resection (152 patients) at three institutions between 1991 and 1997 were reviewed. Follow-up was through office charts, American College of Surgeons cancer registry, or telephone contact. Tumors included (laparoscopic abdominoperineal resection and open abdominoperineal resection, respectively) adenocarcinoma (86 and 92 percent), squamous (12 and 7 percent), and gastrointestinal stromal (2 and 1.4 percent) types; Stages I (17 and 26 percent), II (24 and 33 percent), III (43 and 32 percent), and IV (14 and 9 percent); and those with invasion of pelvic structures (14 and 16 percent). RESULTS: Laparoscopic abdominoperineal resection was converted to open abdominoperineal resection in 21 percent because of vessel injury (33 percent), poor exposure (22 percent), adhesions (22 percent), inguinal hernia (11 percent), or radiation fibrosis (11 percent). Perineal infections occurred more often in the laparoscopic abdominoperineal resection group (24 vs. 8 percent; P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7 vs. 12 days). Radial margins were positive in 12 percent of laparoscopic abdominoperineal resection and 12.5 percent of open abdominoperineal resection specimens. Tumor recurrence was similar for both local (19 and 14 percent) and distant (38 and 26 percent) recurrence. Survival rates were similar by Kaplan-Meier curves, with median follow-up of 19 and 24 months, respectively (P=0.22; log rank). CONCLUSION: Laparoscopic abdominoperineal resection can be performed safely and results in a shorter hospital stay. A randomized, prospective trial is needed to determine the long-term outcome of cancer treatment.

Adenocarcinoma↗
PubMed2003

Resection of hilar cholangiocarcinomas: pivotal prognostic factors and impact of tumor sclerosis.

The well-known poor prognosis of proximal bile duct cancer is due to its unfortunate anatomical location and its late diagnosis. Successful tumor resection, which is considered to be optimal treatment, depends on many factors. Eighty-eight patients suffering from proximal bile duct cancer underwent surgical exploration at our institution between 1977 and 1998. In 37 patients the tumor was resectable; in the remaining 51 patients exploratory laparotomy or a palliative operation was performed. The median survival after tumor resection was 18.6 months, but median survival after a palliative procedure or an exploratory laparotomy was only 3.4 months (p < 0.001). A curative R0 resection was possible in 11 patients, an R1 resection was performed in 22 patients, and 4 patients had an R2 resection. The median survival rate after R0 resection was 83.6 months, 12.3 months after R1 resection, and 2.7 months after R2 resection (p < 0.001). Survival after resection in patients with negative lymph nodes (n = 30) was significantly longer than in those with positive lymph nodes (n = 7) (p = 0.022). Grade of tumor sclerosis tended to have an influence on resectability rate (p = 0.076). The pattern of tumor growth was without statistical influence. Multivariate analysis revealed resection (p < 0.001) as the only significant prognostic marker for patient survival. Radical resection is the only therapy that provides a chance for long-term survival, with sclerosis of the cancer tending to have an influence on univariate analysis.

Aged↗
PubMed1998

Resection of colorectal liver metastases: 25-year experience.

The aim of this retrospective study was to analyze survival and prognostic factors in 111 consecutive patients undergoing curative resection of liver metastases from colorectal cancer. In addition, the time periods 1971-1984 and 1985-1995 were compared; criteria for first liver resection did not change with time, whereas the attitude toward re-resection was more aggressive during the latter period. Operative mortality was 6% during 1971-1984 and 0% during 1985-1995 (3.6% for all patients). The crude 5-year actuarial survivals were 19% and 35% for patients operated during 1971-1984 and 1985-1995, respectively (25% for the whole period). Relapse at any site was observed in 52 patients (81%) operated during the first period and in 29 patients (67%) operated during the second period; re-resection was performed in 12 (23%) and 15 (52%) of these patients, respectively. Five-year survival after hepatic re-resection was 29% (no operative mortality). In the univariate analysis, significant determinants for long-term survival were, in descending order, a clear resection margin, high degree of fibrosis around the tumor, absence of extrahepatic metastases (including metastases to the liver hilum), use of an ultrasound dissector, low preoperative serum carcinoembryonic antigen (CEA) level, year of resection (1985-1995), and low/moderate grade of liver tumor. There were no 5-year survivors when extrahepatic metastases were present, the liver tumor(s) had a low differentiation or satellites, or the resection margin was involved with tumor. In the multivariate analysis, the determinants were grade of liver tumor, absence of extrahepatic tumor, few intraoperative blood transfusions, low preoperative serum CEA level, and year of resection (1985-1995). It is concluded that: (1) an increased rate of hepatic re-resection was partly responsible for the improved outcome after liver resection for colorectal metastases during recent years; (2) patients with extrahepatic metastases did not benefit from liver resection; and (3) surgery should be performed with a clear resection margin and minimal blood loss.

Adult↗
PubMed1998

Determinants of survival following hepatic resection for metastatic colorectal cancer.

Hepatic resection remains the only potentially curative treatment for metastatic colorectal cancer. This retrospective review study was undertaken in an attempt to identify factors that influence patient survival following hepatic resection for metastatic colorectal cancer. From January 1978 to December 1993, a total of 301 patients underwent a total of 345 planned hepatic resections for metastatic colorectal cancer. Of those, 245 patients had one resection, 44 had two resections, and 12 had three resections. For all patients the overall median survival was 20.6 months, operative mortality was 1.1%, and overall morbidity was 17.2%. Average hospital stay was 9 days. Statistical analysis included univariate analysis using log rank comparisons, Kaplan-Meier survival curves, and multivariate analysis using Cox proportional hazards regression. The statistically significant factors that influenced survival were distribution of liver metastases, unilobar versus bilobar (p = 0.0001), resected versus nonresected (p < 0.0001), and tumor-free surgical margins versus positive margins (p = 0.001). Surprisingly, the disease-free interval and the original stage of the primary tumor did not predict survival (p = not significant). Other factors that had no influence on survival were type of resection, size and number of liver metastases, ABO blood group, and the number of perioperative blood transfusions. For those patients who underwent resection of unilobar metastases with tumor-free margins, the 5-year survival rate was 29% with a median survival of 35 months and eight survivors > 7 years. In addition, one patient with bilobar disease had survival > 7 years and five patients who had resection of hepatic metastases and extrahepatic cancer simultaneously had survival > 3 years. Our data support the concept that patients with unilobar metastatic disease who undergo surgical resection with tumor-free surgical margins can be afforded a significant opportunity at long-term survival with acceptable morbidity, mortality, and hospital stay. Also, certain patients with bilobar or extrahepatic disease (or both) who undergo complete resection can enjoy a long-term survival. In these subgroups of patients resection should be considered on an individual basis.

Adenocarcinoma↗
PubMed1994

Influence of surgical resection and brachytherapy in the management of superior sulcus tumor.

We analyzed the results of surgical treatment of all patients presenting with untreated superior sulcus tumors between 1974 to 1991 inclusive at our institution. Most patients received preoperative radiotherapy. We attempted to analyze the influence of surgical resection and intraoperative brachytherapy in obtaining locoregional control and disease-free survival. One hundred twenty-four patients underwent thoracotomy and 100 patients underwent resection. The overall 5-year survival rate was 26% for all patients and 30% for resected patients. Those patients receiving a complete resection achieved a 41% 5-year survival. The best single group were those patients undergoing a lobectomy (versus wedge resection) and en-bloc chest wall resection (60% 5-year survival). We were unable to demonstrate an advantage for the use of intraoperative brachytherapy in those patients with complete resection. For those patients with incomplete resection, the use of brachytherapy combined with preoperative or postoperative external radiation therapy resulted in a 9% 5-year survival. Locoregional failure was significant both in patients with complete resection and in patients with incomplete resection. Adverse prognostic factors included Horner's syndrome, N2 and N3 disease, T4 disease, and incomplete resections. In superior sulcus tumors, every attempt to completely resect the tumor by en-bloc chest wall resection combined with lobectomy and adequate nodal staging remains the surgical treatment of choice together with either preoperative, postoperative, or "sandwich" external radiation therapy.

Adult↗
PubMed2004

Long-term survival after resection of primary adenoid cystic and squamous cell carcinoma of the trachea and carina.

BACKGROUND: Tracheal resection for primary carcinoma may extend survival. We evaluated survival after surgical resection or palliative therapy to identify prognostic factors. METHODS: We conducted a retrospective study of patients diagnosed with primary adenoid cystic carcinoma (ACC) or squamous cell carcinoma (SCC) of the trachea between 1962 and 2002. Laryngotracheal, tracheal, or carinal resection was performed when distant metastasis and invasion of adjacent mediastinal structures were absent and tumor length permitted. Radiotherapy was administered after operation (54 Gy), except in superficial tumors, or as palliation (60 Gy). RESULTS: Of 270 patients with ACC or SCC (135 each), 191 (71%) were resected. Seventy-nine were not resected due to tumor length (67%), regional extent (24%), distant metastasis (7%), or other reasons (2%). Overall operative mortality was 7.3% (14/191) and improved each decade from 21% to 3%. Tumor in airway margins was present in 40% (17/191) of resected patients (ACC 59% versus SCC 18%) and lymph node metastasis in 19.4% (37/191). Overall 5- and 10-year survival in resected ACC was 52% and 29% (unresectable 33% and 10%) and in resected SCC 39% and 18% (unresectable 7.3% and 4.9%). Multivariate analysis of long-term survival found statistically significant associations with complete resection (p < 0.05), negative airway margins (p < 0.05), and adenoid cystic histology (p < 0.001), but not with tumor length, lymph node status, or type of resection. CONCLUSIONS: Locoregional, not distant, disease determines resectability in primary tracheal carcinoma. Resection of trachea or carina is associated with long-term survival superior to palliative therapy, particularly for patients with complete resection, negative airway margins, and ACC.

Carcinoma, Adenoid Cystic↗
PubMed2006

Operative management and outcomes of traumatic lung resection.

BACKGROUND: To analyze the presentation, injury patterns, and outcomes among a large cohort of patients requiring lung resection for trauma, and to compare outcomes stratified by the extent of resection. STUDY DESIGN: Review of all adult patients undergoing lung resections in the National Trauma Data Bank. Patients were categorized by extent of lung resection; wedge resection, lobectomy, or pneumonectomy. Patient factors, injury data, and outcomes were compared between groups using univariate and multivariable analysis for the entire sample, and after excluding patients with severe associated injuries. RESULTS: There were 669 patients who had a lung resection after trauma identified for an overall prevalence of 0.08%, with 325 undergoing wedge resection (49%), 244 had a lobectomy (36%), and 100 underwent complete pneumonectomy (15%). Blunt mechanism was associated with worse outcomes in terms of prolonged hospital stay, complications, disability, and a trend toward higher mortality (38% versus 30%, p = 0.07). Patients undergoing pneumonectomy had a higher mortality (62%) and more complications (48%) compared with patients undergoing lobectomy (35% mortality, 33% complications) and wedge resection (22% and 8%, all p < 0.05). After excluding patients with severe associated injuries (head, abdomen, heart, great vessels), there were 535 patients with "isolated" lung injury. There was again a stepwise increase in mortality by extent of resection, 19% for wedge resection, 27% for lobectomy, and 53% for pneumonectomy. Extent of lung resection remained an independent predictor of mortality for both the entire sample and for patients with isolated lung injury. CONCLUSIONS: Lung resection is infrequently required for traumatic injury, but carries substantial associated morbidity and mortality. The extent of lung resection is an independent predictor of hospital mortality, even after exclusion of patients with severe associated injuries. The worst outcomes were seen after complete pneumonectomy.

Adult↗
PubMed2006

Resection of neurogenic tumors in children: is thoracoscopy superior to thoracotomy?

BACKGROUND: Minimally invasive resection of solid tumors is controversial because of concerns of inadequate resection and local recurrence. Thoracoscopy has been used in the diagnosis of mediastinal tumors in children, but its role in resection is unproved. The purpose of this study was to compare thoracoscopic and open approaches to the resection of thoracic neurogenic tumors in children. STUDY DESIGN: The tumor registry of a regional children's hospital was queried to identify patients who underwent resection of neurogenic tumors over a 6-year period. Thoracoscopic and open groups were compared for demographic, operative, oncologic, and outcomes characteristics. RESULTS: Seventeen children underwent resection of mediastinal neurogenic tumors (10 thoracoscopic resections, 7 open resections). Mean age was 4.7 years (range 6 months to 12 years). The thoracoscopic and open groups showed no difference in operative time or blood loss. Tumors in the two groups were comparable in size (5.2+/-2.2 cm versus 5.7+/-2.6 cm), histology, surgical margin, and stage. Hospital stay was shorter after thoracoscopic resection (1.9+/-0.7 days versus 4.1+/-2.5 days, p<0.05). There were no regional recurrences. Distant metastases developed in one patient in each group. Eight of 10 children with malignant tumors remain disease-free at an average of 25 months of followup (range 3 to 80 months). CONCLUSIONS: Thoracoscopic resection of neurogenic tumors achieved similar local control and disease-free survival when compared with open resection in this preliminary series. These results were accompanied by a shorter hospital stay. These findings suggest that thoracoscopic resection of neurogenic tumors in children may offer advantages to open resection and should be studied in the context of a large, cooperative trial.

Child↗
PubMed2004

Efficacy of complete resection for high-risk neuroblastoma: a Children's Cancer Group study.

BACKGROUND/PURPOSE: Previous reports indicate that complete resection of high-risk neuroblastoma improves outcome but may entail high surgical complication rates. The authors evaluated the effect of complete primary site resection on event-free survival (EFS), overall survival (OS), and complication rates in patients entered on a high-risk neuroblastoma treatment protocol. METHODS: A total of 539 eligible patients with high-risk neuroblastoma were entered on protocol CCG-3891. Patients were assigned randomly to continuation chemotherapy or autologous bone marrow transplantation. Surgical resection was performed at diagnosis or after induction chemotherapy. Surgeons assessed resection as complete (CR), minimal residual (<5%, MR), or partial (PR). Incomplete resections received secondary resection or 10 Gy of external beam radiation. Patients were evaluated for EFS, OS, and complications of surgery based on completeness of overall best resection. RESULTS: The proportion of patients resectable at diagnosis was 27% for CR and 14% for MR. This improved after chemotherapy to 45% and 25%. Complication rates based on completeness of resection were 29%, 38%, and 36% for CR, MR, and PR, respectively. Estimated 5-year EFS rate was 30% +/- 3% for patients who achieved CR (n = 210) compared with 25% +/- 3% (P =.1010) for those with less than CR (n = 258). CONCLUSIONS: Resectability improved after neoadjuvant chemotherapy. Complete resection did not increase complications. There was a small survival benefit for complete resection. This study suggests that complete resection may still be important in the current era of intense chemotherapy and transplant.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2006

Microscopically incomplete resection offers acceptable palliation in pancreatic cancer.

BACKGROUND: Because mortality and morbidity of pancreatic surgery have decreased to acceptable levels, the complex question arises whether pancreatic resection should be performed in patients with preoperatively doubtful resectable pancreatic cancer. METHODS: Perioperative parameters and outcome of 80 patients who underwent a microscopically incomplete (R1) resection were compared with those of 90 patients who underwent a bypass for locally advanced disease for pancreatic adenocarcinoma. All patients initially underwent exploratory laparotomy with the intention to perform a resection. Quality of life was assessed by analyzing readmissions and their indications. RESULTS: Groups were similar with respect to age, presenting symptoms, and preoperative health status. Tumors were significantly larger in the bypass group (3.5 cm vs 2.9 cm, P < .01). Hospital mortality was comparable: zero after R1 resection and 2% after bypass. Of all severe complications, only intra-abdominal hemorrhage occurred significantly more frequently after resection (10% vs 2%; P = .03). Hospital stay after resection was significantly longer than after bypass (16 vs 10 days; P < .01). Survival was significantly longer after R1 resection (15.8 vs 9.5 months, P < .01). Sixty-one percent of patients were readmitted for a total of 215 admissions, equally distributed between groups. After R1 resection, 0.58% of the total survival time after initial discharge was spent in the hospital, after bypass, 0.69%, which was not significantly different. CONCLUSIONS: R1 pancreatic resection and bypass for locally advanced disease can be performed with comparable low mortality and morbidity rates. Readmission rates are also comparable between groups and time spent in the hospital after initial discharge is low. Because resection offers adequate palliation in pancreatic cancer, a more aggressive surgical approach in patients who are found to have a doubtfully resectable tumor could be advocated, even if only an R1 resection can be achieved.

Adenocarcinoma↗
PubMed2000

Inferior head resection of the pancreas for intraductal papillary mucinous tumors.

BACKGROUND: Patients with intraductal papillary mucinous tumor have a favorable prognosis after surgical treatment. When this neoplasm is located in the head of the pancreas, resection has conventionally required pancreatoduodenectomy. Although pancreatoduodenectomy can now be performed with a low mortality rate, morbidity still occurs frequently. METHODS: Between November 1982 and January 1999, 38 intraductal papillary mucinous tumors of the pancreas were resected at the Chiba University Hospital. Seven patients (18%) underwent inferior head resection of the pancreas. In this preliminary study, the operative technique is presented, and its efficacy in improvement of quality of life is evaluated. RESULTS: Patients with intraductal papillary mucinous tumor underwent resection with no perioperative mortality. After discharge from hospital, 6 patients who underwent inferior head resection were still alive without recurrent disease after a median follow-up of 3 years. However, 1 patient developed peritoneal dissemination and died 18 months after inferior head resection. Patients had regained 98% of preoperative weight 1 year after inferior head resection. N-benzoyl-L-tyrosyl-p-amino-benzoic acid (BT-PABA) excretion test showed the same value before (73%) and after (73%) inferior head resection (n = 7). Pancreatic fistulas occurred more frequently after inferior head resection (38%), but the incidence of major complications was similar between inferior head resection and other types of pancreatic head resection. CONCLUSIONS: Pancreatic function was well preserved, and patients regained 98% of preoperative weight after inferior head resection of the pancreas. The authors concluded that the limited involvement of intraductal papillary mucinous tumors enables the surgeons to perform inferior head resection of the pancreas.

Adenocarcinoma, Mucinous↗
PubMed1998

Complete resection is not required in patients with neuroblastoma under 1 year of age.

BACKGROUND/PURPOSE: The prognosis of neuroblastoma (NB) patients when detected before 1 year of age is excellent, particularly in patients whose disease is detected by screening. In some institutions patients with stage I or II NB detected by screening have been observed closely without any treatment. Most showed tumor regression or maturation and are surviving without tumor resection. Resection of infantile NB sometimes is complicated by vascular accidents resulting in vanishing kidney or intestinal infarction. The role of surgery in the treatment of infantile NB therefore is becoming controversial. The authors have treated infants who have easily resectable primary tumors with resection and sampling for lymph node metastases. If the resection of the primary tumor seemed difficult, only biopsy was performed initially followed by chemotherapy with or without resection. The authors analyzed the clinical outcome of the infantile NB in their institution to elucidate the role of surgery in this particular group of patients. METHODS: Thirty-six patients less than 12 months of age were treated between 1982 and 1997. Twenty-five patients who showed no symptoms had NB detected by screening at 6 months. Five patients had stage IVS disease in early infancy. No patients had bone or remote lymph node metastases. N-mycamplification was not detected in any of the 28 tumors examined. There were four diploid and 12 near-triploid tumors. RESULTS: Complete resection was possible in 13 stage I and II patients without any complications. Obvious lymph node metastases were not resected in 13 patients with stage II or III NB. Partial resection leaving gross residual disease was accomplished in three patients with stage III NB. Surgical resection was not attempted in four patients because of unresectability in three patients with stage III or IVS disease and because of marked tumor shrinkage after a short course of chemotherapy in one patient with stage III NB involving the celiac axis. A neonatal cervicomediastinal stage III NB recurred very rapidly after partial resection but started to regress spontaneously 2 months postoperatively. Another neonatal stage II cervical NB progressed to stage IVS with hepatomegaly causing respiratory distress but regressed spontaneously. All the patients are alive and disease free without surgical morbidity. CONCLUSION: All of the 21 patients who underwent partial tumor resection with or without chemotherapy are alive and doing well without tumor, indicating that complete resection is not required in this particular group of patients.

Age Factors↗
PubMed1999

Is resection of pulmonary and hepatic metastases warranted in patients with colorectal cancer?

BACKGROUND: Conventional management of stage IV colorectal carcinoma is palliative. The value of resecting both liver and lung colorectal metastases that occur in isolation of other sites of metastasis is undetermined. OBJECTIVES: Our objectives were to (1) assess the efficacy of resecting both hepatic and pulmonary metastases, (2) investigate the influence of the sequence and timing of metastases, and (3) identify the profile of patients likely to benefit from both hepatic and pulmonary metastasectomy. PATIENTS AND METHODS: Of 48 patients identified with resection of colorectal cancer and, at some point in time, both liver and lung metastases, 25 patients underwent metastasectomy (resection group). The remaining 23 patients comprised the nonresection group. Risk factors for death were identified by multivariable analyses. RESULTS: Median survival was longer after the last metastatic appearance in the resection group (16 months) than in the nonresection group (6 months; P <.001). The pattern of risk also differed; it peaked at 2 years and then declined in the resection group but was constant in the nonresection group. In the resection group, patients with metachronous resections survived longer after colorectal resection (median, 70 months) than patients with synchronous (median, 22 months) or mixed resections (median, 31 months; P <.001). Risk factors for death included older age, multiple liver metastases, and a short disease-free interval. CONCLUSIONS: Younger patients with solitary metachronous metastases to the liver, then the lung, and long disease-free intervals are more likely to benefit from resection of both liver and lung metastases. Patients with risk factors also had better survival with resection than without resection.

Colorectal Neoplasms↗
PubMed2002

A new transurethral resection system: operating in saline environment precludes obturator nerve reflexes.

PURPOSE: We developed a transurethral resection system comprising a uniquely designed resectoscope and high frequency wave generator. The obturator nerve is free of electrical stimulation during transurethral resection since high frequency current is delivered via a resection loop to the sheath of the resectoscope in saline irrigation. Preclinical verification of the system was performed in an animal model to ensure its efficacy and operational safety. MATERIALS AND METHODS: The swine bladder wall was transurethrally resected using the system in a saline environment. Results were subsequently compared with data on identical resection performed with the conventional system in sorbitol solution irrigation. Electrolyte contents were measured after resection for comparative evaluation with corresponding pre-resection data. Also, the depth of heat degeneration was measured in resected tissue. RESULTS: No additional skills were required for bladder resection performed with the new system versus the conventional system. No lower limb adductor contraction was noted except minimal creeping during resection of a site close to the urethra. There were no apparent anomalies of blood electrolytes after transurethral resection. No difference was observed in the mean depth of heat degenerated tissues compared with the conventional system. CONCLUSIONS: The newly developed transurethral resection system was effective in a saline irrigated environment, which inhibited the obturator nerve reflex when applied in an animal model. This finding suggests promising potential for the system as a safe and cost-effective alternative compared with conventional transurethral resection.

Animals↗
PubMed1995

Repeat liver resections from colorectal metastasis. Repeat Hepatic Metastases Registry.

BACKGROUND: A retrospective multiinstitutional study was performed to assess survival benefits of patients undergoing repeat liver resection for colorectal metastasis. An updated report is presented here. METHODS: The series comprised 170 patients from 20 different institutions around the world. Mean age of patients was 58 years (range, 28 to 84 years). The mean and median follow-up were 29 and 25 months, respectively. RESULTS: Three- and 5-year overall survival rates were 45% and 32%, respectively. The Dukes' stage of the primary tumor showed a 34% 5-year survival rate for those patients with negative nodes and 30% if nodes were positive (p = 0.42). The disease-free interval between liver resections showed a better outcome for those who had undergone repeated liver resections less than 1 year from the first liver resection (42% versus 23% 5-year survival rates); the difference was not significant (p = 0.58). The number of metastases found and resected at second procedures did not show significant differences in survival and was probably due to selection criteria. Anatomic resections reached a better 5-year survival rate (39%) than wedge resections (21%). The difference was not statistically significant (p = 0.2). The presence of extrahepatic disease and residual liver tumor left behind when repeat liver resection was performed were the most important prognostic variables in survival. Patients with extrahepatic disease had 19% 5-year survival rate, whereas those without disease outside the liver had 36% 5-year survival rate (p = 0.09). Patients with complete resections and those with residual liver disease after repeat resections had 36% and 17% 5-year survival rates, respectively (p = 0.01). Presence of postoperative morbidity after second liver resections did not show a significant negative impact in survival (p = 0.70). Adjuvant therapies were not widely used after liver resections and did not seem to improve prognosis of patients who were treated (39% versus 29% 5-year survival rates, p = 0.9). CONCLUSIONS: Repeat liver resections for colorectal metastasis is a justified approach because surgery remains the only potentially curative treatment. These procedures are relatively safe with low morbidity and mortality rates. Long-term survival (32%) can only be achieved in selected patients.

Adenocarcinoma↗