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PubMed2003

[Multivisceral resection in locally advanced carcinoma of the colon and rectum].

Locally advanced colorectal canter may require an intraoperative decision for the block resection of surrounding organs or structures to achieve complete tumour removal. This decision must weigh the risk of complications and death of multivisceral resection against a potential survival benefit. Little is known about the prognostic factors and their influence on the outcome of multivisceral resection for colorectal cancer. We demonstrate our experience with multivisceral resections for the primary colorectal cancer. Patients undergoing multivisceral resection for primary colon or rectal cancer between I-I.2000-I-VII.2003 were identified from retrospective database. Multivisceral resection was performed in 41 of 378 patients with a median age of 61 years. Postoperative rates of complications and death in 41 patients were 30.9% and 12.1%. Histologic tumour infiltration was shown in 58.3% of patients with curative resection. Multivisceral resection is safe, and long-term survival after curative resection is similar to that after standard resection. As the palliative resections cannot be predicted accurately at the time of surgery, every effort should be made to achieve complete tumour resection.

Colorectal Neoplasms↗
PubMedDate not supplied

Safety of portal vein resection using centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein.

BACKGROUND/AIMS: To achieve complete resection of pancreatic cancer, portal vein resection has been performed with increasing frequency at the time of pancreaticoduodenal resection (pancreaticoduodenectomy or total pancreatectomy). In the meantime, visceral congestion and liver ischemia are of great concern during the procedure. We investigated safety of portal vein resection using a centrifugal pump-assisted bypass between the superior mesenteric vein and the umbilical vein. METHODOLOGY: A retrospective comparison was performed in 49 consecutive patients who underwent pancreatoduodenal resection with or without portal vein resection using the bypass for pancreatic cancer. Twenty-two patients underwent portal vein resection using the bypass (group 1). The other 27 patients undergoing pancreatoduodenal resection without portal vein resection comprise the control group (group 2). RESULTS: Total operative time was 756 +/- 159 min and 526 +/- 109 min (p<0.001) and median blood loss was 2090 mL and 1200 mL in groups 1 and 2, respectively. However, the centrifugal pump-assisted bypass allowed stable bypass flow, and neither intestinal edema nor ischemic change of the liver was observed during portal vein resection and the subsequent reconstruction. Postoperatively, the peak postoperative AST, ALT and total bilirubin levels showed no significant difference and postoperative day of starting a liquid diet was similar between the groups (9.0 +/- 5.4 vs. 9.8 +/- 3.8 days, p=0.48). In addition, the rates of morbidity (55% vs. 48%) including biliary and pancreatic leak as well as mortality (9% vs. 4%) did not significantly differ between the 2 groups. CONCLUSIONS: The centrifugal pump-assisted bypass may be useful to prevent hepatic ischemia and visceral congestion during portal vein resection procedures, resulting in similar postoperative outcomes to the control after pancreaticoduodenal resection for pancreatic cancer.

Aged↗
PubMedDate not supplied

[The influence of "differentiated trandurethral resection" in the recurrence and progression of superficial bladder cancer].

OBJECTIVES: Experimental data show the relationship between the area of injured urothelium and recurrence rates in superficial bladder cancer. Tumor cell adherence is increased by the exposure to the extracellular matrix (ECM). Transurethral resection uncovers the ECM and might lead to recurrent tumors. The question if recurrences are increased by enlarged urothelium resection areas is difficult to answer because there will be no prospective studies available. We investigated if deeper and larger urothelial injuries, which are caused by differentiated resections lead to higher recurrence and progression rates than regular resections of bladder tumors. METHODS: 163 patients with superficial bladder cancer were retrospectively evaluated. Sixty-six received a differentiated resection and 97 a regular one. We analyzed the recurrence and progression rates over a minimum of 48 months as well as tumor persistence in the second resection. RESULTS: Patients with differentiated resections of bladder tumors were found to have no higher incidence of tumor recurrence and progression but showed a significantly higher percentage of tumor free second resections. CONCLUSIONS: As a model of enlarged urothelial lesions the differentiated resection technique for superficial bladder cancer has no negative influence on recurrence or progression rates. It seems unlikely that the extracellular matrix uncovered by resection is the main reason for the high recurrence rates. The significantly lower incidence of tumor persistence in the second resection favors the differentiated resection technique in the transurethral treatment.

Adult↗
PubMed2006

[Technical aspects of the liver resection procedure--options for combinations of individual methods].

INTRODUCTION: The liver resection procedure as a treatment method of benign and malignant hepatobiliary disorders grows more important due to the fact, that its postoperative morbidity and mortality rates have been reduced, a result of the patients selection method, surgical techniques and perioperative care improvements. The aim of this report was to assess combinations of recent liver transsection techniques, based on the authors' own experience and results of recent studies. MATERIAL, METHODS AND RESULTS: From 1999 to May 2005, in the Surgical Clinic of the Faculty Hospital Královské Vinohrady in Prague, the liver resection procedure was completed in 133 patients with benign or primary and secondary malignant tumors. In the liver transsection procedure, the following instrumentation was used, starting from 1999: harmonic scalpels, ultrasonographic dissectors, water jet scalpel, bipolar diathermia, argon coagulation and radiofrequency. The liver tissue dissection using the ultrasonographic dissector or the water jet scalpel in combination with the harmonic scalpel or bipolar diathemic coagulation, reduced the postoperative blood loss in extensive non-anatomical liver resections. This dissection method was also used in some "centrally" located tumors for their non-anatomical resections. The benefit of the combination of the methods is based on sufficient coagulation and interruption of minor vascular branches and bile ducts in the resection line, without intermittent closure of the blood influx to the liver, using a Pringle manoeuvre. The radiofrequency, as a novel method for the liver tumors ablation, was used in anatomical and non-anatomical liver resections to coagulate the liver tissue prior to its transection prior to the R0 resection. The postoperative morbidity rate was 14% (19 patients). Within 30 postoperative days, no death was recorded. CONCLUSION: 1. The above listed liver transsection techniques, employing the ultrasonographic dissector or water jet scalpel, are safe alternative liver resection methods, reducing the blood loss. 2. Diathermic coagulation is an alternative to the harmonic scalpel for intersecting minor intraparenchymatous vascular branches and bile ducts. 3. A combination of the ultrasonographic dissector technique or water jet scalpel with the harmonic scalpel or diathermic coagulation technique, aids the liver resection by closing and interrupting the vessels and bile ducts in the resection line. 4. Radiofrequency and pre-transsectional coagulation of the liver parenchyma reduces the bleeding during the resection procedure and is a method of choice in resections of centrally located tumors, reducing the loss of the functional parenchyma.

Hepatectomy↗
PubMed2006

[Experience of surgical resection of 103 hilar cholangiocarcinoma].

OBJECTIVE: To summarize the experience of surgical resection of 103 hilar cholangiocarcinoma. METHODS: One hundred and three consecutive cases of hilar cholangiocarcinoma who underwent surgical resection at our hospital over the past ten years were reviewed retrospectively. The clinical data and long-term outcome were analyzed. RESULTS: Out of 103 cases, 43 patients underwent radical resection (41.7%), and 60 patients underwent palliative resection. There were 34 patients developed postoperative complications and 8 patients died in hospital. For the radical resection group, the median survival time was 29.9 months and 1-year, 3-year, 5-year survival rate was 69.6%, 42.0%, 20.9%, respectively, which was significant greater than 34.1%, 10.2%, 0 of the palliative resection group (P < 0.05). Over the past five years, 42 cases underwent pre-operative drainage of bile and the rate of combined liver resection reached 53.8%. The tumor radical resection rate has increased to 45.7%, the median survival time have reached 24.7 months (P < 0.05). CONCLUSIONS: Improvement of pre-operative management, intraoperative pathology for resection margin, and combined liver resection may help in increasing the radical resection rate. Radical resection can improve postoperative survival, and produce a satisfactory outcome for patient with hepatic hilar cholangiocarcinoma.

Adult↗
PubMed1989

[Primary cytoreductive surgery of advanced ovarian cancer with special reference to the significance of bowel resection].

The importance of cf cytoreductive surgery is discussed with special reference to the bowel resection for advanced epithelial ovarian cancer. In the 10.5-year period from January 1978 to June 1988, 134 patients with epithelial ovarian cancer were seen at Toranomon Hospital. Two (15%) out of 13 patients with epithelial ovarian cancer at stage II underwent bowel resection to achieve cytoreduction, 10 (31%) out of 32 at stage III, and 4 (36%) out of 11 at stage IV, respectively. Modified posterior pelvic exenteration was the most common operative procedure among the bowel resections. In this procedure, resection of both sigmoid colon and rectum and end-to-end anastomosis was carried out. Besides bowel resection, all patients at stage II-IV had abdominal hysterectomy, and bilateral salpingo-oophorectomy with or without omentectomy. Comparison of the treatment was by the method of Kaplan-Meier and the Wilcoxon test. The following results were obtained. 1) Five-year survival rate for patients with bowel resection was 60%, compared to 39% for those undergoing operation without bowel resection (p less than 0.05). 2) Two-year survival for patients having residual cancer even after bowel resection was 61%, compared to 28% for those with residual cancer without bowel resection (p less than 0.05). 3) Two-year survival for patients with residual cancer greater than 2 cm was 8%, compared to 62% for those with residual cancer less than 1.9 cm (p less than 0.05). 4) Four patients who died of cancer 15-26 months after the initial treatment including bowel resection spent 65-85% (mean 76%) of the survival period with normal or subnormal activity, against 0-85% (mean 30%) for 6 patients without bowel resection and with the matched survival period of 15-26 months. Also, the former spent 19-33% (mean 27%) of their survival period in the hospital, against 20-67% (mean 39%) by the latter. These results suggest that bowel resection should be encouraged in order to achieve optimal cytoreduction in patients with advanced epithelial ovarian cancer because of its effectiveness in prolonging survival and the inherent benefits for quality of life.

Fallopian Tubes↗
PubMed1993

Synchronous, metachronous, and multiple hepatic resections of liver tumors originating from primary gastric tumors.

BACKGROUND: The role of hepatic resection for noncolorectal gastrointestinal malignancies involving the liver is not well defined. To address this issue we studied our experience with resection of liver tumors arising from primary gastric malignancies. METHODS: A retrospective study of 195 patients who underwent a total of 207 liver resections identified 12 patients with primary gastric cancer who underwent 16 resections for liver involvement. There were 10 adenocarcinomas and two leiomyosarcomas. We examined the type of hepatic surgery, the status of residual disease, and the primary histologic findings. Morbidity, mortality, and actual survival rates were recorded. RESULTS: Thirty-day operative mortality was 8.3% (1 of 12). Hospital mortality was 25% (3 of 12). Operative morbidity occurred in three of nine survivors (33%). Synchronous en bloc resection (n = 3) of stomach and liver for adenocarcinoma produced two long-term survivors (no evidence of disease for 10 and 13 years). Mean survival after synchronous discontinuous resection (n = 4) was 8 months (range, 2 to 17 months). Metachronous resection for adenocarcinoma (n = 3) produced one long-term survivor (74 months), and one patient with recurrent leiomyosarcoma underwent a total of five liver resections and survived 64 months. CONCLUSIONS: For adenocarcinoma, en bloc resection of contiguous liver involvement produced long-term survivors. Synchronous resection of discontinuous metastases did not. Metachronous resection of isolated disease and multiple resections of recurrent isolated disease may have value in carefully selected patients.

Adenocarcinoma↗
PubMedDate not supplied

Segmental liver resections for hilar cholangiocarcinoma.

BACKGROUNDS/AIMS: Liver resection for hilar cholangiocarcinoma is now popular, and combined en bloc resection of the caudate lobe has become general practice, especially in Japan and some European countries. However, surgical procedure is not yet standardized, and many problems concerning surgical treatment of this disease still remain unsolved. METHODOLOGY: From April 1977 to December 1996, 173 patients with hilar cholangiocarcinoma were treated at The First Department of Surgery, Nagoya University Hospital. Of the 173 patients, 138 patients underwent surgical resection, including 124 liver resections and 14 bile duct resections. RESULTS: Several kinds of hepatic segmentectomy with en bloc resection of the caudate lobe were performed in the 124 patients: 109 underwent hepatic lobectomy or more extensive resection including central bisegmentectomy; 15 received resection of one or less segment of the liver. Aggressive resections, including combined portal vein and liver resection (n = 41) and hepatopan-creatoduodenectomy (n = 16), were applied to advanced hilar cholangiocarcinoma. The hospital death rate in hepatectomized patients was 9.7% (12/124). The 3- and 5-year rates for the 97 patients with curative hepatectomy were 42.7%, and 25.8%, respectively. CONCLUSIONS: Aggressive liver resection improves survival of patients with hilar cholangiocarcinoma. Resection procedures should be designed based on a precise diagnosis of the extent of carcinoma.

Bile Duct Neoplasms↗
PubMed1998

Comparison of liver function tests after hepatic lobectomy and hepatic wedge resection.

Prior studies have suggested that changes in liver function tests may vary with the postoperative time interval and may be related to the extent of hepatic resection. This study describes characteristic profiles in parenchymal liver enzymes and other serum liver function tests over a 4-week course comparing anatomic to nonanatomic hepatic resections. The records of 48 patients undergoing successful major hepatic resection during a 3-year period were retrospectively reviewed. Of these 48 patients, 28 underwent formal anatomic resection (hepatic lobectomy), and 20 underwent nonanatomic resections (wedge resection). Routine postoperative management in lobectomy patients included drawing liver function tests and enzymes daily for the first week, then at approximately 2 and 4 weeks postoperatively. These tests included: prothrombin time (PT), partial thromboplastin time, total serum bilirubin, total protein (TP), aspartate transaminase, lactate dehydrogenase (LDH), alkaline phosphatase, albumin (A), and glucose. Patients undergoing wedge resections had these values checked less frequently, approximately 3 to 5 days, 2 weeks, and 4 weeks postoperatively. Profiles of these values were plotted over the 4-week postoperative time course for each group of patients. Patients undergoing hepatic lobectomy showed a characteristic laboratory value profile. PT elevated within 48 hours to a mean high of 16.0 seconds, then returned to normal by postoperative day 4. Partial thromboplastin time levels remained normal throughout the entire perioperative course. Total bilirubin rose slightly, to a mean high of 2.6 mg/100 cc, then returned to normal by postoperative day (POD) 14. Parenchymal liver enzymes aspartate transaminase and LDH rose abruptly to very high levels, then returned abruptly to normal (by POD 5). TP and A both fell to approximately 50 per cent of normal, gradually rising to normal by POD 14. Glucose rose to a mean high of 199 mg/100 cc within the first 5 days, then returned to normal by POD 7. Alkaline phosphatase remained normal initially, then showed a progressive rise to a high of 288 mg/100 cc on POD 14. Patients undergoing wedge resections did not show the same changes in total serum bilirubin, but showed similar trends in all other tests, although the magnitude of these changes was smaller. TP and A levels fell acutely after resection, then began a slow rise toward normal by POD 21. TP and A profiles were similar for both lobectomy patients and those undergoing wedge resection. The only tests that may have altered clinical management were the PT and total bilirubin. Patients undergoing major hepatic resection have characteristic postoperative profiles of liver enzymes and liver function tests. These laboratory profiles differ with the extent of hepatic resection. The profiles reflect changes in volume status, parenchymal liver destruction, transient hepatic insufficiency, and postoperative hepatic regeneration. However, except possibly for PT and bilirubin, the routine use of these tests is not recommended, given that the results do not alter clinical management.

Follow-Up Studies↗
PubMed2001

Cricotracheal resection in children.

OBJECTIVE: To review our experience with cricotracheal resection in a pediatric population. DESIGN: Prospective case review of a cohort of patients undergoing cricotracheal resection. SETTING: Tertiary care pediatric hospital. PATIENTS: Forty-four consecutive patients undergoing cricotracheal resection between January 1, 1993, and December 31, 1998. MAIN OUTCOME MEASURES: Decannulation rates. RESULTS: Thirty-eight (86%) of the 44 children are decannulated. The ultimate decannulation rate was independent of the presenting grade of subglottic stenosis. Fourteen children (100%) had a primary cricotracheal resection; all are decannulated. Twenty-one children had a salvage cricotracheal resection, and 19 (90%) are decannulated. Nine children had an extended cricotracheal resection, of whom 5 (56%) are decannulated. A primary cricotracheal resection was performed on a child on whom no previous open airway procedure had been performed. A salvage cricotracheal resection was performed on a child on whom previous open airway reconstruction had not resulted in an adequate airway. An extended cricotracheal resection was performed on a child on whom the cricotracheal resection was combined with a second procedure, either additional expansion cartilage grafting or an open arytenoid procedure. Most of these children had complex airway pathologic conditions. CONCLUSION: Cricotracheal resection complements standard laryngotracheal reconstruction techniques in a pediatric population.

Adolescent↗
PubMed2002

Combination of neoadjuvant chemotherapy with cryotherapy and surgical resection for the treatment of unresectable liver metastases from colorectal carcinoma.

BACKGROUND: This retrospective study was conducted to assess the safety, efficacy, and long-term results of neoadjuvant chemotherapy and cryotherapy as additional means for eradicating liver metastases from colorectal carcinoma when curative treatment was not possible by resection alone. METHODS: Between January 1996 and December 1997, 131 patients with unresectable liver metastases were referred to our department and received chemotherapy. After 3-6 months of chemotherapy, curative surgery of liver metastases was considered possible in 57 patients, either by resection alone in 33 patients (25%) or cryotherapy associated with resection in 24 patients (18%). Characteristics and survival of patients in the cryotherapy plus resection group were compared with those of the 33 patients in the resection group. RESULTS: All patients in the resection group had partial response to neoadjuvant chemotherapy. In the cryotherapy plus resection group, neoadjuvant chemotherapy resulted in 13 partial responses, 9 stable diseases, and 2 disease progressions. The rate of postoperative complications in the entire series was 14%. No major difference was seen between the two groups. After a median follow-up of 48 months, the median survival time was 39 months. The survival rates at 1, 3, and 4 years were similar in both groups: 94, 58, and 37% in the resection group and 92, 50, and 36% in the cryotherapy plus resection group, respectively. CONCLUSIONS: The combination of neoadjuvant chemotherapy, cryotherapy, and liver resection constitutes a promising treatment strategy for patients with extremely advanced metastatic liver involvement. Patients having more than four liver metastases from a colorectal carcinoma or patients with a poor liver reserve due to previous resection should be screened carefully to determine whether they could be candidates for this procedure.

Adult↗
PubMedDate not supplied

Extended resection for higher-stage non-small-cell lung cancer.

This report reviews the results of extended surgical resection for advanced lung cancer (stage IIIa, IIIb, IV) reported in the Anglo-American literature between 1980 and 1993. Complete resection of stage IIIa (T3) tumors with minimal or no nodal involvement resulted in a 5-year survival approaching 40%. Ipsilateral mediastinal nodal involvement (N2) lowered 5-year survival to 10-15% and to near 0% if bulky disease was present. Historically, resection of stage IIIb disease has failed to improve survival. Radiation therapy has decreased local recurrence in advanced-stage disease but has not improved survival. Preliminary results have recently been reported using induction chemotherapy or chemoradiotherapy followed by resection in subsets of patients with stage IIIa and IIIb disease. Induction chemotherapy for bulky N2 (IIIa) disease resulted in major response rates of up to 77% and a 5-year survival of up to 26% after complete resection. Preliminary results of resection of stage IIIb tumors following induction chemotherapy have achieved 2-year survivals of 40%. Metastatic lung cancer (stage IV) with disseminated disease remains virtually incurable with poor response rates to chemotherapy. However, resection of isolated brain metastases (M1 disease) resulted in a 5-year survival near 25%. Resection of other sites of isolated metastatic disease including the adrenal gland is under investigation. The major prognostic factor in these studies has been the ability to completely resect all tumor. To improve resectability rates, induction therapy and radical resections are being combined more frequently. The increased morbidity and mortality of these aggressive approaches requires careful patient selection.

Carcinoma, Non-Small-Cell Lung↗
PubMed1997

Hartmann's procedure vs. abdominoperineal resection for palliation of advanced low rectal cancer.

UNLABELLED: In managing advanced low rectal adenocarcinomas in medically fit patients, surgical resection offers the best palliation. Tenesmus, bleeding per rectum, sacral pain, and sciatic pain are common complaints, which are not relieved by radiotherapy or fulguration. The most appropriate resection, however, remains controversial. Abdominoperineal resection is faster and simpler to perform but leaves behind a perineal wound with associated complications. Hartmann's procedure requires adequate mobilization below the tumor and may be technically more demanding but avoids a perineal wound. Therefore, an analysis of outcome in patients treated by Hartmann's procedure vs. abdominoperineal resection was made. METHOD: Fifty-four symptomatic patients with advanced rectal adenocarcinoma arising within a median of 5 (range, 4-8) cm from the anal verge treated between June 1989 and October 1995 were studied. Twenty-eight patients (17 males; mean age, 67.6 +/- 10.3 years) had Hartmann's procedure, and 26 patients (12 females; mean age, 68.8 +/- 8.3 years) were treated by abdominoperineal resection. Mean follow-up was 23.5 months (+/-17.5) and 18.6 months (+/-12.9) in Hartmann's procedure and abdominoperineal groups, respectively. RESULTS: Mean operative time was 138.4 +/- 26.7 minutes for Hartmann's procedure group and 124.6 +/- 27.1 minutes for the abdominoperineal resection group (P > 0.05; not significant). Postoperatively, Hartmann's procedure group started oral intake at a mean of 2.3 days, and stomas were functioning at a mean of 3.1 days compared with 2.6 days for oral intake and 3 days for stoma functioning in the abdominoperineal resection group. Hartmann's procedure group was ambulant after a mean of 2.4 days vs. a mean of 3.2 days in the abdominoperineal resection group. Postoperative abdominal wound infection occurred in 18 and 19 percent, respectively, in Hartmann's procedure and abdominoperineal resection groups. Forty-six percent of patients had perineal wound sepsis, and 38 percent had perineal wound pain in the abdominoperineal resection group. These complications were absent in Hartmann's procedure group. Postoperative stay was similar in both groups. CONCLUSION: We conclude that Hartmann's procedure offers superior palliation compared with abdominoperineal resection because it provides good symptomatic control without any perineal wound complications and pain.

Abdomen↗
PubMed1996

Better preservation of immune function after laparoscopic-assisted vs. open bowel resection in a murine model.

UNLABELLED: We evaluated cell-mediated immune function after laparoscopic-assisted and open bowel resection in rats by measuring delayed-type hypersensitivity responses to keyhole limpet hemocyanin (KLH) and phytohemagglutinin (PHA). METHODS: Male Sprague-Dawley rats (n = 120) were sensitized to 1 mg of KLH ten days before investigations. Rats were challenged preoperatively, immediately postoperatively, and on postoperative day (POD) 2 with an intradermal injection of 0.3 mg of KLH and 0.2 mg of PHA (at different sites). Averages of two measures of perpendicular diameters (taken 24 and 48 hours postchallenge) were used to calculate the area of induration using the formula for the area of an ellipse, A = (D1/2 x D2/2) x pi. Anesthesia control animals underwent no procedure (n = 40). Open resection group underwent ligation and resection of the cecum (length = 2 cm) through a 7 cm midline incision (n = 40). In the laparoscopic-assisted resection group, under CO2 pneumoperitoneum (4-6 mmHg), the cecum was identified, dissected free, and exteriorized through a 4 mm port. The cecum was then ligated and resected extracorporeally (n = 40). RESULTS: Preoperative responses to both KLH and PHA were the same in all three groups. Furthermore, within each group, postoperative responses were similar. When groups were compared, the anesthesia group responses were significantly greater than the open resection group responses at all time points (P < 0.05 for all comparisons). Laparoscopic assisted resection group responses differed from control at only two of eight postoperative measures. Laparoscopic resection group responses were significantly greater than open resection group responses to challenge with both KLH and PHA on POD1 (P < 0.02, for both comparisons) and POD 4 (P < 0.05, for both comparisons). CONCLUSIONS: Postoperative cell-mediated immune function is better preserved after laparoscopic-assisted bowel resection than after open resection as assessed by skin antigen testing.

Animals↗
PubMed2002

Endoscopic snare resection of large colonic polyps: how far can we go?

BACKGROUND AND AIMS: Colonoscopic polypectomy is preventing colorectal cancer. Videoendoscopy and new perendoscopic hemostasis techniques make endoscopic polypectomy of large colonic polyps an alternative to the surgical approach. This study examined whether complete snare resection of giant colonic polyps is feasible and safe and for determining how often surgery is necessary due to invasive cancer detected histologically after polypectomy. PATIENTS AND METHODS: The study included 59 consecutive patients with 68 colonic polyps larger 30 mm in diameter. Snare polypectomy was performed after an endoscopic ultrasound with a miniprobe found no sign of invasive, or, depending on the appearance of the polyp, a bleeding prophylaxis had been carried out. Acute procedural or delayed bleeding was treated endoscopically. RESULTS: Of the 68 polyps 26, mostly pedunculated were resected en bloc (38%) and histologically ensured as completely resected; 42 polyps had to be resected by piecemeal technique (62%). Piecemeal resection was performed significantly more often in sessile polyps (38/41, 93%) than in pedunculated polyps (4/27, 15%, P<0.01). Follow-up colonoscopy after 3 months showed remaining adenomatous tissue of piecemeal-resected polyps in 12 cases (28%), which were 12 resected sessile polyps (29%) and no case of resected pedunculated polyp. To achieve complete resection of sessile polyps a second procedure was necessary significantly more often than for resection of pedunculated polyps (12 cases in sessile polyps, 18% vs. no case in pedunculated polyps). Remaining adenomatous tissue was removed in all 12 cases during the first follow-up colonoscopy after 3 months, confirmed by a biopsy 6 months after the initial procedure. Overall coexisting malignancy was found in only 7 polyps (12%). Due to high-risk factors only one of them underwent secondary surgical procedure. CONCLUSION: The present study shows that endoscopic snare resection of giant colonic polyps is a safe procedure, and that secondary operative measures for managing coexisting malignancy are rarely necessary.

Adenomatous Polyps↗
PubMed2004

Hepatic resection in stage IV colorectal cancer: prognostic predictors of outcome.

BACKGROUND AND AIMS: Hepatic resection has been proposed as an effective way to treat metastatic colorectal carcinoma. The aim of the study was to determine if contemporary resection of intestinal primary tumor and hepatic metastases is effective in the treatment of patients with metastases that are recognized at the initial clinical presentation of the primary tumor. METHODS: In a retrospective study, univariate and multivariate models were used to analyze the effect of patient demographics, tumor characteristics, and treatment factors on early and long-term outcome of patients submitted to synchronous intestinal and hepatic resection for colorectal liver metastases. From 1988 to 1999, 78 patients underwent surgical resection of primary colorectal tumor and hepatic metastases with curative intent. Criteria for study recruitment included primary tumor controllable, no extrahepatic disease detectable, and negative surgical margins of hepatic resection. RESULTS: The univariate analysis disclosed as adverse predictors of the long-term outcome the numbers of metastases (</=3; >3), pre-operative CEA value >100 ng/ml, resection margin <10 mm, and portal nodal status. Multivariate analysis confirmed number of metastases, resection margin and portal nodal status as independent predictors. CONCLUSIONS: Our findings confirm hepatic resection as an effective procedure when undertaking combined bowel and hepatic resection. The applicability and the outcome of this surgical strategy is definitively influenced by the chance of a radical resection of the primary tumor, the number of hepatic metastases, resection margin wider than 1 cm, positive portal nodes, and the absence of any extrahepatic metastatic disease.

Adult↗
PubMed1999

Resection of colorectal liver metastases.

INTRODUCTION: Surgical resection is presently the only approach that offers patients with liver metastases from colorectal carcinoma substantial chance of cure. This article summarizes the current literature as well as the author's personal experience. BACKGROUND AND DISCUSSION: Since 1980, 5-year survival figures have ranged from 21% in collected series to 48% in single-institution series. The 30-day mortality of elective liver resection in non-cirrhotic patients ranges now between 0% and 5%. The overwhelming indicator of prognosis is the completeness of tumor removal according to the R-classification. The specific impact of all other factors should therefore be analyzed by excluding non-radical procedures and operative mortality. Among patient characteristics, age and gender do not significantly affect outcome, while the Karnofski stage is important. Regarding the primary tumor, the effect of staging and location is predominantly apparent in patients with synchronous metastases. Timing of metastasis detection is of some importance, as most authors found a slightly better outcome for metachronously detected metastases. With respect to the liver involvement, multiplicity of metastases and bilateral disease both seem to be of minor importance after R0-resection, while satellite lesions are significant in many series. The actual number of metastases is of minor effect, with a slight superiority in 5-year survival for patients with one to three nodules relative to patients with four nodules or more in most series, but identical results in the author's own experience. The maximum diameter as an indicator of tumor burden represents a significant prognosticator in half of the reports analyzed. Extrahepatic disease reduces 5-year survival, but direct tumor invasion to adjacent structures, local recurrent disease, or one or few pulmonary metastases are no contraindication to liver resection as long as a R0-situation can be achieved. In contrast, lymph-node metastases at the liver hilum predict a poor outcome. They are likely to prove as a clear contraindication. With respect to the operative approach, a clear margin of 1 cm or more should be aimed at but, if the size or location of metastases do not allow a 1-cm margin, resection should still be performed, making every surgical effort to ensure a complete rim of unaffected tissue. Anatomic resections reduce the incidence of non-radical procedures and may improve survival. Whether there is an independent effect of operative blood loss, need for blood transfusion, and intraoperative hypotension on prognosis is still unclear. Adjuvant chemotherapy or radiotherapy after R0-resection is unlikely to improve results. There are also no convincing data available demonstrating a prognostic benefit when a non-curative resection is supplemented by any medical treatment. In patients with recurrent disease, a re-resection is possible in roughly 20%. Survival from the time of re-intervention ranges from 21% to 57% after 5 years and, thus, justifies a close follow-up policy after R0-resection of the initial liver metastases. CONCLUSION: The previous "clear" contraindications to liver resection have become less important. Future efforts may be directed to more accurate patient selection and new approaches of neoadjuvant and adjuvant therapeutic strategies.

Colorectal Neoplasms↗
PubMed2004

Early outcomes of 100 patients with laparoscopic resection for rectal neoplasm.

BACKGROUND: Laparoscopic resection has been shown to be a feasible option in patients with colorectal diseases. However, there have been only a few studies on laparoscopic resection for rectal neoplasm. This report aimed to evaluate the early outcomes of patients treated by laparoscopic rectal resection for neoplasm. METHODS: From May 2000 to April 2003, 100 patients underwent laparoscopic resection for rectal neoplasm with mesorectal excision. Data on the patients' demographics, operative details, and outcomes were collected prospectively. In those with successful laparoscopic resection, comparison was made between patients with predominantly intracorporeal surgery (ICS) and those with anterior resection performed with extracorporeal rectal transection and anastomosis following intracorporeal bowel mobilization and vessel ligation (IECS). RESULTS: Sixty-six men and 34 women (median age, 69 years; range, 40-85) were included. Operations included 91 anterior resections, eight abdominoperineal resections, and one Hartmann's procedure. Conversion was required in 15 patients and no conversion was needed in patients treated by laparoscopic abdominoperineal resection. One patient died 30 days after surgery because of liver failure. Postoperative complications occurred in 31 patients. Among them, three had anastomotic leakage and all of them could be treated conservatively. Reoperation was required in one patient with intestinal obstruction. Patients with conversion were found to have significantly more blood loss, longer time to resume diet, a longer hospital stay, and a higher morbidity rate when compared to those with successful laparoscopic surgery. Among those with successful laparoscopic procedures, no difference was observed between patients with ICS (n = 57) and those with IECS (n = 28), except that a shorter incision and less blood loss were found in patients in the former group. CONCLUSIONS: Laparoscopic rectal resection with mesorectal dissection is feasible. The operating mortality and reoperation rates were low. Conversion was associated with an increased morbidity rate, leading to a longer hospital stay. Laparoscopically assisted anterior resection with rectal transection by a transverse stapler through the abdominal incision produced similar results when compared to a procedure that was predominantly intracorporeally performed.

Adult↗