Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Resectable”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 901 records · Page 50Linked to original sources
PubMed1989

Concomitant abdominal aortic aneurysm and colorectal carcinoma: priority of resection.

Seventeen patients (15 men and two women) underwent operation for concomitant abdominal aortic aneurysm (AAA) and colorectal carcinoma (Ca) during a recent 12-year period. Ages ranged from 59 to 89 years (median 75.2 years). Diameter of the AAA ranged from 3.5 to 9.5 cm (median 5.5 cm). The Ca was staged by the Astler-Coller modification of Dukes' classification as B1 in three patients, B2 in eight, C2 in three, D in two, and unclassified in one. Personal preference, presence of symptoms, and extent of malignant involvement determined preference of resection. The Ca was eventually resected in 16 patients and the AAA in nine. Thirteen patients underwent resection of the Ca first, two the AAA first, and two concomitantly. Eight patients (47%) underwent resection of both the AAA and Ca, eight underwent resection of the Ca only, and one underwent resection of the AAA only. There were three deaths in 24 operations. Follow-up ranged from 5 weeks to 8 years (median 1 1/2 years). Only five patients (29.4%) were long-term survivors without evidence of recurrent Ca and all occurred in the eight patients (62.5%) who had undergone resection of both the Ca and AAA. Three late deaths occurred as a result of complications from the unresected AAA in the eight patients who had undergone resection of the Ca only (37.5%). We conclude that if the Ca is not symptomatic and localized the AAA should be resected first. However, both lesions need to be resected eventually for long-term survival.

Aged↗
PubMed2001

Full thickness resection device (FTRD) for endoluminal removal of large bowel tumours: development of the instrument and related experimental studies.

We describe a novel device for full thickness resectioning of large bowel lesions. The device has been assessed in experimental studies. Tumours of the large bowel are a frequent disease with increasing incidence figures. If detected at an early stage, local treatment of colon tumours is possible through an endoluminal access. Currently, full thickness resection can only be performed in the rectum with the TEM technique, while snare resection through the flexible endoscope will only allow mucosa resection. We have developed a new device which allows full thickness bowel wall resections up to the splenic flexure. The device, called full thickness resection device (FTRD) has a flexible shaft and a multifunctional front-end. It can be inserted into the colon over a flexible endoscope. After the device is advanced to the tumour, the head can be opened and the tumour, including safety margins, is pulled into the resection chamber inside the device head by means of two tissue graspers. The bowel wall invagination can be visualised with the endoscope to ensure that the tumour is completely pulled into the resection head. The head is then closed and the resection mechanism is activated. A semicircular stapling suture is fired through the bowel wall and a rotary knife is used to cut the tissue. Specimens of > 3 cm can be harvested with FTRD. Prototypes of the device have been successfully tested in a series of animal experiments in parallel to the technical development of the instrument. These experiments could demonstrate that full thickness bowel wall resection is feasible using a flexible instrument and endoscopic visualisation.

Journal Article↗
PubMed1994

Prediction of surgical resectability in patients with hepatic colorectal metastases.

OBJECTIVE: To evaluate the efficacy of two distinct imaging techniques to predict, before operation, unresectability compared with standard computed tomographic scan (CT). SUMMARY BACKGROUND: Accurate preoperative identification of the number, size, and location of hepatic lesions is crucial in planning hepatic resection for colorectal hepatic metastases. Although infusion-enhanced CT is the standard, its limitations are the imaging of relatively isodense and/or small (< 1 cm) lesions. The increased sensitivity of CT arterial portography (CTAP) may be offset by false-positive results caused by benign lesions and flow artifacts. METHODS: Fifty-eight selected patients considered to be eligible for resection by standard CT had laparotomy. Before operation and in addition to CT, all patients had CT arterial portography and hepatic artery perfusion scintigraphy (HAPS) using radiolabeled macroaggregated albumin. Early studies showed an increased sensitivity for detecting small lesions using the invasive CTAP. Similarly, the HAPS study has detected malignant lesions not observed by standard CT. RESULTS: Of 58 patients having laparotomy, 40 were resectable by either lobectomy (22) or trisegmentectomy (1) and the rest by single or multiple wedge resections. Eighteen patients could not be resected because of combined intra- and extrahepatic disease or the number and location of metastases. Standard CT detected 64% of all lesions (12% of lesions less than 1 cm). Unresectability was accurately predicted by CTAP and HAPS in 16 (88%) and 15 (83%), respectively, of the 18 patients considered ineligible for resection at laparotomy. Of the 40 patients who had resection for possible cure, CTAP and HAPS falsely predicted unresectability in 6 of 40 patients (15%) and in 10 of 40 patients (25%), respectively. The positive predictive value for unresectability of CTAP and HAPS was 73% and 60%, respectively. False-positive lesions after CTAP included hemangiomas, cysts, granulomas, and flow artifacts. False-positive HAPS lesions included patients in whom no tumor was found at surgery but with some identified by intraoperative ultrasound, blind biopsy, and blind resection. CONCLUSIONS: False-positive results by HAPS and CTAP may limit the ability of these tests to accurately predict unresectability before operation and may deny patients the chance for surgical resection. The HAPS study does, however, detect small lesions not seen by CT or CTAP. Standard CT, although less sensitive, followed by surgery and intraoperative ultrasound, does not necessarily preclude patients who could be resected.

Adult↗
PubMed1994

Pelvic resection of recurrent rectal cancer.

OBJECTIVE: The authors describe their experience with pelvic resection of recurrent rectal cancer with emphasis on patient selection for curative intent based on known tumor risk factors. SUMMARY BACKGROUND DATA: Pelvic recurrence is a formidable problem in 30% of patients who have undergone a curative resection of primary rectal cancer. Although radiation can reduce the development of local recurrence and can provide palliation to many patients with localized disease, it is not curative. The authors and others have used the technique of abdominal sacral resection (ABSR) with or without pelvic exenteration to resect pelvic recurrence and its musculoskeletal extensions in selected patients with satisfactory long-term survival. METHODS: The technique of ABSR with or without pelvic exenteration or resection of pelvic viscera, which the authors have described previously, was used in 53 patients with recurrent rectal cancer--47 patients for curative intent and 6 for palliation. Previous surgeries were abdominal perineal resections (APRs) in 26 patients, anterior resections in 19 patients, and other procedures in 2 patients; original primary Dukes' stage was B in 52% and C in 48%. Almost all patients had been irradiated previously, generally in the 4000 to 5900 cGy range. Preoperative carcinoembryonic antigen (CEA) levels (before ABSR) were elevated (> 5 ng/mL) in 54%. RESULTS: Postoperative morbidity was encountered in most patients. Mortality was 8.5% in the curative group. Long-term survival for 4 years was achieved in 14 of 43 patients (33%), and 10 patients were alive with an acceptable quality of life after 5 years. Patients who had previous anterior resections or whose preoperative CEA levels were less than 10 ng/mL had a survival rate of approximately 45%, whereas patients with previous APRs and preoperative CEA levels greater than 10 ng/mL had a survival rate of only 15% to 18%. Patients with bone marrow invasion, positive margins, or pelvic node metastases had a median survival of only 10 months. CONCLUSIONS: Pelvic recurrence of rectal cancer can be resected safely with expectation of long-term survival of 33%. Patient selection based on known risk factors can identify patients most likely to benefit from resection and eliminate those who should be treated for palliation only.

Carcinoembryonic Antigen↗
PubMed1996

Factors influencing postoperative morbidity, mortality, and survival after resection for hilar cholangiocarcinoma.

UNLABELLED: OBJECTIVE; Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patient's survival also were re-evaluated. SUMMARY BACKGROUND DATA: Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis. METHODS: The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival. RESULTS: There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that co-existent hepatolithiasis and lower serum asparate aminotransferase levels (<90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin > or = 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin > or = 10 mg/dL, curative resection, and histologic type as the three most significant independent variables. CONCLUSIONS: Surgical resection provides the best survival for hilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3 g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well-differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.

Adult↗
PubMed2000

Ex vivo and in situ resection of inferior vena cava with hepatectomy for colorectal metastases.

OBJECTIVE: To describe the surgical techniques and early results of inferior vena cava (IVC) resection in patients with advanced liver tumors. SUMMARY BACKGROUND DATA: Involvement of the IVC by hepatic tumors, although rare, is considered inoperable by standard resection techniques. Concomitant hepatic and IVC resection is required to achieve adequate tumor clearance. METHODS: Between February 1995 and February 1999, 158 patients underwent hepatic resection for colorectal metastases in the authors' unit. Eight patients, aged 42 to 80 years (mean 62 years), with hepatic metastases from colorectal cancer underwent concomitant resection of the IVC and four to six hepatic segments. Resections were carried out under total hepatic vascular exclusion in four patients and ex vivo in four patients. Between 30 degrees and 360 degrees of the retrohepatic IVC was resected and replaced with an autogenous vein patch (n = 1), a ringed Gore-Tex tube graft (n = 2), a Dacron tube graft (n = 1), or a patch (n = 3) or was repaired by primary suturing (n = 1). RESULTS: There were two early deaths from multiple organ failure. One patient survived 30 months after ex vivo resection but died of renal cell carcinoma, and another died with recurrent disease at 9 months. The remaining four patients remained alive 5 to 12 months after surgery, with no hepatic failure or venous obstruction; tumor recurrence was present in two. Nonthrombotic occlusion of the neocava occurred in one patient and was stented successfully. CONCLUSIONS: Although concomitant hepatic and IVC resection is associated with a considerable surgical risk, this aggressive surgical approach offers hope for patients with hepatic tumors involving the IVC, who would otherwise have a dismal prognosis. This procedure can be performed under total hepatic vascular exclusion, with or without venovenous bypass, and by ex vivo bench resection.

Adenocarcinoma↗
PubMed2000

Significance of resection margin in hepatectomy for hepatocellular carcinoma: A critical reappraisal.

OBJECTIVE: To evaluate the influence of the width and histologic involvement of the resection margin on postoperative recurrence after resection of hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: The significance of the resection margin in hepatectomy for HCC remains controversial. A precise evaluation of the effects of the width and histologic involvement of the resection margin on postoperative recurrence is required to clarify the issue. METHODS: Two hundred eighty-eight patients with macroscopically complete resection of HCC were divided into groups with narrow (<1 cm) or wide (>/=1 cm) resection margins. The two groups were compared for postoperative recurrence rate and pattern of recurrence. A further analysis was performed to investigate the effects of histologic involvement of the resection margin on postoperative recurrence. RESULTS: Recurrence rates were similar between 150 patients with a narrow margin and 138 patients with a wide margin; the groups were comparable in other clinicopathologic variables. Most recurrent tumors occurred in the liver remnant at a segment distant from the resection margin or at multiple segments. Thirty-four patients had margin involved histologically by microscopic invasion from the main tumor (n = 13), venous tumor thrombi (n = 13), or microsatellites separate from the main tumor (n = 8). These patients had significantly higher recurrence rates than those with a histologically clear margin. However, a positive histologic margin was not a significant risk factor for recurrence by multivariate analysis. Tumor stage and perioperative transfusion were the only independent risk factors. CONCLUSIONS: The width of the resection margin did not influence the postoperative recurrence rates after hepatectomy for HCC. A positive histologic margin was associated with a higher incidence of postoperative recurrence, but in most patients this was related to the underlying venous invasion or microsatellites. Most intrahepatic recurrences were considered to arise from intrahepatic metastasis by means of venous dissemination, which a wide resection margin could not prevent.

Aged↗
PubMed2000

Laparoscopic liver resections: a feasibility study in 30 patients.

OBJECTIVE: To assess the feasibility and safety of laparoscopic liver resections. SUMMARY BACKGROUND DATA: The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. METHODS: A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. RESULTS: From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. CONCLUSION: Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.

Aged↗
PubMed1998

Survival and functional status after resection of recurrent glioblastoma multiforme.

OBJECTIVE: To determine the selection factors for and results of second resections performed to treat recurrent glioblastoma multiforme (GM), we studied 301 patients with GM who were treated from the time of diagnosis using two prospective clinical protocols. METHODS: The patients were prospectively followed from the time of diagnosis, using clinical and radiographic criteria after maximal surgical resection and external beam radiotherapy with or without adjuvant chemotherapy. Resection of recurrent GM was performed at the recommendation of the treating clinicians. The results of the second resections were retrospectively reviewed and analyzed using multivariate logistic regression, Kaplan-Meier-Turnbull survival analysis, Cox regression, and propensity score stratification. RESULTS: Forty-six patients underwent second resections during the study period. The actuarial rate of the second resections was 15% of the patients 1 year after diagnosis and 31% 2 years after diagnosis. Younger age (P = 0.01) and more extensive initial resection (P = 0.02), but not Karnofsky Performance Scale (KPS) score at the time of diagnosis or recurrence, predicted a higher chance of selection for reoperation after initial tumor recurrence. Twenty-eight percent of the patients had improved KPS scores after undergoing reoperation, 49% were stable, and 23% had declines in KPS scores of 10 to 30 points. There was no operative mortality. After reoperation, 85% of the patients received chemotherapy, 11% received brachytherapy or underwent stereotactic radiosurgery, and 17% underwent third resections. The median survival period after reoperation was 36 weeks. Higher preoperative KPS scores predicted longer survival periods after reoperation (P = 0.03). Age and interval since diagnosis were not significant prognostic factors. The median high-quality survival period (KPS score, > or =70) was 18 weeks. The median survival period after first tumor progression was 23 weeks for 130 patients treated using the same protocols who did not undergo reoperations. Patients who did undergo reoperations experienced clinically and statistically significantly longer survival periods. However, this was determined to be partially because of selection bias. CONCLUSION: Survival after resection of recurrent GM remains poor despite advances in imaging, operative technique, and adjuvant therapies. High-quality survival after resection of recurrence to treat GM seems to have increased significantly since an earlier report from our institution.

Adolescent↗
PubMed2001

Intraoperative magnetic resonance imaging to determine the extent of resection of pituitary macroadenomas during transsphenoidal microsurgery.

OBJECTIVE: Well-established surgical goals for pituitary macroadenomas include gross total resection for noninvasive tumors and debulking with optic chiasm decompression for invasive tumors. In this report, we examine the safety, reliability, and outcome of intraoperative magnetic resonance imaging (iMRI) used to assess the extent of resection, and thus the achievement of preoperative surgical goals, during transsphenoidal microneurosurgery. METHODS: Our magnetic resonance operating room contains a Hitachi AIRIS II 0.3-T, vertical-field open magnet (Hitachi Medical Systems America, Inc., Twinsburg, OH). A motorized scanner tabletop moves the patient between the imaging and operative positions. For transsphenoidal surgery, the patient is positioned directly on the scanner tabletop so that the surgical field is located between 1.2 and 1.6 m from the magnet isocenter. At this location, the magnetic field strength is low (<20 G), thus permitting the use of many conventional surgical instruments. Thirty consecutive patients with pituitary macroadenomas underwent tumor resection in our magnetic resonance operating room by use of a standard transsphenoidal approach. After initial resection, the patient was advanced into the scanner for imaging. If residual tumor was demonstrated and deemed surgically accessible, the patient underwent immediate re-exploration. RESULTS: iMRI was performed successfully in all 30 patients. In one patient, iMRI was used to clarify the significance of hemorrhage from the sellar region and resulted in immediate conversion of the procedure to a craniotomy. In the remaining 29 patients, initial iMRI demonstrated that the endpoint for extent of resection had been achieved in only 10 patients (34%) after an initial resection attempt, whereas 19 patients (66%) still had unacceptable residual tumor. All 19 of these latter patients underwent re-exploration. Ultimately, re-exploration resulted in the achievement of the planned endpoint for extent of resection in all of the 29 completed transsphenoidal explorations. Operative time was extended in all cases by at least 20 minutes. CONCLUSION: iMRI can be used to safely, reliably, and objectively assess the extent of resection of pituitary macroadenomas during the transsphenoidal approach. The surgeon is frequently surprised by the extent of residual tumor after an initial resection attempt and finds the intraoperative images useful for guiding further resection.

Adenoma↗
PubMed2003

Recurrence rates at minimum 5-year follow-up: laparoscopic versus open sigmoid resection for uncomplicated diverticulitis.

The aim of the study was to compare the impact of surgical access to sigmoid resection on recurrence rates in patients with uncomplicated diverticulitis of the sigmoid (UDS) at a minimum follow-up of 5 years. Recurrence after surgery was defined as left lower quadrant pain, fever, and leucocytosis with consistent CT and enema findings on admission and at 6 weeks, respectively. Outcome measures included splenic flexure mobilization, specimen length, inflammation at proximal resection margin, and presence of teniae coli at distal resection margin. Seventy-nine patients undergoing laparoscopic sigmoid resection (LSR) were compared with 79 matched controls with open sigmoid resection (OSR) operated on at 2 institutions during the same period. Patients were well matched for age, gender, body mass index, ASA grading, and symptoms duration, but not for follow-up length (81.9 versus 86.9 months, P = 0.046). Differences in rates of splenic flexure mobilization (19 versus 41, P < 0.001), specimen length (16.1 versus 18.3 cm, P = 0.048), inflammation at proximal resection margin (21 versus 4, P < 0.001), and teniae coli at distal resection margin (4 versus 53, P < 0.001) did not show an impact on recurrence rates when comparison was made between LSR and OSR. Three LSR patients and 7 OSR patients had 1 recurrence (P = 0.19). There were no significant differences in rates of flexure mobilization, specimen length, and rates of inflammation present at proximal resection margin in 10 recurring and 145 non-recurring patients. The rate of teniae coli present at distal resection margin was significantly increased in recurring patients (7 versus 43, P = 0.03). Median time of recurrence after surgery was 29 (range 18-74) months. Two of 11 recurrences occurred after 5 years. Surgical access to sigmoid resection for UDS is unlikely to have an impact on recurrence rates provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid.

Aged↗
PubMed2006

Endoscopic resection of early gastric cancer: the Japanese perspective.

PURPOSE OF REVIEW: To examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer. RECENT FINDINGS: Endoscopic mucosal resection of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. Though this minimally invasive technique is a safe, convenient and efficacious method, it is insufficient for larger lesions. Difficulties in correctly assessing the depth of tumour invasion and increases in local recurrence by standard endoscopic mucosal resection have been reported in lesions larger than 15 mm. This is because such lesions are often resected piecemeal due to the technical limitation of standard endoscopic mucosal resection. New developments in endoscopic resection techniques to dissect the submucosa directly, called endoscopic submucosal dissection, allows resections of larger lesions en bloc. There are no limitations in resection size in endoscopic submucosal dissection, which is expected to replace surgery. This technique, however, still has higher complications rates than standard endoscopic mucosal resection and requires highly skilled endoscopists. SUMMARY: The techniques, indications, and pathological assessment methods of endoscopic resection of early gastric cancer are described so that proper treatment guidelines can be established and long-term outcome data can be assessed.

Adenocarcinoma↗
PubMed2005

An anatomical comparison of transpalpebral, endoscopic, and coronal approaches to demonstrate exposure and extent of brow depressor muscle resection.

BACKGROUND: Approaches for exposure of the muscles of brow depression include transpalpebral, endoscopically assisted, and open coronal techniques. The purpose of this anatomical study was to compare the capacity for visualization and amount of brow depressor muscle resection with each technique. METHODS: The corrugator supercilii, depressor supercilii, medial orbicularis oculi, and procerus muscles were studied by gross anatomical dissection carried out on 24 sides of 12 cadaver heads. First, all visible corrugator and depressor supercilii muscles were resected by means of an upper blepharoplasty incision. Subsequently, a subgaleal endoscopic approach was used to evaluate the extent of resection performed and remove the remaining muscle after transpalpebral corrugator resection. This was followed by coronal exposure to assess the anatomical location and extent of muscle resection accomplished by the two previously mentioned techniques. RESULTS: In all dissections, endoscopy demonstrated that up to one-third of the lateral aspect of the transverse heads of the corrugator supercilii remained following transpalpebral resection. Oblique corrugator head resections were complete, without significant residual muscle following transpalpebral corrugator resection. The procerus muscle was able to be blindly transected by means of the transpalpebral incision but exposed and ablated in all 12 specimens using endoscopy. Coronal exposure demonstrated that no significant amount of corrugator, depressor supercilii, or procerus muscle remained in any of the 12 heads following endoscopically assisted exposure and resection. The medial head of the orbital portion of the orbicularis oculi was visualized and accessible regardless of the technique used. CONCLUSIONS: In 24 anatomical dissections, transpalpebral corrugator resection failed to remove up to one-third of the transverse head of the corrugator muscle. Removal of the brow depressor muscles was accomplished with the endoscopic approach, as confirmed by coronal exposure.

Dissection↗
PubMed2003

Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization.

OBJECTIVE: To evaluate the feasibility of an aggressive surgical approach incorporating major hepatic resection after biliary drainage and preoperative portal vein embolization for patients with hilar bile duct cancer. SUMMARY BACKGROUND DATA: Although many surgeons have emphasized the importance of major hepatectomy in terms of curative resection for patients with hilar bile duct cancer, this procedure results in a high incidence of postoperative morbidity and mortality in patients with cholestasis-induced impaired liver function. METHODS: A retrospective cohort study was conducted in 140 patients with hilar bile duct cancer treated from 1990 through 2001. Resectional surgery was performed in 79 patients, 69 of whom underwent major hepatic resection. Thirteen patients underwent concomitant pancreaticoduodenectomy. Preoperative biliary drainage was carried out in all 65 patients who had obstructive jaundice. Portal vein embolization was conducted in 41 of 51 patients undergoing extended right hepatectomy. Short- and long-term outcomes were evaluated. RESULTS: No patient experienced postoperative liver failure (maximum total bilirubin level, 5.4 mg/dL). The in-hospital mortality rate was 1.3% (1 in 79, resulting from cerebral infarction). A histologically negative resection margin was obtained more frequently when the scheduled extended hepatic resection was conducted (75% vs 44%, P = 0.0178). The estimated 5-year survival rate was 40% when histologically negative resection margins were obtained, but only 6% if the margins were positive. Multivariate analysis identified the resection margin and nodal status as independent factors predictive of survival. CONCLUSIONS: Extensive resection, mainly extended right hemihepatectomy, after biliary drainage and preoperative portal vein embolization, when necessary, for patients with hilar bile duct cancer can be performed safely and is more likely to result in histologically negative margins than other resection methods.

Adult↗
PubMed2004

Combined resection of the liver and inferior vena cava for hepatic malignancy.

OBJECTIVE: The objective of this paper is to review the results of combined resection of the liver and inferior vena cava for hepatic malignancy. The morbidity and mortality along with preliminary survival data are assessed in order to determine the utility of this aggressive approach to otherwise unresectable tumors. SUMMARY BACKGROUND DATA: Involvement of the inferior vena cava has traditionally been considered a contraindication to resection for advanced tumors of the liver because the surgical risks are high and the long-term prognosis is poor. Progress in liver surgery allows resection in some cases. METHODS: Twenty-two patients undergoing hepatic resection from 1997 to 2003, that also required resection and reconstruction of the inferior vena cava (IVC), were reviewed. The median age was 49 years (range 2 to 68 years). Resections were carried out for: hepatocellular carcinoma (n = 6), colorectal metastases (n = 6), cholangiocarcinoma (n = 5), gastrointestinal stromal tumor (n = 2), hepatoblastoma (n = 2), and squamous cell carcinoma in 1 patient. Liver resections performed included 13 right trisegmentectomies, 6 right lobectomies extended to include the caudate lobe, and 3 left trisegmentectomies. Complex ex vivo procedures were performed in 2 cases using venovenous bypass while the other 20 cases were performed using varying degrees of vascular isolation. In situ cold perfusion of the liver was used in 1 case. The IVC was reconstructed with ringed Gore-Tex tube graft (n = 14), primarily (n = 6), or with Gore-Tex patches (n = 2). RESULTS: There were 2 perioperative deaths (9%). One cirrhotic patient died of liver failure 3 weeks post operatively and 1 patient with cholangiocarcinoma died of pulmonary hemorrhage secondary to a cavitating pulmonary infection after aspiration pneumonia 6 weeks after resection. Six patients had evidence of postoperative liver failure that resolved with supportive management and 2 patients required temporary dialysis. All vascular reconstructions were patent at last follow-up. With median follow-up of 26 months, 5 patients have died of recurrent malignancy at 44, 40, 32, 26, and 24 months, while an additional patient is alive with disease at 31 months. Actuarial 1-, 3-, and 5-year survivals were 85%, 60%, and 33%, respectively. CONCLUSIONS: IVC involvement by hepatic malignancy does not necessarily preclude resection. Liver resection with reconstruction of the inferior vena cava can be performed in selected cases. The increased risk associated with the procedure appears to be balanced by the possible benefits, particularly when the lack of alternative curative approaches is considered.

Adolescent↗
PubMed2004

First and repeat resection of colorectal liver metastases in elderly patients.

OBJECTIVE: The objective of this study was to evaluate the short- and long-term outcome after first and repeat resection in patients older than 70 years. SUMMARY BACKGROUND DATA: Liver resection is the best treatment for colorectal liver metastases and is currently increasingly performed in elderly patients. The benefit of resection for these patients needs to be evaluated. METHODS: Between 1990 and 2000, 56 first and 16 repeat liver resections were performed in 61 patients older than 70 years. Patients were identified from a prospective database and records were reviewed retrospectively. RESULTS: First and repeat liver resection resulted, respectively, in a 0% and 7% postoperative mortality rate and a 41% and 38% complication rate, respectively. Median survival after first resection of 53 patients with R0 resection was 33 months, and the 5-year survival rate was 22%. Factors associated with poor long-term survival in multivariate analysis were extrahepatic disease, high carcinoembryonic antigen level over 200 ng/mL, and the presence of 3 or more liver metastases. Patients without these risk factors showed a median survival of 42 months and a 5-year survival rate of 36%. Repeat liver resection resulted in a median survival of 17 months and in a 3-year survival rate of 25%. CONCLUSION: First and repeat liver resection for colorectal liver metastases can be performed safely in patients older than 70 years. A 5-year survival rate similar to those of younger patients can be expected after first liver resection for patients without the presence of risk factors.

Aged↗
PubMed2004

Tumor progression while on chemotherapy: a contraindication to liver resection for multiple colorectal metastases?

OBJECTIVE: To evaluate the influence of the response to preoperative chemotherapy, especially tumor progression, on the outcome following resection of multiple colorectal liver metastases (CRM). SUMMARY BACKGROUND DATA: Hepatic resection is the only treatment that currently offers a chance of long-term survival, although it is associated with a poor outcome in patients with multinodular CRM. Because of its better efficacy, chemotherapy is increasingly proposed as neoadjuvant treatment in such patients to allow or to facilitate the radicality of resection. However, little is known of the efficacy of such a strategy and the influence of the response to chemotherapy on the outcome of hepatic resection. METHODS: We retrospectively analyzed the course of 131 consecutive patients who underwent liver resection for multiple (> or =4) CRM after systemic chemotherapy between 1993 and 2000, representing 30% of all liver resections performed for CRM in our institution during that period. Chemotherapy included mainly 5-fluorouracil, leucovorin, and either oxaliplatin or irinotecan for a mean of 9.8 courses (median, 9 courses). Patients were divided into 3 groups according to the type of response obtained to preoperative chemotherapy. All liver resections were performed with curative intent. We analyzed patient outcome in relation to response to preoperative chemotherapy. RESULTS: There were 58 patients (44%) who underwent hepatectomy after an objective tumor response (group 1), 39 (30%) after tumor stabilization (group 2), and 34 (26%) after tumor progression (group 3). At the time of diagnosis, mean tumor size and number of metastases were similar in the 3 groups. No differences were observed regarding patient demographics, characteristics of the primary tumor, type of liver resection, and postoperative course. First line treatments were different between groups with a higher proportion of oxaliplatin- and/or irinotecan-based treatments in group 1 (P < 0.01). A higher number of lines of chemotherapy were used in group 2 (P = 0.002). Overall survival was 86%, 41%, and 28% at 1, 3, and 5 years, respectively. Five-year survival was much lower in group 3 compared with groups 1 and 2 (8% vs. 37% and 30%, respectively at 5 years, P < 0.0001). Disease-free survival was 3% compared with 21% and 20%, respectively (P = 0.02). In a multivariate analysis, tumor progression on chemotherapy (P < 0.0001), elevated preoperative serum CA 19-9 (P < 0.0001), number of resected metastases (P < 0.001), and the number of lines of chemotherapy (P < 0.04), but not the type of first line treatment, were independently associated with decreased survival. CONCLUSIONS: Liver resection is able to offer long-term survival to patients with multiple colorectal metastases provided that the metastatic disease is controlled by chemotherapy prior to surgery. Tumor progression before surgery is associated with a poor outcome, even after potentially curative hepatectomy. Tumor control before surgery is crucial to offer a chance of prolonged remission in patients with multiple metastases.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2005

Papillary phenotype confers improved survival after resection of hilar cholangiocarcinoma.

OBJECTIVE: The current study compares outcome after resection of papillary hilar cholangiocarcinoma to that of the more common nodular-sclerosing subtype. METHODS: Clinical, radiologic, histopathologic, and survival data on all patients with hilar cholangiocarcinoma were analyzed. Resected tumors were reexamined and classified as nodular-sclerosing (no component of papillary carcinoma) or papillary (any component of papillary carcinoma); for papillary tumors, the proportion of invasive carcinoma present was determined. Differences in the clinical behavior and histopathologic features of nodular-sclerosing and papillary tumors were assessed. RESULTS: From January 1991 to November 2003, 279 patients were evaluated, 154 men (55.2%) and 125 women (44.8%), with a mean age of 65.4 +/- 0.7 years (median = 68, range 23-87 years). Of the 215 patients explored, 106 (49.5%) underwent a complete gross resection. An en bloc partial hepatectomy (n = 87) and an R0 resection (n = 82) were independent predictors of favorable outcome. Operative mortality was 7.5% but was 2.8% over the last 4 years of the study, and there were no operative deaths in the last 33 consecutive resections. Twenty-five resected tumors (23.6%) contained a papillary component: 12 were minimally or noninvasive (<10% invasive cancer) and 13 had an invasive component ranging from 10% to 95% (> or =10%). Patients with papillary and nodular-sclerosing tumors had similar demographics, operative procedures, and proportion of R0 resections. By contrast, papillary tumors were significantly larger, more often well-differentiated, and earlier stage. Disease-specific survival after resection of papillary tumors (55.7 months) was greater than after resection of nodular-sclerosing lesions (33.5 months, P = 0.013). The papillary phenotype was an independent predictor of survival, although the benefit was more pronounced for less invasive tumors. CONCLUSIONS: The presence of a component of papillary carcinoma is more common than previous reports have suggested and is an important determinant of survival after resection of hilar cholangiocarcinoma.

Adenocarcinoma, Papillary↗