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PubMed1989

[Significance of extensive surgery in pancreatic cancer].

The pancreas is located in the retroperitoneal space, and its anatomical position is very important in devising a rational surgical approach to pancreatic cancer. In cancer of the pancreas head, cancer cells could invade the portal vein and perineural space of the celiac plexus, and metastasize to regional lymph nodes around the celiac axis. For these reasons, we have performed on extensive operation for cancer of the pancreas head, in which a pancreaticoduodenectomy was performed with extensive resection of the regional lymph nodes around the celiac axis, resection of the celiac plexus and segmental resection of the portal vein. As a result, seven out of 31 resected cases survived more than 5 years after the operation. On the other hand, local recurrence was still found at autopsy in 11 of 12 patients who underwent the extensive operation and died of the recurrent disease. Therefore, further removal of adjacent tissues behind the pancreas and extensive dissection of the regional lymph nodes around the celiac axis seem important for improving the survival of patients with cancer of the pancreas head. Postoperatively, skillful management is also required for severe intestinal malabsorption and diabetic state following the operation.

Adult↗
PubMed1994

Pancreatic cancer and retroperitoneal neural tissue invasion. Its implication for survival following radical surgery.

To analyze the implication of retroperitoneal perineural lymphatic infiltration (rpli) for the survival of patients affected by exocrine pancreatic cancer, we considered 17 cases which underwent radical resection at our Institute from 1980 to 1993. Histology of specimens showed an rpli in 15 cases, without any correlation between this anatomopathologic aspect and the neoplasm size or the presence of lymph node metastases. The 2 patients without rpli are both alive and have been free from disease during a follow-up period of more than 5 years. In the group of 15 patients with positive rpli, 3 (21.4%) have remained free from disease (2 alive and 1 dead for other reason). Eleven remained with disease (1 is alive and 10 have died). One died in the postoperative period and could not be included in the evaluation. These observations have led the surgeon to consider the necessity, during resection, of an accurate dissection not only of the regional lymph nodes but also of the retropancreatic tissue and the neural structures present in this area. This approach may lead to a more correct staging of the neoplasia, a better radical surgery and perhaps a longer survival. Moreover it may represent an important marker for an adjuvant protocol of chemotherapy and/or radiotherapy.

Duodenum↗
PubMed2003

Chylous ascites following surgical treatment for wilms tumor.

PURPOSE: Postoperative chylous ascites is a rare complication of retroperitoneal surgery that has considerable morbidity. We review the pathogenesis and management of chylous ascites following surgical treatment of Wilms tumor. MATERIALS AND METHODS: We identified 9 children with chylous ascites after surgical treatment of Wilms tumor. Of these cases 3 were treated at a single institution during the last 20 years and 6 were identified during retrospective chart reviews of patients enrolled in National Wilms Tumor Studies 3 and 4 to identify surgical complications. Chylous ascites presented as increased abdominal girth and poor feeding. Paracentesis or laparotomy was diagnostic. RESULTS: Patient age at presentation with Wilms tumor ranged from 6 to 95 months (median 15). Left nephrectomy was performed in 5 cases, right nephrectomy in 3, and left nephrectomy and partial right nephrectomy in 1 with bilateral disease. Lymphadenectomy including the hilar and periaortic lymph nodes was performed in 5 patients, 4 of whom also underwent some form of suprahilar lymph node dissection. Three patients underwent lymph node sampling of the hilar, periaortic and some suprahilar lymph nodes. All children received adjuvant chemotherapy and 4 were treated with adjuvant irradiation to the surgical bed before the diagnosis of chylous ascites. The interval between surgery and diagnosis of ascites ranged from 12 to 49 days (median 21). Of the patients 7 were successfully treated with conservative measures, total parenteral nutrition and/or a diet containing primarily medium chain triglycerides, and 2 required invasive procedures, including exploratory laparotomy and ligation of disrupted lymphatic vessels or placement of a peritoneovenous shunt. CONCLUSIONS: Extensive lymph node dissection, particularly above the level of the renal hilum, appears to be associated with the development of postoperative chylous ascites. The National Wilms Tumor Study guidelines do not require formal lymph node dissection for staging and only lymph node sampling is recommended. Elimination of formal lymphadenectomy along with meticulous ligation of lymphatics should decrease the incidence of this complication. Fortunately, conservative treatment with total parenteral nutrition and/or medium chain triglycerides will remedy the problem in the majority of children.

Chemotherapy, Adjuvant↗
PubMed2001

Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse.

PURPOSE: To determine the incidence, pattern, and predictive factors for relapse in patients with low-volume nodal metastases (stage pN1) at retroperitoneal lymphadenectomy (RPLND) and identify who may benefit from chemotherapy in the adjuvant or primary setting. PATIENTS AND METHODS: Fifty-four patients with testicular nonseminomatous germ cell tumor had low-volume retroperitoneal metastases (pathologic stage pN1, 1997 tumor-node-metastasis classification) resected at RPLND, 50 of whom were managed expectantly without adjuvant chemotherapy. The dissection was bilateral in 12 and was a modified template in 38 patients. Retroperitoneal metastases were limited to microscopic nodal involvement in 14 patients. Follow-up ranged from 1 to 106 months (median, 31.4 months). RESULTS: Eleven patients (22%) suffered a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). The most frequent form of recurrence was marker elevation in nine (18%) patients. Persistent marker elevation after orchiectomy and before retroperitoneal lymphadenectomy was a significant independent predictor of relapse (relative risk, 8.0; 95% confidence interval, 2.3 to 27.8; P =.001). Four of five (80%) patients with elevated markers (alpha-fetoprotein alone in three, alpha-fetoprotein and beta human chorionic gonadotropin in one) suffered a relapse, compared with seven of 45 (15.6%) patients with normal markers. CONCLUSION: Clinical stage I and IIA patients with normal markers who have low-volume nodal metastases have a low incidence of relapse and can be managed by observation only if compliance can be assured. In contrast, patients with elevated markers before retroperitoneal lymphadenectomy have a high rate of relapse and should be considered for primary chemotherapy.

Actuarial Analysis↗
PubMed1985

[Surgical results and problems of pancreatic cancer].

Twenty-nine surgically resected specimens of pancreatic head cancer were examined from a clinicopathological stand point. Serial sections 3 to 5 mm in thickness were cut from each specimen to demonstrate the precise histopathological extent of cancer. Tumor size histologically determined was then divided into several groups as follows: t1 (less than 2 cm in diameter), t2a (2.1-3.0 cm), t2b (3.1-4.0 cm), t3 (4.1-6.0 cm) and t4 (greater than 6.1 cm). The number of cases in each group was 3 in t1, 10 in t2a, 9 in t2b, 6 in t3 and 1 in t4. Tumor size was not always correlated with prognosis and it was necessary to consider other important influential factors, namely, invasion to the serosa of the pancreas (s factor), retroperitoneal infiltration beyond the pancreas (rp factor), and regional lymph node metastasis (n factor). All patients with a positive s factor died less than 2 years after surgery, while the survival rate of s factor-negative patients was 41% at 2 years and 8% at 5 years. Survival rate of patients with positive n factor was 13% at 2 years and 6% at 5 years, and that of n factor-negative patients was 71% at 2 years and 33% at 5 years. Survival rate of patients with positive rp factor was 21% at 2 years, while that of rp factor-negative patients was 75% at 2 years and 50% at five years. Positive rp factor patients comprised 100% of t1, 80% of t2a, 89% of t2b and 83% of t3. This suggested that rp factor was the most important factor even in cases of t1. Furthermore, the frequency with which retroperitoneal surgical margins of specimens were infiltrated ranged from 64% of patients with extended retroperitoneal dissection by the translateral retroperitoneal approach, to 100% of those without such procedure. These results indicate that retroperitoneal radical dissection is basically necessary for pancreatic cancer and that a newer approach combined with some other modality also needs to be done.

Humans↗
PubMed1999

Peri-operative care in patients treated for testicular cancer.

The success of combination chemotherapy in treating advanced metastatic germ cell tumors has led to new challenges for the genitourinary oncologic surgeon in the peri-operative care of patients. Surgery remains an integral part of the management of patients with advanced germ cell tumors. Retroperitoneal node dissections following chemotherapy or radiation, or both, are technically more demanding and subject to higher rates of peri-operative complications. Overall post-therapy surgical complication rates range from 33% to 75%, with the highest rates among patients who receive both radiation and chemotherapy. Although most patients with testicular cancer are young and healthy, residual pulmonary, renal, vascular, and neurologic toxicities from chemotherapy can increase the risk of peri-operative complications. In addition, the volume and location of tumor can increase the technical demands, especially when there is a tremendous soft tissue reaction to the chemotherapy. Identification of pre-operative risk factors for peri-operative complications is imperative and the first step in pre-operative planning. Pulmonary toxicity and vascular (cardiac or peripheral) events are the two most immediately life-threatening complications that can occur in the peri-operative period. Due to the high incidence of subclinical pulmonary toxicity, one must consider all patients who have received bleomycin pre-operatively at risk to develop postoperative pulmonary problems. Pre-operative evaluation and judicious fluid management have been shown to reduce the risk of life-threatening respiratory complications in the postoperative period.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2000

[Laparoscopic surgery in gynecologic oncology].

Panoramic retroperitoneal pelviscopy, introduced in 1987 was the first of the laparaoscopic operations used in the field of gyneceologic oncology. It was divised in order to enable the assessment of the pelvic lymph nodes prior to decision making in the management of patients with early cervical cancer. Starting from 1992, laparaoscopic surgery to all fields of gynecologic oncology and all the operations of the classical repertoire were transcribed in the new repertoire. This evolution is not without danger. Direct manipulation of an organ harboring a malignant tumor increases the chances of diffusion of malignant cells. Working with micro-instruments under CO(2) insufflation is likely to favor chances of dissemination. The true place of laparoscopic surgery is, as it has assuredly been since the beginning of its use, in the assessment of tumor surroundings and not in direct manipulation of the organ harboring the tumor. In the cases where imaging clearly shows regional and/or distal spread, it would be better to avoid laparoscopic dissection and retrieval. The most difficult problem in laparaoscopic onco-surgery is not the surgery itself, but in determining in which cases is can be used and in which it cannot.

Female↗
PubMed1985

Modified RLND as a means to preserve ejaculation.

According to the results of this trial it is evident that radical RLND constitutes an overtreatment in NSGCTT pathological stage I. The modified RLND limiting the areas of dissection to recognized sentinel nodes combines accurate pathological staging with low morbidity and equal success in terms of postoperative relapse; it is superior to radical RLND in preserving ejaculatory ability. It will thus come to replace the radical approach and will compete favorably with expectant therapy for some time to come. Results of prospective and long-term investigations will help to define subsets of stage I patients for whom RLND may be unnecessary (DeWys et al. 1983; Oliver et al. 1984).

Adolescent↗
PubMed2006

Preoperative diagnosis of lymph node metastases in gastric cancer by magnetic resonance imaging with ferumoxtran-10.

BACKGROUND: Knowledge regarding the presence and location of lymph node metastasis in gastric cancer is essential in deciding on the operative approach. Lymph node metastases have been diagnosed with imaging tests such as computed tomography (CT) and ultrasonography (US); however, the accuracy of such diagnoses, based on size and shape criteria, has not been adequate. Ferumoxtran-10 (Combidex; Advanced Magnetics) is a lymphotropic contrast agent for magnetic resonance imaging (MRI) whose efficacy for the detection of metastatic lymph nodes in various cancers has been reported by several investigators; however, its efficacy for this purpose has not been reported for gastric cancer. We investigated the efficacy of ferumoxtran-10-enhanced MRI for the diagnosis of metastases to lymph nodes in gastric cancer. METHODS: Seventeen consecutive patients who were diagnosed with a nonearly stage of gastric cancer were enrolled in the study. All the patients were examined by MRI (Signa Horizon 1.5 T; GE Medical; T2*-weighted images) before and 24 h after the intravenous administration of ultrasmall particles of superparamagnetic iron oxide--ferumoxtran-10 (2.6 mg Fe/kg of body weight)--and the presence or absence of metastasis was determined from the enhancement patterns. The imaging results were compared with the corresponding histopathological findings following surgery. RESULTS: Of 781 lymph nodes dissected during surgery, the imaging results of 194 nodes could be correlated with their histopathological findings. Fifty-nine lymph nodes from 11 patients had histopathological metastases. In nonaffected normal lymph nodes, we observed dark signal intensity on MRI caused by the diffuse uptake of the contrast medium by macrophages resident in the lymph nodes, which phagocytose the iron oxide particles of ferumoxtran-10. The number of phagocytic macrophages was decreased in metastatic lymph nodes, and they showed various patterns of decreased uptake of ferumoxtran-10. Three enhancement patterns were observed in lymph nodes: (A) lymph nodes with overall dark signal intensity due to the diffuse uptake of ferumoxtran-10; (B) lymph nodes with partial high signal intensity due to partial uptake; and (C) no blackening of lymph nodes due to no uptake of ferumoxtran-10. Patterns (B) and (C) were defined as metastatic. The sensitivity, specificity, positive predictive value, negative predictive value, and overall predictive accuracy of postcontrast MRI were 100% (59/59), 92.6% (125/135), 85.5% (59/69), 100% (125/125), and 94.8% (184/194), respectively. These parameters for predictive accuracy were much superior to these parameters previously evaluated by CT or US. Nodes in the retroperitoneal and paraaortic regions were more readily identified and diagnosed on the MR images than those in the perigastric region. CONCLUSION: The present study confirmed that ferumoxtran-10-enhanced MRI is useful in the diagnosis of metastatic lymph nodes and that the use of this modality will be helpful in treatment decision-making for gastric cancer patients.

Adult↗
PubMed1983

Primary lymphadenectomy or primary chemotherapy in advanced metastatic testicular tumor?

The treatment of advanced metastasized germ cell tumor consists in a combination of chemotherapy and surgical tumor resection. The sequence of treatment measures is still not uniform. 55 patients with clinically apparent retroperitoneal metastases ('bulky disease') and/or extensive parenchymal metastases are reported. Chemotherapy was performed initially in 40 cases with subsequent resection of the retroperitoneal or parenchymal residues. Of 28 patients with the finding of necrosis/fibrosis or mature teratoma in the dissection preparation, 23 b1e alive and free of tumors. Of 14 patients with the finding of highly malignant tumor, 9 died. In 15 cases, we carried out 'surgical debulking' before chemotherapy: 5 of these patients died as a result of progression in the further course. The advantages and disadvantages of the two treatment modalities are described and discussed. Advanced stages of germ cell tumor with distant metastases should initially be treated with inductive chemotherapy and the tumor residues should subsequently be removed by delayed resection. The sequence in the case of a retroperitoneal 'bulky tumor' without distant metastases is a matter of further discussion and needs a prospective randomized study.

Castration↗
PubMed1994

Laparoscopic retroperitoneal lymphadenectomy for high-risk stage 1 nonseminomatous germ cell tumor: report of four cases.

OBJECTIVE: To evaluate in a prospective fashion the feasibility of performing retroperitoneal lymphadenectomy (RPL) for high-risk Stage 1 nonseminomatous germ cell tumors (NSGCT) using a laparoscopic technique, and to compare the results to historical controls. METHODS: RPL was performed laparoscopically on patients with Stage 1 NSGCT: Each patient had pathologic risk factors associated with an increased likelihood of metastases, and radiologic investigations revealed no evidence of retroperitoneal or distant disease. A modified template lymphadenectomy was performed in each case. The results of these four operations were compared to eight open RPLs performed on a similar group of patients. RESULTS: In 3 of the 4 cases, a thorough dissection was possible. In 1 of these 3, an open laparotomy was required to repair a caval laceration resulting from avulsion of a small lumbar vein at the end of the laparoscopic dissection. Compared to the open approach, there was considerably less postoperative morbidity. CONCLUSIONS: This procedure may represent an alternative approach to surveillance or open RPL for high-risk Stage 1 patients. Further experience is required to determine the sensitivity and effectiveness of this procedure compared to open RPL before its role in clinical practice can be established.

Adult↗
PubMedDate not supplied

Chylous ascites following operation for para-aortic lymph node dissection in a patient with cervical cancer.

This is a case report of chylous ascites caused by performing para-aortic lymph node dissection for a patient with cervical cancer. Postoperative chylous ascites is a rare condition that usually develops as a result of operative trauma to the thoracic duct, cisterna chyli, or their major tributaries. It has mainly occurred in thoracic operations, and chylous ascites has rarely been reported in gynecologic surgery. It is associated with serious nutritional and immunologic consequences due to the constant loss of protein and lymphocytes. Treatment that comprises conservative and surgical procedures is selected based on disease severity. We experienced massive chylous ascites after para-aortic surgery and successfully managed it conservatively with dietary intervention and parenteral nutrition.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1990

Nerve-preserving bilateral retroperitoneal lymphadenectomy: anatomical study and operative approach.

In a study of the sympathetic trunk in 18 cadavers a new anatomical approach for modified bilateral retroperitoneal lymphadenectomy was developed, which is characterized by unilateral preservation of the L3 ganglion and the fibers arising from this ganglion. Furthermore, the sympathetic trunk and its lumbar branches were dissected, including the connections between the right and left sympathetic trunks arising from the L3 and L4 ganglia. On the right side the fibers were found dorsal to the inferior vena cava from where they pass into the aortocaval zone. Caudal to the inferior mesenteric artery these fibers communicate with the left para-aortic fibers. The precise topographic inter-relationship between the L2 and L3 ganglia was studied; the lower margin of the L3 ganglion was located 1 cm. cranial to the origin of the inferior mesenteric artery. Based on these findings a modified operative technique was developed for stages B1 and B2 testicular tumors. With the help of this modification it should be possible to preserve ejaculatory function in 50% of the patients who undergo an operation for small retroperitoneal tumors. However, this modification can be justified only if the recurrence rate is not higher than that with radical bilateral lymphadenectomy.

Adrenergic Fibers↗
PubMed2000

[Endoscopic para-aortic dissection by the extraperitoneal approach: clinical study of 37 patients].

OBJECTIVE: To give the preliminary results of a series of 37 operations for a para-aortic endoscopic curage by the extraperitoneal passage. MATERIAL AND METHODS: Thirty-seven patients, with an average age of 45.8 +/- 12 years, were operated on for cervical cancer, with an average tumor diameter of 4.9 +/- 1 cm. The indications were: the tumor's diameter > or = 4 cm (N = 24), one FIGO stage > or = IIb distal (N = 10), N+ pelvic (N = 3). The irradiation was pelvic (if N-) or abdominopelvic (if N+). RESULTS: The operation lasted 125.3 +/- 36.8 min, and the average number of ganglions removed was 21.2 +/- 10.2. The upper limit of the curage was submesenteric for nine patients and subrenal for 28. The immediate postoperatory complications were: a retroperitoneal hematoma, an acute intestinal occlusion treated by laparotomy, and a ureteral wound on a fixed ganglion, treated by an endoprosthesis. The number of N+ was ten in all, of which three were macroscopic: 0/1 for stage Ib1; 2/12 (16.7%) for Ib2; 4/14 (28.6%) for IIb proximal; 4/10 (40%) for IIb distal or more. There were 6/26 (23.1%) N+ microscopic cases for subrenal curages, versus 1/8 (12.5%) for submesenteric. (Excluding 3 N+ microscopic cases). All were given postoperatory radiotherapy except for one, who had a widened hysterectomy (N-). After an average follow-up of 9.5 +/- 5.9 months, there were two pelvic recurrences and six at a distance (of which four died). We had a lymphocele superinfection at six weeks on the diverticular sigmoiditis. There was an enteritis in a patient who had an abdominal irradiation after a laparotomy for acute occlusion. CONCLUSION: Out of 36 patients having postoperatory radiotherapy, para-aortic extraperitoneal curage diagnosed seven N+ microscopic cases, allowing 26 uniquely pelvic irradiations.

Adult↗
PubMed1992

Esmolol infusion during nitroprusside-induced hypotension: impact on hemodynamics, ventricular performance, and venous admixture.

The impact of esmolol infusion on hemodynamics, ventricular performance, venous admixture, sympathoadrenal, and renin-angiotensin system responses during sodium nitroprusside (SNP)-induced hypotension was studied in 11 patients undergoing lymph node dissection during general anesthesia with 60% nitrous oxide and fentanyl. Radial arterial and thermistor-tipped pulmonary catheters were employed for hemodynamic monitoring. Arterial and mixed venous blood gas tensions, arterial plasma renin activity (PRA), and plasma catecholamine levels were measured. Derived hemodynamic parameters and venous admixture (Qs/Qt) data were obtained from standard equations. Transesophageal echocardiography (6 patients) was used to assess left ventricular performance using the relationship between end-systolic wall stress (ESWS) and velocity of circumferential shortening (VCFC). After surgical incision, arterial hypotension was induced with SNP alone. Esmolol was infused at each of the following rates in sequence: 200, 300, and 400 micrograms/kg/min. Each esmolol infusion lasted 20 minutes and the SNP dose was adjusted to maintain MAP at 55 to 60 mm Hg. The mean dose of SNP required to induce hypotension was 5.5 micrograms/kg/min +/- 0.5 SE. Compared to prehypotension values, SNP induced significant increases in Qs/Qt and reductions in PaO2, systemic vascular resistance (SVR), and stroke volume index (SVI). Esmolol infusion caused dose-dependent (highest with 400 micrograms/kg/min) reductions in the SNP requirement, heart rate (HR), SVI, Qs/Qt, and PRA, and also led to significant increases in SVR and left ventricular (LV) internal diameter in diastole as well as systole. Furthermore, esmolol infusion was associated with a dose-dependent downward and leftward shift of the ESWS versus VCFC relationship, implying diminished contractility.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗
PubMed1996

Carbon dioxide homeostasis during transperitoneal or extraperitoneal laparoscopic pelvic lymphadenectomy: a real-time intraoperative comparison.

The primary goal of this study was to evaluate differences in carbon dioxide metabolism between patients undergoing transperitoneal or extraperitoneal laparoscopic pelvic lymph node dissection (L-PLND) for staging of adenocarcinoma of the prostate (CaP). Eighteen candidates undergoing L-PLND were divided between the transperitoneal (N = 12) and extraperitoneal (N = 6) approaches. End-tidal partial pressure of CO2 (PeCO2) and minute volume of expired CO2 (VCO2) were considered indicators of CO2 absorption. These two parameters were monitored intraoperatively utilizing a metabolic cart and Ohmeda Rascal-II. The cardiostimulatory effect of increasing serum CO2 and the ventilatory countermeasures used to correct the iatrogenic hypercapnia associated with CO2 insufflation were also measured. With the exception of the region of CO2 insufflation, the operative procedure and perioperative care were identical for the two groups. Preoperative patient characteristics were similar. The mean time of CO2 insufflation was 136 minutes for the transperitoneal group and 120 minutes for the extraperitoneal group. The absorption of CO2 was significantly greater and more rapid during extraperitoneal L-PLND. This may be attributable to more profound CO2 absorption from the parietal peritoneal surface compounded by subcutaneous CO2 emphysema. Disruption of microvascular and lymphatic channels during the development of the extraperitoneal working space facilitates direct CO2 absorption into the intravascular space. A minor increase in heart rate and systolic blood pressure was noted during CO2 insufflation. In all but one patient (extraperitoneal group), hypercarbia and acidemia were prevented by an increased ventilatory rate. The potential dysrhythmogenicity of hypercarbia may contraindicate the extraperitoneal approach in patients with cardiopulmonary disease.

Adenocarcinoma↗