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PubMed1998

Effects of resective surgery for left-sided intracranial tumours on language function: a prospective study.

BACKGROUND: Although language disorders occur in about 50% of patients with a left hemispheric tumour and are a significant cause of morbidity, the effects of resective neurosurgery and their relation to tumour pathology are unclear. We report the immediate effects of resective surgery on language functions in a heterogeneous group of patients with left-sided intracranial tumours. METHODS: 40 patients were studied. The Western Aphasia Battery (WAB) and Boston Naming Test (BNT) were administered preoperatively and before discharge following resective neurosurgery. Dexamethasone dose at time of testing was recorded, as was time taken to complete the tests, and tumour neuropathology. FINDINGS: 15 patients with normal aphasia quotients and language quotients before resective surgery all had normal quotients postoperatively. 25 who were dysphasic (ie, aphasia quotient <93.8) preoperatively showed significant postoperative improvements in both their mean aphasia quotient (from 81.8 to 89.1, p=0.004) and their mean language quotient (from 73.4 to 85.4, p=0.001), though 13 remained dysphasic. Two of the 25 dysphasic patients had their WAB scores lowered by tumour resection. The findings and postoperative changes in BNT scores were almost identical to the pattern of those in WAB scores. At second assessment, dexamethasone therapy was significantly (p<0.01) lower than preoperative dose (reduction from mean 10.3 mg/day to 0.7 mg/day in the dysphasic group). Patients with glioblastoma were more likely to have lower aphasia quotients, language quotients, and BNT scores than patients with anaplastic glioma, metastasis, or meningioma. Although the glioblastoma group had the greatest improvements in WAB operative scores, 57% remained dysphasic after resective surgery. Two additional patients declined postoperative assessment. INTERPRETATION: Resective surgery for left-sided intracranial tumours significantly improves language function in dysphasic patients, and is unlikely to impair language functions in non-dysphasic patients. Dysphasia and its response to resective surgery are related to the tumour neuropathology.

Aphasia↗
PubMed2003

The value of a second transurethral resection in evaluating patients with bladder tumours.

OBJECTIVES: To evaluate the usefulness of a second transurethral resection for superficial and muscle-invasive bladder tumours. METHODS: A review of the literature relevant to repeat resection for bladder tumours was conducted using Medline Services. RESULTS: Transurethral resection of the bladder has two shortcomings: underestimating clinical stage, and overlooking other lesions. A second transurethral resection, when performed 2-6 weeks after the initial resection, corrects clinical staging errors in 9-49% of cases and detects residual tumour in 26-83% of cases. A second resection is particularly warranted for T1 tumours since 2-28% of them prove to be muscle-invasive, thus requiring a change in management. For muscle-invasive tumours, a second resection may be performed only if bladder sparing is being considered, as it helps to exclude the presence of tumour sites contra-indicating conservative treatment. CONCLUSIONS: A second transurethral bladder resection may be warranted for T1 tumours, and for invasive tumours when a bladder preservation is planned.

Cystectomy↗
PubMed2000

Iterative surgical resections for local recurrent and second primary bronchogenic carcinoma.

OBJECTIVE: To report our experience with repeated pulmonary resection in patients with local recurrent and second primary bronchogenic carcinoma, to assess operative mortality and late outcome. METHODS: The medical records of all patients who underwent a second lung resection for local recurrent and second primary bronchogenic carcinoma from 1978 through 1998 were reviewed. RESULTS: There were 27 patients. They constituted 2.5% of 1059 patients who had undergone lung resection for bronchogenic carcinoma in the same period. Twelve patients (1.1%) (group 1) had a local recurrence that developed at a median interval of 24 months (range 4-83). The first pulmonary resection was lobectomy in ten patients and segmentectomy in two. The second operation consisted of completion pneumonectomy in ten cases, completion lobectomy in one and wedge resection of the right lower lobe after a right upper lobectomy in one. The other 15 patients (1.4%) (group 2) had a new primary lung cancer that developed at a median interval of 45 months (range 21-188). The first pulmonary resection was lobectomy in 12 patients, bilobectomy in one and pneumonectomy in two. The second pulmonary resection was controlateral lobectomy in seven patients, controlateral sleeve lobectomy in two, controlateral pneumonectomy in 1, controlateral wedge resection in four and completion pneumonectomy in one. Overall hospital mortality was 7.4%, including one intraoperative and one postoperative death in group 1 and 2, respectively. Five-year survival after the second operation was 15.5 and 43% with a median survival of 26 and 49 months in groups 1 and 2, respectively (P=ns). CONCLUSIONS: Long-term results justify complete work-up of patients with local recurrent and second primary bronchogenic carcinoma. Treatment should be surgical, if there is no evidence of distant metastasis and the patients are in good health. Early detection of second lesions is possible with an aggressive follow-up conducted maximally at 4 months intervals for the first 2 years and 6 months intervals thereafter throughout life.

Adenocarcinoma↗
PubMed2000

Therapeutic video-assisted thoracoscopic surgical resection of colorectal pulmonary metastases.

OBJECTIVE: Careful patient selection is vital when video-assisted thoracoscopic surgical (VATS) therapeutic pulmonary metastasectomy of colorectal carcinoma is considered. Complete resection of all metastatic disease remains a vital concept. We reviewed our VATS experience for therapeutic metastasectomy of peripheral colorectal pulmonary metastases. METHODS: Over 90 months, therapeutic VATS metastasectomy was accomplished upon 80 patients with colorectal metastases. Thin cut computed tomography (CT) was central in identifying lesions. The mean interval from primary carcinoma to VATS resection was 41 months (1-156 months; median, 33). A solitary lesion was resected in 60 patients and multiple (2-7) lesions resected in 20 patients. Statistics were obtained using the Student's t-test. RESULTS: No operative mortality or major postoperative complications occurred. The hospital stay was 4.5+/-2. 2 days (range, 1-13). All lesions were resected by VATS, with four conversions to thoracotomy to improve the margins. The mean survival of patients with one lesion was 34.8 months compared with 26.5 months for patients with multiple lesions (P=0.37). The mean survival was 20.5 months when metastases occurred <3 years vs. 28.1 months for >3 years from primary carcinoma resection (P=0.20). Twenty-five (31%) patients are disease free; with a mean interval of 38.7 (3-84; median, 35) months. Sixty-nine percent (55/80) of patients developed a recurrence: 6/80 (8%) local; 19/80 (24%) regional (same hemithorax away from resection); and 30/80 (38%) distant. The overall survival at 1 year was 81.2%, 48.4% at 3 years and 30.8% at 5 years. CONCLUSIONS: Therapeutic VATS resection of colorectal metastases appears efficacious. Preoperative CT can identify peripheral colorectal metastases amenable to VATS. Conversion to thoracotomy is indicated when none of the lesions identified by CT are found or when clear surgical margins are jeopardized.

Adult↗
PubMed2001

Frequency and mortality of acute lung injury and acute respiratory distress syndrome after pulmonary resection for bronchogenic carcinoma.

OBJECTIVE: We reviewed the frequency and mortality of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in our population of patients submitted to pulmonary resection for primary bronchogenic carcinoma. METHODS: From January 1993 to December 1999, a total of 1221 patients received pulmonary resection for primary bronchogenic carcinoma. Of these, 27 met the criteria of post-operative ALI/ARDS. There were 24 men and three women with a mean age of 64 years (range 45--79). Pre-operatively, predicted mean of PaO(2), PaCO(2) and %FEV1 were 72 mmHg (57--86), 37 mmHg (33--42) and 80% (37--114), respectively. Associated cardiac risk factors were present in eight patients. Three patients (11%) had pre-operative radiotherapy. Surgical-pathologic staging included 14 patients at Stage I, 8 patients at Stage II, four patients at Stage IIIa and one patient at Stage IIIb. RESULTS: ALI/ARDS occurred in 2.2% of our operated lung cancer patients. ALI was diagnosed in 10 patients and ARDS in 17 patients. The mean time of presentation following surgery was 4 days (range 1--10) and 6 days (1--13) for ALI and ARDS, respectively. According to the type of operation, the frequency was highest following right pneumonectomy (4.5%), followed by sublobar resection (3.2%), left pneumonectomy (3%), bilobectomy (2.4%), and lobectomy (2%). The frequency following extended operations was 4%. No differences were found between the ALI/ARDS group and the total population of resected lung cancer patients (control group) with respect to sex, mean age, pre-operative blood gases, %FEV1, surgical--pathologic staging and the use of pre-operative radiotherapy. Four patients with ALI (40%) and 10 patients with ARDS (59%) died. Mortality was highest following right pneumonectomy, extended operations and sublobar resections. Hospital mortality of the total population of operated lung cancer patients in the same period was 2.8% (34 patients). ALI/ARDS accounted for 41% of our hospital mortality. CONCLUSIONS: (1) ALI/ARDS is a severe complication following resection for primary bronchogenic carcinoma. (2) We did not detect any significant difference between the ALI/ARDS group and the control group regarding age, pre-operative lung function, staging and pre-operative radiotherapy. (3) ALI/ARDS is associated with high mortality, the highest mortality rates having been observed following right pneumonectomy and extended operation; it currently represents our leading cause of death following pulmonary resection for lung carcinoma. (4) ALI/ARDS may also occur after sublobar resections with an associated high mortality rate.

Carcinoma, Bronchogenic↗
PubMed2003

Unsuspected residual disease at the resection margin after surgery for lung cancer: fate of patients after long-term follow-up.

OBJECTIVE: This retrospective study evaluates the survival impact of the residual margin disease after bronchial resection for cancer and suggests tactics in cases of microresidual disease. METHODS: Between March 1988 and 1998, 4530 consecutive patients underwent surgery for non-small cell lung cancer at our institution. Only incomplete resections after microscopic evaluation (R1) were included in the study. Residual tumour cells were found on the bronchial resection margins of 39 lobectomies, 12 pneumonectomies, 4 segmental resections and one bilobectomy. Histological findings were: squamous cell carcinoma in 38 cases, adenocarcinoma in 15 and large cell carcinoma in three. In all 56 cases, invasive mucosal carcinoma was found exclusively on the bronchial resection margin. Nineteen tumours were stage I; 12, stage II; 17, stage IIIa; 5, stage IIIb; and three, stage IV. Nineteen patients (59.3%) with early stage tumours (I and II) received adjuvant radiation therapy and only three chemotherapy. RESULTS: The prognosis in these cases was disease-stage related (21 and 38.4% of deaths due to the disease). Forty-one percent of the stage IIIa patients received radiation therapy and 17.6% chemotherapy: 70.6% died of tumour relapse. Forty percent of the stage IIIb patients received radiation therapy and 20% chemotherapy: 60% died of disease progression. All of the stage IV patients died within 3 months from surgical resection. At the end of the study, 21 patients were alive after an interval of 22-142 months (18 in stage I or II). The 10-year actuarial survival rate was 44%. The percentage survival for stage IIIa was 16.8, after 10 years, and fell to 45 months for stage IIIb. CONCLUSIONS: The prognosis of our stage I or II patients with microresidual tumour on the bronchial resection margin (R1) was similar to that of the patients in the same disease stage, whose resection was microscopically radical (R0) and the same was true of the patients in stage III. In patients with residual tumour cells on the bronchial stump we did not observe worsened long-term survivals.

Adenocarcinoma↗
PubMed1997

The use of videoassisted thoracic surgery in lung cancer: evaluation of resectability in 296 patients and 71 pulmonary exeresis with radical lymphadenectomy.

OBJECTIVE: To outline the usefulness of videothoracoscopic and videoassisted surgery in the final staging, resectability evaluation and treatment of lung cancer, and its possible advantages over thoracotomy. PATIENTS AND METHOD: Videothoracoscopy was performed on 296 patients suffering from lung cancer. Patient selection criteria are described, as well as techniques for the different kinds of resections. Postoperative care and patient follow-up is also detailed. RESULTS: Of the 296 patients 189 were operated on by open surgery after final staging and resectability evaluation. A total of 30 were considered unresectable by videothoracoscopic exploration, five cases needed exploratory thoracotomy to determine the resectability and in the remaining 72 cases the pulmonary resection was performed by videoassisted surgery: 21 pneumonectomies, five bilobectomies and 46 lobectomies. Three patients were rescued for surgery, after it was proven by intrapericardical videothoracoscopic exploration that the pulmonary artery was free at this level. The mean hospital stay was 48 h for the videothoracoscopic exploration and 6.8 days for the major lung resections. There were ten patients with complications (14%). The perioperatory mortality (30 days) was three cases (4.2%). The outcome (3-40 months follow-up) at the end of the study period was 62% patients alive and free of disease. DISCUSSION: The applications of videothoracoscopic and videoassisted surgery in the treatment of lung cancer are considered: final staging, resectability evaluation, nodule biopsy and major resections with mediastinal lymphadenectomy. Their advantages include minimized pain, better cosmetic results, a shorter hospital stay and fewer complications.

Adult↗
PubMed2001

Bowel resection at the time of primary cytoreduction for epithelial ovarian cancer.

BACKGROUND: The purpose of this study was to determine the morbidity and survival associated with bowel resection at the time of primary cytoreductive surgery for ovarian cancer. STUDY DESIGN: We reviewed all patients undergoing bowel resection by gynecologic oncology faculty at the time of primary cytoreduction for advanced epithelial ovarian cancer diagnosed between 1983 and 1995. RESULTS: There were 105 patients meeting the above criteria. The median age was 65 years (range 34 to 85 years). There were 76 stage III and 25 stage IV cancers. The primary indication for bowel resection was tumor debulking in 92% of the patients. Seventy patients had segmental resection of the colon only, and 22 patients underwent resections that included the large and small bowels. Mean operating time was 260 minutes and mean estimated blood loss was 1,447 mL. Thirty-three (31%) patients were optimally cytoreduced to less than 1 cm residual disease. Ten patients experienced major complications directly related to bowel resection, including bowel fistula (4 patients), early postoperative bowel obstruction (5 patients), and stomal hernia (1 patient). Other morbidity included ileus for more than 10 days (18 patients), cardiac complications (17 patients), pneumonia (8 patients), sepsis (5 patients), and thromboembolism (4 patients). Six patients died and five patients required reexploration within 30 days of operation. Patients with preoperative bowel obstruction and suboptimal residual disease were more likely to have postoperative morbidity. Median survival in the optimally debulked patients was 35 months compared with 18 months in patients suboptimally cytoreduced (p = 0.006). Multivariate analysis demonstrated that optimal debulking (p = 0.009) and platinum chemotherapy (p = 0.00006) were independently associated with improved survival. Age, International Federation of Gynecologia Oncologists stage, American Society of Anesthesiologists class, and paclitaxel chemotherapy did not influence survival. CONCLUSIONS: In patients undergoing bowel resection at the time of primary cytoreduction for ovarian cancer, optimal cytoreduction to less than 1 cm residual disease results in improved survival. Morbidity is common but is comparable to other published series of ovarian cancer patients undergoing primary cytoreductive surgery without bowel resection. Additionally, patients with preoperative bowel obstruction and suboptimal residual disease are more likely to have serious morbidity.

Adult↗
PubMed2002

Selection criteria for hepatic resection in patients with large hepatocellular carcinoma larger than 10 cm in diameter.

BACKGROUND: The role of hepatic resection for large hepatocellular carcinoma (HCC) larger than 10 cm remains unclear. STUDY DESIGN: Perioperative and longterm outcomes of 120 patients with HCC larger than 10 cm who underwent resection (group A) were compared with 368 patients with smaller HCC (group B). The prognostic factors in group A were analyzed. RESULTS: A higher proportion of patients underwent major hepatic resection in group A than in group B (90% versus 57.6%, p = 0.001), but the hospital mortality was similar (5.0% versus 4.6%, p = 0.874). Group A had worse longterm overall survival (median 18.8 months versus 62.8 months, p < 0.001) and disease-free survival (median 5.5 months versus 25.4 months, p < 0.001) than group B. Macroscopic residual tumor, macroscopic venous invasion, and multiple tumors were identified as independent prognostic factors in group A. The median survival of patients with residual tumor and those with curative resection was 7.7 months and 20.8 months, respectively. The median survival of patients with curative resection of solitary HCC larger than 10cm without macroscopic venous invasion was 38.0 months; that of patients with both macroscopic venous invasion and multiple tumors was only 10.5 months. CONCLUSIONS: Hepatic resection is a safe and effective treatment for HCC larger than 10cm when liver function reserve is satisfactory and when curative resection can be expected. Patients with solitary HCC larger than 10cm without macroscopic venous invasion can enjoy longterm survival after surgery, and we propose hepatic resection as a standard treatment for this group of patients.

Carcinoma, Hepatocellular↗
PubMedDate not supplied

Rationale for the combination of cryoablation with surgical resection of hepatic tumors.

Only 5% to 10% of metastatic and primary liver tumors are amenable to surgical resection. Hepatic cryoablation has increased the number of patients who are suitable for curative treatment. The aim of this study was to evaluate survival and intrahepatic recurrence in patients treated with cryoablation and resection. From June 1994 to July 1999, thirty-eight surgically unresectable patients underwent a total of 42 cryoablative procedures for 65 malignant hepatic lesions. Twenty patients underwent cryoablation alone, and 18 patients were treated with a combination of resection and cryoablation, with a minimum of 18 months' follow-up. The 38 patients had the following malignancies: primary hepatocellular carcinoma (n = 8) and metastases from colorectal cancer (n = 21), neuroendocrine tumors (n = 3), ovarian cancer (n = 3), leiomyosarcoma (n = 1), testicular cancer (n = 1), and endometrial cancer (n = 1). Patients were evaluated preoperatively with spiral CT scans and intraoperatively with ultrasound examinations for lesion location and cryoprobe guidance. Local recurrence was detected by CT. Major complications included bleeding in three patients and acute renal failure, transient liver insufficiency, and postoperative pneumonia in one patient each. Two patients (5%) died during the early postoperative interval; mean hospital stay was 7.1 days. Median follow-up was 28 months (range 18 to 51 months). Overall survival according to Kaplan-Meier analysis was 82%, 65%, and 54% at 12, 24, and 48 months, respectively. Forty-eight-month survival was not significantly different between those patients undergoing cryoablation alone (64%) and those treated with a combination of resection and cryoablation (42%). Disease-free survival at 45 months was 36% for patients undergoing cryoablation plus resection compared to 25% for those undergoing cryoablation alone. Local recurrences were detected at five cryosurgical sites, for a rate of 12% overall (5 of 42), 11% (2 of 18) for patients in the cryoablation plus resection group, and 12% (3 of 24) for those in the cryoablation alone group. For patients with colorectal metastases, survival was 70% at 30 months compared to 33% for hepatocellular cancer and 66% for other types of tumors. Patients with tumors larger than 5 cm or numbering more than three did not have significantly decreased survival. Cryoablation of hepatic tumors is a safe and effective treatment for some patients not amenable to resection. The combination of cryoablation and resection results in survival comparable to that achieved with cryoablation alone.

Adult↗
PubMedDate not supplied

Results of salvage abdominoperineal resection for recurrent anal carcinoma following combined chemoradiation therapy.

Combined chemotherapy and radiation therapy is the standard treatment for epidermoid carcinoma of the anal canal. Failures are often not associated with distant recurrence and are therefore potentially amenable to salvage abdominoperineal resection. The aim of this study was to review our experience with abdominoperineal resection following failure of chemoradiation therapy for epidermoid carcinoma of the anus. Between 1980 and 1998, 17 patients underwent salvage abdominoperineal resection following failure of chemoradiation therapy. Four patients were excluded from survival analysis because resection was performed with palliative intent. Survival curves were based on the method of Kaplan and Meier, and univariate analysis of predictive variables was performed using the log-rank test. Twelve patients underwent abdominoperineal resection for persistent disease and five patients for recurrent disease. No operative deaths occurred, but local complications including perineal wound infection and wound breakdown was seen in 8 of 17 patients and 6 of 17 patients, respectively. Patients undergoing omental flap reconstruction (n = 3) or no pelvic reconstruction (n = 5) had a higher incidence of perineal breakdown compared to those undergoing muscle flap reconstruction (n = 9) (P <0.05). The median follow-up time for the patients operated on with curative intent was 53 months. The 5-year actuarial survival was 47%. Potential prognostic factors that were not found to have an impact on survival included margin status of resection, sphincter invasion, and degree of differentiation. Only pathologic tumor size greater than 5.0 cm (P <0.001) and age over 55 years (P <0.05) adversely affected survival. Selected patients with recurrent or persistent anal carcinoma following chemoradiation therapy can be offered salvage abdominoperineal resection. This operation is associated with a high incidence of local wound complications, and muscle flap reconstruction should be considered when possible. Prolonged survival can be achieved in some patients following salvage resection for epidermoid carcinoma of the anal canal.

Anus Neoplasms↗
PubMedDate not supplied

Should hepatic resections be performed at high-volume referral centers?

Recent studies have demonstrated the relationship between clinical outcomes of complex surgical procedures and provider volume. Hepatic resection is one such high-risk surgical procedure. The aim of this analysis was to determine whether mortality and cost of performing hepatic resection are related to surgical volume while also examining outcomes by extent of resection and diagnosis, variables seen with this procedure. Maryland discharge data were used to study surgical volume, length of stay, charges, and mortality for 606 liver resections performed at all acute-care hospitals between January 1990 and June 1996. One high-volume provider accounted for 43.6% of discharges, averaging 40.6 cases per year. In comparison, the remainder of resections were performed at 35 other hospitals, averaging 1.5 cases per year. Data were stratified into these high- and low-volume groups, and adjusted outcomes were compared. The mortality rate for all procedures in the low-volume group was 7.9% compared to 1.5% for the high-volume provider (P <0.01, relative risk = 5.2). No overall differences were observed between low- and high-volume providers in total hospital charges. When analyzing by procedure type and diagnosis, lower mortality was seen in the high-volume center for both minor and major resections, as well as resections for metastatic disease. It was concluded that hepatic resection can be performed more safely and at comparable cost at high-volume referral centers.

Black People↗
PubMed2003

[Intraoperative cortical mapping in the surgical resection of low-grade gliomas located in eloquent areas].

INTRODUCTION: Surgical selection of patients harboring low-grade gliomas based on radiological criteria may be insufficient due to individual variability in eloquent areas location and to the fact that function can be preserved within infiltrated brain tissue. Brain stimulation mapping safety for patients with low-grade gliomas is evaluated, analyzing whether this technique modifies the extent of resection and minimizes postoperative deficits. MATERIAL AND METHODS: Twenty-five patients with lowgrade gliomas (II/IV WHO) located in eloquent areas underwent tumor resection with the aid of intraoperative mapping. Patients underwent surgery under local or general anesthesia depending on the neurological function to be explored. All procedures were performed from an oncological point of view, trying to achieve a radical tumor resection but stopping removal whenever functional tissue was found within or near the lesion. RESULTS: Total or subtotal resection was achieved in 16 patients (64%); in five cases (20%) resection was partial, and in the remaining (16%) only a biopsy was obtained. Tumors located in the supplementary motor area (SMA) or in the operculum were those which could be more often totally resected. Thirteen patients (52%) experienced neurological worsening immediately after surgery but eight of them had almost completely recovered six months after the procedure. CONCLUSIONS: Intraoperative functional mapping can optimize extent of resection minimizing permanent morbidity. Functional tissue can be found within the infiltrated brain and this must be considered in the presurgical planning. SMA and opercular tumors allow radical resection with low morbidity whereas insular tumors remain a challenge even with the aid of this technique.

Adult↗
PubMed1998

Qualitative changes in enteric flora and short-chain fatty acids after intestinal resection.

Our aim was to determine the effect of intestinal transection and resection on the prevalence of enteric flora and evaluate whether any such changes alter luminal SCFA and lactic acid content. Dogs underwent either 50% proximal (PR, N = 6) or distal (DR, N = 7) resection, distal resection with bypass of the ileocecal junction (DRBP, N = 9) or midpoint transection alone performed to serve as the appropriate control for luminal sampling for either proximal (PTC, N = 6) or distal (DTC, N = 7) resection. Studies were performed every four weeks for 12 weeks. Both jejunum and ileum had >10(5)/ml aerobic bacteria, most commonly E. coli. Streptococcal species were more common in the normal jejunum than ileum but were found in the ileal remnant after PR. Significant (>10(5)) anaerobic growth occurred infrequently in the jejunum, and DR did not increase anaerobic growth in jejunum unless DRBP was performed (93% vs 62% DR, 45% DTC, 20% normal jejunum, P < 0.05). Clostridium species increased significantly in the jejunal remnant after DRBP. Significant anaerobic growth occurred infrequently in normal ileum but increased after PR (89% vs 50% PTC, P < 0.05). Flora normally found in the jejunum tended to increase in the ileum after PR. Jejunal SCFA increased after DRBP (3126 +/- 577 microg/ml vs 1600 +/- 301 DTC, P < 0.05) but not DR (1791 +/- 321 microg/ml). Significant (>10(5)) anaerobic bacterial growth was associated with increased SCFA content (2717 +/- 381 vs 1029 +/- 170 microg/ml, P < 0.05) and the presence of lactic acid (30% vs 5%, P < 0.05), but there was no correlation between the presence of specific bacteria and SCFA and lactic acid. Following resection of the proximal small intestine, the intestinal remnant tends to assume the bacteriologic characteristics of the resected segment. Following a distal resection, the presence of an intact ICJ protects against the proliferation of a flora characteristic of the distal intestine; resection with bypass of the ICJ results in the appearance of coliforms in the jejunal remnant. These changes in enteric flora do not correlate with content of specific SCFA and lactic acid in the small intestine.

Animals↗
PubMed2000

Craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex.

OBJECTIVE: Resection or even biopsy of an intra-axial mass lesion in close relationship to eloquent cortex carries a major risk of neurological deficit. We have assessed the safety and effectiveness of craniotomy under local anesthesia and monitored conscious sedation for the resection of tumors involving eloquent cortex. METHODS: We have performed a retrospective review of a consecutive series of 157 adult patients who underwent craniotomy under local anesthesia by one surgeon (P.M.B.) at Brigham and Women's Hospital in Boston. All patients had tumors in close proximity to eloquent cortex, including speech, motor, primary sensory, or visual cortex. In most cases the lesion was considered inoperable by the referring surgeon. All resection was verified by post-operative imaging approximately one month after surgery and all cases were reviewed by an independent neurosurgeon (A.D.). RESULTS: In 122 cases, brain mapping was performed to identify eloquent cortex and in the remainder neurological monitoring was maintained during the procedure. Radiological gross total resection was achieved in 57% of patients and greater than 80% resection was achieved in 23%. Thus 4 out of 5 of patients had major resection despite the close relationship of tumor to eloquent cortex. In 13%, less than 80% of tumor was removed because of danger of neurological deficit. In 7% of patients, only a biopsy could be done because of infiltration into eloquent cortex that could only be assessed at surgery. In 76 patients with pre-operative neurological deficits, there was complete resolution of these deficits in 33%, improvement in 32%, no change in 28%, and long-term worsening in 8%. Among 81 patients with no pre-operative neurological deficit, 1 patient suffered a major permanent neurological deficit, and 2 developed minor deficits. There was a transient post-operative deficit in one-third of cases, but this had resolved at one month in all but three patients. Monitored conscious sedation was performed without anesthetic complications using midazolam, sufentanyl and fentanyl with or without propofol. Only one case needed to be converted to general anesthesia. Patient satisfaction with the procedure has been good. Operating time and hospital stay were lower than the mean for brain tumor craniotomy at this hospital. CONCLUSIONS: Tumor surgery with conscious sedation is a safe technique that allows maximal resection of lesions in close anatomical relationship to eloquent cortex, with a low risk of new neurological deficit. Only 7% of intrinsic cortical tumors were ineligible for partial or complete resection with this technique.

Adolescent↗
PubMed2001

[Resection of liver metastases--goal, timing and results].

If left to run their natural course, numerous malignant diseases will eventually produce liver metastases. Without treatment, afflicted patients have a life expectancy of only eight months. At the present time, the only therapeutic option that offers the patient with liver metastases from colorectal carcinoma the chance of a cure is resection of the metastases. Depending on the primary tumour, this also applies to some patients with carcinomas at sites other than the colorectum. A point of continuing controversy is the timing of such resection. While some authors recommend a test 'of time' ranging from several weeks to months, others call for resection of the metastases immediately after their detection. Solitary synchronous liver metastases involving only a single segment can be resected at the same time as surgical treatment of the primary when, in particular, the surgical access is readily possible and the risk of complications calculable. Most authors advocate surgery in two sessions. The location, number and size of the metastases, together with the presence of concomitant diseases, provide the basis for the decision to perform a resection. At the same time, however, the risk to the patient must be within justifiable limits. This applies in particular to non-colorectal, non-endocrine metastases. Following curative resection of colorectal hepatic metastases, 25-51% of the patients are still alive after 5 years. During the same period, some 51-76% of the patients develop a recurrence. From these data, the calculated resulting median survival for all patients undergoing resection is roughly 30 months. A tumour-free 5-year survival rate of up to 34% is achieved. In view of their different clinical course and prognosis, non-colorectal liver metastases should be classified into non-colorectal neuroendocrine (NCNE) and non-colorectal non-endocrine (NCNN) metastases. While the former group has a 5-year survival rate following curative resection of up to 62%, the figure for the latter group is only 15-35%.

Colorectal Neoplasms↗
PubMed1978

Recovery of immune competence after tumour resection in mice: correlation with loss of suppressor elements.

Changes in the immune competence and levels of suppressore elements were assessed by mitogen stimulation and in vitro antibody production, after resection of a transplantable sarcoma. Spleen cells from tumour-resected animals were found to have depressed responses to conA as well as to the antigens SRBC and DNP-LPS. This inability to respond was gradually overcome and, by Day 21 after resection, spleen cell competence had returned to normal levels. Suppressor cells isolated from the spleens of tumour-resected animals were capable of suppressing the conA response and PFC response of normal syngeneic spleen cells in vitro. The ability to suppress the conA response of normal cells disappeared by Day 1 after resection, while the ability to suppress the anti-SRBC and anti-DNP PFC response of normal cells disappeared by Day 8 and Day 14 respectively. Serum from tumour-resected mice was also found to be suppressive to the conA response of normal spleen cells. The inhibitory material responsible for suppression eluted with the Ig-containing fraction on Sephadex G-150. This inhibitory material gradually disappeared from the serum of tumour-resected mice and was no longer apparent by Day 14. Therefore, it appeared that the return of normal lymphocyte function after tumour-resection was concomitant with the disappearance of splenic suppressor cells and suppressive serum factor.

Animals↗
PubMed2003

Neoadjuvant treatment of hepatic malignancy: an oncolytic herpes simplex virus expressing IL-12 effectively treats the parent tumor and protects against recurrence-after resection.

The objective of the study was to evaluate the utility of NV1042, a replication competent, oncolytic herpes simplex virus (HSV) containing the interleukin-12 (IL-12) gene, as primary treatment for hepatic tumors and to further assess its ability to reduce tumor recurrence following resection. Resection is the most effective therapy for hepatic malignancies, but is not possible in the majority of the patients. Furthermore, recurrence is common after resection, most often in the remnant liver and likely because of microscopic residual disease in the setting of postoperative host cellular immune dysfunction. We hypothesize that, unlike other gene transfer approaches, direct injection of liver tumors with replication competent, oncolytic HSV expressing IL-12 will not only provide effective control of the parent tumor, but will also elicit an immune response directed at residual tumor cells, thus decreasing the risk of cancer recurrence after resection. Solitary Morris hepatomas, established in Buffalo rat livers, were injected directly with 10(7) particles of NV1042, NV1023, an oncolytic HSV identical to NV1042 but without the IL-12 gene, or with saline. Following tumor injection, the parent tumors were resected and measured and the animals were challenged with an intraportal injection of 10(5) tumor cells, recreating the clinical scenario of residual microscopic cancer. In vitro cytotoxicity against Morris hepatoma cells was similar for both viruses at a multiplicity of infection of 1 (MOI, ratio of viral particles to target cells), with >90% tumor cell kill by day 6. NV1042 induced high-level expression of IL-12 in vitro, peaking after 4 days in culture. Furthermore, a single intratumoral injection of NV1042, but not NV1023, induced marked IL-12 and interferon-gamma (IFN-gamma) expression. Both viruses induced a significant local immune response as evidenced by an increase in the number of intratumoral CD4(+) and CD8(+) lymphocytes, although the peak of CD8(+) infiltration was later with NV1042 compared with NV1023. NV1042 and NV1023 reduced parent tumor volume by 74% (P<.003) and 52% (P<.03), respectively, compared to control animals. Treatment of established tumors with NV1042, but not with NV1023, significantly reduced the number of hepatic tumors after resection of the parent tumor and rechallenge (16.8+/-11 (median=4) vs. 65.9+/-15 (median=66) in control animals, P<.025). In conclusion, oncolytic HSV therapy combined with local immune stimulation with IL-12 offers effective control of parent hepatic tumors and also protects against microscopic residual disease after resection. The ease of use of this combined modality approach, which appears to be superior to either approach alone, suggests that it may have clinical relevance, both as primary treatment for patients with unresectable tumors and also as a neoadjuvant strategy for reducing recurrence after resection.

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