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PubMed1997

[The indications and choice of the technic for pancreatic resections].

The progress of pancreatic surgery naturally leads to broadening the scope of indications for resection of the gland. Over the period 1970 through 1993, in the Clinic of Abdominal Surgery are performed 99 pancreatic resections for carcinoma of the pancreas (including cancer of papilla Vateri (45), endocrine-active tumor of pancreas (5), benign tumor (1), chronic pancreatitis (4), pseudocysts of the pancreas (4), cancer of an adjacent organ infiltrating the pancreas (36), benign lesions to a neighbouring organ (4). The size of resection depends on a number of factors of which location of the neoplasm and stage of the disease are the leading ones. Operations done: duodenopancreatic resection--47, left side hemipancreatectomy--13, resection of the body region and tail of pancreas--14, and partial resection--19. The choice of operative technique is discussed against the background of the variety of indications for pancreatic resection. Special attention is focused on the operative technique used in pancreatoduodenal resection. The practicability of performing pylorus-preserving intervention, the need of vagotomy and its scope are precisely determined. Also discussed are issues relating to the choice of organ for anastomosis with the pancreas and its protection, as well as the variants of successiveness of anastomoses with the biliary canal, residual pancreas and stomach. Morbidity and mortality rates show a decrease parallel to the surgical experience gained.

Bulgaria↗

PubMed1998

[Resection of the trachea and bifurcation in newborn infants and children].

From 1973 to 1994, 38 tracheal and/or bifurcation resections were performed in 37 children aged 1 month to 18 years. Twenty-four children had an acquired stenosis, 8 a congenital and 5 a combined stenosis. In 16 children, the stenosis was located in the lower trachea or bifurcation. Other malformations were found in 12 children. The most common intervention was the trachea segment resection in 30 patients; resection of the cricoid cartilage was performed in another 6 cases. The resection was expanded to the bifurcation 5 times, 1 being a left sleeve pneumonectomy. The extent of resection was between 10 and 50 mm. In the 22 children with resections of the upper and middle trachea, 96% were decannulated with 0% morbidity. In the 15 children with distal resections, decannulation was performed in 87% with 6% morbidity. There were no recurrent stenoses caused by growth disorder. With interdisciplinary cooperation, single-session resection is a safe procedure.

Adolescent↗

PubMed2026

Endoscopic mucosal resection with precutting vs. anchoring technique using snare tip for 10-25 mm nonpedunculated colorectal polyps: a randomized controlled trial.

BACKGROUND AND AIMS: Modified endoscopic mucosal resection (EMR) techniques using a snare tip, precutting EMR (P-EMR) and anchoring EMR (A-EMR), have been developed for the effective resection of nonpedunculated colorectal polyps measuring 10-25 mm. Although previous studies have compared either P-EMR or A-EMR with conventional EMR, no study has directly compared these two snare tip-assisted techniques within modified EMR. This study aimed to evaluate P-EMR and A-EMR in terms of the R0 resection rate and procedure duration. METHODS: This prospective randomized controlled trial enrolled patients with nonpedunculated colorectal polyps measuring 10-25 mm. The patients were randomly assigned to the P-EMR or A-EMR groups. The primary outcome was R0 resection rate, defined as en bloc resection with histologically tumor-free margins. Secondary outcomes included the injection-to-snaring time, total procedure time, and adverse events. RESULTS: Each group included 63 polyps, of which 126 were analyzed in the final evaluation. Both groups achieved high R0 resection rates (93.7% for P-EMR and 88.9% for A-EMR), with no significant difference ( P  = 0.344). However, the A-EMR group demonstrated significantly shorter injection-to-snaring time (181.8 ± 81.9 vs. 320.9 ± 143.5 s, P  < 0.001) and total procedure time (259.7 ± 139.7 vs. 479.8 ± 249.0 s, P  < 0.001). Adverse events, including intraprocedural and delayed bleeding, were comparable between the groups. CONCLUSION: Both P-EMR and A-EMR demonstrated high R0 resection rates for nonpedunculated polyps measuring 10-25 mm. However, A-EMR achieved these outcomes with a shorter procedure time than P-EMR.

Humans↗

PubMed2001

Clinical evaluation of a newly developed endoscopic resection device (Rotoresect): physical principle and first clinical results.

BACKGROUND: Endoscopic resection techniques on benign prostatic tissue aim at a high ablation rate and a minimal bleeding rate. Although commercial resection electrodes are effective, they either cause high blood loss (loop electrode) or reduce the bleeding rate with a compromised ablation rate (electrovaporization electrode). To resolve these problems, a new electrosurgical resection device, The Rotoresect, has been developed. METHODS: The Rotoresect incorporates a specially designed working element. The resection electrode is driven by a micromotor with a high-frequency current that enables simultaneous coagulation and vaporization during rotoresection. To date, 40 patients with benign prostatic hyperplasia have undergone transurethral rotoresection of the prostate with this new device. RESULTS: The actively rotating resection electrode enables tissue coagulation and vaporization as well as mechanical tissue ablation. Only slight bleeding was observed during the entire resection procedure. Postoperatively, no significant changes in hemoglobin and sodium concentration were detected. The deobstructive effect of the Rotoresect was comparable to that of the standard loop. CONCLUSIONS: The simultaneous tissue vaporization, coagulation, and mechanical removal by the Rotoresect enables a high ablation rate combined with minimal blood loss. Initial clinical results gained in the transurethral resection of benign prostatic tissue are promising.

Aged↗

PubMed2002

Transurethral prostate resection and bleeding: a randomized, placebo controlled trial of role of finasteride for decreasing operative blood loss.

PURPOSE: Bleeding associated with transurethral prostate resection can often be significant and lead to increased morbidity and occasionally mortality. It has been shown that finasteride decreases bleeding in patients with hematuria of prostatic origin. We hypothesized that bleeding in patients undergoing transurethral prostate resection could be decreased by giving finasteride for 2 weeks before surgery. MATERIALS AND METHODS: A total 70 patients scheduled to undergo elective transurethral prostate resection were randomized to receive 5 mg. finasteride daily or placebo for 2 weeks before surgery. Serum hemoglobin was measured before and after surgery, and the following day. The volume of irrigation fluid used and its hemoglobin concentration as well as resected prostate weight were recorded. RESULTS: Of the 68 patients who underwent transurethral prostate resection 2 were withdrawn before surgery, and so 32 received finasteride and 36 received placebo. There was significantly less mean blood loss in irrigation fluid in the finasteride group than in the control group (43.6 versus 69.3 gm. hemoglobin, p = 0.011). The mean difference was more significant when blood loss per gm. resected prostate was calculated (2.65 versus 4.65 gm. hemoglobin per gm. prostate, p < 0.01). CONCLUSIONS: This study shows that finasteride given for 2 weeks preoperatively decreases bleeding in patients undergoing transurethral prostate resection. Further study is required to determine the optimal timing and dose duration to minimize blood loss and identify how relevant such a decrease in bleeding is in clinical practice.

Aged↗

PubMed2005

Bipolar versus monopolar transurethral resection of prostate: randomized controlled study.

BACKGROUND AND PURPOSE: Transurethral resection of prostate (TURP) using bipolar electrocautery and physiologic saline is a new technical advancement in the field of surgical management of benign prostatic hyperplasia. The purpose of this study was to assess the efficacy and safety of this new technique and to compare the results with those of conventional monopolar TURP. PATIENTS AND METHODS: This study included 60 patients who were randomized 1:1 to bipolar (group 1) or monopolar (group 2) TURP. Bipolar TURP was performed with the Vista CTR resectoscope and generator (ACMI Corp.). Preoperatively, patients were assessed by symptom score, uroflow, and transrectal sonography, and the two groups were comparable with regard to these measures and age. The preoperative and postoperative parameters studied included resection time, amount of tissue resected, irrigant amount, blood loss, fluid absorption, and change in serum sodium and hemoglobin. Postoperatively, patients were assessed for symptoms, symptom score, and uroflow rate at 1 and 3 months. RESULTS: There was no difference in resected tissue amount, irrigant amount, fluid absorption, duration and amount of postoperative irrigation, or fall in hemoglobin. The mean resection rate was 0.61 g/min in group 1 and 0.74 g/min in group 2. Serum Na dropped by 4.6 Eq/L in group 2, whereas it fell only 1.2 mEq/L in group 1 (P < 0.001). Improvement in symptom and QoL scores and Q(max) were similar in the two groups. Postoperative dysuria was less common with bipolar resection. CONCLUSION: Bipolar resection of the prostate is as effective as monopolar TURP. Moreover, it does not lead to any change in serum Na and causes less postoperative dysuria.

Aged↗

PubMed2002

Correlations of urodynamic changes with changes in symptoms and well-being after transurethral resection of the prostate.

PURPOSE: To establish the predictive value of urodynamics on the outcome of transurethral prostate resection for benign prostatic enlargement we correlated urodynamic changes with symptomatic improvement, decreased bother, and increased general well-being and quality of life after transurethral prostate resection. MATERIALS AND METHODS: Men with lower urinary tract symptoms were selected if they met study criteria and underwent tests recommended by the International Scientific Committee on Benign Prostatic Hyperplasia, and if post-void residual urine volume and prostate size were estimated. Patients answered quality of life, symptom index, symptom problem index and benign prostatic hyperplasia impact index questions. Patients also underwent urodynamic evaluation. Men were included in analysis when transurethral prostate resection was selected as the treatment modality. Of the 132 patients included 93 were reevaluated 6 months after transurethral prostate resection. RESULTS: Improvements after transurethral prostate resection were significantly associated with decreased bladder outlet obstruction (p <0.01). However, 32 cases that were unobstructed or equivocal preoperatively also benefited moderately from resection. Effective capacity, that is cystometric capacity minus post-void residual urine volume, increased by an average of 45% postoperatively. The increase in effective capacity contributed to a significant decrease in symptoms and bother, and to improved well-being. Of the men with a urodynamically proved stable bladder 90% maintained a stable bladder after prostatectomy, while in 50% with a urodynamically proved unstable bladder it became stable postoperatively. CONCLUSIONS: Performing urodynamics preoperatively helps to predict the degree of symptom relief, decreased bother and increased well-being after transurethral prostate resection.

Aged↗

PubMed2004

Face, content and construct validity of the University of Washington virtual reality transurethral prostate resection trainer.

PURPOSE: We examined the face, content and construct validity of version 1.0 of the University of Washington transurethral prostate resection (TURP) trainer. MATERIALS AND METHODS: Version 1.0 of a virtual reality based simulator for transurethral skills was developed at our laboratory by integrating TURP hardware with our virtual 3-dimensional anatomy, irrigation control, cutting, bleeding and haptics force feedback. A total of 72 board certified urologists and 19 novices completed a pre-task questionnaire, viewed an introductory training video and performed a pre-compiled 5-minute resection task. The simulator logged operative errors, gm resected, blood loss, irrigant volume, foot pedal use and differential time spent with orientation, cutting or coagulation. Trainees and experts evaluated the simulator on a modified likert scale. The 2-tailed Levene t test was used to compare means between experts and novices. RESULTS: Overall version 1.0 content was between slightly and moderately acceptable. Experts spent less time with orientation (p < 0.0001), resected more total tissue (p < 0.0001), had more gm resected per cut (p = 0.002) and less blood loss per gm resected (p = 0.032), used less irrigant per gm resected (p = 0.02) and performed fewer errors (p < 0.0001) than novices. CONCLUSIONS: We established the face, content and construct validity for version 1.0 of the University of Washington TURP trainer to simulate the skills necessary to perform TURP. A predictive validity study showing a translation of skills from the virtual environment to the operating room will complete the validation of this model.

Adult↗

PubMed2000

[Experiences with routine monitoring of ethanol concentration in expired air in transurethral prostate resection].

During transurethral resection of the prostate (TURP), systemic influx of hypotonic irrigating fluid is a life-threatening event. Its occurrence can lead to TUR syndrome. Addition of ethyl alcohol to the irrigating fluid and analysis of alcohol concentration in the expiratory breath constitute a simple but sensitive monitoring technique for early detection of an influx event and its extent. Clinical experience with this method in 50 patients who underwent TURP is reported. The following parameters were determined: heart beats per minute (heart rate), mean arterial pressure, sodium concentration in the serum, duration of resection, and weight of resected tissue. At 10-min intervals, the alcoholic concentration of the expiratory breath of each patient was measured with the AlcoMed 3011 analyzer (Biotest, Dreieich, Germany). Active measurement was possible in 40 patients, and a passive analytic procedure was used in 5 other patients in whom general anaesthesia was induced. In the remaining 5 patients, the monitoring could not be performed because of a medical history of significant alcohol abuse. A suprapubic trokar was used to decrease intravesical pressure in 16 patients. In 8 of 45 patients, alcohol concentration was > 0.2@1000. Three of them developed TUR syndrome. With regard to the frequency of an influx event, there was no significant difference between resections using a trokar and those performed without a trokar. In addition, there was no correlation between this frequency and the duration of resection or the weight of resected tissue. In single cases, influx of considerable fluid volume was found, whereas in 28 patients, duration of resection was far longer than 60 minutes with no signs of an influx event. Mean arterial pressure and heart rate were not altered in 47 patients during the course of the surgical procedure; however, a decrease in these parameters was observed in the 3 patients who developed TUR syndrome. In each of the 8 patients with increased alcohol concentrations, a significant decrease in the serum sodium concentration was observed. There was no change in sodium concentration during the postoperative course in the remaining 42 patients. The data indicate that monitoring of the alcohol load in the expiratory breath is a simple, non-invasive, reliable and cost-efficient way of detecting an influx of fluids during TURP and allows the anaesthetist to take early steps to prevent the development of TUR syndrome.

Aged↗

PubMed2006

Time to rebrand transurethral resection of the prostate?

PURPOSE OF REVIEW: Transurethral resection of the prostate remains the gold standard treatment for benign prostatic obstruction. Owing to the significant morbidity traditionally associated with the procedure, a large number of expensive, high-energy alternative treatments have been developed, which have enjoyed varying degrees of success. At the same time, transurethral resection of the prostate has evolved into a safer operation whilst maintaining its excellent efficacy. This review aims to outline the major advances that have occurred recently in transurethral resection of the prostate. RECENT FINDINGS: Optimizing each stage of transurethral resection of the prostate can result in reduced morbidity. Preoperative treatment with oral antiandrogens and 5-reductase inhibitors appears to reduce intraoperative bleeding, appropriate prophylactic antibiotic regimens reduce postoperative infection rates, improved instrumentation and diathermy delivery can reduce intraoperative bleeding and hence reduce postoperative irrigation requirements, and alcohol monitoring of irrigant absorption can eliminate transurethral resection syndrome. Careful patient selection, meticulous surgical technique combined with an aggressive postoperative irrigation and catheter removal policy can result in transurethral resection of the prostate being performed safely on a day-case basis. SUMMARY: Whilst our attention has been distracted by the many alternative treatments brought to the market over the past decade or so, transurethral resection of the prostate has been undergoing a quiet evolution. With fine tuning of all aspects of the patient journey we can now offer a procedure with excellent long-term efficacy combined with reduced morbidity and inpatient stay.

Anesthesia, Conduction↗

PubMed1977

Regeneration of nasal skeletal structures after subperiosteal and subperichondrial resection.

The degree of regeneration of nasal structures after surgical resection was evaluated in six mongrel dogs that underwent selective resection of the nasal bones and upper lateral cartilages. Preservation of the periosteal and periochondrial flaps was accomplished during the resection. In several cases, different tissues were interposed between the flaps before their closure. The dogs were killed at two-and eight-month intervals after the original resections. No evidence of new cartilage regeneration was found on microscopic evaluation in the region of the resected upper lateral cartilages. Minimal new bone foci were noted at the edge of the resected nasal bones in three of the cases. The findings failed to support any significant degree of nasal structure regeneration after resection.

Animals↗

PubMed1997

Computer-assisted resection of benign sinonasal tumors with skull base and orbital extension.

OBJECTIVE: To use freehand, real-time, intraoperative, 3-dimensional computed tomography (3-D CT) localization to assist with resection of sinonasal lesions with skull-base and/or orbital extension. DESIGN: The 3-D CT is computer-assisted technology using the preoperative CT scan as a road map for resection of lesions. Previous technology, while resulting in little intraoperative error, required use of a somewhat cumbersome rigid articulated arm and attached probe, limiting mobility and requiring rigid fixation of the head to maintain system reference. A new freehand version of this technology, eliminating these limitations, has been used for resection of benign sinonasal lesions with skull-base and/or orbital extension. SETTING: Tertiary care, university-based practice. PATIENTS: Seven patients prospectively selected with benign lesions involving the sinonasal cavity and orbit and/or skull base. INTERVENTION: All patients underwent surgical resection of their tumors using endoscopic, open, or combined procedures with the assistance of freehand 3-D CT localization. MAIN OUTCOME ASSESSMENTS: Surgeon assessment of usefulness. RESULTS: In several cases, the device assisted the operator in determining the exact location of a displaced optic nerve, ensuring vision preservation, while in other cases, the location and depth of skull-base penetration was clearly determined, allowing resection via a transnasal endoscopic approach. In addition, the device was useful for determining the depth of necessary resection for optimal cosmetic result. In all cases, system accuracy was within less than 2 mm at the operative site. System limitations included need for an additional preoperative CT and time required at the beginning of the case for system setup and registration. CONCLUSIONS: Freehand 3-D CT, while still with limitations, offers the advantage of increased surgical safety, aiding anatomic understanding in distorted surgical fields for resection of benign sinonasal tumors with orbital and skull-base extension.

Adolescent↗

PubMed2000

Major liver resection for carcinoma in jaundiced patients without preoperative biliary drainage.

BACKGROUND: The role of preoperative biliary drainage (PBD) before liver resection in the presence of obstructive jaundice remains controversial. Our patients with proximal duct carcinoma undergo noninvasive assessment followed by rapid laparotomy without PBD if the lesion is deemed resectable. HYPOTHESIS: Our aim was to report operative outcome of these patients and to analyze their specific features by comparison with patients without biliary obstruction who underwent major liver resection. DESIGN: A case-comparison study. SETTING: A tertiary care university hospital in a metropolitan area. PATIENTS: Twenty consecutive jaundiced patients underwent major liver resection without PBD. The jaundiced patients were matched with 27 nonjaundiced patients with normal underlying liver selected from a computer bank of 261 patients undergoing liver resections and identical for age, tumor size, type of liver resection, and vascular occlusion. MAIN OUTCOME MEASURE: Postoperative course including mortality, morbidity, transfusion rates, and results of liver function tests. RESULTS: Seventeen jaundiced patients (85%) and 13 nonjaundiced patients (48%) received blood transfusions (P = .03). Morbidity was 50% in jaundiced and 15% in nonjaundiced patients (P = .006), mainly resulting from subphrenic collections and bile leaks occurring only in jaundiced patients. In contrast, there were no significant differences for mortality (5% vs 0%) and liver failure (5% vs 0%). Postoperative changes in liver function test results were comparable between groups. CONCLUSIONS: Major liver resections without PBD are safe in most patients with obstructive jaundice. Recovery of hepatic synthetic function is identical to that of nonjaundiced patients. Transfusion requirements and incidence of postoperative complications, especially bile leaks and subphrenic collections, are higher in jaundiced patients. Whether PBD could improve these results remains to be determined.

Adult↗

PubMed2001

Reduction in recurrence risk for involved or inadequate margins with edge cryotherapy after liver resection for colorectal metastases.

HYPOTHESIS: The usefulness of additional edge cryotherapy after liver resection for liver metastases from colorectal cancer to improve involved or inadequate (less than 1 cm) margins is uncertain. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Department of surgery at a university hospital. PATIENTS: Eighty-six consecutive patients with hepatic metastases from colorectal cancer in whom we applied additional edge cryotherapy to involved or inadequate margins. This group was compared with 134 patients who underwent resection without edge cryotherapy (control group) during the same period. INTERVENTION: Potentially curative treatment was achieved by adding edge cryotherapy to insufficient resection sites in patients not eligible for further resection. MAIN OUTCOME MEASURES: Edge recurrence rate in the study group; validation of an additional treatment to improve curative resectability; and comparison of morbidity and local recurrence rates with the control group. RESULTS: At a median follow-up of 39 months, 47 patients were alive and 39 had died. Local recurrence at the resection site was diagnosed in 9 patients (10%), of which 7 occurred in patients with involved margins and 2 in patients with resection margin less than 1 cm. Thirty-six patients (42%) experienced recurrence in the remnant liver. Extrahepatic recurrence occurred in 38 patients (44%), the lungs being the most common site (22 patients [26%]). CONCLUSIONS: Edge cryotherapy is a potent additional surgical treatment option in patients with liver metastases from colorectal cancer. The percentage of patients who can be treated for cure can be increased, especially if complex liver surgery is demanded.

Adult↗

PubMed2001

Is any method of vascular control superior in hepatic resection of metastatic cancers? Longmire clamping, pringle maneuver, and total vascular isolation.

HYPOTHESIS: Although control of the hepatic vascular pedicle is commonly used during hepatic resection, the optimal method of vascular control continues to be debated. The utility of total or selective vascular isolation, pedicle inflow occlusion, or the absence of vascular isolation during minor and major hepatectomy needs to be examined. DESIGN: Retrospective review of hepatic resections performed for either isolated colorectal or noncolorectal hepatic metastases. SETTING: The University of Chicago Hospitals, Chicago, Ill, a tertiary-care referral center. PATIENTS: One hundred forty-one patients who underwent hepatic resection for isolated metastatic liver disease were identified through The University of Chicago Hospitals Tumor Registry. MAIN OUTCOME MEASURES: Intraoperative parameters, perioperative morbidity and mortality, and tumor recurrence. RESULTS: Four groups were compared with alternative methods of vascular management, including total vascular isolation, Longmire clamping, Pringle maneuver, or no vascular control. Tumor number and size were not significantly different between groups. Blood loss and transfusion requirements tended to be higher in the total vascular isolation group and were significantly higher compared with the Pringle group (P =.06) and the no vascular control group (P =.04), but this also correlated with a higher incidence of complexity of surgical resection. The highest incidence of postoperative complications occurred in the total vascular isolation group (P<.05). With similar permanent pathologic margins, the rates of intrahepatic recurrence were similar among all groups, with the no vascular control group having the lowest recurrence rate. CONCLUSIONS: All methods of vascular control appeared equivalent with respect to limiting blood loss and transfusion requirements while providing adequate surgical margins. The highest rates of blood requirements and complications were noted in the total vascular isolation group, which corresponded to the highest incidence of complex resections. The Longmire clamp group incurred the lowest incidence of complications and resulted in identical surgical margins. The application of vascular control is beneficial to surgeons during hepatic resection, but the method of control should be selected based on the location and complexity of resection required and preference of the individual surgeon.

Aged↗

PubMed2003

Hepatic resection in the United States: indications, outcomes, and hospital procedural volumes from a nationally representative database.

BACKGROUND: Hepatic resection has become common in the United States for both primary and secondary hepatic tumors. HYPOTHESIS: Variation in outcomes after hepatic resection is related to patient characteristics, the indication for operation, and hospital procedural volume. DESIGN: Observational study using a nationally representative database. PATIENTS: All patients in the Nationwide Inpatient Sample for 1996 and 1997 with a primary procedure code for hepatic resection (N = 2097). MAIN OUTCOME MEASURES: Outcomes included in-hospital mortality and length of stay. Risk-adjusted analyses were performed using hierarchical multivariate models. RESULTS: Overall mortality for the 2097 patients was 5.8%. The most common indications for hepatic resection were secondary metastases (52%), primary hepatic malignancy (16%), biliary tract malignancy (10%), and benign hepatic tumor (5%). High-volume hospitals had a mortality rate of 3.9% vs 7.6% at low-volume hospitals (P<.001). In the multivariate analysis adjusting for patient case-mix, high-volume hospitals had a 40% lower risk of in-hospital mortality compared with low-volume hospitals (odds ratio, 0.60; 95% confidence interval, 0.39-0.92; P =.02). Other predictors of mortality in the multivariate analysis included age older than 65 years, hepatic lobectomy (vs wedge resection), primary hepatic malignancy (vs metastases), and the severity of underlying liver disease. CONCLUSIONS: Hospital procedural volume is an important predictor of mortality after hepatic resection. Patients who require resection of primary and secondary liver tumors should be offered referral to a high-volume center.

Databases, Factual↗

PubMed2003

Is combined partial hepatectomy with segmental resection of inferior vena cava justified for malignancy?

HYPOTHESIS: En bloc partial hepatectomy with inferior vena cava (IVC) resection may be the only curative strategy for patients with hepatic malignancies involving the IVC. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: All consecutive patients undergoing combined partial hepatectomy with segmental IVC resection and reconstruction between 1990 and 2002. Patients with tangential excision of the IVC were excluded. Follow-up was completed by outpatient clinic visits and mail correspondence. MAIN OUTCOME MEASURES: Perioperative outcomes; overall and recurrence-free survival. RESULTS: Nineteen patients (7 men and 12 women) underwent partial hepatectomy and segmental IVC resection and reconstruction. Median age was 59 years (range, 24-74 years). Diagnoses consisted of cholangiocarcinoma (9 patients), metastatic tumor (5 patients), sarcoma (3 patients), and hepatocellular carcinoma (2 patients). Major hepatectomies (>/=3 segments) were performed in 15 patients; the caudate lobe was resected in 13. Hepatic vascular isolation was used in 13 patients. Ringed polytef grafts were used for IVC reconstruction in all but 1 patient. Transfusion was necessary in 18 patients (median requirement, 5 U). Median operative time was 6.3 hours (range, 3.7-9.0 hours), and hospitalization was 10.5 days (range, 6-41 days). Negative margins of resection were achieved in 16 patients. Complications occurred in 8 patients (42%), including 1 perioperative death (5%). There was evidence of mural thrombosis of the graft in 2 patients (both nonocclusive); warfarin sodium was used postoperatively in 14. Late graft thrombosis was evident in 2 patients. Median overall survival was 38 months (5-year survival, 21%), and recurrence-free survival was 11.5 months (5-year survival, 0%). CONCLUSIONS: Patients with large tumors involving both the liver and the IVC are candidates for partial hepatectomy and segmental IVC resection. Resection affords the possibility of negative margins, acceptable perioperative morbidity and mortality, long-term graft patency, and prolonged survival.

Adenocarcinoma↗

PubMed2003

Improved survival for adenocarcinoma of the ampulla of Vater: fifty-five consecutive resections.

HYPOTHESIS: After resection of an adenocarcinoma of the ampulla of Vater, certain clinical and pathologic characteristics influence long-term survival. DESIGN: Retrospective case series. SETTING: Major academic medical and pancreatic surgical center. PATIENTS: Fifty-five consecutive patients who underwent Whipple resection for ampullary adenocarcinoma from 1988 through 2001. INTERVENTIONS: Pylorus-preserving Whipple resection in 32 patients and standard Whipple resection in 23 patients. MAIN OUTCOME MEASURES: Postoperative survival. A multivariate Cox proportional hazards model was used to determine the effects of various factors on long-term survival after resection. RESULTS: There were no operative deaths, and all patients left the hospital. After a mean follow-up of 46.9 months, the overall 5-year Kaplan-Meier survival estimate was 67.7%. The median survival of the entire group has not yet been reached. Five-year postoperative survival estimates for node-negative (n = 32) and node-positive patients (n = 23) were 76.5% and 53.4%, respectively (P =.26). Patients whose tumors demonstrated perineural invasion (n = 12) had a 5-year survival estimate of 29.2% vs 78.8% for those whose did not (P<.001). On multivariate analysis, the absence of perineural invasion (P<.001) was an independent predictor of significantly improved postoperative survival. CONCLUSIONS: Compared with previous reports from our own and other centers, this series demonstrates improved postoperative survival by 10% to 20% in patients undergoing Whipple resection for adenocarcinoma of the ampulla of Vater. The reasons for this improved outcome are unclear, and the effect of adjuvant treatment cannot be determined from this analysis. The major factor associated with prolonged survival was the absence of perineural invasion in the resected tumor specimen.

Adenocarcinoma↗