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PubMed1992

Evaluation of surgical risk in palliation and resection of pancreatic cancer. Perspective study and tables to calculate the risk.

High morbidity and mortality rates are reported for bypass and resective surgery of pancreatic cancer. In a retrospective study we correctly predicted the postoperative course in 88% of the patients who underwent bypass surgery and 83% of those who had a resection for pancreatic cancer. Before starting with clinical application of this scoring system, we undertook a prospective study to confirm its predictive value. Sixty-seven consecutive patients with pancreatic cancer were included: 42 patients underwent bypass surgery and 25 pancreatic resections. The operative mortality was 14% for palliative surgery and 0% for resective surgery. Surgical team and nurses were totally unaware of the predicted risk. The preoperative forecast proved to be correct in 81% of bypass surgery and in 88% of resective surgery, although surgical mortality had decreased from 21 to 14% for bypass surgery and from 17 to 0% for resective surgery. Tables are included to calculate the surgical risk for each of 162 combinations of the risk factors considered in the predictive model (81 for bypass surgery and 81 for resective surgery). Calculation of surgical risk is important when evaluating different treatments for pancreatic cancer are available.

Adult↗
PubMed2004

An increased circulating blood volume does not prevent hypotension after pheochromocytoma resection.

PURPOSE: Pulse dye-densitometry, a novel monitor that measures circulating blood volume (CBV) and cardiac output (CO), was used in patients with pheochromocytoma to determine the relationship between CBV and post resection hypotension. METHODS: Case control study. An alpha blocker was administered for approximately two weeks, and its effect on the expansion of CBV was quantified. CBV was monitored in seven patients admitted for resection of suspected pheochromocytoma before preoperative alpha-blocker therapy, after alpha-blocker therapy and three times during the operation. Relationships between the CBV and blood pressure after resection of the tumour were examined. RESULTS: CBV increased from 72.0 +/- 10.0 mL.kg(-1) to 83.4 +/- 12.2 mL.kg(-1) after alpha blockade. (P < 0.001). We found a significant inverse relationship between the increase in CBV after alpha-blocker therapy and blood pressure after resection of the tumour. CONCLUSIONS: Expansion of the CBV by alpha-blocker therapy was related to lower blood pressures after resection of the pheochromocytoma. Expansion of the CBV by an alpha blocker may have increased the elastance of blood vessels. Preoperative blood volume expansion does not preclude hypotension after tumour resection. Although the CBV value itself is not a predictor for hypotension after tumour resection, pulse dye-densitometry provides values of CO and CBV simultaneously, assisting in the management of volume resuscitation and/or the need for catecholamines.

Adrenal Gland Neoplasms↗
PubMed1998

[Resection and reconstruction of sternum].

In case of sternal resection, it is necessary to preserve bone material indispensable for the stability of the anterior chest wall and air tightness of the thoracic cavity, and the support of the chest wall integrity must be restored by some means. Various techniques have been applied to the reconstruction of the chest wall following resection. During the last 10 years, we have performed reconstructive operation for 6 cases of the chest wall following resection of the sternum in recurrent cases of breast cancer or invaded case of primary breast cancer. In these patients, the chest wall was reconstructed using a rib-latissimus dorsi osteomyocutaneolus flap or a latissimus dorsi myocutaneous flap. The sternum was totally resected in 3 cases, and in all 3 cases, reconstructed using a rib-latissimus dorsi osteomyocutaneous flap. Although postoperative pulmonary function decreased, all cases could be relieved from endotracheal intubation within 17 hours after operation, and had no problems in activities of daily living or occurrence of chest flailing or paradoxical movement of the chest. An artificial material (expanded polytetrafluoroethlene patch) was used in only one patient for the reconstruction of the osseous thorax, but this case developed infection during postoperative chemotherapy. After this experience, we used only biological materials for the reconstruction of the chest wall and postoperatively performed radiotherapy and/or chemotherapy on all cases. We have observed no flap infection or detachment since then. One characteristic of using the latissimus dorsi myocutaneous flap is that it is easily elevated and rarely causes serious postoperative esthetic or functional problems. The flap is also easily utilized to reinforce the osseous thorax because ribs immediately below the latissimus dorsi muscle are readily mobilized as a pedicle graft. Reconstruction of the chest wall following resection of the sternum, described in this report, allowed us to perform radiotherapy and/or chemotherapy without serious postoperative complications on the cases relapsing after treatment of breast cancer. The 2-year survival rate is 50% and one of these cases survived up to 10 years after resection of the sternum. Thus we prefer to perform resection of the sternum for sternal recurrence of breast cancer if there are no metastatic lesions in other organs.

Adult↗
PubMed1998

Hepatocellular cancer: resection or transplantation.

Surgery remains the treatment of choice for hepatocellular carcinoma (HCC). For HCC without underlying cirrhosis resection remains the mainstay treatment option. Prognosis depends on the stage of the tumor. Survival appears to be better for small (less than 5 cm) solitary tumors with negative resection margins and absence of vascular invasion. At present, liver transplantation does not have an established role in the treatment of HCC in a non-cirrhotic liver. Because of the high recurrence rate, it should not be considered for more advanced disease which is not amenable to resection. The surgical approach in cirrhotics depends not only on the stage of the tumor but also on the liver functional reserve. Tumor size, presence of multifocal disease, and vascular invasion determine the risk of HCC recurrence after resection, and the functional stability of the liver determines both resectability and outcome. In societies in which transplantation is not available, small tumors will be treated with liver resection. The outcome in patients with well preserved liver function is relatively good, at least in the medium term. However, recurrent tumor and progressive hepatic decompensation have significant adverse effects on long-term survival. Poor functional reserve may be associated with significant perioperative mortality and lower survival due to progressive liver failure. In our opinion, for small cirrhosis-related HCCs, liver transplantation offers better long-term prospects than resection. Therefore, if liver transplantation is available as an option it should be considered as the treatment of choice, particularly for younger patients with otherwise good life expectancy.

Carcinoma, Hepatocellular↗
PubMed2002

[Extent of resection in surgery of stomach carcinoma].

The extraluminal extent of resection in cases of advanced gastric cancer is controversial. If, however, following meticulous staging--including the detection of free abdominal tumor cells--complete resection seems possible, then multivisceral resection is justified. If complete resection is achieved, the prognosis of these patients can be improved. Left pancreatic resection should be performed only if the tumor invades the pancreas directly. Splenectomy is indicated if the tumor invades the organ directly or if there are locally advanced tumors of the proximal third of the stomach and tumors of the esophageal-gastric junction. However, it has to be kept in mind that splenectomy is an independent negative prognostic factor. The extent of lymphadenectomy (LA) in gastric cancer is still under discussion. According to the 10-year results of the Dutch Gastric Cancer Study, there might be subgroups which have a survival benefit after extended (D2) LA. These include, as the German Gastric Cancer Study corroborated, patients with very early stage II and stage IIIa lymph node metastases. As neither of these stages can at present be diagnosed before or during surgery, D2 lymphadenectomy should be the standard procedure for all patients with gastric cancer. Recent studies have shown that it might be possible with the help of the Sentinel Node Technique to individualize lymphadenectomy in locally gastric cancer as well. The beneficial effects of adjuvant chemoradiation in gastric cancer do not mean, however, that the extent of resection may be reduced. Adjuvant chemoradiation following complete resection and D2 lymphadenectomy should still not be regarded as standard therapy.

Gastrectomy↗
PubMed2005

[Standard surgical resection of colorectal liver metastases].

Liver resection for colorectal metastases can be performed with curative intent in about 15-20% of patients. From a surgical point of view, achieving a radical (R0) resection is of paramount importance. Perioperative mortality is mainly linked to the extent of the resection (class I/II). Results of ischemic or drug-induced preconditioning have been ambiguous, and their clinical use is at most questionable. Five-year survival following primary and repeated liver resection is consistently reported at 30-40%. The options for improving prognosis by purely technical means appear limited. Instead, future strategies must aim at the conversion of primarily irresectable and potentially resectable liver metastases into resectable tumors. This could be achieved preoperatively via portal vein embolisation and neoadjuvant chemotherapy and surgically via sequential resection or a combination of surgery with local ablative therapy. All suggested modalities for primarily inoperable tumors should be systematically evaluated in clinical trials.

Colorectal Neoplasms↗
PubMedDate not supplied

A useful method for planning hump resection of deviated nose.

The deviated nose is a particular challenge because both functional and aesthetic problems must be addressed. A most important challenge is resection of the hump. The nasal bones often are asymmetric in deviated noses. Several methods have been used for resection of the hump. Using the authors' method, it is possible to calculate the extent of hump resection. Clinical analysis of the nasal deviation is performed preoperatively. Digital photographs are taken, and all the landmarks are marked on the life-size photo prints. Planning begins on the deviated side. The ideal dorsal line is drawn, and the extent of hump resection is planned according to the preoperative measurements. Measurements on the deviated side are applied to the other side using the medial canthi and the most prominent part of the alar creases as landmarks. Classical methods emphasize the importance of the chisel position during hump removal. According to the classical approach, the chisel should be positioned lower on the deviated side to resect more bone. However, there is no method for calculating how the chisel should be positioned exactly during hump resection. Therefore, a precise plan has been devised to leave symmetric nasal bones after hump resection. The authors have applied this method in eight cases, achieving satisfactory results.

Adult↗
PubMed2001

Genetic markers of survival and liver recurrence after resection of liver metastases from colorectal cancer.

A significant number of patients with liver metastases from colorectal cancer (CRC) achieve 5-year survival after liver resection. Increased expression of genetic markers in the primary tumor are known to predict outcome after colonic resection, but the predictive value of such markers after resection of hepatic metastases is unknown. The objective of this study was to evaluate whether DNA content and multiple genetic markers, separately or expressed together, can predict patient outcome (liver recurrence and survival) after resection of hepatic metastases. We studied the paraffin-embedded liver tissue of 71 consecutive patients who had undergone a potentially curative resection of hepatic metastases from CRC. Using DNA flow cytometry and immunohistochemical staining techniques we determined the DNA content and the level of co-expression of seven tumor-associated proteins: proliferating cellular nuclear antigen (PCNA), epidermal growth factor receptor (EGFr), p53, c-erbB-2, H-ras, c-myc, and nm23. Three endpoints (liver recurrence, cancer specific, overall survival) were correlated with these tumor markers. The 5-year overall survival of the group was 31.2%. There was no correlation detected between the DNA aneuploidy and overall or cancer-specific survival. Similarly, expression of the individual tumor-associated proteins did not predict survival. Patients whose tumors co-expressed multiple markers had survivals similar to those whose tumors expressed fewer markers. However, a significant difference in hepatic recurrence was found between the p53-positive and p53-negative patients (p = 0.007), with marker-negative tumors having decreased recurrence. In conclusion, this study demonstrates that the DNA content and genetic markers c-myc, c-erbB-2, EGFr, H-ras, p53, PCNA, and nm23 do not predict survival after potentially curative resection of hepatic metastases from CRC. However, the immunoreactivity of p53 may be an important marker of local recurrence in the liver, which may be useful if re-resection of metastatic liver tumors is considered a viable management option in this disease.

Adult↗
PubMed2001

Resection of noncolorectal and nonneuroendocrine liver metastases: late metastases are the only chance of cure.

Resection of liver colorectal metastases allows a 5-year survival in 25% to 35% of patients. The outcome of patients with noncolorectal metastases is unknown because of the heterogeneity of this group. The aim of this retrospective study was to evaluate predictive factors of survival in patients who underwent resection of noncolorectal and nonneuroendocrine (NCRNE) liver metastases. From 1980 to 1997, 284 patients underwent hepatectomy for liver metastases of whom 39 (25 men and 14 women, mean age 55 years) had curative resection for NCRNE liver metastases. No patients had extrahepatic disease. The primary tumors were gastrointestinal (n = 15), genitourinary (n = 12) and miscellaneous (n = 12). The mean number of metastases was 1.8, and the mean size of the lesions was 51 mm. The median disease-free interval was 27 months. Twenty patients had a major hepatectomy and 19 a minor resection, with simultaneous resection of the primary in 6 cases. Overall survival was evaluated using the Kaplan-Meier method. There was no operative mortality, and 8% morbidity. The survival at 1, 3, and 5 years was 81, 40, and 35%, respectively. Patients with a disease-free interval higher than 24 months had a greater survival rate than those with a disease-free interval of less than 24 months (100% vs. 10%; p = 0.0004). Survival was not significantly influenced by age, sex, type of primary tumor, number, size and localization of metastases, type of hepatectomy, or blood transfusion. Resection of NCRNE liver metastases should be justified for patients without extrahepatic disease and resectable metastases, especially for those who have a disease-free interval of more than 24 months.

Adenocarcinoma↗
PubMed2003

Risk and outcome of bowel resection in patients with incarcerated groin hernias: retrospective study.

The goal of this retrospective study was to evaluate factors that increase the risk of bowel necrosis and document the outcome of bowel resection in patients with strangulated hernias. We identified 102 patients (60 men, 42 women) who underwent surgical treatment for an incarcerated hernia at the Kartal Education and Research Hospital Emergency Unit between April 1997 and April 2001. Patients in group 1 required intestinal resection (n = 16), and patients in group 2 did not (n = 86). The median age of the patients was 53 years (range 3-96). Demographic and surgical data were obtained from the patients' charts and compared between the two groups. Women required bowel resections more often than men (p < 0.05). Patients older than 65 years and those with femoral or epigastric hernias required resection more often than patients younger than 65 years and those with inguinal, umbilical, or incisional hernias (p < 0.05 for all). Group 1 patients had a longer hospitalization and experienced more overall complications and wound infections than group 2 (p < 0.05 for all). In conclusion, incarcerated hernias are more common in men, but intestinal resection is required more often in women. The risk of intestinal resection is higher for patients with femoral hernias and those older than 65 years. Patients who undergo intestinal resection have a higher overall complication rate related to wound infections but not an increased risk of other complications or mortality.

Adolescent↗
PubMed2003

Impact of advanced age on the outcome of liver resection.

The aim of this retrospective study was to evaluate the influence of age on the outcome of liver resection. A total of 129 consecutive liver resections were divided into two groups: > or = 70 years old [old group (O-group)] and < 70 years old [young group (Y-group)]. The two groups were first compared for the variables potentially affecting the postoperative course, including diagnosis, concomitant diseases, previous abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of liver resections was evaluated in terms of postoperative mortality, morbidity, transfusions, and length of hospitalization. The Y-group included 97 resections in 95 patients, aged 55.9 +/- 10.5 years (mean +/- SD; range: 23-69 years), and the O-group included 32 resections in 32 patients, aged 73.7 +/- 3.2 years (mean +/- SD; range: 70-82 years. The O-group included more hepatocellular carcinomas (46.9% versus 20.6%, p = 0.002) and cardiovascular diseases (15.2% versus 1.0%, p = 0.004). The two groups were comparable (p > 0.05) when evaluated for all other listed variables. As regards the postoperative outcome, the length of hospitalization was similar (median, range: 9.5 days, 5-60 days in the Y-group and 9 days, 5-48 days in the O-group) and the need for postoperative transfusions were not statistically different. Mortality included one case among young patients, while no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (21.6% versus 9.4%, p = 0.2). In conclusion, the age factor does not negatively affect the outcome of liver resections.

Adult↗
PubMed2004

Micrometastases of solitary hepatocellular carcinoma and appropriate resection margin.

We studied the pattern of intrahepatic micrometastases using large pathologic sections on liver resection specimens with ample resection margins from 113 patients with a solitary hepatocellular carcinoma (HCC). The liver tissues around the HCC were divided into proximal and distal areas according to the direction of the portal vein flow. These areas were further divided into zones based on fixed criteria. Altogether, 273 micrometastases were identified, including 254 (93.0%) intravascular micrometastases and 19 (7.0%) tumor satellite micronodules. The distance of spread of these micrometastases ranged from 0.05 to 6.10 cm. The number of micrometastases was less in the proximal area than in the distal area. In addition, the farther the distance away from the primary tumor, the fewer micrometastases there were. Micrometastases extended beyond the 2 cm margin in only nine (8.0%) patients. In conclusion, micrometastases could spread via invasion of portal vein branches at an early stage even when the tumor was solitary and small. Anatomic segment resection is preferred for patients with a solitary HCC. Nonanatomic resection may be used as an alternative in patients with impaired liver function, but adequate resection margins should be achieved. For HCCs < or = 3 cm, a proximal resection margin and a distal margin of 1.0 cm are recommended. For HCCs > 3 cm, a 1.0 proximal resection margin and a 2.0 cm distal margin are recommended.

Adult↗
PubMed2006

Does resection line involvement affect prognosis in early gastric cancer patients? An Italian multicentric study.

BACKGROUND: Resection line involvement has been indicated as an important prognostic factor for gastric cancer. Its late detection renders the choice of treatment difficult for surgeons. MATERIALS AND METHODS: We describe the multicenter experience of a group of 11 patients with early gastric carcinoma (EGC) and positive resection confirmed at histological examination who did not undergo surgical retreatment for reasons of associated disease, surgical considerations on duodenal stump, or patient refusal. RESULTS: The gastric margin was involved in 4 patients, and 7 patients had duodenal resection line involvement. No surgical complications or postoperative deaths were observed. Five and 8-year survival was 100% and 86%, respectively. The only patient who relapsed did not have lymph node involvement and died from liver metastases, without local recurrence. CONCLUSIONS: It is sometimes difficult to accurately define the resection line in gastric cancer surgery, especially in the early stages of disease, but because of the strongly negative prognostic value of an infiltrated margin, frozen sections are recommended if neoplastic invasion is suspected and a new resection is always recommended if possible. Nevertheless, the good prognosis of resected EGC patients with resection line involvement must be considered before submitting patients with associated diseases to radical surgical retreatment.

Adult↗
PubMed2007

Selected patients with metastatic melanoma may benefit from liver resection.

BACKGROUND: In the last few years there has been expanding use of hepatic resection for non-colorectal metastases. The purpose of this study is to evaluate the experience of liver resection for patients with metastatic melanoma. METHODS: Eighteen patients with metastatic melanoma were explored for possible surgical resection. All patients fitted the following criteria: absence of extra-hepatic disease after evaluation with CT/MRI and FDG-PET scans; disease-free interval longer than 24 months after the resection of the primary melanoma; presumed completely resectable lesions; absence of clinical co-morbidities. RESULTS: Liver resection was performed in 10 patients; 8 out of 18 presented with irresectable tumors and/or peritoneal metastases and were not operated. One patient presented with postoperative biliary fistula and was conservatively managed. No other complications or postoperative mortality were observed. After a mean follow-up of 25.4 months, 5 patients are alive and without evidence of recurrence. Overall median survival was 22 months; overall survival and disease-free survival were 70% and 50% respectively. CONCLUSIONS: Resection of liver metastases from melanoma in a selected group of patients may increase survival. Exploratory laparoscopy should be included in the preoperative armamentarium of diagnostic tools.

Adult↗
PubMed1998

Effect of hepatic invasion on the choice of hepatic resection for advanced carcinoma of the gallbladder: histologic analysis of 32 surgical cases.

The purpose of this study was to assess the patterns of hepatic invasion in advanced carcinoma of the gallbladder by histologically examining surgical specimens obtained in 32 cases of hepatectomy for that carcinoma. Two modes of microscopic tumor extension were observed. The expansive pattern was restricted to liver-bed carcinomas, in which the tumor extends into the liver, primarily from the liver bed. Most of the infiltrating patterns were found with hepatic-hilar carcinomas, in which the tumor invades the hepatic hilum along Glisson's sheath, especially tumors exhibiting a discontinuous front of tumor invasion. The average width for wedge resection of the liver bed was 15.6 +/- 2.9 mm, in contrast to 25.6 +/- 8.1 mm for resection of segments IVa and V and 44.1 +/- 10.3 mm for extensive hepatic resection (both p < 0.01). When the hepatic invasion distance is more than 20 mm, the tumor should be selectively managed by extensive hepatic resection, such as extended right hepatic lobectomy or central bisegmentectomy. The results suggest that wedge resection of the liver bed and resection of segments IVa and V are advisable for carcinoma localized to the gallbladder alone and for liver-bed carcinoma with slight hepatic invasion and an expansive tumor growth pattern. Extensive hepatic resection, however, is recommended for carcinoma of the invasive liver-bed type and carcinoma of the hepatic-hilar type.

Gallbladder Neoplasms↗
PubMed2000

Surgical mortality, survival, and quality of life after resection for gastric cancer in the elderly.

Although there were some studies on clinicopathologic characteristics, operative morbidity, and mortality in elderly patients with gastric cancer, no reports have specifically focused on survival and quality of life after resection. A total of 433 patients aged >/= 65 years (1987-1994) who underwent gastric resection for gastric adenocarcinoma were studied. Two groups were considered: patients aged 65 to 74 years and those > 74 years. Most of the patients (78.1%) had advanced diseases, and nearly half (41. 3%) had associated chronic disease(s). Resections with curative intention were performed in 362 patients (83.6%). The overall operative morbidity rate was 21.7% and mortality rate 5.1%. Although operative procedures were similar in both groups, patients aged >74 years had a higher mortality rate than those aged 65 to 74 years (10. 1% vs. 3.5%; p = 0.034). Age and extent of gastric resection were two independent factors negatively affecting mortality. The cumulative survival rates for patients who underwent curative resection were 86.2%, 72.4%, 67.2%, 62.9%, and 60.0% at 1, 2, 3, 4, and 5 years, respectively. Nearly all patients (96%) after surgery had normal work and daily activities. Some patients appeared to lack energy (16%) or experienced a period of anxiety or depression. There was no statistical difference in survival and quality of life assessed by the Spitzer index after curative resection between the two groups. Therefore resection with curative intention can be performed for the elderly with acceptable morbidity and mortality rates, possible long-term survival, and good quality of life, but a limited operation should be considered in the very elderly patients.

Activities of Daily Living↗
PubMed1999

The impact of extent of resection in the management of malignant gliomas of childhood.

Radical surgical resection of newly diagnosed glioblastoma multiforme (GBM) and anaplastic astrocytoma (AA) in children is the most powerful favorable predictor of outcome when followed by radiation therapy and chemotherapy. In the largest study of childhood malignant gliomas (Children's Cancer Group Study, CCG-945), which was conducted between 1985 and 1992, a radical surgical resection was defined as greater than 90% resection of tumor as seen on imaging studies, predominantly using MRI. Of note is that the training of the neurosurgeon (i.e. in pediatric versus adult neurosurgery) had a significant impact on the extent of surgical resection in patients enrolled on this study. In children with recurrent malignant glial tumors, radical surgical resection has been shown to predict a more favorable survival for children, both with GBM and AA, undergoing high-dose (marrow-ablative) chemotherapy with hematopoietic stem cell rescue. In these studies, radical surgical resection was defined as resection leaving less than 3 cm maximal diameter of enhancing tumor mass in place.

Antineoplastic Agents↗
PubMed2002

Perioperative effects of hepatic resection surgery on hemodynamics, pulmonary fluid balance, and indocyanine green clearance.

BACKGROUND: Major liver resection is a routine surgical treatment, but hemodynamic and pulmonary complications are common. We investigated the effects of hepatic resection on hemodynamics and pulmonary and liver function. PATIENTS AND MEASUREMENTS: Twelve patients who underwent major liver resection due to primary liver tumor, liver metastasis, or hemangioma were investigated prospectively and consecutively. Six patients who underwent gastrectomy due to gastric cancer served as a control group. Hemodynamic parameters (cardiac index, intrathoracic blood volume, mean arterial blood pressure), extravascular lung water, and indocyanine green clearance were measured after the induction of general anesthesia, during the preparation period, during total hilar clamping ("Pringle's maneuver"), at the end of surgery, and 24 and 72 h after surgery. RESULTS: In contrast to gastrectomy, patients who underwent liver resection developed a hyperdynamic circulatory state (cardiac index 72 h postoperatively: 4.6+/-1.2 l/m(2) vs. 3.6+/-0.6 l/m(2)). Simultaneously we observed a significant increase in extravascular lung water in the liver resection group, indicating a moderate pulmonary edema. Indocyanine green clearance did not deteriorate following liver resection. CONCLUSIONS: After liver resection the physiological response resulted in elevated cardiac output and moderate pulmonary edema. Dynamic liver function was elevated within 24 h due to an increase in perfusion and regeneration activity of the remaining parenchyma.

Adult↗