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PubMed1992

Hepatic resections for primary and metastatic tumors using the ultrasonic surgical dissector.

We have previously described the development of new hepatic surgical techniques using the ultrasonic surgical dissector. With 10 years' experience, we have found that major liver resections have been simplified and that the technique is repeatable in hands other than our own. Thirty-three patients had 37 tumors, averaging 5.65 cm in size, resected with an average blood loss of only 1,020 mL per case, which included 5 right trisegmentectomies, 12 lobectomies, 15 segmental resections, and 4 subsegmental resections. Twenty-two patients had metastatic colorectal cancer. Blood transfusion requirements averaged only 2.24 units in long-term survivors, which was significantly less than the 3.5 units received by patients who have since died (p = 0.092). There were no operative deaths. The median survival of these 22 patients was 56 months, and the 5-year actuarial survival rate was 35%. All of the early deaths occurred in patients with more than four tumors, and no patient with less than four tumors died before 42 months with recurrent disease. Six patients had bilateral tumors, and the fact that patients survived into the fourth and fifth post-resectional year indicates that resection was worthwhile. All these patients had Dukes' C primary tumors, but we found no statistical difference in survival between patients with Dukes' B and Dukes' C lesions. The results indicate that hepatic resection with the ultrasonic surgical dissector decreases blood loss, requires few transfusions, is safe to perform, and is associated with excellent long-term survival.

Adolescent↗
PubMed1990

Survival after surgical resection for high-grade chest wall sarcomas.

Indications for chest wall resection of metastatic or locally recurrent sarcoma and for subsequent bony reconstruction are controversial. Twenty-eight patients had chest wall resection for high-grade primary, metastatic, or recurrent sarcoma. In all patients, resection with selective reconstruction of the bony thorax was performed without operative mortality. Since 1980, only patients with four or more ribs resected have had selective bony reconstruction. Follow-up ranged from 8 to 132 months (median follow-up, 42 months). All deaths were related to sarcoma recurrence. The overall actuarial survival rate was 85% at 1 year, 65% at 3 years, and 59% at more than 5 years. The overall actuarial proportion without disease recurrence was 64% at 1 year, 52% at 3 years, and 40% at more than 5 years. There was no significant difference in overall or disease-free survival for patients with primary, metastatic, or recurrent tumors. The most important prognostic factors were positive margins and concomitant pulmonary resection for synchronous lung metastases. These data support aggressive resection to obtain pathologically tumor-free margins for chest wall sarcomas, whether primary, metastatic or recurrent. Reconstruction can be individualized based on the extent of resection.

Adolescent↗
PubMed1992

Renal cell carcinoma: resection of solitary and multiple metastases.

Between 1985 and 1991, 23 patients underwent resection of pulmonary metastases from renal cell carcinoma, of whom 18 had previously received interleukin-2 based immunotherapies. Mean survival from exploration in all patients was 43 months. Survival after resection did not correlate with the number of nodules on preoperative tomograms, the number of nodules resected, or the disease-free interval. Patients who underwent complete resection of metastatic disease (n = 15), however, had a significantly longer survival (mean, 49 months; median not yet achieved) compared with patients with incomplete resection (median, 16 months) (p2 = 0.02). Two of the 15 patients who underwent curative resections are presently free of disease greater than 45 months after exploration. These data support surgical resection of isolated pulmonary metastatic disease from renal cell cancer.

Adult↗
PubMed1994

Pulmonary resection of metastatic renal cell carcinoma.

Between 1965 and 1989, 96 consecutive patients (64 men and 32 women) underwent complete pulmonary resection for metastatic renal cell carcinoma. Median age was 63 years (range, 33 to 82 years). Median time between nephrectomy and pulmonary resection was 3.4 years (range, 0 to 18.4 years). Forty-eight patients had solitary metastasis, 16 had two, 18 had three, and 14 had more than three. Wedge excision was performed in 62 patients, segmentectomy in 3, lobectomy in 25, bilobectomy in 3, and pneumonectomy in 3. Fourteen patients had repeat thoracotomy for recurrent metastasis; 34 other patients also had complete resection of limited extrapulmonary disease. There were no operative deaths. Median follow-up was 3 years (range, 70 days to 19.0 years). Overall 5-year survival was 35.9%. Patients with solitary metastasis had a 5-year survival of 45.6% compared with 27.0% for patients with multiple metastases (p < 0.05). Patients with a tumor-free interval greater than the median of 3.4 years had a better survival (p = 0.05) than those with a tumor-free interval less than or equal to 3.4 years. Five-year survival for patients who underwent repeat thoracotomy or had complete resection of extrapulmonary disease did not differ from overall survival. We conclude that resection of renal lung metastasis is safe and effective, that patients with solitary metastasis have a better survival than those with multiple metastases, that resectable extrapulmonary disease does not necessarily contra-indicate pulmonary resection, and that repeat thoracotomy is warranted in selected patients with recurrent lung metastases.

Adult↗
PubMed1995

Esophageal resection for recurrent achalasia.

BACKGROUND: This study examined esophageal resection as treatment for recurrence or treatment complications of achalasia. METHODS: From 1976 through 1992, 37 patients (20 men and 17 women) underwent esophageal resection after initial surgical treatment for achalasia. The median age was 56 years (range, 19 to 84 years). Initial surgical treatment consisted of modified Heller myotomy in 28 patients, combined myotomy and antireflux procedure in 6, and antireflux procedure alone in 3. Twenty-six patients required an additional surgical procedure before esophageal resection (70.3%). Indication for esophageal resection was obstructive symptoms in 30 patients, cancer in 3, bleeding in 2, and perforation during dilation in 2. Reconstruction was established with the stomach in 26 patients, colon in 6, and small bowel in 5. Anastomosis was at the cervical level in 20 patients (54.1%) and intrathoracic in 17 (45.9%). RESULTS: There were two operative deaths (5.4%), both caused by intraoperative hemorrhage during transhiatal resection. Twelve patients (32.4%) had complications, which included cardiac dysrhythmia in 3, cervical anastomotic leak in 2, transient vocal cord paralysis in 2, pneumonia in 2, pulmonary embolus in 2, and reexploration for bleeding in 1. Follow-up was complete in all patients and ranged from 1.4 to 16 years (median, 6.3 years). Excellent or good long-term functional results were present in 32 patients (91.4%). CONCLUSIONS: Esophageal resection provides reasonable long-term functional results in patients with recurrence or treatment complications of achalasia. In our experience, transhiatal resection is associated with increased morbidity and mortality.

Adult↗
PubMed1996

Early and late morbidity in patients undergoing pulmonary resection with low diffusion capacity.

BACKGROUND: We sought to determine whether low diffusion capacity of the lung to carbon monoxide (DLCO) is a predictor of high postoperative mortality and morbidity after major pulmonary resection and whether major pulmonary resection in patients with low DLCO results in substantial long-term morbidity. METHODS: Sixty-two major pulmonary resections were performed in 61 patients with low DLCO (DLCO < or = 60% predicted for pneumonectomy or bilobectomy; < or = 50% predicted for lobectomy). Contemporaneously, 262 other patients underwent 263 major pulmonary resections (group II). Long-term morbidity was assessed in subsets of patients with low (n = 24) and high (n = 22; DLCO > 60% predicted) DLCO. RESULTS: The hospital mortality rates were equivalent (4.8% low DLCO versus 4.9% group II), whereas respiratory complications were more frequent in patients with low DLCO (18% versus 9.5%; p = 0.05). In the subgroup analyses, patients with low DLCO had more hospitalizations for respiratory compromise and worse median dyspnea scores. Analysis of patients with substantial dyspnea revealed an association with extended pulmonary resection and postoperative radiation therapy in patients with low DLCO. CONCLUSIONS: Patients with low DLCO underwent major pulmonary resection with a low mortality rate and an acceptable, but increased, respiratory complication rate. Long-term respiratory morbidity was increased in patients with low DLCO; however, the extent of pulmonary resection and the use of postoperative radiation therapy may have contributed to the development of dyspnea in these patients.

Aged↗
PubMed1996

Results of resection of T3 non-small cell lung cancer invading the mediastinum or main bronchus.

BACKGROUND: T3 tumors can be divided into several subgroups. Surgical treatment of T3 tumors with chest wall invasion results in good survival. This study shows the results of resection of T3 non-small cell tumors located in the main bronchus or with invasion of mediastinal structures. METHODS: From 1977 through 1993, 108 patients underwent resection for primary non-small cell carcinomas located in the main bronchus or with invasion of mediastinal structures. A complete resection was performed in 70 patients (64.8%). Actuarial survival time was estimated and risk factors for late death were identified. RESULTS: Overall hospital mortality was 8.3%. All deaths followed pneumonectomy. Mean 5-year survival was 29% for all hospital survivors, 35% for patients with complete resection, and 18% for patients with incomplete resection (p = 0.03). In patients with complete resection, mean 5-year survival was 45% for N0 patients and 37% for N1 patients. There were no 5-year survivors in the group of N2 patients. The mean 5-year survival was greater (but not statistically significantly greater) in patients with tumors located in the main bronchus (40%) than in patients with tumors with invasion of mediastinal structures (25%) (p > 0.05). Histology, tumor spill, age, sex, and type of operative procedure were not significant prognostic factors. CONCLUSIONS: Patients with tumors located in the main bronchus have a better survival than patients with invasion of the mediastinal structures. Pneumonectomy increases hospital mortality. Incompleteness of resection and mediastinal lymph node involvement influence survival significantly.

Adult↗
PubMed1991

Hepatic metabolism of cholesterol in Crohn's disease. Effect of partial resection of ileum.

To study cholesterol metabolism in Crohn's disease and especially the effect of ileum resection, liver biopsy specimens were obtained from patients undergoing partial ileal resection because of Crohn's disease (n = 17) and patients with Crohn's colitis undergoing colectomy (n = 3). Gallstone-free patients (n = 16) undergoing cholecystectomy because of adenomyomas or polyps of the gallbladder served as controls. The mean levels of cholesterol 7 alpha-hydroxylase activity and 3-hydroxy-3-methylglutaryl coenzyme A reductase activity, rate-determining enzymes in bile acid, and cholesterol synthesis, respectively, were twofold to threefold higher in the ileum-resected patients than in the controls. Significant positive correlations were obtained between length of resected ileum and cholesterol 7 alpha-hydroxylase activity. Provided patients who had received total parenteral nutrition preoperatively were excluded from analysis, a significant correlation was also observed between length of resected ileum and 3-hydroxy-3-methylglutaryl coenzyme A reductase activity. Significant positive correlations were also obtained between length of resected ileum and serum levels of 7 alpha-hydroxycholesterol (a marker for bile acid biosynthesis) and lathosterol (a marker for cholesterol synthesis). The plasma levels of total and low-density lipoprotein cholesterol were negatively correlated to the length of resected ileum. The expression of hepatic low-density lipoprotein-receptor binding activity was determined in five of the patients and in three of the controls. A significant positive correlation was observed between 3-hydroxy-3-methylglutaryl coenzyme A reductase activity and low-density lipoprotein-receptor binding activity. The results show that malabsorption of bile acids leads to parallel stimulation of cholesterol synthesis, cholesterol degradation, and low-density lipoprotein-receptor expression in human liver. The resulting effect in the present patients was a significant reduction in low-density lipoprotein cholesterol.

Adult↗
PubMed1984

The effects of ileal resection with cholecystectomy on bile salt metabolism in the prairie dog.

The adverse effects of ileal resection on bile salt metabolism may be aggravated by cholecystectomy. Female prairie dogs had either sham laparotomy, cholecystectomy, distal 50% small bowel resection, or cholecystectomy and distal 50% small bowel resection. After 4 weeks the common bile duct was cannulated and bile collected for up to 12 hr. Bile salt pool size and synthetic rate were measured from the washout curve. Bile salt, phospholipid, and cholesterol concentrations were determined. Bile salt pool size was reduced after cholecystectomy and after ileal resection. Cholecystectomy plus ileal resection further lowered the pool size, increased the synthetic rate, and increased the proportion of secondary bile salts. Cholecystectomy increased the synthesis and the concentration of bile salts in hepatic bile and altered the proportions of biliary lipids. Ileal resection decreased the concentration of hepatic bile salts with the formation of noncholesterol stones. The drastic reduction in pool size with the combined operation might be expected to lead to fat malabsorption. The higher concentration of bile salts after the combined operation compared with ileal resection alone reflects a possible beneficial effect of cholecystectomy.

Animals↗
PubMed1991

Insulin-like growth factor II/mannose-6-phosphate receptors are transiently increased in the rat distal intestinal epithelium after resection.

The levels of insulin-like growth factor II/mannose-6-phosphate (IGF-II/Man-6-P) receptor and the insulin-like growth factor I (IGF-I) receptor were measured in the intestinal epithelium after 50% resection of the small intestine. Controls were either pair-fed to match the reduced food intake of the resected group or fed ad libitum. [125I]IGF-II binding was transiently increased 2-fold in the distal segment of the small intestine 3 days after resection compared with the pair-fed control. Receptor levels increased from 2.60 nmol/mg protein (pair-fed) to 4.63 nmol/mg protein (resected; p less than 0.001) with no significant change in affinity of IGF-II binding (Kd = 11.2 vs. 9.8 nmol/l). The increase in IGF-II/Man-6-P receptors coincided with increased activity of thymidine kinase in the distal intestinal segment after the resection. [125I]IGF-I binding remained unchanged after the resection. However, the decreased food intake of the pair-fed and resected groups caused a 2-fold increase in the amount of IGF-I receptors (0.18 nmol/mg protein; p less than 0.001) compared with the control fed ad libitum (0.08 nmol/mg protein). IGF-II/Man-6-P receptors were only moderately increased during restricted food intake (2.60 vs. 1.78 nmol/mg protein; p less than 0.005). These results suggest that the IGF-II/Man-6-P receptor may play a role in the adaptive regenerative response of the intestinal epithelium.

Animals↗
PubMed1989

Treatment of locally advanced rectal cancer with external beam radiation, surgical resection, and intraoperative radiation therapy.

To try to improve the local control and survival of patients with locally advanced rectal cancer we have used a combination of high-dose pre-operative radiation therapy to 5,040 cGy followed by surgical resection and intraoperative electron beam radiation therapy (IORT) when there was visible or palpable residual disease, microscopically positive surgical margins, or persisting tumor adherence. A total of 75 patients were taken to surgery for resection +/- IORT who did not have distant metastases. Of the 49 patients with primary tumors, 11 did not have IORT as the tumor was thought to be completely resected. Of these 11, there were two local recurrences and a 3-year survival of 71%. Thirty-six patients with primary tumors had resection (20 complete, 16 partial) plus IORT, with a 3-year survival of 58% and three local failures. Twenty-six additional patients were treated for locally advanced recurrence of whom four could not receive IORT because of pelvic size or the extent of tumor. Of the 22 who received IORT, 7/9 with complete resection, 2/8 with partial resection, and 1/5 with no resection had local control with an overall 3-year actuarial survival of 32%. The local control and survival results in the primary tumors appear favorable compared to other series in the literature and suggest benefit to the use of IORT. For patients treated for local recurrence, local control and long-term survival can be obtained, but the results are not as encouraging as for the primary tumors.

Combined Modality Therapy↗
PubMedDate not supplied

Relationships between MR-imaged total amount of tissue removed, resection scores of specific mediobasal limbic subcompartments and clinical outcome following selective amygdalohippocampectomy.

Of 204 patients who underwent a selective amygdalohippocampectomy at our hospital, we studied 30 in whom special pre- and postoperative MR imaging was carried out and who were followed up for at least 1 year postoperatively. We measured the total size of the resection and the extent to which the following specific mediobasal temporal lobe structures had been removed: amygdala, hippocampus, pes hippocampi, dentate gyrus, parahippocampal gyrus, uncus and subiculum. Postoperative seizure control was correlated with the overall size of the resection as well as with the resection scores of the above mentioned limbic subcompartments. The mean size of the removed tissue was 7.2 cm3 (range: 2.1-17.7). The mean resection scores of the limbic subcompartments (in percentages) are: amygdala 92%, hippocampus 46%, pes hippocampi 92%, dentate gyrus 45%, parahippocampal gyrus 32%, uncus 92%, subiculum 40%. Although a small resection did not exclude a good outcome, the general tendency was that a better outcome was obtained from a larger resection. With regard to the resection scores of the limbic subcompartments, a positive correlation emerged between good postoperative outcome and the radicality of the removal of the parahippocampal gyrus (and the subiculum, which has been evaluated separately). These findings support our previously formulated amplifier hypothesis for the parahippocampal gyrus.

Adult↗
PubMed1988

Lympho-epithelial thymomas. A retrospective study of 88 resections.

Of 113 lympho-epithelial thymomas retrospectively studied, 56 were epithelial, 20 lymphocytic, 30 mixed and 7 were undefined forms. There were 88 resections (20 stage I, 47 stage II, 13 stage III and 8 stage IV). There were 69 primary resections (followed by radiotherapy in 54 cases) of which 57 were complete and 12 were incomplete. There were 19 secondary resections after radiotherapy: 10 were complete and 9 were incomplete and 25 patients were not operated upon and were treated by radio- and chemotherapy. After primary resection, the actuarial 5-year survival is 64.07% and the 10-year survival is 50.86%. After a secondary resection, the 5 year-survival is 43.74%. After non-surgical treatment, it is 18.67%. After surgery, the prognostic importance of staging is confirmed as more important than the cellular structure. Myasthenic patients are subject to late accidents. Postoperative radiotherapy seems to be justified, but its effect is not statistically significant when resection is complete. Post-radiotherapy surgery is beneficial only in cases of complete resection. The metastatic evolution of thymomas has been underrated and seems to depend upon the local control of the tumour. The use of chemotherapy remains to be defined.

Actuarial Analysis↗
PubMed1990

Median sternotomy and multiple lung resections for metastatic sarcomas.

In the attempt to apply salvage surgery to the majority of patients with pulmonary tumour relapse, we have adopted a new treatment plan consisting of early bilateral lung exploration and resection through median sternotomy in all cases of sarcoma with resectable lung metastases, including synchronous or previously resected ones. The present paper summarizes the early results achieved with this technique in 56 consecutive patients treated between 1985 and 1988. Perioperative mortality was zero, and morbidity negligible. Occult contralateral metastases were resected in about one third of subjects with monolateral clinical lesions. Overall actuarial survival from first pulmonary resection is 51% at 2 years and 35% at 3 years. A slightly more favourable trend is evident for solitary lesions but the difference is not statistically significant. No difference in survival is observed in relation to the initial disease-free interval or to the histological type. The majority of relapses occurred within 6 months of sternotomy (23/35) and were confined to the lungs (21/35). Ten of these 21 patients with pulmonary relapse have undergone further resection and 5 of them are alive, with a median survival of 28 months. Present results are encouraging as far as resectability and early recurrence rate are concerned. Median sternotomy appears a most valuable therapeutic approach to pulmonary metastases from sarcomas, being safe and effective in local control of disease, and compatible with further surgical management of pulmonary recurrences.

Adolescent↗
PubMed1993

The use of tissue adhesive in pulmonary resections.

One hundred eighty-seven consecutive patients underwent resection of primary bronchogenic carcinoma with intraoperative application of monomeric n-butyl-2-cyanoacrylate glue from July 1987 through December 1992. The glue reinforced either the stapled bronchial stump (135 patients), the sutured bronchial anastomosis in sleeve resections (37 patients) or the staple lines of wedge resections (15 patients). Mortality was 1.6% overall (3 of 187), and 5% among pneumonectomies (2 of 40). Bronchopleural fistulae occurred in 0.5% (1 of 187) of all pulmonary resections and 2.5% of pneumonectomies (1 of 40). There was no fistula in the lobectomy or sleeve resection groups. Bronchial anastomosis was accomplished in patients who underwent sleeve resection with four interrupted apposing sutures and airtight closure ensured by the tissue adhesive. There was no incidence of bronchial stenosis. There were no cyanoacrylate adhesive-related complications. A follow-up of the patients up to 68 months has indicated not only its effectiveness but also its safety. Monomeric n-butyl-2-cyanoacrylate glue is safe, offers protection to bronchial margins and may be valuable in preventing bronchial stenosis after sleeve resections.

Adolescent↗
PubMed1994

Chest wall reconstruction following resection of large primary malignant tumors.

Reconstructive procedures following radical resection of large primary malignant chest wall tumors (PMCWT) continue to evolve. Between 1982 and 1993, 32 consecutive patients (18 males/14 females) with a median age of 47 years (range, 12-77) underwent radical resection for large (median 10 +/- 5.4 cm) PMCWTs arising either from the bone (n = 15) or soft tissues (n = 17) of the chest wall. Nine (28%) had previous surgical resection before referral. Sixteen (50%) required extensive skin excision. Twelve sternectomies (5 total and 7 partial) and 20 lateral chest wall resections were performed. In this latter group, 16 patients (80%) had at least three ribs resected. Resection extended to the lung (10 wedge resections, 2 lobectomies and 1 pneumonectomy) in 13 patients, diaphragm in 3, abdominal wall in 2, brachiocephalic and subclavian vessels in 5, superior vena cava in 1 and upper limb in 1. Stability of the chest wall was obtained with prosthetic material in 27 patients, including Marlex (n = 21), polytetrafluoroethylene (PTFE) (n = 4) and polyglactin (n = 2) meshes. After sternectomy, six patients had a methyl methacrylate mesh reinforcement while soft tissue reconstruction was carried out using the pectoralis major muscle (PM), either alone with skin advancement (n = 8) or as a myocutaneous flap in three males (unilateral n = 2, bilateral n = 1) and by a latissimus dorsi (LD) myocutaneous flap in one female. Muscle transposition was used to reconstruct defects of the lateral chest wall and included 10 LD, 6 PM and 2 serratus anterior (SA) muscles, with associated advancement of the diaphragm in two cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Late results of sleeve resection for typical bronchial carcinoids.

The late follow-up was analyzed of 17 patients who underwent a sleeve resection for bronchial carcinoid tumor between 1974 and 1993. The mean age was 38 years (range 22-59). The bronchoplastic resections performed were sleeve lobectomy of the right upper lobe in six patients, sleeve lobectomy of the left lower lobe in three, sleeve resection of the right main bronchus in five and a sleeve resection of the left main bronchus in three patients. Only the pure sleeves are included and all other types of bronchoplastic resections (variant sleeves) for the same type of tumor were excluded. Preoperative laser therapy was applied in eight patients (from 1986 on). On surgical-pathologic staging, ten patients belonged to stage I (8T2N0M0 + 2T1N0M0), one patient belonged to stage II (T2N1M0) and six patients to stage IIIA (T3N0M0). There was no major perioperative morbidity and the hospital mortality was 0%. There were no local tumor recurrences but in one patient a bronchial stenosis at the site of the anastomosis needed a completion pneumonectomy after 16 months. The actuarial survival rate was 100% (+/- 0) at 5, 10 and 15 years. At 5, 10 and 15 years, 94% of the patients were free of major pulmonary events. This large series of bronchial carcinoids from one center treated by pure sleeve resection shows excellent short- and long-term results; therefore it seems to be justified to perform a sleeve resection for bronchial carcinoids when the tumor location and the surgeon's skill permit.

Adult↗
PubMed2005

Feasibility and clinical outcome of laparoscopic colorectal resection for endometriosis.

OBJECTIVE: This study was undertaken to evaluate the feasibility and complications of laparoscopic segmental colorectal resection for endometriosis and its efficacy on gynecologic and digestive symptoms. STUDY DESIGN: After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 40 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires were completed before and after the procedure. Perioperative complications and linear intensity scores for several gynecologic and digestive symptoms were recorded. RESULTS: Thirty-six women (90%) underwent laparoscopic segmental colorectal resection and 4 required laparoconversion. Major complications occurred in 4 cases (10%), including 3 rectovaginal fistulae and 1 pelvic abscess. Transient urinary dysfunction occurred in 7 women (17.5%). Median follow-up after colorectal resection was 15 months (3-22 months). Median overall preoperative and postoperative pain scores were 8 +/- 1 (range 4-10) and 2 +/- 2 (0-10), respectively ( P < .0001). Nonmenstrual pelvic pain ( P = .0001), dysmenorrhea ( P < .0001), dyspareunia ( P = .0001), and pain on defecation ( P < .0005) were improved by colorectal resection. Lower back pain and asthenia were not improved. CONCLUSION: Our results suggest that laparoscopic segmental colorectal resection for endometriosis is feasible but carries a risk of major postoperative complications. Colorectal resection improved gynecologic and digestive symptoms, and the overall pain score.

Adult↗