A Multi-institutional Analysis of Open Versus Minimally-Invasive Surgery for Gastric Adenocarcinoma: Results of the US Gastric Cancer Collaborative

Background

Surgical experience with minimally invasive surgery (MIS) has increased; however, published reports on MIS resection of gastric adenocarcinoma are limited.

Methods

Between 2000 and 2012, 880 patients who underwent surgical resection of gastric adenocarcinoma were identified from a multi-institutional database. Clinicopathological characteristics, operative details, and outcomes were stratified by operative approach (open vs. MIS) and analyzed.

Results

Overall, 70 (8 %) patients had a MIS approach. Patients who underwent a MIS resection were more likely to have a smaller tumor (open 4.5 cm vs. MIS 3.0 cm, p?p?p?=?0.03) and median lymph node yield was good in both groups (open 17 vs. MIS 14, p?=?0.10). MIS had a similar incidence of complications (open 33.1 % vs. MIS 20 %, p?=?0.07) and a similar length of stay (open 9 days vs. MIS 7 days, p?=?0.13) compared with open surgery. In the propensity-matched analysis, median recurrence-free and overall were not impacted by operative approach.

Conclusion

An MIS approach to gastric cancer was associated with adequate lymph node retrieval, a high incidence of R0 resection, and comparable long-term oncological outcomes versus open gastrectomy.     

Clinical Outcomes for Neuroendocrine Tumors of the Duodenum and Ampulla of Vater:A Population-Based Study

Background

Previous case series report that neuroendocrine tumors (NETs) of the ampulla of Vater have worse overall survival (OS) than NETs in the duodenum. We aimed to compare the OS of patients with ampullary NETs to patients with duodenal NETs.

Methods

This retrospective comparative cohort study used the Surveillance, Epidemiology, and End Results (SEER) registry from 1988 to 2009. OS was evaluated using Kaplan–Meier estimates and Cox proportional hazard regression.

Results

Ampullary NETs (n?=?120) were larger (median size 18 vs. 10 mm, p?<?0.001), higher grade (poorly and undifferentiated tumor 42 % vs. 12 %, p?<?0.001), higher SEER historic stage (distant metastasis 16 % vs. 7 %, p?<?0.001), and more often resected (78 % vs. 60 %, p?<?0.001) than duodenal NETs (n?=?1,360). Median OS was significantly worse for patients with ampullary NETs than with duodenal NETs (98 vs. 143 months, p?=?0.037). Local resection was performed for 50.5 % of the resected ampullary NETs and resulted in similar OS compared to locally resected duodenal NETs (HR 1.37, 95 % CI 0.76–2.48, p?=?0.291).

Conclusions

While ampullary NETs are more advanced at presentation and have worse OS than duodenal NETs, long-term survival is possible with proximal small bowel NETs. For locally resected NETs, OS is similar between ampullary and duodenal NETs.     

Predictors of Unsuccessful Laparoscopic Resection of Gastric Submucosal Neoplasms

Background

While laparoscopy has become integral to the performance of foregut surgery, its optimal use in resection of gastric submucosal neoplasms, including gastrointestinal stromal tumors (GISTs), remains uncertain. Concern exists for technical feasibility related to tumor size and location, as well as oncologic outcome.

Methods

From 2002 to 2012, 106 patients underwent resection for gastric submucosal neoplasms, comprising 79 laparoscopic and 27 open resections. Median follow-up was 15 months.

Results

Patients were 62?±?14 years and 56 % male. Mean tumor size was 5.5?±?4.3 cm, with 76 % being GISTs. A total of 8 (10 %) conversions occurred in the laparoscopic cohort. On multivariate analysis, conversion was predicted by size greater than 8 cm, while recurrence was predicted by mitotic index (p?<?0.05). Laparoscopic resection resulted in better perioperative outcomes, with less morbidity, operative time, blood loss, and length of stay (p?<?0.05). No significant difference was seen in survival, with 90 % and 81 % alive 3 years after laparoscopic and open resection, respectively (HR 0.4; 95 % CI 0.1–1.3; p?=?0.13).

Conclusions

Laparoscopic resection is feasible and effective in the management of gastric submucosal neoplasms, including GISTs. Caution should be reserved for tumors greater than 8 cm. Oncologic outcome appears to be predicted by tumor biology as opposed to surgical approach.     

Greater Complexity of Liver Surgery is Not Associated with an Increased Incidence of Liver-Related Complications Except for Bile Leak: An Experience with 2,628 Consecutive Resections

Background

Advances in technique, technology, and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver-related complications.

Methods

A large prospective single-institution database of patients who underwent hepatic resection was used to identify the incidence of liver-related complications. Liver resections were divided into an early era and a late era with equal number of patients (surgery performed before or after 18 May 2006). Patient characteristics and perioperative factors were compared between the two groups.

Results

Between 1997 and 2011, 2,628 hepatic resections were performed, with a 90-day morbidity and mortality rate of 37 and 2 %, respectively. We identified higher rates of repeat hepatectomy (12.2 vs 6.1 %; p?<?0.001), two-stage resection (4.0 vs 1 %; p?<?0.001), extended right hepatectomy (17.6 vs 14.6 %; p?=?0.04), and preoperative portal vein embolization (9.1 vs 5.9 %; p?<?0.001) in the late era. The incidence of perihepatic abscess (3.7 vs 2.1 %; p?=?0.02) and hemorrhage (0.9 vs 0.3 %; p?=?0.045) decreased in the late era and the incidence of hepatic insufficiency (3.1 vs 2.6 %; p?=?0.41) remained stable. In contrast, the rate of bile leak increased (5.9 vs 3.7 %; p?=?0.011). Independent predictors of bile leak included bile duct resection, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic resection, and intraoperative transfusion.

Conclusions

The complexity of liver surgery has increased over time, with a concomitant increase in bile leak rate. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leaks is indicated.     

Laparoscopic versus open resection of gastrointestinal stromal tumors of the stomach

Background

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgical treatment is the only chance of cure for patients with a primary localized GIST. A laparoscopic approach has been considered reasonable for these tumors of gastric origin. The current study compares the outcome of laparoscopic versus open resection of gastric GISTs and compares our series with the few published studies comparing the open versus the laparoscopic approach.

Methods

From a prospectively collected database, we found 53 primary gastric GIST resections that were performed in our department. Laparoscopic (LAP) resections were performed in 37 patients and traditional (OPEN) resections in 16 patients. Clinical and pathologic characteristics and surgical outcomes were analyzed according to surgical procedure.

Results

Patients who underwent LAP or OPEN resection of gastric GISTs did not differ with respect to age at operation, gender, clinical presentation, and tumor size. Operative time was significantly lower for LAP than for OPEN resection, with a mean duration of 45 and 132.5 min, respectively (p < 0.001). LAP resection yielded a significantly shorter length of stay (median 7 vs. 14 days; p = 0.007) and lower 30-day morbidity rate (2.7 % vs. 18.9 %; p = 0.077). The operative mortality was 12.5 % after OPEN resection and there was no operative mortality after LAP (p = 0.087). The recurrence rate was significantly lower after LAP surgery (0 % vs. 37.5 %; p < 0.001). All patients in the LAP group are alive without recurrence, and 25 % (4/16) of the OPEN group are alive with recurrence but in complete remission under imatinib mesylate treatment. Two patients of the open group died due to progression of GIST (p = 0.087).

Conclusions

Compared to open resection, laparoscopic resection of gastric stromal tumors is associated with a shorter operation time, a shorter hospital stay, and a lower recurrence rate.     

Efficacy of the Predicted Operation Time (POT) Strategy for Synchronous Colorectal Liver Metastasis (SCLM): Feasibility Study for Staged Resection in Patients with a Long POT

Background

The optimal surgical strategy for resectable synchronous colorectal liver metastases (SCLM), whether simultaneous or staged resections, still remains obscure. The aim of this study was to assess the efficacy of the predicted operation time (POT) strategy, which recommends staged resections in case of POT ≥6 h, otherwise selecting simultaneous resection.

Methods

This was a prospective, nonrandomized, single-institution study. Fifty-nine patients with SCLM underwent tumor resection according to the POT strategy, with patients with a longer POT (≥6 h) undergoing staged resection. Morbidity, overall hospitalization, tumor resection rates, and survival were compared with that of 86 patients who underwent simultaneous resection for SCLM irrespective of POT from 1992 to 2004.

Results

The former simultaneous and the latter POT strategy groups were similar in terms of patient and tumor demographics as well as surgical procedures. Of the 59 POT group patients, 26 patients (44 %) experienced 40 postoperative complications. Comparing the surgical results of simultaneous resection from 1992 to 2004 and those of resection according to the POT strategy, morbidity (64 vs. 44 %, p?=?0.02), frequency of anastomotic leakage (21 vs. 5 %, p?<?0.01), and length of hospital stay (27 vs. 18 days, p?<?0.01) were significantly lower in the latter group, while tumor resection rates (85 vs. 87 %, p?=?0.77) were not different.

Conclusions

The POT strategy is effective in reducing the morbidity in SCLM patients by selecting staged resections in the high-morbidity-risk group without adverse effects on oncologic outcome.     

Intraoperative adverse events during laparoscopic colorectal resection—better laparoscopic treatment but unchanged incidence. Lessons learnt from a Swiss multi-institutional analysis of 3,928 patients

Purpose

Intraoperative adverse events significantly influence morbidity and mortality of laparoscopic colorectal resections. Over an 11-year period, the changes of occurrence of such intraoperative adverse events were assessed in this study.

Methods

Analysis of 3,928 patients undergoing elective laparoscopic colorectal resection based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery was performed.

Results

Overall, 377 intraoperative adverse events occurred in 329 patients (overall incidence of 8.4 %). Of 377 events, 163 (43 %) were surgical complications and 214 (57 %) were nonsurgical adverse events. Surgical complications were iatrogenic injury to solid organs (n?=?63; incidence of 1.6 %), bleeding (n?=?62; 1.6 %), lesion by puncture (n?=?25; 0.6 %), and intraoperative anastomotic leakage (n?=?13; 0.3 %). Of note, 11 % of intraoperative organ/puncture lesions requiring re-intervention were missed intraoperatively. Nonsurgical adverse events were problems with equipment (n?=?127; 3.2 %), anesthetic problems (n?=?30; 0.8 %), and various (n?=?57; 1.5 %). Over time, the rate of intraoperative adverse events decreased, but not significantly. Bleeding complications significantly decreased (p?=?0.015), and equipment problems increased (p?=?0.036). However, the rate of adverse events requiring conversion significantly decreased with time (p?<?0.001). Patients with an intraoperative adverse event had a significantly higher rate of postoperative local and general morbidity (41.2 and 32.9 % vs. 18.0 and 17.2 %, p?<?0.001 and p?<?0.001, respectively).

Conclusions

Intraoperative surgical complications and adverse events in laparoscopic colorectal resections did not change significantly over time and are associated with an increased postoperative morbidity.     

Preoperative therapy of esophagogastric cancer: the problem of nonresponding patients

Introduction

Preoperative treatment is nowadays standard for locally advanced esophagogastric cancer in Europe. Surprisingly, little attention has been paid to nonresponders so far. The aim of our retrospective exploratory study was the comparison of responder, nonresponder, and primary resected patients in respect of outcome considering the tumor entity.

Patients and methods

From 2001–2011, 607 patients with locally advanced esophagogastric carcinoma (adenocarcinoma of the esophagogastric junction (AEG), n?=?293; squamous cell cancer (SCC), n?=?111; gastric cancer, n?=?203) after preoperative treatment (n?=?281) or primary resection (n?=?326) were included. Histopathological response evaluation (Becker criteria) was available for 263.

Results

A total of 76/263 (28.9 %) were responders (<10 % residual tumor). There was an association of response with increased R0 resections (p?<?0.001) but also with a higher complication rate (p?=?0.008) compared to nonresponse and primary surgery. Mortality was not influenced. Increased R0 resections after response were confirmed in every tumor entity (AEG, p?=?0.010; SCC, p?=?0.023; gastric cancer, p?=?0.006). Median survival was best for responders with 43.5 months [95 % confidence interval (CI), 27.9–59.1], followed by nonresponders with 24.3 months (95 % CI, 21.6–27.0) and primary resected patients with 20.8 months (95 % CI, 17.7–23.9; p?=?0.002). AEG (p?=?0.012) and gastric cancer (p?=?0.017) revealed identical results, but in the subgroup of SCC, the survival of nonresponders (median, 11.6 months; 95 % CI, 6.9–16.3) was even worse than for primary resected patients (median, 23.8 months; 95 % CI, 1.7–46.0; p?=?0.012).

Conclusion

The histopathological response rate was low. Generally, nonresponding patients with AEG or gastric cancer seem not to have a disadvantage compared to primary resected patients, but nonresponders with SCC have a worse prognosis, which strengthens the demand for a critical patient selection in surgery for this tumor entity.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Operative time and length of stay is similar between robotic assisted and laparoscopic colon and rectal resections

Robotic-assisted surgery is increasingly being utilized for colorectal surgery. Data are scarce and contradictory when outcomes are compared between robotic and laparoscopic surgery. All patients undergoing minimally invasive colorectal surgery were compared from 2011 to 2016. Outcomes between the two groups were statistically analyzed. p?<?0.05 was considered statistically significant. 185 patients underwent laparoscopic resection and 70 underwent robotic resection. Demographics, ASA score, and BMI were similar between the two groups (p?>?0.05). There was no statistical difference in median length of stay between laparoscopic and robotic colon (both 4 days; p?=?0.5) and rectal (6 vs 4.5 days; p?=?0.2) resections. Median operative times were also similar between the two approaches for colon (150.5 vs 169.5 min, p?=?0.2) and rectal (197.0 vs 231.5 min, p?=?0.9) resections. There was also no difference in operative time between the two approaches for right (median?=?137 vs 130.5 min; p?=?0.9) and left (median?=?162.0 vs 170.5 min; p?=?0.6) colectomies. Robotic surgery results in similar operative times and length of stay as laparoscopic surgery for patients undergoing colon and rectal resections.     

α-Fetoprotein-to-Total Tumor Volume Ratio Predicts Post-operative Tumor Recurrence in Hepatocellular Carcinoma

Background/Aims

Serum α-fetoprotein (AFP) and total tumor volume (TTV) are important factors linked with post-operative tumor recurrence in hepatocellular carcinoma (HCC) patients. We investigated the role of a new prognostic marker, AFP-to-TTV ratio, in predicting HCC recurrence.

Methods

A total of 655 HCC patients undergoing resection were analyzed.

Results

In the multivariate logistic model, serum AFP level [odds ratio (OR) 32.459, p?=?0.012] and TTV (OR 0.006, p?=?0.01) were independently associated with a higher AFT/TTV ratio. The 1-, 3-, and 5-year tumor recurrence rates were 29 %, 55 %, and 68 %, respectively. In the Cox proportional hazards model, alcoholism (hazard ratio [HR], 1.354, p?=?0.028), international normalized ratio of prothrombin time ≥1.01 (HR, 1.349, p?<?0.001), multiple nodules (HR, 1.381, p?=?0.004), main tumor diameter ≥4?cm (HR, 1.535, p?=?0.001), macrovascular invasion (HR, 1.362, p?=?0.016), and AFP/TTV ratio ≥1.5 (HR, 1.49, p?<?0.001) were independently associated with tumor recurrence. In subgroup analysis, a higher AFP/TTV ratio was significantly associated with tumor recurrence in patients characterized by macrovascular invasion, TTV?≥?40 cm³, or main tumor diameter ≥4cm (all p?=?0.001).

Conclusion

The AFP/TTV ratio, a newly proposed marker for predicting post-operative tumor recurrence in HCC, is a feasible surrogate and may be useful in selecting super-high-risk patients for tumor recurrence.     

Endoscopic resection of large sporadic non-ampullary duodenal polyps: efficacy and long-term recurrence

Background

Endoscopic resection is an alternative to surgery for removal of large duodenal polyps. There are limited data on the safety, efficacy, and long-term recurrence data after endoscopic resection of sporadic, non-ampullary, and large duodenal polyps.

Objective

Our aim was to evaluate the safety and short-term outcomes of the endoscopic removal of the large sporadic duodenal polyps and to determine long-term risk of recurrence and factors predicting recurrence on follow-up.

Methods

Patients with large (>10 mm) sporadic non-ampullary duodenal polyps underwent endoscopic resection from 2001 to 2012 at the Cleveland Clinic. Patients underwent endoscopic polypectomy and argon plasma coagulation. The main outcome measurements were complete polypectomy, complications, short- and long-term recurrence.

Results

A total of 54 patients were included. The mean patient age was 66.4 years. The mean polyp size was 15.1 ± 5.4 mm. Most polyps (N = 48, 88.9 %) were sessile polyps. The median follow-up time was 10.8 (range 0.5–120) months. Most lesions were located in the second part of the duodenum (N = 41, 75.9 %). Adenomas were found in 46 (85.2 %) of lesions overall. Tubular adenoma was the most common histology type found in 33 cases (71.7 %). Tubulovillous and villous were found in 12 (26.1 %) and 1 (2.2 %) cases, respectively. On follow-up, 50 (92.6 %) achieved complete resection with tumor free margins post resection. The 30-day risk of major complications was 5.6 % (N = 3), 1 with perforation and 2 with delayed bleeding. Recurrence was documented in 29 % (N = 16) of patients. All recurrences were managed endoscopically except for one patient who required surgery. The recurrence rate was higher for patients who had villous component in their adenomas compared to those with tubular alone (p = 0.03).

Conclusions

Endoscopic resection is effective for treating large duodenal adenomas. Adenomas with villous features are more likely to recur. Almost all recurrences can be managed endoscopically.     

Factors predicting prognosis and recurrence in patients with esophago-gastric adenocarcinoma and histopathological response with less than 10 % residual tumor

Purpose

Neoadjuvant treatment is an accepted standard approach for treating locally advanced esophago-gastric adenocarcinomas. Despite a response of the primary tumor, a significant percentage dies from tumor recurrence. The aim of this retrospective exploratory study from two academic centers was to identify predictors of survival and recurrence in histopathologically responding patients.

Methods

Two hundred thirty one patients with adenocarcinomas (esophagus: n?=?185, stomach: n?=?46, cT3/4, cN0/+, cM0) treated with preoperative chemotherapy (n?=?212) or chemoradiotherapy (n?=?19) followed by resection achieved a histopathological response (regression 1a: no residual tumor (n?=?58), and regression 1b?<?10 % residual tumor (n?=?173)).

Results

The estimated median overall survival was 92.4 months (5-year survival, 56.6 %) for all patients. For patients with regression 1a, median survival is not reached (5-year survival, 71.6 %) compared to patients with regression 1b with 75.3 months median (5-year survival, 52.2 %) (p?=?0.031). Patients with a regression 1a had lymph node metastases in 19.0 versus 33.7 % in regression 1b. The ypT-category (p?<?0.001), the M-category (p?=?0.005), and the type of treatment (p?=?0.04) were found to be independent prognostic factors in R0-resected patients. The recurrence rate was 31.7 % (n?=?66) (local, 39.4 %; peritoneal carcinomatosis, 25.7 %; distant metastases, 50 %). Recurrence was predicted by female gender (p?=?0.013), ypT-category (p?=?0.007), and M-category (p?=?0.003) in multivariate analysis.

Conclusion

Response of the primary tumor does not guarantee recurrence-free long-term survival, but histopathological complete responders have better prognosis compared to partial responders. Established prognostic factors strongly influence the outcome, which could, in the future, be used for stratification of adjuvant treatment approaches. Increasing the rate of histopathological complete responders is a valid endpoint for future clinical trials investigating new drugs.     

Perioperative Outcome After Pancreatic Head Resection: a 10-Year Series of a Specialized Surgeon in a University Hospital and a Community Hospital

Introduction

Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic resection. Data on perioperative outcome of individual surgeons in different institutions, however, are scarce. We evaluated the perioperative outcome after pancreatic head resections (PHR) performed by a high-volume pancreatic surgeon in a high-volume university department and (later) in a community hospital with low prior experience in major pancreatic surgery.

Methods

We compared the results after PHR were performed by a single experienced surgeon between 2001 and October 2006 in a specialized unit of a German university hospital (n?=?83; group A) with the results after PHR were performed in a community hospital between November 2006 and 2011 (n?=?145; group B). Before the study period (?2001), the surgeon already had a personal caseload of >200 PHR. In addition to the 228 PHR analyzed here, the surgeon also had taught further >150 PHR to residents and consulting surgeons. Comparable surgical and perioperative techniques were applied in both series (e.g., types of resection and reconstruction, abdominal drains, early enteral feeding). The data of both series were prospectively recorded in SPSS databases.

Results

The median age of the patients was lower in group A (58 vs. 66 years in B; p?<?0.01). Indications for PHR were pancreatic cancer (A 39 % vs. B 45 %), other periampullary cancer (A 18 % vs. B 12 %), chronic pancreatitis (A 33 % vs. B 28 %), and others (A 10 % vs. B 15 %). Most PHR were pylorus preserving (64 vs. 75 %), with oncologically indicated portal vein resections in 24 % (A) or 33 % (B). The percentage of duodenum-preserving PHR was lower in group B (14 vs. 26 % in A). Mortality of PHR was 3.6 % in group A and 2.8 % in B (p?=?0.72). Overall morbidity rate was 49 % (A) or 57 % (B; p?=?0.25). Using the expanded Accordion classification, complications classified as grade 4 or higher occurred in 9 % (A) and 11 % (B; p?=?0.74). Postoperative pancreatic leak (any grade) was documented in 26 % (A) and 25 % (B; p?=?0.87).

Conclusions

Surgeon volume and a high individual experience, respectively, contribute to acceptable complication rates and low mortality rates after pancreatic head resection. An experienced surgeon can provide a good perioperative outcome after pancreatic resection even after a change of hospital or medical staff.     

Good Candidates for a Third Liver Resection of Colorectal Metastasis

Background

Having three liver resections for colorectal metastases has long been considered to be associated with a high risk of postoperative complications. The present study was designed to assess the feasibility and survival benefits of three liver resections.

Methods

Between 2004 and 2011, data for 273 consecutive patients with colorectal metastases were analyzed. The patient characteristics, tumor status, operation-related variables, degree of liver steatosis, and short- and long-term outcomes were compared according to the number of liver resections.

Results

The history of preoperative chemotherapy was higher for patients who had had three liver resections as compared with other resections: i.e., one resection 41.0 %, versus two resections 56.8 %, versus three resections 81.8 %; p = 0.04. Patients receiving three liver resections had a high rate of liver steatosis (17.9 vs. 32.4 vs. 59.1 %; p = 0.03). The median operative time for three resections was significantly longer than for the other resections (359 min [range: 115–579 min] vs. 395 min [range: 178–740 min], vs. 482 min [range: 195–616 min]; p = 0.04). However, the complication rate and the postoperative hospital stay did not differ among the three groups. The 1-, 3- and 5-year survival rates did not differ significantly among the three groups (83.3, 57.5, and 44.6 % for one resection vs. 92.3, 52.1, and 35.7 % for two resections vs. 93.3, 49.0, and 34.1 % for three resections). Patients who had <5 tumors at a third liver resection and a recurrence interval of ≥500 days from the second resection were good candidates for three resections.

Conclusions

Undergoing three resections of colorectal metastasis is feasible and provides a similar survival benefit as one or two resections, without increasing morbidity or mortality.     

Neuroendocrine tumours of the ampulla of Vater: clinico-pathological features, surgical approach and assessment of prognosis

Background/aims

Neuroendocrine tumours occur very rarely in the ampulla of Vater and their clinical behaviour is unknown. The aim of this study is to assess the clinico-pathological features, surgical approach and prognosis of these patients.

Methods

Six patients with neuroendocrine tumours of the ampulla of Vater treated with curative intent surgery at a single centre were retrospectively analysed. A univariate analysis of potential prognostic factors was also performed (data provided from the present study and literature review).

Results

Pancreaticoduodenectomy was curative in all the patients. Overall and disease-free survival rates were significantly better for G1/G2 tumours (p?=?0.006 and p?=?0.004, respectively). Although frequent, lymph node metastases did not influenced both overall (p?=?0.760) and disease-free survival rates (p?=?0.745). No significant differences of survival were observed in patients with ENETS stage I/II disease, as compared to ENETS stage III disease (p?=?0.169 and p?=?0.137, respectively). No differences were observed according to UICC staging system (p?=?0.073 and p?=?0.177, respectively). Tumours that are less than 2?cm or limited to the ampulla appear to have a better prognosis.

Conclusion

The WHO 2010 classification appear to accurately predict patient prognosis, while the ENETS or UICC staging systems have a limited value (especially in regard to lymph node metastases). Radical surgery (i.e. pancreaticoduodenectomy with lymphadenectomy) should be the standard approach in most patients with NET of the ampulla of Vater because this procedure removes all the potential tumour-bearing tissue.     

Resection for Hilar Cholangiocarcinoma: Analysis of Prognostic Factors and the Impact of Systemic Inflammation on Long-term Outcome

Introduction

Resection for hilar cholangiocarcinoma is the single hope for long-term survival.

Methods

Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan–Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model).

Results

The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR?=?0.03, 95 % CI 0–0.19, p?<?0.001), caudate lobe invasion (HR?=?6.33, 95 % CI 1.31–30.46, p?=?0.021), adjuvant gemcitabine-based chemotherapy (HR?=?0.38, 95 % CI 0.15–0.94, p?=?0.037), and the neutrophil-to-lymphocyte ratio (HR?=?0.78, 95 % CI 0.62–0.98, p?=?0.036) as independent prognostic factors for disease-free survival. The independent prognostic factors for overall survival were R0 resection (HR?=?0.03, 95 % CI 0–0.22, p?<?0.001), caudate lobe invasion (HR?=?11.75, 95 % CI 1.65–83.33, p?=?0.014), and adjuvant gemcitabine-based chemotherapy (HR?=?0.19, 95 % CI 0.06–0.56, p?=?0.003).

Conclusions

The negative resection margin represents the most important prognostic factor. Adjuvant gemcitabine-based chemotherapy appears to benefit survival. The neutrophil-to-lymphocyte ratio may potentially be used to stratify patients for future clinical trials.     

Perioperative Complications After Neoadjuvant Chemotherapy With and Without Bevacizumab for Colorectal Liver Metastases

Purpose

Bevacizumab has been shown to increase progression free and overall survival in patients with metastatic colorectal cancer. Neoadjuvant bevacizumab is commonly used in patients undergoing liver resection. Our purpose was to evaluate whether bevacizumab is associated with increased rate of perioperative complications in patients undergoing hepatic resection for colorectal liver metastases (CRLM).

Methods

Retrospective analysis of patients undergoing hepatic resection for CRLM who received chemotherapy and bevacizumab (group 1, n?=?134), or chemotherapy alone (group 2, n?=?57). We compared demographics, surgical characteristics, and perioperative course.

Results

Perioperative complications developed in 35 % of patients in group 1, and 47 % in group 2 (p?=?0.11). Of those complications, 15 (11.2 %) in group 1, and 5 (8.8 %) in group 2 were considered major (p?=?0.617). Four patients, all of whom received preoperative bevacizumab, developed enteric leaks following combined liver and bowel resection. The rate of anastomotic leak in group 1 was 10 %, compared with 0 in group 2, p?=?0.56.

Conclusion

Neoadjuvant chemotherapy along with bevacizumab was not associated with an increased risk of postoperative complications after hepatic resection. Possible association of increased morbidity with simultaneous bowel and liver resections following bevacizumab administration was found and we recommend avoiding such treatment combination.     

Liver Resection in the Elderly: Significance of Comorbidities and Blood Loss

Objective

Liver resection is increasingly performed in elderly patients who are suspected of increased postoperative morbidity (PM) and reduced overall survival (OS). Patient selection based on the identification of age-adjusted risk factors may help to decrease PM and OS.

Design and Participants

Prospectively collected data of 879 patients undergoing elective hepatic resection were analyzed. This population was stratified into three age cohorts: >70 years (n?=?228; 26 %), 60–69 years (n?=?309; 35 %), and <60 years (n?=?342; 39 %). Multivariate survival analysis was performed.

Results

The incidence of severe (p?<?0.01) and non-surgical (p?<?0.001) postoperative complications was higher in older compared to younger patients. Major estimated blood loss (EBL; p?=?0.039) and comorbidities (p?=?0.002) independently increased PM. EBL was comparable between all age cohorts. However, preexisting comorbidities, major EBL, and postoperative complications markedly decreased OS in contrast to younger patients. Adjusted for age, independent predictors of OS were comorbidities (HR?=?1.51; p?=?0.001), major hepatectomy (HR?=?1.33; p?=?0.025), increased EBL (HR?=?1.32; p?=?0.031), and postoperative complications (HR?=?1.64; p?<?0.001).

Conclusion

Although increased age should not be a contraindication for liver resection, this study accents the avoidance of major blood loss in elderly patients and a stringent patient selection based on preexisting comorbidities.     

Long-Term Outcomes of Laparoscopic Surgery for Advanced Transverse Colon Cancer

Background

The role of laparoscopic surgery for advanced transverse colon cancer (TCC) remains controversial, especially in terms of long-term oncologic outcomes.

Methods

This retrospective cohort study enrolled 157 consecutive patients who underwent curable resections for advanced TCC between January 2002 and June 2011 (laparoscopic-assisted colectomy (LAC), n?=?74; open colectomy (OC), n?=?83). Short-term outcomes and oncologic long-term outcomes were compared between the two groups.

Results

Compared to the OC group, patients in the LAC group had less blood loss (LAC vs. OC, 79.6?±?70.3 vs. 158.4?±?89.3 ml, p?<?0.001), faster return of bowel function (2.6?±?0.7 vs. 3.8?±?0.8 days, p?<?0.001), and shorter postoperative hospital stay (10.3?±?3.7 vs. 12.6?±?6.0 days, p?=?0.007). Conversions were required in four (5.4 %) patients. Rates of short-term complication, mortality, and long-term complication were comparable between the two groups. The median follow-up time was 54 (26–106) months in the LAC group and 58 (29–113) months in the OC group (p?=?0.407). There were no statistical differences in the rates of 5-year overall survival (73.6 vs. 71.1 %, p?=?0.397) and 5-year disease-free survival (70.5 vs. 66.7 %, p?=?0.501) between the two groups.

Conclusions

Laparoscopic surgery for advanced TCC yield short-term benefits while achieving equivalent long-term oncologic outcomes.