Experience with 225 hepatic resections for hepatocellular carcinoma over a 4-year period.

During the past 4 1/2 years, we have performed hepatic resection on 225 patients with hepatocellular carcinoma (HCC). These patients included 171 men and 54 women, whose ages ranged from 29 to 84 years with an average of 60 years. Underlying cirrhosis of the liver was found in 67% of the patients and chronic hepatitis in 27%. Patients undergoing hepatic resection were classified into five groups according to curability as follows: Group A, resection of the tumor-bearing segment and one additional segment; Group B, complete resection of the tumor with more than 1.0 cm free surgical margin; Group C, complete resection of the tumor with less than 1.0 cm free surgical margin; Group D, incomplete resection of the tumor; Group E, surgical approach for advanced HCC with tumor thrombi in the main trunk or the first branch of the portal vein and/or the inferior vena cava, with multiple daughter nodules in both lobes and with tumor recurrence. The number of patients in Groups A, B, C, D, and E was 12 (5%), 83 (37%), 58 (26%), 14 (6%) and 58, (26%), respectively. There were 4 deaths (2.4%) among the 167 patients in Groups A to D within 30 days after operation and 12 deaths (20.7%) in Group E. The 3-year survival rate of Groups A, B, C, D, and E was 100%, 74%, 21%, 0%, and 35%, respectively.     

Current treatment modalities for hepatocellular carcinoma.

OBJECTIVE: This study evaluated the currently available treatment modalities for hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: One of the most common tumors worldwide, HCC has several known risk factors. Untreated HCC typically has a dismal prognosis. Early detection remains the key to successful treatment of this malignancy. Surgical resection has been the mainstay of treatment for HCC, but newer modalities have been recently introduced. METHODS: The authors evaluated the treatment modalities for HCC. RESULTS: Surgical resection affords 5-year survival rates as high as 45% with more favorable subgroups having 1) small tumors, 2) well-differentiated tumors, 3) unifocal tumors, 4) lack of vascular invasion, 5) absence of cirrhosis, and 6) the fibrolamellar variant (FL-HCC). Resection has been limited primarily by low resectability rates and recurrent disease. Newer therapeutic modalities that appear the most promising are transarterial chemoembolization and percutaneous ethanol injection. Neither therapy has been evaluated in a prospective randomized manner. Combination chemotherapy and surgical intervention may provide the best results, but randomized controlled trials with long-term follow-up are needed. As single-treatment modalities, radiation therapy, intravenous chemotherapy, intra-arterial chemotherapy, and immunotherapy play limited palliative roles. CONCLUSIONS: Surgical resection in the form of partial or total hepatectomy is the preferred treatment for HCC. The early detection of tumors by screening high-risk populations is crucial. Randomized trials of combinations of chemotherapy and surgical resection are needed to demonstrate their potential utility for treatment.     

Alveolar proteinosis: diagnosis and treatment over a 10-year period.

Ten years' experience of using bronchoalveolar lavage in the treatment of 10 patients with alveolar proteinosis is reported. The diagnosis was often missed. The interval between onset of symptoms and diagnosis varied from six weeks to six years (median 2 years), so that the start of treatment was often delayed. Some patients experienced severe progressive disability before they had treatment. Whole-lung lavage proved to be a safe, repeatable procedure which provided symptomatic, physiological, and radiological improvement and allowed all 10 patients treated to return to full-time employment.     

Laparoscopic cholecystectomy without operative cholangiogram: 2038 cases over a 5-year period in two district general hospitals.

The place of cholangiography in laparoscopic cholecystectomy is debatable. This retrospective study reviews the outcome of 2061 patients operated upon for symptomatic gallstones in two district general hospitals. Intraoperative cholangiography was not used because all patients were submitted to a policy of selective preoperative investigation of the extrahepatic ducts. The conversion rate to open cholecystectomy was 3.1% and 88% of patients were discharged home within 48 h of surgery. No major duct injuries occurred and only 12 patients have presented with a proven retained stone after operation (0.7%). This policy of preoperative investigation and treatment for extrahepatic bile duct stones without intraoperative cholangiography has been employed in over 2000 patients and is at least as safe as published results using routine intraoperative cholangiography.     

Spinal chordomas — results of treatment over a 17-year period

Summary Among a series of 511 spinal tumours treated in the Department of Neurosurgery at the Nordstadt Hospital in Hannover, Germany, between September 1977 and August 1994, 23 operations for spinal chordomas in 9 patients (3 females, 6 males) were performed. After an average period of 7±12 months (2 weeks to 5 years) patients presented at an average age of 45±17 years with pain (68%), gait ataxia (14%), motor weakness (9%) or sphincter disturbances (9%). A complete resection was achieved in 11 operations and a subtotal tumour removal in 12 instances. After subtotal removal, 5 tumours were treated postoperatively using local high dose radiotherapy (60–70 Gy). Overall, every chordoma recurred with the passage of time unless en-bloc resection of the tumour had been performed. The recurrence-free interval tended to be longer after radiotherapy. Analysis of postoperative results revealed a significant positive effect of radiotherapy for motor function, pain, Karnofsky score, and survival.In conclusion, en-bloc resection should be performed whenever localization and extension of the tumour allow one to do so. Surgery should be followed by local high dose radiotherapy.     

Tuberculum and diaphragma sella meningioma – surgical technique and visual outcome in a series of 20 cases operated over a 2.5-year period

Summary Background. A retrospective analysis of 20 cases of tuberculum sella meningioma with emphasis on the surgical technique and visual outcome. Methods. Between 2003 and 2006 twenty patients with tuberculum and diaphragma sella meningioma were treated at the Tel Aviv medical center. There were 17 females and 3 males. The age range was 28–83. Most patients presented with visual deterioration. Surgery was performed using the subfrontal approach. The visual function before and after surgery was evaluated as the main outcome parameter of the surgical treatment of these tumours. Findings. In 16 patients complete tumour resection was achieved and in 4 subtotal removal was performed. Visual acuity improved in 32% of the eyes and deterioration was observed in two eyes (5%). Visual field improved in 28% of the eyes and deteriorated in 14%. There was no complete vision loss as a result of surgery. There was no mortality in our series. Conclusions. Tuberculum and diaphragma sella meningioma can be safely resected using the subfrontal approach with preservation and even improvement of visual function after surgery. Early surgery with better pre-operation visual function and smaller tumour size were associated with a better outcome.     

Clinicopathological features and surgical outcome of patients with fibrolamellar hepatocellular carcinoma(experience with 22 patients over a 15-year period)

AIM To evaluate the clinicopathological features and the surgical outcomes of patients with fibrolamellar hepato-cellular carcinoma(FL-HCC)over a 15-year period. METHODS This is a retrospective study including 22 patients with a pathologic diagnosis of FL-HCC who underwent hepatectomy over a 15-year period. Tumor characteristics,survival and recurrence were evaluated. RESULTS There were 11 male and 11 female with a median age of 29 years(range from 21 to 58 years). Two(9%)patients had hepatitis C viral infection and only 2(9%)patients had alpha-fetoprotein level 200 ng/m L. The median size of the tumors was 12 cm(range from 5-20 cm). Vascular invasion was detected in 5(23%)patients. Four(18%)patients had lymph node metastases. The median follow up period was 42 mo and the 5-year survival was 65%. Five(23%)patients had a recurrent disease,4 of them had a second surgery with 36 mo median time interval. Vascular invasion is the only significant negative prognostic factor CONCLUSION FL-HCC has a favorable prognosis than common HCC and should be suspected in young patients with non cirrhotic liver. Aggressive surgical resection should be done for all patients. Repeated hepatectomy should be considered for these patients as it has a relatively indolent course.     

Surgical treatment of anal fistulas. Personal experience on 1,000 patients over a 20-year period

BACKGROUND: Considering their long experience acquired during the period October 1981 and October 2001 related to the treatment of 1,000 patients suffering from anal fistulas, the authors reasses the problem of this affection from an etiopathogenic, classifying, diagnostic and therapeutic point of view. METHODS: Surgical treatment of Arnous's French School was performed; these methods foresee the division of the operative times and slow sphincteric sectioning by an elastic constriction. RESULTS: Results were excellent: 99.2% of complete recoveries and very few failures and complications: 0.5% incomplete recovery, 0.3% relapse, 1.3% soiling, 1.5% gas temporary incontinence. CONCLUSIONS: The main premise to obtain the patient's recovery is to perform a faultless technique and to follow assiduously and minutely the long postoperative period of surgical wounds.     

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影像医学的进步 ,为原发性肝癌 (以下简称肝癌 )预后的改善作出了巨大的贡献 ,使人们可以发现更多的相对早期的肝癌 ,从而得到早期、及时的治疗。外科手术切除仍是影响肝癌预后的最主要因素 ,是目前首选的治疗方法之一 ,但术后复发率仍很高 ;因而 ,对切除后复发 (再发 )、转移的研究已成为进一步提高生存率的关键。肝癌局部治疗有了很大发展 ;综合和序贯治疗是不能切除肝癌的重要治疗途径 ;随手术技术的提高 ,很多巨大肝癌可获得切除 ,术后再给予经导管肝动脉插管化疗栓塞 (ｔｒａｎｓｃａｔｈｅｔｅｒｈｅｐａｔｉｃａｒｔｅ ｒｉａｌｃｈ…     

Small hepatocellular carcinoma. Diagnosis and treatment of 40 cases]

In 40 patients with small hepatocellular carcinoma, the lesions were less than 5 cm in diameter, with a mean diameter of 3.4 +/- 1.1 cm. The smallest was 1.1 x 1.3 cm. 39 patients were first detected by ultrasonic scanning, and one was discovered during emergency operation because of spontaneous tumor rupture. 36 patients were treated by means of hepatic resection. One (2.7%) died within 30 days after operation. Four patients with severe hepatic cirrhosis and significant prolongation of prothrombin time (4 seconds over control) were subjected to selective transcatheter arterial embolization combined with transcatheter arterial infusion of chemotherapeutic agent. The diagnosis and treatment of small hepatocellular carcinoma was discussed.     

原发性肝癌的手术治疗：附408例分析

目的　探讨原发性肝癌的手术治疗效果及影响疗效的因素。方法　回顾性分析近 8年外科手术治疗的原发性肝癌 40 8例患者的临床资料。结果　 40 8例占同期原发性肝癌住院之 43 .9% ,大肝癌占 81.9% ,伴门静脉癌栓者占 8.5 % ,伴胆管癌栓者 4.8%。 40 8例中行左外叶切除 118例 ,左半肝切除 97例 ,右半肝切除 112例 ,右肝肿瘤所在区段切除 73例 ,左、右叶肿瘤同时切除 8例。同时行门静脉癌栓 (左、右支或主支 )取栓术 3 5例 ,同时行肝内外胆管癌栓取栓术 2 0例 ;加行全植入或药泵置入 (DDS) 48例 (3 5例有门静脉癌栓者均经门静脉置入 )。术后发生并发症共 3 0 2例次。包括膈下脓肿、肺部感染 ,上消化道出血 ,胸腔积液、腹水、伤口裂开等。手术死亡率 2 .7% ,残癌率为18.4% ,术后复发或转移率为 73 .0 %。 1,3 ,5年生存率分别为 73 .9% ,5 1.3 % ,3 5 .5 %。结论　原发性肝癌接受手术治疗者的病期均较晚 ,术后复发和 /或转移是影响远期疗效的主要因素。     

The Hastings hip in osteoarthritis. A study of 47 cases with a 5-year follow-up period

A prospective study of the use of the Hastings biarticular hemiarthroplasty for the treatment of osteoarthritis of the hip in 47 hips in elderly patients (mean age, 76 years), with a mean follow-up period of 5 years, is reported. Seventy-four percent of these patients were pain-free or had slight pain only. The results were best in patients older than 80 years. Survivorship analysis showed an 86.2% cumulative success rate at 7 years. Surgical complications occurred in only 4%. There were no deaths attributable to surgery. Acetabular erosion greater than 2 mm occurred in 22% but did not correlate with symptoms. This operation is useful in the management of elderly, unfit patients.     

Anesthesia-related mortality and morbidity over a 5-year period in 2,363,038 patients in Japan

BACKGROUND: Statistical data of mortality and morbidity related to anesthesia have not been reported in Japan since World War II. The need to comprehensively examine the events of cardiac arrest as well as mortality prompted the first national study in Japan. METHODS: Confidential questionnaires were sent to all Japan Society of Anesthesiologists Certified Training Hospitals every year from 1994 through 1998. Collected data were analyzed for incidence of cardiac arrest and other critical events during anesthesia and surgery, and their outcomes within 7 postoperative days. The principal causes of the critical incidents were also analyzed. RESULTS: With an average response rate of 39.9%, a total of 2,363,038 cases were documented over 5 years. The average incidence per year of cardiac arrest during surgery due to all etiologies and that totally attributable to anesthesia was 7.12 [95%CI: 6.30,7.94] and 1.00 [0.88, 1.12]) per 10,000 cases, respectively. The average mortality per year in the operating room or within 7 postoperative days due to all etiologies and that totally attributable to anesthesia was 7.18 [6.22, 8.13] and 0.21 [0.15, 0.27] per 10,000 cases, respectively. The two principal causes of cardiac arrest during anesthesia and surgery due to all etiologies were massive hemorrhage (31.9%) and surgery (30.2%), and those totally attributable to anesthesia were drug overdose or selection error (15.3%) and serious arrhythmia (13.9%). Preventable human errors caused 53.2% of cardiac arrest and 22.2% of deaths in the operating room totally attributable to anesthesia. CONCLUSIONS: The rates in Japan of cardiac arrest and death during anesthesia and surgery due to all etiologies as well as those totally attributable to anesthesia are comparable to those of other developed countries.