Risk of Occult Irresectable Disease at Liver Resection for Hepatic Colorectal Cancer Metastases: A Contemporary Analysis

Introduction

Traditionally, rates of irresectable disease at laparotomy for colorectal liver metastases (CRLM) have ranged from 15 to 70%. Diagnostic laparoscopy has been shown to be effective at preventing nontherapeutic laparotomy in selected patients. The purpose of this study was to analyze the resectability rate and role of diagnostic laparoscopy in a contemporary cohort.

Methods

Using a prospectively maintained database, we identified patients who were explored for presumed resectable CRLM. Clinical and pathologic data associated with the finding of irresectable disease were analyzed.

Results

From 2008–2010, 455 patients were explored. Of these, 35 (7.7%) did not undergo a resection and/or ablation. Of the 35 patients with irresectable disease, 15 (43%) had disease limited to the liver, 17 (49%) had extrahepatic disease (EHD), and 3 (9%) had other reasons precluding resection. Of the whole cohort, 45 patients (9.9%) were found to have EHD, and 27 of these (60%) underwent complete resection or ablation. The only factor associated with irresectable disease was a prior history of EHD, which was present in 29% of those found irresectable versus 13% of those resected (p = 0.022). Diagnostic laparoscopy was performed in 55 patients. Four of these patients had irresectable disease, and three were spared unnecessary laparotomy. Therefore, the yield was 5% and the sensitivity 75%.

Conclusions

The finding of irresectable disease is a rare event with modern radiologic assessment and the expansion of indications for resection. Diagnostic laparoscopy has a low yield and should be considered if there is a history of EHD or suspicious findings on preoperative imaging.     

Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients

OBJECTIVE: To evaluate the benefit of staging laparoscopy in patients with gallbladder cancer and hilar cholangiocarcinoma. SUMMARY BACKGROUND DATA: In patients with extrahepatic biliary carcinoma, unresectable disease is often found at the time of exploration despite extensive preoperative evaluation, thus resulting in unnecessary laparotomy. METHODS: From October 1997 to May 2001, 100 patients with potentially resectable gallbladder cancer (n = 44) and hilar cholangiocarcinoma (n = 56) were prospectively evaluated. All patients underwent staging laparoscopy followed by laparotomy if the tumor appeared resectable. Surgical findings, resectability rate, length of stay, and operative time were analyzed. RESULTS: Patients underwent multiple preoperative imaging tests, including computed tomography scan, ultrasound, magnetic resonance cholangiopancreatography, and direct cholangiography. Laparoscopy identified unresectable disease in 35 of 100 patients. In the 65 patients undergoing open exploration, 34 were found to have unresectable disease. Therefore, the overall accuracy for detecting unresectable disease was 51%. There was no difference in the accuracy of laparoscopy between patients with gallbladder cancer and hilar cholangiocarcinoma. Laparoscopy detected the majority of patients with peritoneal or liver metastases but failed to detect all locally advanced tumors. In patients undergoing biopsy only, laparoscopic identification of unresectable disease significantly reduced operative time and length of stay compared with patients undergoing laparotomy. The yield of laparoscopy was 48% in patients with gallbladder cancer (56% in those who did not undergo previous cholecystectomy), but only 25% in patients with hilar cholangiocarcinoma. However, in patients with locally advanced but potentially resectable hilar cholangiocarcinoma, the yield of laparoscopy was greater, 36% (12/33, T2/T3 tumors) versus 9% (2/23, T1 tumors). CONCLUSIONS: Laparoscopy identifies the majority of patients with unresectable hilar cholangiocarcinoma or gallbladder carcinoma, thereby reducing both the incidence of unnecessary laparotomy and the length of stay. The yield of laparoscopy is lower for hilar cholangiocarcinoma but can be improved by targeting patients at higher risk of occult unresectable disease. All patients with potentially resectable primary gallbladder cancer and patients with T2/T3 hilar cholangiocarcinoma should undergo staging laparoscopy before surgical exploration.     

Liver transplantation for hilar cholangiocarcinoma—a single-centre experience

Background

Cholangiocarcinoma is an infrequent malignancy, often unresectable at the time of diagnosis. Liver transplantation may offer a chance for cure, but results in the past have been disappointing, prompting transplant centres to adopt multimodal treatment protocols and extreme patient selection.

Purpose

This study was designed to evaluate the outcome of patients with irresectable hilar cholangiocarcinoma undergoing liver transplantation in order to determine criteria for patient selection.

Methods

We reviewed our prospective cancer registry for patients with hilar cholangiocarcinoma treated by transplantation since 1997. Data were evaluated regarding tumour location, stage, overall survival, recurrence rates and prognostic factors.

Results

Liver transplantation with lymphadenectomy was realised in 16 patients with hilar cholangiocarcinoma. Seven patients received a living donor graft. Lymph node metastases were found in eight patients with a median of 13 harvested nodes and had a statistically significant negative impact on overall survival irrespective of tumour size. Only one patient underwent neoadjuvant brachytherapy and developed fatal septic complications; 3- and 5-year survival rates were 63 and 50 % in lymph node-negative patients without neoadjuvant treatment.

Conclusions

Acceptable survival rates can be achieved by transplantation for hilar cholangiocarcinoma with lymph node metastases as the only exclusion criterion. We recommend staging laparotomy with lymphadenectomy along the common hepatic artery prior to liver transplantation.     

Hilar Cholangiocarcinoma: Preoperative Liver Optimization with Multidisciplinary Approach. Toward a Better Outcome

Introduction

The diagnosis and treatment of hilar tumors requires a multidisciplinary approach based on the synergy of radiologists, surgeons, oncologists, and gastroenterologists. Klatskin tumor is a relatively rare disease with a poor prognosis. Currently, the only possible treatment is represented by the removal of the tumor associated with radical surgery, even though its results are still jeopardized by significant morbidity and mortality. A proper preoperative optimization of the patient, including staging laparoscopy, biliary drainage, and portal vein embolization, may improve short-term outcome. The purpose of this study was to evaluate the short- and long-term impact of preoperative optimization in patients affected by hilar cholangiocarcinoma.

Methods

From January 2004 to May 2012, 94 patients with preoperative diagnosis of Klastkin tumors were candidates for surgery at the Hepatobiliary Surgery Unit of the Hospital San Raffaele in Milan. The data of all patients were prospectively collected and retrospectively reviewed. The outcome was evaluated in terms of perioperative morbidity and mortality and overall and disease-free survival. Short-term outcome of patients undergoing preoperative optimization was compared with outcome of patients who did not undergo it in terms of intraoperative data, morbidity and mortality.

Results

Of 94 patients undergoing surgery, 80 underwent hepatic and biliary confluence resection. Fourteen patients were considered unresectable due to the presence of peritoneal carcinomatosis or advanced disease seen during staging laparoscopy or at laparotomy and therefore were excluded from the analysis. Seventy-five (93.7 %) patients underwent major liver resections: in 14 of these, surgery was performed at a distance of 30–40 days from PVE. In 55 patients, biliary drainage was preoperatively placed for palliation of obstructive jaundice. The postoperative morbidity rate was 51.2 % and mortality 6.2 %. The most frequent cause of death was postoperative liver failure. Five-year survival rate was 29 %. Patients undergoing preoperative optimization experienced a significant reduction of postoperative morbidity, especially in terms of infectious related events.

Conclusions

Klatskin tumor remains a disease associated with poor prognosis, but a correct preoperative diagnostic and therapeutic management provides tools to perform this type of surgery with acceptable morbidity and mortality, thus improving long-term results.     

Role of staging laparoscopy in peri-pancreatic and hepatobiliary malignancy

Even after extensive preoperative assessment, staging laparoscopy may allow avoidance of non-therapeutic laparotomy in patients with radiographically occult metastatic or locally unresectable disease. Staging laparoscopy is associated with decreased postoperative pain, a shorter hospital stay and a higher likelihood of receiving systemic therapy compared to laparotomy but its yield has decreased with improvements in imaging techniques. Current uses of staging laparoscopy include the following: (1) In the staging of pancreatic adenocarcinoma, laparoscopic staging allows for the identification of sub-radiographic metastatic disease in locally advanced cancer in approximately 30% of patients and, in radiographically resectable cancer, may identify metastatic disease in 10%-15% of cases; (2) In colorectal liver metastases, selective use of laparoscopic staging in patients with a clinical risk score of over 2 identifies unresectable disease in approximately 20% of patients; (3) In hepatocellular carcinoma, laparoscopic staging could be selectively used in high-risk patients such as those with clinically apparent liver cirrhosis and in patients with major vascular invasion or bilobar tumors; and (4) In biliary tract malignancy, staging laparoscopy may be used in all patients with potentially resectable primary gallbladder cancer and in selected patients with T2/T3 hilar cholangiocarcinoma. Because of the decreasing yield of SL secondary to improvements in imaging techniques, staging laparoscopy should be used selectively for patients with pancreatic and hepatobiliary malignancy to avoid unnecessary non-therapeutic laparotomy and to improve resource utilization. Each individual surgeon should apply his or her threshold as to whether staging laparoscopy is indicated according to the quality of preoperative imaging studies and the availability of resources at their own institution.     

Diagnostic accuracy of staging laparoscopy for detecting metastasized or locally advanced perihilar cholangiocarcinoma: a systematic review and meta-analysis

Background

Despite extensive preoperative staging, still almost half of patients with potentially resectable perihilar cholangiocarcinoma (PHC) have locally advanced or metastasized disease upon exploratory laparotomy. The value of routine staging laparoscopy (SL) in these patients remains unclear with varying results reported in the literature. The aim of the present systematic review was to provide an overview of studies on SL in PHC and to define its current role in preoperative staging.

Methods

A systematic review and meta-analysis were performed in PubMed and EMBASE regarding studies providing data on the diagnostic accuracy of SL in PHC. Primary outcome measures were the overall yield and sensitivity to detect unresectable disease. Secondary outcomes were the yield and sensitivity for recent studies (after 2010) and large study cohorts (≥100 patients) and specific (metastatic) lesions. Methodological quality of studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool.

Results

From 173 records, 12 studies including 832 patients met the inclusion criteria. The yield of SL in PHC varied from 6.4 to 45.0 % with a pooled yield of 24.4 % [95 % confidence interval (CI) 16.4–33.4]. Sensitivity to detect unresectable disease ranged from 31.6 to 75 % with a pooled sensitivity of 52.2 % (95 % CI 47.1–57.2). Sensitivity was highest for peritoneal metastases (80.7 %, 95 % CI 70.9–88.3). Subgroup analysis revealed that the yield and sensitivity tended to be lower for studies after 2010. Considerable heterogeneity was detected among the studies.

Conclusions

The results of the pooled analyses suggest that one in four patients with potentially resectable PHC benefits from SL. Given considerable heterogeneity, a trend to lower yield in more recent studies and further improvement of preoperative imaging over time, the routine use of SL seems discouraging. Studies that identify predictors of unresectability, that enable selection of patients who will benefit the most from this procedure, are needed.

     

Utility of staging laparoscopy in subsets of biliary cancers

Background The aim of this study was to evaluate the utility of staging laparoscopy in patients with biliary cancers in the era of modern diagnostic imaging. Methods From September 2002 through August 2004, 39 consecutive patients with potentially resectable cholangiocarcinoma underwent preoperative staging laparoscopy before laparotomy. Preoperative imaging included ultrasonography and triphasic computed tomography for all patients and magnetic resonance cholangiography in 35 patients (90%). Final pathological diagnosis included 20 hilar cholangiocarcinomas (HC), 11 intrahepatic cholangiocarcinomas (IHC), and eight gallbladder carcinomas (GBC). Results During laparoscopy, unresectable disease was found in 14/39 patients (36%). The main causes of unresectability were peritoneal carcinomatosis (11/14) and liver metastases (5/14). At laparotomy, nine patients (37%) were found to have advanced disease precluding resection. Vascular invasion and nodal metastases were the main causes of unresectability during laparotomy (eight out of nine). In detecting peritoneal metastases and liver metastases, laparoscopy had an accuracy of 92 and 71%, respectively. All patients with vascular or nodal involvement were missed by laparoscopy. For prediction of unresectability disease, the yield and accuracy of laparoscopy were highest for GBC (62% yield and 83% accuracy), followed by IHC (36% yield and 67% accuracy) and HC (25% yield and 45% accuracy) Conclusion Staging laparoscopy ensured that unnecessary laparotomy was not performed in 36% of patients with potentially resectable biliary carcinoma after extensive preoperative imaging. In patients with biliary carcinoma that appears resectable, staging laparoscopy allows detection of peritoneal and liver metastasis in one third of patients. Both vascular and lymph nodes invasions were not diagonsed by this procedure. Due to these limitations, laparoscopy is more useful in ruling out dissemination in GBC and IHC than in HC.     

The incremental benefit of two quadrant lavage for peritoneal cytology at staging laparoscopy for oesophagogastric adenocarcinoma

Background

Patients with positive peritoneal cytology from oesophagogastric cancer have a poor prognosis. The purpose of this study was to compare lavage cytology from the pelvis alone with the pelvis and subphrenic areas at staging laparoscopy in patients with potentially resectable oesophagogastric adenocarcinoma.

Methods

Between November 2006 and November 2010, all patients with operable oesophagogastric adenocarcinoma on spiral CT considered fit for surgical resection underwent staging laparoscopy. Subphrenic and pelvic peritoneal lavage for cytology was performed followed by laparoscopic biopsy of any visible peritoneal disease. Patients were divided into groups: macroscopic peritoneal metastases (P+), no macroscopic peritoneal disease with negative cytology (P?C?), no macroscopic peritoneal disease with positive pelvic cytology (P?PC+), no macroscopic peritoneal disease with positive subphrenic cytology (P?SC+), or both (P?PSC+).

Results

A total of 316 staging laparoscopy procedures were performed; 245 patients (78 %) were P?C?, 28 (9 %) were P+, and 43 (14 %) were P?C+, of whom 29 (9 %) were P?PSC+, 10 (3 %) were P?SC+, and 4 (1 %) were P?PC+. Pelvic cytology alone had 76.7 % sensitivity for peritoneal disease, and subphrenic cytology alone had 90.7 % sensitivity.

Conclusions

Peritoneal lavage for cytology at staging laparoscopy has an incremental benefit for staging oesophagogastric adenocarcinoma in the absence of macroscopic metastatic disease. Subphrenic washings have the highest yield of positive results. Performing isolated pelvic washings for cytology will understage 23.3 % of patients with microscopic peritoneal disease. The routine use of subphrenic in combination with pelvic lavage for cytology at staging laparoscopy in patients with oesophagogastric adenocarcinoma has an incremental benefit in detecting cytology-positive disease over either pelvic or subphrenic cytology alone.     

Clinical Risk Score Can be Used to Select Patients for Staging Laparoscopy and Laparoscopic Ultrasound for Colorectal Liver Metastases

Background

Despite advanced staging investigations, some patients with potentially resectable colorectal liver metastases (CLM) are unresectable at laparotomy. Staging laparoscopy and laparoscopic ultrasound (Lap + LUS) detects a subset of these unresectable patients before a major laparotomy. Clinical risk scoring may be helpful to identify this subgroup. The goal of our study was to evaluate the role of Lap + LUS and to assess the value of the Memorial Sloan Kettering clinical risk score (CRS) in identifying this subset.

Methods

Patients were identified from the regional multidisciplinary team (MDT) cancer database and operative records for a 5-year period. All patients whose tumors were deemed resectable proceeded to Lap + LUS. LUS findings were recorded and any change in MDT plan was noted. LUS findings were compared with resectability at open surgery. The CRS (Memorial Sloan-Kettering) based on five factors was calculated.

Results

A total of 79 patients were identified. In 15 of 74 patients, LUS prevented an unnecessary laparotomy by predicting the benign nature of lesions or demonstrating unresectability. The CRS ranged from 0 to 4. Lap + LUS prevented an operation in only 7% of patients with a CRS of ≤2. However in patients with a CRS > 2, Lap + LUS prevented an operation in 24% of patients.

Conclusions

LUS prevented an unnecessary laparotomy in 20% of patients. This may reduce inpatient stay, morbidity, and mortality, allowing some patients to proceed to palliative treatments earlier. The benefit of Lap + LUS is limited in patients with a CRS of ≤2. It is worth considering selective use of Lap + LUS for the staging of CLM.     

Conversion in endometrial cancer patients scheduled for laparoscopic staging: a large multicenter analysis

Background

Data on patients with endometrial cancer converted to laparotomy are totally lacking. The aim of the present study was to evaluate surgical and oncological outcomes in patients with endometrial cancer scheduled for laparoscopic staging but converted to laparotomy.

Methods

Data of consecutive patients who had undergone surgery for staging endometrial cancer in seven Italian centers were reviewed. Patients’ characteristics and surgical and oncological data were noted and analyzed according to surgery, i.e. laparotomy, laparoscopy, and laparoscopy converted to laparotomy.

Results

Seventy-one out of 512 (13.9 %) patients scheduled to laparoscopy were converted to laparotomy for reasons related to anesthesiology [38/71 (53.5 %)] or surgery [33/71 (46.5 %)]. The conversion rate varied among stages [41/460 (8.9 %), 13/27 (48.1 %), 17/25 (68.0 %) in patients with stage I, II, and endometrial cancers, respectively]. Significant (P < 0.05) differences among groups were detected in patients’ age, body mass index and previous pelvic surgery, and in the distribution of stages and histotype of endometrial cancers. The Kaplan–Meier procedure showed that the cumulative probability of first recurrence (P = 0.089, 0.590 and 0.084 for stage I, II and III, respectively) and of death (P = 0.108, 0.567 and 0.372 for stage I, II and III, respectively) categorized by stages did not attain statistical significance by log-rank testing after correction for confounding factors.

Conclusions

The surgical and oncological outcomes of converted patients are no different from those of patients staged successfully with laparoscopy or with laparotomy. The conversion to laparotomy should be not considered per se a complication.     

The Role of Staging Laparoscopy in Hepatobiliary Malignancy: Prospective Analysis of 401 Cases

Background:Patients with potentially resectable hepatobiliary malignancy are frequently found to have unresectable tumors at laparotomy. We prospectively evaluated staging laparoscopy in patients with resectable disease on preoperative imaging.Methods:Staging laparoscopy was performed on 410 patients with potentially resectable hepatobiliary malignancy. The preoperative likelihood of resectability was recorded. Data on preoperative imaging, operative findings, and hospital course were analyzed.Results:Laparoscopic inspection was complete in 291 (73%) patients. In total, 153 patients (38%) had unresectable disease, 84 of whom were identified laparoscopically, increasing resectability from 62% to 78%. On multivariate analysis, a complete examination, preoperative likelihood of resection, and primary diagnosis were significant predictors of identifying unresectable disease at laparoscopy. The highest yield was for biliary cancers, and the lowest was for metastatic colorectal cancer. In patients with unresectable disease identified at laparoscopy, the mean hospital stay was 3 days, and postoperative morbidity was 9%, compared with 8 days and 27%, respectively, in patients found to have unresectable disease at laparotomy.Conclusions:Laparoscopy spared one in five patients a laparotomy while reducing hospital stay and morbidity. Targeting laparoscopy to patients at high risk for unresectable disease requires consideration of disease-specific factors; however, the surgeons preoperative impression of resectability is also important.     

Catheter Tract Recurrence After Percutaneous Biliary Drainage for Hilar Cholangiocarcinoma

Background

Despite its wide use, catheter tract recurrence after percutaneous biliary drainage (PBD) is rarely reported. However, one recent large-scale study reported a catheter tract recurrence rate as high as 5.2 % in patients with perihilar or distal bile duct cancer. We report on our 20 years of experience with catheter tract seeding after PBD for hilar cholangiocarcinoma.

Methods

The medical records of 441 patients who underwent operation for hilar cholangiocarcinoma between 1991 and 2011 were retrospectively analyzed.

Results

Of the 441 patients with hilar cholangiocarcinoma, PBD was performed in 315 patients, and 232 others underwent resection of hilar cholangiocarcinoma with PBD. Catheter tract recurrence developed in 6 patients (2.6 %). The median drainage duration was 30 days, and 1 patient had multiple PBDs. The median time to catheter recurrence after surgery was 10.9 months. Three patients underwent curative resection of the abdominal wall followed by chemotherapy, 1 patient underwent chemotherapy only, and 2 patients received conservative treatment. Five patients in whom the catheter tract recurrence was their first recurrence died of systemic recurrence at median 3.9 months after detection of catheter tract seeding. T1 or 2 disease (66.7 vs. 31.3 %; p = 0.086) tended to have catheter tract seeding with marginal significance. The overall survival rate was lower in patients with catheter tract seeding than in those without (median 17.5 vs. 23.0 months; p = 0.089).

Conclusions

The PBD catheter tract recurrence rate for hilar cholangiocarcinoma was 2.6 %. However, patients with catheter tract recurrence had a poor prognosis despite complete surgical metastasectomy.     

ALPPS in Right Trisectionectomy: a Safe Procedure to Avoid Postoperative Liver Failure?

Introduction

To induce rapid hepatic hypertrophy and to reduce post-hepatectomy liver failure (PHLF), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients with a limited future liver remnant. The aim of this study was to further assess the perioperative risk of this procedure and its specific indications.

Patients and Methods

The study was performed between November 2010 and April 2012 for patients undergoing right trisectionectomy by the ALPPS approach. Liver volume, intra- and postoperative complications, including PHLF, and residual tumour status were compared for patients with different diagnoses.

Results

The interval between two operations in nine patients undergoing ALPPS was 13 days (median). Sufficient hepatic hypertrophy was achieved with a volume gain of 87.2 % (median). All patients underwent right trisectionectomy without residual tumours. In contrast to six patients with uneventful intra- and postoperative course, bile leak, vancomycin-resistant enterococcus infection, PHLF and sepsis developed in two of three patients with hilar cholangiocarcinoma as the preoperative diagnosis.

Conclusion

ALPPS leads to sufficient hepatic hypertrophy within 2 weeks, avoiding PHLF in most patients. In patients with hilar cholangiocarcinoma, ALPPS should be applied with extreme caution due to high morbidity and mortality.     

The utility of laparoscopic assessment in the preoperative staging of suspected hilar cholangiocarcinoma

The aim of this study was to review the role of laparoscopic assessment in the staging algorithm of suspected hilar cholangiocarcinoma and to identify factors highly likely to be associated with unresectable disease. Data prospectively collected between 1992 and 2003 were analyzed. Demographics, symptoms, preoperative radiologic staging, laparoscopic assessment, and final outcome were recorded. Yield was defined as the number of unresectable patients detected by laparoscopic assessment divided by the total number of patients undergoing laparoscopic assessment. Accuracy was defined as the number of unresectable patients detected by laparoscopic assessment divided by the total number of unresectable cases. Eighty-four patients underwent laparoscopic assessment for suspected hilar cholangiocarcinoma, of which 20 (23.8%) underwent resection. The yield from laparoscopy alone was 24.3% (20 of 82), which increased to 41.5% (35 of 82) with the addition of intraoperative ultrasound. The overall accuracy was 53.1% (35 of 66). The use of a preoperative radiologic staging system predicted the likelihood of unresectable disease (P = 0.007). The use of laparoscopic assessment in the preoperative staging of patients with suspected hilar cholangiocarcinoma is justified given it will spare 42.2% of patients an unnecessary laparotomy. Accurate staging of cholangiocarcinoma remains a challenge, but the use of a preoperative radiologic staging system may help to stratify a patient's risk of unresectable disease.     

Role of Repeat Staging Laparoscopy in Locoregionally Advanced Gastric or Gastroesophageal Cancer after Neoadjuvant Therapy

Introduction

Staging laparoscopy (SL) can identify occult, subradiographic metastatic (M1) disease in patients with gastric or gastroesophageal (G/GEJ) cancer who are unlikely to benefit from gastrectomy. The purpose of this study is to determine the yield of repeat SL following neoadjuvant therapy for G/GEJ adenocarcinoma after initial negative pretreatment SL.

Methods

Retrospective review of a prospective database identified patients with locoregionally advanced (T3–4Nany or TanyN+) G/GEJ adenocarcinoma who underwent pretreatment SL. The yield of repeat SL following neoadjuvant therapy was determined.

Results

From 1994 to 2010, 276 patients with locoregionally advanced G/GEJ adenocarcinoma were identified, of whom 244 proceeded to operation after neoadjuvant therapy, at a median time of 105 days. One hundred sixty-four patients (67 %) underwent repeat SL, and 80 patients (33 %) proceeded directly to laparotomy. Occult M1 disease was identified in 12 (7.3 %) and 6 (7.5 %) patients, respectively. In the repeat SL cohort, M1 disease was identified at laparoscopy in nine patients (5.5 %). M1 disease not identified by laparoscopy was discovered at laparotomy in three patients (1.8 %). The median follow-up for the study population was 31 months. For patients with M1 disease, median overall survival was 15 months, versus 41 months for patients resected without M1 disease (p < 0.0001).

Conclusions

Occult, subradiographic M1 disease develops in approximately 7 % of patients following neoadjuvant therapy for locoregionally advanced G/GEJ adenocarcinoma. These patients have poor prognosis, and repeat SL can be a valuable tool in selecting patients with locoregionally advanced G/GEJ tumors for potentially curative resection after neoadjuvant therapy.     

Staging laparoscopy in patients with hepatocellular carcinoma: is it useful?

Background

Staging laparoscopy (SL) is not regularly performed for patients with hepatocellular carcinoma (HCC). It may change treatment strategy, preventing unnecessary open exploration. An additional advantage of SL is possible biopsy of the nontumorous liver to assess fibrosis/cirrhosis. This study aimed to determine whether SL for patients with HCC still is useful.

Methods

Patients with HCC who underwent SL between January 1999 and December 2011 were analyzed. Their demographics, preoperative imaging studies, surgical findings, and histology were assessed.

Results

The 56 patients (34 men and 22 women; mean age, 60 ± 14 years) in this study underwent SL for assessment of extensive disease or metastases. For two patients, SL was unsuccessful because of intraabdominal adhesions. For four patients (7.1 %), SL showed unresectability because of metastases (n = 1), tumor progression (n = 1), or severe cirrhosis in the contralateral lobe (n = 2). An additional five patients did not undergo laparotomy due to disease progression detected on imaging after SL. Exploratory laparotomy for the remaining 47 patients showed 6 (13 %) additional unresectable tumors due to advanced tumor (n = 5) or nodal metastases (n = 1). Consequently, the yield of SL was 7 % (95 % confidence interval (CI), 3–17 %), and the accuracy was 27 % (95 % CI, 11–52 %). A biopsy of the contralateral liver was performed for 45 patients who underwent SL, leading to changes in management for 4 patients (17 %) with cirrhosis.

Conclusions

The overall yield of SL for HCC was 7 %, and the accuracy was 27 %. When accurate imaging methods are available and additional percutaneous liver biopsy is implemented as a standard procedure in the preoperative workup of patients with HCC, the benefit of SL will become even less.     

Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma

Purpose

This study evaluated the impact of ductal bile bacteria (bactibilia or cholangitis) on the development of surgical site infection (SSI) or in-hospital mortality after resection for hilar cholangiocarcinoma.

Materials and methods

A retrospective analysis was conducted on 81 patients who underwent a combined major hepatic (hemihepatectomy or more extensive hepatectomy) and bile duct resection for hilar cholangiocarcinoma. Ductal bile was submitted for bacterial culture before or during the operation.

Results

The incidence of SSI was higher in patients with preoperative bactibilia (83%) than in patients without (52%; P?=?0.008). Preoperative bactibilia was an independent variable associated with SSI (relative risk 9.003; P?=?0.002). The incidence of in-hospital mortality was higher in patients with preoperative cholangitis (33%) than in patients without (6%; P?=?0.009). Preoperative cholangitis was the only independent variable associated with in-hospital mortality (relative risk 9.115; P?=?0.006).

Conclusions

Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma, whereas preoperative bactibilia independently increases SSI.     

Preoperative prediction of complete resection in pancreatic cancer

BACKGROUND: Accurate preoperative staging is essential in pancreatic cancer to select the 15% of patients who can benefit from surgery and avoid surgery in the 85% with advanced disease. With improvements in computed tomography (CT) scanning, the value of routine laparoscopy for preoperative staging of pancreatic cancer has been questioned because it changes the preoperative plan in less than 20% of unselected cases. METHODS: We retrospectively reviewed our experience with preoperative staging in 88 consecutive patients with pancreatic cancer. All patients had preoperative CT scans, and selective criteria were used to determine which patients would also undergo preoperative staging laparoscopy. Patients were categorized preoperatively as resectable or not resectable (locally advanced or metastatic). Medical records, operative, and pathology reports were reviewed to determine the accuracy of preoperative predictions. RESULTS: Thirty patients were deemed resectable based on CT alone and 27 (90%) were resected (25 R0, 2 R1). Two (7%) had metastatic disease discovered at laparotomy and one (3%) had a R2 resection. Only 19 patients (39%) of 49 patients deemed resectable by CT met our selective criteria for preoperative staging laparoscopy. Laparoscopy changed the treatment plan in 11 (58%) of these patients. Eight were still deemed resectable after staging laparoscopy and 7 (88%) were resected (6 R0, 1 R1). One patient (12%) had metastatic disease diagnosed at laparotomy. If selective staging laparoscopy were eliminated from our algorithm, 49 patients would have been deemed potentially resectable based on CT alone, 34 (69%) would have been found to be resectable at laparotomy (31 R0, 3 R1), and 15 (31%) would have been found to be unresectable at laparotomy (positive predictive value of 69%). The addition of selective staging laparoscopy avoided unnecessary laparotomy in 11 patients and increased the positive predictive value to (34/38) 89%. CONCLUSION: Selective use of laparoscopy increases the positive predictive value of preoperative staging in pancreatic cancer and avoids unnecessary laparoscopy in the majority of patients.     

Impact of laparoscopic liver resection for hepatocellular carcinoma with F4-liver cirrhosis

Background

Although the utility of laparoscopic liver resection for hepatocellular carcinoma (HCC) has been recognized in recent years, the impact of the laparoscopic liver resection for HCC with complete liver cirrhosis (F4) is still unknown.

Methods

Retrospective analysis of 56 patients who underwent partial hepatectomy for HCC (3 cm or smaller in a diameter) and had complete liver cirrhosis (F4) diagnosed histologically was performed. Of the 56 patients, partial hepatectomy was performed under laparotomy in 28 patients (laparotomy group) or under laparoscopy in 28 patients (laparoscopy group). Perioperative outcome was analyzed in the two groups.

Results

There were no significant differences in the results of the preoperative liver function tests and the operation time between the two groups. The intraoperative blood loss was lower in the laparoscopy group than the laparotomy group (p = 0.0003). The incidence of the postoperative complications was significantly higher in the laparotomy group (20/36 patients) than in the laparoscopy group (3/28 patients, p < 0.0001). The incidences of surgical site infection, especially incisional infection, and intractable ascites were significantly higher in the laparotomy group than in the laparoscopy group (p = 0.0095, p < 0.0001, respectively). The proportions of patients who were classified into Clavien’s grade I and IIIa were higher in the laparotomy group than in the laparoscopy group (p = 0.0043, p = 0.051, respectively). The duration of the postoperative hospital stay was significantly shorter in the laparoscopy group than in the laparotomy group (p < 0.0001).

Conclusions

The postoperative morbidity, such as surgical site infection and intractable ascites, decreased by the induction of laparoscopic liver resection in patients with liver cirrhosis. As the results, the necessity of invasive treatment for postoperative complications decreased and the duration of the postoperative stay was shortened.     

TROP2 Correlates with Microvessel Density and Poor Prognosis in Hilar Cholangiocarcinoma

Background

Trophoblast cell surface antigen 2 (TROP2) was found to be associated with tumor progression and poor prognosis in a variety of epithelial carcinomas. The aim of the study was to investigate TROP2 expression and its prognostic impact in hilar cholangiocarcinoma.

Methods

Immunohistochemistry and quantitative real-time PCR were used to determine TROP2 expression in surgical specimens from 70 hilar cholangiocarcinoma patients receiving radical resection. The relationship between TROP2 expression and microvessel density was investigated and standard statistical analysis was used to evaluate TROP2 prognosis significance in hilar cholangiocarcinoma.

Results

High TROP2 expression by immunohistochemistry was found in 43 (61.4 %) of the 70 tumor specimens. Quantitative real-time PCR confirmed that TROP2 level in tumor was significantly higher than in non-tumoral biliary tissues (P?=?0.001). Significant correlations were found between TROP2 expression and histological differentiation (P?=?0.016) and tumor T stage (P?=?0.031) in hilar cholangiocarcinoma. TROP2 expression correlated with microvessel density in hilar cholangiocarcinoma (P?=?0.026). High TROP2 expression patients had a significantly poorer overall survival rate than those with low TROP2 expression (30 vs. 68.5 %, P?=?0.001), and multivariate Cox regression analysis indicated TROP2 as an independent prognostic factor for hilar cholangiocarcinoma (P?=?0.004).

Conclusion

TROP2 expression correlates with microvessel density significantly and is an independent prognostic factor in human hilar cholangiocarcinoma.