Experience with subcutaneous infusion ports in three hundred patients

Subcutaneous infusion ports (SIP) were inserted for chronic venous access during 329 procedures in 300 patients over the past five years at the University of Michigan Medical Center, with a total follow-up experience of 318 patient years. Seventy-four per cent of the SIP were surgically implanted while patients were hospitalized. The SIP were used for chemotherapeutic agents (83.0 per cent), blood products (29.0 per cent) or hyperosmolar total parenteral nutrition (8.5 per cent) and accessed a median of three occasions. Eighty-four per cent were used in an outpatient setting at least part of the time. Thirty-nine per cent of SIP were associated with complications, including local infection or sepsis (16.4 per cent), thrombosis of the catheter or central vein (9.7 per cent) and extravasation from the port secondary to needle dislodgement (6.4 per cent). The risk of complication was slightly higher in those SIP first used ten to 14 days after placement as compared with those used earlier or later (p less than 0.05). In 23 of 32 episodes, clinically diagnosed local infection unassociated with systemic sepsis or skin necrosis was successfully treated without removal of the port using aggressive intravenous and oral antibiotics. Treatment of thrombosis of the catheter with either urokinase or streptokinase infusion was successful in ten of 15 attempts. Seventy-two (22 per cent) of SIP were eventually removed, either after completion of the chemotherapy (20) or because of a complication (52) with 29 SIP being replaced. There was no correlation between the risk of infection or thrombosis and the perioperative use of antibiotics, frequency of SIP use or preoperative white blood cell count, platelet count, coagulation profile, blood urea nitrogen or albumen concentration. SIP provide an excellent method of chronic venous access, having a lower rate of infection and thrombosis in historical comparison with external vascular access devices.     

Experience with reduced-size liver transplantation

Orthotopic liver transplantation with reduced-size liver transplants (RLT) has been proposed as a way of alleviating the limited availability of size-matched donor organs for pediatric recipients. The use of RLT should increase the pool of available donors and decrease the number of pediatric patients who die while awaiting a full-size hepatic graft. Between May 1988 and April 1989, 15 RLT were placed in 12 patients. Twelve were left lobe and three were extended right lobe grafts. The mean donor to recipient ratio was 9.0:1.0 (range of 3.3:1.0 to 19.9:1.0). Graft complications occurred in four RLT, and extrahepatic complications occurred in five patients. Preservation of grafts with University of Wisconsin solution was used in all instances, with a mean preservation time of 14.1 hours (range of 8.5 to 19.5 hours). Retransplantation with RLT was successful in three of four patients. The actual patient survival rate was 83 per cent after a mean follow-up interval of 6.7 months (range of one to 11 months). Our experience indicates that patient survival with RLT is comparable with full-size grafting and should be offered as an acceptable method of therapy for end-stage liver disease in pediatric patients. The application of RLT techniques in a more elective setting may yield further improvements in patient survival.     

Techniques of ultrasonic dissection in resection of the liver

The ultrasonic device allows dissection of hepatic parenchyma without damage to vascular or ductal structures. With it, both standard hepatic resections and more radical ones are made safer. It is an instrument useful for hepatic operations.     

Hepatic resection as part of secondary cytoreductive surgery for recurrent ovarian cancer involving the liver

Purpose  

The aims of this study were to assess the surgical outcomes and to also determine the prognostic factors in patients with surgically resectable liver metastases for recurrent ovarian cancer.     

Major liver resection in pregnancy: three cases with different etiologies and review of the literature

Background: Major liver resection during pregnancy is extremely rare. When required, the associated physiologic and anatomic changes pose specific challenges and greater risk for both mother and fetus

Materials and methods: Three cases of major liver resection during pregnancy due to different etiologies are presented. The relevant literature is reviewed and discussed.

Results: We present three cases of major liver resection due to giant liver hemangioma with Kasabach–Merrit syndrome, giant hydatid cyst, and intrahepatic cholangiocarcinoma, at gestational week (GW) 17, 19, and 30, respectively. All patients had an uneventful postoperative course, continued the pregnancy and gave birth at GW 38.

Conclusion: Major liver resection can be performed safely during pregnancy. A multidisciplinary team of surgeons, anesthesiologists and gynecologists, in a highly experienced tertiary hepatobiliary center, should be involved.     

Surgical resection of hepatocellular carcinoma in the cirrhotic liver.

A total of 80 patients with asymptomatic small hepatocellular carcinoma (HCC) associated with liver cirrhosis underwent a liver resection. The patients were divided into 4 groups according to the location of their tumor: group A (n = 9): left lateral segmentectomy or left hepatectomy, group B (n = 42): atypical partial hepatectomy on the lateral aspect of the right lobe, group C (n = 25): subsegmentectomy on either the anterior or the posterior surface of the right lobe, group D (n = 4): subsegmentectomy in the hilar area. There were two postoperative deaths (both in group D) and five cases of hospital mortality (1 case due to myocardial infarction in group C; 1 case due to bleeding esophageal varices in group B and 2 cases in group C; and 1 case due to fulminating hepatitis in group B). There was no any significant difference in tumor size, the preoperative serum bromosulfaphthalein retention rate or the postoperative peak serum conjugated bilirubin level among all the groups (p less than 0.05). The weights of the resected specimens were higher in groups A and B (259 +/- 58 g, 230 +/- 154 g) than in groups C and D (54 +/- 32 g, 37.5 +/- 15.0 g) (p less than 0.05). The amount of blood required for transfusion during surgery in group D (3,625 +/- 3,146 mL) was significantly greater than in the other three, groups (p less than 0.05); and was also greater in groups B and C (1,649 +/- 880 mL, 1,635 +/- 1,156 mL), than in group A (444 +/- 273 mL; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

PCNA和p53蛋白作为原发性肝癌分子切缘界定指标的研究

目的:通过分析PCNA和p53蛋白在癌组织和癌旁不同距离组织中的差异表达,探讨原发性肝癌手术切缘的分子边界。方法:应用免疫组织化学方法研究51例原发性肝癌和癌旁不同距离组织(距离肿瘤1、2、3cm)中PCNA和p53蛋白的表达情况。结果:PCNA和p53蛋白在原发性肝癌和癌旁不同距离组织中的表达呈现逐渐减弱的趋势,其递减表达差异具有统计学意义(P均<0.05)。结论:PCNA和p53蛋白在原发性肝癌和癌旁不同距离组织中趋势性差异表达,原发性肝癌手术切缘组织中存在分子边界。     

Intra-arterial infusion chemotherapy with cisplatin in the management of advanced uterine cervical cancer]

To improve the cure rate for locally advanced cervical cancer, intra-arterial infusion chemotherapy with cisplatin (I-A chemotherapy) was performed before starting radiation therapy. Twenty-five patients, having a large central tumor (over 5 cm in antero-posterior diameter by CT scan), were treated by I-A chemotherapy. The catheter was inserted selectively into the uterine artery. The dose of cisplatin was 120 mg/m2. After the chemotherapy, all the patients were treated by radiation therapy. Eighteen of 25 patients treated with I-A chemotherapy were evaluable. Seven patients (38.8%) experienced partial tumor regression (greater than 50% reduction in the measured diameter). The survival rate (Kaplan-Meier Method) for combined therapy with I-A chemotherapy and radiotherapy was significantly higher than that for 23 patients treated by conventional radiation therapy alone. The toxicity of I-A chemotherapy was similar to that of systemic administration. There were three catheter complications. Intra-arterial chemotherapy with cisplatin followed by radiation therapy is effective for advanced uterine cervical cancer.     

Role of surgical resection for lung, liver, and central nervous system metastases in patients with gynecological cancer: a literature review

Many reports of ovarian, cervical, and uterine cancers metastatic to lung, liver, and brain have been published. A fewer number of them focused on the surgical treatment for these patients. We reviewed the published literature, regarding surgical management of metastatic disease in patients with gynecological cancer. Some prognostic factors in the patients with metastatic lesions from these three different cancers were found in common. Favorable prognostic factors for a prolonged survival were good performance status of the patients, long disease-free interval, absence of other systemic disease, and the resectability, preferably with a clear margin. These factors should be considered as the criteria for surgery. In well-selected patients, survival could be extended from the surgical procedure with minimal complications. Other types of treatment such as radiation therapy or chemotherapy could also be given in conjunction with surgery, depending on tumor type and disease status of the primary cancer, other systemic diseases, and residual metastatic lesions after surgery.     

Modified technique of Pringle's maneuver in resection of the liver.

Crushing of the hepatic parenchyma with hepatic clamps to minimize blood loss during resection of the liver leads to mechanical damage of hepatocytes. Pringle's maneuver may precipitate liver failure by hepatic warm ischemia as well. Therefore, we controlled bleeding from the surface of the resection by using light compression on the hepatic parenchyma with a band while applying a hepatic arterial clamp at the hepatic hilus. This vascular control method can be done because the portal pressure is about one-tenth of the hepatic artery pressure and provides an efficient and harmless transection of the liver.     

Repeat hepatic resection for primary and metastatic carcinoma of the liver

During the last 15 years, 19 patients underwent repeated hepatic resections for malignant lesions of the liver. The first hepatic resection had been performed four to 40 months earlier for treatment of hepatocellular carcinoma (nine patients) or hepatic metastases (ten patients), eight of which were of colorectal origin. Repeat resection was an extensive hepatectomy in six, a segmentectomy in six and a local excision in seven. In one patient, three wedge resections and, finally, hepatic transplantation were subsequently performed after an initial extended right lobectomy. The operative mortality rate was 5.2 per cent. The three year actuarial survival rate was 64 per cent after the second resection.     

Experience with the induction of second-trimester abortion by extra-amniotic physiological saline infusion. Report of 127 cases

In 127 women with normal second-trimester pregnancy we induced abortion by extra-amniotic (EA) physiological saline infusion. All women aborted within 72 h, most of them during the first 24 h. Besides a transient fever in one case, no complications or sideeffects were recorded. This method is safe and cheap, and entirely without contraindications. Therefore, it may be used in cases when other methods would have been dangerous or failed. As for the mechanism of action of this method, it is probably by the secretion of intrinsic prostaglandins, produced by the decidual cells. But this hypothesis remains to be proved.     

Experience with the management of neutropenia in gynecologic cancer patients receiving carboplatin-based chemotherapy

Objective. There exists limited information in the medical literature regarding the incidence and severity of carboplatin-associated neutropenia, outside the setting of a clinical trial. We wished to examine this issue in a large single institution experience involving patients receiving both single agent and combination carboplatin-based chemotherapy for management of a female pelvic malignancy. Patients and methods. The medical records of women with gynecologic cancers treated with carboplatin-based chemotherapy at the Cleveland Clinic from January 1, 1998 through December 31, 2002 were retrospectively reviewed to determine the incidence and severity of neutropenia. Results. During the time period encompassed by this analysis, a total of 323 patients received 2145 cycles of carboplatin-based chemotherapy (total of 441 courses; median cycles/patient: 6 [range 1-27]). The total number of each program utilized, and the incidence of grades 3 and 4 neutropenia observed (lowest nadir/regimen), were as follows: single agent carboplatin (178 courses; 5% grade 3, and <1% grade 4), carboplatin/paclitaxel (198; 23% and 6%), carboplatin/docetaxel (42; 17% and 73%) and carboplatin/paclitaxel/irinotecan (23; 39% and 61%). Febrile neutropenia was uncommon, and there was only a single neutropenic-related death. Conclusion. Both single-agent carboplatin and carboplatin/paclitaxel result in a very low incidence of grade 4 neutropenia. While combining docetaxel with carboplatin or adding a "third drug" to carboplatin/paclitaxel substantially increases the incidence of severe neutropenia, neutropenic fever, and required hospitalizations for septic episodes are uncommon. The prophylactic oral administration of a broad-spectrum antibiotic (e.g., ciprofloxicin) in the presence of grade 4 neutropenia appears to be an effective strategy to minimize the risk of subsequent febrile events.