Randomized Controlled Single-Center Trial Comparing Pancreatogastrostomy Versus Pancreaticojejunostomy After Partial Pancreatoduodenectomy

Background

The aim of this single-center randomized trial was to compare the perioperative outcome of pancreatoduodenectomy with pancreatogastrostomy (PG) vs pancreaticojejunostomy (PJ).

Methods

Randomization was done intraoperatively. PG was performed via anterior and posterior gastrotomy with pursestring and inverting seromuscular suture; control intervention was PJ with duct?Cmucosa anastomosis. The primary endpoint was postoperative pancreatic fistula (POPF).

Results

From 2006 to 2011, n?=?268 patients were screened and n?=?116 were randomized to n?=?59 PG and n?=?57 PJ. There was no statistically significant difference regarding the primary endpoint (PG vs PJ, 10?% vs 12?%, p?=?0.775). The subgroup of high-risk patients with a soft pancreas had a non-significantly lower pancreatic fistula rate with PG (PG vs PJ, 14 vs 24?%, p?=?0.352). Analysis of secondary endpoints demonstrated a shorter operation time (404 vs 443?min, p?=?0.005) and reduced hospital stay for PG (15 vs 17?days, p?=?0.155). Delayed gastric emptying (DGE; PG vs PJ, 27 vs 17?%, p?=?0.246) and intraluminal bleeding (PG vs PJ, 7 vs 2?%, p?=?0.364) were more frequent with PG. Mortality was low in both groups (<2?%).

Conclusions

Our randomized controlled trial shows no difference between PG and PJ as reconstruction techniques after partial pancreatoduodenectomy. POPF rate, DGE, and bleeding were not statistically different. Operation time was significantly shorter in the PG group.     

Patients with Multiple Hepatocellular Carcinomas Within the UCSF Criteria Have Outcomes After Curative Resection Similar to Patients Within the BCLC Early-Stage Criteria

Background

Surgical strategies for the treatment of multiple hepatocellular carcinomas (HCC) remain controversial. This study compared the prognostic power of the University of California, San Francisco (UCSF) criteria with the Barcelona Clinic Liver Cancer (BCLC) early-stage criteria.

Methods

Clinical and survival data of 162 multiple-HCC patients in Child-Pugh class A who underwent curative resection were retrospectively reviewed. Prognostic risk factors were analyzed using univariate and multivariate analyses.

Results

UCSF criteria were shown to independently predict overall and disease-free survival. In patients within the UCSF criteria, 3-year overall and disease-free survivals were significantly better than in those exceeding the UCSF criteria (68 vs. 34?% and 54 vs. 26?%, respectively; both p?p?=?0.506 and 57 vs. 50?%, p?=?0.666, respectively). Tumors within the UCSF criteria were associated with a lower incidence of high-grade tumor (p?=?0.009), microvascular invasion (p?=?0.005), 3-month death (p?=?0.046), prolonged Pringle’s maneuver (p?=?0.005), and surgical margin <0.5?cm (p?Conclusions Multiple HCC patients within the UCSF criteria benefit from curative resection. Expansion of curative treatment is justified.     

Clinical features and surgical outcomes of primary cauda equina tumours

Background

To identify clinical features, radiological findings and surgical outcomes of primary cauda equina tumours.

Methods

A consecutive series of 64 operations in 60 patients with primary cauda equina tumours from April 1999 to May 2009 at one institution comprised the study. The cases were divided into tumours of neural sheath origin (TNS, n?=?48) and tumours of non-neural sheath origin (TNNS, n?=?22). We analysed pain intensity, neurological abnormalities, MRI findings, surgical extent and functional outcome.

Results

The TNS group showed more leg pain (76 % vs. 44 %, p?=?0.019) with higher intensity (6.1?±?1.5 vs. 4.6?±?1.9, p?=?0.04). Motor weakness and bladder dysfunction were more common in the TNNS group (p?=?0.028 and p?=?0.00 in each). Flow voids of MRI were more frequently observed in TNNS (50 % vs. 4 %, p?=?0.01). The TNS group achieved total removal in all operations compared with total removal in 77 % in the TNNS group (p?=?0.001). The TNNS group showed higher recurrence rates (18 % vs. 0 %, p?=?0.009). The TNS group showed higher improvement of JOA scores postoperatively (p?=?0.049). Surgical complications were observed less frequently in the TNS group (19 % vs. 78 %, p?=?0.000).

Conclusions

TNS differs from TNNS by causing more frequent leg pain, higher pain intensity and more frequent flow voids. TNS has better surgical outcomes than TNNS in terms of higher rates of total removal, fewer surgical complications, better functional outcomes and less recurrence.     

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.     

Does left side renal cell carcinoma (RCC) with renal vein/vena cava thrombus predict worse prognosis than equivalent right side RCC tumor thrombus?

Purpose

To determine whether renal cell carcinoma (RCC) thrombi that reach the vena cava from the left kidney are associated with a greater risk of RCC death than equivalent thrombi?from the right kidney.

Methods

Two hundred and fifty-nine patients treated with radical nephrectomy (1970?C2006) for unilateral, sporadic RCC with level 1?C4 RCC tumor thrombus were identified. Clinicopathologic features between patients with right-sided (N?=?183) and left-sided (N?=?76) thrombus were compared utilizing Wilcoxon rank sum and Fisher??s exact tests. Associations with RCC-specific death using hazard ratios (HR) and 95?% confidence intervals (CIs) from Cox proportional hazards models were evaluated.

Results

Left-sided RCC patients with thrombus are less likely to be clear cell subtype (85?% vs. 93?%; p?=?0.013) and more likely to have nodal involvement (28?% vs. 16?%; p?=?0.018) compared to right side RCC patients with thrombus. Overall, there is little evidence that the risk of RCC death is higher for left versus right-sided RCC thrombus (HR?=?1.11; 95?% CI 0.81?C1.53; p?=?0.52). However, among those patients with a thrombus that has reached the vena cava (level III/IV), we observe evidence after multivariate adjustment that the risk of RCC death is higher for left versus right side patients (HR?=?2.02; 95?% CI 0.91?C4.47; p?=?0.08).

Conclusions

Left side RCC with tumor thrombus is not associated with worse prognosis than right-sided tumors (all tumor thrombi levels). Our data suggest that among RCC patients with advanced tumor thrombi (level III/IV), a left side thrombus may be associated with worse prognosis compared to a right side thrombus.     

Does fellow participation in laparoscopic Roux-en-Y gastric bypass affect perioperative outcomes?

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) requires specialized training commonly acquired during a fellowship. We hypothesized that fellows affect patient outcomes and this effect varies during training.

Methods

We included all LRYGB from the 2005 to 2009 American College of Surgeons-National Surgical Quality Improvement Program database. Cases without trainees (attending) were compared to those with trainees of ??6?years (fellow). Outcomes were pulmonary, infectious, and wound complications and deep venous thrombosis (DVT). Multivariable regression controlled for age, BMI, and comorbidities.

Results

Of the 18,333 LRYGB performed, 4,349 (24?%) were fellow cases. Fellow patients had a higher BMI (46.1 vs. 45.7, p?<?0.001) and fewer comorbidities. Mortality was 0.2 and 0.1?% and overall morbidity was 4.8 and 6.0?% for attending and fellow groups, respectively. On adjusted analysis, mortality was similar, but fellow cases had 30?% more morbidity (p?=?0.001). Specifically, fellows increased the odds of superficial surgical site infections (SSSIs) [odds ratio (OR)?=?1.4, p?=?0.01], urinary infections (UTIs) (OR?=?1.7, p?=?0.002), and sepsis (OR?=?1.5, p?=?0.05). During the first 6 months, fellows increased the odds of DVT (OR?=?4.7, p?=?0.01), SSIs (OR?=?1.5, p?=?0.001), UTIs (OR?=?1.8, p?=?0.004), and sepsis (OR?=?1.9, p?=?0.008). By the second half of training, fellow cases demonstrated outcomes equivalent to attending cases.

Conclusions

Involving fellows in LRYGB may increase DVT, SSIs, UTIs, and sepsis, especially early in training. By completion of their training, cases involving fellows exhibited outcomes similar to cases without trainees. This supports both the need for fellowship training in bariatric surgery and the success of training to optimize patient outcomes.     

Systematic Pelvic and Aortic Lymphadenectomy in Advanced Ovarian Cancer Patients at the Time of Interval Debulking Surgery: A Double-Institution Case–Control Study

Background

The prognostic role of systematic lymphadenectomy remains unclear in advanced ovarian cancer (AOC). Only few retrospective case series have investigated the percentage of lymph node metastases after neoadjuvant chemotherapy. This multi-institutional case-control study analyzed the prognostic role of systematic lymphadenectomy in AOC patients at the time of interval debulking surgery (IDS).

Methods

From January 2005 to December 2010, the records of patients with AOC admitted to IDS at the Catholic University of Rome (n?=?101, controls) and at the University of Bologna (n?=?50, cases) were retrospectively analyzed. The cases, routinely submitted to systematic pelvic and aortic lymphadenectomy, were matched 1:2 with the controls, who did not routinely undergo lymphadenectomy. To correctly assess the prognostic role of lymphadenectomy, only patients with optimally debulked disease were included. Progression-free survival and overall survival were analyzed by a log-rank test.

Results

After an overall mean follow-up of 36?months (95?% confidence interval 33?C39), 35 and 63 recurrences (70.0 vs. 62.4?%; p?=?NS) and 15 and 24 deaths due to disease (30 vs. 23.7?%; p?=?NS) were observed in the case and controls, respectively. The 2-year progression-free survival rate was 36 versus 25?% (p?=?0.834), and the 2-year overall survival rate was 69 versus 88?% (p?=?0.777), in the case and controls, respectively. The median operating time was longer, and the percentage of patients requiring blood transfusions was higher in the cases than in the controls (225 vs. 210?min, p?=?0.023, and 54 vs. 22.8?%, p?=?0.0001, respectively).

Conclusions

Lymphadenectomy at the time of IDS could be omitted, at least in high-risk patients.     

A Review of Risk Factors and Timing for Postoperative Hematoma After Thyroidectomy: Is Outpatient Thyroidectomy Really Safe?

Background

Although postoperative hematoma after thyroidectomy is uncommon, patients traditionally have been advised to stay overnight in the hospital for monitoring. With the growing demand for outpatient thyroidectomy, we assessed its safety and feasibility by evaluating the potential risk factors and timing of postoperative hematoma after thyroidectomy.

Methods

From 1995–2011, 3,086 consecutive patients underwent thyroidectomy at our institution; of these, 22 (0.7?%) developed a postoperative hematoma that required surgical reexploration (group I). Potential risk factors were compared between group I and those without hematoma (n?=?3,045) or with hematoma but not requiring reexploration (n?=?19; group II). Variables that were significant in the univariate analysis were entered into multivariate analysis by binary logistic regression analysis.

Results

Group I was significantly more likely to have undergone previous thyroid operation than group II (27.3 vs. 8.2?%, p?=?0.007). The median weight of excised thyroid gland (71.8 vs. 40?g, p?=?0.018) and the median size of the dominant nodule (4.1 vs. 3?cm, p?=?0.004) were significantly greater in group I than group II. Previous thyroid operation (odds ratio (OR)?=?4.084; 95?% confidence interval (CI), 1.105–15.098; p?=?0.035) and size of dominant nodule (OR?=?1.315; 95?% CI, 1.024–1.687; p?=?0.032) were independent factors for hematoma. Sixteen (72.7?%) had hematoma within 6?h, whereas the other 6 (27.3?%) had hematoma at 6–24?h.

Conclusions

Previous thyroid operation and large dominant nodule were independent risk factors for hematoma requiring surgical reexploration. Given that a quarter of hematoma occurred between 6 to 24?h after surgery, routine outpatient thyroidectomy could not be recommended.     

What is the importance of “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture?

Summary

We investigated the importance, risk factors, and clinical course of the radiolucent “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture. Preoperative osteonecrosis and a lump cement pattern were the most important risk factors for the peri-cement halo phenomenon, and it was associated with vertebral recollapse.

Introduction

We observed a newly developed radiolucent area around the bone cement following vertebral augmentation for osteoporotic compression fractures. Here, we describe the importance of the peri-cement halo phenomenon, as well as any associated risk factors and long-term sequelae.

Methods

In total, 175 patients (202 treated vertebrae) were enrolled in this study. The treated vertebrae were subdivided into two groups: Group A (with halo, n?=?32) and Group B (without halo, n?=?170), and the groups were compared with respect to multiple preoperative (age, sex, BMD, preoperative osteonecrosis) and perioperative factors (operative approach: vertebroplasty or kyphoplasty; cement distribution pattern; cement leakage; cement volume), and postoperative results (VAS score, recollapse). Logistic regression analysis was used to evaluate the relationship between the incidence of the peri-cement halo and all of the parameters described above.

Results

Rates of osteonecrosis were also significantly higher in Group A than in Group B (62.5% vs. 31.2%, p?p?p?p?p?=?0.001), KP (OR?=?3.630; 95% CI?=?1.628–8.095; p?=?0.002), lump pattern (OR?=?13.870; 95% CI?=?2.907–66.188; p?=?0.001), and vertebral recollapse (OR?=?5.356; 95% CI?=?1.897–15.122; p?=?0.002) were significantly associated with peri-cement halo.

Conclusions

The peri-cement halo was found to be associated with vertebral recollapse, this sign likely represents a poor prognostic factor after vertebral augmentation for osteoporotic compression fractures.     

Clinical Features and Outcome of Postoperative Peritonitis Following Bariatric Surgery

Background

We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS).

Methods

In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP).

Results

Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45?±?10 versus 63?±?16 years; p?<?0.0001), had lower rates of fatal underlying disease (39 vs 64 %; p?=?0.002), and the same SOFA score at the time of reoperation (8?±?4 vs 8?±?3; p?=?0.8) as the cPOP patients. BS patients had higher proportions of Gram-positive cocci (48 vs 35 %; p?=?0.007) and lower proportions of Gram-negative bacilli (33 vs 44 %; p?=?0.03), anaerobes (4 vs 10 %; p?=?0.04), and multidrug-resistant strains (20 vs 40 %; p?=?0.01). Despite higher rates of adequate empiric antibiotic therapy (82 vs 64 %; p?=?0.024) and high de-escalation rates (67 % in BS cases and 51 % in cPOP cases; p?=?0.06), BS patients had similar reoperation rates (53 vs 44 %; p?=?0.278) and similar mortality rates (24 vs 32 %; p?=?0.32) to cPOP patients. In multivariate analysis, none of the risk factors for death were related to BS.

Conclusions

The severity of POP in BS patients resulted in high mortality rates, similar to the results observed in cPOP. Usual empiric antibiotic therapy protocols should be applied to target multidrug-resistant microorganisms, but de-escalation can be performed in most cases.     

American College of Surgeons Oncology Group (ACOSOG) Z0011: Impact on Surgeon Practice Patterns

Introduction

The ACOSOG Z0011 trial has been described as practice-changing. The goal of this study was to determine the impact of the trial on surgeon practice patterns at our institution.

Methods

This is a review of practice patterns comparing the year before release of Z0011 to the year after an institutional multidisciplinary meeting discussing the results. Patients meeting Z0011 inclusion criteria were identified. Clinicopathologic data were compared between the cohorts.

Results

There were 658 patients with clinical T1-2 tumors planned for breast conservation: 335 in the pre-Z0011 cohort and 323 post-Z0011. Sixty-two (19?%) patients were sentinel lymph node (SLN) positive in the pre-Z0011 group versus 42 (13?%) post-Z0011 (p?=?0.06). Before Z0011, 85?% (53/62) of SLN-positive patients underwent axillary node dissection (ALND) versus 24?% (10/42) after Z0011 (p?p?=?0.09), lobular histology (p?=?0.01), fewer SLNs (1 vs. 3, p?=?0.09), larger SLN metastasis size (4 vs. 2.5?mm, p?=?0.19), extranodal extension present (20 vs. 6?%, p?=?0.16), or a higher probability of positive non-SLNs (p?=?0.03). Surgeons were less likely to perform intraoperative nodal assessment post-Z0011 (26 vs. 69?%, p?p?Conclusions Surgeons at our institution have implemented Z0011 results for the majority of patients; however, clinicopathologic factors still impact the decision to perform ALND. Z0011 results have significantly impacted practice by decreasing rates of ALND, use of intraoperative nodal evaluation, and operative times.     

Routine Anterior Approach During Right Hepatectomy: Results of a Prospective Randomised Controlled Trial

Trial Design

A prospective randomised controlled trial was designed to evaluate the advantages of routine application of the anterior approach during right hepatectomy.

Methods

The study was conducted between March 2005 and April 2009 in a tertiary hepatobiliary?Cpancreatic centre. Patients scheduled for right hepatectomy for primary or metastatic tumours, without infiltration of segment 1, inferior vena cava or main bile duct, were randomly assigned to right hepatectomy using either an anterior or a classic approach. The primary study endpoint was overall blood loss.

Results

Sixty-six patients were randomly allocated to undergo right hepatectomy with an anterior (AA group n?=?33) or a classic approach (CA group n?=?33). Sixty-five patients were included in the analysis (33 in AA group and 32 in CA group). There was no significant difference in patient age, diagnosis, preoperative hepatic biochemistry and tumour size between the two groups. Overall blood loss (437?ml?±?664 in AA group vs.500?ml?±?532.3 in CA group; p?=?0.960) and bleeding during transection (p?=?0.973) were similar between two groups. Perioperative blood transfusion rates were 18?% in the AA group and 9.3?% in the CA group (p?=?0.253). Time of parenchymal transsection was significantly longer in AA group (75.1?±?26.6?min vs. 56.7?±?17.5?min, p?=?0.01). There was no difference between both groups for postoperative prothrombin time, serum transaminase and total bilirubin levels. One patient died in each group (p?=?0.746). The two groups had similar morbidity rates.

Conclusion

Routine application of the anterior approach during right hepatectomy does not decrease intraoperative blood loss and morbidity rate.     

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.     

Laparoscopic surgery for palliative resection of the primary tumor in incurable stage IV colorectal cancer

Background

The purpose of the study was to evaluate the feasibility and efficacy of laparoscopic palliative resection in patients with incurable stage IV colorectal cancer.

Methods

We reviewed 100 patients with incurable stage IV colorectal cancer who underwent palliative resection of the primary tumor between 2002 and 2009 at National Cancer Center Hospital East (NCCHE). Outcomes and postoperative course were compared between patients who underwent open and laparoscopic surgery.

Results

Of the 100 patients, 22 were treated with a laparoscopic procedure and 78 underwent an open surgical procedure. There was no difference in the preoperative characteristics of the two groups. In the laparoscopic group, the mean operation time was significantly longer (177 vs. 148?min, p?=?0.007) and the amount of blood loss was significantly lower (166 vs. 361?ml, p?=?0.002). Postoperative complications occurred in 5 patients (22.7?%) after laparoscopic surgery and in 21 patients (26.9?%) after open surgery, with no significant difference between the two groups. Time to flatus, time to start of food intake, and hospital stay were all shorter after laparoscopic surgery (3.0 vs. 3.8?days, p?=?0.003; 3.6 vs. 5.0?days, p?<?0.001; and 12.0 vs. 15.0?days, p?=?0.005; respectively). Significantly more patients in the laparoscopic group had >15?% lymphocytes on postoperative day 7 (p?=?0.049). Overall survival rates were 73.7 and 75.5?% at 1?year after laparoscopic surgery and open surgery, respectively (p?=?0.344).

Conclusions

A laparoscopic procedure should be considered for palliative resection of the primary tumor for incurable stage IV colorectal cancer, because the results of this study indicate that the procedure is safe and effective.     

The Role of Gender in Primary Hyperparathyroidism: Same Disease, Different Presentation

Background

Hyperparathyroidism is much more common in women and therefore may represent different diseases in men and women. In order to understand the role of gender in hyperparathyroidism, we reviewed our experience.

Methods

We analyzed a prospective database of 1309 consecutive patients with primary hyperparathyroidism who underwent parathyroidectomy at our institution between March 2001 and August 2010.

Results

The female-to-male ratio was 3.3:1, and female patients were older at presentation (60?±?0 vs. 57?±?1?years, p?p?=?0.005) and the most common symptom for men was kidney stones (23?% vs. 13?%, p?p?p?=?0.03), higher parathyroid hormone level (140?±?7 vs. 124?±?4?pg/ml, p?=?0.04), higher urinary calcium level (376?±?10 vs. 314?±?5?mg/24?h, p?p?p?=?0.004). The operative approach as well as the number of glands involved and their location did not significantly differ between the groups. The mean gland weight for a single adenomas was higher in male patients (1123?±?128 vs. 636?±?32?mg, p?=?0.001). No significant difference was identified in the immediate and remote postoperative course.

Conclusions

Hyperparathyroidism appears to present differently depending on gender. Male patients more often present without symptoms, present with vitamin D deficiency, and have larger parathyroid glands. Importantly, surgical outcomes were equivalent between men and women.     

Is Resection Equivalent to Transplantation for Early Cirrhotic Patients with Hepatocellular Carcinoma? A Meta-Analysis

Background

Whether liver resection or liver transplantation is optimal therapy for patients with hepatocellular carcinoma (HCC) remains undefined. A meta-analysis was conducted to answer this question.

Study Design

This study performed a systematic review of the published literature between January 2000 and April 2012.

Results

Nine retrospective studies, totaling 2,279 patients (989 resected and 1,290 transplanted), met the selection criteria. Older patients with larger tumors and less severe cirrhosis were identified in the resection group. At 1?year, resection demonstrated significantly higher overall [odds ratio (OR)?=?1.54; 95?% confidence interval (CI), 1.19?C1.98; p?=?0.001], but equivalent disease-free survival (OR?=?0.93; 95?% CI, 0.53?C1.63; p?=?0.80). At 5?years, there was no difference in overall survival (OR?=?0.86; 95?% CI, 0.61?C1.21; p?=?0.38), but a higher disease-free survival in transplanted patients was observed (OR?=?0.39; 95?% CI, 0.24?C0.63; p?<?0.001). When limiting our analysis to studies conducted in an intent-to-treat fashion, there was no difference in 5?year overall survival (OR?=?1.18; 95?% CI, 0.92?C1.51; p?=?0.19), but a significantly higher disease-free survival (OR?=?0.76; 95?% CI, 0.57?C1.00; p?=?0.05) in transplanted patients. At 10?years, transplantation had higher overall and disease-free survival rates.

Conclusion

Liver transplantation in patients with HCC results in increased late disease-free and overall survival when compared with liver resection. Nonetheless, the benefit of liver transplantation is offset by higher short-term mortality, donor organ availability, and long transplant wait times associated with more patient deaths. Understanding these differences in survival is helpful in guiding treatment. However, a properly controlled prospective trial is needed to define how best to treat HCC patients who are candidates for either therapy.     

Clinical Outcome of IBD-Associated versus Sporadic Colorectal Cancer: A Matched-Pair Analysis

Purpose

This study assesses the perioperative course and long-term survival of inflammatory bowel disease (IBD)-associated vs. sporadic colorectal cancer (IBD-CRC vs. SCRC) after elimination of known confounders.

Methods

Between 1991 and 2007, n?=?3,299 patients underwent surgery for CRC at our institution. Thirty-three IBD patients were identified and compared to 165 SCRC using a matched-pair analysis (1:5 scenario). As matching parameters were used: age, gender, Union Internationale Contre le Cancer (UICC) stage, site of primary lesion, and date of surgery. After univariate analysis of the perioperative course, a multivariate survival analysis (Cox) of all patients (n?=?198) was performed.

Results

Significant differences were shown for preoperative symptoms (p?=?0.022), transfusion rate (p?=?0.01), ileostomy construction rate (p?=?0.001), total complication rate (p?=?0.042), and hospital stay (15 vs. 11 days, p?<?0.001). Local tumor recurrence was three times higher in IBD-CRC (p?=?0.004), and the 5-year survival rate was lower (49 % vs. 67 %, p?=?0.03). IBD, advanced UICC stage, and synchronous liver metastasis were identified as independent prognostic factors.

Conclusion

We demonstrate for the first time survival differences between IBD-CRC and SCRC after elimination of five known confounders. This might be caused by a difference in tumor biology resulting in a higher local recurrence rate in IBD-CRC.     

Simultaneous Medullary and Differentiated Thyroid Cancer: A Population-Level Analysis of an Increasingly Common Entity

Background

Simultaneous medullary thyroid carcinoma (MTC) and differentiated thyroid carcinoma (DTC) is a rare entity. This is the first population-level analysis of the characteristics and outcomes of simultaneous MTC/DTC.

Methods

In the Surveillance, Epidemiology, and End Results (SEER) database (1988?C2008), patients with simultaneous MTC/DTC were retrospectively compared with those with MTC alone using ??², ANOVA, log-rank tests, Cox multivariate regression, and Kaplan?CMeier analyses.

Results

A total of 162 patients had simultaneous MTC/DTC; 1,699 had MTC alone. MTC was diagnosed first in 67.9?% of simultaneous MTC/DTC cases. Simultaneous MTC/DTC increased from 2.7?% of all MTCs in 1988?C1997 to 12.3?% in 2003?C2008. Compared with MTC alone, simultaneous MTC/DTC had smaller mean MTC tumor size (2.9 vs. 2.2?cm; p?=?0.005) and lower rates of MTC extrathyroidal extension (25.4 vs. 16.8?%; p?=?0.015) and distant metastases (15.7 vs. 9.3?%; p?=?0.032). Patients diagnosed with DTC first had smaller mean MTC tumor sizes (p?=?0.01), whereas patients diagnosed with MTC first had tumor sizes similar to those of MTC alone. Compared with MTC alone, patients with simultaneous MTC/DTC were more likely to receive thyroidectomy (84.7 vs. 93.2?%; p?=?0.003) and radioisotopes (4.4 vs. 25?%; p?p?=?0.056).

Conclusions

Simultaneous MTC/DTC is diagnosed earlier in tumor development than MTC alone, with a trend toward better prognosis. This entity likely represents a primary tumor with an incidental pathologic finding of a second malignancy. Each malignancy should be treated according to its respective stage and current guidelines.     

Influence of Neoadjuvant Radiotherapy on Anastomotic Leak After Restorative Resection for Rectal Cancer

Purpose

This study was undertaken to determine whether neoadjuvant radiotherapy is associated with an increased risk of anastomotic leak for rectal cancer patients undergoing restorative resection.

Methods

From 1980 to 2010, patients who underwent restorative resection for rectal cancer (tumors within 15?cm of anal verge) were identified from a prospective institutional database and grouped based on whether they received neoadjuvant radiotherapy (+RT) or not (?RT). The main outcome was anastomotic leak documented by imaging (contrast leak), intra-operative or clinical (signs of peritonitis) findings and confirmed by staff surgeon assessment. Using multivariate (MV) analysis risk factors for leak were identified, presented as OR (95?% CI).

Results

One thousand eight hundred sixty-two patients were included in the analysis, 28?% in the +RT group. Eighty-six percent of +RT patients received neoadjuvant chemoradiotherapy. The overall leak rate was 6.3?%, with no significant difference in +RT and ?RT groups (8?% vs 5.7?%, p?=?0.06). The +RT group had a lower mean age at surgery (58 vs 63?year, p?<?0.001), more male (75?% vs 62?%, p?<?0.001) and more ASA 3/4 (44?% vs 35?%, p?<?0.001) patients, greater use of defunctioning ostomy (87?% vs 44?%, p?<?0.001) and colo-anal anastomosis (77?% vs 34?%, p?<?0.001). Mean tumor distance from the anal verge was lower in +RT group (6.6 vs 9.7?cm, p?<?0.001). On MV analysis, male sex (OR 1.64 (1.03?C2.62), p?=?0.038), ASA 4 (OR 4.70 (2.07?C10.7), p?<?0.001), tumor distance from anal verge????5?cm (OR 2.49 (1.37?C4.52), p?=?0.003), and tumor size at surgery????4?cm (OR 1.75 (1.15?C2.65), p?=?0.009) were independently associated with leak. +RT was not independently associated with leak (OR 1.44 (0.85?C2.46), p?=?0.18), while defunctioning ostomy did not reduce leak occurrence (OR 0.75 (0.44?C1.28), p?=?0.29).

Conclusions

The findings suggest that neoadjuvant radiotherapy is not independently associated with an anastomotic leak for rectal cancer patients undergoing restorative resection and support a selective policy towards the use of a defunctioning ostomy on a case by case basis based on intra-operative judgment and consideration of tumor location, size, and patient characteristics.