Resection of Colorectal Liver Metastases: Is a Resection Margin of 3 mm Enough?

Background

A safety margin of ≥10 mm is generally accepted in surgery for colorectal metastases. It is reasonable that modern methods of liver parenchyma dissection may allow for a reduction in this distance.

Methods

A total of 333 patients were included in a multicenter trial after resection of colorectal liver metastases. Dissection of the liver had been performed with a CUSA^®, UltraCision^®, or water-jet dissector. The size of the resection margin was correlated with recurrence risk and survival.

Results

The median hepatic recurrence-free survival reached 35 months for all patients; median recurrence-free survival was 24 months and overall survival was 41 months. Univariate analysis of different groups denoting the extent of resection margin (≥10 mm, 6–9 mm, 3–5 mm, 1–2 mm, 0 mm (R1)) indicated that a margin of 1–2 mm leads to a significantly reduced median hepatic recurrence-free survival of 20 months (p = 0.004) and recurrence-free survival of 19 months (p = 0.011). Patients with R1 resection had the worst prognosis. Overall survival was not influenced by the size of the resection margin. Surgical margins were significantly reduced in simultaneous resections of four or more liver metastases and in cases in which metastatic infiltration of central liver segments was present. At multivariate analysis, resection margins of 1–2 mm and 0 mm were independent predictors of hepatic recurrence and overall recurrence.

Conclusion

The indication for resection of metastases can be safely extended to cases in which tumors sit closer than 1 cm to nonresectable structures.     

Resection of lung metastases--risk or chance?

INTRODUCTION: The resection of pulmonary metastases can extend life of patients, even offering the possibility of cure. A risk analysis of the surgical procedure under the current practice of the thoracic surgery has been performed in this study. MATERIALS AND METHODS: Using a prolective method, data from 199 patients with 300 lung resections for pulmonary metastases done in our university department (1/1994-01/2003) were evaluated. Risk factors and therapy results were investigated in an uni- and multivariate analysis (Fishers Exact Test, Chi-Square and logistic regression). RESULTS: Overall lethality was 1 % and the total morbidity rate was 19 %. The 232 atypical resections were associated with 14 % morbidity rate, while the anatomical and combined ones were associated with 38 % (p = 0.0001). 19 patients revealed a FEV (1) < 1.6 l linked with a morbidity of 42 %. In patients without FEV (1) restriction morbidity was 18 % (p = 0.0172). Both, risk factors and the anatomical resection showed in the multivariate analysis a statistically significant increased morbidity. Additional risk factors (ASA > 2, age over 65, sex or cardial risk factors) did not influence postoperative morbidity. DISCUSSION: According to our data, no patient with good lung function should be withhold from atypical resection of pulmonary metastases offering the possibility of cure with low morbidity. However the indication should be critically evaluated if anatomical resection is required.     

Transurethral Resection of Non–muscle-invasive Bladder Cancer

Transurethral resection of the bladder (TURB) is the initial and critical step in the management of bladder tumours. The aim of the procedure is to establish the histologic diagnosis, determine the tumour stage and grade, and achieve complete removal of papillary non–muscle-invasive tumours. Although TURB is a frequently performed procedure, its results are limited by the high recurrence rate and by the risk of tumour understaging. The major prerequisite for optimal outcomes is a systematically and meticulously performed procedure by a well-trained urologist. Smaller tumours can be resected en bloc; tumours >1 cm should be resected separately in fractions. Deep resection, including the detrusor muscle, is essential for correct staging. The biopsy should be taken from all areas suggestive of carcinoma in situ (CIS), and biopsies from normal-looking mucosa are recommended only in patients with positive cytology or non-papillary tumours. TURB should be performed with modern equipment, including new telescopes and video systems. Moreover, urologists should be aware of promising innovations, including new imaging techniques, and their possible benefits.Re-TUR can improve recurrence-free survival (RFS) and tumour staging. It is recommended in any patient with a T1 or high-grade tumour at initial resection and when the pathologist has reported that the specimen contained no muscle. It should also be considered in cases where the urologist is not sure that the initial resection was complete, especially in extensive and multiple tumours.     

Reconstruction With β-Tricalcium Phosphate After Navicular Tumor Resection

Postresection reconstruction of the navicular bone is challenging. A composite hemangioendothelioma is an intermediate malignancy characterized by an admixture of differing vascular components. In the present report, a 40-year-old male with a composite hemangioendothelioma presented with multiple soft tissue lesions of the leg and sole and a navicular bone lesion. The navicular bone was resected and reconstructed using β-tricalcium phosphate of strong compression resistance with plating. The current reconstruction method can be applied, not only for tumors, but also for trauma.     

Radical Resection or Chemoradiotherapy for Cervical Esophageal Cancer?

Background  

The prognosis and quality of life (QOL) for those with cervical esophageal cancer is extremely poor, and chemoradiotherapy remains the mainstay treatment. During the past few years, our surgical teams has implemented a more aggressive and radical resection: total laryngopharyngectomy with neck dissection, total esophagectomy, and reconstruction with stomach. This study compares the results of chemoradiotherapy and that of the aforementioned surgical approach.     

Is Hepatic Resection the Best Treatment for Hydatid Cyst?

Background

Hydatid disease is a serious public health problem in endemic areas, and the management is controversial. Operative treatment is generally accepted especially in patients presenting complications. Our policy is to perform radical surgery and, whenever possible, anatomic hepatic resection. The purpose is to report our experience and results in the management of liver hydatid disease.

Methods

Between January 1991 and December 2010, 97 patients were referred to our department for surgical treatment of hepatic hydatid cyst. Data were retrospectively reviewed. Patients were divided into three treatment groups: conservative surgery (CS), total pericystectomy (PC), and hepatic resection (HR). The main outcome measures were the mortality, morbidity, and recurrence rate.

Results

Median patient age was 45?years (range, 30?C56?years). A total of 105 hydatid cysts were treated. Radical surgery was performed in 85 patients: major HR in 43 patients, minor HR in 9, and total PC in 33. CS was performed in 12 cases. There were no postoperative deaths, and the overall morbidity was 20?%. Postoperative morbidity in the HR group was 20?%. Minor (Grade I/II) and major (Grade III/IV) complications were comparable between groups (p?=?ns). No statistical difference in duration of hospitalization was observed between the CS and the HR group. One patient in the HR group developed a recurrence.

Conclusions

The findings of this study suggest that surgical resection is not associated with much more postoperative and cyst cavity-related complications than the other groups. In addition, there was no mortality and a low recurrence rate.     

Extended Resection: Is It Feasible for Pulmonary Metastases?

Background  

Extended resections may be necessary to achieve tumor-free borders for secondary pulmonary malignancies. This study was performed to analyze the outcomes that result from extended resections of pulmonary metastases.     

Should Diaphragmatic Involvement Preclude Resection of Large Hepatic Tumors?

Background

Treatment of peripherally located liver tumors with diaphragmatic invasion is technically demanding but does not preclude resection for cure. The aim of the present study was to compare patients undergoing combined liver and diaphragmatic resection with those submitted to hepatectomy alone so as to evaluate the safety, effectiveness, and value of this complex surgical procedure.

Methods

From January 2000 to September 2011, 36 consecutive patients underwent en bloc liver-diaphragm resection (group A). These were individually matched for age, gender, tumor size, pathology, and co-morbitidies with 36 patients who underwent hepatectomy alone during the same time (group B). Operative time, warm ischemia time, blood loss, required transfusions, postoperative complications, and long-term survival were evaluated.

Results

Mean operative time was significantly longer in group A than in group B (165 vs 142 min; P = 0.004). The two groups were comparable regarding warm ischemia time, intraoperative blood loss, required transfusions, and postoperative laboratory value fluctuations. Some 33 % of group A patients developed complications postoperatively as opposed to 23 % of group B patients (P = 0.03). The mortality rate was 2.8 % in group A compared to 0 % in group B. Postoperative follow-up demonstrated 60 % 1-year survival for group A patients as opposed to 80 % 1-year survival for group B patients, a difference that is practically eliminated the longer the follow-up period is extended (35 vs 40 % 3-year survival and 33 vs 37 % 5-year survival for group A and group B patients, respectively).

Conclusions

En bloc diaphragmatic and liver resection is a challenging but safe surgical procedure that is fully justified when diaphragmatic infiltration cannot be ruled out and the patient is considered fit enough to undergo surgery.     

Mandatory Resection of Strangulation Marks in Small Bowel Obstruction?

Background

No evidence is available on how to treat intraoperatively detected band-shaped strangulation marks of the bowel wall originating from an adhesive band or hernia ring. The authors prefer to resect these hazardous strangulation marks to avoid secondary small bowel perforation. This retrospective study investigated the prevalence of intraoperatively unrecognized ulceration and transmural necrosis at the site of the strangulation marks.

Methods

From July 2003 to July 2011, a total of 31 of 461 patients with acute bowel obstruction underwent small bowel resection due to strangulation marks, exclusively. Seven patients had two strangulation marks, resulting in 38 strangulation marks to be analyzed.

Results

From 38 examined strangulation marks, 14 (36.8 %) exhibited deep ulceration or transmural necrosis. Four (10.5 %) necrotic lesions had already been recognized intraoperatively, while 7 (18.4 %) unsuspicious strangulation marks showed deep ulceration and 3 (7.9 %) showed transmural necrosis exclusively at final histopathologic examination. The number of strangulation marks that needed to be resected for prevention of one missed deep ulceration and/or transmural necrosis of the small bowel was 3.4. The presence of deep ulceration or transmural necrosis is associated with an obvious decrease in bowel diameter caudad to the strangulation mark. No anastomotic leak occurred.

Conclusion

The severity of small bowel damage at the site of band-shaped strangulation marks may be underestimated by surgeons. The present series showed favorable results with a resection-per-principle policy for these strangulation marks. If an obvious decrease of bowel diameter aborally to the strangulation mark is present, resection or seromuscular invagination of the later is particularly recommended.     

Are There Indications for Palliative Resection in Pancreatic Cancer?

Controversy exists about the indication for a palliative pancreatoduodenectomy. A palliative resection for patients with a pancreatic carcinoma can be performed safely nowadays with low mortality and acceptable morbidity in centers with experience. The early results in terms of mortality and morbidity are not different from resections with curative intent or even after bypass surgery. The procedure seems effective for controlling symptoms of the disease, and the quality of life after a palliative resection is acceptable and not worse than after bypass surgery. It is, however, still doubtful whether the incidence of symptom recurrence, such as jaundice, obstruction, and pain, is lower after resection than after bypass surgery. The longer survival after palliative resection could also be due to patient selection and postoperative treatment. There are no randomized trials to prove the superiority of palliative resection over bypass surgery. The safety of pancreatic resection for cancer has already changed the policy in centers with experience, and surgeons are more willing to perform a resection because the results are better or at least the same as after bypass surgery. There are, however, no results to confirm that a palliative resection should be performed routinely or to justify resection as a debulking procedure.     

Resectable Pancreatic Cancer: Who Really Benefits From Resection?

Background  

The 1-year disease-related mortality after resection for pancreatic cancer is approximately 30%. This study examined potential preoperative parameters that would help avoid unnecessary surgery.     

Contemporary Management of Adult Intussusception: Who Needs a Resection?

Background

Surgical resection is often recommended in adults with intestinal intussusception (AI) because of its potential association with malignancy. We provide a contemporary algorithm for managing AI by focusing on the probability of discovering a lead point.

Methods

This is a retrospective study of adult patients with computed tomography (CT)-confirmed intussusception who underwent operative management of AI between 1996 and 2011 at a single academic institution.

Results

Sixty-four patients were diagnosed with AI by CT scan and then managed operatively. The incidence of colonic (CI), small bowel (SBI), and retrograde intussusception (RI) was 14, 55, and 31 %, respectively. All patients with CI had a lead point, whereas none were found among patients with RI. Some 46 % of patients with SBI had a lead point. The probability of discovering a lead point in SBI was increased by past history of malignancy (RR, 3.7, p < 0.001), a mass seen on preoperative CT scan (RR, 2.9, p = 0.005), and age over 60 years (RR, 2.2, p = 0.07).

Conclusions

A pathologic lead point is likely with CI but not with RI. Patients with SBI who are over the age of 60 years and have a history of malignancy or a mass noted on CT scan have a higher likelihood of harboring a pathologic lead point.     

Non-Anatomic Hepatic Resection Using Chang’s Needle for Porcelain Gallbladder

We present a simple technique of nonanatomic resection of liver parenchyma for porcelain gallbladder infiltrating gallbladder bed, that is, segments IVb and V of the liver. The resection has been carried out with the use of straight 18-gauge stainless steel multi-use needle designed for hepatic resections (Chang’s needle). This simple, safe, and cost-effective technique can be used for nonanatomic liver resections by surgeons less experienced in liver surgery.     

Palliative Resection of Colorectal Cancer: Does It Prolong Survival?

BACKGROUND: It is still a matter of debate as to whether resective surgery of the primary tumor may prolong the survival of patients affected by incurable colorectal cancer (CRC). The main goal of this retrospective study, carried out on patients not undergoing any therapy other than surgery, was to quantify the benefit of primary tumor removal in patients with differently presenting incurable CRC. METHODS: One hundred and thirty consecutive patients were operated on for incurable CRC (83 undergoing resective and 47 non-resective procedures). With the purpose of comparing homogenous populations and of identifying patients who may benefit from primary tumor resection, the patients were classified according to classes of disease, based on the "metastatic pattern" and the "resectability of primary tumor." RESULTS: In patients with "resectable" primary tumors, resective procedures are associated with longer median survival than after non-resective ones (9 months vs 3). Only patients with distant spread without neoplastic ascites/carcinosis benefit from primary tumor removal (median survival: 9 months vs 3). Morbidity and mortality of resective procedures is not significantly different from that of non-resective surgery, either in the population studied or in any of the groups considered. CONCLUSIONS: Palliative resection of primary CRC should be pursued in patients with unresectable distant metastasis (without carcinomatosis), and, intraoperatively, whenever the primary tumor is technically resectable.     

Labral Resection or Preservation During FAI Treatment? A Systematic Review

Background

Open and arthroscopic treatment of femoroacetabular impingement and resultant labral pathology has increased significantly over the past decade. Although the functional importance of the labrum and the labral seal has been established in biomechanical studies, good clinical results have been reported for both labral debridement and labral refixation.

Questions/Purposes

The purpose of this paper is to summarize existing literature on the surgical treatment of labral pathology to provide treatment recommendations and direct future research. A systematic review was performed with the following research question in mind: Does preservation of the hip labrum improve outcomes as compared to labral debridement for the treatment of labral pathology?

Methods

The MEDLINE database was searched for level I, II, or III articles in English or German comparing labral debridement to labral refixation. Five studies were included in the analysis.

Results

Good short-term results were reported for both groups. Three out of five papers report improved outcomes after labral refixation as compared to labral debridement.

Conclusions

In short-term follow-up, labral refixation appears to have slightly better outcomes than labral debridement. Studies with prospectively defined cohorts and longer follow-up are, however, necessary to provide definitive recommendations for labral treatment.