Hepatectomy for Hepatocellular Carcinoma in Elderly Patients Aged 75 Years or More

Background  The aim of this study was to clarify the characteristics of elderly hepatocellular carcinoma (HCC) patients aged 75 years or more who underwent hepatectomy and to clarify whether elderly patients with HCC benefit from hepatectomy. Methods  Between January 1990 and December 2006, 570 patients underwent curative hepatectomy for HCC. Elderly patients were defined as those aged 75 years or more. Clinicopathological data and outcomes after hepatectomy for 64 elderly and 502 younger patients were prospectively collected and compared. Results  The proportion of elderly patients with chronic viral infection was less than that of younger patients (p < 0.001). Cirrhotic patients in the elderly group were less than those in the younger group (p = 0.03). The elderly patients had better liver function than did the younger patients (p = 0.007) but had more advanced HCC with microscopic vascular invasion than did the younger patients (p = 0.04). There was no operative mortality in the elderly patients and there was no significant difference in postoperative complication rates and long-term survival after hepatectomy between the two groups. Conclusions  Hepatectomy for elderly patients with resectable HCC is safe and feasible. Selected elderly patients with HCC might benefit from hepatectomy. This work originated from the Department of Surgery, Division of Frontier Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.     

Early Carotid Endarterectomy in Selected Stroke Patients

Although there are several reports suggesting the safety of performing carotid endarterectomy (CE) within 4 weeks (early) of a nondisabling stroke, at many institutions it is not standard practice. Benefits of early surgery may include reduction in the number of strokes or carotid occlusions during the time between stroke and surgery, as well as a reduction in the cost of medical care due to the elimination of interval anticoagulation and close follow-up. This review examines the outcomes of early CE in selected patients after a nondisabling stroke. A total of 1065 CEs were performed between November 1991 and April 1998. Seventy-five patients were identified by computerized hospital record and office chart review as having CE after a nondisabling stroke. Criteria for early surgery included 1) nondisabling stroke ipsilateral to a carotid stenosis >50%, 2) neurological stability, and 3) no evidence of hemorrhagic stroke or significant cerebral edema by CT/MRI evaluation. This review suggests that early CE can be performed in selected patients with an acceptable perioperative morbidity and mortality.     

Chronic Renal Insufficiency and Risk of Early Mortality in Patients Undergoing Carotid Endarterectomy

We compared early outcome after carotid endarterectomy (CEA) in patients (n = 857 with 1,011 CEA interventions) with and without chronic renal insufficiency (CRI). Two groups were compared: a group with normal renal function (n = 909) and a group with CRI (creatinine ≥1.5 mg/dL and clearance of ≤30 mL/min, as well as dialysis and transplant patients, n = 102). Mean age was significantly higher in CRI patients (71.22 vs. 68.33 years, p = 0.001). The incidence of smokers was 53.9% in the non-CRI group vs. 39.2% in CRI patients (p = 0.005). Hypertension (88.2% vs. 75.1, p = 0.003) and cardiac disease (58.8% vs. 47.4%, p = 0.029) were more common in the CRI group. The perioperative mortality rate was significantly higher in CRI patients (3.9% vs. 1.0%, p = 0.013). Multivariate logistic regression analysis showed a significant association between CRI and 30-day death rate (odds ratio = 3.76, p = 0.032). In this series, CRI patients presented an increased mortality. The mortality risk may be related to the increased rates of preoperative hypertension and coronary disease and perioperative myocardial infarction. A more reserved attitude seems indicated in planning CEA for patients with renal dysfunction in combination with a history of coronary artery disease.     

The Importance of Early Carotid Endarterectomy in Symptomatic Patients

INTRODUCTION

Early carotid endarterectomy (CEA) in symptomatic patients may prevent repeat cerebral events. This study investigates the relationship between waiting time for CEA and the incidence of repeat cerebral events prior to surgery in symptomatic patients.

PATIENTS AND METHODS

A prospective database of consecutive patients undergoing CEA between January 2002 and December 2006 was reviewed. Repeat event rates prior to surgery were calculated using Kaplan–Meier analysis and predictive factors identified using Cox regression analysis.

RESULTS

A total of 118 patients underwent CEA for non-disabling stroke, TIA and amaurosis fugax. Repeat cerebral events occurred in 34 of 118 (29%) patients at a median 51 days (range, 2–360 days) after the first event. The estimated risk of repeat events was 2% at 7 days and 9% at 1 month after first event (Kaplan–Meier survival analysis). Age (HR 1.059; 95% CI 1.014–1.106; P = 0.009] was identified as a predictor of repeat events. Patients underwent surgery at median 97 days (range, 7–621 days) after the first event. Eleven of 60 (18%) patients waiting ≤?97 days for surgery and 23 of 58 (40%) patients waiting >?97 days had repeat events. (P = 0.011, chi-squared test).

CONCLUSIONS

Delays in surgery should be reduced in order to minimise repeat cerebral events in patients with symptomatic carotid stenosis, particularly in the elderly population.     

Stroke From Carotid Endarterectomy: When and How to Reduce Perioperative Stroke Rate?

OBJECTIVES: To analyse four years of CEA with respect to the underlying mechanisms of perioperative stroke and the role of intraoperative monitoring in the prevention of stroke. PATIENTS AND METHODS: From January 1996 through December 1999, 599 CEAs were performed in 404 men and 195 women (mean age: 65 years, range: 39-88). All operations were performed under general anaesthesia using computerised electroencephalography (EEG) and transcranial Doppler (TCD). Any new or any extension of an existing focal cerebral deficit, as well as stroke-related death were registered. Perioperative strokes were classified by time of onset (intraoperative or postoperative), outcome (minor or major stroke), and side (ipsilateral or contralateral). Stroke aetiology was assessed intraoperatively by means of EEG, TCD, completion arteriography or immediate re-exploration, and postoperatively by duplex sonography, computerised tomography (CT) or magnetic resonance imaging (MRI) of the head. RESULTS: Perioperative stroke or death occurred in 20 (3.3%) patients. In four operations stroke was apparent immediately after surgery. Mechanisms of these strokes were ipsilateral carotid artery occlusion (1) and embolisation (3). In 16 patients stroke developed after a symptom-free interval (2-72 h, mean 18 h) due to occlusion of the internal carotid artery on the side of surgery (9). Other mechanisms were: contralateral occlusion of the internal carotid artery (1), postoperative hyperperfusion syndrome (1), intracerebral haemorrhage (1), and contralateral ischaemia due to prolonged clamping (1). In three procedures the cause was unknown. CONCLUSIONS: In our experience most strokes from CEA developed after a symptom-free interval and mainly due to thromboembolism of the operated artery. We suggest the introduction of additional TCD monitoring during the immediate postoperative phase.     

Carotid Endarterectomy Benefits Patients with CKD and Symptomatic High-Grade Stenosis

Endarterectomy is generally recommended for symptomatic high-grade (70 to 99%) stenosis of the internal carotid artery, but whether this procedure is beneficial among patients with chronic kidney disease (CKD) is unknown. In this re-analysis of data from the North American Symptomatic Carotid Endarterectomy Trial, we included patients with symptomatic stenosis and either stage 3 CKD (n = 524) or preserved kidney function (n = 966; estimated GFR ≥ 60). For medically treated patients with high-grade stenosis, risk for ipsilateral stroke at 2 yr was significantly higher in patients with CKD than in those with preserved renal function (31.6 versus 19.3%; P = 0.042); carotid endarterectomy significantly reduced this risk by 82 and 51%, respectively. To prevent one ipsilateral stroke, the number needed to treat by endarterectomy was four for patients with CKD and 10 for patients with preserved renal function. Compared with patients with preserved renal function, those with CKD had similar rates of perioperative stroke and death but higher rates of cardiac events. In conclusion, patients with stage 3 CKD and symptomatic high-grade carotid stenosis gain a large benefit in stroke risk reduction after endarterectomy.Approximately 795,000 people in North America have a stroke every year, 185,000 of whom have recurrent strokes.¹ As a secondary prevention strategy, current practice guidelines recommend carotid endarterectomy for patients with symptomatic high grade (70 to 99%) carotid stenosis.² Endarterectomy is also offered to patients with moderate-grade (50 to 69%) stenosis, after considering factors such as age, gender, comorbidities, and severity of recent symptoms.²It is estimated that >15 million Americans have chronic kidney disease (CKD), and the prevalence is increasing.³ Patients with CKD are at high risk for cardiovascular^4–6 and cerebrovascular disease, including stroke^7,8; however, patients with CKD are less likely than others to undergo invasive procedures to reduce this risk,⁹ a phenomenon sometimes called “renalism.”¹⁰ Although patients with CKD are prone to adverse events from procedures and treatments,^11,12 in some situations patients with CKD derive larger absolute benefits than others because of their high baseline risk.^13–16Little is known about the effectiveness and safety of carotid endarterectomy in patients with CKD. No randomized trial has exclusively focused on endarterectomy in the CKD population, and it remains unlikely that such a trial will ever be conducted. The next best approach is to re-analyze previously conducted trials. Three large randomized trials have examined the benefit of carotid endarterectomy, namely the Asymptomatic Carotid Atherosclerosis Study (ACAS),¹⁷ the European Carotid Surgery Trial (ECST),¹⁸ and the North American Symptomatic Carotid Endarterectomy Trial (NASCET).¹⁹ Of the three trials, only NASCET collected baseline serum creatinine for all trial participants. The aim of this study was to examine the outcomes of patients with and without CKD among those enrolled in NASCET.     

Prophylactic Carotid Endarterectomy in Patients with High-Grade Carotid Stenosis Undergoing Coronary Bypass: Does It Decrease the Incidence of Perioperative Stroke?

p = 0.001) and permanent neurologic defects (p= 0.005) in those patient undergoing prophylactic CE (Group II). Patients with 80%-99% carotid stenosis undergoing CEA prior to or in conjunction with isolated CABG have a decreased incidence of neurologic events postoperatively.     

Perioperative and Long-term Outcomes of Carotid Endarterectomy for Japanese Asymptomatic Cervical Carotid Artery Stenosis: A Single Institution Study

As the recently developed medical treatments for asymptomatic cervical carotid artery stenosis (ACCAS) have shown excellent stroke prevention, carotid endarterectomy (CEA) should be carried out for more selected patients and with lower complication rates and better long-term outcomes. We have performed CEA for Japanese ACCAS patients with a uniform surgical technique and strict perioperative management. In this study, we retrospectively investigated the perioperative complications and long-term outcomes of our CEA series. A total of 147 CEAs were carried out in 139 Japanese ACCAS patients. All patients were routinely checked for their cardiac function and high risk coronary lesions were preferentially treated before CEA. All CEAs were performed under general anesthesia using a shunt system. The postoperative cerebral blood flow was routinely measured under continued sedation to prevent postoperative hyperperfusion. The 30-day perioperative morbidity rate was 2.04%, including a perioperative stroke rate of 0.68%. There were no perioperative deaths. With regard to the long-term outcomes of the 134 followed-up patients, 9 patients were dead and 5 patients suffered from strokes, including 2 patients with ipsilateral hemispheric ischemia. The annual rates of death, all stroke and ipsilateral ischemic stroke were 1.15%, 0.64%, and 0.25%, respectively. These results showed that the perioperative morbidity and mortality rates of our CEAs were lower than those in the previous large trials. Furthermore, the long-term outcomes of this series were favorable to those reported in the latest medical treatment trials for ACCAS patients. CEA may be useful for preventing ischemic stroke in Japanese ACCAS patients.