Fluorescence-guided surgery with 5-aminolevulinic acid for resection of brain tumors in children—a technical report

Background

5-aminolevulinic acid (5-ALA) can be used as an adjunct for the surgery of adult malignant glioma and improves the rate of gross total resection and patient survival. So far, only three casuistic reports of fluorescence-guided surgery used in children have been published. We report our pilot series of 16 pediatric brain tumors treated with 5-ALA.

Methods

Sixteen patients (mean age 9 years, range 1–16 years) received a standardized 5-ALA dose according to the published protocol after informed parental consent. The fluorescence status (positive versus negative) in correlation with histology as well as blood samples and adverse clinical symptoms were recorded.

Results

Histology revealed pilocytic astrocytoma (n?=?7), classical medulloblastoma (n?=?4), anaplastic astrocytoma (n?=?1), glioblastoma (n?=?3) and anaplastic ependymoma (n?=?1). Positive fluorescence was observed in cases of anaplastic astrocytoma, glioblastoma, and medulloblastoma, respectively. Significant increases were registered for alanine aminotransferase (14.92?±?1.106 U/l vs. 37.70?±?3.795 U/l, P?=?0.0020) and gamma glutamyl transpeptidase (12.69?±?1.638 U/l vs. 39.29?±?6.342 U/l, P?=?0.0156), correlated with young age. No further adverse reactions were evident.

Conclusion

Positive fluorescence was observed in two high-grade gliomas and one medulloblastoma after oral administration of 5-ALA. Thus, 5-ALA appears capable of inducing fluorescence in pediatric high-grade tumors. Adverse reactions observed in children were similar to those reported for adults, although very young children might be at increased risk. Further studies are required to elucidate pharmacokinetic and pharmacodynamic properties of 5-ALA in children and to assess its prognostic role in the resection of pediatric brain tumors.     

5-ALA complete resections go beyond MR contrast enhancement: shift corrected volumetric analysis of the extent of resection in surgery for glioblastoma

Background

The technique of 5-aminolevulinic acid (5-ALA) tumor fluorescence is increasingly used to improve visualization of tumor tissue and thereby to increase the rate of patients with gross total resections. In this study, we measured the resection volumes in patients who underwent 5-ALA-guided surgery for non-eloquent glioblastoma and compared them with the preoperative tumor volume.

Methods

We selected 13 patients who had received a complete resection according to intraoperative 5-ALA induced fluorescence and CRET according to post-operative T1 contrast-enhanced MRI. The volumes of pre-operative contrast enhancing tissue, post-operative resection cavity and resected tissue were determined through shift-corrected volumetric analysis.

Results

The mean resection cavity (29 cm³) was marginally smaller than the pre-operative contrast-enhancing tumor (39 cm³, p?=?0.32). However, the mean overall resection volume (84 cm³) was significantly larger than the pre-operative contrast-enhancing tumor (39 cm³, p?=?0.0087). This yields a mean volume of resected 5-ALA positive, but radiological non-enhancing tissue of 45 cm³. The mean calculated rim of resected tissue surpassed pre-operative tumor diameter by 6 mm (range 0–10 mm).

Conclusions

Results of the current study imply that (i) the resection cavity underestimates the volume of resected tissue and (ii) 5-ALA complete resections go significantly beyond the volume of pre-operative contrast-enhancing tumor bulk on MRI, indicating that 5-ALA also stains MRI non-enhancing tumor tissue. Use of 5-ALA may thus enable extension of coalescent tumor resection beyond radiologically evident tumor. The impact of this more extended resection method on time to progression and overall survival has not been determined, and potentially puts adjacent and functionally intact tissue at risk.     

Changes in elastin density in different locations of the vaginal wall in women with pelvic organ prolapse

Introduction and hypothesis

The purpose of this study was to analyze the histomorphometric properties of the vaginal wall in women with pelvic organ prolapse (POP).

Methods

In 15 women undergoing surgery for POP, full-thickness biopsies were collected at two different sites of location from the anterior and/or posterior vaginal wall. Properties of the precervical area (POP-Q point C/D) were compared with the most distal portion of the vaginal wall (POP-Q point Ba/Bp) using histological staining and immunohistochemistry. The densities of total collagen fibers, elastic fibers, smooth muscle cells, and blood vessels were determined by combining high-resolution virtual imaging and computer-assisted digital image analysis.

Results

The mean elastin density was significantly decreased in the lamina propria and muscularis layer of the vaginal wall from the most distal portion of the prolapsed vaginal wall compared with the precervical area. This difference was statistically significant in the lamina propria for both anterior (8.4?±?1.2 and 12.1?±?2.0, p?=?0.048) and posterior (6.8?±?0.5 and 10.1?±?1.4, p?=?0.040) locations, and in the muscularis for the anterior (5.2?±?0.4 and 8.4?±?1.2, p?=?0.009) vaginal wall. There were no statistically significant differences in the mean densities of collagen fibers, smooth muscle cells or blood vessels between the two locations.

Conclusions

In this study, we observed changes in elastin density in two different locations of the vaginal wall from women with POP. The histomorphometric properties of the vaginal wall can be variable from one place to another in the same patient. This result supports the existence of most vulnerable locations within the vaginal wall and the potential benefit of site-specific prolapse surgery.     

Outcome of conventional treatment and prognostic factor in elderly glioblastoma patients

Background

Glioblastoma (GBM) is the most life-threatening primary brain tumour. Especially in elderly patients, a poorer outcome is noticeable. Until now, the effectiveness of the conventional active treatment has been controversial. The purpose of this study is to find the optimal treatment for elderly patients with newly diagnosed GBM.

Method

The authors retrospectively reviewed 301 patients who were diagnosed with GBM at a single centre from January 2006 to December 2010. All patients were divided into younger and elderly groups based on the cut-off age of 65 years, and the treatment outcome was analysed.

Results

Of 301 patients, 67 (23.3 %) patients were 65 years old or older, and 234 (77.7 %) patients were younger than 65 years. In the elderly group, 49 patients received surgical resection and 18 patients received biopsy. Forty-seven patients (70.1 %) underwent concomitant chemoradiotherapy (CCRT) and 38 patients (56.7 %) underwent adjuvant temozolomide (TMZ) chemotherapy. The median overall survival (OS) of elderly patients was 12.0 months and the progression-free survival (PFS) was 8.5 months. The median OS of elderly patients who underwent CCRT and adjuvant TMZ chemotherapy increased to 16.2 months. On the multivariate analysis, tumour infiltration (p?=?0.005), and resection (p?=?0.001) were significant independent prognostic factors in elderly patients. The grade 3 or 4 complication rate was not statistically different between the younger group (n?=?22, 9.4 %) and the elderly group (n?=?8, 12 %).

Conclusion

Elderly patients diagnosed with GBM had a survival benefit and a low complication rate with the conventional treatment. Therefore, elderly patients should be encouraged to receive the conventional active treatment.     

The impact of improved treatment strategies on overall survival in glioblastoma patients

Background

The introduction of ALA-Fluorescence-guided surgery (FGS) followed by concomitant radiochemotherapy according to the Stupp-protocol is representative of the major changes in glioblastoma therapy in the past years. We were interested in the impact of this new first-line treatment on the overall survival of patients suffering from newly diagnosed primary glioblastoma in a retrospective single-centre study.

Method

For this retrospective analysis, data was derived from a prospective single-centre database. Patients were divided into three treatment groups: A (FGS?/radiochemotherapy?), B (FGS?/radiochemotherapy+) and C (FGS+/radiochemotherapy+). Further stratification was applied regarding MGMT-methylation status and degree of resection. Statistical analysis was performed to determine factors (treatment regime, age, gender, performance status, MGMT promoter methylation status) significantly influencing overall survival (OAS).

Results

Two hundred and fifty-three patients suffering from primary glioblastoma treated by cytoreductive surgery between 2002 and 2009 were included in this survey. Median OAS differed significantly between the treatment groups (A?=?8.8, B?=?16.6, C?=?20.1, p?<?0.01). Resection data was available in all 253 patients. The usage of FGS highly significantly correlated with a complete resection (p?<?0.01). Complete resection was positively correlated with an increase in OAS (complete 20.3 months vs. incomplete 9.3 months, p?<?0.01).

Conclusions

FGS and radiochemotherapy according to the Stupp protocol have induced an impressive improvement in overall survival in glioblastoma patients. This effect is not limited to clinical trials, but is reproducible in daily routine.     

Fluorescence-guided surgery in high grade gliomas using an exoscope system

Background

Fluorescence-guided microsurgical resections of high-grade gliomas using 5-aminolevulinic acid (5-ALA) is superior to conventional microsurgery. An optical device, usually a modified microscope, is needed for these procedures. However, an exoscope may be implemented for fluorescence techniques. We present the use of an exoscope to perform tumor resection guided by 5-ALA fluorescence in 21 consecutive patients with high-grade glioma and two neuronavigation-guided biopsies.

Methods

Twenty-three patients underwent operations. Tumor volume and localization were quantified with pre- and postoperative volumetric MRI in non-biopsy cases.

Results

In non-biopsy cases, the age range was 20 to 79 years, with a median of 56 (interquartile range?=?45-66). Histological analysis indicated that 14 had glioblastoma multiforme, 2 grade-III oligodendrogliomas and 1 anaplastic astrocytoma, 3 metastases and 1 low-grade astrocytoma. Total resection was achieved in 15 cases; subtotal resection was performed in 5 patients. The result was partial resection in one case. There was no perioperative mortality. The median fluorescence intensity, on a scale of 1–5, was 4.5 in the GBM group (IQR?=?4-5), 3 (IQR?=?2.5-3.5) in anaplastic glioma, and 2.5 (IQR?=?2.25-2.75) for oligodendrogliomas. Of the three metastases, one showed fluorescence level 4. As for the two biopsy cases, one was anaplastic astrocytoma and one glioblastoma multiforme. The samples obtained were fluorescent in both cases.

Conclusions

An exoscope can be also used for fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) and neuronavigation-guided biopsy. With an important advantage of low cost, this allows the surgeon to perform collaborative surgeries and adds agility to the procedure.     

Prothrombin complex concentrate facilitates emergency spinal surgery in anticoagulated patients

Background

Oral anticoagulants are commonly used in the ageing population and therefore, spine surgeons are increasingly confronted with anticoagulated patients requiring surgical therapy. ‘Bridging therapies’ with heparins are established in elective settings, but the time frame for haemostasis restoration may be too long for patients presenting with acute spinal pathology and impending disability. The goal of this study was to analyse the feasibility of prothrombin complex concentrate (PCC) administration to facilitate emergency spinal surgery in anticoagulated patients.

Method

A retrospective analysis of the institutional database of neurosurgical patients receiving PCC from February 2007 to December 2013 (n?=?485) identified 18 patients who received PCC prior to emergency spinal surgery. Clinical characteristics, as well as modalities of PCC administration and parameters of haemostasis were analysed. Furthermore, haemorrhagic complications and thromboembolic events in the further course were evaluated.

Results

Spinal pathologies requiring urgent neurosurgical decompression were spinal haematoma (n?=?9), spinal metastasis (n?=?5), vertebral body fracture (n?=?2), and disc herniation (n?=?2). The mean international normalized ratio (INR) on admission was 2.27?±?1.20 and after administration of PCC (mean: 1,944?±?953 I.U.), INR significantly decreased to 1.12?±?0.10 (p?<?0.001). Emergency surgery was initiated within 4.4 h after PCC administration (range: 0–16.6 h). Postoperatively, symptoms improved in 12 patients (66.7 %). There were two deaths (11 %), one caused by acute myocardial infarction on the fourth postoperative day. Bleeding complications occurred in two patients (epidural haemorrhage n?=?1, rectal tumour haemorrhage n?=?1).

Conclusions

The administration of PCC facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation.     

Kinetics of porphyrin fluorescence accumulation in pediatric brain tumor cells incubated in 5-aminolevulinic acid

Background

Fluorescence-guided surgery with 5-aminolevulinic acid (5-ALA) enables more complete resections of tumors in adults. 5-ALA elicits accumulation of fluorescent porphyrins in various cancerous tissues, which can be visualized using a modified neurosurgical microscope with blue light. Although this technique is well established in adults, it has not been investigated systematically in pediatric brain tumors. Specifically, it is unknown how quickly, how long, and to what extent various pediatric tumors accumulate fluorescence. The purpose of this study was to determine utility and time course of 5-ALA–induced fluorescence in typical pediatric brain tumors in vitro.

Methods

Cell cultures of medulloblastoma [DAOY and UW228], cPNET [PFSK] atypical teratoid rhabdoid tumor [BT16] and ependymoma [RES196] were incubated with 5-ALA for either 60 minutes or continuously. Porphyrin fluorescence intensities were determined using a fluorescence-activated cell sorter (FACS) after 1, 3, 6, 9, 12 and 24 hours. C6 and U87 cells served as controls.

Results

All pediatric brain tumor cell lines displayed fluorescence compared to their respective controls without 5-ALA (p?<?0.05). Sixty minutes of incubation resulted in peaks between 3 and 6 hours, whereas continuous incubation resulted in peaks at 12 hours or beyond. 60 minute incubation peak levels were between 52 and 91 % of maxima achieved with continuous incubation. Accumulation and clearance varied between cell types.

Conclusions

We demonstrate that 5-ALA exposure of cell lines derived from typical pediatric central nervous system (CNS) tumors induces accumulation of fluorescent porphyrins. Differences in uptake and clearance indicate that different application modes may be necessary for fluorescence-guided resection, depending on tumor type.     

Hypervolemia rather than arterial calcification and extracoronary atherosclerosis is the main determinant of pulse pressure in hemodialysis patients

Introduction

Pulse pressure (PP) has been reported as an independent predictor of cardiovascular mortality in hemodialysis patients. In this study, we aimed to investigate association of PP with echocardiographic and vascular structural changes such as atherosclerosis and arterial calcifications in HD patients.

Patients and methods

In this cross-sectional study, 108 chronic hemodialysis patients (49 male, 59 female, mean age: 46?±?13?years) were included. Biochemical analyses, echocardiographic and high-resolution carotid Doppler examinations were done. Aortic wall and coronary artery calcifications were measured with electron beam computed tomography. The degree of carotid artery stenosis was measured at four different sites (communis, bulbus, interna and externa) in both carotid arteries.

Results

PP was strongly correlated with systolic (r: 0.82) and diastolic (r: 0.33) blood pressure, left ventricular mass index (r: 0.58), left ventricle end diastolic diameter (r: 0.38) and weakly correlated with aortic wall calcification score (r: 0.26) and carotid plaque score (r: 0.27), but not with coronary artery calcification score. Patients with carotid plaque had higher PP than patients without plaque (50?±?16?mmHg versus 44?±?14?mmHg, P?=?0.05). Patients were divided into three groups according to aortic wall calcification score. PP was significantly higher in patients with higher aortic wall calcification (54?±?16?mmHg) than patients with lower aortic wall calcification (44?±?15?mmHg, P?=?0.04). However, on multivariate linear regression analysis for predicting PP, the only significant factor retained was left ventricle end diastolic diameter.

Conclusion

PP was weakly associated with large vessel calcification and atherosclerosis in hemodialysis patients. The bulk of the effect on PP seems to be due to hypervolemia.     

Is laparoscopic surgery for recurrent Crohn’s disease beneficial in patients with previous primary resection through midline laparotomy? A case-matched study

Background

Patients undergoing abdominal surgery for Crohn??s disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn??s through midline laparotomy is controversial.

Methods

Patients with previous open resection for intestinal Crohn??s disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5?years), gender, body mass index (±2?kg/m²), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3?years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data.

Results

26 patients undergoing laparoscopic ileocolectomy (n?=?14), proctocolectomy (n?=?5), small bowel resection (n?=?4), abdominoperineal resection (n?=?1), extended right colectomy (n?=?1), and strictureplasty (n?=?1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12?%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158?min, p?=?0.94), estimated blood loss (222 versus 427?ml, p?=?0.32), overall morbidity (39 versus 69?%, p?=?0.051), reoperation rates (8 versus 0?%, p?=?0.5), postoperative return of bowel function (3.5?±?1.4 versus 3.9?±?1.7?days, p?=?0.3), mean length of hospital stay (6.4?±?6.2 versus 6.9?±?3.5?days, p?=?0.12), and readmission rates (8 versus 12?%, p?=?0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27?%, p?=?0.01).

Conclusions

Surgery for recurrent Crohn??s disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.     

The impact of fluorescence guidance on spinal intradural tumour surgery

Purpose

5-Aminolevulinic acid (5-ALA)-based fluorescence-guided surgery was shown to be beneficial for cerebral malignant gliomas. Extension of this technique for resection of meningiomas and cerebral metastasis has been recently evaluated. Aim of the present study is to evaluate the impact of fluorescence-guided surgery in spinal tumor surgery.

Methods

Twenty-six patients with intradural spinal tumors were included in the study. 5-ALA was administered orally prior to the induction of anesthesia. Intraoperative, 440 nm fluorescence was applied after exploration of the tumor and, if positive, periodically during and at the end of resection to detect tumor-infiltrated sites.

Results

Tumors of WHO grade III and IV were found in five patients. In detail intra- or perimedullary metastasis of malignant cerebral gliomas was found including glioblastoma WHO grade IV (n = 2), anaplastic astrocytoma WHO grade III (n = 1), anaplastic oligoastrocytoma WHO grade III (n = 1). In addition, one patient suffered from a spinal drop metastasis of a cerebellar medulloblastoma WHO grade IV. Tumors of WHO grade I were diagnosed in 18 patients: Eight cases of meningioma (two recurrences), six cases of neurinoma, one neurofibroma, two ependymoma and one plexus papilloma. At least, benign pathologies were histologically proven in three patients. All four spinal metastasis of malignant glioma (100 %), seven of eight meningiomas (87.5 %) and one of two ependymoma (50 %) were found to be ALA-positive.

Conclusion

The present study demonstrates that spinal intramedullary gliomas and the majority of spinal intradural meningiomas are 5-ALA positive. As a surgical consequence, especially in intramedullary gliomas, the use of 5-ALA fluorescence seems to be beneficial.     

Laparoscopic colorectal resection for cancer: effects of conversion on long-term oncologic outcomes

Background

The effects of conversion to open surgery during laparoscopic resection for colorectal cancer on long-term oncologic outcomes still are unclear.

Methods

All 450 laparoscopic colorectal resections for cancer performed at a single center between 1994 and 2008 and included in a prospectively maintained database were considered. Patients who required conversion to open surgery (CONV) were matched 1:2 with laparoscopically completed cases (LAP) and 1:5 with open surgery cases (OPEN) for age, American Society of Anesthesiologists (ASA) score, year of surgery, tumor location, and tumor stage. Fisher’s exact, chi-square, and Wilcoxon tests were used as appropriate. Kaplan–Meier curves were compared to analyze survival.

Results

In this study, 31 CONV cases were independently compared with 62 LAP and 155 OPEN cases. Compared with the LAP and OPEN patients, the CONV patients were characterized by a numerically higher rate of preoperative comorbidity (61.3% vs LAP, 51.6; P?=?0.4 and OPEN, 48.4%; P?=?0.2), male gender (77.4% vs LAP, 59.7%; P?=?0.09 and OPEN, 58.1%; P?=?0.05), and a significantly higher mean body mass index (29.6 vs LAP, 26.8; P?=?0.012 and OPEN, 28.8; P?=?0.3). The pathologic tumor stage, location, and chemotherapy and radiotherapy rates were comparable among the groups. After a median follow-up period of 4.1, 4.2, and 4.6?years, the 5-year disease-free survival rate was significantly lower for the CONV patients (40.2%) than for the LAP (70.7%, P?=?0.01) or the OPEN (63.3%, P?=?0.04) patients. However, the 5-year cancer-specific survival rates were similar among the CONV (94.4%), LAP (86.1%, P?=?0.36), and OPEN (84.9%, P?=?0.14) patients.

Conclusions

Conversion to open surgery does not affect oncologic outcomes, although CONV patients have increased comorbidity rates affecting long-term mortality.     

Large and giant vestibular schwannomas: does cisterna magna hyperproteinorrhachia influence visual status?

Background

Hyperproteinorrhachia associated with vestibular schwannomas (VSs) may influence visual status independent of the effect caused by raised intracranial pressure. The role of cisterna magna CSF protein levels (CMCP) in determining visual outcome in patients with large to giant vestibular schwannomas (VSs) was prospectively investigated.

Methods

The mean CMCP levels in VSs and control group; and, levels in VSs with or without visual deterioration were compared. Spearman’s rank correlation coefficient tested for relationships between CMCP level with symptom duration and tumour volume (Kawamoto’s method). Vision was regarded as normal when visual acuity was >6/18; and, deteriorated when it was between 6/18 and PL negative in the worse eye. Papilloedema (n?=?26)/secondary optic atrophy (n?=?6) and hydrocephalus (based on Evan’s ratio, mild to moderate: n?=?22; none: n?=?18) were also recorded. The analysis of factors predicting diminished vision was done using logistic regression analysis (p?<?0.05 significant).

Findings

There was a significant difference (p?<?0.001) in mean CMCP levels between VS (456.3 SD 213.6 mg/dl) and control groups (96.3 SD 74.3 mg/dl). The mean CMCP levels in the VS group were also markedly higher than the ventricular mean protein levels. The CMCP levels in patients with visual diminution (<6/18 to PL negative; n?=?23) was 561.4 SD 186.9 mg/dl and those without visual loss (n?=?17) was 314.2 SD 160.8 mg/dl (p?<?0.001). Their grade of visual diminution had a positive correlation with mean CMCP levels (p?<?0.001). There was a negative correlation between total duration of symptoms and CMCP levels (p?<?0.015). Logistic regression analysis using five independent factors (symptom duration, papilloedema/secondary optic atrophy, tumour volume, hydrocephalus and mean CMCP level) revealed that only CMCP level had a significant association with visual diminution.

Conclusion

Elevated cisternal CSF proteins may play an important role in determining visual outcome in large to giant VSs. Ventricular CSF analysis is often unable confirm the presence of VS-associated cisternal hyperproteinorrhachia. High CMCP levels may influence decision-making while instituting a permanent CSF diversion for postoperative hydrocephalus or recalcitrant pseudomeningocoele.     

The Effect of Weight Loss on the Cardiac Structure and Function After Laparoscopic Adjustable Gastric Banding Surgery in Morbidly Obese Individuals

Background

Herein, we investigate the anthropometric, biochemical and left ventricle (LV) geometry changes following the laparoscopic adjustable gastric banding (LAGB) operation in morbidly obese individuals.

Methods

Eighty-three morbidly obese participants (mean age, 46.1?±?11.5 years; 30.1 % men), scheduled for elective LAGB were examined before and 12 months after the surgery. LV geometry and diastolic function were investigated by 2-dimensional echocardiography, whereas laboratory tests assessed the glycaemic, serum lipid and inflammatory marker profiles.

Results

Twelve months after the operation, body mass index (BMI) decreased from 46.9?±?7.2 kg/m² to 40.1?±?8.2 kg/m² (p?p?p?2.7 vs. 52.0?±?12.3 g/m^2.7, p?p?=?0.0001) and BMI (ß?=?0.26, p?=?0.015) were both associated with diminished LV mass. Additionally, a statistically significant correlation between LV mass and changes in BMI (R?=?0.29, p?=?0.007), waist circumference (R?=?0.32, p?=?0.004), LV end-diastolic diameter (R?=?0.63, p?=?0.0001) and E-wave deceleration time (R?=??0.24, p?=?0.03) were observed within our study population.

Conclusions

LV mass decreases 12 months after LAGB surgery, but no improvements in LV geometry and function occur. The regression of LV mass is better predicted by weight loss than by reduction in blood pressure or changes in metabolic parameters.     

Feasibility and Oncological Outcomes of Limited Duodenal Resection in Patients with Primary Nonmetastatic Duodenal GIST

Introduction

Duodenal gastrointestinal stromal tumors (GISTs) are rare but still represent approximately 30?% of primary duodenal tumors. This study aimed to audit the feasibility and oncological outcomes of limited duodenal resection in patients with primary nonmetastatic duodenal GIST.

Methods

Twelve patients who underwent surgery at our institution since 2002 were prospectively followed up. The duodenal GISTs were located in the first (n?=?3), second (n?=?1), third (n?=?3), and fourth of duodenum (n?=?1). Involving both D1/D2 (n?=?2), D2/D3 (n?=?1), and D3/D4 (n?=?1). The primary endpoint for this analysis was disease-free survival.

Results

The commonest presentation was melena and anemia (83?%). All the patients underwent limited resection; six wedge resections with primary closures and six segmental resections with end-to-end anastomosis. The median tumor size was 8?cm (range, 5?C16?cm). According to Fletcher scale, two GISTs were low risk, while 10 patients were intermediate and high risk. The latter received adjuvant therapy. All the patients had a complete resection with no postoperative mortality. One patient had three liver metastases 4?months after limited resection and had partial hepatectomy. After median follow-up of 45 (15?C78)?months, all patients are alive and disease free.

Conclusion(s)

When technically feasible, limited resection should be considered a reliable and curative option for duodenal GIST achieving satisfactory disease-free survival. The technical feasibility is guided by the tumor size, possible adjacent organ involvement, and its exact anatomical location.     

Staging of muscle-invasive bladder cancer: can computerized tomography help us to decide on local treatment?

Objectives

To assess the power of multi-detector row computerized tomography (MDCT) in daily routine as a basic staging procedure for the decision on local treatment of patients with bladder cancer.

Patients and methods

We retrospectively analysed 276 patients who had undergone radical cystectomy between 2004 and 2008 and correlated the MDCT findings with pathological findings, number of removed lymph nodes and type of urinary diversion.

Results

Accuracy of MDCT in predicting pathological tumour stage was 49% (kappa coefficient, 0.23; P?<?0.001). Overstaging occurred in 23.4%, and understaging occurred in 24.7%. Accuracy in predicting lymph node metastases was 54% (kappa coefficient, 0.04; P?=?0.297). Overstaging and understaging occurred in 8.3 and 29.4%, respectively. Significantly more ileal conduits were performed in patients with high postoperative pathological tumour stages (P?=?0.04) and positive lymph nodes (P?=?0.013). In contrast, there was no correlation between preoperative CT tumour/nodal stage and the number of removed lymph nodes (P?=?0.44 and P?=?0.732, respectively), and between preoperative tumour stage and type of urinary diversion (P?=?0.126).

Conclusions

MDCT as a preoperative staging procedure has a low accuracy in predicting the correct tumour and nodal stage, and therefore, it has little impact on decision-making for local treatment of muscle-invasive bladder cancer during radical cystectomy.     

Lifestyle After Bariatric Surgery: a Multicenter, Prospective Cohort Study in Pregnant Women

Background

To ensure a good pregnancy outcome after bariatric surgery, a healthy life-style and a multidisciplinary prenatal follow-up is recommended. The aim of this prospective multicenter trial was to compare diet quality and physical activity (PA) of pregnant women with bariatric surgery with current lifestyle recommendations.

Methods

Pregnant women (>18?years, prepregnancy BMI 28?±?6?kg/m2, 39?% nulliparae, 25?% smokers) with a history of bariatric surgery were recruited and allocated to two groups according to surgery type: restrictive (N?=?18) and bypass group (N?=?31). One 7-day dietary record and one Kaiser questionnaire on PA were collected during the first and second trimester. Dietary quality was assessed using the Healthy Eating Index.

Results

The diet quality did not change during pregnancy (restrictive group p?=?0.050; bypass group p?=?0.975) and was comparable between groups (first trimester p?=?0.426; second trimester p?=?0.937). During the first trimester, 15?% of the pregnant women had a healthy diet quality, 82?% had a diet that needed improvement, and 3?% had a poor diet quality. This was independent of surgery type and was comparable in the second trimester (p?=?0.525). No difference between groups was observed for the PA level, but the PA level in the bypass group significantly decreased from the first to the second trimester (p?=?0.033).

Conclusions

Nutritional advice and lifestyle coaching in this high-risk population seems recommendable since only 15?% of the pregnant women had a healthy diet quality, 25?% was smoking at the beginning of pregnancy, and the reported PA levels were low.     

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.     

Laparoscopic and robotic partial nephrectomy without renal ischaemia for tumours larger than 4?cm: perioperative and functional outcomes

Purpose

To evaluate the technical feasibility, safety and functional outcomes of zero ischaemia laparoscopic and robotic partial nephrectomy with controlled hypotension for renal tumours larger than 4?cm.

Methods

We evaluated 121 consecutive patients with American Society of Anaesthesiologists (ASA) scores 1–2 who underwent laparoscopic (n?=?70) or robotic (n?=?51) partial nephrectomy with controlled hypotension with either tumour size ≤4?cm (group 1, n?=?78) or tumour size >4 cm (group 2, n?=?43) performed by a single surgeon from December 2010 to December 2011. Operative data, complications, serum creatinine, estimated glomerular filtration rates and effective renal plasma flow calculated from 99mTc-mercaptoacetyltriglycine renal scintigraphy were compared. Differences between groups were evaluated by the Chi-square test and the Student’s t test.

Results

A significant difference in mean intraoperative blood loss and postoperative complications was found between the two groups: 168?ml (range: 10–600?ml in group 1) and 205?ml (range: 90–700?ml in group 2); p?=?0.005, and 6.4?% versus 18.6?%; p?=?0.004, respectively. The mean percentage decrease of ERPF of the operated kidney was 1.8?% in group 1 and 4.1?% in group 2.

Conclusions

Laparoscopic and robotic partial nephrectomy with controlled hypotension for tumours >4?cm in ASA 1–2 patients was feasible with significant higher intraoperative blood loss and postoperative complications compared to smaller renal masses. The benefits of avoiding hilar clamping to preserve kidney function seem excellent.     

Ergonomic and geometric tricks of laparoendoscopic single-site surgery (LESS) by using conventional laparoscopic instruments

Background

The aim of this study was to explore the feasibility and safety of performing laparoendoscopic single-site surgery (LESS) with conventional laparoscopic instruments.

Methods

We retrospectively reviewed our data from 175 patients who underwent various urological LESS procedures via the same ergonomic and geometric principles between 2008 and 2011. LESS procedures performed included adrenalectomy (N?=?23), radical nephrectomy (N?=?5), radical nephroureterectomy with bladder cuff resection (N?=?5), varicocelectomy (N?=?12), nephropexy (N?=?4), lumbar sympathectomy (N?=?4), orchiectomy for intra-abdominal testis (N?=?1), pyeloureterostomy (N?=?1), dismembered pyeloplasty (N?=?1), and adult inguinal hernia mesh repair (N?=?119).

Results

All procedures were completed successfully without the use of ancillary ports or articulating instruments except two cases that required laparoscopic conversion. The mean patient age was 48.9?years. Mean operative time was 99.7?min, mean estimated blood loss was 17.3?ml, and mean hospital stay was 2.1?days. There were no intraoperative complications.

Conclusion

According to our ergonomic and geometric principles, use of conventional laparoscopic instruments is feasible and safe in LESS procedures.