Hepatic resection for metastatic cancer.

One-year survival is infrequent in patients with metastatic cancer to the liver. This report includes 21 patients who underwent hepatic resection between 1974 and 1981. Operative procedures included one trisegmentectomy, 12 right hepatic lobectomies, two left hepatic lobectomies, two left lateral segmentectomies, and four wedge resections. Operative morbidity and mortality rates were 43% and 5%, respectively. Life-table analysis revealed an overall 7-year survival rate of 34%. The subset of patients (16) with colorectal adenocarcinoma had a 7-year survival rate of 29% after hepatic resection. In three patients with colorectal adenocarcinoma, frequent CEA determinations were made after surgery in order to calculate the serum half-life of CEA. The data fitted a biexponential function yielding two half-lives for CEA disappearance, 0.8 +/- 0.5 days and 25.9 +/- 10.3 days. We conclude that hepatic resection for isolated hepatic metastases can be performed with acceptable morbidity, low mortality, and prolongation of patient survival.     

The preoperative assessment and postoperative surveillance of patients with colon and rectal cancer

Many advances have been made in the field of colorectal cancer follow-up since the pioneering efforts of Wangensteen and others with second-look operations in the 1950s. The understanding of the biology and natural history of colorectal malignancy has been advanced. Diagnostic methods for detection of recurrent disease have also advanced tremendously with CEA monitoring, immunoscintigraphy. CT, MRI, and PET imaging. As has been discussed in this article, however, no strategy of postoperative follow-up has been shown unequivocally to produce improved survival benefit or cure rate. It is quite possible that benefit will be shown, but well-controlled trials will be required. Cost considerations will likely prove important, because the rate of detection of curable disease will likely.be low. Quality of life issues will also be important in such trials. Better treatment and outcome ol recurrent disease would provide a strong rationale for vigorous postoperative surveillance. New recommendations are currently evolving [54]. Early diagnosis seems likely to enhance the curability of both local and distant relapses and second primary tumors. Furthermore, there may be a survival and quality of life advantage that results from the early institution of chemotherapy, even for those tumors found to be inoperable [55]. In devising a plan for follow-up in patients, it is important to recognize the anatomic and temporal patterns of recurrence as well as their relationships to the initial tumor staging. Although there is little proof that the identification of recurrent disease in follow-up programs increases the likelihood of resectability, cure, or prolonged survival, many physicians have witnessed successful treatment of recurrent colorectal cancer. These anecdotal experiences, the unproven belief that follow-up is beneficial, and traditions imparted during training are among the likely motivating factors for most physicians caring for colorectal cancer patients.     

Hepatic resection for recurrent metastatic ovarian cancer

BACKGROUND: The role for liver resection in metastatic ovarian cancer has not been defined. The aim of the current study was to investigate the validity of hepatic resection as a treatment option in metastatic ovarian cancer. METHODS: Retrospective review of a single institution's experience of patients undergoing hepatic resection for metastatic ovarian cancer from 1998-2006. RESULTS: Ten patients underwent resection for metastatic ovarian cancer. Primary tumor type included serous cystadenocarcinoma (n = 8), granulosa cell (n = 1), and yolk sac (n = 1). Median disease-free interval was 48 months. Liver resections included trisegmentectomy (n = 4), lobectomy (n = 4), and bisegmentectomy(n = 1). Additional surgeries included diaphragm resection (n = 60), bowel resection, (n = 30), and adrenalectomy (n = 10). The median overall survival following liver resection was 33 months. CONCLUSION: Liver resection for metastatic ovarian cancer is safe and is associated with long-term survival in some patients. Larger analysis may lead to the identification of prognostic factors associated with improved outcomes.     

An experimental evaluation of three preoperative radiation regimens for resectable rectal cancer

Background We investigated the degree of tumor cell killing after radiotherapy regimens commonly used in clinical practice in comparison with an accelerated schedule. Methods Mtln3 mammary adenocarcinoma tumor cells were inoculated subcutaneously in the hind leg of syngeneic Fischer 344 rats. Tumors were irradiated with 5×5 Gy in 5 days, 10×3 Gy over 10 days, or 5×(2×3) Gy in 5 days. After excision of the irradiated tumors, the dye exclusion, a tetrazolium-based colorimetric and the clonogenic assays were used to determine tumor cell viability and surviving fractions. Results Estimated potential doubling time values indicate a rapid proliferation capacity, comparable with potential doubling time values in human rectal cancer. The dye exclusion and clonogenic assays revealed a significantly higher degree of cell killing after the hypofractionated and the accelerated regimens of, respectively, 5×5 Gy and 5×(2×3) Gy over 5 days compared with 10×3 Gy over 10 days. Conclusions A shorter treatment time offered the best therapeutic efficacy. The schedule involving two daily fractions of 3 Gy over 5 days should be less toxic than 5×5 Gy and may therefore provide a therapeutic advantage.     

Hepatic resection for metastatic disease

Hepatic resection for metastatic disease is reviewed in 30 patients (mean age 58.9 years). The primary site was the colorectum in 25; the other primary tumours were leiomyosarcoma, plasmacytoma, and adenocarcinoma (all of gastric origin), ocular melanoma and an unknown primary. Operative procedures included 7 wedge resections, 5 segmentectomies and 21 lobectomies (11 right, 4 extended right and 6 left). Major complications in seven patients included intraoperative hemorrhage in three, two of whom died, bile-duct injury in two, small-bowel infarction in one and cerebrovascular accident in one. Operative death rate was 6.7% (2 of 30). Thirteen patients were alive and free of disease a mean of 24 months after hepatic resection while 5 more were alive with disease at a mean of 36.9 months. Life-table analysis projected a 5-year survival of 50.3% for those with colorectal primaries, with no apparent difference in survival between patients with single (55.0%) and multiple (54.0%) metastases. Improved survival was projected for patients with metachronous (66.6%) versus synchronous (45.0%) tumours, primary Dukes' class A or B (66.1%) versus Dukes' class C (46.0%) tumours and those having wedge resection or segmentectomy (66.6%) versus lobectomy or extended lobectomy (48.0%). Hepatic resection for metastatic disease can be done with acceptable morbidity and mortality and the expectation of substantially prolonged survival particularly in patients with metachronous lesions or Dukes's A or B colorectal primary lesions.     

The postoperative surveillance of patients with colon cancer and rectal cancer

BACKGROUND: Colon cancer is relatively common; however, the results of treatment have marginally improved over the last half century. Though about 85% of patients have colorectal tumors resected with curative intent, a significant number of these patients will eventually die from cancer. As a result, many clinicians have advocated intensive follow-up in such patients as an attempt to increase survival. DATA SOURCES: A review of the literature focusing on studies that have specifically addressed postoperative surveillance programs in patients with colorectal cancer was conducted. Only studies with level A evidence were included. Further references were obtained through cross-referencing the bibliography cited in each work. CONCLUSION: One of the six prospective randomized studies demonstrated a statistically significant survival benefit. Undoubtedly, survival benefits can be shown with a well-designed evidence-based follow-up strategy. However, well-designed large prospective multi-institutional randomized studies are needed to establish a consensus for follow-up.     

多模态超声参数术前评估与直肠肿瘤术后病理结果的对比分析

目的:探讨直肠肿瘤的多模态超声参数术前评估与术后病理结果的差异。方法:选取2020年1月—2022年4月在我院治疗的直肠占位病变患者100例,术前接受经直肠超声(ERUS)、剪切波弹性成像(SWE)和超声造影(CEUS)检查,分析直肠恶性与良性病灶的ERUS、SWE和CEUS参数差异,同时用ERUS、SWE和CEUS参数构建Logistic回归方程预测直肠恶性病灶的价值。结果:恶性病灶最大径、血流峰值流速和阻力指数高于良性病灶[(4.20±1.00)cm、(25.12±3.81)cm/s和(0.80±0.14)vs(3.18±0.98)cm、(16.60±4.11)和(0.66±0.12)cm/s],差异有统计学意义(P＜0.05);恶性病灶内部回声不均匀、血流信号丰富、形态不规则和边缘模糊高于良性病灶[72.15%、75.95%、64.56%和72.15% vs 33.33%、14.29%、23.81%和47.62%],差异有统计学意义(P＜0.05)。恶性病灶平均杨氏模量(Emean)、最大杨氏模量(Emax)和最小杨氏模量(Emin)高于良性病灶[(81.19±15.53)kPa、(110.20±23.32)kPa和(61.18±15.02)kPa vs (51.14±11.40)kPa、(70.05±21.05)kPa和(36.60±11.68)kPa],差异有统计学意义(P＜0.05)。恶性病灶上升时间(RT)、达峰时间(TTP)和平均渡越时间(mTT)短于良性病灶[(6.22±1.34)s、(8.78±1.82)s和(14.65±2.34)s vs (9.10±1.32)s、(12.21±2.01)s和(18.82±2.51)s],差异有统计学意义(P＜0.05),造影剂呈“快进快出”比例高于良性病灶[70.89% vs 28.57%],差异有统计学意义(P＜0.05)。EURS、SWE、CEUS参数构建Logistic回归方程,该方程预测直肠恶性病灶的ROC曲线下面积为0.892(95%CI:0.828～0.956),灵敏度和特异度分别为83.50%和76.20%。结论:构建多模态超声参数在鉴别直肠恶性病灶方面有较好的应用价值,值得进一步研究。     

Hepatic resection for primary and metastatic tumors

Thirty-four hepatic resections were performed on 33 patients. These included 4 trisegmentectomies, 14 lobectomies, 7 segmentectomies, and 9 wedge resections. Twenty patients had metastatic colorectal cancer, 4 had a primary liver tumor, 2 had giant cavernous hemangioma, 1 had metastatic leiomyosarcoma, 5 had various benign lesions including focal nodular hyperplasia, and 1 patient had resection for trauma. Operative morbidity included four subphrenic abscesses, one bile leak, one bile duct injury, one case of cholestasis, and one case of phlebitis. There were no operative deaths. The median survival of the patients with metastatic colorectal cancer was 40 months, and the 5-year actuarial survival rate was 35 percent. Survival rates were not significantly different between patients with a solitary metastasis and those with multiple lesions and was not influenced by size of the metastases. However, survival was significantly better in patients whose primary colorectal lesion was Dukes' B as compared with those whose lesion was Dukes' C. The results indicate that liver resection can be performed safely with acceptable morbidity and improved long-term survival.     

手助腹腔镜直肠癌根治术的优势与评价

手辅助腹腔镜手术作为腹腔镜手术的重要组成部分,近年来在直肠癌根治手术中的应用越来越多.虽然其手术步骤与全腹腔镜手术大概一致,但由于腹腔内有灵敏触觉的手存在,因此兼顾了微创腹腔镜和开放手术的优势.手辅助腹腔镜直肠癌手术具有学习曲线短、中转开腹率低、手术时间短、适应证广等优点,并且可以快速有效控制出血等术中意外的发生,提高了手术的安全性.手虽然给腹腔镜直肠癌手术带来许多便利,但同时也会占据腹腔内的有限空间,造成腹腔内气腹严密性减低,术者的辅助手易疲劳等缺点.     

腹腔镜直肠前切除术后并发症及其相关因素分析

目的分析腹腔镜直肠前切除术后并发症发生率及其相关危险因素,进一步预防术后并发症的发生。方法回顾性分析解放军总医院普通外科2013年1月至2016年6月间施行腹腔镜直肠前切除术的663例病人的临床资料,观察术后并发症发生情况,对发生术后并发症的危险因素进行分析,分析并发症组与无并发症组临床资料的差异性。结果全组663例病人出现并发症76例(11.5%);单因素分析显示:病人的性别、肥胖、术前合并症、肿瘤位置、淋巴结清扫数目、TNM分期、手术时间与腹腔镜直肠前切除术后并发症相关(P0.05)。多因素回归分析显示:性别(OR=2.120,95%CI:1.150~3.909)、术前合并症(OR=2.618,95%CI:1.483~4.621)、肿瘤位置(OR=10.338,95%CI:5.672~18.842)、TNM分期(OR=3.111,95%CI:1.774~5.457)是影响术后并发症发生的独立危险因素(均P0.05)。结论性别、术前合并症、肿瘤位置、TNM分期是腹腔镜直肠前切除术后并发症发生的危险因素,腹腔镜直肠前切除术后并发症以吻合口瘘常见。     

Preoperative evaluation and postoperative follow-up for patients with rectal cancer

Rectal cancer has a wide variety of presentations. In most cases, it is the surgeon who is faced with the challenge of determining the extent of disease and advising the patient how to proceed with treatment. Utilizing diagnostic tests of the highest accuracy and relevance will help in the selection of the best initial therapy, which is critical for achieving the highest cure rate while also avoiding over-treatment and unnecessary morbidity. Following curative treatment, surveillance testing for detection of recurrence is traditionally done, but the efficacy of this practice has been questioned. Surveillance will detect a number of asymptomatic recurrences that are treatable by potentially curative salvage surgery, but to what extent early detection improves salvage therapy is not well established. In this brief review, the goals, methods, and expected benefits of rectal cancer staging and surveillance are assessed.     

Risk factors for anastomotic leakage after resection for rectal cancer

Background

Controversy still exists concerning the impact of patient and tumor characteristics on anastomotic dehiscence after resection for rectal cancer.

Methods

Between January 1986 and July 2006, 472 patients underwent curative rectal resection. Patient and tumor characteristics, details of treatment, and postoperative results were recorded prospectively. Univariate and multivariate analysis were applied to identify risk factors for anastomotic leakage.

Results

In our patients, the anastomotic leak rate was 10.4% (49 of 472 patients), and mortality was 2.2% (1 of 49 patients). In univariate analysis, tumor diameter and absence of a protective stoma were associated with increased anastomotic leak rate, whereas American Society of Anesthesiologists (ASA) score and tumor localization showed borderline significance. In multivariate analysis, tumor diameter, tumor localization, and absence of a protective stoma were significantly associated with anastomotic leakage.

Conclusions

Patients with large and low lying rectal tumors are at high risk for anastomotic leakage. A protective stoma significantly decreases the rate of clinical leaks and subsequent reoperation after low anterior resection.