Factores pronósticos tras resección hepática de metástasis hepáticas de cáncer colorrectal

Introduction

There are many studies that analyse preoperative factors with a poor prognosis in patients undergoing surgery for colorectal carcinoma liver metastases, in order to avoid unnecessary surgery. However, there are few studies that evaluate the intraand postoperative prognostic factors. The aim of this study is to analyse pre-, intra- and postoperative prognostic factors in a series of 210 patients undergoing surgery for colorectal carcinoma liver metastases, with special emphasis on the postoperative factors that can give us information on the aggressiveness of the tumour and the curative effectiveness of the surgery.

Patients and method

Between September 1996 and December 2006, 210 patients undergoing surgery for colorectal carcinoma liver metastases in whom we analysed pre-, intra- and postoperative factors of survival. Mean follow-up was 55 ± 3 months (range: 12-124 months).

Results

The postoperative mortality rate was 1.4% and the morbidity rate was 22%. Actuarial and disease-free survival at 1-, 3- and 5-years was 89.9% vs 63%, 66.9% vs 32%, and 53.8% vs 23%, respectively. Among the preoperative factors analysed, the age > 65 years and LM size > 5 cm were independent predictors of poor overall survival, whereas the other two significant factors were obtained from those analysed postoperatively: presence of microsatellitosis and postoperative CEA levels (at 1 and 3 months).

Conclusions

In patients with colorectal carcinoma liver metastases we must take into account certain postoperative factors that can give us information on the aggressiveness of the tumour and the effectiveness of the surgery.     

Estudio prospectivo, aleatorizado: cirugía laparoscópica con asistencia robótica versus cirugía laparoscópica convencional en la resección del cáncer colorrectal

Introduction

Robotic-assisted surgery is playing an increasingly important role in the last few years in the treatment of colorectal oncological disease. However, there are still no studies that objectively demonstrate the advantages of this type of surgery.We present a prospective randomised study in order to compare the short-term results between colorectal robotic surgery and laparoscopic surgery.

Material and method

A total of 56 patients diagnosed with colorectal cancer between January 2008 and January 2009, were randomised and assigned to the robotic or laparoscopic group. Age, body mass index, tumour location, conversions in each group, complications during and after surgery, and histological characteristics of the specimens obtained, were all compared.

Results

There were no significant differences between age (P=.055), body mass index (P=.12), or tumour location (P=.91). Only one patient in the robotic group required a transfusion and none in the laparoscopic group. The percentage of conversions was the same in both groups, however, the preparation times and operating times were significantly longer in patients intervened using the robotic device (P=.0001 and P=.017, respectively). There were no differences as regards the rate of complications or in the percentage of re-interventions (14.2% and 7.1%). The mean hospital stay of the patients was 9.3 (8.1) days in the robotic group and 9.2 (6.8) days in the laparoscopic (P=.79). The distal resection margin was greater in the specimen obtained using robotic surgery (P =.003) as well as the number of lymph nodes obtained in the specimen (P =.23).

Conclusion

Robotic colorectal was performed safely and effectively, and with similar clinical results.International Trial Number for this study is: ISRCTN60866560.     

Nueva técnica de proctectomía trasanal con escisión total del mesorrecto totalmente robótica en el tratamiento del cáncer de recto

Anterior resection with total mesorectal excision is the standard method of rectal cancer resection. However, this procedure remains technically difficult in mid and low rectal cancer. A robotic transanal proctectomy with total mesorectal excision and laparoscopic assistance is reported in a 57 year old male with BMI 32 kg/m2 and rectal adenocarcinoma T2N1M0 at 5 cm from the dentate line.     

Mamoplastia de reducción en la cirugía del cáncer de mama

Reduction mammaplasty techniques enable the breast cancer surgeon to provide an integral surgical treatment, thus significantly increasing and improving surgical options. These techniques are used to correct problems after the conservative treatment of type 1 breast cancer and to achieve symmetry between the breasts after mastectomy. They are also the basis of cosmetic reconstruction techniques in conservative oncoplastic surgery.     

La resección laparoscópica de los segmentos del lóbulo hepático izquierdo debe ser el abordaje inicial en centros con experiencia

Introduction

The resection of tumours of the anatomical left lobe is normally straightforward using either left lateral sectionectomy (LLSEC) or segmentectomy II or III. Our objective is to present the results of the laparoscopic approach and to consider whether this could be the “ideal technique” in liver surgery units where the surgeons have experience of laparoscopic liver surgery (LLSURG).

Patients and methods

We have studied patients with resected solid tumours of the anatomical left lobe using LLSURG (n=18): 10 cases with LLSEC and 8 cases with segmentectomy II or III. We carried out a comparative study with a control group of 18 patients operated on using the same surgical technique using open surgery (OS).

Results

There were no cases of mortality in either of the 2 groups (n=36). Morbidity was similar (5.5% per group). For LLSEC, the LLSURG group (n=10) had a shorter hospital stay (p=0.005) and less surgical time (141 vs. 159 min) (differences not significant.), than the OS group. For segmentary resections II or III, in the LLSURG group (n=8) there was greater use of the Pringle manoeuvre (p=0.05), greater surgical time (p=0.05) and a shorter hospital stay (4.8 vs. 5.6 days) (differences not significant), than in the OS group.

Conclusions

LLSEC should be carried out by laparoscopy in centres where they have considerable experience. The patients may have a shorter hospital stay and spend less time in surgery than when OS is performed, with the same morbidity and mortality rates. Segmentectomy resections II or III carried out by laparoscopy involve a shorter hospital stay but longer surgery time and therefore the advantages are not as evident as they are for LLSEC.     

Implicaciones pronósticas del estudio estandarizado de los márgenes de resección en el cáncer de páncreas

Introduction

Involvement of surgical resection margins is a fundamental prognostic factor in pancreatic oncological surgery. However, there is a lack of standardized histopathology definition. The aims of this study are to investigate the real rate of R1 resections when surgical specimens are evaluated according to a standardized protocol and to study its survival implications.

Patients y methods

One hundred consecutive surgically resected patients with pancreatic ductal adenocarcinoma were included in the study. They were further divided in 2 groups: pre-protocol, evaluated before the introduction of the standardized protocol and post-protocol, analyzed with the standardized protocol.

Results

R0 resection rate in the pre-protocol group was 78%, falling to 47% after the introduction of the standardized protocol (p = 0,003). The posterior retroperitoneal margin was the most frequently involved margin. In cases with tumors located at the pancreatic head and analyzed according to the standardized protocol R1 involvement negatively affected survival. Median survival in the R0 group was 22 months versus 16 in those with the margin involved (HR: 2.044; IC 95% 1,00-4,16; P=.043).

Conclusions

Standardized evaluation of the retroperitoneal margins in pancreatic cancer increases the rate of R1 patients. In cases with pancreatic cancer located at the pancreatic head involvement of posterior retroperitoneal margin significantly decreases survival.     

Aprendizaje de la cirugía del cáncer de recto por laparoscopia sin aumento de la morbimortalidad

Introduction

The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis.

Objective

Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumour location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins.

Results

Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins.

Conclusions

It is possible to learn this complex surgical technique without compromising the patient's safety and oncological outcome.     

Cirugía radical en el cáncer de vesícula incidental: valor del hallazgo de enfermedad residual en el estudio histopatológico diferido

Background

Surgical treatment of gallbladder cancer is still controversial. The extent of the radical surgery and its therapeutic efficacy continue to be debated.

Objective

Analyze the efficacy of radical resection in patients with incidental gallbladder cancer evaluating the presence of residual disease in the resection specimen and analyzing the associated factors of survival.

Methods

A retrospective analysis of patients with incidental GC between June 1999 and June 2010 was performed. Incidental (I) tumors were included. Data covering demographic features, clinical characteristics, local pathological stage, histological features and factors for long term survival were analyzed. p< 0.05 were considered significant.

Results

A total of 28 patients: 78,6% females. Median age 56 years. All treated by resection of segments 4b/5 and lymphadenectomy. Histological examination revealed residual disease in 42% (37% liver), residual disease was related to tumoral (T) stage (p 0,001). Patients with residual disease presented a DSS and DFS of 10 and 6.5 months respectively vs 56 months in those without residual disease (p 0,001). Variables associated with survival were T stage (P .006), TNM stage (P<.001), and residual disease in the resected specimen (P<.001).

Conclusions

Aggressive re-resection of incidental GC offers the only chance for cure but its efficacy depends on the extent of the disease found at the time of repeated surgery and in the deferred pathological study.     

Cáncer gástrico por laparoscopia: análisis de los datos del Registro Nacional de Cirugía Gástrica por Laparoscopia

Objective

To study the data from the Laparoscopic Gastric Surgery Spanish National Register of laparoscopic Gastric Surgery and to analyse the type of surgery, the conversion to laparotomy, postoperative complications and mortality.

Patients and Method

From March 2005 to July 2008, details of 302 laparoscopic gastric surgical interventions were sent to the Association of Spanish Surgeons web-site. Details of surgical technique, reconversion, clinical and pathological data, morbidity and mortality were collected and analysed.

Results

A total of 245 patients had gastric adenocarcinoma, 35 of them stromal tumours and 22 other gastric pathologies. In gastric adenocarcinoma patients, resection was performed in 232 cases (95%). The most frequent histology was intestinal, mainly located in the distal third of the stomach, with 34% of the tumours being locally advanced. D2 lymphadenectomy was performed in 117 cases, D1 in 105, and D0 in 6. Reconversion was needed in 21 cases (9%), with technical difficulty being the most frequent cause . Postoperative complications were reported in 72 patients (31%), with anastomotic leak being one of the most significant. Postoperative mortality was 6%, with sepsis due to anastomotic leak and cardiac or respiratory complications the most frequent causes. The mean hospital stay of patients without complications was 9.2±3 days.

Conclusions

Laparoscopic gastrectomy for gastric cancer is a feasible but technically demanding procedure. Potential benefits of minimal invasive surgery can be reduced due to a high rate of postoperative complications.     

Técnicas oncoplásticas para el manejo de tumores centrales de mama

Central tumors of the breast are in a difficult location for breast conservation that in many occasions had resulted in mastectomy. At the present time, the use of oncoplastic techniques have increased conservative management in this group of women, with an adequate oncological resection and good aesthetic results being achieved. This article describes oncoplastic procedures for the removal of breast central tumors with special interest in conservation and reconstruction of the areola-nipple complex.     

Resultados tras resección hepática laparoscópica: una opción adecuada en patología maligna

Introduction

The laparoscopic approach is not yet widely used in liver surgery, but has proven to be safe and feasible in selected patients even in malignant disease. The experience and results of a hepato-pancreato-biliary (HPB) surgery unit in the treatment of malignant liver disease by laparoscopic approach is presented.

Material and methods

Between February 2002 and May 2011, 71 laparoscopic liver resections were performed, 43 for malignant disease (only patients with more than one year of follow-up were included). Mean age was 63 years old and 58% of the patients were male. Forty-nine per cent of the lesions were located in segments ii-iii. Thirty segmentectomies were performed, 7 limited resections and 6 major hepatectomies.

Results

The median operative time was 163 min. There were 3 conversions. Five cases (11%) required blood transfusion. The oral intake began at 32 h and the median hospital stay was 6.7 days. There were no reoperations and there was one case of mortality. Nine patients (21%) had postoperative complications. The mean number of resected lesions was 1.2, with an average size of 3.5 cm. All resections were R0. The median survival after resection of colorectal liver metastases (CLM) was 69% and 43.5% at 36 and 60 months, respectively, and 89% and 68% at 36 and 60 months, respectively, in hepatocellular carcinoma (HCC).

Conclusion

The laparoscopic liver resection in malignant disease is feasible and safe in selected patients. The same oncological rules as for open surgery should be followed. In selected patients it offers similar long-term oncological results as open surgery.     

El análisis molecular intraoperatorio (one-step nucleic acid amplification) del ganglio centinela como alternativa al estudio histopatológico diferido en el cáncer de mama: análisis coste-beneficio

Introduction

Intraoperative molecular analysis for sentinel lymph node (SLN) metastases using the OSNA (one-step nucleic acid amplification) method has been already validated in breast cancer. The authors compared the cost of OSNA versus the conventional postoperative histopathologic evaluation in patients with breast cancer.

Methodology

Patients with operable breast cancer and clinically and sonographic negative evaluation of the axilla, and who subsequently were operated on between the 15th of October 2008 and the 15th of December 2009 were included in this retrospective cost-benefit analysis. The SLN was assessed by conventional postoperative histological evaluation in Group 1 (45 patients), and by OSNA in Group 2 (35 patients). The following variables were analysed: age, tumour size, histological type, number of SLNs, biopsy result, duration of surgery, days in hospital, postoperative complications, positive lymph nodes in the case of axillary lymphadectomy, cost per patient, hospitalisation cost, and cost per operation.

Results

The duration of surgery of the first operation in Group 1 was significantly shorter, but the total time was also higher in this group. The mean hospital stay was longer in Group 1 (P < .001). The mean cost of the hospital stay was higher in Group 1 compared to Group 2 (P < .001), with a mean difference of 199.69 €. The mean cost of the surgery was higher in Group 1 (P < .001), with a mean difference of 157.49 €. The mean cost per SLN analysis was significantly higher in Group 1, with a mean difference of 162.5 €. The cost per patient was significantly higher in Group 1 (P < .005). A mean saving of 439.67 € per patient was achieved by using the OSNA method.

Conclusion

Intraoperative molecular analysis for SLN metastases using the OSNA method reduces the number of admission days, duration of surgery, and achieves a saving of 439.67 € per patient.     

Resultados de la esofagectomía por cáncer tras la creación de un Comité de Tumores Esofagogástricos

Introduction

Treatment of oesophageal cancer with curative intent requires a multidisciplinary approach. Neoadjuvant therapy, the radicality of resection and extension of lymphadenectomy have been associated with increased operative morbidity and mortality. The aim of this study was to assess the results of surgical treatment of oesophageal cancer since the presence of an interdisciplinary esophagogastric tumour board.

Methods

Patients with cancer of the oesophagus and oesophagogastric junction who underwent oesophagectomy between January 2005 and March 2012 were included in this retrospective study. Data concerning type of resection, postoperative complications, mortality and survival were analysed.

Results

Of the 392 patients with a diagnosis of oesophageal cancer over the study period, 100 underwent oesophagectomy. Seventy-four patients received neoadjuvant treatment. Eighty-two patients underwent transthoracic resection while a transhiatal was used in 10 patients. Colon interposition was required in 8 cases. An R0 resection was achieved in 98 patients. Anastomotic leaks developed in 15 patients, 9 were intrathoracic and 6 were cervical. Postoperative morbidity occurred in 42% of patients, and intra-hospital and 90-day mortality was 2%. Median length of hospital stay was 16 days. The respective actuarial survival at 1 and 5 years were 82% and 56%.

Conclusions

Surgical treatment with curative intention for oesophageal cancer is only possible in a quarter of patients diagnosed. The high morbidity rate was mainly due to intrathoracic complications.     

Complicaciones del tratamiento de la oclusión del colon distal con prótesis endoluminales

Introduction

The high morbidity and mortality of emergency surgery, has led to the use of endoluminal self-expanding metal implants (stents) in the management of intestinal occlusion.The purpose of this study was to review the results of the management of intestinal occlusion treatment in a Colorectal Surgery Unit in those patients who had a stent implant, and the relationship between chemotherapy and complications.

Material and methods

A retrospective study was carried out on patients treated with a stent in a university hospital between 2004 and 2010.

Results

A total of 93 patients were treated, of which 77 were considered palliative for a stage IV neoplasm of the colon with non-resectable metastases or due to a performance status > 2. Other indications were 7 ASA IV patients with acute renal failure, 6 with benign disease, and 3 due to other causes.The technical and clinical success of the procedure was 93.5% and 78.5%, respectively. Delayed occlusion was 19.3% and perforation 6.4%. There was migration (2.1%) and intestinal bleeding (2.1%) and 1.1% with tenesmus. No significant differences were seen between complications and chemotherapy.The overall mortality was 17.2%.

Conclusions

Stents, as a definitive treatment option in palliative patients with and without chemotherapy, is an alternative treatment that is not exempt from complications. We believe that in patients with mortality risk factors and patients with tumours with non-resectable metastases it could be the initial treatment of choice.     

Irradiación parcial acelerada con multicatéteres en la cirugía conservadora por cáncer de mama

Introduction

Accelerated partial breast irradiation (APBI) with multicatheters after lumpectomy for breast cancer (BC) may be an alternative to whole breast irradiation in selected patients. The aim is to show our 5 year experience.

Method

Between June 2007 and June 2012, 87 BC patients have been evaluated for APBI. Inclusion criteria were: age over 40 years, unifocal tumour, infiltrating ductal or intraductal carcinoma, tumour size smaller than 3 cm and no lymph node involvement. Complications, cosmetic results and local and distant recurrences were evaluated.

Results

Treatment was completed in 48 patients and contraindicated in 39. The average age of treated patients was 59 years. Operating time was 123 min with 9 implanted catheters in each patient. No complications were observed during surgery or radiotherapy. Patients were discharged from hospital after 4 days. Tumour size was 11 mm. Of these, 35 were infiltrating ductal and 13 intraductal carcinomas. A total of 44 patients received adjuvant treatment. Mean follow-up was 22 months with no evidence of local or distant recurrence. The cosmetic outcome was good or excellent in 66% of cases.

Conclusions

APBI with multicatheter placed after lumpectomy for BC is feasible and safe but requires a strict selection of patients.     

Resección hepática por laparoscopia: lecciones aprendidas tras 132 resecciones

Introduction

After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc.

Aim

To report our experience in laparoscopic liver resections (LLRs).

Patients and method

Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS. Surgical technique: 6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections.

Results

There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150 min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively.

Conclusion

LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.     

Estudio prospectivo controlado y aleatorizado sobre la necesidad de la preparación mecánica de colon en la cirugía programada colorrectal

Introduction

Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC.

Material and method

Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into two groups. The “Preparation” group (MPC) received MPC and the “non-preparation” group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models and morbidity-mortality.

Results

Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of “no preparation” as regards morbidity (43.55 % with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis.

Conclusions

Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.     

Inversion of the sequence of surgery after neoadjuvant chemotherapy for synchronous liver metastases from colorectal cancer

In some patients with colorectal cancer and synchronous liver metastases, chemotherapy and current combinations of chemotherapy allow the size of these metastases to be reduced so that they can be surgically resected. However, in many patients, the initial systematic treatment of the primary tumor is associated with growth of the metastases (which predict the patient's life expectancy). This metastatic growth contraindicates surgical treatment that might otherwise be curative. We report the case of a patient with advanced recto-colonic cancer, which responded well to chemotherapy given as neoadjuvant treatment prior to surgery, in which the hepatic metastases were resected before excision of the primary tumor.     

Esofagogastrostomía cervical diferida: Una opción técnica cuando se evidencia isquemia del tubo gástrico en el momento de la esofagectomía

Ischemia of the gastric conduit after esophagectomy represents a setback that increases the risk of anastomotic leak. In order to prevent this severe complication, a surgical alternative has been proposed which consists in delaying the reconstruction until gastric perfusion improves. By adopting this strategy we can avoid two other surgical options that may significantly increase the risk of complications: 1) performing an esophagogastrostomy with a poorly perfused gastric tube and 2) resecting the gastric conduit followed by a complex reconstruction.