Radical Surgical Therapy of Abdominal Cystic Hydatid Disease: Factors of Recurrence

A series of 74 consecutive patients (48 women, 26 men) were operated for abdominal hydatid disease between June 1949 and December 1995. The patients ranged in age from 15 to 81 years (median 49 years). In 69 cases only the liver was affected; two patients had concomitant extrahepatic disease (one spleen, one spleen and lung), and 3 had cysts in the spleen only. Cysts were multiple in 11 patients and calcified in 24. Conservative surgical procedures were used for 22 cysts in 20 patients [open partial (n= 3), open total (n= 6), closed total cystectomy (n= 9), marsupialization (n= 2), drainage (n= 2)] and radical surgical procedures for 72 cysts in 54 patients [pericystectomy (n= 41), wedge liver resection or hemihepatectomy (n= 25), splenectomy (n= 5), radical resection of a lung cyst (n= 1)]. Altogether 37 patients (50%) were given perioperative antihelmintic chemotherapy with mebendazole (18 patients) or albendazole (19 patients). Operative mortality rates were 5.0% after conservative surgery and 1.8% after radical surgery. Morbidity rates were 25.0% following conservative surgery and 24.1% following radical surgery. Antihelmintic therapy was well tolerated by all but five patients. All side effects were entirely reversible. Among the 74 patients, 60 (81.0%) were available for long-term follow-up (median 7.2 years; range 2.0–47.0 years). Recurrence of disease was seen in 9 of 60 patients at an interval of 3 months to 20 years from the first operation. The rate of recurrence was significantly lower after radical surgical procedures (p= 0.03) and after closed removal of the cyst (p= 0.04).     

Adrenocortical Carcinoma: Is Prognosis Different in Nonfunctioning Tumors? Results of Surgical Treatment in 31 Patients

From 1980 to 1998 a series of 265 patients with adrenal tumors underwent surgery, with an adrenocortical carcinoma found in 31 (11.7%). Altogether, 17 (54.8%) patients (group A) had Cushing syndrome (n= 15) or virilization (n= 2), and 14 (45.2%) patients (group B) had nonfunctioning adrenal tumors. Tumor staging was as follows: (groups A/B): stage I, n= 5 (3/2), stage II, n= 14 (9/5), stage III, n= 5 (1/4), stage IV, n= 7 (4/3) patients. There were 12 (38.7%) men and 19 (61.3%) women (median age 51 years, range 25–73 years), and the size of the mass ranged from 3.5 to 20.0 cm (median 8.0 cm), with no differences (p= NS) between groups A and B. Two (6.4%) patients (stage IV) did not undergo surgery and received only palliative drug treatment; 6 (19.4%) were treated with debulking surgery; 15 (48.4%) had unilateral adrenalectomy; and 8 (25.8%) had an extended adrenalectomy. Eighteen (58.0%) patients underwent adjuvant postoperative mitotane treatment, and in 8 (25.8%) patients one or more reoperations for recurrence were required. Nine (29.0%) patients are still alive with a mean follow-up of 34 months; 22 (71.0%) died 2 to 60 months (median 20 months) after surgery. The overall 2- and 5-year survival rates were 62.1% and 10.3%, with no difference (p= NS) between groups A and B. The survival rates at the 1- and 3-year follow-ups were 90.3% and 32.3% (stages I and II) and 71.0% and 6.5% (stages III and IV). In conclusion, adrenocortical carcinoma remains a highly malignant tumor, and stage III–IV patients still have a poor prognosis; but nonfunctioning tumors do not seem to be more aggressive.     

Perioperative Blood Transfusion as a Prognostic Indicator in Patients with Hepatocellular Carcinoma

We studied the relation of perioperative blood transfusion and the outcomes in 175 patients with hepatocellular carcinoma (HCC) who underwent hepatic resection from 1986 to 1994 in our hospital. Hepatectomy was performed in 23 (13.1%) patients with and 152 (86.9%) without blood transfusions. The cumulative cancer-free survival rates for patients who had received blood transfusion was significantly lower than that for patients who had not received blood transfusions (p= 0.003). Further examinations revealed a significant difference in cancer-free survival rates for stage I–II patients (n= 75) of HCC (p= 0.02) but not for stage III–IV patients (n= 56) (p= 0.06). Cox regression analysis for recurrence revealed that blood transfusion was the most significant prognostic indicator (p= 0.001) for recurrence in stage I–II patients but not in stage III–IV patients (p= 0.99). These results suggest that a perioperative blood transfusion may be a significant prognostic indicator for patients with HCC who had underwent hepatectomy, especially in stage I–II patients of HCC.     

Reoperative Surgery for Organic Hyperinsulinism: Indications and Operative Strategy

n = 3), MEN-I syndrome ( n = 1), and diffuse/nodular hyperplasia ( n = 2). The duration between diagnosis and reintervention ranged from 1 to 10 years. Preoperative diagnosis was able to localize tumors in three patients (computed tomography 1, angiography 2, calcium stimulation 1). Operative procedures were multiple enucleations in two patients with sporadic disease, subtotal resection plus enucleation in the case of MEN-I syndrome, subtotal resection for diffuse hyperplasia, left resection for adenomatosis, and tumor extirpation after multiple previous operations. Long-term clinical and biochemical cure was achieved in five of six patients (mean follow-up 5 years). Octreotide therapy shows good symptomatic control in the patient with operative failure. Reintervention for organic hyperinsulinism is successful (80% cure) and requires preoperative imaging and individual surgical management.     

Thymoma with Dissemination: Efficacy of Macroscopic Total Resection of Disseminated Nodules

Background  Advanced thymomas with disseminated nodules are difficult to manage, and the treatment strategy remains undefined. Methods  A total of 28 thymoma patients with pleural and/or pericardial disseminated nodules were treated at Nagoya City University Hospital. Among them, 21 patients underwent resection of thymoma and pleural disseminated nodules. These patients were reviewed in the present study. Results  Preoperative steroid pulse therapy was performed in 14 patients. Macroscopic total resection of all tumors was achieved in 15 patients. Postoperative adjuvant radiotherapy was performed for the mediastinum in 20 patients and hemithoracic irradiation (HTR) in 11 patients. The overall survival rate of operated 21 patients was 73.1% at 5 years. The patients who underwent resection showed a better prognosis than the patients without resection (p = 0.0006). Relapse was diagnosed in 14 of 21 patients who underwent resection. Disease-free survival was 67.5% at 1 year, 39.8% at 3 years, and 13.3% at 5 years. HTR alone did not improve the disease-free survival. Among the patients who underwent total resection, relapse-free survival was better than in the patients with subtotal resection (p = 0.009). Achievement of a trimodality therapy with preoperative steroid pulse, total resection, and postoperative HTR was associated with prolonged relapse-free survival in the operated patients (p = 0.027, hazard ratio 6.452). Conclusions  Pursuing total resection for thymoma and disseminated nodules may be beneficial for stage IV thymoma. The combination of preoperative steroid pulse therapy, macroscopic total resection, and postoperative HTR may prolong the interval to relapse, but it did not lead to cure.     

Laparoscopic resection of extraperitoneal rectal cancer: a comparative analysis with open resection

Purpose  The aim of this study was to compare the outcomes of laparoscopic surgery with those of open resection in patients with extraperitoneal rectal cancer. Methods  Five hundred forty-four patients with extraperitoneal rectal cancer who underwent curative resection between 1996 and 2007 were included. Patients were divided into a laparoscopic surgery group (LAP, n = 170) and an open surgery group (OPEN, n = 374). Results  Morbidity requiring surgical correction was 5.8% in the LAP group and 4.8% in the OPEN group (p = 0.75). The anastomotic leakage rate was similar in both groups (5.7% in both; p = 0.98). Differences were found in preoperative carcinoembryonic antigen (CEA) (LAP group 4.6 ng/ml, OPEN group 7.7 ng/ml, p = 0.001), sphincter preservation (LAP group 82.9%, OPEN group 69.8%, p = 0.001), and mean distance from anal verge (LAP group 4.6 cm, OPEN group 5.2 cm, p = 0.002). Local recurrence and metastasis were similar by stage. Conclusions  The results of this study show that laparoscopic resection of extraperitoneal rectal cancer was safe and effective.     

Surgical multimodality treatment for baseline resectable stage IIIA-N2 non-small cell lung cancer. Degree of mediastinal lymph node involvement and impact on survival

Objective: Analysis of single centre results and identification of prognostic factors of surgical combined modality treatment in pathological proven stage IIIA-N2 non-small cell lung cancer (NSCLC). Methods: Out of a total of 996 resections for NSCLC between 2000 and 2006, 92 patients with radiological response or stable disease after induction chemotherapy for pathologically proven ipsilateral positive lymph nodes (N2-disease) underwent surgical exploration with the aim of complete resection. Adenocarcinoma and squamous cell carcinomas were equally present (48% vs 43%). Median follow-up of surviving patients (n = 36) was 51 (10–94) months. Results: Complete resection (i.e., tumour with free margins and negative highest mediastinal lymph nodes, R0) was achieved in 68% (n = 63), resection was uncertain or incomplete in 24% (n = 22), while surgery was explorative in 8% (n = 7). Pneumonectomy was performed in 24%, (bi)lobectomy in 62%, and sleeve lobectomy in 13% of patients. In-hospital mortality was 2.3%. Overall need for ICU stay was 18% (30% after pneumonectomy). Median hospital stay was 10 days (6–157). Downstaging of mediastinal lymph nodes (ypN0-1) was found in 43% (n = 40). Overall survival at 5 years (5YS) was 33% (n = 92), and after complete resection 43% (n = 63). Detection of multilevel compared to single level positive nodes at initial mediastinoscopy was related to lower 5YS (17% vs 39%; p < 0.005), and this was identified as an independent prognostic factor in a multivariate analysis of the examined presurgical variables. We found a trend for a better 5YS in patients with mediastinal nodal downstaging compared to patients with persistent N2 disease (49% vs 27%; p = 0.095). In the subgroup with persistent N2 disease, single level disease has a significantly better survival (37% vs 7% 5YS, p < 0.005). Multivariate survival analysis of the examined surgical variables identified completeness of resection and classification of ypN category (ypN0-1 and ypN2-single level vs multilevel-ypN2 and ypN3) as independent prognostic factors. Conclusions: Surgery after induction chemotherapy for stage IIIA-N2 NSCLC can be performed with an acceptable mortality and morbidity. Baseline single level N2 disease is an independent prognostic factor for long-term survival. Patients with mediastinal downstaging, but also a subgroup of patients with single level persistent N2 disease, after induction therapy have a rewarding survival.     

Hyperparathyroidism in multiple endocrine neoplasia type I: surgical trends and results of a 256-patient series from Groupe D'etude des Néoplasies Endocriniennes Multiples Study Group

The French and Belgian GENEM study group's multiple endocrine neoplasia type I (MEN-I) database was used to evaluate trends in clinical presentation, surgical treatment of primary hyperparathyroidism (pHPT) (n= 245), and prognostic factors for hypercalcemia correction among 256 MEN-I cases. The patients were retrieved through the GENEM network from various Belgian and French instititutions with the help of genetics laboratories. Among the 245 pHPT patients (96%), 42% were men. The mean age at the time of diagnosis was 39.5 ± 13.3 years. Trends were studied for three periods: before 1986, from 1986 to 1990, and thereafter. After 1990 MEN-I patients were more often diagnosed with isolated pHPT (8%, 11%, 28%, for the three periods, respectively; p= 0.002); it was seen more often in screened patients (31%, 28%, 53%; p= 0.001), more often among those in already known MEN-I families (64%, 45%, 72%; p= 0.005), and among those with lower preoperative calcemia (2.93, 2.87, 2.79 mmol/L; p= 0.001). The age at pHPT diagnosis remained constant throughout the study. The percentage of cervical explorations dropped during the entire study (87%, 87%, 53%; p < 0.0001). After 1985 the percentage of subtotal parathyroidectomies increased (25%, 59%, 51%; p= 0.0004). Pathology disclosed more hyperplasias (59%, 85%, 74%; p= 0.008). Postoperative hypercalcemia decreased (47%, 15%, 19%; p < 0.0001); and postoperative hypocalcemia increased nonsignificantly (5%, 15%, 15%; p= 0.1). Subtotal parathyroidectomy [odds ratio (OR) 13], no MEN-I family background (OR 3), and the most recent study period (> 1985) (OR 3) were significant predictive factors of hypercalcemia correction according to the multivariate analysis. This is the first multicentric study on the management of MEN-I-related pHPT. Immediate postoperative hHPT cure increased, but only 80% of the operated patients were cured after 1990. Fifteen percent were hypocalcemic. Because MEN-I-related hHPT cure remains difficult to achieve, we advocate that subtotal parathyroidectomies be performed in specialized centers.     

Simultaneous cardiac surgery with pulmonary resection: presentation of series and review of literature

Background: The issue of performing simultaneous pulmonary resection and cardiac surgery in patients with coexisting lung carcinoma and ischaemic heart disease remains controversial. We report our experience and review the literature. Methods: Thirteen patients (male ten, female three; mean age 65 years) underwent simultaneous cardiac surgery and pulmonary resection. Lung pathology consisted of primary lung carcinoma (n=10), benign disease (n=2) and carcinoid (n=1). Lung resections included pneumonectomy (n=3), lobectomy (n=4), segmentectomy (n=1) and local excision (n=5). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 11, aortic valve replacement in one and mitral valve repair with CABG in one patient. In all but one case the lung resection was performed prior to heparinization and cardiopulmonary bypass (CPB). In two patients, with suitable coronary anatomy, myocardial revascularization without CPB was performed to reduce morbidity. Results: There was no hospital mortality. Postoperative blood loss and ventilation requirements were reduced in the patients who were operated on without CPB. Prolonged ventilatory support was required in two cases. All patients with benign pathology are alive. In the lung cancer group there have been five late deaths: disseminated metastatic disease (n=3), anticoagulant related haemorrhage (n=1) and broncho-pleural fistula (n=1). Of the remaining five patients four are alive and disease free 7–23 months post-operatively; one patient has recurrent disease 40 months post-operatively. Conclusions: Simultaneous pulmonary resection and cardiac surgery is associated with acceptable operative morbidity and mortality. In patients with lung carcinoma long-term survival was determined by tumour stage. The avoidance of CPB may be advantageous by decreasing blood loss and ventilation requirements.     

Laparoscopic colectomy for recurrent and complicated diverticulitis: a prospective study of 396 patients

Background It was the aim of this prospective study to evaluate the outcome of laparoscopic surgery for diverticular disease.Methods All patients who underwent elective laparoscopic colectomy for diverticular disease within a 10-year period were prospectively entered into a PC database registry. Indications for laparoscopic surgery were acute complicated diverticulitis (Hinchey stages I and IIa), chronically recurrent diverticulitis, sigmoid stenosis or outlet obstruction caused by chronic diverticulitis. Surgical procedures (sigmoid and anterior resection, left colectomy and resection rectopexy) included intracorporeal dissection and colorectal anastomosis. Parameters studied included age, gender, stage of disease, procedure, duration of surgery, intraoperative technical variables, transfusion requirements, conversion rate, total complication rate including major (requiring re-operation), minor (conservative treatment) and late-onset (post-discharge) complication rates, stay on ICU, hospitalisation, mortality, and recurrence. For objective evaluation, only laparoscopically completed procedures were analysed. Comparative outcome analysis was performed with respect to stage of disease and experience.Results A total of 396 patients underwent laparoscopic colectomy. Conversion rate was 6.8% (n=27), so that laparoscopic completion rate was 93.2% (n=369). Most common reasons for conversion were directly related to the inflammatory process, abscess or fistulas. The most common procedure was sigmoid resection (n=279), followed by anterior resection (n=36) and left colectomy (n=29). Total complication rate was 18.4% (n=68). Major complication rate was 7.6% (n=28), whereas the most common complication requiring re-operation was haemorrhage in 3.3% (n=12). Anastomotic leakage occurred in 1.6% (n=6). Minor complications were noted in 10.7% (n=40), late-onset complications occurred in 2.7% (n=10). Mortality was 0.5% (n=2). Mean duration of surgery was 193 (range 75–400) min, return to normal diet was completed after 6.8 (range 3–19) days. Mean hospital stay was 11.8 (range 4–71) days. No recurrence of diverticulitis occurred.Conclusion Laparoscopic surgery for diverticular disease is safe, feasible and effective. Therefore, laparoscopic colectomy has replaced open resection as standard surgery for recurrent and complicated diverticulitis at our institution.     

Resection Versus Laparoscopic Radiofrequency Thermal Ablation Of Solitary Colorectal Liver Metastasis

Purpose  There is scant data in the literature regarding radiofrequency thermal ablation (RFA) versus resection of colorectal liver metastases. The aim of this study is to compare the clinical profile and survival of patients with solitary colorectal liver metastasis undergoing resection versus laparoscopic RFA. Methods  Between 1996 and 2007, 158 patients underwent RFA (n = 68) and open liver resection (n = 90) of solitary liver metastasis from colorectal cancer. Patients were evaluated in a multidisciplinary fashion and allocated to a treatment type. Data were collected prospectively for the RFA patients and retrospectively for the resection patients. Results  Although the groups were matched for age, gender, chemotherapy exposure and tumor size, RFA patients tended to have a higher ASA score and presence of extra-hepatic disease (EHD) at the time of treatment. The main indication for referral to RFA included technical reasons (n = 25), patient comorbidities (n = 24), extra-hepatic disease (n = 10) and patient decision (n = 9). There were no peri-operative mortalities in either group. The complication rate was 2.9% (n = 2) for RFA and 31.1% (n = 28) for resection. The overall Kaplan–Meier median actuarial survival from the date of surgery was 24 months for RFA patients with EHD, 34 months for RFA patients without EHD and 57 months for resection patients (p < 0.0001). The 5-year actual survival was 30% for RFA patients and 40% for resection patients (p = 0.35). Conclusions  This study shows that, although patients in both groups had a solitary liver metastasis, other factors including medical comorbidities, technically challenging tumor locations and extra-hepatic disease were different, prompting selection of therapy. With a simultaneous ablation program, higher risk patients have been channeled to RFA, leaving a highly selected group of patients for resection with a very favorable survival. RFA still achieved long-term survival in patients who were otherwise not candidates for resection.     

Experiences of laparoscopic liver resection including lesions in the posterosuperior segments of the liver

Background  There is a growing interest in laparoscopic liver resection because of its minimal invasiveness, the increased experience with laparoscopic procedures, and the advances of the laparoscopic devices. The authors describe their experience with laparoscopic liver resection, including its use for lesions in the posterosuperior segments of the liver (segments 1, 7, and 8, and the superior part of segment 4). Methods  A retrospective analysis was performed for the clinical data of 128 patients who underwent laparoscopic liver resection between January 2004 and December 2007. The patients were classified into two groups according to the location of the lesion: the anterolateral (AL) group (n = 92) and the posterosuperior (PS) group (n = 36). Results  The study enrolled 76 men and 52 women with a mean age of 57 years. The indications for resection were hepatocellular carcinoma (n = 57), hepatolithiasis (n = 39), liver metastasis from colorectal cancer (n = 21), and benign liver tumor (n = 11). There were no differences between the groups in terms of preoperative patient demographic characteristics or indications for liver resection. Major liver resection was performed more frequently for the PS group than for the AL group (p < 0.001). The mean operative time and the rate of intraoperative transfusion were significantly greater in the PS group than in the AL group (p = 0.009 and 0.015, respectively). However, the mean postoperative hospital stay and the complication rate were similar in the two groups (p = 0.345 and 0.733, respectively). Four patients underwent conversion to open hepatectomy (3.1%), with no difference in the rate of conversion between the two groups (p = 0.323). The complication rate was 18%, and all the patients were managed conservatively without the need for additional surgery. Conclusions  Laparoscopic liver resection, including that for lesions in the posterosuperior part of the liver, is technically feasible and safe. This study was supported by a grant of the Korea Healthcare Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A060299).     

Borderline Resectable Adrenal Cortical Carcinoma: A Potential Role for Preoperative Chemotherapy

Background

Adrenal cortical carcinoma (ACC) may have tumor or patient characteristics at presentation that argue against immediate surgery because of an unacceptable risk of morbidity/mortality, incomplete resection, or recurrence. This clinical stage can be characterized as borderline resectable ACC (BRACC). At present, systemic therapies in ACC can reduce tumor burden in some patients, creating an opportunity in BRACC for a strategy of preoperative chemotherapy (ctx) followed by surgery.

Materials and Methods

A single-institution retrospective review was conducted of all patients considered for surgery for primary ACC. Patients with BRACC treated with preoperative ctx were categorized as follows: group A, imaging suggesting a need for multiorgan/vascular resection; group B, imaging suggesting potentially resectable oligometastases; and group C, patients having marginal performance status/comorbidities precluding immediate surgery. Both the disease-free survival (DFS) and the overall survival (OS) were compared in BRACC patients treated with preoperative ctx+surgery and those who had upfront surgery.

Results

Fifty-three patients with primary ACC were considered for surgery (median follow-up: 49.9 months). Thirty-eight patients (71.7 %) had initial surgery and 15 of them (28.3 %) were considered BRACC and received preoperative therapy. Of these 15 patients, 12 (80 %) received combination therapy with mitotane and etoposide/cisplatin-based ctx, 2 (13 %) received mitotane alone, and 1 (7 %) received ctx alone. Six patients were defined as group A, 5 as group B, and 4 as group C. Thirteen (87 %) BRACC patients underwent surgical resection. BRACC patients were younger but had more advanced disease than the patients having initial surgery (stage IV in 40 vs 2.6 % [p < 0.01]). By Response Evaluation Criteria In Solid Tumors criteria, 5 patients (38.5 %) had a partial response, 7 (53.8 %) had stable disease, and 1 (7.7 %) had disease that progressed. Postoperative mitotane use was similar between groups (p = .15). Median DFS for resected BRACC patients was 28.0 months [95 % confidence interval (CI), 2.9–not attained] vs 13 months (95 % CI, 5.8–46.9) (p = 0.40) for initial surgery patients. Five-year OS rates were also similar: 65 % for resected BRACC vs 50 % for initial surgery (p = 0.72).

Conclusions

The favorable outcome of patients with BRACC, despite more advanced stage of disease compared to those treated with surgery first, together with uncommon disease progression, suggests a benefit of neoadjuvant treatment sequencing in patients with BRACC.     

Timing of Multimodality Therapy for Resectable Synchronous Colorectal Liver Metastases: A Retrospective Multi-Institutional Analysis

The optimal timing of chemotherapy relative to resection of synchronous colorectal liver metastases (SCRLM) is not known. The objective of this retrospective multi-institutional study was to assess the influence of chemotherapy administered before and after hepatic resection on long-term outcomes among patients with initially resectable SCRLM treated from 1995 to 2005. Clinicopathologic data, treatments, and long-term outcomes from patients with initially resectable SCRLM who underwent partial hepatectomy at three hepatobiliary centers were reviewed. Four hundred ninety-nine consecutive patients underwent resection; 297 (59.5%) and 264 (52.9%) were treated with chemotherapy before and after resection. Chemotherapy strategies included pre-hepatectomy alone (n = 148, 24.7%), post-hepatectomy alone (n = 115, 23.0%), perioperative (n = 149, 29.0%), and no chemotherapy (n = 87, 17.4%). Male gender (p = 0.0029, HR = 1.41 [1.12–1.77]), node-positive primary tumor (p = 0.0046, HR = 1.40 [1.11–1.77]), four or more SCRLM (p = 0.0005, HR = 1.65 [1.24–2.18]), and post-hepatectomy chemotherapy treatment for 6 months or longer (p = 0.039, HR = 0.75 [0.57–0.99]) were associated with recurrence-free survival after discovery of SCRLM. Carcinoembryonic antigen >200 ng/ml (p = 0.0003, HR = 2.33 [1.48–3.69]), extrahepatic metastatic disease (p = 0.0025, HR = 2.34 [1.35–4.05]), four or more SCRLM (p = 0.033, HR = 1.43 [1.03–2.00]), and post-hepatectomy chemotherapy treatment for 2 months or longer (p < 0.0001, HR = 0.59 [0.45–0.76]) were associated with overall survival. Pre-hepatectomy chemotherapy was not associated with recurrence-free or overall survival. Patients treated with perioperative chemotherapy had similar outcomes as patients treated with post-hepatectomy chemotherapy only. We conclude that chemotherapy administered after but not before resection of SCRLM was associated with improved recurrence-free and overall survival. However, prospective randomized trials are needed to determine the optimal timing of chemotherapy.     

<Emphasis Type="Bold">Invited commentary to:</Emphasis> ‘Survival following oncological minimally invasive colorectal procedures’ (Eur. Surg. 2002;34:354–358)

Summary   Background: Since 1992, oncological minimally invasive colorectal procedures are routinely performed at our institution. The aim of this study was to evaluate postoperative survival. Methods: A retrospective analysis assessing postoperative survival following oncological minimally invasive colorectal procedures conducted from March 1992 to September 1998 is presented. Mean postoperative follow-up for all patients was 5.5 years. Results: Minimally invasive colorectal procedures were conducted in 105 patients for treatment of carcinoma of caecum (n=8); ascending (n=21), transverse (n=4), descending (n=7) and sigmoid colon carcinoma (n=30); and rectal carcinoma (n=35). The procedures conducted were ileocaecal resection (n=3), right hemicolectomy (n=26), resection of transverse colon (n=4), left hemicolectomy (n=4), resection of descending colon (n=3), sigmoid resection (n=30), rectal resection (n=26), amputation of the rectum (n=8), and sigmoidostomy (n=1). Postoperative mortality was 1.0 % (n=1). Following 90 curative colorectal resections, local recurrence developed in five patients (5.6 %) and two trocar-site metastases were observed (2.2 %). Mean 5-year survival for stages I–III was 68 % for curative colorectal resections (87 %, 91 % and 28 % for stages I, II and III, respectively,n=83; 44 % vs. 20 % for IIIA vs. IIIB,n=29). Seven patients (8 %) died from tumour-unrelated causes. Mean survival following palliative resections was 10.5 months (n=15). Conclusions: Up to now, in our experience, postoperative survival following minimally invasive colorectal resections is comparable to that following ‘open’ surgery. Additional trials are required in order to compare long-term outcomes.     

Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome

Background: Laparoscopic resection is not an established treatment for tumors of the pancreas. We report our preliminary experience with this innovative approach to pancreatic disease. Methods: Thirty two patients with pancreatic disease were included in the study on an intention-to-treat basis. The preoperative indications for surgery were as follows: neuroendocrine tumors (n=13), unspecified tumors (n=11), cysts (n=2), idiopathic thrombocytopenic purpura with ectopic spleen (n=2), annular pancreas (n=1), trauma (n=1), aneurysm of the splenic artery (n=1), and adenocarcinoma (n=1). Results: Enucleations (n=7) and distal pancreatectomy with (n=12) and without splenectomy (n=5) were performed. Three patients underwent laparoscopic exploration only. Four procedures (13%) were converted to an open technique. One resection was converted to a hand-assisted procedure. The mortality rate for patients undergoing laparoscopic resection was 8.3% (two of 24). Complications occurred after resection in nine of 24 procedures (38%). The median hospital stay was 5.5 days (range, 2–22). Postoperatively, opioid medication was given for a median of 2 days (range, 0–13). Conclusion: Resection of the pancreas can be performed safely via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.     

Nodal Microinvolvement in Patients with Carcinoma of the Papilla of Vater Receiving No Adjuvant Chemotherapy

Background  To assess the prognostic significance of nodal microinvolvement in patients with carcinoma of the papilla of Vater. Methods  From 1993 to 2003 at the University Clinic Hamburg, 777 patients were operated upon pancreatic and periampullary carcinomas. The vast majority of patients were operated upon pancreatic ductal adenocarcinoma (n = 566, 73%), followed by carcinomas of the papilla of Vater (n = 112, 14%), pancreatic neuroendocrine carcinomas (n = 39, 5%), intraductal papillary mucinous neoplasms (n = 33, 4%), and distal bile duct carcinomas (n = 27, 3%). Fresh-frozen tissue sections from 169 lymph nodes (LNs) classified as tumor free by routine histopathology from 57 patients with R0 resected carcinoma of the papilla of Vater who had been spared from adjuvant chemotherapy were immunohistochemically (IHC) examined, using a sensitive IHC assay with the anti-epithelial monoclonal antibody Ber-EP4 for tumor cell detection. With regard to histopathology, 39 (63%) of the patients were staged as pT1/pT2, 21 (37%) as pT3/pT4, 30 (53%) as pN0, while 38 (67%) as G1/G2. Results  Of the 169 “tumor-free” LNs, 91 LNs (53.8%) contained Ber-EP4-positive tumor cells. These 91 LNs were from 40 (70%) patients. The mean overall survival in patients without nodal microinvolvement of 35.8 months (median—not yet reached) was significantly longer than that in patients with nodal microinvolvement (mean 16.6; median 13; p = 0.019). Multivariate Cox regression analysis for overall survival revealed that grading was the most significant independent prognostic factor (p = 0.001), followed by nodal microinvolvement (p = 0.013). Conclusions  The influence of occult tumor cell dissemination in LNs of patients with histologically proven carcinoma of the papilla of Vater supports the need for further tumor staging through immunohistochemistry.     

Comparison of laparoscopic versus open liver tumor resection: a case-controlled study

Background  Although there are data in the literature about the safety and efficacy of laparoscopic liver resections, there are not many studies comparing laparoscopic versus open approaches in a case-matched design. The purpose of this study is to compare the perioperative outcome of laparoscopic versus open liver resections from a single institution. Methods  Thirty-one patients underwent laparoscopic liver resection between April 1997 and August 2007, with a prospective laparoscopic program started in April 2006 (n = 25). This group of patients was compared with 43 consecutive patients undergoing open resection who were matched by size of the lesion (5 cm or less for malignant and 8 cm or less for benign), anatomical location (segments 2, 3, 4b, 5, 6), and type of resection (wedge resection, segmentectomy, partial liver resection). Data were obtained from medical records as well as from a prospective database. Statistical analysis was performed using t-test and chi-square. All data are expressed as mean ± standard error on the mean (SEM). Results  Mean age in the laparoscopic group was 57.6 ± 2.7 years versus 61.9 ± 2.3 years in the open group (p = 0.2). There were more women in the laparoscopic group [74% females (n = 23) and 26% males (n = 8)] versus in the open group [40% females (n = 17) and 60% males (n = 26)] (p = 0.003). There were more patients with malignant lesions in the open group (73%) versus in the laparoscopic group (45%) (p = 0.01). Eight patients underwent partial and 23 patients segmental/wedge liver resection in the laparoscopic group versus 15 patients who underwent partial and 28 patients segmental/wedge liver resection in the open group (p = 0.7). Mean tumor size was 3.9 ± 0.4 cm in the laparoscopic group versus 4.2 ± 0.3 cm in the open group (p = 0.5). Ten (32%) out of 31 cases in the laparoscopic group were hand-assisted. Inflow occlusion was used in 1 case (3%) in the laparoscopic group versus 16 (37.2%) in the open group. Mean operating time was 201 ± 15 min for the laparoscopic group and 172 ± 12 min for the open group (p = 0.1). Mean estimated blood loss during the procedure was 122.5 ± 45.4 cc for the laparoscopic group and 299.6 ± 33.6 cc for the open group (p = 0.002). Surgical margin was similar for malignant cases in both groups. Mean hospital stay was 3.2 ± 1.0 days for the laparoscopic group and 6.8 ± 0.7 days for the open group (p = 0.004). The incidence of postoperative complications was 13% (n = 4) in the laparoscopic and 16% (n = 7) in the open group (p = 0.7). Conclusion  This study shows that, with a longer operative time, the laparoscopic approach, despite the learning curve, offers advantages regarding operative blood loss, postoperative analgesic requirement, time to regular diet, hospital stay, and overall cost compared with the open approach for minor liver resections. A part of this study was presented as a poster at the 2008 SAGES Meeting April 9-12, 2008 in Philadelphia, PA. An erratum to this article can be found at     

Curative Resection of Colorectal Adenocarcinoma: Multivariate Analysis of 5-Year Follow-up

The purpose of this study was to evaluate the influence of clinicopathologic factors on colorectal cancer, especially the age factor. From 1986 to 1992 a total of 2082 cases of colorectal cancers underwent operation in our institution. After exclusion of familial adenomatous polyposis, multiple cancer, Dukes' D stage, and nonadenocarcinoma patients, there were 1124 patients with single colorectal adenocarcinoma who had undergone curative operation; 1110 cases were included in the study after exclusion of surgical mortalities (14 cases, 1.2%). Age distribution ranged from 19 to 91 years (mean 58 years). The patients were divided into three age groups: < 40 years (grade 1), 40–69 years (grade 2), ≥ 70 years (grade 3); other clinicopathologic factors including gender, tumor gross type, location, pathology, and stage were also evaluated in the study. The colonic/rectal cancer ratio was 1.00:1.74, and that of the male/female distribution was 1.00:0.84. The overall 5-year cancer-free rate was 69.9% after curative resection. The young age (< 40 years) patients comprised more women (53.6%) and had a colon location in 41%. Although they had a higher percentage of scirrhous type lesions (1.8%), worse histology (17%), and more advanced stage (49.1%) than the older groups, their survival rate was only slightly lower than the other two groups (67% vs. 70% and 72%, respectively), which was not statistically significant (p= 0.83). By univariate analysis, the factors that influenced the 5-year cancer-free rate were gender (p= 0.031), tumor location (p= 0.003), gross type (p= 0.000), pathology (p= 0.000), and stage (p= 0.001). The independent factors determined for the 5-year cancer-free rate after multivariate analysis were similar to those assessed by univariate analysis. There 5-year survival of colorectal adenocarcinoma was not poorer in young patients. Poor survival factors were male gender, rectal location, scirrhous type, poor and mucinous histology, and advanced stage (Dukes' C) found at curative resection for colorectal adenocarcinoma.     

Prospective randomized study of stress and immune response after laparoscopic vs conventional colonic resection

Methods: In order to evaluate the stress and immunological response to laparoscopic and conventional colon resection we operated on male Wistar rats (350–380 g), performing either laparoscopic (n= 15) or open colon resection (n= 15). A third group (n= 10) underwent anesthesia only. Immediately before and after surgery as well as 1 and 7 days postoperatively a 1 ml sample of blood was taken from the retrobulbar veinous plexus. Stress (corticosterone) and immune parameters (neopterin and interleukin [IL] 1-β) were measured. Furthermore, the body weight as a parameter of postoperative recovery was monitored. Results: The analysis of variance showed significant differences between the three groups over a period of 1 week (p < 0.0001 for corticosterone, p= 0.0854 for IL 1-β, p= 0.0045 for neopterin). Additionally in a t-test significant differences were found between the laparoscopic and conventional group with regard to corticosterone (p= 0.08), to neopterin (p= 0.045), and to IL 1-β (p= 0.0043) at the end of the operation. One week after the operation the stress and immune parameters were back to normal levels in each group except IL 1-β, but the recovery indicated by body weight was different according to the kind of the applied operative procedure: 7 days postoperatively the rats lost 5.99% of their body weight after open surgery and only 2.4% after laparoscopic surgery. After anesthesia only the body weight increased by about 4.8%. Conclusion: Laparoscopic colon resection alters the stress and immune system of healthy rats less than open colon resection. This observation is confirmed by the quicker recovery in laparoscopically operated rats.