Effect of being overweight on postoperative morbidity and long‐term surgical outcomes in proximal gastric carcinoma1

Background and Aim: The prevalence of being overweight has risen remarkably in Korea. This study sought to clarify the relationship between being overweight and surgical outcomes in gastric cancer patients. Methods: A total of 410 patients who underwent curative total gastrectomies with D2 dissection from January 2000 to December 2003 were retrospectively studied from a prospectively designed database. The patients were assigned to two groups based upon their body mass index (BMI): non‐overweight, BMI < 25 kg/m²; overweight, BMI ≥ 25 kg/m². Perioperative surgical outcomes, postoperative morbidity, mortality, recurrence, and prognosis were analyzed. Results: The overweight group had longer operation time and more postoperative complications than the non‐overweight group. The two groups were similar in terms of transfusion volumes, postoperative bowel movement, time to initiation of a soft diet, and postoperative hospital stay. Patterns of recurrence and cumulative survival rates were similar for each group. Multivariate analysis showed that being overweight was not a risk factor for recurrence or poor prognosis. Conclusion: Although being overweight was associated with increased operation time and higher risk of complications in gastric cancer patients undergoing curative total gastrectomy, it had no effect on recurrence or long‐term survival.     

Surgical management of patients with bowel obstructions secondary to gastric cancer

AIM: To assess whole-body fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in the management of small bowel obstructions (SBOs) secondary to gastric cancer and its role in treatment strategies. METHODS: The medical records of all of the patients who were admitted for an intestinal obstruction after curative resection for gastric cancer were retrospectively reviewed. PET/CT was performed before a clinical treatment strategy was established for each patient. The patients were divided into 2 groups: patients with no evidence of a tumor recurrence and patients with evidence of a tumor recurrence. Tumor recurrences included a local recurrence, peritoneal carcinomatosis or distant metastases. The primary endpoint was the 1-year survival rate, and other variables included patient demographics, the length of hospital stay, complications, and mortality. RESULTS: The median time between a diagnosis of gastric cancer and the detection of a SBO was 1.4 years. Overall, 31 of 65 patients (47.7%) had evidence of a tumor recurrence on the PET/CT scan, which was the only factor that was associated with poor survival. Open and close surgery was the main type of surgical procedure reported for the patients with tumor recurrences. R0 resections were performed in 2 patients, including 1 who underwent combined adjacent organ resection. In the group with no evidence of a tumor recurrence on PET/CT, bowel resections were performed in 7 patients, adhesiolysis was performed in 7 patients, and a bypass was performed in 1 patient. The 1-year survival curves according to PET/CT evidence of a tumor recurrence vs no PET/CT evidence of a tumor recurrence were significantly different, and the 1-year survival rates were 8.8% vs 93.5%, respectively. There were no significant differences (P = 0.71) in the 1-year survival rates based on surgical vs nonsurgical management (0% with nonoperative treatment vs 20% after exploratory laparotomy). CONCLUSION: 18 F-FDG PET/CT can be used to identify the causes of bowel obst     

Radiofrequency ablation-assisted liver resection a step toward bloodless liver resection

BACKGROUND: Liver resection is currently the most efficient curative approach for a wide variety of liver tumors. The application of modern techniques and new surgical devices has improved operative outcomes. Radiofrequency ablation is used more often for liver parenchymal transection. This study aimed to assess the efficacy and safety of radiofrequency ablation-assisted liver resection.METHODS: A retrospective study of 145 consecutive patients who underwent radiofrequency ablation-assisted liver resection was performed. Intraoperative blood loss, need for transfusion or intraoperative Pringle maneuver, the duration of liver parenchymal transection, perioperative complications, and postoperative morbidity and mortality were all evaluated.RESULTS: Fifty minor and ninety-five major liver resections were performed. The mean intraoperative blood loss was 251 m L, with a transfusion rate of 11.7%. The Pringle maneuver was necessary in 12 patients(8.3%). The mean duration for parenchymal transection was 51.75 minutes. There were 47 patients(32.4%) with postoperative complications. There is no mortality within 30 days after surgery. CONCLUSIONS: Radiofrequency ablation-assisted liver resection permits both major and minor liver resections with minimal blood loss and without occlusion of hepatic inflow. Furthermore it decreases the need for blood transfusion and reduces morbidity and mortality.     

Radical resection in obstructing colorectal carcinomas

Emergency resections of obstructing colorectal carcinomas usually involve only limited rather than radical lymphadenectomy, which may contribute to the poor long-term survival of these patients. Thirty patients with ileus due to colorectal cancer have been included in a prospective follow-up study since January 1995. Seventeen of these underwent potentially curative resections with radical locoregional lymphadenectomy according to current standards of elective oncological surgery; 2 had radical right and 15 had radical left hemicolectomies. Postoperative morbidity was 18%. An 89-year-old patient died following postoperative bleeding from the colostomy site. During the same period, 13 patients with a metastasizing colorectal carcinoma underwent palliative emergency surgery with a resection rate of only 38%. Morbidity and mortality were 69% and 46%, respectively. These results suggest that emergency radical resections can be safely performed in the majority of patients with obstructing colorectal cancer without increasing the complication rate. Accepted: 15 September 1998     

Liver resection for colorectal liver metastases in older patients

INTRODUCTION: Seventy-six percentages of patients with a newly diagnosed colorectal carcinoma are between 65 and 85 years old. A substantial proportion will develop liver metastases, for which resection is the only potential curative treatment. This study was conducted to investigate both the feasibility, and short- and long-term outcomes of liver resection for colorectal liver metastases in elderly patients. METHODS: Between August 1990 and April 2007 data were prospectively collected on patients over 70 years of age who underwent a liver resection for colorectal liver metastases in a single centre. RESULTS: One hundred and eighty-one liver resections were performed in 178 consecutive patients (median age 74 years). Thirty-four patients (18.8%) received neoadjuvant chemotherapy (all FOLFOX) prior to liver surgery and the majority (57.5%) of liver resections involved more than two Couinaud's segments. Median hospital stay was 13 days, 70 (38.5%) patients had postoperative complications, and overall in hospital mortality was 4.9% (9 patients). Overall- and disease-free survival rates at 1, 3 and 5 years were 86.1%, 43.2% and 31.5% and 65.8%, 26% and 16%, respectively. In multivariate analysis: T3 primary staging; major liver resections; more than three liver lesions; and the occurrence of postoperative complications were associated with inferior overall survival. CONCLUSIONS: Liver resection for colorectal liver metastases in elderly patients is safe and may offer long-time survival to a substantial percentage of patients. We strongly recommend considering senior patients for surgical treatment whenever possible.     

Morbidity and mortality after liver resection for benign and malignant hepatobiliary lesions

Aim: Although most partial liver resections are performed for malignant lesions, an increasing contingent of benign lesions is also considered for surgery. The aim was to assess post‐operative morbidity and mortality after liver resection for benign hepatobiliary lesions in comparison with outcome after resection of malignant lesions. Methods: A total of 286 liver resections were undertaken between January 1992 and December 2004. After exclusion of resection for bile duct tumours or hepatocellular carcinoma, 205 partial liver resections were retrospectively analysed. Results: Patients with benign lesions comprised 34% of the group (n=70). Benign lesions mainly consisted of focal nodular hyperplasia (n=12; 17%) and liver haemangiomas (11; 15.7%). The malignant lesions consisted of colorectal tumour metastases (n=121; 89%). Patients with benign lesions predominantly underwent minor liver resections (66 vs. 47%; P=0.013). The overall post‐operative morbidity occurred in 31% (64/205). Major morbidity occurred in 16% (22/135) in the malignant group compared with 9% (6/70) in the benign group (P=0.099). No differences were seen in major post‐operative morbidity in the earlier period compared with the later period (14 vs. 14.3%, P=0.950). In multivariate analysis, only presence of comorbidity (P=0.017), prolonged surgical procedure (P=0.021) and surgical irradicality (P=0.039) maintained significance as independent risk factors for major morbidity. Conclusion: Limited liver resections for the treatment of a wide range of benign hepatobiliary lesions are associated with low morbidity and no mortality. However, the indications must be assessed with care. The presence of comorbidity, prolonged surgical time and incomplete resections were associated with major morbidity.     

Outcome and complications of stenting for malignant obstruction

Malignant colorectal obstruction is not an uncommon clinical condition as it is frequently cited that obstruction occurs in 7%-29% of patients with colorectal cancer. The severity of this condition is illustrated by its high postoperative mortality (up to 24%) and morbidity (up to 78%) rates after these patients have undergone conventional emergency resection of the obstructing tumor. In the past decade, the application of self-expandable metal stents (SEMSs) as treatment of malignant large bowel obstruction has expanded rapidly to reduce these alarming numbers by ‘bridge to surgery’ treatment from an emergency to an elective operation. However, the randomized controlled trials published on this topic show conflicting results regarding the outcome of SEMS placement as a bridge to surgery. Recently, a number of meta-analyses have been published on the outcomes of SEMS placement as bridge to surgery compared with emergency surgery, and data are also developing on the long-term oncological consequences of preoperative SEMS placement in the curative setting of malignant large bowel obstruction. Therefore, this review provides an overview of the current evidence on the use of SEMSs in the treatment of malignant large bowel obstruction.     

New aspects of prognostic factors in adenocarcinomas of the small bowel.

BACKGROUND/AIMS: Primary small bowel tumors are rare and the prognosis is generally considered to be poor. Histologically chiefly adenocarcinomas are reported. The surgeon is challenged in their treatment, because of the infrequency, unspecific symptoms and delay in diagnosis. Retrospectively we investigated the surgical therapy, combined morbidity, survival rates and prognostic factors in a large series of primary adenocarcinomas of the small bowel at a single surgical center. METHODOLOGY: Between 1985 and 1998, 94 patients with a primary tumors of the small bowel (malignant n = 62 [65.9%], benign n = 32 [34.1%]) were operated on. The subgroup of the adenocarcinomas (n = 22) were considered for this study. RESULTS: The median follow-up is 8.4 years (range: 0.9-14.2 years). Sixteen patients had a follow-up more than 5 years. The main surgical procedure was a small bowel segment resection. Morbidity was 13.6% (only in patients with a duodenal tumors) and the 30-day mortality 5.6%. The estimated 2-year-survival rate was 66%, the 5-year-survival rate 45%. Univariate analysis identified the presence of the residual tumor (R-status) (P = 0.004), tumor stage according to the UICC (P = 0.01), lymph node metastasis (P = 0.007), distant metastasis (P = 0.001), lymphangiosis carcinomatosa (P = 0.001) and vascular invasion (P = 0.0008) as prognostic factors. CONCLUSIONS: A complete macroscopic and microscopic tumor resection including a systemic lymph node dissection has to be the aim of any curative surgical approach in patients with adenocarcinoma of the small bowel.     

Toward Lowering Morbidity,Mortality, and Stoma Formation in Emergency Colorectal Surgery: The Role of Specialization

INTRODUCTION: Surgical management of left-sided large bowel emergencies has been evolving toward single-staged procedures. Selection for single or staged resection remains the most controversial issue. METHODS: The results from a series of 336 emergency colorectal procedures performed between January 1990 and December 2000 for cancer and diverticular disease by two different surgical units in one hospital are reported: one with a specific interest in colorectal surgery, and one specialized in upper gastrointestinal surgery. RESULTS: A primary anastomosis was performed in 142 (64.3 percent) patients by colorectal surgeons and in 42 (36.5 percent) by noncolorectal surgeons (P < 0.0001). The overall morbidity and mortality rates were lower for colon and rectal surgeons (14.5 vs. 24.3 percent and 10.4 vs. 17.4 percent, respectively). Trainees were more likely to perform anastomoses when assisted by colorectal consultants (72.1 percent of cases) than when a noncolorectal consultant was present (47.5 percent of cases; P < 0.05). The 30-day mortality for patients with primary anastomosis was 6 percent, and anastomotic dehiscence occurred in nine (4.9 percent) patients. The mortality for patients undergoing staged resections (21.1 percent) was significantly higher than those who had primary resections performed (P < 0.001). CONCLUSIONS: Primary anastomosis for left-sided colorectal diseases can be performed with low morbidity and mortality in selected patients. Specialization increased anastomotic rates and reduced morbidity. This study suggests that colon and rectal surgeons should manage colorectal emergencies, and trainees should not be left unsupervised.     

Simultaneous versus staged liver resection of synchronous liver metastases from colorectal cancer

Background and aims The surgical strategy for treatment of synchronous liver metastases from colorectal cancer remains controversial. This retrospective analysis was conducted to compare the postoperative outcome and survival of patients receiving simultaneous resection of liver metastases and primary colorectal cancer to those receiving staged resection. Materials and methods Between January 1988 and September 2005, 219 patients underwent liver resection for synchronous colorectal liver metastases, of whom, 40 patients received simultaneous resection of liver metastases and primary colorectal cancer, and 179 patients staged resections. Patients were identified from a prospective database, and records were retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on postoperative morbidity and mortality as well as on long-term survival. Results Simultaneous liver resections tend to be performed for colon primaries rather than for rectal cancer (p = 0.004) and used less extensive liver resections (p < 0.001). The postoperative morbidity was comparable between both groups, whereas the mortality was significantly higher in patients with simultaneous liver resection (p = 0.012). The mortality after simultaneous liver resection (n = 4) occurred after major hepatectomies, and three of these four patients were 70 years of age or older. There was no significant difference in long-term survival after formally curative simultaneous and staged liver resection. Conclusion Simultaneous liver and colorectal resection is as efficient as staged resections in the treatment of patients with colorectal cancer and synchronous liver metastases. To perform simultaneous resections safely a careful patient selection is necessary. The most important criteria to select patients for simultaneous liver resection are age of the patient and extent of liver resection.     

Laparoscopic versus open bowel resection for Crohn's disease.

BACKGROUND: Laparoscopic bowel resection is an alternative to open surgery for patients with Crohn's disease requiring surgical resection. The present report describes a seven-year experience with the laparoscopic treatment of Crohn's disease compared with the open technique in a tertiary Canadian centre. PATIENTS AND METHODS: A retrospective analysis of 61 consecutive patients undergoing elective resection for Crohn's disease was carried out between October 1992 and June 1999. This analysis included 32 laparoscopic resections (mean age 33 years) and 29 open resections (mean age 42 years). Patient demographics were compared, as well as short and long term outcomes after surgery (mean follow-up 39 months). RESULTS: Patients in the laparoscopic group were younger and had fewer previous bowel surgeries than patients who had open resections. Indications for surgery and operative times were similar between the groups. Patients who underwent laparoscopic resections required fewer doses of narcotic analgesics. The resumption of bowel function after surgery, and tolerance of a clear liquid and solid diet was quicker in the laparoscopic group. Patients who underwent laparoscopic resections had significantly shorter hospital stays than those who underwent open resections. Fifteen patients (48.4%) in the laparoscopic group experienced recurrence of disease compared with 13 patients (44.8%) in the open group. In both groups, the most common site of recurrence was at the anastomosis. The disease-free interval was the same length for both groups (23.9+/-17.3 months for the laparoscopic resection patients compared with 23.9+/-20.2 months for the open resection patients; P=1.00). CONCLUSIONS: Laparoscopic resection for Crohn's disease can be performed safely and effectively. Quicker resumption of oral feeds, less postoperative pain and earlier discharge from hospital are advantages of the laparoscopic method. No differences in the recurrence rate or the disease-free interval were noted.     

The importance of complete excision of the caudate lobe in resection of hilar cholangiocarcinoma

Background: The numbers of margin-negative resections and survival times have greatly improved because of a more aggressive surgical approach to resectable hilar cholanciocarcinoma (Klatskin tumour). It was shown initially by Japanese authors that complete resection of the caudate lobe together with partial hepatectomy leads to more margin-negative resections. However, this concept has not been unanimously taken up by Western authors. The aim of this study was to examine the role of complete caudate lobe resection in our series of resected hilar cholangiocarcinomas. Methods: Between January 1993 and January 2003, 54 patients underwent resection for Klatskin tumours. These patients were divided into two groups, according to the two 5-year periods in which they had been operated. In the first period, patients did not routinely undergo complete excision of the caudate lobe, whereas in the second period, partial liver resection was combined with complete excision of the caudate lobe in 15 patients. These two patient groups were evaluated with respect to postoperative morbidity and mortality, microscopic tumour margins and survival time. Results: Postoperative complications occurred in 59% of patients in total, while overall mortality was 11%. No difference was found in postoperative morbidity or mortality between the two periods. A significantly higher number of margin-negative resections was found in the second 5-year period, together with improved survival. Conclusion: Concomitant complete excision of segment 1 for patients with hilar cholangiocarcinoma did not lead to increased morbidity or mortality. Therefore the addition of complete excision of segment 1 is a safe procedure contributing to a higher rate of R0 resections and improved survival.     

Surgical results of hepatic resection for hepatocellular carcinoma with gross diaphragmatic invasion

BACKGROUND/AIMS: Gross diaphragmatic invasion is not uncommon in patients undergoing hepatectomy for hepatocellular carcinoma. The aim of the study is to evaluate retrospectively the surgical results of hepatocellular carcinoma with gross diaphragmatic invasion undergoing en-bloc resection of diaphragm. METHODOLOGY: Between January 1989 and December 2002, 640 patients underwent curative resections for hepatocellular carcinoma in our hospital. Fifty-three patients (8.3%) who had hepatocellular carcinoma with gross diaphragmatic invasion found during operation undergoing en-bloc resection of diaphragm were assigned to group A. The other 587 patients who had hepatocellular carcinoma without gross diaphragmatic invasion were assigned to group B. The clinicopathological features, operative mortality and morbidity and long-term result of the patients between group A and B were compared. RESULTS: Of the 53 patients in group A with gross diaphragmatic invasion of hepatocellular carcinoma undergoing en-bloc resection of diaphragm, seven (13.2%) were pathologically proved to have muscular invasion of diaphragm and the other 46 (86.8%) were fibrous adhesion only or free of tumor. Primary repair of diaphragm was adequate in 52 patients (98.1%) and one required a mesh repair, Thirteen patients (24.5%) developed postoperative complication but no operative mortality occurred. There was no significant difference in operative mortality and postoperative complication rate between the two groups of patients with (group A) and without (group B) gross diaphragmatic invasion. If compared by each TNM staging (stage I, II and III) there was no significant difference between the patients of group A and B in five-year cumulative and disease-free survival. Among the 53 patients in group A, the long-term prognosis was also not significantly different between the patients with (group A1) and without (group A2) histological muscular invasion. CONCLUSIONS: En-bloc resection of diaphragm in patients with gross diaphragmatic invasion of hepatocellular carcinoma is justified since it does not significantly increase the operative mortality or postoperative complication rate and the long-term prognosis at each TNM staging is comparable to that of patients without gross diaphragmatic invasion.     

Pelvic exenteration for T4 rectal cancer: a series of 15 ressectable cases

BACKGROUND: Pelvic exenteration is the best therapeutic choice for treatment of T4 rectal cancer. Although, this operation still presents considerable mortality and high morbidity. AIM: To report on a series of 15 patients with a T4 rectal cancer at a general hospital and describe the outcomes (morbidity, mortality and long-term survival) following pelvic exenteration. METHODS: Complete follow-up data were available on 15 patients who underwent pelvic exenteration for T4 rectal cancer between 1998 and 2006. These subjects comprised seven men and eight women with a mean age of 65 years. All of them presented serious incapacitating complaints. The surgical procedures included: infraelevator exenteration (n = 6), supraelevator exenteration (n = 4), posterior exenteration (n = 3) and, posterior exenteration plus partial cystectomy and ureterectomy (n = 2). RESULTS: The mean duration of surgery was 403 minutes (280-485). The mean blood loss was 1620 mL (300-4.800). The postoperative mortality was 6,66% (n = 1). The overall rate morbidity was 53,3% (n = 8). The pathological examination showed that all resections were R0. Lymph node involvement was present in four patients (26,66 %), and all of them died due to tumor recurrence. The overall 5-year survival rate was 35,7%. CONCLUSION: In spite of its aggressive nature and high morbidity, pelvic exenteration seems justified in rectal carcinoma when the disease extends to the urinary or genital tract. This procedure may offer long-term disease control.     

Surgical treatment of severe late radiation injury to the bowel: a retrospective analysis of 83 cases

BACKGROUND/AIMS: The aim of this study was to determine the best surgical approach for the treatment of late radiation injury to the bowel. METHODOLOGY: Clinical and follow-up charts of 83 patients operated in our institution for late radiation injury to the bowel were retrospectively reviewed. The type of operation (resection-anastomosis or bypass) mortality, postoperative complications and reoperation rate were recorded. Seventy-six underwent resection with immediate anastomosis. A bypass or viscerolysis was performed in only 7 patients. RESULTS: Postoperative mortality was 2.4%, morbidity was 23. Twenty-seven patients underwent further surgery; early reoperation (within 1 month) was necessary in 12 (morbidity 41%). A late reoperation has been performed in 15 patients (no mortality, morbidity 53.5%). CONCLUSIONS: From the results of our study it can be concluded that resection with immediate anastomosis for late radiation injury to the bowel is safe and should be the first option for these patients.     

Chylothorax complicating repairs of the descending and thoracoabdominal aorta

BACKGROUND: Chylothorax occurring during thoracic aortic surgery is an infrequent but serious complication. The purpose of this study was to analyze our experience with this complication and the resulting outcomes. METHODS: From January 1991 to July 2005, we performed 1,233 descending thoracic and thoracoabdominal aortic surgical procedures. A retrospective review was performed to analyze and identify preoperative and operative risk factors as well as management outcomes of postoperative chylothorax (PCT). RESULTS: PCT developed in five patients (0.4%). All five cases occurred with descending thoracic aortic aneurysm repair, and 80% (four of five patients) were undergoing aortic reoperation. All patients were managed successfully with no mortality. Risk factors for the development of chylothorax were descending thoracic aortic repair (p = 0.006) and thoracic aortic reoperations (p = 0.0003). Nonoperative management was successful in 60% (three of five patients). Two patients required left thoracotomy with direct ligation. Mean hospital length of stay was 35 days (range, 15 to 60 days). Mean follow-up was 33 months (range, 3 to 69 months) with no recurrence of chylothorax or additional morbidity or mortality. CONCLUSIONS: Chylothorax is more likely to occur with reoperations and repairs involving the descending thoracic aorta. Although PCT is associated with longer hospital length of stay, it is not associated with increased infectious complications. Early identification and prompt treatment may decrease both early and late morbidity and mortality.     

Radical surgical treatment of recurrent hepatic hydatidosis

BACKGROUND/AIMS: The treatment of relapsing hydatidosis must aim at the reduction of both morbidity and mortality rates and the risk of new recurrences. METHODOLOGY: Thirty-three patients with recurrence of hepatic ecchinococcosis were observed between January 1975 and May 2001. All selected patients received a first conservative surgical treatment, and recurrences developed in a period ranging from 1 to 46 years from the therapy. All patients with secondary hydatidosis were then submitted to radical surgical treatment. Ultrasound examinations, the first after 3 months from surgery, were performed to evaluate disease recurrence. Intraoperative morbidity and mortality were also evaluated. RESULTS: No intraoperative mortality was encountered. Intraoperative and postoperative morbidity were 6% and 12% respectively. During follow-up, (mean duration 53 months) no recurrences were recorded. CONCLUSIONS: Radical surgical approach is the best treatment of recurrent hydatid cysts as it represents a valid compromise between the need of a surgical radicality and a low intraoperative and postoperative morbidity.     

Emergency Surgery for Colon Carcinoma

PURPOSE: Emergency surgery for colon cancer is widely thought to be associated with increased likelihood of surgical morbidity and mortality; however, other coexistent factors such as advanced disease, the age of the patient, and medical comorbid conditions may also influence these outcomes. The primary purpose of this study was to identify the relative risk for surgical morbidity and/or mortality conferred by emergency surgery compared with elective surgery for patients with colon cancer. METHODS: An Institutional Review Board-approved, case-control study was performed. During the period from January 1, 1995, to June 30, 2001, a total of 184 primary surgeries for colon cancer were performed. Emergency indications for surgery were defined as peritonitis, intra-abdominal abscess, or complete bowel obstruction at presentation (defined as emesis, distention on examination, and confirmatory plain radiograph films). By this definition, 29 patients (15.7 percent) met the criteria for inclusion. These patients were age and stage matched with 29 patients derived from the remaining 155 patients. Information was collected on surgical morbidity and mortality, length of stay, and survival. RESULTS: Age, medical comorbidities, and stage of disease were well matched between groups. The indications for the 29 emergency surgeries were as follows: 6 for peritonitis, 2 for abscesses, and 21 for complete obstructions. Nine patients did not have their primary tumor removed. Sixteen patients underwent resection and anastomosis; the remaining four patients underwent a Hartmanns procedure. Overall surgical morbidity (64 vs. 24 percent; odds ratio, 5.1; 95 percent confidence interval, 1.7–16) and mortality (34 vs. 7 percent; odds ratio, 7.1; 95 percent confidence interval, 1.4–36.2) were significantly higher for patients undergoing emergency surgery. Among patients surviving surgery, there was no difference in overall survival between patients undergoing emergency compared with elective operation. CONCLUSIONS: Emergency surgery has a strong negative influence (beyond that which is expected based on stage of disease) on immediate surgical morbidity and mortality. The similarity between the two groups in overall survival for patients surviving the perioperative period suggests that the negative impact of emergency surgery is confined to the immediate postoperative period.     

Klatskin-mimicking lesions--a case series and literature review

Obstruction of the hepatic hilum in patients without prior surgery is generally due to hilar adenocarcinoma (Klatskin tumor). However, not all the hilar strictures are malignant. Although uncommon, benign strictures of the proximal bile duct should be taken into consideration in differential diagnosis of Klatskin tumors, since the incidence could reach up to 25% of patients with presumed Klatskin tumor diagnosis. This group of benign proximal bile duct strictures (Klatskin-mimicking lesions) is usually represented by segmental fibrosis and non-specific chronic inflammation. The clinical and imaging features can not differentiate between benign and malignant strictures. Herein, we present a case series of three patients with benign proximal bile duct strictures (representing 4.1% of 73 patients resected with presumptive preoperative diagnosis of Klatskin tumor) and literature review. There are presented the clinical and biochemical features, imaging preoperative workup, surgical treatment and histological analysis of the specimen, along with postoperative outcome. For benign strictures of the hilum limited resections are curative. However, despite new diagnosis tools developed in the last years, patients with hilar obstructions still require unnecessary extensive resections due to impossibility of excluding the malignancy. In all cases of proximal bile duct obstruction presumed malignant, they should be managed accordingly, even with the risk of over-treatment for some benign lesions.     

Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients

AIM: To evaluate the risk of esophagectomy for carcinoma of the esophagus in the elderly (70 years or more) compared with younger patients (< 70 years) and to determine whether the short-term outcomes of esophagectomy in the elderly have improved in recent years. METHODS: Preoperative risks, postoperative morbidity and mortality in 60 elderly patients (> or = 70 years) with esophagectomy for carcinoma of the esophagus were compared with the findings in 1782 younger patients (< 70 years) with esophagectomy between January 1990 and December 2004. Changes in perioperative outcome and short-time survival in elderly patients between 1990 to 1997 and 1998 to 2004 were separately analyzed. RESULTS: Preoperatively, there were significantly more patients with hypertension, pulmonary dysfunction, cardiac disease, and diabetes mellitus in the elderly patients as compared with the younger patients. No significant difference was found regarding the operation time, blood loss, organs in reconstruction and anastomotic site between the two groups, but elderly patients were more often to receive blood transfusion than younger patients. Significantly more transhiatal and fewer transthoracic esophagectomies were performed in the elderly patients as compared with the younger patients. Resection was considered curative in 71.66% (43/60) elderly and 64.92% (1157/1782) younger patients, which was not statistically significant (P>0.05). There were no significant differences in the prevalence of surgical complications between the two groups. Postoperative cardiopulmonary medical complications were encountered more frequently in elderly patients. The hospital mortality rate was 3.3% (2/60) for elderly patients and 1.1% (19/1 782) for younger patients without a significant difference. When the study period was divided into a former (1990 to 1997) and a recent (1997 to 2004) period, operation time, blood loss, and percentage of patients receiving blood transfusion of the elderly patients significantly improved from the former period to the recent period. The hospital mortality rate of the elderly patients dropped from the former period (5.9%) to the recent period (2.3%), but it was not statistically significant. CONCLUSION: Preoperative medical risk factors and postoperative cardiopulmonary complications after esophagectomy are more common in the elderly, but operative mortality is comparable to that of younger patients. These encouraging results and improvements in postoperative mortality and morbidity of the elderly patients in recent period are attributed to better surgical techniques and more intensive perioperative care in the elderly.