Current trends in the management of carcinoma of the pancreatic head

Between 1965 and 1987, 783 patients were treated for ductal adenocarcinoma. Of these, 59% had carcinoma of the pancreatic head and 22% presented with carcinoma of the body or tail. In 19% of the cases the entire organ was involved. Two hundred and twenty-six patients (25.5%) underwent exploratory laparotomy; 420 patients (55%) had palliative operations, and 137 (18.5%) were resected for cure. In the past 3 years the resection rate increased from an original 18.5% to 28% (43 resective procedures in 153 patients). In 37 of the 137 patients (28%) surgery had to be extended to the portal vein, the superior mesenteric vein, the kidneys, adrenals, colon, stomach, liver and lymph nodes to ensure adequate radicality. At the same time in-hospital mortality (including deaths after extended procedures) dropped to 7%. Of the 137 patients resected for cure, 47% were alive at 1 year, 22% at 2 years, 12% at 3 years, 7% at 4 years, and 5% at 5 years. Mean survival time excluding in-hospital deaths was 18.65 months. In the first 15 months after surgery there was no difference in survival between standard resections and extended resections. Patients undergoing partial pancreaticoduodenectomy fared significantly better (p less than 0.01; Mantel) than those who had total resections, in terms of both median survival (10.8 versus 5.4 months) and mean survival (19.0 versus 7.82 months).(ABSTRACT TRUNCATED AT 250 WORDS)     

Polyamine plasma levels and liver regeneration following partial hepatic resection in man.

Polyamines (putrescine, spermidine, and spermine) are widely distributed in animal and vegetal tissues, where their intracellular concentration strictly correlates with normal and pathological cell growth and protein synthesis. By means of a sensitive HPLC technique, the fasting plasma concentrations of polyamines were measured serially in 11 patients who underwent partial hepatic resection because of focal liver lesions. Samples were obtained before surgery and over the next 6 months, during hepatic regeneration. Liver volume was also measured by ultrasound on the basis of the 3 maximum diameters of the liver. From 2 to 4 weeks after surgery, plasma putrescine increased by a maximum of 78%, and spermidine by approximately 50%. No changes were observed in spermine levels. The spermidine/spermine ratio nearly doubled during liver regeneration. The volume of the liver decrease from 1505 [SD 236] ml to 743 [151] ml after resection, and returned to nearly normal values after 6 months (1231 [100] ml, p < 0.05 vs. basal values). The liver regeneration rate was highest 2-4 weeks after resection, and declined thereafter, when prevailing polyamine concentrations returned to normal. These data show that liver regeneration is accompanied by a significant increase in fasting putrescine and spermidine concentrations, which might be biochemical signals of active liver cell regeneration.     

Near total hepatectomy in two steps for surgical treatment of liver metastasis of colorectal tumor

Liver resections for metastases of colorectal carcinomas are generally accepted. The 5-year survival rate is higher than 30 percent. Major resections can be performed safely with normal remnant liver. The liver regenerates following extended hepatectomies or other major resections. Authors operated on a 57-year-old man for a secondary liver tumor. The primary tumor was in the colon sigmoideum and sigma-resection was made at another hospital 16 months before. The metastasis was in the right lobe of the liver. Authors performed right extended hepatectomy. After systemic chemotherapy, 4.5 months later a new metastasis developed in the left lobe. Despite locoregional chemotherapy, chemoembolization and radiofrequency treatment, the tumor was still growing so a left lobectomy was performed. The patient is macroscopically tumor-free 17 months after the first hepatic resection. The interest in this case is that segments IV to VIII were removed first time, and segments II and III at the second liver resection. Liver regeneration after the first resection made the second operation possible. Only segment I of the original segments remained. Utilizing the regeneration of the liver we can make an effort to perform a complete tumor ablation in two steps.     

Hepatocarcinoma: considerations on surgical treatment in a personal series of 23 patients.

BACKGROUND/AIMS: Surgical treatment of primary liver tumors has undergone significant changes in recent years because of improved surgical and anesthesiological techniques and better pre- and post-operative care. We review our personal series from 1987-1995. METHODOLOGY: Of 31 cases of hepatocellular carcinoma (HCC) observed in the years 1987-1995, 23 underwent curative resective surgery for a total of 24 liver resections: 6 hepatectomies; 10 segmentectomies; 4 atypical subsegmentectomies; 2 extended resections, with excision of neoplastic thrombi within the portal vein; 1 orthotopic liver transplantation in another institution, and 1 limited segmental resection for tumor recurrence. In 7 recent cases, pre-operative transcatheter arterial chemoembolization (TAE) was used. RESULTS: The mean survival of the 13 patients that are known to be deceased is 27 months (range: 7-114 months). Perioperative mortality was nil. Actuarial 5-year survival rate is 27%. Pre-operative TAE was used in 7 patients: 4 out of 7 lesions were significantly reduced at computed tomography (CT) scan control 21 days following TAE, while in 3 the tumor size was unchanged. CONCLUSIONS: Liver surgery, even major resections, has become safe with no perioperative mortality in our series. In our experience, pre-operative TAE has often produced significant reduction of the mass, but its real efficacy is still the subject of debate. TAE and percutaneous ethanol injection (PET) should be evaluated as part of combined multimodality treatment in the therapy of large lesions previously considered inoperable.     

Liver regeneration and restoration of liver function after partial hepatectomy in patients with liver tumors

Liver regeneration and restoration of liver function were studied in six patients who underwent partial hepatectomy with removal of 30-70% of the liver. Liver volume and liver regeneration were studied by single-photon computed tomography (SPECT), using 99mTc-colloid as tracer. The method was assessed in 11 patients by comparing the pre- and post-operative volume measurements with the volume of the resected liver mass. The correlation coefficient between these methods was 0.899 (P less than 0.01). Liver function was determined by measuring the galactose elimination capacity and the caffeine clearance. After a postoperative follow-up period of 50 days the liver had regenerated maximally to a volume of 75 +/- 2% of the preoperative liver mass. Maximal restoration of liver function was achieved 120 days after operation and amounted to 75 +/- 10% for the caffeine clearance and to 100 +/- 25% for the galactose elimination capacity. This study shows that SPECT is a useful method for assessing liver regeneration in patients after partial hepatectomy. Our study furthermore shows that caffeine clearance correlates well with total liver volume, whereas the galactose elimination capacity overestimates total liver volume after partial hepatectomy.     

Liver resection for breast cancer metastases

BACKGROUND/AIMS: The prognosis of patients with hepatic metastases (HM) from breast cancer receiving no treatment is extremely poor. Results of systemic and regional chemotherapy as well as other treatment modalities, such as immunotherapy or hormonal therapy, are disappointing in this group of patients, with median survival rates hardly exceeding 1 year. METHODOLOGY: We performed a retrospective analysis of patients undergoing resection of isolated HM from breast cancer to determine the morbidity, mortality and prognosis following this procedure. RESULTS: Fifteen female patients underwent liver resection between September 1985 and April 1997. Two patients had synchronous and 13 patients had metachronous HM. The mean number of HM was 3.3 (1-9) (bilobar in 6 patients) with a mean diameter of 5.3 cm (2-11 cm). The following resections were performed: wedge resection (4), left lateral segmentectomy (2), right hemihepatectomy (3), left hemihepatectomy (1), extended right hemihepatectomy (3) and extended left hemihepatectomy (2). There was no hospital mortality. Morbidity (transient hepatic failure (n=2) and intra-operative hemorrhage necessitating splenectomy (n=1)) occurred in 3 patients. Median follow-up was 12 (1-88) months. Six patients developed recurrent liver disease; 2 relapsed elsewhere. Six of these 8 patients died. Overall median survival following liver resection was 57 months with 1-, 2- and 3-year survival rates of 100%, 71.4% and 53.6% respectively. CONCLUSIONS: Liver resection is a viable treatment option for selected patients with isolated HM from breast cancer that can be performed safely. It should be considered in individual patients if the operative risk is low, if no extrahepatic disease is present and provided a complete resection with clear margins is technically feasible.     

Surgery for non-small cell carcinoma in geriatric patients: 15-year experience

The purpose of this study was to determine the clinical patterns, short- and long-term survival in elderly patients after surgery for non-small cell lung carcinoma. The 273 patients aged over 70 years who underwent curative resection from 1986 to 2001 were retrospectively assessed. Mean age was 73.2+/-3.1 years, (11% were>80 years). The mean follow-up was 31 months. Standard procedures were used: 151 lobectomies, 49 bilateral lobectomies, 42 pneumonectomies, 9 sleeve resections, and 22 wedge resections. The 30-day mortality was 5.4%. Multivariate analysis showed that extended procedures, male sex, and age were predictors of mortality. Overall survival rates at 5, 10, and 15 years were 35.6%, 10.5%, and 2.5%, respectively. Advanced disease stage, low forced expiratory volume in 1 second, and previous cardiac disease were independent predictors that adversely influenced survival. Geriatric patients with non-small cell lung carcinoma can undergo resection safely with acceptable long-term survival. Lobectomy is the procedure of choice, extended resections should only be carried out in highly selected patients. Careful attention to preoperative clinical staging is important as the elderly beyond the early stage of disease fare poorly. Surgery is justified for the treatment of stage I-II lung cancer.     

Percutaneous portal vein embolisation in preparation for extended hepatic resection of primary nonresectable liver tumours

BACKGROUND: In patients with malignant primary and secondary liver tumours or proximal bile duct carcinoma radical surgery is superior to all other therapeutic modalities in terms of survival and quality of life. Radical resection, however, often requires the removal of a large amount of liver parenchyma, resulting in a marked reduction of functional liver tissue with the risk of liver failure. AIM: Preoperative partial portal vein embolisation induces hypertrophy of the controlateral liver and thereby increases the safety of extended liver resections. PATIENTS AND METHODS: Between January 1997 and February 2001 we applied this strategy in 19 patients with primary and secondary nonresectable hepatobiliary malignancies, in whom the estimated amount of the remnant liver was < or =25% of the liver volume. RESULTS: The increase in volume ranged between 7 and 245%. Radical extended liver resection was performed in 13 patients (68%) without mortality. After a mean observation time of 22 months patient survival was 19 months with six tumour-related deaths during the second year after surgery. The remaining seven patients are alive and well with tumour recurrence in one. CONCLUSION: Preoperative partial portal vein embolisation allows more patients with previously unresectable liver tumours to benefit from a potentially curative resection.     

Long-term follow-up of chronic hepatitis C patients with sustained virological response to alpha-interferon.

BACKGROUND/AIMS: This study aimed to determine the long-term outcome of hepatitis C virus (HCV)-infected patients who respond to interferon treatment with clearance of serum HCV RNA. METHODS: We performed a long-term biochemical, virological, and histological follow-up of all sustained virological responders, defined as those who became HCV RNA negative at follow-up 6 months after the end of treatment, from 3 controlled interferon trials performed in Sweden between 1988 and 1994. RESULTS: At biochemical and virological long-term follow-up performed in 26 sustained virological responders 3.5-8.8 years (mean +/- SD, 5.4+/-1.6 years) after the end of IFN therapy, 22 patients (85%) had normal serum ALT levels, and 24 patients (92%) were HCV RNA negative in serum. Liver biopsies performed in 23 patients 2.1-8.7 years (mean +/- SD, 5.0+/-1.8 years) after end of treatment showed no or minimal inflammation, whereas mild and probably irreversible fibrosis was seen in a few patients. CONCLUSION: In this well-defined material of sustained responders to IFN therapy, the long-term prognosis was excellent. Nearly all had a durable response, not only biochemically and virologically, but more importantly also histologically with normalisation or near normalisation of previous histological lesions.     

The influence of spleen size on liver regeneration after major hepatectomy in normal and early cirrhotic liver.

BACKGROUND/PURPOSE: The relationship between liver regeneration and spleen size after major hepatectomy in normal and cirrhotic liver was studied by single photon emission computed tomography (SPECT). MATERIALS AND METHODS: Twenty-six patients, 18 patients with normal liver and eight patients with cirrhotic liver, receiving major hepatectomy were included. Liver and spleen volumes were measured by SPECT before major hepatectomy, 6 months, 1 year and 2 years after operation. The correlation of liver and spleen volume during liver regeneration was analyzed. RESULTS: In both groups, the residual liver volume increased within the first year and decreased in the second year. No difference in regeneration ability was found. The spleen volume in cirrhotic liver was increased, with a trend similar to normal liver during the first year. In contrast, the increased spleen volume persisted up to the second year in cirrhotic patients. Age per year, the female sex, and body surface index had a positive correlation with increased percentage of liver volume. The spleen volume per 100 ml with time played a significantly negative role in increasing percentage of liver volume, confidence interval: -2.16 to -27.92, P=0.011. CONCLUSION: In early cirrhotic liver within normal functional limits, the liver still could regenerate as a normal liver after major hepatectomy in 1 year. Age, the female sex, and body surface index had positive correlation but the size of spleen volume played a negative role to regenerative liver volume.     

Surgery and long-term follow-up of hepatic echinococcosis outside endemic regions

The aim of the study was to characterize the therapeutic pathways in patients with echinococcal hydatids in an institution outside the endemic areas but with a high frequency of oncological hepatic surgery.PATIENTS AND METHODS: 44 patients with echinococcosis from 1987-1997 were reviewed. To evaluate the long-term results, clinical examination, chest x-ray, serology and liver ultrasound were performed. According to the study protocol 39 patients were evaluable. 89.7 % of the patients suffered from a primary disease, whereas 7.7 had a local recurrence and another 2.5 of patients showed a second site of manifestation after former operation. E. cysticus occurred in 82.5 %, E. alveolaris in 17.5 %.RESULTS: In 66.7 % of all cases a resecting procedure (pericystectomy, atypic resection, regular and extended hemihepatectomy) was performed. One patient underwent an orthotopic liver transplantation and in 10 % the surgical procedure included only an open drainage of the cysts. A simple cystectomy was performed in 23 %. One patient died from multiple organ failure as a consequence of local bleeding complications. The overall complication rate was 38.5 %, including the postoperative death and 7.7 % reoperations. The complication rate following pericystectomy was much higher than after simple cystectomy. At the time of follow-up (median 66 months) no patient showed a recurrent disease.CONCLUSION: Compared to reports from endemic regions the rate of resective procedures was much higher. The therapeutic strategy lead to excellent long-term results. Simple cystectomy should be preferred as pericystectomy showed a higher morbidity.     

Liver regeneration after liver resection: Clinical aspects and correlation with infective complications

AIM:To investigate whether early liver regeneration after resection in patients with hepatic tumors might be influenced by post-operative infective complications.METHODS:A retrospective analysis of 27 liver resections for tumors performed in a single referral center from November 2004 to January 2010.Regeneration was evaluated by multidetector computed tomographyat a mean follow-up of 43.85 d.The Clavien-Dindo classification was used to evaluate postoperative events in the first 6 mo after transplantation,and Centers for Disease Control and Prevention definitions were used for healthcare associated infections data.Generalized linear regression models with Gaussian family distribution and log link function were used to reveal the principal promoters of early liver regeneration.RESULTS:Ten of the 27 patients(37%)underwent chemotherapy prior to surgery,with a statistically significant prevalence of patients with metastasis(P=0.007).Eight patients(30%)underwent embolization,3 with primary tumors,and 5 with secondary tumors.Twenty patients(74%)experienced complications,with 12(60%)experiencing Clavien-Dindo Grade 3a to 5 complications.Regeneration≥100%occurred in 10(37%)patients.The predictors were smaller future remnant liver volume(-0.002;P<0.001),and a greater spleen volume/future remnant liver volume ratio(0.499;P=0.01).Patients with a resection of≥5 Couinaud segments experienced greater early regeneration(P=0.04).Nine patients experienced surgical site infections,and in 7 cases Clavien-Dindo Grade 3a to 4 complications were detected(P=0.016).There were no significant differences between patients with primary or secondary tumors,and either onset or infections or severity of surgical complications.CONCLUSION:Regardless of the onset of infective complications,future remnant liver and spleen volumes may be reliable predictors of early liver regeneration after hepatic resection on an otherwise healthy liver.     

Survival after repeat hepatic resection for recurrent colorectal metastases.

BACKGROUND/AIMS: This is a retrospective study examining survival of patients undergoing repeat hepatic resection for recurrent colorectal metastases. METHODOLOGY: The records of 41 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resections (negative resection margin and no extrahepatic disease) were attempted in all patients. Recurrence developed in 26 (63%) patients, with disease being confined to the liver in 16 (39%) patients. Ten of them (24%) underwent hepatic resection and make up the study population. RESULTS: Ten patients (4 women, 6 men; mean age: 62 years, range: 50-82 years) developed recurrence confined to the liver at the median interval of 16 months (range: 5-34 months) after the first hepatectomy. In 6 patients the recurrent cancer(s) involved both the area near the resection line and remote sites from the site of the first hepatic resection. In 3 patients recurrent cancer(s) was located at sites remote from the first liver resection. In 1 patient the recurrent cancer was located in the same area as the original hepatic resection. Three formal hepatectomies and seven non-anatomical (wedge) resections were performed. The mean blood loss was 900 cc (range: 100-2700 cc); the mean hospital stay was 19 days (range: 8-34 days). There was no perioperative mortality. Morbidity was 20%. Four patients died of recurrent disease, with a mean disease-free survival of 13 months (range: 5-21 months). Two patients had a second recurrence resected at 10 and 24 months, respectively, after the second hepatic resection. One of these 2 patients had a fourth hepatic resection for hepatic recurrence and is still alive with no evidence of disease. Six patients are alive, 4 of them without evidence of disease, with a median follow-up time of 30 months (range: 22-64 months). Actuarial 4-year specific survival was 44%. Actuarial disease-free survival at 4 years was 18%. CONCLUSIONS: In appropriately selected patients, repeat hepatic resection for colorectal metastases is a worthwhile treatment. Mortality, morbidity, and survival are similar to those following the initial resection.     

Clinical usefulness of ^18F-FDG PET/CT in the restaging of esophageal cancer after surgical resection and radiotherapy

AIM： To evaluate the clinical usefulness of lSF-fluorodeoxyglucose positron emission and computed tomography QSF-FDG PET/CT） in restaging of esophageal cancer after surgical resection and radiotherapy. METHODS： Between January 2007 and Aug 2008, twenty histopathologically diagnosed esophageal cancer patients underwent 25 PET/CT scans （three patients had two scans and one patient had three scans） for restaging after surgical resection and radiotherapy. The standard reference for tumor recurrence was histopathologic confirmation or clinical follow-up for at least ten months after ^18F-FDG PET/CT examinations. RESULTS： Tumor recurrence was confirmed histopathologically in seven of the 20 patients （35%） and by clinical and radiological follow-up in 13 （65%）. ^18F-FDG PET/CT was positive in 14 patients （68.4%） and negative in six （31.6%）. ^18F-FDG PET/CT was true positive in 11 patients, false positive in three and true negative in six. Overall, the accuracy of ^18F-FDG PET/CT was 85%, negative predictive value （NPV） was 100%, and positive predictive value （PPV） was 78.6%.The three false positive PET/CT findings comprised chronic inflammation of mediastinal lymph nodes （n = 2） and anastomosis inflammation （n = 1）. PET/ CT demonstrated distant metastasis in 10 patients. ^18F-FDG PET/CT imaging-guided salvage treatment in nine patients was performed. Treatment regimens were changed in 12 （60%） patients after introducing ^18F-FDG PET/CT into their conventional post-treatment follow-up program. CONCLUSION： Whole body ^18F-FDG PET/CT is effective in detecting relapse of esophageal cancer after surgical resection and radiotherapy. It could also have important clinical impact on the management of esophageal cancer, influencing both clinical restaging and salvage treatment of patients.     

Management of liver hemangiomas according to size and symptoms

BACKGROUND AND AIM: Liver hemangiomas are the most common benign liver tumors. These lesions are usually incidental findings during imaging studies of the abdomen performed for other reasons. The indication for surgical resection of these lesions remains controversial. METHODS: Records of patients referred for evaluation of radiologically and/or histopathologically proven liver hemangiomas, from June 1991 to February 2006, were retrospectively analyzed. Reason for referral, results of imaging studies, and surgical treatment and outcome were reviewed. RESULTS: There were 34 patients identified. The hemangioma size was <5 cm in 15 patients (44%) and >5 cm in 19 patients. The most common reason for referral was right upper abdominal pain in 59% (20/34) of patients. Abdominal ultrasound was conclusive in 66.7% (16/24) and four-phase computed tomography (CT) in 82.6% (19/23) of patients. Surgical resection was undertaken in 14 patients (41%) after a mean follow-up time of 36.5 months. The indication for treatment was progressive abdominal pain in 78.6% (11/14). Mean size of resected lesions was larger compared to non-resected lesions (10.3 vs 4.8 cm; P = 0.004). Postoperative morbidity occurred in three patients (21.4%). One patient had persisting abdominal pain after resection of an 8-cm hemangioma. Twenty patients were observed and showed no complications related to the liver hemangioma during follow-up. CONCLUSIONS: Liver hemangiomas can be readily diagnosed by ultrasound or multiphase contrast-enhanced helical CT. The indications for surgical resection are progressive abdominal pain in combination with size >5 cm. Observation is justified in patients with minimal or no symptoms, even in patients with giant hemangiomas.     

Intrahepatic biliary cystadenoma: a need for radical resection

BACKGROUND: Intrahepatic biliary cystadenoma (IBC) is a rare liver tumour, which has strong tendency to recur and malignant potential as it can progress to cystadenocarcinoma (IBCa). METHODS: From June 2003 to December 2006, four patients diagnosed with hepatic cystadenoma were operated on our Liver Surgical Unit. All patients were females with median age of 51 years (range 45-63 years). Liver resections included three left and one right hepatectomies. In two patients, IBC was diagnosed by abdominal imaging and serum tumour markers but the rest of the patients were initially misdiagnosed as simple cysts, treated by laparoscopic fenestration and referred to our unit after cyst recurrence. RESULTS: In all cases, the pathology report was consistent with liver cystadenomas. The postoperative course was uneventful and the median hospital stay was 8 days (range 5-12 days). In a median 18-month follow-up (range 2-40 months), all patients are alive and free of recurrence. CONCLUSION: Liver cystadenomas can be easily misdiagnosed with other hepatic cystic lesions. An aggressive surgical approach is recommended, due to their malignant potential and high recurrence rate after fenestration.     

Suppressive therapy with levothyroxinefor solitary thyroid nodules

OBJECTIVE: To evaluate the effect of treatment with TSH suppressive dose of levothyroxine in patients with benign thyroid nodules. DESIGN: Prospective randomized study. Group A (n = 20) patients received levothyroxine and group B (n = 20) patients did not. The dose of levothyroxine was adjusted to obtain an effective suppression of TSH. A clinical, analytical and morphological (with ultrasound) review was performed every 3 months. The mean +/- SD follow-up period was 10.6 +/- 2.2 months. PATIENTS: Forty euthyroid women with solitary thyroid nodule on palpation, cold on scintigraphy and cytologically benign without contraindication participated. MEASUREMENTS: At entry: biochemical and hormonal parameters, thyroid scintigraphy and thyroid ultrasonography. Every 3 months additional determinations of thyroid hormones and TSH levels were carried out, if necessary, to verify effective TSH suppression. Every 6 months thyroid ultrasound imaging was performed. RESULTS: Patients were euthyroid at entry into the study. The mean dose of levothyroxine necessary to obtain TSH suppression was 2.82 +/- 0.6 micrograms/kg/day. No significant modification in the thyroid nodule diameter (mean +/- SD 2.6 +/- 1.2 vs 2.5 +/- 1.2 cm) or in the thyroid nodule volume (10.3 +/- 11.9 vs 10.1 +/- 12.2 ml) were observed in group A. In group B the results were similar (2.8 +/- 0.9 vs 2.7 +/- 1.8 cm and 9.2 +/- 6.4 vs 9.2 +/- 9.5 ml, respectively). No differences were found in either group in the number of nodules that reduced significantly their volume (four and three, respectively). CONCLUSIONS: The suppressive therapy with levothyroxine was not effective in reducing nodule sizes in patients with solitary benign thyroid nodules.     

Hot spotting surgical patients undergoing hepatopancreatic procedures

BackgroundThe burden of health care spending in the United States is a major concern, as health care costs have exponentially increased during the last three decades. The objective of the current study was to investigate the degree of cost-concentration among Medicare patients undergoing liver and pancreatic surgery.MethodsMedicare claims data from 2013 to 2015 were used to identify patients undergoing elective liver and pancreatic resections. Patients were divided into four groups: 1) non-complex pancreatic procedures; 2) complex pancreatic procedures; 3) non-complex liver procedures; and 4) complex liver procedures. Unadjusted price-standardized Medicare payments were calculated and payments were divided into quintiles. Patient-level factors associated with payments were analyzed by multivariable linear regression.ResultsA total of 17,125 patients were included in the study. Patients in the top quintile of spending accounted for over 40% of payments for all liver and pancreatic procedures. Patients with comorbidity scores ≥5, male sex, open surgical approach and a diagnosis of congestive heart failure were associated with higher costs.ConclusionPatients undergoing liver and pancreatic resections on the top 20% of payments were responsible for a disproportionate share of Medicare payments – over 40% of total expenditures. Overall hospital surgical volume was lower among the highest quintile of payments.     

Effect of vascular endothelial growth factor on hepatic regenerative activity following partial hepatectomy in rats.

BACKGROUND/AIMS: Vascular endothelial growth factor (VEGF) is an angiogenic factor with a growth-promoting effect that is thought to be restricted to vascular endothelial cells. Its essential role during liver regeneration has yet to be determined. The aim of this study was to document the effect of exogenous VEGF administration on liver regeneration in rats undergoing submaximal hepatic resections. METHODS: Adult male Sprague-Dawley rats (n = 4/group) undergoing 30% partial hepatectomy were administered 200 ng VEGF165 intravenously and were sacrificed at 24, 36, and 48 h postoperatively. Liver regeneration was monitored by measuring the restituted liver mass, proliferating cell nuclear antigen (PCNA) immunostaining, and hepatic PCNA protein by Western blot. RESULTS: Changes in restituted liver mass 48 h postsurgery were more prominent, but did not differ statistically between VEGF-treated and control rats (47% vs. 29%; p<0.06). Nevertheless, PCNA immunostaining showed increased labeling index of hepatocytes, apparent at 36 and 48 h after partial hepatectomy (38% vs. 18% [p<0.041 and 42% vs. 11% [p<0.021], respectively). Hepatic PCNA proteins measured by Western blot showed a 3-fold increase in VEGF-treated rats 48 h postsurgery compared with controls (p<0.01). CONCLUSION: Exogenous VEGF administration early after partial hepatectomy stimulates liver regeneration in rats. Whether or not VEGF165 is a direct mitogen for hepatocytes remains to be determined.