Impact of intra-operative ultrasonography in liver surgery.

BACKGROUND/OBJECTIVE: Intra-operative ultra-sonography (IOUS) during surgery for primary and metastatic hepatic tumors identifies additional lesions and helps in determining the most optimal surgical strategy. We assessed the impact of IOUS in liver surgery at our hospital, a tertiary-care cancer center. METHODS: Patients with potentially resectable hepatic tumors underwent surgical exploration. The relationship of the tumor with regard to the intrahepatic vasculature was determined by IOUS. A search was also made for additional lesions not detected by pre-operative imaging modalities. In appropriate cases, IOUS was also used to assist resection and radiofrequency ablation/ethanol injection. RESULTS: Between January 2003 and January 2005, 52 patients underwent surgery for primary or secondary hepatic tumors. IOUS was performed in 48 of these patients. It detected additional hepatic lesions in 14 patients (29.2%). IOUS contributed to changing the operative plan in 21 patients (43.8%). It was directly responsible for avoiding resection or ablation in 7 patients (14.6%), 5 of whom had multiple bilobar lesions, 1 had IOUS-guided biopsy that revealed caseating granuloma on frozen section, and 1 patient had no lesion on IOUS. Three patients had extent of resection changed based on IOUS findings. IOUS also guided radiofrequency ablation in 8 patients and ethanol injection in one patient. CONCLUSION: IOUS is an essential tool in surgery for hepatic tumors. In addition to accurate staging, it also aids in safe resection and radiofrequency ablation in appropriate cases.     

Avoiding Surgery in Patients With Colorectal Polyps

PURPOSE: Colonic polyps are sometimes difficult to remove endoscopically and are referred for surgical resection. This study was performed to determine how many polyps referred for surgery could actually be managed endoscopically. METHODS: An endoscopic database with data entered prospectively and consecutively was used to identify patients referred for surgery for a colonic polyp. Rectal polyps were excluded. All patients underwent colonoscopy before surgery to see if the polyp could be managed endoscopically. Cases were reviewed to see the method and outcome of treatment. RESULTS: The study population consists of 58 patients referred for surgical resection of a colorectal polyp. Endoscopic polypectomy was initially successful in 48. Five of the 48 needed surgery later for a final success rate of 43/58 avoiding surgery. There were no deaths, four complications of endoscopic polypectomy (three bleeds, one post-polypectomy syndrome) and two patients had complications of surgery (one splenic injury, one ventral hernia). Polyps ranged in size from 1.5 cm to 8.0 cm. Seven polyps contained invasive cancer (three needing surgical resection), eight contained intramucosal cancer (one operated) and 11 had severe dysplasia (three operated). Rate of persistent polyp was 16/37 at first follow up, 7/23 at second, 1/14 at third and 0/8 at fourth. CONCLUSION: Most polyps referred for surgical resection were successfully managed endoscopically. Patients with colonic polyps that are difficult or potentially dangerous to remove endoscopically should be sent for a second opinion before surgery is performed.     

For “difficult” benign colorectal lesions referred to surgical resection a second opinion by an experienced endoscopist is mandatory: A single centre experience

AIM: To assess how many patients with benign "difficult" colorectal lesions(DCRLs) referred to surgical resection, may be treated with endoscopic resection(ER) rather than surgical resection.METHODS: The prospectively collected colonoscopy database of our Endoscopic Unit was reviewed to identify all consecutive patients who, between July 2011 and August 2013, underwent an endoscopic reevaluation before surgical resection due to the presence of DCRLs with a histological confirmation of benignancy on forceps biopsy. ER was attempted when the lesion did not have definite features of deeply invasive cancer. The "nonlifting sign" excluded ER only in naive lesions without a prior attempted resection. Lesions were classified, using the Kyoto-Paris classification for mucosal neoplasia. For sessile and non-polypoid lesions the "inject and cut" resection technique was used. Pedunculated and semi-pedunculated lesions were transected at the stalk just below the polyps head and before or after resection, metal clips or a loop were applied on the stalk to prevent bleeding. The lesions were histologically classified according to the Vienna criteria and for the pedunculated lesions the Haggitt classification was used.RESULTS: Eighty-two patients(42 females, mean age 62 years) with 82 lesions(mean size 37 mm) were included in the study. Sixty-nine(84%) lesions were endoscopically resected, while 13 underwent surgical resection since ER was deemed unsuitable. On histology, cancer was found in 21/69 lesions(14 intramucosal, 7 sub-mucosal) and was associated with the size(P 0.001) and with type 0-Ⅱa +Ⅰs(P = 0.011) and 0-Ⅱa + Ⅱc(P 0.001) lesions. All patients with sub-mucosal cancer, underwent surgical resection. Complications occurred in 11/69 patients(7 bleedings, 2 transmural burn syndromes, 2 perforations), all managed endoscopically or conservatively, and were associated with presence of invasive cancer(P = 0.021). During follow-up recurrence/residual tissue was found in 14/51 sessile or non-polypoid lesions(13 treated endoscopically, 1 underwent surgical resection) and was associated with type 0-Ⅱa + Ⅰs lesions(P = 0.001), piecemeal resections(P = 0.01) and with lesion size(P = 0.004). Overall, 74% of patients avoided surgery. Surgical resection was significantly associated with type 0-Ⅱa + Ⅰs(P = 0.01) and 0-Ⅱa + Ⅱc(P = 0.001) lesions, with sub-mucosal invasion on histology(P 0.001), with presence of the "nonlifting sign"(P 0.001), and related to the dimension of the lesions(P = 0.001). In the logistic regression analysis, the only independent predictor for surgical resection was the dimension of the lesions(P = 0.002).CONCLUSION: Before submitting patients to surgical resection for a benign DCRL, a second opinion by an experienced endoscopist is mandatory to avoid unnecessary surgery.     

Endoscopic mucosal resection for treatment of early gastric cancer

BACKGROUND: In Japan, endoscopic mucosal resection (EMR) is accepted as a treatment option for cases of early gastric cancer (EGC) where the probability of lymph node metastasis is low. The results of EMR for EGC at the National Cancer Center Hospital, Tokyo, over a 11 year period are presented. METHODS: EMR was applied to patients with early cancers up to 30 mm in diameter that were of a well or moderately histologically differentiated type, and were superficially elevated and/or depressed (types I, IIa, and IIc) but without ulceration or definite signs of submucosal invasion. The resected specimens were carefully examined by serial sections at 2 mm intervals, and if histopathology revealed submucosal invasion and/or vessel involvement or if the resection margin was not clear, surgery was recommended. RESULTS: Four hundred and seventy nine cancers in 445 patients were treated by EMR from 1987 to 1998 but submucosal invasion was found on subsequent pathological examination in 74 tumours. Sixty nine percent of intramucosal cancers (278/405) were resected with a clear margin. Of 127 cancers without "complete resection", 14 underwent an additional operation and nine were treated endoscopically; the remainder had intensive follow up. Local recurrence in the stomach occurred in 17 lesions followed conservatively, in one lesion treated endoscopically, and in five lesions with complete resection. All tumours were diagnosed by follow up endoscopy and subsequently treated by surgery. There were no gastric cancer related deaths during a median follow up period of 38 months (3-120 months). Bleeding and perforation (5%) were two major complications of EMR but there were no treatment related deaths. CONCLUSION: In our experience, EMR allows us to perform less invasive treatment without sacrificing the possibility of cure.     

Endoscopic Therapy of Early Colorectal Cancer (pT1) - A Prospective Study

INTRODUCTION: In a prospective study initiated in 1982, we have been investigating the question as to whether - and if so, which - pT1 carcinomas of the colorectum can be treated exclusively via the endoscope. METHOD: In the period between February 1, 1982 and April 30, 2001, a total of 5,470 polyps were removed endoscopically at the Medical Department I of the Klinikum Ludwigsburg. Among these lesions, a total of 144 (2.6 %) pT1 carcinomas were found in 141 patients. We were able to follow 120 patients with 123 pT1 carcinomas over a mean follow-up period of 46 months (range: 1-60). In low-risk situations (definitive removal in healthy tissue, G1-G2, no lymphatic involvement), endoscopic treatment alone usually represented sufficient treatment. In high-risk cases (removal in healthy tissue uncertain or negative, and/or lymphatic vessel involvement, and/or G3/G4), subsequent surgical resection was carried out. RESULTS: 64 cases were classified as high-risk, 59 as low-risk. Nevertheless, 9 patients with 10 low-risk carcinomas were submitted to surgery (young age, patient's own request). In none of these 10 cases was residual tumour or lymph node metastasis detected in the surgical specimen. 47 patients with 49 low-risk carcinomas were treated solely by endoscopic polypectomy using the diathermy snare, and 45 patients with 47 carcinomas remained recurrence-free during the follow-up period. In a single case, a local recurrence was detected 2 months after polypectomy and underwent curative resection. In another case, peritoneal carcinosis with tumour infiltrating into the colon developed 8 months after initial treatment; this, however, was most probably a recurrence of a previously operated carcinoma of the uterus. Among the high-risk cases, 10 were not submitted to surgery on account of advanced age and/or rejection of an operation by the patient; all remained recurrence-free. Among the surgically treated high-risk carcinomas, 3 surgical specimens contained residual tumour, while 2 revealed a lymph node metastasis. In our group of patients, no tumour-related mortality was seen among endoscopically treated patients. DISCUSSION: In the light of the fact that the reported mortality rate associated with open surgery for colorectal carcinoma is 3 % as compared with about 1 % risk of lymph node metastasis and 0,1 % mortality rate for the endoscopic modality, endoscopic removal of a pT1 tumour in a low-risk situation followed by appropriate surveillance can be considered as adequate treatment.     

平坦型大肠肿瘤内镜下浸润深度的判断与治疗方式的选择

目的探讨内镜在平坦型大肠肿瘤浸润深度判断及治疗方式选择中的作用。方法222例大肠平坦型病变根据腺管开口类型及空气介导变形试验和抬举试验判断肿瘤浸润深度,空气介导变形试验和抬举试验均为阳性选择内镜下治疗,否则行手术治疗。经内镜或外科手术切除的标本均完整送检,按WHO的病理学标准做出组织病理学诊断。计算空气介导变形试验和抬举试验判断肿瘤浸润深度的敏感度、特异度、阳性预测值、阴性预测值和准确度。结果空气介导变形试验和抬举试验阳性者212例,其中192例行内镜黏膜切除术（EMR）,15例行内镜下黏膜分片切除术（EPMR）,2例行EPMR＋外科手术治疗,3例行手术治疗。空气介导变形试验和（或）抬举试验阴性者10例,4例行手术治疗。空气介导变形试验和抬举试验判断肿瘤浸润深度的敏感度为97．2％,特异度为44．4％,阳性预测值为97．6％,阴性预测值为40．0％。结论空气介导变形试验和抬举试验可大致判断平坦型大肠肿瘤浸润深度,指导即时的治疗方式选择,有利于防止过度治疗或治疗不足。     

Radical operation for recurring gastric carcinoma

BACKGROUND/AIMS: The effectiveness of surgical treatment for recurring gastric carcinoma is unclear. We conducted a retrospective review of our results with a radical surgical approach to the treatment of gastric cancer metastases. METHODOLOGY: Nine patients who underwent radical resection of recurring gastric cancer between 1990 and 2003 were examined and follow-up was completed by March 2003. RESULTS: The surgically removed recurring sites included local lesions (4 patients), as well as metastases in the liver (4 patients) and ovary (1 patient). There were no major complications or operative deaths. The mean operative time was 380 minutes; the mean intraoperative blood loss was approximately 525mL and the mean volume of transfused blood was 178mL. Re-recurrence appears in 8 patients between 1.5 and 26 months (average 8.5 months) following surgical resection. The sites of re-recurrence included the peritoneum, liver, lymph nodes, bone, as well as local lesions. One patient currently shows no evidence of disease more than 6 years after resection of the local recurrence. Two other patients remain alive, but presented with re-recurrence at 4 and 10 months postoperatively. The remaining 6 patients died of cancer between 2 and 28 months after surgery for recurring lesions. CONCLUSIONS: Radical surgery for recurring gastric cancer both liver and extrahepatic lesions is a safe treatment with a good prognosis for long-term survival in a select patient subpopulation.     

Detection and treatment of synchronous lesions in colorectal cancer： The clinical implication of perioperative colonoscopy

AIM： To evaluate the clinical significance of preand intra-operative colonoscopy for the detection of synchronous lesions in colon cancer.
METHODS： Two hundred and sixty-five pre-operative and 51 intra-operative colonoscopic evaluations were performed in 316 colorectal cancer patients who underwent curative resection from January 2001 to June 2006. The incidence and characteristics of synchronous lesions and their influence on surgery were evaluated.
RESULTS： Two hundred and eighty-two synchronous lesions were detected in 124 （39.2%） of 316 patients including all lesions regardless of their histologic type. True adenomatous polyps were found in 91 （28.8%） of 326 patients, and 27 （5.4% of all patients） patients had synchronous colon cancers. The preoperative identification of synchronous lesions altered the planned surgery in 37 （14.0%） of 265 patients. In 18 patients among the surgically removed cases, the lesions were removed by extending the resection range. Further segmental resection or polypectomy through enterotomy was necessary in 29 patients. Nineteen （37.2%） of 52 intraoperative colonoscopy cases had synchronous lesions. Additional surgical procedures including segmental bowel resection and polypectomy with enterotomy were necessary in 7 （23.7%） of 52 intraoperative colonoscopy cases to remove the lesions.
CONCLUSION： Synchronous colorectal polyps or cancer are frequent and their preoperative detection is important for optimal surgical planning and treatment. Intraoperative colonoscopy is a useful option in cases where a preoperative colonoscopy is not feasible.     

Pulmonary metastasectomy following chemotherapy in patients with testicular tumors: experience in 52 patients

BACKGROUND: Surgical resection is an important form of treatment for residual post-chemotherapy pulmonary masses in patients with non-seminomatous germ cell tumors. We analyzed the outcome and prognostic factors after surgery. METHODS: Between 1996 and 2001, 52 patients underwent pulmonary resection of thoracic masses following cisplatin-based chemotherapy. These patients' records were subsequently reviewed. RESULTS: The overall 5-year survival rate was 75.8 %. A significantly longer survival was observed using multivariate analysis in patients with normal serum AFP and/or hCG tumor marker levels and after complete surgical resection. In patients with viable malignant tumor cells in the resected specimen and in patients with only necrosis/fibrosis or teratoma, the 5-year survival rates were 49.6 % and 82.8 %, respectively. This difference was only statistically significant in univariate analysis. CONCLUSIONS: We conclude that pulmonary resection in metastatic non-seminomatous germ cell tumors is a safe and effective treatment modality. Incomplete resection and elevated tumor marker levels, AFP and/or hCG, were identified as prognosis-related criteria for a poor outcome in multivariate analysis.     

Endoscopic mucosal resection for early esophageal cancer and esophageal dysplasia

BACKGROUND/AIMS: Advances in diagnostic technology have led to increased detection of early esophageal cancer, which is suitable for endoscopic treatment. We performed endoscopic esophageal mucosal resection of such cancer and dysplasia using the endoscopic esophageal mucosal resection tube and evaluated the clinical benefit of this technique. METHODOLOGY: Twenty-nine patients with esophageal mucosal cancer (27 cases with 33 lesions) or dysplasia (2 cases with 2 lesions) diagnosed between September 1992 and March 1998 were assessed endoscopically for the depth and extent of invasion by double staining with toluidine blue and iodine. Endoscopic ultrasonography was also performed to assess the depth of invasion in 22 cases with 22 lesions. RESULTS: The 35 esophageal lesions comprised 27 esophageal carcinomas and 8 areas of dysplasia. Twenty of the 35 lesions were resected en bloc and 15 were resected piecemeal. Subsequent surgery was performed for 5 cases with 7 lesions out of 10 cases with 15 lesions that were histopathologically diagnosed as m3 or more invasive. No recurrence has been detected in 24 evaluable cases (including 1 who died of another disease, 2 in whom surgery could not be performed due to complications, and 3 who refused subsequent surgery). No patients died of esophageal cancer after a mean follow-up period of 30.9 +/- 18.9 months. The 4-year survival rate was 100% in the m2 or less invasive group of 19 cases with 20 lesions, 75% in the m3 or higher invasive group of 5 cases with 8 lesions and 100% in the surgery group of 5 cases with 7 lesions (NS). No serious complications occurred except for 1 patient. Circumferential mucosal resection was done in this patient, resulting in esophageal stenosis, which responded to esophageal dilation. CONCLUSIONS: Esophageal mucosal resection using the endoscopic esophageal mucosal resection tube is safe and beneficial for early esophageal cancer and dysplasia.     

Endoscopic management of duodenal diverticular bleeding

BACKGROUND: Although the presence of a duodenal diverticulum is usually asymptomatic, bleeding in this tissue is sometimes difficult to diagnose and treat. OBJECTIVE: To investigate the strategy for treatment, we reviewed the clinical data of patients diagnosed and treated for duodenal diverticular bleeding. DESIGN: Retrospective case series. SETTING: Single tertiary-referral center. PATIENTS: Seven consecutive patients with bleeding from a duodenal diverticulum (mean age, 73.7 +/- 3.4 years old). INTERVENTIONS: The clinical characteristics, endoscopic findings, and treatment strategy for duodenal diverticular bleeding. MAIN OUTCOME MEASUREMENTS: All 7 patients achieved hemostasis. Six of 7 patients were treated endoscopically. There were no complications with endoscopic treatment. RESULTS: Three patients bled from diverticula located at the second portion of the duodenum, and 4 patients bled from that located at the third portion. In 6 of 7 patients, lesions were identified and treated endoscopically with hemoclips, hypertonic saline solution and epinephrine (HSE), and/or 1% polidocanol injection. In 1 case, the lesion could not be detected during the first endoscopic examination, and the patient, therefore, was treated with transarterial embolization followed by surgical resection. LIMITATIONS: This preliminary case series described the feasibility of the endoscopic treatment. However, optimal management, including angiography and/or surgery, should be individualized to the patients, location, and type of hemorrhage. CONCLUSIONS: Bleeding from a duodenal diverticulum should be considered in the case of upper-GI bleeding of unknown origin. An endoscopy may be an effective alternative to surgery in the management of a bleeding duodenal diverticulum.     

Endoscopic ultrasound-assisted endoscopic resection of carcinoid tumors of the gastrointestinal tract.

INTRODUCTION: Usually found in the gastrointestinal tract, carcinoids are the most frequent neuroendocrine tumors. Most of these lesions are located in areas that are difficult to access using conventional endoscopy (small intestine and appendix); carcinoid tumors found in the gastroduodenal tract and in the large intestine can be studied endoscopically; in these cases, if localized disease is confirmed, local treatment by endoscopic resection may be the treatment of choice. Since endoscopic ultrasonography has been shown to be the technique of choice for the study of tumors exhibiting submucosal growth, the selection of patients who are candidates for a safe and effective local resection should be based on this technique. PATIENTS AND METHOD: We selected patients with gastrointestinal carcinoid tumors who were endoscopically treated between 1997 and 2002. Those patients with tumors measuring less than 10 mm, which had not penetrated the muscularis propria, and those with localized disease were considered candidates for endoscopic resection. The endpoints of this study were to assess the effectiveness (complete resection) and safety (complications) of the technique. Follow-up consisted of eschar biopsies performed one month and twelve months after the resection. RESULTS: During the aforementioned period, we resected endoscopically 24 tumors in 21 patients (mean age: 51.7 years; 71.5% males). Most lesions were incidental discoveries made during examinations indicated for other reasons. Resection was indicated in most cases as a result of the suspected presence of a carcinoid tumor after endoscopic ultrasonography. Endoscopic ultrasonography also enabled us to clearly identify the layer where the lesion had originated, as well as the size of the lesion. The carcinoid tumor was removed in 13 cases (54.2%) by using the conventional snare polypectomy technique, in 9 cases (37.5%) assisted by a submucosal injection of saline solution and/or adrenaline, and in 2 cases (8.3%) after ligating the lesion with elastic bands. In all cases the resection was complete, with no recurrence during the follow-up period, and no major complications, except for a single case in which a post-polypectomy hemorrhage occurred that was endoscopically solved. CONCLUSIONS: In properly selected patients, the endoscopic resection of carcinoid tumors is a safe and effective technique that permits a complete resection in all cases with few complications. Endoscopic ultrasonography is the technique of choice for selecting the patients who are candidates for endoscopic resection.     

Long-term outcomes after treatment for T1 colorectal carcinoma

Purpose

Long-term outcomes of patients with T1 colorectal carcinoma (CRC) treated by endoscopic resection (ER) or surgical resection are unclear in relation to the curative criteria in the Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines. The aim of this study was to retrospectively compare the long-term outcomes among patients with T1 CRC in relation to the treatment methods.

Methods

We examined 322 T1 CRC cases treated between January 1992 and August 2008 at Hiroshima University Hospital. Patients who did not meet the curative criteria in the JSCCR guidelines were defined as “non-endoscopically curable” and classified into three groups: underwent ER alone (group A: 45 patients), underwent additional surgery after ER (group B: 106 patients), and underwent surgical resection alone (group C: 92 patients).

Results

Of the 322 T1 CRC patients, 79 were categorized as endoscopically curable and 243 as non-endoscopically curable. Among the endoscopically curable T1 CRC patients, recurrence and 5-year OS rates were 0 and 94.2 %, respectively. In groups A, B, and C, recurrence rates were 4.4, 6.6, and 4.3 %, and OS rates were 85.6, 95.1, and 96.3 %, respectively (p?<?0.05). Local recurrence or distant/lymph node metastasis was observed in 13 patients (group A: 2; group B: 7; group C: 4). Death due to primary CRC occurred in six patients (group B: 4; group C: 2).

Conclusion

Long-term outcomes support the curative criteria according to the JSCCR guidelines. ER for T1 CRC did not worsen clinical outcomes in cases that required additional surgical resection.

     

Endorectal Ultrasound in the Management of Patients With Malignant Rectal Polyps

PURPOSE This study was designed to determine the efficacy of endorectal ultrasound in the management of patients with malignant rectal polyps removed by snare excision during colonoscopy.METHODS A retrospective review of the medical records and endorectal ultrasound images of 63 patients with endoscopically removed rectal polyps containing invasive adenocarcinoma subsequently staged by endorectal ultrasound. Patients underwent surgery or were followed at a single institution. The polyp characteristics and ultrasound images were compared with the presence of residual tumor in the surgical specimen in patients who underwent further surgery or with recurrence in patients who did not.RESULTS The morphology of the polyps was described in 31 patients (49 percent); they were sessile in 26 (41 percent) and pedunculated in 6 (9 percent). The margins were positive in 22 patients (35 percent), negative in 19 (30 percent), and not specified in 22 (35 percent). Most tumors were well or moderately differentiated; only 3 (5 percent) were poorly differentiated. Thirty-three patients underwent further surgery (3 low anterior resection, and 30 transanal excision); 30 had no further surgery. The accuracy of endorectal ultrasound in assessing the presence of residual cancer in the rectal wall in patients who had surgery was 54 percent, with a 39 percent positive predictive value and 65 percent negative predictive value. Endorectal ultrasound accurately identified metastatic lymph nodes in two of three patients who had radical surgery. Endorectal ultrasound was more useful than polyp morphologic or histologic criteria to determine the presence of residual cancer in the rectal wall.CONCLUSIONS Endorectal ultrasound does not definitely exclude the possibility of residual tumor in the rectal wall or mesenteric nodes of patients who had a malignant polyp snared endoscopically. Consequently, decisions regarding the definitive management of these patients cannot be based exclusively on the endorectal ultrasound images of the polypectomy site.Reprints are not available.Read at the meeting of the Minnesota Surgical Society, St. Paul, Minnesota, May 5, 2000.     

Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury

AIM:To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury.METHODS:From a prospective database of patients treated for benign biliary strictures at our hospital,cases that underwent liver resections were reviewed.All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy(open or laparoscopic).Liver resection was indicated in patients with Strasberg E3/E4(hilar stricture)bile duct lesions associated with vascular damage(arterial and/or portal),ipsilateral liver atrophy/abscess,recurrent attacks of cholangitis,and failure of previous hepaticojejunostomy.RESULTS:Of 148 patients treated for benign biliary strictures,nine(6.1%)underwent liver resection;eight women and one man with a mean age of 38.6 years.Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery.The mean number of surgical procedures before definitive treatment was 2.4.All patients had Strasberg E3/E4injuries,and vascular injury was present in all cases.Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality.Mean time of follow up was 69.1 mo and after longterm follow up,eight patients are asymptomatic.CONCLUSION:Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.     

Surveillance of colorectal cancer

PURPOSE: The authors evaluate the effectiveness of routine colonoscopy and marker evaluation in diagnosis of intraluminal recurrent cancer. METHODS: Chart review was conducted on 481 patients who underwent curative resection for colorectal cancer between 1980 and 1990. Clinical visits were scheduled and carcinoembryonic antigen evaluation was performed every three months, and colonoscopy was performed preoperatively, 12 to 15 months after surgical treatment, and then with intervals of 12 to 24 months or when symptoms appeared. RESULTS: About 10 percent of patients developed intraluminal recurrences. More than one-half of metachronous lesions arose within the first 24 months, and median time to diagnosis was 25 months. Patients with left-sited tumors in the advanced stage had a higher risk of developing recurrent intraluminal disease. Twenty-nine patients underwent a second surgical operation, of which 17 cases were radical. In this group, the five-year survival was 70.6 percent, although no nonradically treated or nonresected patients survived longer than 31 months. Twenty-two patients were asymptomatic at time of diagnosis of recurrence, and of these, 12 patients underwent radical operation; on the other hand, of the 24 symptomatic patients, only 5 were treated radically. Carcinoembryonic antigen was the first sign of recurrence in eight cases. Colonoscopy must be performed within the first 12 to 15 months after operation, whereas an interval of 24 months between examinations seems sufficient to guarantee early detection of metachronous lesions. CONCLUSION: Serial tumor marker evaluation is of help in earlier diagnosis of local recurrences. Asymptomatic patients more frequently undergo another operation for cure and thus have a better survival rate.     

Recurrent colorectal cancer after endoscopic resection when additional surgery was recommended

AIM: To evaluate the type of recurrence after endoscopic resection in colorectal cancer patients and whether rescue was possible by salvage operation.METHODS: Among 4972 patients who underwent surgical resection at our institution for primary or recurrent colorectal cancers from January 2005 to February 2015, we experienced eight recurrent colorectal cancers after endoscopic resection when additional surgical resection was recommended.RESULTS: The recurrence patterns were: intramural local recurrence(five cases), regional lymph node recurrence(three cases), and associated with simultaneous distant metastasis(three cases). Among five cases with lymphatic invasion observed histologically in endoscopic resected specimens, four cases recurred with lymph node metastasis or distant metastasis. All cases were treated laparoscopically and curative surgery was achieved in six cases. Among four cases located in the rectum, three cases achieved preservation of the anus. Postoperative complications occurred in two cases(enteritis).CONCLUSION: For high-risk submucosal invasive colorectal cancers after endoscopic resection, additional surgical resection with lymphadenectomy is recommended, particularly in cases with lymphovascular invasion.     

Surgical treatment of 42 patients with cerebral cschistosomiasis caused by Schistosoma japonicum

目的 目的 探讨脑型血吸虫病外科治疗效果。方法 方法 回顾性分析42例由日本血吸虫感染引起的脑型血吸虫病患者病例资 料, 评估外科手术治疗脑型血吸虫病效果。结果 结果 25例患者接受血吸虫性肉芽肿全切除术, 17例患者因病灶累及功能区或2个以 上脑叶而接受血吸虫性肉芽肿全切除术。术中无患者死亡。术后随访发现, 31例患者完全恢复, 且能正常工作、 生活; 2例肢体轻 度麻木; 3例术后癫痫发作; 2例死于血吸虫性肝硬化; 1例自然死亡。结论 结论 外科手术是一种有效治疗脑型血吸虫病的方法。     

Hepatic primary and secondary malignancies: comparison of helical CT and helical CT during arterial portography

BACKGROUND/AIMS: To compare the sensitivity of helical CT to that of helical CT arterial portography in the detection of hepatic primary or secondary malignancies, in 20 patients who subsequently underwent surgery to confirm findings. METHODOLOGY: Twenty patients with suspected primary hepatic or secondary malignancies who all underwent helical CT and helical CT arterial portography preoperatively were prospectively evaluated. All the images were reviewed by two radiologists. The results were subsequently correlated with surgical and pathological findings. The sensitivity and the positive predictive values for lesion detection were determined for each modality. RESULTS: There were 39 pathologically confirmed hepatic malignant lesions. The overall sensitivity and positive predictive value of helical CT arterial portography were 87.1% and 82.5%, respectively, while of helical CT were 84.6% and 94.2%, respectively. CONCLUSIONS: Helical CT arterial portography and helical CT of the liver were approximately equivalent for lesion detection in patients who were evaluated preoperatively for resection of liver malignancies. The lower cost and non-invasive nature of helical CT suggest that it should be the preferred modality.     

Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus

BACKGROUND: The aim of this study was to prospectively evaluate endoscopic resection (ER) combined with photodynamic therapy (PDT) for the treatment of selected patients with early neoplasia in Barrett's esophagus. METHODS: Patients with Barrett's esophagus and neoplastic lesions <2 cm in diameter and no sign of submucosal infiltration, positive lymph nodes, or distant metastasis underwent diagnostic ER (cap technique). Patients with a T1sm tumor in the resection specimen were referred for surgery; those with a T1m or a less invasive tumor underwent additional endoscopic therapy (ER, PDT, and/or argon plasma coagulation [APC]), or they were followed. PDT was performed with 5-aminolevulinic acid and a light dose of 100 J/cm 2 at lambda = 632 nm. RESULTS: Thirty-three patients underwent diagnostic ER. Endoscopic treatment was not performed in 5 patients, who underwent surgery (4 T1sm; 1, patient preference). Five patients were immediately entered into a follow-up protocol, and 23 received additional endoscopic treatment (13 additional ER, 19 PDT, 3 APC). Endoscopic treatment was successful in 26/28 patients; no severe complication was observed. During follow-up (median 19 months, range 13-24 months), 5/26 patients had a recurrence of high-grade dysplasia: all were successfully re-treated with ER. At the end of follow-up, 26/33 originally enrolled patients (79%) and 26/28 endoscopically treated patients (93%) were in local remission. CONCLUSIONS: Endoscopic therapy is safe and effective for selected patients with early stage neoplasia in Barrett's esophagus.