Usefulness of Contrast-Enhanced Intraoperative Ultrasonography (CE-IOUS) in Patients with Colorectal Liver Metastases after Preoperative Chemotherapy

Aims

The aim of this study was to evaluate the ability of contrast-enhanced intraoperative ultrasonography to detect colorectal liver metastases after preoperative chemotherapy compared with intraoperative ultrasound and preoperative imaging techniques.

Methods

From January 2010 to December 2011, 28 patients with colorectal liver metastases underwent intraoperative ultrasonography and contrast-enhanced intraoperative ultrasonography during hepatectomy following preoperative chemotherapy. The findings were compared to preoperative imaging using contrast-enhanced ultrasonography, computed tomography, magnetic resonance imaging, and/or fluorodeoxyglucose positron emission tomography.

Results

Preoperative imaging techniques detected 58 metastatic lesions in 28 patients. In 32 % of patients (n?=?9), intraoperative ultrasound detected 24 missed hepatic nodules. In 14 % of patients (n?=?4), contrast-enhanced intraoperative ultrasonography detected an additional six nodules and change in operative management occurred in 18 % of patients. Using univariate analysis, we found three factors significantly related to detection of additional metastases with contrast-enhanced intraoperative ultrasonography: three or more metastases before chemotherapy (p?=?0.047), resolution of at least one metastasis (p?=?0.011), and small liver metastases (largest lesion size ≤20 mm) after chemotherapy (p?=?0.007).

Conclusion

In patients undergoing surgery for colorectal liver metastases after chemotherapy, contrast-enhanced intraoperative ultrasonography improved both the sensitivity of intraoperative ultrasonography to detect liver metastases and the R0 hepatic resection rate.     

Surgical Outcomes and Prognostic Factors for T2 Gallbladder Cancer Following Surgical Resection

Background

Depth of tumor invasion is an important prognostic factor for gallbladder cancer. The aim of this study was to investigate the clinicopathological prognostic factors of T2 gallbladder cancer.

Methods

We retrospectively reviewed the clinicopathological data and survival for 83 patients with T2 gallbladder cancers who underwent surgical resection between January 1995 and December 2007.

Results

The overall survival rates were 48.9% at 3 years and 29.3% at 5 years. Univariate analysis revealed that R0 resection (P?<?0.001), extended surgery (P?=?0.028), lymph node dissection (P?=?0.024), non-infiltrative tumors (P?=?0.001), well differentiation (P?=?0.001), absence of lymphatic (P?=?0.025), perineural (P?=?0.001), and vascular (P?=?0.025) invasion, absence of lymph node metastasis (P?=?0.001), negative resection margin (P?=?0.016), and stage (P?=?0.002) were significantly better predictors for survival. A significant difference in survival between Rx and R1 was not found. R0 resection, lymph node dissection, well differentiation, and absence of perineural and vascular invasion were significantly independent prognostic factors for overall survival. Recurrence occurred in 48 patients (57.8%). Age older than 65 years, R0 resection, non-infiltrative tumors, and good differentiation were significant independent predictors of disease-free survival by multivariate analysis.

Conclusions

For T2 tumors, radical surgery including lymph node dissection should be performed to achieve R0 resection. Tumors with infiltrative types and suspicious lymph node metastasis in the intraoperative findings were candidates for aggressive surgical management to improve patient survival.     

Neither Neoadjuvant nor Adjuvant Therapy Increases Survival After Biliary Tract Cancer Resection with Wide Negative Margins

Background

We investigated the role of neoadjuvant/adjuvant therapies on survival for resectable biliary tract cancer. We hypothesized that neoadjuvant and adjuvant therapy should improve the survival probability in these patients.

Methods

This was a retrospective review of a prospective database of patients resected for gallbladder cancer (GBC) and cholangiocarcinoma (CC). One hundred fifty-seven patients underwent resection for primary GBC (n?=?63) and CC (n?=?94). Fisher??s exact test, Student??s t test, the log-rank test, and a Cox proportional hazard model determined significant differences.

Results

The 5-year overall survival rate after resection of GBC and CC was 50.6 % and 30.4?%, respectively. Of the patients, 17.8?% received neoadjuvant chemotherapy, 48.7?% received adjuvant chemotherapy, while 15.8?% received adjuvant chemoradiotherapy. Patients with negative margins of at least 1?cm had a 5-year survival rate of 52.4?% (p?<?0.01). Adjuvant therapy did not significantly prolong survival. Neoadjuvant therapy delayed surgical resection on average for 6.8?months (p?<?0.0001). Immediate resection increased median survival from 42.3 to 53.5?months (p?=?0.01).

Conclusions

Early surgical resection of biliary tract malignancies with 1?cm tumor-free margins provides the best probability for long-term survival. Currently available neoadjuvant or adjuvant therapy does not improve survival.     

Preoperative Cholangitis and Metastatic Lymph Node Have a Negative Impact on Survival After Resection of Extrahepatic Bile Duct Cancer

Background

The significance of the presence of preoperative inflammation for the prognosis of patients with extrahepatic bile duct cancer (BDCA) was evaluated.

Methods

The clinical data of 84 patients who underwent surgery for BDCA from August 2003 to May 2009 were reviewed, and survival analysis was performed. The patients were classified into two groups according to the presence of preoperative cholangitis: Group A had no cholangitis (n?=?59), and group B had cholangitis (n?=?25).

Results

There were no differences in sex, mean age, TNM stage, biliary drainage, type of resection, or radicality between the two groups (p?>?0.05). The 3-year disease-specific survival (DSS) and disease-free survival (DFS) rates for the group B patients (21.5 and 11.9?%, respectively) were significantly lower than those for the group A patients (66.1 and 57.3?%, respectively; p?=?0.013 and 0.001, respectively). The multivariate analysis showed that preoperative inflammation and lymph node metastasis were the independent prognostic factors for both overall survival (OS) [p?=?0.021, relative risk (RR)?=?2.224 and p?=?0.015, RR?=?2.367, respectively] and DFS (p?=?0.014; RR?=?2.192 and p?=?0.013; RR?=?2.240, respectively). The rates of angiolymphatic and perineural invasion were higher for group B than those for group A (p?=?0.016 and 0.030, respectively).

Conclusions

The presence of preoperative inflammation is an independent poor prognostic factor for OS and DFS for patients with BDCA.     

Resection rectopexy—laparoscopic neuromapping reveals neurogenic pathways to the lower segment of the rectum: preliminary results

Purpose

Nerve sparing in functional pelvic floor surgery is strongly recommended as intraoperative damage to the autonomic nerves may predispose to persistent or worsened anorectal and urogenital function. The aim of this study was to investigate the intraoperative neural topography above the pelvic floor in patients undergoing laparoscopic resection rectopexy in combination with electrophysiologic neuromapping.

Methods

Ten consecutive female patients underwent laparoscopic resection rectopexy for rectal prolapse. Intraoperative identification of pelvic autonomic nerves was carried out with a novel intraoperative neuromonitoring system based on electric stimulation under simultaneous electromyography of the internal anal sphincter and manometry of the bladder. Neuromonitoring results were compared to patients' preoperative anorectal and urogenital function and their functional results at the 3-month follow-up.

Results

Laparoscopy in combination with electrophysiologic neuromapping revealed neurogenic pathways to the lower segment of the rectum during surgical mobilization. In all procedures, intraoperative neuromonitoring finally confirmed functional nerve integrity to the internal anal sphincter and the bladder. Patients with preoperatively diagnosed fecal incontinence were continent at the 3-month follow-up. The Wexner score improved in median from preoperative 4 (range 1–18) to 1 (range 0–3) at follow-up (p?=?0.012). Cleveland Clinical Constipation Score improved in median from 10 (range 5–17) to 3 (range 1–7; p?=?0.005). In none of the investigated patients a new onset of urinary dysfunction did occur. No change in sexual function was observed.

Conclusions

Laparoscopy in combination with electrophysiologic neuromapping during nerve-sparing resection rectopexy identified and preserved neurogenic pathways heading to the lower segment of the rectum above the level of the pelvic floor.     

Gastrectomy in Advanced Gastric Cancer Effectively Palliates Symptoms and May Improve Survival in Select Patients

Background

The role of gastrectomy in the face of incurable gastric cancer is evolving. We sought to evaluate our experience with incomplete (i.e., R2) gastrectomy in advanced gastric cancer.

Methods

We reviewed 210 locally advanced or metastatic gastric cancers (1992–2008). Patient characteristics and outcomes were compared between three groups: gastrectomy (N?=?99), exploration without resection (N?=?66), and no surgery (N?=?45).

Results

Clinicopathologic characteristics were similar between groups. Symptoms successfully resolved after gastrectomy in 48 % with a complication rate of 32 % and mortality of 6 %. Overall median survival for all patients was 6.2 months: 10.0 months after gastrectomy, 4.1 months after exploration without resection, and 5.3 months for no surgery (p?<?0.001). Perioperative complications were the only predictor of symptom resolution following resection (OR?=?0.175). Resolution of symptoms (p?<?0.001, Hazards Ratio (HR)?=?0.09) and preoperative nausea/vomiting (p?=?0.017, HR?=?0.55) improved survival, while linitis plastica (p?=?0.035, HR?=?4.05) and spindle cell morphology (p?=?0.011, HR?=?1.98) were predictors of poor survival in patients undergoing resection.

Conclusions

Gastrectomy in the setting of advanced gastric cancer may be useful in up to half of patients with an acceptable perioperative mortality rate. Symptom resolution offers a potential survival advantage but is dependent upon a complication-free course, so should only be considered selectively.     

What is the importance of “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture?

Summary

We investigated the importance, risk factors, and clinical course of the radiolucent “halo” phenomenon around bone cement following vertebral augmentation for osteoporotic compression fracture. Preoperative osteonecrosis and a lump cement pattern were the most important risk factors for the peri-cement halo phenomenon, and it was associated with vertebral recollapse.

Introduction

We observed a newly developed radiolucent area around the bone cement following vertebral augmentation for osteoporotic compression fractures. Here, we describe the importance of the peri-cement halo phenomenon, as well as any associated risk factors and long-term sequelae.

Methods

In total, 175 patients (202 treated vertebrae) were enrolled in this study. The treated vertebrae were subdivided into two groups: Group A (with halo, n?=?32) and Group B (without halo, n?=?170), and the groups were compared with respect to multiple preoperative (age, sex, BMD, preoperative osteonecrosis) and perioperative factors (operative approach: vertebroplasty or kyphoplasty; cement distribution pattern; cement leakage; cement volume), and postoperative results (VAS score, recollapse). Logistic regression analysis was used to evaluate the relationship between the incidence of the peri-cement halo and all of the parameters described above.

Results

Rates of osteonecrosis were also significantly higher in Group A than in Group B (62.5% vs. 31.2%, p?p?p?p?p?=?0.001), KP (OR?=?3.630; 95% CI?=?1.628–8.095; p?=?0.002), lump pattern (OR?=?13.870; 95% CI?=?2.907–66.188; p?=?0.001), and vertebral recollapse (OR?=?5.356; 95% CI?=?1.897–15.122; p?=?0.002) were significantly associated with peri-cement halo.

Conclusions

The peri-cement halo was found to be associated with vertebral recollapse, this sign likely represents a poor prognostic factor after vertebral augmentation for osteoporotic compression fractures.     

Greater Complexity of Liver Surgery is Not Associated with an Increased Incidence of Liver-Related Complications Except for Bile Leak: An Experience with 2,628 Consecutive Resections

Background

Advances in technique, technology, and perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The purpose of this study was to determine if this increasing complexity has been accompanied by a rise in liver-related complications.

Methods

A large prospective single-institution database of patients who underwent hepatic resection was used to identify the incidence of liver-related complications. Liver resections were divided into an early era and a late era with equal number of patients (surgery performed before or after 18 May 2006). Patient characteristics and perioperative factors were compared between the two groups.

Results

Between 1997 and 2011, 2,628 hepatic resections were performed, with a 90-day morbidity and mortality rate of 37 and 2 %, respectively. We identified higher rates of repeat hepatectomy (12.2 vs 6.1 %; p?<?0.001), two-stage resection (4.0 vs 1 %; p?<?0.001), extended right hepatectomy (17.6 vs 14.6 %; p?=?0.04), and preoperative portal vein embolization (9.1 vs 5.9 %; p?<?0.001) in the late era. The incidence of perihepatic abscess (3.7 vs 2.1 %; p?=?0.02) and hemorrhage (0.9 vs 0.3 %; p?=?0.045) decreased in the late era and the incidence of hepatic insufficiency (3.1 vs 2.6 %; p?=?0.41) remained stable. In contrast, the rate of bile leak increased (5.9 vs 3.7 %; p?=?0.011). Independent predictors of bile leak included bile duct resection, extended hepatectomy, repeat hepatectomy, en bloc diaphragmatic resection, and intraoperative transfusion.

Conclusions

The complexity of liver surgery has increased over time, with a concomitant increase in bile leak rate. Given the strong association between bile leak and other poor outcomes, the development of novel technical strategies to reduce bile leaks is indicated.     

Reoperations for primary hyperparathyroidism—improvement of outcome over two decades

Purpose

Reoperations (R-PTX) for primary hyperparathyroidism (pHPT) are challenging, since they are associated with increased failure and morbidity rates. The aim was to evaluate the results of reoperations over two decades, the latter considering the implementation of Tc^99msestamibi-SPECT (Mibi/SPECT), intraoperative parathormone (IOPTH) measurement, and intraoperative neuromonitoring (IONM).

Patients and methods

Data of 1,363 patients who underwent surgery for pHPT were retrospectively analyzed regarding reoperations. Causes of persistent (p) pHPT or recurrent (r) pHPT, preoperative imaging studies, surgical findings, and outcome were analyzed. Data of patients who underwent surgery between 1987 and 1997 (group 1; G1) and between 1998 and 2008 (group 2; G2) with the use of Mibi/SPECT, IOPTH, and IONM were evaluated.

Results

One hundred twenty-five patients with benign ppHPT (n?=?108) or rpHPT (n?=?17) underwent reoperations (R-PTX). Group 1 included 54, group 2 71 patients. Main cause of ppHPT (G1?=?65 % vs. G2?=?53 %) and rpHPT (G1?=?80 % vs. G2?=?60 %) was the failed detection of a solitary adenoma (p?=?0.2). Group 1 patients had significantly less unilateral/focused neck re-explorations (G1?=?23 % vs. G2?=?57 %, p?=?0.0001), and more sternotomies (G1?=?35 vs. G2?=?14 %, p?=?0.01). After a median follow-up of 4 (range 0.9–23.4) years, reversal of hypercalcemia was achieved in 91 % (G1) and in 98.6 % in group 2 (p?=?0.08, OR 7.14 [0.809–63.1]). The rates of permanent recurrent laryngeal nerve palsy (G1?=?G2?=?9 %, p?=?1) and of postoperative permanent hypoparathyroidism (G1?=?9 % vs. G2?=?6 %, p?=?0.5) were not significantly different. Other complications such as wound infection, postoperative bleeding, and pneumonia were significantly lower in group 2 (p?<?0.001).

Conclusion

Nowadays, cure rates of R-PTX are nearly the same as in primary operations for pHPT. These results can be achieved in high-volume centers by routine use of well-established preoperative Mibi/SPECT and US in combination with IOPTH. However, morbidity is still considerably high.     

Surgical Outcomes and Predicting Factors of Curative Resection in Patients with Hilar Cholangiocarcinoma: 10-Year Single-Institution Experience

Background

The surgical resection of hilar cholangiocarcinoma is extremely challenging because the tumor is closely related with the complicated hilar structures. We investigated to identify the outcomes for patients who underwent surgical resection and to identify the parameters that influenced radical resection.

Methods

From January 2000 to December 2009, 105 patients underwent surgical resection for hilar cholangiocarcinoma. The clinicopathological parameters and surgical outcomes were retrospectively analyzed.

Results

There were 15 operative mortalities (14.3%). Seventy-four patients underwent curative resection (70.5%). The median overall survival time for R0, R1, and R2 were 58, 28, and 19?months, respectively. Caudate lobectomy (p?=?0.044; odds ratio [OR], 4.386) and perineural invasion (p?=?0.01; OR, 0.062) were correlated with curative resection. Total bilirubin levels of more than 3?g/dl just before the operation (p?=?0.042; hazard ratio [HR], 2.109) and extent of resection (R1 and 2 vs R0; p?=?0.05; HR, 2.309) were selected as significantly negative factors affecting overall survival on the multivariate analysis.

Conclusions

Caudate lobectomy and neurectomy may be thought of as adjustable territories by the surgeon??s efforts to achieve curative resection. R0 resection achieved through those efforts and liver optimization using preoperative biliary drainage may offer the patients a chance of cure.     

Perioperative Complications After Neoadjuvant Chemotherapy With and Without Bevacizumab for Colorectal Liver Metastases

Purpose

Bevacizumab has been shown to increase progression free and overall survival in patients with metastatic colorectal cancer. Neoadjuvant bevacizumab is commonly used in patients undergoing liver resection. Our purpose was to evaluate whether bevacizumab is associated with increased rate of perioperative complications in patients undergoing hepatic resection for colorectal liver metastases (CRLM).

Methods

Retrospective analysis of patients undergoing hepatic resection for CRLM who received chemotherapy and bevacizumab (group 1, n?=?134), or chemotherapy alone (group 2, n?=?57). We compared demographics, surgical characteristics, and perioperative course.

Results

Perioperative complications developed in 35 % of patients in group 1, and 47 % in group 2 (p?=?0.11). Of those complications, 15 (11.2 %) in group 1, and 5 (8.8 %) in group 2 were considered major (p?=?0.617). Four patients, all of whom received preoperative bevacizumab, developed enteric leaks following combined liver and bowel resection. The rate of anastomotic leak in group 1 was 10 %, compared with 0 in group 2, p?=?0.56.

Conclusion

Neoadjuvant chemotherapy along with bevacizumab was not associated with an increased risk of postoperative complications after hepatic resection. Possible association of increased morbidity with simultaneous bowel and liver resections following bevacizumab administration was found and we recommend avoiding such treatment combination.     

Perioperative Blood Transfusion Practices in Oncologic Thoracic Surgery: When, Why, and How

Introduction

Available information on perioperative blood transfusion practices in oncologic thoracic surgery is scant and outdated. The purpose of this study was to investigate transfusion requirements in patients undergoing curative resection for lung cancer and to identify possible factors predictive of perioperative blood transfusion in our cohort of patients.

Methods

From 1st January 2009 to 31st December 2009, 317 patients underwent anatomic pulmonary resection. Patients who received at least 1 unit of red blood cells comprised the ??transfused?? group. Each case in this group was matched for surgical procedure with a control subject who did not require blood transfusion and was operated on during the same year; these patients comprised the ??not transfused?? group.

Results

A total of 75 patients (23.6%) received at least 1 unit of red blood cells during the perioperative period. Factors conditioning perioperative blood transfusion were: preoperative hemoglobin level (p?p?=?0.017); body mass index (p?p?=?0.017); redo procedure (p?=?0.021). Age, sex, histology, stage, ASA score, side, intraoperative blood loss, and fluid infusion did not affect perioperative blood transfusion practices.

Conclusions

Preoperative hemoglobin level is the major risk factor for perioperative blood transfusion practices in oncologic thoracic surgery; procedure duration, body mass index, induction therapies, and redo procedure may condition transfusional needs, although they were actually not predictive on multivariate analysis.     

Intraoperative adverse events during laparoscopic colorectal resection—better laparoscopic treatment but unchanged incidence. Lessons learnt from a Swiss multi-institutional analysis of 3,928 patients

Purpose

Intraoperative adverse events significantly influence morbidity and mortality of laparoscopic colorectal resections. Over an 11-year period, the changes of occurrence of such intraoperative adverse events were assessed in this study.

Methods

Analysis of 3,928 patients undergoing elective laparoscopic colorectal resection based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery was performed.

Results

Overall, 377 intraoperative adverse events occurred in 329 patients (overall incidence of 8.4 %). Of 377 events, 163 (43 %) were surgical complications and 214 (57 %) were nonsurgical adverse events. Surgical complications were iatrogenic injury to solid organs (n?=?63; incidence of 1.6 %), bleeding (n?=?62; 1.6 %), lesion by puncture (n?=?25; 0.6 %), and intraoperative anastomotic leakage (n?=?13; 0.3 %). Of note, 11 % of intraoperative organ/puncture lesions requiring re-intervention were missed intraoperatively. Nonsurgical adverse events were problems with equipment (n?=?127; 3.2 %), anesthetic problems (n?=?30; 0.8 %), and various (n?=?57; 1.5 %). Over time, the rate of intraoperative adverse events decreased, but not significantly. Bleeding complications significantly decreased (p?=?0.015), and equipment problems increased (p?=?0.036). However, the rate of adverse events requiring conversion significantly decreased with time (p?<?0.001). Patients with an intraoperative adverse event had a significantly higher rate of postoperative local and general morbidity (41.2 and 32.9 % vs. 18.0 and 17.2 %, p?<?0.001 and p?<?0.001, respectively).

Conclusions

Intraoperative surgical complications and adverse events in laparoscopic colorectal resections did not change significantly over time and are associated with an increased postoperative morbidity.     

Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome

Background

After abdominoperineal excision (APE), the presence of tumor cells in the circumferential resection margin (R1) and iatrogenic tumor perforations are still frequent and result in an increased rate of local recurrences. In this study, a standardized supine APE with an increased focus on the perineal dissection (sPPD) is compared to the customary supine APE.

Methods

From 2000 to 2010, a total of 246 patients underwent APE for rectal cancer (sPPD and customary supine APE). All patients were staged with preoperative magnetic resonance imaging (MRI) and received neoadjuvant treatment (n?=?203) when margins were involved or threatened (cT3?+?and T4). As a result of a quality improvement program in 2006, the surgical technique was modified: it became standardized, emphasis was placed on the perineal dissection, and pelvic dissection was limited to avoid false routes when following the total mesorectal excision planes deep into the pelvis.

Results

Overall, the percentage of involved circumferential resection margins (CRMs) was 10%. In the period before introducing sPPD, the R1 percentages for cT0?C3 and cT4 tumors were 6.8 and 30.2%, compared to 2.2 and 5.7% after introduction of sPPD (P?=?0.001). Risk factors for R1 resection were preoperative T4 tumors (14.9%, P?=?0.011), tumor perforation (33.3%, P?=?0.002), fistulating tumors (35.7%, P?=?0.002), mucus-producing tumors (23.1%, P?=?0.006), or bulky tumors (66.7%, P?Conclusions The objective of surgical treatment of low rectal cancer is to obtain negative resection margins and subsequently reduce the risk of local recurrence. A combination of the appropriate preoperative treatment and standardized surgical technique such as sPPD can achieve this goal.     

Nonfunctional Pancreatic Neuroendocrine Tumors <2 cm on Preoperative Imaging are Associated with a Low Incidence of Nodal Metastasis and an Excellent Overall Survival

Background

The optimal surgical management of small nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) remains controversial. We sought to identify (1) clinicopathologic factors associated with survival in NF-PNETs and (2) preoperative tumor characteristics that can be used to determine which lesions require resection and lymph node (LN) harvest.

Methods

The records of all 116 patients who underwent resection for NF-PNETs between 1989 and 2012 were reviewed retrospectively. Preoperative factors, operative data, pathology, surgical morbidity, and survival were analyzed.

Results

The overall 5- and 10-year survival rates were 83.9 and 72.8 %, respectively. Negative LNs (p?=?0.005), G1 or G2 histology (p?=?0.033), and age <60 years (p?=?0.002) correlated with better survival on multivariate analysis. The 10-year survival rate was 86.6 % for LN-negative patients (n?=?73) and 34.1 % for LN-positive patients (n?=?32). Tumor size ≥2 cm on preoperative imaging predicted nodal positivity with a sensitivity of 93.8 %. Positive LNs were found in 38.5 % of tumors ≥2 cm compared to only 7.4 % of tumors <2 cm.

Conclusions

LN status, a marker of systemic disease, was a highly significant predictor of survival in this series. Tumor size on preoperative imaging was predictive of nodal disease. Thus, it is reasonable to consider parenchyma-sparing resection or even close observation for NF-PNETs <2 cm.     

Assessment of ISGLS Definition of Posthepatectomy Liver Failure and Its Effect on Outcome in Patients with Hepatocellular Carcinoma

Background

Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy. As there was no standardized definition, the International Study Group of Liver Surgery (ISGLS) defined PHLF as increased international normalized ratio and hyperbilirubinemia on or after postoperative day 5 in 2010. We evaluated the impact of the ISGLS definition of PHLF on hepatocellular carcinoma (HCC) patients.

Methods

We retrospectively analyzed 210 consecutive HCC patients who underwent curative hepatectomy at our facility from 2005 to 2010. The median follow-up period after hepatectomy was 35.2 months.

Results

Thirty-nine (18.6 %) patients fulfilled the ISGLS definition of PHLF. Overall survival (OS) rates at 1, 3, and 5 years in patients with/without PHLF were 69.1/93.5, 45.1/72.5, and 45.1/57.8 %, respectively (P?=?0.002). Recurrence-free survival (RFS) rates at 1, 3, and 5 years in patients with/without PHLF were 40.9/65.9, 15.7/38.3, and 15.7/20.3 %, respectively (P?=?0.003). Multivariate analysis revealed that PHLF was significantly associated with both OS (P?=?0.047) and RFS (P?=?0.019). Extent of resection (P?<?0.001), intraoperative blood loss (P?=?0.002), and fibrosis stage (P?=?0.040) were identified as independent risk factors for developing PHLF.

Conclusion

The ISGLS definition of PHLF was associated with OS and RFS in HCC patients, and long-term survival will be improved by reducing the incidence of PHLF.     

Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma

Purpose

This study evaluated the impact of ductal bile bacteria (bactibilia or cholangitis) on the development of surgical site infection (SSI) or in-hospital mortality after resection for hilar cholangiocarcinoma.

Materials and methods

A retrospective analysis was conducted on 81 patients who underwent a combined major hepatic (hemihepatectomy or more extensive hepatectomy) and bile duct resection for hilar cholangiocarcinoma. Ductal bile was submitted for bacterial culture before or during the operation.

Results

The incidence of SSI was higher in patients with preoperative bactibilia (83%) than in patients without (52%; P?=?0.008). Preoperative bactibilia was an independent variable associated with SSI (relative risk 9.003; P?=?0.002). The incidence of in-hospital mortality was higher in patients with preoperative cholangitis (33%) than in patients without (6%; P?=?0.009). Preoperative cholangitis was the only independent variable associated with in-hospital mortality (relative risk 9.115; P?=?0.006).

Conclusions

Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma, whereas preoperative bactibilia independently increases SSI.     

Robot-Assisted Versus Conventional Laparoscopic Surgery for Colorectal Disease, Focusing on Rectal Cancer: A Meta-analysis

Background

Robotic colorectal surgery may solve some of the problems inherent to conventional laparoscopic surgery (CLS). We sought to evaluate the advantages of robot-assisted laparoscopic surgery (RALS) using the da Vinci Surgical System over CLS in patients with benign and malignant colorectal diseases.

Methods

PubMed and Embase databases were searched for relevant studies published before July 2011. Studies clearly documenting a comparison of RALS with CLS for benign and malignant colorectal diseases were selected. Operative and postoperative measures, resection margins, complications, and related outcomes were evaluated. Weighted mean differences, relative risks, and hazard ratios were calculated using a random-effects model.

Results

The meta-analysis included 16 studies comparing RALS and CLS in patients with colorectal diseases and 7 studies in rectal cancer. RALS was associated with lower estimated blood loss in colorectal diseases (P?=?0.04) and rectal cancer (P?<?0.001) and lower rates of intraoperative conversion in colorectal diseases (P?=?0.03) and rectal cancer (P?<?0.001) than CLS. In patients with colorectal diseases, however, operating time (P?<?0.001) and total hospitalization cost (P?=?0.06) were higher for RALS than for CLS.

Conclusions

RALS was associated with reduced estimated blood loss and a lower intraoperative conversion rate than CLS, with no differences in complication rates and surrogate markers of successful surgery. Robotic colorectal surgery is a promising tool, especially for patients with rectal cancer.     

Laparoscopic surgery for palliative resection of the primary tumor in incurable stage IV colorectal cancer

Background

The purpose of the study was to evaluate the feasibility and efficacy of laparoscopic palliative resection in patients with incurable stage IV colorectal cancer.

Methods

We reviewed 100 patients with incurable stage IV colorectal cancer who underwent palliative resection of the primary tumor between 2002 and 2009 at National Cancer Center Hospital East (NCCHE). Outcomes and postoperative course were compared between patients who underwent open and laparoscopic surgery.

Results

Of the 100 patients, 22 were treated with a laparoscopic procedure and 78 underwent an open surgical procedure. There was no difference in the preoperative characteristics of the two groups. In the laparoscopic group, the mean operation time was significantly longer (177 vs. 148?min, p?=?0.007) and the amount of blood loss was significantly lower (166 vs. 361?ml, p?=?0.002). Postoperative complications occurred in 5 patients (22.7?%) after laparoscopic surgery and in 21 patients (26.9?%) after open surgery, with no significant difference between the two groups. Time to flatus, time to start of food intake, and hospital stay were all shorter after laparoscopic surgery (3.0 vs. 3.8?days, p?=?0.003; 3.6 vs. 5.0?days, p?<?0.001; and 12.0 vs. 15.0?days, p?=?0.005; respectively). Significantly more patients in the laparoscopic group had >15?% lymphocytes on postoperative day 7 (p?=?0.049). Overall survival rates were 73.7 and 75.5?% at 1?year after laparoscopic surgery and open surgery, respectively (p?=?0.344).

Conclusions

A laparoscopic procedure should be considered for palliative resection of the primary tumor for incurable stage IV colorectal cancer, because the results of this study indicate that the procedure is safe and effective.