Is major hepatectomy with pancreatoduodenectomy justified for advanced biliary malignancy?

Background/Purpose

Major hepatectomy with concomitant pancreatoduodenectomy (M-HPD) is usually indicated for the resection of diffuse bile duct cancer or advanced gallbladder cancer. This is the only procedure that can potentially cure such advanced cancers, so both a low mortality rate and long-term survival could potentially justify performing this procedure.

Methods

Between 1990 and 2005, the morbidity, mortality, and long-term survival of 26 patients with advanced biliary tract carcinoma 14 with diffuse bile duct cancer, 9 with advanced gallbladder cancer, and 3 with hilar bile duct cancer, who underwent hepatopancreatoduodectomy (HPD) were reviewed and analyzed.

Results

The overall morbidity and mortality rates were 30.8% and 0%, respectively. Postoperative infectious complications occurred in 6 patients (23.0%). The 5-year survival rate of the 14 patients with diffuse bile duct cancer who underwent HPD was 51.9%, while the 5-year survival rate in the 12 of these patients who underwent M-HPD was 61.4%. Patients with diffuse bile duct cancer without residual tumor and those without lymph node metastasis had 5-year survival rates of 68.6% and 80%, respectively. Thirty-three percent (2 of 6) of the patients who underwent M-HPD for advanced gallbladder cancer survived for more than 5 years.

Conclusions

Preoperative biliary drainage, portal embolization, complete external drainage of pancreatic juice, reduction of intraoperative bleeding, and prevention of bacterial colonization of bile may enable the incidence of mortality and hepatic failure to approach zero in patients who undergo HPD. Surgeons should strive for complete clearance of the tumor with a negative surgical margin to achieve long-term survival when performing M-HPD.

     

A pooled analysis of en bloc right hemicolectomy with pancreaticoduodenectomy for locally advanced right-sided colon cancer

Purpose

The aim of this study was to evaluate the safety and efficacy of en bloc right hemicolectomy with pancreaticoduodenectomy (RHCPD) for locally advanced right-sided colon cancer (LARCC).

Method

A pooled data analysis was performed on individual patients identified from the literature and the authors’ institutions. The short- and long-term outcomes were assessed.

Results

Recruited in this study were 81 LARCC patients undergoing RHCPD, including 75 patients reported in the literature and 6 patients from our own institutions. R0 resection was achieved in 97.5% cases. Morbidity and the 30-day mortality rate were 53.8 and 3.7%, respectively. The median survival duration was 70.4 months, and the 1-, 3- and 5-year overall survival rates were 77.8, 64.6, and 55.2%, respectively. Multivariable analysis identified only lymph node metastasis (hazard ratio 3.474, 95% confidence interval 1.323–9.120; P?=?0.011) as independent predictors of poor survival.

Conclusion

En bloc RHCPD for LARCC can be performed safely with a high proportion of R0 resection and a good postoperative survival outcome.

     

Re-evaluation of lipiodolized transarterial chemoembolization therapy for intrahepatic recurrence of hepatocellular carcinoma after curative liver resection

Background/Purpose

While lipiodolized transarterial chemoembolization (lip-TACE) is effective for treating unresectable hepatocellular carcinoma (HCC), its effect for treating recurrent HCC after curative liver resection needs to be clarified.

Methods

Of 163 patients who had undergone curative liver resection between 1992 and December 2003, 65 patients (39.8%) had recurrent HCC in the liver without extrahepatic recurrence and were indicated for lip-TACE. The overall survival rate after lip-TACE was calculated, and its correlation with factors such as the histology of the primary HCC and background noncancerous tissue were analyzed.

Results

The overall survival rates after lip-TACE after the detection of the first recurrent HCC were 82.6%, 44.5%, and 24.8% at 1, 3, and 5 years, respectively. The factors affecting patient survival after lip-TACE were microscopic portal venous involvement of HCC at liver resection, grade of inflammation in the noncancerous liver parenchyma, and recurrence within 1 year after the initial liver resection. Multivariate analysis showed that the period between the resection and first recurrence had the highest hazard ratio.

Conclusions

Lip-TACE is a reasonable procedure for treating recurrent HCC in selected patients who are not eligible for hepatic re-resection. When HCC recurred within 1 year from the primary liver resection, the effect of lip-TACE on patient survival was limited.

     

Portal Cavernoma Cholangiopathy

Purpose of Review

Portal cavernoma cholangiopathy is a rare condition, a proper recognition of which is critical. Solid data on this condition are scarce. This review aims at updating current knowledge on its definition, manifestations, diagnosis, and management.

Recent Findings

A consensus has been reached to prefer the denomination portal cavernoma cholangiopathy for the bile duct irregularities associated with portal cavernoma. Such irregularities are characterized by stenosis with or without dilatation and are mostly related to the impinging on bile duct lumen by portoportal collaterals. While bile duct irregularities are found in over 80% of patients with portal cavernoma, clinical manifestations, and complications (cholecystitis and biliary stones, but rarely cholestasis) occur in only 5–35% of them. Diagnosis can be and should be based on findings at magnetic resonance cholangiography and portography. Differential diagnosis includes primary and secondary sclerosing cholangitis, and cholangiocarcinoma. Asymptomatic patients may be managed expectantly. Endoscopic procedures are to be used in the first line for complications. Combined endoscopic and surgical approaches including portosystemic shunting can be considered in refractory or recurrent cases.

Summary

Portal cavernoma cholangiopathy mostly is a morphologic entity which is present in a majority of patients with portal cavernoma. The minority of patients with acute biliary complications should be treated as conservatively as possible. Late consequences of chronic cholestasis appear to be rare.

     

Characterization of intrahepatic cholangiocarcinoma after curative resection: outcome,prognostic factor,and recurrence

Background

Intrahepatic cholangiocarcinoma (ICC) is a relatively rare subtype of cholangiocarcinoma. The study herein gathered experience of surgical treatment for ICC, and aimed to analyze the prognosis of patients who had received curative-intent liver resection.

Methods

A total of 216 patients who had undergone curative-intent liver resection for ICC between January 1977 and December 2014 was retrospectively reviewed.

Results

Overall, the rates of 5-years recurrence-free survival (RFS) and overall survival (OS) were 26.1 and 33.9% respectively. Based on multivariate analysis, four independent adverse prognostic factors including morphology patterns, maximum tumor size >?5?cm, pathological lymph node involvement, and vascular invasion were identified as affecting RFS after curative-intent liver resection for ICC. Among patients with cholangiocarcinoma recurrence, only 27 (16.9%) were able to receive surgical resection for recurrent cholangiocarcinoma that had a significantly better outcome than the remaining patients.

Conclusion

Despite curative resection, the general outcome of patients with ICC is still unsatisfactory because of a high incidence of cholangiocarcinoma recurrence after operation. Tumor factors associated with cholangiocarcinoma remain crucial for the prognosis of patients with ICC after curative liver resection. Moreover, aggressive attitude toward repeat resection for the postoperative recurrent cholangiocarcinoma could provide a favorable outcome for patients.

     

Choledocho- und Cholezystolithiasis

Background

Gallstones are present in approximately 10–20?% of the German population. Up to one fourth of them will develop symptoms or complications during their lifetime.

Objective

Based on recent guidelines, this paper reviews the evidence-based management of patients with gallstone disease.

Materials and methods

Most relevant recommendations of the updated S3 guidelines on the diagnosis and treatment of gallstone disease are provided. Developments are depicted in relation to the 2007 version of these guidelines. Complementary recommendations of the S2k guidelines on quality requirements for gastrointestinal endoscopy and of the European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) guidelines on interventional ultrasound in gallstone disease are referred to.

Results

Based on recent scientific evidence, the guideline recommendations for diagnosis and treatment of patients with gallstone disease are presented. Requirements are rising for early surgical treatment of patients with acute cholecystitis (24 h), the timely management of patients with acute cholangitis and biliary pancreatitis (depending on severity) and on the sequential treatment of patients with simultaneous gallbladder and common bile duct stones (laparascopic cholecystectomy within 72 h after endoscopic bile duct clearance).

Conclusions

Up-to-date guideline-based management of patients with gallstone disease is an interdisciplinary task and requires comprehensive management concepts. A guideline-based algorithm is introduced.

     

Clinical and functional results of laparoscopic intersphincteric resection for ultralow rectal cancer: is there a distinction between the three types of hand-sewn colo-anal anastomosis?

Purpose

The purpose of this study is to compare the clinical and functional outcomes of three types of hand-sewn colo-anal anastomosis (CAA) after laparoscopic intersphincteric resection (Lap-ISR) for patients with ultralow rectal cancer.

Methods

A total of 79 consecutive patients treated by Lap-ISR for low-lying rectal cancer in an academic medical center from June 2011 to February 2016. According to the distal tumor margin and individualized anal length, the patients underwent three types of hand-sewn CAA including partial-ISR, subtotal-ISR, and total-ISR.

Results

Of the 79 patients, 35.4% required partial-ISR, 43% adopted subtotal-ISR, and 21.5% underwent total-ISR. R0 resection was achieved in 78 patients (98.7%). In addition to distal resection margin, there were no significant differences in clinicopathological parameters and postoperative complications between the three groups. The type of hand-sewn CAA did not influence the 3-year disease-free survival (DFS) or local relapse-free survival (LFS). At 24-months follow-up, in spite of higher incontinence scores in total-ISR group, there were not statistically significant differences in functional outcomes including Wexner score or Kirwan grade between the groups. Nevertheless, patients with chronic anastomotic stricture showed worse anal function than those without the complication.

Conclusion

The type of hand-sewn CAA after Lap-ISR may not influence oncological and functional outcomes, but chronic stricture deteriorates continence status.

     

Endoscopic Management of Difficult Bile Duct Stones

Purpose of Review

In 10–15% of the cases, conventional methods for removing bile duct stones by ERCP/balloon-basket extraction fail. The purpose of this review is to describe endoscopic techniques in managing these “difficult bile duct stones.”

Recent Findings

Endoscopic papillary large balloon dilation with balloon extraction ± mechanical lithotripsy is the initial approach used to retrieve large bile duct stones. With advent of digital cholangioscopy, electrohydraulic and laser lithotripsy are gaining popularity. Enteroscopy-assisted or laparoscopic-assisted approaches can be used for those with gastric bypass anatomy.

Summary

Difficulties in removing bile duct stones can be related to stone-related factors such as the size and location of the stone or to altered anatomy such as stricture in the bile duct or Roux-en-Y anatomy. Several endoscopy approaches and techniques have described in the recent past that have greatly enhanced our ability to remove these “difficult” bile duct stones.

     

Braun anastomosis lowers the incidence of delayed gastric emptying following pancreaticoduodenectomy: a meta-analysis

Background

Delayed gastric emptying (DGE) is one of the most frequent complications following pancreaticoduodenectomy. This meta-analysis aimed to evaluate the impact of Braun enteroenterostomy on DGE following pancreaticoduodenectomy.

Methods

A systematic review of the literature was performed to identify relevant studies. Statistical analysis was carried out using Review Manager software 5.3.

Results

Eleven studies involving 1672 patients (1005 in Braun group and 667 in non-Braun group) were included in the meta-analysis. Braun enteroenterostomy was associated with a statistically significant reduction in overall DGE (odds ratios [OR] 0.32, 95% confidence intervals [CI] 0.24 to 0.43; P <0.001), clinically significant DGE (OR 0.27, 95% CI 0.15 to 0.51; P <0.001), bile leak (OR 0.50, 95% CI 0.29 to 0.86; P?=?0.01), and length of hospital stay (weighted mean difference -1.66, 95% CI -2.95 to 00.37; P?=?0.01).

Conclusions

Braun enteroenterostomy minimizes the rate and severity of DGE following pancreaticoduodenectomy.

     

Long-term outcomes of extended radical resection combined with intraoperative radiation therapy for pancreatic cancer

Background/Purpose

Systemic and/or local recurrence often occurs even after curative resection for pancreatic cancer (PC). To prevent local relapse we adopted an extended radical resection combined with intraoperative radiation therapy in patients with PC, and all the patients were followed for more than 5 years.

Methods

We assessed the long-term outcomes of 41 patients who underwent this combined therapy. The cumulative survival curve in this series was depicted using the Kaplan-Meier method. Statistical analyses were performed using the logrank test.

Results

The actual 5-year survival rate was 14.6%, with a median survival time of 17.6 months. Six patients have been 5-year survivors. Local recurrence occurred in only 2 patients (5.0%). Cancer-related death occurred in 32 patients, 18 of whom had liver metastases. The patients with liver metastases had a significantly shorter survival time than those with other cancer-related causes of death. Patients with n3 lymph node involvement, extrapancreatic nerve plexus invasion, and stage IV disease had significantly poorer prognoses than patients without these characteristics.

Conclusions

Our combined therapy for patients with PC contributed to local control; however, it provided no survival benefit, because of liver metastases.

     

Choice of the optimal pancreaticojejunal anastomosis technique: how can we improve patient safety in pancreatic surgery?

Background/Purpose

The cause of the morbidity and mortality following pancreaticoduodenectomy (PD) in the surgical treatment of benign and malignant diseases of the periampullary region is leakage from the pancreaticojejunal anastomosis. The size of the main pancreatic duct and the texture of the remnant pancreas are very important factors for a secure pancreaticojejunal anastomosis.

Methods

A new technique was developed for patients having pancreatic ducts smaller than 3 mm and a hard remnant pancreas.

Results

Pylorus-preserving PD was performed for 28 patients who underwent PD at our hospital between January 2004 and January 2007, without mortality. The new technique was used in the 8 patients who had pancreatic ducts smaller than 3 mm and a hard remnant pancreas. With our new technique, different from other previously described techniques, the anastomosis was performed with the sutures passing from the cut-surface of the parenchyma of the pancreas. All patients were operated on by the same surgeon and surgical team. None of the patients developed a fistula.

Conclusions

We believe that this anastomosis technique can be performed securely in patients having a hard remnant pancreas and a main pancreatic duct smaller than 3 mm.

     

Use of an opened umbilical vein patch for the reconstruction of the injured biliary tract

Background/Purpose

When iatrogenic biliary tract injury occurs, there is the risk of complications such as bile leak and biliary stricture, and hepaticojejunostomy is the conventional procedure used for injury repair. However, this procedure can be complicated by retrograde biliary tract infection and the procedure can destroy the normal anatomical structure.

Methods

We report here a method of end-to-end biliary tract reconstruction that uses an opened umbilical vein (OUV) patch and two stents to reduce bile leakage and biliary stricture formation following injury to the common bile duct or right main bile duct. The postoperative courses of four patients are reviewed.

Results

In two of the patients, there was a small amount of postoperative bile drainage (for 3 days in the first patient and 2 days in the second patient). Of the two stents, the first stent was removed 1 month postoperatively, and the second stent at 2 to 3 months postoperatively. Three patients have returned to normal activity without symptoms after 44, 62, and 93 months, respectively. One patient died of a liver tumor recurrence in the fifth postoperative month, without a biliary problem.

Conclusions

An OUV patch for end-to-end biliary reconstruction reduced the volume and duration of bile leakage. Further research is needed to accurately evaluate the stenting period so as to reduce its duration.

     

Indications for surgical treatment of intrahepatic cholangiocarcinoma with lymph node metastases

Background/Purpose

The postoperative outcome of patients who have intrahepatic cholangiocarcinoma with lymph node metastases is extremely poor, and the indications for surgery for such patients have yet to be clearly established.

Methods

The demographic and clinical characteristics of 133 patients who underwent lymph node dissection during hepatic resection of intrahepatic cholangiocarcinoma were retrospectively analyzed.

Results

Multivariate analysis identified three independent prognostic factors: intrahepatic metastasis, nodal involvement, and tumor at the margin of resection. Of the patients with tumor-free surgical margins, none of the 24 patients who had both lymph node metastases and intrahepatic metastases survived for 3 years. In contrast, the survival rates for the 23 patients who had lymph node metastases associated with a solitary tumor were 35% at 3 years and 26% at 5 years.

Conclusions

Surgery alone cannot prolong survival when both lymph node metastases and intrahepatic metastases are present, while surgery may provide a chance for long-term survival in some patients who have lymph node metastases associated with a solitary intrahepatic cholangiocarcinoma tumor.

     

Postoperative infectious complications-driven recurrence after radical resection for esophageal cancer

Background

Few reports have reported the long-term outcome of esophageal cancer patients suffering from postoperative infectious complications. Here, we investigated the impact of postoperative infectious complications in patients who had undergone curative resection for esophageal cancer.

Methods

The study population comprised 97 patients who underwent radical resection for esophageal cancer with curative intent between 2001 and 2008. Postoperative infectious complications were defined as surgical site infections and pneumonia. We compared clinical features, tumor histology, recurrence, and overall survival between patients with postoperative infections and those who did not.

Results

Of the 97 patients studied, 37 had postoperative infectious complications. The disease-free and overall survival rates of the entire cohort did not significantly differ between patients with and without postoperative infectious complications. Univariate analysis revealed that among patients with stage III esophageal cancer, those with postoperative infectious complications demonstrated significantly shorter disease-free survival than those without. Multivariate analysis demonstrated that postoperative infectious complications were independent prognostic indicators for disease-free survival of stage III esophageal cancer patients.

Conclusions

Our findings suggest that postoperative infectious complications in stage III esophageal cancer patients have a negative impact on disease-free survival.

     

Long-term outcomes after resection of para-aortic lymph node metastasis from left-sided colon and rectal cancer

Purpose

Para-aortic lymph node (PALN) metastasis from colorectal cancer is rare and often not suitable for surgery. However, in selected patients, radical resection may bring about longer survival. The aim of this study was to evaluate long-term outcomes of resection of left-sided colon or rectal cancer with simultaneous PALN metastasis.

Methods

The study included 2122 patients with left-sided colon or rectal cancer (30 patients with and 2092 patients without PALN metastasis) who underwent resection with curative intent between 2002 and 2013. Clinicopathological characteristics, long-term outcomes of resection, and factors related to poor postoperative survival in patients with PALN metastasis were investigated.

Results

Of a total of 2122 total patients, 16 of 50 patients (32.0%) with lymph node metastasis at the root of the inferior mesenteric artery had PALN metastasis. The 5-year overall survival rates for 18 patients who underwent R0 resection and 12 patients who did not were 29.1 and 10.4%, respectively (p = 0.017). Factors associated with poor postoperative survival among patients who underwent R0 resection were presence of conversion therapy, lack of adjuvant chemotherapy, carcinoembryonic antigen >20 ng/mL, and lateral lymph node metastasis in rectal cancer patients. The 5-year recurrence-free survival rate was 14.8%.

Conclusions

Although recurrence was frequent, R0 resection for left-sided colon or rectal cancer with PALN metastasis was associated with longer survival than R1/R2 resection. Furthermore, the 5-year overall survival rate in the R0 group was relatively favorable for stage IV. Therefore, R0 resection may prolong survival compared with chemotherapy alone in selected patients.

     

Anastomotic leakage following low anterior resection for rectal cancer

Aim

Aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.

Patients and methods

Between 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME).

Results

A total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy.

Conclusion

The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

     

Outcome of transarterial chemoembolization in Egyptian patients with hepatocellular carcinoma and branch portal vein thrombosis

Background/Aim

Portal vein tumor thrombosis (PVTT) is a common complication in hepatocellular carcinoma (HCC) and it was considered a relative contraindication for transarterial chemoembolization (TACE) by many centers. This study aimed to assess the outcomes after TACE in patients with branch PVT regarding Child classification, radiological response, and 1-year survival.

Methods

Thirty HCC patients (24 male, 6 females) Child A cirrhotics with branch PVT underwent TACE. Follow up was done at 1, 3, 6, and 12 months after first TACE. All patients underwent laboratory investigations including liver function tests to assess deterioration in liver functions and triphasic spiral computed tomography to assess radiological response according to modified response evaluation criteria in solid tumors (mRECIST) criteria, and survival analysis was recorded.

Results

TACE succeeded to achieve disease control in 93.3%, 86.3%, 57.7%, and 44.4% of patients after 1, 3, 6, and 12 months, respectively. Post-TACE liver decompensation occurred in the form of ascites in 30%, jaundice in 10%, and hepatic encephalopathy in 3.3% within 1 month of TACE. One month survival after TACE was 100%, 3 months was 96.6%, 6 months was 86.6%, and 1-year survival was 60%. Mean overall survival of the included patients was 17 months (SE?=?1.59).

Conclusion

TACE seems an alternative option for patients with unrespectable HCC with portal vein thrombosis in patients with good liver function tests.

     

RETRACTED ARTICLE: Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy

Background/Purpose

The prevention of pancreatic fistula is still a major problem in distal pancreatectomy (DP). We have recently adopted preoperative endoscopic pancreatic stenting with the aim of preventing the leakage of pancreatic juice from the resection plane of the remnant pancreas after DP. We reviewed ten patients who underwent this intervention.

Methods

One to 6 days before surgery, the patients underwent an endoscopic transpapillary pancreatic stent (7 Fr., 3 cm) placement. The perioperative short-term outcomes were assessed.

Results

Preoperative endoscopic pancreatic stenting was successfully performed in all ten patients. Two (20%) patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the ten patients developed pancreatic fistula. The pancreatic stent was removed 8–28 days (mean, 11 days) postoperatively.

Conclusions

Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP.

     

Comparison of the clinical results of abdominoperanal intersphincteric resection and abdominoperineal resection for lower rectal cancer

Background

The aim of this study was to compare the oncologic results of abdominoperanal intersphincteric resection (ISR) and abdominoperineal resection (APR).

Methods

Between 2003 and 2014, 277 consecutive patients with stage I–III low rectal cancer located within 5 cm from the anal verge underwent curative ISR and APR. A retrospective comparison of these two procedures was performed.

Results

Overall, 128 patients underwent ISR and 149 underwent APR. The ISR group had earlier clinical stages and shorter distal margins (p < 0.01). The 5-year relapse-free survival rates in patients who underwent ISR/APR were 84.7/74.7% with T1–2 tumors and 51.3/67.6% with T3–4 tumors. In T3–4 tumors, the rate of local recurrence was higher in the ISR group (13.2%) than in the APR group (3.8%). The 5-year relapse-free survival rates in patients who underwent ISR/APR were 89.7/92.3% for stage I cases, 84.4/87.5% for stage II cases, and 39.8/51.8% for stage III cases. Patients with stage III tumors had high rates of distant recurrence in both groups (24.3 vs. 26.3%).

Conclusion

ISR is a feasible surgical procedure for T1–2 tumors. Patients with stage III tumors should be considered for adjuvant therapy to control distant recurrence regardless of the surgical procedure.

     

Selection of EMR and ESD for Laterally Spreading Lesions of the Colon

Introduction

Colonic laterally spreading lesions (LSL) are increasingly managed using endoscopic methods that comprise two main techniques: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

Purpose of Review

In this review, we aimed to review the most recent literature on selection of the best endoscopic technique in the management of colonic LSL.

Recent Findings

EMR and ESD are complimentary techniques in the management of patients with colonic LSL.

Summary

EMR is safe and effective in most patients with LSL, except for cancers with submucosal invasion in whom R0 resection is favored.