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Alan Koffron

Publications and source records attributed to Alan Koffron.

6 recordsLinked to original sources
PubMed2006

Laparoscopic liver surgery: Shifting the management of liver tumors.

Laparoscopic liver surgery has evolved rapidly over the past 5 years in a select number of centers. The growing experience with these procedures has resulted in a shift in the diagnostic and therapeutic approach to common liver tumors. The fact that resection of benign and malignant hepatic masses can now be accomplished laparoscopically with relatively low morbidity has influenced the decision-making process for physicians involved in the diagnosis and management of these lesions. For example, should a gastroenterologist or hepatologist seeing a 32-year-old woman with an asymptomatic 4 cm hepatic lesion that is radiologically indeterminate for adenoma or focal nodular hyperplasia (FNH): (1) continue to observe with annual computed tomography/magnetic resonance imaging (CT/MRI) scans, (2) subject the patient to a liver biopsy, or (3) refer for laparoscopic resection? For a solitary malignant liver tumor in the left lateral segment, should laparoscopic resection be considered the new standard of care, assuming the surgeon can perform the operation safely? We present current data and representative case studies on the use of laparoscopic liver resection at 2 major medical centers in the United States. We propose that surgical engagement defined by the managing physician's decision to proceed with a surgical intervention is increasingly affected by the availability of, and experience with, laparoscopic liver resection.

Adenoma↗
PubMed2005

Living donor liver transplant for malignancy.

Adult-to-adult living donor liver transplantation (ALDLT) is being increasingly utilized to treat patients with locally advanced hepatocellular carcinoma and cholangiocarcinoma who are not prioritized under the MELD allocation system. A single institution retrospective chart review examined ALDLTs performed for malignancy to identify indications, complications, and transplant outcome. Since 1997, 18 ALDLTs have been performed for malignancy as the primary indication. Thirteen patients were transplanted for HCC. The median survival following transplant was 18.6 months and four patients developed recurrent HCC. Five patients were transplanted for cholangiocarcinoma, with a 100% recurrence free survival at a mean follow up of 18 months among patients given neo-adjuvant chemoradiation. ALDLT can be safely performed for malignancy with an acceptable peri-operative mortality rate. However, HCC patients with large tumors experience a high rate of recurrence. The use of ALDLT for cholangiocarcinoma appears promising specifically in the context of neo-adjuvant therapy.

Adult↗
PubMed2004

Safety and efficacy of combined orthotopic liver transplantation and coronary artery bypass grafting.

Advanced coronary artery disease (CAD) is increasingly common in patients awaiting orthotopic liver transplantation (OLT). Unfortunately, in patients whose coronary artery anatomy is not amenable to angioplasty, coronary artery bypass grafting (CABG) alone may precipitate hepatic decompensation. Thus, combined liver transplant and coronary artery bypass grafting (CABG-OLT) may be required to effectively treat both conditions. Clinical records were analyzed for 5 CABG-OLT procedures at a single institution. Operative indications, technical details, and postoperative course were determined for each patient. Patients undergoing CABG-OLT had a mean age of 57.8 years (range, 54-66) and were predominantly male (80%). All patients had significant 3-vessel coronary atherosclerotic disease with preserved left ventricular function. There were no intraoperative deaths. At mean 25 months of follow-up (range, 8.0-25) there was an 80% graft and patient survival. Overall average length of stay was 21 days (range, 7-59 days). In conclusion, CABG-OLT procedure appears to be safe and effective in the population of patients with advanced CAD and liver disease. In this series, patients appear to benefit from multidisciplinary preoperative evaluation, coordination between cardiac and transplant surgeons, careful graft selection, and use of sapheno-atrial veno-veno bypass.

Aged↗
PubMed2004

Intrahepatic biliary cystadenoma: role of cyst fluid analysis and surgical management in the laparoscopic era.

BACKGROUND: Recent interest in cyst fluid analysis (CFA) for carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA), and the introduction of laparoscopic surgery (LS) in the management of hepatic cysts have resulted in sporadic reports of elevated CA 19-9 and CEA levels in intrahepatic biliary cystadenoma (IBC) CFA, and the application of LS in the management of simple cysts. However, the role of CA 19-9 and CEA in the diagnosis of IBC and the role of LS in the management of IBC have not been previously defined. METHODS: We studied 34 patients with IBC at a single institution (8 years). The first 12 patients with IBC were managed with open surgical intervention. We subsequently developed a diagnostic and treatment algorithm for IBC that included, in the last 22 patients, prospective analysis of CFA for CA 19-9 and CEA, and LS for management RESULTS: All patients with IBC who underwent CFA had elevated CA 19-9 (range, 2247-1,757,510; N <33 U/mL) and mildly elevated CEA (range, 3.3-212,; N <3 ng/ml). In all 22 patients the cyst lining consisted of biliary epithelium +/- mesenchymal stroma (MS). In 1/22 patients (highest CA 19-9 level), the cyst epithelium did not contain either MS or intestinal metaplasia. In contrast, control patients (simple cysts, n=8) had normal CFA. In the previous 12 patients managed with laparotomy, 6/12 patients had biliary epithelium alone; the other 6 also contained MS with 1 patient exhibiting intestinal metaplasia and cystadenocarcinoma. CONCLUSIONS: We have proposed a management algorithm for IBC that incorporates CFA and laproscopic surgical management that allows for selective minimally invasive cyst wall sampling for patients with IBC.

Algorithms↗
PubMed2002

Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy.

HYPOTHESIS: Multiple centers have reported on bile duct injuries after cholecystectomy, but few have reported on the impact of concomitant vascular injuries. DESIGN: Twenty-seven life-threatening complex injuries (CIs) (Bismuth level III, IV, or V or combined arterial-ductal injuries) were retrospectively compared with 22 noncomplex injuries (NCs) (level I or II). SETTING: Tertiary referral center. MAIN OUTCOME MEASURES: The incidence and level of biliary and arterial injuries and their resulting morbidity and mortality. RESULTS: Bismuth classifications of all injuries were as follows: level I in 6 patients (12%), II in 19 (39%), III in 12 (24%), IV in 8 (16%), and V in 4 (8%). Diagnosis was based on peritonitis (n = 13 [27%]), endoscopic retrograde pancreatography (n = 19 [39%]), and percutaneous transhepatic cholangiography (n = 7 [14%]). Delayed referral was more common in levels I through IV (100 days) than in level V (15 days) (P<.001). Repairs were attempted in level IV (75%), III (67%), V (25%), and II (11%). Thirteen arterial injuries (26%) occurred irrespective of ductal injury level: I (n = 1), II (n = 3), III (n = 1), IV (n = 5), and V (n = 3). There was, however, a higher incidence of repairs before referral in the CI group (59% vs 5%; P<.01), with resulting higher rates of complication (70% vs 23%; P<.01). Five deaths occurred in the CI group vs 1 in the NC group (P =.14). In univariate analysis, the presence of arterial injury vs no arterial injury was a predictor of mortality (5 [38%] of 13 patients vs 1 [3%] of 36 patients; P<.001). CONCLUSION: Bile duct injuries after cholecystectomy can be morbid and lethal with the incidence of arterial injury grossly underestimated.

Adult↗