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J Peter A Lodge

Publications and source records attributed to J Peter A Lodge.

18 recordsLinked to original sources
PubMed2006

Hepatic resection for colorectal metastasis: impact of tumour size.

BACKGROUND: Many colorectal liver metastasis patients are denied surgical resection on the basis of tumour size. The aim of this study was to explore the impact of metastasis size on modern liver resection. METHODS: Using a prospectively collected database, this was a retrospective analysis of 484 consecutive patients who underwent liver resection for colorectal liver metastases between 1993 and 2003. The cohort was divided into two groups: smaller metastases (< 8 cm) and larger metastases (> or = 8 cm). Those with larger metastases were then further stratified into big metastases (8-12 cm) and giant metastases (> 12 cm). Demographic, pathological, surgical technique and outcome data were compared between the groups. RESULTS: There were 88 (18%) patients with metastases measuring 8 cm or larger. There was an association between higher carcinoembryonic antigen (CEA) and cancer antigen (CA) 19-9 levels and larger metastases. The actuarial 5-year survival for patients with larger metastases was 38% compared with 42% for smaller metastases (not statistically significant). Patients with giant metastases had poorer overall and disease-free survival (both nonsignificant) compared with those with big metastases: 29% and 28% at 5 years, respectively. CONCLUSION: Patients with colorectal liver metastasis greater than 8 cm and up to 12 cm in size should not be treated differently from those with smaller lesions.

Adult↗
PubMed2005

Liver metastases in candidates for hepatic resection: comparison of helical CT and gadolinium- and SPIO-enhanced MR imaging.

PURPOSE: To prospectively compare accuracy of dynamic contrast material-enhanced thin-section multi-detector row helical computed tomography (CT), high-spatial-resolution three-dimensional (3D) dynamic gadolinium-enhanced magnetic resonance (MR) imaging, and superparamagnetic iron oxide (SPIO)-enhanced MR imaging with optimized gradient-echo (GRE) sequence for depiction of hepatic lesions; surgery and histologic analysis were the reference standard. MATERIALS AND METHODS: Local ethics committee approval was granted, and written informed consent was obtained. Fifty-eight patients (45 men, 13 women; age range, 47-82 years) with hepatic metastases were imaged with multi-detector row CT (3.2-mm section thickness), 3D dynamic gadolinium-enhanced MR imaging (2.5-mm effective section thickness), and SPIO-enhanced MR by using an optimized T2-weighted GRE sequence. Images were reviewed independently by two blinded observers who identified and localized lesions with a four-point confidence scale. Accuracy of each technique was measured with alternative free-response receiver operating characteristic analysis. Results were correlated with findings at surgery with intraoperative ultrasonography or histopathologic examination. Statistical differences among techniques for each observer were measured. RESULTS: Accuracy values for each observer for all metastases (n = 215) and 1.0-cm or smaller metastases (n = 80), respectively, follow: For CT, those for reader 1 were 0.82 and 0.65; for reader 2, 0.81 and 0.68. For gadolinium-enhanced MR imaging, those for reader 1 were 0.92 and 0.79; for reader 2, 0.90 and 0.76. For SPIO-enhanced MR imaging, those for reader 1 were 0.92 and 0.83; for reader 2, 0.92 and 0.81. For all metastases for both observers, there was no significant difference between MR techniques, but both were significantly more accurate than CT (P < .01). For metastases 1.0 cm or smaller and one observer, there was no significant difference between MR techniques, but both were more accurate than CT (P < .01); for the other observer, SPIO-enhanced MR imaging was more accurate than gadolinium-enhanced MR imaging (P < .05) and CT (P < .02), but there was no significant difference between gadolinium-enhanced MR imaging and CT (P = .2). CONCLUSION: Accuracy for gadolinium-enhanced MR imaging and SPIO-enhanced MR imaging was similar. Both techniques were significantly more accurate than CT.

Aged↗
PubMed2005

Multicenter, randomized study of the effectiveness of basiliximab in avoiding addition of steroids to cyclosporine a monotherapy in renal transplant recipients.

BACKGROUND: Steroid therapy is associated with an increased risk of cardiovascular events and well-documented adverse effects, but two thirds of patients initiated on monotherapy with cyclosporine A (CsA) microemulsion require addition of steroids. METHODS: In this 12-month randomized, double-blind, multicenter study, 108 renal transplant recipients were randomized and received basiliximab (n=52) or placebo (n=56) to assess whether basiliximab reduces the need for addition of steroids or other adjunctive immunosuppressive drugs to CsA monotherapy. RESULTS: The primary endpoint of the study (requirement for additional immunosuppression at 12 months posttransplant) occurred significantly less frequently with basiliximab (54%) than placebo (73%) (P=0.046). By the end of the study, 25% of basiliximab-treated patients were receiving maintenance steroids versus 61% of placebo-treated patients (P=0.0006). During the trial, 33% of basiliximab-treated patients received oral steroids at some time compared with 61% of placebo-treated patients (P=0.004). The proportion of patients experiencing biopsy-proven rejection was not significantly different between the basiliximab (29%) and placebo (43%) groups (P=0.16). Median serum creatinine at 12 months was 141 mumol/L with basiliximab and 164 mumol/L with placebo (not significant). One-year graft and patient survivals were 88% and 98% for basiliximab and 88% and 96% for placebo (not significant), respectively. Adverse events were similar in the basiliximab and placebo treatment groups. CONCLUSIONS: These findings demonstrate that the addition of basiliximab significantly reduces the need to modify the initial treatment regimen in patients scheduled to receive steroid-free CsA therapy, suggesting that basiliximab induction may be useful as a strategy in other steroid-avoidance regimens.

Acute Disease↗
PubMed2005

Efficacy and safety of repeated perioperative doses of recombinant factor VIIa in liver transplantation.

Patients undergoing orthotopic liver transplantation (OLT) have excessive blood loss during surgery that requires blood transfusions, leading to increased postoperative morbidity and mortality. We studied the efficacy and safety of activated recombinant factor VII (rFVIIa) in reducing transfusion requirements in OLT. This multicenter, randomized, double-blind, placebo-controlled trial enrolled patients undergoing OLT because of cirrhosis (Child-Turcotte-Pugh class B or C). Patients received a repeated intravenous bolus regimen of rFVIIa 60 or 120 microg/kg or placebo. The primary efficacy endpoint was the total number of red blood cell (RBC) units transfused during the perioperative period. A total of 182 patients were analyzed for efficacy and 183 for safety. No significant effect of rFVIIa was observed on the number of RBC units transfused or intraoperative blood loss compared with the placebo group. A significantly higher number of patients in the rFVIIa study groups avoided RBC transfusion. Administration of rFVIIa but not placebo restored the preoperative prolonged prothrombin time to normal value during surgery. Patients receiving rFVIIa and placebo did not experience a significant difference in rate of thromboembolic events. Additionally, there was no statistically significant effect of rFVIIa treatment on hospitalization rate, total surgery time, and the proportion of patients undergoing retransplantation. In conclusion, use of rFVIIa during OLT significantly reduced the number of patients requiring RBC transfusion. There was no increase in thromboembolic events with rFVIIa administration compared with placebo.

Adult↗
PubMed2005

Assessment of hepatic reserve for the indication of hepatic resection: how I do it.

This author has personally carried out in excess of 700 major hepatic resections for tumor, and runs a unit with a current resection rate of 200 per year, yet uses no scientific tests designed to judge hepatic reserve. In our unit, we have an advantage in that we deal with a northern European population, with a low rate of viral hepatitis, although alcoholism is becoming an increasing feature within our practice and we are dealing with more elderly patients that in the past, and more who have undergone neoadjuvant chemotherapy. In these patients, there appear to be greater risks of postoperative sepsis and slower regeneration. Approximately 65% of our current resection practice is hemihepatectomy or more and the majority is trisectionectomy (extended hepatectomy) and bilateral resection work. Preoperative, operative, and postoperative factors affect the occurrence of postoperative hepatic failure and these aspects are considered. Case series studies are presented to illustrate the incidence of significant hepatic failure we have encountered.

Blood Transfusion↗
PubMed2005

Recombinant coagulation factor VIIa in major liver resection: a randomized, placebo-controlled, double-blind clinical trial.

BACKGROUND: Prevention of bleeding episodes in noncirrhotic patients undergoing partial hepatectomy remains unsatisfactory in spite of improved surgical techniques. The authors conducted a randomized, placebo-controlled, double-blind trial to evaluate the hemostatic effect and safety of recombinant factor VIIa (rFVIIa) in major partial hepatectomy. METHODS: Two hundred four noncirrhotic patients were equally randomized to receive either 20 or 80 microg/kg rFVIIa or placebo. Partial hepatectomy was performed according to local practice at the participating centers. Patients were monitored for 7 days after surgery. Key efficacy parameters were perioperative erythrocyte requirements (using hematocrit as the transfusion trigger) and blood loss. Safety assessments included monitoring of coagulation-related parameters and Doppler examination of hepatic vessels and lower extremities. RESULTS: The proportion of patients who required perioperative red blood cell transfusion (the primary endpoint) was 37% (23 of 63) in the placebo group, 41% (26 of 63) in the 20-microg/kg group, and 25% (15 of 59) in the 80-microg/kg dose group (logistic regression model; P = 0.09). Mean erythrocyte requirements for patients receiving erythrocytes were 1,024 ml with placebo, 1,354 ml with 20 microg/kg rFVIIa, and 1,036 ml with 80 microg/kg rFVIIa (P = 0.78). Mean intraoperative blood loss was 1,422 ml with placebo, 1,372 ml with 20 microg/kg rFVIIa, and 1,073 ml with 80 microg/kg rFVIIa (P = 0.07). The reduction in hematocrit during surgery was smallest in the 80-microg/kg group, with a significant overall effect of treatment (P = 0.04). CONCLUSIONS: Recombinant factor VIIa dosing did not result in a statistically significant reduction in either the number of patients transfused or the volume of blood products administered. No safety issues were identified.

Adult↗
PubMed2005

Left hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role.

OBJECTIVE: To analyze results of 70 patients undergoing left hepatic trisectionectomy and to clarify its current role. SUMMARY BACKGROUND DATA: Left hepatic trisectionectomy remains a complicated hepatectomy, and few reports have described the long-term results of the procedure. METHODS: Short-term and long-term outcomes of 70 consecutive patients who underwent left hepatic trisectionectomy from January 1993 to February 2004 were analyzed. RESULTS: Of the 70 patients, 36 had colorectal liver metastasis, 24 had cholangiocarcinoma, 4 had hepatocellular carcinoma, and the remaining 6 had other tumors. Overall morbidity, 30-day and 90-day mortality rates were 46%, 7%, and 9%, respectively. Multivariate analysis disclosed that preoperative jaundice and intraoperative blood transfusion were positive independent predictors for postoperative morbidity; however, there were no independent predictors for postoperative mortality. Postoperative morbidity (87% versus 35%, P < 0.001) and mortality (20% versus 5%, P = 0.108) were observed more frequently in patients with preoperative obstructive jaundice than in those without jaundice. Each survival according to tumor type was acceptable compared with reported survivals. Survival for patients with colorectal liver metastasis undergoing left hepatic trisectionectomy with concomitant partial resection of the remnant liver was similar to those without this concomitant procedure. This concomitant procedure was not associated with postoperative morbidity and mortality. CONCLUSIONS: Left hepatic trisectionectomy remains a challenging procedure. Preoperative obstructive jaundice considerably increases perioperative risk. Concomitant partial resection of the remaining liver appears to be safe and offers the potential for cure in patients with colorectal metastasis affecting all liver segments.

Adult↗
PubMed2004

Current techniques and results of liver resection for colorectal liver metastases.

Colorectal cancer remains the second most common cause of cancer death in the West. Every year in the UK alone, around 14 000 patients develop secondary hepatic deposits from a primary colorectal cancer. Surgery remains the mainstay of treatment for liver metastases. Although not every patient is a candidate for surgery, earlier referral and rapid assessment are required to improve outcome. With the use of most recent technologies and radical surgery, increasing numbers of patients should have therapy with curative intent. This paper reviews preoperative patient evaluation and selection, surgical strategies, adjuvant therapy and postoperative follow-up. Other treatment modalities to increase tumour resectability are also described.

Catheter Ablation↗
PubMed2004

Bile duct strictures after hepatobiliary surgery: assessment with MR cholangiography.

PURPOSE: To establish the accuracy of magnetic resonance (MR) cholangiography for diagnosis of postsurgical bile duct strictures. MATERIALS AND METHODS: Sixty-seven patients suspected of having bile duct strictures after liver transplantation (n = 54), cholecystectomy (n = 8), hepatic resection (n = 4), or pancreaticoduodenectomy (n = 1) underwent MR cholangiography. Thick-slab single-shot fast spin-echo (repetition time msec/echo time msec, 4,500/940) imaging was performed in the coronal through sagittal planes with rotation in 10 degrees increments, and contiguous thin-section images were obtained in the transverse and the optimal coronal oblique planes by using half-Fourier rapid acquisition with relaxation enhancement (1,900/96). Three blinded observers independently reviewed the MR images and recorded diagnostic features including presence of biliary stricture by using a five-point confidence scale. Receiver operating characteristic analysis was used to measure the accuracy of MR cholangiography. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Final diagnosis was established at surgery (n = 29) and direct cholangiography (23 of 29) or at direct cholangiography, liver biopsy, and/or serial liver function tests (n = 38). RESULTS: Thirty-three of 67 patients had strictures confirmed with the reference standard. MR cholangiography enabled correct diagnosis and depicted the site of strictures in all cases. Findings of stricture at MR cholangiography were false-positive in five patients with moderate duct dilatation and caliber change at the level of the anastomosis. Mean accuracy, sensitivity, specificity, PPV, and NPV were 94%, 97%, 74%, 86%, and 96%, respectively. CONCLUSION: MR cholangiography is as sensitive as direct cholangiography for the assessment of bile duct strictures after hepatobiliary surgery but may lead to overestimation of the importance of duct dilatation and caliber change.

Adult↗
PubMed2004

Hemostasis in liver resection surgery.

Although patients with liver tumors are considered as challenging by hepatic surgeons, advances in liver resection procedures mean that virtually no liver tumor should be considered as unresectable. Newer techniques, such as in situ hypothermic perfusion, the "ante situm technique," and ex vivo liver resection have been recently introduced. The aim of these techniques is to provide a bloodless field and a prolonged and more precise dissection. The use of recombinant factor VIIa (rFVIIa), a hemostatic agent previously developed for bleed management in patients with hemophilia and inhibitors, has recently been investigated as a means of reducing red blood cell transfusion requirements during major liver surgery. This paper reviews details of this clinical trial, as well as current and future methods to manage hemostasis during liver resection surgery.

Blood Loss, Surgical↗
PubMed2004

Hepatic resection and transplantation for primary carcinoid tumors of the liver.

OBJECTIVE: To discuss the diagnosis and management of primary carcinoid tumors of the liver in light of our experience and a literature review. SUMMARY BACKGROUND DATA: Carcinoid tumors of the liver are rare and pose a diagnostic and management dilemma. This series is the largest reported and the only one to include liver transplantation as a treatment option. METHODS: Between March 1994 and May 2002, we treated 8 patients (4 male, 4 female) with primary hepatic carcinoid tumors. Carcinoid syndrome complicated only 1 of the cases. Treatment was by liver resection in 6 patients and orthotopic liver transplantation in 2. RESULTS: The diagnosis was confirmed histologically with light microscopy and immunohistochemistry in the absence of an alternative primary site. Six patients remain alive and disease free after follow-up of more than 3 years: 39, 43, 45, 50, 50, and 95 months. Two patients are recently postoperative. CONCLUSIONS: Active exclusion of an extrahepatic primary site is essential for the diagnosis of primary carcinoid of the liver. The mainstay of treatment should be liver resection, although liver transplantation may be considered in patients with widespread hepatic involvement. A radical surgical approach is warranted as this disease carries a better prognosis than for other primary hepatic tumors and for secondary hepatic carcinoids.

Adult↗
PubMed2004

A pathophysiologic study of the kidney tubule to optimize organ preservation solutions.

BACKGROUND: Tissue damage at the time of organ transplantation has a negative impact on the subsequent success of the procedure, both in the immediate and longer term. Hypothermia is the principal element used to prolong organ viability ex vivo, but paradoxically also induces cellular edema through inhibition of energy-dependent adenosine triphosphatases (ATPases). This induces an electrolyte imbalance that leads to fluid influx and cell swelling. It is important, therefore, that improvements are made in the preservation of ischemic organs to reduce this injury. METHODS: This study has applied a novel in vitro system to model cold and warm ischemic-induced renal tubule swelling that characterizes tissue damage in ischemia/reperfusion injury. Biochemical blockade of ATPases in this system using strophanthidin modeled the effects of energy depletion and induced cell swelling. By measuring such tubule swelling and changes to tubular cell volume in isolated rabbit renal proximal tubules, an analysis was made that defined the basis on which an optimal preservation solution may be developed. RESULTS: The data show that our model could reproduce ischemically induced cell swelling and characterized the response at the cellular level of tubules to different components of preservation solutions. The data indicate that an isosmolar, phosphate-buffered, sucrose solution prevented tubule swelling more effectively than Euro-Collins, hyperosmolar citrate, or University of Wisconsin solutions that are in routine clinical use. CONCLUSION: Future developments in organ preservation may significantly improve transplant outcomes. Our novel analysis forms the basis of future whole-organ studies that ultimately may allow us to propose an optimum platform for improved preservation solutions.

Animals↗
PubMed2003

The effect of the selective cyclooxygenase-2 inhibitor rofecoxib on human colorectal cancer liver metastases.

BACKGROUND & AIMS: Cyclooxygenase-2 (COX-2) is a potential target for chemotherapy of colorectal cancer (CRC). We tested the antineoplastic activity of the selective COX-2 inhibitor rofecoxib on human CRC liver metastases by measuring surrogate markers of tumor growth and angiogenesis in a randomized, double-blind, placebo-controlled trial. METHODS: Patients undergoing liver resection surgery for metastatic disease were randomized to receive rofecoxib 25 mg daily or placebo before surgery (duration, >14 days). The apoptosis index (AI; neocytokeratin 18), proliferation index (PI; Ki-67), and microvessel density (MVD; CD31) were measured in metastases by immunohistochemistry. The effect of rofecoxib on COX-2-positive HCA-7 human CRC cell PGE(2) synthesis, proliferation, and apoptosis in vitro was also investigated. RESULTS: Patients who received rofecoxib (n = 23) and placebo (n = 21) were well matched regarding clinical and metastasis characteristics. The mean (range) duration of rofecoxib therapy was 26 (14-46) days. Rofecoxib-treated metastases had a 29% decrease in MVD (mean, 25.1 [SEM, 2.7] per hpf) compared with placebo-treated tissue (32.5 [SEM, 4.5] per hpf; P = 0.15). There was little difference in AI (rofecoxib mean, 2.03% [SEM, 0.43%] vs. placebo 1.39% [SEM, 0.39%]) or PI (rofecoxib 54.7% [SEM, 5.1%] vs. placebo 52.6% [SEM, 5.6%]). Rofecoxib-induced growth arrest and apoptosis of HCA-7 cells occurred only at concentrations (>10 micromol/L), which were significantly higher than the IC(50) for COX-2 inhibition. CONCLUSIONS: Rofecoxib may negatively regulate angiogenesis in human CRC liver metastases. The absence of a significant, direct effect of rofecoxib on epithelial cells in liver metastases in vivo mirrors the lack of activity on human CRC cells at pharmacologically relevant concentrations in vitro.

Aged↗
PubMed2003

The value of intraoperative ultrasound during hepatic resection compared with improved preoperative magnetic resonance imaging.

BACKGROUND: Patients with colorectal metastases confined to the liver may be cured by resection. Combined bimanual palpation and intraoperative ultrasound (IOUS) augment the detection of colorectal hepatic metastases. The importance of IOUS in the surgical management of hepatic tumors has been demonstrated and should arguably be considered the final diagnostic procedure. OBJECTIVE: To determine the relevance of routine IOUS prior to hepatic resection compared with improved preoperative Magnetic resonance imaging (MRI). PATIENTS AND METHODS: Eighty patients with metastatic colorectal adenocarcinoma underwent hepatic resection between 1998 and 2001. The IOUS results were compared with preoperative MRI, bimanual palpation, and resection histopathology. The preoperative surgical plan was compared with the surgical procedure performed. Data were retrospectively analyzed. RESULTS: IOUS provided additional useful information not available preoperatively for 37 (47%) patients, including the identification of subcentimetre metastatic lesions, characterization of the lesion, and the anatomy of the hepatic vasculature. The preoperative surgical plan was changed secondary to the IOUS findings alone in 14/80 (18%) patients. IOUS did not provide any additional useful information for 43 (53%) patients. A correlation was demonstrated between the preoperative diagnosis, intraoperative findings, and resection histopathology. CONCLUSION: Accurate diagnostic studies facilitate critically decisive actions during planned hepatic resection(s). The current findings suggest that IOUS provide the most useful additional information for hepatic lesions, despite recent improvements in preoperative MRI scanning. Furthermore, routine IOUS should be employed during hepatic resection for colorectal metastases.

Adenocarcinoma↗
PubMed2002

Surgical strategy for cystic diseases of the liver in a western hepatobiliary center.

The aim of this study was to define the indications and evaluate the results of various management options in patients with cystic liver disease. Between 1992 and 1999 we managed 60 consecutive patients with cystic liver disease. Diagnoses included a simple cyst (solitary 12, multiple 10), adult polycystic liver disease (APLD 17), Caroli's disease (8), hydatid cysts (4), and neoplastic cysts (9). Half of the patients with simple cysts had mild or no symptoms and required no treatment. Percutaneous drainage in eight patients (simple cyst 4, APLD 4) was followed by symptomatic recurrence in three. Laparoscopic deroofing in three patients (multiple simple cysts 2, APLD 1) was followed by symptomatic enlargement of the remaining cysts that required further intervention (laparoscopic deroofing 2, transplantation 1). Laparoscopic hepatectomy was successful in three patients with solitary simple cysts. Of 18 patients who underwent open hepatic resection (neoplastic 8, Caroli's 4, simple cysts 3, hydatid cysts 2, APLD 1), 2 patients with Caroli's disease required liver transplantation for disease progression. Nine patients (Caroli's 5, APLD 4) underwent liver transplantation, and three had a concomitant renal transplant. Seven patients developed complications, and three died (5%). Cholangiocarcinoma developed in three patients with bilateral Caroli's disease, and all died. Radiologic treatment has a limited role in the management of patients with simple cysts or APLD. Laparoscopic deroofing of simple cysts may have to be repeated, whereas resection minimizes cyst recurrence. Unilobar Caroli's disease may be resected, whereas bilateral disease requires early liver transplantation owing to the high risk of malignancy. Transplantation is a reserved option in patients with extensive APLD.

Adult↗