Biomedical subjects

W Jarnagin

Publications and source records attributed to W Jarnagin.

13 recordsLinked to original sources

PubMed2006

Prospective, blinded comparison of helical CT and CT arterial portography in the assessment of hepatic metastasis from colorectal carcinoma.

OBJECTIVE: This prospective blinded comparison of helical CT and helical CT arterial portography aimed to detect liver metastasis from colorectal carcinoma. METHODS AND MATERIALS: 50 patients with colorectal carcinoma were evaluated comparing helical CT with helical CT arterial portography. Each imaging study was evaluated on a 5-point ROC scale by radiologists blinded to the other imaging findings, and the results were compared, with the surgical and pathologic findings as the gold standard. RESULTS: Of the 127 lesions found at pathology identified as metastatic colorectal cancer, helical CT correctly identified 85 (69%) and CT portography 96 (76%). When subgroups with lesions <3 cm (48 patients) and patients with maximum tumor size <3 cm (18 patients) were considered, CT portography was always better than helical CT in terms of sensitivity, specificity, positive predictive value, and negative predictive value. ROC analysis adjusting for multiple lesions per patient revealed significantly greater area under the curve (AUC) for the subgroup of lesions <3 cm (CT-AUC of 77% and CT portography AUC of 81%; P = 0.002). CONCLUSIONS: For identification of large metastases, helical CT and CT portography have similar yield. However, for detection of small liver metastases, CT portography remains superior for lesion detectability.

Colorectal Neoplasms↗

PubMed2005

Initial experience with hand-assisted laparoscopic distal pancreatectomy.

BACKGROUND: Hand-assisted laparoscopic distal pancreatectomy, with or without splenectomy, is gradually gaining acceptance, although its ultimate benefit is yet to be confirmed. This study aimed to report our initial experience with hand-assisted laparoscopic distal pancreatectomy. METHODS: A retrospective review of a prospectively collected database including 17 patients during the period 2002-2004 was conducted. The median age was 60 years (range, 29-85 years), and the female-to-male ratio was 13:4. The preoperative diagnoses included benign and malignant conditions. Besides two to three ports, a hand port was placed in the upper midline to aid in dissection. The pancreas was divided with a stapler in all the patients, and drains were placed in 10 patients (70%). RESULTS: One patient was found to be unresectable because of celiac artery involvement, and 2 of the remaining 16 patients underwent conversion to an open procedure. The median operating time was 196 min (range, 128-235 min). The mean tumor size was 4 cm (range, 2-7 cm), and the estimated blood loss was 125 ml (range, 50-1,250 ml). The median time to resumption of a regular diet was 3.5 days (range, 2-9 days), and the time to conversion to oral pain medications was 3 days (range, 2-9 days). The length of hospital stay was 5.5 days (range, 4-18 days), with a majority of the patients (11 patients, 78%) staying less than 7 days. There were no mortalities. The overall postoperative morbidity rate was 25%, and the morbidities consisted of pancreatic leak/fistula (2 patients, 14%) and fever (1 patient). The margins were negative in 10 (76%) of the relevant 13 patients. At a median follow-up period of 3.8 months (range, 5-14 months), 11 (84%) of 13 patients had no evidence of disease recurrence. CONCLUSIONS: The minimally invasive approach to pancreatic disease is safe and technically feasible. Further large studies with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the management of pancreatic disease.

Adult↗

PubMed2003

Phase I/II study of hepatic arterial therapy with floxuridine and dexamethasone in combination with intravenous irinotecan as adjuvant treatment after resection of hepatic metastases from colorectal cancer.

PURPOSE: Patients who undergo resection of liver metastases from colorectal cancer have an average 2-year survival of 65%. With hepatic arterial infusion (HAI) plus systemic fluorouracil and leucovorin, 2-year survival increased to 86%. For further improvement in both local and systemic control, combinations of new systemic drugs with HAI are being explored. The purpose of this study was to determine the maximum-tolerated dose (MTD) of systemic irinotecan (CPT-11) and HAI floxuridine (FUDR) plus dexamethasone (DEX) as combination adjuvant therapy after liver resection. PATIENTS AND METHODS: Ninety-six patients who underwent complete resection of liver metastases from colorectal cancer were treated with six monthly cycles of HAI FUDR plus DEX for 14 days of each 4-week cycle plus escalating doses of systemic CPT-11. The primary end points of the phase I/II study were the MTD and efficacy of this regimen. RESULTS: The MTD for combined systemic CPT-11 and HAI FUDR was CPT-11 at 200 mg/m2 every other week and FUDR at 0.12 mg/kg x pump volume / pump flow rate. The dose-limiting toxicities were diarrhea and neutropenia. With a median follow-up time of 26 months, the 2-year survival rate is 89%. All of the 27 patients who were treated at the MTD are alive. CONCLUSION: In patients who undergo resection of liver metastases from colorectal cancer, adding systemic CPT-11 to HAI therapy in an adjuvant regimen is feasible. This regimen seems to have comparable activity to fluorouracil and leucovorin, but further studies are needed to assess whether it improves local control or decreases extrahepatic recurrences.

Adenocarcinoma↗

PubMed2003

Intrahepatic cholangiocarcinoma. Current management.

Peripheral/Intrahepatic Cholangiocarcinoma (IHC), a malignant epithelial tumor originating from the intrahepatic bile ducts, is the second most common primary liver cancer after hepatocellular carcinoma. Unlike hepatocellular carcinoma, however, IHC is infrequently associated with chronic underlying liver disease. A recent study from the United States has demonstrated a 9% annual percentage increase and an overall 10-fold increase in mortality related to IHC since 1973. Despite this observation, however, IHC remains a rare disease in Western countries. Of the approximately 4000 patients seen at Memorial Sloan-Kettering Cancer Center with hepatic lesions since from 1995-2001, 7% had a diagnosis of cholangiocarcinoma and only 1% had IHC. As a result, progress in elucidating the pathogenesis and clinical behavior of these tumors has been slow. However, the increasing number of reports in recent years has increased awareness of IHC and provided some insight into its biology. At present, complete resection is the only therapy that offers the possibility of long-term survival. Single agent or combination chemotherapy and radiation therapy have not been shown to have a significant impact, either as primary treatment or as an adjuvant to resection. This report reviews the relevant literature pertaining to IHC with emphasis on clinical presentation, radiologic evaluation, treatment and outcome.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2002

Staging laparoscopy for potentially resectable noncolorectal, nonneuroendocrine liver metastases.

BACKGROUND: Carefully selected patients with noncolorectal, nonneuroendocrine (NCNN) liver metastases may benefit from hepatic resection. The incidence of occult unresectable disease and the possible benefits of staging laparoscopy in these patients are not known. METHODS: From December 1997 to July 2000, staging laparoscopy was performed in 30 consecutive patients with NCNN metastases before planned open exploration and resection. Demographics, extent of preoperative imaging, operative and postoperative findings, and factors associated with laparoscopic identification of unresectable disease were analyzed. RESULTS: Twenty-four patients (80%) had a complete laparoscopic examination, and 23 had laparoscopic ultrasonography. All patients underwent preoperative computed tomography or magnetic resonance imaging, and 21 (70%) patients had 2 or more preoperative radiological studies. Overall, nine patients had unresectable disease, six of whom were identified by laparoscopy. Of the remaining 24 patients believed to have resectable disease at laparoscopy, 21 went on to a potentially curative procedure. Laparoscopy did not identify irresectability because of vascular involvement in three patients. Laparoscopy added a median of 30 minutes of operative time to those patients going on to laparotomy. CONCLUSIONS: Laparoscopy identified the majority of patients with occult unresectable disease, improved resectability, and should be routine in patients being considered for potentially curative hepatic resection.

Adult↗

PubMed2001

Phase I study of hepatic arterial infusion of floxuridine and dexamethasone with systemic irinotecan for unresectable hepatic metastases from colorectal cancer.

PURPOSE: To determine the maximum-tolerated dose (MTD) and dose-limiting toxicities of concurrent systemic irinotecan and hepatic arterial infusion (HAI) of floxuridine (FUDR) and dexamethasone in patients with unresectable hepatic metastases from colorectal cancer, to determine the safety of this combination in patients who have undergone cryosurgery, and to evaluate the pharmacokinetic effects of HAI FUDR on the metabolism of irinotecan. PATIENTS AND METHODS: Forty-six previously treated patients with unresectable liver metastases and no known extrahepatic disease were treated concurrently with intravenous irinotecan weekly for 3 weeks and with HAI of FUDR and dexamethasone for 14 days (both were recycled in 28 days). Parallel cohorts of patients treated with or without cryosurgery were entered at escalating dose levels. RESULTS: The MTD for patients who did not undergo cryosurgery was 100 mg/m2 of irinotecan weekly for 3 weeks every 4 weeks with concurrent HAI FUDR (0.16 mg/kg/d x pump volume/flow rate) plus dexamethasone for 14 days of a 28-day cycle. The dose-limiting toxicities were diarrhea and neutropenia. The response rate (complete and partial) among all patients who did not undergo cryosurgery was 74%. All patients in the cryosurgery group responded, and seven of the eight cryosurgery patients developed normal positron emission tomography scans after chemotherapy. HAI FUDR had no effect on the metabolism of irinotecan. CONCLUSION: Combination therapy with HAI FUDR and dexamethasone plus systemic irinotecan may be safely administered to patients with unresectable hepatic metastases from colorectal cancer. The MTD has been reached for patients with unresectable disease, and we continue to investigate the MTD for patients who have undergone cryosurgery. Although the main objective of this study was to evaluate the toxicity of the combined regimen, a high response rate (74%) was observed.

Adult↗

PubMed2001

Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality.

BACKGROUND: Extended hepatic resection (more than four liver segments) is a major operative procedure that is associated with significant risk. The purpose of this study was to assess the impact of perioperative variables on in-hospital mortality after extended hepatectomy. STUDY DESIGN: Consecutive patients who underwent extended hepatic resection were studied. The prognostic value of 29 perioperative variables was evaluated using in-hospital mortality as the endpoint. For each variable, the odds ratio (95% confidence interval) for in-hospital mortality was calculated. Those variables with a lower confidence limit > 1 were considered important risk factors. The population was stratified into categories of patients having the same number of risk factors, and mortality was estimated for each group. These data were used to develop a risk assessment algorithm. RESULTS: There were 14 deaths (6%) in 226 patients. Three preoperative variables (cholangitis, creatinine > 1.3 mg/dL, and total bilirubin > 6 mg/dL) and two operative variables (blood loss > 3 L and vena caval resection) appear to be important factors for in-hospital mortality. The mortality associated with the presence of any two of the five factors was 100% (5 of 5), and the mortality associated with the absence of these factors was 3% (6 of 191). CONCLUSIONS: Perioperative evaluation of patients undergoing extended hepatic resection should include the quantitation of mortality risk factors. The combination of any two factors among preoperative cholangitis, elevated serum creatinine, elevated serum bilirubin, high operative blood loss, and vena cava resection may carry a high mortality risk. These results require prospective validation.

Adolescent↗

PubMed2001

Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection.

OBJECTIVE: To test the hypothesis that routine intraperitoneal drainage is not required after pancreatic resection. SUMMARY BACKGROUND DATA: The use of surgically placed intraperitoneal drains has been considered routine after pancreatic resection. Recent studies have suggested that for other major upper abdominal resections, routine postoperative drainage is not required and may be associated with an increased complication rate. METHODS: After informed consent, eligible patients with peripancreatic tumors were randomized during surgery either to have no drains placed or to have closed suction drainage placed in a standardized fashion after pancreatic resection. Clinical, pathologic, and surgical details were recorded. RESULTS: One hundred seventy-nine patients were enrolled in the study, 90 women and 89 men. Mean age was 65.4 years (range 23-87). The pancreas was the tumor site in 142 (79%) patients, with the ampulla (n = 24), duodenum (n = 10), and distal common bile duct (n = 3) accounting for the remainder. A pancreaticoduodenectomy was performed in 139 patients and a distal pancreatectomy in 40 cases. Eighty-eight patients were randomized to have drains placed. Demographic, surgical, and pathologic details were similar between both groups. The overall 30-day death rate was 2% (n = 4). A postoperative complication occurred during the initial admission in 107 patients (59%). There was no significant difference in the number or type of complications between groups. In the drained group, 11 patients (12.5%) developed a pancreatic fistula. Patients with a drain were more likely to develop a significant intraabdominal abscess, collection, or fistula. CONCLUSION: This randomized prospective clinical trial failed to show a reduction in the number of deaths or complications with the addition of surgical intraperitoneal closed suction drainage after pancreatic resection. The data suggest that the presence of drains failed to reduce either the need for interventional radiologic drainage or surgical exploration for intraabdominal sepsis. Based on these results, closed suction drainage should not be considered mandatory or standard after pancreatic resection.

Adult↗

PubMed2000

Hand-assisted laparoscopic liver resection: lessons from an initial experience.

BACKGROUND: Recent innovations in laparoscopic instrumentation make routine resection of solid organs a clinical possibility. HYPOTHESIS: Hand-assisted laparoscopic liver resection is a safe and feasible procedure for solitary cancers requiring removal of 2 segments of liver or less. DESIGN AND PATIENTS: Eleven patients with liver tumors deemed technically resectable by laparoscopic techniques were subjected to laparoscopic evaluation and attempted hand-assisted laparoscopic resection between July 1998 and July 1999. During the same period, 230 patients underwent open liver resection. SETTING: Tertiary care referral center for liver cancer. MAIN OUTCOME MEASURES: Success of laparoscopic resection, reasons for conversion to open liver resection, blood loss, tumor clearance margin, complications, and length of hospital stay. RESULTS: Five patients underwent successful resection by the hand-assisted laparoscopic technique. Data from the 5 successful cases and the 6 aborted cases are presented to outline the issues and the lessons learned. CONCLUSIONS: In selected patients, hand-assisted laparoscopic liver resection can be safely performed and might have potential advantages over traditional liver resection if the tumor is limited to the left lateral segment or is at the margins of the liver.

Adult↗

PubMed2000

Hepatic neuroendocrine metastases: does intervention alter outcomes?

BACKGROUND: In most instances, advanced neuroendocrine tumors follow an indolent course. Hepatic metastases are common, and although they can cause significant pain, incapacitating endocrinopathy, and even death, they are usually asymptomatic. The appropriate timing and efficacy of interventions, such as hepatic artery embolization (HAE) and operation, remain controversial. STUDY DESIGN: The records of 85 selected patients referred for treatment of hepatic neuroendocrine tumor metastases between 1992 and 1998 were reviewed from a prospective database. A multidisciplinary group of surgeons, radiologists, and oncologists managed all patients. Overall survival among this cohort is reported and prognostic variables, which may be predictive of survival, are analyzed. RESULTS: There were 37 men and 48 women, with a median age of 52 years. There were 41 carcinoid tumors, 26 nonfunctional islet cell tumors, and 18 functional islet cell tumors. Thirty-eight patients had extrahepatic metastases, and in 84% of patients, the liver metastases were bilobar. Eighteen patients were treated with medical therapy or best supportive care, 33 patients underwent HAE, and 34 patients underwent hepatic resection. Both the HAE-related mortality and the 30-day operative mortality rates were 6%. By univariate analysis, earlier resection of the primary tumor, curative intent of treatment, and initial surgical treatment were associated with prolonged survival (p < 0.05). On multivariate analysis, only curative intent to treat remained significant (p < 0.04). Patients with bilobar or more than 75% liver involvement by tumor were least likely to benefit from surgical resection. One-, 3-, and 5-year survival rates for the entire group were 83%, 61%, and 53%, respectively. The 1-, 3-, and 5-year survivals for patients treated with medical therapy, HAE, and operation were 76%, 39%, and not available; 94%, 83%, and 50%; and 94%, 83%, and 76%, respectively. CONCLUSIONS: Hepatic metastases from neuroendocrine tumors are best managed with a multidisciplinary approach. Both HAE and surgical resection provide excellent palliation of hormonal and pain symptoms. In select patients, surgical resection of hepatic metastases may prolong survival, but is rarely curative.

Adult↗

PubMed2000

Regional muramyl tripeptide phosphatidylethanolamine administration enhances hepatic immune function and tumor surveillance.

BACKGROUND: Immune status of the liver may affect growth of liver metastases. We analyzed the ability of muramyl tripeptide phosphatidylethanolamine (MTP-PE), an immunomodulatory bacterial cell wall analog, to stimulate Kupffer cells (KCs) and protect against tumor growth, with or without an immunosuppressive partial hepatectomy (PH). Impact of MTP-PE's route of administration on KC function was assessed. METHODS: Buffalo rats (n = 7 to 12/group) were treated with saline, 40 microg MTP-PE intraportally (portal) or intravenously (IV) and challenged with 5 x 10(5) hepatoma cells, and tumors counted on day 21. To assess MTP-PE's impact on KC stimulation in animals undergoing PH, a known stimulant of tumor cell growth, groups were treated with saline or MTP-PE and challenged with tumor and underwent 30% PH. KCs were harvested and analyzed for superoxide production. Statistical analysis was performed with Mann-Whitney U test or chi-square test. RESULTS: MTP-PE-treated animals had fewer tumor nodules than control animals (19 vs 184, P <.005). MTP-PE-portal animals had fewer nodules than MTP-PE-IV (2 vs 36, P <.05). MTP-PE treatment before PH resulted in fewer tumor nodules compared with control animals (192 vs 276, P <. 05). MTP-PE administration increased macrophage superoxide production (20.6 +/- 2 vs 11.9 +/- 1.1 nmol/10(6) cells, P <.005). CONCLUSIONS: MTP-PE improved KC function and decreased growth of microscopic tumor cells. MTP-PE's effects persist after an immunosuppressive hepatectomy. Portal administration was the most effective. MTP-PE administration may be useful as a neoadjuvant therapy for patients undergoing resection of liver malignancies.

Acetylmuramyl-Alanyl-Isoglutamine↗

PubMed2000

Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention.

OBJECTIVE: To compare patients with gallbladder cancer presenting for therapy with and without prior operation elsewhere to determine if an initial noncurative procedure alters outcome. SUMMARY BACKGROUND DATA: Nihilism has traditionally surrounded treatment of gallbladder cancer, particularly since the majority of cases are discovered during exploration for presumed gallstone disease when unsuspected cancers cannot be handled definitively and tumor is often violated. METHODS: Presentation, operative data, complications, and survival were examined for 410 patients presenting between July 1986 and March 2000. In particular, the 248 patients presenting for therapy after prior operation elsewhere were compared with the remainder who presented without prior operation to determine if an initial noncurative procedure alters outcome. RESULTS: Overall Outcome: 51 patients were inoperable, 92 were subjected to exploration and biopsy only, 135 to noncurative cholecystectomy, 30 to surgical bypass, and 102 to potentially curative resections consisting of portal lymph node dissection and liver parenchymal resections. Operative mortality was 3.9%. T-stage predicted likelihood of distant metastases and resectability. Median survival for resected patients was 26 months and 5-year survival was 38%, and for patients not resected, 5.4 months and 4% (P <.0001). Effect of Prior Operation: 22 patients subjected to potentially curative resection as the first surgical procedure were compared to 80 patients resected after prior exploration elsewhere. Mortality, complication, and long-term survival were the same. By multivariate analysis (Cox regression), resectability and stage were independent predictors (P <.001) of long-term survival, but prior surgical exploration was not. CONCLUSION: Unresected gallbladder cancer is a rapidly fatal disease. Radical resection can provide long-term survival, even for large tumors with extensive liver invasion. Long-term survival can be achieved for patients presenting after prior noncurative surgical exploration.

Aged↗

PubMed1999

An analysis of 412 cases of hepatocellular carcinoma at a Western center.

OBJECTIVE: Using a large single-institution experience at a Western referral center, the authors examine partial hepatectomy as treatment of hepatocellular carcinoma and relate treatment outcomes to clinical parameters, including the etiology of underlying cirrhosis. METHODS: Four hundred and twelve patients seen between December 1991 and January 1998 were identified in a prospective database. Data about the surgical procedure, perioperative complications, and long-term outcome were examined. RESULTS: One hundred twenty-six patients did not have underlying cirrhosis. Of the 286 patients with cirrhosis, 119 were the result of hepatitis B, 39 hepatitis C, 36 both B and C, 43 ethanol abuse, and the remainder other causes. Two hundred forty-three patients underwent surgical exploration, and 154 patients underwent hepatic resection. Seven (4.5%) died from the surgery. One hundred forty-three patients were treated by ablative methods. Patients with cirrhosis had smaller tumors but nevertheless had a lower resectability rate. Neither the presence of cirrhosis nor the etiology of the cirrhosis altered the perioperative morbidity or mortality rate. The greatest determinant of long-term outcome was resectability. The size of the lesion, an alpha-fetoprotein level >2000 ng/ml, and vascular invasion were also determinants of poor outcome. The presence of cirrhosis was a detrimental factor when analysis was stratified for size of tumor. The cause of cirrhosis did not influence the long-term outcome. The 5-year survival rate was 57% for patients with resected lesions <5 cm and 32% for patients with tumors >10 cm. CONCLUSION: Partial hepatectomy is safe, effective, and potentially curative therapy for hepatocellular carcinoma. The presence of cirrhosis did not affect the surgical mortality rate but did affect the long-term survival rate. The cause of cirrhosis did not influence outcome. As treatment for small hepatocellular carcinomas, partial hepatectomy produces results similar to those of transplantation. For patients with large tumors who are poor candidates for transplantation, resection results in long-term survival in one third of patients.

Carcinoma, Hepatocellular↗