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PubMedDate not supplied

Role of the ileocecal junction in the motor response to intestinal resection.

Extensive resections of the distal small intestine are associated with motor disruption in the proximal remnant. Luminal contents such as bacteria and short-chain fatty acids may play a role. We evaluated the effect of bypass of the ileocecal junction (ICJ) on the motor response to a 50% distal resection. Thirty-five dogs were divided into three groups: transection control (TC, n = 11); 50% distal resection with intact ICJ (DR, n = 12), and 50% distal resection with jejunocolostomy to bypass the ICJ (DRBP, n = 12). Motor activity, intestinal transit, nutrition, absorption, and motor active hormones were studied over a 3-month period. Caloric intake was reduced and nutritional status similarly impaired in both resected groups. Steatorrhea, however, was significantly greater after DRBP. Intestinal structural adaptation was similar in both resected groups at 12 weeks. Animals in the bypass group demonstrated elevated intraluminal short-chain fatty acid and anaerobic bacterial counts. Migrating motor complex frequency was similar in the three groups; distal starts, however, were more frequent in both resected groups. Clustered contractile activity was prominent in the remnant after both DR and DRBP (50% and 32% recording time occupied by clusters, respectively [not significant]). Basal levels of peptide YY were increased following resection and this increase was unaffected by ICJ bypass. Postprandial neurotensin concentrations were transiently increased after distal bowel resection. In contrast, the postprandial neurotensin response was abolished following resection with bypass of the ICJ. Basal motilin levels were reduced following resection alone but not after resection with ICJ bypass. The motor response to resection does not appear to be related to alterations in circulating levels of hormones localized to the distal ileum; neither does it seem to be influenced by luminal bacteria and short-chain fatty acids or retention of a sphincteric mechanism at the ICJ. These findings also raise questions about the role of short-chain fatty acids and bacteria in the generation of the various distinctive motor patterns of the distal ileum. Resection of the distal ileum through loss of the receptor site for either retarding reflexes or bile salt absorption may be of greater importance in determining the motor response to resection.

Anastomosis, Surgical↗

PubMed2001

Selection of eligible patients with supratentorial glioblastoma multiforme for gross total resection.

The purpose of this study is to clarify whether gross total tumor resection can prolong the survival in adult patients with supratentorial glioblastoma multiforme (GBM), and to clarify what subset of these patients obtains a survival advantage by gross total tumor resection without postoperative neurological deterioration. Eighty-two adult patients with supratentorial GBM were retrospectively reviewed. Overall, the median survival time was 13 months, and the 1- and 2-year survival rates were 53.7% and 14.6%, respectively. In a univariate analysis for survival rate by log-rank test, age (< 40 years), Karnofsky performance scale (KPS) score (70-100%) and extent of surgery (gross total resection) were revealed to be significant good prognostic factors. A Cox proportional hazard multivariate regression analysis confirmed that the KPS and extent of surgery were independent, significant good prognostic factors. Nine patients (11%) suffered postoperative neurological deterioration. A topographical GBM staging system (Stages I, II and III) with the integration of tumor location, size and eloquence of adjacent brain based on MRI (for explanation of Stages see text) was originally proposed. In Stage I, gross total resection had a strong tendency toward a better prognostic factor in a univariate analysis and was revealed to be a significant independent good prognostic factor in a multivariate analysis. In also Stage II, the survival of patients who underwent gross total resection was better than that of patients with less than gross total resection, although not significant. In Stage III, there were no patients who underwent gross total tumor resection. Risk probabilities of postoperative neurological deterioration, overall, were 0%, 22.2%, and 20% in Stages I, II, and III, respectively, and those after gross total resection were 0% and 16.7% in Stages I and II, respectively. Although gross total tumor resection is associated with prolongation of the survival time of patients with GBM, the risk of postoperative neurological deficit increases with radical tumor resection. To select an eligible subset of patients that benefit in survival from gross total tumor resection without postoperative risk, the following surgical policy for GBM resection is suggested. GBM in Stage I should be resected as radically as possible. Regarding Stage II, risky surgical resection extending to the area adjacent to the critical zone should be avoided and more meticulous and careful surgical planning is needed than that in Stage I. In Stage III, radical gross total tumor resection is not recommended at present.

Adult↗

PubMed2000

[Liver resection for liver metastases--1998 Bern Symposium].

The increasing knowledge of the anatomy and function of the liver made the surgical resection of liver metastases currently to the therapy of choice. Although liver metastasis is an advanced stage in tumor-progression, surgery achieves the best long-term results due to a better understanding of the carcinogenesis (i.e. micrometastases) and the prognostic risk factors. This study summarizes the results of 109 resections of colorectal and non-colorectal liver metastases during a period of 59 months at our department. Four different surgical techniques (extended hepatectomy vs. segmental resection vs. atypical resection vs. biopsy) were investigated. For resections a tumour-free resection margin of at least 10 mm was always attempted to achieve. The accumulated morbidity of all techniques together was 23%. Although the morbidity was higher for extended resections (Encephalopathy 16% vs. 2.3% for segmental resections, Liver insufficiency 23% vs. 4.7%), compared to the limited resection procedures, the long-term survival improved. The overall mortality was 2.7%. Survival was higher in patients with resection of colorectal than non colorectal metastases. Our results indicate that liver resection, under observance of the anatomical and functional margins (i.e. an adequate resection margin), is the only potentially curative therapy for liver metastases. An extensive formal resection, although inducing a higher perioperative morbidity, is superior to the limited resection techniques and results in an increased long-term survival. One reason is the increased probability of co-resection of preoperatively undetected local micrometastases.

Adolescent↗

PubMed1992

Management strategies in resection for hilar cholangiocarcinoma.

Between 1960 and 1990, resection was performed in 23 of 122 patients who underwent surgical treatment for hilar cholangiocarcinoma. Local excision of the lesion alone was performed in 10 cases (43%). Hepatic resection for tumor extending to the secondary bile ducts or hepatic parenchyma was performed in 13 cases (57%): extended right hepatectomy (3), right hepatectomy (1), extended left hepatectomy (6), left hepatectomy (2), and left lobectectomy (1). In three other cases, resection by total hepatectomy and liver transplantation was performed, but these were not included in the analysis of results for resection. Significant operative complications occurred in only two cases (8.7%), and the operative mortality rate was zero. In four cases, complete excision of the tumor could not be achieved macroscopically (macroscopic curative resection rate 19/122; 15.6%). In nine cases, the margins of the resected specimens were free from tumor on histologic examination (microscopic curative resection rate, 9/122; 7.4%). In 10 cases, the resection margins were found to contain tumor on histologic examination. The overall survival rate was 87% at 1 year, 63% at 2 years, and 25% at 3 years (median survival, 24 months). The survival and freedom from recurrence rates for patients with free resection margins was superior to that for patients with involved resection margins or residual macroscopic disease. A potentially curative resection, with histologically negative margins and no recurrence to date, was achieved in seven patients using the following procedures: local excision for two type I lesions; left hepatectomy plus excision of segment 1 for two type IIIb lesions and one type IV lesion; right hepatectomy and right hepatectomy plus excision of segment 1 for two type IIIa lesions. These results indicate that improved survival in hilar cholangiocarcinoma can be achieved by resection, with minimal morbidity and zero mortality rates, if histologically free resection margins are obtained. To achieve this, we recommend the following procedures for each type of lesion, based on our experience and on anatomic considerations: local excision for type I; local excision plus resection of segment 1 for type II; local excision, resection of segment 1, and right or left hepatectomy for types IIIa and b; hepatectomy plus liver transplantation for type IV.

Adenoma, Bile Duct↗

PubMed2001

Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma.

OBJECTIVE: To analyze resectability and survival in patients with hilar cholangiocarcinoma according to a proposed preoperative staging scheme that fully integrates local, tumor-related factors. SUMMARY BACKGROUND DATA: In patients with hilar cholangiocarcinoma, long-term survival depends critically on complete tumor resection. The current staging systems ignore factors related to local tumor extent, preclude accurate preoperative disease assessment, and correlate poorly with resectability and survival. METHODS: Demographics, results of imaging studies, surgical findings, pathology, and survival were analyzed prospectively in consecutive patients. Using data from imaging studies, all patients were placed into one of three stages based on the extent of ductal involvement by tumor, the presence or absence of portal vein compromise, and the presence or absence of hepatic lobar atrophy. RESULTS: From March 1991 through December 2000, 225 patients were evaluated, 77% of whom were seen and treated within the last 6 years. Sixty-five patients had unresectable disease; 160 patients underwent exploration with curative intent. Eighty patients underwent resection: 62 (78%) had a concomitant hepatic resection and 62 (78%) had an R0 resection (negative histologic margins). Negative histologic margins, concomitant partial hepatectomy, and well-differentiated tumor histology were associated with improved outcome after all resections. However, in patients who underwent an R0 resection, concomitant partial hepatectomy was the only independent predictor of long-term survival. Of the 9 actual 5-year survivors (of 30 at risk), all had a concomitant hepatic resection and none had tumor-involved margins; 3 of these 9 patients remained free of disease at a median follow-up of 88 months. The rates of complications and death after resection were 64% and 10%, respectively. In the 219 patients whose disease could be staged, the proposed system predicted resectability and the likelihood of an R0 resection and correlated with metastatic disease and survival. CONCLUSION: By taking full account of local tumor extent, the proposed staging system for hilar cholangiocarcinoma accurately predicts resectability, the likelihood of metastatic disease, and survival. Complete resection remains the only therapy that offers the possibility of long-term survival, and hepatic resection is a critical component of the surgical approach.

Adult↗

PubMed2002

Multivisceral resection for locally advanced primary colon and rectal cancer: an analysis of prognostic factors in 201 patients.

OBJECTIVE: To review a single-center experience with 201 multivisceral resections for primary colorectal cancer to determine the accuracy of intraoperative prediction of potential curability, to identify prognostic factors, and to examine the effect of surgical experience on immediate outcome and long-term results. SUMMARY BACKGROUND DATA: Locally advanced colorectal cancer may require an intraoperative decision for en bloc resection of surrounding organs or structures to achieve complete tumor removal. This decision must weigh the risk of complications and death of multivisceral resection against a potential survival benefit. Little is known about prognostic factors and the influence of surgical experience on the outcome of multivisceral resection for colorectal cancer. METHODS: Patients undergoing multivisceral resection for primary colon or rectal cancer between 1982 and 1998 were identified from a prospective database. Patients were followed up according to a standard protocol. RESULTS: Multivisceral resection was performed in 201 of 2,712 patients with a median age of 64 years. Postoperative rates of complications and death in 201 patients were 33% and 7.5%, respectively. A potentially curative resection was possible in 130 of 201 patients (65%) and histologic tumor infiltration was shown in 44% of patients with curative resection. Intraoperative assessment of curability was unreliable. After curative resection, the local recurrence rate was 11% and the overall 5-year survival rate was 51%. Multivariate analysis identified intraoperative blood loss (relative risk 1.7-6.4, P <.001), age 64 years or older (RR 3.7; P <.001), and UICC stage as independent prognostic factors (RR 2.0; P =.009). No prognostic significance was found for histologic tumor infiltration, the number of resected organs, or surgical experience. CONCLUSIONS: Multivisceral resection is safe, and long-term survival after curative resection is similar to that after standard resection. Because palliative resections cannot be predicted accurately at the time of surgery, every effort should be made to achieve complete tumor resection. Major blood loss but not surgical experience per se is an independent prognostic factor.

Aged↗

PubMed1993

Are there indications for partial rib resection in patients with adolescent idiopathic scoliosis treated with Cotrel-Dubousset instrumentation?

In adolescent idiopathic scoliosis the cosmetically unacceptable rib prominence is one of the main reasons patients seek treatment. Ninety-eight patients were reviewed with Cotrel-Dubousset (CD) instrumentation (average follow-up, 27 months; average preoperative curve, 53 degrees) and 27 patients with Harrington instrumentation and rib resection (average follow-up, 43 months; average preoperative curve, 52 degrees). Of the 98 patients who had CD instrumentation, 15 underwent concomitant rib resection. Of the 83 patients without rib resection, 71 (72%) were rated satisfactory and 12 unsatisfactory by cosmetic criteria based on residual rib deformity. These results were compared to those of 27 patients receiving Harrington rod instrumentation and rib resection, of whom 23 (85%) were rated as satisfactory. All 15 patients with CD and rib resection were rated satisfactory. The CD patients were then redivided into two groups (rib resection indicated or rib resection not indicated) as follows: the 12 unsatisfactory CD patients without rib resection (in whom a rib resection should have been done) were grouped with the 15 CD patients who underwent rib resection, for a total of 27 rib resections indicated, or 28%. This group was compared to the 71 satisfactory CD patients without rib resection (rib resection not indicated). Patients with a rib prominence of > 15 degrees preoperatively had or should have had a rib resection. Patients with a higher chance of needing rib resection included those with a curve severity greater than 60 degrees, curve flexibility less than 20%, a preoperative rib prominence > 10 degrees, or intraoperative curve correction of less than 50%.

Adolescent↗

PubMed1993

Cervical stability after sequential capsule resection.

A portion of the cervical facet joint must be resected to expose and decompress cervical nerve roots from a posterior approach. When posterior fusion is performed, it is common to remove the facet capsule only for the joints being fused. This study was performed to examine the effect of resection of the facet capsule alone, without disruption of the bony facet to determine what degree of facet-capsule resection leads to acute instability. Seven human cervical cadaveric spines were used in the experiment. Nondestructive biomechanical testing was performed in axial load, flexion, extension, and torsion. Each specimen was tested intact and after sequential resection of 25%, 50%, 75%, and 100% of the C5-6 facet capsules. Axial stiffness changed very little during the experiment. In torsion, the displacement increased 1% after a 25% capsule resection, 19% after a 50% resection, and 25% after a 75% or 100% resection. No gross subluxation was seen during the torsional test. In the flexion test, posterior displacement increased 4% after a 25% resection, 5% after a 50% resection, 32% after a 75% resection, and 22% after a 100% resection. There was a statistically increased displacement seen during the flexion test after 75% or 100% of capsule resection. Thus, significant hypermobility did occur during both torsion and flexion testing with greater than 50% resection of the facet capsules. Great care should be taken when exposing an unfused facet to limit facet-capsule resection to less than 50%. With resection of greater than 50% of the capsule, postoperative hypermobility can occur and may require stabilization.

Biomechanical Phenomena↗

PubMed2003

Liver resection as a bridge to transplantation for hepatocellular carcinoma on cirrhosis: a reasonable strategy?

OBJECTIVE: To assess the viability of a strategy of primary resection with secondary liver transplantation (LT) for hepatocellular carcinoma (HCC) on cirrhosis. SUMMARY BACKGROUND DATA: LT is the optimal treatment of HCC with cirrhosis. Owing to organ shortage, liver resection is considered as a reasonable first-line treatment of patients with small HCC and good liver function, with secondary LT as a perspective in case of recurrence. The viability of such strategy, positively explored in theoretical models, is not documented in clinical practice. METHODS: Among 358 consecutive patients with HCC on cirrhosis treated by liver resection (n = 163; 98 of whom were transplantable) or transplantation (n = 195), the feasibility and outcome of secondary transplantation was evaluated in a 2-step fashion. First, secondary LT for tumor recurrence after resection (n = 17) was compared with primary LT (n = 195), to assess the risk and the outcome of secondary LT in patients who effectively succeeded to be treated by this approach. Second, primary resection in transplantable patients (n = 98) was compared with that of primary LT (n = 195) on an intention-to-treat basis, to assess the outcome of each treatment strategy and to determine the proportion of resected patients likely to be switched for secondary LT. Transplantability of resected patients was retrospectively determined according to selection criteria of LT for HCC. RESULTS: Operative mortality (< or =2 months) of secondary LT was significantly higher than that of primary LT (28.6% versus 2.1%; P = 0.0008) as was intraoperative bleeding (mean transfused blood units, 20.7 versus 10.5; P = 0.0001). Tumor recurrence occurred more frequently after secondary than after primary LT (54% versus 18%; P = 0.001). Posttransplant 5-year overall survival was 41% versus 61% (P = 0.03), and disease-free survival was 29% versus 58% (P = 0.003) for secondary and primary LT, respectively. Of 98 patients treated by resection while initially eligible for transplantation, only 20 (20%) were secondarily transplanted, 17 of whom (17%) for tumor recurrence and 3 (3%) for hepatic decompensation. Transplantability of tumoral recurrence was 25% (17 of 69 recurrences). Compared with primarily transplanted patients, transplantable resected patients had a decreased 5-year overall survival (50% versus 61%; P = 0.05) and disease-free survival (18% versus 58%; P < 0.0001), despite the use of secondary LT. On a multivariate analysis including 271 patients eligible for transplantation and treated by either liver resection or primary LT, liver resection alone (P < 0.0001; risk ratio [RR] = 3.27) or liver resection with secondary LT (P < 0.05; RR= 1.87) emerged as negative independent factors of disease-free survival as compared with primary LT. A number of nodules > 3 (P = 0.002; RR= 2.02) and a maximum tumor size exceeding 30 mm (P < 0.0001; RR=1.93) were also predictive of lower disease-free survival. CONCLUSIONS: LT after liver resection is associated with a higher operative mortality, an increased risk of recurrence, and a poorer outcome than primary LT. In addition, liver resection as a bridge to LT impairs the patient transplantability and the chance of long-term survival of cirrhotic patients with HCC. Primary LT should therefore remain the ideal choice of treatment of a cirrhotic patient with HCC, even when the tumor is resectable.

Analysis of Variance↗

PubMed2005

Prognostic impact of anatomic resection for hepatocellular carcinoma.

OBJECTIVES: To evaluate the prognostic impact of anatomic versus nonanatomic resection on the patients' survival after resection of a single hepatocellular carcinoma (HCC). SUMMARY OF BACKGROUND DATA: Anatomic resection is a reasonable treatment option for HCC; however, its clinical significance remains to be confirmed. METHODS: Curative hepatic resection was performed for a single HCC in 210 patients; the patients were classified into the anatomic resection (n = 156) and nonanatomic resection (n = 54) groups. In 84 patients assigned to the anatomic resection group, segmentectomy or subsegmentectomy was performed. We evaluated the outcome of anatomic resection, including segmentectomy and subsegmentectomy, in comparison with that of nonanatomic resection, by the multivariate analysis taking into consideration 14 other clinical factors. RESULTS: Both the 5-year overall survival and disease-free survival rates in the anatomic resection group were significantly better than those in the nonanatomic resection group (66% versus 35%, P = 0.01, and 34% versus 16%, P = 0.006, respectively). In the segmentectomy and subsegmentectomy group, the 5-year overall and disease-free survival rates were 67% and 28%, respectively, both of which were also higher than the corresponding rates in the nonanatomic resection group (P = 0.007 and P = 0.001, respectively). The results of multivariate analysis revealed that anatomic resection was a significantly favorable factor for overall and disease-free survivals: the hazard ratios were 0.57 (95% confidence interval, 0.32-0.99, P= 0.04), and 0.65 (0.43-0.96, P = 0.03). CONCLUSION: Anatomic resection for a single HCC yields more favorable results rather than nonanatomic resection.

Adolescent↗

PubMed1993

Neurocognitive efficiency following left temporal lobectomy: standard versus limited resection.

Decreased memory and learning efficiency may follow left temporal lobectomy. Debate exists as to whether the acquired deficit is related to the size of the surgical resection. This study addresses this question by comparing changes in cognitive performance to the extent of resection of both mesial temporal structures and lateral cortex. The authors retrospectively reviewed 47 right-handed patients who underwent left temporal lobectomy for medically intractable seizures. To examine the effects of the extent of mesial resection, the patients were divided into two groups: those with resection at the anterior 1 to 2 cm of mesial structures versus those with resection greater than 2 cm. To examine the effects of the extent of lateral cortical resection, patients were again divided into two groups: those with lateral cortex resections of 4 cm or less versus those with resections greater than 4 cm. Statistical analyses showed no difference in cognitive outcome between the groups defined by the extent of mesial resection. Likewise, no difference in cognitive outcome was seen between the groups defined by the extent of lateral cortical resection. Associated data analyses did, however, reveal a negative correlation of cognitive change with patient age at seizure onset. These results showed that the neurocognitive consequences of extended mesial resections were similar to those of limited mesial resections, and that the neurocognitive consequences of extended lateral cortical resections were similar to those of limited lateral cortical resections. The risk of cognitive impairment depends more on age at seizure onset than on the extent of mesial or lateral resection.

Adult↗

PubMedDate not supplied

Survival after repeat hepatic resection for recurrent colorectal metastases.

BACKGROUND/AIMS: This is a retrospective study examining survival of patients undergoing repeat hepatic resection for recurrent colorectal metastases. METHODOLOGY: The records of 41 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resections (negative resection margin and no extrahepatic disease) were attempted in all patients. Recurrence developed in 26 (63%) patients, with disease being confined to the liver in 16 (39%) patients. Ten of them (24%) underwent hepatic resection and make up the study population. RESULTS: Ten patients (4 women, 6 men; mean age: 62 years, range: 50-82 years) developed recurrence confined to the liver at the median interval of 16 months (range: 5-34 months) after the first hepatectomy. In 6 patients the recurrent cancer(s) involved both the area near the resection line and remote sites from the site of the first hepatic resection. In 3 patients recurrent cancer(s) was located at sites remote from the first liver resection. In 1 patient the recurrent cancer was located in the same area as the original hepatic resection. Three formal hepatectomies and seven non-anatomical (wedge) resections were performed. The mean blood loss was 900 cc (range: 100-2700 cc); the mean hospital stay was 19 days (range: 8-34 days). There was no perioperative mortality. Morbidity was 20%. Four patients died of recurrent disease, with a mean disease-free survival of 13 months (range: 5-21 months). Two patients had a second recurrence resected at 10 and 24 months, respectively, after the second hepatic resection. One of these 2 patients had a fourth hepatic resection for hepatic recurrence and is still alive with no evidence of disease. Six patients are alive, 4 of them without evidence of disease, with a median follow-up time of 30 months (range: 22-64 months). Actuarial 4-year specific survival was 44%. Actuarial disease-free survival at 4 years was 18%. CONCLUSIONS: In appropriately selected patients, repeat hepatic resection for colorectal metastases is a worthwhile treatment. Mortality, morbidity, and survival are similar to those following the initial resection.

Aged↗

PubMed2005

[Anatomical resection for liver metastases of the carcinoma of the large intestine and the rectum].

UNLABELLED: Resection of the colorectal carcinoma liver metastases is an effective therapeutical procedure with a five-year survival rate in 20-50% of the operated. Opinions on the most optimal type of the resection procedure remain to be controversial. The aim of this study was to assess all indication criteria for anatomical resections of the colorectal carcinoma liver metastases. SUBJECTS AND METHODOLOGY: This retrospective study analyzed 98 patients with liver resection for colorectal metastases. In 31 patients, extensive anatomical resections of the liver were conducted, segmentotomie were conducted in 20 patients and nonanatomical wedge resections in 47 patients. Extensive anatomical resections were conducted in cases of tumorous foci larger than 2cm and located marginally between individual segments of a single lobe, and in cases of multiple tumorous foci affecting a single liver lobe. The nonanatomical resections were conducted in cases of metastases smaller than 2 cm, localized on the liver surface or in cases of multiple peripheral foci, including cases when both liver lobes were affected. RESULTS: In the group with the wedge-type resections, a histologically positive border was found in 4 cases. Postoperative complications were recorded in 10 (19.6%) patients with the anatomical resection and in 9 (19.1%) with the wedge resection. CONCLUSION: 1. Anatomical resection of the liver for the colorectal carcinoma metastases is indicated in cases of larger foci (over 2 cm), located marginally between segments or in multiple metastases affecting a single liver lobe. 2. Anatomical approach to the resection lowers the rates of histologicaly non-radical resections (R 1). 3. The new surgical technique of the liver transsection lowered, even in cases of anatomical resections, the postoperative morbidity rates.

Adult↗

PubMed2006

Portal vein resection for hilar cholangiocarcinoma.

Hilar cholangiocarcinoma remains a difficult challenge for the surgeon. Achieving negative surgical margins when resecting this relatively uncommon tumor is technically demanding as a result of the close proximity of the bile duct bifurcation to the vascular inflow of the liver. A recent advance in surgical treatment is the addition of portal vein resection to the procedure. Resection of the portal vein increases the number of patients offered a potentially curative approach but is technically more difficult and may increase the risk of the procedure. This study reviews the results of portal vein resection for hilar cholangiocarcinoma. Between 1998 and 2005, 60 patients underwent potentially curative resections of hilar cholangiocarcinoma. Mean patient age was 64 +/- 12 years (range, 24-85 years). Liver resections performed along with biliary resection included 49 trisegmentectomies (37 right, 12 left) and 10 lobectomies (8 left, 2 right). One patient had only the bile duct resected. Four patients also had simultaneous pancreaticoduodenectomy performed. Twenty-six patients required portal vein resection and reconstruction to achieve negative margins, 3 of which also required reconstruction of the hepatic artery. Operative mortality was 8 per cent with an overall complication rate of 40 per cent. Patients who underwent portal vein resection had an operative mortality of 4 per cent, which was not different from the 12 per cent mortality in patients who did not undergo portal vein resection (P = 0.39). There was no difference in actuarial patient survival between patients who underwent portal vein resection and those who did not (5-year survival 39 per cent vs. 41 per cent, P = not significant). Negative margins were achieved in 80 per cent of cases and were associated with improved survival (P < 0.01). Five-year actuarial survival in patients undergoing resection with negative margins was 45 per cent. There was no difference in margin status or long-term survival between those patients who underwent portal vein resection and those who did not. Only negative margin status was associated with improved survival by multivariate analysis. Portal vein resection for hilar cholangiocarcinoma is safe and allows a chance for long-term survival in otherwise unresectable patients.

Adult↗

PubMed1995

[Liver resection of metastases from colorectal cancer].

From 1978 to the end of 1991, 66 patients were operated on for liver metastases from colorectal cancer. All patients had had a curative resection of their colorectal cancer. Forty resections of the liver were major anatomic resections. This study was undertaken to determine the indications for and value of liver resection for metastases from colorectal cancer. Five patients died in the postoperative period. All resections were intended to be curative, but in 16 of the patients the resection became noncurative. None of these patients lived more than two years after liver resection. Fifty patients with a curative resection had a three-year survival rate of 36 percent, postoperative death included. Recurrence in the liver was observed in 30 patients (60 percent) from three to 33 (median 11) months after the liver resection. Four patients had repeated resections performed. Two of them are alive without recurrence at respectively 34 and 60 months after the first liver resection. The difference in survival between curative and noncurative liver resection was highly significant (p = 0.01). Sex, age, Dukes' stage of primary colorectal cancer, synchronous or metachronous appearance of metastases, or number of metastases could not predict long-term prognosis. The only factors of predictive value were tumour size, a free resection margin, and no extrahepatic tumour. If it is possible to perform a curative resection, there should be few contraindications against liver surgery as it is the only treatment that can demonstrate long-term survival for approximately one-third of the patients, and it is the only possibility of cure. Palliative resection is not recommended.

Adult↗

PubMed1998

Role of the ileocecal junction in the motor response to intestinal resection

Extensive resections of the distal small intestine are associated with motor disruption in the proximal remnant. Luminal contents such as bacteria and short-chain fatty acids may play a role. We evaluated the effect of bypass of the ileocecal junction (ICJ) on the motor response to a 50% distal resection. Thirty-five dogs were divided into three groups: transection control (TC, n = 11); 50% distal resection with intact ICJ (DR, n = 12), and 50% distal resection with jejunocolostomy to bypass the ICJ (DRBP, n = 12). Motor activity, intestinal transit, nutrition, absorption, and motor active hormones were studied over a 3-month period. Caloric intake was reduced and nutritional status similarly impaired in both resected groups. Steatorrhea, however, was significantly greater after DRBP. Intestinal structural adaptation was similar in both resected groups at 12 weeks. Animals in the bypass group demonstrated elevated intraluminal short-chain fatty acid and anaerobic bacterial counts. Migrating motor complex frequency was similar in the three groups; distal starts, however, were more frequent in both resected groups. Clustered contractile activity was prominent in the remnant after both DR and DRBP (50% and 32% recording time occupied by clusters, respectively [not significant]. Basal levels of peptide YY were increased following resection and this increase was unaffected by ICJ bypass. Postprandial neurotensin concentrations were transiently increased after distal bowel resection. In contrast, the postprandial neurotensin response was abolished following resection with bypass of the ICJ. Basal motilin levels were reduced following resection alone but not after resection with ICJ bypass. The motor response to resection does not appear to be related to alterations in circulating levels of hormones localized to the distal ileum; neither does it seem to be influenced by luminal bacteria and short-chain fatty acids or retention of a sphincteric mechanism at the ICJ. These findings also raise questions about the role of short-chain fatty acids and bacteria in the generation of the various distinctive motor patterns of the distal ileum. Resection of the distal ileum through loss of the receptor site for either retarding reflexes or bile salt absorption may be of greater importance in determining the motor response to resection.

Journal Article↗

PubMed2000

Preoperative chemotherapy, radiotherapy, and surgical resection of locally advanced pancreatic cancer.

HYPOTHESIS: Neoadjuvant therapy has the potential to induce regression of high-risk, locally advanced cancers and render them resectable. Preoperative chemoradiotherapy is proposed as a testable treatment concept for locally advanced pancreatic cancer. DESIGN: Fourteen patients (8 men, 6 women) with locally advanced pancreatic cancer were surgically explored to exclude distant spread of disease, to perform bypass of biliary and/or gastric obstruction, and to provide a jejunostomy feeding tube for long-term nutritional support. A course of chemotherapy with fluorouracil and cisplatin plus radiotherapy was then initiated. Reexploration and resection were planned subsequent to neoadjuvant therapy. MAIN OUTCOME MEASURES: Tumor regression and survival. INTERVENTIONS: Surgically staged patients with locally advanced pancreatic cancer were treated by preoperative chemotherapy with bolus fluorouracil, 400 mg/m2, on days 1 through 3 and 28 through 30 accompanied by a 3-day infusion of cisplatin, 25 mg m2, on days 1 through 3 and 28 through 30 and concurrent radiotherapy, 45 Gy. Enteral nutritional support was maintained via jejunostomy tube. RESULTS: Of 14 patients who enrolled in the protocol and were initially surgically explored, 3 refused the second operation and 11 were reexplored; 2 showed progressive disease and were unresectable and 9 (81%) had definitive resection. Surgical pathologic stages of the resected patients were: Ib (2 patients), II (2 patients), and III (5 patients). Pancreatic resection included standard Whipple resection in 1 patient, resection of body and neck in 1 patient, and extended resection in 6 patients (portal vein resection in 6, arterial resection in 4). One patient who was considered too frail for resection had core biopsies of the pancreatic head, node dissection, and an interstitial implant of the tumorous head. Pathologic response: 2 patients had apparent complete pathologic response; 1 patient had no residual cancer in the pancreatectomy specimen, the other patient who had an iridium 192 interstitial implant had normal core biopsies of the pancreatic head. Five patients had minimal residual cancer in the resected pancreas or microscopic foci only with extensive fibrosis, and 2 patients had fully viable residual cancer. Lymph node downstaging occurred in 2 of 4 patients who had positive peripancreatic nodes at the initial surgical staging. There was 1 postoperative death at 10 days. Sepsis, prolonged ileus, and failure to thrive were major complications. In the definitive surgery group the median survival was 19 months after beginning chemoradiotherapy and 16 months after definitive surgery. The absolute 5-year survival was 11% of 9 patients, 1 is surviving 96 months (with no evidence of disease) after chemoradiotherapy and extended pancreatic resection including resection of the superior mesenteric artery and the portal vein for stage III cancer. In the nonresected group the mean survival was 9 months (survival range, 7-12 months) after initiation of chemoradiotherapy. CONCLUSION: A pilot study of preoperative chemoradiotherapy with infusional cisplatin and radiation induced a high rate of clinical pathologic response in patients with locally advanced pancreatic cancer and merits further study in these high-risk patients.

Adult↗

PubMed1994

Resection of liver metastases from colorectal cancer. Indications and results.

PURPOSE: This study was undertaken to determine the indications for and value of liver resection for metastases from colorectal cancer. METHODS: From 1978 through 1991, 66 patients were operated on for liver metastases from colorectal cancer. All patients had had a curative resection of their colorectal cancer. Forty resections of the liver were major anatomic resections. RESULTS: Five patients died in the postoperative period. All resections were intended to be curative, but in 16 of the patients the resection became noncurative. None of these patients lived more than two years after liver resection. Fifty patients with a curative resection had a three-year survival rate of 36 percent, postoperative death included. Recurrence in the liver was observed in 30 patients (60 percent) from 3 to 33 (median, 11) months after the liver resection. Four patients had repeated resections performed. Two of them are alive without recurrences 34 and 60 months after the first liver resection, respectively. The difference in survival between curative and noncurative liver resection was highly significant (P = 0.01). CONCLUSIONS: Sex, age, Dukes stage of primary colorectal cancer, synchronous or metachronous appearance of metastases, or number of metastases could not predict long-term prognosis. The only factors of predictive value were tumor size less than 4 cm in diameter, a free resection margin, and no extrahepatic tumor. If it is possible to do a curative resection, there should be few contraindications against liver surgery as it is the only treatment that can demonstrate long-term survival for approximately one-third of the patients, and it is the only possibility of a cure.

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