Anstein Bergan

A comparative study of the short-term outcome following open and laparoscopic liver resection of colorectal metastases

Background: Laparoscopic resection of liver tumors is feasible, but few studies have compared short-term outcome of the laparoscopic approach to that of a conventional technique. Methods: Eighteen tumor resections performed during 14 procedures (14 patients) by conventional surgery were compared to 21 similar resections performed laparoscopically during 15 procedures (13 patients). All patients had colorectal liver metastases. Results: No perioperative mortality occurred. Surgical time, peroperative bleeding and blood transfusion requirement were similar in the two groups. The resection margin was involved by tumor tissue in one specimen laparoscopically resected and in two specimens conventionally resected (p = 0.58). Patients operated laparoscopically remained in hospital for median 4 days, while patients operated conventionally stayed median 8.5 days (p <0.001). Patients operated laparoscopically required less opioid medication than patients having conventional surgery (median 1 vs 5 days; p = 0.001). Conclusions: Short-term outcome of laparoscopic liver resection compares to that of conventional surgery, with the additional benefits derived from minimal invasive therapy.

Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome

Background: Laparoscopic resection is not an established treatment for tumors of the pancreas. We report our preliminary experience with this innovative approach to pancreatic disease. Methods: Thirty two patients with pancreatic disease were included in the study on an intention-to-treat basis. The preoperative indications for surgery were as follows: neuroendocrine tumors (n=13), unspecified tumors (n=11), cysts (n=2), idiopathic thrombocytopenic purpura with ectopic spleen (n=2), annular pancreas (n=1), trauma (n=1), aneurysm of the splenic artery (n=1), and adenocarcinoma (n=1). Results: Enucleations (n=7) and distal pancreatectomy with (n=12) and without splenectomy (n=5) were performed. Three patients underwent laparoscopic exploration only. Four procedures (13%) were converted to an open technique. One resection was converted to a hand-assisted procedure. The mortality rate for patients undergoing laparoscopic resection was 8.3% (two of 24). Complications occurred after resection in nine of 24 procedures (38%). The median hospital stay was 5.5 days (range, 2–22). Postoperatively, opioid medication was given for a median of 2 days (range, 0–13). Conclusion: Resection of the pancreas can be performed safely via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

Hepatic resection for colorectal metastases: Can preoperative scoring predict patient outcome?

A retrospective study was performed to define patient selection, safety, and efficacy of hepatic resection for colorectal metastases. The recently proposed preoperative clinical risk score (CRS) for selection of patients for surgery was also assessed. In all, 146 consecutive hepatic resections in 137 patients operated in the period between 1977 and 1999 were studied. Of these patients, 113 were classified into five CRS groups. Perioperative mortality was 1.4% (2 patients; no death in 120 patients operated after 1985) and morbidity was 38%. Five-year actuarial survival (perioperative mortality included) was 29% (median 37 months), and actual 5-year survival was 25% (17/69 patients). Patients operated after 1995 lived longer than those operated before 1995. Multiple regression analyses identified preoperative carcinoembryonic antigen CEA<100 µg/L, nodal status at resection of primary tumor, and RO vs. R1/R2 resection as prognostic parameters. CRS grouping had prognostic importance. The relative risk (hazard rate) of tumor recurrence in patients with CRS 3–4 was 2.1, compared to that of patients with CRS 0–2. Five-year actuarial survival in the two groups was 12% and 40%, respectively. Fourteen of 15 long-term survivors (τ;5 years) classified by the CRS system had CRS of 2 or less. Resection for colorectal liver metastases is safe, and long-term survival rates are acceptable. CRS predicts patient outcome, but the clinical role in patient selection will have to be defined in prospective studies.ResumeUne étude rétrospective a été réalisée pour définir la sélection des patients, la sûreté et l’efficacité de la résection hépatique pour métastases d’origine colorectale. Le score préopératoire «Clinical Risk Score» (CRS), proposé récemment pour la sélection des patients candidats à la chirurgie, a été évalué chez 146 patients consécutifs ayant eu une résection hépatique entre 1977 et 1999; 113 de ces patients ont été classés en cinq groupes selon le CRS. La mortalité périopératoire a été de 1.4% (2 patients; aucune mortalité parmi 120 patients opérés après 1985) et la morbidité, de 38%. La survie actuarielle à 5 ans (mortalité périopératoire incluse) a été de 29% (médiane de 37 mois) et la survie actuelle à 5 ans a été de 25% (17/69 patients). Les patients opérés après 1995 ont survécu plus longtemps que ceux opérés avant 1995. L’analyse par régression multiple a identifié comme facteurs pronostiques, le taux d’ACE inférieur à 100 ng/1, l’état ganglionnaire au moment de la résection tumorale primitive et une résection R0 vs. une résection R1/R2. Le risque relatif de récidive chez les patients CRS 3–4 a été de 2.1 comparé à celui des patients CRS 0–2. La survie actuarielle à 5 ans a été, respectivement, de 12% et de 40%. Quatorze des 15 survivants à long terme (τ; 5 ans), classés par le système CRS, avaient un score de 2 ou moins. La résection des métastases colorectales est sure et la survie à long terme, acceptable. Le score CRS prédit l’évolution mais son rôle clinique dans la sélection des patients reste à être défini par des études prospectives.ResumenPara seleccionar de manera eficaz y segura a los pacientes subsidiarios de resección hepática por padecer metástasis en hígado de un cáncer colorrectal, se realiza un estudio retrospectivo, en el que se valoró la clasificación reciente de Riesgo Clínico (CRS). Se estudiaron 146 resecciones hepáticas en 137 pacientes intervenidos entre 1977 y 1999. 113 de estos pacientes se clasificaron en alguno de los cinco grupos de la CRS. La mortalidad perioperatoria fue del 1.4% (2 pacientes; no se registró mortalidad alguna en los 120 pacientes intervenidos después del año 1985) y la morbilidad del 38%. La supervivencia actuarial a los 5 años (incluyendo la mortalidad perioperatoria) fue del 29% (media 37 meses) y la supervivencia actual a los 5 años fue del 25% (17/69 pacientes). Los enfermos intervenidos después de 1995 vivieron más tiempo que los operados con anterioridad. Los análisis de regresión múltiple señalaron como parámetros pronósticos: CEA preoperatorio menor de 100 ng/1, grado de afectación ganglionar en la resección del tumor primario y resección R0 vs R1/R2. La clasificación CRS tiene importancia pronóstica. El riesgo relativo de recidiva tumoral en pacientes de los grupos CRS 3–4 fue 2.1 en relación con la de los grupos CRS 0–2. La supervivencia actuarial a los 5 años fue respectivamente del 12% y 40%. 14 de los 15 supervivientes a largo plazo (τ;5 años) clasificados con el sistema CRS pertenecían a los grupos CRS 2 ó menores. El sistema CRS permite pronosticar los resultados, pero el papel del estudio clínico en la selección de los pacientes ha de definirse mejor en próximos estudios prospectivos.

The importance of anal endosonography in the evaluation of idiopathic fecal incontinence

PURPOSE: The aim of the study was to evaluate the use of anal endosonography in idiopathic incontinence. METHODS: In 29 patients and 26 normal controls, the relationship between sonography images and physiologic parameters was studied. RESULTS: External anal sphincter function, measured as fiber density by single-fiber electromyography (P=0.0001) and pudendal nerve terminal motor latency (P=0.04), was significantly impaired in patients with idiopathic incontinence compared with controls. Both the external and internal anal sphincter could be identified by anal endosonography, and the thickness directly measured. The thickness of the external anal sphincter was significantly negatively correlated to muscle fiber density (r=−0.65,P=0.0002) and to pudendal nerve distal conduction velocity (r=−0.74,P=0.008). The thickness of the internal anal sphincter was significantly correlated to resting pressure (r=−0.67,P=0.0001). CONCLUSION: The ratio between the thickness of the external and internal sphincter muscles measured on the sonography screen was significantly reduced in patients with neurogenic incontinence compared with controls (P<0.01).

Laparoscopic cholecystectomy: bile duct and vascular injuries: management and outcome.

Background: This is a retrospective study of 32 consecutive patients referred in the period 1992-2000 for management of serious bile duct injuries caused by elective laparoscopic cholecystectomy. Methods: The patients were referred on median 29 days (0 days to 34 months). Only 7 patients were referred immediately after discovery of the injury. At the local hospital, 25 patients underwent various procedures in attempts at repair. Ten of the patients were treated for bile duct strictures after previous repairs in other hospitals. Results: At referral, 23 patients (72%) had complete transection of the bile duct, while 9 had bile leakage injuries. Additional complications were occlusion of the right hepatic artery in 8 patients (24%) and occlusion of the mesenteric superior artery in 1 patient. Infectious complications were prominent in 21 patients (70%), 6 of whom had septicaemia. Operative management with hepaticojejunostomy Roux-Y was employed in 22 patients. Various non-operative strategies were chosen, including endoscopically or transhepatic stenting of the bile duct and embolization of the right hepatic artery. There was no difference in hospital stay between operative and non-operative procedures which on median was 16 days ( range 7-69 days). Three patients died: one had thrombosis of the superior mesenteric artery, while the other two died of complications to bile peritonitis. Median observation period is 5 years (5 months to 8 years). Two patients have cholangitis; both had injury to the right hepatic artery. The other patients all had normal ultrasonograms of the liver and normal/almost normal liver function tests. Conclusions: Bile duct injuries continue to occur, are serious and may result in death. Injury to the right hepatic artery is present in many cases. Patients are referred late to a competent center, resulting in serious infection in 70%.

Loop Ileostomy: technical aspects and complications

OBJECTIVE To study the incidence of complications of construction and closure of loop ileostomies and the final outcome for the patients. DESIGN Retrospective study. SETTING University hospital, Norway. SUBJECTS 100 patients with 103 loop ileostomies, operated on between 1980 and 1990. MAIN OUTCOME MEASURES Number of complications after ileostomy construction and closure. RESULTS 7 required re-operation after construction of the loop ileostomy and 11 after its closure. The most common cause was small intestinal obstruction (4 after construction and 6 after closure). 2 developed stomal necrosis. The mean duration of hospital stay was 13 and 10 days for primary and secondary loop ileostomy, respectively, and the mean time before closure was 31 weeks. After closure another 6 developed leaks from the ileal anastomosis that required further operation. Patients with secondary loop ileostomies had their stomas significantly longer than those with primary loop ileostomies (21 compared with 43 weeks, p = 0.00005). CONCLUSION Despite the number of complications, we think that faecal diversion is still justified in complex pelvic surgery and we should try to reduce the complication rate further.

Liver Transplantations in the Nordic Countries, 1982-1998: Changes of Indications and Improving Results

BACKGROUND Liver transplantation has become an established therapeutic option for patients with life-threatening liver disease. The aim of the present study was to analyse the results of and developments in liver transplantation in the Nordic countries during a 15-year period. METHODS Data on all patients receiving a liver allograft in the Nordic countries during 1982-98 and waiting list data for all patients listed for a liver transplantation after 1989 were obtained from the Nordic Liver Transplantation Registry. RESULTS A total of 1485 first liver transplantations were performed during 1982-98. The annual number of first liver transplantations increased steadily up to 1993, thereafter remaining around 150-170 per year. There are major differences between countries both in the number of transplants adjusted to populations performed per year, with more than twice as many performed in Sweden as in Norway, and in the relative distribution of patients in accordance with diagnosis. The number of patients more than 60 years old increased and comprised 13%-14% of the total patient population during 1996-98. Primary biliary cirrhosis, primary sclerosing cholangitis, acute hepatic failure, malignant liver disease, and alcoholic cirrhosis are the five most frequent diagnoses. The over-all 1-year patient survival probability has increased from 66% among patients receiving a transplant in 1982-89 to 83% in 1995-1998. The waiting time remains stable, with a median waiting time of 35 days during 1990-98. The mortality of patients while on the waiting list is 7.4% and is not increasing. CONCLUSION Results of liver transplantation in the Nordic countries are very similar to those obtained in other countries. Waiting time and mortality remain low. There are, however, major differences between the countries both as to the number of transplantations performed and as to distribution of diagnoses.

Magnetic‐resonance‐guided percutaneous cryoablation of hepatic tumours

OBJECTIVE To study the feasibility of percutaneous cryoablation of hepatic tumours monitored by magnetic resonance imaging (MRI). DESIGN Prospective study SETTING University hospital, Norway PATIENTS Six patients with hepatic metastases from colorectal cancer. INTERVENTIONS Percutaneous cryoprobe positioning under general anaesthesia. Positioning and freezing monitored by near-real-time MRI using an open 0.5 Tesla MRI configuration system. MAIN OUTCOME MEASURES Safety and feasibility of the procedure. Measurement of volumes of cryolesions. RESULTS One patient developed a biliary leakage that had to be drained. Four patients developed pleural fluid. Two small tumours were adequately cryoablated. In the remaining 4 patients with large (>4 cm) tumours, an adequate cryolesion could not be formed. Cryolesion volumes larger than 105 cm3 were not produced even using 3-4 probes. MRI visualised the growing cryolesion well, but positioning of the cryoprobes was time-consuming. CONCLUSION MR guided cryoablation is clinically feasible and gives good visualisation of the procedure. Patients with small tumours (<3 cm) seem to be best suited to this percutaneous approach as cryolesion volumes claimed to be adequate for tumour destruction can be produced. Measurement of tumour volume preoperatively may help to select patients who will respond.

Cryoablation of colorectal liver metastases: minimally invasive tumour control.

Background: Freezing is used for in situ destruction (ablation) of liver tumours not eligible for resection. The procedure is typically done during laparotomy. The objective of this report was to study tumour control at the site of freezing and a minimally invasive approach to cryoablation of colorectal liver metastases. Methods: A prospective study of 19 patients was conducted between 1999 and 2003. Twenty‐five tumours were ablated during 24 procedures (i.e. 5 reablations). Sixteen procedures were performed percutaneously, 5 during laparotomy and 3 laparoscopically. Magnetic resonance imaging (MRI) was used for intraprocedural monitoring during most procedures. Nine patients had concomitant liver resections performed (5 during laparoscopy, 4 during laparotomy). Results: Out of 25 ablations, 18 (72%) were assumed adequate. Total ice‐ball volume during percutaneous procedures was median 62 cm 3 (range 32–114). Excellent imaging of the extent of freezing was achieved using MRI. Hospital stay for patients treated percutaneously was median 4 days (range 3–30). No perioperative mortality occurred. Tumour recurrence at the site of ablation occurred in 8 of 18 (44%) tumours adequately ablated. Actuarial 2‐year tumour‐free survival at site of ablation was 48%. At the time of analyses 12 out of 13 (92%) patients assumed to be adequately ablated were alive. Of all patients, 14 out of 19 (74%) survived. Conclusions: Short‐term tumour control can be achieved following cryoablation of colorectal liver metastases. A minimally invasive approach is feasible but the diameter of metastases considered for percutaneous cryoablation should not exceed 3 cm.

Liver tumors and minimally invasive surgery: A feasibility study

Laparoscopic liver resection has not yet been established, although recent reports document that liver resection can be performed safely by the laparoscopic approach. Other interventional procedures like cryoablation have also been introduced in treatment of liver metastases. In this report 11 liver resections performed laparoscopically in eight patients are presented. Six patients had colorectal metastases, one a metastases from a malignant melanoma, and one patient had focal nodular hyperplasia. Two patients received synchronous cryoablation of remaining liver metastases. During follow up, two patients received percutaneous cryoablation of liver recurrences monitored by an open configuration magnetic resonance scanner. All except one of the tumors we attempted to remove had free resection margins (re-resection of new metastasis). No complications occurred except an atelectasis of the left lower pulmonary lobe in one patient. Median postoperative hospital stay was 3 days, and median postoperative opioid-dependent days was 1. The report demonstrates that minimally invasive techniques may safely be combined in hepatic intervention, and that the advantages of minimally invasive surgery, such as reduced hospital stay and less patient discomfort, also applies to liver resections.