George Sgourakis

Operations for Intrahepatic Cholangiocarcinoma : Single-Institution Experience of 158 Patients

BACKGROUND Intrahepatic cholangiocarcinoma (ICC) is a rare primary liver malignancy. Until now, outcomes and prognostic factors after liver resection for these tumors have not been well-documented. STUDY DESIGN Between April 1998 and December 2006, a total of 158 patients underwent surgical exploration in our institution for intended liver resection of ICC. Prospectively collected data of patients undergoing liver resection (n = 83) were analyzed with regard to preoperative findings, operative details, perioperative morbidity and mortality, pathologic findings, outcomes measured by tumor recurrence and survival, and prognostic factors for outcomes. RESULTS Tumors were solitary in 47 patients. R0 resections were achieved in 53 patients. Vascular infiltration and lymph node metastasis were detected in 41% and 34%, respectively. After resection, the calculated 1-, 3-, and 5-year-survival rates were 71%, 38%, and 21%, respectively, with corresponding rates of 83%, 50%, and 30% in R0 resections. For 14 variables evaluated, only gender (p = 0.008), Union Internationale Contre le Cancer stage (p = 0.014), and R classification (p = 0.001) showed predictive value in the multivariate Cox proportional hazard regression. CONCLUSIONS Results presented outline that an R0 resection leads to substantially prolonged survival in ICC and represents the considerable input of the surgeon to the outcomes of these patients. Union Internationale Contre le Cancer stage remains an important factor.

Comparison of skin-sparing mastectomy versus non-skin-sparing mastectomy for breast cancer: a meta-analysis of observational studies

Objectives:To evaluate differences in outcomes of breast cancer patients undergoing either conventional mastectomy without reconstruction (NSSM) or skin-sparing mastectomy (SSM) with immediate reconstruction. Data Sources:All comparative studies published between 1997 and 2009 were used to evaluate local recurrence and distant relapse in the 2 study groups. Review Methods:Meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, was carried out to evaluate the robustness of the pooled estimates and assess the between-study heterogeneity. Results:Nine studies, comprising of 3739 patients (1104 SSM and 2635 NSSM) were included in the analysis. There were no significant differences in the disease stage or the proportion of invasive cancers between groups (73.9% vs. 83.8%, P = 0.65). There was no significant difference in local recurrence between the SSM versus NSSM groups (7 studies, 3436 patients, 6.2% vs. 4.0%, odds ratio = 1.25, 95% CI: 0.81–1.94) and there was no significant heterogeneity between the studies. The SSM group had a lower proportion of distant relapses compared with the NSSM group (5 studies, 2122 patients, 10.0% vs. 12.7%, odds ratio = 0.67, 95% CI: 0.48–0.94) but this should be interpreted with caution since the grade of the tumors was not adequately reported in the studies considered. Conclusions:Our results suggest that in breast cancer patients, SSM was not significantly different from NSSM, in terms of rates of local recurrence. As no randomized control trial has addressed this question to date, the present meta-analysis reports the best evidence on the subject.

Corticosteroid-free immunosuppression in liver transplantation: a meta-analysis and meta-regression of outcomes.

To examine the impact of steroid withdrawal from the immunosuppression protocols in liver transplantation. The electronic databases Medline, Embase, Pubmed and the Cochrane Library were searched. Meta‐analysis pooled the effects of outcomes of a total of 2590 patients enrolled into 21 randomized controlled trials (RCTs), using classic and modern meta‐analytic methods. Meta‐analysis of RCTs addressing patients transplanted for any indication showed no differences between corticosteroid‐free immunosuppression and steroid‐based protocols in most of the analyzed outcomes. More importantly, steroid‐free cohorts appeared to benefit in terms of de novo diabetes mellitus development [R.R = 1.86 (1.43, 2.41)], Cytomegalovirus (CMV) infection [R.R = 1.47 (0.99, 2.17)], cholesterol levels [WMD = 19.71 (13.7, 25.7)], the number of patients that received the allocated treatment [O.R = 1.55 (1.17, 2.05)], severe acute rejection [R.R = 1.71 (1.14, 2.54)] and overall acute rejection [R.R = 1.31 (1.09, 1.58)] (when steroids were replaced in the steroid‐free arm). Taking RCTs into account independently when steroids were not replaced, overall acute rejection was favoring the steroid‐based arm [R.R = 0.75 (0.58, 0.98)]. Studies addressing exclusively transplanted HCV patients demonstrated a significant advantage of steroid‐free protocols considering HCV recurrence [R.R = 1.15 (1.01, 1.13)], acute graft hepatitis [O.R = 3.15 (1.18, 8.40)], and treatment failure [O.R = 1.87 (1.33, 2.63)]. No unfavorable effects were observed after steroid withdrawal during short‐term follow‐up. On the contrary, significant advantages were documented.

Orthotopic Liver Transplantation: T-tube or Not T-tube? Systematic Review and Meta-analysis of Results

Background. The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation. Methods. We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models. Results. The “without T-tube” and “with T-tube” groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The “without T-tube” group had better outcomes when considering “fewer episodes of cholangitis,” “fewer episodes of peritonitis,” and showed a favorable trend for “overall biliary complications.” Although the “with T-tube” group showed superior result for “anastomotic and nonanastomotic strictures,” the incidence of interventions was not diminished. Conclusions. Our systematic review and meta analysis favor the abandonment of T-tubes in orthotopic liver transplantation.

Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: is there any evidence-based information?

BACKGROUND The aim of this study was to test the hypothesis that minimally invasive video-assisted thyroidectomy (MIVAT) affords comparable safety and efficacy as to the open conventional surgery in dealing with patients with small thyroid nodules. METHODS Randomized controlled trials comparing the MIVAT with open thyroidectomy were ascertained by methodical search using Medline, Embase, Pubmed, and The Cochrane Library. Primary meta-analysis outcomes were adverse events (laryngeal nerve palsy and hypoparathyroidism), and cosmesis and secondary outcomes were operative time, blood loss, and early and late postoperative pain. RESULTS Operative time was significantly less with open thyroidectomy than with MIVAT, while MIVAT was associated with less pain at 6 hours postoperatively. Blood loss did not reached significance between procedures. Comparisons between two procedures concerning pain score of 24 and 48 hours, respectively, depicted statistically significant differences in favor of the MIVAT but only in the fixed effects model. MIVAT was associated with less scarring. There were no statistically significant differences for the presence of transient recurrent laryngeal nerve palsy and the presence of transient hypoparathyroidism. CONCLUSIONS MIVAT is a safe procedure that produces outcomes; in view of short-term adverse events, similar to those of open thyroidectomy, it needs a longer operative time to be accomplished and is superior in terms of immediate postoperative pain and cosmetic results.

Risk of lymph node metastasis in submucosal esophageal cancer: a review of surgically resected patients.

Objectives: Endoscopic local procedures are increasingly applied in patients with superficial esophageal cancer as an alternative to radical oncologic resection. The objective of this article is to determine the risk of nodal metastases in submucosal (sm) esophageal cancer, comparing the two predominating histologic tumor types, squamous cell cancer (SCC) and adenocarcinoma (ADC). Methods: A query of PubMed, MEDLINE, Embase and Cochrane Library (1980–2009) using predetermined search terms revealed 675 abstracts, of which 485 full-text articles were reviewed. A total of 105 articles met the selection criteria. A review of article references and consultation with experts revealed additional articles for inclusion. Studies that enrolled patients with submucosal esophageal cancer and provided adequate extractable data were included. Results: The pooled outcomes of 7645 patients with esophageal cancer involving the sm level of infiltration were included in the analysis. Overall, the percentage of lymph node metastasis in submucosal cancer was 37%. Lymph node (N), lymphatic (L) and vascular (V) invasion in sm1 esophageal cancers was 27, 46 and 22%, respectively. Within sm2 lesions, N, L and V invasion were involved in 38, 63 and 38% of patients, respectively. Finally, N, L and V involvement in patients with sm3 lesions was 54, 69 and 47%, respectively. The rates of lymph node metastasis for sm1 and sm2 were higher in SCC compared with ADC, whereas the lymph node metastasis for sm3 was comparable, with >50% involvement in both histologic subtypes. SCC revealed an overall more aggressive behavior compared with ADC (N+: 45 vs 26%; L+: 57 vs 37%; V+: 40 vs 18%). Discussion: While endoscopic therapy may be adequate in selected patients with ‘low-risk’ sm1 ADC, submucosal SCC necessitates esophageal resection and systematic lymphadenectomy because of its aggressive nature and tendency for early metastasis.

Liver Transplantation as a Primary Indication for Intrahepatic Cholangiocarcinoma: A Single-Center Experience

BACKGROUND Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC). PATIENTS AND METHODS Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration. RESULTS Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Those who underwent transplantation in the early period had a preoperative diagnosis of inoperable ICC (n = 4) and ICC in the setting of primary sclerosing cholangitis (n = 2). In the latter period the subjects had a diagnosis of HCC in cirrhosis (n = 3) or recurrent ICC after an extended right hepatectomy (n = 1). Median survival was 25.3 months for the whole series and 32.2 months (range, 18-130 months) when hospital mortality was excluded (n = 3). Four patients are currently alive after 30, 35, 42, and 130 months post-OLT, respectively. Two patients died of tumor recurrence at 18 and 21 months post-OLT, respectively. One-, 3-, and 5-year survival rates were 70%, 50%, and 33%, respectively. CONCLUSIONS The role of OLT in the setting of ICC may be re-evaluated in the future under strict selection criteria and with prospective multicenter randomized studies. Potential candidates to be included are those with liver cirrhosis and no hilar involvement who meet the Milan criteria for HCC.

Laparoscopic common bile duct exploration after failed endoscopic stone extraction

BackgroundOur objective was to present the technical aspects and results of laparoscopic common bile duct (CBD) exploration following failed endoscopic stone extraction.MethodFrom April 1997 to December 2006, 32 patients were referred to us after unsuccessful attempts at endoscopic CBD stone extraction. Transcholedochal laparoscopic CBD exploration was used in all patients. Previous operations, several pathologic entities, and stone impaction were studied as potential predictors of failure of the laparoscopic approach.ResultsPrevious operations, cholangitis, anatomic abnormalities, and stone impaction were the principal reasons for failure of endoscopic retrograde cholangiopancreatography (ERCP). Stone extraction under direct laparoscopic choledochotomy was achieved in 20 of 31 patients (64.51%). Biliary stents were inserted in 7 patients (21.8%) and T tubes were placed in 21 patients (65.6%). Five laparoscopic choledochoduodenostomies were performed. There were 11 conversions to open surgery. Morbidity was 12.5%.ConclusionsLaparoscopic choledochotomy is an efficacious procedure in dealing with unsuccessful endoscopic CBD clearance.

Detection of lymph node metastases in esophageal cancer

Lymph node status is the most important single prognostic factor in esophageal cancer. The detection of involved lymph nodes is therefore the key to cure. This article will provide a meta-analysis and metaregression analysis on the diagnostic performances of current lymph node-detection devices; discuss the recent status of the sentinel lymph node concept in esophageal cancer by the two sentinel node-mapping procedures (the radio-guided and the blue dye techniques) and the developing computed tomography (CT) lymphography; discuss the detection of micrometastases; and the potential clinical application of molecular-based patients’ profiles. Combined use of endoscopic ultrasonography fine-needle aspiration and CT significantly improves the diagnostic performance for regional lymph node metastases. Endoscopic ultrasonography is highly sensitive and specific for celiac lymph node metastases, while CT should mostly be performed in order to exclude other abdominal lymph node metastases. Sentinel lymph node navigation may be feasible for cT1N0 or cT2N0 esophageal cancer, and immunohistochemical staining of micrometastatic disease might be feasible in combination with this modality.

The Use of Self-Expanding Stents in Esophageal and Gastroesophageal Junction Cancer Palliation: A Meta-Analysis and Meta-Regression Analysis of Outcomes

BackgroundThe objective of this study was to examine the impact of self-expanding stents versus locoregional treatment modalities in the setting of esophageal cancer palliation.MethodsThe present meta-analysis pooled the effects of outcomes of 1,027 patients enrolled in 16 randomized controlled trials.ResultsThe meta-analysis revealed an advantage to the use of stents compared to locoregional modality treatments with respect to the number of patients requiring reinterventions, although the latter treatment arm had a higher 1-year survival. No difference was observed between the use of the antireflux stents and conventional stents in relieving reflux. Previous chemoradiotherapy had no impact on complications, procedural deaths, and overall patient survival. Differences in outcomes among stents were minimal.ConclusionsConventional self-expanding stents and anti-reflux stents are equally effective. Although the risk difference for 1-year survival favoured locoregional palliative treatment modalities, the latter were associated with a higher number of patients requiring reintervention.