Joaquin S. Aldrete

Resection of the liver for colorectal carcinoma metastases. A multi-institutional study of long-term survivors.

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to 1-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primarycarcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

Hepatic resection of metastasis from colorectal carcinoma. Morbidity, mortality, and pattern of recurrence.

To identify the factors that determine the morbidity and mortality of liver resection of metastases from colorectal carcinoma and the variables that may influence the pattern of recurrence, the survival time and the disease-free rate, a univariate and-multivariate statistical analysis (30 variables using Students t-test, Fischers exact test, and chi square test) was performed. Intraoperative blood loss of greater than 3500 ml was found to be a significant risk factor to developing postoperative complications (p less than 0.05 by x2). After a mean follow-up of 25.8 months, 26 of the 35 patients studied (74%) had recurrent disease. In the univariate analysis, the following factors appear to be reliable predictors of early recurrence: poor degree of differentiation of the primary colorectal tumor, the presence of multiple liver metastases, the male gender, and the presence of tumor at the margin of the resected hepatic tissue (p less than 0.05). However, only the latter two factors appeared also to affect the survival time and the disease-free rates at 2 years after hepatic resection of metastases (p less than 0.05). In the multivariate analysis (factors tested simultaneously), presence of an advanced liver metastatic disease (Stage II or III) consistently indicated early recurrence and poor survival (p less than 0.005). The liver was the most common site of recurrence as the sole site of recurrence (54%) or in combination with other sites (88%)--followed by the lungs (31%) and the site of colonic resection (8%). Twenty-nine (83%), 14 (40%), and nine (26%) patients survived without recurrent disease at 1, 2, and 3 or more years, respectively, after hepatic resection of metastases. In six patients (17%), no significant palliation was noted, primarily because of early recurrence (less than 6 months). From this data, resection of hepatic metastases from colorectal cancer appears to offer a realistic therapeutic option to a selected group of patients, but only if the resective procedure can be performed with an operative mortality rate of less than 5%.

Abdominal wound closure. A randomized prospective study of 571 patients comparing continuous vs. interrupted suture techniques.

A randomized, prospective study was designed to compare a continuous with an interrupted technique for closing an abdominal incision. Five hundred seventy-one patients were randomized between the closure methods and stratified as to type of wound: clean, clean-contaminated, or contaminated. In mid-line incisions, the dehiscence rate was 2.0% (5/244) for the continuous group versus 0.9% (2/229) for the interrupted group. The difference was not statistically significant. Ventral hernias formed in 2.0% (4/201) of the continuous group vs. 0.5% (1/184) of the interrupted group. The type of wound had no influence on the results. In oblique incisions, 0% (0/39) of wounds closed continuously dehised while 2% (1/50) of incisions closed interruptedly dehised. No ventral hernias formed. Further analysis of the data indicated that dehiscence was more likely related to improper surgical technique than to the method of closure. An abdominal incision could be closed with a continuous suture in approximately half the time required for placing interrupted sutures (20 vs. 40 minutes). A continuous closure is preferred because it is more expedient and because it has the same incidence of wound disruption compared with an interrupted closure.

Gastrointestinal and hepatic complications affecting patients with renal allografts

Of 126 renal allograft recipients, 34 were found to have gastrointestinal and hepatic complications. In order of frequency, these included: mild liver dysfunction, severe hepatitis usually associated with cytomegalovirus infection, peptic ulceration complicated by bleeding, intestinal obstruction, and pancreatitis. These complications did not appear to influence the long-term survival or function of the renal allograft, but proved to be fatal when massive infection of cytomegalovirus affected the gastrointestinal tract and especially the liver. Gastrointestinal and pancreatic complications occurring in renal allograft recipients can be managed in the same manner as in patients who are not receiving immunosuppression. When surgical intervention is required, it should be performed promptly. The fact that these patients are receiving immunosuppressive therapy should not be a contraindication to early surgical intervention. When the presence of ulcerative lesions of the gastrointestinal mucosa, pancreatitis, or hepatitis is confirmed, the possibility of these lesions being caused by viral agents, especially cytomegalovirus, should be considered and attempts to confirm this diagnosis should be made. If cytomegalovirus infection is confirmed and the patient is experiencing rejection of the allograft, careful consideration should be given to immediate discontinuation of immunosuppressive therapy followed by removal of the renal allograft. In this way the relentless and fatal course of the cytomegalovirus infection seen in some of the patients reported in this study may be avoided.

Choledochoduodenostomy. Analysis of 71 cases followed for 5 to 15 years.

To investigate the long-term effectiveness of choledochoduodenostomy (CDD), the experience with 71 patients followed for 5 or more years after CDD was analyzed retrospectively. From 1968 to 1984, 134 patients underwent CDD. Eight patients (6%) died in the immediate postoperative period, 55 left the hospital, 8 of them were lost to follow-up, and 47 were followed but died before 5 years elapsed after CDD. The remaining 71 patients form the data base for this analysis: 38 were followed for more than 5 years, 25 were followed for more than 10 years, and 8 were followed for more than 15 years (mean 12.1 years +/- 1.3 SEM). Choledocholithiasis, chronic pancreatitis, and postoperative stricture were the indications for CDD. Cholangitis was observed in only three patients. The diameter of the common bile duct (CBD) was large in most patients (mean 18 mm +/- 0.9 SEM). These results infer that CDD is effective to treat non-neoplastic obstructing lesions of the distal CBD on a long-term basis and that the presence of a dilated CBD (more than 16 mm) that allows the construction of a CDD more than 14 mm is essential to obtain good results.

Pancreaticoduodenectomy for metastatic tumors to the periampullary region

Although operative resection of metastatic lesions to the liver, lung, and brain has proved to be useful, only recently have there been a few reports of pancreaticoduodenectomies in selected cases of metastases to the periampullary region. In this report we present four cases of proven metastatic disease to the periampullary region in which the lesions were treated by pancreaticoduodenectomy. Metastatic tumors corresponded to a melanoma of unknown primary site, choriocarcinoma, high-grade liposarcoma of the leg, and a small cell cancer of the lung. All four patients survived the operation and had no major complications. Two patients died of recurrence of their tumors, 6 and 63 months, respectively, after operation; the other two patients are alive 21 and 12 months, respectively, after operation. It can be inferred from this small but documented experience, as well as a review of the literature, that pancreaticoduodenectomy for metastatic disease can be considered in selected patients, as long as this operation is performed by experienced surgeons who have achieved minimal or no morbidity and mortality with it.

Bullet Emboli to the Pulmonary Artery: A Report of 2 Patients and Review of the Literature

Bullet embolization to the pulmonary artery is a rare event. The purpose of this study is to report our experience with 2 patients and to review the 15 patients reported in the literature, with special emphasis on a rather peculiar complication that has occurred in 4 of the 9 patients who underwent bullet embolectomy: dislodgment of the missile during the surgical procedure and migration to the down-side lung, for which a second thoracotomy was required in 3 of those patients. The usual untoward effects of foreign bodies in the vascular system were seen in this series: embolization with thrombosis, sepsis, erosion and hemorrhage, and vascular occlusion with infarction. This review suggests that operative removal of a bullet in the pulmonary artery is necessary. The operation is safe and uncomplicated if precautions are taken to prevent the missile from migrating during manipulation of the lung.

Economics of pancreatoduodenectomy in the elderly

BACKGROUND Managed care and the increasing percentage of surgical procedures performed in the elderly have renewed the focus on hospital charges and expenditures. The objective of this study was to determine whether septuagenarians and octogenarians accrue more hospital charges or have a higher risk of morbidity and death. METHODS We retrospectively reviewed the charges and pertinent clinical outcomes data that were available on 70 of the last 100 pancreatoduodenectomies performed at our institution (1989 to 1994). Charges from four cost centers were analyzed and normalized to 1995 dollars by using the Consumer Price Index and Wilcoxon rank sum test. Patients were divided into two groups: group 1, 70 years of age or older (n = 21); group 2, younger than 70 years of age (n = 49). RESULTS Anesthetic charges were

Gastrointestinal complications after cardiac transplantation. Potential benefit of early diagnoses and prompt surgical intervention.

2657 +/-

Acute Chylous Peritonitis

835 for group 1 versus