Muhammet Akyuz

A new risk stratification algorithm for the management of patients with adrenal incidentalomas

BACKGROUNDnAlthough adrenal incidentalomas (AI) are detected in ≤5% of patients undergoing chest and abdominal computed tomography (CT), their management is challenging. The current guidelines include recommendations from the National Institutes of Health, the American Association of Endocrine Surgeons (AAES), and the American Association for Cancer Education (AACE). The aim of this study was to develop a new risk stratification model and compare its performance against the existing guidelines for managing AI.nnnMETHODSnA risk stratification model was designed by assigning points for adrenal size (1, 2, or 3 points for tumors <4, 4-6, or >6xa0cm, respectively) and Hounsfield unit (HU) density on noncontrast CT (1, 2, or 3 points for HU <10, 10-20, or >20, respectively). This model was applied retrospectively to 157 patients with AI managed in an endocrine surgery clinic to assign a score to each tumor. The utility of this model versus the AAES/AACE guidelines was assessed.nnnRESULTSnOf the 157 patients, 54 (34%), had tumors <4xa0cm with HU <10 (a score of 2). One third of these were hormonally active on biochemical workup and underwent adrenalectomy. The remaining two thirds were nonsecretory lesions and have been followed conservatively with annual testing. In 103 patients (66%), the adrenal mass was >4xa0cm and/or had indeterminate features on noncontrast CT (HU >10, irregular borders, heterogeneity), and adrenalectomy was performed after hormonal evaluation was completed (10 were hormonally active on biochemical testing). Seven of these patients (7%) had adrenocortical cancer on final pathology with tumor size <4xa0cm in 0, 4-6xa0cm in 1, and >6xa0cm in 5 patients. Of the hormonally inactive patients, 32% had a score of 3, 38% 4, and 30% 5 or 6. The incidence of adrenocortical cancer in these subgroups was 0, 0, and 25%, respectively.nnnCONCLUSIONnThis study shows that an algorithm that utilizes the hormonal activity at the first decision step followed by a consolidated risk stratification, based on tumor size and HU density, has a potential to spare a substantial number of patients from unnecessary diagnostic surgery for AI.

Predictors of recurrence in pheochromocytoma

BACKGROUNDnThe recurrence rate of pheochromocytoma after adrenalectomy is 6.5-16.5%. This study aims to identify predictors of recurrence and optimal biochemical testing and imaging for detecting the recurrence of pheochromocytoma.nnnMETHODSnIn this retrospective study we reviewed all patients who underwent adrenalectomy for pheochromocytoma during a 14-year period at a single institution.nnnRESULTSnOne hundred thirty-five patients had adrenalectomy for pheochromocytoma. Eight patients (6%) developed recurrent disease. The median time from initial operation to diagnosis of recurrence was 35 months. On multivariate analysis, tumor size >5 cm was an independent predictor of recurrence. One patient with recurrence died, 4 had stable disease, 2 had progression of disease, and 1 was cured. Recurrence was diagnosed by increases in plasma and/or urinary metanephrines and positive imaging in 6 patients (75%), and by positive imaging and normal biochemical levels in 2 patients (25%).nnnCONCLUSIONnPatients with large tumors (>5 cm) should be followed vigilantly for recurrence. Because 25% of patients with recurrence had normal biochemical levels, we recommend routine imaging and testing of plasma or urinary metanephrines for prompt diagnosis of recurrence.

Safety and Efficacy of a New Bipolar Energy Device for Parenchymal Dissection in Laparoscopic Liver Resection.

Background: Despite emerging technologies, parenchymal transection still remains challenging in liver resection. The aim of this study is to assess the safety and efficacy of a new articulating vessel sealer for laparoscopic hepatectomy. Our hypothesis was that this new device would facilitate parenchymal transection and reduce intraoperative costs in laparoscopic hepatectomy. Methods: Within 18 months, a 5 cm bipolar articulating vessel sealer was used in 32 laparoscopic liver resections (LLR). By excluding 4 patients who underwent concomitant colorectal resections, the outcomes of the remaining 28 patients (group 1) were compared with 28 patients who underwent LLR by the same surgical group using other energy devices (group 2). Results: Tumor type was malignant in 71% of patients (n=20) in group 1 and 89% of the patients (n=25) in group 2 (P=0.360). The number and size of tumors were similar in both groups, as well as the type of resections performed. In group 1, there was a less number of adjunctive devices (ie, energy, clip appliers, staplers) used (median 2) compared with group 2 (median 3, P=0.032). Parenchymal transection time (mean±SEM 28.2±3.5 vs. 55.2±4.1 min, respectively, P<0.001) and total operative time (200.1±13.7 vs. 242.7±14.4 min, respectively, P=0.036) were shorter for group 1 versus group 2. Estimated blood loss, transfusion rate, margin status, and length of stay were similar between the groups. There was no mortality. Morbidity was 11% (n=3) in group 1 and 18% (n=5) in group 2 (P=NS). The overall intraoperative costs were an average of

Initial experience with a new articulating energy device for laparoscopic liver resection

3000 less in group 1 (95% confidence interval,

A Critical Analysis of Postoperative Morbidity and Mortality After Laparoscopic Radiofrequency Ablation of Liver Tumors

1090-

Oncologic results of laparoscopic liver resection for malignant liver tumors.

4930, P=0.0029) compared with group 2. Conclusions: This study demonstrates the safety and efficacy of a new energy device for LLR. Our experience suggested that this new device provided the functionality of both a vessel sealer and a stapler with its large jaw and articulation.

A comparison of perioperative outcomes in elderly patients with malignant liver tumors undergoing laparoscopic liver resection versus radiofrequency ablation

AbstractBackgroundAlthough significant advances have been made in laparoscopic liver resection (LLR), most techniques still rely on multiple energy devices and staplers, which increase operative costs. The aim of this study was to report the initial results of a new multifunctional energy device for hepatic parenchymal transection. nMethodsFourteen patients who underwent LLR using this new device were compared to 20 patients who had LLR using current laparoscopic techniques (CL). Data were collected prospectively.ResultsThe groups were similar demographics and tumor type and size. Although the type of resection was similar between the groups, the parenchymal transection time was less in the Caiman group (32xa0±xa05 vs. 63xa0±xa04xa0min, respectively, pxa0=xa00.0001). The operative time was similar (194xa0±xa021 vs. 233xa0±xa016xa0min, respectively, pxa0=xa00.158). There was reduction of the number of advanced instrumentation used in the Caiman group, including the staplers. Estimated blood loss, size of surgical margin, and hospital stay were similar. There was no mortality, and morbidity was 7 % in the Caiman and 20 % in the CL group.ConclusionsThis initial study shows that the new device is safe and efficient for LLR. Its main advantage is shortening of hepatic parenchymal transection time. This has implications for increasing efficiency and cost saving in LLR.

Local recurrence after laparoscopic radiofrequency ablation of malignant liver tumors: Results of a contemporary series

BackgroundAlthough the laparoscopic approach provides certain advantages over the percutaneous radiofrequency thermal ablation (RFA), the morbidity needs to be defined. The aim of this study is to analyze the morbidity and underlying risk factors after laparoscopic RFA of liver tumors.MethodsBetween 1996 and 2012, 910 patients underwent 1,207 RFA procedures for malignant liver tumors in a tertiary academic center. The 90-day morbidity and mortality were extracted from a prospective IRB-approved database. Statistical analyses were performed using regression, t, and χ2 tests.ResultsComplications occurred in 50 patients (4xa0%) and were gastrointestinal in 13 patients (1.1xa0%), infections in 10 (0.8xa0%), hemorrhagic in 9 (0.7xa0%), urinary in 7 (0.6xa0%), cardiac in 4 (0.3xa0%), pulmonary in 3 (0.3xa0%), hematologic in 2 (0.2xa0%), and neurologic in 2 (0.2xa0%). The complication rates for an RFA done alone (5xa0%) versus concomitantly with ancillary procedure (6xa0%) were similar (pxa0=xa0.6). In all patients who developed postoperative bleeding from the liver, the ablations had been performed on lesions located in the right posterior sector. Of 9 patients with bleeding, 5 (55xa0%) required a laparotomy. Also, 60xa0% of liver abscesses occurred in patients with a prior bilioenteric anastomosis (BEA). The 90-day mortality was 0.4xa0% (nxa0=xa05). Hospital stay was 1.2xa0±xa00.1xa0days and was prolonged to 4.4xa0±xa00.3xa0days in case of complications.ConclusionsThis study describes the morbidity and mortality to be expected after a laparoscopic RFA procedure. Our results show that additional caution should be used to prevent bleeding complications in patients with tumors located in the right posterior sector and infections in patients with a history of BEA.

Laparoscopic management of liver metastases from uveal melanoma

There are scant data regarding oncologic outcomes of laparoscopic liver resection (LLR). The aim of this study is to analyze the oncologic outcomes of LLR for malignant liver tumors (MLT).

Perioperative and oncologic outcomes of minimally invasive liver resection for colorectal metastases: A case-control study of 130 patients.

BackgroundLiver resection is the treatment option with the best chance for cure in patients with malignant liver tumors. However, there are concerns regarding postoperative recovery in elderly patients, which may lead to a preference of non-resectional therapies over hepatectomy in this patient population. Although laparoscopic liver resection (LLR) is associated with a faster recovery compared to open hepatectomy, there are scant data on how elderly patients tolerate LLR. The aim of this study was to analyze the perioperative outcomes of LLR in elderly patients with hepatic malignancies, with a comparison to laparoscopic RFA (LRFA).MethodsA retrospective analysis of a prospective database for liver tumors identified a total of 82 patients older than 65xa0years who underwent laparoscopic treatment of their liver tumors in a single tertiary care center between 2000 and 2014. These patients were equally distributed into LLR and LRFA treatment arms.ResultsMean age, American Society of Anesthesiologists (ASA) score and tumor type (predominantly metastatic colorectal cancer) were similar in both groups. Patients in the LRFA group had more tumors (2.1xa0±xa01.8 vs. 1.2xa0±xa00.6, pxa0<xa00.01), whereas tumors were larger in the LLR group (3.8xa0±xa01.6 vs. 2.8xa0±xa01.1xa0cm, pxa0<xa00.01). Although the operative time (116 vs. 214xa0min, pxa0<xa00.01) and hospital stay (2.1 vs. 3.4xa0days, pxa0=xa00.010) were shorter for the LRFA versus LLR group, respectively, morbidity (4.8 vs. 7.3xa0%) and mortality (0 vs. 0xa0%) were similar. Local recurrence was significantly higher in the LRFA versus LLR group (29 vs. 2.4xa0%, respectively, pxa0=xa00.002). However, there was no statistical difference in disease-free and overall survival between two groups (28 vs. 30 and 51 vs. 54xa0months, pxa0=xa00.443 and 0.768, respectively).ConclusionsThis study showed that LLR was tolerated as well as LRFA in elderly patients with similar comorbidities. We suggest LLR to be considered as an option in selected elderly patients who are deemed poor candidates for open hepatectomy.