Sherif S. Hanna

Pancreatic resection for metastatic renal cell carcinoma: presentation, treatment, and outcome.

Background: The diverse natural history of renal cell carcinoma (RCC) includes metastases to the pancreas, a very unusual site for distant spread of other cancers. Considering the relatively indolent behavior of some cases of metastatic RCC, pancreatic resection is offered to select patients.Methods: We reviewed the records of patients at three affiliated university hospital centers who had prior nephrectomy for RCC and subsequent pancreatic resection of metastases.Results: Fourteen patients—9 women and 5 men with a median age of 63.8 years—underwent a total of 15 pancreatic resections for metastatic RCC. Nine (64%) had solitary metastases. The median interval from nephrectomy to diagnosis of pancreatic metastases was 83 months. The median size of metastases was 4.6 cm. There was one perioperative death. Pancreatic recurrence occurred in five patients (36%), and one patient underwent repeat resection. At a median follow-up of 32 months, seven patients (50%) are alive without evidence of disease, and four patients (28%) are alive with recurrent disease.Conclusions: Resection of pancreatic metastases from RCC is associated with long-term survival and should be considered for patients in whom complete resection is possible.Background: The diverse natural history of renal cell carcinoma (RCC) includes metastases to the pancreas, a very unusual site for distant spread of other cancers. Considering the relatively indolent behavior of some cases of metastatic RCC, pancreatic resection is offered to select patients. Methods: We reviewed the records of patients at three affiliated university hospital centers who had prior nephrectomy for RCC and subsequent pancreatic resection of metastases. Results: Fourteen patients—9 women and 5 men with a median age of 63.8 years—underwent a total of 15 pancreatic resections for metastatic RCC. Nine (64%) had solitary metastases. The median interval from nephrectomy to diagnosis of pancreatic metastases was 83 months. The median size of metastases was 4.6 cm. There was one perioperative death. Pancreatic recurrence occurred in five patients (36%), and one patient underwent repeat resection. At a median follow-up of 32 months, seven patients (50%) are alive without evidence of disease, and four patients (28%) are alive with recurrent disease. Conclusions: Resection of pancreatic metastases from RCC is associated with long-term survival and should be considered for patients in whom complete resection is possible.

Reversal of hepatic encephalopathy after occlusion of total portasystemic shunts

Abstract In conclusion, therefore, we recommend selective distal splenorenal shunt for patients with hepatopetal flow and nonselective total portasystemic shunt for most patients with hepatofugal flow in order to minimize the incidence of postshunt encephalopathy. Patients with hepatopetal flow who are treated by a nonselective shunt and develop chronic, refractory encephalopathy are candidates for shunt ligation if they have good liver function.

Microsatellite Instability as a Prognostic Factor in Resected Colorectal Cancer Liver Metastases

Background: Two distinct genetic mutational pathways characterized by either chromosomal instability or high-frequency microsatellite instability (MSI-H) are currently recognized in the pathogenesis of colorectal cancer (CRC). Recently, it has been shown that patients with primary CRC that displays MSI-H have a significant, stage-independent, multivariate survival advantage. Untreated CRC hepatic metastases are incurable and are associated with a median survival of 4 to 12 months. Conversely, surgical resection in selected patients results in a 20% to 50% cure rate. The aim of this study was to investigate the prognostic importance of MSI-H in patients undergoing resection of hepatic CRC metastases.Methods: DNA was extracted from paraffin-embedded, resected metastatic CRC liver lesions and corresponding normal liver parenchyma from 190 patients. MSI-H status was determined by polymerase chain reaction–based evaluation of the noncoding mononucleotide repeats BAT-25 and BAT-26.Results: MSI was detected in tumors from 5 (2.7%) of the 190 CRC patients. All MSI-H tumors were in patients with node-positive CRC primary tumors. The median survival after hepatic resection of MSI-H and non–MSI-H tumors was 67 and 61 months, respectively (P = .9).Conclusions: These data suggest that MSI-H is not a common feature in resected CRC liver metastases and do not suggest a role for MSI in stratifying good versus poor prognosis in these patients.

Multimodal CME for surgeons and pathologists improves colon cancer staging.

BACKGROUND Optimal treatment of localized colorectal cancer (CRC) depends on accurate retrieval and assessment of lymph nodes (LN) in the resected specimen. METHODS Formal CE, informal opinion leadership and reinforcing strategies aimed at pathologists and surgeons to improve LN assessment were implemented. RESULTS In the pre-intervention period a median of 8 lymph nodes were assessed in making a designation of Stage II CRC (n = 115). Thirty months later (post-intervention period) the median number of LN reported in Stage II CRC increased to 18 (n = 41), p < 0.001. CONCLUSION A durable improvement in staging was realized through a multipronged change initiative aimed at both surgeons and pathologists.

Minimising blood loss and transfusion requirements in hepatic resection

BACKGROUND Substantial blood loss and the requirement for blood transfusion remain major considerations for hepatic surgeons. We analysed the impact of a systematic protocol aimed at reducing intraoperative blood loss and homologous blood (HB) transfusion associated with hepatic resection. METHODS Prospective clinical data were collected from 151 elective liver resections performed during the period between 1980 and 1999. Further data directly related to blood loss and anaesthesia were retrospectively collected from the anaesthetic intra-operative record. Strategies implemented in 1991 included preoperative autologous blood donation, low central venous pressure anaesthesia, aprotinin administration, ultrasonic dissection, hepatic vascular inflow occlusion and a Cell Saver. Blood loss and transfusion requirements were studied before and after the implementation of these strategies. RESULTS There was no difference in the patient demographics, indications for operation or the scope of resections in the two time periods evaluated. Blood-saving strategies resulted in decreased estimated blood loss (4500 mL vs. 1000 mL p<0.001). In addition, the number of patients requiring transfusion decreased (91.8% vs. 25.5% respectively, p<0.001) and the mean number of units of HB transfusion was lower (I 3.7 vs. 2.3, p<0.001). Morbidity and mortality were also decreased (57.1% vs. 25.5%, p<0.001 and 10.2% and 4.9% p<0.001, respectively). No complications directly referrable to low CVP anesthesia were identified. CONCLUSION Systematic implementation of strategies designed to control blood loss are effective and may reduce morbidity and mortality associated with hepatic resections.

Effect of portal vein occlusion on liver blood flow in normal and cirrhotic dogs

The purpose of this study was to demonstrate that galactose clearance (GC) can measure acute changes in liver blood flow (LBF) in normal and cirrhotic dogs. Ten dogs were studied. GC was measured preop. At laparotomy, GC, hepatic artery (HA) flow, portal vein (PV) flow, and cardiac output (CO) were measured at baseline, 50% portal vein occlusion (PVO), and portal vein release. HA and PV flows were measured using a flow probe (FP). Common bile duct ligation was then performed to cause cirrhosis and all measurements were repeated in 7 weeks. Statistical analyses showed that on PVO in both normal dogs (n = 10) and cirrhotic dogs (n = 5) the GC, HA flow, and CO were significantly different from their baseline values. In both groups PVO caused HA flow to increase, thus keeping FP-LBF unchanged while GC-LBF was significantly reduced compared to baseline. The possible explanations for this are discussed in the text. PVO also caused a significant reduction in CO due to splanchnic pooling in both normal and cirrhotic dogs. In both groups PVO results in an increased percentage of CO going to FP-LBF, while the percentage of CO going to GC-LBF remains unchanged. We conclude that GC can measure acute changes in LBF caused by a 50% PVO in both normal and cirrhotic dogs.

Classification of liver trauma.

The classification of liver injuries is important for clinical practice, clinical research and quality assurance activities. The Organ Injury Scaling (OIS) Committee of the American Association for the Surgery of Trauma proposed the OIS for liver trauma in 1989. The purpose ofthe present study was to apply this scale to a cohort ofliver trauma patients managed at a single Canadian trauma centre from January 1987 to June 1992.170 study patients were identified and reviewed. The mean age was 30, with 69% male and a mean ISS of 33.90% had a blunt mechanism ofinjury. The 170 patients were categorized into the 60IS grades ofliver injury. The number of units of blood transfused, the magnitude of the operative treatment required, the liver-related complications and the liver-related mortality correlated well with the OIS grade. The OIS grade was unable to predict the need for laparotomy or the length of stay in hospital. We conclude that the OIS is a useful, practical and important tool for the categorization of liver injuries, and it may prove to be the universally accepted classification scheme in liver trauma.

Use of a collagen‐sealing device in hepatic resection: a comparative analysis to standard resection technique

BACKGROUND Blood transfusion has been reported as an independent risk factor for poor outcome after liver resection in spite of its well known benefits. Refinements in parenchymal dissection have been pursued to reduce blood loss and transfusion. A collagen-sealing device (CSD) has recently been touted as an alternative technique that aids in blood conservation. We report the results of our initial series of patients undergoing a CSD-assisted resection and present a historical comparison. PATIENTS AND METHODS Consecutive patients who were undergoing liver resection at a single tertiary cancer centre were enrolled in this study. The Ligasure Atlas device (Valleylab Inc., Division of Tyco Healthcare) was used for parenchymal division in the CSD group. Known blood conservation techniques (i.e. low central venous pressure, ultrasonic dissection, Pringle clamp) were standardized in both groups. Clinical and outcome variables including operative time, estimated blood loss and transfusion requirements were collected. All statistical analyses were performed with SAS version 8.2e. RESULTS In all, 28 consecutive patients underwent CSD-assisted hepatic resection between October 2003 and September 2004. The control group included 188 patients treated between January 1991 and September 2003. In the CSD group, we observed a reduction in mean estimated blood loss (930 vs 1450 ml, p=0.002) and mean transfusion requirements (0.46 vs 1.19 units, p=0.002). There was no increase in operative time with the new instrument (326 vs 363 min, p=0.167). DISCUSSION Use of a CSD has the potential to further reduce blood loss and transfusion requirements without increasing operative time.

A novel approach to the intraoperative assessment of the uncinate margin of the pancreaticoduodenectomy specimen

BACKGROUND Currently, there is no consensus regarding the pancreaticoduodenectomy (PD) margins examined intraoperatively or the technical protocol for frozen section examination. The aim of this work was to summarize our experience regarding the intraoperative examination of the uncinate margin and to compare it with the published literature. MATERIALS AND METHODS Our local protocol for the intraoperative assessment of the uncinate margin of the PD specimen is described in this article. A PubMed search limited to English language publications using terms along the theme of pancreaticoduodenectomy and margin was performed. Retrieved articles were categorized according to whether they discussed frozen section margin examination. RESULTS Ten articles published between 1981 and 2005 were retrieved which discussed the intraoperative examination of PD specimens. Of the 10 articles, 5 discussed the intraoperative consultation for diagnostic purposes only, 2 discussed the consultation for both diagnostic purposes and assessment of margins, and 3 discussed intraoperative assessment of margins only. Of the total of five articles that discussed the intraoperative assessment of margins, none detailed the technical protocol for examining the uncinate margin. DISCUSSION Our proposed protocol for the intraoperative assessment of the uncinate margin of PD specimens allows for its accurate evaluation and has not been described previously in the English literature.

Utility of preoperative imaging in evaluating colorectal liver metastases declines over time

OBJECTIVES Reports on the sensitivity and accuracy of contrast-enhanced helical computed tomography (HCT) in the preoperative evaluation of colorectal liver metastases (CLM) have been conflicting. Few studies have controlled for and reported on the time interval between HCT and eventual surgery. METHODS A multi-institution, retrospective review of consecutive patients who underwent hepatic resection for CLM from January 1999 to September 2004 was conducted. Data regarding lesion characteristics and resectability were extracted from radiology reports, operative findings and histopathological records. Findings in HCT were evaluated according to their sensitivity for detecting CLM and ability to predict resectability. RESULTS A total of 217 consecutive patients who underwent hepatic resection for CLM were identified. The overall sensitivity of HCT for detection of CLM was 83.2%. Prolonged time between imaging and surgery was a negative predictor for HCT sensitivity in univariate and multivariate analysis (P < 0.001). In predicting resectability, preoperative HCT was accurate 77.0% of the time. The time interval to surgery was negatively correlated with HCT prediction accuracy in univariate and multivariate analyses (P < 0.001). CONCLUSIONS The utility of HCT as a preoperative tool to evaluate CLM is inversely proportional to the time interval between imaging and surgery. This may explain conflicting reports of the accuracy of HCT in the current literature.