Steven C. Stain

Recurrence and Outcomes Following Hepatic Resection, Radiofrequency Ablation, and Combined Resection/Ablation for Colorectal Liver Metastases

Objective:To examine recurrence and survival rates for patients treated with hepatic resection only, radiofrequency ablation (RFA) plus resection or RFA only for colorectal liver metastases. Summary Background Data:Thermal destruction techniques, particularly RFA, have been rapidly accepted into surgical practice in the last 5 years. Long-term survival data following treatment of colorectal liver metastasis using RFA with or without hepatic resection are lacking. Methods:Data from 358 consecutive patients with colorectal liver metastases treated for cure with hepatic resection ± RFA and 70 patients found at laparotomy to have liver-only disease but not to be candidates for potentially curative treatment were compared (1992–2002). Results:Of 418 patients treated, 190 (45%) underwent resection only, 101 RFA + resection (24%), 57 RFA only (14%), and 70 laparotomy with biopsy only or arterial infusion pump placement (“chemotherapy only,” 17%). RFA was used in operative candidates who could not undergo complete resection of disease. Overall recurrence was most common after RFA (84% vs. 64% RFA + resection vs. 52% resection only, P < 0.001). Liver-only recurrence after RFA was fourfold the rate after resection (44% vs. 11% of patients, P < 0.001), and true local recurrence was most common after RFA (9% of patients vs. 5% RFA + resection vs. 2% resection only, P = 0.02). Overall survival rate was highest after resection (58% at 5 years); 4-year survival after resection, RFA + resection and RFA only were 65%, 36%, and 22%, respectively (P < 0.0001). Survival for “unresectable” patients treated with RFA + resection or RFA only was greater than chemotherapy only (P = 0.0017). Conclusions:Hepatic resection is the treatment of choice for colorectal liver metastases. RFA alone or in combination with resection for unresectable patients does not provide survival comparable to resection, and provides survival only slightly superior to nonsurgical treatment.

Postoperative hyperglycemia and surgical site infection in general surgery patients.

HYPOTHESIS Postoperative hyperglycemia is an independent risk factor for postoperative surgical site infection (SSI). DESIGN Retrospective medical record review. SETTING Academic tertiary referral center. PATIENTS A total of 2090 general and vascular surgery patients in an institutional quality improvement database between November 1, 2006, and April 30, 2009. MAIN OUTCOME MEASURE Postoperative SSI. RESULTS Postoperative glucose levels were available for 1561 patients (74.7.0%), of which 803 (51.4%) were obtained within 12 hours of surgery. The significant univariate predictors of SSI in general surgery patients were increasing age, emergency status, American Society of Anesthesiologists physical status classes P3 to P5, operative time, more than 2 U of red blood cells transfused, preoperative glucose level higher than 180 mg/dL (to convert to millimoles per liter, multiply by 0.0555), diabetes mellitus, and postoperative hyperglycemia. On multivariate adjustment, increasing age, emergency status, American Society of Anesthesiologists classes P3 to P5, operative time, and diabetes remained significant predictors of SSI for general surgery patients. After adjustment for postoperative glucose level, all these variables ceased to be significant predictors of SSI; only incremental postoperative glucose level remained significant. Subanalysis revealed that a serum glucose level higher than 140 mg/dL was the only significant predictor of SSI (odds ratio, 3.2; 95% confidence interval [CI], 1.4-7.2) for colorectal surgery patients. Vascular surgery patients were 1.8 times (95% CI, 1.3-2.5 times) more likely to develop SSI than were general surgery patients. Operative time and diabetes mellitus were the only significant univariate predictors of SSI among vascular surgery patients, and postoperative hyperglycemia was not associated with SSI. CONCLUSIONS Postoperative hyperglycemia may be the most important risk factor for SSI. Aggressive early postoperative glycemic control should reduce the incidence of SSI.

Does an infected peripancreatic fluid collection or abscess mandate operation

OBJECTIVE To assess the treatment of peripancreatic fluid collections or abscess with percutaneous catheter drainage (PCD). SUMMARY BACKGROUND DATA Surgical intervention has been the mainstay of treatment for infected peripancreatic fluid collections and abscesses. Increasingly, PCD has been used, with mixed results reported in the literature. METHODS A retrospective chart review of 1993 to 1997 was performed on 82 patients at a tertiary care public teaching hospital who had computed tomography-guided aspiration for suspected infected pancreatic fluid collection or abscess. Culture results, need for subsequent surgical intervention, length of stay, and death rate were assessed. RESULTS One hundred thirty-five aspirations were performed in 82 patients (57 male patients, 25 female patients) with a mean age of 40 years (range 17-68). The etiologies were alcohol (41), gallstones (32), and other (9). The mean number of Ransons criteria was four (range 0-9). All patients received antibiotics. Forty-eight patients had evidence of pancreatic necrosis on computed tomography scan. Cultures were negative in 40 patients and positive in 42. Twenty-five of the 42 culture-positive patients had PCD as primary therapy, and 6 required subsequent surgery. Eleven patients had primary surgical therapy, and five required subsequent surgery. Six patients were treated with only antibiotics. The death rates were 12% for culture-positive patients and 8% for the entire 82 patients. CONCLUSIONS Historically, patients with positive peripancreatic aspirate culture have required operation. This series reports an evolving strategy of reliance on catheter drainage. PCD should be considered as the initial therapy for culture-positive patients, with surgical intervention reserved for patients in whom treatment fails.

The role of anticoagulation in pylephlebitis

BACKGROUND Pylephlebitis may complicate any intra-abdominal infection and carries a high mortality rate. Acute cases are usually anticoagulated to prevent thrombus extension and enteric ischemia; however, the role of anticoagulation has not been clearly defined. METHODS Over a 3-year period, pylephlebitis was diagnosed in 44 patients with portal vein thrombosis on computed tomography scan with fever, leukocytosis, and/or positive blood cultures. The charts were reviewed for etiology, extent of venous thrombosis, and method and results of treatment. RESULTS Eighteen patients were hypercoagulable, due to clotting factor deficiencies (6), malignancy (8), or AIDS (4). Fifteen patients had mesenteric vein involvement. Thirty-two patients were not anticoagulated, and 5 died (3 with hypercoagulable states and 2 with normal clotting function). Twelve patients were anticoagulated, and none developed subsequent bowel infarction or died. CONCLUSION Patients with pylephlebitis and a hypercoagulable state due to neoplasms or clotting factor deficiencies should be anticoagulated. Patients with normal clotting function and mesenteric vein involvement may also benefit. We believe anticoagulation in patients with thrombus isolated to the portal vein and normal clotting function may be unnecessary.

Improvements in survival by aggressive resections of hilar cholangiocarcinoma.

The operative management of hilar Cholangiocarcinoma has evolved because of advances in diagnostic imaging that have permitted improved patient selection, and refinements in operative techniques that have lowered operative mortality rates. Over a 4-year period, 48 patients with hilar Cholangiocarcinoma were managed. Twenty-seven patients were treated by palliative measures. Preoperative investigation identified 29 patients who were judged fit for operation without proven irresectability by radiologic studies, and 21 of the 29 patients had tumor removal (72%). Twenty-three operative procedures were performed: local excision (n = 12) (two had subsequent hepatic resection), and hepatic resection primarily (n = 9). Eight patients had complications (35%), and one patient died (4.3%). The mean actuarial survival after local excision is 36 months, and after hepatic resection, 32 months. Palliation as assessed by personal interview was excellent for more than 75% of the months of survival. A combination of careful patient selection and complete radiologic assessment will allow an increased proportion of patients to be resected by complex operative procedures with low mortality rate, acceptable morbidity rate, and an increase in survival with an improved quality of life.

Choledochal cyst in the adult.

ObjectiveThe authors examined the natural history of choledochal cysts in adults treated surgically. BackgroundAn initial diagnosis of choledochal cyst is uncommon in adults. The recommended treatment is excision, rather than bypass, to achieve effective biliary drainage and because of the risk of cancer. MethodsA retrospective study of 27 adult patients was completed to determine the frequency of anastomotic complications and the incidence of cancer. ResultsFifteen patients were treated by cyst excision, and one developed an anastomotic stricture, treated by percutaneous dilation. Eight of 11 patients treated by cyst enterostomy required additional surgery for anastomotic revision. A final patient was treated by T-tube drainage. Five of the seven patients with cancer have died at a mean of 21.6 months. ConclusionThis experience documents the high incidence of cancer (26%), and high rate of stricture after cyst enterostomy (73%). The dismal prognosis once cancer has developed warrants cyst excision, even in asymptomatic patients, including those with prior cyst enterostomies.

Quantitation of intratumoral thymidylate synthase expression predicts for resistance to protracted infusion of 5-fluorouracil and weekly leucovorin in disseminated colorectal cancers: Preliminary report from an ongoing trial

A clinical trial for patients with measurable, disseminated colorectal cancer is being conducted to determine: (1) if intratumoral expression of thymidylate synthase (TS) affects response to protracted-infusion 5-fluorouracil (5FU); and (2) whether intratumoral expression of TS increases when clinical resistance is found after response to 5-FU. Polymerase chain reaction technology is employed to determine TS expression. Using beta-actin as an internal standard, TS expressions for 26 patients range from 0.5 x 10(-3) to 22.6 x 10(-3). Currently, 22 patients are evaluable for response and TS quantitation of their measurable tumour. 8 patients (36%) have had partial responses; 3 responding patients had been previously treated with 5-FU. A strong statistical association between TS expression and resistance to therapy has been found (P = 0.004). No patient with TS expression of 4.0 x 10(-3) or greater has responded. On average, patients previously treated with 5-FU have slightly higher levels of TS expression in their measurable tumours (P = 0.4). Whether responding patients will develop increased expressions of TS upon clinical progression of their cancer remains to be determined. Confirmation of these results in a larger cohort could lead to a scientific rationale for deciding upon specific therapy for patients with disseminated colorectal cancers.

Understanding racial disparities in cancer treatment and outcomes.

o p p f r 2 w i t t t recent report from the Institute of Medicine documents idespread racial disparities in medical treatment and ealth outcomes. Such disparities are particularly apparent mong patients with cancer. For many types of cancer, lack Americans have markedly higher cancer-specific ortality rates than members of other racial and ethnic roups—more than 2-fold higher in some instances. Exess cancer mortality in this group is partly attributable to igher cancer incidence rates. However, increased cancer ortality among black patients is also due in large part to orse prognoses among those already diagnosed. Reasons for higher mortality among minorities encomass both patient factors and provider and health care sysem effects. Patient factors include characteristics associted with decreased longevity, such as socioeconomic status SES), health behaviors, and comorbid conditions. At the rovider level, higher cancer mortality may reflect underse of screening, resulting in later stage at diagnosis, and nderuse of cancer-directed surgery and adjuvant therapy. inally, racial disparities may be associated with differences n the quality of care delivered by providers and by the elected settings where black patients cluster for care. Some f these settings have been associated with higher cancer ortality rates and may be less likely to provide high uality comprehensive, transitional, and follow-up care afer surgery.

Enucleation of giant hemangiomas of the liver. Technical and pathologic aspects of a neglected procedure.

Cavernous hemangiomas arc the most common benign tumors of the liver. Giant cavernous hemangiomas, defined as those larger than 4 cm in diameter, can reach enormous proportions. Newer imaging modalities, although often demonstrating characteristic features that strongly suggest the diagnosis, should not be augmented by biopsy because of the risk of hemorrhage. Elective surgical resection may be indicated for symptomatic giant lesions and for those with an atypical appearance where the diagnosis is in doubt. Between October 1986 and May 1991, we treated 10 patients with giant hemangiomas by enuclcation or enuclcation plus resection. Median operative blood loss was 800 mL (range, 200 to 3000 mL). One patient required reoperatin for control of postoperative hemorrhage. Detailed pathologic examination has demonstrated an interface between hemangiomas and the normal liver tissue that allows enucleation. Enucleation is an underused procedure that if carefully performed allows resection of giant hcmangiomas with a reduced blood loss and the preservation of virtually all normal hepatic parenchyma.

Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients

BACKGROUND Warfarin and antiplatelet agents (WAA) are prevalent among trauma patients, but the impact of these agents on patient outcomes has not been clearly defined. In this study, we examined the impact of preinjury WAA on outcomes in trauma patients. METHODS A 40-month (September 2004 to December 2007) retrospective review of data in the trauma registry at a New York State level 1 trauma center was performed. Patients on WAA were compared to those not on these medications. The primary outcome of interest was mortality, and the secondary outcomes of interest were as length of stay (LOS) and disposition on discharge. A separate analysis was done for patients with intracranial hemorrhage (ICH). The chi-square test, the Student t test, and the modified Poisson regression analysis were used to estimate the incident risk ratios for the outcomes. RESULTS A total of 3,436 trauma patients were identified, of whom 456 were taking anticoagulants (warfarin, n = 91 patients; aspirin, n = 228; clopidogrel, n = 43; and various combinations, n = 94). Patients on warfarin were 3.1 times more likely to die (relative risk [RR], 3.2; 95% confidence interval [CI], 1.6-6.6), after adjusting for potential confounders. Aspirin and clopidogrel were not associated with increased mortality, but WAA were associated with increased risk of ICH (49.8% vs 30.5%; RR, -1.6; 95% CI, 1.4-1.9). WAA did not affect LOS or disposition. Among patients with ICH, only warfarin increased mortality (28.9% vs 5.8%; RR, -3.1; 95% CI, 1.3-7.2). CONCLUSION Preinjury warfarin treatment was found to be an independent risk factor for mortality. WAA agents increased risk of ICH. Among those patients with ICH, only warfarin was associated with increased mortality. Antiplatelet agents did not affect mortality or LOS.