Thomas Biehl

LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: A COMPARISON WITH THE CONVENTIONAL OPEN APPROACH

PURPOSE Laparoscopic live donor nephrectomy is an emerging technique that has not yet gained widespread acceptance in the transplant community due to perceived technical difficulties. However, the potential advantages of decreasing donor morbidity, decreasing hospital stay and improving convalescence while producing a functional kidney for the recipient may prove to enhance living related renal transplantation. We report our early experience with laparoscopic live donor nephrectomy. MATERIALS AND METHODS We retrospectively reviewed the medical records of 50 consecutive laparoscopic nephrectomies performed from October 1998 to May 2000 and compared them with 50 consecutive open donor nephrectomies, which served as historical controls. RESULTS Donor age, donor sex and number of HLA mismatches did not differ statistically in the 2 groups. In the laparoscopic and open nephrectomy groups mean followup was 109 and 331 days (p = 0.0001), mean operative time was 234 and 208 minutes (p = 0.0068), mean estimated blood loss was 114 and 193 ml (p = 0.0001), and mean hospital stay was 3.5 and 4.7 days (p = 0.0001), respectively. Average renal warm ischemia time was 2.8 minutes in the laparoscopic nephrectomy group. Serum creatinine did not differ statistically in the 2 groups preoperatively or postoperatively at days 1 and 5, and 1 month. The rate of recipient ureteral complications in the laparoscopic and open nephrectomy groups was 2% (1 of 50 cases) and 6% (3 of 50), respectively (not significant). CONCLUSIONS Laparoscopic live donor nephrectomy is an attractive alternative to open donor nephrectomy. Laparoscopic nephrectomy results in less postoperative discomfort, an improved cosmetic result and more rapid recovery for the donor with equivalent functional results and complications.

Benefits and safety of hepatic resection for colorectal metastases

BACKGROUND Metastatic colorectal carcinoma to the liver is a potentially curable disease. The purpose of this study was to determine the safety and efficacy of hepatic resection for metastatic colorectal carcinoma. METHODS One hundred twenty-one consecutive hepatic resections in 110 patients with metastatic colorectal cancer between January 1978 and September 1998 performed by a single surgeon were reviewed. RESULTS The actuarial 5-year survival for all patients in the series was 46%. Of the patients operated on before 1993, the actual 5-year survival was 43% and actual disease-free 5-year survival was 28%. The actual 10-year survival was 27%, and of all patients operated on in the last 20 years, 48% are alive today. When comparing initial regional lymph node status, the 5-year survival was 54% for the patients with negative lymph nodes and 40% for patients with positive nodes. Only 18% of patients required a perioperative blood transfusion, and the median length of stay was 7 days. There were complications in 34% of cases, and the operative mortality was 4%. CONCLUSIONS Hepatic resection for metastatic colon cancer is safe, and significant longevity and cure can be obtained after resection.

Management and long-term follow-up of hepatic cysts

PURPOSE To provide an algorithm for the management of hepatic cysts through an analysis of our series over 16 years. METHOD We reviewed the surgical management and outcome of patients with hepatic cysts between 1984 and 2000 at a single institution. Data were collected by chart review, telephone interview, and follow-up hepatic ultrasonography. RESULTS Forty-four patients (36 females, 8 males) underwent a total of 46 operations for hepatic cysts (mean size 12.0 +/- 5.2 cm) with a mean follow-up of 5.1 +/- 4.0 years. We treated 28 simple cysts, 4 polycystic liver disease (PCLD), 7 cystadenomas, 2 hydatid cysts, 1 cystadenocarcinoma, 1 endometrioma, and 1 hepatic foregut cyst. Operations included simple drainage, wide unroofing (open and laparoscopic), and hepatic resection. Four patients experienced a symptomatic recurrence after definitive treatment; 3 of these patients had PCLD. Four of the 7 patients with cystadenomas had undergone previous operations that required subsequent definitive resection without a recurrence. CONCLUSIONS The preoperative distinction between simple cysts and cystadenomas/cystadenocarcinomas can be difficult, yet the management is different. Unroofing is a safe and effective operation for patients with simple cysts. Patients with PCLD frequently have recurrences. Cystadenomas should be completely resected owing to the likelihood of recurrence after partial excision and the risk of eventual cystadenocarcinoma. We present a treatment algorithm for the preoperative evaluation and management of hepatic cysts based on the largest number of patients with the longest follow-up reported to date.

Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period

BACKGROUND Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. OBJECTIVE To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. DESIGN A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. SETTING Tertiary referral center. PATIENTS One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. INTERVENTIONS Endoscopic management of ampullary lesions. MAIN OUTCOME MEASUREMENTS The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. RESULTS One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. CONCLUSIONS Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

Cost-effectiveness of laparoscopy versus laparotomy for initial surgical evaluation and treatment of potentially resectable hepatic colorectal metastases: a decision analysis.

Approximately 10–40% of colorectal cancer patients with potentially resectable hepatic metastases are incorrectly deemed resectable on standard pre‐operative evaluation, including contrast‐enhanced CT. Laparoscopy can identify unresectability in a majority of patients at highest risk of being incorrectly deemed resectable, sparing them an unnecessary laparotomy. However, laparoscopy requires an added investment by surgeons, patients, and payers. This analysis seeks to ascertain whether that investment is cost‐effective.

Explosion From Argon Cautery During Proctoileoscopy of a Patient With a Colectomy

We report a unique case of a 70-year-old woman with Gardners syndrome who had a subtotal colectomy with ileoproctostomy. Since then, she has undergone 12 uncomplicated proctoileoscopies, each time with argon plasma coagulation ablation of small polyps without any bowel preparation. However, during the most recent procedure, when we attempted to cauterize some rectal polyps, an immediate explosion occurred, leading to multiple rectal and ileal perforations that required surgical repair with a temporary end ileostomy. This event suggests that bacterial fermentation of colonic content or visible feces is not necessary for combustion because we observed a cautery-related explosion in the absence of a colon. This case shows the need for adequate bowel preparation if cautery is to be used, even in patients who have undergone a colectomy.

Local resection for duodenal gastrointestinal stromal tumors

BACKGROUND Duodenal gastrointestinal tumors (GIST) present infrequently, and surgical resection with negative margins remains the mainstay of therapy; however, given the lack of lymphatic and submucosal spread and anatomic location near the bile duct and pancreas, the optimal approach for resection is unknown. Options include local resection (LR), segmental resection, and pancreaticoduodenectomy (PD). METHODS All cases of gastrointestinal stromal tumors originating from the duodenum from 2000 to 2015 were identified from administrative databases. Clinical and pathologic information was abstracted from the medical record and compared between patients who received LR vs PD. The chi-square with Fishers exact test was used to detect differences between groups. RESULTS Fifteen patients met the inclusion criteria, of which 7 had an LR and 8 had a PD. The second portion of the duodenum was the most common origin of GIST in the PD group, whereas the third portion was most common in the LR group. Patients who underwent LR tended to be younger, but there was no difference in tumor size, mitotic rate, margin positivity, readmission rate, or recurrence. PD was associated with more complications, higher blood loss, and longer length of stay. CONCLUSIONS Local resection is a reasonable option for resection of duodenal GIST and should be routinely considered if technically feasible.

Classification and techniques of en bloc venous reconstruction for pancreaticoduodenectomy

BACKGROUND Surgical resection is the only cure for hepato-pancreato-biliary (HPB) malignancy. In the era of multidisciplinary approaches and neoadjuvant therapies for locally advanced, borderline resectable tumors, the feasibility and efficacy of en bloc vascular resection has been validated across multiple studies. However, the variability of venous anatomy within the perihepatic and peri-portal regions necessitates familiarity with alternative resection and reconstruction techniques appropriate to the specific region of tumor invasion. METHODS To organize these paradigms, the venous system has been divided into five zones: 1) hepatic hilum; 2) hepatoduodenal ligament; 3) portal vein/splenic vein confluence, which is further subdivided into right (3a) and left (3b); 4) infra-confluence; and 5) splenic vein. RESULTS This study systematically analyzes the anatomic considerations and clinical scenarios specific to each zone to organize the necessary preparative maneuvers, surgical procedures, and vascular reconstruction techniques to achieve an R0 resection. The anatomic and tumor-specific factors which deem a specimen unresectable are also explored. Surgical videos demonstrating these techniques are presented. DISCUSSION Preparation and familiarity with venous reconstruction maneuvers is essential for an oncologically effective operation, and can be safely achieved by utilizing this logical anatomic and procedural framework.

Initiation of adjuvant therapy following surgical resection of pancreatic ductal adenocarcinoma (PDAC): Are patients from rural, remote areas disadvantaged?

Although race and socioeconomic status have been shown to affect outcomes in pancreatic ductal adenocarcinoma (PDAC), the impact of rural residence on the delivery of adjuvant therapy (AT) has not been studied.

Use of anti tumor necrosis factor-alpha monoclonal antibody for ulcerative jejunoileitis

Ulcerative jejunoileitis is an uncommon clinical syndrome consisting of abdominal pain, weight loss associated with diarrhea, and multiple inflammatory ulcerations and strictures of the small bowel. Ulcerative jejunoileitis can complicate established celiac disease or develop in patients de novo. Increased levels of tumor necrosis factor-alpha (TNF-α) in the small intestine of patients with untreated celiac disease are associated with a role in the immune pathogenesis of this disorder. No specific therapy has been shown to change the course of ulcerative jejunoileitis. We report a case of severe ulcerative jejunoileitis previously unresponsive to traditional therapies, including high dose corticosteroids and cyclosporine. The patient had a dramatic resolution of symptoms and a complete normalization of endoscopic findings after anti-TNF-α monoclonal antibody, infliximab (Remicade(®)).