There are numerous factors which can affect the lymph node (LN) retrieval in colon cancer specime... more There are numerous factors which can affect the lymph node (LN) retrieval in colon cancer specimens. LN yield is frequently reduced in older, obese patients and those with male sex and increased in patients with right sided, large, and poorly differentiated tumors. Our aim was to identify both modifiable and nonmodifiable factors that could affect colonic resection specimen LN retrieved. A total of 2797 patients who underwent colorectal cancer surgery between January 1993 and June 2016 were retrospectively evaluated. Tumor classification was done by TNM stage. Information on pathologic staging and lymph node count was obtained from the synoptic pathology report. All patients underwent surgical resection. Factors that may affect colorectal resection specimen LN yield were the following: age, patient gender, tumor size, laparoscopy, BMI, neoadjuvant chemoradiation in rectal cancer. The number of LNs examined per patient was the main endpoint of interest. Mean and median numbers of LNs examined according to individual patient characteristics were estimated both for patients with colon cancer and for patients with rectal cancer. Separate analyses were done for the colon and rectal cohorts. A P value <.05 was considered statistically significant. All analyses were performed using SPSS 14.0 software. The mean age (_ standard deviation [SD]) at diagnosis was 67.7 _ 11,3 years for patients with colon cancer and 72 _ 10,1 years for patients with rectal cancer. (p ¼ ns). Overall, 59% of patients were men and 52% were colon cancer patients. The mean number of LN retrieved (_ standard deviation [SD]) was 22,35 (_13,07) and 14,34 (_9,1) in colon and rectal cancer patients, respectively. The patient age, gender, BMI, and tumor size had an effect on the number of LN retrieved (p ¼ .0001). The laparoscopic approach had no effect on the number of LN retrieved (p ¼ ns). In rectal cancer neoadjuvant chemoradiation affected the number of LN retrieved (p ¼ 0,0001). Conclusions Our results confirmed that LN retrieval from colorectal surgical specimens is the result of interplay between patient demographic and clinical factors. Patient factors like age, sex, BMI, tumor size, neoadjuvant chemoradiation in rectal cancer have an effect on the number of LN yield. Type of surgery (laparoscopy vs open access) does not influence the number of LN retrieved.
Surgical technique and peri-operative management of rectal carcinoma have developed substantially... more Surgical technique and peri-operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re-operations in relation to anastomotic leakage. In a nine-year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient- and surgery-related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients. The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30-day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (&amp;amp;amp;amp;lt; or = 6 cm), pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients without leakage was 10 days (range 5-61 days) and for patients with leakage 22 days (3-110 days). In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30-day mortality was 2.1%. Low anastomosis, pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.
Few reports have analyzed short- and long-term outcomes in the subset of patients with hepatocell... more Few reports have analyzed short- and long-term outcomes in the subset of patients with hepatocellular carcinoma (HCC) on non-cirrhotic liver. From January 1985 to December 2002, 277 patients underwent liver resection for HCC; in only 47 the liver was normal or showed mild chronic hepatitis at histology. A major hepatectomy (MHR) was accomplished in 37 cases (78.7%) including an extended hepatic resection in 18 (38.3%). In-hospital mortality was nil. The rate of complications was 40.4%. Overall and disease-free survival rates at 5 years were 30.9% and 33.9%. Fifteen patients are actually alive with a median survival of 33.3 months. By multivariate analysis, tumor size > 10cm and presence of satellite nodules were independent predictive factors of 5-year survival; median survival of thirteen patients with HCCs < or = 10cm and without daughter nodules was 60 months. Twenty-six patients had a margin less than 1cm and without cancer involvement; overall and recurrence-free survival...
Surgical Endoscopy And Other Interventional Techniques, 2004
Background: Several studies reporting preliminary longterm survival data after laparoscopic resec... more Background: Several studies reporting preliminary longterm survival data after laparoscopic resections for colonic adenocarcinoma did not show any detrimental effect in comparison with historic studies of laparotomies. A previous randomized study has reported an unforeseen better long-term survival for node-positive patients treated by laparoscopic colectomy. Methods: A single-institution prospective nonrandomized trial compared short-and long-term results of laparoscopic and open curative resection for adenocarcinoma of the left colon or rectum in 255 consecutive patients from January 1996 to December 2000. Results: In this study, 34 left hemicolectomy, 202 anterior resections, and 19 abdominoperineal resections were performed. A total of 74 patients underwent a laparoscopic resection (LR), and 181, an open resection (OR). The tumor site was the descending colon in 32 cases, the sigmoid colon in 98 cases, and the rectum in 125 cases, including 87 mid-low rectal cancers. Ten LR procedures (13.5%) were converted to open surgery. The hospital mortality was 0.08%, and in hospital morbidity was 16.2% for LR and 13.3% for OR (p = 0.56). The median postoperative stay was 1 day shorter for LR (9 days) than for OR (10 days) (p = 0.09). The mean number of lymph nodes retrieved were 13.8 ± 5.7 for OR and 12.7 ± 5; for LR (p = 0.23). Age exceeding 70 years, T stage, N stage, grading, mid-low rectal site, and laparoscopy were found by multivariate analysis to be significant prognostic factors for disease-free and cancer-related survival. When patients were stratified by stage, a trend toward a better disease-free and cancerrelated survival was identifyed in stage III patients undergoing LR. Conclusions: Laparoscopic colonic resection is a safe procedure in terms of postoperative outcome and longterm survival. Multivariate analysis showed that laparoscopy is a positive prognostic factor for disease-free and cancer-related survival. The current data agrees with the data for the only randomized study reported so far. Both suggest a better outcome for node-positive patients treated by laparoscopy.
Most T2 gallbladder cancers are diagnosed at final pathology after cholecystectomy. Reoperations ... more Most T2 gallbladder cancers are diagnosed at final pathology after cholecystectomy. Reoperations including liver resection and regional lymph node dissection are needed to achieve better long-term results. The aim of this study is to evaluate long-term results of reresections after prior non-curative surgery for T2 carcinomas. Retrospective study from January 1985 to July 2001. Twelve out of 14 pT2 cancers were found postoperatively. All but one underwent reresection: these 11 patients are the basis of our series. The in-hospital mortality rate was 0%. Overall 5-year survival was 63.5% with a median survival of 25 months. Median and 5-year survival of the eight cases without preoperative signs of disease (Group A) were 46.7 months and 100%. These results were significantly better than those obtained in the subset (Group B: three cases) with preoperative signs of disease (P = 0.01): all these patients died of recurrence within 25 months from the reoperation. Mean time between cholecystectomy and reresection was 2.2 and 11.3 months in the Group A and B (P = 0.01), respectively. T2 cancers discovered incidentally after simple cholecystectomy should be reoperated on as soon as possible, as the appearance, before reoperation, of a recurrence is significantly related to a dismal prognosis.
Background: The seventh TNM edition introduced a new, specific staging structure for intrahepatic... more Background: The seventh TNM edition introduced a new, specific staging structure for intrahepatic cholangiocarcinoma (IHC). Objective: To compare the accuracy of the sixth and the new seventh edition to predict survival after hepatectomy for IHC. Methods: In all, 434 consecutive patients who underwent hepatectomy at 16 tertiary-care centres (1990-2008) were identified. End points were overall (OS) and recurrence-free survival (RFS) for both T cohorts and stage strata. Results: After a median follow-up of 32.4 months, 3-and 5-year OS and RFS estimates were 47.1% and 32.9%, and 26.5% and 19.1%, respectively. Overall, both the editions were statistically significant discriminators of OS and RFS (P < 0.05). However, the survival curves of the new T2a and T2b cohorts appear superimposed. Conversely, the old T2 and T3 cohorts accurately stratify patients into distinct prognostic groups (P < 0.01). The seventh edition does not show monotonicity of gradients (the T4 category demonstrates significantly better OS and RFS compared with T2 patients). The seventh edition stage I and II are significantly different whereas the old stage I and II were not. Conclusions: The new seventh edition of the AJCC/UICC Staging System proved to be adequate although further studies are need to confirm its superiority compared with the previous edition.
Background Laparoscopic liver surgery must reproduce open surgical steps. Intraoperative ultrason... more Background Laparoscopic liver surgery must reproduce open surgical steps. Intraoperative ultrasonography (IOUS) is mandatory, but reliability of laparoscopic IOUS has been poorly evaluated. The aim of this study was to compare laparoscopic versus open IOUS in staging liver tumours. Methods All patients scheduled for liver resection between September 2009 and March 2011 were considered. Inclusion criteria were primary and metastatic tumours. Exclusion criteria were: hilar/gallbladder cholangiocarcinoma, ten or more lesions, repeat resection, laparoscopic hepatectomy, adhesions and unresectability. Following percutaneous ultrasonography and thoracoabdominal computed tomography (CT), and on indication contrast-enhanced (CE) liver magnetic resonance imaging (MRI) and/or positron emission tomography (PET)–CT, patients were scheduled for laparoscopy, laparoscopic IOUS, then laparotomy, open IOUS and Partial hepatectomy. Data were collected prospectively. Reference standards were final pat...
Objectives To examine the outcomes of a hepatectomy for intrahepatic cholangiocarcinoma (IHC) and... more Objectives To examine the outcomes of a hepatectomy for intrahepatic cholangiocarcinoma (IHC) and to clarify the prognostic impact of a lymphadenectomy and the surgical margin. Large series of patients who were surgically treated for IHC are scarce. Thus, prognostic factors and long-term survival after resection of IHC remain uncertain. Design Prospective study of patients who were surgically treated for IHC. Clinicopathologic, operative, and long-term survival data were analyzed. Setting Prospectively collected data of all consecutive patients with pathologically confirmed IHC who had undergone liver resection with a curative intent at 1 of 16 tertiary referral centers were entered into a multiinstitutional registry. Patients All consecutive patients who underwent a hepatectomy with a curative intent for IHC (1990-2008) were identified from a multi-institutional registry. Results A total of 434 patients were included in the analysis. Most patients underwent a major or extended hepatectomy (70.0%) and a systematic lymphadenectomy (62.2%). The incidence of lymph node metastases (overall, 36.9%) increased with increased tumor size, with 24.4% of patients with a small IHC (diameter ≤3 cm) having N1 disease. Almost one-third of patients required an additional major procedure to obtain a R0 resection in 84.6% of the cases. In these patients, the median time of survival was 39 months, and the 5-year survival rate was 39.8%. Lymph node metastases (hazard ratio, 2.21; P < .001), multiple tumors (hazard ratio, 1.50; P = .009), and an elevated preoperative cancer antigen 19.9 level (hazard ratio, 1.62; P = .006) independently predicted an adverse prognosis. Conversely, survival was not influenced by the width of a negative resection margin (P = .61). The potential survival benefit of a lymphadenectomy was assessed with the therapeutic value index, which was calculated to be 5.9 points.
About 20% of patients with colorectal cancer have synchronous un-resectable liver metastases. Res... more About 20% of patients with colorectal cancer have synchronous un-resectable liver metastases. Resection of colorectal cancer in patients with moderate-severe symptoms is mandatory before starting chemotherapy. Surgical treatment of asymptomatic colorectal cancers is still a matter of discussion. From January 2000 to December 2004, we prospectively collected data on 35 consecutive patients who were treated straightaway by chemotherapy without primary tumor resection. All patients underwent FOLFOX6 as first-line chemotherapy. The aim of the study was to evaluate the rate of surgical complications related to un-resected colorectal tumor. The mean interval between diagnosis and start of chemotherapy was 23.1 days (95% CI: 17.3-28.8). Fifteen of the 35 patients (42.9%) were down-staged to surgery; the mean interval between chemotherapy start and colon-rectum cancer resection was 6.5 months (95% CI: 5.5-7.5). None of them developed complications related to the primary tumor during chemotherapy. Of the other 20 patients who did not undergo any curative surgery, 16 received a second line chemotherapy and 10 a third line: six patients are alive and without intestinal symptoms (mean follow up 22.5 months, 95% CI: 11.2-33.9). Only one patient (2.8%) developed clinical signs of intestinal occlusion 5.6 months from the start of chemotherapy and required urgent colostomy. The rate of complications related to the non-resected colorectal tumor is very low using oxaliplatin as first line chemotherapy. Non-operative management of asymptomatic colorectal cancers with un-resectable liver metastases is a safe approach.
Objectives: To determine which method of liver volumetry is more accurate in predicting a safe re... more Objectives: To determine which method of liver volumetry is more accurate in predicting a safe resection. Background: Before major or extended hepatectomy, assessment of the future liver remnant (FLR) is crucial to reduce the risk of postoperative hepatic insufficiency. The FLR volume is usually expressed as the ratio of FLR to nontumorous total liver volume (TLV), which can be measured directly by computed tomography (mTLV) or estimated (eTLV) on the basis of correlation existing with the body surface area. To date, these 2 methods have never been compared. Methods: All consecutive, noncirrhotic patients who underwent resection of 3 or more liver segments between April 2000 and April 2012 and for whom (i) preoperative computed tomographic scans and (ii) body surface area were available entered the study. The mTLV (calculated as TLV − tumor volume) was compared with the eTLV (calculated as −794.41 + 1267.28 × body surface area) using volumetric data (cm 3) and clinical outcome measures (specifically, hepatic insufficiency and 90-day mortality). Definition of hepatic insufficiency was peak postoperative serum total bilirubin level of more than 7 mg/dL or, in jaundiced patients, an increasing bilirubin level on day 5 or thereafter. Results: Two-hundred forty-three patients who had undergone major (n = 135) or extended (n = 108) hepatectomies met the inclusion criteria. Twentyeight patients (11.5%) developed hepatic insufficiency, whereas 7 patients (2.9%) died postoperatively. Compared with the eTLV, the mTLV underestimated the liver volume in 60.1% of the patients (P < 0.01). Forty-seven and 73 patients had an inadequate FLR based on mTLV and eTLV, respectively. Portal vein occlusion (PVO) was used in 44 patients. In patients (n = 162) in whom both methods did not evidence the need for PVO, postoperative hepatic insufficiency and mortality were 4.9% and 0.6%, respectively. Conversely, in patients (n = 27) in whom the eTLV but not the mTLV evidenced the need for PVO, and thus PVO was not performed, hepatic insufficiency (22.2%; P = 0.001) and mortality (3.7%; P = ns) were higher. Conclusions: The use of eTLV identifies a subset of patients (∼11%) in whom liver volumetry with the mTLV underestimates the risk of hepatic insufficiency.
Objective: To assess the survival benefit of additional resection of an intraoperative positive p... more Objective: To assess the survival benefit of additional resection of an intraoperative positive proximal bile duct margin (BD Marg) in patients undergoing hepatectomy for hilar cholangiocarcinoma (HCCA). Summary Background Data: Intraoperative evidence of invasive cancer at the proximal BD Marg is associated with a dismal survival irrespective of whether a final negative BD Marg is achieved with an additional resection. Methods: Clinicopathologic, operative, and survival data of consecutive patients undergone curative intent hepatectomy with bile duct resection (n = 75) for HCC (1989-2010) were analyzed. Results: Frozen-section examination of the proximal BD Marg revealed invasive cancer in 19 of the 67 patients. After additional resection, which was possible in 18 cases, a secondary R0 BD Marg resection was achieved in 15 patients (83.3%), with 2 of these having, at final pathology, positive radial and distal margins. Eventually, 8 patients were classified as R1 and 67 as R0 (54 primary R0 and 13 secondary R0). Median survival of patients who had a secondary R0 resection (30.6 months) was similar to that of primarily R0resected patients (29.3 months) and significantly better than that of R1 patients (14.9 months) (P = 0.026). Median time to recurrence and site of recurrence were similar in R0 patients independently of the performance of an additional resection. The incidence of biliary fistula was significantly increased (44.4% vs 17.5%; P = 0.02) in patients necessitating a margin re-resection. Conclusions: Additional resection of a positive proximal BD Marg , albeit associated with an increased risk of biliary fistula, offers a significant survival benefit and should be attempted whenever possible.
The aim of this work was to inspect the presence of asbestos fibers in colon tissue from a patien... more The aim of this work was to inspect the presence of asbestos fibers in colon tissue from a patient, with history of indirect exposure to asbestos and affected by colon cancer, who underwent surgery. Variable pressure scanning electron microscopy, coupled with energy dispersive spectroscopy (VP-SEM/EDS), was used for identification of inorganic fibers and for their morphological- chemical characterization. Fresh tissue samples from both, healthy area close to the neoplasia and from the neoplastic regions, were separately digested to eliminate the biological matrix. The precipitate was analyzed by VP-SEM/EDS, identifying in samples from healthy tissue asbestos bodies and small asbestos fibers, and in samples from neoplastic tissue long fibers of asbestos, free from covering. A quantification of the asbestos bodies and the free fibers in the two type of specimens is proposed. Moreover, to locate the fibers in the biological medium, histological sections from the colon of the same patie...
European Journal of Surgical Oncology the Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, Nov 1, 2005
Recent advances in patient selection and surgical technique have resulted in low mortality and mo... more Recent advances in patient selection and surgical technique have resulted in low mortality and morbidity rates after liver resections. The aim of this study was to evaluate the operative risks of liver trisectionectomies in comparison with major resections. The data prospectively collected of patients who underwent trisectionectomies (TR Group, n = 54) and major hepatectomies (MH Group, n = 175) without biliary reconstruction were compared. Besides, the early results of patients who underwent right trisectionectomies (RTR Group, n = 36) and left trisectionectomies (LTR Group, n = 18) were compared. There was no significant difference in patient characteristics of MH and TR groups excluded for a high portal vein embolization (PVE) in TR group. Mortality (1% in MH group and 3.7% in TR group, p = 0.206) and overall morbidity rates (39% in MH group and 48% in TR group, p = 0.225) were similar between two groups. A higher proportion of patients in TR group developed liver failure (p = 0.024) and required blood transfusion (30 vs. 11%, p \ 0.001). The median hospital stay after trisectionectomies was higher in TR group than MH group (p = 0.053). There was no significant difference in patient characteristics of LTR and RTR groups excluded for lymphadenectomy which was higher in LTR group (p = 0.008) and PVE rate higher in RTR group (p = 0.01). The overall morbidity (44 vs. 55%) and mortality (2.7 vs. 5.5%) were comparable between two groups. A higher proportion of patients in RTR group required blood transfusion (39 vs. 11%, p = 0.032). At multivariate analysis, age was the only positive predictor for morbidity after trisectionectomies (p = 0.010). Trisectionectomies can be performed safely. Left trisectionectomies are as safe as right trisectionectomies. The accurate preoperative selection is necessary to reduce operative risks.
BACKGROUND: Preservation of hepatic parenchyma should be attempted whenever possible in order to ... more BACKGROUND: Preservation of hepatic parenchyma should be attempted whenever possible in order to reduce the risk of liver failure and increase the chance to re-resect the recurrence. STUDY DESIGN: The presence of a lesion in segments 7-8 infiltrating the right hepatic vein is usually an indication for right hepatectomy. If a thick inferior right hepatic vein is seen, a bisegmentectomy 7-8 can be performed. We review our experience with this uncommon liver resection. RESULTS: In 11 of 332 patients with colorectal liver metastases, a lesion was localized in segments 7-8 infiltrating the right hepatic vein. Six underwent resection of segments 7-8. The mean estimated rate of remnant liver volume (segments 2-4 plus caudate lobe) was 23.7%; 4 patients had neoadjuvant chemotherapy. Intraoperative mean blood loss was 200 mL without transfusions; no patients developed postoperative liver failure, and there was no in-hospital mortality. Surgical margin was negative in all patients. Median survival was 25 months, with 3 patients alive and disease-free. One patient with an intrahepatic recurrence underwent re-resection. CONCLUSIONS: Bisegmentectomy 7-8 is an uncommon but safe procedure that allows curative resections without unnecessary sacrifice of functional parenchyma.
There are numerous factors which can affect the lymph node (LN) retrieval in colon cancer specime... more There are numerous factors which can affect the lymph node (LN) retrieval in colon cancer specimens. LN yield is frequently reduced in older, obese patients and those with male sex and increased in patients with right sided, large, and poorly differentiated tumors. Our aim was to identify both modifiable and nonmodifiable factors that could affect colonic resection specimen LN retrieved. A total of 2797 patients who underwent colorectal cancer surgery between January 1993 and June 2016 were retrospectively evaluated. Tumor classification was done by TNM stage. Information on pathologic staging and lymph node count was obtained from the synoptic pathology report. All patients underwent surgical resection. Factors that may affect colorectal resection specimen LN yield were the following: age, patient gender, tumor size, laparoscopy, BMI, neoadjuvant chemoradiation in rectal cancer. The number of LNs examined per patient was the main endpoint of interest. Mean and median numbers of LNs examined according to individual patient characteristics were estimated both for patients with colon cancer and for patients with rectal cancer. Separate analyses were done for the colon and rectal cohorts. A P value <.05 was considered statistically significant. All analyses were performed using SPSS 14.0 software. The mean age (_ standard deviation [SD]) at diagnosis was 67.7 _ 11,3 years for patients with colon cancer and 72 _ 10,1 years for patients with rectal cancer. (p ¼ ns). Overall, 59% of patients were men and 52% were colon cancer patients. The mean number of LN retrieved (_ standard deviation [SD]) was 22,35 (_13,07) and 14,34 (_9,1) in colon and rectal cancer patients, respectively. The patient age, gender, BMI, and tumor size had an effect on the number of LN retrieved (p ¼ .0001). The laparoscopic approach had no effect on the number of LN retrieved (p ¼ ns). In rectal cancer neoadjuvant chemoradiation affected the number of LN retrieved (p ¼ 0,0001). Conclusions Our results confirmed that LN retrieval from colorectal surgical specimens is the result of interplay between patient demographic and clinical factors. Patient factors like age, sex, BMI, tumor size, neoadjuvant chemoradiation in rectal cancer have an effect on the number of LN yield. Type of surgery (laparoscopy vs open access) does not influence the number of LN retrieved.
Surgical technique and peri-operative management of rectal carcinoma have developed substantially... more Surgical technique and peri-operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re-operations in relation to anastomotic leakage. In a nine-year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient- and surgery-related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients. The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30-day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (&amp;amp;amp;amp;lt; or = 6 cm), pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients without leakage was 10 days (range 5-61 days) and for patients with leakage 22 days (3-110 days). In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30-day mortality was 2.1%. Low anastomosis, pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.
Few reports have analyzed short- and long-term outcomes in the subset of patients with hepatocell... more Few reports have analyzed short- and long-term outcomes in the subset of patients with hepatocellular carcinoma (HCC) on non-cirrhotic liver. From January 1985 to December 2002, 277 patients underwent liver resection for HCC; in only 47 the liver was normal or showed mild chronic hepatitis at histology. A major hepatectomy (MHR) was accomplished in 37 cases (78.7%) including an extended hepatic resection in 18 (38.3%). In-hospital mortality was nil. The rate of complications was 40.4%. Overall and disease-free survival rates at 5 years were 30.9% and 33.9%. Fifteen patients are actually alive with a median survival of 33.3 months. By multivariate analysis, tumor size > 10cm and presence of satellite nodules were independent predictive factors of 5-year survival; median survival of thirteen patients with HCCs < or = 10cm and without daughter nodules was 60 months. Twenty-six patients had a margin less than 1cm and without cancer involvement; overall and recurrence-free survival...
Surgical Endoscopy And Other Interventional Techniques, 2004
Background: Several studies reporting preliminary longterm survival data after laparoscopic resec... more Background: Several studies reporting preliminary longterm survival data after laparoscopic resections for colonic adenocarcinoma did not show any detrimental effect in comparison with historic studies of laparotomies. A previous randomized study has reported an unforeseen better long-term survival for node-positive patients treated by laparoscopic colectomy. Methods: A single-institution prospective nonrandomized trial compared short-and long-term results of laparoscopic and open curative resection for adenocarcinoma of the left colon or rectum in 255 consecutive patients from January 1996 to December 2000. Results: In this study, 34 left hemicolectomy, 202 anterior resections, and 19 abdominoperineal resections were performed. A total of 74 patients underwent a laparoscopic resection (LR), and 181, an open resection (OR). The tumor site was the descending colon in 32 cases, the sigmoid colon in 98 cases, and the rectum in 125 cases, including 87 mid-low rectal cancers. Ten LR procedures (13.5%) were converted to open surgery. The hospital mortality was 0.08%, and in hospital morbidity was 16.2% for LR and 13.3% for OR (p = 0.56). The median postoperative stay was 1 day shorter for LR (9 days) than for OR (10 days) (p = 0.09). The mean number of lymph nodes retrieved were 13.8 ± 5.7 for OR and 12.7 ± 5; for LR (p = 0.23). Age exceeding 70 years, T stage, N stage, grading, mid-low rectal site, and laparoscopy were found by multivariate analysis to be significant prognostic factors for disease-free and cancer-related survival. When patients were stratified by stage, a trend toward a better disease-free and cancerrelated survival was identifyed in stage III patients undergoing LR. Conclusions: Laparoscopic colonic resection is a safe procedure in terms of postoperative outcome and longterm survival. Multivariate analysis showed that laparoscopy is a positive prognostic factor for disease-free and cancer-related survival. The current data agrees with the data for the only randomized study reported so far. Both suggest a better outcome for node-positive patients treated by laparoscopy.
Most T2 gallbladder cancers are diagnosed at final pathology after cholecystectomy. Reoperations ... more Most T2 gallbladder cancers are diagnosed at final pathology after cholecystectomy. Reoperations including liver resection and regional lymph node dissection are needed to achieve better long-term results. The aim of this study is to evaluate long-term results of reresections after prior non-curative surgery for T2 carcinomas. Retrospective study from January 1985 to July 2001. Twelve out of 14 pT2 cancers were found postoperatively. All but one underwent reresection: these 11 patients are the basis of our series. The in-hospital mortality rate was 0%. Overall 5-year survival was 63.5% with a median survival of 25 months. Median and 5-year survival of the eight cases without preoperative signs of disease (Group A) were 46.7 months and 100%. These results were significantly better than those obtained in the subset (Group B: three cases) with preoperative signs of disease (P = 0.01): all these patients died of recurrence within 25 months from the reoperation. Mean time between cholecystectomy and reresection was 2.2 and 11.3 months in the Group A and B (P = 0.01), respectively. T2 cancers discovered incidentally after simple cholecystectomy should be reoperated on as soon as possible, as the appearance, before reoperation, of a recurrence is significantly related to a dismal prognosis.
Background: The seventh TNM edition introduced a new, specific staging structure for intrahepatic... more Background: The seventh TNM edition introduced a new, specific staging structure for intrahepatic cholangiocarcinoma (IHC). Objective: To compare the accuracy of the sixth and the new seventh edition to predict survival after hepatectomy for IHC. Methods: In all, 434 consecutive patients who underwent hepatectomy at 16 tertiary-care centres (1990-2008) were identified. End points were overall (OS) and recurrence-free survival (RFS) for both T cohorts and stage strata. Results: After a median follow-up of 32.4 months, 3-and 5-year OS and RFS estimates were 47.1% and 32.9%, and 26.5% and 19.1%, respectively. Overall, both the editions were statistically significant discriminators of OS and RFS (P < 0.05). However, the survival curves of the new T2a and T2b cohorts appear superimposed. Conversely, the old T2 and T3 cohorts accurately stratify patients into distinct prognostic groups (P < 0.01). The seventh edition does not show monotonicity of gradients (the T4 category demonstrates significantly better OS and RFS compared with T2 patients). The seventh edition stage I and II are significantly different whereas the old stage I and II were not. Conclusions: The new seventh edition of the AJCC/UICC Staging System proved to be adequate although further studies are need to confirm its superiority compared with the previous edition.
Background Laparoscopic liver surgery must reproduce open surgical steps. Intraoperative ultrason... more Background Laparoscopic liver surgery must reproduce open surgical steps. Intraoperative ultrasonography (IOUS) is mandatory, but reliability of laparoscopic IOUS has been poorly evaluated. The aim of this study was to compare laparoscopic versus open IOUS in staging liver tumours. Methods All patients scheduled for liver resection between September 2009 and March 2011 were considered. Inclusion criteria were primary and metastatic tumours. Exclusion criteria were: hilar/gallbladder cholangiocarcinoma, ten or more lesions, repeat resection, laparoscopic hepatectomy, adhesions and unresectability. Following percutaneous ultrasonography and thoracoabdominal computed tomography (CT), and on indication contrast-enhanced (CE) liver magnetic resonance imaging (MRI) and/or positron emission tomography (PET)–CT, patients were scheduled for laparoscopy, laparoscopic IOUS, then laparotomy, open IOUS and Partial hepatectomy. Data were collected prospectively. Reference standards were final pat...
Objectives To examine the outcomes of a hepatectomy for intrahepatic cholangiocarcinoma (IHC) and... more Objectives To examine the outcomes of a hepatectomy for intrahepatic cholangiocarcinoma (IHC) and to clarify the prognostic impact of a lymphadenectomy and the surgical margin. Large series of patients who were surgically treated for IHC are scarce. Thus, prognostic factors and long-term survival after resection of IHC remain uncertain. Design Prospective study of patients who were surgically treated for IHC. Clinicopathologic, operative, and long-term survival data were analyzed. Setting Prospectively collected data of all consecutive patients with pathologically confirmed IHC who had undergone liver resection with a curative intent at 1 of 16 tertiary referral centers were entered into a multiinstitutional registry. Patients All consecutive patients who underwent a hepatectomy with a curative intent for IHC (1990-2008) were identified from a multi-institutional registry. Results A total of 434 patients were included in the analysis. Most patients underwent a major or extended hepatectomy (70.0%) and a systematic lymphadenectomy (62.2%). The incidence of lymph node metastases (overall, 36.9%) increased with increased tumor size, with 24.4% of patients with a small IHC (diameter ≤3 cm) having N1 disease. Almost one-third of patients required an additional major procedure to obtain a R0 resection in 84.6% of the cases. In these patients, the median time of survival was 39 months, and the 5-year survival rate was 39.8%. Lymph node metastases (hazard ratio, 2.21; P < .001), multiple tumors (hazard ratio, 1.50; P = .009), and an elevated preoperative cancer antigen 19.9 level (hazard ratio, 1.62; P = .006) independently predicted an adverse prognosis. Conversely, survival was not influenced by the width of a negative resection margin (P = .61). The potential survival benefit of a lymphadenectomy was assessed with the therapeutic value index, which was calculated to be 5.9 points.
About 20% of patients with colorectal cancer have synchronous un-resectable liver metastases. Res... more About 20% of patients with colorectal cancer have synchronous un-resectable liver metastases. Resection of colorectal cancer in patients with moderate-severe symptoms is mandatory before starting chemotherapy. Surgical treatment of asymptomatic colorectal cancers is still a matter of discussion. From January 2000 to December 2004, we prospectively collected data on 35 consecutive patients who were treated straightaway by chemotherapy without primary tumor resection. All patients underwent FOLFOX6 as first-line chemotherapy. The aim of the study was to evaluate the rate of surgical complications related to un-resected colorectal tumor. The mean interval between diagnosis and start of chemotherapy was 23.1 days (95% CI: 17.3-28.8). Fifteen of the 35 patients (42.9%) were down-staged to surgery; the mean interval between chemotherapy start and colon-rectum cancer resection was 6.5 months (95% CI: 5.5-7.5). None of them developed complications related to the primary tumor during chemotherapy. Of the other 20 patients who did not undergo any curative surgery, 16 received a second line chemotherapy and 10 a third line: six patients are alive and without intestinal symptoms (mean follow up 22.5 months, 95% CI: 11.2-33.9). Only one patient (2.8%) developed clinical signs of intestinal occlusion 5.6 months from the start of chemotherapy and required urgent colostomy. The rate of complications related to the non-resected colorectal tumor is very low using oxaliplatin as first line chemotherapy. Non-operative management of asymptomatic colorectal cancers with un-resectable liver metastases is a safe approach.
Objectives: To determine which method of liver volumetry is more accurate in predicting a safe re... more Objectives: To determine which method of liver volumetry is more accurate in predicting a safe resection. Background: Before major or extended hepatectomy, assessment of the future liver remnant (FLR) is crucial to reduce the risk of postoperative hepatic insufficiency. The FLR volume is usually expressed as the ratio of FLR to nontumorous total liver volume (TLV), which can be measured directly by computed tomography (mTLV) or estimated (eTLV) on the basis of correlation existing with the body surface area. To date, these 2 methods have never been compared. Methods: All consecutive, noncirrhotic patients who underwent resection of 3 or more liver segments between April 2000 and April 2012 and for whom (i) preoperative computed tomographic scans and (ii) body surface area were available entered the study. The mTLV (calculated as TLV − tumor volume) was compared with the eTLV (calculated as −794.41 + 1267.28 × body surface area) using volumetric data (cm 3) and clinical outcome measures (specifically, hepatic insufficiency and 90-day mortality). Definition of hepatic insufficiency was peak postoperative serum total bilirubin level of more than 7 mg/dL or, in jaundiced patients, an increasing bilirubin level on day 5 or thereafter. Results: Two-hundred forty-three patients who had undergone major (n = 135) or extended (n = 108) hepatectomies met the inclusion criteria. Twentyeight patients (11.5%) developed hepatic insufficiency, whereas 7 patients (2.9%) died postoperatively. Compared with the eTLV, the mTLV underestimated the liver volume in 60.1% of the patients (P < 0.01). Forty-seven and 73 patients had an inadequate FLR based on mTLV and eTLV, respectively. Portal vein occlusion (PVO) was used in 44 patients. In patients (n = 162) in whom both methods did not evidence the need for PVO, postoperative hepatic insufficiency and mortality were 4.9% and 0.6%, respectively. Conversely, in patients (n = 27) in whom the eTLV but not the mTLV evidenced the need for PVO, and thus PVO was not performed, hepatic insufficiency (22.2%; P = 0.001) and mortality (3.7%; P = ns) were higher. Conclusions: The use of eTLV identifies a subset of patients (∼11%) in whom liver volumetry with the mTLV underestimates the risk of hepatic insufficiency.
Objective: To assess the survival benefit of additional resection of an intraoperative positive p... more Objective: To assess the survival benefit of additional resection of an intraoperative positive proximal bile duct margin (BD Marg) in patients undergoing hepatectomy for hilar cholangiocarcinoma (HCCA). Summary Background Data: Intraoperative evidence of invasive cancer at the proximal BD Marg is associated with a dismal survival irrespective of whether a final negative BD Marg is achieved with an additional resection. Methods: Clinicopathologic, operative, and survival data of consecutive patients undergone curative intent hepatectomy with bile duct resection (n = 75) for HCC (1989-2010) were analyzed. Results: Frozen-section examination of the proximal BD Marg revealed invasive cancer in 19 of the 67 patients. After additional resection, which was possible in 18 cases, a secondary R0 BD Marg resection was achieved in 15 patients (83.3%), with 2 of these having, at final pathology, positive radial and distal margins. Eventually, 8 patients were classified as R1 and 67 as R0 (54 primary R0 and 13 secondary R0). Median survival of patients who had a secondary R0 resection (30.6 months) was similar to that of primarily R0resected patients (29.3 months) and significantly better than that of R1 patients (14.9 months) (P = 0.026). Median time to recurrence and site of recurrence were similar in R0 patients independently of the performance of an additional resection. The incidence of biliary fistula was significantly increased (44.4% vs 17.5%; P = 0.02) in patients necessitating a margin re-resection. Conclusions: Additional resection of a positive proximal BD Marg , albeit associated with an increased risk of biliary fistula, offers a significant survival benefit and should be attempted whenever possible.
The aim of this work was to inspect the presence of asbestos fibers in colon tissue from a patien... more The aim of this work was to inspect the presence of asbestos fibers in colon tissue from a patient, with history of indirect exposure to asbestos and affected by colon cancer, who underwent surgery. Variable pressure scanning electron microscopy, coupled with energy dispersive spectroscopy (VP-SEM/EDS), was used for identification of inorganic fibers and for their morphological- chemical characterization. Fresh tissue samples from both, healthy area close to the neoplasia and from the neoplastic regions, were separately digested to eliminate the biological matrix. The precipitate was analyzed by VP-SEM/EDS, identifying in samples from healthy tissue asbestos bodies and small asbestos fibers, and in samples from neoplastic tissue long fibers of asbestos, free from covering. A quantification of the asbestos bodies and the free fibers in the two type of specimens is proposed. Moreover, to locate the fibers in the biological medium, histological sections from the colon of the same patie...
European Journal of Surgical Oncology the Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, Nov 1, 2005
Recent advances in patient selection and surgical technique have resulted in low mortality and mo... more Recent advances in patient selection and surgical technique have resulted in low mortality and morbidity rates after liver resections. The aim of this study was to evaluate the operative risks of liver trisectionectomies in comparison with major resections. The data prospectively collected of patients who underwent trisectionectomies (TR Group, n = 54) and major hepatectomies (MH Group, n = 175) without biliary reconstruction were compared. Besides, the early results of patients who underwent right trisectionectomies (RTR Group, n = 36) and left trisectionectomies (LTR Group, n = 18) were compared. There was no significant difference in patient characteristics of MH and TR groups excluded for a high portal vein embolization (PVE) in TR group. Mortality (1% in MH group and 3.7% in TR group, p = 0.206) and overall morbidity rates (39% in MH group and 48% in TR group, p = 0.225) were similar between two groups. A higher proportion of patients in TR group developed liver failure (p = 0.024) and required blood transfusion (30 vs. 11%, p \ 0.001). The median hospital stay after trisectionectomies was higher in TR group than MH group (p = 0.053). There was no significant difference in patient characteristics of LTR and RTR groups excluded for lymphadenectomy which was higher in LTR group (p = 0.008) and PVE rate higher in RTR group (p = 0.01). The overall morbidity (44 vs. 55%) and mortality (2.7 vs. 5.5%) were comparable between two groups. A higher proportion of patients in RTR group required blood transfusion (39 vs. 11%, p = 0.032). At multivariate analysis, age was the only positive predictor for morbidity after trisectionectomies (p = 0.010). Trisectionectomies can be performed safely. Left trisectionectomies are as safe as right trisectionectomies. The accurate preoperative selection is necessary to reduce operative risks.
BACKGROUND: Preservation of hepatic parenchyma should be attempted whenever possible in order to ... more BACKGROUND: Preservation of hepatic parenchyma should be attempted whenever possible in order to reduce the risk of liver failure and increase the chance to re-resect the recurrence. STUDY DESIGN: The presence of a lesion in segments 7-8 infiltrating the right hepatic vein is usually an indication for right hepatectomy. If a thick inferior right hepatic vein is seen, a bisegmentectomy 7-8 can be performed. We review our experience with this uncommon liver resection. RESULTS: In 11 of 332 patients with colorectal liver metastases, a lesion was localized in segments 7-8 infiltrating the right hepatic vein. Six underwent resection of segments 7-8. The mean estimated rate of remnant liver volume (segments 2-4 plus caudate lobe) was 23.7%; 4 patients had neoadjuvant chemotherapy. Intraoperative mean blood loss was 200 mL without transfusions; no patients developed postoperative liver failure, and there was no in-hospital mortality. Surgical margin was negative in all patients. Median survival was 25 months, with 3 patients alive and disease-free. One patient with an intrahepatic recurrence underwent re-resection. CONCLUSIONS: Bisegmentectomy 7-8 is an uncommon but safe procedure that allows curative resections without unnecessary sacrifice of functional parenchyma.
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Papers by Marco Amisano