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Peter D Peng,
Mark G van Vledder, Susan Tsai,
Mechteld C de Jong,
Martin Makary,
Julie Ng,
Barish H Edil,
Christopher L Wolfgang,
Richard D Schulick,
Michael A Choti,
Ihab Kamel,
Timothy M Pawlik
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ABSTRACT: As indications for liver resection expand, objective measures to assess the risk of peri-operative morbidity are needed. The impact of sarcopenia on patients undergoing liver resection for colorectal liver metastasis (CRLM) was investigated.
Sarcopenia was assessed in 259 patients undergoing liver resection for CRLM by measuring total psoas area (TPA) on computed tomography (CT). The impact of sarcopenia was assessed after controlling for clinicopathological factors using multivariate modelling.
Median patient age was 58 years and most patients (60%) were male. Forty-one (16%) patients had sarcopenia (TPA ≤ 500 mm(2) /m(2) ). Post-operatively, 60 patients had a complication for an overall morbidity of 23%; 26 patients (10%) had a major complication (Clavien grade ≥3). The presence of sarcopenia was strongly associated with an increased risk of major post-operative complications [odds ratio (OR) 3.33; P= 0.008]. Patients with sarcopenia had longer hospital stays (6.6 vs. 5.4 days; P= 0.03) and a higher chance of an extended intensive care unit (ICU) stay (>2 days; P= 0.004). On multivariate analysis, sarcopenia remained independently associated with an increased risk of post-operative complications (OR 3.12; P= 0.02). Sarcopenia was not significantly associated with recurrence-free [hazard ratio (HR) = 1.07] or overall (HR = 1.05) survival (both P > 0.05).
Sarcopenia impacts short-, but not long-term outcomes after resection of CRLM. While patients with sarcopenia are at an increased risk of post-operative morbidity and longer hospital stay, long-term survival is not impacted by the presence of sarcopenia.
HPB 07/2011; 13(7):439-46. · 1.60 Impact Factor
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ABSTRACT: Alagille syndrome is a multi-system developmental disorder associated with paucity of interlobular bile ducts and cholestasis, rarely associated with hepatocellular carcinoma. Associated syndromic co-morbidities may complicate surgical management. As such, we herein review the modern management of a large hepatocellular carcinoma in an adult patient with Alagille syndrome and review the literature of adult Alagille patients with hepatocellular carcinoma.
A 29-year-old woman with a history of Alagille syndrome was referred with biopsy-proven 12 × 8 cm hepatocellular carcinoma replacing her right liver. Biopsy of the contralateral liver demonstrated findings consistent with Alagille syndrome, but no underlying cirrhosis. CT volumetrics demonstrated a future liver remnant of 40%. Extensive hematologic and cardiac work-up was performed pre-operatively, given the syndrome's associated bleeding dyscrasias and cardiac abnormalities. The patient underwent a margin-negative right hepatectomy using the "hanging" technique through a thoracoabdominal approach. The patient developed a transient hyperbilirubinemia but no hepatic insufficiency and did well post-operatively.
Since Alagille syndrome affects multiple organ systems, preoperative evaluation of cardiac, hematologic, and hepatic function should be considered. This case illustrates the peri-operative management of an Alagille patient, and highlights several key technical points that contributed to a successful resection.
Digestive Diseases and Sciences 11/2010; 55(11):3052-8. · 2.12 Impact Factor
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Mechteld C de Jong, Susan Tsai,
John L Cameron,
Christopher L Wolfgang,
Kenzo Hirose,
Mark G van Vledder,
Frederic Eckhauser,
Joseph M Herman,
Barish H Edil,
Michael A Choti,
Richard D Schulick,
Timothy M Pawlik
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ABSTRACT: The management of patients with peri-ampullary liver metastasis remains controversial. We sought to assess the safety and efficacy of curative intent surgery for peri-ampullary liver metastasis.
Between 1993 and 2009, 40 patients underwent curative intent surgery (resection and/or radiofrequency ablation (RFA)) for peri-ampullary liver metastasis. Clinicopathologic and outcome data were collected and analyzed.
Location of the primary tumor was pancreas head (n = 20), ampulla of Vater (n = 10), distal bile duct (n = 5), or duodenum (n = 5). Most patients (n = 27) presented with synchronous disease, while 13 patients presented with metachronous disease following a median disease-free interval of 22 months. Most patients (n = 25) presented with hepatic metastasis from pancreaticobiliary origin (pancreatic or distal common bile duct) compared with 15 patients who had metastasis from an intestinal-type primary (ampullary or duodenal). There were no differences in metastatic tumor number or size between these groups (P > 0.05). Post-operative morbidity and mortality was 30% and 5% respectively. Overall 1- and 3-year survival was 55% and 18%. Patients who underwent resection of liver metastasis from intestinal-type tumors experienced a longer survival compared with patients who had pancreaticobiliary lesions (median: 13 months vs. 23 months; P = 0.05).
Curative intent surgery for peri-ampullary liver metastasis was associated with post-operative morbidity and a 5% mortality rate. Although the overall survival benefit was modest, patients with liver metastasis from intestinal-type tumors experienced improved survival following resection of liver metastasis compared with pancreaticobiliary lesions.
Journal of Surgical Oncology 09/2010; 102(3):256-63. · 2.10 Impact Factor
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Updates in surgery. 08/2010; 62(1):5-9.
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Susan Tsai,
Michael A Choti,
Lia Assumpcao,
John L Cameron,
Ana L Gleisner,
Joseph M Herman,
Frederic Eckhauser,
Barish H Edil,
Richard D Schulick,
Christopher L Wolfgang,
Timothy M Pawlik
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ABSTRACT: To examine the effect of body mass index (BMI) on clinicopathologic factors and long-term survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma.
Data on BMI, weight loss, operative details, surgical pathology, and long-term survival were collected on 795 patients who underwent pancreaticoduodenectomy. Patients were categorized as obese (BMI > 30 kg/m(2)), overweight (BMI 25 to <30 kg/m(2)), or normal weight (BMI < 25 kg/m(2)) and compared using univariate and multivariate analyses.
At the time of surgery, 14% of patients were obese, 33% overweight, and 53% normal weight. Overall, 32% of patients had preoperative weight loss of >10%. There were no differences in operative times among the groups; however, higher BMI was associated with increased risk of blood loss (P < 0.001) and pancreatic fistula (P = 0.01). On pathologic analysis, BMI was not associated with tumor stage or number of lymph nodes harvested (both P > 0.05). Higher BMI patients had a lower incidence of a positive retroperitoneal/uncinate margin versus normal weight patients (P = 0.03). Perioperative morbidity and mortality were similar among the groups. Obese and overweight patients had better 5-year survival (22% and 22%, respectively) versus normal weight patients (15%; P = 0.02). After adjusting for other prognostic factors, as well as preoperative weight loss, higher BMI remained independently associated with improved cancer-specific survival (overweight: hazard ratio, 0.68; obese: hazard ratio, 0.72; both P < 0.05).
Obese patients had similar tumor-specific characteristics, as well as perioperative outcomes, compared with normal weight patients. However, obese patients undergoing pancreaticoduodenectomy for pancreatic cancer had an improved long-term survival independent of known clinicopathologic factors.
Journal of Gastrointestinal Surgery 07/2010; 14(7):1143-50. · 2.83 Impact Factor
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ABSTRACT: Two-stage hepatectomy has been proposed for patients with bilateral colorectal liver metastases. The present study assesses the feasibility and outcome of two-stage hepatectomy for the treatment of colorectal liver metastases.
From January 1994 to December 2008, 720 patients underwent liver resections at two institutions for colorectal liver metastases. The feasibility and outcomes of two-staged hepatectomies were evaluated.
Forty-five patients were eligible for the two-stage approach and both stages were completed in 35 patients (78%). Reasons for failure included disease progression (n= 7), poor performance status (n= 1) and death after the first stage (n= 2). Patients who completed both stages had significantly fewer lesions than patients who failed to complete the second stage (5 vs. 8; P= 0.02). No differences between the two groups were observed with regard to lesion size, receipt of radiofrequency ablation (RFA) or presence of extrahepatic disease. Post-operative morbidity (24% vs. 26%; P= 0.9) and mortality (4% vs. 5%; P= 0.8) was similar between the first and second stages. Median overall survival was 16 months. Three-year survival was significantly worse for patients failing to complete both stages (18%) compared with patients completing both stages (58%) (P < 0.001). Similar survival rates were observed between patients who completed two-stage vs. patients treated with a planned single-stage hepatectomy (58% vs. 53%; P= 0.34).
The two-stage strategy for colorectal liver metastases can be performed with acceptable morbidity and mortality. The second stage will not be feasible in 20-25% of patients. Patients who are able to complete the two-stage approach, however, may have long-term survival comparable to patients treated with a planned single-stage hepatectomy.
HPB 05/2010; 12(4):262-9. · 1.60 Impact Factor
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ABSTRACT: The number of melanoma cases in the elderly (>65 years) will rise over the coming decades, making it an important public health problem. Elderly white men are the demographic group who are at highest risk of being diagnosed with melanoma and of dying from this cancer. Among patients with melanoma, older age is recognized as an independent poor prognostic factor, but it remains unclear whether this relationship is due to a change in the biology of the disease with increasing patient age, declining host defenses, or both. Most elderly patients can have surgery to control locoregional disease, but might not be candidates for intensive biologic therapies for advanced melanoma because of comorbidities and inability to tolerate the adverse side effects of these treatments. Early detection remains an important strategy for the management of melanoma. Further research is needed to determine why older melanoma patients have a worse prognosis than their younger counterparts, even when matched for all other clinical and pathological predictors of survival outcomes.
Nature Reviews Clinical Oncology 02/2010; 7(3):148-52. · 11.96 Impact Factor
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Annals of Surgical Oncology 07/2009; 16(9):2422-8. · 4.17 Impact Factor
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ABSTRACT: Hepatocellular carcinoma (HCC) usually affects patients with chronic liver disease. While resection is the primary treatment of HCC in patients without cirrhosis, in the setting of moderate to severe cirrhosis, liver transplantation is the preferred therapy, as it simultaneously treats the tumor and the underlying liver condition. The optimal management of patients with HCC and early cirrhosis remains controversial. Although liver transplantation for HCC within the Milan criteria has been shown to have excellent long-term survival rates and low recurrence rates, its application is limited by organ availability. Due to the shortage of donors, a portion of patients drop out from the waiting list due to tumor progression. One alternative to transplantation is hepatic resection. In addition to the reported 50% 5-year survival rates, resection allows a better understanding of tumor biology through pathologic examination of the specimen, which may guide decision-making regarding salvage liver transplantation. Other nonsurgical locoregional therapies, such as transarterial chemoembolization and radiofrequency ablation, also serve as primary therapies and as a bridge to transplantation. The management of patients with early HCC is complex and multidimensional. The care of these patients is best served by a multidisciplinary approach, with consideration of the feasibility of transplantation weighed against the aggressiveness of the tumor biology and underlying hepatic dysfunction. All modalities of therapy should be viewed as complementary, not exclusive, therapeutic strategies.
Annals of Surgical Oncology 04/2009; 16(7):1820-31. · 4.17 Impact Factor
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ABSTRACT: PSC is an idiopathic chronic cholestatic disease of the liver that has a variable clinical course. Patients should be managed based on the degree of liver dysfunction, as well as the degree of biliary obstruction and symptoms. Endoscopic biliary dilations provides symptomatic and biochemical relief with minimal morbidity and mortality. Endoscopic procedures, however, result in shorter overall and transplant-free survival than resection and may not decrease the incidence of cholangiocarcinoma. Dominant strictures that fail endoscopic management may harbor an underlying cholangiocarcinoma and surgical therapy should not be delayed. While transplantation is the option of choice in PSC patients with cirrhosis, extrahepatic biliary resection including the bifureation is a good therapeutic option in noncirrhotic patients. Resection of the extrahepatic biliary tree with the hepatic duct bifurcation should be considered in patients with a dominant extrahepatic stricture and preserved liver function. In the appropriately selected patient, extrahepatic biliary resection affords patients with survival rates equivalent to that of transplantation. In fact, extrahepatic biliary resection can potentially significantly delay or avoid transplantation. Extrahepatic biliary resection is a good durable option for noncirrhotic patients with PSC and a dominant extrahepatic stricture.
Advances in Surgery 01/2009; 43:175-88.
