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ABSTRACT: The optimal abdominal incision for partial hepatectomy has not been established.
A prospective hepatobiliary surgery database was retrospective reviewed. Patients with Mercedes and extended right subcostal (ERSC) incisions were identified and compared.
Between December 1991 and September 2001 a total of 1426 patients met the inclusion criteria. Among them, 856 (60%) had a Mercedes incision and 570 (40%) an ERSC incision. The two groups were well matched for demographics and operative variables. Perioperative morbidity and pulmonary complications were similar for the two groups as well. There was no difference in terms of early wound complications, although incisional hernias occurred in 9.8% of patients with a Mercedes incision compared to 4.8% of those with an ERSC incision (P = 0.0001). On multivariate analysis, the incision type, along with gender, body mass index, and age, were significant predictors of incisional hernia.
An ERSC incision for partial hepatectomy provides adequate, safe access and is associated with fewer long-term wound complications.
World Journal of Surgery 04/2006; 30(3):410-8. · 2.36 Impact Factor
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ABSTRACT: IntroductionThe optimal abdominal incision for partial hepatectomy has not been established.
MethodsA prospective hepatobiliary surgery database was retrospective reviewed. Patients with Mercedes and extended right subcostal
(ERSC) incisions were identified and compared.
ResultsBetween December 1991 and September 2001 a total of 1426 patients met the inclusion criteria. Among them, 856 (60%) had a
Mercedes incision and 570 (40%) an ERSC incision. The two groups were well matched for demographics and operative variables.
Perioperative morbidity and pulmonary complications were similar for the two groups as well. There was no difference in terms
of early wound complications, although incisional hernias occurred in 9.8% of patients with a Mercedes incision compared to
4.8% of those with an ERSC incision (P = 0.0001.) On multivariate analysis, the incision type, along with gender, body mass index, and age, were significant predictors
of incisional hernia.
ConclusionsAn ERSC incision for partial hepatectomy provides adequate, safe access and is associated with fewer long-term wound complications.
World Journal of Surgery 01/2006; 30(3):410-418. · 2.36 Impact Factor
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Archives of Surgery 04/2005; 140(3):311-2. · 4.24 Impact Factor
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ABSTRACT: Combined major hepatectomy with pancreatectomy (MHP) is a rarely used operation for the treatment of hepatobiliary cancer. Few reports have discussed the utility of this procedure and its indications are poorly defined. The aim of this study was to review our experience with MHP.
A review of our prospective hepatobiliary surgical database between January 1994 and July 2000 identified 17 patients who had undergone MHP. Preoperative radiographic and laboratory data, intraoperative findings, hospital outcomes, and longterm followup were obtained.
A total of 3,579 patients with hepatobiliary malignancy were seen at our institution, of which 1,280 underwent resection and 17 (1.3%) had an MHP. The median age was 58 years (range 24 to 76). Histology was as follows: eight neuroendocrine carcinoma, three sarcoma, two cholangiocarcinoma, one ampullary carcinoma, one gallbladder carcinoma, one gastric carcinoma recurrence, and one benign fibrosis. All 17 patients underwent resection of two or more hepatic segments. Nine patients underwent a distal pancreatectomy and eight underwent a pancreaticoduodenectomy. Median operative time was 6 hours (range 4 to 8) and the median blood loss was 900 mL (range 150 to 2,500). Postoperative complications occurred in eight patients (47%), and there were three perioperative deaths (18%). All three deaths occurred in patients who underwent a pancreaticoduodenectomy combined with a hemi-hepactomy or greater. Eight patients are free of disease with a median followup of 54 months. Six patients have recurred, two of whom have died of disease with a median disease-free interval of 8 months.
MHP is associated with a high morbidity and mortality and should only be considered in highly selected patients when a significant potential oncologic benefit is possible.
Journal of the American College of Surgeons 05/2004; 198(4):570-6. · 4.55 Impact Factor
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ABSTRACT: The prospective randomized controlled trial (PRCT) is agreeably the gold standard in reporting data on patient management. This study evaluates the impact of specialty training on the leadership, development, and enrollment in PRCT.
Questionnaires were sent to surgical oncology as well as general surgery graduates from 1985 to 1999.
A total of 67% (201 of 300) of the surgeons responded, with one half of the respondents completing a surgical oncology (SO) fellowship (50%, 100 of 201), 33% (66 of 201) another type of fellowship (OF), and 17% (35 of 201) general surgery (GS) training alone. The utilization of PRCT in the decision making of their clinical practice was reported by a majority of SO graduates (99%) as well as GS graduates (88%) with a smaller number (77%) of OF trained surgeons. The opinions on PRCT were evenly distributed with breast disease, colorectal cancer, and melanoma having the greatest impact on surgeons practicing in these fields. A greater percentage of SO (89%) reported participation in a PRCT than did the GS (42%) or OF (54%). The most frequent reason for the lack of participation in a PRCT by both GS and OF trained graduates was absence of active recruitment (80%) to participate with the second most common being no time available (18%).
PRCT are utilized and continue to change surgeons' decision making for a majority of the surgeons surveyed. There are certain disease sites for which PRCT have failed to influence practice decisions. Unfortunately, few surgeons take a leadership role in PRCT. Emphasizing the existence of PRCT at both meetings, and in journals, with a more aggressive recruitment of participating surgeons with minimal time commitment, should enhance the patients included in prospective randomized controlled trials.
The American Journal of Surgery 04/2003; 185(3):239-43. · 2.78 Impact Factor
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ABSTRACT: Ewing sarcoma (ES) is the second most common primary osseous malignancy in childhood and adolescence. The improvement in survival is primarily associated with the combination of surgery and chemotherapy.
Little is known about the outcome of adults with soft tissue ES or primitive neuroectodermal tumors (PNET). Certain prognostic factors from soft tissue sarcomas (tumor size, tumor location, margin status, and initial presentation) in adults (>16 years) with ES/PNET will help to identify factors associated with outcome.
Between July 1, 1982, and June 30, 2000, we identified 59 adult patients with primary soft tissue ES/PNET. Clinicopathologic factors were correlated with the end points studied: patient factors, tumor factors, pathologic factors, status of surgical margins, adjuvant chemotherapy, and radiation therapy.
There were 41 male and 18 female patients, with a median age of 27 years (range, 16-72 years). Median tumor size was 8 cm, with all lesions being high grade. The most common site was the trunk (n = 22), with an even distribution of retroperitoneal, pelvis, buttock, and lower extremity (all n = 5). The median follow-up was 29 months (range, 6-222 months), with local recurrence identified in 13 patients (22%), with a median time to recurrence of 15 months (range, 5-200 months). Overall 5-year survival was 60%. Initial presentation was the only predictor of long-term survival, with primary tumor-only presentation having a 5-year survival of 60% (median not reached) compared with primary tumor plus metastatic disease having a 5-year survival of 33% (median, 17 months) (P =.02).
Initial presentation of disease represents the only predictor of survival identified in this small group of adult patients with ES/PNET.
Archives of Surgery 03/2003; 138(3):281-5. · 4.24 Impact Factor
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ABSTRACT: Major hepatic resection is indicated for selected patients with colorectal metastasis to the liver. Transfusion of fresh frozen plasma (FFP) might be required after major hepatectomy because of blood loss or coagulopathy, but there are no standard criteria for the use of FFP in this setting.
We identified 260 patients from our prospective database who underwent major (> or =3 Couinaud segments) hepatectomy between May 1997 and February 2001 for colorectal metastasis. FFP use was determined and tested for its relationship to clinical and pathologic factors. A survey on FFP use was sent to 12 other hepatobiliary centers worldwide.
There were 142 (55%) men, 118 (45%) women, and the median age was 63 years. The most common hepatic resections performed were right lobectomy (37%) and extended right lobectomy (33%). There were 83 (32%) patients who received FFP. In these patients, a total of 405 units of FFP were administered with a median of 4 units. The majority of patients who received FFP were transfused within the first two postoperative days, while there were only five (2%) patients who initially received FFP beyond that time. FFP was administered for a median prothrombin time of 16.9. Only one (0.4%) patient required reoperation for bleeding. Right lobectomy and extended right lobectomy were found to predict FFP use on multivariate analysis. Postoperative complications did not correlate with FFP use. The criteria used for FFP administration at other major hepatobiliary centers were found to be variable.
There is no universal standard for FFP use following major hepatic resection for colorectal metastasis. Our criterion of a prothrombin time of 16-18 seconds is conservative but results only rarely in reoperation for bleeding. Prospective evaluation of a higher threshold for FFP administration, such as an International Normal Ratio of 2.0, should be performed to better define the guidelines for FFP use in patients undergoing major hepatectomy who have normal underlying hepatic parenchyma.
Journal of the American College of Surgeons 03/2003; 196(3):402-9. · 4.55 Impact Factor
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ABSTRACT: There has been an increasing incidence and mortality from peripheral cholangiocarcinoma (PC) in the United States over the past 24 years. PC has been classified into two principal types, a mass-forming type and a periductal-infiltrating type, with a significant difference in the clinical behavior between the two. A third type, demonstrating a noninvasive intraductal growth of PC, was described as papillary PC. Rarely, papillary hepatic tumors composed of oncocytic cells have been described. Intraductal oncocytic papillary carcinomas (IOPCs) of the liver present as large, mucin-filled, cystic lesions lined by noninvasive or focally microinvasive oncocytic tumors.
From June 1999 to August 2001, three patients with hepatic IOPCs were identified in the files of the Hepatobiliary Service, Department of Surgery, and the Department of Pathology at Memorial Sloan-Kettering Cancer Center. They form the basis of this study. We report the clinicopathologic presentation, as well as the outcome, with a review of the literature.
All three cases presented with well defined intrahepatic cystic masses ranging in size from 7.2 to 21.1 cm. The most prominent cells of the lining epithelium were columnar with oncocytic features showing abundant eosinophilic granular cytoplasm and centrally located nucleoli. All three patients underwent resection with one demonstrating local bile duct recurrence that was managed with stenting. Review of the literature has identified 39 patients with papillary PC and 2 patients with IOPC. The biology of these reported cases has been variable with overall survival better than that of nonpapillary PC patients, with recurrence in 15% of the reported cases.
Papillary PC is a rare type of cholangiocarcinoma that includes an interesting variant: IOPC. These tumors are predominantly found in men, who present with large (> 5 cm) mucinous cystic lesions of the bile duct. A noninvasive histology is seen, and long-term survival may be achieved with complete resection. Invasive variants of IOPC have been reported in the literature and have a worse overall prognosis.
Cancer 11/2002; 95(10):2180-7. · 4.77 Impact Factor
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ABSTRACT: To characterize factors predictive of improved survival following gastrectomy with additional organ resection for the treatment of gastric cancer.
Recent large series have reported significant survival disadvantages to patients who have undergone gastrectomy with splenectomy or pancreaticosplenectomy, and yet gastrectomy with additional organ resection is needed to accomplish an R0 resection in some cases. Gastrectomy with splenectomy and other organ resections has been associated with advanced T-stage, positive resection margins, and higher postoperative morbidity and mortality rather than an absolute predictor of survival.
The authors reviewed the Department of Surgery prospective gastric database at Memorial Sloan-Kettering Cancer Center from July 1985 to July 2000. During this period, of the 2,112 patients with primary gastric cancer, 1,133 underwent an R0 resection. The R0 resection group included 865 patients who underwent gastrectomy alone and 268 patients who underwent gastrectomy with another organ resection. Clinicopathologic, operative, complication, and survival data were compared between these two groups. Chi-square analysis and the Kaplan-Meier method were used to compare and estimate median survival.
The most common organs resected were the spleen and pancreas, with an even distribution of other organs. Pathologic factors revealed that the gastrectomy with organ resection group had significantly larger lesions, greater T-stage, and a higher incidence of advanced nodal disease than the group who did not undergo additional organ resection. The incidence of pathologically confirmed T4 cancers in the additional organ resection group was only 14%. The overall 5-year survival rate for patients with T3/T4 disease was 27% with additional organ resection. The overall 5-year survival rate for the gastrectomy with organ resection group (32%, median 32 months) was significantly less than the group that did not undergo additional resection (50%, median 63 months) on univariate analysis. However, additional organ resection was not a predictor of survival on multivariate analysis. Multivariate analysis identified advanced T-stage (T3 or greater) and nodal stage (N1 or greater) as adverse predictors of survival in this group.
Long-term survival following gastrectomy with additional organ resection is possible. Depth of invasion and the extent of lymph node metastasis are the most important predictors of survival following gastrectomy with additional organ resection, and a R0 resection has been achieved. Judicious use of additional organ resection for the treatment of advanced gastric cancer must be emphasized, given the increased overall morbidity and infrequent finding of actual T4 disease. Additional organ resection can be performed with minimal morbidity and can improve the chance of overall survival in patients with advanced T-stage disease.
Annals of Surgery 09/2002; 236(2):159-65. · 7.49 Impact Factor
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ABSTRACT: To identify 10 critical elements of accurate and comprehensive reports of surgical complications.
Despite a venerable tradition of weekly morbidity and mortality conferences, inconsistent complication reporting is common in the surgical literature.
An analysis of articles reporting short-term outcomes after pancreatectomy, esophagectomy, and hepatectomy was performed. Randomized clinical trials (RCTs) published from 1975 to 2001 and retrospective series of more than 100 patients published from 1990 to 2001 were reviewed.
A total of 119 articles reporting outcomes in 22,530 patients were analyzed. This included 42 RCTs and 77 retrospective series. Of the 10 criteria developed, no articles met all criteria; 2% met 9 criteria, 38% 7 or 8, 34% 5 or 6, 40% 3 or 4, and 12% 1 or 2. Outpatient information (22% of articles), definitions of complications provided (34% of articles), severity grade used (20% of articles), and risk factors included in analysis (29% of articles) were the most commonly unmet quality reporting criteria. Type of study (RCT vs. retrospective), site of institution (U.S. vs. non-U.S.) and journal (U.S. vs. non-U.S.) did not influence the quality of complication reporting.
Short-term surgical outcomes are routinely included in the data reported in the surgical literature. This is often used to show improvements over time or to assess the impact of therapeutic changes on patient outcome. The inconsistency of reporting and the lack of accepted principles of accrual, display, and analysis of complication data argue strongly for the creation and generalized use of standards for reporting this information.
Annals of Surgery 07/2002; 235(6):803-13. · 7.49 Impact Factor
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ABSTRACT: In gastric adenocarcinoma, only complete resection (R0) translates into survival benefit. Given the potential for increased morbidity and mortality from multiple organ resection we asked the question as to whether extended (multiple organ) resection was justified for advanced gastric cancer.
From July 1985 to July 2000, 1,283 patients underwent gastric resection for adenocarcinoma at Memorial Sloan-Kettering Cancer Center, and were entered and followed in a prospectively recorded database. Four hundred eighteen patients (33%) underwent primary resection and had one or more organs resected in addition to the stomach. Eight hundred twenty-six patients (64%) underwent gastrectomy alone, with 39 patients (3%) not undergoing gastrectomy. Clinicopathologic, operative, and morbidity data were evaluated in this group. Complications were categorized by severity on a scale from 0 to 5, 0 being no complication to 5 being death. Chi-square analysis and the logistic regression method were used to compare and estimate factors significantly associated with having a complication.
Three hundred thirty-seven patients had a single additional organ resected, 63 had two organs, and 18 had three organs. Five hundred eighty complications occurred in 33% of patients (404 of 1,283). The perioperative mortality was 4% (48 patients). Logistic regression identified the number of organs resected, two or greater, to be predictive of complications (RR 2.0), as well as age greater than 70 years old (RR 1.57). When excluding minor complications (values 1 and 2), only the number of organs resected (RR 3.8) was a major factor for severe complications (values 3, 4, and 5).
Resection of two or more adjacent organs in advanced gastric adenocarcinoma is associated with a greater risk of developing a complication. The use of a graded surgical complication scale is needed for better reporting and comparison of complications. Achieving an R0 resection should still be considered the goal, even in locally advanced gastric cancer, but resection of additional organs should be performed judiciously.
Journal of the American College of Surgeons 06/2002; 194(5):568-77. · 4.55 Impact Factor
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ABSTRACT: Primary hepatocellular carcinoma (HCC) remains among the most common malignancies in the world. Many of the advances in the treatment of this disease have come from combinations of early detection in endemic areas, improved radiologic evaluation in defining extent of disease, an increased use of nonsurgical treatment and improvements in surgical technique.
Surgical Oncology Clinics of North America 02/2002; 11(1):193-205, x. · 1.12 Impact Factor
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ABSTRACT: Solid-pseudopapillary tumors (SPTs) of the pancreas have been reported as rare lesions with "low malignant potential" occurring mainly in young women. This study was designed to define the clinicopathological characteristics and the effect of surgical intervention.
A retrospective review from January 1985 to July 2000 was performed. Clinicopathological, operative, and survival data were obtained. The Kaplan-Meier method and chi2 analysis were performed. All cases were re-reviewed by a senior pathologist.
During this time, 24 patients were diagnosed as having SPTs (0.9%). Twenty females and four males were identified, with a median age of 39 years (range, 12-79). The median size of the lesions was 8.0 cm (range, 1-20). Two patients' tumors were found to be unresectable at initial presentation because of vascular invasion; both patients have remained alive with disease, one for 13 years and the other 1 year. At a median follow-up of 8 years, one recurrence occurred in 17 patients who underwent complete resection. Microscopic margin positive (P = .26), invasion of surrounding structures (P = .51), and size >5 cm (P = .20) were not significant predictors of survival. Four patients presented with synchronous liver metastasis and underwent resection of the primary tumor and the liver metastasis, with one patient dying of progression of metastatic disease at 8 months, another alive with recurrence in the liver at 6 years, and the last two alive without evidence of disease at 1 month and 11 years.
SPT occurs predominantly in women (82%), although it can occur in men; all age groups are affected. Complete resection is associated with long-term survival even in the presence of metastatic disease.
Annals of Surgical Oncology 9(1):35-40. · 4.17 Impact Factor
