Enhanced recovery pathway in elderly patients undergoing colorectal surgery: is there an effect of increasing ages? Results from the perioperative Italian Society Registry.

Previous studies reported that enhanced recovery pathway (ERP) is safe in elderly who did not require a specifically tailored protocol. In previous studies, elderly have been considered as a homogeneous cohort and the cut-off value to identify them was different. The aim of the present study is to assess the compliance to ERP and its impact on postoperative outcome in three subgroups of elderly patients with increasing ages. Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. 315 elderly patients undergoing elective colorectal resection were divided into three groups. Group 1: 71-75 years (n = 105), Group 2: 76-80 years (n = 117), Group 3: over 80 years (n = 93). Primary endpoints of the study were adherence to ERP and time to readiness for discharge (TRD). Compliance to ERP was similar in the three groups. No difference among groups was found for mortality, overall morbidity, major complications, reoperation rate and readmission rate. Median TRD and length of hospital stay (LOS) were progressively longer with increasing age (p = 0.018 and p = 0.078, respectively). Increasing age did not impact on adherence to ERP and postoperative morbidity, but delayed both TRD and LOS.

Asymptomatic colorectal cancer with un-resectable liver metastases: immediate colorectal resection or up-front systemic chemotherapy?

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Portal hypertension: contraindication to liver surgery?

INTRODUCTION: In recent decades liver resection has become a safe procedure, mainly because of better patient selection. Despite this progress, however, outcomes of hepatectomy in cirrhotic patients with portal hypertension are still uncertain. The aim of this study was to elucidate early and long-term outcomes of liver resection in these patients. METHODS: Between 1985 and 2003, a total of 245 cirrhotic patients underwent hepatectomy for HCC. Altogether, 217 patients were eligible for this analysis and were divided into two groups according to the presence of portal hypertension at the time of surgery: 99 patients with portal hypertension and 118 without it. RESULTS: Patients with portal hypertension had worse preoperative liver function (Child-Pugh A class patients: 66.7% vs. 94.9%; P<0.0001). No differences were encountered in terms of intraoperative and pathology data. Operative mortality was similar (11.1% vs. 5.1%; P=0.100), but patients with portal hypertension had higher morbidity (43.4% vs. 30.5%; P=0.049) and received a higher rate of blood and plasma transfusions (51.5% vs. 32.2%, P=0.004; 77.8% vs. 57.6%, P=0.0017). Considering only Child-Pugh A patients, short-term results were similar in the two groups in terms of mortality, morbidity, and transfusion rates. The 5-year survival rate was significantly higher in patients without portal hypertension (39.8% vs. 28.9%; P=0.020), although when considering only Child-Pugh A patients no difference of survival was encountered. Multivariate analysis identified Child-Pugh classification, tumor diameter, and vascular invasion as independent predicting factors for survival. CONCLUSIONS: Portal hypertension should not be considered an absolute contraindication to hepatectomy in cirrhotic patients. Child-Pugh A patients with portal hypertension have short- and long-term results similar to patients with normal portal pressure.

Bisegmentectomy 7-8 as alternative to more extensive liver resections.

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.

Major liver resections for hepatocellular carcinoma on cirrhosis: early and long-term outcomes.

Since the lack of donors, liver resections continue to be the treatment of choice for cirrhotic patients with good liver function and resectable hepatocellular carcinoma (HCC). Moreover, over the past 2 decades, an increasing number of major hepatic resections have been performed. The aim of this study is to evaluate short- and long-term outcomes of 55 cirrhotic patients undergoing major hepatic resection with particular attention to the survival of the patients with gross portal vein invasion or large size tumors. Twenty-two patients (40%) required intra- or post-operative blood transfusion. Medium tumor size was 66.6 +/- 29.2 mm; 7 patients had large size (>10 cm) HCCs. A single node was present in 38 cases (69.1%). There was a gross portal vein tumor thrombus (PVTT) in 13 patients (23.6%). Resection was non-curative in 4 cases. In-hospital mortality and morbidity rates were 5.5% and 30.9%, respectively. The overall and disease-free survival rates were 36.2% and 42.8%, respectively. Overall 5-year survival rates of patients with large size tumors was 17.1%. Ten patients with a gross PVTT had an R0 resection with a 26.6% 5-year survival rate. In conclusion, major hepatic resections for HCC can be performed with low mortality and morbidity rates. HCCs with PVTT or greater than 10 cm in size have very limited options of treatment; the favorable long-term results of our study suggest that they should undergo surgery if a radical resection can be achieved.