Circumstances and implications of conversion from minimally invasive to open liver resection: a multi-center analysis from the AMILES registry.

BACKGROUND: Minimally invasive approaches to liver resection (MILR) are associated with favorable outcomes. The aim of this study was to determine the implications of conversion to an open procedure on perioperative outcomes. METHODS: Patients who underwent MILR at 10 North American institutions were identified from the Americas Minimally Invasive Liver Resection (AMILES) database. Outcomes of patients who required conversion were compared to those who did not. Additionally, outcomes after conversion due to unfavorable findings (poor visualization/access, lack of progress, disease extent) versus intraoperative events (bleeding, injury, cardiopulmonary instability) were compared. RESULTS: Of 1675 patients who underwent MILR, 102 (6.1%) required conversion. Conversion rate ranged from 4.4% for left lateral sectionectomy to 10% for right hepatectomy. The primary reason for conversion was unfavorable findings in 67 patients (66%) and intraoperative adverse events in 35 patients (34%). By multivariable analysis, major resection, cirrhosis, prior liver surgery, and tumor proximity to major vessels were identified as risk factors for conversion (p < 0.05). Patients who required conversion had higher blood loss, transfusion requirements, operative time, and length of stay, (p < 0.05). They also had higher major complication rates (23% vs. 5.2%, p < 0.001) and 30-day mortality (8.8% vs. 1.3%, p < 0.001). When compared to those who required conversion due to unfavorable findings, patients who required conversion due to intraoperative adverse events had significantly higher major complication rates (43% vs. 14%, p = 0.012) and 30-day mortality (20% vs. 3.0%, p = 0.007). CONCLUSIONS: Conversion from MILR to open surgery is associated with increased perioperative morbidity and mortality. Conversion due to intraoperative adverse events is rare but associated with significantly higher complication and mortality rates, while conversion due to unfavorable findings is associated with similar outcomes as planned open resection. High-risk patients may benefit from early conversion in a controlled fashion if difficulties are encountered or anticipated.

Surgical treatment of borderline and malignant phyllodes tumors: the effect of the extent of resection and tumor characteristics on patient outcome.

INTRODUCTION: Malignant phyllodes tumors are rare fibroepithelial breast neoplasms. Appropriate surgical management remains a subject of debate. The purpose of our study was to define optimal surgical treatment and to identify factors associated with outcome. METHODS: After confirmatory pathology review, we identified 67 patients with borderline (n = 15) and malignant (n = 52) phyllodes tumors treated at our institution between 1971 and 2008. We used Cox proportional hazards models to evaluate associations between treatment, patient and tumor characteristics, and disease-free (DFS) and cancer-specific survival (CSS). RESULTS: Median patient age was 47 years. For 32 patients, definitive surgical treatment was wide local excision (WLE): 27 with margins ≥1 cm and 5 with margins <1 cm. Thirty-five underwent mastectomy. Two patients received radiotherapy after WLE and two after mastectomy with microscopically positive margins. After 10 years median follow-up, 16 patients (24 %) recurred locally (8 postmastectomy and 8 after WLE). Treatment type and margin extent did not impact local recurrence. Fifteen patients (22 %) developed distant disease. Overall 5-year DFS was 67.9 % and CSS 80.1 %. Tumor size >5 cm, mitotic rate ≥10/10 HPF, stromal overgrowth and cellularity (all p < 0.05) predicted DFS, whereas CSS was associated with the latter three variables. CSS was diminished for mastectomy patients who were significantly more likely to harbor tumors with adverse features. CONCLUSIONS: With long-term follow-up, extent of surgical resection did not affect DFS for patients with borderline and malignant phyllodes tumors. Tumor features, most notably stromal overgrowth, were predictive of recurrence and survival, suggesting these high-risk patients may benefit from additional therapeutic strategies.

Reoperative experience with papillary thyroid cancer.

BACKGROUND: Intense postoperative monitoring has resulted in increasing detection of patients with recurrent papillary thyroid cancer (PTC). Our goals included quantifying successful reoperation, and analyzing surgical complications and reasons for relapse. METHODS: From 1999 to 2008, a total of 410 patients underwent reoperation for PTC relapse. We analyzed post-reoperative disease outcomes, reasons for relapse, and complications. RESULTS: Bilateral reoperative thyroidectomy was performed in 13 (3 %) patients; lobectomy, 34 (8 %); central neck (VI) soft tissue local recurrence excision, 47 (11.5 %); bilateral VI node dissection, 107 (26 %); unilateral VI dissection, 112 (27 %); levels II-V dissection, 93 (23 %); levels III-V, 86 (21 %); lateral single- or two-compartment dissection, 51 (12 %); and node picking, 20 (5 %) of level VI and 53 (13 %) lateral neck. Complications occurred in 6 %; including hypoparathyroidism, 3 %; unintentional recurrent laryngeal nerve (RLN) paralysis, 3 %; phrenic nerve injury, 0.5 %; spinal accessory nerve injury, 0.5 %; and chyle leak in 1.6 %. Of 380 (93 %) patients with follow-up (mean 5.2 years); 274 (72 %) patients are alive with no structural evidence of disease, 38 % developed disease relapse (mean 2.1 years), 42 (11 %) died from PTC, and 55 (14 %) are alive with disease. The reason for relapse was a false negative pre-reoperative ultrasound (US) in 18 (5 %), nodal recurrence in the operative field in 37 (10 %), a combination of these two reasons in 10 (3 %), and disease virulence (local or systemic recurrence) in 81 (21 %). CONCLUSIONS: Although 72 % of patients were rendered structurally disease free after reoperation, nearly 40 % suffered additional relapse. Improved surgical technique or preoperative localization might positively affect 15-20 %; at least 20 % reflect the biologic aggressiveness of the disease.

Thyroid cancer detection with dual-isotope parathyroid scintigraphy in primary hyperparathyroidism.

BACKGROUND: Thyroid cancer cells have been shown to take up (99m)Tc-sestamibi. The role for (99m)Tc-sestamibi scintigraphy (Tc-MIBI) in the diagnosis of thyroid cancer in patients with primary hyperparathyroidism (PHPT) is unclear. Our aim was to determine whether dual-isotope parathyroid scintigraphy is useful in identifying thyroid cancer. METHODS: A prospective database of 3,187 patients who underwent neck exploration for PHPT was reviewed to identify patients who had concurrent thyroid resection. Patients with benign and malignant thyroid disease were comparatively analyzed. RESULTS: A total of 470 patients underwent both thyroidectomy and parathyroidectomy (reoperations in 21%). Benign disease (n = 391, 83%) was more common than malignancy [papillary thyroid cancer (n = 75) and medullary thyroid cancer (n = 5); 1 had both]. Dual-isotope scintigraphy obtained in 374 patients (80%) had a sensitivity of 67% and a positive predictive value of 66% for parathyroid adenoma localization in these patients with thyroid disease. False-positive scintigraphy occurred in 22% with benign and 45% with malignant thyroid disease (P = 0.002). On Tc-MIBI imaging, 54 (86%) of 63 patients with malignancy had hot nodules, compared to 248 (81%) of 308 patients with benign disease (P = 0.49). On I-123 imaging, 34 (54%) of 63 patients with malignancy had cold nodules, compared to 42 (14%) of 304 patients with benign disease (P < 0.001). A dual-isotype phenotype of both Tc-MIBI-Hot and I-123-Cold had sensitivity 52%, specificity 88%, positive predictive value 47%, and negative predictive value 90% for detecting a thyroid malignancy. CONCLUSIONS: A Tc-MIBI-Hot/I-123-Cold phenotype is very specific for detecting thyroid malignancy. Patients with this imaging phenotype should strongly be considered for preoperative ultrasound-guided biopsy. Patients found intraoperatively to have false-positive parathyroid scintigraphy should be evaluated for thyroid cancer.

Operative Management of T1b Gallbladder Carcinoma with Concurrent Hepatic Anastomosing Hemangioma.

We report a case of stage T1b gallbladder carcinoma with concurrent hepatic anastomosing hemangioma managed by operative resection. We review the work-up and surgical management of this patient. We also discuss the relevant literature of both gallbladder cancer and hepatic anastomosing hemangioma, a recently described and rare variant of capillary hemangioma.

Standardization and streamlining of a pancreas surgery practice improves outcomes and resource utilization: A single institution's 20-year experience.

BACKGROUND: In the past two decades, pancreas surgery (PS) has undergone significant advances in operative techniques and with a focus on multidisciplinary high-volume practices. METHODS: A review of patients undergoing PS from 3/1995-2/2015 was conducted; dividing patients into group A (1995-2005) and group B (2005-2015) for a detailed comparison. Effect of surgeon volume in group B was determined. RESULTS: A total of 1001 patients underwent PS (group A: 259; group B: 742). The mean age was 62.7 years and 52.8% were female. Group B patients were associated with a higher rate of pylorus preservation and minimally invasive resection and a lower rate of morbidity, pancreas fistula (PF), and delayed gastric emptying (DGE) than group A. High-volume surgeons (HVS) had lower operative blood loss (300 mL vs 600 mL), transfusion requirements, PF (14% vs 20%), DGE, surgical site infections, reoperations, and major morbidity rate (15.5 vs 39%) than low-volume surgeons. CONCLUSIONS: This study demonstrates improved patient outcomes and hospital resource utilization over the past 20 years. Concentration of PS to HVS results in superior results.

Intussusception in adults and the role of evolving computed tomography technology.

BACKGROUND: The purpose of this study was to describe a single institution's experience with adult intussusception and determine how this was influenced by evolving computed tomography (CT) technology. METHODS: Adults treated between 1978 and 2013 for intussusception were reviewed. CT utilization and utilization of multislice technology over time were determined. Sensitivity of CT was calculated. RESULTS: A total of 318 patients were identified. CT utilization was 72% and it increased over time. The number of channels ranged from 1 to 128. CT sensitivity was greater than 85% for single and multislice scanners. A lead point was identified in 69% of patients and a malignancy in 40%. Surgical exploration was required in 60% of patients and 40% were managed nonoperatively. CONCLUSIONS: The diagnosis of intussusception in adults is increasing over time, particularly idiopathic intussusception. This is associated with increased utilization of highly sensitive CT technology, which facilitates the safe nonoperative management in many patients.

Adenomas of the ampulla of Vater: a comparison of outcomes of operative and endoscopic resections.

BACKGROUND: Data comparing operative and endoscopic resection of adenomas of the ampulla of Vater are limited. Our aims were to evaluate and compare the long-term results and outcomes of endoscopic and operative resections of benign tumors of the ampulla of Vater as well as to determine which features of benign periampullary neoplasms would predict recurrence or failure of endoscopic therapy and therefore need for operative treatment. METHODS: Retrospective review of all patients treated for adenomas of ampulla of Vater at our institution from 1994 to 2009. RESULTS: Over a 15-year span, 180 patients (mean age 59 years) were treated for benign adenomas of the ampulla of Vater with a mean follow-up of 4.4 years. Obstructive jaundice was more common in the operative resection group (p = 0.006). The adenomas were tubular in 83 patients (44%), tubulovillous in 77 (45%) and villous in 20 (11%). Endoscopic resection alone was performed in 130 patients (78%). Operative resection was performed in 50 patients (28%), with pancreatoduodenectomy in 40, transduodenal local resection in 9, and pancreas-sparing total duodenectomy in 1. Nine patients who underwent endoscopic resection initially were endoscopic treatment failures. Fifty-eight percent of endoscopically treated patients required one endoscopic resection, while 58 (42%) required two or more endoscopic resections (range 2-8). Patients who underwent operative resection had larger tumors with a mean size of 3.7 ± 2.8 versus 1.8 ± 1.5 cm in those treated by endoscopic resection (p < 0.001) or intraductal extension (p = 0.02). Intraductal extension and ulceration had no effect on recurrence if completely resected endoscopically (p = 0.41 and p = 0.98, respectively). Postoperative complications occurred in 58% of patients, and post-endoscopic complications in 29% (p < 0.001). Endoscopic resection was associated with a greater than fivefold risk of recurrence than operative resection (p = 0.006); 4% of recurrences had invasive carcinomas. When comparing patients who underwent local resections only (endoscopic and operative), there was no difference in the recurrence rate between endoscopic resection and operative transduodenal resection (32 versus 33%; p = 0.49). The need for two or more endoscopic resections for complete tumor removal was associated with 13-fold greater risk of recurrence (p < 0.001). CONCLUSION: There is no significant difference between endoscopic and local operative resections of benign adenomas of ampulla of Vater; recurrences are more common when two or more endoscopic resections are required for complete tumor removal. Appropriate adenomas for endoscopic resection included tumors <3.6 cm that do not extend far enough intraductally (on EUS) to preclude an endoscopic snare ampullectomy.

15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas.

BACKGROUND: The aim of our study was to compare the outcomes of periampullary and extra-ampullary duodenal adenocarcinomas and segmental duodenal resection versus pancreatoduodenectomy and to evaluate prognostic factors. METHODS: We performed a retrospective review of all adults treated for duodenal adenocarcinoma by operative resection at a large tertiary referral center from 1994 to 2009. RESULTS: One hundred twenty-four patients had an operation for duodenal adenocarcinoma over a 15-year period (periampullary, n = 25, and extra-ampullary, n = 99). Ninety-nine patients (80%) underwent curative resection, including 24 (96%) with periampullary and 75 (76%) with extra-ampullary carcinomas. The average number of lymph nodes sampled was eight with segmental resection and 12 with pancreatoduodenectomy (p < 0.001). Five-year overall survivals were 37% for the entire cohort (n = 124), 37% in the extra-ampullary group, and 38% in the periampullary group. Tumor size (p = 0.20), positive nodes (p = 0.60), segmental resection versus pancreatoduodenectomy (p = 0.55), adjuvant therapy (p = 0.23), and R(1) versus R(0) resection (p = 0.21) were not associated with survival. In contrast, advanced T stage and pathologic grade were associated with poor survival. CONCLUSION: Extra-ampullary and periampullary duodenal adenocarcinomas have similar survival after resection. For distal duodenal tumors, survival is improved by curative resection without being compromised by limited resection. The number of lymph nodes sampled was significantly less with segmental resection than pancreatoduodenectomy.

Neoadjuvant treatment of duodenal adenocarcinoma: a rescue strategy.

AIM: To evaluate the role of neoadjuvant chemoradiation therapy and rescue surgery in the management of unresectable or recurrent duodenal adenocarcinoma. METHODS: Retrospective review of all adults treated with neoadjuvant therapy and rescue surgery for locally unresectable or locally recurrent duodenal adenocarcinoma from 1994 to 2010. RESULTS: Ten patients received various forms of neoadjuvant therapy prior to operative exploration for potential resection. Six patients presented with locally unresectable disease, while four had local recurrences. Six patients had vascular encasement, three had retroperitoneal extension with vascular invasion, and one had invasion of surrounding organs. Of the six patients with locally advanced disease, preoperative therapy consisted of chemotherapy alone (3) or chemoradiotherapy (3). Of the four patients with local recurrences, preoperative therapy consisted of chemotherapy alone (1), chemoradiotherapy alone (1), chemoradiotherapy after chemotherapy (1), and chemoradiotherapy followed by combination chemotherapy (1). Nine of ten patients became resectable after neoadjuvant therapy. Clinically, two patients had complete responses, and four had partial responses. Histopathology revealed complete pathologic response in two patients and near-complete pathologic response in one (<1 mm of residual disease). Currently, five patients are alive (range 18-83 months postoperatively). All have no evidence of disease. CONCLUSION: Neoadjuvant therapy may convert locally unresectable duodenal adenocarcinoma to resectable disease with subsequent prolonged survival.

Long-term outcomes of laparoscopic totally extraperitoneal inguinal hernia repairs performed by supervised surgical trainees.

BACKGROUND: Long-term outcomes of laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs performed by supervised surgical trainees are absent. METHODS: Retrospective review of TEP inguinal hernioplasties performed by trainees at our institution. RESULTS: From 1995 to 2009, a total of 1,479 inguinal hernia repairs on 976 patients were performed by supervised surgical trainees. The mean patient age was 54 years (range 5-86). Men (97%), direct defects (51%), and bilateral repairs (52%) predominated. Recurrent hernias compromised 17%. Four (.4%) patients were converted to open surgery because of scarring. Postoperative complications consisted of urinary retention (8%), seroma (3%), and hematoma (2%). Trainee participation included interns (46%), PGY-2s (10%), PGY-3s (2%), PGY-4s (3%), and PGY-5s (39%). With a mean follow-up of 6.1 years, recurrence and bothersome groin pain rates were 2.6% and 1.5%, respectively. CONCLUSIONS: With adequate supervision, surgical trainees can safely perform the TEP repair with good long-term outcomes.

Fifty-three-year experience with pediatric umbilical hernia repairs.

PURPOSE: The aim of this study was to evaluate the long-term surgical and patient-reported outcomes of pediatric umbilical hernia (UH) repairs. METHODS: A retrospective review of all children (<18 years old) who underwent UH repair at Mayo Clinic-Rochester in the last half century was done. Follow-up was obtained by mailed survey. RESULTS: From 1956 to 2009, 489 children (boys, 251; girls, 238) underwent a primary UH repair. The mean age was 3.9 years (range, 0.01-17.8 years). Complicated UHs that required emergent repair (n = 34, or 7%) included recurrent incarceration (22), enteric fistula (7), strangulation (4), and evisceration (1). Mean UH size was 1.3 cm (range, 0.2-7.0 cm), varying by operative indication (1.0 cm emergent vs 1.5 cm elective repairs, P = .008) and decade of repair (2.2 cm, 1950s-60s vs 1.3 cm, 1990s-2000s; P = .001). Postoperative morbidity (2%) consisted of superficial wound infection (7), hematoma (3), and seroma (1). With a 66% survey response rate and mean follow-up of 13.0 years (range, 0-53.8 years), 8 (2%) patients experienced a recurrence. Most patients reported satisfaction (90%) with the cosmetic appearance of their umbilicus and are pain free (96%). CONCLUSION: Pediatric UH repairs have low morbidity and recurrence rates. Most patients are satisfied and pain free. Importantly, complicated UHs were more likely to be associated with smaller defects; therefore, parental counseling for signs of incarceration is recommended even in small defects.