Laparoscopic microwave ablation of liver tumors: our experience.

BACKGROUND/AIMS: Microwave ablation is the most recent development in the field of tumor ablation and is a well established and safe local ablative method available for liver tumors (both primary and secondary tumors). The technique allows for flexible approaches to treatment, including percutaneous, laparoscopic, and open surgical access. Laparoscopic technique has the advantages of accurate tumor staging, better tolerability and low cost. It can be performed in tumors which are close to the vital organs. The aim of this study was to evaluate the feasibility and safety of laparoscopic microwave ablation of liver tumors. METHODOLOGY: During January 2001 to December 2005, 57 patients with liver tumors were treated with laparoscopic microwave ablation in the department of Surgical Oncology. There were 34 male and 23 female patients. Out of 57 patients, 11 patients had hepatocellular carcinoma and 46 patients had secondaries in the liver. The most common source of secondaries was colorectal cancers. Laparoscopic microwave ablation of tumors was performed in these patients. RESULTS: During the study period, 57 patients with no evidence of extrahepatic disease underwent laparoscopic microwave ablation of unresectable hepatic tumors. No major intraoperative complications occurred. Postoperatively all the patients did well. Four patients developed liver abscess at the ablation area. Two patients required percutaneous aspiration of the liver abscess. No other major complications occurred. Follow-up CT scan shows complete necrosis of the tumors. Patients were followed-up at regular intervals. CONCLUSIONS: Laparoscopic microwave ablation is a feasible and safe alternative to open microwave ablation of the liver tumors. It carries all the advantage of minimal invasive surgery. In experienced hands, microwave ablation using laparoscopic technique can be done safely and effectively.

Pancreatic neuroendocrine tumors: our approach.

BACKGROUND/AIMS: Pancreatic neuroendocrine tumors constitute a small percentage of pancreatic tumors. Surgical resection is the best treatment for these types of tumors. Aggressive surgical resection including multivisceral resection provides long-term survival. Even palliative resection of the tumor is justifiable. Here we share our experience with the management of pancreatic neuroendocrine tumors. METHODOLOGY: Between January 1993 and April 2007 we operated on 54 patients with pancreatic neuroendocrine tumor. We have analyzed our data retrospectively. Patients were analyzed in terms of demographic characteristics, operative procedure, postoperative outcome and survival. RESULTS: Out of 54 patients, 31 patients had nonfunctional tumor and 23 patients had functional tumors. Neuroendocrine carcinoma was found in 19 patients. Pancreaticoduodenectomy was performed in 21 patients. Simultaneous liver resection was performed in 4 patients and multiorgan resection for locally advanced pancreatic tumor was performed in 3 patients. CONCLUSIONS: Surgical resection is the best option for the treatment of pancreatic neuroendocrine tumors. Aggressive resection provides survival benefit and a better quality of life. If the entire gross tumor can be resected, multiorgan resection or simultaneous liver resection is justifiable.

Microwave ablation in locally advanced pancreatic carcinoma--a new look.

BACKGROUND/AIMS: Pancreatic carcinoma is by far the most common malignancy and is the 5th most lethal cancer in the world and 40% of these carcinomas are locally advanced and unresectable at the time of presentation. Palliative surgery and chemoradiotherapy have not produced significant improvement in survival. The overall prognosis of these pancreatic cancers is poor, if left untreated without any form of palliation. Out of many palliative methods adopted for such locally advanced pancreatic carcinoma, none has shown much survival benefit. Microwave ablation is a well established and safe local ablative method for liver tumors and microwave ablation for locally advanced pancreatic tumors has been extensively used around the world. This is our largest series of microwave ablation in 15 patients with locally advanced pancreatic head carcinoma. The aim of this study was to evaluate the safety, efficacy, feasibility and complications of microwave ablation in unresectable locally advanced pancreatic carcinoma. METHODOLOGY: In total, 15 patients, from January 2004 to December 2006, were included in this study all having locally advanced pancreatic tumors which were found to be unresectable on radiological evaluation. The 15 patients (10 male and 5 female) with a mean age of 67 years were subjected to open microwave ablation after laparotomy and additional palliative procedure like biliary bypass (end-to-side hepaticojejunostomy) and gastric obstruction bypass by antecolic gastrojejunostomy was performed in 6 patients. The location of tumor was predominantly in the head and/or uncinate portion of the pancreas (n=12) and head and body (n=3). The average size of tumor was 6cm (range 4-8cm) and almost all had major regional vascular invasion on CT or MR angiogram. All tumors were histologically proven before the procedure by core needle and frozen section biopsy. Patients with distant metastasis were not included in this study. RESULTS: In all 15 patients, partial necrosis was achieved. There was no major procedure-related morbidity or mortality. Minor complications were seen in 6 out of 15 patients, mild pancreatitis (2), asymptomatic hyperamylasia (2), pancreatic ascites (1), and minor bleeding (1). All patients had close follow-up and the longest surviving patient had a follow-up of 22 months. CONCLUSIONS: Microwave ablation is a beneficial therapy as a local effective procedure which is feasible and safe with acceptable minor complications in a locally advanced pancreatic tumor which can be used as part of a palliative or multimodality treatment, however, further long-term and properly designed studies are required to prove its usefulness in achieving survival benefit.

Leiomyosarcoma of the inferior vena cava--an unusual case.

Primary tumors arising from great vessels like the aorta, pulmonary artery or inferior vena cava (IVC) are rare. The latter is the commonest site of its occurrence. It arises from the smooth muscle cells of the vessel wall. Aggressive surgical management should be attempted to excise it whenever possible. We describe a case of primary inferior vena cava tumor involving all three segments of the abdominal inferior vena cava infrarenal, suprarenal and retrohepatic vena cava, along with right kidney, right adrenal as well as right hepatic vein and left renal vein. We resected it completely without reconstruction of the IVC. The patient is doing well seven months after surgery without having any renal insufficiency, hepatic insufficiency or leg edema and having optimum quality of life. To our knowledge, this is the first case of such a long segment IVC leiomyosarcoma treated without IVC reconstruction, and despite its extent and concomitant involvement of the right kidney, right adrenal, right hepatic vein and left renal vein, it had a favorable response combining prolongation of survival and satisfactory quality of life.

Pancreas-preserving total duodenectomy without pancreato-enteric anastomosis.

BACKGROUND/AIMS: Pancreas-preserving total duodenectomy is a challenging surgical technique with organ preservation and has limited indications. We assessed the safety, feasibility and short-term functional outcome of PPTD without the need of pancreato-enteric anastomosis in our surgical technique. METHODOLOGY: During the two-year period from 2005 to 2007, three patients underwent pancreas-preserving total duodenectomy at our center. Two patients had diffuse adenomatous polyposis; another had previous transduodenal excision for polyp with recurrence. In all three patients pancreas-preserving total duodenectomy was performed without the pancreato-jejunal anastomosis and were analyzed prospectively. The surgical procedure and outcome is described. RESULTS: Out of three patients who underwent pancreas-preserving total duodenectomy, one patient had pancreatitis postoperatively and recovered well with conservative line of management. The other two patients had an uneventful postoperative course. All the patients were closely followed up and were symptom free, in a good condition with good functional status. CONCLUSIONS: To the best of our knowledge this is the first series of pancreas-preserving total duodenectomy without pancreato-enteric anastomosis ever reported. Although the indication for pancreas-preserving total duodenectomy is limited, it can be performed safely with good surgical expertise and knowledge of pancreato-duodenal anatomy. It can be beneficial in elderly patients with concomitant heart disease and associated risk factors. Although it is technically demanding requiring high surgical skills, it excludes the need of pancreas resection with maintenance of gastrointestinal function and the procedure can be performed safely and in less time. But the procedure should be contraindicated in the presence of malignancy and the operated patient should be under long-term surveillance.

Gastrointestinal stromal tumor of gastrohepatic omentum in a patient with von Recklinghausen's disease (neurofibromatosis type 1).

It is very rare to find large gastrointestinal stromal tumors arising from the gastrohepatic omentum in a patient with neurofibromatosis type 1. We here document a case of two large gastrointestinal stromal tumors arising from the gastrohepatic omentum in a patient with von Recklinghausen's disease. In the present case, two large tumors in the lesser sac were evident on preoperative computed tomography and magnetic resonance imaging and were surgically removed successfully. Biopsy was suggestive of gastrointestinal stromal tumors.

An update and our experience with metastatic liver disease.

Metastatic liver disease remains a challenging and life-threatening clinical situation with an obscure and dismal prognosis and outcome. The liver is the most common site of metastatic spread of colorectal cancer and nearly half of the patients with colorectal cancer ultimately develop liver metastasis during the course of their diseases. Death from colorectal cancer is often a result of liver metastases. Over half of these patients die from their metastatic liver diseases. At the time of diagnosis, hepatic metastases are present in 15-25% of patients, and another 25-50% will develop metachronous liver metastases within 3 years following resection of the primary tumor. Over the last decade, there have been tremendous advances in the treatment of metastatic liver disease. Hepatic resection still remains the gold standard for the treatment of metastatic lesions which are amenable to surgery. Unfortunately, up to 40 percent of patients are identified as having additional disease at the time of exploration, and 20 percent are found to be unresectable. Regional therapies such as radiofrequency ablation, microwave ablation and cryotherapy may be offered to patients with isolated unresectable metastases. Other options like hepatic artery chemotherapy and chemoembolization, portal vein embolization and immunotherapy also play a vital role in management of metastatic liver disease when used in combination with other therapies. This article reviews the history of metastatic liver disease, epidemiology, diagnosis and various treatment modalities available for liver metastases along with our experience in management of advance metastatic liver disease.