The Data Mounts: 261 Cleft Lifts for Complex Pilonidal Disease and Excisional Failures.

INTRODUCTION:  The Bascom cleft-lift procedure is a superior approach for treating pilonidal disease. The purpose of this study was to establish healing time after cleft-lift, operative success, and any associated clinical or operative variables. METHODS: The study group comprises all patients who underwent cleft-lift procedures at our center between December 2021 and February 2023. Many clinical and operative variables were collected before surgery. Postoperatively, patients were examined every two weeks until full epithelialization was achieved; thereafter, they were seen at 6, 16, and 30 months and as needed for recurrence surveillance. A successful cleft-lift was defined as one that fully healed by 120 days and showed no recurrence within 18 months of follow-up. Patients with failed cleft lifts were offered revision. RESULTS: In total, 261 cleft -lifts were performed in 258 patients. Of these patients, 40.3% had at least one previous excisional surgery and 19.4% had a chronically open surgical wound. The median follow-up time was 19.8 (6.5 to 25.5) months. There were a total of 12 failed cleft-lifts, yielding an operative success rate of 95.4%. Recurrence was detected in two (0.08%) cases. The median healing time was 43 (15-387) days and did not differ by any covariate. Previous Limberg flap surgery and a shorter distance from the inferior extent of the wound/disease to the anal mucosa were associated with decreased operative success. CONCLUSION:  Our data reinforce that the cleft-lift procedure is a highly successful cure for this disease and its surgical failures. Notably, the operation was a successful cure for many patients with extensive disease and previously failed excisional surgeries, including flap reconstructions.

Recurrence of hepatocellular cancer after resection: patterns, treatments, and prognosis.

OBJECTIVE: We sought to determine the factors associated with survival after recurrence of hepatocellular cancer (HCC) after resection and the outcome of our prospectively applied treatment protocol. BACKGROUND: Very little is known about the prognosis of HCC that recurs after resection and the outcomes associated with treatments applied to recurrent tumors. METHODS: A total of 661 HCC patients undergoing resection from January 1988 to January 2011 were reviewed to identify those with recurrence. Single recurrences with preserved liver function, and no portal hypertension were treated with resection. Patients with multiple intrahepatic tumors or poor liver function and no major comorbidities were listed for transplantation. Patients with up to 3 tumors, each 4 cm or smaller, and not eligible for transplantation, received ablation. Patients not eligible for ablation received embolization. Other treatments such as systemic therapy and radiation were used in remaining patients, but not in a systematic manner. RESULTS: Recurrent HCC developed in 356 (54%) patients at a median time of 22 months from primary resection. Median survival from time of recurrence to death was 21 months. Variables independently associated with survival from recurrence included time from primary resection to recurrence, alpha-fetoprotein more than 100 ng/mL at recurrence, recurrent tumor larger than 3 cm, BCLC stage at recurrence, and type of treatment rendered for the recurrence. All variables except treatment modality were significantly correlated with characteristics of the original primary tumor. CONCLUSIONS: Most of the variables associated with outcome after recurrence are linked to the primary tumor at initial presentation. Nevertheless, meaningful survival can be achieved with appropriate treatment of recurrent tumors.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis: outcomes from a single tertiary institution.

BACKGROUND: Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) is an effective but morbid procedure in the treatment of peritoneal carcinomatosis. We report our outcomes at a single tertiary institution. METHOD: A total of 170 consecutive patients underwent CRS-HIPEC for peritoneal carcinomatosis between July 2007 and August 2012. The peritoneal cancer index (1-39) was used for peritoneal carcinomatosis (PC) staging. Mitomycin C (88.8%) was administered intraperitoneally at 42 °C for 90 mins. Risk factors associated with major morbidities were analyzed. The Kaplan-Meier method was used for survival analyses. RESULTS: The mean age was 55.1 (±11.3) years, and the majority (77.1%) of patients had complete cytoreduction (CC0-1). Tumor types included colorectal (n = 51, 30.0%), appendiceal (n = 50, 29.4 %), pseudomyxoma peritonei (n = 16, 9.4%), and other (n = 53, 31.2%). Factors associated with major complications were estimated blood loss (>400 ml), length of stay (>1 week), intraoperative blood transfusion, operative time (>6 h), and bowel anastomosis. Intraoperative blood transfusion was the only independent prognostic factor on multivariate analysis (p = 0.031). Median follow-up was 15.7 months (±1.2). The recurrence rates for colorectal and appendiceal carcinoma at 1 and 3 years were 40%, 53.5% and 68%, 79.1%, respectively. The 1- and 3-year overall survival for colorectal and appendiceal carcinomatosis was 74.0%, 32.5% and 89.4%, 29.3%, respectively. Intraoperative peritoneal cancer index (PCI) score (>16) and need for blood transfusion were factors independently associated with poor survival (p < 0.05). CONCLUSION: Our single institution experience of CRS/HIPEC procedures for peritoneal carcinomatosis demonstrates acceptable perioperative outcome and long-term survival. Optimal cytoreduction was achieved in the majority of cases. Intraoperative PCI > 16 was associated with poor survival. This series supports the safety of CRS-HIPEC in selected patients.

Outcomes for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the elderly.

BACKGROUND: Cytoreductive surgery (CRS) with heated intraperitoneal chemotherapy (HIPEC) has gained acceptance in the treatment of peritoneal carcinomatosis (PC) with reported morbidity and mortality rates of 27-56% and 0-11% respectively. The safety and outcome of such major operation in the elderly remains unclear. We report our experience at a high volume tertiary center. METHOD: A total of 170 consecutive patients underwent CRS-HIPEC for peritoneal carcinomatosis between March 2007 and July 2012. Mitomycin C (88.8%) was administered intraperitoneally at 42 °C for 90 min. Patients were categorized into two groups according to the age at the time of surgery: Group 1 (≤65 years-old) and Group 2 (>65 years-old). Differences between the groups were analyzed. Univariate and multivariate analyses were performed to identify variables associated with major morbidity. RESULTS: Of the 170 patients, 35 were older than 65 years. The two most common tumor sites were colorectal and appendiceal cancer. The perioperative morbidity and mortality rates in the elderly were 18.8% and 8.6% respectively. Gender, tumor type, estimated blood loss >400 mL, intraoperative blood transfusion, operative time >6 h, bowel anastomosis, intraoperative PCI >16, and extent of cytoreduction (Δ PCI) were not associated with major morbidity in the older group (p > 0.05). At a median follow-up of 15.7 months (0.2-53.5 months), recurrence rate for colorectal/appendiceal PC at 1 year was 48.0% in Group 1 and 44.3% in Group 2 (p = NS). Median survival for the colorectal/appendiceal carcinomatosis patients in Group 1 (n = 81) was 29.79 (SE 4.7) months and in Group 2 (n = 20) was 21.2 (SE 3.0) months, (p = 0.06, NS). CONCLUSION: CRS-HIPEC procedures for peritoneal carcinomatosis in the elderly demonstrate comparable perioperative outcome in well-selected patients. Optimal cytoreduction was achieved in the majority of cases and survival was not significantly different from that of the younger group.

Surgical resection for hepatocellular carcinoma in the noncirrhotic: the Western experience.

Although hepatocellular carcinoma (HCC) is most often a sequela of severe hepatic fibrosis or cirrhosis, a proportion of cases arise in the noncirrhotic patient. The gold standard therapy in such cases is surgical resection. Innovations in operative technique allow for this treatment to be implemented with very low mortality and acceptable morbidity at high-volume hepatobiliary centers. This chapter discusses various etiologies of noncirrhotic HCC and presents a large single-center experience that is compared to other Western series.

Resection of large hepatocellular carcinoma (≥10 cm): a unique western perspective.

BACKGROUND AND OBJECTIVES: Few Western centers have surgically treated a high volume of large hepatocellular carcinoma 10 cm or more in diameter. The study aim was to analyze a large Western cohort of these patients, and to present our outcomes in the context of the more extensive Eastern experience. METHODS: We retrospectively reviewed all patients at our center receiving partial hepatectomy from January 1992 to August 2010, and analyzed a cohort with hepatocellular carcinoma ≥10 cm in diameter. RESULTS: One hundred thirty patients comprised the cohort. One hundred three (79.2%) of the patients received major anatomic resections, and 23 (17.7%) patients underwent tumor thrombectomy as an adjunct procedure. Perioperative mortality was observed in 9 (6.9%) of cases, but from January 2002 onward, only 2 (2.3%) of the 86 resections performed resulted in a mortality. The survival rate at 1, 3, and 5 years was 56.9%, 30.3%, and 18.8%, respectively; the median survival was 17.0 months. The subgroup of 39 patients without gross vascular invasion and satellite nodules achieved a median survival of 40.3 months. CONCLUSIONS: Resection of large hepatocellular carcinoma can be done with safety at a large Western center, and a subgroup of patients will achieve long-term survival.

Resection or transplant-listing for solitary hepatitis C-associated hepatocellular carcinoma: an intention-to-treat analysis.

OBJECTIVES: The relative roles of liver resection (LR) and liver transplantation (LT) in the treatment of a solitary hepatocellular carcinoma (HCC) remain unclear. This study was conducted to provide a retrospective intention-to-treat comparison of these two curative therapies. METHODS: Records maintained at the study centre for all patients treated with LR or listed for LT for hepatitis C-associated HCC between January 2002 and December 2007 were reviewed. Inclusion criteria required: (i) an initial diagnosis of a solitary HCC lesion measuring ≤ 5 cm, and (ii) Child-Pugh class A or B cirrhosis. The primary endpoint analysed was intention-to-treat survival. RESULTS: A total of 75 patients were listed for transplant (LT-listed group) and 56 were resected (LR group). Of the 75 LT-listed patients, 23 (30.7%) were never transplanted because they were either removed from the waiting list (n = 13) or died (n = 10). Intention-to-treat median survival was superior in the LR group compared with the LT-listed group (61.8 months vs. 30.6 months), but the difference did not reach significance. Five-year recurrence was higher in the LR group than in the 52 LT patients (71.5% vs. 30.5%; P < 0.001). CONCLUSIONS: In the context of limited donor organ availability, partial hepatectomy represents an efficacious primary approach in properly selected patients with hepatitis C-associated HCC.

Resection of nonalcoholic steatohepatitis-associated hepatocellular carcinoma: a Western experience.

Introduction. Hepatocellular carcinoma is now known to arise in association with nonalcoholic steatohepatitis. The aim of this study is to examine the clinicopathological features of this entity using liver resection cases at a large Western center. Methods. We retrospectively reviewed all cases of partial liver resection for hepatocellular carcinoma over a 10-year period. We included for the purpose of this study patients with histological evidence of nonalcoholic steatohepatitis and excluded patients with other chronic liver diseases such as viral hepatitis and alcoholic liver disease. Results. We identified 9 cases in which malignancy developed against a parenchymal background of histologically-active nonalcoholic steatohepatitis. The median age at diagnosis was 58 (52-82) years, and 8 of the patients were male. Median body mass index was 30.2 (22.7-39.4) kg/m(2). Hypertension was present in 77.8% of the patients and diabetes mellitus, obesity, and hyperlipidemia in 66.7%, respectively. The background liver parenchyma was noncirrhotic in 44% of the cases. Average tumor diameter was 7.0 ± 4.8 cm. Three-fourths of the patients developed recurrence within two years of resection, and 5-year survival was 44%. Conclusion. Hepatocellular carcinoma may arise in the context of nonalcoholic steatohepatitis, often before cirrhosis has developed. Locally advanced tumors are typical, and long-term failure rate following resection is high.

Diaphragmatic hernia after hepatic resection: case series at a single Western institution.

BACKGROUND: Diaphragmatic hernia (DH) after hepatic resection (HR) is a rare and not well-described complication. We report our experience with DH following a high volume of HRs in a tertiary center. METHODS: Records of patients undergoing major HR for liver tumors between April 1992 and November 2011 were reviewed. The definitive diagnosis of DH was made based on radiologic studies. Primary repair was used for defects <10 cm in size. Transthoracic repair was used in patients with recurrent or complex hernias. Univariate analysis was performed to determine risk factors associated with posthepatectomy DH. RESULTS: DH developed in 10 out of 993 patients (1%) at a median time interval of 15 months after HR. DH was not associated with old age (m = 48.5 years), gender (male = 50%), or high body mass index (m = 24.5). However, mean tumor size was large (m = 9.2 cm). The majority of patients presented with symptoms (80 %), small (60%) and right-sided (80%) hernias, and underwent elective repair via an abdominal approach (70%). Large defects (>10 cm; 30%) were successfully repaired with prosthetic mesh. Increased incidence of DH was associated with diaphragmatic resection at the time of HR (5.4 vs. 0.7%, p = 0.001). At a median follow-up of 36 months (range, 10-167 months) after hernia repair, recurrence occurred in one patient. CONCLUSION: Diaphragmatic resection at the time of HR and large tumor size may put patients at risk of developing posthepatectomy DH. Early detection and prompt treatment is associated with low recurrence and offers the advantage of primary repair.

Hepatic resection for primary hepatolithiasis: a single-center Western experience.

BACKGROUND: The incidence (0.6% to 1.3%) of primary hepatolithiasis (PHL), also known as Oriental cholangiohepatitis, is increasing in Western countries and the treatment remains challenging. We analyzed the outcomes of patients undergoing hepatic resection (HR) for PHL at a single Western center. STUDY DESIGN: The records of all patients undergoing HR for PHL between August 1998 and January 2012 were reviewed. Patients were required to have preserved liver function (Child-Pugh class A) with no evidence of portal hypertension. Diagnosis of disease recurrence was based on radiographic and clinical findings. RESULTS: Of the 30 patients who underwent HR, 63.3% presented with earlier failed therapeutic strategies. The majority of the patients were female (63.3%), presented with cholangitis (66.6%), left-sided (66.6%), and unilateral (90.0%) disease, and underwent left-sided hepatic resection (76.6%). Previously created choledochoduodenostomies (13.3%) were all revised into Roux-en-Y hepaticojejunostomy anastomoses in conjunction with the HR. The incidence of concomitant cholangiocarcinoma was 23.3%, with a mean tumor size of 4.2 cm. Perioperative morbidity and mortality rates were 6.6% and 0%, respectively. At a median follow-up of 35 months, all patients had complete intrahepatic stone clearance. One patient required postoperative ERCP. Of the 7 patients with cholangiocarcinoma, 2 had cancer recurrence within the first year of the HR. The remaining patients are disease-free at a median follow-up of 21 months. CONCLUSIONS: Hepatic resection is a safe and definitive treatment option in the management of PHL. It achieves excellent short- and long-term results. The high incidence of concomitant cholangiocarcinoma makes a compelling argument for resection of all involved hepatic segments, when possible.

Resection of hepatocellular carcinoma without cirrhosis.

OBJECTIVE: The aim of this study was to examine the features and outcomes of noncirrhotic patients undergoing resection for hepatocellular carcinoma. BACKGROUND: Ten percent to 40% of hepatocellular carcinoma cases arise within a noncirrhotic liver parenchyma. Resection is the standard therapy, yet the published resection series from the West are small. METHODS: From January 1987 to December 2009, our center performed 206 partial liver resections for nonfibrotic or minimally fibrotic (Scheuer stage 0-2) hepatocellular carcinoma. We retrospectively reviewed these cases and performed univariate and multivariate analyses for predictors of long-term outcomes. RESULTS: Eighty-one patients (39.3%) had chronic hepatitis B infection and 23 patients (11.2%) had chronic hepatitis C. The remaining 83 (39.8%) had no underlying liver disease. Average age was 60.2 years, and 68.4% of the patients were male. Average tumor size was 8.2 cm. Overall survival at 5 years was 46.3%. Recurrence at 5 years was 50.0%. Independent predictors for decreased survival were tumor size larger than 7.0 cm, creatinine more than 1.0 mg/dL, satellite nodules, albumin less than 3.5 gm/dL, alpha-fetoprotein more than 100 ng/mL, and any vascular invasion. Chronic hepatitis B virus infection predicted longer survival. Independent predictors for decreased time to recurrence were albumin less than 3.5 gm/dL, any vascular invasion, age more than 60 years, tumor size larger than 7.0 cm, and alpha-fetoprotein more than 100 ng/mL. Treatment of recurrence with either repeat resection or ablation was associated with a median survival of 50.4 months from time of recurrence. CONCLUSIONS: Hepatocellular carcinoma can develop in a minimally fibrotic hepatitis C patient. Tumor-related factors such as vascular invasion primarily determine long-term outcomes. Hepatitis B virus-associated tumors seem to have a better prognosis in the nonfibrotic or minimally fibrotic population. Aggressive treatment of recurrence is warranted.