Elderly and very elderly patients with hepatocellular carcinoma. Strategy for a first line treatment.

AIM: Health-status of elderly patients with hepatocellular carcinoma (HCC) may limit surgical approach; other options are thus auspicable. METHODS: The authors reviewed 98 selected patients, aged 65 to 90 years, with 149 HCC treated between 2002 and 2011. According to the extent of malignancy, health status and treatment, patients were divided into 3 groups. Sixty-one, submitted to major and minor curative resections, were in group A and B while group C included 37 patients, unsuitable for high-risk procedures and percutaneous ablation, submitted to intraoperative-radiofrequency ablation (IRFA) alone or combined with minor resections. Assessment of safety and therapeutic efficacy of this managment was evaluated. RESULTS: A postoperative mortality rate of 1,02% and an overall survival rate at 5 years of 62.3% were observed. Indeeed matched post-operative morbidity and mortality rates of A, B, C groups were 45%, 8%, 16.21% (p < 0.004) and 9 %, 0%, 0% (p= 0.112 ) respectively. 3 years overall-survival was not statistically different (p= 0.585). However 5 years survival rate and disease-free-survival rate were significantly higher in patients of group A and B (p= 0.003; p< 0.001). CONCLUSION: Treatment strategies to minimize treatment-related morbidity and mortality have resulted satisfactory for early and late outcomes of an heterogeneous group of elderly patients with HCC.

Treatment of congenital liver cysts. A surgical technique tailored through a 35-year experience.

BACKGROUND: The most important aims of the treatment of CLC are long-term relief of symptoms and elimination of cysts. Treatment of choice is yet debated. METHODS: Data of patients treated for CLC during a 35-years experience were retrospectively analyzed. Variables analyzed were: age, sex, hepatic cyst location, cyst diameter, symptoms, surgical procedure, short and long-term outcomes. RESULTS: We examined 49 consecutive patients treated for CLC (mean follow-up, 76 months). The study was divided into two periods: 1975-1999 and 2000-2010. Procedures performed in the first period were needle aspiration and sclerotherapy (n= 6), hepatic resections (9), cystojejunostomy (4), open unroofing (10), and laparoscopic unroofing (8). Omentopexy within the residual cystic cavity was associated with seven open and two laparoscopic unroofing cases. Rates of morbidity and recurrence were 23.5% and 44.1%, respectively. One patient died in the peri-operative period. Procedures performed in the second period were open unroofing (9), laparoscopic unroofing (5), and hepatic resection (1). Omentopexy was associated with all open procedures and two laparoscopic procedures. Overall morbidity in this group was 16.6%, and recurrence occurred in one patient (6.7%). CONCLUSIONS: Cyst unroofing and omentopexy is a safe and highly effective procedure for the treatment of CLC. Laparoscopy is confirmed as the procedure of choice except for cases in which the cysts are in the posterior right liver, where a wide mobilization of the liver is necessary.

Desmoplastic fibroblastoma of the thigh. A case report.

Desmoplastic fibroblastoma (DF) is an extremely rare benign soft tissue tumor, prevalent in adult men, mostly arising in deep regions of extremities. The tumor presents with a slowly growing and no recurrence or metastases after surgical excision. Histologically, DF is characterized by a collagenous stroma that contains spindle- and stellated-shaped fibroblastic cells positive for vimentin. Differential diagnosis with locally aggressive soft tissue tumors could be difficult. This case report deals with the clinical pathological and immunoistochemical features of a DF of the left thigh in a 63-years old man.

Urgent surgery for sigmoid diverticulitis. Retrospective study of 118 patients.

OBJECTIVE: Aim of our study was to identij5 the risk factors for operative morbility and mortality after urgent surgery for complicated sigmoid diverticulitis. A further end point was define the adequate surgical approach in these patients. METHODS: Data fJom 118 patients who were admitted for emergency surgery between 2000 and 2009 for non-haemorrhagic complicated diverticulitis of the sigmoid colon were retrospectively evaluated and analysed. Operative options included resection with primary anastomoses (PA), Hartmann's procedure (HP) and colostomy. All operative complications were noted and potential risk factors listed. RESULTS: One hundred eighteen patients were enrolled in this study. Surgery for peritonitis was indicated for 102 patients and for intestinal obstruction in the remainder. Overall morbidity and mortality rates were 37.3% and 9.3%, respectively. Primary resection was performed on 113 patients (95.8%). Age greater than 70 years, diffuse peritonitis, Mannheim Peritonitis Index (MPI) above 18, and symptoms lasting longer than 24 hours are considered as independent risk factors for operative morbidity and mortality. DISCUSSION: Our results confirmed that while age older than 70 years and delaying treatment (>24h) are independent risk factors for operative morbidity and mortality, comorbidity is not. According to general guidelines, first target of surgery was to attempt a primary resection of the diseased colon (95.8% of our patients). In our series an high rate of Hartmann procedure (HP) in Hinchey's class 2 patients was observed. This unusually high number is explained by the rate (68.4%) of pelviperitonitis diagnosed in these patients. Extended pelvic peritonitis is generally defined as a local peritonitis (class 2 Hinchey), which is not accurate. Colonic resection in these cases would not completely remove peritoneal contamination and renders the indication for PA questionable. CONCLUSIONS: Emergency surgery for complicated diverticulitis is characterised by high rates of morbidity and mortality. Age greater than 70 years, symptoms lasting longer than 24 hours, MPI above 18, and diffuse peritonitis were significant predictors. Early eradication of septic focus is the main goal of surgery. Primary anastomosis is recommended only if sepsis is completely removed.

Anastomotic leakage and septic complications: impact on local recurrence in surgery of low rectal cancer.

PURPOSE: We thought to determine the influence of anastomotic leakages (AL) and septic complications (SC) on the incidence of local recurrence (LR) in patients undergoing curative surgery for rectal cancer. METHODS: The records of 479 patients (286 male, 193 female; median age 67 years) who received, between 1966 and 1975 (Group A) and 1976 and 1985 (Group B), curative surgery for middle to low rectal cancer were retrospectively reviewed. All patients received mesorectal excision in the course of abdominoperineal excision (Group A) and of anterior resection with colorectal anastomosis (Group B). The outcome of SC in both groups and that of AL in Group B were investigated. AL were divided into clinical leaks (CL) and radiological leaks (RL). All patients surviving surgery were followed up for a mean period of 71 months. The development of pelvic recurrence was registered. The effect of SC and AL on LR was statistically analyzed. RESULTS: LR was diagnosed in 24 (9.3%) patients of Group A. No difference was detected between patients with SC (9.3%) and those without (9.3%). In Group B, LR occurred in 28 (12.7%) patients: 12.5% without SC and 12.7% with SC. A significant difference in the prevalence of LR was found between patients with CL (14.2%) and those with RL (30.0%). When CL were excluded, RL resulted as an independent predictor of LR. DISCUSSION: Many factors have been shown to affect the rate of LR, including operative technique and surgeon expertise as well as margins of clearance and tumor stage. In our study, overall LR rate of Group B was 13.2%. The incidence of this event in patients with AL (24%) was significantly higher than that in the nonleakage group (11.1%). Correspondent results have been reported by some authors who evidenced RL as a negative prognostic factor for higher rates of LR. The mechanism by which AL affects LR remains to be elucidated. CONCLUSIONS: All were found to be associated with higher rates of LR, especially if associated with prolonged inflammatory local reaction.

Surgical treatment of hydatid disease of the liver: 25 years of experience.

BACKGROUND: The aim of this study was to evaluate the results of conservative and radical treatment of liver hydatid disease. METHODS: Records of patients who underwent surgery for liver hydatid disease between 1980 and 2005 were reviewed. Outcomes measured were operative morbidity and mortality, hospital stay, and recurrence. RESULTS: Two hundred fourteen patients underwent conservative treatment (external drainage, marsupialization, omentoplasty), and 240 had radical surgery (hepatic resection, cystopericystectomy). Operative morbidity was 79.9% and 16.2% for conservative and radical procedures, respectively (P < .001). Operative mortality was 6.5% for conservative procedures and 9.2% for radical procedures (P = .3). The recurrence rate was 30.4% in patients having conservative surgery and 1.2% in patients undergoing radical surgery (P < .001). No recurrences occurred in patients with clear cysts after conservative surgery. CONCLUSIONS: Cystopericystectomy was a safe and effective procedure that achieved excellent immediate and long-term results. Hepatic resection should be considered only in exceptional cases, because it involves the unnecessary sacrifice of healthy hepatic parenchyma. Conservative surgery and alternative procedures should be restricted to the treatment of clear cysts and to patients who cannot undergo radical surgery.

Ghost ileostomy: real and potential advantages.

Loop ileostomy is created to minimize the clinical impact of colorectal anastomotic leak. However, a lot of complications may be associated with ileostomy presence and with its reversal. Moreover, patients hardly accept the quality of life resulting from ileostomy. We describe a simple technique (ghost ileostomy) to combine all the advantages of a disposable ileostomy without entailing its complications in patients submitted to low rectal resection. In case of uneventful postoperative course, the ghost ileostomy prevents all complications related to defunctioning ileostomy. At the same time, in case of anastomotic leakage, the ghost ileostomy is easily and safely converted into a defunctioning ileostomy.

Indications and results for transduodenal sphincteroplasty in the era of endoscopic sphincterotomy.

BACKGROUND: Transduodenal sphincterotomy (TS) has fallen into disuse since endoscopists developed techniques to treat sphincter problems nonsurgically. However, some patients experience recurrent sphincter strictures after endoscopic sphincterotomy (ES), with the ampulla endoscopically inaccessible, and pancreas divisum (PD); these patients are referred to a surgeon because they are unsuitable for ES. METHODS: The medical records of patients who underwent TS at the First Department of Surgery of the Medical School, University of Rome "La Sapienza," between January 1997 and December 2005 were reviewed. A total of 82 patients, including 47 women and 35 men with a mean age of 47 years (range, 26-67 y), underwent TS in our unit in the aforementioned period. Previous unsuccessful endoscopic retrograde cholangiography and ES were the indications for TS in 44 patients, and previous gastric surgery with duodenal bypass was the indication for TS in 21 patients. Five patients underwent TS because of a PD and 10 because of the intraoperative findings of daughter hydatid cysts in the common bile duct and of a wide communication between the cyst cavity and the intrahepatic biliary tree. Two patients were referred to our institution after a surgical papillotomy performed elsewhere. Symptoms included abdominal pain in 100% of patients, nausea and/or vomiting in 78% of patients, and referred back pain in 56% of patients. Acute pancreatitis was present in the history of 26 patients, including 23 with previous ES. All patients underwent TS. Sphincteroplasty of the accessory papilla was performed in all patients with PD. Cornerstones of a successful TS are depicted. RESULTS: Asymptomatic hyperamylasemia was observed in 37 patients, and cholangitis and pancreatitis, which was resolved with conservative management, occurred in 2 patients. One patient developed an intra-abdominal abscess that was treated with image-guided percutaneous drainage. No perioperative deaths occurred in this series. The mean length of follow-up evaluation was 84.4 months (range, 16-115 mo). Good results were achieved in 53 patients (73.6%), fair results in 17 patients (23.6%), and poor results in 2 patients (2.7%). Both patients with poor results required reoperation because of recurrent pancreatitis and pancreatic pseudocyst. CONCLUSIONS: TS still represents, although undoubtedly with updated indications compared with the past, a surgical procedure that must be up to date, ensuring absolutely satisfactory results.

Incidence and circumstances of cervical hematoma complicating thyroidectomy and its relationship to postoperative vomiting.

BACKGROUND: Cervical hematoma is hardly a predictable complication of thyroid surgery. Postoperative vomiting has been reported as a likely risk factor. METHODS: Five hundred sixty-two patients undergoing thyroidectomy were prospectively enrolled in the study and divided into 2 groups. Patients in group A received ondansetron to prevent postoperative vomiting. In group B, patients with low vomiting risk received ondansetron whereas patients at high risk received ondansetron plus dexamethasone. Postoperative outcomes of the groups were analyzed and compared. RESULTS: Cervical hematomas developed in 3 patients (0.53%): 2 in group A and 1 in group B. All hematomas occurred after 6 hours. The incidence of postoperative vomiting was 11.4% in group A and 6.4% in group B (p = .04). CONCLUSION: Careful hemostasis remains of prime importance in preventing cervical hematoma. Postoperative vomiting has not been confirmed by this study as a risk factor for the development of hematoma. Ambulatory thyroid surgery is not advisable.

Outcome of chronic pilonidal disease treatment after ambulatory plain midline excision and primary suture.

BACKGROUND: Pilonidal sinus (PS) is a common chronic disorder of the sacrococcygeal region. The optimal treatment for PS remains controversial, and recent reports have advocated different surgical approaches. METHODS: A prospective study was performed on 103 patients with nonrecurrent quiescent chronic discharging sinus. Excision with primary closure was performed on all patients. Patients were subdivided randomly into 2 groups. In group A, the excision was associated with drainage of the wound; in group B, the wound was not drained. RESULTS: Excision with primary closure and drainage was performed in 53 patients (group A). Drainage was omitted in 50 patients (group B). Minor wound complications occurred in 3 patients in group A and in 36 patients in group B. No complete dehiscence of the wound was observed in patients in group A and in 8 patients in group B. Complete healing was fastest in patients in group A. Sinus recurrence occurred in 1 patient in group A and in 2 patients in group B. CONCLUSION: Short- and long-term results suggest that limited midline excision with primary closure and wound drainage is a simple and effective procedure in the surgical treatment of uncomplicated PS. More demanding flap techniques and plasties should be reserved for complicated PS, which requires a wider excision.

Intra-operative ultrasound for detection of liver metastases from colorectal cancer.

OBJECTIVE: The aim of this study was to evaluate the accuracy of intra-operative ultrasound (IOUS) imaging in detecting liver secondaries at the time of primary colorectal surgery and to evaluate the impact of IOUS on patient management. METHODS: Data from 167 patients with primary colorectal cancer who were admitted for elective surgery between January 1995 and December 2003 were prospectively evaluated and analysed. All patients underwent pre-operative abdominal ultrasonography (US) and computed tomography (CT), as well as IOUS. The final diagnosis of liver metastases was made by means of histological examination of either biopsy or surgical specimens. The sensitivities of pre-operative US and CT were compared with the sensitivity of IOUS, referred to histology. Changes in surgical management owing to IOUS findings were noted. RESULTS: IOUS supplied additional information in the case of 31 patients. In 28 of these patients, this information had a major impact on the intra-operative strategy, in that the procedure was altered. CONCLUSIONS: IOUS is safe, simple to perform and more accurate than pre-operative imaging. It reduces the number of patients subjected to superfluous surgery. The use of IOUS is therefore encouraged during colorectal cancer surgery.

Treatment of hydatid bronchobiliary fistulas: 30 years of experience.

BACKGROUND: Bronchobiliary fistula (BBF) is an uncommon but severe complication of hydatid disease of the liver. Operation is considered the treatment of choice but the most appropriate operation is uncertain. The aim of this study was to evaluate the early and long-term outcomes following different surgical procedures. METHODS: A retrospective evaluation of 31 patients with BBF was performed. Surgical access consisted of laparotomy, thoracotomy or a thoracoabdominal (TA) incision. Surgical procedures for the treatment of the cyst were classified as conservative or radical. RESULTS: Radical treatment including lung resection and pericystectomy was performed in all patients in whom the surgical exposure was obtained by either thoracotomy or TA. Of the patients treated by laparotomy, two had a pericystectomy, and four had drainage of the cyst. There were two deaths among the seven thoracotomy patients and one among the 18 TA patients. Pleural effusion was observed in six of the TA, two of the thoracotomy, and three of the laparotomy patients. Biliary fistula occurred in two of the five thoracotomy patients surviving operation and in two laparotomy patients (2/6). Progression of the lung disease was observed in four laparotomy patients and in one thoracotomy patient. CONCLUSIONS: The better outcome achieved in TA patients is the result of the simultaneous radical treatment of all the pathological aspects of BBF.

Surgical treatment of liver metastases from colorectal cancer in elderly patients.

INTRODUCTION: The liver is the most frequent site of liver metastases (LM) from colorectal cancer. Because of short life expectancies and improved nonoperative modalities, the role of liver resection in elderly patients with LM is unclear. METHODS: During a 15-year period, 197 patients underwent liver resection for colorectal metastases. This study was designed to compare morbidity, mortality, and long-term outcome after hepatic resection in patients aged 70 years and older and in patients younger than 70. According to the age at the time of operation, patients were divided into two groups. Group A included patients aged 70 years or older and group B included younger patients. RESULTS: The clinical and pathologic parameters of the two groups were compared and tested as factors affecting early and long-term outcomes after resection. A modified oncologic clinical risk score (CRS) was tested on this series of patients. Overall morbidity was 16.3% (group A 20.7% vs group B 14.6%; P=0.18). Hospital mortality was 3% (5.7% in group A and 2.1% in group B; P=0.19). Actuarial 5 years survival were 30% in group A and 38% in group B (P=ns). DISCUSSION: The presence of more than three Fong's CRS parameters and microscopic involvement of resectional margin directly affected survival. Under meticulous preoperative assessment and postoperative care, liver resection for LM is justified in patients over 70 years of age; age by itself may not be a controindication to surgery.

Low correspondence between K-ras mutations in pancreatic cancer tissue and detection of K-ras mutations in circulating DNA.

OBJECTIVE: K-ras is the most frequently mutated gene in pancreatic cancer; reported rates range from 70% to 90%. The aim of this study was to evaluate the correspondence between K-ras mutations in pancreatic cancer tissue and in circulating DNA and the value of K-ras mutations as serological marker. METHODS: The research was conducted in 30 patients with pancreatic cancer in whom both plasma and neoplastic tissues were available. Such research was extended to circulating DNA isolated from 40 patients with chronic pancreatitis. Mutations in codon 12 were examined by mutant allele-specific amplification method and by direct sequencing. Serum values of routinely used tumor markers such as carbohydrate antigen (Ca) 19.9, carcinoembryonic antigen, Ca 50, and Ca 242 have been tested in all the patients enrolled in this study. RESULTS: K-ras mutations were detected in 70% of neoplastic tissue samples, but no mutated DNA resulted in circulating DNA samples. The 60% of patients with tissue K-ras mutation showed elevation of some tumor markers among Ca 19.9, carcinoembryonic antigen, Ca 50, and Ca 242. As a whole, these last showed low sensitivity (20%-56.67%) and specificity (56.67%-77.5%) when compared with chronic pancreatitis. CONCLUSION: Over the years, there has been no change in the direction of an earlier diagnosis by serological markers, and also, these data indicate that K-ras mutation in serum is an unsatisfactory method for the detection in patients with pancreatic cancer as well as in patients with high risk of progression toward neoplastic pancreatic disease.

Surgical treatment of pancreatic head carcinoma in elderly patients.

HYPOTHESIS: The treatment of cancer in elderly patients has become a global clinical issue, considering the increasingly longer life expectancy. Three quarters of patients with pancreatic adenocarcinoma are older than 60 years. Surgical resection is the only chance of cure, and early outcome of pancreaticoduodenectomy in elderly patients is comparable with that obtained in a younger population. DESIGN: During an 11-year period, 166 patients underwent curative pancreaticoduodenectomy for pancreatic adenocarcinoma. Clinical and demographic factors were evaluated by univariate and multivariate analyses to test their effect on early outcome. SETTING: State university medical school tertiary care center. PATIENTS: One hundred sixty-six patients underwent curative pancreaticoduodenectomy for pancreatic adenocarcinoma. They were divided into 2 groups according to age (group A for patients older than 70 years, group B for patients younger than 70 years). INTERVENTION: Pancreaticoduodenectomy was performed using a Whipple procedure. An end-to-end pancreaticojejunostomy was constructed. Lymphadenectomy was carried out along the hepatoduodenal ligament, common hepatic artery, vena cava, superior mesenteric vein, and along the right side of the superior mesenteric artery. Four abdominal drainage sites were routinely used. MAIN OUTCOME MEASURES: The postoperative hospital stay was calculated and morbidity and mortality were assessed. RESULTS: Significantly higher operative morbidity and mortality were observed in group A (group A, 49.1% vs group B, 45.8% and 10.5% vs 3.7%, respectively). Underlying comorbid conditions in group B patients influenced postoperative morbidity but not mortality. Rate and nature of surgical complications were indicated as causes of significant higher mortality in group B patients. CONCLUSIONS: An aggressive surgical approach is justified for elderly patients with pancreatic adenocarcinoma. However, surgical complications that lead to reoperation are responsible for a high mortality in elderly patients. In addition to general causes, such as concomitant disorders, reduced functional reserve, poor tolerance to stress, and the texture of the pancreatic remnant, there are specific prognostic factors affecting pancreaticojejunostomy leakage and related mortality.

Treatment of giant intramuscular hemangioma: a multistep approach in three patients.

BACKGROUND: Giant intramuscular hemangioma (GIH) is a rare, progressively enlarging benign tumor, characterized by variable presentation and usually initially diagnosed in childhood. Large volume, rapid enlargement and particular radiologic imaging create suspicion of malignancy. Radiologic investigations and needle or small excisional biopsy are not always reliable for an accurate diagnosis; therefore, histology on a large surgical specimen is often requested. The timing and modality of treatment of these tumors is a matter of debate. PATIENTS AND METHODS: Data on 3 patients with GIH of the upper trunk and neck are reported. Associated vascular anomalies were found in all patients. All 3 patients had surgery because of the effect of the growth on their function, the severe symptoms and suspicion of malignancy. RESULTS: A one-step excision of an enormous tumor was carried out in one patient, who died from severe postoperative complications. A second patient was successfully treated by a multistep surgical and multidisciplinary approach. An uneventful removal of part of the tumor was performed on the third patient, who is currently in follow-up for completion of treatment. CONCLUSION: Surgery remains the most effective mode of treatment for GIH and often results in permanent cure. The authors suggest performing the surgical removal of these tumors at first diagnosis, when their smaller size requires less demanding procedures, presents lower rates of morbidity and offers a better chance of complete excision.

Lymph node dissection in papillary or follicular thyroid carcinoma.

BACKGROUND: Prospective randomized studies aimed at evaluating the different therapeutic protocols for the treatment of papillary or follicular carcinoma are lacking at the moment. Although total thyroidectomy is widely accepted, indication to locoregional lymphadenectomy is strongly debated. MATERIALS AND METHODS: Fifty-four patients with papillary or follicular thyroid carcinoma (45 papillary and 9 follicular) underwent functional evaluation of the gland before intervention, FNAB included Surgical management was carried out as follows: 41 total thyroidectomy, 6 lobectomy with further totalization in 5, 6 total thyroidectomy plus central compartment lymphadenectomy and 1 left laterocervical lymphadenectomy (papillary carcinoma, treated elsewhere through total thyroidectomy plus central and right laterocervical lymphadenectomy). All operated patients were submitted to whole body scintigraphy and treated thereafter by radiometabolic therapy and chronic hormone suppressive therapy. RESULTS: Fifty-one patients are currently alive, 3 died from non-related causes; surgical complications included 1 permanent impairment of inferior laryngeal nerve function and 1 case of hypoparathyroidism. The follow-up was from 1 to 139 months. DISCUSSION: The optimal treatment of lymph node metastases, especially for papillary carcinomas, has not yet been defined. Two trends are evident concerning lymphadenectomy: the first one suggests routine lymphadenectomy, the second supports lymphadenectomy by necessity. In follicular carcinoma lymphadenectomy is recommended only in the presence of clinical evidence of lymph node involvement. Occult differentiated carcinoma does not require any further treatment of lymph nodes. CONCLUSION: Considering the high efficacy of radiometabolic treatment after total thyroidectomy combined with chronic TSH inhibition through L-tyrosine administration, lymphadenectomy is suggested only by necessity.

Hepatic resection in stage IV colorectal cancer: prognostic predictors of outcome.

BACKGROUND AND AIMS: Hepatic resection has been proposed as an effective way to treat metastatic colorectal carcinoma. The aim of the study was to determine if contemporary resection of intestinal primary tumor and hepatic metastases is effective in the treatment of patients with metastases that are recognized at the initial clinical presentation of the primary tumor. METHODS: In a retrospective study, univariate and multivariate models were used to analyze the effect of patient demographics, tumor characteristics, and treatment factors on early and long-term outcome of patients submitted to synchronous intestinal and hepatic resection for colorectal liver metastases. From 1988 to 1999, 78 patients underwent surgical resection of primary colorectal tumor and hepatic metastases with curative intent. Criteria for study recruitment included primary tumor controllable, no extrahepatic disease detectable, and negative surgical margins of hepatic resection. RESULTS: The univariate analysis disclosed as adverse predictors of the long-term outcome the numbers of metastases (3), pre-operative CEA value >100 ng/ml, resection margin <10 mm, and portal nodal status. Multivariate analysis confirmed number of metastases, resection margin and portal nodal status as independent predictors. CONCLUSIONS: Our findings confirm hepatic resection as an effective procedure when undertaking combined bowel and hepatic resection. The applicability and the outcome of this surgical strategy is definitively influenced by the chance of a radical resection of the primary tumor, the number of hepatic metastases, resection margin wider than 1 cm, positive portal nodes, and the absence of any extrahepatic metastatic disease.

Total lateral sphincterotomy for anal fissure.

BACKGROUND AND AIMS: Initial experience with the posterior sphincterotomy for treating anal fissures was unsatisfactory, with a significant rate of recurrences and anal incontinence. This report describes the lateral approach to complete section of the internal sphincter. PATIENTS AND METHODS: Between 1997 and 2001 we surgically treated 164 patients for anal fissure. Preoperative and postoperative anal manometries were recorded. Postoperative course and early and long-term results were recorded. RESULTS: No fissure failed to heal. Early complications included bleeding, hematoma, and pain. A transient, variable degree of incontinence occurred in 15 patients and persistent incontinence to flatus and soiling in 5. After total sphincterotomy no long-term complication was observed. Patient satisfaction was 96%. CONCLUSION: Total subcutaneous, internal sphincterotomy is a safe, effective procedure for the treatment of chronic anal fissure.