Multiorgan resection for advanced abdominal malignancies--is it feasible?

BACKGROUND/AIMS: In everyday clinical practice many unfortunate patients present with advanced abdominal malignancies and are referred to a medical oncologist for palliative chemoradiotherapy and very few of them are offered surgical treatment. Many such patients, detected either preoperatively or on exploration, are considered to be inoperable and left to live a short and morbid life. The aim of this study was to assess the feasibility and effect of aggressive surgical management with adjuvant chemotherapy in advanced abdominal malignancies requiring resection of one or more organs along with the primary organ of the disease. We retrospectively analyzed our experience of treating such patients. METHODOLOGY: A total of 62 patients were included in this study attending the clinic between January 2001 and January 2006. These patients were diagnosed to have advanced abdominal malignancies because of spread of the disease from the organ of origin to either contiguous or noncontiguous abdominal organ(s). The patients with ovarian and uterine (n=18) malignancy underwent resection of colon (5), omentum (18), distal pancreatectomy and splenectomy (2), cystectomy (4), parietal peritoneal excision (9), small bowel excision in various combinations along with radical hysterectomy. Twelve patients with advanced colorectal carcinoma (n=12) along with abdominoperineal excision, anterior resection or colonic resection underwent cystectomy (3), hysterectomy (4), small bowel resection (4), hepatic resection (7) or parietal peritoneal excision (4) in various combinations. A total of 14 patients with gastric and gastroesophageal junction malignancy (n=14) underwent gastrectomy or gastroesophagectomy with omentectomy (14), distal pancreatico-splenectomy (5), hepatic resection (9), transverse colectomy (2) and parietal peritoneal excision (2) due to advanced disease. Patients with pancreatic carcinoma (n=12) underwent Whipple's pancreaticoduodenectomy or distal pancreatectomy with hepatic resection (6), transverse colectomy (1), splenectomy (3), left nephrectomy and adrenalectomy (3), small bowel excision (1) and parietal peritoneal excision (3). Along with excision of nonsolid organ retroperitoneal tumors (n=6) the organs resected were left kidney with adrenal (2), spleen (2) right kidney and adrenal (2), segmental inferior vena cava (1) and colon (2). All patients (except those who died in the early postoperative period) received adjuvant chemotherapy (43) or chemobiologic therapy (12) or radiotherapy. RESULTS: Out of the total 62 patients who underwent multiorgan resection 7 patients died in the immediate postoperative period due to massive pulmonary embolism (2), cardiorespiratory insufficiency (2) or sepsis (3). Important morbidities seen in the early postoperative period were anastomotic leak (3), hemorrhage (2), pulmonary infection (5), pancreatitis (1), wound infection (4) and urinary tract infection (2). There was 100% postoperative follow-up of the patients. The survival rate was 77% in the first, 56.45% in the second, 47% in the third, 32% in the fourth and 22% at the end of the five-year follow-up. CONCLUSIONS: Aggressive surgical intervention by multiorgan resection and adjuvant chemo or chemobiological therapy is a feasible option in patients with advanced abdominal malignancies with statistically improved survival rate. Furthermore, it helps in getting better response to therapeutic manipulations and improved quality of life of the patients.

Challenges in everyday surgical practice: synchronous bilobar hepatic colorectal metastases--newer multimodality approach.

BACKGROUND/AIMS: This study was designed to assess the efficacy of two-stage liver surgery and hepatic directed chemo-biological therapy in treatment of synchronous bilobar hepatic metastases of colorectal origin. METHODOLOGY: A total of thirty-two patients were included in this study that were diagnosed to have colorectal carcinoma with synchronous bilobar hepatic metastases. During stage one surgery along with excision of primary colorectal carcinoma; ligation and transection of main portal branch on side of bulky metastases disease (right branch in 28 and left in 4 patients) was performed. The metastatic nodules in the opposite lobe were ablated by microwave therapy and a hepatic arterial jet port catheter was introduced via the gastroduodenal artery for liver directed chemo-biological therapy. The catheter was connected to a subcutaneously placed port. Three cycles of chemotherapeutic drugs and Avastin (Bevacizumab) were given via hepatic arterial infusion (HAI) at intervals of twenty-five days. During the second stage surgery hepatic resection was carried out followed by continuation of hepatic arterial infusion of chemobiological drugs as adjuvant therapy. RESULTS: In the follow-up period of 31 months, 1-year survival of 100% and 2-year survival of 80% with a mean 28 months survival was noted. CONCLUSIONS: Combined approach of ligating the portal branch, microwave ablation, hepatic regional chemo-biological therapy and staged liver surgery (a multimodality approach) in the treatment of advanced liver metastatic disease synchronous with colorectal cancer is an effective method of treatment which improves the overall survival and quality of life of the patient with hepatic bilobar metastases synchronous with colorectal carcinoma. Avastin, a monoclonal antibody against vascular endothelial growth factor; used for inhibition of tumor growth has shown its efficacy in early results and holds good promise for the future.

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.

Carcinoma of the pancreas with portal vein involvement--our experience with a modified technique of resection.

BACKGROUND/AIMS: Up to 40% of the patients with pancreatic carcinoma are not fit for curative resection due to the locally advanced nature of the disease in the form of vascular involvement. In recent years a more aggressive approach of vascular resection with pancreaticoduodenectomy (PD) has resulted in the increase in resectability rate and survival in this group of patients. The most important determinant of survival in these patients is negative resection margins. The aim of the present study is to present our experience of vascular resection using a modified technique, in patients with pancreatic cancer. METHODOLOGY: This is a retrospective study of 48 patients who underwent portal vein/superior mesenteric vein (PV/SMV) resection along with PD using the modified technique of resection, during 1982-2004. The principle modification is the initial extensive retroperitoneal dissection for the assessment of the extent of tumor involvement of the superior mesenteric vessels and division of retroperitoneal margin before the division of the pancreas. All patients also underwent extended lymphadenectomy. RESULTS: The subtotal PD was done in 26 and total PD in 22 patients, with resection of the PV/SMV in all of them. The end-to-end anastomosis was possible after adequate mobilization of the PV and SMV in 40 patients. In 4 patients reconstruction was able to be done with the use of a graft. The portal vein occlusion time was 8-15 minutes. Histopathological examination showed negative margins in all the resected specimens. Postoperative complications occurred in 16.66% with reoperation rate of 8.33%, and mortality of 6.25%. After a mean follow-up of 110 months, mean survival was 40 months with the range of 18-250 months. The five-year and 10-year survival was 18% and 10% respectively. The venous patency rate was 100% at three years. CONCLUSIONS: In conclusion, PD with en bloc resection of the PV/SMV confluence can safely be done with morbidity and mortality similar to that of standard PD. The survival advantage is directly related to the attainment of negative resection margins. The modified technique is a useful way of doing vascular resection with the least amount of bowel congestion and securing negative resection margins.

Recent advances in the treatment of colorectal liver metastases.

Liver metastases are the major cause of death coloroctal resection for cancer. Colorectal liver metastases are unique because of the potential for cure. Presently surgical resection is the gold standard of treatment. Complete R0 resection gives 5-year survival of up to 24-44%. Over the years there have been extensive efforts in devising new modalities of treatment for this disease. These include methods to increase the resectability such as portal after vein emolization & two-stage surgery, py with newer drugs and methods such chronotherapy & hepatic artery infusion chemotherapy, newer methods of radiotherapy, local ablative therapies such as cryoablation, radiofequency ablation, microwave ablation & laser interstitial thermal therapy, and biological therapy. Biological therapy is largely investigational, but holds great promise for the future.

Reappraisal of a method of reconstruction after pancreatoduodenectomy.

BACKGROUND/AIMS: After pancreatoduodenectomy (PD), pancreatic leak and the functional pancreatic and gastrointestinal disorders are the most important complications. Still there is no single method which takes care of all of them. After identifying the various reasons behind these complications, the senior author started performing the present method in the 1980s. Since then we have been able to bring these complications to a very low incidence. The present study is designed to substantiate the claims of various advantages of this method of PD and reconstruction and to explain the rationale behind this method. METHODOLOGY: This is a retrospective study of 225 consecutive PD procedures done for periampullary cancers, during the period of 1993-2004. The shortterm and long-term results assessed were mortality rate, morbidity rate, early reoperation, survival, steatorrhea, pancreatic enzyme supplementation requirement, occurrence of bile gastritis, dumping, new onset of diabetes, marginal ulcers, cholangitis, postoperative weight trends and frequency of hospital readmission for symptom management. Follow-up was done 6 monthly in all the patients with the aim of diagnosis of recurrence and assessment of long-term gastrointestinal and pancreatic function and nutritional status. In addition, in 15 patients, upper gastrointestinal endoscopy (UGIE) with gastric and jejunal biopsy, 99Tc-HIDA scan, determination of fecal fat loss after a standard 100-g fat diet for three days, fecal elastase-1 measurement (ELISA) and MRCP were done to objectively document the changes in gastrointestinal and pancreatic function. The data were compared with the results available in the literature. RESULTS: The mean age was 56 years with a range of 27-85 years. There were 130 males and 95 females. Preoperatively 18 patients had diabetes and preoperative weight loss varied from 5-30 kilograms with a mean of 12 kilograms. Of all the PD cases 57 were for ampullary, 70 were for lower end cholangiocarcinoma and 98 were for pancreatic head cancer. The postoperative complications occurred in the form of intra-abdominal bleed (5), pancreaticojejunostomy leak (12), intra-abdominal abscess (4) and pneumonia (5). Delayed gastric emptying was not seen in any of the patients. In 8/12 patients with PJ leak the closure was achieved with the conservative treatment. The 30-day mortality was 6/225 (2.66%). The causes were sepsis in 3, intra-abdominal bleed in 2 and pulmonary embolism in 1 patient. There was no mortality related to PJ leak. The median follow-up was of 36 months. The overall 5-year survival for ampullary, lower end cholangio- and pancreatic head carcinoma were 65%, 25% and 20% respectively. After surgery none of the patients had clinical evidence of steatorrhea, gastritis, peptic ulcer disease, cholangitis, dumping and there was no new case of diabetes. After 6-12 months 80% of the patients gained weight similar to their preoperative levels. UGIE with gastric and jejunal biopsies, 99Tc-HIDA scan, fecal fat loss estimation, fecal elastase estimation and MRCP were done in 15 patients and were found to be normal. CONCLUSIONS: Our method of PD and reconstruction produces encouraging results with respect to PJ leak, mortality, DGE, malabsorption, bile gastritis, dumping, marginal ulcers and diabetes. We recommend this technique as a safe and effective method even to the low volume centers.

Adenocarcinoma of the pancreas--past, present and future.

Adenocarcinoma of the pancreas has always been a disease with a dismal prognosis. Almost every patient with this cancer dies of the tumor. Over the years there has been extensive advancement in the understanding of etiology, molecular biology, diagnosis and treatment of this disease. Presently, surgical resection is the only potentially curative option available for these patients. It is now clear that surgery alone cannot increase the survival of these patients. With the understanding of molecular biology of pancreatic cancer new management strategies are under a preclinical stage of development. These new diagnostic and therapeutic modalities hopefully will improve the outcome of patients with pancreatic cancer.

Changing trends in the management of Klatskin tumor.

BACKGROUND/AIMS: To evaluate the long-term outcome of a multidisciplinary approach for advanced Klatskin tumor involving the hepatic hilus. METHODOLOGY: A retrospective analysis was undertaken in 110 patients between 1993 and 2003. The patients were divided into Group A (n=42) and Group B (n=58). Group A patients underwent local excision of the tumor and Group B patients underwent combined tumor and liver resection with or without resection of the regional vascular structures. On admission, all patients underwent percutaneous transhepatic biliary drainage. Where hepatectomy was planned, portal vein branch ligation and transection was done ipsilateral to the liver lobe where the tumor was present. An arterial catheter was introduced into the hepatic artery at the end of the surgery, for adjuvant locoregional immunochemotherapy, which was carried out in all patients. The second-stage resectional surgery was carried out 35 days later. RESULTS: The overall mean survival for Group A patients was 29 months (range 14 to 76). The mean disease-free survival was 28 months (range 10-52). Five-year survival rate was 5% and five-year disease-free survival was 0%. The overall mean survival for Group B patients was 39 months (range 28 to 79). The mean disease-free survival was 32 months (range 17-72). Five-year survival rate was 20% and five-year disease-free survival was 10%. CONCLUSIONS: The concept of a multidisciplinary approach has significantly improved survival in patients with a grave disease like Klatskin tumor.

Experimental remarks on the utilization of biological tissue adhesives in lymphovenous anastomosis.

The present experimental study deals with the utilization of biological tissue adhesives in an effort to estimate their value in lympho-venous anastomoses. The entire experimental work was carried out on 8 dogs, using the thoracic duct and the jugular vein for a lympho-venous anastomosis. The study also describes the experimental steps and overall technique. The anastomoses were carried out in an end to side fashion with four stitches and were completed with a biological adhesive substance later ( Fibrinkleber ). All the anastomoses were re-investigated for occlusion, formation of thrombus or a lymphatic fistula. There were no deaths. One of the anastomoses was occluded by a thrombus but no fistula was found in any of the dogs. The above results indicate that biological adhesive substances can be used satisfactorily as an adhesive substance in lymphovenous anastomosis.