Laparoscopic hyperthermic intraperitoneal chemotherapy as adjuvant modality following radical surgery for advanced rectal cancer a new look to an old problem.

BACKGROUND/AIMS: The benefits of adjuvant chemotherapy for colorectal cancer has been well accepted over the last decade. Published data so far has been focused in the direction of giving the right chemotherapy dose, schedule, and combinations, in order to increase the efficacy and decrease the toxicity. METHODOLOGY: Eighty-seven patients with histological proved stage III rectal carcinoma were subjected to a combined adjuvant modality using laparoscopic heperthermic endoperitoneal chemotherapy (HIPEC) and systemic chemotherapy twenty days following the initial surgery. RESULTS: Seventy patients who completed a one year follow-up had a disease free survival. Among forty patients who completed the two year follow-up, two patients developed local recurrence. CONCLUSIONS: Cytoreduction followed by HIPEC improves survival in patients with rectal carcinoma and lymphnode positive and neurovascular involvement.

The management of colorectal liver metastases: Expanding the role of hepatic resection in the age of multimodal therapy.

Colorectal cancer (CRC) caused nearly 204,000 deaths in Europe in 2004. Despite recent advances in the treatment of advanced disease, which include the incorporation of two new cytotoxic agents irinotecan and oxaliplatin into first-line regimens, the concept of planned sequential therapy involving three active agents during the course of a patient's treatment and the integrated use of targeted monoclonal antibodies, the 5-year survival rates for patients with advanced CRC remain unacceptably low. For patients with colorectal liver metastases, liver resection offers the only potential for cure. This review, based on the outcomes of a meeting of European experts (surgeons and medical oncologists), considers the current treatment strategies available to patients with CRC liver metastases, the criteria for the selection of those patients most likely to benefit and suggests where future progress may occur.

Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study.

BACKGROUND/AIMS: Anastomotic leakage is a major problem in colorectal surgery particularly in low rectal cancer. The defunctioning loop ileostomy was introduced as a technique to create a manageable stoma that would divert the fecal stream from a more distal anastomosis in order to reduce the consequences of any anastomotic leakage. Therefore, the use of a defunctioning stoma has been suggested, but limited data exist to clearly determine the necessity of routine diversion. This study was designed to evaluate early morbidity, mortality and hospital stay in patients undergoing lower rectal cancer surgery concerned with or without loop ileostomy. METHODOLOGY: This is a prospective randomized study that was performed between May 2001 and March 2008. There were 256 patients who underwent elective low anterior resection and stapler anastomosis. They were divided into two groups. Group A consisted of 120 patients who underwent straight anastomosis without ileostomy and group B consisted of 136 patients who underwent straight anastomosis with loop ileostomy. Data regarding patient demographics, underlying pathology, anastomotic problems, and ileostomy-related problems were gathered. The patients were all monitored closely after surgery for an anastomotic leak and all stoma-related complications were recorded. Inclusion criteria consisted of biopsy proven adenocarcinoma of the rectum located at < or = 5 cm above the anal verge, age > or = 22 years, and informed consent. Exclusion criteria included age more than 90 years, associated co morbid conditions Stage IV with disease spread to liver and peritoneum. RESULTS: Indications for surgery were lower rectal cancer (n=256). Mean age 55.5 years (range 22-90 years) and a male: female ratio of 1.1:1. All patients were undergoing elective surgery for lower rectal cancer. In our study 12 patients in group A developed anastomotic leak, two of them were re-explored for anastomotic leak and Hartman's colostomy was carried out. There were two deaths in Group A. In group B anastomotic leak was seen in three patients. In all three, anastomotic healing took place at a later period of time on the 18th, 20th, and 25th postoperative day respectively without any additional morbidity and mortality. Ileostomy-related problems were minor and limited to the stoma and complaints requiring stoma nurse evaluation (n=8), dehydration requiring outpatient care (n=3), bleeding at the stoma closure site (n=l). No stoma site hernias have been identified so far. CONCLUSIONS: The use of defunctioning loop ileostomy in all patients undergoing lower rectal surgery with stapler anastomosis is beneficial and safe. Defunctioning loop ileostomy use has resulted in no anastomotic leak rate and considerable low morbidity. So according to our study, we strongly recommend defunctioning loop ileostomy as a routine procedure in patients undergoing lower rectal cancer surgery.

Postoperative hemorrhage after major pancreatobiliary surgery: an update.

In recent years, mortality associated with pancreaticoduodenectomy has come down to less than 5% but morbidity still remains high. Pancreatic fistula is one of the most common complications following pancreaticoduodenectomy. Postpancreatectomy hemorrhage is a rare but disastrous complication and associated with poor outcome. Early bleeding is usually due to some surgical mishap, but the management is simpler. Delayed hemorrhage has more complex pathophysiology and requires a multimodality approach for its management. In this paper, we review the recent articles related to postoperative hemorrhage after major pancreatobiliary surgery. Here we discuss the incidence, cause, investigations and management of early and late postoperative hemorrhage.

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.

Management of rectal cancer: strategies and controversies.

Colorectal cancer is one of the most common cancers in the western world. The goal of this review is to outline some of the important surgical issues surrounding the management of rectal cancer. In patients with early rectal cancer (T1), local excision may be an alternative approach in highly selected patients. For more advanced rectal cancer, radical surgical resection is the treatment of choice. Total mesorectal excision and negative radial margin (>1 mm) decreases the local recurrence rate and improves survival. In appropriate patients, laparoscopic resection allows for improved patient comfort, shorter hospital stays, and earlier returns to preoperative activity level. In patients with locally advanced disease, neoadjuvant chemoradiotherapy followed by radical excision according to the principles of TME has become widely accepted. Surgical resection is the treatment of choice for resectable liver metastasis of colorectal origin. Surgical resection improves disease-free and overall survival rate. For patients with unresectable metastatic disease, multimodality approach may increase the resectability rate and hence survival.

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.

Life-threatening hemorrhage due to cytomegalovirus infection of the gastrointestinal tract.

Cytomegalovirus infection of the gastrointestinal tract of normal hosts is very rare. On the other hand, this is a common cause of morbidity in immunocompromised hosts. Herein we describe the case of a 52-year-old male who underwent a gastrectomy due to a severe gastrointestinal hemorrhage. Histological examination showed the characteristic cytomegalovirus inclusion bodies. The diagnosis was confirmed with immunohistochemistry and his immune system revealed no abnormality. We believe that, although it is very rare, cytomegalovirus infection should be kept in mind for non-immunocompromised patients with upper gastrointestinal bleeding or multiple gastric ulcers.

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.

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.

"Acute abdomen": early laparoscopy or active laparotomic-laparoscopic observation?

BACKGROUND/AIMS: Acute abdomen accounts for 13-40% of all emergency surgical admissions. The aim of this prospective randomized controlled study was to examine the role of early laparoscopy in the management of acute abdomen compared with the more traditional active observation. METHODOLOGY: From July 1993 to August 2004, 522 patients consecutively, admitted with "acute abdomen", were randomized to either early laparoscopy (260 patients) (group 1) or active observation and non-invasive investigation (262 patients) (group 2). Baseline investigations included a full blood count, a pregnancy test in women of reproductive age, chest and/or abdominal radiograph if indicated clinically. RESULTS: Sixty-two patients in the laparoscopy group underwent a total of 116 radiological investigations compared with a total of 558 investigations in all patients in the observation group (P < 0.05). In the observation group 34.7% of patients remained without a clear diagnosis compared with 4.2% of patients in the early laparoscopic group (P < 0.0001). The morbidity rate was 1.1% in group 1 and 27% in group 2 (P < 0.0001). The duration of hospital stay was significantly shorter in group 1 (3.1 vs. 7.3 days) (P < 0.01). Eight patients in group 1 required readmission (total readmission 46 days) compared with 58 patients in group 2 who stayed a total of 201 days (P < 0.05). CONCLUSIONS: Early laparoscopy is valuable in the management of acute abdomen. It provides a significantly higher diagnostic accuracy and a better improvement in quality of life than the more traditional approach observation.

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.

Effects of cholecystectomy (laparoscopic versus open) on PMN-elastase.

BACKGROUND/AIMS: Polymorphonuclear leukocytes (PMN) are well recognized as being the principal cells in inflammatory response reaction. During the surgical procedures there is a massive release of elastase (PMN-elastase) from the neutrophils, along with other proteinases. Therefore the measurement of the PMN-elastase might be a useful indicator of the degree of surgical trauma. Laparoscopic cholecystectomy (LC) is a so-called "mini-invasive" surgical procedure and on the basis of this consideration the aim of the present prospective, non-randomized study, is to examine (a) whether the serum levels of PMN-elastase concentration are modified and how, in patients undergoing LC compared to patients undergoing open cholecystectomy (OC), (b) whether these findings are indicative of an increased risk to develop infectious complications and therefore whether they are clinically significant. METHODOLOGY: Plasma granulocyte elastase was determined photometrically, using an immune-activation immunoassay, in 86 patients (42 patients underwent OC and 44 LC). The levels of C reactive protein (CRP), an acute phase protein, were measured using a competitive CRP ELISA kit. Blood samples were collected from all patients a day before operation and at days 1, 3, 6 and 12 after operation. We established a reference range for elastase by measuring the serum elastase concentration in 68 normal control patients without gallbladder cholelithiasis or other diseases. RESULTS: On day, 1, 3 and 6 after surgery, patients that underwent OC showed a significant increase (p < 0.05) in plasma elastase concentration, while it was almost unchanged in LC patients. The mean values of the serum CRP on p.o. days 1, 3 and 6 were also significantly lower in the LC group than those in OC group (p < 0.05). We recorded three cases (7.1%) of postoperative infections in the "open" group. The CRP concentration remained high for 1, 3 and 6 days and normalized 10-12 days after surgery while the PMN-elastase normalized after 13, 14 and 16 days. CONCLUSIONS: The peripheral leukocyte function may be better preserved after LC in comparison to OC. Laparoscopic surgery, associated with a small skin incision and the avoidance of open laparotomy, can thus minimize surgical stress, and provide more favorable postoperative conditions for patients. Indeed excessive and prolonged post-injury elevations of PMN-elastase and CRP are associated with increased morbidity. Moreover, the PMN-elastase is a more sensible marker of inflammation in comparison to the CRP.

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.

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.

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.

Surgical management of choledochal cysts in adults.

BACKGROUND/AIMS: Choledochal cysts are congenital malformations of the pancreatico-biliary system. Some aspects of optimal surgical management of choledochal cysts remain controversial. The purpose of this paper is to present our series of 14 patients with choledochal cysts, analyzing surgical management and long-term results. METHODOLOGY: Between January 1975 and December 2001, 15 adult patients with choledochal cysts were treated at our Department. Sex, age, clinical symptoms, associated diseases, surgical management and postoperative morbidity and mortality were reviewed. Choledochal cysts were classified according to the Alonso-Lej classification with Todani et al.'s, modification, based on radiographic and operative findings. RESULTS: There were 15 patients, 6 males and 9 females, with an age ranging from 28 to 82 years and a mean age at the time of surgery 58.3 years. Seven patients had a solitary fusiform extrahepatic cyst (Type I), five patients had an extrahepatic supraduodenal diverticulum (Type II), one patient had a choledochocele (Type III), while two patients had a Type IVB cyst. Symptoms were vague and intermittent. Recurrent upper abdominal pain, jaundice, fever, nausea and vomiting were the most common findings, usually occurring in combination. Two patients presented with cholestatic cirrhosis. Five patients had laboratory evidence of hepatocellular dysfunction and two patients had hyperamylasemia. A variety of operations was performed such as cystoduodenostomy, cyst excision and hepaticojejunostomy, cyst excision and choledochoduodenostomy. Postoperative follow-up ranged from 30 months to 12 years in all patients except of two patients who were lost to follow-up. CONCLUSIONS: Total or partial excision of the choledochal cysts is the optimal treatment because of the lower incidence of postoperative complications and the better survival rate after the operation.