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.

Symptomatic nonparasitic hepatic cysts: options for and results of surgical management.

BACKGROUND: Management options for symptomatic nonparasitic hepatic cysts (SNHC) lack verification through comparative studies with respect to safety and long-term effectiveness. HYPOTHESIS: Open cystectomy is the treatment of choice for patients with SNHC. SETTING: University hospital department of surgery. PATIENTS: Data were retrospectively analyzed from the clinical charts of 34 patients (26 women and 8 men) undergoing surgery for SNHC from January 1, 1975, through January 1, 1999. Charts were obtained from the original hospital referral. MAIN OUTCOME MEASURES: Morbidity rates and long-term recurrence. We considered the following variables for analysis: age, sex, hepatic cyst location, diameter of the cyst at primary surgery, symptoms, surgical procedure, postoperative morbidity and mortality, length of postoperative hospital stay, and long-term outcome. RESULTS: The 34 patients underwent 47 operations for SNHC (mean diameter, 15.0 cm), with a mean follow-up of 50.0 months. Ten patients underwent open and 8, laparoscopic deroofing of the cyst. Enucleation of the cyst and hepatic resections were performed as primary procedures in 4 and 2 patients, respectively, and as secondary procedures in 6 and 7 patients, respectively. Two recurrences (25%) were found after laparoscopic deroofing and 3 (30%) after open deroofing. Two (50%) and 6 (100%) recurrences were found after cystojejunostomy and needle aspiration, respectively. No symptomatic recurrences occurred after 10 cystectomies and 9 hepatectomies. One operative death (3%) occurred; however, morbidity rates were 18% (6/34) and 15% (2/13) after primary and secondary surgery, respectively. CONCLUSIONS: These results support our policy of performing open radical procedures in the treatment of SNHC; cystectomy is performed for primary surgery and hepatic resections for recurrences and complications. Conservative procedures have shown higher rates of recurrence and the need for further surgery. Only further technological improvements will allow a systematic and safe use of laparoscopy for radical surgery for SNHC.

Adenocarcinoma of the third and fourth portions of the duodenum: results of surgical treatment.

HYPOTHESIS: To verify the adequacy of duodenal segmentectomy after intestinal derotation in the treatment of primary adenocarcinoma of the third and fourth portions of the duodenum. DESIGN: A retrospective review of the surgical management of patients who underwent derotation of the third and fourth portions of the duodenum was undertaken to determine long-term outcome. SETTING: Departments of surgery in 3 university hospitals. PATIENTS: Between January 1, 1980, and December 31, 2000, 47 patients with primary adenocarcinoma of the third and fourth portions of the duodenum were surgically treated at 3 different institutions. MAIN OUTCOME MEASURES: Details of primary surgery were abstracted from clinical records of the original hospital referral. Postoperative clinical course and long-term outcome were evaluated by a review of the hospital records and follow-up. RESULTS: The results of a barium swallow test series was positive in 38 cases (80.8%) and esophagogastroduodenoscopy was primarily diagnostic in 30 patients (63.8%). In all cases duodenal segmentectomy was attempted. Twenty-two patients underwent palliative gastrojejunal bypass and in 9 patients pancreaticoduodenectomy was performed. In 16 cases duodenal segmentectomy was performed after intestinal derotation. Anastomoses were performed manually in all cases. Fifteen of the resected patients died of recurrent disease. A median (SD) disease-free survival of 36 (23.6) months (range, 6-85 months) was observed. The median (SD) overall survival was 37.5 (23.9) months (range, 11-85 months), the overall 5-year survival rate was 23% (11 patients), and the actuarial 5-year survival rate was 51% (24 patients). CONCLUSIONS: Duodenal segmentectomy associated with intestinal derotation was shown to be a straightforward, safe procedure for the treatment of the primary adenocarcinoma of the third and fourth portions of the duodenum. This surgical procedure should be preferred to pancreaticoduodenectomy because it is associated with negligible rates of morbidity and mortality, while allowing for satisfactory margin clearance and adequate lymphadenectomy.

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.

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.