Vascular resection and reconstruction for hilar cholangiocarcinoma / 中华肝胆外科杂志

Completed surgical resection is the only treatment to patients with resectable hilar cholangiocarcinoma (HCCA).R0 resection is considered as a positive factor in long-term survive of patients.However,achieving negative surgical margins often ends in failure as the bile duct bifurcation is very close to the vascular inflow to the liver.Combined resection and reconstruction (CRR) of the portal vein (PV) and/or hepatic artery (HA),is introduced and has been performed widely.This paper focuses on this operation.

Laparoscopic combined organ resection for gastrointestinal cancer / 中华消化外科杂志

Currently adopted surgical approaches of laparoscopic combined organ resection for gastrointestinal cancer include laparoscopic pancreaticoduodenectomy and gastrectomy, laparoscopic gastrectomy combined distal pancreatectomy and splenectomy, laparoscopic gastrectomy and cholecystectomy, laparoscopic rectal anterior resection and total hysterectomy with bilateral salpingo-oophorectomy, and laparescopic colorectal and hepatic metastases resection. Satisfactory clinical outcomes of these procedures for gastrointestinal cancer were obtained in the reported cases. However, the number of cases in current studies on laparoscopic combined organ resection for gastrointestinal cancer was too small and no control groups involved, and multicenter clinical trials were not yet conducted. In conclusion, the future of laparoscopic combined organ resection for gastrointestinal cancer is promising, while its feasibility and safety require further investigation.

Clinicopathological Features and Prognostic Factors for Patients with Clinical T4 Gastric Cancer that Underwent Combined Resection of Invaded Organs

PURPOSE: The surgical treatment of gastric cancer that invades adjacent organs is a radical gastrectomy with combined resection including the adjacent organs or a palliative operation by performing either a gastrojejunostomy or gastrectomy. However, since it is impossible to determine the exact stage of the cancer, either T or N, in the case of palliative surgery, it is inappropriate to predict patient prognosis. This study analyzes the prognoses for patients whose final TNM stages are determined by a combined resection performed due to macroscopical infiltration into the adjacent organs. MATERIALS AND METHODS: Of 2,452 patients that underwent surgery for gastric cancer at our hospital from 1983 to 2002, we evaluated 102 patients where a combined resection was performed because direct infiltration into the adjacent organs was discovered. RESULTS: Univariate analysis showed that the survival rate differed by the depth of invasion into the gastric walls, the degree of lymph node metastasis, distant metastasis, pathological TNM stage, surgical curability, the location of tumor, and histological differentiation. By multivariate analysis, it was found that the surgical curability, the location of the tumor and the degree of lymph node metastasis were independent prognostic factors. CONCLUSION: It is suggested that even when infiltration into adjacent organs is suspected, radical surgery should be performed as to allow a prediction of prognosis through an exact determination of disease stage, and to improve the survival rate.

Surgical Treatment of Gastric Cancer Invading the Pancreatic Head or Duodenum

PURPOSE: Combined resection of an invaded organ in advanced gastric cancer (AGC) with infiltration of adjacent organs is essential to achieve R0 resection. However, when the tumor invades the head of the pancreas or duodenum, R0 resection interferes with the lower resectability and results in a higher morbidity. Wereviewed these cases retrospectively and considered the proper extent of the surgical resection. MATERIALS AND METHODS: We retrospectively analyzed cases where patients underwent surgery for gastric adenocarcinoma at the Department of Surgery, Presbyterian Medical Center, between January 1998 and December 2003. Among the 45 patients who were suspected to have pancreatic head or duodenum invasion by a primary tumor or metastatic lymph nodes based on the operative findings, we included 22 patients without incurable factors. The patients were classified into three groups: 4 patients that underwent a combined resection (PD group), 12 patients that underwent a palliative subtotal gastrectomy (STG group) and 6 patients that underwent bypass surgery only (GJ group). We analyzed the clinicopathological features, operative data and results. RESULTS: The patients of the PD group achieved R0 resection by PD with D3 Dissection in all Patients. A pancreatic fistula was observed in one patient (morbidity 25%). There was no surgery-associated mortality (mortality 0%). All patients of the PD group were in stage IV. However, the 2-year survival rate (SR) was 75% and the 5-year SR was 50%. Six patients of the STG group underwent surgery with marginal resection and the other six patients of the STG group had a positive distal resection margin. The 2-year SR was 41.7% and the 5-year SR was 16.7%. Most of the patients of group GJ were of old age (mean age: 72.7+/-8.6 years) or had chronic diseases. The 2-year SR was 0%. CONCLUSION: Combined resection of the pancreas and duodenum in AGC with pancreatic head invasion is relatively safe with moderate morbidity and a lower mortality. One can expect long-term survival if combined resectionis performed in cases without incurable factors.

Combined Resection of Invaded Organ in Patients with T4 Gastric Cancer

PURPOSE: Combined resection of invaded organ in advanced gastric cancer has been performed for complete removal of tumor and clearance of regional lymph node. However, higher morbidity and mortality associated with this procedure have been reported in recent large series and the efficacy of the procedure in survival remains controversial. In this study, we analyzed the efficacy of gastrectomy combined with invaded organ resection. METHODS: The medical records of 153 patients with T4 gastric carcinoma who underwent operation at Department of Surgery, Kangnam St. Mary's Hospital, The Catholic University of Korea from 1990 to 1998 were evaluated retrospectively. The patients were divided into three groups. Thirty five patients with combined resection were included in group I, and 72 patients with gastrectomy alone were in group II and 46 patients with no resection were included in group III. RESULTS: Pancreas was the most frequently invaded organ (100 patients: 65.4%), followed by colon (57 patients: 37.3%). The patients of group III were older than that of group I, and the tumor size was bigger in group I than group II. Incidence of the lower one third of the gastric cancer was higher in group II and III than that of group I. Histologically, undifferentiated carcinomas were more frequent in all groups. Postoperative complications in group I occurred in 11 patients (31.5%): intraabdominal abscess (4 patients: 11.4%), duodenal stump leakage (2 patients: 5.7%), renal failure (2 patients: 5.7%), and followed by bleeding, pulmonary complication, pancreatitis. Operative mortality of group I was 2.9%. The 5-year survival rate of group I and II was 15.6% and 3.1%, respectively and 0% in group III. In patients without peritoneal or liver metastasis, the 5-year survival rate of group I and II was 27.0% and 5.5%, respectively. But in patients with incurable factors, there was no difference in survival between the two groups. Median survival of group I with incurable factors was only 7 months. CONCLUSION: Combined resection of invaded organ in patients with T4 gastric carcinoma is a relatively safe procedure. Combined resection should be considered in patients without incurable factors such as peritoneal or liver metastasis.

The Change of Ocular Position According to the Amount of Recession after Superior Rectus Muscle Resection on White Rabbit

PURPOSE: To compare the effect of combined recession and resection on ocular position. METHODS: We designed a study with three groups of white rabbits. A recession was performed by differing the amount, 9 mm, 12 mm and 15 mm, according to the group, after 12 mm resection on superior rectus muscle. Before and 1 week after the operation, distance from lower margin to upper corneal limbus was measured using photographs. RESULTS: In 12 mm recession group, the distance before and after the operation was 9.44 mm and 9.19 mm respectively, showing no statistically significant change (P=0.2344). In 15 mm recession group, the ocular position showed significant depression, from 9.13 to 7.87 mm (P=0.0017), whereas in 9 mm recession group ocular position showed significant elevation from 9.11 to 10.85 mm (P=0.0078). CONCLUSIONS: The result of this study showed that when combined resection and recession on the same extraocular muscle were made in the same amount, eye alignment at primary ocular position was kept. Furthermore this procedure enables adjustable surgery to be considerable in incomitant strabismus.

Combined Resection in Advanced Gastric Cancer / 대한암학회지

PURPOSE: Prognosis of primary gastric cancer invading neighboring organs is very poor. However, with en bloc resection, a relatively favorable prognosis can be expected even in patients with such advanced cancer. But there has been controversy on the effectiveness of gastrectomy combined with en bloc resection of the invaded organs, and we conducted this study to evaluate the prognostic effects as well as the outcome of the combined resection. MATERIALS AND METHODS: Among 2,603 who underwent gastrectomy due to gastric carcinoma from January 1987 to December 1994 at the Department of Surgery, Yonsei University College of Medicine, 157 patients (6.0%) in whom curative combined resections of grossly invaded adjacent organs (cT4) were perfonned entered this study. Any case with distant metastasis was excluded. Comparisons and multivariate analysis between the invasion (pT3) group and the non-invasion (pT4) group were made for age, sex, tumor size, location, Borrmann type, depth of invasion, lymph node metastasis, histologic type and 5-year survival rate. RESULTS: One-organ combined resection was done in 60 (38.2%) patients; Two-organ, in 80 (51.0%) patients; and three-organ, in 17 (10.8%) patients. Most commonly combined organ was distal pancreas and transverse colon was the next. Histologic confirmation of invasion was made in 40.9%. 157 patients with T4 were divided into pT3 or pT4. Significant differences were found in type of operation, location of tumor, and TNM staging. Postoperative complications of combined resection were observed in 48 cases (30.6%) and the wound infection was the most frequent one. There were only 2 cases (1.3%) of immediate postoperative mortality in the combined group, and the causes of death were pulmonary complication and acute renal failure. Five-year survival rate (5-YSR) of pT3 group was 43.0% and that of pT4 was 26.2%. In comparison of 5-YSR according to TNM stages, no significant difference was found between pT3 and pT4 (45.0% vs. 66.7% in IIIa; 25.4% vs. 18.4% in IV). No difference of 5-YSR was observed in the groups categorized according to the number of resected organs. The comparison of 5-YSR between the 157 curatively-combined cases and the 63 palliatively-combined cases showed a significant difference (35.6% vs. 4.2%, p=0.000). Multivariate analysis showed that lymph node metastasis and microscopic tumor invasion served as significant parametets. CONCLUSION: En bloc combined resection of adjacent invaded organs along with systematic lymph node dissection would be beneficial to gastric cancer patients with neighboring organ invasion.