Quantitative evaluation of hepatic steatosis using attenuation imaging in a pediatric population: a prospective study.

BACKGROUND: Obesity and fatty-liver disease are increasingly common in children. Hepatic steatosis is becoming the most common cause of chronic liver disease during childhood. There is a need for noninvasive imaging methods that are easily accessible, safe and do not require sedation in the diagnosis and follow-up of the disease. OBJECTIVE: In this study, the diagnostic role of ultrasound attenuation imaging (ATI) in the detection and staging of fatty liver in the pediatric age group was investigated using the magnetic resonance imaging (MRI)-proton density fat fraction as the reference. MATERIALS AND METHODS: A total of 140 children with both ATI and MRI constituted the study group. Fatty liver was classified as mild (S1, defined as ≥ 5% steatosis), moderate (S2, defined as ≥ 10% steatosis), or severe (S3, defined as ≥ 20% steatosis) according to MRI-proton density fat fraction values. MRI studies were performed on the same 1.5-tesla (T) MR device without sedation and contrast agent. Ultrasound examinations were performed independently by two radiology residents blinded to the MRI data. RESULTS: While no steatosis was detected in half of the cases, S1 steatosis was found in 31 patients (22.1%), S2 in 29 patients (20.7%) and S3 in 10 patients (7.1%). A strong correlation was found between attenuation coefficient and MRI-proton density fat fraction values (r = 0.88, 95% CI 0.84-0.92; P < 0.001). The area under the receiver operating characteristic curve values of ATI were calculated as 0.944 for S > 0, 0.976 for S > 1 and 0.970 for S > 2, based on 0.65, 0.74 and 0.91 dB/cm/MHz cut-off values, respectively. The intraclass correlation coefficient values for the inter-observer agreement and test-retest reproducibility were calculated as 0.90 and 0.91, respectively. CONCLUSION: Ultrasound attenuation imaging is a promising noninvasive method for the quantitative evaluation of fatty liver disease.

Utility of lung radiodensity ratios in diagnosis of radiolucent foreign body aspiration in children: a practical approach.

OBJECTIVE: To evaluate the utility of radiodensity ratio between lungs on chest X-ray for the diagnosis of radiolucent foreign body aspiration (FBA) in children. METHODS: X-rays of 33 patients with confirmed diagnosis of FBA by bronchoscopy were compared to 66 control patients. We divided the study group into three subgroups: symmetric (13-patients), right-oblique (RO;12-patients) and left-oblique (LO;8-patients). RESULTS: When we compared FBA-symmetric-subgroup to symmetric-control-group, FBA-RO-subgroup to RO-control-group and FBA-LO-subgroup to LO-control-group, radiodensity ratios were significantly higher in the FBA subgroups. CONCLUSION: The calculated radiodensity ratio between lungs on X-ray would be a useful and practical tool for the diagnosis of radiolucent FBA in children.

A confounding rib variation: bilateral symmetric aberrant posterior rib articulations and bridgings.

INTRODUCTION: Although mild bone angulation with osseous enlargement often suggests fractures with callus formation, in some cases the diagnosis is synchondrosis. CASE REPORT: We present a rare variation of the chest wall in a 15-year-old male with a history of lymphoma. Bilateral multi-level posterior rib enlargements revealing mild 18F-fluorodeoxyglucose uptake were detected via positron-emission tomography/computed tomography. The variations were identified as healing fractures, although the more accurate diagnosis was determined to be multi-level posterior rib synchondroses with consecutive bridgings. Although variant bone anatomies are commonly seen in radiological practice, such multiple symmetrical posterior rib synchondroses associated with consecutive bridgings and articulations have not been clearly demonstrated before. CONCLUSION: Awareness of such a rare combination of a well-known variation is crucial for radiologists to exclude malignancies, possibility of fracture and suspicion of child abuse.

Oncologic results of laparoscopic liver resection for malignant liver tumors.

BACKGROUND: There are scant data regarding oncologic outcomes of laparoscopic liver resection (LLR). The aim of this study is to analyze the oncologic outcomes of LLR for malignant liver tumors (MLT). METHODS: This was a prospective IRB-approved study of 123 patients with MLT undergoing LLR. Kaplan-Meier disease-free (DFS) and overall survival (OS) was calculated. RESULTS: Tumor type was colorectal in 61%, hepatocellular cancer in 21%, neuroendocrine in 5% and others in 13%. Mean tumor size was 3.2 ± 1.9 cm and number of tumors 1.6 ± 1.2. A wedge resection or segmentectomy was performed in 63.4%, bisegmentectomy in 24.4%, and hemihepatectomy in 12.2%. Procedures were totally laparoscopic in 67% and hand-assisted in 33%. Operative time was 235.2 ± 94.3 min, and conversion rate 7.3%. An R0 resection was achieved in 90% of patients and 94% of tumors. Median hospital stay was 3 days. Morbidity was 22% and mortality 0.8%. For patients with colorectal liver metastasis, DFS and OS at 2 years was 47% and 88%, respectively. CONCLUSIONS: This study shows that LLR is a safe and efficacious treatment for selected patients with MLT. Complete resection and margin recurrence rate are comparable to open series in the literature.

The utility of neck ultrasound and sestamibi scans in patients with secondary and tertiary hyperparathyroidism.

INTRODUCTION: Secondary hyperparathyroidism (SHPT) and tertiary hyperparathyroidism (THPT) are disease entities in patients with chronic kidney disease that are caused by parathyroid hyperplasia. The role of preoperative localization studies in patients undergoing parathyroidectomy for these conditions remains poorly defined. AIM: To evaluate the utility of surgeon-performed neck ultrasound (US) as well as sestamibi scans in the localization of parathyroid glands in patients with SHPT/THPT. MATERIALS AND METHODS: A retrospective analysis of patients with SHPT/THPT who underwent parathyroidectomy at a single institution. Results of preoperative localization studies were compared to intraoperative findings. RESULTS: One hundred and three patients underwent parathyroidectomy for SHPT/THPT. All patients underwent surgeon-performed neck US, while 92 (89%) underwent sestamibi scans. US failed to localize any of the parathyroids in 4 patients (3.8%), while sestamibi was negative in 11 (12%). Forty-seven ectopic glands were identified in 38 patients in whom sestamibi was performed. In five patients (13%), ectopic glands were identified by both modalities, by US only in 6 (16%), by sestamibi only in 8 (21%), and by neither study in 19 patients (50%). US showed new thyroid nodules in 19 patients (18.4 %), leading to lobectomy or thyroidectomy at the time of parathyroidectomy in 16 patients (15.5%). Pathology showed malignancy in 7 patients (6.8%). CONCLUSION: US and MIBI offer little benefit in localizing ectopic glands and rarely change the conduct of a standard four-gland exploration. Although there was a benefit of US in the assessment of thyroid nodules, in only 8.7% of patients was sestamibi of benefit in identifying ectopic glands.

An analysis of whether surgeon-performed neck ultrasound can be used as the main localizing study in primary hyperparathyroidism.

BACKGROUND: Tc-99 sestamibi (MIBI) scan is the imaging study most frequently used in primary hyperparathyroidism (PHP). Transcutaneous cervical ultrasonography (US) is the other modality used for preoperative localization. The aim of this study was to determine whether surgeon-performed neck US can be used as the primary localizing study in PHP. METHODS: This was a prospective study of 1,000 consecutive patients with first-time, sporadic PHP who underwent parathyroidectomy at a tertiary academic center. All patients had surgeon-performed neck US and MIBI before bilateral neck exploration. RESULTS: The findings at exploration were 72% single adenoma, 15% double adenoma, and 13% hyperplasia. When US suggested single-gland disease (n = 842), MIBI was concordant in 82.5%, discordant and false in 8%, negative in 7%, and discordant but correct in 2.5%. When US suggested multigland disease (n = 68), MIBI was concordant in 47%, discordant and false in 41%, and negative in 12%. When US was negative (n = 90), MIBI was positive and correct in 43%, negative in 31%, and positive but false in 26%. Surgeon-performed neck US identified unrecognized thyroid nodules in 326 patients (33%), which led to fine-needle aspiration biopsy in 161 (49%) patients and thyroid surgery in 103 (32%) patients, with a final diagnosis of thyroid cancer in 24 (7%) patients. CONCLUSION: Our results show that MIBI provides additional useful information in only a minority of patients with a positive US in PHP. Nevertheless, MIBI benefits about half of patients with a negative US. Because one-third of this patient population has unrecognized thyroid nodules as well, we propose that the most cost-effective algorithm would be to do US first and reserve MIBI for US-negative cases.

Predictors of recurrence in pheochromocytoma.

BACKGROUND: The recurrence rate of pheochromocytoma after adrenalectomy is 6.5-16.5%. This study aims to identify predictors of recurrence and optimal biochemical testing and imaging for detecting the recurrence of pheochromocytoma. METHODS: In this retrospective study we reviewed all patients who underwent adrenalectomy for pheochromocytoma during a 14-year period at a single institution. RESULTS: One hundred thirty-five patients had adrenalectomy for pheochromocytoma. Eight patients (6%) developed recurrent disease. The median time from initial operation to diagnosis of recurrence was 35 months. On multivariate analysis, tumor size >5 cm was an independent predictor of recurrence. One patient with recurrence died, 4 had stable disease, 2 had progression of disease, and 1 was cured. Recurrence was diagnosed by increases in plasma and/or urinary metanephrines and positive imaging in 6 patients (75%), and by positive imaging and normal biochemical levels in 2 patients (25%). CONCLUSION: Patients with large tumors (>5 cm) should be followed vigilantly for recurrence. Because 25% of patients with recurrence had normal biochemical levels, we recommend routine imaging and testing of plasma or urinary metanephrines for prompt diagnosis of recurrence.

A new risk stratification algorithm for the management of patients with adrenal incidentalomas.

BACKGROUND: Although adrenal incidentalomas (AI) are detected in ≤5% of patients undergoing chest and abdominal computed tomography (CT), their management is challenging. The current guidelines include recommendations from the National Institutes of Health, the American Association of Endocrine Surgeons (AAES), and the American Association for Cancer Education (AACE). The aim of this study was to develop a new risk stratification model and compare its performance against the existing guidelines for managing AI. METHODS: A risk stratification model was designed by assigning points for adrenal size (1, 2, or 3 points for tumors <4, 4-6, or >6 cm, respectively) and Hounsfield unit (HU) density on noncontrast CT (1, 2, or 3 points for HU <10, 10-20, or >20, respectively). This model was applied retrospectively to 157 patients with AI managed in an endocrine surgery clinic to assign a score to each tumor. The utility of this model versus the AAES/AACE guidelines was assessed. RESULTS: Of the 157 patients, 54 (34%), had tumors <4 cm with HU <10 (a score of 2). One third of these were hormonally active on biochemical workup and underwent adrenalectomy. The remaining two thirds were nonsecretory lesions and have been followed conservatively with annual testing. In 103 patients (66%), the adrenal mass was >4 cm and/or had indeterminate features on noncontrast CT (HU >10, irregular borders, heterogeneity), and adrenalectomy was performed after hormonal evaluation was completed (10 were hormonally active on biochemical testing). Seven of these patients (7%) had adrenocortical cancer on final pathology with tumor size <4 cm in 0, 4-6 cm in 1, and >6 cm in 5 patients. Of the hormonally inactive patients, 32% had a score of 3, 38% 4, and 30% 5 or 6. The incidence of adrenocortical cancer in these subgroups was 0, 0, and 25%, respectively. CONCLUSION: This study shows that an algorithm that utilizes the hormonal activity at the first decision step followed by a consolidated risk stratification, based on tumor size and HU density, has a potential to spare a substantial number of patients from unnecessary "diagnostic" surgery for AI.

Bilateral posterior retroperitoneal robotic adrenalectomy for ACTH-independent Cushing syndrome.

BACKGROUND: Laparoscopic posterior retroperitoneal (PR) adrenalectomy is preferable in patients with bilateral adrenal masses, as it obviates the need for repositioning. Robotic adrenalectomy has been reported to improve surgeon ergonomics and facilitate dissection. Although robotic bilateral transabdominal lateral adrenalectomy has been described in the literature, to our knowledge, the robotic bilateral PR approach has not been reported before. Herein, we report a case of a bilateral macronodular adrenal hyperplasia managed with robotic bilateral PR adrenalectomy. METHODS: A 60-year-old man was incidentally found to have bilateral macronodular adrenal masses on a computed tomography scan performed for abdominal pain. His laboratory workup was significant for adrenocorticotropic hormone-independent bilateral macronodular adrenal hyperplasia. He was consented for bilateral PR robotic adrenalectomy. RESULTS: The procedure was performed robotically through a PR approach. Three robotic arms were used for the procedure on both sides using 5-mm instruments. Bilateral adrenalectomy was performed with a skin-to-skin operative time of 268 minutes (98 min for the left and 170 min for the right side). The patient was discharged on postoperative day 1 uneventfully on steroid supplementation. The final pathology revealed bilateral adrenal cortical hyperplasia. CONCLUSIONS: To our knowledge, this is the first report of bilateral robotic PR adrenalectomy. This technique enables the resection of bilateral tumors without the need to reposition and may also provide potential advantages over laparoscopy, regarding the ease of dissection and surgeon ergonomics.

A critical analysis of postoperative morbidity and mortality after laparoscopic radiofrequency ablation of liver tumors.

BACKGROUND: Although the laparoscopic approach provides certain advantages over the percutaneous radiofrequency thermal ablation (RFA), the morbidity needs to be defined. The aim of this study is to analyze the morbidity and underlying risk factors after laparoscopic RFA of liver tumors. METHODS: Between 1996 and 2012, 910 patients underwent 1,207 RFA procedures for malignant liver tumors in a tertiary academic center. The 90-day morbidity and mortality were extracted from a prospective IRB-approved database. Statistical analyses were performed using regression, t, and χ (2) tests. RESULTS: Complications occurred in 50 patients (4 %) and were gastrointestinal in 13 patients (1.1 %), infections in 10 (0.8 %), hemorrhagic in 9 (0.7 %), urinary in 7 (0.6 %), cardiac in 4 (0.3 %), pulmonary in 3 (0.3 %), hematologic in 2 (0.2 %), and neurologic in 2 (0.2 %). The complication rates for an RFA done alone (5 %) versus concomitantly with ancillary procedure (6 %) were similar (p = .6). In all patients who developed postoperative bleeding from the liver, the ablations had been performed on lesions located in the right posterior sector. Of 9 patients with bleeding, 5 (55 %) required a laparotomy. Also, 60 % of liver abscesses occurred in patients with a prior bilioenteric anastomosis (BEA). The 90-day mortality was 0.4 % (n = 5). Hospital stay was 1.2 ± 0.1 days and was prolonged to 4.4 ± 0.3 days in case of complications. CONCLUSIONS: This study describes the morbidity and mortality to be expected after a laparoscopic RFA procedure. Our results show that additional caution should be used to prevent bleeding complications in patients with tumors located in the right posterior sector and infections in patients with a history of BEA.

The utility of intraoperative ultrasound in modified radical neck dissection: a pilot study.

BACKGROUND: Although the value of surgeon-performed neck ultrasound (SPUS) for thyroid nodules has been validated, the utility of intraoperative ultrasound (US) in modified radical neck dissection (MRND) has not been reported in the literature. The aim of this study was to analyze the utility of intraoperative SPUS in assessing the completeness of MRND for thyroid cancer. METHODS: Between 2007 and 2011, a total of 25 patients underwent MRND by 1 surgeon for thyroid cancer. All patients underwent intraoperative SPUS, which was repeated at the end of the neck dissection (completion US) to look for missed lymph nodes (LNs). RESULTS: There were 10 male and 15 female patients. Pathology included 23 papillary and 2 medullary carcinomas. The number of LNs removed per case was 23 ± 2, and the number of positive was LNs 5 ± 1. In 4 (16%) cases, intraoperative US detected 7 residual LNs, which would have been missed, if completion US were not done. These missed LNs were located in low-level IV (3 nodes), high-level II (2 nodes), and posterior level V (2 nodes) and measured 1.4 ± 0.2 cm. At follow-up, recurrence was seen in 2 (8%) patients, including a superior mediastinal recurrence in a patient with tall cell cancer and a jugular LN recurrence at level II in another patient with papillary thyroid cancer. CONCLUSION: This pilot study shows that intraoperative SPUS can help assess the completeness of MRND. According to our results, intraoperative completion US identifies LNs missed by palpation 16% of the time.

Initial experience with a new articulating energy device for laparoscopic liver resection.

BACKGROUND: Although significant advances have been made in laparoscopic liver resection (LLR), most techniques still rely on multiple energy devices and staplers, which increase operative costs. The aim of this study was to report the initial results of a new multifunctional energy device for hepatic parenchymal transection. METHODS: Fourteen patients who underwent LLR using this new device were compared to 20 patients who had LLR using current laparoscopic techniques (CL). Data were collected prospectively. RESULTS: The groups were similar demographics and tumor type and size. Although the type of resection was similar between the groups, the parenchymal transection time was less in the Caiman group (32 ± 5 vs. 63 ± 4 min, respectively, p = 0.0001). The operative time was similar (194 ± 21 vs. 233 ± 16 min, respectively, p = 0.158). There was reduction of the number of advanced instrumentation used in the Caiman group, including the staplers. Estimated blood loss, size of surgical margin, and hospital stay were similar. There was no mortality, and morbidity was 7 % in the Caiman and 20 % in the CL group. CONCLUSIONS: This initial study shows that the new device is safe and efficient for LLR. Its main advantage is shortening of hepatic parenchymal transection time. This has implications for increasing efficiency and cost saving in LLR.

Clinical scenarios associated with local recurrence after laparoscopic radiofrequency thermal ablation of colorectal liver metastases.

BACKGROUND: Over the last decade, radiofrequency thermal ablation (RFA) has been incorporated into the treatment algorithm of patients with unresectable colorectal liver metastases (CLM). For this population, the local recurrence (LR) rate is a key parameter used to assess the success of RFA. LR is defined as development of new tumor abutting and/or in 1 cm of an ablation zone. The aim of this study is to correlate LR with other hepatic or extrahepatic recurrence and patient survival. METHODS: Between 2000 and 2011, 252 patients with CLM underwent laparoscopic RFA of 883 lesions. These patients were followed under a prospective protocol with quarterly liver computed tomography and blood work, including carcinoembryonic antigen levels quarterly for the first 2 years and then biannually. Clinical scenarios associated with LR were identified and categorized as being "isolated LR," "LR associated with new liver disease," or "LR associated with systemic disease." Demographic, clinical, and survival data were assessed using analysis of variance, Chi-square test, and univariate and multivariate Kaplan-Meier analysis. RESULTS: One hundred eighteen patients (47%) developed LR after their initial laparoscopic RFA. These were 85 men (72%) and 33 women (28%), with a mean age of 70 ± 8 years. For this cohort, the mean of number of lesions was 3.1 ± 0.2 cm (range, 1-11) and dominant tumor size 2.9 ± 0.1 cm (range, 0.7-6.5) at the time of initial RFA. The LR rate per lesion was 29%. Of the patients who developed treatment failure at the RFA site, this was an isolated LR in 31 (26%) patients, associated with new liver disease in 51 (43%) and systemic metastases in 36 patients (31%). When patients with different clinical scenarios associated with LR were compared, no clinical predictors were identified to differentiate these subgroups. At a median follow up of 30 months (range, 3-113), the Kaplan-Meier median overall survival (OS) for patients with and without LR were 28 vs 31 months, respectively (P = .103). The OS for patients whose LR was isolated, associated with new liver and systemic recurrences was 39, 26, and 22 months, respectively (P = .009). CONCLUSION: This study shows that, although the presence of LR does not negatively impact on survival, the pattern of recurrent disease does. LR after RFA for CLM is most often associated with new liver and systemic recurrences, reflecting the aggressive biology of cancer in patients channeled to this treatment modality.

A comparison of laparoscopic radiofrequency ablation versus systemic therapy alone in the treatment of breast cancer metastasis to the liver.

OBJECTIVES: There is controversy about the roles of locoregional therapies in patients with liver metastases from breast cancer (LMBC). The aim of this study was to analyse survival after laparoscopic radiofrequency ablation (RFA) of LMBC and to compare this with survival in patients receiving systemic therapy (ST) alone. METHODS: During 1996-2011, 24 patients who had failed to respond or had shown an incomplete response to ST underwent laparoscopic RFA for LMBC. Outcomes in these patients were compared with those in 32 patients with LMBC matched by tumour size and number, but treated with ST alone. Clinical parameters and overall survival were compared using t-tests, chi-squared tests and Kaplan-Meier analysis. RESULTS: The groups were similar in hormone receptor status and chemotherapy exposure. In the laparoscopic RFA and ST groups, respectively, the mean ± standard deviation size of the dominant liver tumour and the number of tumours per patient were 3.7 ± 0.4 cm and 2.4 ± 0.4 cm, and 2.6 ± 0.4 tumours and 3.3 ± 0.4 tumours, respectively. These differences were not significant. At a median follow-up of 20 months in the laparoscopic RFA group, 42% of patients were found to have developed local liver recurrence, 63% had developed new liver disease and 38% had developed extrahepatic disease. Overall survival after the diagnosis of liver metastasis was 47 months in the laparoscopic RFA group and 9 months in the ST-only group (P = 0.0001). Five-year survival after the diagnosis of liver metastasis was 29% in the RFA group and 0% in the ST-only group. CONCLUSIONS: This is the first study to compare outcomes in RFA and ST, respectively, in LMBC. The results show that survival after laparoscopic RFA plus ST is better than that after ST alone.

Robotic versus laparoscopic adrenalectomy for pheochromocytoma.

BACKGROUND: Although initial reports demonstrated the safety and feasibility of robotic adrenalectomy (RA), there are scant data on the use of this approach for pheochromocytoma. The aim of this study is to compare perioperative outcomes and efficacy of RA versus laparoscopic adrenalectomy (LA) for pheochromocytoma. METHODS: Within 3 years, 25 patients underwent 26 RA procedures for pheochromocytoma. These patients were compared with 40 patients who underwent 42 LA procedures before the start of the robotic program. Data were retrospectively reviewed from a prospectively maintained, IRB-approved adrenal database. RESULTS: Demographic and clinical parameters at presentation were similar between the groups, except for a larger tumor size in the robotic group. In both groups, skin-to-skin operative time, estimated blood loss less, and intraoperative hemodynamic parameters were similar. The conversion to open rate was 3.9 % in the robotic and 7.5 % in the laparoscopic group (p = .532). There was no morbidity or mortality in the robotic group; morbidity was 10 % (p = .041) and mortality 2.5 % in the laparoscopic group. The pain score on postoperative day 1 was lower, and the length of hospital stay shorter in the robotic group (1.2 ± .1 vs. 1.7 ± .1 days, p = .036). CONCLUSIONS: To our knowledge, this is the first study comparing robotic versus laparoscopic resection of pheochromocytoma. Our results show that the robotic approach is similar to the laparoscopic regarding safety and efficacy. The lower morbidity, less immediate postoperative pain, and shorter hospital stay observed in the robotic approach warrant further investigation in future larger studies.

Robotic endocrine surgery: state of the art.

Over the last decade, developments in technology have led a rapid progress in robotic endocrine surgery applications. Robotics is attractive to the surgeon because of the three-dimensional image quality, articulating instruments, and stable surgical platform. Safety and effectiveness of robotic adrenalectomy and thyroidectomy have been shown in many studies. While these robotic procedures offer better ergonomics for the surgeon, they provide similar outcomes compared to the laparoscopic approach for adrenalectomy and better cosmetic results versus the conventional option for thyroidectomy. Recently, while the robotic approach for adrenalectomy has been popularized, enthusiasm for robotic thyroidectomy has decreased. In the present review we aim to describe emerging robotic procedures and review the literature regarding outcomes.

Efficacy of laparoscopic radiofrequency ablation for the treatment of patients with small solitary colorectal liver metastasis.

BACKGROUND: Although radiofrequency ablation (RFA) has been incorporated to the treatment algorithm of patients with unresectable colorectal liver metastasis (CLM), its utility in patients with resectable disease has not been well studied. The aims of this study were to define the clinical profile of patients with a solitary CLM who underwent laparoscopic RFA and to analyze their oncologic outcomes. METHODS: Between 2000 and 2011, 44 patients underwent laparoscopic RFA and 60 patients resection of solitary CLM ≤3 cm. Data were analyzed from a prospectively maintained institutional review board-approved database using Student's t test, Chi-square, and Kaplan-Meier tests. RESULTS: The indications for RFA were patient decision in 61% (n = 27), comorbidities in 34% (n = 15), and intraoperative findings in 5% (n = 2). In comparison with the resection group, RFA patients had a greater American Society of Anesthesiologists score (3.0 ± 0.1 vs 2.6 ± 0.1, respectively; P = .002), more frequent incidence of cardiopulmonary comorbidities (60% vs 38%, respectively; P = .045), and tumors located deeper in the liver parenchyma (39% vs 12%) that would have required a formal lobectomy. The 2 groups were otherwise similar for age, gender, carcinoembrradyogenic antigen, synchronous versus metachronous presentation of CLM, tumor size, and tumor and nodal status of primary colorectal cancer. The local recurrence rate was 18% after RFA and 4% after resection (P = .012). The overall Kaplan-Meier, cancer-specific, 5-year survival was 47% for RFA and 57% for resection (P = .464). Median disease-free survival was 25 months after RFA and 22 months after resection (P = .973). CONCLUSION: Our results suggest that laparoscopic RFA might spare a number of patients at greater risk with a small solitary CLM the risk of morbidity from a formal liver resection. Furthermore, laparoscopic RFA might also be acceptable as the first line of therapy for patients with tumors that otherwise would have required a formal lobectomy or open resection. Nevertheless, the local recurrence rate of RFA should be kept in mind and the patients followed closely to treat failures promptly.

Complementary use of resection and radiofrequency ablation for the treatment of colorectal liver metastases: an analysis of 395 patients.

BACKGROUND: Liver resection and radiofrequency ablation (RFA) are two surgical options in the treatment of patients with colorectal liver metastases (CLM). The aim of this study was to analyze patient characteristics and outcomes after resection and RFA for CLM from a single center. METHODS: Between 2000 and 2010, 395 patients with CLM undergoing RFA (n = 295), liver resection (n = 94) or both (n = 6) were identified from a prospective IRB-approved database. Demographic, clinical and survival data were analyzed using univariate and multivariate analyses. RESULTS: RFA patients had more comorbidities, number of liver tumors and a higher incidence of extrahepatic disease compared to the Resection patients. The 5-year overall actual survival was 17 % in the RFA, 58 % in the Resection group (p = 0.001). On multivariate analysis, multiple liver tumors, dominant lesion >3 cm, and CEA >10 ng/ml were independent predictors of overall survival. Patients were followed for a median of 20 ± 1 months. Liver and extrahepatic recurrences were seen in 69 %, and 29 % of the patients in the RFA, and 40 %, and 19 % of the patients in the Resection group, respectively. CONCLUSIONS: In this large surgical series, we described the characteristics and oncologic outcomes of patients undergoing resection or RFA for CLM. By having both options available, we were able to surgically treat a large number of patients presenting with different degrees of liver tumor burden and co-morbidities, and also manage liver recurrences in follow-up.