[Combined multimodal treatment for liver and lung metastasis from colorectal cancer: a new therapeutic option?]. / Il trattamento multimodale combinato delle metastasi epatiche e polmonari da cancro colorettale: una nuova opzione terapeutica?

The authors analyse which therapeutic strategy to adopt on the basis of prognostic factors and staging of hepatic and pulmonary metastases from colorectal cancer. They underline the effectiveness of combined multimodal therapy in the treatment of very advanced metastatic stages. 218 patients with metastases from colorectal cancer (12 pulmonary and 206 hepatic metastases) were treated from January 1980 to October 2000. Among these patients, 159 underwent surgery (4 pulmonary and 155 hepatic resections), 16 were reoperated on for metastatic relapse, 14 with multiple metastases underwent locoregional therapy and 29, deemed unresectable initially, were treated with neoadjuvant chemo- and radiotherapy. In the operated patient group the 5-year actuarial survival rate was 22% with an operative mortality of 3.8% and a morbidity of 17.5%. The 16 patients reoperated on for metastatic relapse had a 5-year actuarial survival of 21% with an operative mortality of 6.2% and a morbidity of 15.8%. The 14 patients treated with locoregional therapy had a median survival of 6 months whereas the 29 patients treated in two different periods with combined multimodal treatment had a response rate of 59.2%. Five patients had a complete response and 4 are currently disease-free. Surgical resection is at present the best known treatment for metastatic disease. In very advanced, as yet undisseminated stages, in which there is no surgical indication for metastases a neoadjuvant treatment is proposed if the primary tumour has already been completely resected. The aim of this therapeutic strategy, called combined multimodal therapy, is to obtain the disease regression with the aid of systemic chemo- and radiotherapy and to offer a chance of re-staging the disease.

Intrahepatic lithiasis above a bilio-digestive anastomosis.

The authors review their experience of twenty-five cases of intrahepatic lithiasis proximal to a bilio-digestive anastomotic stricture. Patients were operated on between 1970 and 1990, with a later follow-up in 1993. The pathogenesis of stone formation, in these cases, was relatable to multiple factors: biliary infection, presence of lithogenic nuclei (e.g. foreign bodies such as suture stitches), biliary stasis due to the stenosis. Management of this peculiar disease must take into account both surgical options and percutaneous as well as endoscopic methods. Our approach is the reconstruction of the stenotic anastomosis at its highest point, associated with intraoperative lithotomy followed by post-operative lithotomy and lithotripsy (if necessary) using PTCS (percutaneous transhepatic cholangioscopy). The best results are achieved with cooperation between surgeon, radiologist and endoscopist, aimed at preventing post-operative complications and severe consequences for the patient.

Neoplasm of the hepatic hilum: the role of resection.

A series of one hundred cases of primitive tumors of the biliary confluence (Klatskin tumor) observed between 1970 and 1990 are reviewed with respect to the variations occurring in the diagnostic backup and treatment policy. The need for peroperative staging is noted: On the basis of their clinical experience, the authors restricted the preoperative study to those investigations providing more information about endo- and exobiliary diffusion of tumoral mass (ultrasound, direct cholangiography). The review demonstrates the possibilities of a surgical approach to a palliative or resectional treatment in all patients in whom no local or general contraindications are present. Other cases are treated with percutaneous or endoscopic biliary stenting. The authors conclude that tumor resection with bilio-digestive anastomosis is the treatment of choice in selected patients, and results in a better quality of life with an improved "comfort index".

Primitive hepatic hilum neoplasm.

One hundred ten cases of primitive hepatic hilum neoplasms (Klatskin tumor) observed from January 1970 to June 1992 are reviewed and the variations occurring in the diagnostic back-up and treatment policy are considered. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations supplying most informations about endo- and esobiliary diffusion of the tumoral mass (ultrasound, direct cholangiography, portography). This paper demonstrates that a surgical approach with both palliative or resective aims is suitable for all patients with no local or general contraindications. Other cases are treated with percutaneous or endoscopic biliary stenting. The authors conclude by pointing out that tumoral resection with biliodigestive anastomosis is in any case the treatment of choice in these patients as it gives a better quality of life (improved "comfort index").

Percutaneous transhepatic biliary drainage--twelve years' experience.

Our experience with percutaneous transhepatic biliary drainage in a total of 362 patients carried out between January 1977 and December 1988 is described. Three hundred and fifty drains were correctly placed, and results were good in 285 (81.5%), fair in 53 (15.1%) and poor in 12 (3.4%). In 12 of the total number of cases (3.4%) it was not possible to position the drain effectively. The mortality rate of the method was 0.8% (3 cases). Complications were as follows: obstruction 7 (1.9%), dislodgement 15 (4.1%), hemobilia 15 (4.1%), hemoperitoneum 1 (0.2%), cholangitis 6 (1.6%), and choleperitoneum 10 (2.7%). In view of the good results and low incidence of complications the conclusion is that in skilled hands, percutaneous transhepatic biliary drainage is a very useful method that should be available in any center specializing in hepatobiliary surgery.

Percutaneous transhepatic biliary drainage twelve years' experience.

Experience with a total of 362 percutaneous transhepatic biliary drainage (PTBD) carried out between January 1977 and December 1988, is described. Of these, 350 drains were correctly placed and 285 (81.5%) showed a good result, 53 (15.1%) a fair result and 12 (3.4%) a poor outcome. In 12 of the total number of cases (3.4%) it was not possible to position the drain effectively. The mortality rate of the method was 0.8% (3 cases). Complications were as follows: obstruction 7 (1.9%), dislodgement 15 (4.1%), hemobilia 15 (4.1%), hemoperitoneum 1 (0.2%), cholangitis 6 (1.6%), choleperitoneum 10 (2.7%). In view of the good results and low incidence of complications it is concluded that in skilled hands PTBD is a very useful method that should be available at any center specializing in hepatobiliary surgery.

Percutaneous fibercholangioscopies.

This is a report on our experience in 309 percutaneous fiberendoscopies of the biliary tract done in 106 patients of the 115 scheduled for the procedure. We describe the relevant approaches, techniques, complications and results. In particular, percutaneous transhepatic cholangioscopies (PTCS) were accomplished on transhepatic percutaneous drainages located radiologically in 35 patients: in 13 for differential diagnosis to distinguish between malignant and benign stenoses (diagnostic accuracy in 92% of the biopsies), in 22 cases with therapeutic intent, including 14 lithotomies for extrahepatic biliary tract calculosis, combined in 4 cases with a simple dilatation of the papilla and a percutaneous "descending" papillotomy; in 7 patients a dilatation of the biliary tract (BT) or of the stenosis of a biliodigestive anastomosis was accomplished (malignant in 4 patients, benign in 3 patients). In 38 patients postoperative percutaneous transhepatic cholangioscopies were performed along surgically located transparietohepatic drains, both to assess the biliodigestive anastomosis healing process carried out by two different techniques (30 patients), and to complete the biliary tract drainage as part of the primary and secondary endoscopic surgical treatment of massive intrahepatic lithiasis. In two further patients affected by such pathology, PTCS was done in combination with fibercholangioscopy performed via a transjejunal approach using a Völker drain on a Y-shaped loop. Nine of these patients were treated successfully and one patient later underwent a left hepatectomy, since attempts to drain that area had remained unsuccessful. The transjejunal approach was carried out in 3 patients as a diagnostic measure: in two cases to check the lithotomy, and in one case to check a cholangiojejunal anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Technique and endoscopic monitoring of the healing process in bilioenteric anastomoses.

Thirty-three patients were given cholangiojejunoanastomoses: 13 for benign postoperative stenoses of the biliary tract (BT) with or without lithiasis; five for massive intra and extra-hepatic lithiasis; 15 for malignant stenoses on the upper third of the biliary ways. The 15 patients in Group A were given a muco-mucosal anastomosis and the 18 in Group B extramucosal anastomosis after excision of the excess mucosa on the jejunotomy. In both groups an interrupted suture using fine, slow-absorption thread was employed. Three patients (two from Group A and one from Group B) were excluded from the study due to postoperative filtration of the anastomosis. Transhepatic cholangioscopic monitoring of the healing process on the 15th, 20th, 30th and 40th day showed that while both types of anastomosis were equally secure, the extramucosal suture after excision of excess mucosa produced wider anastomoses and is therefore advisable in all cases of bilioenteric anastomosis (BEA) but especially when the biliary ways are narrow or tendentially thin-walled.

Percutaneous transhepatic cholangioscopy.

The authors present their experience with 39 cases of pre and postoperative percutaneous transhepatic cholangioscopy (PTCS), listing the indications and advantages of this new tool for the study of the biliary tract and the therapy of several pathological conditions that would otherwise be untreatable.