Anastomotic leakage and functional outcomes following total mesorectal excision with delayed and immediate colo-anal anastomosis for rectal cancer: Two single-arm phase II trials.

BACKGROUND: Anastomotic leakage (AL) remains a major cause of morbidity following total mesorectal excision (TME). A diverting ileostomy reduces the risk of AL but impairs quality of life (QoL). Delayed colo-anal anastomosis (DCAA) may be an alternative to immediate colo-anal anastomosis (ICAA) without creation of a diverting ileostomy. STUDY DESIGN: Patients with T3 or N+ rectal tumours were treated with neoadjuvant chemoradiation and TME. To evaluate DCAA or ICAA with diverting ileostomy, a two multicenter single-arm phase II trials was designed. The primary endpoint was the rate of AL requiring a diverting ileostomy up to 30 days postoperatively. Secondary endpoints were 30-day postoperative complications, 1- and 2-year disease-free survival; QoL at baseline, 6 months and anorectal function measured by the low anterior resection syndrome questionnaire and Wexner score at baseline, 6 months and a late assessment at median 8 years following surgery. RESULTS: AL requiring diverting ileostomy occurred in one patient (2.1%; 95% confidence interval (CI) [0; 11.1]) in the DCAA group and in five patients (8.6%; 95%CI [3.2; 21.0]) in the ICAA group. Thirty-day postoperative complications occurred in 13 patients (27.1%) in the DCAA group and in 10 patients (19.2%) in the ICAA group. Short and long-term functional outcomes showed similar patterns. CONCLUSION: These two single-arm phase II trials showed that DCAA has low rates of AL requiring a diverting ileostomy and acceptable long-term functional results. DCAA seems a good choice to restore bowel continuity.

Surgical Management of Retrorectal Tumors: A French Multicentric Experience of 270 Consecutives Cases.

OBJECTIVE: To report the largest multicentric experience on surgical management of retrorectal tumors (RRT). BACKGROUND: Literature data on RRT is limited. There is no consensus concerning the best surgical approach for the management of RRT. METHODS: Patients operated for RRT in 18 academic French centers were retrospectively included (2000-2019). RESULTS: A total of 270 patients were included. Surgery was performed through abdominal (n = 72, 27%), bottom (n = 190, 70%), or combined approach (n = 8, 3%). Abdominal approach was laparoscopic in 53/72 (74%) and bottom approach was Kraske modified procedures in 169/190 (89%) patients. In laparoscopic abdominal group, tumors were more frequently symptomatic (37/53, 70% vs 88/169, 52%, P = 0.02), larger [mean diameter = 60.5 ± 24 (range, 13-107) vs 51 ± 26 (20-105) mm, P = 0.02] and located above S3 vertebra (n = 3/42, 7% vs 0%, P = 0.001) than those from Kraske modified group. Laparoscopy was associated with a higher risk of postoperative ileus (n = 4/53, 7.5% vs 0%, P = 0.002) and rectal fistula (n = 3/53, 6% vs 0%, P=0.01) but less wound abscess (n = 1/53, 2% vs 24/169, 14%, P = 0.02) than Kraske modified procedures. RRT was malignant in 8%. After a mean follow up of 27 ±39 (1-221) months, local recurrence was noted in 8% of the patients. After surgery, chronic pain was observed in 17% of the patients without significant difference between the 2 groups (15/74, 20% vs 3/30, 10%; P = 0.3). CONCLUSIONS: Both laparoscopic and Kraske modified approaches can be used for surgical treatment of RRT (according to their location and their size), with similar long-term results.

Sphincter-saving surgery for ultra-low rectal carcinoma initially indicated for abdominoperineal resection: Is it safe on a long-term follow-up?

BACKGROUND: Rate of abdominoperineal resection (APR) varies from countries and surgeons. Surgical impact of preoperative treatment for ultra-low rectal carcinoma (ULRC) initially indicated for APR is debated. We report the 10-year oncological results from a prospective controlled trial (GRECCAR 1) which evaluate the sphincter saving surgery (SSR). METHODS: ULRC indicated for APR were included (n = 207). Randomization was between high-dose radiation (HDR, 45 + 18 Gy) and radiochemotherapy (RCT, 45 Gy + 5FU infusion). Surgical decision was based on tumour volume regression at surgery. SSR technique was standardized as mucosectomy (M) or partial (PISR)/complete (CISR) intersphincteric resection. RESULTS: Overall SSR rate was 85% (72% ISR), postoperative morbidity 27%, with no mortality. There were no significant differences between the HDR and RCT groups: 10-year overall survival (OS10) 70.1% versus 69.4%, respectively, 10.2% local recurrence (9.2%/14.5%) and 27.6% metastases (32.4%/27.7%). OS and disease-free survival were significantly longer for SSR (72.2% and 60.1%, respectively) versus APR (54.7% and 38.3%). No difference in OS10 between surgical approaches (M 78.9%, PISR 75.5%, CISR 65.5%) or tumour location (low 64.8%, ultralow 76.7%). CONCLUSION: GRECCAR 1 demonstrates the feasibility of safely changing an initial APR indication into an SSR procedure according to the preoperative treatment tumour response. Long-term oncologic follow-up validates this attitude.

Surgery for Crohn's disease during pregnancy: A nationwide survey.

BACKGROUND AND AIMS: Crohn's disease (CD) frequently affects young women and may require surgery during pregnancy. Data regarding operation for CD in expectant mothers are scare. MATERIALS AND METHODS: This was a retrospective nationwide survey from the GETAID Chirurgie. Any woman with CD undergoing surgery during pregnancy was eligible. RESULTS: A total of 15 cases were collected between 1992 and 2015. Most operations were performed due to penetrating or stricturing complications. Mean gestational age at delivery was 34 weeks, with a mean birth weight of 2507 g. Maternal post-operative complications occurred in two-thirds of cases. Maternal mortality rate was 6.7% and neonatal mortality rate 9.1%. CONCLUSIONS: This is the largest case series of surgery for CD during pregnancy. This operation may have significant morbidity and mortality for mother, fetus, and newborn. Indication needs to be tailored to maternal status, disease severity, and gestational age. Surgery should be managed by experienced gynecologists, physicians, and surgeons. Active CD may be associated with a greater risk to the fetus than the surgical procedure itself.

Long-term outcomes of robotic ventral mesh rectopexy for external rectal prolapse.

INTRODUCTION: Nowadays in Europe, laparoscopic ventral mesh rectopexy is the gold standard treatment of external rectal prolapse (ERP). The benefits of robot ventral mesh rectopexy (RVMR) are not clearly defined. The primary objective of the study was to evaluate the long-term results of RVMR. The secondary objective was to determine predictive factors of recurrence. DESIGN: Monocentric, retrospective study. Data, both pre-operative and peri-operative, were collected, and follow-up data were assessed prospectively by a telephone questionnaire. The study was performed in a tertiary referral center. METHODS: Between August 2007 and August 2017, we evaluate all consecutive patients who underwent RVMR for ERP by three different surgeons. The primary outcome was the recurrence rate perceived by patients. Secondary outcome were functional results based on Knowles-Eccersley-Scott-Symptom score for constipation and Wexner score for incontinence, compared before and after surgery. RESULTS: During the study period 96 patients (86 women) underwent RVMR. The mean age was 62.3 years (range 16-90). Twelve patients had a history of ERP repair. Sixty-nine patients were analyzed for long-term outcomes with a mean follow-up of 37 months (range 2.3-92 months). Recurrence rate was 12.5%. After surgery, constipation was significantly reduced: 44 patients were constipated before surgery versus 23 after surgery. Six patients described de novo constipation (6.25%). Fecal incontinence was significantly reduced: 59 patients were incontinent before surgery versus 14 after surgery. No predictive factor for recurrence was identified after multivariate analysis. No mesh related complications were related. CONCLUSIONS: In conclusion, RVMR presents good long-term functional result and a recurrence rate similar to LVMR as published in the literature. The rate of mesh related complications seems lower.

Feasibility, acceptability of enteral tube feeding and self-insertion of a nasogastric tube in the nutritional management of digestive cancers, impact on quality of life.

No study has evaluated the feasibility of enteral tube feeding (ETF) in undernourished patients with newly diagnosed gastrointestinal (GI) cancer. OBJECTIVES: Evaluate the acceptability of ETF in patients unable to increase their dietary intake and with a weight loss >10% or albuminemia <30 g/L or BMI <18.5 before surgery, or a weight loss >5% during chemotherapy. The feasibility of self-insertion of a nasogastric tube was also assessed. RESULTS: A total of 308 patients were nutritionally screened during a one-year period. ETF was indicated in 123 cases. Overall acceptability was 78.9% and was higher when weight loss was >10% (p < 0.0001) and before surgery (p < 0.0001), lower during chemotherapy (p < 0.0001), while not influenced by dietary intake or location of the cancer. Forty patients managed a daily self-insertion of the feeding tube (45.5%) and 48 had a nasogastric tube maintained in place. All Quality of Life (QoL) parameters were significantly improved, notably physical role functioning (+20.9% ± 24.0, p < 0.005) and mental health (+21.0% ± 17.7 p < 0.005). CONCLUSION: According to the present algorithm, ETF was indicated in 39.9% of cases and accepted in 78.9% of newly diagnosed patients with primary GI cancer while improving QoL. This study strengthens the place of self-insertion of feeding tubes in clinical practise.

Robotic-assisted unilateral adrenalectomy: risk factors for perioperative complications in 303 consecutive patients.

BACKGROUND: There is no consensus about the utility of using the robotic platform to perform a unilateral lateral transabdominal adrenalectomy in comparison with conventional laparoscopy. In some groups, obese patients (Body Mass Index > 30 kg/m2) and patients with tumor size > 5 cm have been considered as good candidates for robotic adrenalectomy. However, evaluation of incidence and risk factors for perioperative complications is currently lacking in large series of patients. The aim of this study was to evaluate incidence and predictive factors for intraoperative (conversion and capsular rupture) and postoperative complications (morbidity) after unilateral robotic-assisted transabdominal lateral adrenalectomy. METHODS: From 2001 to 2016, consecutive patients undergoing unilateral lateral transabdominal robotic adrenalectomy were included in a prospectively maintained database and analyzed retrospectively (clinicaltrials.gov NCT03410394). RESULTS: A total of 303 consecutive patients were analyzed. Between the first and last 100 of patients, mean tumor size increased from 2.9 to 4.2 cm (p < 0.001) and mean operating time decreased from 99 to 77 min (p < 0.001). Postoperative complications occurred in 28 patients (9.2%) and no postoperative death was observed. Nine patients (3%) were converted to open laparotomy and capsular rupture was observed in nine patients (3%). BMI was not a significant risk factor for conversion, capsular rupture, or postoperative complication. Tumor size > 5 cm remained the only predictive factor for conversion to laparotomy (OR 7.47, 95% CI 1.81-30.75; p = 0.005). History of upper gastrointestinal surgery was the only predictive factor for capsular rupture (OR 13.6, 95% CI 2.33-80.03; p = 0.004). Conversion to laparotomy (OR 8.35, 95% CI 1.99-35.05; p = 0.003) and patient age (OR 1.039, 95% CI 1.006-1.072; p = 0.019) remained independent predictive factors for postoperative complications. CONCLUSIONS: This study identified independent risk factors for perioperative complications after robotic-assisted unilateral adrenalectomy. These factors should be taken into account when evaluating robotic-assisted transabdominal lateral adrenalectomy.

The computed tomography adrenal wash-out analysis properly classifies cortisol secreting adrenocortical adenomas.

PURPOSE: Adrenocortical lesions are characterized through imaging, hormonal and histopathological analysis. Our aim was to compare the radiological features of adrenocortical lesions with their cortisol-secreting status and histopathological Weiss score. METHODS: Seventy five patients operated between 2004 and 2016 in the University Hospital of Nancy for either adrenocortical carcinomas (ACC) or adrenocortical adenomas (ACA) were enrolled in this study. We collected cortisol parameters, Computed Tomography (CT) scans (unenhanced density, wash-out (WO) analysis) and 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) datas. The histopathological Weiss score ultimately differentiates ACA (score ≤ 2) from ACC (score ≥ 3). One-way ANOVA, Fisher's exact and unpaired t tests were used for statistical analysis with significancy reached at p < 0.05. RESULTS: There were 23 ACC and 52 ACA with 40 patients (53%) who had an autonomous secretion of cortisol. On CT scan, ACC were larger compared to ACA (108 vs. 37 mm, p < 0.0001). A roughly similar proportion of cortisol-secreting (22/25) and non-secreting (15/19) ACA were atypical (i.e., unenhanced density value ≥ 10 Hounsfield Units [HU]), however 85% of cortisol-secreting vs. 40% of non-secreting ACA were classified as benigns by the relative WO analysis (p = 0.08). Likewise, there was a trend for a higher 18F-FDG uptake in cortisol-secreting ACA compared to non-secreting ACA (p = 0.053). CONCLUSIONS: The relative adrenal WO analysis consolidates the benign nature of an ACA, especially in case of cortisol oversecretion, a condition known to compromise the diagnostic accuracy of the 10 HU unenhanced CT attenuation threshold.

Face and content validity of Xperience™ Team Trainer: bed-side assistant training simulator for robotic surgery.

In robotic surgery, the coordination between the console-side surgeon and bed-side assistant is crucial, more than in standard surgery or laparoscopy where the surgical team works in close contact. Xperience™ Team Trainer (XTT) is a new optional component for the dv-Trainer® platform and simulates the patient-side working environment. We present preliminary results for face, content, and the workload imposed regarding the use of the XTT virtual reality platform for the psychomotor and communication skills training of the bed-side assistant in robot-assisted surgery. Participants were categorized into "Beginners" and "Experts". They tested a series of exercises (Pick & Place Laparoscopic Demo, Pick & Place 2 and Team Match Board 1) and completed face validity questionnaires. "Experts" assessed content validity on another questionnaire. All the participants completed a NASA Task Load Index questionnaire to assess the workload imposed by XTT. Twenty-one consenting participants were included (12 "Beginners" and 9 "Experts"). XTT was shown to possess face and content validity, as evidenced by the rankings given on the simulator's ease of use and realism parameters and on the simulator's usefulness for training. Eight out of nine "Experts" judged the visualization of metrics after the exercises useful. However, face validity has shown some weaknesses regarding interactions and instruments. Reasonable workload parameters were registered. XTT demonstrated excellent face and content validity with acceptable workload parameters. XTT could become a useful tool for robotic surgery team training.

Hemodynamic instability during surgery for pheochromocytoma: comparing the transperitoneal and retroperitoneal approach in a multicenter analysis of 341 patients.

BACKGROUND: Intraoperative hemodynamic instability is a major challenge during adrenalectomy for pheochromocytoma. Typically, pheochromocytoma is performed laparoscopically either through the retroperitoneal or transperitoneal approach. We aimed to determine if the operative approach affects intraoperative hemodynamic instability during surgery for pheochromocytoma in a large multicenter multicenter cohort. METHODS: Retrospective, multicenter analysis of consecutive patients with pheochromocytoma who underwent total unilateral laparoscopic adrenalectomy without conversion were included. Statistical analysis was performed using established intraoperative criteria for intraoperative hemodynamic instability: 1) systolic blood pressure >160 mm Hg; 2) systolic blood pressure > 200 mm Hg; 3) mean arterial pressure <60 mm Hg; 4) systolic blood pressure >160 mm Hg + mean arterial pressure <60 mm Hg; and 5) systolic blood pressure >200 mm Hg + mean arterial pressure <60 mm Hg; and 6) intravenous vasopressor + vasodilator. RESULTS: In total, 341 patients met the inclusion criteria, 101 (29.6%) underwent retroperitoneal adrenalectomy and 240 (70.4%) transperitoneal adrenalectomy. Multivariate analysis showed that retroperitoneal adrenalectomy carries greater risk for mean arterial pressure <60 mm Hg (odds ratio 6.255, confidence interval 1.134-34.235, P = .035) compared with transperitoneal adrenalectomy. Overall and cardiovascular morbidity rates were comparable between the 2 approaches. The medical center was a significant independent influencing factor for all 6 intraoperative hemodynamic instability definitions. CONCLUSION: Variability in institutional management of pheochromocytoma intraoperatively has significant impact on all 6 intraoperative hemodynamic instability definitions. Standardization of anesthesia should be considered to reduce this variability.

Value of cross-sectional imaging in assessing active Crohn's disease before stoma reversal.

BACKGROUND: There are currently no guidelines on the need to assess disease activity before stoma reversal in Crohn's disease (CD). We sought to determine the value of cross-sectional imaging for detecting active CD before stoma reversal. METHODS: 38 CD patients underwent cross-sectional imaging before stoma reversal. CD activity was blindly evaluated by an independent radiologist. Postoperative outcomes were recorded. RESULTS: Before stoma reversal, cross-sectional imaging identified active CD in 20 of the 38 study participants (52.6%). In 9 out of 10 tested patients, radiologic and endoscopic assessments gave concordant findings with regard to CD recurrence before stoma reversal. Stoma reversal was delayed in half of the patients with active CD and in none of the patients without active CD. Before stoma reversal, tumor necrosis factor alpha antagonists or immunosuppressants were initiated in 45% of the patients with active CD and 5.6% of the patients without active CD. In the year following stoma reversal, the recurrence rate (in a radiologic assessment) was higher in patients with active CD than in patients without active CD (75.0% vs. 30.8%, respectively; p=0.04). CONCLUSION: Cross-sectional imaging revealed postoperative recurrence in about a quarter of patients before stoma reversal; this finding may influence the postoperative treatment strategy and outcomes.

Risk factors for postoperative complications in robotic general surgery.

The feasibility and safety of robotically assisted procedures in general surgery have been reported from various groups worldwide. Because postoperative complications may lead to longer hospital stays and higher costs overall, analysis of risk factors for postoperative surgical complications in this subset of patients is clinically relevant. The goal of this study was to identify risk factors for postoperative morbidity after robotic surgical procedures in general surgery. We performed an observational monocentric retrospective study. All consecutive robotic surgical procedures from November 2001 to December 2013 were included. One thousand consecutive general surgery patients met the inclusion criteria. The mean overall postoperative morbidity and major postoperative morbidity (Clavien >III) rates were 20.4 and 6 %, respectively. This included a conversion rate of 4.4 %, reoperation rate of 4.5 %, and mortality rate of 0.2 %. Multivariate analysis showed that ASA score >3 [OR 1.7; 95 % CI (1.2-2.4)], hematocrit value <38 [OR 1.6; 95 % CI (1.1-2.2)], previous abdominal surgery [OR 1.5; 95 % CI (1-2)], advanced dissection [OR 5.8; 95 % CI (3.1-10.6)], and multiquadrant surgery [OR 2.5; 95 % CI (1.7-3.8)] remained independent risk factors for overall postoperative morbidity. It also showed that advanced dissection [OR 4.4; 95 % CI (1.9-9.6)] and multiquadrant surgery [OR 4.4; 95 % CI (2.3-8.5)] remained independent risk factors for major postoperative morbidity (Clavien >III). This study identifies independent risk factors for postoperative overall and major morbidity in robotic general surgery. Because these factors independently impacted postoperative complications, we believe they could be taken into account in future studies comparing conventional versus robot-assisted laparoscopic procedures in general surgery.

NOD2 gene variant is a risk factor for postoperative complications in patients with Crohn's disease: A genetic association study.

BACKGROUND: Postoperative complications are relatively frequent in Crohn's disease (CD) and several risk factors have been identified. The influence of genetic factors, however is unknown. METHODS: CD patients who underwent CD-related bowel resection were identified from the "Nancy IBD cohort." Postoperative complications were defined as intraabdominal infectious complications and non-intraabdominal infectious complications occurring within 90 days after operation. The influence of 203 single nucleotide polymorphisms on postoperative complication rates was analyzed. RESULTS: Of the 137 patients who had undergone a CD-related bowel resection in our cohort, postoperative complications occurred in 34 cases (24.8%). Postoperative intraabdominal infections occurred in 18 cases (13.1%): 12 had anastomotic leakage and 6 had intraabdominal abscesses. In multivariate analysis, current smoker status (odds ratio [OR], 2.71; 95% CI, 1.18-6.21; P = .02) and homozygosity for the risk allele (T) Nucleotide-binding Oligomerization Domain-containing protein 2 (rs5743289; NOD2; OR, 2.07 [95% CI 1.15-3.72]; P = .01) were independent risk factors of postoperative intraabdominal infectious complications. Current smoker status NOD2 homozygosity for the risk allele (T) were not associated with non-intraabdominal infectious complications. CONCLUSION: Current smoker status was associated with increased risk of postoperative intraabdominal infectious complications. A novel association between the NOD2 allele and an increased risk of postoperative intraabdominal infectious complications was observed in this study.

Predictive factors for postoperative morbidity after laparoscopic adrenalectomy for pheochromocytoma: a multicenter retrospective analysis in 225 patients.

BACKGROUND: Since the 1950s, preoperative medical preparation has been widely applied in patients with pheochromocytoma to improve intraoperative hemodynamic instability and postoperative complications. However, advancements in preoperative imaging, laparoscopic surgical techniques, and anesthesia have considerably improved management in patients with pheochromocytoma. In consequence, there is no validated consensus on current predictive factors for postoperative morbidity. The aim of this study was to determine perioperative factors which are predictive for postoperative morbidity in patients undergoing laparoscopic adrenalectomy for pheochromocytoma. STUDY DESIGN: It is a retrospective analysis of prospectively maintained databases in five medical centers from 2002 to 2013. Inclusion criteria were consecutive patients who underwent non-converted laparoscopic unilateral total adrenalectomy for pheochromocytoma. RESULTS: Two-hundred and twenty-five patients were included. All-cause and cardiovascular postoperative morbidity rates were 16% (n = 36) and 4.8% (n = 11), respectively. Preinduction blood pressure normalization after preoperative medical preparation had no impact on postoperative morbidity. However, past medical history of coronary artery disease (OR [CI95%] = 3.39; [1.317-8.727]) and incidence of intraoperative hemodynamic instability episodes (both SBP ≥ 160 mmHg and MAP < 60 mmHg) (OR [CI95%] = 3.092; [1.451-6.587]) remained independent predictors for postoperative all-cause morbidity. Similarly, past medical history of coronary artery disease (OR [CI95%] = 14.41; [3.119-66.57]), female sex (OR [CI95%] = 12.05; [1.807-80.31]), and incidence of intraoperative hemodynamic instability episodes (both SBP ≥ 200 mmHg and MAP < 60 mmHg) (OR [CI95%] = 4.13; [1.009-16.90]) remained independent predictors for postoperative cardiovascular morbidity. CONCLUSIONS: This study identifies risk factors for cardiovascular and all-cause postoperative morbidity after laparoscopic adrenalectomy in current clinical setting. These data can help physicians to guide intra-operative blood pressure management and have to be taken into account in further studies.

CARD8 gene variant is a risk factor for recurrent surgery in patients with Crohn's disease.

BACKGROUND AND AIMS: Post-operative recurrence is frequent in Crohn's disease. Genetic factors associated with post-operative recurrence remain poorly understood. Identification of genetic variants associated with repeat surgery would allow risk stratification of patients who may benefit from early aggressive therapy and/or post-operative prophylactic treatment. METHODS: Crohn's disease patients who had at least one bowel resection were retrospectively identified from the "Nancy IBD cohort". Covariates and potential interactions were assessed using the Cox proportional hazard model. Kaplan-Meier curves for time to surgical recurrence were developed for 200 genetic variants and analyzed with the log-rank test. RESULTS: 137 patients had at least 1 resection in our cohort: 38 had a surgical recurrence (28%). In multivariate analysis, current smoker status (OR 6.97, 95% CI 1.85-26.22, p=0.004), post-operative complications after prior surgery (OR 2.72, 95% CI 1.02-7.22, p=0.044), and Caspase recruitment domain-containing protein 8 (CARD8) homozygosity for the risk allele (OR 7.56, 95% CI 1.13-50.37, p=0.036) remained significantly and independently associated with surgical recurrence. CONCLUSION: Current smoker status was associated with increased risk of surgical recurrence. A novel association between CARD8 and increased risk of surgical recurrence in Crohn's disease was observed. CARD8 could be a new marker for risk stratification and prevention of recurrent surgery.

Robotic lateral transabdominal adrenalectomy.

Laparoscopic transabdominal adrenalectomy is considered to be the standard of care for adrnalectomy. Widespread adoption of robotic technology has positioned robotic adrenalectomy as an option in some medical centers. Many studies have compared laparoscopic versus robotic approaches to perform adrenalectomy and evaluated potential advantages to balance higher costs. This review summarizes current available data regarding the use of the robotic system to perform adrenalectomy (RA) and its comparison with laparoscopic adrenalectomy (LA).

Is intraoperative ultrasound still useful for the detection of colorectal cancer liver metastases?

BACKGROUND: Debate on the optimal mode of preoperative imaging in the management of colorectal liver metastases (CRLM) is ongoing and, despite its longstanding use, the precise role of intraoperative ultrasonography (IOUS) is not well established. This study evaluates the impact of IOUS in the era of high-quality, cross-sectional imaging techniques. METHODS: All patients who underwent liver resection for CRLM in a tertiary care referral centre from January 2006 to December 2013 were included. All patients were submitted to computed tomography (CT) and/or liver magnetic resonance imaging (MRI) before surgery. Intraoperative US was performed mainly to detect previously non-diagnosed tumours that would change the surgical strategy. RESULTS: A total of 225 liver resections were performed. Liver MRI and CT scans were available for 202 patients (89.8%) and 225 patients (100%), respectively. Radiological reports recorded 632 liver tumours in 219 patients (i.e. 2.9 lesions per patient). The median time between preoperative liver MRI and surgical resection was 36 days. Intraoperative inspection, palpation and US found 20 additional lesions in 18 patients (8.0%), in three of whom lesions were diagnosed only on IOUS (1.4%). Overall, only 12 of the 20 lesions were malignant. CONCLUSIONS: Although CT and liver MRI are commonly used, IOUS alone allows the discovery of a few additional lesions that result in a change of surgical strategy in 1.4% of cases.

Both preoperative alpha and calcium channel blockade impact intraoperative hemodynamic stability similarly in the management of pheochromocytoma.

BACKGROUND: Alpha-blockade is the standard management preoperatively to prevent intraoperative hemodynamic instability (IHD) during resection of a pheochromocytoma. Calcium channel blockers also have been shown to lessen the risk of IHD. We aim to determine differences between these classes of antihypertensive agents in minimizing IHD. METHODS: This was a retrospective analysis from a tri-institutional database. Inclusion criteria were unilateral transabdominal adrenalectomy for pheochromocytomas between 2002 and 2012. IHD was defined as at least one systolic blood pressure (SBP) measurement >160 mm Hg and at least one episode of mean arterial pressure 60 mm Hg. RESULTS: A total of 155 patients were included: 110 receiving calcium channel blockers, 41 alpha-blockade, and 4 no medication. Intraoperatively, mean maximal SBP was less after alpha-blockade (P < .0001) as well as the incidence and duration of episodes of SBP >200 mm Hg (P < .01); however, severe hypotensive episodes (MAP <60 mm Hg) were more frequent (P < .001) and longer (P < .0001) with alpha-blockade. Consequently, intraoperative vasoactive drugs were used more frequently (P = .03), and mean fluid volume infused was larger (P < .001). Fifty-four patients had IHD, but these were independent of type of preoperative medication used. Familial disease was the only independent predictor of IHD. CONCLUSION: IHD was independent of type of preoperative medical management but was dependent on familial disease. These findings broaden options for clinicians in the preoperative management of pheochromocytoma.

Effect of portal vein ligation on tumor growth and liver regeneration in rat cirrhotic liver lobes.

The aim of the present study was to investigate the effect of portal vein ligation (PVL) on the tumor growth rate and liver regeneration in rat cirrhotic liver lobes. A total of 45 male Wistar rats were randomly divided into PVL, hepatic tumor (HT) and HT + PVL groups (n=15 per group). Liver regeneration and tumor growth in ligated and non-ligated lobes were evaluated prior to and following PVL. In addition, serum alanine transaminase, total bilirubin levels and liver tissue samples were evaluated. The results indicated that PVL induced apparent hypertrophy in normal and HT rats. However, the ratio of non-ligated lobes to total liver weight or body weight in the HT + PVL group was significantly lower when compared with the PVL group (P<0.05). Compared with the HT group, the tumor growth rate in the ligated lobes of the HT + PVL group significantly increased (P<0.05). However, tumor growth in the non-ligated lobes exhibited no statistically significant difference between the HT and HT + PVL groups. In addition, Knodell scores indicated that fibrosis was more apparent in the non-ligated lobes of the HT + PVL group when compared with the HT group (P<0.05). Therefore, tumor growth was accelerated in ligated lobes following PVL, but not in non-ligated lobes. PVL also induced liver regeneration in cirrhotic liver lobes with lower efficiency than that in the non-cirrhotic lobes. However, hypertrophy in the contralateral cirrhotic lobes appeared to be non-functional.