Incidence Of Port Site Recurrence Research Articles

Port Site Squamous Cell Carcinoma Following Video Endoscopic Inguinal Lymphadenectomy

Port site metastasis is one of the feared complications following laparoscopic oncosurgery. We present the case report of port site recurrence following video endoscopic inguinal lymphadenectomy (VEIL) for carcinoma penis. A 54-year-old gentleman had undergone total penectomy with bilateral videoendoscopic inguinal lymphadenectomy 2 years back. Histopathology was reported as well-differentiated squamous cell carcinoma. Fifteen nodes on the right side and 8 nodes in the left were found negative for tumour. Ten months later, he presented with an indurated swelling in right mid-thigh with serous discharge at the site of camera and extraction port of VEIL. Core needle biopsy was done and reported as moderately differentiated squamous cell carcinoma. PET CT was done, and no other sites of activity were seen. Hence, wide local excision of the lesion with local rotation flap cover was done. Right iliac lymphadenectomy was done. The histopathology confirmed negative margins. Twelve iliac lymph nodes were negative for tumour. He received 3 cycles of cisplatin-based chemotherapy. This is the first case report of port site recurrence of squamous cell carcinoma following VEIL. The probable mechanisms are pneumatic spread or spill during extraction. The possibility of second primary should also be considered, due to negative lymph nodes in first biopsy. Port site recurrence is a rare but definite possibility following VEIL. Precautions should be taken like preventing air leak, using extraction bag and avoiding trocar slip to decrease the incidence of port site recurrence.

This Month in Adult Urology

This Month in Adult Urology

A Case of Cholangiocarcinoma Diagnosed by Skin Biopsy

A 72-year-old man presented to an outside hospital with abdominal pain, jaundice, and a 30 lb weight loss. CT showed choledocholithiasis and suspected cholecystitis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) which revealed stones in the common bile duct (CBD). Sphincterotomy and stone extraction with stent placement was performed. A laparoscopic cholecystectomy was done, revealing a hydropic gallbladder (GB) that was pierced open, suctioned and subsequently removed in an endobag. A JP drain was left in the GB bed and pulled through a port site. The patient's jaundice did not improve and he was transferred to another facility where endoscopic ultrasound demonstrated a hilar mass with an associated CBD stricture. An ERCP with brush and biopsy of the CBD stricture was also done, and cytology returned showing only atypia. Both procedures were repeated two weeks later and results were again negative. In the interim, the patient underwent skin biopsy of an enlarging subcutaneous nodule located at a previous surgical port site and the results returned as metastatic adenocarcinoma. A GI pathologist re-examined the GB specimen obtained during the laparoscopic cholecystectomy and noted that there was evidence of cholangiocarcinoma (CCA) within the GB wall. CCA carries a dismal prognosis when detected in an advanced stage and early diagnosis is a challenge. The prevalence of incidental GB carcinoma is between 1% and 2% of all cholecystectomies performed with some studies reporting an incidence as high as 7.4%. Removal of unsuspected GB carcinoma laparoscopically can lead to seeding of tumor cells into the abdominal wall. Incidence of port site recurrence after laparoscopic cholecystectomy for unsuspected GB cancer can be as high as 14%. Intraoperative GB perforation can raise this rate of recurrence to 40%. Recurrences usually occur 6 to 16 months after the operation as was seen in this case. There are several proposed mechanisms of port site recurrence, the most popular of which include: direct wound contamination from laparoscopic instruments; the bile itself containing exfoliated tumor cells which can spread with bile spillage; and also, whether insufflation of the peritoneum can enhance wound metastases. In this case, JP drain placement along with GB perforation may also have been a route of seeding. Physicians should be aware of the risk of tumor seeding when CCA is a possibility in order to avoid the acceleration of metastatic disease.

Laparoscopic resection for rectal cancer

BACKGROUND: Laparoscopic colorectal procedures for the treatment of benign disorders are increasingly appreciated and have become the standard procedure for e.g. surgical treatment for recurrent diverticulitis. METHODS: Data show that even laparoscopic surgery for left sided colon cancer is seen as oncologically equal to the classic open resection. Laparoscopic resections offer several benefits e.g. minimal impairment of gastrointestinal and pulmonary functions, lower immunosuppression, shorter hospital stay, and faster reconvalescence. RESULTS: However, laparoscopic resections for rectal cancer are still discussed controversially as concerns are raised in terms of oncologic radicality, port-site metastases, autonomic nerve preservation, and completeness of total mesorectal excision especially in obese male patients with a tight pelvis. CONCLUSIONS: The clinical reality and several studies demonstrate that laparoscopic rectal surgery for cancer is oncologically feasible, lymph node dissection is equivalent to open surgery, and the incidence of port-site recurrence is not increased compared to wound recurrence in conventional laparotomy.

Laparoscopic-Assistedvs.Open Colectomy for Colon Cancer: A Prospective Randomized Trial

Although laparoscopic-assisted colectomy (LAC) has evolved as a technical option in the treatment of benign colonic diseases, its role in the treatment of malignancies remains controversial. The purpose of this prospective randomized trial was to compare perioperative parameters and outcomes between LAC vs. open colectomy (OC) in patients with stage I-III colon cancer. Eligible patients with colon cancer who were scheduled for an elective colon resection from January 1995 to February 2001 were randomized to either the LAC or the OC treatment group. The two groups were compared with regard to operative time, blood loss, complications, pathologic findings and lymph node yield, length of postoperative hospital stay, gastrointestinal function, use of analgesic drugs, recurrence, and survival rates. The median follow-up was 35 months (range, 3-69 months). A total of 49 patients were enrolled in the study: 20 were randomized to OC and 29 to LAC, one of whom was lost to follow-up. Thirteen patients in the LAC group had to be converted to OC (COC), and were analyzed in a separate group. The three patient groups were comparable with regard to age, gender distribution, tumor site, lymph node harvest, operative procedure, anastomotic type, perioperative complication, recurrence, and survival rates. Tumor margins were clear in all patients. No incidence of port-site recurrence in the LAC group, or wound recurrence in the OC and COC groups, was found. Three patients died of cancer-related causes, one in each patient group. The LAC patients had significantly shorter hospital stay, faster recovery of gastrointestinal function, and less use of intravenous analgesia. Short-term outcomes revealed that LAC could be performed safely and has therapeutic results similar to OC for colon cancer. Conversion of LAC to an open procedure was frequent but was not associated with a negative outcome.

No incidence of port-site recurrence after endosurgical procedure for pediatric malignancies.

Port-site recurrence (PSR) following laparoscopic procedures has been an unpredictable complication in adult cancer patients; however, no data exist about this phenomenon in the pediatric field. The aim of this study was to determine whether PSR, following endosurgical procedure for malignancies, is a typical complication or a rare event in the pediatric population. Eighty-one questionnaires were mailed to members of The Japanese Society of Pediatric Endosurgeons. They were asked to provide a list of their institutions that had experience with PSR after endosurgical procedures for pediatric malignancies. Among 29 institutions, a total of 129 endosurgical procedures for pediatric malignancies were reported; these included 85 laparoscopic and 44 thoracoscopic procedures, performed on 104 neuroblastomas, 8 hepatoblastomas, 7 nephroblastomas, and 10 other tumors. Of the 104 neuroblastomas, 83 were found by mass screening using high levels of urinary vanillylmandelic acid and homovanillic acid. Sixty-five of the 83 patients had their tumor excised, and 18 had their tumor biopsied by endosurgical procedures. Additionally, 47 of these patients did not require any postoperative chemotherapy. No incidence of PSR was reported in any of the patients that underwent endosurgical procedures. The PSR following endosurgical procedure is a rare phenomenon in the pediatric population. Both, laparoscopic and thoracoscopic procedures, are safe and recommended for treating pediatric malignancies, especially mass-screened neuroblastomas.

VATS port site recurrence: a technique dependent problem.

Video-assisted thoracic surgery (VATS) has become an accepted approach for the diagnosis and treatment of thoracic malignancies. Port site tumor recurrence is a reported complication of VATS. However, the true incidence of this problem is unknown. To try to determine the incidence of port site recurrence, we analyzed our experience with patients undergoing VATS wedge resection for malignancy. Data were obtained from our prospective VATS database. The analysis was confined to patients undergoing VATS wedge resection for malignancy, excluding those having a pleural biopsy only. Parameters analyzed included demographic factors, surgical technique, and port site recurrences identified by physical examination, CT scan, or both. From 1992 to 1996, 410 patients (182 men, 228 women; median age = 61 years) underwent a VATS wedge resection for malignancy. The procedure was performed for diagnosis or staging in 90% of cases. Access incisions plus port sites were used in 97 (24%) patients; port sites only were used in 313 (76%) patients. Conversion to thoracotomy was necessary in 102 patients (25%) either for definitive resection (58 patients) or because VATS was not technically adequate (44 patients). Specimens were retrieved via access incisions or port sites with or without a specimen bag. The operative mortality was 0.25%. With long-term follow-up (median = 25 months) available for 374 patients (91%), only one port site recurrence was identified (0.26%). Our experience confirms the safety of VATS wedge resection in cancer patients. The incidence of port site tumor recurrence is low when oncologic principles are respected. In our institution, these principles include performing VATS wedge resection only for lesions that can be widely removed; converting to thoracotomy for definitive or extensive cancer operation; and using meticulous technique for the extraction of specimens from the pleural space.

Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsuspected gallbladder carcinoma

Background: We sought to determine the incidence of recurrence of carcinoma at the port site and the outcome of patients with such recurrences after exploratory laparoscopy/laparoscopic cholecystectomy for unsuspected gallbladder carcinoma and analyzed aspects of the laparoscopic procedure associated with recurrences at the port site. Methods: Thirty-seven patients with preoperatively unknown adenocarcinoma of the gallbladder were analyzed. The patients were part of a large prospective study of the Swiss Association of Laparoscopic and Thoracoscopic Surgery including 10,925 patients undergoing laparoscopic cholecystectomy. Results: Preoperatively undiagnosed adenocarcinoma of the gallbladder is rarely encountered in patients undergoing laparoscopic cholecystectomy (0.34%). The incidence of recurrence of carcinoma at the port site in these patients is 14% (5 of 37) and is similar whether the primary tumor is confined to the gallbladder (T1/T2) or locally advanced (T3/T4). The recurrences at the port site were diagnosed within 6 to 16 months (median 10 months) after the operation. Patients with an intraoperative perforation of the gallbladder had a higher incidence of recurrences at the port site (40%) than had patients without perforation (9%; P = .13). All patients with recurrences at the port site had distant metastases and all died of the disease 12 to 35 months (median 19 months) after cholecystectomy; all patients with such recurrences and stage T1/T2 tumors subsequently had peritoneal metastases. Conclusions: Patients with a preoperatively undiagnosed adenocarcinoma of the gallbladder undergoing laparoscopy or laparoscopic cholecystectomy have a high incidence of recurrences at the port site, and the incidence increases when a gallbladder perforation occurs during the operation. All patients with such recurrences died of the disease. The diagnosis of an isolated recurrence at the port site may therefore be an indicator of disseminated disease in most cases. (Surgery 1998;124:831-8.)

Incidence of port site recurrence after laparoscopic cholecystectomy for preoperatively unsuspected gallbladder carcinoma

Background: We sought to determine the incidence of recurrence of carcinoma at the port site and the outcome of patients with such recurrences after exploratory laparoscopy/laparoscopic cholecystectomy for unsuspected gallbladder carcinoma and analyzed aspects of the laparoscopic procedure associated with recurrences at the port site. Methods: Thirty-seven patients with preoperatively unknown adenocarcinoma of the gallbladder were analyzed. The patients were part of a large prospective study of the Swiss Association of Laparoscopic and Thoracoscopic Surgery including 10,925 patients undergoing laparoscopic cholecystectomy. Results: Preoperatively undiagnosed adenocarcinoma of the gallbladder is rarely encountered in patients undergoing laparoscopic cholecystectomy (0.34%). The incidence of recurrence of carcinoma at the port site in these patients is 14% (5 of 37) and is similar whether the primary tumor is confined to the gallbladder (T1/T2) or locally advanced (T3/T4). The recurrences at the port site were diagnosed within 6 to 16 months (median 10 months) after the operation. Patients with an intraoperative perforation of the gallbladder had a higher incidence of recurrences at the port site (40%) than had patients without perforation (9%; P = .13). All patients with recurrences at the port site had distant metastases and all died of the disease 12 to 35 months (median 19 months) after cholecystectomy; all patients with such recurrences and stage T1/T2 tumors subsequently had peritoneal metastases. Conclusions: Patients with a preoperatively undiagnosed adenocarcinoma of the gallbladder undergoing laparoscopy or laparoscopic cholecystectomy have a high incidence of recurrences at the port site, and the incidence increases when a gallbladder perforation occurs during the operation. All patients with such recurrences died of the disease. The diagnosis of an isolated recurrence at the port site may therefore be an indicator of disseminated disease in most cases. (Surgery 1998;124:831-8.)

Laparoscopic resections of malignant diseases of the gastrointestinal tract

As the importance of laparoscopic surgery for benign diseases of the gastrointestinal tract continues to grow, the application of this approach in cases of malignancy remains controversial. Although the concept of cancer recurrence in the area of surgical wounds is not new, the incidence of port site recurrence is the most obvious concern. Indications and contraindications for surgery as well as a standardized nomenclature describing the type of laparoscopic procedures being performed are some other issues that need to be clarified. Complete laparoscopic procedures or the combination of laparoscopy with open techniques can offer advantages and disadvantages that surgeons will have to take into consideration when making decisions. The skill of the operating team and the extent of disease define the boundaries of laparoscopic surgery possible. The continued research as well as development of intelligent instruments and standardized techniques might give laparoscopy a clear role in the treatment of abdominal malignancies.