Multiorgan Resection Research Articles

Complete and safe resection of challenging retroperitoneal tumors: anticipation of multi-organ and major vascular resection and use of adjunct procedures.

BackgroundRetroperitoneal tumors are often massive and can involve adjacent organs and/or vital structures, making them difficult to resect. Completeness of resection is within the surgeon's control and critical for long-term survival, particularly for malignant disease. Few studies directly address strategies for complete and safe resection of challenging retroperitoneal tumors.MethodsFifty-six patients representing 63 cases of primary or recurrent retroperitoneal tumor resection between 2004-2009 were identified and a retrospective chart review was performed. Rates of complete resection, use of adjunct procedures, and perioperative complications were recorded.ResultsIn 95% of cases, complete resection was achieved. Fifty-eight percent of these cases required en bloc multi-organ resection, and 8% required major vascular resection. Complete resection rates were higher for primary versus recurrent disease. Adjunct procedures (ureteral stents, femoral nerve monitoring, posterior laminotomy, etc.) were used in 54% of cases. Major postoperative complications occurred in 16% of cases, and one patient died (2% mortality).ConclusionsComplete resection of challenging retroperitoneal tumors is feasible and can be done safely with important pre- and intraoperative considerations in mind.

Laparoscopic Left Nephrectomy with “En Bloc” Distal Splenopancreatectomy

Multiorgan resection for cancer is considered a demanding laparoscopic procedure. We report a laparoscopic radical nephrectomy and distal splenopancreatectomy for a locally advanced kidney tumor. A 67-year-old woman presented with left flank pain and hematuria. CT scan showed a left kidney upper pole large mass with direct extension to spleen and pancreatic tail, but not metastases. With the patient on the right flank, three 10-mm trocars were placed forming an isosceles triangle in the left subcostal arch. Entering the lesser sac, splenic vessels were separately divided between clips. The pancreatic tail was dissected free and divided with Ultracision. The left renal vein was dissected free, and the aorta was exposed to perform the lymphadenectomy. Superior mesenteric artery and left renal vein and artery were isolated, and renal vessels were separately divided with a vascular stapler. The left kidney was mobilized. The specimen was inserted in a bag and retrieved transvaginally through a posterior colpotomy. Total operation time was 210 minutes. Estimated blood loss was 250 mL. The patient was discharged after 7 days. Final stage of disease was pT4N0M0 G2 R0 renal cell carcinoma. The patient came back 6 years later presenting a ductal adenocarcinoma of pancreatic head. At the second look laparoscopy, very few adhesions were found in right upper quadrant, and the posterior colpotomy scar was very small. The patient died 1 year after Whipple operation. Oncologic rules of an "en bloc" resection can be respected also with a laparoscopic approach.

Surgical outcomes and survival after extended multiorgan resection for T4 gastric cancer

Background Extended multiorgan resection (EMR) for locally advanced (T4) gastric cancer remains controversial. The aim of this study was to evaluate the effectiveness of this approach with regard to morbidity, mortality, and survival. Methods Between 2005 and 2009, 41 patients underwent aggressive surgery for clinical T4 gastric cancer. Univariate and multivariate analyses were used to identify prognostic factors for surgical outcomes and survival in these patients. Results Curative resection was performed in 29 patients (70.7%); postoperative morbidity and mortality rates were 17.1% and 4.9%, respectively. The survival rate in R0 resection patients was significantly longer than that in patients undergoing R1 or R2 resection. Multivariate analysis identified resectability and tumor size (≥10 cm) as independent prognostic factor for patients with T4 gastric cancer undergoing combined resection. Conclusions EMR should be performed for patients with T4 gastric cancer in whom curative resection can be used.

Peritoneal carcinomatosis

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is now an established therapy with a curative option for patients with gastrointestinal and gynecological peritoneal carcinomatosis as well as for primary peritoneal carcinomatous tumors. Decisive for the prognosis is a complete cytoreduction, which in most cases necessitates multi-organ resection in addition to a partial or subtotal parietal peritonectomy (PE). The highest priority is given to maintain an adequate quality of life for the patient while performing maximum tumor resection. The morbidity following PE and HIPEC in experienced centers lies between 25% and 35% with a mortality risk of <5%. Consideration must be given not only to the technical surgical aspects and the intraoperative decision-making but also to the intraoperative management, intensive care therapy, pain therapy, management of complications, physiotherapy and many more. The greatest challenge in the management of peritoneal carcinomatosis is still patient selection. Computed tomography imaging together with (18)fluorodeoxyglucose positron emission tomography (FDG-PET) plays an important role in the assessment of operability.

Aggressive Surgical Approach for Patients with T4 Gastric Carcinoma: Promise or Myth?

Surgical outcomes of multiorgan resection (MOR) for T4 gastric carcinoma reported in the literature are widely variable. We herein report a large surgical series of T4 gastric carcinoma. One hundred seventy-nine patients with cT4 gastric carcinoma were recruited onto the study. Patient characteristics, surgical strategy and related complications, long-term survival, and prognostic factors of T4 gastric carcinoma were analyzed. Of 179 cT4 gastric carcinoma, there were 57 cT4 (pT3) with MOR, 91 pT4 with MOR, and 31 cT4 without MOR. pT4 with MOR were more likely to be associated with nodal metastasis, cellular dedifferentiation, and lymphoperineural infiltration compared to those of pT0-3 (P<0.01 for all). For 91 pT4 with MOR, their surgical mortality and morbidity rates were 4.4 and 28.6%, respectively; their 1-, 3-, and 5-year overall survival rates were 55.2, 22.4, and 12.2%, respectively. The long-term survival of cT4 (pT3) with MOR was superior to pT4 with MOR (P=0.006) and cT4 without MOR (P=0.004). There was a striking difference between pT4 with MOR, R0 and pT4 with MOR, and R1 or R2 (P=0.007). By means of multivariate analysis, lymph node status, liver invasion, and positive surgical margin were independent prognostic factors. Aggressive surgical management of pT4 gastric carcinoma should be limited to patients without adverse prognostic factors such as advanced nodal involvement and pancreatic invasion.

Analysis of treatment and prognosis in 132 patients with gastric gastrointestinal stromal tumors

To investigate the clinicopathological characteristics, diagnosis, treatment and prognostic factors of gastric gastrointestinal stromal tumors(GIST) in the stomach. The clinicopathological data of 132 patients with gastric GIST between January 1998 and December 2008 were analyzed retrospectively, and the prognostic factors were evaluated. Tumor locations were the cardia or fundus (50, 37.9%), the stomach body (62, 47%),the antrum (13, 9.8%), and two regions were found in 6 cases (4.5%), three regions in 1 cases (0.8%). Tumor size ranged from 1.0 to 27.0 cm with an average of 9.4 cm. All the patients underwent complete tumor resection, including multi-organ resection in 41 cases. Thirty-four cases underwent lymph node dissection. All the lymph nodes were negative. The positive rate was 93.2% (23/132) for CD 117 and 82.6% (109/132) for CD34. The 1-,3- and 5-year survival rates of the 118 cases with follow up were 94.7%, 80.2%, and 56.6%, respectively. Univariate analysis revealed that the differences in Fletcher classification, tumor size, infiltration to surrounding tissue, preoperative metastasis, and adjuvant postoperative therapy with imatinib were related to the survival rates. Multivariate analysis demonstrated that Fletcher classification, preoperative metastasis and adjuvant postoperative therapy with imatinib were independent poor prognostic factors for survival. Preoperative metastasis is an independent factor predicting poor prognosis of gastric GIST. Fletcher classification can be used to evaluate the biological behaviors and prognosis, while surgery is the main therapy and targeted therapy can improve survival of gastric GIST.

Surgical management of gallbladder cancer

Gallbladder cancer is a very common malignancy in the northern part of India. Surgery is the only potentially curative modality of treatment for this disease. Radical cholecystectomy is the optimal surgical standard for resectable gallbladder cancer. This includes cholecystectomy, liver resection (wedge, segments 4b and 5, or extended right hepatectomy), and regional lymphadenectomy along the hepatoduodenal ligament, behind the duodenum and pancreatic head, common hepatic artery and celiac axis. Controversies regarding extent of liver resection, lymphadenectomy and role of multiorgan resection have been discussed. Incidental gallbladder cancer is often detected on histopathologic examination of the simple cholecystectomy specimen removed for a presumed gallstone disease. Revision surgery should be performed for incidental cancers that invade muscularis propria or beyond (T1b or more). Advanced gallbladder cancer should be treated non-operatively with a palliative intent. Obstructive jaundice in the setting of an advanced gallbladder cancer can be palliated with biliary stenting by endoscopic or transhepatic means. Occasionally, a surgical biliary bypass may be indicated to relieve intractable pruritus in a jaundiced patient with gallbladder cancer. There is no role of a planned R2 resection of advanced gallbladder cancer for the purpose of cytoreduction. Further improvement in the management of gallbladder cancer will need integration of systemic chemotherapy with radical surgery.

Advanced cytoreductive surgery: American perspective

Over the past 3 to 4 decades a special knowledge and understanding of the pathophysiology and behavior of gynecologic peritoneal surface malignancies has led to a significant improvement of the relevant treatment modalities, mirroring advances in chemotherapy approaches and improved knowledge of tumor biology. The surgical management of advanced ovarian, primary peritoneal, and fallopian tube cancers has evolved from the performance of basic gynecologic procedures to the incorporation of more comprehensive surgical procedures. This extensive surgical approach is of great importance for estimating the prognosis and guiding further treatment of affected patients. These complex procedures involving multi-organ resections are generally long and require excellent knowledge of upper abdominal anatomy. This article will focus on the role and program development of advanced cytoreductive surgery in patients with gynecologic peritoneal malignancies. This review is an attempt to provide guidance for the rationale and strategic approach to develop the surgical skill set, meet institutional requirements, and implement the concept of a comprehensive cytoreductive surgical team.

Appropriate selection of patients for combined organ resection in cases of gastric carcinoma invading adjacent organs

Proper patient selection for multi-organ resection in T4 gastric carcinoma remains controversial. Our aim was to investigate which patients might benefit from multi-organ resection. Among 1,775 consecutive patients receiving gastric cancer surgery, 71 had adjacent organ invasion. Short- and long-term surgical outcomes and associations between clinicopathological factors and overall survival were investigated. Forty-seven patients underwent curative surgery with multi-organ resection, and 24 underwent non-curative surgery, with or without multi-organ resection. Postoperative morbidity and mortality rates were 31.7% and 3.3%, respectively. Patients receiving curative surgery via multi-organ resection survived longer than those without (MST, 31.5 months vs. 19.1 months, P = 0.046). Multi-organ resection did not affect survival when performed in non-curative surgery. N3 lymph node metastasis was an independent prognostic factor for poor outcome (HR = 3.89, 95% CI = 1.40-10.83) in curatively resected patients; patients with N3 lymph node metastasis showed similar survival to patients receiving non-curative surgery. Multi-organ resection should be performed only when no incurable factors are present, and R0 resection is most likely. Multi-organ organ resection does not, however, seem to be effective in patients with N3 lymph node metastasis, even when curative resection is performed.

Laparoscopy in the Management of Peritoneal Carcinomatosis

The use of videolaparoscopy in the assessment of peritoneal carcinomatosis extent is now universally accepted. This procedure allows us to define with certainty the origin of the neoplasm, the peritoneal cancer index (PCI), the involvement of the small bowel and its mesentery, the feasibility of surgery and the index of attainable cytoreduction, the evaluation of an eventual multiorgan resection, and finally results in no mortality and very low morbidity.The indications for laparoscopy are as follows: staging of the carcinomatosis already diagnosed with imaging (CT scan and MRI), staging of carcinomatosis of dubious origin (biopsy), restaging after neoadjuvant chemotherapy, restaging during follow-up in the case of dubious imaging, and restaging after adjuvant chemotherapy.Open (Hasson) technique has always been used in the introduction of the first trocar, and the changing position of the surgical bed allows for the evaluation of all the abdominal quadrants, limiting viscerolysis to the essential minimum to avoid iatrogenic lesions. Associating the intraoperative ultrasound has allowed us to reduce understaging of lesions at the depth of the diaphragm, of hepatic metastases and neoplastic masses at the pancreatic tail, and of the omental retrocavity.In all the cases in which diagnostic laparoscopy was followed by peritonectomy, we found a good correlation between open surgery data and the laparoscopic PCI. We excluded patients from peritonectomy if the staging laparoscopy showed a significant involvement of the small bowel or mesentery.We used videolaparoscopy to stage 197 cases of peritoneal carcinomatosis and achieved full laparoscopic PCI assessment in 196 of 197 (99.49%) cases, whereas only 4 of 197 (2.03%) cases were understaged before the routine use of laparoscopic ultrasound. Four complications were observed: 2 cases (1.02%) involved an infection of the trocar insertion site, which was treated with antibiotic therapy, and 2 cases (1.02%) involved diaphragm perforation and intraoperative bleeding, respectively, both resolved with videolaparoscopic technique. Two trocars were sufficient in 184 of 197 cases. There was no mortality and no port site metastasis.More recently, we have used videolaparoscopic surgery in the treatment of neoplastic ascites that did not respond to chemotherapy for palliative purposes, which resulted in the total disappearance of the ascites. It is now possible, in light of acquired experience, to evaluate with precision the indications, the technique, and the limits of the method both in the assessment of the carcinomatosis extent and in its palliation. In 28 cases of neoplastic ascites nonrespondent to chemotherapy, we were able to implement fully laparoscopic hyperthermic chemotherapy for the palliative treatment of the ascites, with total disappearance of it in all cases. The l-hyperthermic intraperineal chemotherapy was carried out at 42 degrees C for 90 minutes with 1.5% dextrose solution as a carrier. The chemotherapy solution was cisplatin and doxorubicin, or mitomycin, depending on the type of primary tumor. The drains were left in place and were removed when profuse drainage ceased.Ascites were controlled in all treated cases. A computed tomography scan performed in follow-up showed a small, clinically undetectable, fluid accumulation in the pelvis of 1 patient. Neither mortality nor morbidity was observed in connection with the procedure.

Analysis of clinicopathology and prognosis in 181 patients with gastrointestinal stromal tumors

To investigate the therapeutic experience of gastrointestinal stromal tumors (GIST) and to analyze the pathological features and prognostic factors of GIST. The clinicopathological and follow-up data of 181 patients with GIST admitted in Renji Hospital between January 1999 and December 2007 were analyzed retrospectively. All the cases were grouped according to Fletcher's risk scheme. Life table and COX regression model were used to evaluate the prognostic factors. Out of 181 tumors, 107(59.1%) were located in stomach, 51 (28.2%) in intestine and 23(12.7%) in colorectum or other sites. Distant metastases,including liver metastases were found in 7 patients intraoperatively. Tumor size ranged from 0.5 to 30 cm with the mean of 7.02 cm. The positive rate of CD117 was 94.5% (171/181) and that of CD34 was 86.2% (156/181). One hundred and seventy-six patients underwent complete resections, including multi-organ resections in 26 patients. The other patients underwent palliative operations. The 1-, 3- and 5-year overall survival rates of 181 patients were 95.2%, 87.9% and 78.5% respectively. Univariate analysis revealed age, tumor size, primary organ of tumor, mitotic count, Fletcher's classification and multi-organ resection were associated with survival rate. No significant difference of sex was existed among groups. COX hazard proportional model revealed that advanced stage and large tumor size indicated worse prognosis. Eight patients with high risk of recurrence and 3 patients with recurrence and metastasis were stable after receiving imatinib therapy. The diagnosis of GIST depends on endoscope and CT. Fletcher's classification is simple and effective to evaluate GIST behavior and prognosis. Surgical resection is still the main therapy for GIST and targeted therapy will play a more important role for prognosis in the future.

Clinical analysis of 63 cases with gastric gastrointestinal stromal tumors

To analyze the clinicopathological characteristics of gastric gastrointestinal stromal tumors (gastric GISTs) and to explore the diagnosis, treatment and prognosis of gastric GISTs. Clinical data of 63 cases with gastric GISTs from January 1997 to May 2007 were analyzed retrospectively. All patients were treated by surgery. All the 63 cases were grouped according to the Fletcher 4-tier system for predicting the aggressiveness of GISTs. Survival was calculated by Kaplan-Meier method. Univariate and multivariate analyses were performed using log-rank analysis and Cox regression model respectively to evaluate the prognostic factors. The accuracy of preoperative ultrasonography, CT and EUS was 72.2%, 81.0% and 94.3% respectively. The diagnostic accuracy of EUS was significantly higher than those of ultrasonography and CT(chi(2)=6.065, P<0.05). Of the 63 gastric GISTs, 31 cases(49.20%) were at fundus. Immunohistochemistry staining revealed that the positive rates of CD117 and CD34 were 88.9% and 95.1% respectively. The 1-, 3- and 5-year total survival rates of 63 patients were 96.4%, 84.7% and 71.7% respectively. Univariate analysis revealed that the differences of Fletcher classification and tumor size were significant. No significant differences in gender, age, mitotic index, immunohistochemistry expression and multi-organ resection existed among the groups. Multivariate analysis demonstrated that Fletcher classification was the independent poor prognostic factor for survival. The preoperative diagnostic accuracy of EUS is significantly higher than those of ultrasonography and CT. Fletcher classification is reasonable and feasible to evaluate the prognosis of gastric GISTs.

EVALUATION OF A COMPLICATION GRADING SYSTEM FOR PANCREATIC SURGERY

Background: Morbidity after pancreatic resections (PR) is high but comparison between centers is difficult due to the lack of a unified grading system of the severity of complications. The aim was to test the utility and ability of one suggested system (DeOliveira et al. 2006) on a consecutive series of PR. Methods: Prospectively registered complications Jan 2005-Dec 2007 were retrospectively graded (I-II: conservative management; III: invasive intervention, with (A) or without (B) general anesthesia; IV: organ failure at ICU, V: death. Results: PR = 194 (Whipple 136, Distal 31, Total 14, Beger 11, Segment 2) of which 28 were extended resections (EPR; vein- and/or multiorgan resections). Overall complications, n = 103 (53%). The grade of complication correlated with length of stay (LOS grade 0 = 9 days; I-II = 12d; IIIA = 16d; IIIB = 19d; IV = 41d; V = 17d. Whereas there was no difference in the total number of complications between PR and EPR, EPR had more severe grades (p = 0.006). Delayed gastric emptying (DGE, n = 23, 12%) was grade I-II in 87%. Pancreatic leakage (PL, n = 22, 12%) was mainly handled by minimally invasive procedures (IIIA 68%). Bleeding occurred in 11 patients (5.6%) with a mortality (grade V) of 27%. No patients with DGE or PL died. DGE had lower grade complications compared to PL (p < 0.001) and PL had lower grades than bleeding (p = 0.02). Conclusion: The suggested system discriminates well the severity of complications according to the extent of surgery and correlates with LOS. It seems useful for morbidity comparisons between pancreatic centers.

Giant retroperitoneal liposarcoma

BackgroundLiposarcoma is the most frequent histopathological variety of the retroperitoneum, surgery is the gold standard for treatment.Case presentationWe present the case of a 24-year-old male who was diagnosed with a giant retroperitoneal liposarcoma. The patient received palliative treatment due to non-resectability on the basis of chemotherapy. We decided to perform surgery after no benefit was received with systemic treatment. Complete macroscopic resection of the tumor was performed, without multi-organ resection. The patient is currently alive and disease free at 14 months of evolution.ConclusionRetroperitoneal liposarcomas represent a unique situation and require a more aggressive surgical approach including multiple resections for recurrences. Based on the ability of the patient to tolerate the procedure, surgery is suggested to evaluate resectability of the tumor. We must take into consideration whether prolonged survival will be attained and tumor removal will result in palliation of symptoms.

Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer

Background Multiple organ resection for locally advanced (assumed T4) gastric cancer is associated with high morbidity and mortality. Our aim was to evaluate the efficacy of these surgeries with regard to surgical morbidity, mortality, and survival. Methods Fifty-six patients underwent potentially radical gastrectomy combined with invaded organ resection. Early and late results of multiorgan resection and clinicopathologic factors influencing these results were evaluated. Results Forty patients (71.4%) received 1 additional organ resection and 16 patients (28.6%) received 2 or more additional organ resections. Postoperative morbidity and mortality was 37.5% and 12.5%, respectively. Resection of 2 or more additional organs increased postoperative morbidity and advanced age increased mortality. The 1- and 3-year survival rates were 53.3% and 28.1%, respectively. Advanced age, lymph node metastasis, and resection of more than 1 additional organ were significant prognostic factors for survival. Conclusions For patients with locally advanced gastric carcinoma, multiple organ resection is worthwhile with careful patient selection.

Selection of best candidates for multiorgan resection among patients with T4 gastric carcinoma

Indications for gastrectomy in T4 gastric carcinoma (GC) remain controversial. Our aim was to define prognostic factors to select those patients with best chance to benefit from multiorgan resection. A cohort of patients with T4 GC treated in a 19-year period. Surgical morbidity-associated factors were identified by logistic regression analysis. Prognostic factors were defined by Kaplan-Meier and Cox methods. Seven hundred eighteen patients were included (gastrectomy performed in 169). Surgical morbidity and mortality were 39% and 10.7%, respectively. Surgical morbidity were associated to extent of gastrectomy, age, serum albumin, and lymphocyte count (P = 0.0001). Presence of metastasis (hazard ratio [HR], 1.68; 95% confidence interval [95% CI], 1.19-2.36), albumin <3 g/dl plus lymphocytes <1,000 cells/mm(3) (HR, 2.9; 95% CI, 1.8-4.6), presence of ascites (HR, 2.1; 95% CI, 1.06-4.2), age >or=50 (HR, 1.37; 95% CI, 1.02-1.8), and unresectable disease (HR, 2.6; 95% CI, 1.7-4.1) defined poor survival (P = 0.00001). Performing a multiorgan resection must be balanced between chances for long-term survival and surviving a potentially fatal operation. Absence of metastases, serum albumin levels >3 g/dl, and accomplishment of R0 resection select patients with high probability of benefit from multiorgan resection.

Surgical Outcomes of Patients with Gastrointestinal Stromal Tumors in the Era of Targeted Drug Therapy

BackgroundThe discovery of the c-KIT mutation and the advent of targeted drug therapy with imatinib mesylate have revolutionized the management of gastrointestinal stromal tumors (GISTs). The outcome of patients with surgically treated GISTs treated in the era of targeted drug therapy was assessed and factors associated with adverse outcomes determined. Materials and MethodsPatients with GISTs requiring surgery at a tertiary care center from 2002 to 2007 were reviewed and prognostic factors determined. ResultsForty patients were surgically treated for GISTs. The median age at presentation was 59 years. The stomach (55%) was the main site of primary disease. The median tumor size was 7 cm. Eleven (28%) patients had metastatic disease at presentation. Surgery was undertaken in all patients with curative intent. Multi-organ resection was required in 10 (25%) patients. Imatinib mesylate was administered postoperatively in 68% of cases. Median follow-up was 24 months. There was a 40% recurrence rate with 63% undergoing repeat surgical resection. The peritoneum and liver were the main sites of recurrent disease. The 5-year disease-specific survival and disease-free survival (DFS) were 65% and 35%, respectively. High mitotic rate (P = 0.017) and tumor size greater than 10 cm (P = 0.009) were the only prognostically significant adverse factors of DFS on multivariate analysis, independent of imatinib mesylate treatment. ConclusionAggressive surgical treatment and follow-up of GISTs, combined with targeted drug therapy, leads to long-term DFS survival. Tumor recurrence is independently associated with a high tumor mitotic rate and size greater than 10 cm, despite the use of adjuvant targeted drug therapy.

Morbidity and Mortality Following Multivisceral Resections in Complex Hepatic and Pancreatic Surgery

Complex multivisceral resections in major hepatic and pancreatic surgery are relatively infrequent, and information regarding the morbidity and mortality associated with such resections is scant. The purpose of this paper is to describe the outcomes following such aggressive surgical treatment. A retrospective review of the outcomes following multiorgan resection in the setting of major liver or pancreatic resection was conducted from 2002 until July 2006. Patients who had a major hepatic or pancreatic resection plus resection of at least one other organ were included. The primary outcome measures analyzed were the postoperative morbidity and mortality. Secondary outcomes included recurrence rates and survival. Twenty-seven patients met the inclusion criteria. There were two postoperative deaths (7%). Complications occurred in 59% of patients. Complications were minor in 26% and severe in 33%. Complications were more frequent in older patients and in patients with pancreatic resections. Mortality was significantly increased in the setting of a pancreaticoduodenectomy. These more aggressive procedures should be considered to carry a higher risk of complications, particularly in patients undergoing pancreaticoduodenectomies. Patients should be selected carefully when undertaking complex multivisceral resections in major hepatic and pancreatic surgery.

Multiorgan Resections for Cancer, Advanced Surgical Techniques

Multiorgan Resection for Cancer, Advanced Surgical Techniques covers an impressive array of surgical oncology procedures at the extremes of curative surgery. The operative procedures (technical steps) are presented in a logical stepwise fashion. Tumor biology, extent of disease (local and metastatic), and signs of unresectability are addressed. The indications and contraindications, and surgical pitfalls are addressed for each surgical intervention. Each topic is logically and systematically approached: preoperative evaluation, surgical positioning, operative technique complications and results. This text is written for a surgical audience with special interest in abdominal oncology. Surgeons in training (residents and fellows) and practicing surgeons will find the text helpful. Each chapter provides lessons learned from experience with a specific emphasis on anatomy and technique. The editors have compiled an extensive list of surgical topics, which include upper and lower gastrointestinal tracts, pelvic, retroperitoneal, and peritoneal diseases. Color illustrations are numerous but vary in educational value and quality. This is not a standard “how to” book and should be read with some caution. Some topics addressed are clearly controversial and unproven. Some procedures are best performed by experienced teams at high-volume hospitals. The best aspect of this text is its ability to present a balanced view of heroic surgical techniques with the natural history of the disease or tumor biology.

A method to identify the best candidates for multiorgan resection among patients with T4 gastric carcinoma

15141 Background: Background: Indications for gastrectomy in T4 gastric carcinoma (GC) remain controversial. Our aim was to develop a method for the selection of patients with T4 GC with best chances to receive a benefit from multiorgan resection. Methods: We analyzed a cohort of patients with T4 GC treated from January 1987 to December 2005. Relevant clinical, pathological and therapeutic variables were recorded. Prognostic factors associated with survival were defined by Kaplan-Meier and Cox’s methods. Factors associated to surgical morbidity were selected by Logistic Regression analysis. Results: 718 patients were included (gastrectomy performed in 169). Presence of metastasis (Hazard ratio=1.68 [HR], 95% confidence interval [CI] 1.19–2.36), albumin &lt;3 g/dL plus lymphocytes &lt;1,000 cells/mm3 (HR=2.9, 95% CI 1.8–4.6), presence of ascites (HR=2.1, 95% CI 1.06–4.2), 50 years old or more (HR=1.37, 95% CI 1.02–1.8) and surgical resection not possible (HR=2.6, 95% CI 1.7–4.1) define patients with the worst survival (model p=0.00001). Including only patients who underwent surgical resection, presence of metastases, extent of gastrectomy, serum albumin level and R1-R2 residual were determinants of poor survival (model p=0.00001). Surgical morbidity and mortality were 39% and 10.7%, respectively. The significant factor associated to surgical morbidity were extent of gastrectomy, age, serum albumin and lymphocyte count (model p=0.0001). Conclusion: The decision to perform a curative gastrectomy in patients with T4 GC must be balanced between the chances of long-term survival and the chances to survive a potentially fatal operation. Abscence of lymph node and distant metastases, adequate blood lymphocyte count and normal serum albumin levels could help to select those patients with high probability to receive benefit from multiorgan resection as long as R0 resection is performed. The role of preoperative chemoradiation or perioperative chemotherapy in T4 GC must be defined. No significant financial relationships to disclose.