Parenchyma-sparing Resection Research Articles

Hepatobiliary cystadenomas

Hepatobiliary cystadenomas are rare cystic tumours that can arise from any portion of the biliary tract but most commonly develop intrahepatically. They typically cause non-specific symptoms and are often detected incidentally. Cystadenomas can be mistaken for simple hepatic cysts on radiological imaging, which leads to inadequate treatment. Hepatobiliary cystadenomas have a malignant predisposition and a high recurrence rate. Complete excision including hepatic resection is therefore generally recommended. Three cases of hepatobiliary cystadenoma were identified at one unit over a six-month period. Their clinical details and management are reported. Three female patients are described aged 25, 37 and 73 years. One patient presented because of recurrent infection, one presented because of pressure related symptoms and one lesion was identified incidentally. All patients were investigated by ultrasonography and computed tomography (CT), two additionally had magnetic resonance imaging (MRI) and one had a liver biopsy. The tumours were 4-16cm in size and all lesions were excised by non-anatomical, parenchyma sparing resections. Histology revealed mixed epithelium with underlying ovarian-like stroma. The management of hepatic cystadenomas as well as operative and pathological findings are discussed. Preoperative ultrasonography, CT and MRI is recommended, and early referral for specialist hepatobiliary review is advised. Operative resection is also recommended and complete excision was achieved in these cases. This strategy is supported by the current literature and recurrence has been shown to be unlikely.

Teres Hepatis Ligament Flap Plasty to Prevent Pancreatic Fistula after Tumor Enucleation

Due to the rapid technical progresswith development of high quality imaging tools, incidental diagnosis of small pancreatic lesionsdincluding cystic and solid pathologiesdhas significantly increased in recent years. Besides solid tumors (eg, small neuroendocrine tumors), especially small cystic lesions (eg, side-branch intraductal papillary mucinous neoplasms) bear a relevant risk of malignant transformation. Therefore, surgical management is required for a considerable proportion of these findings. Because these often premalignant lesions do not necessarily require radical oncologic resection, parenchyma-sparing resections have been accepted as surgical standards, among them tumor enucleation (TE) for lesions not exceeding a diameter of 2 cm and lacking signs of malignancy. These techniques offer maximum pancreatic tissue preservation to avoid exocrine and endocrine insufficiencies, which are observed in a considerable number of patients after standard procedures such as pancreaticoduodenectomy or distal pancreatectomy. Postoperative pancreatic fistula (POPF) has been reported as the most frequent complication after TE, with a reported rate between 18% and 50%. Although POPFs after TE are mainly uncomplicated (mostly International Study Group on Pancreatic Fistula [ISGPF] grade A), they remain an unsolved and potentially long-lasting clinical problem. The versatility of the teres hepatis ligament and its use as a surgical cover structure has been described in various procedures, including filling of liver defects after hydatid cysts resection in order to prevent bile leakage, covering the gastroduodenal artery stump during pancreaticoduodenectomy, and covering the resection margin after distal pancreatectomy to prevent leakage. To our knowledge, there have been no reports on teres hepatis

Entwicklung der Pankreaschirurgie in den letzten 10 Jahren

Pancreatic surgery has undergone significant progress during recent years. Specialised centres with interdisciplinary expertise have led to improved patient care with decreased morbidity and mortality. Regarding evidence-based medicine, consensus definitions on morbidity as well as high-quality studies, systematic reviews and meta-analyses on different topics of pancreatic surgery have been published. In acute pancreatitis paradigms have shifted towards conservative management, in chronic pancreatitis parenchyma-sparing resection techniques have widely become accepted. Management of cystic lesions - especially intraductal papillary mucinous neoplasms (IPMN) - has attracted great interest in surgical practice. In pancreatic cancer treatment not only surgical resection techniques have improved but also the central impact of adjuvant treatment has been demonstrated in large multicentre trials.

Impact of resection techniques on postoperative lung function parameters in pulmonary metastasectomy

Pulmonary metastasectomy with curative intent is nowadays a common practice in thoracic surgery. The impact of metastasectomy on respiratory function has become a relevant factor in the treatment algorithm of these patients. However, no sufficient data on the loss of lung function following pulmonary metastasectomy is available to date. A prospective single center study was designed to determine changes in lung function parameters in patients undergoing metastasectomy. Forty-five consecutive patients were included in the study. In 19 patients, metastases were removed by enucleation (laser = 10; electrocautery = 9), in 19 patients by wedge resection, and 7 patients received a lobectomy in order to achieve clear resection margins. Lung function testing was obtained from all patients preoperatively and 3 months after hospital discharge. A significant decrease in FEV1 and VC was found when comparing enucleation/wedge/lobectomy patients (FEV1: 3.4 ± 0.7, 7.6 ± 1.5, 14.2 ± 3.0; VC: 2.4 ± 1.6, 4.7 ± 1.6, 16.9 ± 2.9; respectively). However, no differences were found regarding the loss of FEV1 per resected nodule between laser and electrocautery enucleations. These findings were confirmed by a volumetric analysis of the resected tissue and did not correlate with size of metastases as determined by preoperative CT evaluations. The surgical resection of pulmonary metastases is associated with a detectable but mild loss of lung function. Lung parenchyma sparing resection methods—e.g. electrocautery or laser enucleations—should be preferred over less tissue-sparing techniques.

CURRENT ROLE OF BRONCHOPLASTIC PROCEDURE FOR LUNG CANCER

The indication for a sleeve resection is well established: a tumor arising at the origin of a lobar bronchus but not infiltrating as far as to require pneumonectomy. In addition, a sleeve resection may be indicated when N1 nodes infiltrate the bronchus from the outside, as is often the case in the left upper lobe tumors. From a functional point of view, sleeve lobectomy is strictly indicated in patients who cannot withstand pneumonectomy, but recent experiences have shown that the advantages of sparing lung parenchyma are evident also in patients without cardio-pulmonary impairment. Most studies show similar or better survival results for parenchymal sparing resections if compared with pneumonectomy. Moreover, in the analysis of 5-year survival according to stage, sleeve lobectomy results in higher survival rates for stage I, II. The survival advantage in stage III appears to be limited and the benefit is not always confirmed for stage III-N2 patients. Postoperative morbidity and mortality data reveal overall better results for patients undergoing sleeve lobectomy with respect to pneumonectomy. The preservation of lung parenchyma has been indicated by some authors as the possible cause of a theoretical increased risk for locoregional recurrence after sleeve lobectomy. However, although in some experiences a higher local recurrence rate is reported for sleeve resection with advanced nodal status (N2), the few studies analysing risk factors for recurrence, show that the tumor stage and the nodal status are the only negative predictive factors, rather than the type of operation performed.

High Risk of Biliary Fistula After Isolated Segment VIII Liver Resection

For tumors deeply located in segment VIII (S8), right hepatectomy (RH) often is thought to solve the issue of technical accessibility. Yet, the common existence of an associated underlying diseased liver raises the question of parenchymal-sparing resection. From 2002 to 2011, 34 patients underwent isolated S8 resection, and their operative and postoperative characteristics were compared to 34 matched patients who underwent RH for lesions located in S8. Indications and preoperative characteristics were comparable between the two groups except for larger tumors in RH patients compared with S8 patients (48 vs. 40 mm; p = 0.001). Achieving S8 resection required significantly longer clamping time (45 vs. 37 min, p = 0.011), more additional biliostasis because of obvious biliary leak (65 vs. 18 %, p < 0.001), and subsequently increased application of sealant material (56 vs. 9 %, p < 0.001) compared with RH. The overall complication rate was similar between the two groups (59 vs. 62 %, p = 0.804), although a trend toward a higher rate of biliary fistula was observed in S8 patients (20 vs. 6 %, p = 0.07). Routine CT scan performed on postoperative day 7 found significantly more subphrenic collections in S8 patients compared with RH patients (53 vs. 9 %, p = 0.003). On pathological examination, surgical margin width was comparable between the two groups. Anatomical S8 resection remains a technically demanding procedure with an elevated risk of postoperative biliary fistula but allows achieving adequate carcinologic resection. Increasing consideration for parenchymal sparing resection should lead to favor this approach as a treatment of choice for small and medium-sized tumors located in this segment.

The Role of Residual Tumor Resection in the Management of Nonseminomatous Germ Cell Cancer of Testicular Origin

To assess the outcome of patients with testicular nonseminomatous germ cell tumors (TNSGCT) undergoing intrathoracic residual tumor resection (RTR) after previous chemotherapy (CT) at a single institution. The office records of all patients who underwent intrathoracic RTR for TNSGCT after CT at a single institution from January 2000 through December 2006 were reviewed. There were 124 consecutive patients (age 33.1 ± 8.4 years) with residual masses who underwent 189 surgical procedures. Morbidity and mortality rates were 12.7 and 0.5%, respectively. Complete resections could be achieved in 121 patients (97.6%). In the resected lung masses, necrosis was the predominant histology, (44.4 vs. 29% in mediastinal masses p = 0.018). Mature teratoma was the leading histology in the mediastinum (62.1 vs. 39.5% in lung masses, p = 0.0006). Fifty-nine out of 124 patients (47.6%) required interventions at both lungs and had discordant histological results in 20.3% (12/59) of the cases. Mean survival was 86.6 ± 2.6 months. The overall 5-year-survival and 10-year survival rates were 87 and 85%, respectively. Viable cancer, incomplete resections, age ≥ 34 years, and major pulmonary resections were associated with inferior survival in a univariate Cox proportional hazards model. In a multivariable Cox proportional hazards model, viable cancer, incomplete resections, and major pulmonary resections remained significant prognostic factors. In selected TNSGCT patients with residual masses, RTR can be performed safely after CT. RTR should be attempted at all sites because of possible discordant histological differentiation. Complete and parenchyma-sparing resections are associated with excellent long-term survival, which can be influenced by the surgeon.

Invited Commentary

The optimal surgical management of pulmonary carcinoids remains a contentious issue. The low incidence of the disease (≤ 5% of all lung cancers) practically precludes a randomized, controlled trial providing the gold standard answer to the ideal operative management of carcinoids in the lung. In the absence of level 1 evidence, most surgeons would adopt a strategy that has stood the test of time in their hands and is often the practice in their parent institution. The literature is replete with case series and reports that favor a limited, parenchymal sparing resection for typical carcinoids.

Comparative evaluation of laparoscopic liver resection for posterosuperior and anterolateral segments

BackgroundTotally laparoscopic liver resection of lesions located in the posterosuperior segments is reported to be technically challenging. This study aimed to define whether these technical difficulties affect the surgical outcome.MethodsA total of 220 patients underwent laparoscopic liver resection during 244 procedures from August 1998 to December 2010. The patients who underwent primary minor single liver resection for malignant tumors affecting either posterosuperior segments 1, 7, 8, and, 4a (group 1) or anterolateral segments 2, 3, 5, 6, and 4b (group 2) were included in the study. Seventy-five procedures found to be eligible for the study, including 28 patients in group 1 and 47 patients in group 2. Intraoperative unfavorable incidents were graded on the basis of the Satava approach and postoperative complications were graded in agreement with the Accordion classification.ResultsThe operative time (median, 127 min) and blood loss (median, 200 ml) were equivalent in the two groups. The rates for blood transfusions and intraoperative accidents did not differ statistically between the groups. A tumor-free margin resection was achieved in 94.7% of the procedures, equivalently in both groups. The postoperative course was similar in the two groups. Postoperative complications developed in 2 cases (7.1%) in group 1 and 2 cases (4.3%) in group 2 (p = 0.626). The median hospital stay was 2 days in both groups.ConclusionsLaparoscopic liver resection for lesions located in posterosuperior segments represents certain technical challenges. However, appropriate adjustment of surgical techniques and optimal patient positioning enables the laparoscopic technique to provide safe and effective parenchyma-sparing resections for lesions located in both posterosuperior and anterolateral segments.

Intraoperative bronchoscopy for bronchial carcinoid parenchymal-sparing resection: a pediatric case report

Bronchial carcinoid tumors are the most common primary pulmonary neoplasm in the pediatric population. The widely accepted treatment for carcinoid tumors is surgical, specifically aiming at being as much as conservative on lung parenchyma, while the entire tumor is resected. A brief case is described, highlighting the importance and advantages of a surgical and endoscopic combined approach.

Primary myoepithelial carcinoma of the lung: a rare entity treated with parenchymal sparing resection

Primary lung myoepithelial carcinomas are rare neoplasms arising from the salivary glands of the respiratory epithelium. Given the rare occurrences and reports of these tumors, appropriate recommendations for resection are difficult to formulate. Although classified as low-grade neoplasms, these tumors have a significant rate of recurrence and distant metastasis.

Interdisziplinäre Therapie des nicht-kleinzelligen Lungenkarzinoms

At the time of diagnosis of non-small cell lung cancer, about two thirds of the patients manifest tumor disease limited to the lungs without distant metastases. In this group localized tumor spread (stages I and II) can be distinguished from locally advanced spread including lymph node metastases (stages IIIA and B). In stages I and II with sufficient cardiopulmonary function, surgical resection is considered the standard treatment approach. If lobe resection is not possible due to comorbidities or limited pulmonary function, parenchyma-sparing resection or definitive radiotherapy is advocated. Postoperative adjuvant chemotherapy is recommended for individual cases in stage IB and as the standard treatment in stage II. In stages IIIA and IIIB interdisciplinary consultation involving pneumologists/oncologists, surgeons, and radiation oncologists is necessary to reach decisions on treatment recommendations. Generally multiple treatment modalities are employed in these stages, such as induction chemotherapy followed by surgery and subsequent irradiation or simultaneous chemoradiotherapy. These treatment combinations with curative intent should be differentiated from the numerous treatment methods with palliative intent.

One Hundred Thirty Resections for Pancreatic Neuroendocrine Tumor: Evaluating the Impact of Minimally Invasive and Parenchyma-Sparing Techniques

BackgroundIncreasingly, surgeons apply minimally invasive and parenchyma-sparing techniques to the management of pancreatic neuroendocrine tumor (PNET). The aim of this study was to evaluate the impact of these approaches on patient outcomes. MethodsWe retrospectively collected data on patients with PNET and compared perioperative and pathologic variables. Survival was analyzed using the Kaplan–Meier method. Factors influencing survival were evaluated using a Cox proportional hazards model. ResultsOne hundred thirty patients underwent resection for PNET. Traditional resections included 43 pancreaticoduodenectomies (PD), 38 open distal pancreatectomies (DP), and four total pancreatectomies. Minimally invasive and parenchyma-sparing resections included 25 laparoscopic DP, 11 central pancreatectomies, five enucleations, three partial pancreatectomies, and one laparoscopic-assisted PD. Compared to traditional resections, the minimally invasive and parenchyma-sparing resections had shorter hospital stays. By univariate analysis of neuroendocrine carcinoma, liver metastases and positive resection margins correlated with poor survival. There was an increase in minimally invasive or parenchyma-sparing resections over the study period with no differences in morbidity, mortality, or survival. ConclusionIn this series, there has been a significant increase in minimally invasive and parenchyma-sparing techniques for PNET. This shift did not increase morbidity or compromise survival. In addition, minimally invasive and parenchyma-sparing operations yielded shorter hospital stays.

Parenchyma‐sparing resection for pancreatic neoplasms

To the Editor,We read with great interest the article by Crippa et al. [1]published online on 29 October 2009 in the Journal ofHepatobiliary and Pancreatic Surgery.In recent years parenchyma-sparing resections havebeen increasingly performed for isolated, benign, border-line, or low-grade malignant lesions of the pancreas.Probably the increased confidence with the treatment ofpancreatic fistulas, and the better knowledge of the naturalhistory of pancreatic neoplasms, have encouraged surgeonsto preserve as much pancreatic parenchyma as possible.Enucleation is the simplest and most parenchyma-spar-ing procedure. Intraoperative ultrasound (IOUS) can helpin choosing the best procedure for the patient. The aboveauthors reported a 26% increase in the enucleation rate,thanks to IOUS, in patients who were initially candidatesfor standard pancreatectomy.However, in spite of IOUS their reported fistula rate wasquite high (38%), with a clinically significant fistula rateof 23%. This may have been due to the short distance(2–3 mm) from the main pancreatic duct accepted toconsider the patient a candidate for enucleation and, mostimportant, the lack of an ultrasonographic check of themain pancreatic duct after completing the procedure.After selecting patients with at least 4–5 mm distancebetween the tumor and the main pancreatic duct, and veri-fying by IOUS the morphology of the main pancreatic ductaftertheprocedure,ourfistularatewas15%(5/33),withonlyone (3%) clinically significant pancreatic fistula [2].References

Extent of surgical resections for intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) can involve the main pancreatic duct (MD-IPMNs) or its secondary branches (BD-IPMNs) in a segmental of multifocal/diffuse fashion. Growing evidence indicates that BD-IPMNs are less likely to harbour cancer and in selected cases these lesions can be managed non operatively. For surgery, clarification is required on: (1) when to resect an IPMN; (2) which type of resection should be performed; and (3) how much pancreas should be resected. In recent years parenchyma-sparing resections as well as laparoscopic procedures have being performed more frequently by pancreatic surgeons in order to decrease the rate of postoperative pancreatic insufficiency and to minimize the surgical impact of these operations. However, oncological radicality is of paramount importance, and extended resections up to total pancreatectomy may be necessary in the setting of IPMNs. In this article the type and extension of surgical resections in patients with MD-IPMNs and BD-IPMNs are analyzed, evaluating perioperative and long-term outcomes. The role of standard and parenchyma-sparing resections is discussed as well as different strategies in the case of multifocal neoplasms.

Bilateral cystic pulmonary glial heterotopia and palatinal teratoma causing respiratory distress in an infant

We report on a male infant with extensive, bilateral cystic and solid lung lesions who presented postnatally with respiratory distress caused by bilateral cystic lung lesions. Parenchyma-sparing resections were performed. Histology revealed the presence of neuroglial cell-lined cysts and glial nodules. In addition, a neural element containing palatinal teratoma was detected and excised. Based on previously published cases, the pathogenesis and clinical features of pulmonary neuroglial heterotopia are discussed.

Parenchyma‐sparing resections for pancreatic neoplasms

In recent years there has been an increase in the indications for pancreatic resection of benign or low-grade malignant lesions, especially in young patients with long life expectancy. In this setting, patients may benefit from parenchyma-sparing resections in order to decrease the risk of development of exocrine/endocrine insufficiency. A review of the literature and authors experience was undertaken. Parenchyma-sparing resections of the pancreas including enucleation, middle pancreatectomy (MP) and middle-preserving pancreatectomy are described. Short and long-term outcomes after surgery are analyzed with special regard to postoperative morbidity/mortality, and oncological and functional long-term results. Parenchyma-sparing resections are safe and effective procedures for treatment of benign and low-grade malignant neoplasms. Despite a significant postoperative morbidity they are associated with good long-term functional and oncological results. Enucleation should preferentially be performed laparoscopically whenever possible.

Results of cutting-edge surgery in stage IIIA-N2 nonsmall cell lung cancer

To describe the state-of-the-art of the surgical management of stage IIIA-N2 nonsmall cell lung cancer. When completely resected, occult N2 found at thoracotomy, skip metastases, and single-level N2 in selected locations are reported to portend acceptable survival rates. Conversely, preoperatively proven ipsilateral mediastinal nodal involvement requires a multidisciplinary approach on the basis of neoadjuvant chemotherapy or chemoradiation. In these patients, complete resection of the primary tumor remains among the strongest prognosticators of survival. When technically feasible, radical mediastinal lymphadenectomy could be of added value. Given the demonstrated increase in postoperative morbidity and mortality, pneumonectomy should be avoided when possible, whereas lobectomy and parenchymal sparing resections should be favored if compatible with the resection of the original extent of the primary on tumor-free margins. Only selected patients with N2 disease may benefit from primary surgery. The impact of postoperative morbidity after induction treatment is still being evaluated. In this setting, differences in treatment sequence and combination (chemotherapy alone or chemoradiation) may influence postsurgical outcome. Patients' selection revolves around the modern concepts of oncologic operability and surgical resectability intended as assessment of survival benefit and ability to completely resect all residual tumor after neoadjuvant therapy.

A comparison of right and extended right hepatectomy with all other hepatic resections for colorectal liver metastases: A ten-year study

Aims Colorectal liver metastases are treated by a combination of adjuvant chemotherapy followed by liver resection. In this study we compared all major right-sided resections with left or parenchymal sparing resections. Methods Consecutive patients ( n = 283) who had successful hepatic resections for colorectal metastases from September 1996 to November 2006 were prospectively studied. Early and late outcomes of those who had right and extended right hepatectomies (RH) were compared with those who had all other types of liver resection (AOLR). Adjuvant therapy and pre-operative assessment were standardised for all. Results The 1-, 3- and 5-year overall survival rates in the RH group were 84.1%, 54.3% and 38.9%, respectively. The 1-, 3- and 5-year overall survival rates in the AOLR group were 95.4%, 65.9% and 53.3%, respectively. The difference was statistically significant ( p = 0.03). The 1-, 3- and 5-year disease-free survival rates in the RH group were 69.5%, 34.4% and 25.5%, respectively and 68.4%, 34.91% and 34.91%, respectively in the AOLR group ( p = 0.46). Operative mortality was 3.9% in the RH group and 0.7% in the AOLR group ( p = 0.04). Morbidity was 31.3% in the RH group and 18% in the AOLR group. Conclusion Patients undergoing right and extended right hepatectomies for colorectal metastases have a greater operative morbidity and mortality and have a significantly worse overall survival compared to all other liver resections for the same disease.

Sleeve Resections and Bronchoplastic Procedures in Typical Central Carcinoid Tumours

Typical carcinoids are low grade malignant neuroendocrine neoplasms, mostly located centrally in the tracheobronchial tree. The aim of our study was to analyse the long-term survival and surgical treatment outcome in patients submitted to parenchyma-sparing resections for typical central carcinoid tumours. We retrospectively reviewed the data of 70 patients who underwent sleeve resections or bronchoplastic procedures. We performed 21 sleeve lobectomies, 9 sleeve resections of the main bronchus, 25 bronchoplasties associated with lung resections and 15 isolated wedge bronchoplasties. Nine patients (12.8%) had nodal metastases. There was no operative mortality; postoperative complications occurred in one patient (1.4%) who presented an empyema. At long-term follow-up evaluation, we were able to report good results: all patients were alive and nobody manifested recurrence; one patient had a late cicatricial bronchial stenosis, which was treated with laser therapy. This series of central typical bronchial carcinoids, treated with sleeve or bronchoplastic resection, demonstrated an excellent outcome. Our results suggest that, in experienced and skilled hands, conservative procedures must be considered the treatment of choice for the management of these tumours.