Pancreatic resection for periampullary cancer in elderly patients

BACKGROUND/AIMS

Major abdominal surgery in elderly patients has traditionally been thought to carry a high operative risk. Recent data, however, have suggested that with proper selection, elderly patients can withstand pancreatic resection.

METHODOLOGY

The medical records of 102 patients who underwent pancreatic resection for pancreatic or periampullary tumors were retrospectively reviewed. Twenty-nine patients were aged 70 years or older (mean age: 74 years) and 73 patients were younger (mean age: 56 years). Concomitant comorbid conditions were evaluated in the patients of both groups, and no significant differences were identified. A pancreaticoduodenectomy was performed in 81 cases and a total pancreatectomy in 21.

RESULTS

The operative mortality rate was 0% in the older patients and 6.8% in the younger patients. Major complications occurred in 28% of the patients. There were no significant differences in morbidity among the two age groups. The overall actuarial survival curves showed similar trends in both groups.

CONCLUSIONS

With appropriate preoperative selection, pancreatic resection can be performed with low operative risk in elderly patients. Chronological age alone should not be considered an absolute contraindication for pancreatic resection.

Choledochocele: changing trends in diagnosis and management

Eighty-four patients with choledochocele collected from the world literature and one personal observation are reviewed. The main issues regarding clinical presentation, diagnostic work-up, and the treatment of this uncommon lesion are discussed. Abdominal pain was the most common clinical feature (91% of cases), followed by pancreatitis (38%), nausea or vomiting (35%), and jaundice (26%). In addition, associated lithiasis was found in 43% of the cases. Endoscopic retrograde cholangiopancreatography was the most useful diagnostic procedure and resulted in a correct diagnosis in all but one of the patients investigated by this method. Surgical excision of the duodenal luminal portion of the choledochocele was the treatment most commonly used (65% of cases). In recent years, operative endoscopy has also been increasingly used, with good results.

Urachal adenocarcinoma. A case report

A 21-year-old woman, previously operated for an acute abdomen from an infected urachal cyst, developed an urachal carcinoma. The importance of systematically and completely exciding urachal cysts is stressed by clinical considerations of the uncommon neoplasm that is associated with a poor prognosis.

[Conservative meso-pancreatectomy for cystic papillary tumor: apropos a case report]

A case of papillary-cystic neoplasm of the pancreas is reported in a 22-year-old woman. The only symptom was a palpable pulsating mass in her upper left abdomen. A conservative surgical treatment was adopted, consisting of pancreatic body resection (meso-pancreatectomy) and pancreaticojejunostomy to distal pancreatic stump. These neoplasms are quite uncommon, and can be difficult to differentiate from other cystic lesions of the pancreas. Surgical excision is curative in these tumors and is the treatment of choice due to its low morbidity and good long-term survival.

Accurate specimen preparation and examination is mandatory to detect lymph nodes and avoid understaging in colorectal cancer

Lymph node involvement in colorectal cancer, one of the most important prognostic factors, can be sometimes underestimated. In this study the authors report the results of two different techniques of specimen preparation and examination. In 240 patients (Group I), histologic examination was performed using a conventional procedure. In Group II (60 cases) the resected bowel and its mesentery were separately stretched, pinned on to a cork board, and fixed. The mesentery was divided according to node location (intermediate and principal) and evaluated by sight and palpation to identify lymph nodes. The bowel segment was divided from 5 cm proximally to 5 cm distally to the tumor every 10 mm in serial 3 mm slices. Three and 10 mm slices were then carefully examined by sight and palpation. Isolated lymph nodes embedded in groups (10-12 per paraffin block) were stained and investigated for neoplastic involvement. The specimen examination procedure used in Group II resulted in identification of a higher number of lymph nodes (mean = 41.1) and nodal metastases (mean = 10) compared to the standard technique used in Group I (mean = 11.3 and 2.4, respectively--P < .05). The percentage of N+ cases also was increased in Group II (48.3%) when compared to that in Group I (30.4%; P < .05). The new technique is simple, inexpensive, and efficacious for the detection of lymphatic metastases in colorectal cancer.

Whole liver intraoperative irradiation after partial hepatectomy produces minimal functional and pathologic lesions

Intraoperative radiation therapy (IORT) was delivered to remnant rat liver after partial hepatectomy to determine the chronic effects of treatment on survival, blood chemistry, liver weight, and histology. Survival at one year was 100%. Remnant liver weight was markedly increased in all animals. Liver function appeared to be unaltered in all groups and at all observation times. Inflammatory cell infiltration occurred immediately after treatment in all animals, showing a slight progression until day 45; by day 180 the values had returned to baseline. Vascular changes were seen early in all groups, then progressively decreased; the vascular score was back to baseline at days 180 and 365. Nuclear alterations were observed in both irradiated and nonirradiated hepatic cells; in all cases these were limited to isolated or focal areas of hepatocytes. There was little fibrosis formation and by day 180 all scores were back to baseline. We conclude that the chronic effects of whole liver IORT after one-third hepatectomy are minimal in the rat and are similar to those observed after surgery alone.

Adenocarcinoma of the small intestine

We examined eight patients with adenocarcinoma of the small intestine: four were localized in the duodenum and four in the jejunum. We performed six curative resections: two pancreatoduodenectomy, two total pancreatectomy and two jejunal resections; in two cases, only by-pass was performed. Three patients who were resected are alive after more than five years; the other patients died between nine and forty-one months after surgery. The evaluation of the data from our experience and from literature shows that the consistently negative results are related to a delay in diagnosis and therapy.

Prognostic factors in colorectal cancer: current status and new trends

The clinical, laboratory, and pathologic data of 361 patients who had curative resections for colorectal cancers were collected and analyzed in a multiple stepwise regression model. In univariate analysis, among clinical factors, bowel obstruction and emergency surgery showed the most significant prognostic value (P = 0.002, P = 0.004, respectively). Vegetating growth, Astler-Coller stage of tumor, intramural spread, lymph node involvement, and synchronous liver metastases resulted in the pathologic variable significantly affecting the prognosis (P = 0.006, P less than 0.001, P = 0.036, P less than 0.001, P less than 0.001, respectively). In the multivariate analysis, stage was the predictive factor with the highest hazard ratio in conjunction with bowel obstruction (P less than 0.0001 in both cases). Processing data excluding stage ("multiparametric factor" itself), hepatic metastases, lymph node involvement, bowel obstruction, and intramural spread appeared as independent predictors of survival (P less than 0.0001, P less than 0.0001, P = 0.0004, P = 0.0316, respectively). Other variables, as biologic and molecular factors, should be more widely tested in order to assess their impact on prognosis.