Combined treatment of uveal melanoma liver metastases

Uveal melanoma (UM) is the most prevalent intraocular malignant tumor in the Western world. The prognosis of survival in the presence of metastatic disease is 2-7 months, depending on the treatment applied.

This article presents a case of metastatic UM with successful complex treatment of liver metastases.

A 49-year old female, underwent removal of the right eyeball in 1996 due to a histologically confirmed uveal melanoma. After 11 years, CT revealed a mass in the left kidney and multiple metastases in the liver. After left nephrectomy, 6 chemotherapy courses with dacarbazine were performed. The increasing liver metastases were observed. Additional 4 intraarterial (i/a) chemotherapy courses were administered using cisplatin, doxorubicin, fluorouracil, and interferon alfa. After few courses increase in CTC Grade 4 liver transaminases was seen. A partial response was observed, and in December 2008 the patient underwent surgery removing all liver metastases by 7 wedge or atypical resections. All margins were tumor-free. 21 months after liver resections and 14 years since diagnosis, the patient is alive without evidence of disease.

Successful treatment of metastatic uveal melanoma was due to a timely application of a combination of several treatment methods and good prognostic factors of the patient.

Three-port retroperitoneoscopic necrosectomy in management of acute necrotic pancreatitis

INTRODUCTION

Because of major morbidity and mortality after open surgery in acute necrotic pancreatitis, an interest in minimally invasive necrosectomy approaches has increased. We report the results of a recently developed minimally invasive technique that we adopted in 2007.

MATERIAL AND METHODS

This article contains a retrospective analysis of cases and description of original retroperitoneoscopic necrosectomy technique. There were eight patients aged 25-58 years, who underwent retroperitoneoscopic pancreatic necrosectomy in the Center of Abdominal Surgery, Vilnius University Hospital Santariskiu Klinikos, between 2007 and 2009. All patients had at least 30% pancreatic necrosis with extensive retroperitoneal fluid collections on the left side, proved by CT scan. Operations were performed on the 21st-56th days of illness (median, 36th day).

RESULTS

The mean postoperative hospital stay was 49 days (range, 14-99 days). All patients survived. Two patients underwent three additional procedures; two patients, one additional procedure due to remaining infected necrosis. Three patients had no requirement for additional procedures. One patient underwent laparotomy because of bleeding.

CONCLUSIONS

We assume that minimally invasive techniques should be considered a first-choice surgical option in patients with acute necrotic pancreatitis, whenever it is possible. Pancreatic necrosis less than 30% with large fluid collections in the left retroperitoneal space facilitates employment of three-port retroperitoneoscopic necrosectomy.

Orthotopic liver transplantation: the first experience and results of the Vilnius University Hospital Santariskiu Klinikos

BACKGROUND

Liver transplantation has become the treatment of choice for chronic and acute end-stage liver failure as well as for selected cases of malignancies and metabolic disorders. We report our first experience of the orthotopic liver transplantation.

MATERIAL/METHODS

Between 2005 and 2008 16 cadaveric orthotopic liver transplantations in 16 adults (12 males, 4 females, mean age 44 years) were performed. Main indications for orthotopic liver transplantation were cholestatic liver disease (31%), viral-induced cirrhosis (25%), alcoholic liver disease (19%), hepatocellular carcinoma associated with hepatitis virus infection (13%), autoimmune cirrhosis (6%), cryptogenic acute liver failure (6%). Mean follow-up was 15 month (range: 4 days - 43 month).

RESULTS

Intraabdominal haemorrhage was observed in 6 patients (37.5%). Vascular complications were observed in 3 patients (18.75%). Biliary complication were observed in 3 patients (18.75%). Overall 1 year patient survival was 87,5%. Four (25%) patients died during follow-up. All patients died because of sepsis and multiorgan system failure.

CONCLUSIONS

Our first results showed that secret of successful liver transplantation is perfect interdisciplinary team approach, including selection of the recipient and timing of transplantation, the operative procedure itself, prevention and treatment of complications, the perioperative anaesthesiological and intensive-care management, and careful follow up after transplantation.

[Laparoscopic surgery for malignancies of the colon, rectum, and anus in Lithuania in 2008]

THE OBJECTIVE OF THIS STUDY: was to analyze data on laparoscopic surgery for malignant diseases of the colon, rectum, and anus in Lithuania during the period of January 1, 2005, to February 15, 2008.

MATERIAL AND METHODS

During the above-mentioned period in Lithuania, 130 laparoscopic surgeries for malignancies of colon, rectum, and anus were performed in seven different hospitals. There were 73 males and 57 females with a mean age of 68 years (range, 35-85 years). Laparoscopic procedures were attempted in 140 cases. Out of them, 130 were completed laparoscopically; 10 operations were converted to open, and conversion rate was 7.1%. Twenty-seven (20.8%) patients had stage I, 45 (34.6%) stage II, 45 (34.6%) stage III, and 13 (10%) stage IV disease. Ninety-two (70.8%) patients underwent straight laparoscopic surgery and 38 (29.2%) - hand-assisted laparoscopic surgery. Time in surgery was from 50 to 365 min, with a mean of 183 min. During 130 operations, in 11 (8.5%) cases, blood vessels were ligated through specimen retrieval site. Out of 104 operations, where anastomosis was performed (23 abdominoperineal resections and 3 Hartmann's procedures), in 68 (65.4%) cases it was done laparoscopically and in 36 (34.6%) cases using conventional extracorporal suturing.

RESULTS

Hospital stay ranged from 7 to 59 days, with a mean of 12 days. One (0.8%) patient died. Postoperative complications occurred in 27 (20.8%) cases. Reoperation rate was 4.6% (6 cases). Complications were as follows: suture insufficiency (3 cases), eventration (3 cases), wound infection (7 cases), intraperitoneal abscess (1 case), abdominal wall phlegmon (1 case), intra-abdominal infiltrate (1 case), perineal hematoma (1 case), proctovaginal fistula (2 case), intraoperative bleeding from uterus (1 case), urinary retention (4 cases), cystitis (1 case), pneumonia (1 case), acute cardiovascular insufficiently (1 case). In histological specimens, 10 lymph nodes were found on the average (range, 2 to 27).

CONCLUSIONS

Laparoscopic surgery for malignant diseases of the colon, rectum, and anus is dominating among laparoscopic surgeries for colorectum. Complication rate is similar to other authors. To evaluate disease relapse and outcomes, observation time is not sufficient yet.

The comparison of 2-dimensional with 3-dimensional hepatic visualization in the clinical hepatic anatomy education

OBJECTIVE

To determine whether 2-dimensional or 3-dimensional hepatic visualization is better for the medical students to be used while studying the clinical hepatic anatomy.

MATERIAL AND METHODS

Twenty-nine patients who underwent surgical intervention due to focal hepatic pathology at the Department of General Surgery, University of Heidelberg, and at Clinics of Santariskes, Vilnius University Hospital were included in the retrospective cohort study. Before the surgical intervention, the computed tomography (CT) liver scan and 3-dimensional (3D) hepatic visualization were performed. A total of 58 2-dimensional and 3-dimensional digital liver images, mixed up in random sequence not to follow each other with a specially designed questionnaire, were presented to the students of Faculty of Medicine, Vilnius University. Their aim was to determine tumor-affected liver segments, to plan which liver segments should be resected, and to predict anatomical difficulties for liver resection. Results were compared with the data of real operation.

RESULTS

The students achieved better results for tumor localization analyzing 3D liver images vs. CT scans. This was especially evident determining the localization of tumor in segments 5, 6, 7, and 8 (P<0.05). Furthermore, the results of proposed extent of liver resection have been found to be better with 3D visualization (mean+/-SD - 0.794+/-0.175) in comparison with CT scans (mean+/-SD - 0.670+/-0.200), (P<0.001).

CONCLUSIONS

Computer-generated 3D visualizations of the liver images helped the medical students to determine the tumor localization and to plan the prospective liver resection operations more precisely comparing with 2D visualizations. Computer-generated 3D visualization should be used as a means of studying liver anatomy.

Controlled-surgical education in clinical liver transplantation is not associated with increased patient risks

INTRODUCTION

A qualified surgical team is required to perform liver transplantation (LTX). Growing numbers of transplants at transplant centers and large variations of transplant frequencies make a continuous education to train young surgeons on this complex field of hepato-biliary surgery mandatory, both from the organizational and motivational point of view (job enrichment and professional growth). On the contrary, perioperative patient risk management is of major importance in surgical practice and given growing organizational concern in hospitals. A retrospective clinical study was performed to describe and evaluate the process of surgical training for orthotopic LTX. Patient risks associated with or caused by the education process in clinical LTX were analyzed.

METHODS

Perioperative patient data and details of surgical strategies were collected for 155 consecutive LTX carried out at a single center. Operative and follow-up data were correlated with the degree of surgical experience of the first operating surgeon. Two groups were defined. In group A, transplant surgeons with >30 personally performed LTXs (n = 3) and in group B, transplant fellows with >30 assistance in LTx (n = 3) performed the operations. All LTX operations were standardized based on modified piggyback technique described by Belghiti. Group B operations were performed under close supervision/assistance of the ''transplant surgeon.'' Selection of patients for exposure to surgical training was based on the pre-operative estimation of surgical difficulty. Operative time, blood loss, liver function, post-operative morbidity, and survival rate data were compared in both groups.

RESULTS

A total of 155 LTX were performed in 131 patients and were analyzed, and 106 operations (68.3%) were performed by group A and 49 operations (31.6%) were performed by transplant fellows under supervision (group B). No significant differences concerning mean patient age, distribution of type of disease, operating time, the Model for Endstage Liver Disease (MELD) score and frequency of category Child A, B and C were detected between groups. Overall post-operative complication rate was 21.9% (n = 34). Transplant surgeons and transplant fellows had 19.8% (n = 21) and 26.5% (n = 13) of complication rate, respectively (p > 0.05). Overall patients survival rate was 94% and 89% at 45 days for the patients operated in groups A and B, respectively (p > 0.05). Survival rate, blood loss, intraoperative transfusion requirements and operating time did not differ significantly between groups.

CONCLUSIONS

Liver transplantation requires team performance to minimize patient risks. Incidence of complications was associated with the severity of disease but not with the education process. It could be demonstrated that with careful patient selection and supervision of the transplant fellow with a more experienced surgeon, the results are equal to those obtained when the experienced transplant surgeon is the prime operator.

Surgical strategies for liver transplantation in the case of portal vein thrombosis--current role of cavoportal hemitransposition and renoportal anastomosis

Portal vein thrombosis (PVT), a common complication of end stage liver disease, is no longer considered a definite contraindication for liver transplantation (LTx). The clinical decision to perform an LTx in the case of PVT depends on the degree of PVT and the experience of the surgeon. Eversion thromboendovenectomy was suggested by most authors as the surgical technique of choice for PVT grade 1, 2, and 3. If PVT obstructs more extended parts of the porto-mesenteric venous circulation, surgical options would include different types of venous jump graft reconstructions or arterialization of the portal vein. Combined liver and small bowel transplantation is another possible alternative. Cavoportal hemitransposition (CPHT) and renoportal anastomosis (RPA) were recently particularly advocated as creative surgical strategies in case of diffuse PVT. In this work, we focus on CPHT and RPA surgical techniques during LTx, which attempts to secure the portal flow to the liver graft in case of pre-existent diffuse PVT. We provide a review of all reported clinical experience at international clinical centers using these techniques. According to our meta-analysis a total of 15 studies were published on this topic between 1996 and 2005. In summary, a total of 56 orthotopic LTx have been performed in 53 patients (28 men, 25 women) combined with either CPHT or RPA, for the purpose of providing the donor graft with adequate inflow. Mean age was 44 yr including two patients who were infants, with the youngest recipient being two yr old. Main indications for LTx were liver cirrhosis caused by viral hepatitis, alcoholic cirrhosis and cryptogenic cirrhosis. CPHT was performed in 46 cases, and RPA in 10 cases. Thirty-five of 53 patients (66%) had surgery previous to LTx. Of these, 13 patients (37%) [corrected] presented with a history of other previous surgical procedures for decompression of portal hypertension or treatment of associated complications (portocaval shunts, splenectomy, etc). Ascites, renal dysfunction, lower extremity and torso edema and variceal bleeding were dominant post-operative complications after CPHT or RPA noted in 22 cases (41.5%), 18 cases (34%), 17 cases (32%) and 13 cases (24.5%) respectively. Patients' follow-up ranged from two to 48 months. Thirty nine of 53 patients [corrected] (74%) survived [corrected] and 14 patients died (26%) [corrected] during the course of observation. Based on the literature, we conclude that the ideal technique to overcome PVT during LTx is still controversial. Short-term follow-up results of both methods are promising, however, long-term results are unknown at present. Furthermore, clinical follow-up and basic experimental work is required to evaluate the influence of systemic venous inflow to the liver graft with respect to long-term liver function and liver regeneration.

[Treatment of rectal tumors with transanal endoscopic microsurgery]

OBJECTIVE

The aim of this study was to assess one and a half years experience gained in Lithuania while treating rectal tumors with transanal endoscopic microsurgery in the Centre of Abdominal Surgery of Vilnius University Hospital "Santariskiu klinikos".

MATERIALS AND METHODS

The patients who had rectal adenomas and low-risk T1 carcinomas of good or moderate differentiation, with no lymphatic and vascular invasion were selected for surgery. Tumor stage was determined by transanal endosonoscopy and rectoscopy with multiple macrobiopsies before surgery.

RESULTS

A total of 47 patients were operated on. The average tumor size was 3.4+/-1.4 cm (ranged from 1 to 7 cm). Overall 25 (52.1%) carcinomas and 23 (47.9%) adenomas were removed. Pre-operative diagnoses did not correspond to the final clinical diagnoses in 14 (29.8%) cases. Forty-three (89.6%) radical operations (R0) and 5 (10.6%) doubtful complete operations (RX) were performed. One (2.1%) intra-operative complication and one (2.1%) post-operative complication were observed. After the removal of Ca T2 three patients underwent adjuvant radiotherapy. Twenty-six patients were followed up for 3-17 months after operation: 17 after removal of cancer and 9 after removal of adenoma. One (2.1%) recurrence of a tubulovillous adenoma was diagnosed. No other complications were reported.

CONCLUSIONS

Initial results of transanal endoscopic microsurgery obtained while treating rectal adenomas and low-risk T1 cancers are promising. The low rate of complications and recurrences in this group offers many hopes. The experience of the treatment of T2 cancers with transanal endoscopic microsurgery and adjuvant radiotherapy is limited but the results are encouraging. It is obvious that the results of randomized and controlled trials need to be awaited before definite conclusions can be drawn.

[Difficulties of differential diagnosis of pancreatic pseudocysts and cystic neoplasms]

OBJECTIVE

Surgical resection is indicated in potentially malignant pancreatic cystic neoplasms. Drainage operations are performed in large (5-6 cm) and/or symptomatic pseudocysts. Misdiagnosis results in a considerable delay in an appropriate treatment. Our aims were to compare clinical, morphological, biochemical features of cystic neoplasms and pseudocysts, in which diagnosis of cystic neoplasm was suspected preoperatively, and to determine characteristics, which could predict the misdiagnosis of cystic neoplasms as "pseudocysts".

MATERIAL AND METHODS

One hundred and thirty four patients were operated because of pancreatis cystic lesions (22 cystic neoplasms and 112 pseudocysts) between January 1999 and May 2004. Two groups of patients were evaluated retrospectively. Group I included 22 (10 serous and 8 mucinous cystoadenomas, 3 mucinous cystadenocarcinomas, 1 solid papillary tumor) resected neoplasms. Group II included 11 patients in whom neoplasm was suspected during investigation, but definitive diagnosis of pseudocyst was established. Clinical manifestation, morphologic characteristics and data of instrumental investigations were also compared. Preoperative and postoperative diagnoses were compared with histopathological findings.

RESULTS

Women predominated in group I (67.2%) and men in group II (81.2%). Group I patients were older (mean age 57.9+/-14.55 versus 49.27+/-10.07 years). All pseudocysts were symptomatic. Two (9.1%) incidental cystic neoplasms and 2 drainage operations were performed previously because of misdiagnosed "pseudocysts" in other hospitals. Abdominal pain, 81.8% and 100%, and abdominal mass, 31.8% and 54.4%, were recorded most frequently, group I and group II respectively. Neoplasms (median diameter 59.6 mm) were mainly located in pancreatic head (31.8%) and body (36.4%). Most of pseudocysts (median diameter 71.1 mm) were located in pancreatic head (45.5%). Diagnostic sensitivity of ultrasonography (86.4%) and computed tomography scan (84.2%) was higher in group I than in group II (63.6% and 77.8%). Two serous oligocystic and 1 mucinous cystoadenomas were misdiagnosed as "pseudocyst" preoperatively. In one case malignancy of mucinous tumor diagnosed only postoperatively.

CONCLUSIONS

Differentiating serous and mucinous cystoadenomas from pseudocysts may be difficult. Malignant neoplasms may be undetermined preoperatively. Resection should always be performed in instances where findings cannot be clearly identified.