Inferior vena cava resection in HPB surgery
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Vol. 9, No. 4 2005 Abstracts 559 resection with curative intent. Seven (25%) underwent palliative pro- cedures and 7 (25%) had diagnostic explorations. Analysis of all vari- ables revealed that the only factors with statistically significant relationship to survival were TNM staging and operative resection with curative intent. Our experience with intrahepatic cholangiocarci- noma demonstrated a dismal prognosis. The survival benefit from operative resection demonstrates the need for early diagnosis and hepatectomy in these patients. 131 VASCULAR RESECTION (PORTAL VEIN, SUPERIOR MESENTERIC VEIN, AND HEPATIC ARTERY) IN HPB SURGERY Emilio Vicente, MD, Yolanda Quijano, MD, Carmelo Loinaz, MD, Carlos Monroy, MD, Isabel Prieto, MD, Rafael Beni, MD, Francisca Garcia-Moreno, MD, Jacobo Caban ˜ as, MD, Gonzalo Bueno, MD, Javier Rodriguez, MD, Hospital Madrid MontePrı ´ncipe, Boadilla Del Monte. Madrid, Spain; Hospital Ramon y Cajal, Madrid, Spain Vascular resection for cases of advanced tumors remains controversial, because of the high risk of postoperative complications and extremely poor long-term survival. Recent advances in surgical technique have contributed to an increased resectability rate and to an improved prognosis and outcome with respect to early morbidity and mortality rates, as well as vascular reconstruction patency. 13 patients (14 vascu- lar resections) required a concomitant resection of a major vascular structure and vascular reconstruction in an attempt to achieve com- plete tumor resection. Six males and 7 females. Ages ranging from 32 to 79 years (mean age: 51 years). Superior mesenteric vein and portal vein was resected in 9 cases: portal vein (7), portal vein and left portal vein (1) and superior mesenteric vein and right hepatic artery (1). The primary disease was pancreas cancer (3), solid tumor pancre- atic head (1), gallbladder cancer (2), cholangiocarcinoma (2), and recurrent liver metastasis from colon cancer (1). Multivisceral resec- tion was performed: pancreatoduodenectomy (4), pancreatoduode- nectomy central hepatectomy (2), right hepatectomy extended to segment IV extrahepatic biliary duct resection (1), liver segmentec- tomy (S IV) partial gastroduodenectomy extra and intrahe- patic biliary duct resection (1), and extrahepatic biliary duct resection (1). Hepatic artery was resected in 4 cases: main (1) and right hepatic artery (3). The surgical technique was pancreatoduodenectomy (3) and left hepatectomy biliary duct confluence (1). The morbidity and mortality related to vascular reconstruction was 14% (2/14) and 7% (1/13), respectively. The early and late patency vascular reconstruction was 100%. The 1-year survival was 100%, 66%, and 33% for patients operated by liver metastasis, gallbladder cancer, and cholangiocarci- noma, respectively. Our initial experience suggests that vascular resec- tions in advanced HPB tumors can be performed in selected cases safely with acceptable morbidity and mortality. Multivisceral resection associated to vascular resection can be offer a good palliation for patients with advanced tumors. 132 INFERIOR VENA CAVA RESECTION IN HPB SURGERY Emilio Vicente, MD, Yolanda Quijano, MD, Eldiberto Fernandez, MD, Carlos Monroy, MD, Carmelo Loinaz, MD, Isabel Prieto, MD, Rafael Beni, MD, Hospital Madrid MontePrı ´ncipe, Boadilla Del Monte. Madrid, Spain; Hospital Ramon y Cajal, Madrid, Spain Due its proximity to a number of important regional vascular struc- tures, tumors of the liver, biliary tract, pancreas, retroperitoneum area, and kidney are often associated with regional invasion or compression of the inferior vena cava (IVC). We describe the personal experience and policy concerning technical considerations for inferior vena cava resection in selected cases of advanced tumors. Twelve patients required a concomitant resection of IVC with and without reconstruction in order to obtain a complete tumor resection with free margin. Five males and 7 females. Ages ranging from 32 to 54 years (mean age, 45 years). The primary disease was: Liver metastasis from colon cancer (4), ruptured hydatid cyst into IVC with hydatid thrombus in IVC and atrium and pulmonary dissemination (2), Intra- hepatic cholangiocarcinoma (1), renal cancer tumoral thrombus into IVC (2), tumoral thrombus into IVC (2) and tumoral thrombus into IVC liver infiltration (segment V) (1). Total (3) and retrohepatic (3) IVC was performed in 6 patients. In 2 and 4 patients, we resected IVC with renal veins and hepatic vein bifurcation, respectively. Multi- visceral resection was performed: Right hepatectomy extended to seg- ment IV (4), hepatic segmentectomy (segment V) (1), total excision hydatid cyst (2) one of them with IVC and atrium thrombectomy, nephrectomy (3), and tumor thrombus resection (2). The general morbidity of the procedures was 29%, related to the vascular resection (8%). The early and late patency vascular reconstruction was 91%. One patient has a graft thrombosis after IVC resection and graft replacement. One patient died in the postoperative period due to liver failure. The 1-year survival was 100% for patients operated by liver metastasis and tumoral thrombus secondary to renal cancer, respectively. Our initial experience suggest that the IVC resection can be performed in selected cases with a low risk of morbidity and mortality. Long-term patient outcome is not determined by the need to perform a concomitant vascular resection but rather by the biological behavior of the resected malignancy. 133 HEPATIC NEOPLASMS: ROLE OF HELICAL CT AND INTRAOPERATIVE ULTRASOUND (IOUS) Justin J. Burdick, MD, Bryan K. Holcomb, MD, Lewis E. Jacobson, MD, Eric A. Wiebke, MD, Indiana University School of Medicine, Indianapolis, IN Several studies have shown that IOUS is a more sensitive imaging tool than CT for staging hepatic neoplasms. The purpose of this study is to evaluate the role of IOUS in the management of hepatic neo- plasms and to compare intraoperative findings to preoperative helical CT staging. The study was a retrospective review. From 1993-2004, 77 cases were identified with IOUS evaluation of presumed surgically treatable hepatic neoplasms. We reviewed preoperative helical CT scans for number of lesions seen and medical records for planned procedure. Pathology reports were reviewed. Operative notes were reviewed for number of lesions found on IOUS and procedure per- formed. Preoperative staging and planned procedure were compared to IOUS findings and actual procedure performed. Of 77 patients, 34 (44%) were male and 43 (56%) female, with an average age of 54 years. The most common cancers were metastatic colon cancer (n 45; 58%), hepatocellular carcinoma (n 9; 12%), and metastatic testicular cancer (n 4; 5%). In 7 cases (9%), intraoperative in- spection/palpation revealed lesions not seen on CT and changed planned procedure; 5 procedures were aborted. In 16 cases (21%) IOUS changed the planned procedure; 7 procedures were aborted and in 9 cases, the planned procedure was changed. In all cases in which an IOUS-guided resection was performed, the presence or absence of neoplasia identified by IOUS was confirmed by pathology. Other changes included the addition of RFA to resection (n 3), addition of wedge resection to RFA (n 2), conversion from RFA to wedge resection (n 2), conversion from bilobar resection to segmentectomy (n 1), and conversion from RFA to bilobar resection (n 1). In only 12 cases (16%) was attempted surgical treatment aborted because of intraoperative findings not identified by helical CT. IOUS is an important imaging modality for surgical management of hepatic neoplasms. IOUS changed the management in 21% of
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Transcript of Inferior vena cava resection in HPB surgery
Vol. 9, No. 42005 Abstracts 559
resection with curative intent. Seven (25%) underwent palliative pro-cedures and 7 (25%) had diagnostic explorations. Analysis of all vari-ables revealed that the only factors with statistically significantrelationship to survival were TNM staging and operative resectionwith curative intent. Our experience with intrahepatic cholangiocarci-noma demonstrated a dismal prognosis. The survival benefit fromoperative resection demonstrates the need for early diagnosis andhepatectomy in these patients.
131
VASCULAR RESECTION (PORTAL VEIN, SUPERIORMESENTERIC VEIN, AND HEPATIC ARTERY) IN HPBSURGERYEmilio Vicente, MD, Yolanda Quijano, MD, Carmelo Loinaz, MD,Carlos Monroy, MD, Isabel Prieto, MD, Rafael Beni, MD, FranciscaGarcia-Moreno, MD, Jacobo Cabanas, MD, Gonzalo Bueno, MD,Javier Rodriguez, MD, Hospital Madrid MontePrıncipe, Boadilla DelMonte. Madrid, Spain; Hospital Ramon y Cajal, Madrid, Spain
Vascular resection for cases of advanced tumors remains controversial,because of the high risk of postoperative complications and extremelypoor long-term survival. Recent advances in surgical technique havecontributed to an increased resectability rate and to an improvedprognosis and outcome with respect to early morbidity and mortalityrates, as well as vascular reconstruction patency. 13 patients (14 vascu-lar resections) required a concomitant resection of a major vascularstructure and vascular reconstruction in an attempt to achieve com-plete tumor resection. Six males and 7 females. Ages ranging from 32to 79 years (mean age: 51 years). Superior mesenteric vein and portalvein was resected in 9 cases: portal vein (7), portal vein and leftportal vein (1) and superior mesenteric vein and right hepatic artery(1). The primary disease was pancreas cancer (3), solid tumor pancre-atic head (1), gallbladder cancer (2), cholangiocarcinoma (2), andrecurrent liver metastasis from colon cancer (1). Multivisceral resec-tion was performed: pancreatoduodenectomy (4), pancreatoduode-nectomy � central hepatectomy (2), right hepatectomy extended tosegment IV� extrahepatic biliary duct resection (1), liver segmentec-tomy (S IV) � partial gastroduodenectomy � extra and intrahe-patic biliary duct resection (1), and extrahepatic biliary duct resection(1). Hepatic artery was resected in 4 cases: main (1) and right hepaticartery (3). The surgical technique was pancreatoduodenectomy (3)and left hepatectomy� biliary duct confluence (1). Themorbidity andmortality related to vascular reconstruction was 14% (2/14) and 7%(1/13), respectively. The early and late patency vascular reconstructionwas 100%. The 1-year survival was 100%, 66%, and 33% for patientsoperated by liver metastasis, gallbladder cancer, and cholangiocarci-noma, respectively. Our initial experience suggests that vascular resec-tions in advanced HPB tumors can be performed in selected casessafely with acceptable morbidity andmortality.Multivisceral resectionassociated to vascular resection can be offer a good palliation forpatients with advanced tumors.
133
HEPATIC NEOPLASMS: ROLE OF HELICAL CT ANDINTRAOPERATIVE ULTRASOUND (IOUS)Justin J. Burdick, MD, Bryan K. Holcomb, MD, Lewis E. Jacobson,MD, Eric A. Wiebke, MD, Indiana University School of Medicine,Indianapolis, IN
Several studies have shown that IOUS is a more sensitive imagingtool than CT for staging hepatic neoplasms. The purpose of this studyis to evaluate the role of IOUS in the management of hepatic neo-plasms and to compare intraoperative findings to preoperative helicalCT staging. The study was a retrospective review. From 1993-2004,77 cases were identified with IOUS evaluation of presumed surgicallytreatable hepatic neoplasms. We reviewed preoperative helical CTscans for number of lesions seen and medical records for plannedprocedure. Pathology reports were reviewed. Operative notes werereviewed for number of lesions found on IOUS and procedure per-formed. Preoperative staging and planned procedure were comparedto IOUS findings and actual procedure performed. Of 77 patients,34 (44%) were male and 43 (56%) female, with an average age of 54years. The most common cancers were metastatic colon cancer (n �
45; 58%), hepatocellular carcinoma (n � 9; 12%), and metastatictesticular cancer (n � 4; 5%). In 7 cases (9%), intraoperative in-spection/palpation revealed lesions not seen on CT and changedplanned procedure; 5 procedures were aborted. In 16 cases (21%)IOUS changed the planned procedure; 7 procedures were abortedand in 9 cases, the planned procedure was changed. In all cases inwhich an IOUS-guided resection was performed, the presence orabsence of neoplasia identified by IOUS was confirmed by pathology.Other changes included the addition of RFA to resection (n � 3),addition of wedge resection to RFA (n � 2), conversion from RFAto wedge resection (n � 2), conversion from bilobar resection tosegmentectomy (n� 1), and conversion fromRFA to bilobar resection(n � 1). In only 12 cases (16%) was attempted surgical treatmentaborted because of intraoperative findings not identified by helicalCT. IOUS is an important imaging modality for surgical managementof hepatic neoplasms. IOUS changed the management in 21% of
132
INFERIOR VENA CAVA RESECTION IN HPB SURGERYEmilio Vicente, MD, Yolanda Quijano, MD, Eldiberto Fernandez,MD, Carlos Monroy, MD, Carmelo Loinaz, MD, Isabel Prieto, MD,Rafael Beni, MD, Hospital Madrid MontePrıncipe, Boadilla DelMonte. Madrid, Spain; Hospital Ramon y Cajal, Madrid, Spain
Due its proximity to a number of important regional vascular struc-tures, tumors of the liver, biliary tract, pancreas, retroperitoneumarea, and kidney are often associated with regional invasion orcompression of the inferior vena cava (IVC).We describe the personalexperience and policy concerning technical considerations for inferior
vena cava resection in selected cases of advanced tumors. Twelvepatients required a concomitant resection of IVC with and withoutreconstruction in order to obtain a complete tumor resection withfree margin. Five males and 7 females. Ages ranging from 32 to 54years (mean age, 45 years). The primary disease was: Liver metastasisfrom colon cancer (4), ruptured hydatid cyst into IVC with hydatidthrombus in IVC and atrium and pulmonary dissemination (2), Intra-hepatic cholangiocarcinoma (1), renal cancer � tumoral thrombusintoIVC(2), tumoral thrombus intoIVC(2) andtumoral thrombus intoIVC � liver infiltration (segment V) (1). Total (3) and retrohepatic(3) IVC was performed in 6 patients. In 2 and 4 patients, we resectedIVC with renal veins and hepatic vein bifurcation, respectively. Multi-visceral resection was performed: Right hepatectomy extended to seg-ment IV (4), hepatic segmentectomy (segment V) (1), total excisionhydatid cyst (2) one of them with IVC and atrium thrombectomy,nephrectomy (3), and tumor thrombus resection (2). The generalmorbidity of the procedures was 29%, related to the vascular resection(8%). The early and late patency vascular reconstruction was 91%.One patient has a graft thrombosis after IVC resection and graftreplacement. One patient died in the postoperative period due toliver failure. The 1-year survival was 100% for patients operated byliver metastasis and tumoral thrombus secondary to renal cancer,respectively. Our initial experience suggest that the IVC resectioncan be performed in selected cases with a low risk of morbidity andmortality. Long-termpatient outcome is not determinedby the need toperform a concomitant vascular resection but rather by the biologicalbehavior of the resected malignancy.
