Microscopically incomplete resection offers acceptable palliation in pancreatic cancer

BACKGROUND: Because mortality and morbidity of pancreatic surgery have decreased to acceptable levels, the complex question arises whether pancreatic resection should be performed in patients with preoperatively doubtful resectable pancreatic cancer. METHODS: Perioperative parameters and outcome of 80 patients who underwent a microscopically incomplete (R1) resection were compared with those of 90 patients who underwent a bypass for locally advanced disease for pancreatic adenocarcinoma. All patients initially underwent exploratory laparotomy with the intention to perform a resection. Quality of life was assessed by analyzing readmissions and their indications. RESULTS: Groups were similar with respect to age, presenting symptoms, and preoperative health status. Tumors were significantly larger in the bypass group (3.5 cm vs 2.9 cm, P < .01). Hospital mortality was comparable: zero after R1 resection and 2% after bypass. Of all severe complications, only intra-abdominal hemorrhage occurred significantly more frequently after resection (10% vs 2%; P = .03). Hospital stay after resection was significantly longer than after bypass (16 vs 10 days; P < .01). Survival was significantly longer after R1 resection (15.8 vs 9.5 months, P < .01). Sixty-one percent of patients were readmitted for a total of 215 admissions, equally distributed between groups. After R1 resection, 0.58% of the total survival time after initial discharge was spent in the hospital, after bypass, 0.69%, which was not significantly different. CONCLUSIONS: R1 pancreatic resection and bypass for locally advanced disease can be performed with comparable low mortality and morbidity rates. Readmission rates are also comparable between groups and time spent in the hospital after initial discharge is low. Because resection offers adequate palliation in pancreatic cancer, a more aggressive surgical approach in patients who are found to have a doubtfully resectable tumor could be advocated, even if only an R1 resection can be achieve

A prospective evaluation of anorectal function after total mesorectal excision in patients with a rectal carcinoma

Background. Rectum resection with total mesorectal excision (TME) and neorectal anastomosis often compromises anorectal function. Insight into the underlying mechanisms is lacking. Therefore, a prospective study was designed to investigate the relationship between clinical and functional outcomes preoperatively and postoperatively. Methods. Eleven patients with rectal cancer were examined before and 4 and 12 months after surgery and compared with 11 healthy volunteers (HVs). Anorectal (neorectal) function was examined by clinical outcome questionnaire, anal manometry, rectal compliance, and sensation. Six HVs also underwent barostat measurements in the sigmoid colon. Results. Clinical parameters of soiling and passive incontinence (loss of stool without sensation) increased significantly until 12 months postoperatively, whereas urgency and tenesmus increased temporarily, returning to preoperative values at 12 months. In anorectal measurements, anal sphincter function was grossly preserved; however, rectal-anal inhibitory reflex (RAIR) was decreased at 4 months but recovered after 1 year. Neorectal compliance was similar to that of HV sigmoid, increasing slightly after 12 months but still significantly lower than that of normal rectum. Neorectal sensation to pressure distention was similar to that of normal rectum, however accompanied by smaller volumes. Neorectal distention induced contractions of large amplitude at 4 months, returning to normal after 12 months. Conclusions. Our results suggest that the transient increase in urgency and tenesmus after surgery results from a temporary increase in neorectal "irritability " accompanied by some adaptation of compliance in time. In contrast, episodes of incontinence and soiling are increased after I year most likely because of reduced neorectal capacity and RAIR recovery in the presence of a low basal anal sphincter pressur

Indicators of prognosis after transhiatal esophageal resection without thoracotomy for cancer

Background: Various techniques have been described for the surgical treatment of esophageal cancer. The transhiatal approach has been debated for its safety and oncologic results. Study design: Between January 1993 and September 1996, 115 patient, underwent a transhiatal esophagectomy with curative intent for adenocarcinoma or squamous cell carcinoma of the middle or distal esophagus or esophagogastric junction. Procedure-related hazards, pathologic results, and prognostic factors for survival were evaluated. Median duration of postoperative followup was 27 months (range 1 to 74 months) for all patients and 45 months (range 30 to 74 months) for those alive at final followup. Results: No emergency thoracotomies were experienced. In-hospital mortality was 3.5%. Vocal cord dysfunction (24%) and pulmonary complications (23%) were the most frequent early postoperative complications. A microscopically radical resection was achieved in 73% of patients. Overall survival was 45% at 3 years. In univariate analysis, the most pronounced indicators of longterm survival (p <0.0001) were radicality of the resection, lymph node involvement, lymph node ratio (ie, the ratio of invaded to removed lymph nodes), and pathologic tumor stage. Multivariate ana-lysis identified the lymph node ratio (p <0.0001) as the strongest independent predictor of long-term survival, followed by radicality of the resection (p=0.0064) and duration of ICU stay (p=0.027). Conclusions: Transhiatal esophagectomy without thoracotomy can be considered a safe procedure for resectable cancer of the midesophagus, distal esophagus, or esophagogastric junction, Radicality and survival results were in line with the data reported for traditional transthoracic approaches. A prognostic value of the lymph node ratio was observed. It emphasizes the need for controlled trials aimed at delineating the prognostic impact of an extended lymph node dissection. (J Am Coll Surg 2002;194:28-36. (C) 2002 by the American College of Surgeons