Early perioperative res ults in 53 cases of locally rec urrent colorectal cancer

Purpose: The objective of this study was to analyze retrospectively the early perioperative results in a cohort of 53 patients with localy reccurent colorectal cancer (CRC).Material and methods: The study covered 53 patients with CRC 21 males and 32 females at a mean age of 62 years treated in the Clinic of Liver, Biliary, Pancreatic and General Surgery, Tokuda Hospital of Sofia, during the period from January 2007 to March 2013. Any necessary diagnostic and surgical methods were applied.Results: The locally recurrent CRC is a challenge for the surgeon because of the fact that in most cases it engages adjacent anatomical structures and organs, on the one hand, and it is accompanied by complications, on the other hand.Conclusion: Achievement of good late results in patients with recurrent CRC is due to radicality of the interventions. Most often, they should be multivisceral resections. The presence of intestinal obstruction of varying degree and of synchronous peritoneal and liver metastases commonly limit the possibilities for surgical interference with the disease. Particular attention should be paid to possible neoadjuvant treatment capable of reducing the stage of diasease and improving the perioperative outcomes. Therapeutic behaviour should be strictly individual and consider any possible options. The experience of the surgical team is extremely important, too

Multivisceral ‘en-bloc` resections of colorectal tumours - milestones in the surgical techniques

Purpose: Colorectal tumours (CRT) consisting mainly of colorectal cancer (CRC) are diagnosed sometimes at an advanced T4 stage, i. e. local involvement of neighbouring organ/organs and anatomical structure/ structures. Aggressive surgical approach preceded and/or followed by neo-adjuvant/adjuvant therapy is advocated because of proven benefit for the patient. The aim of this study was to carry out a literature survey, on the one hand, and to analyze the cases from the authors` institutional experience, on the other hand, in an attempt to submit for consideration the milestones of the multivisceral en-block resections in cases of locally advanced CRTs, i.e. to describe the specific surgical approaches depending on different tumour location and peritumoural involvement of adjacent structures and organs.Material and methods: A retrospective analysis of 154 cases of CRT was performed, all of them operated in the Clinic of Liver, Biliary, Pancreatic and General Surgery, Tokuda Hospital of Sofia, from January 1, 2007 to March 31, 2013. All the patients were diagnosed in an advanced T4-stage and received multivisceral en-bloc resections. Three main groups of methods that had been used were analyzed: 1) preoperative diagnosis, giving a hint of multivisceral en-bloc resection; 2) intraoperative assessment - gross tumour appearance, frozen sections (?), final histological examinations, and 3) surgical methods.Results: Early morbidity and mortality rates were 22,6% and 5,8%, respectively, without any significant difference when compared with ‘simple` colon and rectum resections and with literature data available.Conclusion: Multivisceral en-bloc resection for CRCs has been performed in more than 10% of the cases. It benefits the long-term prognosis. Tumour location and number of resected organs are essential characteristics of these procedures and they are independently associated with the quantity of intraoperative blood loss, higher early morbidity rates and more frequent local recurrence

Locally advanced adenocarcinoma of the supramesocolic part of the colon . Feat ures of surgical treatment and challenges

Purpose: The objective of the present study was to analyze the early results from the surgical treatment of locally advanced carcinoma of the colon in its transverse section and the two flexures.Material and methods: The study covered 36 patients with locally advanced colonic carcinoma, 19 males and 17 females at a mean age of 65,6 years, treated in the Clinic of Liver, Biliary, Pancreatic and General Surgery, Tokuda Hospital of Sofia during the period from January 2007 to March 2013. Any necessary diagnostic and surgical methods were applied.Results: Multivisceral resections were commonly performed in order to achieve a radical surgery in cases of locally advanced disease. Great surgeon`s experience in liver, biliary and pancreatic interventions is obligatorily required. In this paper we share our experience in the treatment of this disease for a period of 6 years.Conclusion: Our application of the multivisceral resections results in surgical radicality along with acceptable levels of perioperative morbidity and mortality rates when compared to other studies in in the foreign literature available

Clinico-pathological prognostic factors in hematogenously disseminated colorectal cancer

Background: Ekberg`s criteria for liver resections (LR) of colorectal cancer liver metastases (CRCLM) have been accepted as a `dogma` and the procedure - as a `gold standard` since 1986. There are many wellknown predictive factors for the early and long-term results in this field of surgery. However, some of them are still a matter of debate.Aim: Study on the possible prognostic value of some clinical-pathological factors for the early and late results after major LR (≥ 2 segments) of CRCLM.Material and methods: A total of 143 radical (R0) major LR (≥ 2 segments) of synchronous and metachronous CRCLM were performed between 01.01.20007 - 31.12.2014 in the Clinic of Liver, Biliary, Pancreatic and General Surgery, Tokuda Hospital Sofia. The design of the study was `a single center` and `retrospective`. We analyzed the data with possible predictive value - demography, comorbidity, liver function, ASA group, neoadjuvant chemotherapy, type and characteristics of the surgical procedure, pathological data (T,N,G,H) and time of detection of metastases (synchronous or metachronous). The early postoperative morbidity and mortality rates were compared with these factors looking for correlation. The long-term follow-up period was ≥ 12 months for 86 patients (60.1%).Results: The early postoperative mortality rate was 2.8% (4 cases) for the whole series. The specific morbidity rates were significantly higher in patients above 65 years of age, with ≥ 3 comorbid conditions, multivisceral resections in cases of synchronous metastases and atypical (non-anatomical) LR. The majority of CRCLM cases were ≥ Т2, N (+) positive and G2-3. Unfavorable prognostic factors were the detection of metachronous lesions earlier than 12 months after a curative previous resection especially on the basis of adequate chemotherapy.Conclusions: The knowledge on prognostic factors in patients with CRCLM as well as on indications and contraindications helps the correct preoperative judgment on choosing the right and appropriate type and volume of surgical procedures

Comparative analyses between the early postoperative results after major liver resections of colorectal and noncolorectal cancer liver metastases

Background: Liver resections (LR) are an obligatory element in the multimodal treatment scheme of colorectal cancer liver metastases (CRCLM). Nowadays still there are debates about the benefit of any aggressive surgical approach in noncolorectal cancer liver metastases (NCRCLM) because many authors report desperately high rates of early specific post-resection complications (SPRC) followed by unsatisfactory long term results.Aim: Comparative analyses between the SPRC after major liver resections (MLR), i.e. ≥ 2 segments of CRCLM and NCRCLM for confirming or denying the hypothesis of higher risk in the group of NCRLM.Material and methods: A total of 331 MLR of benign and malignant tumors were performed between 01.01.2007 - 31.12.2014 in the Clinic of Liver, Biliary, Pancreatic and General Surgery, Tokuda Hospital Sofia. Radical resections received 143 CRCLM patients and 58 NCRCLM patients, both synchronous and metachronous. The design of the study was `a single center` and `retrospective`. The perioperative data of these 201 patients were analyzed and finally 59 cases of CRCLM (Group 1) and 36 cases of NCRCLM (Group 2) were included in the study. All the metastases were metachronous and no significant differences in demography, comorbidity, liver function, ASA group, neoadjuvant chemotherapy and surgery specificity were detected between the two groups. Cases that were indicated for MLR were those under 65 years of age, with preserved liver function, without serious pulmonary and cardiac concomitant diseases, and estimated as ASA group ≤ III. Data about SPRC were collected and analyzed. Results: The entire early postoperative mortality rate was 3.2% (3 fatal outcomes) - 1/59 (1.7%) in group 1 and 2/36 (5.5%) in group 2. The cause of death was liver failure, sepsis and pulmonary embolism. The rate of SPRC was significantly higher in group 2, affecting 16/36 patients (44.4%) while only 18 out of all the 59 patients (30.5%) in group 1 suffered specific complications. However only 5.1% and 8.3% of the SPRC necessitated reoperations in group 1 and group 2 respectfully. The comparative analysis denied any prognostic value for the early SPRC played by the time of metastases detection, adjuvant chemotherapy, the duration of liver resection procedure and the necessity of blood transfusion. Conclusions: Both mortality and specific morbidity after MLR affected patients with ≥3 comorbid conditions which proved to be the only predictive factor for SPRC. SPRC were more frequent in group 2 (NCRCLM) but the great majority of them were solved by conservative measures, less often by interventional procedure and reoperations were indicated very rarely

Is the Reoperative Thyroid Surgery Riskier in Recurrent Goiter?

Reoperative surgery of the thyroid gland is feared because of the higher risks of complications. The goal of our study was to evaluate the risks from reoperative procedures of the thyroid gland in patients with recurrent thyroid diseases. For a period from 2001 to 2015 we operated on 709 patients with different thyroid pathologies. In 81 patients, we had to perform reoperation for recurrence . Only 2 patients had postoperative unilateral palsy of the recurrent laryngeal nerve and 3 patients had temporary hypoparathyroidism with Ca level

Micellar solubilization of poorly water-soluble drugs: effect of surfactant and solubilizate molecular structure

<p><b>Objective:</b> This study aims to clarify the role of surfactant and drug molecular structures on drug solubility in micellar surfactant solutions.</p> <p><b>Significance:</b> (1) Rationale for surfactant selection is provided; (2) the large data set can be used for validation of the drug solubility parameters used in oral absorption models.</p> <p><b>Methods:</b> Equilibrium solubility of two hydrophobic drugs and one model hydrophobic steroid in micellar solutions of 19 surfactants was measured by HPLC. The drug solubilization locus in the micelles was assessed by UV spectrometry.</p> <p><b>Results:</b> Danazol is solubilized much more efficiently than fenofibrate by ionic surfactants due to ion–dipole interactions between the charged surfactant head groups and the polar steroid backbone. Drug solubilization increases linearly with the increase of hydrophobic chain length for all studied surfactant types. Addition of 1–3 ethylene oxide (EO) units in the head group of dodecyl sulfate surfactants reduces significantly the solubilization of both studied drugs and decreases linearly the solubilization locus polarity of fenofibrate. The locus of fenofibrate solubilization is in the hydrophobic core of nonionic surfactant micelles and in the palisade layer of ionic surfactant micelles.</p> <p><b>Conclusions:</b> Highest drug solubility can be obtained by using surfactants molecules with long chain length coupled with hydrophilic head group that provides additional drug–surfactant interactions (i.e. ion–dipole) in the micelles.</p

Anatomical Versus Atypical Liver Resections - Advantages and Disadvantages

Background: Liver resections (LR) are a daily practice rather than exception with the aim of radicalism (sometimes `radicalism` is the excuse and justification of the surgeon). From a different point of view, an aggressive approach may predispose to specific post-resection complications (SPRC). There still are debates about the most proper procedure - anatomical versus atypical LRs. Aim: The aim of this article is an analysis of the structure and rate of SPRC (acute liver failure=ALF, biliary leakage, bleeding) with a focus on a possible correlation to the surgical technique. Materials and Methods: 344 liver resections in total were performed at the authors` institution from January 1, 2007 to December 31, 2015. All the procedures were indicated by benign tumors as well as by primary and metastatic malignancies. The study design was single-center, retrospective and randomized. Inclusion criteria were the following: (1) Age ≤ 70 years; (2) Presence of ≤ 3 cormobid conditions; (3) Major LR, i.e. removal of ≥ 2 segments or ≥ 30% of liver parenchyma; (4) No synchronous (Н1) liver metastases or metachronous metastases + local recurrence necessitating a single-stage multivisceral resections. We collected all the data from the medical records. Finally, 102 cases were selected according to the above-formulated criteria and they were divided into 2 groups: (A) Anatomical LR (AnatLR) - 44 patients; (B) Atypical LR (AtypLR) - 58 patients. The incidence rate and other characteristics of SPRC were analyzed and a possible correlation between SPRC and the group affiliation was investigated. Results: The early mortality and SPRC rates were 2.8% (3 cases) and 19.4% (21 complications in 20 patients), respectively. Fatal outcome was caused by ALF after right hepatectomy (2 cases) and sepsis leading to MODS and MOF (1 case). Four patients (3.7%) received reoperation due to biliary leakage and/or bleeding from the resection surface. The remaining 17 SPRCs were overcome by conservative treatment. There was no statistically significant difference in mortality and morbidity rates in group A and group B. Conclusions: A successful outcome after a major LR depends on many factors: preserved preoperatively liver function, definitive bilio- and hemostasis on the resection surface, as minimal as possible blood loss and prevention of postoperative biliary hypertension. In our study, we found that an AnatLR is an aggressive and risky procedure for acute liver failure, while a precise AtypLR may guarantee also a low rate of SPCR. The advantages and disadvantages of both techniques must be researched based on late results in oncologic cases

Non-Colorectal Liver Metastases - Where Are the Limits of a Reasonable Aggressive Surgical Approach in the Multimodal Treatment Scheme?

Background: Resection of non-colorectal liver metastases (NCRLM) is one of the recent fields in hepatic surgery. It was just 10-12 years ago when those procedures were totally denied as `risky` and `useless` and therefore, they were performed as an exception. Aim: The aim of this paper is to present analyses of early and late postoperative results in our series of resections of NCRLM, discussion of the indications for surgery and evaluation of the possible benefit of surgery as an element of multimodal treatment scheme. Materials and Methods: The study design was a single-center retrospective and prospective for a 9-year period (January 1, 2007-December 31, 2015). A total of 62 patients received R0 resections of metachronous and synchronous NCRLM. Metastatic pancreatic and gastric cancer cases predominated (n=49, 80.3%). The indications for aggressive surgery included age ≤ 60(65) years, absence of serious concomitant diseases, ASA ≤ III, no data of other distant organ involvement, no peritoneal lesions, no local recurrence (in metachronous cases) and resectable primary tumor (in synchronous cases). The early postoperative results were analyzed and outpatient follow-up was done every 3 months. Disease-free survival (DFS) and overall survival (OAS) rates were studied. Results: The early postoperative mortality rate was 4.2% in the whole series (2 fatal outcomes in gastric and 1 in pancreatic NCRLM). The specific morbidity rate was very high (N=33, 54.1%) and more often ascertained after multivisceral resections of synchronous NCRLM but 84.8% of them were treated by conservative or interventional methods. Reoperation was performed on 5 patients (15.2%). Fifty-six patients (91.8%) were followed for ≥12 months or until the patient`s death was registered. DFS (8.9-22.4 months) and OAS rates (10.7-57.3 months) varied in broad range and demonstrated statistical dependence on the primary tumor location, time of detection and „N`, „G` and `R` categories. Conclusion: Indicated and reasonable resections of synchronous and metachronous NCRLM had morbidity and mortality rates comparable to that of other multivisceral resections and they lead to a positive impact on the survival rates and the quality of life

Specific Postoperative Complications After Pancreatic Resections - Structure, Predictors, Prevention and Treatment in a Single Institution Series of 173 Cases

Introduction: The morbidity rate after pancreatic resections (PR) remains oppressively high and reaches up to 50% in some current studies of world-leading centres and schools. Specific complications are still one of the main problems because they deteriorate the patient`s quality of life, deteriorate the prognosis, prolong the hospital stay and the trеatment expenses exceed by more than 3 times the cost of uncomplicated cases. Aim: The aim of this paper is to conduct an analysis of the early postoperative results after PR and a study on the structure, predictive factors, treatment and prevention of early specific complications. Materials and Methods: A total of 173 PR (135 duodenohemipancreatectomies and 38 left pancreatectomies) have been performed at the authors` institution since January 1, 2007 till December 31, 2015. The study design was single-center, retrospective and randomized. Exclusion criteria were the following: (1) a benign pancreatic disease and/or a neighboring tumor of a different than pancreatic primary site that necessitated PR; (2) R1,2 positive resections; (3) synchronous 1-metastases, i.e. single-stage multivisceral resections; (4) age ≥ 70 years; (5) the presence of ≥ 3 comorbid conditions. Finally, we selected 108 cases and collected and analyzed perioperative data, specific characteristics of the procedure (duration, blood loss, technical aspects of the anastomosis, protective drainages) and the early postoperative results. Results: The early (within 30 days after surgery) mortality and specific morbidity rates were 3.7% (4 cases) and 31.5% (42 complications in 34 patients), respectively. Reoperation was indicated in 3 cases (2.8%) while the remaining 31 patients were treated conservatively and/or by interventional procedures. We performed correlative analyses for dependence between: (1) mortality and specific morbidity rates on the one hand and (2.1.) preoperative condition, respectively adequate preparation, and jaundice cure on the other; (2.2.) type and technique of anastomoses; (2.3.) pancreatic duct diameter; (2.4.) quantity of operative blood loss. Conclusion: In our series of right and left PR we found prognostic value of the preoperative patient`s condition, anastomosis construction and operative blood loss for a specific morbidity