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70 POSTER Pulmonary gas embolism complicating argon fulguration of superficial hepatic metastases during liver surgery
Poster session: Hepatobiliary and pancreatic cancer approach for the analysis of technical innovations (Lilford RJ et al. BMJ 2000;320:43-6.). 70
POSTER
Pulmonary gas embolism complicating argon fulguration of superficial hepatic metastases during liver surgery M. Molina 1 , P. Bretcha 1 , J. Farre 1 , C. Cozacov 1 , M. Sureda 2 , J. Rebollo 2 , J. Cano 3 . 1 Usp Hospital San Jaime, Surgical Oncology, Torrevieja (Alicante), Spain; 2 Usp Hospital San Jaime, Oncology, Torrevieja (Alicante); 3 Usp Hospital San Jaime, Anesthesiology, Torrevieja (Alicante) We report a peroperative incident recently experienced in our institution. We believe that the case discussed below is one of few cases reported of a pulmonary gas embolism caused by localized argon fulguration of superficial hepatic metastases. A 66-yr-old woman was scheduled to undergo radiofrecuency ablation of multiple liver colon metastases under general anesthesia. The surgeon used an Argon beam coagulator for fulguration superficial hepatic metastases unkow. This was followed by a sudden, reduction in end-tidal carbon dioxide partial pressure, in hemoglobin oxygen saturation, and in systolic arterial pressure. And atsame time aperance echocardiographic images of intrahepatic gas-like bubbles defined as hyperechoic dots. Immediately, argon coagulator was interrupted. Spontaneous recovery was observed within 5 min, and there were no significant postoperative complications. Argon enhanced coagulation is a method of operative coagulation of tissues that uses a jet of argon gas encompassing an electrofulguration arc. We hypothesize that argon was injected under pressure in hepatic vein that caused pulmonary gas embolism. Surgeons and anesthesiologists should be aware that the potential for harmful venous gas embolism exists. In patients where extensive use of argon gas coagulator it’s appropriate to plan monitoring and precautions for gas embolism. 71
POSTER
Non colorectal non neuroendocrine liver metastases. Surgical approach F. Romano, F. Uggeri, M. Conti, R. Caprotti, G. Cesana, V. Motta, F. Uggeri. San Gerardo Hospital, University of Milan Bicocca, Department of Surgical Sciences, Monza, Italy Background: Hepatic resection for metastatic disease for colorectal cancer is increasingly carried out and extend survival. However the role of liver resection for hepatic metastases from non colorectal, non-neuroendocrine (NCNN) cancer is less well-defined. Our aim was to evaluated the risk and benefits of surgical resection for NCNN liver metastases. A retrospective review of twelve years experience (1990-2002) was collected. 74 patients were observed and 38 (19 males and 19 females) underwent surgical resection (resectability 52%). Inclusion criteria were: absence of extrahepatic disease and concomitant illness contraindicating liver surgery. Mean age was 66 years (range 44-86), liver resection was synchronous, combined with primary tumor in 14 cases (37%), and metachronous in the remnant 28 (63%). Indications were gastrointestinal (GI) origin metastases in 22 cases (stomach and pancreas) and non-GI origin metastases (kidney, breast, ovarian, melanoma, sarcoma) in 16. Nine patients (24%) had major hepatectomy (more than two Coinaud segments and 29 (76%) minor resections (two or less liver segments). All patients underwent surgery for cure. Perioperative mortality was zero. Median follow up was 72 months. Morbidity was 23%. Overall five years survival rate was 31%, and five years survival rate was better for patients with non-GI origin metastases (55% versus 21%, p<0.05). The extent of resection, presence of synchronous metastases or disease-free interval from original disease to liver metastases diagnosis were not predictive of outcome. Resection of NCNN liver metastases should be justified for patients without extrahepatic disease and radically resectable metastases, with low morbidity and zero perioperative mortality. Expectation of prolonged survival seems to be limited to non-GI origin metastases.
72
S23 POSTER
Survival of polyethylene biliary stent does not increase with diameter when used to relieve malignant biliary obstruction E. McEvoy 1 , J.K. Loehry 2 , R.A. Frost 2 . 1 Salisbury District Hospital, Department of General Surgery, Salisbury, United Kingdom; 2 Salisbury District Hospital, Department of Radiology, Salisbury, United Kingdom Polyethylene biliary stents, placed endoscopically, are widely used to relieve malignant biliary obstruction. Current practice in Salisbury is to use CottonLeung stents (Cook UK) at 11.5 French Gauge (Fr) diameter where possible. We performed an audit to ascertain whether the survival of the larger stent was comparable to the conventional 10 Fr stent. All patients undergoing endoscopic retrograde cholangiopancreatogram and biliary stenting for malignant obstruction of the biliary tree from December 2004 to June 2006 were identified from the radiology database. Case notes were examined for all patients stented with a Cotton-Leung stent. Data on stent diameter, date of insertion, date of blockage, date of death and bilirubin level at death was collected and analysed. 29 patients, 18 female and 11 male, having 53 Cotton-Leung stents (29 at 10Fr, 24 at 11.5Fr) were identified. Median stent survival for the 10Fr stents was 86 days (range 11-454), and for the 11.5Fr stents median survival was 84 days (range 3-251). 5 patients achieved jaundice free death in the 10Fr group, compared to 10 in the 11.5Fr group. We conclude that there is no significant difference in survival (stent patent and functioning) for different diameters of polyethylene stent, but that there is widespread variation within each stent group. 73
POSTER
Resectability of liver metastases from colorectal carcinoma following irinotecan-based chemotherapy W. Polkowski, M. Lewicka, W. Budny, R. Wierzbicki, J. Mielko, A. Kurylcio, A. Stanislawek. Medical University of Lublin, Department of Surgical Oncology, Lublin, Poland Background: In patients with liver metastases (LM) from colorectal carcinoma, liver resection offers the chance of long-term survival. However, resectability rate in patients untreated with chemotherapy, is only 10-25% due to multiple bilobar LM or infiltration of main hepatic/portal vein branches. Modern neoadjuvant chemotherapy has the potential ability to render formerly unresectable patients resectable. Aim: Aim of the present study is to assess influence of chemotherapy with irinotecan-based regimen on resectability rate of LM in patients with colorectal carcinoma. Patients and Methods: Between January 2004 and March 2005, 66 patients with metastatic colorectal carcinoma were treated with the CLF1 regimen (Irinotecan 180 mg/m2 30-90 minutes infusion day 1; 5-FU 400 mg/m2 2 hours infusion day 1 followed by 5-FU 600 mg/m2 days 1 and 2, 44-46 hours infusion; Leucovorin 200mg/m2 2 hours infusion days 1 and 2) every two weeks. In 35 out of the 66 patients (53%), liver was the only metastatic site of the disease. Results: Seventeen patients were scheduled for primary surgical exploration. In 5 patients understaging of the disease in the preoperative work-up was found and further resection was postponed. In 12 patients following resection procedures were performed (12/17; resectability: 71%): hemihepatectomy – 7 (2 extended right-, 4 right- and 1 left- hemihepatectomy), bisegmentectomy – 4 (in 1 patient bilobar lesions), (mono)segmentectomy – 1. None of the 5 initially explored patients did have a response justifying re-exploration and resection, after subsequent chemotherapy with CLF1. Whereas out of 18 patients with primary non-resectable LM, three patients were subsequently explored due to partial response to the chemotherapy. Resection of LM was done in 1 out of the 3 patients. Altogether, resectability rate of primary non-resectable tumours following CLF1 chemotherapy was 4.4% (1/23). Moreover, in 1 patient following initial bisegmentectomy and on further CLF1 treatment, repeat hemihepatectomy was necessary for recurrent LM. Conclusion: Irinotecan-based chemotherapy in patients with initially nonresectable LM from colorectal carcinoma renders limited resectability.
POSTER
Pulmonary gas embolism complicating argon fulguration of superficial hepatic metastases during liver surgery M. Molina 1 , P. Bretcha 1 , J. Farre 1 , C. Cozacov 1 , M. Sureda 2 , J. Rebollo 2 , J. Cano 3 . 1 Usp Hospital San Jaime, Surgical Oncology, Torrevieja (Alicante), Spain; 2 Usp Hospital San Jaime, Oncology, Torrevieja (Alicante); 3 Usp Hospital San Jaime, Anesthesiology, Torrevieja (Alicante) We report a peroperative incident recently experienced in our institution. We believe that the case discussed below is one of few cases reported of a pulmonary gas embolism caused by localized argon fulguration of superficial hepatic metastases. A 66-yr-old woman was scheduled to undergo radiofrecuency ablation of multiple liver colon metastases under general anesthesia. The surgeon used an Argon beam coagulator for fulguration superficial hepatic metastases unkow. This was followed by a sudden, reduction in end-tidal carbon dioxide partial pressure, in hemoglobin oxygen saturation, and in systolic arterial pressure. And atsame time aperance echocardiographic images of intrahepatic gas-like bubbles defined as hyperechoic dots. Immediately, argon coagulator was interrupted. Spontaneous recovery was observed within 5 min, and there were no significant postoperative complications. Argon enhanced coagulation is a method of operative coagulation of tissues that uses a jet of argon gas encompassing an electrofulguration arc. We hypothesize that argon was injected under pressure in hepatic vein that caused pulmonary gas embolism. Surgeons and anesthesiologists should be aware that the potential for harmful venous gas embolism exists. In patients where extensive use of argon gas coagulator it’s appropriate to plan monitoring and precautions for gas embolism. 71
POSTER
Non colorectal non neuroendocrine liver metastases. Surgical approach F. Romano, F. Uggeri, M. Conti, R. Caprotti, G. Cesana, V. Motta, F. Uggeri. San Gerardo Hospital, University of Milan Bicocca, Department of Surgical Sciences, Monza, Italy Background: Hepatic resection for metastatic disease for colorectal cancer is increasingly carried out and extend survival. However the role of liver resection for hepatic metastases from non colorectal, non-neuroendocrine (NCNN) cancer is less well-defined. Our aim was to evaluated the risk and benefits of surgical resection for NCNN liver metastases. A retrospective review of twelve years experience (1990-2002) was collected. 74 patients were observed and 38 (19 males and 19 females) underwent surgical resection (resectability 52%). Inclusion criteria were: absence of extrahepatic disease and concomitant illness contraindicating liver surgery. Mean age was 66 years (range 44-86), liver resection was synchronous, combined with primary tumor in 14 cases (37%), and metachronous in the remnant 28 (63%). Indications were gastrointestinal (GI) origin metastases in 22 cases (stomach and pancreas) and non-GI origin metastases (kidney, breast, ovarian, melanoma, sarcoma) in 16. Nine patients (24%) had major hepatectomy (more than two Coinaud segments and 29 (76%) minor resections (two or less liver segments). All patients underwent surgery for cure. Perioperative mortality was zero. Median follow up was 72 months. Morbidity was 23%. Overall five years survival rate was 31%, and five years survival rate was better for patients with non-GI origin metastases (55% versus 21%, p<0.05). The extent of resection, presence of synchronous metastases or disease-free interval from original disease to liver metastases diagnosis were not predictive of outcome. Resection of NCNN liver metastases should be justified for patients without extrahepatic disease and radically resectable metastases, with low morbidity and zero perioperative mortality. Expectation of prolonged survival seems to be limited to non-GI origin metastases.
72
S23 POSTER
Survival of polyethylene biliary stent does not increase with diameter when used to relieve malignant biliary obstruction E. McEvoy 1 , J.K. Loehry 2 , R.A. Frost 2 . 1 Salisbury District Hospital, Department of General Surgery, Salisbury, United Kingdom; 2 Salisbury District Hospital, Department of Radiology, Salisbury, United Kingdom Polyethylene biliary stents, placed endoscopically, are widely used to relieve malignant biliary obstruction. Current practice in Salisbury is to use CottonLeung stents (Cook UK) at 11.5 French Gauge (Fr) diameter where possible. We performed an audit to ascertain whether the survival of the larger stent was comparable to the conventional 10 Fr stent. All patients undergoing endoscopic retrograde cholangiopancreatogram and biliary stenting for malignant obstruction of the biliary tree from December 2004 to June 2006 were identified from the radiology database. Case notes were examined for all patients stented with a Cotton-Leung stent. Data on stent diameter, date of insertion, date of blockage, date of death and bilirubin level at death was collected and analysed. 29 patients, 18 female and 11 male, having 53 Cotton-Leung stents (29 at 10Fr, 24 at 11.5Fr) were identified. Median stent survival for the 10Fr stents was 86 days (range 11-454), and for the 11.5Fr stents median survival was 84 days (range 3-251). 5 patients achieved jaundice free death in the 10Fr group, compared to 10 in the 11.5Fr group. We conclude that there is no significant difference in survival (stent patent and functioning) for different diameters of polyethylene stent, but that there is widespread variation within each stent group. 73
POSTER
Resectability of liver metastases from colorectal carcinoma following irinotecan-based chemotherapy W. Polkowski, M. Lewicka, W. Budny, R. Wierzbicki, J. Mielko, A. Kurylcio, A. Stanislawek. Medical University of Lublin, Department of Surgical Oncology, Lublin, Poland Background: In patients with liver metastases (LM) from colorectal carcinoma, liver resection offers the chance of long-term survival. However, resectability rate in patients untreated with chemotherapy, is only 10-25% due to multiple bilobar LM or infiltration of main hepatic/portal vein branches. Modern neoadjuvant chemotherapy has the potential ability to render formerly unresectable patients resectable. Aim: Aim of the present study is to assess influence of chemotherapy with irinotecan-based regimen on resectability rate of LM in patients with colorectal carcinoma. Patients and Methods: Between January 2004 and March 2005, 66 patients with metastatic colorectal carcinoma were treated with the CLF1 regimen (Irinotecan 180 mg/m2 30-90 minutes infusion day 1; 5-FU 400 mg/m2 2 hours infusion day 1 followed by 5-FU 600 mg/m2 days 1 and 2, 44-46 hours infusion; Leucovorin 200mg/m2 2 hours infusion days 1 and 2) every two weeks. In 35 out of the 66 patients (53%), liver was the only metastatic site of the disease. Results: Seventeen patients were scheduled for primary surgical exploration. In 5 patients understaging of the disease in the preoperative work-up was found and further resection was postponed. In 12 patients following resection procedures were performed (12/17; resectability: 71%): hemihepatectomy – 7 (2 extended right-, 4 right- and 1 left- hemihepatectomy), bisegmentectomy – 4 (in 1 patient bilobar lesions), (mono)segmentectomy – 1. None of the 5 initially explored patients did have a response justifying re-exploration and resection, after subsequent chemotherapy with CLF1. Whereas out of 18 patients with primary non-resectable LM, three patients were subsequently explored due to partial response to the chemotherapy. Resection of LM was done in 1 out of the 3 patients. Altogether, resectability rate of primary non-resectable tumours following CLF1 chemotherapy was 4.4% (1/23). Moreover, in 1 patient following initial bisegmentectomy and on further CLF1 treatment, repeat hemihepatectomy was necessary for recurrent LM. Conclusion: Irinotecan-based chemotherapy in patients with initially nonresectable LM from colorectal carcinoma renders limited resectability.