Segment oriented resection in the management of hepatic neoplasms

A137S SSATABSTRACTS • S0021

LAPAROSCOPIC VS. OPEN INGUINAL HERNIORRAPHY, A RANDOMIZED CONTROLLED TRIAL. JS Barkun. MJ Wexler. M Fernandez. JL Meakins. McGill University, Montreal, Canada. Over a 28 month period, 124 patients with a unilateral inguinal hernia were recruited into a randomized controlled trial comparing open (OH) to laparoscopic inguinal heruiorraphy (LH). The primary endpoint was duration of convalescence. There was no difference in baseline parameters across groups with respect to: Age, Sex, Body mass index, American Society of Anaesthetists score, Employment status, incidence of symptoms, hernia type, or quality of life scores ((QOL), using two validated instruments). Sixty five patients underwent OH and 59 LH. Before operation, LH patients anticipated a significant shorter duration of convalescence than OH (14.2 + 9.6 days vs. 18.4-+ 10.8 days p=0.027). The mean duration of operating room time utilization was 73.5 -+ 26.2 rain for OH and 88.8 -+34 rain for LH (p=0.007). Only 39% of OH patients and all LH patients underwent general anesthesia. Eighty one percent of LH repairs were performed using a trans-abdominai properitoneal technique, whereas 50% of OH patients had a tension-free repair. The median duration of hospital stay was one day in both groups. The total does of morphine equivalents required was 41.4_+ 33 mg in OH and 27.9 _+34.7mg in LH (p=0.0035). The duration of time till return to work (for employed patients) and return to full activities (for unemployed or retired patients) was 11.4-+ 7.7 days in OH and 9.8 + 7.4 days in LH (NS). This result was confirmed by survival analysis of the percentage of activities which could be performed at the time of post-operative follow-up interviews. There was a significant greater proportion Of LH patients willing to undergo the same procedure (95% Odds ratio = 2.9-17.6, p<0.001). There was no difference however in QOL or morbidity between groups. After a median follow-up of 3 years one OH and three LH patients exhibited an asymptomatic recurrent hernia. Conclusions: Although no difference in convalescence or QOL could be demonstrated across groups, LH patients reported significant benefits in postOP pain and procedural satisfaction. (Funded in part by Ethicon Canada) S0022 RESULTS OF A MULTICENTER CLINICAL TRIAL OF PEFLOXACIN VERSUS IMIPENEM IN SEVERE PANCREATITIS. C. Bassi. M. Falconi~ G. Talamini*, G, U0mo**, G. Papa¢ci9***, C. Dervenis °, E. Bertazzoni °', R. Salvia, A. Valerio, P. Pederz01i. Surgical, Medical* and Pharmacological" Depts Verona, Athens",Naples**, Italy; Mestre***,Greece Prevention of infected necrosis (I.N.) is one of the main goal in the management of severe pancreatitis (S.P.). In our experience Imipenem (1) was able to reduce significantly the incidence of I.N. when compared to controls. Because of good pancreatic penetration and antimicrobial activity Pefloxacin (P), from the hypotetical point of view, should represent a suitable alternative to I. In a multicenter study 56 patients suffering from S.P. with an extensive necrosis (> 50 % of the gland) were randomly assigned to have P 400 mg x 2/daily (27 pts) or I 500 mg t.i.d.e.v. (29 pts) for two weeks. Between groups sex, age, body weight, Ranson (overall mean value 4.6), Apache II (overall mean value 11.5), PCR (overall mean value 307 mg/L), etiology and days between pain onset and treatments (overall mean time two days) did not significant differ. The rates of LN. and extrapancreatic infections were in P and I groups 37 % vs 10.3 % and 48 % vs 20.6 % respectivelly (p<0.05). The deaths (all due to sepsis) were not significantly different (18.5 % in P and 10.3 % in I). I.N. was polimicrobial in 4 cases of P group and in 2 of I group. The main isolated bacteria were Staphy. Aureus, Candida and Pseudo Aeruginosa in P group, Staphy Aureus and Candida in I group. Despite the promising background P is not superior to I in the prevention of I.N. during S.P. S0023

HISTOPATHOLOGIC STUDY IN TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS). J.I. Bilbao (1), I. Sola (2). J.M. Longo (11. B. Sam, ro (3), M.D. Barettino (1), J.A.-Cienfuegos (4). Dpts. of Radiology (1), Pathology (2), Hepatology (3) and General Surgery (4). Clfnica Universitaria. Universidad de Navarra. Pamplona. Spain. Purpose: To analyse and compare the morphological findings in TIPS specimens at different stages of their development and with different degrees of permeability. Material and Methods: Hepatectomy specimens from 26 cirrhotic patients (pts) who had been treated with TIPS were studied. They had been obtained by transplant (22), or by autopsy (4). During the procedure, contrast was observed in the bile ducts on 4 occasions. One prosthesis (Wallstent) was inserted in 22 pts, and 4 pts required 2. During follow-up, 11 pts presented stenoses, either in the hepatic vein (4), in the tract (5) or both (2). All were treated by angioplasty (PTA) and 7 by a further stenting. The mean functioning life of the PTA was 7,1 months (4d-50m). The specimens were cut along the longitudinal axis. From one half (n=26) the wires were extracted, we then proceeded to perform a microscopic study of at least three areas of interest. The macroscopic findings were studied in the other half (available in 24). Results: Eight specimens presented no abnormalities, but in the others one or several of the following findings were observed: Partial~complete thrombosis of the TIPS (6), clear biliary contamination of the pseudointima and bile duct

GASTROENTEROLOGY Vol. 114, No. 4

injury were observed in 3. Stenosis in the intraparenchymal tract (7), which was not related to the number prior PTS; in 3 cases biliary contamination in the stenotic area was detected, and in another 3 there was a clear increase in the mastocyte count. Stenosis of the hepatic vein (8), in all cases there was considerable hyperplasia of the neointima, without biliary contamination, damage to the vein wall or a raised mastocyte count. Conclusion: A significant relationship was observed between biliary contamination and the presence of stenosis and/or thrombosis into the shunt. All the specimens from patients treated with PTA presented re-stenosis. The etiology of the stenosis of the hepatic vein is still uncertain, and would seem to be different from that of intraparenchymal stenosis. S0024 SEGMENT ORIENTED RESECTION IN THE MANAGEMENT OF HEPATIC NEOPLASMS. K.G. Billin~,slev. M.D., Y, Fong, M.D,, L.H. Blumgart. M.D, Memorial Sloan-Kettering Cancer Center, New York, NY. Increased understanding of intrahepatic anatomy and evolving imaging technology have facilitated a segment-oriented approach to liver resection. In contrast to wedge resection, which is associated with a rate of margin positivity between 19-35%, segmental resection has the theoretical advantages of conserving hepatic parenchyma and providing tumor clearance. This study reports the technical features and the results of a prospective evaluation of sectoral and segmental resections in the treatment of maligant hepatic neoplasms. Methods: From 1/92 to 7/97, 79 patients (36 female, 43 male; median age 62 years) underwent resection of a single anatomic segment (I, n=6, II, n=2, III, n=12, IV, n=10,V, n=2, VI, n=3, VII, n=2, VIII, n=7) or anatomic sector (2 segments, n=35) for malignant neoplasms of the liver. Pathology included 16 cases of HCC (21%), 47 metastatic colorectal cancers (58%), and 16 other metastatic neoplasms (21%). For 18 patients this was performed as a second resection for metastatic colorectai cancer. Comparison is by t-test. Results: Patients with HCC are compared to non-HCC liver metastases. Primary liver resection is also compared to repeat resection. Six patients had a positive resection margin(7.6%), 3 of the 6 were undergoing repeat resection. There were 22 complications in 21 patients (28%). There were 2 perioperative deaths in patients with HCC and cirrhosis (2.5%). *p<0.05 Tumor and Margin Required Ablations Total Ablation Time

3cm 1 10min

4cm 8 80

5cm 14 140

6cm 19 190

7cm 25 250

Conclusions:Segmental and sectoral resections can be performed safely in patients with HCC and metastatic liver tumors. In non-HCC patients, segmental resections are performed with low blood loss and minimal transfusion requirements. The rate of margin positivity is greatest in repeat resection however, tumor clearance is secured in the majority of cases with maximal preservation of normal parenchyma. S0025

TIlE UTILITY OF TRANSRECTAL ULTRASOUND IN EVALUATING SMALL RECTAL CANCERS. EH Birnbaum. IJ Kodner. TE Read, MS McNevin, RJ Mverson. JW Fleshman. Section of Colon and Rectal Surgery, Washington University School of Medicine. St. Louis, MO. Purpose: To evaluate transrectal ultrasound (TRUS) for staging rectal cancer prior to treatment with short course high does radiotherapy and to correlate TRUS stage with post-treatment pathology stage. Methods: All patients who had TRUS prior to radiotherapy (2000cGy) were evaluated. TRUS stage (uTNM) was reviewed retrospectively by an observer in a blind study and correlated with the original uTNM stage. The uTNM stage was compared to post-treatment pathology stage (pTNM). Results: 40 patients underwent 2000 cGy prior to surgery for rectal cancer between 4/90 and 3/97.21 patients had TRUS prior to surgery (20 proctectomies, 1 transanal excision). The original TRUS reading correlated with the blinded reading for 17/20 uT stage and 15/20 uN stage, uT stage correlated with pT stage in 11/21 patients. TRUS overcalled the uT stage in 8 patients (5 uT3-pT2, 2 uT2-pT1, 1 uT3-pTis) and undercalled 2 (1 uT2-pT3, 1 uT3-pT2), uN stage correlated with pathology in 11 patients, overcalled 4 and undercalled 4. Overall stage was undercalled by TRUS in 4 patients (3 ulI-plII; 1 uI-plII) and overcalled in 8 (4 ulI-pl, 3 ulII-pI, 1 ulII-plI). Conclusion: TRUS correlated between readings, but was not accurate in predicting the pathologic stage of small rectal cancers. Downstaging of rectal cancer may occur even with short course, high dose radiotherapy. S0026 SEGMENTAL PORTAL HYPERTENSION IN CHRONIC PANCREATITIS: A N OLD PROBLEM REVISITED. C Bloechle, KF Binmoeller, G Domschneider, A Machens, WT Knoefel, WG Zoller, DK Wilker, JR Izbicki. Departs. of General Surgery and Endoscopic Surgery, University Hospital Eppendorf, University of Hamburg, and Departs. of Surgery and Internal Medicine, Klinikum Innenstadt, University of Munich, Germany. Objective: In chronic pancreatitis, compression of the splenic vein and/or the superior mesenteric vein by an inflammatory mass may cause segmental portal hypertenion. This study was divised to evaluate the impact of concomitant segmental portal hypertension in chronic pancreatitis on immediate and long-term postoperative outcome after major pancreatic surgery. Methods: In a prospective follow-up study 129 patients (95 male and 34 female) with at least a 12 month history of pancreatitis, severe