Monthly Archives: December 2018

Simultaneous vs staged colorectal and hepatic resections

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One discussion this week involved the comparison of simultaneous and staged resections of colorectal cancer and synchronous colorectal liver metastases (SCRLM).

Reference: Reddy SK, et al. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Annals of Surgical Oncology. 2007 Dec;14(12):3481-3491. doi:10.1245/s10434-007-9522-5

Summary: In a retrospective study of 610 patients at three institutions between 1985 and 2006, the authors compared postoperative morbidity and mortality after simultaneous and staged resections of colorectal cancer and SCRLM.

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Neoadjuvant chemotherapy for initially unresectable intrahepatic cholangiocarcinoma

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One discussion this week included using chemotherapy to enable initially unresectable intrahepatic cholangiocarcinoma (ICC) to be resectable.

Reference: Le Roy B, et al. Neoadjuvant chemotherapy for initially unresectable intrahepatic cholangiocarcinoma. The British Journal of Surgery. 2018 Jun;105(7):839-847. doi: 10.1002/bjs.10641

Summary: Surgical resection is the standard treatment for ICC, with a 5-year survival rate of 25-35% for those presenting with potentially resectable disease. Those with initially unresectable ICC are treated with chemotherapy alone and have a poor prognosis (p.839). The strategy of conversion to secondary resectability through chemotherapy regimens has resulted in good long-term survival for other tumors (colorectal liver and neuroendocrine liver metastases).  The authors state there is no published data on the use of neoadjuvant chemotherapy to achieve secondary resectability in locally advanced ICC.

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Small bowel obstruction: clinical and radiographic predictors for surgical intervention

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One discussion this week included the clinical and radiographic signs for operation or nonoperation in the setting of adhesive small bowel obstruction (ASBO).

Reference: Kulvatunyou N, et al. A multi-institution prospective observational study of small bowel obstruction: Clinical and computerized tomography predictors of which patients may require early surgery. The Journal of Trauma and Acute Care Surgery. 2015. 79(3);393-398. doi:10.1079/TA.0000000000000759.

Summary: The absence of flatus and the CT finding of free fluid and high-grade obstruction have been identified by Kulvatunyou et al (2015) as predictors that early operative intervention would be beneficial. This prospective observational study involved 200 patients at three academic and tertiary referral medical centers; 148 in the nonoperative group, 52 in the operative group.

Clinical signs: The only clinical sign identified as a predictor for surgical intervention, “no flatus” was listed in 58% of the operative group, 34% of the nonoperative group. Too large to include here, Table 3 in the text (p.397) lists the univariate analysis of all clinical signs.

CT findings: Individual CT signs listed include transition point, free fluid, multiple fluid locations, small bowel fecalization, mesenteric edema, closed loop, and high-grad obstruction. All had low PPVs, ranging 21-41%. Using the three predictors identified, the PPV improved but remained low at 37-56% (p.397).

The table below (p.397) illustrates the utility of the three variables in a few combinations.

predictors

In the article, the authors state that they are currently (2015) pursuing a study applying the predictors to a different ASBO patient population so as to cross-validate this predictor model. A search for such a study in the published literature was not successful.

Additional Reading: Catena F, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2010 evidence-based guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2011 Jan 21;6:5. doi: 10.1186/1749-7922-6-5.