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Background: Hepatic recurrence is seen in approximately 40 % of patients undergoing hepatectomy for colorectal metastases. The authors assessed the benefit and the main prognostic factors for a second liver resection of recurrent colorectal metastases., Methods: This study reports the experience with second liver resections for recurrent liver metastases at a German University Hospital. A total of 39 parameters from 60 patients were identified from a prospective database and analysed as to their influence on recurrence-free survival and overall survival., Results: At a median follow-up of 26 months (range: 2-173 months) after second hepatic resection, recurrence-free survival at 3 and 5 years were 50 % and 37 %, respectively. The overall survival at three and five years were 61 % and 52 %, respectively. Recurrence was identified in 58.3 % of the patients. Recurrences involved exclusively the liver in 19 patients (31.6 %). By multivariate analysis (Cox proportional hazard model), a time interval between diagnosis of the liver metastases of less than 24 months after operation for colorectal primary carcinoma (HR: 6.47, p = 0.002), a CEA level of 4.0 ng/mL or more (HR: 3.48, p = 0.004) at the time of first liver metastases and a size of second liver metastases of 80 mm or more (HR: 4.73, p = 0.007) were independent prognostic factors for a reduced recurrence-free survival. A repeat recurrence of liver metastases without the option of curative resection was the only risk factor for overall survival after second hepatic resection (p = 0.009). In these cases, mortality risk was 4.51-fold, however, when the second liver recurrence was resectable, the mortality risk increased only 1.4-fold., Conclusions: Technically resectable recurrent colorectal hepatic metastases should be resected the same as the first metastases. Characteristics of the primary metastasis as well as parameters of the hepatic recurrence are shown to influence the prognosis of patients after resection of recurrent liver metastases. Repeat resection of colorectal liver metastases allows for improved survival in patients even after two previous liver operations., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Neurofibromatosis I may rarely predispose to pheochromocytoma and gastrointestinal stromal tumors., Methods: A 59-year-old woman with neurofibromatosis I presented with pheochromocytoma of the left adrenal gland. During surgery, 3 gastrointestinal stromal tumors adjacent to the stomach and small intestine were removed. Despite appropriate thrombosis prophylaxis, the patient died of a pulmonary embolus 2 days postoperatively. The second patient, a 55-year-old man with neurofibromatosis I and bilateral pheochromocytomas, had several small gastrointestinal stromal tumors adjacent to the jejunum during surgery. A review of the literature was conducted to identify patients with neurofibromatosis I with concurrence of pheochromocytoma and gastrointestinal stromal tumors and to define the specific clinical features of these patients., Results: In addition to our 2 patients, 12 other cases of neurofibromatosis I with concomitant occurrence of pheochromocytomas and gastrointestinal stromal tumors have been reported. Pheochromocytomas had adrenal locations in all patients. Two of the 14 patients had a mixed pheochromocytoma/ganglioneuroma. In 4 of the 14 patients, gastrointestinal stromal tumors were located along the stomach. The gastrointestinal stromal tumors in our 2 patients showed no somatic mutations in KIT and PDGFRA genes. A pulmonary embolism was diagnosed in 4 patients., Conclusions: The simultaneous occurrence of pheochromocytoma and gastrointestinal stromal tumor should be considered in all patients with neurofibromatosis I presenting with an abdominal mass with symptoms suggestive of pheochromocytoma. Therefore, a pheochromocytoma should be excluded before a patient with neurofibromatosis I undergoes surgery for a gastrointestinal stromal tumor because an undiagnosed pheochromocytoma carries a high risk of life-threatening cardiovascular complications during surgery. Finally, this combination may be associated with an increased risk for thromboembolic events, but more studies are necessary to confirm this., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background/aims: Despite advances in diagnosis and treatment, the rate of complications after resection for colorectal liver metastases remains high. An awareness of risk factors is essential for the rates of morbidity and mortality to fall to optimal levels., Materials and Methods: Of the 240 patients who underwent resection for the first manifestation of colorectal liver metastases, 49 patients with lobectomy or extended hepatectomy (major resections) and 58 with wedge resections within only one liver segment (minor resections) form the basis of this report. A total of 16 variables were analyzed to find the risk factors linked to postoperative morbidity and mortality., Results/findings: Thirty-four patients (31.8%) suffered postoperative complications, and one patient died during the hospital stay (0.9%). In the major resection group, multivariate analysis showed that neoadjuvant chemotherapy [odds ratio (OR): 2.4; p = 0.005], vascular clamping (OR: 1.4; p = 0.008), and intraoperative blood loss with transfusion of three to six packed red cell units (OR: 1.2; p = 0.029) were significantly associated with postoperative morbidity. Vascular clamping was an independent predictor for biliary fistula (OR: 1.2; p = 0.029). Postoperative temporary liver failure was influenced by neoadjuvant chemotherapy (OR: 3.4; p = 0.010), vascular clamping (OR: 1.5; p = 0.015), and requirement of blood transfusion (OR: 2.1; p = 0.016). After minor resections, only a decreased postoperative serum cholinesterase B level was an independent predictor for complications (OR: 2.2; p = 0.001), as well as for hemorrhage (OR: 1.6; p = 0.023). Postoperative mortality was not predicted by any of the factors that were analyzed., Interpretation/conclusion: Factors for complications differ depending on the extent of colorectal liver metastasis resection. Only knowledge and particular consideration of these factors may provide for an optimal postoperative outcome for the individual patient.

Background: Patients suffering from locally advanced esophageal carcinoma are generally treated using multimodal therapies. This prospective, non-randomized trial was performed to evaluate the survival benefit of neoadjuvant radiochemotherapy prior to surgery in comparison with surgery only., Patients & Methods: Histopathological outcomes and survival were compared between 61 patients who underwent neoadjuvant radiochemotherapy and 64 comparable control patients who had been under-staged. After neoadjuvant therapy, tumor regression was assessed using the method described by Mandard in 1994. Survival curves for the two groups were estimated using the Kaplan-Meier method, and compared with the log-rank test., Results: Median and 3-year recurrence-free survival for the entire group were 26 months and 39.7%, respectively. The median and 3-year overall survival reached 34 months and 48.1%. Patients who showed complete response to neoadjuvant therapy had significantly improved survival (35 months) compared to patients with residual tumor cells (28 months), patients with tumors unresponsive to radiochemotherapy (22 months), or patients who received surgery only (control group, 29 months). Patients with nodal-negative carcinomas showed significantly longer survival after surgery only and after neoadjuvant therapy compared to patients with lymph node-positive cancers., Conclusions: Complete response after neoadjuvant radiochemotherapy is associated with significantly improved survival. Negative nodal status is a major determinant of outcomes following primary operation or neoadjuvant treatment.

Background: Patient outcome after resection of colorectal liver metastases can be predicted by various prognostic factors., Aims: Development of a model for risk stratification based on analysis of prognostic factors., Methods: Data of 201 patients were collected prospectively and included in a single-centre trial. A total of 20 factors were analysed as to their influence on recurrence-free and overall survival. Independent prognostic factors were entered into a model of a clinical risk score., Results: Median recurrence-free survival reached 24 months for all patients; median overall survival was 50 months. Only a synchronous manifestation of primary colorectal carcinoma and liver metastases, the presence of four or more metastases and a carcino-embryonic antigen level of 200 ng/ml or more significantly influenced recurrence-free and overall survival in the multivariate analysis. The derived risk stratification grouped the patients according to the following criteria: low risk, zero prognostic factors (n=112); intermediate risk, one factor (n=74); high risk, two or more factors (n=15). The median recurrence-free survival for low, intermediate and high risk were 30.0, 23.0 and 11.0 months, respectively; the median overall survival was 94.0, 40.0 and 33.0 months. Compared with the low-risk group, patients with intermediate risk demonstrated an increased hazard ratio (HR) of 1.57-fold for recurrence (P=0.018) and 1.91-fold for mortality (P=0.007). For the high-risk group, the HR rose significantly to 3.26 for recurrence (P<0.0005) and to 3.10 for mortality (P=0.001)., Conclusions: The presented clinical score may allow for patients with colorectal liver metastases to be stratified appropriately and for optimization of their subsequent therapeutic management.

Background: Controversy surrounds the safety and practicality of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) compared with other percutaneous methods., Methods: We used the Fantoni tracheostomy for 245 patients in our intensive care unit (ICU) over a period of 3 years 6 months and conducted a prospective analysis., Results: We are able to report a low incidence of complications (1.2%) with the Fantoni procedure. Advantages of the method are reduced tissue trauma and optimal adaptation of the stoma to the cannula, leading to less stomal bleeding and fewer infectious complications. We observed no procedure-related mortality. Under mandatory bronchoscopic control, proper puncture location and cannula placement are ensured, which prevents tracheal wall injury and paratracheal placement of the cannula., Conclusions: Our experience shows that the major advantage of the use of the Fantoni tracheostomy is the retrograde dilatation of the stoma, which prevents serious complications compared with other techniques., (Copyright 2005 Wiley Periodicals, Inc.)

Aims: The aim of this study was the evaluation of early results of esophageal resection for cancer including the assessment of pre-operative risk factors and post-operative mortality (risk score developed by Barthels et al. 1998)., Methods: One hundred and eighty one patients with esophageal cancer were operated with curative intention between October 1993 and December 2002. In a prospective analysis were reviewed: patient characteristics, characteristics of the esophageal cancer, part and type of esophageal resection, radicality, complications and mortality., Conclusion: In total, a resection of the tumor could be achieved in 143 cases (79.0%). The overall complication rate was 52.5%, mainly cardio-pulmonary complications (25.9%) were seen. The surgical complications were determined by anastomotic leak (12.6%) and recurrent nerve injury (9.1%). Both types of complications were observed significantly more often after esophageal resection with a cervical anastomosis (p = 0.03 and p < 0.01). The hospital mortality was 8.4%. The 30 days mortality was 4.9%. Using a preoperative risk score retro- and prospectively, our data showed a lower mortality in patients with a low risk profile (2.4% and 2.3%) compared to those with a medium risk profile (7.4% and 6.4%). The only patient with a high risk profile died after resection., Discussion and Summary: The results of this analysis show that resection of esophageal cancer can be accomplished with acceptable morbidity and mortality. However, it has to be taken into account that the increase of pre-operative factors leads to an increase in post-operative mortality.

Background: Patient age has a decisive impact on the short-term postoperative results in surgery for carcinoma., Patients and Methods: This prospective multicenter study involved 75 German hospitals and 3756 patients undergoing treatment in 1999: 1447 aged under 65 years, 1847 aged 65-79 years, and 458 aged over 80 years., Results: In the oldest patient group, there was a significantly higher proportion of extensive, localized tumors (UICC stage II: 25.9%, 28.4%, and 36.1%, respectively) and significant differences were found among the three groups in operation rates (98.8%, 98.6%, and 96.5%), resection rate (94.2%, 93.2%, and 83.9%), general postoperative complications (21.5%, 28.6%, and 41.2%), morbidity (36.5%, 42.6%, and 50.0%) and mortality (2.7%, 6.6%, and 11.8%)., Conclusion: In the elderly, locally advanced tumors, but not metastasizing tumors, are to be expected. The increase in postoperative morbidity and mortality rates with increasing age was due to the increase in general postoperative complications. Surgery for colorectal carcinoma in patients of advanced age is not associated with any increase in intraoperative or specific postoperative complications.