1
|
Thomson BNJ. ERCP remains a critical skill for HPB, Upper GI & General Surgeons. ANZ J Surg 2023; 93:1738-1739. [PMID: 37565640 DOI: 10.1111/ans.18599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Benjamin N J Thomson
- Surgical Services, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- University of Melbourne Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Victorian Department of Health, Collaborations & Systems Improvement, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Drysdale HRE, Watters DA, Leang Y, N J Thomson B, Brown WA, Wilson A. Victoria's surgical response to the COVID-19 pandemic: the first two years. ANZ J Surg 2023; 93:476-486. [PMID: 36757821 DOI: 10.1111/ans.18311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/10/2023]
Abstract
Victoria suffered three major waves during the first two years of the COVID-19 pandemic. Melbourne became the longest locked down city in the world at 267 days. This narrative review documents the chronological waves of COVID-19 in Victoria and key themes influencing the State-wide surgical response. In 2020, Victoria needed to secure supplies of personal protective equipment (PPE) and later, recognizing the importance of aerosol transmission, introduced a respiratory protection program to protect health care workers (HCWs) with fit-tested N-95 masks. It established routine preoperative PCR testing for periods when community prevalence was high and developed strategies to restrict elective surgery when hospital capacity was limited. In 2021, three short-term outbreaks were contained and eliminated whilst vaccination of HCWs and the vulnerable was taking place. A third major wave (Delta) occurred July to November 2021, succeeded by another involving the Omicron variant from December 2021. Planned surgery waiting list numbers, and waiting times for surgery, doubled between March 2020 and March 2022. In early 2022, almost 300 patients underwent surgery when infected with Omicron, with a low mortality (2.6%), though mortality was significantly higher in the unvaccinated (7.3% versus 1.4%). In conclusion, the Victorian response to COVID-19 involved tight state-wide social restrictions, contact tracing, furlough, escalating PPE guidance and respiratory protection. HCW infections were greatly reduced in 2021 compared with 2020. Pre-operative PCR testing gave confidence for emergency and urgent elective surgery to proceed during pandemic waves. Other elective cases were performed as health system capacity allowed, without compromising outcomes.
Collapse
Affiliation(s)
- Henry Richard Edward Drysdale
- Departmentof Surgery, Barwon Health, Geelong, Victoria, Australia
- School of Medicine and Health Sciences, Deakin University, Geelong, Victoria, Australia
| | - David Allan Watters
- Departmentof Surgery, Barwon Health, Geelong, Victoria, Australia
- School of Medicine and Health Sciences, Deakin University, Geelong, Victoria, Australia
| | - Yit Leang
- Departmentof Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Benjamin N J Thomson
- Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Wendy Ann Brown
- Centre for Obesity Research and Education, Monash University, Melbourne, Victoria, Australia
| | | | | |
Collapse
|
3
|
Peng CC, Tay J, Tham N, Tully EK, Shakerian R, Furlong T, Thomson BNJ, Hayes IP. Use of Temporary Abdominal Closure in Non-Trauma Surgery: A Cohort Study. World J Surg 2023; 47:1477-1485. [PMID: 36847850 DOI: 10.1007/s00268-023-06960-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Damage control surgery in trauma is widely used but the evidence for the use of laparostomy in non-trauma abdominal emergencies is limited. This study aimed to characterise outcomes in emergency abdominal surgery by comparing laparostomy to one-stage laparotomy for patients of similar illness severity. METHODS A retrospective study of adult patients requiring emergency abdominal surgery and post-operative intensive care stay was performed between 2016 and 2020 at a major Australian metropolitan hospital. Case selection was from a prospectively maintained database, and case notes were reviewed. Patients having delayed abdominal closure were compared with those having one-stage abdominal closure. The primary outcome was odds of in-hospital mortality. The secondary outcomes included intensive care unit length of stay (LOS), overall hospital LOS, definitive stoma rate and discharge destination. Multivariable logistic regression analysis was performed to adjust for potentially confounding variables. RESULTS Two hundred and eighteen patients met inclusion criteria (80 laparostomy and 138 non-laparostomy). The most common indications for laparostomy were bowel ischaemia (41.3%), sepsis (26.3%) and physiological instability (22.5%). There was no evidence of difference in odds of in-hospital mortality between groups (adjusted OR = 1.67, CI: 0.85-3.28; p = 0.138). Patients requiring laparostomy had a slightly longer median ICU LOS (4 vs. 3 days; p < 0.001), similar median hospital LOS (19 vs. 14 days, p = 0.245) and similar discharge destination. There was no difference in stoma rate (35.0% vs. 35.5%). CONCLUSION Compared with standard one-stage laparotomy, laparostomy resulted in similar odds of in-hospital mortality in emergency abdominal surgery patients requiring intensive care.
Collapse
Affiliation(s)
- Calvin C Peng
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia.
| | - Jia Tay
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia
| | - Nicole Tham
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia.,Department of Surgery, University of Melbourne, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Emma K Tully
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia
| | - Rose Shakerian
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia
| | - Tim Furlong
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia
| | - Benjamin N J Thomson
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia.,Department of Surgery, University of Melbourne, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ian P Hayes
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Level 6 East, 300 Grattan St, Parkville, Melbourne, VIC, 3050, Australia.,Department of Surgery, University of Melbourne, Royal Melbourne Hospital, Melbourne, VIC, Australia
| |
Collapse
|
4
|
Lee JD, Prabhakaran S, Wilkie BD, Peng C, Thomson BNJ. Massive gastric distension due to bulimia nervosa: a hotpot emergency. J Surg Case Rep 2022; 2022:rjac193. [PMID: 35983501 PMCID: PMC9381299 DOI: 10.1093/jscr/rjac193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022] Open
Abstract
Acute massive gastric distension is a rare but potentially life-threatening surgical complication of bulimia nervosa. This results from repeated binge eating and is likely compounded by increased gastric compliance and delayed gastric emptying. We describe a case of acute massive gastric distension in a 26-year-old female with undiagnosed bulimia nervosa who underwent a laparotomy and anterior gastrotomy after failed conservative measures for gastric decompression. It highlights the importance of early recognition of a potentially life-threatening condition and that a multi-disciplinary approach is necessary to prevent the recurrence and morbidity associated with it.
Collapse
Affiliation(s)
- Jordan D Lee
- Correspondence address. 300 Grattan St, Parkville, Victoria 3052, Australia. Tel: +61-393427000; E-mail:
| | - Sowmya Prabhakaran
- Department of General Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Bruce D Wilkie
- Department of General Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Calvin Peng
- Department of General Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Benjamin N J Thomson
- Department of General Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| |
Collapse
|
5
|
Douglas N, Gregorevic K, Law M, Thomson BNJ, Johnson DF. Advocacy for COVID-19 vaccination at perioperative consultations: An opportunity for protection. ANZ J Surg 2021; 91:1964-1965. [PMID: 34251735 PMCID: PMC8420485 DOI: 10.1111/ans.17066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ned Douglas
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Proactive care of Older People having Surgery at the Royal Melbourne Hospital (POPS - RMH), Melbourne, Victoria, Australia.,Department of Critical Care, University of Melbourne Faculty of Medicine and Health Sciences, Melbourne, Victoria, Australia
| | - Katherine Gregorevic
- Proactive care of Older People having Surgery at the Royal Melbourne Hospital (POPS - RMH), Melbourne, Victoria, Australia.,Department of Geriatric Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mandy Law
- COVID-19 Vaccination Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Benjamin N J Thomson
- Department of General Surgical Specialties, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne Faculty of Medicine and Health Sciences, Melbourne, Victoria, Australia
| | - Douglas F Johnson
- Department of General Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Chandrananth ML, Zhang A, Voutier CR, Skandarajah A, Thomson BNJ, Shakerian R, Read DJ. 'No zone' approach to the management of stable penetrating neck injuries: a systematic review. ANZ J Surg 2021; 91:1083-1090. [PMID: 33480177 DOI: 10.1111/ans.16600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aim: to review outcomes of the 'no zone' approach to penetrating neck injuries (PNIs) with the advent of high-fidelity computed tomography-angiography (CT-A) in order to determine the most appropriate management for stable PNIs. DESIGN Systematic review. POPULATION Retrospective and prospective cohort studies of patients who sustained penetrating neck trauma, as defined by an injury which penetrates the platysma, and whose initial management involved CT-A evaluation. METHODS An extensive literature search was performed in July 2019 using the following databases: Pubmed Central, EMBASE, Medline and Cochrane CENTRAL. Only studies published in English from the last 15 years were included. RESULTS Nine cohort studies met inclusion criteria. There has been an increase in CT-A focussed evaluation of PNIs in recent years. CT-A is a highly sensitive and specific imaging choice and reduces negative neck exploration rates. A new management algorithm for stable patients involving initial radiological assessment using CT-A, and subsequent selective surgical exploration, is safe and effective. CONCLUSION The results of this review provide level 2A evidence that the 'no zone' approach to PNIs, complemented by CT-A and thorough clinical assessment, is a safe management strategy which reduces negative neck exploration rates.
Collapse
Affiliation(s)
- Meera L Chandrananth
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew Zhang
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Catherine R Voutier
- Health Sciences Library, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anita Skandarajah
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Benjamin N J Thomson
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rezvaneh Shakerian
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David J Read
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,The University of Melbourne Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
7
|
Chandrananth ML, Li R, Thomson BNJ, Chandra R. Pneumopericardium, pneumoperitoneum, small bowel obstruction and pancreatitis: Occam's razor or multiple pathologies? ANZ J Surg 2021; 91:E546-E547. [PMID: 33394538 DOI: 10.1111/ans.16548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/17/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Meera L Chandrananth
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ran Li
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin N J Thomson
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgical Oncology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Raaj Chandra
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Colorectal Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
8
|
Gavin DJ, Wilkie BD, Tay J, Loveday BPT, Furlong T, Thomson BNJ. Assessing the risk of viral infection from gases and plumes during intra-abdominal surgery: a systematic scoping review. ANZ J Surg 2020; 90:1857-1862. [PMID: 32808418 PMCID: PMC7461014 DOI: 10.1111/ans.16242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/05/2020] [Accepted: 07/28/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to identify the current evidence regarding the risk of acquiring viral infections from gases or plumes during intra-abdominal surgery. Peritoneal fluids may contain cellular material and virus particles. Electrocautery smoke and plumes from energy devices may aerosolize harmful substances and viral particles. Insufflation and desufflation during laparoscopic surgery may also aerosolize and distribute biological material. A systematic scoping review was performed to assess the evidence and inform safe surgical practice. METHODS A systematic search of the PubMed and Medline databases was undertaken until June 2020, observing Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology, to identify articles associating viral infection of operating room staff from surgical gases and plumes. All evidence levels were included. The search strategy utilized the search terms 'surgery', 'laparoscopy', 'laparoscopic' 'virus', 'smoke', 'risk', 'infection'. RESULTS The literature search identified 74 articles. Eight articles relevant to the subject of this review were included in the analysis, two of which specifically related to intra-abdominal surgery. Of the remaining six, four involved gynaecological surgery and two were in-vitro studies. No evidence that intra-abdominal surgery was associated with an increased risk of acquiring viral infections from exsufflated gas or smoke plumes was identified. CONCLUSION There is currently no evidence that respiratory viruses can be found in the peritoneal fluid. Whilst there is currently no evidence that desufflated carbon dioxide or surgical smoke plumes present a significant infectious risk, there is not a wealth of literature to inform current practice. Further clinical research in this area is required.
Collapse
Affiliation(s)
- Dominic J. Gavin
- Department of General Surgical SpecialtiesThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Bruce D. Wilkie
- Department of General Surgical SpecialtiesThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Jia Tay
- Department of General Surgical SpecialtiesThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Benjamin P. T. Loveday
- Department of General Surgical SpecialtiesThe Royal Melbourne HospitalMelbourneVictoriaAustralia
- Department of SurgeryUniversity of AucklandAucklandNew Zealand
| | - Timothy Furlong
- Department of General Surgical SpecialtiesThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Benjamin N. J. Thomson
- Department of General Surgical SpecialtiesThe Royal Melbourne HospitalMelbourneVictoriaAustralia
- Department of Surgery, The Royal Melbourne HospitalThe University of MelbourneMelbourneVictoriaAustralia
| |
Collapse
|
9
|
Rowcroft A, Loveday BPT, Thomson BNJ, Banting S, Knowles B. Systematic review of liver directed therapy for uveal melanoma hepatic metastases. HPB (Oxford) 2020; 22:497-505. [PMID: 31791894 DOI: 10.1016/j.hpb.2019.11.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/29/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Uveal melanoma (UM) is a rare malignancy with a propensity for metastasis to the liver. Systemic chemotherapy is typically ineffective in these patients with liver metastases and overall survival is poor. There are no evidence-based guidelines for management of UM liver metastases. The aim of this study was to review the evidence for management of UM liver metastases. METHODS A systematic review of English literature publications was conducted across Ovid Medline, Ovid MEDLINE and Cochrane CENTRAL databases until April 2019. The primary outcome was overall survival, with disease free survival as a secondary outcome. RESULTS 55 studies were included in the study, with 2446 patients treated overall. The majority of these studies were retrospective, with 17 of 55 including comparative data. Treatment modalities included surgery, isolated hepatic perfusion (IHP), hepatic artery infusion (HAI), transarterial chemoembolization (TACE), selective internal radiotherapy (SIRT) and Immunoembolization (IE). Survival varied greatly between treatments and between studies using the same treatments. Both surgery and liver-directed treatments were shown to have benefit in selected patients. CONCLUSION Predominantly retrospective and uncontrolled studies suggest that surgery and locoregional techniques may prolong survival. Substantial variability in patient selection and study design makes comparison of data and formulation of recommendations challenging.
Collapse
Affiliation(s)
- Alistair Rowcroft
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin P T Loveday
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Benjamin N J Thomson
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Simon Banting
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Brett Knowles
- Department of Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
| |
Collapse
|
10
|
Qin Y, Shembrey C, Smith J, Paquet-Fifield S, Behrenbruch C, Beyit LM, Thomson BNJ, Heriot AG, Cao Y, Hollande F. Laminin 521 enhances self-renewal via STAT3 activation and promotes tumor progression in colorectal cancer. Cancer Lett 2020; 476:161-169. [PMID: 32105676 DOI: 10.1016/j.canlet.2020.02.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/30/2020] [Accepted: 02/19/2020] [Indexed: 02/07/2023]
Abstract
Remodeling of basement membrane proteins contributes to tumor progression towards the metastatic stage. One of these proteins, laminin 521 (LN521), sustains embryonic and induced pluripotent stem cell self-renewal, but its putative role in cancer is poorly described. In the present study we found that LN521 promotes colorectal cancer (CRC) cell self-renewal and invasion. siRNA-mediated knockdown of endogenously-produced laminin alpha 5, as well as treatment with neutralizing antibodies against integrin α3β1 and α6β1, were able to reverse the effect of LN521 on self-renewal. Exposure of CRC cells to LN521 enhanced STAT3 phosphorylation, and incubation with STAT3 inhibitors Napabucasin and Stattic was sufficient to block the LN521-driven self-renewal increase. Robust expression of laminin alpha 5 was detected in 7/10 liver metastases tissue sections collected from CRC patients as well as in mouse liver metastasis xenografts, in most cases within areas expressing metastasis cancer stem cell markers such as c-KIT and CD44v6. Finally, retrospective analysis of multiple CRC datasets highlighted the significant association between high LN521 mRNA expression and poor clinical outcome in colorectal cancer patients. Collectively our results indicate that high Laminin 521 expression is a frequent feature of metastatic dissemination in CRC and that it promotes cell invasion and self-renewal, the latter through engagement of integrin isoforms and activation of STAT3 signaling.
Collapse
Affiliation(s)
- Yan Qin
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia
| | - Carolyn Shembrey
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia
| | - Jai Smith
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia
| | - Sophie Paquet-Fifield
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia
| | - Corina Behrenbruch
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Parkville, VIC 3010, Australia
| | - Laura M Beyit
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia
| | - Benjamin N J Thomson
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Parkville, VIC 3010, Australia; University of Melbourne Department of Surgery, Royal Melbourne Hospital, Grattan Street, Parkville, VIC3010, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Parkville, VIC 3010, Australia
| | - Yuan Cao
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia
| | - Frédéric Hollande
- Department of Clinical Pathology, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia; University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, VIC3000, Australia.
| |
Collapse
|
11
|
MacCallum C, Da Silva N, Gibbs P, Thomson BNJ, Skandarajah A, Hayes I. Accuracy of administrative coding data in colorectal cancer resections and short-term outcomes. ANZ J Surg 2018; 88:876-881. [DOI: 10.1111/ans.14714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 04/14/2018] [Accepted: 04/23/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Caroline MacCallum
- Colorectal Surgery Unit; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of General Surgical Specialities; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
| | - Nigel Da Silva
- Colorectal Surgery Unit; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of General Surgical Specialities; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
| | - Peter Gibbs
- Walter and Eliza Hall Institute of Medical Research; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - Benjamin N. J. Thomson
- Department of General Surgical Specialities; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
| | - Anita Skandarajah
- Department of General Surgical Specialities; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
| | - Ian Hayes
- Colorectal Surgery Unit; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of General Surgical Specialities; The Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
| |
Collapse
|
12
|
Behrenbruch C, Shembrey C, Paquet-Fifield S, Mølck C, Cho HJ, Michael M, Thomson BNJ, Heriot AG, Hollande F. Surgical stress response and promotion of metastasis in colorectal cancer: a complex and heterogeneous process. Clin Exp Metastasis 2018; 35:333-345. [PMID: 29335811 DOI: 10.1007/s10585-018-9873-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 01/06/2018] [Indexed: 12/12/2022]
Abstract
Surgery remains the curative treatment modality for colorectal cancer in all stages, including stage IV with resectable liver metastasis. There is emerging evidence that the stress response caused by surgery as well as other perioperative therapies such as anesthesia and analgesia may promote growth of pre-existing micro-metastasis or potentially initiate tumor dissemination. Therapeutically targeting the perioperative period may therefore reduce the effect that surgical treatments have in promoting metastases, for example by combining β-adrenergic receptor antagonists and cyclooxygenase-2 (COX-2) inhibitors in the perioperative setting. In this paper, we highlight some of the mechanisms that may underlie surgery-related metastatic development in colorectal cancer. These include direct tumor spillage at the time of surgery, suppression of the anti-tumor immune response, direct stimulatory effects on tumor cells, and activation of the coagulation system. We summarize in more detail results that support a role for catecholamines as major drivers of the pro-metastatic effect induced by the surgical stress response, predominantly through activation of β-adrenergic signaling. Additionally, we argue that an improved understanding of surgical stress-induced dissemination, and more specifically whether it impacts on the level and nature of heterogeneity within residual tumor cells, would contribute to the successful clinical targeting of this process. Finally, we provide a proof-of-concept demonstration that ex-vivo analyses of colorectal cancer patient-derived samples using RGB-labeling technology can provide important insights into the heterogeneous sensitivity of tumor cells to stress signals. This suggests that intra-tumor heterogeneity is likely to influence the efficacy of perioperative β-adrenergic receptor and COX-2 inhibition, and that ex-vivo characterization of heterogeneous stress response in tumor samples can synergize with other models to optimize perioperative treatments and further improve outcome in colorectal and other solid cancers.
Collapse
Affiliation(s)
- Corina Behrenbruch
- Department of Pathology, University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Level 10, 305 Grattan Street, Melbourne, VIC, 3000, Australia
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - Carolyn Shembrey
- Department of Pathology, University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Level 10, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Sophie Paquet-Fifield
- Department of Pathology, University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Level 10, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Christina Mølck
- Department of Pathology, University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Level 10, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Hyun-Jung Cho
- Biological Optical Microscopy Platform, The University of Melbourne, Medical Building, Grattan Street, Parkville, 3010, Australia
| | - Michael Michael
- Division of Cancer Medicine, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - Benjamin N J Thomson
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
- Department of Surgery, Royal Melbourne Hospital, The University of Melbourne, 300 Grattan St, Parkville, 3000, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia
| | - Frédéric Hollande
- Department of Pathology, University of Melbourne Centre for Cancer Research, The University of Melbourne, Victorian Comprehensive Cancer Centre, Level 10, 305 Grattan Street, Melbourne, VIC, 3000, Australia.
| |
Collapse
|
13
|
Musiienko AM, Shakerian R, Gorelik A, Thomson BNJ, Skandarajah AR. Impact of introduction of an acute surgical unit on management and outcomes of small bowel obstruction. ANZ J Surg 2015. [PMID: 26207527 DOI: 10.1111/ans.13238] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The acute surgical unit (ASU) is a recently established model of care in Australasia and worldwide. Limited data are available regarding its effect on the management of small bowel obstruction. We compared the management of small bowel obstruction before and after introduction of ASU at a major tertiary referral centre. We hypothesized that introduction of ASU would correlate with improved patient outcomes. METHODS A retrospective review of prospectively maintained databases was performed over two separate 2-year periods, before and after the introduction of ASU. Data collected included demographics, co-morbidity status, use of water-soluble contrast agent and computed tomography. Outcome measures included surgical intervention, time to surgery, hospital length of stay, complications, 30-day readmissions, use of total parenteral nutrition, intensive care unit admissions and overall mortality. RESULTS Total emergency admissions to the ASU increased from 2640 to 4575 between the two time periods. A total of 481 cases were identified (225 prior and 256 after introduction of ASU). Mortality decreased from 5.8% to 2.0% (P = 0.03), which remained significant after controlling for confounders with multivariate analysis (odds ratio = 0.24, 95% confidence interval 0.08-0.73, P = 0.012). The proportion of surgically managed patients increased (20.9% versus 32.0%, P = 0.003) and more operations were performed within 5 days from presentation (76.6% versus 91.5%, P = 0.02). Fewer patients received water-soluble contrast agent (27.1% versus 18.4%, P = 0.02), but more patients were investigated with a computed tomography (70.7% versus 79.7%, P = 0.02). CONCLUSION The ASU model of care resulted in decreased mortality, shorter time to intervention and increased surgical management. Overall complications rate and length of stay did not change.
Collapse
Affiliation(s)
- Anton M Musiienko
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | - Rose Shakerian
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alexandra Gorelik
- The Melbourne EpiCentre, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Benjamin N J Thomson
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anita R Skandarajah
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
14
|
Affiliation(s)
- Benjamin N J Thomson
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | | |
Collapse
|
15
|
Suen K, Hayes IP, Thomson BNJ, Shedda S. Effect of the introduction of an emergency general surgery service on outcomes from appendicectomy. Br J Surg 2013; 101:e141-6. [DOI: 10.1002/bjs.9320] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2013] [Indexed: 12/16/2022]
Abstract
Abstract
Background
Appendicectomy is a common general surgical emergency procedure and may be used as a surrogate marker to evaluate quality in surgical management. The aim of this study was to assess the outcomes of appendicectomy before and after the introduction of a consultant-led emergency general surgery (EGS) service at a large metropolitan tertiary referral centre.
Methods
A retrospective historical control study was performed that included all adult patients undergoing appendicectomy during two 18-month periods, before and after the introduction of the EGS service. Data collected included patient demographics, use of radiological investigations, time to surgery, length of hospital stay and histopathology findings. Outcome measures were time to surgery, hospital length of stay, use of radiological investigations, negative appendicectomy rate and perforation rate.
Results
A total of 675 patients were identified of whom 276 had an appendicectomy before the EGS service was introduced (2008–2009) and 399 after its introduction (2011–2012). The EGS service resulted in an increase in time to surgery (15 versus 18 h; P < 0·001) with no increase in length of hospital stay (3 days for both periods; P = 0·424). An increase in the rate of appendicectomies performed within office hours was seen (54·3 versus 64·4 per cent; P < 0·001), with no significant increase in negative appendicectomy (13·0 versus 15·8 per cent; P = 0·322) or perforation (8·3 versus 5·5 per cent; P = 0·149) rates. The use of preoperative computed tomography reduced from 38·4 to 26·6 per cent (P = 0·001).
Conclusion
The introduction of a consultant-led EGS service resulted in a decrease in the use of computed tomography and a greater proportion of appendicectomies performed within office hours, with no increase in length of stay. Overall negative appendicectomy and perforation rates did not change.
Collapse
Affiliation(s)
- K Suen
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - I P Hayes
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - B N J Thomson
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - S Shedda
- Department of Specialist General Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
16
|
Barker LA, Gray C, Wilson L, Thomson BNJ, Shedda S, Crowe TC. Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial. Eur J Clin Nutr 2013; 67:802-7. [PMID: 23801093 DOI: 10.1038/ejcn.2013.117] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 04/28/2013] [Accepted: 05/17/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND/OBJECTIVES Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients. SUBJECTS/METHODS Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost. RESULTS A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1 ± 4.1 compared with 8.8 ± 6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3 ± 3.5 vs 12.3 ± 9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37). CONCLUSIONS Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.
Collapse
Affiliation(s)
- L A Barker
- Nutrition Department, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | | | | | | | | | | |
Collapse
|
17
|
Tie J, Lipton L, Desai J, Gibbs P, Jorissen RN, Christie M, Drummond KJ, Thomson BNJ, Usatoff V, Evans PM, Pick AW, Knight S, Carne PWG, Berry R, Polglase A, McMurrick P, Zhao Q, Busam D, Strausberg RL, Domingo E, Tomlinson IPM, Midgley R, Kerr D, Sieber OM. KRAS mutation is associated with lung metastasis in patients with curatively resected colorectal cancer. Clin Cancer Res 2011; 17:1122-30. [PMID: 21239505 DOI: 10.1158/1078-0432.ccr-10-1720] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Oncogene mutations contribute to colorectal cancer development. We searched for differences in oncogene mutation profiles between colorectal cancer metastases from different sites and evaluated these as markers for site of relapse. EXPERIMENTAL DESIGN One hundred colorectal cancer metastases were screened for mutations in 19 oncogenes, and further 61 metastases and 87 matched primary cancers were analyzed for genes with identified mutations. Mutation prevalence was compared between (a) metastases from liver (n = 65), lung (n = 50), and brain (n = 46), (b) metastases and matched primary cancers, and (c) metastases and an independent cohort of primary cancers (n = 604). Mutations differing between metastasis sites were evaluated as markers for site of relapse in 859 patients from the VICTOR trial. RESULTS In colorectal cancer metastases, mutations were detected in 4 of 19 oncogenes: BRAF (3.1%), KRAS (48.4%), NRAS (6.2%), and PIK3CA (16.1%). KRAS mutation prevalence was significantly higher in lung (62.0%) and brain (56.5%) than in liver metastases (32.3%; P = 0.003). Mutation status was highly concordant between primary cancer and metastasis from the same individual. Compared with independent primary cancers, KRAS mutations were more common in lung and brain metastases (P < 0.005), but similar in liver metastases. Correspondingly, KRAS mutation was associated with lung relapse (HR = 2.1; 95% CI, 1.2 to 3.5, P = 0.007) but not liver relapse in patients from the VICTOR trial. CONCLUSIONS KRAS mutation seems to be associated with metastasis in specific sites, lung and brain, in colorectal cancer patients. Our data highlight the potential of somatic mutations for informing surveillance strategies.
Collapse
Affiliation(s)
- Jeanne Tie
- Ludwig Colon Cancer Initiative Laboratory, Ludwig Institute for Cancer Research, Parkville, Melbourne, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
BACKGROUND Biliary injury during cholecystectomy can be managed successfully by biliary reconstruction in the majority of patients; however, a proportion of patients may require hepatic resection or even liver transplantation. METHODS Data on all patients referred with biliary injuries were recorded prospectively. The details of patients who required hepatic resection or transplantation were analyzed and compared to those patients managed with biliary reconstruction alone. RESULTS From November 1984 until November 2003 there were 119 patients referred with Strasberg grade E injuries to the biliary tree, 14 of whom (9 women, 5 men) required hepatic resection or transplantation. The median age of these 14 patients was 48 (range: 30-81) years. Nine patients were considered for hepatic resection, and of these six underwent right hepatectomy, two had a left lateral sectionectomy, and one patient was deemed unfit for surgery and underwent metal stenting of the right hepatic duct. All patients are alive and remain well. Five patients developed hepatic failure and were considered for liver transplantation. Two patients who were unfit for transplantation died, and another died while on the waiting list for transplantation. The remaining two patients underwent liver transplantation, and one of them died from overwhelming sepsis. Concomitant vascular injury was demonstrated in 8 of the 14 patients (57%), and in 3 of the 4 (75%) patients that died. CONCLUSIONS Hepatic atrophy or sepsis after biliary injury can be managed successfully with hepatic resection. Liver transplantation is required occasionally for patients with secondary biliary cirrhosis, but is rarely successful for early hepatic failure following iatrogenic biliary injury.
Collapse
Affiliation(s)
- B N J Thomson
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | |
Collapse
|
19
|
Lim E, Thomson BNJ, Heinze S, Chao M, Gunawardana D, Gibbs P. Optimizing the approach to patients with potentially resectable liver metastases from colorectal cancer. ANZ J Surg 2008; 77:941-7. [PMID: 17931254 DOI: 10.1111/j.1445-2197.2007.04287.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Liver metastases are a common event in colorectal carcinoma. Significant advances have been made in managing these patients in the last decade, including improvements in staging and surgical techniques, an increasing armamentarium of chemotherapeutics and multiple local ablative techniques. While combination chemotherapy significantly improves median patient survival, surgical resection provides the only prospect of cure and is the focus of this review. Interpretation of published work in this field is challenging, particularly as there is no consensus to what is resectable disease. Of particular interest recently has been the use of neoadjuvant treatment for downstaging and downsizing disease in patients with initially unresectable liver metastases, in the hope of response leading to potentially curative surgery. This review summarizes the recent developments and consensus guidelines in the areas of staging, chemotherapy, local ablative techniques, radiation therapy and surgery, emphasizing the multidisciplinary approach to this disease and ongoing controversies in this field and examines the changing paradigms in the management of colorectal hepatic metastases.
Collapse
Affiliation(s)
- Elgene Lim
- The Walter & Eliza Hall Institute of Medical Research, Department of Surgery, Royal Melbourne Hospital, Victoria, Australia
| | | | | | | | | | | |
Collapse
|
20
|
Thomson BNJ, Banting SW, Gibbs P. Pancreatic cancer - current management. Aust Fam Physician 2006; 35:212-7. [PMID: 16642237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Pancreatic cancer remains a common and lethal cancer with a median survival of approximately 6 months. OBJECTIVE This article discusses the current management of pancreatic cancer, both potentially curative and palliative treatment. DISCUSSION Surgical resection of the primary tumour is only possible in about 10% of cases as many patients have locally advanced or metastatic disease at the time of presentation. For the majority of patients, treatment is palliative and may include surgical treatments or endoscopic or percutaneous stenting to relieve obstructive jaundice or gastric obstruction, chemotherapy, radiotherapy or interventional radiological techniques. Adequate pain relief and treatment of pancreatic insufficiency are important components of treatment.
Collapse
|
21
|
Thomson BNJ, Parks RW, Redhead DN, Welsh FKS, Madhavan KK, Wigmore SJ, Garden OJ. Refining the role of laparoscopy and laparoscopic ultrasound in the staging of presumed pancreatic head and ampullary tumours. Br J Cancer 2006; 94:213-7. [PMID: 16434983 PMCID: PMC2361120 DOI: 10.1038/sj.bjc.6602919] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Laparoscopy and laparoscopic ultrasound have been validated previously as staging tools for pancreatic cancer. The aim of this study was to identify if assessment of vascular involvement with abdominal computed tomography (CT) would allow refinement of the selection criteria for laparoscopy and laparoscopic ultrasound (LUS). The details of patients staged with LUS and abdominal CT were obtained from the unit's pancreatic cancer database. A CT grade (O, A-F) of vascular involvement was recorded by a single radiologist. Of 152 patients, who underwent a LUS, 56 (37%) had unresectable disease. Three of 26 (12%) patients with CT grade O, 27 of 88 (31%) patients with CT grade A to D, 17 of 29 (59%) patients with CT grade E and all nine patients with CT grade F were found to have unresectable disease. In all, 24% of patients with tumours <3 cm were found to have unresectable disease. In those patients with tumours considered unresectable, local vascular involvement was found in 56% of patients and vascular involvement with metastatic disease in 17%, while 20% of patients had liver metastases alone and 5% had isolated peritoneal metastases. The remaining patient was deemed unfit for resection. Selective use of laparoscopic ultrasound is indicated in the staging of periampullary tumours with CT grades A to D.
Collapse
Affiliation(s)
- B N J Thomson
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - R W Parks
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK. E-mail:
| | - D N Redhead
- Department of Radiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - F K S Welsh
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - K K Madhavan
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - S J Wigmore
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - O J Garden
- Department of Clinical and Surgical Sciences (Surgery), 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| |
Collapse
|
22
|
Abstract
BACKGROUND Considerable debate surrounds the timing of repair of injury to the common bile duct following cholecystectomy. In the absence of sepsis or significant peritoneal soiling, repair within the first week may be optimal. This study compared the outcome of early (within the first 2 weeks) and delayed (between 2 weeks and 6 months) repair. METHODS Data on all patients referred with biliary injuries were recorded prospectively. In the absence of sepsis or significant peritoneal soiling, repair was considered within 2 weeks. RESULTS Between November 1988 and November 2003, 123 patients were referred with injury to the biliary tree. Repair of the injury had been attempted in 55 patients (44.7 per cent) before referral. Of the 68 patients with no previous repair, nine were managed without surgery and 59 required subsequent surgical reconstruction of the ductal injury. Within the first 2 weeks after injury, 22 patients underwent primary biliary repair and three had revision of a failed biliary repair. Between 2 weeks and 6 months, a further 22 injuries were repaired. Successful repair was possible in 22 of 25 early repairs compared with 20 of 22 delayed repairs (P = 0.615). The overall operative mortality rate for patients undergoing repair was 4 per cent (two of 47 patients). CONCLUSION A successful outcome was achieved in a high proportion of patients (42 of 47) when repair of the bile duct injury was undertaken in a unit experienced in the management of biliary injury. In selected patients, early repair within the first 2 weeks resulted in a similar outcome to that of delayed repair.
Collapse
Affiliation(s)
- B N J Thomson
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | | | | | | | | |
Collapse
|
23
|
Abstract
INTRODUCTION Laparoscopic adrenalectomy is well described and many series include patients with phaeochromocytoma. Our aim was to establish whether laparoscopic adrenalectomy for phaeochromocytoma was a safe and feasible technique at our institution. METHODS Patients requiring adrenalectomy were entered into a prospective database that included patient details, operative data, hormone excretion, tumour size, hospital stay and complications. All operations were performed under the supervision of a single surgeon. Analysis was performed for those patients with a diagnosis of phaeochromocytoma. RESULTS Of 60 patients having laparoscopic adrenal surgery, 18 had phaeochromocytoma as the indication. Seventeen (89%) of 19 tumours in these 18 patients were successfully removed laparoscopically. Median operative time was 180 min (range 130-300 min) and this was significantly longer compared with other adrenal pathology. The median tumour size was 6 cm which was significantly larger than other adrenal tumours. Seven (38%) patients developed complications and median postoperative inpatient stay was 5 days (range 3-8 days). CONCLUSIONS The postoperative stay was equivalent to other laparoscopic series and laparoscopic removal was successful in 89%. The laparoscopic approach to the adrenal gland in phaeochromocytoma is safe and effective treatment.
Collapse
|
24
|
Thomson BNJ, Parks RW. Palliation of pancreatic neoplasms. MINERVA CHIR 2004; 59:113-22. [PMID: 15238886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Pancreatic adenocarcinoma accounts for 80% of pancreatic tumours. The majority are unresectable at diagnosis and only 10% of patients survive to 1 year. Therefore, selection of appropriate palliative procedures for jaundice, gastric outlet obstruction or pain is a vitally important aspect of the management of these patients. Overall survival is equivalent following surgical or non-surgical palliation of biliary obstruction. Operative biliary bypass is a more major intervention but is associated with longer relief of symptoms and fewer readmissions compared to non-operative procedures. Prognostic factors such as histopathology, presence of metastatic disease and C reactive protein levels may allow better prediction of survival, therefore aiding selection of the most appropriate palliative techniques.
Collapse
Affiliation(s)
- B N J Thomson
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Edinburgh, UK
| | | |
Collapse
|
25
|
Wigmore SJ, Redhead DN, Thomson BNJ, Parks RW, Garden OJ. Predicting survival in patients with liver cancer considered for transarterial chemoembolization. Eur J Surg Oncol 2004; 30:41-5. [PMID: 14736521 DOI: 10.1016/j.ejso.2003.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Transarterial chemoembolization (TACE) has been used extensively to treat tumours confined to the liver in patients unsuitable for surgical resection. This study attempts to identify patients with liver cancer most likely to benefit from this type of treatment. PATIENTS AND METHODS All patients undergoing TACE for liver cancer between 1989 and 2001 were included in the study. RESULTS In a group of 137 consecutive patients undergoing TACE, univariate analysis identified a number of pre-treatment factors that were associated with poor prognosis. Multivariate analysis of these factors subsequently identified three pre-treatment factors; age greater than 60, serum alkaline phosphatase concentration >120U/l and albumin less than 35 g/l; that were independently and significantly associated with reduced survival duration. A scoring system was devised with one point allocated for each adverse factor which produced median survivals related to points scored as follows, 0 points-20 months, 1 point-12 months, 2 points-7 months and 3 points-4 months. To validate this scoring system the next 40 consecutive patients undergoing TACE were studied prospectively. These patients had median survival durations related to points scored as follows 0 points not calculable, 1 point-10 months, 2 points-7 months, 3 points-4 months. CONCLUSION This simple scoring system can be used to predict prognosis in patients with liver cancer and may assist in clinical decision making in the selection of patients likely to benefit from TACE.
Collapse
Affiliation(s)
- S J Wigmore
- Department of Clinical and Surgical Science, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, EH16 4SA Edinburgh, UK.
| | | | | | | | | |
Collapse
|
26
|
Abstract
BACKGROUND Pancreatico-bronchial fistulas are a rare complication of acute or chronic pancreatitis. Both conservative and surgical management have been described previously. CASE OUTLINE The management of a 68-year-old woman with acute pancreatitis complicated by a pancreatico-bronchial fistula was reviewed. CT scanning and magnetic resonance cholangio-pancreatography demonstrated a pancreatic pseudocyst with extension into the posterior mediastinum and right pleura. Despite conservative management as well as ERCP with pancreatic stent insertion, the fistula failed to resolve. Successful management of this difficult problem was achieved with distal pancreatectomy and intercostal drainage. DISCUSSION Pancreatico-bronchial fistulas may be managed conservatively, but there should be a low threshold for surgical intervention if endoscopic measures fail.
Collapse
Affiliation(s)
- BNJ Thomson
- Clinical and Surgical Sciences (Surgery), Royal Infirmary of EdinburghEdinburghUK
| | - SJ Wigmore
- Clinical and Surgical Sciences (Surgery), Royal Infirmary of EdinburghEdinburghUK
| |
Collapse
|
27
|
Abstract
Transarterial chemoembolisation of liver tumours is typically followed by elevated body temperature and liver transaminase enzymes. This has often been considered to indicate successful embolisation. The present study questions whether this syndrome reflects damage to tumour cells or to the normal hepatic tissue. The responses to 256 embolisations undertaken in 145 patients subdivided into those with hepatocyte-derived (primary hepatocellular carcinoma) and nonhepatocyte-derived tumours (secondary metastases) were analysed to assess the relative effects of tumour necrosis and damage to normal hepatocytes in each group. Cytolysis, measured by elevated alanine aminotransferase, was detected in 85% of patients, and there was no difference in the abnormalities in liver function tests measured between the two groups. Furthermore, cytolysis was associated with a higher rate of postprocedure symptoms and side effects, and elevated temperature was associated with a worse survival on univariate analysis. Multivariate analysis demonstrated that there was no benefit in terms of survival from having elevated temperature or cytolysis following embolisation. Cytolysis after chemoembolisation is probably due to damage to normal hepatocytes. Temperature changes may reflect tumour necrosis or necrosis of the healthy tissue. There is no evidence that either a postchemoembolisation fever or cytolysis is associated with an enhanced tumour response or improved long-term survival in patients with primary or secondary liver cancer.
Collapse
Affiliation(s)
- S J Wigmore
- Department of Clinical and Surgical Sciences (Surgery), University of Edinburgh, Royal Infirmary, SI Little France Crescent, Edinburgh EH16 4SA, UK.
| | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
INTRODUCTION Injuries to the extrahepatic biliary tree at laparoscopic cholecystectomy cause major morbidity and are a major source of litigation. Injuries are often diagnosed late, leading to further complications and decreasing the chance of a successful repair. METHODS A prospective study was carried out of all patients with extrahepatic biliary injuries from cholecystectomy who were referred to the surgeons of the Universities of Melbourne Hepatobiliary Group between 1997 and 1999. RESULTS Twenty-seven patients sustained biliary injuries to the extrahepatic biliary tree. Twenty patients (74%) had unrecognized injuries at the time of cholecystectomy. The median time to referral was 9 days. Only two of 11 operative cholangiograms were interpreted as showing a biliary injury. CONCLUSION Biliary injuries are still occurring at laparoscopic cholecystectomy. Guidelines about the management of a suspected biliary injury are discussed. Clinical, radiological and pathological assessment should enable prompt diagnosis and management should be instituted early, preferably with the involvement of a hepatobiliary specialist.
Collapse
|
29
|
Abstract
BACKGROUND Oesophagectomy for high-grade dysplasia is controversial. METHODS A prospective study was carried out on all patients who presented between 1993 and 2001 with dysplasia or early adeno-carcinoma who were considered fit for surgery. Details of endoscopic biopsies, appearance, surveillance, operative pathology and outcome were recorded. RESULTS Of 18 patients, one had low-grade dysplasia, six had high-grade dysplasia and 11 had early adenocarcinoma. No patient had their biopsy diagnosis down-staged following final pathology, but two patients with high-grade dysplasia on biopsy were upstaged to adenocarcinoma. Our only death from disease occurred in a 39-year-old man who had undergone yearly surveillance for 86 months until adenocarcinoma was confirmed. There was no operative mortality. CONCLUSION Oesophagectomy for early adenocarcinoma and dysplasia in Barrett's oesophagus can be done with acceptable rates of mortality and morbidity. Surveillance until adenocarcinoma is confirmed does not guarantee curable disease.
Collapse
|