David Canes

Background: In most instances, advanced neuroendocrine tumors follow an indolent course. Hepatic metastases are common, and although they can cause significant pain, incapacitating endocrinopathy, and even death, they are usually asymptomatic. The appropriate timing and efficacy of interventions, such as hepatic artery emobolization (HAE) and operation, remain controversial. Study Design: The records of 85 selected patients referred for treatment of hepatic neuroendocrine tumor metastases between 1992 and 1998 were reviewed from a prospective database. A multidisciplinary group of surgeons, radiologists, and oncologists managed all patients. Overall survival among this cohort is reported and prognostic variables, which may be predictive of survival, are analyzed. Results: There were 37 men and 48 women, with a median age of 52 years. There were 41 carcinoid tumors, 26 nonfunctional islet cell tumors, and 18 functional islet cell tumors. Thirty-eight patients had extrahepatic metastases, and in 84% of patients, the liver metastases were bilobar. Eighteen patients were treated with medical therapy or best supportive care, 33 patients underwent HAE, and 34 patients underwent hepatic resection. Both the HAE-related mortality and the 30-day operative mortality rates were 6%. By univariate analysis, earlier resection of the primary tumor, curative intent of treatment, and initial surgical treatment were associated with prolonged survival (p < 0.05). On multivariate analysis, only curative intent to treat remained significant (p < 0.04). Patients with bilobar or more than 75% liver involvement by tumor were least likely to benefit from surgical resection. One-, 3-, and 5-year survival rates for the entire group were 83%, 61%, and 53%, respectively. The 1-, 3-, and 5-year survivals for patients treated with medical therapy, HAE, and operation were 76%, 39%, and not available; 94%, 83%, and 50%; and 94%, 83%, and 76%, respectively. Conclusions: Hepatic metastases from neuroendocrine tumors are best managed with a multidisciplinary approach. Both HAE and surgical resection provide excellent palliation of hormonal and pain symptoms. In select patients, surgical resection of hepatic metastases may prolong survival, but is rarely curative.

PURPOSE: We present the initial 4 patients undergoing single port transumbilical live donor nephrectomy. Scar-free abdominal surgery via natural body orifices is called NOTES (natural orifice translumenal endoscopic surgery). In a similar manner the umbilicus, an embryonic (E) natural orifice, permits abdominal access with hidden scar of entry. We propose the term E-NOTES for embryonic natural orifice transumbilical endoscopic surgery. MATERIALS AND METHODS: Through an intra-umbilical incision a novel single access tri-lumen R-port was inserted into the abdomen. No extra-umbilical skin incisions were made whatsoever. A 2 mm Veress needle port, inserted via skin needle puncture to establish pneumoperitoneum, was used to selectively insert a needlescopic grasper for tissue retraction. Donor kidney was pre-entrapped and extracted transumbilically. RESULTS: E-NOTES donor nephrectomy was successful in all 4 patients. Median operating time was 3.3 hours, blood loss was 50 cc, warm ischemia time was 6.2 minutes and hospital stay was 3 days. Median length of harvested renal artery was 3.3 cm, renal vein 4 cm and ureter 15 cm. No intraoperative complications occurred. Donor visual analog scores were 0/10 at 2 weeks. Each allograft functioned immediately on transplantation. CONCLUSIONS: The initial experience with E-NOTES donor nephrectomy is encouraging. Excellent donor vascular and tissue dissection could be performed, and a quality donor kidney was retrieved transumbilically without any extra-umbilical skin incision. E-NOTES donor nephrectomy appears to have relevance and promise, especially for this typically younger, altruistic population. Natural orifices present an unprecedented opportunity for scar-free surgery.