Between July 1, 1970 and December 31, 1988, 453 patients underwent hepatic resection by the senior author. Ninety of these patients were more than 64 years old and are the subject of this review. The 30-day operative mortality rate for all patients undergoing hepatic resection was 3.3%: major hepatic resection was 4.4% and subsegmental resection was 1.4%. The operative mortality rate for patients undergoing major hepatic resection increased incrementally with age: for patients up to age 55 years it was 0.70%, for those between 55 and 64 years it was 3.6%, and for patients older than 64 years it increased to 11.1%. This higher operative mortality rate in the elderly reflects the mortality rate for extended right hepatic lobectomy in this age group of 30.7%. If this procedure is excluded, the operative mortality rate for patients older than age 64 was 7.6%. Sixty per cent of the operative deaths were due to hepatic insufficiency. The data presented demonstrate that major hepatic resection can be performed in the elderly with a low but somewhat increased mortality risk. However, because of its markedly increased operative risk, extended right hepatic lobectomy should be performed in elderly patients only in selected cases until better methods of estimating hepatic reserve are available.

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Background. Most patients with colorectal carcinoma metastatic to the liver have relapses after surgical resection of hepatic metastases with failures divided equally between hepatic and extrahepatic sites. A pilot study was begun using a regimen combining intrahepatic floxuridine (FUDR) and systemic 5‐fluorouracil (5‐FU) and leucovorin (LV) to determine its safety and efficacy. Methods. Because this was a pilot study, 21 patients with unresectable hepatic metastases from colorectal carcinoma were treated to assess the regimen's toxicity. Eight patients had liver metastases that were resected completely; then they received treatment. FUDR was given by hepatic arterial pump through a 14‐day continuous infusion at 0.25 mg/kg/day. Systemic therapy consisted of LV 200 mg/m2 and 5‐FU 280 mg/m2 using a bolus dose of 5‐FU for 5 days with escalation of the 5‐FU dose in separate patient cohorts. The maximally tolerated 5‐FU dose was 325 mg/m2. Results. The median survival in the 21 unresectable patients was 16 months with a partial response rate of 56% (10 of 18 evaluable patients; 95% confidence interval, 38–79%). The major systemic toxicity was diarrhea, Grade 3 or 4, in 54% of patients being treated in the 4‐week regimen and 19%, in the 5‐week regimen. The level of hepatic toxicity was similar to that in previous studies using intrahepatic chemotherapy alone, i.e., 48% of patients had a 200% increase in alkaline phosphatase levels and 10% had bilirubin elevations of more than 3.0 mg/dl (one patient had documented biliary sclerosis). All eight patients treated with adjuvant therapy were alive without disease after a median follow‐up of 23 months. Conclusions. Systemic 5‐FU and LV can be combined safely with intraarterial FUDR without loss of efficacy or increased biliary toxicity. Eight patients treated with this regimen as adjuvant therapy after liver metastasis resection were alive and disease‐free after a median follow‐up of 23 months.

BackgroundGallbladder cancer typically follows an aggressive course, with chemotherapy the standard of care for advanced disease; complete remissions are rarely encountered. The epidermal growth factor receptor (EGFR) is a promising therapeutic target but the activity of single agent oral EGFR tyrosine kinase inhibitors is low. There have been no previous reports of chemotherapy plus an EGFR-tyrosine kinase inhibitor (TKI) to treat gallbladder cancer or correlations of response with the mutation status of the tyrosine kinase domain of the EGFR gene.Case presentationA 67 year old man with metastatic gallbladder cancer involving the liver and abdominal lymph nodes was treated with gemcitabine (1000 mg/m2) on day 1 and 8 every 21 days as well as daily erlotinib (100 mg). After four cycles of therapy, the CA 19-9 normalized and a PET/CT showed a complete remission; this response was maintained by the end of 12 cycles of therapy. Gemcitabine was then discontinued and single agent erlotinib was continued as maintenance therapy. The disease remains in good control 18 months after initiation of therapy, including 6 months on maintenance erlotinib. The only grade 3 toxicity was a typical EGFR-related skin rash. Because of the remarkable response to erlotinib plus gemcitabine, we performed tumor genotyping of the EGFR gene for response predicting mutations in exons 18, 19 and 21. This disclosed the wild-type genotype with no mutations found.ConclusionThis case report demonstrates a patient with stage IV gallbladder cancer who experienced a rarely encountered complete, prolonged response after treatment with an oral EGFR-TKI plus chemotherapy. This response occurred in the absence of an EGFR gene mutation. These observations should inform the design of clinical trials using EGFR-TKIs to treat gallbladder and other biliary tract cancers; such trials should not select patients based on EGFR mutation status.

Our study demonstrated considerable differences in the distribution of wound classifications of appendectomies among our ORNs and retrospective reviewers. A review of the surgical literature supports our finding that the incision classification system utilized commonly lacks precision, at least in the rating of appendectomies. We recommend that further studies be performed to determine whether changes in the definitions of wound classes are warranted.