Am J Surg

Extracorporeal shock-wave lithotripsy for bile duct calculi.

White DM. Correa RJ. Gibbons RP. Ball TJ. Kozarek RJ. Thirlby RC.
Virginia Mason Medical Center, Seattle, Washington 98111, USA.
BACKGROUND: Bile duct calculi (BDC) can be cleared or treated with modern endoscopic techniques in most patients. However, large stones, bile duct strictures, or unusual anatomy may make endoscopic clearance difficult. The purpose of the present study was to determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in treating patients with complicated BDC. METHODS: Between 1989 and January 1995, 16 patients with BDC were treated at our institution with ESWL using a Dornier HM-3 lithotropter. The average age of patients was 62 years (range 32 to 88). Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and attempted stone extraction (100%), nasobiliary drainage (83%), and biliary stents (6%) were used prior to ESWL. Eleven patients (61 %) had solitary stones, ranging in diameter from 0.5 to 2.6 cm, whereas 7 patients had multiple stones, ranging in diameter from 0.5 to 5.0 cm. The indications for ESWL were stone impaction (56%), stone size (38%), and bile duct stricture (6%). RESULTS: The 16 patients received 27 ESWL treatments (mean = 2101 shock at 21 kV); with 4 patients (22%) requiring multiple treatments. Stone fragmentation was achieved in 94% of patients. All patients had ERCP performed post-ESWL, and only 2 (13%) patients required immediate operations. At discharge, 94% of patients were stone-free. Minor complications (eg, pain, hematuria) were common. With an average follow-up of 3 years, only 1 patient (6%) has required retreatment for BDC. Hepatic transplantation was required in an additional patient. CONCLUSIONS: In this cohort of patients with both major medical comorbidities and/or technical contraindications to standard methods of endoscopic and surgical clearance of BDC, we found that ESWL facilitated stone clearance in 94% of patients with minimal morbidity and no mortality. In our opinion, ESWL should be used more frequently in the treatment of these complex patients.

A prospective randomized clinical trial of perioperative treatment with octreotide in pancreas transplantation.

Benedetti E. Coady NT. Asolati M. Dunn T. Stormoen BM. Bartholomew AM. Vasquez EM. Pollak R.
Department of Surgery, University of Illinois at Chicago, 60612, USA.
BACKGROUND: Technical failures continue to plague clinical pancreas transplantation. The somastatin analogue octreotide has been shown able to decrease morbidity after pancreatic resection. We studied the effect of perioperative treatment with octreotide on technical complications after pancreas transplant. PATIENTS AND METHODS: Seventeen recipients of bladder-drained transplant were randomized to receive either octreotide, 100 microg TID SQ for 5 days after transplant (n = 10) or no additional treatment (n = 7). We compared the two groups in terms of patient and graft survival and incidence of graft pancreatitis, intra-abdominal infections, and anastomotic leaks. RESULTS: In the untreated group, 1 patient developed a bladder leak and 2 had intra-abdominal infections, while no complications occurred in the octreotide-treated patients (P = 0.05). Six-month patient and pancreas survival was 100% and 90%, respectively, in octreotide-treated patients versus 86% and 86% in the control group (P = NS). CONCLUSION: Perioperative treatment with octreotide seems able to reduce the incidence of technical complications after pancreas transplantation.

Localization and surgical treatment of pancreatic insulinomas guided by intraoperative ultrasound.

Huai JC. Zhang W. Niu HO. Su ZX. McNamara JJ. Machi J.
Department of Surgery, Second Affiliated Hospital, Henan Medical University, Zhengzhou, PR China.
BACKGROUND: Approximately 20% to 60% of insulinomas cannot be localized preoperatively, and 10% to 20% cannot be found even during surgery. The operative complications associated with the blind surgical explorations are relatively high. METHODS: Between January 1987 and December 1995, intraoperative ultrasound was used to localize insulinomas and guide surgical procedures in 28 patients. RESULTS: Insulinomas were found by intraoperative systematic palpation in 24 patients (85.7%), while intraoperative ultrasound localized the tumors in 27 patients (96.4%). By the combination of these two techniques, all tumors were discovered. The surgical procedures were guided by intraoperative ultrasound. The operative complication rate was 14.3%. CONCLUSION: Intraoperative ultrasound can accurately localize insulinoma, and delineate the spatial relationship between tumor and vital structures, such as pancreatic duct, common bile duct, and critical blood vessels. It can thereby help to increase the successful rate of surgery and avoid unnecessary blind pancreatectomy.

Long-term results of hepaticojejunostomy for benign lesions of the bile ducts.

Rothlin MA. Lopfe M. Schlumpf R. Largiader F.
Department of Surgery, Zurich University Hospital, Switzerland.
BACKGROUND: Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared. METHODS: A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation. RESULTS: Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition. CONCLUSIONS: Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.

Long-term quantitative results following fundoplication and antroplasty for gastroesophageal reflux and delayed gastric emptying in children.

Dunn JC. Lai EC. Webber MM. Ament ME. Fonkalsrud EW.
Department of Nuclear Medicine, UCLA School of Medicine, Los Angeles, California 90095, USA.
BACKGROUND: The operative management of children with combined gastroesophageal reflux and delayed gastric emptying is controversial. This study measures the long-term follow-up of gastric emptying in children who have undergone gastroesophageal fundoplication combined with antroplasty. METHODS: Fifteen randomly selected children with gastroesophageal reflux and scintigraphically demonstrated delayed gastric emptying underwent fundoplication and antroplasty. Each patient had another gastric emptying scintigraphic study performed an average of 3.6 years postoperation. RESULTS: All patients reported improvement of their symptoms compared with before the operation, and none required further medical therapy for gastroesophageal reflux or experienced dumping syndrome. Eleven of the 15 patients had significant long-term improvement of their gastric emptying postoperatively. The mean percent of isotope meal remaining in the stomach at 90 minutes improved from 72% preoperatively to 40% postoperatively (P = 0.0005). CONCLUSIONS: Gastric emptying in children with gastroesophageal reflux and delayed gastric emptying is significantly improved for several years in three-fourths of patients after fundoplication and antroplasty. Fundoplication and concomitant antroplasty are recommended for symptomatic children with documented gastroesophageal reflux and delayed gastric emptying.

A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus.

Nishihira T. Hirayama K. Mori S.
Second Department of Surgery, Tohoku University School of Medicine, Sendai, Japan.
BACKGROUND: Recurrence of thoracic esophageal carcinoma in the cervical and superior mediastinal lymph nodes occurs frequently and contributes to a poor prognosis. Extensive lymphadenectomy has been advocated. Findings in support of this to date, however, have been based on a comparison with historical controls. We herein report a prospective randomized trial of extended and conventional lymphadenectomy. METHODS: Cases of thoracic esophageal carcinoma meeting criteria predictive of complete resection were randomized into conventional and extended cervical and superior mediastinal lymphadenectomy groups. RESULTS: In the extended and conventional lymphadenectomy groups, respectively, mean operative time was 487 +/- 47 and 396 +/- 43 minutes, blood loss was 850 +/- 429 and 576 +/- 261 mL, node count was 82 +/- 22 and 43 +/- 15, hospital deaths occurred in 3% and 7%, 2-year survival was 83.3% and 64.8%, 5-year survival was 66.2% and 48.0%, and recurrence rate was 19.9% and 24.1%. CONCLUSION: Extended lymphadenectomy may prevent recurrence and prolong survival after resection of thoracic esophageal carcinoma.

Three helpful techniques for facilitating abdominal procedures, in particular for surgery in the obese.

Buchwald H.
Department of Surgery of the University of Minnesota Medical School, Minneapolis 55455, USA.
Three helpful techniques for facilitating abdominal procedures, in particular in the obese, are presented. Midline abdominal exposure is aided by the manual separation of the subcutaneous fat and Scarpa's fascia by a lateral tearing motion simultaneously performed from opposite sides of the table. Exposure of the upper abdomen is best achieved by utilization of a fixed-support retractor system placed with the patient in the Trendelenburg position, followed by positioning the patient in the reverse Trendelenburg position for the conduct of the operation. Ventral hernia repair is promoted when the three mobile layers of anterior rectus sheath, rectus muscle, and posterior rectus sheath are approximated with a continuous suture to create a neo-linea alba.

The role of cytokines in the pathogenesis of acute pancreatitis.

Norman J.
Department of Surgery, University of South Florida, Tampa 33601, USA.
BACKGROUND: The systemic manifestations of acute pancreatitis are responsible for the majority of pancreatitis-associated morbidity and mortality and are now believed to be due to the actions of specific inflammatory cytokines. This report summarizes what is known about the role of cytokines in the pathogenesis of acute pancreatitis. METHODS: Comprehensive literature review of experimental pancreatitis as well as all reports of cytokine involvement during clinical pancreatitis. RESULTS: Several cytokines and other noncytokine inflammatory mediators are produced rapidly during pancreatitis. These mediators arise in many tissues in a predictable fashion independent of the animal model used or the underlying etiology in human disease. Preventing the activities of these mediators has a profound beneficial effect in experimental animals. CONCLUSIONS: A few recently described inflammatory mediators are believed to be primarily responsible for the systemic manifestations of acute pancreatitis and its associated distant organ dysfunction. The predictable nature in which they are produced may allow for novel approaches to treating this disease. Am J Surg.

Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique.

Year 1998
Tsiotos GG. Luque-de Leon E. Soreide JA. Bannon MP. Zietlow SP. Baerga-Varela Y. Sarr MG.
Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
METHODS: From 1983 to 1995, 72 patients with necrotizing pancreatitis were treated with a general approach involving planned reoperative necrosectomies and interval abdominal wound closure using a zipper. RESULTS: Hospital mortality was 25%. Multiple organ failure without sepsis caused early mortality in 3 of 4 patients and sepsis caused late mortality in 11 of the remaining 14. The mean number of reoperative necrosectomies/debridements was 2 (0 to 7). Fistulae developed in 25 patients (35%); 64% were treated conservatively. Recurrent intraabdominal abscesses developed in 9 patients (13%) but were drained percutaneously in 5. Hemorrhage required intervention in 13 patients (18%). Prognostic factors included APACHE-II score on admission < 13 (P = 0.005), absence of postoperative hemorrhage (P = 0.01), and peripancreatic tissue necrosis alone (P < 0.05). CONCLUSIONS: The zipper approach effectively maximizes the necrosectomy and decreases the incidence of recurrent intraabdominal infection requiring reoperation. APACHE-II score > or = 13, extensive parenchymal necrosis, and postoperative hemorrhage signify worse outcome.

Intraoperative ultrasound does not improve detection of liver metastases in resectable pancreatic cancer.

Year 1998
Finlayson C. Hoffman J. Yeung R. Kessler H. Guttmann M. Shaer A. Clair M.
Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA.
BACKGROUND: In colorectal cancer, intraoperative ultrasound (IOUS) is superior to other imaging studies in characterizing hepatic metastases. The value of IOUS in detecting liver metastases from pancreatic cancer has not been evaluated previously. METHODS: Between 1990 and 1995, IOUS was prospectively employed to evaluate the liver for metastases in 32 patients with resectable pancreatic adenocarcinoma. Preoperatively, all patients had computed tomography (CT) and 22 patients had CT portography. RESULTS: At exploration, 5 of the 32 patients (15%) had extrapancreatic disease, 3 (9%) with liver implants. IOUS did not identify any additional hepatic metastases. Four preoperative studies were suspicious for metastatic disease in the liver. In these 4 patients, no hepatic metastases were identified by exploration or intraoperative ultrasound. CONCLUSIONS: We no longer routinely perform hepatic IOUS when evaluating patients with pancreatic adenocarcinoma for pancreaticoduodenectomy. When a preoperative study indicates possible hepatic involvement, IOUS can confirm the presence or absence of liver metastases.

Surgical indications for small polypoid lesions of the gallbladder.

Year 1998
Shinkai H. Kimura W. Muto T.
First Department of Surgery, University of Tokyo, Japan.
BACKGROUND: To determine which polyps of the gallbladder should be operated upon, we investigated the size and number of polyps in resected gallbladders, and studied changes in gallbladder polyps using ultrasonography (US). METHODS: We studied 74 resected gallbladders with small polypoid lesions less than 20 mm in diameter, and 60 patients with gallbladder polyps by US. The polyps in resected gallbladders were classified into four groups histologically, and clinical features, maximum diameter, and number of lesions were compared among the groups. In the followed-up cases with gallbladder polyps, the size and number of polyps were examined by US, and changes during the observation period were studied. RESULTS: The mean diameter of adenoma was 6.00 +/- 3.39 mm (mean +/- SD) and that of cancer 10.8 +/- 4.16 mm; 97% of cholesterol polyps were less than 10 mm in diameter (3.66 +/- 2.68 mm). Neoplastic polyps tended to be single (adenoma, n = 1.40 +/- 0.89; cancer, n = 1.16 +/- 0.40), whereas half of the cholesterol polyps were multiple (n = 3.09 +/- 3.31). However, when there were fewer than 3 lesions, the incidence of neoplasm was 37% among polyps 5 to 10 mm in diameter. A low incidence (6%) of neoplasm was also observed among polyps less than 5 mm in diameter. CONCLUSIONS: These data indicate that an aggressive surgical approach for small gallbladder polyps is warranted when there are fewer than 3 polyps, regardless of their size.

Long-term results after curative resection for carcinoma of the gallbladder. French University Association for Surgical Research.

Year 1998
Benoist S. Panis Y. Fagniez PL.
Service de Chirurgie Digestive, Hopital Henri-Mondor, Creteil, France.
BACKGROUND: The surgical management of gallbladder carcinoma is controversial, especially as regards the indications for radical resection. The aim of this study was to evaluate the results of surgical treatment for gallbladder carcinoma with special reference to the extent of its histological spread. METHODS: Eighty-six patients from 25 French centers underwent resection for cure and were included in this study. They comprised 65 women and 21 men (mean age 65 +/- 21 years). Resection included radical resection in 21 patients (partial hepatectomy, regional lymphadenectomy, and common bile duct resection) and simple cholecystectomy in 65. RESULTS: There were 3 postoperative deaths (3.5%). The mean follow-up period was 25 +/- 24 months. The overall 5-year actuarial survival rate was 26%. The 5-year actuarial survival rate was 27% for patients who had radical resection. Eight patients with nodal metastasis had a 5-year survival rate of 0%, but the rate for 13 patients without such metastasis was 43% (P

Extended surgical resection in T4 gastric cancer.

Year 1998
Shchepotin IB. Chorny VA. Nauta RJ. Shabahang M. Buras RR. Evans SR.
Department of Surgery, Georgetown University Medical Center, Washington, DC 20007, USA.
BACKGROUND: Some physicians still consider invasion of adjacent organs by the carcinoma of stomach as a sign of incurable disease. METHODS: This retrospective study has been done with particular reference to 353 T4 gastric cancer patients who underwent combined gastrectomies with adjacent organs. RESULTS: Subtotal gastrectomy was performed in 237 (67.1%) patients and total gastrectomy was performed in 116 (32.9%) patients. Organs most commonly resected with the stomach were the transverse colon in 159 (45%) cases, the tail of pancreas and spleen in 150 (42.5%), the left lobe of liver in 101 (28.5%), and the head of pancreas in 37 (10.5%) patients. A total of 110 postoperative complications occurred in this subset of patients corresponding to a complication rate of 31.2%. A total of 48 postoperative deaths occurred in this subset of patients corresponding to a mortality rate of 13.6%. The 5-year survival rate for all patients who underwent combined gastrectomy with adjacent organs was 25%. Of the node-negative T4 gastric cancer resections, 37% survived 5 years whereas the T4 node-positive resections have only a 15% 5-year survival. CONCLUSIONS: Patients who present with T4 gastric cancer (about 20% of the patient population) will benefit from aggressive en bloc surgical resection and should not be considered unresectable.

Effects of a urinary trypsin inhibitor on acute circulatory insufficiency after surgical operation.

Year 1998
Tani T. Abe H. Endo Y. Hanasawa K. Kodama M.
First Department of Surgery, Shiga University of Medical Science, Otsu, Japan.
OBJECTIVE: To assess the effectiveness of an urinary trypsin inhibitor (UTI) on a surgical stress, particularly the influences on cytokines and diuretic hormones. SUBJECTS AND METHODS: Sixteen patients with carcinoma of the digestive system and predicted to suffer from circulatory insufficiency were enrolled. Selection of group was divided alternatively. UTI was administered for 5 consecutive days, at a dose of 300,000 units per day. Urine and blood specimens were collected before, immediately after, and 1, 3, and 5 days after surgery. Interleukin 8 (IL-8), polymorphonuclear leukocyte elastase (PMNE), vasopressin (ADH), atrial natriuretic peptide (ANP), angiotensin II (AT-II), and endothelin 1 (ET-1) in the blood, and N-acetyl-D-glucosaminidase (NAG) in the urine, were determined. RESULTS: A UTI group was 9 patients, and a control group was 7 patients. The operation time was significantly longer in the UTI group than in the control group. In the UTI group, the elevation of IL-8, PMNE/WBC, ADH, urinary NAG, and BUN were significantly inhibited. AT-II and ET-1, in the UTI group, tended to be suppressed, and ANP showed the similar changes in the two groups. CONCLUSION: UTI is considered effective in the prevention of excessive reaction against major surgery.

The utility of the Hartmann procedure.

Year 1998
Desai DC. Brennan EJ Jr. Reilly JF. Smink RD Jr.
Department of Surgery, Lankenau Hospital, Wynnewood, Pennsylvania, 19096, USA.
BACKGROUND: In 1923 the French surgeon Henri Hartmann described an operation for rectosigmoid cancer as an alternative to abdomino-perineal resection for high-risk patients. In the subsequent years, the indications for performing the Hartmann procedure have broadened to include complicated diverticulitis, ischemic bowel, iatrogenic perforations, volvulus, and colitis. METHODS: We have retrospectively reviewed our experience in 185 patients who underwent the Hartmann procedure from January 1981 to December 1995. Charts were reviewed for indications, morbidity, and mortality and to determine the outcome of patients who underwent the Hartmann procedure. RESULTS: The main indications for performing the Hartmann procedure were complicated diverticulitis (including perforation, obstruction, and abscesses) in 108 patients, rectosigmoid cancer in 31 patients, and other indications in 46 patients. There were a total of 27 deaths for an in-hospital mortality of 14%. All complications occurred at a rate of less than 9%. Of the 158 surviving patients, 90 (57%) eventually underwent the second stage of the operation to restore bowel continuity. The average length of time between initial resection and reanastomosis was 149 days. There were no deaths associated with the second stage of the procedure and complications occurred at a rate less than 4%. CONCLUSIONS: This is the largest reviewed series of the Hartmann procedure. Mortality is lower than in other reported series, and morbidity is low. Our data demonstrate that the second stage of the procedure, in properly selected individuals, is a procedure that can be performed with minimal morbidity and no mortality. This is different from other published reports. We conclude that the Hartmann procedure is a safe and efficacious option for the surgeon confronted with the complex pathology of the rectosigmoid area, with acceptable morbidity and mortality.

Is radical hepatic surgery safe?

Year 1998
Brancatisano R. Isla A. Habib N.
Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London, United Kingdom.
BACKGROUND: A prospective review of 200 consecutive liver resections performed for benign and malignant disease, between 1989 and 1995 at the Hammersmith Hospital, was undertaken to evaluate the safety of radical hepatic resection. METHODS: The indications for operation were: hepatocellular carcinoma (n = 39), cholangiocarcinoma (n = 21), gall bladder carcinoma (n = 8), colorectal secondaries (n = 75), noncolorectal secondaries (n = 35), and benign disease (n = 26). Twenty patients were cirrhotic and 36 were jaundiced. Major resections were performed in 74% of cases and included 63 extended hepatectomies, 17 repeated resections for recurrent colorectal metastases, and 17 resections combined with vascular reconstruction. Total vascular exclusion of the liver was used in the majority of cases. RESULTS: The overall mortality rate was 5%. Thirty-day mortality was 2.5%. Sepsis and not hemorrhage was the most common cause of death. There were 101 complications that occurred in 37% of the patients. The main complications were subphrenic abscess and biliary leak. The extent of liver resection (major versus minor) significantly increased the risk of morbidity (46% versus 16%). Blood loss greater than 100 mL increased the risk of morbidity from 12% to 25%. CONCLUSIONS: Major hepatic resection can be achieved with acceptable mortality but high morbidity rates.

The inflammatory response to open tension-free inguinal hernioplasty versus conventional repairs.

Year 1998
Gurleyik E. Gurleyik G. Cetinkaya F. Unalmiser S.
Department of Surgery, Haydarpasa Numune Hospital, Istanbul, Turkey.
BACKGROUND: The tension-free inguinal hernioplasty is now a popular method because of less postoperative disability and low recurrence rate. The laboratory evaluation of the inflammatory response to the injury is an objective approach to determine the stress status of a surgical procedure. The aim of this study is to evaluate and to compare inflammatory responses to open tension-free and conventional repairs of inguinal hernias. METHODS: Forty-eight male patients with primary indirect inguinal hernias were treated with elective operations, and separated into three groups according to surgical procedure: 12 pediatric patients treated with dissection of hernia sac in group 1, 16 adult patients with open tension-free hernioplasty in group 2, and 20 adult patients with conventional repairs in group 3. Ten healthy adult volunteers formed group 4 as control. The repair was performed with polypropylene mesh and suture as the Lichtenstein technique in group 2, and with polypropylene suture as one of Bassini, McVay, or Shouldice techniques in group 3. The inflammatory response was evaluated with serum interleukin-6 (IL-6) levels at 12 hours and serum C-reactive protein (CRP) levels at 48 hours postoperatively. Serum levels of IL-6 and CRP were measured in group 4 as control. Patient characteristics, operating time, and IL-6 and CRP levels were compared among the four groups. RESULTS: There were no significant differences in mean age and operating time between the two groups of adult patients with hernia repair. Mean serum IL-6 levels of 12.1 +/- 5.2 and 8.2 +/- 2.7 pg/mL, and CRP levels of 34.3 +/- 13.8 and 7.5 +/- 4 mg/L in pediatric and control groups, respectively, were significantly lower than in the other two hernia groups. Mean serum IL-6 levels were 58.9 +/- 25.4 pg/mL in group 2 (tension-free repair) and 44.3 +/- 18.1 pg/mL in group 3 (conventional repair) (P > 0.05). Mean serum CRP levels were 111.3 +/- 41.3 and 83 +/- 43.2 mg/L in groups 2 and 3, respectively (P > 0.05). The differences not being statistically significant, a similar and considerable inflammatory response was noted in patients with either prosthetic mesh repair or with conventional repairs of indirect inguinal hernias. CONCLUSIONS: The reinforcement of the posterior wall of the inguinal canal induces significant cytokine response regardless of tension-free or conventional repair. Open tension-free hernioplasty offered no advantages over conventional repairs from the standpoint of the inflammatory and acute phase response.

A comparison of adrenalectomy with other resections for metastatic cancers.

Year 1998
Wade TP. Longo WE. Virgo KS. Johnson FE.
Department of Surgery, John Cochran VA Medical Center and St. Louis University School of Medicine, Missouri, USA.
BACKGROUND: Although adrenal metastases were once considered incurable, recent anecdotal reports recommend adrenalectomy for isolated metastases. METHODS: Computerized files of all US Department of Veterans Affairs (DVA) hospital admissions and deaths from 1988 to 1994 identified patients undergoing isolated adrenal resections, and hospitalization records were obtained. Patients without a death record were assumed to be alive. RESULTS: In 47 patients with adrenalectomy for metastases, only 5 patients did not die within 3 years: 2 each had metachronous renal or colorectal metastases, and 1 had a pulmonary primary. Thirteen patients with other primary sites all expired within 3 years. Operative mortality was 4% in these 47 patients and also in 706 other adrenalectomies without metastases. CONCLUSIONS: Adrenalectomy for metastatic carcinoma in the DVA was safe, with a projected 5-year survival rate (13%) that is significantly inferior (P < or = 0.05) to resections for colorectal metastases to lung (36%) or liver (26%), but superior to brain (none).

Restoration of anal sphincter function by single-stage dynamic graciloplasty with a modified (split sling) technique.

Year 1998
Rosen HR. Novi G. Zoech G. Feil W. Urbarz C. Schiessel R.
Ludwig Boltzmann Research Institute for Surgical Oncology, Danube Hospital / SMZ-Ost, Vienna, Austria.
BACKGROUND: Controlled muscle fiber conversion by electrostimulation makes transformation of fast twitching type II muscle fibers to slow twitching type I fibers possible, which gives skeletal muscles the capacity for tetanic contraction. This phenomenon has been recently applied in the so-called "dynamic graciloplasty" to restore function of an insufficient or excised anal sphincter. This paper describes our results with this method in patients with fecal incontinence or following an abdomino-perineal resection (APR) of the anorectum. METHODS: From April 1992 through April 1997, 28 patients (12 women and 16 men) were treated by dynamic graciloplasty. The median age was 53.5 years (range 16 to 79). Indications were as follows: APR + synchronous restoration of the excised sphincter by graciloplasty (n = 12); total anorectal reconstruction (TAR) following APR in the past (n = 6); Patients with acquired fecal incontinence (n = 4); and Congenital atresia (n = 6). Muscle transposition, implantation of stimulation electrodes and pulse generator were done as a single-stage procedure, the "neosphincter" was wrapped in a modified technique (split-sling technique). Muscle transformation was performed by controlled neuromuscular stimulation during 8 weeks (from 1992 to 1995) and 4 weeks (since 1996), respectively. RESULTS: No postoperative mortality (90 days) was observed in either group. In our early experience, rectal injury occurred in 4 patients as the most prominent complication. Evaluation of the functional outcome showed the best results in patients operated either for congenital of acquired incontinence who achieved a continence for solids and liquids or solids alone, respectively (1 or 2 according to Williams' score) in 90%, while patients following APR showed a satisfying outcome (continence for solids and liquids, solids alone or with occasional episodes for liquids) in only 55.5%. In patients following APR, defecation disorders turned out to be the most prominent functional problem and had to be treated by enemas. CONCLUSION: In this series, we have been able to perform dynamic graciloplasty as a one-stage procedure using a modified muscle wrap (split-sling-technique) thus reducing the time period until continence could be achieved to 7 weeks. We found the appropriate tension of the muscle wrap essential to prevent direct injury to the rectum as it was seen in our early experience. For this reason, we have introduced a modified device to perform intraoperative anal manometry and to measure pressures created by the neosphincter objectively.

Initial clinical experience with colonic stent placement.

Year 1998
Wholey MH. Levine EA. Ferral H. Castaneda-Zuniga W.
Section of Interventional Radiology, Louisiana State University Medical Center, New Orleans 70112, USA.
BACKGROUND: The purpose of this study is to review initial experience with a colonic stent as an alternative to colostomy in patients with colonic obstruction. METHODS: Ten patients diagnosed with acute colonic obstructions from both benign and malignant causes underwent stent placement. Self-expandable metallic stents were deployed using fluoroscopic guidance. Patients were followed up clinically until removal of the stent or death. RESULTS: Nine of the 10 patients who underwent colonic stent placement achieved clinical decompression within 6 hours. Six patients underwent standard mechanical bowel preparation and elective resection of obstructing lesions. The other 4 patients received stent placement for palliative purposes. Complications included 4 cases of migration and 1 death. Migrated stents in the rectum were easily retrieved and replaced using fluoroscopic techniques. There were no perforations. CONCLUSION: Placement of self-expandable metallic stents for acute colonic obstructions may allow patients to undergo elective surgical resection avoiding possible colostomy.

The type of K-ras mutation determines prognosis in colorectal cancer.

Year 1998
Cerottini JP. Caplin S. Saraga E. Givel JC. Benhattar J.
Department of Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
BACKGROUND: Mutations involving the oncogene K-ras in colorectal cancer may be related to tumor aggressiveness. However, the value of K-ras gene determination as a prognostic marker has not been clearly established. PATIENTS AND METHODS: The results from 98 patients recruited in a prospective study analyzing the effect of a K-ras mutation as a prognostic factor in colorectal cancer are reported. RESULTS: Disease-free (P = 0.02) and overall survival (P = 0.03) were significantly reduced for patients harboring a K-ras mutation. Two specific mutations demonstrated a significantly increased risk of disease recurrence, namely, 12-TGT (P = 0.04) and 13-GAC substitutions (P = 0.002). Patients with either of these substitutions had a 2-year disease-free survival rate of 37% compared with that of 67% for the group of patients harboring any other mutation type or a wild-type status (P = 0.01). CONCLUSIONS: The results herein presented suggest that K-ras acts as a prognostic factor in colorectal cancer and that this effect is probably related to a limited number of defined mutations.

Comparison of endoscopic retrograde and magnetic resonance cholangiopancreatography in the surgical diagnosis of pancreatic diseases.

Year 1998
Yamaguchi K. Chijiwa K. Shimizu S. Yokohata K. Morisaki T. Tanaka M.
Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan.
BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a newly developing noninvasive examination of the biliopancreatic trees. Roles of MRCP in the diagnosis of pancreatic diseases have not been scrutinized. METHODS: Endoscopic retrograde cholangiopancreatography (ERCP) and MRCP were reviewed in 52 Japanese patients with various pancreatic diseases and 6 patients with normal pancreas to compare their diagnostic usefulness and limitation. RESULTS: In those with normal pancreas, only the main pancreatic duct was visualized by MRCP, while both the main pancreatic and branch ducts were clearly delineated by ERCP. In 3 patients with serous cystadenoma, the tumor was not visualized by ERCP, whereas it was visible as a high-intensity mass on MRCP. Of 18 patients with a "mucin hypersecreting" tumor of the branch type, MRCP demonstrated cystically dilated branch ducts in all, while ERCP failed to visualize the dilated ducts in 6 patients. However, the details of the cystic lesions (mural nodule, communication with the main pancreatic duct) were more exactly demonstrated by ERCP than MRCP. In 5 patients with a mucin hypersecreting tumor of the main pancreatic duct type, the dilated main pancreatic duct and the presence of mural nodules were similarly demonstrated both by ERCP and MRCP. In 12 patients with pancreatic adenocarcinoma, indirect findings were similarly demonstrated both by ERCP and MRCP, ie, stenosis (4 patients) and obstruction (8) together with dilation of the main pancreatic duct (9). In 3 patients, the center of the mass showed high intensity on MRCP, suggesting the secondary change of pancreatic carcinoma. In 8 patients with obstruction of the main pancreatic duct due to carcinoma, the distal pancreatic duct was visualized by MRCP but not by ERCP. In 9 patients who had undergone pylorus-preserving or standard pancreatoduodenectomy, follow-up MRCP was obtainable in all examined and displayed the main pancreatic duct. CONCLUSIONS: MRCP plays a complementary role in the surgical diagnosis of pancreatic disorders and is especially useful to examine the pancreatic duct after pancreatoduodenectomy.

Effects of aging on the functional outcome of coloanal anastomosis with colonic J-pouch.

Year 1998
Dehni N. Schlegel D. Tiret E. Singland JD. Guiguet M. Parc R.
Department of Alimentary Tract Surgery, Hospital and Faculty of Medicine Saint Antoine, University Pierre and Marie Curie, Paris, France.
BACKGROUND: Many low rectal cancers can be treated radically by proctectomy with total mesorectal excision followed by colonic J-pouch anal anastomosis (CPAA). In elderly patients, the fear of poor function might reduce indications for CPAA in favor of abdomino-perineal excision with end stoma. METHODS: Among 198 patients with CPAA operated on for low rectal cancer between 1984 and 1992, 20 patients over 75 years old were alive without recurrence at the time of telephone interview (July 1995). Minimal follow-up was 3 years (mean 8) for all patients. Their functional results were compared with those of 37 younger patients operated consecutively during the last 5 years of the study period. RESULTS: The two groups were well matched for gender, tumor distance from the anal verge, histologic staging, and use of adjuvant radiotherapy. Follow-up was longer in the elderly group than in the young group (96 versus 63 months, respectively). The elderly group had a median of 1 bowel movement per day and the young group a median of 1.5 (P = 0.13). The presence of irregular intestinal transit was reported in 48% of the aged and in 35% of the young group (P = 0.6), but fragmented defecation was less frequent (25% versus 47%, respectively; P = 0.15). Urgency was noted, respectively, in 15% and 22% of elderly and young patients (P = 0.7) and constipation in 40% and 22% (P = 0.2). Incontinence for feces (15%) and for flatus (40%) in elderly were not significantly different from the younger group (14% and 46%, P = 1.0 and P = 0.8, respectively). Laxatives were used in 32% of elderly and 17% of young patients (P = 0.3). CONCLUSION: Functional outcome may be good to excellent in elderly patients after CPAA and compares well with that obtained in younger patients. Constipation, however, may be more frequent in the elderly. Age is not a contraindication for CPAA if the sphincter tone is clinically normal.

Biliary tract cancer accompanied by anomalous junction of pancreaticobiliary ductal system in adults.

Year 1998
Tanaka K. Ikoma A. Hamada N. Nishida S. Kadono J. Taira A.
Second Department of Surgery, Kagoshima University, Japan.
BACKGROUND: Anomalous junction of the pancreaticobiliary ductal system (AJPBDS) is a congenital anomaly in which the junction is located outside the duodenal wall. Recently, attention has been focused on the high incidence of malignancy in this anomaly. The purpose of this study was to clarify the clinicopathological features of this anomaly and to determine the appropriate surgical approach for biliary tract cancer associated with AJPBDS. METHODS: The data for 38 patients with AJPBDS, including 14 who had been treated for biliary tract cancer (2 with bile duct cancer and 12 with gallbladder cancer), were retrospectively reviewed. We assessed the clinical features, characteristics of the tumor, operative procedure, and outcome for each patient. RESULTS: The incidence of malignancy in AJPBDS was 17.8% (2 patients with bile duct cancer and 3 with gallbladder cancer) in the bile duct dilatation group (n = 28) and 90% (9 patients with gallbladder cancer) in the no-dilatation group (n = 10) . The mean length of the common channel was 24.7 mm (range 20 to 35 mm) . Resection with lymphadenectomy was performed in 9 (64.3%) of 14 patients, and curative resection in 5 of these 9 patients. Ten (71%) of the 14 patients had lymph node involvement noted either at the time of initial diagnosis or at surgery. The incidence of lymph node metastasis was closely related to the depth of tumor involvement. Ten patients died of recurrence or primary cancer, from 3 to 30 months after operation. Four patients are still alive without recurrent disease from 2.5 to 13 years after operation. CONCLUSION: For patients with AJPBDS without bile duct dilatation, prophylactic cholecystectomy is recommended even if no malignant lesion is found in the gallbladder because of the high incidence of gallbladder cancer and the poor prognosis. Both early detection and curative resection of the tumor are essential for successful treatment of biliary tract cancer.

Segments I and IV resection as a new approach for hepatic hilar cholangiocarcinoma.

Year 1998
Miyazaki M. Ito H. Nakagawa K. Ambiru S. Shimizu H. Shimizu Y. Okuno A. Nozawa S. Nukui Y. Yoshitomi H. Nakajima N.
First Department of Surgery, School of Medicine, Chiba University, Japan.
Major hepatic resection for biliary tract carcinoma with obstructive jaundice has been reported on as bringing about high surgical morbidity and mortality rates. It has been also revealed that the extent of hepatic resection is closely associated with the occurrence of postoperative complications. Therefore, hepatic resection, limited as much as possible to what is necessary for curative resection, should be performed according to cancer extent. We performed a new surgical approach in 3 patients with hepatic hilar cholangiocarcinoma that included total resection of hepatic segments I and IV (by Couinaud's classification) and bile duct resection with hepaticojejunostomy of 4 to 6 intrahepatic bile duct stumps. All patients underwent curative surgical resections and were discharged within 6 weeks after surgery, without any serious complications. This limited resection of hepatic segments I and IV could be an effective radical surgical procedure for hepatic hilar cholangiocarcinoma, to avoid the occurrence of postoperative liver failure.

Is abdominal cavity culture of any value in appendicitis?

Year 1998
Bilik R. Burnweit C. Shandling B.
Department of Surgery, University of Toronto, The Hospital for Sick Children, Ontario, Canada.
BACKGROUND: Intraperitoneal culturing during appendectomy is a routine procedure. Significant decrease in the mortality and dramatic improvement in the morbidity were achieved by using antibiotics perioperatively. The value of intraoperative abdominal cavity culture was assessed in our study. METHODS: A total of 499 patients formed two groups, those with acute nonperforated appendicitis (group A) and those with perforated appendicitis (group B). Intraoperative abdominal cavity culture were taken randomly in both groups. The perioperative morbidity, the validity, and the impact of positive culture on the antibiotic treatment were examined in both groups. RESULTS: Clinical diagnosed perforation was confirmed histologically in 176 patients (98.3% accuracy). Intraperitoneal cultures were obtained in 30.1% of the patients in group A and in 67.1% of group B. The majority of the patients in group A were treated preoperatively and postoperatively by a single antibiotic agent whereas 58.0% of the patients in group B were started on triple-agent antibiotics for significantly longer periods (22.4 +/- 9.4 versus 5.7 +/- 7.4 doses, respectively; P < 0.0001). No significant difference was found in both groups in the postoperative complication rate (wound infection, intra-abdominal abscess and small bowel obstruction) whether intra-abdominal culture was obtained or not (5.9% versus 4.7% in group A and 21.2% versus 21.9% in group B; P > 0.05). CONCLUSION: Traditional intraoperative abdominal cavity culture can be abandoned. In perforated appendicitis, colonic flora can be predicted, and antibiotic therapy should begun without any abdominal cavity culture results. This practical approach will save money and reduce laboratory work without affecting the patient's morbidity.

Minimally invasive antireflux surgery.

Year 1998
McKernan JB. Champion JK.
Department of Surgery, Medical College of Georgia, Augusta, USA.
BACKGROUND: Previous reports of minimally invasive antireflux surgery for gastroesophageal reflux disease (GERD) have been small, short-term series utilizing only a laparoscopic approach. We conducted a retrospective review and report our 66-month experience with more than 1,000 laparoscopic and thoracoscopic antireflux procedures. METHODS: Between September 1991 and October 1997, 968 adults underwent 1,003 minimally invasive antireflux procedures on a tailored basis, based on their preoperative evaluation. Procedures performed were laparoscopic Nissen (626), Toupet (348), paraesophageal (33), and thoracoscopic Belsey (22). A total of 23% (233) of patients underwent an ancillary procedure (esophageal myotomy 85, vagotomy 67, pyloromyotomy 13, and cholecystectomy 66). RESULTS: Follow-up averaged 33 months (range 1 to 66), operative mortality was 0.1%. Complications occurred in 2.7% with a 1% long-term dysphagia rate. Demonstrated recurrence rate was 3.8% to date, with an associated 3.4% reporting symptoms of GERD. CONCLUSION: Minimally invasive antireflux procedures provide sustained relief of GERD symptoms with low morbidity and rapid recovery.

Clinical evaluation of nerve-sparing surgery combined with preoperative radiotherapy in advanced rectal cancer patients.

Year 1998
Saito N. Sarashina H. Nunomura M. Koda K. Takiguchi N. Nakajima N.
Department of Surgery, Chiba University School of Medicine, Japan.
BACKGROUND: Since 1984, we have studied nerve-sparing surgery (NSS) combined with preoperative radiotherapy (XRT) in patients with advanced rectal cancer to preserve the genitourinary function without compromising radicality. The present aim was to evaluate the prognosis and the postoperative genitourinary function. METHODS: A total of 167 patients with advanced rectal cancer underwent curative nerve-sparing surgery. Among them, 60 underwent the preoperative therapy using irradiation (42.6 Gy) and tegafur suppository. Survival, local recurrence, and postoperative genitourinary function were investigated in these patients. RESULTS: The 5-year survival rate was 80.9% and the local recurrence rate was 6.7% in the NSS+XRT group. Almost all of the patients receiving NSS could micturate spontaneously, but preservation of sexual function was not as successful. CONCLUSIONS: Better local control and preservation of urinary function were possible in advanced rectal cancer patients by NSS+XRT.

Accuracy of computed tomography in determining resectability for locally advanced primary or recurrent colorectal cancers.

Year 1998
Farouk R. Nelson H. Radice E. Mercill S. Gunderson L.
Division of Colon and Rectal Surgery, Mayo Foundation, Rochester, Minnesota, USA.
AIM: To determine the accuracy of computed axial tomography (CT) in determining tumor resectability in patients with locally advanced primary (T4) or locally recurrent colorectal cancer. METHODS: Computed tomography scans of 84 patients with "resectable" locally advanced primary rectal cancer (n = 12) or recurrent colorectal cancer (n = 72) were compared with the operative findings to assess the accuracy of abdominal and pelvic CT in determining extent of disease and resectability. RESULTS: At surgery, disease was confined to the pelvis in 63 patients, the abdomen in 7, and involved both the pelvis and abdomen in 14. Computed tomography correctly identified these anatomic sites of tumor in 87% of patients, with 89% and 80% accuracies for pelvic and abdominal disease, respectively. Tumor resection was performed in 71 patients (85%), but was not in 13 patients because of locally unresectable disease in 8 and metastatic disease in 5. The accuracy of predicting tumor-related operability was 85%. With regard to adjacent organ resection, CT was accurate in determining the need for sacrectomy or hysterectomy, but overestimated the need for urinary organ resection. Based on histological examination of resection margins, CT correctly staged (n = 45) or overstaged (n = 9) 54 patients (64%) and understaged the remaining 30. The ability of CT to preoperatively predict a locally advanced tumor after preoperative radiation therapy as not being fixed was 30%, fixed but resectable 75%, and fixed but not resectable 25%. CONCLUSIONS: Computed tomography is generally reliable at identifying disease as being confined to one region, and for predicting the need for adjacent organ resection. It is less discriminating for predicting local tumor resectability.

Treatment of local recurrence of rectal cancer.

Year 1998
Huguier M. Houry S.
Department of Surgery, Hopital Tenon, University Paris VI, France.
BACKGROUND: Treatment of local recurrence of rectal cancer remains a challenge. Preoperative irradiation and total mesorectal excision halve the risks of local failure, but increase morbidity and even mortality. The results of re-resection of recurrent rectal cancer suggest need to reexamine therapeutic strategies for initial treatment. METHODS: Seventy-one patients operated on for rectal carcinoma without radiotherapy developed local recurrence (29 with metastatic disease). Thirty underwent a curative re-resection (8 had combined resection of metastases). RESULTS: The incidence of asymptomatic recurrence was higher after anterior resection (38%) than after abdominoperineal resection (16%). The actuarial 5-year survival rate was 19%; 28% in asymptomatic patients and 8% in symptomatic (P = 0.04). CONCLUSIONS: Early detection of recurrence of rectal cancer leads to an improved re-resection rate and survival. In patients who did not undergo radiotherapy at the time of the original resection, re-resection can be achieved safely. The place for radiation in the treatment of rectal cancer must be redefined.

Surgical strategy for insulinomas in multiple endocrine neoplasia type I.

Year 1998
Lo CY. Lam KY. Fan ST.
Department of Surgery, University of Hong Kong, Queen Mary Hospital, Pokfulam, China.
BACKGROUND: Hyperinsulinemia in multiple endocrine neoplasia type I (MEN-I) is a rare but potentially curable condition that presents difficulties not encountered in sporadic cases. METHODS: The present report documents our surgical approach to 3 MEN-I patients with hyperinsulinemia. RESULTS: Primary hyperparathyroidism was manifested in all 3 patients at the time of presentation. Distal subtotal pancreatectomy with enucleation of tumor at the head of pancreas detected intraoperatively resulted in immediate cure of 2 patients. Persistent disease occurred in 1 patient after enucleation of tumor at the head of the pancreas guided by preoperative imaging elsewhere. The patient was subsequently cured by distal subtotal pancreatectomy. Pathology revealed multiple tumors (4 to 14) in all patients. CONCLUSIONS: A different surgical strategy with an aim of distal subtotal pancreatectomy and enucleation of any tumor identified in the head of pancreas is the treatment of choice for hyperinsulinemia in MEN-I patients.

Prophylactic cholecystectomy is not indicated following renal transplantation.

Year 1998
Melvin WS. Meier DJ. Elkhammas EA. Bumgardner GL. Davies EA. Henry ML. Pelletier R. Ferguson RM.
Department of Surgery, Ohio State University, Columbus 43210, USA.
BACKGROUND: The appropriate management of gallstones in patients undergoing renal transplantation is controversial. Screening for gallstones and subsequent prophylactic cholecystectomy has been recommended by some authors for kidney transplant candidates. Our program does not practice routine pretransplant screening for gallstones, and we reviewed our data to determine the outcome of our management approach. METHODS: We reviewed the records of the 1,364 currently followed patients who have undergone kidney transplant at our institution since 1985 in order to evaluate the morbidity and mortality of biliary disease in the post-transplant period. We attempted to contact all patients by telephone or mail survey for the presence of biliary tract disease or operations. RESULTS: Six hundred and sixty-two patients were fully evaluated. Fifty-two (7.85%) required cholecystectomy for stone disease. Seven patients underwent incidental cholecystectomy during other operations, 2 patients developed acalculus cholecystitis, and 14 patients with asymptomatic cholelithiasis are being followed up. Surgical indications included 38 biliary colic, 9 acute cholcystitis, 3 gallstone pancreatitis, and 2 patients who were asymptomatic. Fifty-two patients underwent 30 laparoscopic cholecystectomies, 20 open cholecystectomies, and 2 conversions. Surgery occurred from 7 days to 9.6 years following transplantation. Overall, the median hospital stay (no postoperative stay) was 4 days (range 1 to 57). Patients undergoing laparoscopy had a median stay of 2 days compared with 7 days for those undergoing an open procedure. Complications were seen in 6 patients (11.5%) with no morbidity and no graft loss. The 1-, 2-, and 5-year graft survival was 98%, 96%, and 85%, respectively, in patients undergoing cholecystectomy. CONCLUSIONS: Transplant patients are not at an increased risk for developing biliary tract disease compared with nontransplant patients. Gallstone disease does not have a negative impact on graft survival. Treatment of gallstones has a low risk and does not represent an increased risk of complications in patients following renal transplantation.

Biliary surgery after heart transplantation.

Year 1998
Menegaux F. Dorent R. Tabbi D. Pavie A. Chigot JP. Gandjbakhch I.
Department of General and Gastrointestinal Surgery, Hopital de la Pitie, Paris, France.
BACKGROUND: Biliary tract diseases are frequent in heart transplant recipients, with significant morbidity and mortality. Since the first presentation of gallstones in this population is often acute cholecystitis, asymptomatic cholelithiasis should not be considered benign. PATIENTS AND METHODS: We retrospectively reviewed 18 heart transplant recipients who underwent cholecystectomy from January 1991 to June 1997. We intentionally chose to perform a straightforward open procedure when acute cholecystitis was suspected (3 patients). A laparoscopic cholecystectomy was performed in all the other cases (15 patients) without conversion to open procedure. CONCLUSION: Since no significant complications were observed in our patients, we believe that transplant recipients with cholelithiasis should undergo laparoscopic cholecystectomy in their posttransplantation course regardless of the symptomatic status of their biliary tract.

Sequential percutaneous microwave coagulation therapy for liver tumor.

Year 1998
Sato M. Watanabe Y. Kashu Y. Nakata T. Hamada Y. Kawachi K.
Department of Surgery II, Ehime University School of Medicine, Japan.
BACKGROUND: Percutaneous microwave coagulation therapy (PMCT) is effective for small liver tumors. To enhance the radicality of PMCT, we developed a sequential coagulation technique. METHODS: After inserting the first guide-needle under sonography, multiple needles were placed through a disk-type introducer that was devised to guide needle puncture at regular intervals, and microwaves were irradiated. Six patients, including 4 with hepatocellular carcinoma and 2 with liver metastasis, underwent this technique for tumors of 15 to 80 mm in diameter. RESULTS: This technique can coagulate an area up to 60 mm in diameter in one session. Insertion of multiple needles, ranging from 2 to 11, was successful without complications. Three patients undergoing curative PMCT developed no tumor recurrence. The other 3 received incomplete PMCT due to the large size and location of the tumor. CONCLUSIONS: This preliminary study indicates the efficacy of this technique to facilitate and secure PMCT in selected patients with liver tumors.

A randomized comparison of acute phase response and endotoxemia in patients with perforated peptic ulcers receiving laparoscopic or open patch repair.

Year 1998
Lau JY. Lo SY. Ng EK. Lee DW. Lam YH. Chung SC.
Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories.
BACKGROUND: In patients with peritonitis from perforated peptic ulcers, we compared acute stress responses, endotoxemia, and bacteremia following laparoscopic or open surgery. PATIENTS AND METHODS: Consecutive patients with peritonitis from perforated peptic ulcers were randomized to receive laparoscopic sutured or open omental repair. Undiluted peritoneal fluid was obtained at surgery for quantitative bacterial and endotoxin (Limulus Amoebocyte Lysate) assay. Serial blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, and at 12, 24, 48, 72, and 120 hours for determinations of quantitative bacterial and endotoxin assays, interleukin-6 (IL-6), C-reactive protein (CRP), and cortisol. RESULTS: Twenty-two patients were randomized: laparoscopy group (n = 12), open repair group (n = 10). Conversions were required in 3 patients assigned to laparoscopy, leaving 9 patients for analysis. The two groups were comparable in their demographic data, median duration of perforation (13.5 hours versus 10 hours), severity of peritoneal contamination as indicated by viable bacterial count (5.9 x 102 versus 1.5 x 10(2) colony forming unit/mL) and endotoxin concentration in peritoneal fluid (27.2 versus 24.6 EU/mL). No significant endotoxemia or bacteremia was detected in these patients. Median interleukin-6 was highest at 0 hour (1520 versus 962 pg/mL) and fell rapidly following surgery. C-reactive protein peaked at 24 hours and plateaued thereafter. Cortisol was highest intraoperatively and fell thereafter. No difference was noted between the two treatment groups with respect to these inflammatory markers (IL-6 P = 0.19, CRP P = 0.14, cortisol P = 0.56, multivariate analysis of variance). CONCLUSION: Endotoxemia and bacteremia are insignificant in most patients with perforated peptic ulcers. In patients with perforated peptic ulcers, laparoscopic patch repair does not reduce acute stress responses when compared with open surgery.

Prospective randomized study comparing laparoscopic and open tension-free inguinal hernia repair with Shouldices operation.

Year 1998
Zieren J. Zieren HU. Jacobi CA. Wenger FA. Muller JM.
Department of Surgery, Charite, Humboldt University of Berlin, Germany.
BACKGROUND: Although tension-free techniques of hernia repair using synthetic meshes revealed encouraging results, the best method of inguinal hernia repair is still unclear. METHODS: In a prospective randomized phase-II-B study, early postoperative results of laparoscopic transabdominal preperitoneal repair (n = 80), open plug and patch repair (n = 80), and Shouldice's operation (n = 80) were compared. Postoperative pain and patient's comfort were defined as main endpoints. RESULTS: The laparoscopic approach had significantly longer operation time and was more expensive (61 +/- 12 minutes; $1,211) than plug and patch repair (36 +/- 14 minutes; $124) and Shouldice's operation (47 +/- 17 minutes; $69). Main postoperative complications were wound hematomas, seromas, and superficial wound infection, without significant difference between the groups. Postoperative pain, analgesia requirements, limitation of daily activities, and return to work did not differ between laparoscopic and open tension-free repair but were significantly lower in both groups compared with Shouldice's operation. So far, no recurrence was observed after a mean follow-up of 25 months. CONCLUSION: Open plug and patch repair is a promising technique of hernia repair in adults, because it offers the same excellent patient comfort as the laparoscopic repair but is less expensive and can be performed under local anesthesia.

Hepatic allograft abscess with hepatic arterial thrombosis.

Year 1998
Rabkin JM. Orloff SL. Corless CL. Benner KG. Flora KD. Rosen HR. Keller FS. Barton RE. Lakin PC. Petersen BD. Saxon RR. Olyaei AJ.
Department of Surgery, Oregon Health Sciences University and Portland Veterans Affairs Medical Center, 97201-3098, USA.
BACKGROUND: Intrahepatic abscess (IA) is an uncommon complication after liver transplantation (OLTx) usually found in the setting of hepatic arterial thrombosis (HAT) often with associated biliary tree necrosis and/or stricture. Conventional treatment of IA in this setting has required retransplantation. METHODS: A retrospective review of 274 patients (287 OLTx) from September 1991 through September 1996 was performed. Median follow-up was 3.6 years. Diagnosis of HAT was confirmed by arteriography and IA was documented by computerized tomography. Percutaneous drainage of the abscess and stenting of biliary strictures, if present, was achieved using conventional interventional radiology techniques. RESULTS: The diagnosis of hepatic artery complication was made in 14 patients (5.1%), 2 of whom required retransplantation. Hepatic artery thrombosis associated with solitary IA was found in 3 patients (1%) who were transplanted in our center and in 1 additional patient followed up at our center but transplanted elsewhere. All 4 patients had complete resolution of IA using this approach. Three of the 4 patients are alive and well, with the fourth patient succumbing to recurrent hepatitis B infection resulting in allograft failure. CONCLUSIONS: Solitary hepatic allograft abscesses associated with HAT respond to percutaneous drainage and antibiotics, obviating the need for retransplantation in this setting.

Transanal local excision of selected low rectal cancers.

Year 1998
Taylor RH. Hay JH. Larsson SN.
Division of Surgery, British Columbia Cancer Agency, Vancouver Cancer Center, Canada.
BACKGROUND: To determine if transanal local excision (TALE) of selected early low rectal cancer is an effective alternative to more radical resection and to determine the need for adjuvant radiotherapy in these patients. METHODS: A retrospective analysis of all 47 cases referred for consideration of radiotherapy after TALE for low rectal cancer. RESULTS: Indications for TALE were elective, 32; concurrent medical problems, 11; and refusal of radical resection, 4. Median follow-up was 52 months. Local recurrence occurred in 7 of 27 T1 cases, 5 of 17 T2, and 2 of 3 T3. Three of 23 irradiated patients developed local recurrence, compared with 11 of 24 unirradiated (P = 0.023). Of 28 cases with favorable histological features, 1 of 13 irradiated patients developed local recurrence, compared with 4 of 16 unirradiated (P = 0.22). Seven patients had salvage resection, and 3 of these are alive with no evidence of disease at 21, 39, and 71 months postsalvage. Recurrence-free survival at 5 years was 81 % in the irradiated patients and 52% in the unirradiated (P = 0.025). CONCLUSIONS: Transanal local excision of selected low rectal cancers, combined with adjuvant radiotherapy, results in a low recurrence rate and is, therefore, an effective alternative to more radical resection.

The association between telomerase, p53, and clinical staging in colorectal cancer.

Year 1998
Brown T. Aldous W. Lance R. Blaser J. Baker T. Williard W.
Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington 98431, USA.
BACKGROUND: A proposed etiology of tumor activation involves p53 mutations while telomerase may serve as a key enzyme for maintenance of tumor cell proliferation. METHODS: Telomerase activity levels were measured in colorectal adenocarcinomas and corresponding normal tissue using a modified telomeric repeat amplification protocol, and p53 mutations were identified using immunohistochemical staining. Results were compared with staging data using regression analysis. RESULTS: Telomerase activity was present in 23 of 23 (100%) of the tumors and only 2 (9%) of normal specimens (P

Comparison of outcomes of open versus laparoscopic Nissen fundoplication performed in a single practice.

Year 1998
Eshraghi N. Farahmand M. Soot SJ. Rand-Luby L. Deveney CW. Sheppard BC.
Department of Surgery, Oregon Health Sciences University and Veteran Administration Medical Center, Portland 97207, USA.
BACKGROUND: We reviewed Nissen fundoplications performed in a single practice from January 1989 to March 1997, encompassing our transition from open to laparoscopic procedures. Because all operations were done by two surgeons in the same two hospitals, the study is well controlled for comparisons. METHODS: Records of 271 consecutive patients were reviewed. RESULTS: From 1989 to 1992 all patients underwent open fundoplication (n = 78). Thereafter, with increasing frequency, laparoscopic fundoplication was performed. The laparoscopic group was slightly younger (48 +/- 14 years) than the open group (54 +/- 13 years), but gender distribution and body mass index (BMI) did not differ. Mean operating time for laparoscopic cases was 163 +/- 58 minutes compared with 148 +/- 59 minutes for open cases (NS). Intraoperative complication rate was 8% for both groups. Length of hospitalization was shorter for patients undergoing laparoscopic surgery (2.4 days versus 7.2 for open procedures, P

Unusual abscess patterns following dropped gallstones during laparoscopic cholecystectomy.

Year 1998
Horton M. Florence MG.
Department of Surgery, Swedish Medical Center, Seattle, Washington, USA.
BACKGROUND: Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis. Numerous clinical trials have deemed it a safe procedure, regardless of the known increased risk of bile duct injury. However, the consequences and incidence of less well-known complications are still being addressed. METHODS: Between 1993 and 1995, 1,130 laparoscopic cholecystectomies were performed at two major metropolitan medical centers. Of these patients, we know of 3 (0.3%) who subsequently developed abscesses as a consequence of dropped stones during the laparoscopic cholecystectomy. One additional patient who underwent prior laparoscopic cholecystectomy at another institution developed late infection as well. RESULTS: All 4 patients developed late purulent abscesses that ultimately required open surgical drainage, and 1 patient developed trocar site "tumor" masses that were secondary to inflammatory tissue around gallstone fragments. All patients were successfully treated by surgical drainage, stone removal, and antibiotics. Trocar site inflammatory masses required excision only. Significant costs were involved in the diagnosis, management, and duration of therapy for these problems. CONCLUSIONS: This experience closely resembles that of other centers and points out the existence of a late postoperative complication following laparoscopic cholecystectomy that was rarely encountered with open cholecystectomy. Strategies for avoiding this problem are discussed. Whether dropped stones are an indication for conversion to open cholecystectomy remains unclear. Thorough irrigation at time of laparoscopic cholecystectomy with or without placement of a drain in the subhepatic space does not prevent this complication.

Incidence of abdominal wall hernia in aortic surgery.

Year 1998
Adye B. Luna G.
No information.
BACKGROUND: True aneurysms of the abdominal aorta and its branches are at least in part due to defects in the structural integrity of the arterial wall. Whether the defect is isolated to the vascular wall is unclear. If the structural weakness involves other tissues, patients with aneurysmal disease should have a higher incidence of collagen and fascial defects, such as abdominal and inguinal hernias. METHOD: We reviewed 100 patients who underwent elective aortic reconstruction for aneurysmal or occlusive disease. All patients were operated on by the same group of vascular surgeons, through a midline incision, with fascia closed using running absorbable suture. Midline incisional and inguinal hernias were identified, and all patients were followed up for at least 1 year. Comparisons between groups were made for established risk factors for ventral hernias. RESULTS: Incisional hernias occurred in 18 of 58 (31%) aneurysm patients, compared with 5 of 42 (12%) occlusive disease patients (P = 0.025). Inguinal hernias occurred in 11 of 58 (19%) aneurysm patients versus 2 of 42 (5%) occlusive disease patients (P = 0.037). Risk factors were equally distributed between the two groups. Neither the size of the aneurysm nor the presence of an iliac artery aneurysm affected the incidence of abdominal wall hernias in the aneurysm patients. CONCLUSION: This study emphasizes the increased incidence of abdominal wall hernias in patients undergoing aortic surgery for aneurysm disease compared with aortoiliac occlusive disease. The size of the aneurysm and the association of an iliac artery aneurysm did not affect the incidence of hernias among these patients. Genetic and biochemical abnormalities are considered as possible explanations.

Recent trends in diagnosis and treatment of Clostridium difficile in a tertiary care facility.

Year 1998
Butterworth SA. Koppert E. Clarke A. Wiggs B. MacFarlane JK.
Department of Surgery, University of British Columbia, Vancouver, Canada.
BACKGROUND: With the prevalence of antibiotic use, the diagnosis and management of Clostridium difficile disease requires assessment. METHODS: In a retrospective review, patients with a positive culture, toxin, or both during 1 year were identified. Recent literature was reviewed. Results of culture and toxin, prior antibiotic use, antibiotic treatment history and cost were analyzed. RESULTS: Of 592 patients tested, 101 were positive; 96 of 101 were available for review. Of those positive tested for both, 45% were positive for toxin and culture. Sixty-two of 96 were treated with antibiotics; metronidazole was used in 90%. Ten of 62 antibiotic treatments were changed (mean 3 days). Ten days of metronidazole is 1/200th the cost of vancomycin. CONCLUSIONS: In 55% of the positive cases in which culture and toxin were obtained, one test was negative. As metronidazole's efficacy and cost compares favorably with vancomycin, metronidazole is the drug of choice. Any changes made to antibiotic regimens occurred prior to the 6 days recommended in the literature.

Hepatic artery chemoembolization for management of patients with advanced metastatic carcinoid tumors.

Year 1998
Drougas JG. Anthony LB. Blair TK. Lopez RR. Wright JK Jr. Chapman WC. Webb L. Mazer M. Meranze S. Pinson CW.
Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee 37232-4753, USA.
BACKGROUND: Patients with advanced metastatic carcinoid tumors who have disease progression despite conventional therapy are left with few therapeutic options. Hepatic artery chemoembolization (HACE) may play a role in palliating these patients' symptoms. METHODS: Fifteen patients with biopsy-proven advanced bilobar hepatic carcinoid metastases who demonstrated progression of symptoms and/or tumor size despite treatment with somatostatin analogues were treated with intra-arterial chemotherapy and HACE to determine efficacy and safety. Five days of intra-arterial 5-fluorouracil (1 g/m2) were followed by HACE with adriamycin (60 mg), cisplatin (100 mg), mitomycin C (30 mg), and polyvinyl alcohol (Ivalon); 200 micron to 710 micron). Patients were continued on octreotide at the same dose (150 to 2000 microg subcutaneous q 8 hours) before, during, and after the procedure. RESULTS: Efficacy of treatment was assessed by comparing pretreatment and 3-month clinical, laboratory, radiographic, and quality of life parameters. Symptoms were improved in 8 of 12 patients who had diarrhea, 7 of 12 who had flushing, 9 of 12 who had abdominal pain, and in 4 of 7 who had malaise. Elevated tumor markers decreased in all patients. Biochemical markers (mean +/- SE) at 3 months decreased by 60% +/- 6% for 5-HIAA, 75% +/- 10% for chromogranin A and 50% +/- 7% for neuron-specific enolase. Tomographic assessment revealed tumor liquefaction in 10 of 13 patients. The Karnofsky performance status improved from a mean of 66 +/- 2 to 84 +/- 2 (P

Surgical management of adenocarcinoma of the cardia.

Year 1998
Graham AJ. Finley RJ. Clifton JC. Evans KG. Fradet G.
Division of Thoracic Surgery, University of British Columbia, Vancouver Hospital & Health Sciences Centre, Canada.
BACKGROUND: The incidence of adenocarcinoma of the cardia is increasing. The surgical management remains controversial. The present study reviews our experience with surgically resected adenocarcinoma of the cardia. METHODS: A retrospective review of 153 cases of surgically resected adenocarcinoma of the cardia was performed. Preoperative radiotherapy was used in 31 patients. The surgical approach, morbidity, mortality, impact of preoperative radiotherapy, and survival were determined. RESULTS: The type of resection performed was a transhiatal esophagogastrectomy in 78%, a transthoracic esophagogastrectomy in 21%, and a transabdominal esophagogastrectomy in 1%. The in-hospital mortality rate was 4%. The frequency of complications was not associated with the use of preoperative radiotherapy or surgical approach. The 1-year (61%), 2-year (38%), 3-year (23%), and 5-year (16%) survival were not affected by the use of preoperative radiotherapy or surgical approach. Survival was significantly associated with stage and the presence of lymph node metastasis. CONCLUSIONS: Adenocarcinoma of the cardia is associated with a poor long-term prognosis. The long-term survival does not appear to be affected by the use of preoperative radiotherapy or by surgical approach.

Relationships between operative approaches and outcomes in esophageal cancer.

Year 1998
Pommier RF. Vetto JT. Ferris BL. Wilmarth TJ.
Division of General Surgery, Oregon Health Sciences University, Portland 97201, USA.
BACKGROUND: Controversy exists whether patients with esophageal carcinoma are best managed with Ivor-Lewis (IL) or transhiatal (TH) esophagectomy. The TH approach is presumed to be superior with respect to operative time, leak rates, morbidity/mortality, and length of stay (LOS), but may represent an inferior cancer operation compared with formal IL. Accordingly, we reviewed the results of our esophageal resections to compare these outcome parameters for each operative approach. METHODS: We performed a retrospective review of all esophagectomies performed at Oregon Health Sciences University and Portland Veterans Affairs Medical Center between 1987 and 1996. Survival was determined by the Kaplan-Meier method, and comparisons between the IL and TH groups were made with Student's t test, Fisher's exact test, and log-rank analysis. RESULTS: Seventy-eight patients were identified. Forty patients had IL and 38 had TH. Fifty-eight patients had adenocarcinoma, 19 had squamous cell, and 1 had an unknown histology. Mean operative time was 389 minutes for IL versus 275 minutes for TH (P = 0.0001). Leak rates were 7.5% for IL and 13% for TH (P = 0.21). There were no significant differences between IL and TH with respect to other types of complications, operative deaths, blood loss, need for transfusion, LOS, stricture rates, or need for dilatation. Overall mean survival was 12 months. Mean survival rates were 8 months for IL and 12 for TH (P = NS), and were also equivalent when compared by histology and stage for stage. CONCLUSIONS: We conclude that IL and TH are comparable operations with equivalent survival rates. The TH approach did not decrease the incidence of complications, transfusions, leaks, strictures, or subsequent dilatations. Although TH requires less operating room time, this does not translate into a decrease in LOS. Either approach appears to be acceptable depending on surgeons' preferences and appropriate patient selection.

Intraductal neoplasms of the pancreas.

Year 1998
Traverso LW. Peralta EA. Ryan JA Jr. Kozarek RA.
Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington 98111, USA.
BACKGROUND: Since 1980 a group of pancreatic tumors have been termed intraductal papillary mucinous tumors (IPMT). Because these tumors occupy an intraductal position they are demonstrated by pancreatography to reside in the main pancreatic duct (MPD) or side branch ducts (SBD). Lesions of IPMT result in abdominal pain or pancreatitis symptoms because mucin production or papillary growth results in ductal obstruction. Only 104 cases had been reported in the literature by 1996 but more are being presented in abstract form. We reviewed our own 33 cases to assist defining operative decision-making criteria. METHODS: All cases of IPMT between 1989 and 1997 were reviewed for clinical presentation, anatomy by endoscopic retrograde cholangiopancreatography and computed tomography, histologic findings, and long-term outcomes. RESULTS: Our cases were older (65 years) and presented with disease centered mainly in the head of the gland. Clinical presentation was epigastric pain (82%), pancreatitis (56%), weight loss (36%), diabetes (27%), and jaundice (9%). Operations were pancreatectomy in 31 (Whipple n = 15, total n = 5, distal n = 10, local n = 1), bypass only (n = 1), and no operation (n = 1). Malignancy was found in 14 of 33 (42%). Factors significantly associated (P