Ann Surg | ГастроПортал

Laparoscopic Nissen fundoplication: two-year comprehensive follow-up of a technique of minimal paraesophageal dissection.

Anvari M. Allen C.
Department of Surgery, St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada.
OBJECTIVE: To provide a comprehensive follow-up of 381 patients after laparoscopic Nissen fundoplication (LNF) using a technique of minimal paraesophageal dissection. METHODS: Patients underwent a 24-hour pH recording, esophageal manometry, and symptom score assessment for six symptoms of gastroesophageal reflux disease preoperatively. To date, 260 patients have undergone repeat studies at 6 months and 108 patients at 2 years. RESULTS: LNF was associated with a significant (p < 0.0001) increase in the lower esophageal sphincter (LES) pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours and symptom score 6 and 24 months after surgery when compared to preoperative values. Twelve patients (3%) have experienced recurrence of reflux symptoms, 8 presenting in the first 6 months and 4 by the second year after surgery, but only 1 has required repeat surgery. The incidence of clinical dysphagia was found to be 1.3% of the patient group. CONCLUSIONS: LNF remains an effective antireflux procedure at 2 years. Most recurrences occur early, and there is no significant deterioration in the high-pressure zone at the LES, the percentage reflux in 24 hours, or symptom control between 6 months and 2 years after surgery, suggesting that the long-term results should be satisfactory.

The denervated stomach as an esophageal substitute is a contractile organ.

Collard JM. Romagnoli R. Otte JB. Kestens PJ.
Department of Surgery, Louvain Medical School, Brussels, Belgium.
OBJECTIVE: To determine whether the denervated stomach as an esophageal substitute is an inert conduit or a contractile organ. SUMMARY BACKGROUND DATA: The motor response of gastric transplants to deglutition suggests that the stomach pulled up to the neck acts as an inert organ. METHODS: The gastric motility of 11 healthy volunteers and 33 patients having either a gastric tube (GT) (n = 10) or their whole stomach (WS) (n = 23) as esophageal replacement was studied with perfused catheters during the fasting state, after a meal, and after intravenous administration of erythromycin lactobionate. A motility index was established for each period of recording by dividing the sum of the areas under the curves of all contractions of >9 mmHg by the time of recording. RESULTS: Over years, the denervated stomach recovers more and more motor activity, even displaying a real phase 3 motor pattern in 6 of the 10 WS patients and 1 of the 7 GT patients with >3 years of follow-up. Erythromycin lactobionate generates a phase 3-like motor pattern regardless of the length of follow-up. Extrinsic denervation of the whole stomach does not significantly modify the fasting motility index established >3 years after surgery (+17% on average, p > 0.05), but it reduces that in the fed period by an average of 62% (p = 0.0016). Tubulization of the denervated whole stomach lowers the fasting motility index by an average of 60% (p = 0.0248) and further impairs that in the fed period by an average of 67% (p = 0.0388). CONCLUSIONS: The denervated stomach as an esophageal substitute is a contractile organ that may even generate complete migrating motor complexes. Motor recovery is better in the fasting than in the fed period, and it is more marked in WS patients than in GT patients.

Treatment of Barrett''s esophagus by endoscopic laser ablation and antireflux surgery.

Salo JA. Salminen JT. Kiviluoto TA. Nemlander AT. Ramo OJ. Farkkila MA. Kivilaakso EO. Mattila SP.
Department of Thoracic and Cardiovascular Surgery, Helsinki University Central Hospital, Finland.
OBJECTIVE: The regeneration of intestinal metaplasia by squamous epithelium in 17 patients with Barrett's esophagus after endoscopic laser ablation in a reflux-free environment after successful antireflux surgery was prospectively examined. METHODS: All patients had antireflux surgery, and healing of reflux was verified at postoperative endoscopy and 24-hour esophageal pH monitoring. Thereafter, in 11 patients, the whole Barrett's epithelium was ablated using endoscopic Nd-YAG laser energy in 1 to 8 sessions (mean, 4). The needed energy was 965 to 11,173 joules (mean 4709), or about 1000 joules per centimeter of Barrett's esophagus. Six patients had no laser ablation but were treated by antireflux surgery and served as a control group. RESULTS: In all laser-treated patients, the regenerated epithelium was histologically of squamous type in the tubular esophagus, but two patients still had intestinal metaplasia in the gastric cardia. In controls, the length of Barrett's esophagus and intestinal metaplasia remained unchanged. The length of follow-up was 26 months after the last laser session and 21 months in the control group. CONCLUSIONS: The regenerated esophageal epithelium arising after laser ablation in reflux-free environment surgery is of squamous type. This treatment may have a role in preventing the development of esophageal adenocarcinoma arising in Barrett's esophagus.

The role of radical gastrectomy with systematic lymphadenectomy for the diagnosis and treatment of primary gastric lymphoma.

Kodera Y. Yamamura Y. Nakamura S. Shimizu Y. Torii A. Hirai T. Yasui K. Morimoto T. Kato T. Kito T.
Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan.
OBJECTIVE: We evaluated the therapeutic efficacy of radical gastrectomy for primary B-cell lymphoma of the stomach and attempted to identify patients who could be adequately treated with surgery alone. SUMMARY BACKGROUND DATA: Several recent gastric lymphoma reports have discussed the therapeutic benefits of various treatment strategies for stage IE and IIE lymphoma. However, few studies have been based on patients accurately staged by systematic lymphadenectomy with subsequent pathologic examination. METHODS: A retrospective study was performed to evaluate the survival and biologic behavior of lesions in 60 patients with gastric lymphoma who were treated by radical gastrectomy alone. Tumors were classified according to the histopathologic concept of mucosa-associated lymphoid tissue (MALT)-derived lymphoma. RESULTS: A low histopathologic grade was associated with a significantly lower incidence of nodal metastasis (p = 0.07) and less extensive infiltration of the gastric wall (p < 0.005) despite larger tumor size. A 5-year survival rate of >95% was attained with surgery alone for MALT lymphoma and for true stage IE lymphoma diagnosed by pathologic examination of up to N2 lymph nodes routinely performed after radical gastrectomy. CONCLUSIONS: Surgery alone is adequate treatment for stage IE or pure MALT lymphoma, provided that the staging is performed after radical gastrectomy.

Prognostic significance of DNA replication errors in young patients with colorectal cancer.

Lukish JR. Muro K. DeNobile J. Katz R. Williams J. Cruess DF. Drucker W. Kirsch I. Hamilton SR.
Department of Surgery, National Naval Medical Center, Bethesda, Maryland, USA.
OBJECTIVE: To determine the DNA replication error (RER) status in young patients with colorectal cancer (CRC), and to compare the clinical and pathologic characteristics of RER-positive and RER-negative cases. SUMMARY BACKGROUND DATA: Recent studies suggest that patients with RER-positive CRC have an improved prognosis. Further data are required to confirm this observation in young CRC patients. METHODS: All patients 40 years of age and younger with CRC admitted to the National Naval Medical Center between 1970 and 1992 were considered for inclusion in the study. After review, 36 patients for whom the original archived pathology specimen could be retrieved served as the study population. The RER status was determined using a previously described polymerase chain reaction-based assay. The clinical and pathologic features and survival data were compared to RER status. RESULTS: RER-positive tumors were found in 17 cases (47%). There was no significant difference in Dukes' stage or histologic grade at the time of diagnosis between patients with RER-positive tumors compared to RER-negative tumors. Patients with RER-positive tumors were found to have an improved prognosis: the 5-year survival probability for patients with RER-positive tumors was 68%, as compared to 32% for patients with RER-negative tumors (p < 0.05). CONCLUSIONS: RER-positive tumors are common in young patients with CRC, and patients with RER-positive tumors have a significantly improved prognosis. Because of their young age, survival data and prognosis play an important role in the overall treatment plan of young patients with CRC. Therefore, knowledge of RER status could affect initial therapy, postoperative chemotherapy, and follow-up.

APC genotype, polyp number, and surgical options in familial adenomatous polyposis.

Wu JS. Paul P. McGannon EA. Church JM.
Department of Colon and Rectal Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA.
OBJECTIVE: This study was performed to examine the relation between phenotypic expression in patients with familial adenomatous polyposis (FAP) and the site of mutations in the APC (adenomatous polyposis coli) gene. The ability of APC mutations to predict surgical outcome was also investigated. SUMMARY BACKGROUND DATA: Germline mutations in the APC gene cause FAP and can now be identified by direct mutational analysis. Such an analysis can identify affected persons for close surveillance and spare unaffected persons. Phenotypic expression varies within and among FAP kindreds, but certain mutations have been associated with severe disease. Patients with severe polyposis are frequently offered total proctocolectomy rather than colectomy and ileorectal anastomosis out of concern for increased rectal cancer risk. Mutation analysis may offer a more rational basis for these decisions. METHODS: The postsurgical courses of 58 patients from 19 FAP kindreds with identified APC gene mutations were reviewed. APC gene mutations were identified by analysis of leukocyte DNA using single-strand conformational analysis and DNA sequencing. FAP severity was defined according to the number of polyps in the colon at the time of resection (< 1000, mild; > 1000, severe). Operations included subtotal colectomy with ileorectal anastomosis (IRA), total proctocolectomy with ileal pouch/anal anastomosis, total proctocolectomy with end ileostomy, and partial colectomy (PC). RESULTS: Eight different APC mutations were identified. Mutations at codons 1309 and 1328 in exon 15G were associated with a uniformly severe polyposis phenotype. For other mutations, the phenotype was more variable. Patients with APC mutations at codons 1309 and 1328 more commonly underwent proctectomy. Among the 43 patients who initially underwent either IRA or PC, the rectum was later removed in 8. Seven of these patients had a mutation at codon 1309 or 1328. With one exception, all patients with mutations outside the 1309 or 1328 site who initially had IRA have retained their rectum. CONCLUSIONS: Our data support an association between severe polyposis phenotype and mutations at APC gene codons 1309 and 1328. For patients with these mutations, the prognosis for retaining the rectum is poor.

Clinical studies of mucin-producing cholangiocellular carcinoma: a study of 22 histopathology-proven cases.

Chen MF. Jan YY. Chen TC.
Department of Surgery and Pathology, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan.
OBJECTIVE: We present the clinical features and outcomes of 22 surgically treated and histopathology-proven cases of mucin-producing cholangiocellular carcinoma (MPCCC). BACKGROUND: Cholangiocellular carcinoma (CCC) is an uncommon malignancy. Unlike hepatocellular carcinoma, it is difficult to set up a high-risk group, and a specific tumor marker has yet to be found. Chronic liver disease is usually not found to be associated with CCC. Information about patients with MPCCC is limited, and the frequency of MPCCC in all patients with CCC has not been reported. METHODS: The clinical features of 22 surgically treated and histopathology-proven cases of MPCCC were reviewed, including morbidity, mortality, and follow-up results. Factors that may influence the outcomes were also analyzed. Clinical features and outcomes of 148 patients with non-mucin-producing cholangiocellular carcinoma (non-MPCCC) were also summarized for comparison. RESULTS: Of 170 cases of CCC, 22 (12.9%) were MPCCC. Imaging studies were important in the differential diagnosis of CCC. Operative findings (e.g., gross appearance of the liver, mucobilia found by common bile duct exploration, choledochoscopic findings, and frozen section) were useful in the diagnosis of MPCCC. Surgical procedures included common bile duct exploration, or hepaticostomy, and intraoperative choledochoscopy in all 22 patients. Hepatic resection was done in 14 of the 22 cases (63.6%). No early surgical mortality was noted. Wound infections (two patients), bile leak (one patient), and intraabdominal abscess (one patient) were the postoperative complications. The 1-, 2-, 3-, 4-, and 5-year survival rates were 86.5%, 68.5%, 59.0%, 38.5%, and 31.0%, respectively. A significant difference in survival pattern was found between the MPCCC and non-MPCCC patient groups. Patients with hepatic resection had a significantly better prognosis than those without resection. Although patients with hepatolithiasis had a better survival pattern than those without hepatolithiasis, the difference was not statistically significant. CONCLUSIONS: We present the clinical features and outcomes of 22 surgically treated and histopathology-proven cases of MPCCC. Patients with hepatic resection were found to have better survival rates.

Liver resection for hilar and peripheral cholangiocarcinomas: a study of 62 cases.

Madariaga JR. Iwatsuki S. Todo S. Lee RG. Irish W. Starzl TE.
Department of Surgery, University of Pittsburgh, School of Medicine, Pennsylvania, USA.
OBJECTIVE: To analyze a single center's 14-year experience with 62 consecutive patients with hilar (HCCA) and peripheral (PCCA) cholangiocarcinomas. SUMMARY BACKGROUND DATA: Long-term survival after surgical treatment of HCCA and PCCA has been poor. METHODS: From March 1981 until December 1994, 62 consecutive patients with HCCA (n = 28) and PCCA (n = 34) underwent surgical treatment. The operations were individualized and included local excision of the tumor and suprapancreatic bile duct, lymph node dissection, vascular reconstruction, and subtotal hepatectomy. Clinical and pathologic risk factors were examined for prognostic influence. RESULTS: Patients were followed for a median of 25 months (12-102 months). Postoperative morbidity and mortality (at 30 days) were 32% and 14%, respectively, for HCCA and 24% and 6% for PCCA. The survival rates for HCCA and PCCA were 79% (+/-8%) and 67% (+/-8%) at 1 year; 39% (+/-10%) and 40% (+/-9%) at 3 years; and 8% (+/-7%) and 35% (+/-10%) at 5 years, respectively. The median survival was 24 (+/-4) months for HCCA and 19 (+/-8) months for PCCA. The disease-free survival rates for HCCA and PCCA were 85% (+/-10%) and 77% (+/-9%) at 1 year; 18% (+/-11%) and 41% (+/-12%) at 3 years; and 18% (+/-11%) and 41% (+/-12%) at 5 years, respectively. Nearly 80% of these patients had TNM stage IV tumors. With HCCA, no risk factors were associated with patient survival. For PCCA, multiple tumors (relative risk [RR] = 3.5; 95% confidence interval [CI] = 1.2-10.5) and incomplete resection (RR = 8.3; 95% CI = 2.3-29.6) were independently associated with a worse prognosis. For HCCA, there was a trend for lower disease-free survival in females (p = 0.056; log rank test). For PCCA, tumor size >5 cm was the only factor associated with disease recurrence (p = 0.024; log rank test). CONCLUSIONS: Even though rare, 5-year survival by resection can be achieved in both HCCA and PCCA, but new adjuvant treatments are clearly needed.

Prognostic factors after repeat hepatectomy for recurrent hepatocellular carcinoma.

Shimada M. Takenaka K. Taguchi K. Fujiwara Y. Gion T. Kajiyama K. Maeda T. Shirabe K. Yanaga K. Sugimachi K.
Department of Surgery II, Faculty of Medicine, Kyushu University, Maidashi, Fukuoka, Japan.
OBJECTIVE: The aims of this study were to identify prognostic factors in patients who developed recurrent hepatocellular carcinoma (HCC) after repeat hepatectomy and to elucidate the role of multicentric occurrence in the second tumor after a first hepatectomy. SUMMARY BACKGROUND DATA: A repeat hepatectomy for recurrent HCC has been established as the most effective treatment modality, whenever it is possible. However, the prognostic factors for recurrent HCC after repeat hepatectomy have yet to be clarified. METHODS: Forty-one patients who underwent a curative repeat hepatectomy were retrospectively studied. Patient survival and disease-free survival after recurrence were univariately and multivariately analyzed using 38 clinicopathologic variables. The histologic grade of HCC at repeat hepatectomy was also compared with that at first hepatectomy. RESULTS: Patient survival after repeat hepatectomy did not differ substantially from that in 312 patients undergoing primary hepatectomy. However, the disease-free survival after repeat hepatectomy was significantly lower than that in patients with only a primary hepatectomy (p < 0.05). Multivariate analysis revealed only portal vein invasion in the first hepatectomy to be an independent and significantly poor prognostic factor. Regarding multicentric occurrence at repeat hepatectomy, only 6 of 40 patients (15%) whose specimens could be evaluated histologically were determined to be Edmondson and Steiner's Grade 1. CONCLUSIONS: The only prognostic factor identified in patients with recurrent HCC after repeat hepatectomy was portal vein invasion in the first hepatectomy. Most second tumors after the first hepatectomy are considered to be caused by metastatic recurrence, not by multicentric occurrence.

Enhanced expression of TGF-betas and their receptors in human acute pancreatitis.

Friess H. Lu Z. Riesle E. Uhl W. Brundler AM. Horvath L. Gold LI. Korc M. Buchler MW.
Department of Visceral and Transplantation Surgery, University of Bern, Switzerland.
OBJECTIVES: To determine which mechanisms are involved in pancreatic remodeling, repair, and fibrosis after acute necrotizing pancreatitis (NP) in humans. SUMMARY BACKGROUND DATA: Transforming growth factor betas (TGF-betas) are multifunctional polypeptides that have been implicated in the regulation and formation of extracellular matrix and fibrosis. They exert their functions by binding to specific receptors. In this study, we analyze the expression of TGF-beta1, TGF-beta2, and TGF-beta3 and their receptors type I (Tbeta-RI [ALK5]), type II (Tbeta-RII), and type III (Tbeta-RIII) in NP. PATIENTS: Pancreatic tissue samples were obtained from 6 female and 8 male patients with a median age of 65 years (range, 37 to 77 years) undergoing surgery for NP. The median Ranson score of the patients was 6 (range, 2 to 9). The operation was performed a median 5.5 days (range, 4 to 17 days) after the onset of acute pancreatitis. Pancreatic tissue obtained from 12 previously healthy organ donors (6 male, 6 female; median age of 43 years) served as controls. METHODS: The expression of TGF-beta1, TGF-beta2, TGF-beta3, Tbeta-RI (ALK5), Tbeta-RII, Tbeta-RIII, and collagen type I mRNA was analyzed by Northern blot analysis. In addition, immunohistochemical analysis using polyclonal antibodies was performed to detect TGF-beta1, TGF-beta2, TGF-beta3, Tbeta-RI (ALK5), and Tbeta-RII. RESULTS: Northern blot analysis showed an increase in TGF-betas and their receptors in NP tissue samples compared with samples from normal controls. The increase was 3.5-fold for TGF-beta1 (p < 0.05), 2.7-fold for TGF-beta2 (p < 0.05), 3.5-fold for TGF-beta3 (p < 0.05), 10-fold for Tbeta-RI (ALK5) (p < 0.05), 5.7-fold for Tbeta-RII (p < 0.05), and 1.4-fold for Tbeta-RIII (not significant). Collagen type I mRNA was also markedly increased in NP samples and correlated with the level of TGF-betas. Immunohistochemical analysis demonstrated intense TGF-beta1, TGF-beta2, TGF-beta3, Tbeta-RI (ALK5), and Tbeta-RII immunoreactivity in the remaining acinar and ductal cells in most NP samples; in the normal control pancreas, there was weak to moderate immunoreactivity for these factors only in some acinar cells and a few ductal cells. CONCLUSION: The marked increase in expression of TGF-betas and their signaling receptors Tbeta-RI (ALK5) and Tbeta-RII suggests a role for TGF-betas in the repair process after the onset of NP in humans and raises the possibility that TGF-betas might be involved in tissue remodeling and the fibrotic reaction that occurs in the pancreas after necrosis.

Incidence of infectious complications associated with the use of histamine2-receptor antagonists in critically ill trauma patients.

O'Keefe GE. Gentilello LM. Maier RV.
Department of Surgery, University of Washington, Harborview Medical Center, Seattle, USA.
OBJECTIVE: To determine the impact of histamine2 (H2)-receptor antagonist use on the occurrence of infectious complications in severely injured patients. SUMMARY BACKGROUND DATA: Some previous studies suggest an increased risk of nosocomial pneumonia associated with the use of H2-receptor blockade in critically ill patients, but other investigations suggest an immune-enhancing effect of H2-receptor antagonists. The purpose of this study was to determine whether H2-receptor antagonist use affects the overall incidence of infectious complications. METHODS: Patients enrolled in a randomized trial comparing ranitidine with sucralfate for gastritis prophylaxis were examined for all infectious complications during their hospitalization. Data on the occurrence of pneumonia were prospectively collected, and other infectious complications were retrospectively obtained from the medical record. The relative risk of infectious complications associated with ranitidine use and total infectious complications were analyzed. RESULTS: Of 98 patients included, the charts of 96 were available for review. Sucralfate was given to 47, and 49 received ranitidine. Demographic factors were similar between the groups. Ranitidine use was associated with a 1.5-fold increased risk of developing any infectious complication (37 of 47 vs. 26 of 47; 95% confidence interval, 1.04 to 2.28). Infectious complications totaled 128 in the ranitidine-treated group and 50 in the sucralfate-treated group (p = 0.0014). These differences remained after excluding catheter-related infections (p = 0.0042) and secondary bacteremia (p = 0.0046). CONCLUSIONS: Ranitidine use in severely injured patients is associated with a statistically significant increase in overall infectious complications when compared with sucralfate. These results indicate that ranitidine should be avoided where possible in the prophylaxis of stress gastritis.

Laparoscopic Nissen fundoplication: two-year comprehensive follow-up of a technique of minimal paraesophageal dissection.

The denervated stomach as an esophageal substitute is a contractile organ.

Treatment of Barretts esophagus by endoscopic laser ablation and antireflux surgery.

The role of radical gastrectomy with systematic lymphadenectomy for the diagnosis and treatment of primary gastric lymphoma.

Prognostic significance of DNA replication errors in young patients with colorectal cancer.

APC genotype, polyp number, and surgical options in familial adenomatous polyposis.

Clinical studies of mucin-producing cholangiocellular carcinoma: a study of 22 histopathology-proven cases.

Liver resection for hilar and peripheral cholangiocarcinomas: a study of 62 cases.

Prognostic factors after repeat hepatectomy for recurrent hepatocellular carcinoma.

Enhanced expression of TGF-betas and their receptors in human acute pancreatitis.

Incidence of infectious complications associated with the use of histamine2-receptor antagonists in critically ill trauma patients.

Surgeon-related factors and outcome in rectal cancer.

Porter GA. Soskolne CL. Yakimets WW. Newman SC.
Department of Surgery, University of Alberta, Edmonton, Canada.
OBJECTIVE: To determine whether surgical subspecialty training in colorectal surgery or frequency of rectal cancer resection by the surgeon are independent prognostic factors for local recurrence (LR) and survival. SUMMARY BACKGROUND DATA: Variation in patient outcome in rectal cancer has been shown among centers and among individual surgeons. However, the prognostic importance of surgeon-related factors is largely unknown. METHODS: All patients undergoing potentially curative low anterior resection or abdominoperineal resection for primary adenocarcinoma of the rectum between 1983 and 1990 at the five Edmonton general hospitals were reviewed in a historic-prospective study design. Preoperative, intraoperative, pathologic, adjuvant therapy, and outcome variables were obtained. Outcomes of interest included LR and disease-specific survival (DSS). To determine survival rates and to control both confounding and interaction, multivariate analysis was performed using Cox proportional hazards regression. RESULTS: The study included 683 patients involving 52 surgeons, with > 5-year follow-up obtained on 663 (97%) patients. There were five colorectal-trained surgeons who performed 109 (16%) of the operations. Independent of surgeon training, 323 operations (47%) were done by surgeons performing < 21 rectal cancer resections over the study period. Multivariate analysis showed that the risk of LR was increased in patients of both noncolorectal trained surgeons (hazard ratio (HR) = 2.5, p = 0.001) and those of surgeons performing < 21 resections (HR = 1.8, p < 0.001). Stage (p < 0.001), use of adjuvant therapy (p = 0.002), rectal perforation or tumor spill (p < 0.001), and vascular/neural invasion (p = 0.002) also were significant prognostic factors for LR. Similarly, decreased disease-specific survival was found to be independently associated with noncolorectal-trained surgeons (HR = 1.5, p = 0.03) and surgeons performing < 21 resections (HR = 1.4, p = 0.005). Stage (p < 0.001), grade (p = 0.02), age (p = 0.02), rectal perforation or tumor spill (p < 0.001), and vascular or neural invasion (p < 0.001) were other significant prognostic factors for DSS. CONCLUSION: Outcome is improved with both colorectal surgical subspecialty training and a higher frequency of rectal cancer surgery. Therefore, the surgical treatment of rectal cancer patients should rely exclusively on surgeons with such training or surgeons with more experience.

Diverticulectomy, myotomy, and fundoplication through laparoscopy: a new option to treat epiphrenic esophageal diverticula?

Rosati R. Fumagalli U. Bona S. Bonavina L. Peracchia A.
Istituto Clinico Humanitas-Milano, Division of General and Minimally Invasive Surgery, Milan, Italy.
OBJECTIVE: To describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap for epiphrenic diverticula of the esophagus. SUMMARY BACKGROUND DATA: The epiphrenic diverticulum of the esophagus is a rare disease probably caused by a longstanding impairment of the esophageal motor activity. Although there is almost universal agreement to operate only on symptomatic patients, the optimal treatment is controversial. The best-accepted guideline is to treat the underlying motor disorder. This is generally done through a left thoracotomic approach that allows diverticulectomy, esophageal myotomy, and partial fundoplication. METHODS: From January 1994 through February 1996, 4 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. A thorough preoperative study was done with barium swallow, esophagoscopy, and manometry in all patients; 24-hour pH monitoring was done in one case. RESULTS: No postoperative complications were observed. Short- and medium-term results are satisfactory. CONCLUSIONS: No theoretical objection should be made to this approach, because the principle of treatment of the diverticular pouch and the underlying motor disorder and the prevention of reflux is respected. Longer follow-up and a wider series are mandatory to substantiate these initially favorable results.

Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research.

Merad F. Hay JM. Fingerhut A. Flamant Y. Molkhou JM. Laborde Y.
Surgical Unit, Hopital Louis Mourier, Colombes, France.
OBJECTIVE: To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection. SUMMARY BACKGROUND DATA: It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this. METHODS: Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths. RESULTS: Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups. CONCLUSION: OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Is age relevant to functional outcome after restorative proctocolectomy for ulcerative colitis?: prospective assessment of 122 cases.

Takao Y. Gilliland R. Nogueras JJ. Weiss EG. Wexner SD.
Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA.
OBJECTIVE: Restorative proctocolectomy for mucosal ulcerative colitis is well established. However, the effect of age on physiologic sphincter parameters is poorly understood. Our objective was to determine whether age at the time of restorative proctocolectomy correlates with physiologic changes. SUMMARY BACKGROUND DATA: In the approximately 20 years during which restorative proctocolectomy has been performed for ulcerative colitis, the indications have changed. Initially, the procedure was recommended only in patients under approximately 50 years. However, the procedure has been considered in older patients because of the increasing age of our population, the increasing frequency of recognition of patients during the "second peak" of mucosal ulcerative colitis, and the decreasing morbidity rates, due to the learning curve and to newer techniques, such as double-stapling. Few authors have presented data analyzing the effects of this operation in older patients. METHODS: One hundred twenty-two patients who had undergone a two-stage restorative proctocolectomy for mucosal ulcerative colitis were divided into three groups according to age: group I (>60 years), 11 men, 6 women; group II (40-60 years), 29 men, 18 women; and group III (

Symptomatic cholelithiasis: a different disease in men? Connecticut Laparoscopic Cholesystectomy Registry.

Russell JC. Walsh SJ. Reed-Fourquet L. Mattie A. Lynch J.
Connecticut Society of American Board Surgeons, Wallingford, USA.
OBJECTIVE: To determine the importance of gender in the clinical presentation and subsequent clinical outcome (risk of conversion from laparoscopic to open technique and risk of postoperative mortality) for patients undergoing cholecystectomy. SUMMARY BACKGROUND DATA: Age and clinical presentation have consistently been found to be important predictors of cholecystectomy outcomes; male gender has been cited in disparate studies as possibly having prognostic significance. METHOD: A statewide cholecystectomy registry (30,145 cases between 1989-1993) was analyzed. Hierarchical log-linear modeling was used to identify associations between characteristics of clinical presentation. Multivariate logistic regression analysis was used to determine predictions of conversion and mortality. RESULTS: Male gender was associated with twice the expected incidence of acute cholecystitis and pancreatitis in the elderly (> or = 65 years). Males had a significantly increased risk for conversion to open technique, but this decreased during the time frame of the study. Mortality was twice as high among males (confidence interval, 1.4-2.9, p = 0.0001). CONCLUSIONS: Males presenting for cholecystectomy are more likely to have severe disease. Independent of clinical presentation, they face increased risks of conversion to open technique and of postoperative mortality.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts.

Cotton PB. Geenen JE. Sherman S. Cunningham JT. Howell DA. Carr-Locke DL. Nickl NJ. Hawes RH. Lehman GA. Ferrari A. Slivka A. Lichtenstein DR. Baillie J. Jowell PS. Lail LM. Evangelou H. Bosco JJ. Hanson BL. Hoffman BJ. Rahaman SM. Male R.
Medical University of South Carolina, Charleston, USA.
OBJECTIVE: To provide current information on the risks of endoscopic sphincterotomy for stone. SUMMARY BACKGROUND DATA: In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients. METHODS: Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria. RESULTS: Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (

Increased intestinal permeability and altered mucosal immunity in cholestatic jaundice.

Welsh FK. Ramsden CW. MacLennan K. Sheridan MB. Barclay GR. Guillou PJ. Reynolds JV.
Department of Pathology, St. James's University Hospital, Leeds, England.
OBJECTIVE: To examine the effects of cholestatic jaundice on gut barrier function. SUMMARY BACKGROUND DATA: Gut barrier failure occurs in animal models of jaundice. In humans, the presence of endotoxemia indirectly implicates failure of this host defense, but this has not previously been investigated in jaundiced patients. METHODS: Twenty-seven patients with extrahepatic obstructive jaundice and 27 nonicteric subjects were studied. Intestinal permeability was measured using the lactulose-mannitol test. Small intestinal morphology and the presence of mucosal immunologic activation were examined in endoscopic biopsies of the second part of the duodenum. Systemic antiendotoxin core IgG antibodies and serum interleukin-6 and C-reactive protein were also quantified. Intestinal permeability was remeasured in 9 patients 5 weeks after internal biliary drainage. RESULTS: The median lactulose-mannitol ratio was significantly increased in the jaundiced patients. This was accompanied by upregulation of HLA-DR expression on enterocytes and gut-associated lymphoid tissue, suggesting immune activation. A significant increase in the acute phase response and circulating antiendotoxin core antibodies was also observed in the jaundiced patients. After internal biliary drainage, intestinal permeability returned toward normal levels. CONCLUSIONS: A reversible impairment in gut barrier function occurs in patients with cholestatic jaundice. Increased intestinal permeability is associated with local immune cell and enterocyte activation. In view of the role of gut defenses in the modern paradigm of sepsis, these data may directly identify an important underlying mechanism contributing to the high risk of sepsis in jaundiced patients.

Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure.

Izbicki JR. Bloechle C. Broering DC. Kuechler T. Broelsch CE.
Department of Surgery, University Hospital Eppendorf, University of Hamburg, Germany.
OBJECTIVE: The technique of longitudinal V-shaped excision of the ventral pancreas for small duct chronic pancreatitis is presented and its efficacy in terms of pain relief and improvement of quality of life is evaluated. SUMMARY BACKGROUND DATA: Small duct chronic pancreatitis has been regarded as a classical indication for more or less extensive resection, in which the therapeutic success of pain relief is offset by the considerable risk of significant perioperative mortality and morbidity and the burden of substantial loss of pancreatic function. METHODS: Thirteen patients with severe pain who were diagnosed with small duct pancreatitis (defined as maximal Wirsungian ductal diameter of 2 mm) underwent longitudinal V-shaped excision of the ventral pancreas. In addition to routine pancreatic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of exocrine and endocrine function included fecal chymotrypsin and the pancreolauryl test as well as oral glucose tolerance, serum concentrations of insulin, C-peptide, and hemoglobin A1c. The interval between symptoms and surgery ranged from 12 months to 10 years (mean, 5.4 years). Median follow-up was 30 months (range, 12-48 months). RESULTS: There were no deaths. Overall morbidity was 15.4%. In 92% of patients, complete relief of symptoms was obtained. Median pain score decreased by 95%. Physical status, working ability, and emotional and social functioning scores improved by 40%, 50%, 67%,, and 75%, respectively. Global quality-of-life index increased by 67%. Occupational rehabilitation was achieved in 69% of patients. Exocrine and endocrine pancreatic function was well preserved. CONCLUSIONS: In small duct chronic pancreatitis, longitudinal V-shaped excision of the ventral pancreas is a safe and effective alternative to resection procedures. The new technique provides pain relief and improvement of quality of life, thus offering the benefit of a resection procedure without its burden.

Phospholipase A2 isoforms are altered in chronic pancreatitis.

Kashiwagi M. Friess H. Uhl W. Graber H. Duarte R. Zimmermann A. Buchler MW.
Department of Visceral and Transplantation Surgery, University of Bern, Switzerland.
OBJECTIVE: To determine if phospholipase A2 (PLA2) type II and type IV mRNA expression and protein are altered in chronic pancreatitis. SUMMARY BACKGROUND DATA: PLA2s have an important regulatory function in several signaling pathways, especially in inflammation. In this study, we examined the expression of three PLA2 isoforms (type I, type II, and type IV) in chronic pancreatitis. METHODS: The distribution of PLA2 was studied in 15 pancreas samples obtained from patients with chronic pancreatitis using immunohistochemical, Northern blot, and in situ hybridization techniques. Normal pancreas obtained from healthy organ donors served as control. RESULTS: Northern blot analysis revealed enhanced mRNA levels of PLA2 type II (5.7-fold) and type IV (5.1-fold) in chronic pancreatitis (p < 0.01) versus normal pancreas. In normal pancreas, intense PLA2 type I immunostaining was present in acinar cells, whereas PLA2 type II immunostaining was visible only in some acinar cells. In chronic pancreatitis, PLA2 type II immunostaining was present more frequently and with higher intensity in acinar cells. Furthermore, PLA2 type II immunoreactivity was more abundant in metaplastic ductal cells in the chronic pancreatitis samples. By in situ hybridization, areas with ductal metaplasia in chronic pancreatitis exhibited intense PLA2 type IV mRNA signals. All chronic pancreatitis tissues with concomitantly increased mRNA expression for PLA2 type II and type IV exhibited a higher degree of degeneration, ductal metaplasia, and fibrosis. CONCLUSIONS: Upregulation of PLA2 types II and IV in areas with more histologic damage suggests that these PLA2 isoforms might contribute to the morphologic changes that occur in chronic pancreatitis.

Surgical decision-making affected by clinical and genetic screening of a novel kindred with von Hippel-Lindau disease and pancreatic islet cell tumors.

Curley SA. Lott ST. Luca JW. Frazier ML. Killary AM.
Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
OBJECTIVE: We report a unique, previously undescribed multigeneration kindred with von Hippel-Lindau (VHL) disease in whom clinical or genetic screening led to the detection of surgically resectable neoplastic disease in several family members. SUMMARY BACKGROUND DATA: Patients with VHL disease have a propensity to develop neoplasms of several different organ sites. Retinal angiomas, cerebellar and spinal hemangioblastomas, solid organ cysts, and renal carcinoma are common lesions; pheochromocytomas and pancreatic islet cell tumors occur less frequently but are important causes of morbidity and mortality. METHODS: A detailed pedigree was constructed based on clinical screening and family history that describes the development of pancreatic islet cell tumors in four of five female siblings. VHL mutation analysis was performed in an attempt to determine if genotype-phenotype correlations could be made in this interesting family. RESULTS: The age of onset of VHL-associated neoplasms for three affected siblings was in the third decade of life and in the fourth decade for the fourth sibling. The mother of the four siblings affected with pancreatic tumors developed bilateral pheochromocytomas in the seventh decade of life; she has no pancreatic or kidney tumors. We identified maternal transmission of a missense mutation in codon 238 in exon 3 of the VHL gene in the four affected siblings with pancreatic islet cell tumors. Mutation screening on unaffected family members showed no abnormalities in the VHL gene. Interestingly, one of the four affected siblings had no evidence of VHL on her initial clinical screening evaluation; however, she was followed closely because of her mutated VHL gene. Four years after initial screening, she developed two pancreatic islet cell tumors and a premalignant renal cyst. CONCLUSIONS: Clinical and genetic screening for VHL in this family had a significant impact on surgical management by detecting early-stage islet cell tumors or pheochromocytomas. Furthermore, we conclude that the preponderance of pancreatic islet cell tumors in this family cannot be explained by a strict genotype-phenotype correlation. This suggests that additional genetic abnormalities, possibly on chromosome 3p where the VHL gene is located, may be responsible for the variety of VHL-associated neoplasms.

Hemorrhage after pancreatoduodenectomy.

Rumstadt B. Schwab M. Korth P. Samman M. Trede M.
Department of Surgery Klinikum Mannheim, University of Heidelberg, Germany.
OBJECTIVE: The authors reviewed the hemorrhagic complications of patients who underwent pancreatoduodenectomies between 1972 and 1996. SUMMARY BACKGROUND DATA: Although recent studies have demonstrated a reduction in the mortality of pancreatic resection, morbidity is still high. Bleeding is a close second to anastomotic dehiscence in the list of dangerous postoperative complications. METHODS: The medical records from a prospective data bank of 559 patients who underwent pancreatic resection at the Surgical Clinic of Mannheim (Heidelberg University) were analyzed in regard to postoperative hemorrhagic complications. Differences were evaluated with the Fisher exact test. RESULTS: The overall mortality rate was 2.7%. Postoperative bleeding occurred in 42 patients (7.5%), with 6 episodes ending fatally (14.3%). Erosive bleeding after pancreatic leak was noted in 11 patients (26.2%), 4 of whom died. Gastrointestinal hemorrhage occurred in 22 patients, and operative field hemorrhage was present in 20 cases. Relaparotomy was necessary in 29 patients. An angiography with interventional embolization for recurrent bleeding was performed in three patients. Seven hemorrhages (4.6%) occurred after pancreatectomy for chronic pancreatitis and 35 episodes of bleeding (8.6%) were encountered after pancreatectomy for malignant disease. Obstructive jaundice was present in 359 patients (63.9%). In this group of patients, 32 (8.9%) postoperative hemorrhages occurred. Preoperative biliary drainage did not influence the type and mortality rate of postoperative hemorrhage in jaundiced patients. CONCLUSION: The prevention of these bleeding complications depends in the first place on meticulous hemostatic technique. Preoperative biliary drainage does not lower postoperative bleeding complications in jaundiced patients. Continuous, close observation of the patient in the postoperative period, so as to detect complications in time, and expeditious hemostasis are paramount.

Albumin synthesis rates are not decreased in hypoalbuminemic cachectic cancer patients with an ongoing acute-phase protein response.

Fearon KC. Falconer JS. Slater C. McMillan DC. Ross JA. Preston T.
University Department of Surgery, Royal Infirmary, Edinburgh, United Kingdom.
OBJECTIVE: To determine whether suppression of albumin synthesis contributes to the hypoalbuminemia observed in weight-losing cancer patients with evidence of an ongoing acute-phase protein response (APPR). BACKGROUND DATA: Proinflammatory cytokines such as tumor necrosis factor (TNF) and interleukin 6 (IL-6) are known to downregulate albumin synthesis and increase acute-phase protein production in isolated hepatocytes. However, whether albumin synthesis is suppressed in hypoalbuminemic cancer patients with evidence of an ongoing acute-phase response is unknown. METHODS: Albumin synthesis rates were determined in six healthy controls and in six weight-losing pancreatic cancer patients with an ongoing APPR using a flooding dose technique with [2H5]-phenylalanine. The presence of an APPR was defined as a serum C-reactive protein concentration >10 mg/L. Serum cytokines (TNF, IL-6) and soluble TNF receptors (sTNF-R 55 and 75), along with serum cortisol and insulin, were also measured in both groups. RESULTS: Cancer patients had reduced serum albumin (median 32 [range, 23-36] vs. 42 g/L [40-45]; p < 0.01) and increased serum C-reactive protein concentrations (72 [23-126] vs.

Living related liver transplantation in adults.

Kawasaki S. Makuuchi M. Matsunami H. Hashikura Y. Ikegami T. Nakazawa Y. Chisuwa H. Terada M. Miyagawa S.
First Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
OBJECTIVE: To evaluate the outcome of living related liver transplantation (LRLT) in adult patients and to assess graft size disparity and graft regeneration. SUMMARY BACKGROUND DATA: Although LRLT has been accepted as an optional life-saving procedure for pediatric patients with end-stage liver disease, the feasibility of LRLT for adult patients has not been reported with reference to a clinical series. METHODS: Adult-to-adult LRLT was performed using whole left lobar grafts in 13 patients (5 with primary biliary cirrhosis, 6 with familial amyloid polyneuropathy, 1 with biliary atresia, and 1 with citrullinemia). The 13 donors comprised 5 husbands, 3 sons, 2 sisters, 2 fathers, and 1 mother. The ratio of the graft volume to standard liver volume (GV/SV ratio) was calculated for use as a parameter of graft size disparity. RESULTS: Although the liver graft was markedly small for size (GV/SV ratio 32%-59% at the time of LRLT), none of the 13 patients developed postoperative liver failure. Eleven of the patients are still alive and well with satisfactory graft function 2 to 35 months after LRLT. Graft liver volume increased rapidly after LRLT and approximated the standard liver volume with time. CONCLUSIONS: Our LRLT program for adult patients has produced good results. LRLT in adults can be indicated for selected donor-recipient combinations.

Portal vein reconstruction in pediatric liver transplantation from living donors.

Saad S. Tanaka K. Inomata Y. Uemoto S. Ozaki N. Okajima H. Egawa H. Yamaoka Y.
Second Department of Surgery, Kyoto University Faculty of Medicine, Japan.
OBJECTIVE: The authors analyze the surgical pattern and the underlying rationale for the use of different types of portal vein reconstruction in 110 pediatric patients who underwent partial liver transplantation from living parental donors. SUMMARY BACKGROUND DATA: In partial liver transplantation, standard end-to-end portal vein anastomosis is often difficult because of either size mismatch between the graft and the recipient portal vein or impaired vein quality of the recipient. Alternative surgical anastomosis techniques are necessary. METHODS: In 110 patients age 3 months to 17 years, four different types of portal vein reconstruction were performed. The portal vein of the liver graft was anastomosed end to end (type I); to the branch patch of the left and right portal vein of the recipient (type II); to the confluence of the recipient superior mesenteric vein and the splenic vein (type III); and to a vein graft interposed between the confluence and the liver graft (type IV). Reconstruction patterns were evaluated by their frequency of use among different age groups of recipients, postoperative portal vein blood flow, and postoperative complication rate. RESULTS: The portal vein of the liver graft was anastomosed by reconstruction type I in 32%, II in 24%, III in 14%, and IV 29% of the cases. In children

Split liver transplantation: Kings College Hospital experience.

Rela M. Vougas V. Muiesan P. Vilca-Melendez H. Smyrniotis V. Gibbs P. Karani J. Williams R. Heaton N.
Liver Transplantation Surgical Service, Department of Radiology, King's College Hospital, London, UK.
BACKGROUND: The purpose of split liver transplantation is to increase the source of pediatric grafts without compromising the adult donor pool. Early results have been discouraging because of technical complications and selection of poor risk patients. METHODS: The results of a single center experience of 41 split liver transplantations were analyzed. Patient and graft survival and complications related to the technique were analyzed. RESULTS: Patient and graft survival for the whole group was 90% and 88% respectively at a median follow up of 12 months (range 6-70 months). Patient and graft survival for the right lobe graft was 95% and the left lateral segment 86% and 82% respectively. Four patients died, of which two of the patients were first two splits following technical complications. Two others died, one from cerebral lymphoma and the other of multiorgan failure secondary to sepsis. One patient has been retransplanted for chronic biliary sepsis. CONCLUSION: Split liver transplantation has now become an acceptable treatment option for both adult and pediatric recipients with end stage liver disease. Right lobe recipients are not disadvantaged by the procedure. Good results can be achieved with better patient selection and by the use of good quality organs.

The impact of Clostridium difficile on a surgical service: a prospective study of 374 patients.

Kent KC. Rubin MS. Wroblewski L. Hanff PA. Silen W.
Department of Surgery, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts, USA.
OBJECTIVE: To evaluate the epidemiology of Clostridium difficile colitis (CDC) in a subset of patients admitted specifically to a surgical service. SUMMARY BACKGROUND DATA: CDC is an increasingly prevalent nosocomial infection that can prolong hospitalization and adversely affect patient outcome. Although this disease has been investigated extensively in patients admitted to medical services, the incidence and risk factors for the development of this disease in patients admitted to a surgical service have not been studied. METHODS: Over a 5-month period, 374 patients admitted to the general, vascular, thoracic, and urologic surgery services were monitored for the development of symptomatic CDC (defined as >3 bowel movements per 24 hours and a positive cytotoxin assay or culture). RESULTS: Twenty-one patients developed CDC (incidence, 5.6%). Factors that independently predisposed to infection included admission from a skilled care facility, use of the antibiotic cefoxitin, and an operative procedure for bowel obstruction. Other factors associated with CDC included colectomy, treatment with any antibiotic, nasogastric tube suction, advanced age, and prior antibiotic treatment. Abdominal pain and fever were also more common in patients with CDC. Morbidity included prolonged hospitalization in all patients and urgent colectomy in one. CONCLUSIONS: CDC frequently affects surgical patients, producing morbidity ranging from mild diarrhea to life-threatening illness. A variety of factors, many of which are associated with intestinal stasis, predispose to the development of CDC.

Total parenteral nutrition with glutamine dipeptide after major abdominal surgery: a randomized, double-blind, controlled study.

Morlion BJ. Stehle P. Wachtler P. Siedhoff HP. Koller M. Konig W. Furst P. Puchstein C.
Department of Anesthesiology and Intensive Care Medicine, Marienhospital Herne, Ruhr-University of Bochum, Germany.
OBJECTIVE: To assess the efficacy of glutamine (Gln) dipeptide-enriched total parenteral nutrition (TPN) on selected metabolic, immunologic, and clinical variables in surgical patients. SUMMARY BACKGROUND DATA: Depletion of Gln stores might lead to severe clinical complications. Recent studies indicate that the parenteral provision of Gln or Gln-containing dipeptides improves nitrogen balance, maintains the intracellular Gln pool, preserves intestinal permeability and absorption, and shortens hospital stay. METHODS: Twenty-eight patients (age range, 42-86 years, mean 68 years) undergoing elective abdominal surgery were allocated, after randomization, to two groups to receive isonitrogenous (0.24 g nitrogen kg(-1) day(-1)) and isoenergetic (29 kcal/122 kJ kg(-1) day(-1)) TPN over 5 days. Controls received 1.5 g of amino acids kg(-1) day(-1), and the test group received 1.2 g of amino acids and 0.3 g of L-alanyl-L-glutamine (Ala-Gln) kg(-1) day(-1). Venous heparinized blood samples were obtained before surgery and on days 1, 3, and 6 after surgery for routine clinical chemistry and for the measurement of plasma free amino acids. Lymphocytes were counted and the generation of cysteinyl-leukotrienes from polymorphonuclear neutrophil granulocytes was analyzed before surgery and on days 1 and 6 after surgery. Nitrogen balances were calculated postoperatively on days 2, 3, 4, and 5. RESULTS: No side effects or complaints were noted. Patients receiving Gln dipeptide revealed improved nitrogen balances (cumulative balance over 5 days: -7.9 +/- 3.6 vs. -23.0 +/- 2.6 g nitrogen), improved lymphocyte recovery on day 6 (2.41 +/- 0.27 vs. 1.52 +/- 0.17 lymphocytes/nL) and improved generation of cysteinyl-leukotrienes from polymorphonuclear neutrophil granulocytes (25.7 +/- 4.89 vs. 5.03 +/- 3.11 ng/mL). Postoperative hospital stay was 6.2 days shorter in the dipeptide-supplemented group. CONCLUSION: We confirm the beneficial effects of Gln dipeptide-supplemented TPN on nitrogen economy, maintenance of plasma Gln concentration, lymphocyte recovery, cysteinyl-leukotriene generation, and shortened hospital stay in surgical patients.

Utility of FDG-PET for investigating unexplained plasma CEA elevation in patients with colorectal cancer.

Year 1998
Flanagan FL. Dehdashti F. Ogunbiyi OA. Kodner IJ. Siegel BA.
Division of Nuclear Medicine, Edward Mallinckrodt Institute of Radiology, St. Louis, Missouri, USA.
OBJECTIVE: To assess the potential role of positron emission tomography (PET) with 2-[18F]fluoro-2-deoxy-D-glucose (FDG) in patients with unexplained rising carcinoembryonic antigen (CEA) levels after the treatment of colorectal cancer. BACKGROUND: A rising CEA level after the resection of colorectal cancer is an early indicator of tumor recurrence. However, conventional imaging techniques have limited sensitivity for detecting recurrent disease in such patients. Especially after surgical intervention, FDG-PET is rapidly gaining an important role in establishing the extent of disease in the oncology patient. METHODS: Twenty-two patients with abnormal CEA levels and normal results of conventional methods of tumor detection were studied with FDG-PET. The PET results were compared with pathologic findings (n = 9) and long-term radiologic and clinical follow-up (n = 13). RESULTS: FDG-PET was abnormal in 17 of 22 patients. Tissue sampling was available in 7 of these 17 patients; all of these had recurrent disease. Definitive curative surgical intervention was performed in four patients. Subsequent dedicated imaging findings and clinical course confirmed the presence of extensive disease in 8 of the remaining 10 patients; the PET results in the other 2 patients were considered falsely positive. FDG-PET was negative in 5 of 22 patients. No disease was found by tissue sampling (n = 2) and clinical follow-up (n = 3). Overall, the positive-predictive value for PET was 89%, (15 of 17) and the negative-predictive value was 100% (5 of 5). CONCLUSIONS: When conventional examinations are normal, FDG-PET is a valuable imaging tool in patients who have a rising CEA level after colorectal surgery.

Laparoscopically assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients.

Year 1998
Stevenson AR. Stitz RW. Lumley JW. Fielding GA.
Department of Surgery, Royal Brisbane Hospital, Australia.
PURPOSE: The objectives of this study were to refine the technique of laparoscopically assisted anterior resection (LAR) for diverticular disease and to analyze the morbidity and mortality rates, and longer term follow-up of the first 100 consecutive patients. METHODS: Data were collected prospectively, and follow-up was performed by an independent assessor using a standardized questionnaire. RESULTS: The median duration of surgery was 180 minutes, the median time for passage of flatus was 2 days after surgery, and the median length of hospital stay was 4 days. Overall, the morbidity rate was 21%, and the wound infection rate was 5%. There were no deaths. Eight patients underwent open laparotomy. The rate of complications was significantly greater in the latter group of patients (75%) than in those who underwent laparoscopy (16%, p = 0.002). The comparison between the first 20 cases and the last 20 patients revealed a significantly shorter duration of surgery (median 225 min. vs. 150 min.; p < 0.0001) and decreased length of stay (6 days vs. 4 days, p < 0.0001). Apart from a nonsignificant increase in the length of surgery, there were no differences in other study parameters when comparisons were made between those patients who underwent LAR for complicated diverticular disease and those patients who underwent uncomplicated diverticular disease. FOLLOW-UP: Ninety patients were available for follow-up at a median time of 37 months. Ninety-three percent of the patients reported that the surgery had improved their symptoms. No patient required hospitalization, and no one was treated with antibiotics for recurrent symptoms. CONCLUSION: Laparoscopically assisted anterior resection for diverticular disease has acceptable morbidity and mortality rates and a median postoperative hospital stay of only 4 days. Follow-up investigations revealed no recurrence of diverticulitis, and patients reported satisfaction regarding cosmetic and functional results.

Esophagectomy for carcinoma of the esophagus in the elderly: results of current surgical management.

Year 1998
Poon RT. Law SY. Chu KM. Branicki FJ. Wong J.
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
OBJECTIVE: This study aims to evaluate the risk of esophagectomy in the elderly compared with younger patients and to determine whether results of esophagectomy in the elderly have improved in recent years. SUMMARY BACKGROUND DATA: An increased life expectancy has led to more elderly patients presenting with carcinoma of the esophagus in recent years. Esophagectomy for carcinoma of the esophagus is associated with significant morbidity and mortality, and advanced age is often considered a relative contraindication to esophagectomy despite advances in modern surgical practice. METHODS: The perioperative outcome and long-term survival of 167 elderly patients (70 years or more) with esophagectomy for carcinoma of the esophagus were compared with findings in 570 younger patients with esophagectomy in the period 1982 to 1996. Changes in perioperative outcome and survival between 1982 to 1989 and 1990 to 1996 were separately analyzed. RESULTS: The resection rate in the elderly was 48% (167/345), lower than the 65% (570/874) resection rate in younger patients (p < 0.001). There were significantly more preoperative risk factors and postoperative medical complications in the elderly, but no significant differences were observed in surgical complications. The 30-day mortality rate was higher in the elderly (7.2%) than in younger patients (3.0%) (p = 0.02), but the hospital mortality rate was not significantly different in the elderly (18.0%) and younger age groups (14.4%) (p = 0.27). The long-term survival after curative resection in elderly patients was worse than younger patients (p = 0.01). However, when deaths from unrelated medical conditions were excluded from analysis, survival was similar between the two age groups (p = 0.23). A comparison of data for the periods 1982 to 1989 and 1990 to 1996 revealed that the resection rate had increased from 44% to 54% in the elderly, with significantly fewer postoperative complications and lower 30-day and hospital mortality rates. Long-term survival has also improved, although this has not reached a statistically significant level. CONCLUSIONS: With current surgical management, esophagectomy for carcinoma of the esophagus can be carried out with acceptable risk in the elderly, but intensive perioperative support is required. The improved results of esophagectomy in the elderly in recent years are attributed to increased experience and better perioperative management. Long-term survival was similar to that of younger patients, excluding deaths caused by unrelated medical conditions.

Prognostic value of platelet-derived growth factor-A (PDGF-A) in gastric carcinoma.

Year 1998
Katano M. Nakamura M. Fujimoto K. Miyazaki K. Morisaki T.
Department of Surgery, Saga Medical School, Nabeshima, Japan.
OBJECTIVE: Because our previous study indicated that PDGF-A mRNA expression in biopsy specimens might identify a subgroup of high-risk patients with gastric carcinoma, in this study we analyzed the prognostic value of platelet-derived growth factor-A (PDGF-A) gene expression in gastric carcinoma biopsy specimens. METHODS: Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to analyze the PDGF-A gene expression in 65 gastric carcinoma endoscopic biopsy specimens. The 65 patients were divided into a PDGF-A-positive group (29 patients) and a PDGF-A-negative group (36 patients). RESULTS: On the basis of 2-year follow-up data, the PDGF-A-positive group demonstrated a shorter overall survival rate compared with the PDGF-A-negative group (p < 0.0001). A similar correlation was found in 34 advanced-stage patients (p = 0.003) and in 24 advanced-stage patients who underwent a curative resection (p = 0.003). Multivariance analysis indicated that the transcription of PDGF-A gene is a potent prognostic factor that is independent of the traditional pathologic parameters. CONCLUSIONS: Expression of PDGF-A mRNA in gastric biopsy specimens may be a new preoperative prognostic parameter in gastric carcinoma.

Isolated tumor cells are frequently detectable in the peritoneal cavity of gastric and colorectal cancer patients and serve as a new prognostic marker.

Year 1998
Schott A. Vogel I. Krueger U. Kalthoff H. Schreiber HW. Schmiegel W. Henne-Bruns D. Kremer B. Juhl H.
Department of Surgery, University Hospital Kiel, Germany.
OBJECTIVE: To evaluate the prognostic significance of isolated tumor cells detected by a panel of various monoclonal antibodies. SUMMARY BACKGROUND DATA: Previously, we showed by using immunocytology that cancer cells are frequently found in bone marrow and peritoneal cavity samples of gastrointestinal cancer patients. METHODS: Findings in bone marrow and peritoneal cavity samples were compared and correlated with the 4-year survival rate of 84 gastric and 109 colorectal patients with cancer. RESULTS: Although positive results in the bone marrow showed little prognostic significance, the peritoneal cavity results correlated with the 4-year survival rate (gastric cancer: p = 0.0038; colorectal cancer: p = 0.0079). Additionally, in subgroups of patients with early (gastric cancer: p = 0.02, colorectal cancer: p = 0.48) and advanced (gastric cancer: p = 0.02, colorectal cancer: p < 0.0001) tumor stages, a correlation of immunocytologic findings and the survival rate was seen. CONCLUSIONS: The detection of minimal residual disease in the peritoneal cavity serves as a new prognostic marker.

Preoperative hyperthermia combined with radiochemotherapy in locally advanced rectal cancer: a phase II clinical trial.

Year 1998
Rau B. Wust P. Hohenberger P. Loffel J. Hunerbein M. Below C. Gellermann J. Speidel A. Vogl T. Riess H. Felix R. Schlag PM.
Virchow Klinikum at the Humboldt University of Berlin, Division of Surgery and Surgical Oncology, Robert-Roessle Hospital and Tumor Institute, Germany.
OBJECTIVE: A prospective phase II study was performed to determine the feasibility and efficacy in terms of response rate, resectability, and morbidity in patients with locally advanced rectal cancer who received preoperative regional hyperthermia combined with radiochemotherapy (HRCT). SUMMARY BACKGROUND DATA: Recent studies suggest that preoperative radiochemotherapy in locally advanced rectal cancer can induce downstaging, but after resection the incidence of local recurrences remains high. Hyperthermia (HT) may add tumoricidal effects and improve the efficacy of radiochemotherapy in a trimodal approach. PATIENTS AND METHODS: Thirty-seven patients with histologically proven rectal cancer and T3 or T4 lesions, as determined by endorectal ultrasound and computed tomography, entered the trial. 5-Fluorouracil (300-350 mg/m2) and leucovorin (50 mg) were administered on days 1 to 5 and 22 to 26. Regional HT using the SIGMA 60 applicator (BSD-2000) was given once a week before radiotherapy (45 Gy with 1.8-Gy fractions for 5 weeks). Surgery followed 4 to 6 weeks after completion of HRCT. RESULTS: Preoperative treatment was generally well tolerated, with 16% of patients developing grade III toxicity. No grade IV complications were observed. The overall resectability rate was 32 of 36 patients (89%), and 31 resection specimens had negative margins (R0). One patient refused surgery. In 5 patients (14%), the histopathologic report confirmed no evidence of residual tumor (pCR). A partial remission (PR) was observed in 17 patients (46%). The survival rate after 38 months was 86%. In none of the patients was local recurrence detected after R0(L), but five patients developed distant metastases. CONCLUSION: Preoperative HRCT is feasible and effective and may contribute to locoregional tumor control of advanced rectal cancer, which is to be proven in an ongoing phase III trial.

Effect of glucagon on protein synthesis in human rectal cancer in situ.

Year 1998
Hartl WH. Demmelmair H. Jauch KW. Koletzko B. Schildberg FW.
Department of Surgery, Klinikum Grosshadern, Munich, Germany.
OBJECTIVE: The purpose of this study was to determine the effect of glucagon or placebo on the rate of tumor fractional protein synthesis in situ in patients with localized rectal cancer who were not malnourished, demonstrated normal glucagon concentrations, and could therefore be used as a model to study the glucagon effect. SUMMARY BACKGROUND DATA: Cancer cachexia is associated with an increased concentration of counterregulatory hormones, including glucagon. This altered hormonal milieu may not only contribute to malnutrition, but also promote tumor growth, because previous experimental work suggests that glucagon can cause human colorectal tumor cells to proliferate. Corresponding mechanisms in vivo have, thus far, not been investigated. METHODS: Advanced mass spectrometry techniques (capillary gas chromatography [GC]/combustion isotope ratio mass spectrometry [IRMS]) were used to determine directly the incorporation rate of 1-[13C]-leucine into tissue protein. Because GC/IRMS requires only a small sample volume, three consecutive endoscopic biopsies could be obtained from the same tumor to determine isotopic enrichments at baseline, after a 4-hour glucagon infusion (3 ng/kg/min), or after placebo. RESULTS: In patients with localized rectal cancer, glucagon caused the tumor fractional protein synthetic rate to double (2.25+/-0.49 %/hr, p < 0.05 vs. 1.16+/-0.30 basal). In contrast, tumor protein synthesis declined over time in controls (placebo) (0.67+/-0.09 %/hr, p < 0.05 vs. 1.11+/-0.16 basal). CONCLUSIONS: Tumor protein synthesis and growth can be stimulated by glucagon in situ. Therefore, elevated glucagon concentrations in cachectic cancer patients should be considered detrimental and attempts made to prevent this specific response of the body to the malignant disease.

Marked elevation of serum interleukin-6 in patients with cholangiocarcinoma: validation of utility as a clinical marker.

Year 1998
Goydos JS. Brumfield AM. Frezza E. Booth A. Lotze MT. Carty SE.
Department of Surgery, University of Pittsburgh, Pennsylvania, USA.
OBJECTIVE: To determine if the serum level of interleukin-6 (IL-6) was elevated in patients with hepatic malignancies or correlated with radiologic tumor burden. SUMMARY BACKGROUND DATA: High serum levels of IL-6 signify an adverse prognosis in many patients with cancer. IL-6 is a growth factor for bile duct epithelium. METHODS: Using bioactive and enzyme-linked immunosorbent assays, serum level of IL-6 was measured in 35 healthy adults and in 60 patients presenting for definitive management of cholangiocarcinoma (CC) (15 patients), hepatocellular carcinoma (HCC) (14), metastatic colorectal cancer (MCRC) (26), and benign biliary disease (BBD) (5). Patients with clinical conditions known to raise the serum level of IL-6 were excluded. Tumor burden was calculated from concurrent computed tomography scans. IL-6 levels were measured 2 weeks after resection in 3 CC patients. Secretion of IL-6 was examined in 3 human CC cell lines. RESULTS: An elevated level of bioactive IL-6 was detected in every patient with CC and in 13 of 14 patients with HCC, 14 of 26 patients with MCRC, 2 of 5 patients with BBD, and 3 of 35 healthy adults. Median and mean levels of bioactive IL-6 were higher in CC than in other neoplasms (p < 0.026) and for all tumor groups differed from healthy adults (p < or = 0.026). IL-6 level was elevated more often in primary than in secondary liver neoplasms (p = 0.02), distinguished patients with CC or MCRC from BBD (p = 0.014 and 0.031, respectively), correlated with tumor burden in CC (p < 0.001), and dropped sharply after CC resection. CC line SG231 secreted bioactive IL-6. CONCLUSIONS: In selected patients, a high serum level of IL-6 marks patients with CC and correlates with tumor burden both before and after resection. IL-6 levels are elevated in patients with other liver neoplasms and may distinguish patients with hepatic malignancies from those with benign disease.

The pattern of infiltration at the proximal border of hilar bile duct carcinoma: a histologic analysis of 62 resected cases.

Year 1998
Sakamoto E. Nimura Y. Hayakawa N. Kamiya J. Kondo S. Nagino M. Kanai M. Miyachi M. Uesaka K.
First Department of Surgery, Nagoya University School of Medicine, Japan.
OBJECTIVE: To clarify the importance of different patterns of infiltration at the proximal border of hilar bile duct carcinomas. SUMMARY BACKGROUND DATA: There are few detailed pathologic studies on the proximal resection margins in patients with hilar bile duct carcinoma. METHODS: Serial sections of 62 specimens of resected hilar bile duct carcinoma were examined histologically to determine the involved layers and routes of invasion at the proximal border. The degree of cancer extension was determined, and the relation between the length of the tumor-free resection margin and postoperative anastomotic recurrences was analyzed. RESULTS: Mucosal extension was predominant in papillary and nodular tumors, but submucosal extension was predominant in diffusely infiltrating and nodular-infiltrating tumors. Submucosal extension usually consisted of direct or lymphatic invasion. The mean length of submucosal extension was 6.0 mm. Superficial spread of cancer, defined as mucosal extension of more than 20 mm from the main lesion, was seen in 8 specimens. No patient had an anastomotic recurrence when the tumor-free resection margin was greater than 5 mm. CONCLUSIONS: The pattern of infiltration at the proximal border of resected hilar bile duct carcinomas is closely related to the gross tumor type. The length of submucosal extension is usually less than 10 mm. Superficial spread of cancer is seen in more than 10% of cases. A tumor-free proximal resection margin of 5 mm appears to be adequate in hilar bile duct carcinoma.

Primary sclerosing cholangitis: resect, dilate, or transplant?

Year 1998
Ahrendt SA. Pitt HA. Kalloo AN. Venbrux AC. Klein AS. Herlong HF. Coleman J. Lillemoe KD. Cameron JL.
Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
OBJECTIVE: The current study examines the results of extrahepatic biliary resection, nonoperative endoscopic biliary dilation with or without percutaneous stenting, and liver transplantation in the management of patients with primary sclerosing cholangitis (PSC). SUMMARY BACKGROUND DATA: Primary sclerosing cholangitis is a progressive inflammatory disease leading to secondary biliary cirrhosis. The most effective management of sclerosing cholangitis before the onset of cirrhosis remains unclear. METHODS: From 1980 to 1994, 146 patients with PSC were managed with either resection of the extrahepatic bile ducts and long-term transhepatic stenting (50 patients), nonoperative endoscopic biliary dilation with or without percutaneous stenting (54 patients), medical therapy (28 patients), and/or liver transplantation (21 patients). RESULTS: Procedure-related morbidity and mortality rates were similar between surgically resected and nonoperatively managed patients. In noncirrhotic patients, the serum bilirubin level was significantly (p < 0.05) reduced from preoperative levels (8.3+/-1.5 mg/dL) 1 (1.7+/-0.4 mg/dL) and 3 (2.7+/-0.9 mg/ dL) years after resection, but not after endoscopic or percutaneous management. For noncirrhotic PSC patients, overall 5-year survival (85% vs. 59%) and survival until death or transplantation (82% vs. 46%) were significantly longer (p < 0.05) after resection than after nonoperative dilation with or without stenting. For cirrhotic patients, survival after liver transplantation was longer than after resection or nonoperative dilation with or without stenting. Five patients developed cholangiocarcinoma, including three (6%) of the nonoperatively managed patients but none of the resected patients. CONCLUSIONS: In carefully selected noncirrhotic patients with PSC, resection and long-term stenting remains a good option. Patients with cirrhosis should undergo liver transplantation.

Survival and recurrence after liver transplantation versus liver resection for hepatocellular carcinoma: a retrospective analysis.

Year 1998
Otto G. Heuschen U. Hofmann WJ. Krumm G. Hinz U. Herfarth C.
Department of Transplantation Surgery, University of Mainz, Germany.
OBJECTIVE: This study compares the results of liver transplantation (LTx) and liver resection (LR) for hepatocellular carcinoma (HCC) to test the widespread hypothesis that LTx is the preferable approach for small HCCs. SUMMARY BACKGROUND DATA: With respect to scarcity of donor organs and poor results, LTxs for large HCCs are obsolete. Small HCC transplantations have been reported to result in an excellent survival rate. However, the data of comparative studies are controversial. METHODS: Patients who were treated curatively by LTx (n = 50) or LR (n = 52) for HCC were included in this retrospective study. Survival and freedom from recurrence were analyzed. Patients were stratified according to prognostic factors (pT classification, tumor size, number of tumor nodules, vascular infiltration, and cirrhosis). RESULTS: Overall, after LTx and LR the 3-year survival rate and recurrence rate were not significantly different. In the Cox analysis, tumor size (p = 0.02) and vascular infiltration (p = 0.04) were independent variables after LTx, whereas after LR, none of the tested prognostic parameters was significant. With regards to recurrence, tumor size was the only independent factor, after both LTx and LR (p = 0.02, respectively). Directly comparing the two therapeutic approaches, a 3-year survival rate in pT 1/2, oligocentric (1-5 nodules), and oligocentric and small tumors proved to be superior after LTx. The recurrence rate after LTx was superior to LR in pT 1/2 and oligocentric tumors. Remarkably, for small (< or = 5 cm) tumors, LTx and LR resulted in a similar 3-year survival rate and freedom from recurrence. CONCLUSIONS: According to our analysis, the oncological advantage of LTx compared with LR is questionable. This applies especially for small tumors. Superior results of LTx in early stage HCC and particularly in oligocentric tumors may be attributed to incorrect preoperative diagnosis. Nevertheless, LTx is a reasonable treatment for patients with early stage tumors if a LR is impossible because of tumor localization or poor functional hepatic capacity.

Surgical intervention for patients with stage IV-A hepatocellular carcinoma without lymph node metastasis: proposal as a standard therapy.

Year 1998
Ikai I. Yamaoka Y. Yamamoto Y. Ozaki N. Sakai Y. Satoh S. Shinkura N. Yamamoto M.
Department of Gastroenterological Surgery, Kyoto University Graduate School of Medicine, Japan.
OBJECTIVE: The aim of this study was to evaluate the effects of surgical treatments for patients with stage IV-A hepatocellular carcinoma (HCC) without lymph node metastasis. SUMMARY BACKGROUND DATA: Nonsurgical therapy for highly advanced HCC patients has yielded poor long-term survival. Surgical intervention has been initiated in an effort to improve survival. METHODS: The outcome of 150 patients who underwent hepatic resection was studied. Survival analysis was made by stratifying stage IV-A HCC patients into two groups-those with and those without involvement of a major branch of the portal or hepatic veins. Those with involvement were further divided into subgroups according to major vascular invasions. RESULTS: Patients who had multiple tumors in more than one lobe without vascular invasion had a significantly better 5-year survival rate (20%) than those with vascular invasion (8%) (p < 0.01). The survival rate of patients with hepatic vein tumor thrombi (10%) was better than the rate for those with tumor thrombi in the inferior vena cava (0%), in whom no patients survived more than 2 years, although the survival rate for those with portal vein tumor thrombi in the first branch (11%) was no different from the rate for that in the portal trunk (4%). The operative mortality decreased from 14.3% in the first 6 years to 1.4% in the following 5 years. CONCLUSIONS: Surgical intervention for stage IV-A HCC patients brought longer survival rates for some patients. We recommend surgical intervention as an effective therapeutic modality for patients with advanced HCC.

Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.

Year 1998
Lo CM. Liu CL. Fan ST. Lai EC. Wong J.
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, China.
OBJECTIVE: A prospective randomized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates. It is not known whether there is a role for initial conservative treatment followed by interval elective operation. METHOD: During a 26-month period, 99 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n = 49) or delayed interval surgery after initial medical treatment (delayed group, n = 50). Thirteen patients (four in the early group and nine in the delayed group) were excluded because of refusal of operation (n = 6), misdiagnosis (n = 5), contraindication for surgery (n = 1), or loss to follow-up (n = 1). RESULTS: Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n = 3) and persistent fever (n = 5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs. 11%; p = 0.174) and complication rate (29% vs. 13%; p = 0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p = 0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p < 0.001) and recuperation period (19 days vs. 12 days; p < 0.001). CONCLUSIONS: Initial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.

Effects of glutamine supplements and radiochemotherapy on systemic immune and gut barrier function in patients with advanced esophageal cancer.

Year 1998
Yoshida S. Matsui M. Shirouzu Y. Fujita H. Yamana H. Shirouzu K.
First Department of Surgery, Kurume University, School of Medicine, Japan.
OBJECTIVE: The objective of this study was to determine whether oral glutamine supplements can protect lymphocyte and gut barrier function in patients with advanced esophageal cancer undergoing radiochemotherapy. SUMMARY BACKGROUND DATA: Glutamine supplements improved protein metabolism in tumor bearing rats who underwent chemotherapy and reduced the toxicity of chemotherapy through an enhancement of glutathione production in rats. METHODS: Thirteen patients with esophageal cancer were randomly placed in either a control or a glutamine group. Glutamine was administered orally (30 g/day) at the start of radiochemotherapy and for the subsequent 28 days. All patients underwent mediastinal irradiation and chemotherapy consisting of 5-fluorouracil and cisplatin. The lymphocyte count was determined, and blast formation was assessed after stimulation with phytohemagglutinin and concanavalin A. Gut barrier function was assessed by measuring the total amount of phenolsulfonphthalein excreted in the urine after the oral administration of phenolsulfonphthalein. RESULTS: Glutamine supplements prevented a reduction in the lymphocyte count (control: 567 +/- 96/mm3 vs. glutamine: 1007 +/- 151, p < 0.05), and blast formation of lymphocyte (phytohemagglutinin, control: 19478 +/- 2121 dpm vs. glutamine: 33860 +/- 1433, p < 0.01, concanavalin A, control: 19177 +/- 1897 dpm vs. glutamine: 29473 +/- 2302, p < 0.01), and amount of phenolsulfonphthalein excretion in the urine was greater with control than with glutamine group (control: 15.4 +/- 2.4% vs. glutamine: 7.4 +/- 1.2, p < 0.05) 7 days after the initiation of radiochemotherapy. CONCLUSIONS: Oral glutamine supplementation protects lymphocytes and attenuates gut permeability in patients with esophageal cancer during radiochemotherapy.

Comparison of primary and reoperative surgery in patients with Crohns disease.

Year 1998
Heimann TM. Greenstein AJ. Lewis B. Kaufman D. Heimann DM. Aufses AH Jr.
Department of Surgery, The Mount Sinai School of Medicine, New York, New York, USA.
OBJECTIVE: This study was performed to determine the clinical results of patients with Crohns disease who require surgical resection. The outcome of patients undergoing initial surgery was compared with those having reoperation. METHODS: One hundred sixty-four patients undergoing intestinal resection for Crohns disease at The Mount Sinai Hospital from 1976 to 1989 were studied prospectively. The mean duration of follow-up was 72 months. RESULTS: Ninety patients (55%) underwent initial intestinal resection whereas 74 patients (45%) underwent reoperation for recurrent disease. Patients undergoing reoperation were older (33.4 vs. 38.7 years), had longer durations of disease (8.7 vs. 15.2 years), had shorter resections (60 vs. 46 cm), and were more likely to require ileostomy. Forty-seven percent of the patients with multiple previous resections required an ileostomy. This group also received a mean of 2.3 U blood in the perioperative period and showed a trend to increased symptomatic recurrence (49% vs. 71% at 5 years). CONCLUSIONS: Patients with Crohns disease undergoing first and second reoperation have outcomes similar to those in patients undergoing primary resection. Patients requiring multiple reoperations are more likely to require blood transfusions and permanent ileostomy and to show a greater trend to early symptomatic recurrence.

Outcome of 67 patients with hepatocellular cancer detected during screening of 1125 patients with chronic hepatitis.

Year 1998
Izzo F. Cremona F. Ruffolo F. Palaia R. Parisi V. Curley SA.
Department of Surgical Oncology at the G. Pascale National Cancer Institute, Naples, Italy.
OBJECTIVE: We performed this prospective screening trial in chronic hepatitis virus-infected patients to determine the incidence of hepatocellular cancer (HCC) and the resectability and long-term survival rates of these HCC patients. SUMMARY BACKGROUND DATA: Chronic hepatitis B or C virus infection is a major etiologic factor in human HCC. It is not clear if routine screening of chronic viral hepatitis patients improves the survival of patients who develop HCC. METHODS: Screening for HCC was offered to patients chronically seropositive (>5 years) for hepatitis B or C infection. All patients underwent percutaneous core liver biopsy to assess the histologic severity of chronic liver injury. Patients were screened initially and every 3 months thereafter with serum alpha-fetoprotein and transabdominal ultrasound evaluations; HCC was confirmed by needle biopsy of liver tumors. RESULTS: Screening was performed on 1125 hepatitis-positive patients (804 with hepatitis C, 290 with hepatitis B, 31 with both). On liver biopsy, 800 patients had mild chronic active hepatitis and 325 had severe chronic active hepatitis, cirrhosis, or both. Initial screening detected HCC in 61 patients. HCC was detected in six more patients during follow-up; thus, the incidence of HCC was 5.9% (67/1125). However, 66 of the 67 HCC cases (98.5%) arose in the 325 patients with severe chronic active hepatitis or cirrhosis (66/325 [20.3%] vs. 1/800 [0.1%], p < 0.0001 [Wilcoxon signed rank]). Median follow-up of the 67 HCC patients was 24 months. Locally advanced or metastatic, unresectable HCC occurred in 43 patients (64.2%); 24 patients (35.8%), including the 6 patients detected during follow-up screening, underwent margin-negative resection. The median survival for the 24 resected patients was 26 months, compared to 6 months for the 43 patients with unresectable cancer (p < 0.0001, Wilcoxon signed rank). CONCLUSIONS: HCC was found to arise in 20.3% of patients with chronic hepatitis B or C infection and severe liver injury. Initial screening detected resectable lesions in less than half the HCC patients. Routine screening of chronic hepatitis B or C virus-infected patients with ultrasound and alpha-fetoprotein determination should be reserved for patients with severe chronic active hepatitis, cirrhosis, or both.

Induction of long-term remission in advanced hepatocellular carcinoma with percutaneous isolated liver chemoperfusion.

Year 1998
Ku Y. Iwasaki T. Fukumoto T. Tominaga M. Muramatsu S. Kusunoki N. Sugimoto T. Suzuki Y. Kuroda Y. Saitoh Y. Sako M. Matsumoto S. Hirota S. Obara H.
Department of Surgery I, Kobe University School of Medicine, Japan.
OBJECTIVE: The aim of this study was to report the long-term results of percutaneous isolated liver chemoperfusion with hepatic venous isolation and charcoal hemoperfusion (HVI-CHP) in patients with multiple advanced hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: The results of conventional chemotherapy including regional and systemic chemotherapy in patients with HCC remain dismal, and long-term survivors after treatment are rare among patients with multiple advanced HCC. In an effort to improve this situation, we previously developed a novel system of percutaneous isolated liver chemoperfusion with HVI-CHP. METHODS: Doxorubicin (60 to 150 mg/m2) was administered via the hepatic artery, under conditions of extracorporeal drug elimination by HVI-CHP in 28 consecutive patients with advanced HCC (39 total treatments). Hepatic venous isolation and charcoal hemoperfusion was accomplished mainly by the single catheter technique using a newly developed 4-lumen-balloon catheter, which was used to isolate and capture total hepatic venous outflow and, at the same time, to direct the filtered blood to the right atrium. RESULTS: Complete remission was achieved in five patients, of which four received repeated treatments (two or three times). Although 1 of 5 patients with complete remission died of pulmonary metastases at 8 months, the other 4 remain healthy and free of disease at 20, 24, 27, and 42 months after the first treatment. Partial responses were observed in 12 patients. Duration of response in responders (complete and partial) with repeated treatments was significantly longer than that with a single treatment (p = 0.01). The overall survival rate by the Kaplan-Meier method was 39.7% at 5 years. The treatments were well-tolerated, and the primary side effects were mild to moderate chemical hepatitis and reversible myelosuppression. CONCLUSIONS: The results suggest that percutaneous isolated liver chemoperfusion with HVI-CHP is an effective palliative treatment in the majority of patients and yields long-term complete remission in some patients with multiple advanced HCC.

Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma.

Year 1998
Lo CM. Lai EC. Liu CL. Fan ST. Wong J.
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, China.
OBJECTIVE: This prospective study evaluates the value of laparoscopy and laparoscopic ultrasonography (USG) in avoiding exploratory laparotomy in patients with hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: Laparotomy and intraoperative USG is the gold standard to determine the resectability of HCC. No palliation can be offered to patients found to have unresectable disease, and the surgical exploration causes morbidity. METHODS: From June 1994 to June 1996, 110 of 370 patients (30%) with HCC were considered candidates for possible hepatic resection. Preoperative liver function was assessed using Child-Pugh grading and indocyanine green retention test. The extent of disease was evaluated with radiologic studies, including percutaneous USG, computerized tomography scan, and hepatic angiogram. Nineteen patients were excluded from the study because of previous upper abdominal surgery (n = 12), ruptured tumors (n = 4), refusal by patients (n = 2), and instrument failure (n = 1). Laparoscopy and laparoscopic USG was performed on 91 patients immediately before a planned laparotomy aiming at hepatic resection. Laparotomy was aborted when definite evidence of unresectable disease was found on laparoscopic examination. RESULTS: The median time required for laparoscopy and laparoscopic USG was 30 minutes (range, 10 to 120 minutes). Fifteen patients had evidence of unresectable disease on laparoscopic examination. Among the remaining 76 patients who underwent laparotomy, 9 had exploration only and 67 underwent hepatic resection. Thus, exploratory laparotomy was avoided in 63% of patients with unresectable disease. The laparoscopic examination failed to confirm unresectable disease more often when the tumor was >10 cm in diameter. The procedure accurately assessed the adequacy of the liver remnant and the presence of intrahepatic metastases, but it was less sensitive in determining the presence of tumor thrombi in major vascular structures and the extent of invasion of adjacent organs. When unresectable disease was detected without the need for a laparotomy, the postoperative recovery was faster, and the nonoperative treatment for the tumor could be initiated earlier. CONCLUSIONS: Laparoscopy with laparoscopic USG avoids unnecessary laparotomy in patients with HCC and should precede a planned laparotomy aiming at hepatic resection.

Surgical margin in hepatic resection for colorectal metastasis: a critical and improvable determinant of outcome.

Year 1998
Cady B. Jenkins RL. Steele GD Jr. Lewis WD. Stone MD. McDermott WV. Jessup JM. Bothe A. Lalor P. Lovett EJ. Lavin P. Linehan DC.
Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
OBJECTIVE: To update the analysis of technical and biologic factors related to hepatic resection for colorectal metastasis in a large single-institution series to identify important prognostic indicators and patterns of failure. SUMMARY BACKGROUND DATA: Surgical therapy for colorectal carcinoma metastatic to the liver is the only potentially curable treatment. Careful patient selection of those with resectable liver-only metastatic disease is crucial to the success of surgical therapy. METHODS: Two hundred forty-four consecutive patients undergoing curative hepatic resection for metastatic colorectal carcinoma were analyzed retrospectively. Variables examined included sex, stage of primary lesion, size of liver lesion(s), number of lesions, disease-free interval, ploidy, differentiation, preoperative carcinoembryonic antigen level, and operative factors such as resection margin, use of cryotherapy, intraoperative ultrasound, and blood loss. RESULTS: Surgical margin, number of lesions, and carcinoembryonic antigen (CEA) levels significantly control prognosis. Patients with only one or two liver lesions, a 1-cm surgical margin, and low CEA levels have a 5-year disease-free survival rate of more than 30%. Disease-free interval, original stage, bilobar involvement, size of metastasis, differentiation, and ploidy were not significant predictors of recurrence. The pattern of failure correlates with surgical margin. Routine use of intraoperative ultrasound resulted in an increased incidence of negative surgical margin during the period examined. CONCLUSIONS: Surgical resection or cryotherapy of hepatic metastasis from colorectal cancer is safe and curable in appropriately selected patients. Biologic factors, such as number of lesions and carcinoembryonic antigen levels, determine potential curability, and surgical margin governs the patterns of failure and outcome in potentially curable patients. Optimization of selection criteria and surgical resection margins will improve outcome.

Severe acute respiratory distress syndrome secondary to acute pancreatitis successfully treated with extracorporeal membrane oxygenation in three patients.

Year 1998
Peek GJ. White S. Scott AD. Hall AW. Moore HM. Sosnowski AW. Firmin RK.
Heartlink ECMO Center, Glenfield Hospital, Leicester, United Kingdom.
OBJECTIVE: To review three patients who underwent extracorporeal membrane oxygenation (ECMO) for acute respiratory failure secondary to pancreatitis. SUMMARY BACKGROUND DATA: Severe acute pancreatitis often causes the acute respiratory distress syndrome (ARDS), and if ventilation is required, the mortality rate is more than 50%. If the ratio of PaO2/FiO2 falls below 100 mm Hg or the Murray lung injury score exceeds 3.5, the mortality rate rises to more than 80%. Three patients who have severe ARDS secondary to pancreatitis, who were hypoxic despite ventilation with 100% oxygen and high airway pressures, and who were all successfully treated with ECMO are reported here. The consensus here is that all three patients would have died without ECMO. METHODS: Retrospective chart review and discussion of the literature. RESULTS: Pre-ECMO data: mean PaO2/FiO2 59.3 mm Hg, mean Murray lung injury score 3.7, one patient administered 20 ppm inhaled nitric oxide. ECMO data: mean extracorporeal flow at initiation of ECMO 56.3 mL/kg per minute, all patients administered veno-venous ECMO, mean duration of ECMO 104.7 hours. All patients were successfully weaned from ECMO and extubated. One patient had a protracted hospital stay because of a colo-cutaneous fistula. All patients are long-term survivors. CONCLUSIONS: Extracorporeal membrane oxygenation proved an effective therapy for severe ARDS complicating acute pancreatitis. Extracorporeal membrane oxygenation was conducted without bleeding complications in these three patients.

Biliary atresia-polysplenia syndrome: surgical and clinical relevance in liver transplantation.

Year 1998
Varela-Fascinetto G. Castaldo P. Fox IJ. Sudan D. Heffron TG. Shaw BW. Langnas AN.
Department of Surgery, University of Nebraska Medical Center, Omaha 68198-3280, USA.
OBJECTIVE: To review a single center's 10-year experience with liver transplantation (LTx) for the biliary atresia-polysplenia syndrome (BA-PS) and to define surgical and clinical guidelines for its management. SUMMARY BACKGROUND DATA: BA is the most common indication for pediatric liver transplantation (LTx) and is associated with PS in 12% of cases. Only a few studies of LTx for BA-PS have been reported, and the optimal management of BA-PS patients undergoing LTx has yet to be determined. METHODS: From July 1985 to September 1995, 166 liver transplants were performed in 130 patients with BA and were included in the study. The malformations most commonly associated with BA-PS, surgical techniques used to overcome these anomalies, and surgical pitfalls that could have contributed to the outcome were characterized. Actuarial 10-year patient and graft survival for patients undergoing LTx for BA-PS were calculated and compared to those with isolated BA. RESULTS: Ten patients (7.8%) with BA had associated PS. An additional patient with PS without BA was included in the study. The diagnosis of PS was unknown before the transplantation in 72% of cases. Thirteen liver transplants were performed in these 11 patients. Modifications of the usual surgical technique were used to overcome the complex anatomy encountered. There was no association between the type of anomaly and the outcome, nor were there any significant differences in patient survival (72% vs. 73.5%, p = 0.79) or graft survival (56.4% vs. 54.6%, p = 0.54). CONCLUSIONS: The association of BA with various anomalies should be considered a spectrum that may vary widely from patient to patient. The finding of two or more of these malformations in a patient awaiting transplantation should lead the surgeon to look systematically for other associated anomalies. With some special surgical considerations, the outcome in BA-PS patients should not differ from those with isolated BA.

Guidelines for surgical procedures after liver transplantation.

Year 1998
Testa G. Goldstein RM. Toughanipour A. Abbasoglu O. Jeyarajah R. Levy MF. Husberg BS. Gonwa TA. Klintmalm GB.
Baylor University Medical Center, Transplant Department, Dallas, Texas 75246, USA.
OBJECTIVE: The first purpose of this study is to identify the types and incidences of surgical procedures in patients who have previously undergone liver transplantation, with particular focus on the complication rates and the lengths of hospital stay. The second purpose is to present the management guidelines for patients with liver transplants at the preoperative, intraoperative, and postoperative stages of surgical procedure. SUMMARY BACKGROUND DATA: The surgical literature on this issue is scant, and with the growing liver transplant patient population it is not unlikey for any surgery specialist to have to operate on a patient who has undergone liver transplantation. METHODS: A sample of 409 patients with available hospital records, with a minimum of a 2-year follow-up, and with telephone access for interviews was chosen. Type of surgery, time from the liver transplant, hospital stay, immunosuppressive regimen, and complications were recorded. RESULTS: A large proportion of patients (24.2%) underwent some type of surgical procedure 2 to 10 years after liver transplantation. The authors demonstrate that most of the elective procedures can be safely carried out without an increased incidence of complication and without longer hospital stay than the general population. Conversely, emergent procedures are plagued by a greater incidence of complications that not only affect the function of the liver graft but may risk the life of the patient.

Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis.

Year 1998
Selim N. Fendley MJ. Boyer TD. Galloway JR. Branum GD.
Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
OBJECTIVE: The authors demonstrate the feasibility of converting failed transjugular intrahepatic portosystemic shunt (TIPS) to distal splenorenal shunt (DSRS) in patients with good hepatic reserve for long-term control of variceal bleeding. SUMMARY BACKGROUND DATA: TIPS is an effective method for decompressing the portal venous system and controlling bleeding from esophageal and gastric varices. TIPS insufficiency is, however, a common problem, and treatment alternatives in patients with an occluded TIPS are limited because most have already failed endoscopic therapy. METHODS: The records of five patients who underwent conversion from TIPS to DSRS because of TIPS failure or complication in the past 36 months were reviewed. RESULTS: Four patients had ethanol-induced cirrhosis and one patient had hepatitis C virus cirrhosis. Three patients were Child-Pugh class A and two were class B. All patients had excellent liver function, with galactose elimination capacities ranging from 388 to 540 mg/min (normal 500 +/- 100 mg/min). The patients had TIPS placed for acute (2) or sclerotherapy-resistant (3) variceal hemorrhage. All five TIPS stenosed 3 to 23 months after placement, with recurrent variceal hemorrhage and failed TIPS revision. One patient had stent migration to the superior mesenteric vein that was removed at the time of DSRS. All five patients underwent successful DSRS, and none have had recurrent hemorrhage 18 to 36 months after surgery. CONCLUSIONS: TIPS provides inadequate long-term therapy for some Child-Pugh A or B patients with recurrent variceal hemorrhage. TIPS failure in patients with good liver function can be salvaged by DSRS in many cases.

Preoperative terminal ileal and colonic resection histopathology predicts risk of pouchitis in patients after ileoanal pull-through procedure.

Year 1998
Schmidt CM. Lazenby AJ. Hendrickson RJ. Sitzmann JV.
Department of Surgery, Georgetown University Medical Center, Washington, DC 20007, USA.
OBJECTIVE: This study seeks to compare the histopathology of preoperative terminal ileal and colonic resection specimens with pouch biopsies after the ileoanal pull-through (IAPT) procedure. SUMMARY BACKGROUND DATA: Pouchitis is the most frequent complication of transanal continent reservoirs in patients after IAPT. METHODS: The authors conducted 751 consecutive pouch biopsies on 73 patients with inflammatory bowel disease or familial adenomatous polyposis who underwent IAPT by a single surgeon over a 10-year period. In this preliminary report, a pathologist, in blinded fashion, has graded 468 of the IAPT pouch biopsies and 67 of the patients' preoperative terminal ileal and colonic resection histopathology to date. Colonic histopathology was graded by the extent and severity of disease, terminal ileal and pouch histopathology by active inflammation, chronic inflammation, lymphocyte aggregates, intraepithelial lymphocytes, eosinophils, and villous blunting. RESULTS: Extent of colonic disease (gross and microscopic) was a significant predictor of active inflammation in subsequent IAPT pouch biopsy specimens. Also, the gross extent of colonic disease exhibited a significant linear association with pouch inflammation. However, the severity of colonic disease was not significantly predictive of active inflammation in subsequent IAPT pouch biopsies. Terminal ileal active and chronic inflammation were significant predictors of subsequent IAPT pouch inflammation. Although lymphocyte aggregates and intraepithelial lymphocytes were not predictive, terminal ileum eosinophils and villous blunting were significant predictors of active inflammation in subsequent IAPT pouch biopsy specimens. CONCLUSIONS: Preoperative terminal ileal and colonic histopathology predicts active inflammation of pouches after IAPT. Patients who are preoperatively assessed to have extensive disease of the colon, ileal disease ("backwash ileitis"), or both appear to be at greater risk for the development of pouchitis after IAPT.

Collis-Nissen gastroplasty for shortened esophagus: long-term evaluation.

Year 1998
Richardson JD. Richardson RL.
Department of Surgery, University of Louisville School of Medicine, Kentucky 40292, USA.
OBJECTIVE: The authors studied the short- and long-term results of an esophageal lengthening procedure (Collis gastroplasty) combined with a Nissen fundoplication in the management of patients with shortened esophagus and stricture secondary to gastroesophageal reflux disease. Summary Background Data There are several options for managing a shortened esophagus. There have been few long-term series with analysis of results regarding a lengthening procedure combined with a total fundoplication. METHODS: A personal series of 52 patients was examined with complete follow-up available for an average of 7 years. RESULTS: There were no deaths, esophageal leaks, or esophageal complications in the early postoperative period. Control of reflux was excellent and all patients had their dysphagia improved. The majority of patients with preoperative strictures required at least one postoperative dilation, but in most the need for dilation was short term. CONCLUSIONS: The Collis-Nissen procedure is a safe and reasonable alternative in the small subset of patients with severe reflux disease causing a shortened esophagus and stricture.

269

Версия для печати

Источник: https://gastroportal.ru/science-articles-of-world-periodical-eng/ann-surg.html