Arch Surg

Cholecystectomy in cardiothoracic organ transplant recipients.

Lord RV. Ho S. Coleman MJ. Spratt PM.
Department of Surgery, St Vincent's Hospital, Sydney, NSW, Australia.
OBJECTIVES: To assess the risks associated with cholelithiasis and cholecystectomy in cardiothoracic organ transplant recipients at this hospital and to identify any differences with potential causal significance between the group with known gallstones and the transplant recipient group as a whole. DESIGN: Medical records survey. SETTING: Tertiary care university hospital. PATIENTS: Six hundred forty-five patients had cardiothoracic organ transplantation at this hospital between February 1, 1984, and May 31, 1996. Gallstones were detected in 37 (5.7%) of these patients and 32 patients underwent cholecystectomy, of which 29 operations were performed primarily for symptomatic gallstone disease. All cholecystectomies were performed after transplantation. MAIN OUTCOME MEASURES: Mortality, morbidity, postoperative biliary disease. RESULTS: Patients with gallstones were significantly older than the transplant patient group as a whole (Student t test, P=.001); they were more likely to be female (chi2 test, P=.05); and they had a higher body mass index (t test, P=.001). There were no significant differences in the maximum serum bilirubin level during the transplantation admission, incidence of diabetes mellitus, cholestyramine use, or cyclosporine dosage during the first 12 months after transplantation. Cholecystectomy was performed after a median 5-month symptomatic period, mostly by the minilaparotomy method. Forty-five percent of cholecystectomies were urgent or semi-urgent. One patient died of lung infection on the second postoperative day. The median postoperative stay was 3 days. At a median 33 months' follow-up, 4 patients have had further biliary problems (2 patients with common bile duct stones, 1 patient with intrahepatic stones, and 1 patient with biliary dyskinesia). Four other patients with asymptomatic gallstones who did not receive cholecystectomy have remained asymptomatic for between 15 and 67 months. CONCLUSIONS: Cholecystectomy by the minilaparotomy or laparoscopic methods, with routine operative cholangiography, is the preferred treatment for symptomatic gallstones in cardiothoracic organ transplant recipients. Although the optimum management of asymptomatic gallstones in these patients remains unclear, our favorable experience with a policy of reserving cholecystectomy for symptomatic cases seems noteworthy.

Helical computed tomography in the diagnosis of portal vein invasion by pancreatic head carcinoma: usefulness for selecting surgical procedures and predicting the outcome.

Furukawa H. Kosuge T. Mukai K. Iwata R. Kanai Y. Shimada K. Yamamoto J. Ushio K.
Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan.
OBJECTIVE: To evaluate the use of helical computed tomography (CT) in diagnosing portal vein (PV) invasion by pancreatic head carcinoma and its usefulness in predicting outcome. DESIGN: Validation cohort study. SETTING: Tertiary care public hospital. PATIENTS: Twenty-seven patients with carcinoma involving the pancreatic head were preoperatively studied with helical CT. All patients underwent resection. MAIN OUTCOME MEASURE: By quantifying the contact between the tumor and PV on helical CT, the relationship between them was classified into 1 of 4 types: type 1, visible fat layer between PV and the tumor; type 2, with the total PV circumference defined as 360 degrees, contact between the tumor and PV was considered to be 90 degrees or less; type 3, contact ranged between 91 degrees and 180 degrees; and type 4, contact greater than 180 degrees. Helical CT results were compared with intraoperative observation, histological findings of the resected specimen, and postoperative course. RESULTS: When helical CT showed type 3 or 4, the case was diagnosed as positive for PV invasion. Sensitivity, specificity, and overall accuracy were 83%, 100%, and 89% when compared with the intraoperative assessment, and 92%, 79%, and 85% with the histological assessment, respectively. One- and 2-year survival rates were 86% and 69% for type 1, 100% and 75% for type 2, and 33% and 12% for type 3, respectively. The survival rates of patients with types 1 and 2 were significantly higher than that of those with type 3 (P

Is splenectomy necessary in devascularization procedures for treatment of bleeding portal hypertension?

Orozco H. Mercado MA. Martinez R. Tielve M. Chan C. Vasquez M. Zenteno-Guichard G. Pantoja JP.
Portal Hypertension Clinic, Instituto Nacional de la Nutricion, Salvador Zubiran, Mexico City, Mexico.
OBJECTIVE: To investigate whether splenectomy as a part of devascularization procedures is necessary. DESIGN: Prospective, controlled, randomized trial. SETTING: University hospital, referral center. PATIENTS: A total of 55 patients (Child-Pugh class A and B) with a history of bleeding portal hypertension were treated by means of a modified Sugiura-Futagawa procedure. Twenty-three patients underwent splenectomy and 22 did not. METHODS: Postoperative outcome was recorded and comparison of the 2 groups was done with the Fisher exact test. Kaplan-Meier survival curves were constructed. Main outcome and postoperative differences between the patients who underwent splenectomy and those who did not were investigated. RESULTS: Both groups were comparable in the postoperative period. Significant differences were observed in transfusion requirements and postoperative portal vein thrombosis, both favoring the group without splenectomy. No differences in rebleeding, encephalopathy rate, operative time, or postoperative complications were observed. CONCLUSION: Splenectomy is not routinely necessary in devascularization procedures for bleeding portal hypertension.

Angiography for preoperative evaluation in patients with lower gastrointestinal bleeding: are the benefits worth the risks?

Cohn SM. Moller BA. Zieg PM. Milner KA. Angood PB.
Department of Surgery, Yale University School of Medicine, New Haven, Conn 06520, USA.
OBJECTIVE: To evaluate the benefits and risks of selective angiography for the evaluation of acute lower gastrointestinal (GI) bleeding to identify the site of bleeding and theoretically limit the extent of colonic resection. DESIGN: Retrospective chart review. SETTING: Tertiary care hospital. PATIENTS: Sixty-five patients undergoing 75 selective angiograms for evaluation of acute lower GI bleeding. Mean age was 71 years (range, 27-93 years), and 37 (57%) were women. MAIN OUTCOME MEASURES: Demographic data were collected that included any associated medical problems, potential factors contributing to an increased risk for bleeding, and the diagnostic methods used in evaluating the source of lower GI bleeding. The details of angiography procedures were recorded with special attention to the impact of the procedure on clinical management and any associated complications. RESULTS: Twenty-three patients (35%) had positive angiography findings, and 14 of them (61%) required operations. Forty-two patients (65%) had negative angiography findings, and 8 of them (19%) required operations. Surgery for the 22 patients included hemicolectomy in 11 patients, subtotal colectomy in 10 patients, and small-bowel tumor resection in 1 patient. In 9 patients, a hemicolectomy was performed on the basis of angiography findings. Three patients (2 with negative angiography findings) experienced rebleeding after a hemicolectomy and required a subsequent subtotal colectomy. Overall, only 8 (12%) of the 65 patients underwent a segmental colon resection that was based on angiography findings and did not bleed after their operation. Complications from angiography occurred in 7 patients (11%). CONCLUSION: Selective angiography appears to add little clinically useful information in patients with acute lower GI bleeding and carries a relatively high complication risk.

Surgery in the aged in Korea.

Kim JP. Kim SJ. Lee JH. Kim SW. Choi MG. Yu HJ.
Department of Surgery, College of Medicine, Seoul National University Hospital, Korea. jpkim@plaza.snu.ac.kr
OBJECTIVE: To compare clinical characteristics, including postoperative outcomes, in Korean patients 65 years and older with those of younger patients. DESIGN: A retrospective medical record review. SETTING: An adult university hospital. PARTICIPANTS: All patients who underwent various operative procedures, especially for stomach cancer, acute surgical abdomen, and abdominal wall hernia, in the Department of Surgery at Seoul National University Hospital, Seoul, Korea, in 1994 and 1995. MAIN OUTCOME MEASURES: Demographics, disease pattern, length and extent of operation, hospital course including postoperative complications, and mortality. RESULTS: A clear increase in the patients 65 years and older was found. Of 2893 patients who underwent surgery in 1994, 735 were 40 years and younger (group 1), 1691 were 41 to 64 years old (group 2), and 467 were 65 years and older (group 3). The most common disease was stomach cancer in all age groups, with the highest incidence in group 3. Emergency operations were performed most often in group 1 (P

Unsuspected cirrhosis discovered during elective obesity operations.

Brolin RE. Bradley LJ. Taliwal RV.
Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick 08903, USA.
OBJECTIVE: To determine the incidence and outcome of cirrhosis encountered unexpectedly during gastric bariatric operations. DESIGN: A cohort study. SETTING: A tertiary care center. PATIENTS: One hundred twenty-five patients in whom cirrhosis was discovered during gastric bariatric operations. Cirrhosis may have been caused by severe obesity in 93 (74%) of the patients. INTERVENTIONS: A questionnaire survey of bariatric surgeons worldwide, including one of us (R.E.B.). RESULTS: One hundred twenty-six (52%) of the 243 surgeons responded to the survey. Planned bariatric operations were performed in 91 (73%) of the cases. Seventeen (14%) of the remaining cases were closed after the discovery of cirrhosis. There were no intraoperative deaths. However, the perioperative mortality rate was 4% and there were 7 late deaths, 6 due to complications of liver disease. Eleven other patients are described as alive with progressive hepatic dysfunction. The remaining 50 patients are "alive and well." The survey also included opinion questions. Regarding the appropriate operation to perform after discovering cirrhosis, 40% replied "perform liver biopsy only and close"; the remaining 60% would perform a bariatric procedure. Regarding bariatric operations that can be safely performed in patients with cirrhosis, 59% would perform banded gastroplasty, 39% would perform standard Roux-en-Y gastric bypass, 5% would perform biliopancreatic bypass, and 27% would perform none of the above. CONCLUSION: Although operative mortality is higher in cirrhotic vs other bariatric patients, most surveyed surgeons believe that gastric restrictive operations can be performed safely in this group of patients.

A thoracoabdominal hepatectomy and a transdiaphragmatic hepatectomy for patients with cirrhosis and hepatocellular carcinoma.

Takenaka K. Fujiwara Y. Gion T. Maeda T. Shirabe K. Shimada M. Yanaga K. Sugimachi K.
Department of Surgery II, Faculty of Medicine, Kyushu University, Fukuoka, Japan.
OBJECTIVE: To evaluate the results of a thoracoabdominal hepatectomy and a transdiaphragmatic hepatectomy for hepatocellular carcinoma in patients with impaired liver function. DESIGN: Retrospective study. SETTING: A university hospital in Japan. PATIENTS: Twenty-seven patients who from 1991 to 1996 underwent a thoracoabdominal hepatectomy for hepatocellular carcinoma located mainly in the superior portion of the liver and 20 patients who underwent a transdiaphragmatic hepatectomy for hepatocellular carcinoma located near the diaphragm. MAIN OUTCOME MEASURES: Morbidity, survival, and disease-free survival after each operation. Comparisons were then made with 183 patients who had undergone an ordinary transabdominal hepatectomy during the same period. RESULTS: In the thoracoabdominal hepatectomy group, 17 patients underwent a partial resection, 4 patients underwent a subsegmentectomy, and another 6 patients underwent either a segmentectomy or a procedure that was greater in size than a segmentectomy, whereas all of the patients in the transdiaphragmatic group underwent a partial resection. The morbidities in the thoracoabdominal group included pleural effusion in 6 patients (22%); intra-abdominal infection in 5 patients (19%); and hepatic failure in 3 patients (11%), of whom 1 died (mortality rate, 4%). In the transdiaphragmatic group, only 2 patients (10%) had non-life-threatening complications. The cumulative survival rates and the disease-free survival rates of the patients at 3 years were 51% and 24% in the thoracoabdominal hepatectomy group and 62% and 30% in the transdiaphragmatic hepatectomy group; no significant differences were observed when these findings were compared with those of patients who had undergone a transabdominal hepatectomy. CONCLUSION: The outcomes of the patients undergoing thoracoabdominal hepatectomy and those undergoing a transdiaphragmatic hepatectomy were generally satisfactory in spite of the fact that these procedures were performed on patients with cirrhosis and impaired liver function.

Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections.

Gambiez LP. Denimal FA. Porte HL. Saudemont A. Chambon JP. Quandalle PA.
Clinique Chirurgicale Ouest, Hopital Claude Huriez, Centre Hospitalier Regional Universitaire, Lille, France.
OBJECTIVE: To review the results of the different modalities of treatment of acute necrotizing pancreatitis that have been used by a single team during a 6-year period to assess the technique and indications of an endoscopic method of retroperitoneal drainage that is routinely performed for the management of peripancreatic necrosis. DESIGN AND SETTING: Retrospective study of 53 patients in a tertiary care center. RESULTS: All patients had signs of peripancreatic necrosis on initial computed tomography scan, 20 patients experienced organ failure during the first 7 days of the disease, and bacterial contamination was proved in 22 (56%) of 39 samples of peripancreatic necrosis. Methods of treatment included supportive therapy alone (group 1), percutaneous drainage (group 2), endoscopic retroperitoneal drainage (group 3), and laparotomy and transperitoneal drainage (group 4). Mortality and mean hospital stay were as follows: group 1, 0% and 23 days; group 2, 20% and 89 days; group 3, 10% and 62 days; and group 4, 33% and 86 days. Percutaneous drainage was beneficial in only 3 cases of sterile collection. Two local complications were related to the method of endoscopic drainage. Primary laparotomy was not routinely performed except in patients with an intraperitoneal complication. Overall mortality was 13.2%; mortality was significantly higher in patients with an infected necrosis (32%). CONCLUSIONS: The use of endoscopic retroperitoneal drainage seemed to be a significant factor in the observed improvement by providing a reliable drainage of the peripancreatic areas and avoiding the opening of the peritoneal cavity. This surgical approach is not exclusive and may be combined with a secondary laparotomy when needed. The preferred indications of this method are heterogeneous collections of necrosis with bacterial contamination.

Long-term outcome after open treatment of severe intra-abdominal infection and pancreatic necrosis.

Kriwanek S. Armbruster C. Dittrich K. Beckerhinn P. Schwarzmaier A. Redl E.
First Department of Surgery, Rudolfstiftung-Hospital, Vienna, Austria.
BACKGROUND: Outcome assessment after surgical treatment of intra-abdominal infections and pancreatic necrosis has concentrated on postoperative complications and survival, while long-term results have received little attention. OBJECTIVES: To evaluate hospital costs and long-term outcome for patients undergoing open treatment of intra-abdominal infection or pancreatic necrosis and to determine whether results justify costs. DESIGN: Cohort study and cost-effectiveness analysis. SETTING: Referral center. PATIENTS: From January 1, 1988, through June 30, 1996, we used open treatment for 147 patients with pancreatic necrosis (n=75; group 1), severe intra-abdominal infections due to benign diseases (n=50; group 2), and infections due to malignant neoplasm (n=22; group 3). All surviving patients (n=92) were followed up. Fifty-seven patients in group 1, 25 patients in group 2, and 10 patients in group 3 survived. INTERVENTIONS: The effective costs of treatment per surviving patient (including restorative surgery) were calculated. The patients were interviewed, and the residence location, medical treatment, degree of recovery, functional state, and employment status were assessed. We assessed the quality of life by using the short general health survey (SF-36). MAIN OUTCOME MEASURES: Costs, survival, and long-term outcome. RESULTS: The effective costs per survivor studied were $175000 (group 1) and $232400 (groups 2 and 3). Most patients experienced good long-term results, ie, employment status was unchanged for 69 (75%) of the patients, and the functional state was unchanged for 81 (88%) of the patients. Readmission to a hospital was necessary for 14 (15%) of the patients, and 5 (6%) required care in nursing homes. Of the patients studied, 75% described their quality of life as good. Patients in group 3 had significantly worse results for survival, functional status, and quality of life (P

Biliary complications after hepatic resection: risk factors, management, and outcome.

Lo CM. Fan ST. Liu CL. Lai EC. Wong J.
Department of Surgery, Queen Mary Hospital, University of Hong Kong, People's Republic of China.
OBJECTIVE: To identify the risk factors for the development of biliary complications after hepatic resection and to evaluate management in relation to the outcomes of these patients. DESIGN: Biliary complications are a common cause of major morbidity after hepatic resection. A survey was made of all patients undergoing hepatic resection at 1 institution. Perioperative risk factors related to the development of biliary complications were identified using multivariate analysis. Management and outcome were analyzed also. SETTING: A tertiary referral center. PATIENTS: From January 1, 1989, to October 31, 1995, 347 consecutive patients underwent 229 major and 118 minor hepatic resections. MAIN OUTCOME MEASURE: Development of postoperative biliary complications. RESULTS: Biliary complications developed in 28 (8.1%) of 347 patients; these complications carried high risks for liver failure (35.7%) and operative mortality (39.3%). Stepwise logistic regression analysis identified increasing age, higher preoperative white blood cell count, left-sided hepatectomy, and prolonged operation time as the independent predictors of development of biliary complications. Conservative treatment or nonoperative measures alone, such as percutaneous drainage or endoscopic therapy, were effective in treating the complication in 13 of 19 patients, but those who required reoperation had a high mortality rate (7 [77.8%] of 9 patients). Patients with demonstrable leakage from the common bile duct or its bifurcation tended to have poor outcomes. CONCLUSIONS: Biliary complications are a common and serious cause of morbidity after hepatic resection. Preresection cholangiography for finding biliary tract anomaly is recommended before left-sided hepatectomy. Although nonoperative measures are the preferred approach for selected patients with biliary complications, those with demonstrable leakage from the common bile duct or its bifurcation have a grave prognosis and may benefit from early surgical intervention.

Prediction of common bile duct stones prior to cholecystectomy: a prospective validation of a discriminant analysis function.

Trondsen E. Edwin B. Reiertsen O. Faerden AE. Fagertun H. Rosseland AR.
Department of Surgical Gastroenterology, Central Hospital of Akershus, Nordbyhagen, Norway.
BACKGROUND: Selection routines for preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients with symptomatic gallstone disease should give a low frequency of both false-negative ERCP results and residual common bile duct stones (CBDS). OBJECTIVE: To validate a discriminant function (DF) based on retrospectively collected data, for characterization of patients with symptomatic gallstone disease as regards presence of CBDS, and to compare clinical, ultrasonographic, and DF characterization. DESIGN: Prospective registration of CBDS criteria in consecutive patients with symptomatic gallstone disease. SETTING: A department of surgical gastroenterology in a Norwegian central hospital. PATIENTS: One hundred ninety-two patients with gallbladder stones. INTERVENTION: Laparoscopic cholecystectomy or ERCP with or without endoscopic sphincterotomy. MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of the clinical, ultrasonographic, and DF characterizations, and test of the validity of the DF. RESULTS: Thirty-two patients had CBDS. The clinical criteria of CBDS were present in 152 patients (79.2%): 21.1% of these patients had CBDS and there were no false-negative results (sensitivity, 100%; specificity, 25%). The risk of CBDS in patients with normal bile ducts at ultrasonographic examination was 8 of 124, and in patients with dilated ducts or suspected CBDS, 17 of 47 (sensitivity, 68%; specificity, 80%). The DF was positive in 50 patients (26%): 60% of these had CBDS, and there were 2 false-negative results (sensitivity, 94%; specificity, 88%). A discriminant analysis of the prospectively registered data selected the same set of CBDS criteria, and a new DF did not alter the characterization of any patient. CONCLUSIONS: Clinical characterization had a higher sensitivity for CBDS detection than ultrasonography alone, but a lower specificity. The DF analysis was both more sensitive and specific than ultrasonography, and seemed efficient in selecting symptomatic gallstone patients for ERCP. It was reproducible and simple to use.

Underlying disease as a predictor for rejection after liver transplantation.

Berlakovich GA. Rockenschaub S. Taucher S. Kaserer K. Muhlbacher F. Steiniger R.
Department of Transplant Surgery, University of Vienna, Austria.
BACKGROUND: As significantly more patients die of infection than of rejection after liver transplantation, we have to conclude that overimmunosuppression is common. Our analysis was performed to investigate underlying disease as an appropriate parameter for individually reduced immunosuppression. DESIGN: A consecutive series of patients receiving primary liver transplantation was analyzed with regard to acute rejection. SETTING: Department of transplantation surgery in a university hospital. PATIENTS AND METHODS: From 1988 to 1995, 252 patients received liver transplantation for posthepatitic cirrhosis, alcoholic cirrhosis, cholestatic disease, or hepatoma and were analyzed in a univariate and multivariate manner. MAIN OUTCOME MEASURE: The influence of various underlying diseases on the incidence of acute rejection. RESULTS: The estimated risk for freedom from acute rejection and analysis of cumulative rates of acute rejection stratified by group showed significant differences between the groups, except for alcoholic and posthepatitic cirrhosis. Severity of acute rejection episodes, as assessed by the need for rescue therapy, was similar in both univariate analysis and cumulative rates for alcoholic and posthepatitic cirrhosis. As expected, patients with cholestatic disease exhibited a significantly increased requirement for rescue therapy. For patients with hepatoma, a low incidence of initial and a high rate of repeated rescue therapy were observed. The varying immunological behavior within this group may have influenced both expansion of the tumor and severity of acute rejection. Multivariate analysis of potential risk factors identified underlying disease as a variable of independent prognostic significance for acute rejection and the need to receive rescue therapy. CONCLUSION: These results indicate the importance of taking the original disease into consideration where immunosuppressive therapy is concerned.

Laparoscopic cholecystectomy vs open cholecystectomy in the treatment of acute cholecystitis: a prospective study.

Lujan JA. Parrilla P. Robles R. Marin P. Torralba JA. Garcia-Ayllon J.
Departamento de Cirugia General, Hospital Universitario Virgen de la Arrixaca, El Palmar (Murcia), Spain.
OBJECTIVE: To compare the results of laparoscopic cholecystectomy (LC) with those of open cholecystectomy (OC) in the treatment of acute cholecystitis. DESIGN: A prospective, nonrandomized trial. SETTING: "Virgen de la Arrixaca" University Hospital, El Palmar (Murcia), Spain. PATIENTS: One hundred fourteen patients underwent LC, and 110 underwent OC. The patients underwent surgery within 72 hours of the onset of symptoms. The patients were selected for LC or OC depending on the surgeon's experience in laparoscopic surgery. MAIN OUTCOME MEASURES: Operating time, rate of conversion from LC to OC, complications, and length of hospital stay. RESULTS: Conversion from LC to OC was necessary in 15% of the patients. The mean operating time was 77 minutes for the OC group and 88 minutes for the LC group (P

Postoperative adjuvant chemotherapy after curative resection of hepatocellular carcinoma: a randomized controlled trial.

Lai EC. Lo CM. Fan ST. Liu CL. Wong J.
Department of Surgery, The University of Hong Kong, Queen Mary Hospital, People's Republic of China.
OBJECTIVE: To study the effect of adjuvant chemotherapy after curative hepatic resection in patients with hepatocellular carcinoma. DESIGN: A randomized controlled trial. SETTING: A tertiary referral center. PATIENTS: During a 54-month period, 142 patients with hepatocellular carcinoma underwent hepatic resection at 1 institution. Sixty-six patients who survived the operation and had no demonstrable evidence of residual disease on ultrasonographic examination and hepatic angiographic testing at 1 month after surgery agreed to participate in the study. The median follow-up time was 28.3 months. INTERVENTION: Thirty patients received a combination of intravenous epirubicin hydrochloride (8 doses of 40 mg/m2 each at 6-week intervals) and transarterial chemotherapy using an emulsion of iodized oil and cisplatin (3 courses with a maximum dose of 20 mL each at 2-month intervals). Thirty-six patients had no adjuvant treatment. MAIN OUTCOME MEASURES: Recurrence rate and disease-free survival. RESULTS: A total of 138 courses of intravenous epirubicin was given to the 30 patients. Sixty-one courses of transarterial chemotherapy were given to only 29 of the 30 patients assigned to the treatment group, because the hepatic artery in 1 patient was thrombosed. Six patients (20%) had chemotherapy-related complications with no mortality. Twenty-three of 30 patients in the treatment group and 17 of 36 patients in the control group had recurrences (P=.01). Patients who received adjuvant chemotherapy had a higher incidence of extrahepatic metastases (11 patients vs 5 patients; P=.03). The respective disease-free survival rates at 1, 2, and 3 years were 50%,36%, and 18% for the treatment group and 69%, 53%, and 48% for the control group (P=.04). CONCLUSION: In a group of patients who underwent curative resection of hepatocellular carcinoma, postoperative adjuvant chemotherapy using the present regimen was associated with more frequent extrahepatic recurrences and a worse outcome.

The pancreas: a symposium in honor of Charles Frederick Frey, MD.

Peskin GW.
Department of Surgery, University of California, Davis-East Bay, Oakland, USA.
On October 3, 1997, the University of California, Davis, under the leadership of James E. Goodnight, Jr, MD, chair of the Department of Surgery, gathered together 5 distinguished authorities in surgical pancreatic disease to present a symposium in honor of the retiring professor of 21 years, Charles F. Frey, MD. The atmosphere was one of informality and "give and take," and the result was not only a thorough and up-to-date review of many aspects of pancreatic disease but a wonderful tribute to a colleague who has spent a lifetime in this area of endeavor. Dr Frey has been a leader in this field, both scientifically in refining and extending our treatment of severe acute pancreatitis and administratively in organizing the Pancreas Club and promoting the concept that one could manage the pancreas, not in fear, but with confidence of success.

Pyogenic liver abscesses in patients with malignant disease: a report of 52 cases treated at a single institution.

Year 1998
Yeh TS. Jan YY. Jeng LB. Hwang TL. Chao TC. Chien RN. Chen MF.
Department of Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan.
BACKGROUND: Prognosis of pyogenic liver abscesses in patients with malignant disease is generally considered poor. The discrepancy between the outcomes of liver abscesses caused by hepatopancreatobiliary malignant disease and those caused by other malignant diseases, however, to our knowledge has never been investigated. OBJECTIVES: To clarify the clinical course of pyogenic liver abscess in patients with different types of cancer, and to compare outcomes in abscesses caused by hepatopancreatobiliary malignant disease and other malignant disease. DESIGN: Retrospective review of case series in our experience from 1980 through 1993. SETTING: Tertiary care university teaching hospital. PATIENTS: Fifty-two patients with pyogenic liver abscess related to the underlying cancer were divided into 2 groups. Group 1 (n=32) was composed of patients with cancer originating from the hepatic parenchyma, bile duct, and pancreas; group 2 (n=20) was composed of patients with cancer originating from other sites. INTERVENTIONS: Parenteral antibiotics, percutaneous drainage, surgical drainage, or hepatectomy, in combinations, were employed. MAIN OUTCOME MEASURES: Patient characteristics, symptoms, laboratory data, abscess characteristics, microbiological study, management, and outcome of the 2 groups were analyzed. RESULTS: Thirteen patients (41%) in group 1 and 16 patients (80%) in group 2 had undergone prior anticancer treatment. Jaundice was encountered more often in group 1 than in group 2 (29 patients [91%] vs 6 patients [30%], respectively, P=.001), whereas nausea and vomiting were more frequently seen in group 2 than in group 1 (17 patients [52%] vs 6 patients[31%], respectively, P=.04). Leukocytosis, hypoalbuminemia, hyperbilirubinemia, and reversed albumin-globulin ratio were more pronounced in group 1 than in group 2 (P=.001, .02, .003, and .03, respectively). Abscesses communicating with the intrahepatic biliary tree were more frequently encountered in group 1 than in group 2 (11 patients [34%] vs 2 patients [10%], respectively, P=.03). Escherichia coli and Klebsiella pneumoniae predominated in group 1, while the bacteria species in group 2 were more diverse. The hospital mortality rates of group 1 and group 2 were 28% (9 of 32 patients) vs 10% (2 of 20 patients) (P=.04), respectively. Twenty-three patients (72%) of group 1 died of uncontrolled biliary sepsis or progressive cancer or both within 6 months after the diagnosis, while 17 patients (85%) of group 2 survived longer than 1 year without relapse of the abscess and continued with anticancer treatment. CONCLUSIONS: Pyogenic liver abscess could be a presentation of hepatopancreatobiliary malignant disease at the preterminal stage, and carries a grave prognosis. Pyogenic liver abscess in patients with nonhepatopancreatobiliary malignant disease has a better chance of favorable outcome.

Effects of sucralfate vs antacids on gastric pathogens: results of a double-blind clinical trial.

Year 1998
Ephgrave KS. Kleiman-Wexler R. Pfaller M. Booth BM. Reed D. Werkmeister L. Young S.
Surgical Service, Veterans Affairs Medical Center, Iowa City, Iowa, USA.
BACKGROUND: Unblinded studies suggested that sucralfate prophylaxis for stress ulcers is associated with a lower rate of nosocomial pneumonia than acid-reducing approaches. We performed a randomized, double-blind, double-sham clinical trial comparing the exact microbial effects of each treatment. METHODS: One hundred forty patients entered this study before major elective surgery, allowing baseline cultures of gastric and pulmonary secretions to be obtained intraoperatively. Postoperatively, the patients were treated with standard doses of either sucralfate or antacids, plus a sham of the other drug. Cultures were repeated twice daily for 3 days. Molecular epidemiological typing was used to track the appearance of specific microbes and their transmission from site to site, and clinical end points were compared. The number of patients chosen was for sufficient statistical power to detect differences in the microbial measures, as detecting differences in clinical measures would have required increasing the sample size by an order of magnitude. RESULTS: Gastric pH was affected by the form of stress ulcer prophylaxis throughout the study, and this pH effect affected the number of new gastric organisms appearing in the 2 different groups. Colonization of the airway with new gastric organisms occurred more frequently in the antacid than in the sucralfate group, and colonization of the airway with organisms of gastric origin was associated with occurrence of postoperative pneumonia. CONCLUSIONS: Both sucralfate and antacids offered safe and effective stress ulcer prophylaxis in this double-blind clinical trial of postoperative patients in an intensive care unit. In association with the drug's effects on gastric pH, more new pathogens appeared in the gastric contents of antacid-treated than sucralfate-treated patients.

Intraoperative pancreatoscopy with the ultrathin pancreatoscope for mucin-producing tumors of the pancreas.

Year 1998
Kaneko T. Nakao A. Nomoto S. Furukawa T. Hirooka Y. Nakashima N. Nagasaka T.
Department of Surgery II, Faculty of Medicine, University of Nagoya, Japan.
OBJECTIVE: To evaluate the diagnostic accuracy of intraoperative pancreatoscopy with the ultrathin pancreatoscope for the main pancreatic lesions of mucin-producing tumors of the pancreas (MPT). DESIGN: Prospective diagnostic test study with a criterion standard of pathologic examination and masked comparison. SETTING: A university hospital. PATIENTS: Twenty-four consecutive patients with MPT referred for surgery in whom endoscopic retrograde pancreatography, endoscopic ultrasonography, and computed tomography had been performed as a diagnostic examination. All patients underwent surgery and the diagnosis was confirmed by pathologic examination. INTERVENTION: Intraoperative pancreatoscopy was performed with the ultrathin pancreatoscope. MAIN OUTCOME MEASURES: Findings of intraoperative pancreatoscopy, endoscopic retrograde pancreatography, and endoscopic ultrasonography were confirmed by pathologic examination of resected specimens. The diagnostic accuracy of these 3 modalities in detection of MPT lesions in the main pancreatic duct was compared. RESULTS: The diagnostic criterion of MPT lesions in the main pancreatic duct by intraoperative pancreatoscopy was a granular and papillary mural nodule. An MPT lesion in the main pancreatic duct was found in 17 of 24 cases. Intraoperative pancreatoscopy detected 10 cases of intraductal MPT lesions that could not be detected by endoscopic ultrasonography or endoscopic retrograde pancreatography. Five of 10 cases were intraductal multicentric lesions. In 3 of these 5, additional pancreatic resection was performed. For diagnosis of MPT lesions, the sensitivity, specificity, and overall accuracy of intraoperative pancreatoscopy were all 100%; respective values were 43.8%, 100%, and 60.9% for endoscopic retrograde pancreatography and 47%, 100%, and 62.5% for endoscopic ultrasonography. CONCLUSIONS: Intraoperative pancreatoscopy is safe and effective in diagnosing the intrapancreatic duct extension and multicentric lesions of MPT. It provides important information for operative strategy and contributes to successful pancreatic surgery.

Long-term evaluation of modified lateral anorectal myomectomy for low-segment Hirschsprung disease.

Year 1998
Shehata SM. El-Banna IA. Gaber AA. El-Samongy AM. Attia MA.
Department of Pediatric Surgery, Sophia Children's Hospital, Rotterdam, The Netherlands. illsley@CHIS.AZR.NL
OBJECTIVES: To provide a simple myomectomy technique for low-segment Hirschsprung disease and evaluate the efficacy of the new modification. DESIGN: Case series of 19 patients followed up for 12 to 56 months (mean, 39.1 months). SETTING: Tanta University Hospital, Tanta, Egypt. PARTICIPANTS: Nineteen patients aged 4 months to 10 years complaining of chronic constipation, with radiological and clinical data suggestive of low-segment Hirschsprung disease proven by histological examination. INTERVENTION: Modified lateral anorectal myomectomy. MAIN OUTCOME MEASURES: Clinical and radiological improvement measured by postoperative barium enema, bowel habits, and patient's relief of symptoms. RESULTS: Seventeen of 19 patients improved clinically and 13 showed radiological improvement 3 years postoperatively. There was poor response in 2 patients, who were subjected to further Soave procedures. CONCLUSION: Modified lateral anorectal myomectomy is an effective and technically simple procedure in patients suspected of having low-segment Hirschsprung disease.

Endoscopic retrograde cholangiopancreatography and endoscopic endoprosthesis insertion in patients with Klatskin tumors.

Year 1998
Liu CL. Lo CM. Lai EC. Fan ST.
Department of Surgery, the University of Hong Kong, Queen Mary Hospital, People's Republic of China.
OBJECTIVE: To assess the value and the associated morbidity of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic endoprosthesis insertion in the treatment of patients with Klatskin tumors. DESIGN: Retrospective study. SETTING: A tertiary referral center. PATIENTS: Fifty-five consecutive patients with Klatskin tumors diagnosed through typical cholangiographic and computed tomographic findings. INTERVENTION: Standard ERCP with endoscopic stenting technique was employed. Once the diagnosis of Klatskin tumor was confirmed on cholangiogram, endoscopic stenting was performed to bypass the stricture. Multiple stents were inserted if necessary to ensure adequate biliary drainage. MAIN OUTCOME MEASURES: The success rate of ERCP and endoscopic endoprosthesis insertion, successful drainage rate, early complications of endoscopic procedure, procedure-related mortality, and long-term outcome of endoprosthesis. RESULTS: Of the 55 patients, cholangiography was performed in 53 (96%). In the 49 patients in whom endoscopic stenting was attempted, the procedure was successful in 28 patients (57%) at the first attempt and 8 patients (16%) at the second attempt, resulting in a cumulative success rate of 73%. Only 20 of these patients had satisfactory biliary drainage, resulting in an overall successful drainage rate of 41%. Early complications, including acute cholangitis, acute pancreatitis, and postpapillotomy bleeding occurred in 14 patients (25%). Three patients (5%) died of procedure-related complications. The median patency of the first endoprosthesis inserted was 1 week (range, 0-8 wk). The 30-day mortality rate was 18%. CONCLUSIONS: In patients with Klatskin tumors, ERCP and endoscopic endoprosthesis insertion have a low successful drainage rate, are associated with high morbidity and procedure-related mortality, and have a limited effect on long-term palliation. Endoscopic retrograde cholangiopancreatography and endoscopic endoprosthesis insertion have a limited value in the management of patients with Klatskin tumors.

Embryologic bases of extended radical resection in pancreatic cancer.

Year 1998
Borghi F. Gattolin A. Garbossa D. Bogliatto F. Garavoglia M. Levi AC.
Department of Clinical Physiopathology, University of Turin, Italy.
OBJECTIVE: To analyze whether an embryologic "rationale" exists to the clinical and anatomicopathological data that suggest the execution of extended resections in patients with pancreatic cancer. METHODS: Reconstruction of serial histological sections of 18 human embryos and fetuses regarding the pancreatic region; anatomical microdissections of two 9-month fetuses. RESULTS: The ventral and dorsal pancreatic buds can be identified until the eighth week of development. A close developmental relationship between the dorsal pancreas and the lymphatic and nervous structures in the dorsal mesogastrium is observed. Other lymphatic stations are exclusively related to the ventral pancreas. The posterior fusion of the dorsal mesogastrium is a late event in embryologic development. CONCLUSIONS: The complete fusion of the 2 pancreatic buds occurs later than previously reported in the literature. The close embryologic relations of these buds with the lymphatic and nervous peripancreatic structures may support the need for extended resections in patients with pancreatic cancer.

Quality of life in patients with cancer of the esophagus and gastric cardia: a case for palliative resection.

Year 1998
Branicki FJ. Law SY. Fok M. Poon RT. Chu KM. Wong J.
Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Pokfulam. branicki@hkucc.hk
OBJECTIVE: To evaluate quality-of-life (QOL) parameters in patients undergoing esophagectomy, curative or palliative, for carcinoma. DESIGN: Nonconsecutive case series. PATIENTS: Eighty-eight patients who underwent esophagectomy for cancer (curative, n=49 [56%]; palliative, n=39 [44%]) provided QOL assessments over an 18-month period. SETTING: Procedures for referral care were performed by a single team of clinicians in a tertiary referral center. Evaluations of QOL were made by 1 independent trained investigator. OUTCOME MEASURES: Data were documented by questionnaire at interview and parameters evaluated included an esophageal module for the type and quantity of food intake, severity of related symptoms on eating, Eastern Cooperative Oncology Groups (ECOG) performance status, sleep, pain, leisure activity, working capacity, outlook on life, general well-being, and support from family and friends. A summation of selected parameters was used to calculate a total score. RESULTS: Significant improvements were recorded in both the curative and palliative groups for at least 1 year following surgery in the type (P

Middle segment pancreatectomy: a novel technique for conserving pancreatic tissue.

Year 1998
Warshaw AL. Rattner DW. Fernandez-del Castillo C. Z'graggen K.
Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston 02114, USA.
Pancreatoduodenectomy and extended distal pancreatectomy for benign tumors in the pancreatic neck and body incur a notable waste of normal tissue and unnecessary risk of both diabetes mellitus and splenic loss. We describe the technique of a limited resection of the middle portion of the pancreas, termed middle segment pancreatectomy, and report our results in 12 patients. Middle segment pancreatectomy was used in 12 consecutive patients with pancreatic tumors of the neck or body. The transected pancreatic head was sutured with duct ligation, and a Roux-en-Y loop of jejunum was anastomosed to the tail using mucosa-to-mucosa duct approximation and a 5F catheter for duct stenting and drainage. In 12 patients, 7 with cystic tumors (5 patients with serous cystadenoma; 2 patients with mucinous cystic neoplasms), 3 with islet cell adenomas, 1 with islet cell carcinoma, and 1 with intraductal papillary mucinous tumor, the tumor was resected by a middle segment pancreatectomy. In each case, the tumor, measuring 0.9 to 5.2 cm, lay in the neck or body of the pancreas and could not be safely enucleated without compromising the pancreatic duct. Each tumor was resected with clear margins. Two patients had a temporary pancreatic fistula; 1 patient had delayed gastric emptying. Median postoperative length of stay was 8 days. No patient became diabetic or required oral pancreatic enzyme supplements. No local recurrences occurred after a mean follow-up of 18 months. Middle segment pancreatectomy is a safe and effective technique for resecting selected pancreatic tumors in the neck and body of the pancreas while preserving pancreatic endocrine and exocrine function and the spleen.

Implications of peritoneal cytology for pancreatic cancer management.

Year 1998
Makary MA. Warshaw AL. Centeno BA. Willet CG. Rattner DW. Fernandez-del Castillo C.
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
OBJECTIVE: To assess the implications of positive cytology for malignant cells (positive results) from peritoneal washings in the management of patients with pancreatic cancer. DESIGN: Retrospective cohort study. SETTING: Referral practice in a university hospital. PATIENTS: A total of 32 consecutive pancreatic cancer patients with positive results from peritoneal washings during a 4-year period, 17 with visible biopsy-proven intraabdominal metastases at the time of laparoscopy or laparotomy and 15 without visible metastases. A treatment-matched control group of 30 patients was randomly selected from a group of 105 patients with negative cytology for malignant cells (negative results) from peritoneal-fluid cytology. INTERVENTIONS: Eight of 17 patients with visible metastases underwent treatment with chemotherapy, radiation, or both; 13 of the 15 patients with no visible metastases underwent further treatment, including pancreatic resection in 2 patients and external beam radiation in 13 patients (3 with intraoperative radiation therapy). MAIN OUTCOME MEASURES: Time to metastases and mortality. RESULTS: Median survival among patients with and without visible metastasis was 7.8 months and 8.6 months, respectively (P=.95), despite the fact that patients without visible metastases received more treatment. Patients without visible metastases at presentation were found to have metastatic disease as documented by computed tomographic scan or subsequent laparotomy at a median time of 2.9 months. The survival of treatment-matched patients with negative cytology was significantly longer (median, 13.5 months; P=.04). CONCLUSIONS: Pancreatic cancer patients with peritoneal micrometastases have a dismal outcome even without macroscopic metastases. Since these patients do not benefit from local therapy, the finding of a positive result from peritoneal-fluid cytologic testing contraindicates further irradiation or surgery, except for specific complications.

Is there a role for abdominal computed tomographic scans in appendicitis?

Year 1998
Schuler JG. Shortsleeve MJ. Goldenson RS. Perez-Rossello JM. Perlmutter RA. Thorsen A.
Department of Surgery, Mount Auburn Hospital, Cambridge, Mass 02238, USA.
OBJECTIVE: To better define the effectiveness of abdominal computed tomographic scanning (ACTS) in adult patients with suspected appendicitis. DESIGN: Retrospective analysis. SETTING: A community teaching hospital. PATIENTS: Ninety-seven patients with appendicitis in the differential diagnosis, whose clinical findings were insufficient to perform surgery or to discharge from the hospital, during a 14-month period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Accuracy of ACTS, rate of appendectomies that show no appendicitis (negative appendectomy rate), and frequency of ACTS as a definitive diagnostic test. RESULTS: Forty-nine of the 50 patients with appendicitis were correctly diagnosed by ACTS. Forty-three of the 47 patients without appendicitis were correctly diagnosed by ACTS. Positive predictive value was 92%, negative predictive value was 98%, and accuracy was 96%. The ACTS group had a negative appendectomy rate of 5.8% (3/52), lower than the hospital rate of 14% for the preceding 3 years. The ACTS established an alternative diagnosis in 16 patients, allowed 10 other patients to be discharged early or not admitted, and was the critical diagnostic test in 30 of the patients with appendicitis. Therefore, the ACTS played a definitive role in the treatment of 56 (57.7%) of the 97 patients. CONCLUSIONS: The ACTS was an accurate test in the diagnosis of appendicitis and was of significant benefit in 57.7% of the patients studied. However, it was difficult to predict which patients were most likely to benefit. Expanded selective use of ACTS for patients with clinically indeterminate appendicitis may result in a lower negative appendectomy rate and fewer patient admissions for observation.

Long-term complications associated with prosthetic repair of incisional hernias.

Year 1998
Leber GE. Garb JL. Alexander AI. Reed WP.
Department of Surgery, Baystate Medical Center Campus of Tufts University School of Medicine, Springfield, Mass 01199, USA.
OBJECTIVE: To determine whether the type of prosthetic material and technique of placement influenced long-term complications after repair of incisional hernias. DESIGN: Retrospective cohort analytic study. SETTING: University-affiliated hospital. PATIENTS: Two hundred patients undergoing open repair of abdominal incisional hernias with prosthetic material between 1985 and 1994. INTERVENTIONS: Four types of prosthetic material were used and placed either as an onlay, underlay, sandwich, or finger interdigitation technique. The materials were monofilamented polypropylene mesh (Marlex, Davol Inc, Cranston, RI), double-filamented mesh (Prolene, Ethicon Inc, Somerville, NJ), expanded polytetrafluroethylene patch (Gore-Tex, WL Gore & Associates, Phoenix, Ariz) or multifilamented polyester mesh (Mersilene, Ethicon Inc). MAIN OUTCOME MEASURES: The incidence of recurrence and complications such as enterocutaneous fistula, bowel obstruction, and infection with each type of material and technique of repair were compared with univariate and multivariate analysis. RESULTS: On univariate analysis, multifilamented polyester mesh had a significantly higher mean number of complications per patient (4.7 vs 1.4-2.3; P

Metastases to the pancreas and their surgical extirpation.

Year 1998
Z'graggen K. Fernandez-del Castillo C. Rattner DW. Sigala H. Warshaw AL.
Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston 02114, USA.
BACKGROUND: The pancreas is an unusual but occasionally favored site for metastases, notably from carcinomas of the kidney and lung. The pancreas may be the only identified locus of spread, and therefore may provide an opportunity for significant palliation or even cure using pancreatectomy. OBJECTIVE: To report the treatment and outcome of patients presenting with metastases to the pancreas. DESIGN: Five-year survey. SETTING: Tertiary referral center. PATIENTS: Ten patients with apparently isolated metastases to the pancreas were identified from January 1, 1991, to December 31, 1995. All patients were followed up until death or to September 1997. RESULTS: The patients had been treated previously for carcinoma of the lung (n=4), renal cell carcinoma (n=2), sarcoma (n=2), breast carcinoma (n=1), and endometrial carcinoma (n=1). The interval between primary treatment and presentation of the metastases averaged 70 months (14-24 months for lung cancer, 10 and 22 years for renal cell carcinoma, 4 and 6 years for sarcoma, 8 years for breast cancer, and 36 months for endometrial carcinoma). Metastases were initially misdiagnosed as primary pancreatic cancers in 7 patients. In 4 patients (those with renal cell cancer and sarcomas), the tumor was completely resected using total pancreatectomy (n=3) or Whipple resection (n=1). Survival after diagnosis averaged 22 months. Two of the 4 patients undergoing pancreatic resection remain alive and well 20 and 25 months after pancreatectomy. CONCLUSIONS: The pancreas may be the presenting and perhaps sole locus for metastasis, typically years after treatment for certain extrapancreatic malignant neoplasms. Recognition and surgical treatment can provide worthwhile palliation and long-term survival.

Preemptive pain control in patients having laparoscopic hernia repair: a comparison of ketorolac and ibuprofen.

Year 1998
Mixter CG 3rd. Meeker LD. Gavin TJ.
Department of Surgery, Exeter Hospital, NH, USA.
OBJECTIVES: To determine if nonsteroidal anti-inflammatory drugs provide adequate pain control for patients having laparoscopic hernia repair and to compare the effectiveness of ketorolac tromethamine with ibuprofen in reducing postoperative laparoscopic hernia pain. DESIGN AND SETTING: Prospective double-blind randomized study at a 100-bed community hospital. PATIENTS: Seventy patients ranging in age from 16 to 83 years scheduled for elective laparoscopic inguinal hernia repair. INTERVENTIONS: Patients undergoing laparoscopic hernia repair were enrolled in a double-blind randomized study to compare the 2 treatments. Group 1 received a placebo capsule 1 hour before surgery and ketorolac tromethamine, 60 mg intravenously, at the time of trocar insertion. Group 2 received ibuprofen, 800 mg an hour before surgery, and isotonic sodium chloride solution, 2 mL intravenously, at the time of trocar insertion. In addition, all patients received local infiltration of 30 mL of bupivacaine hydrochloride into their trocar sites. All patients were discharged within 5 hours of the operation and were instructed to take 400 mg of ibuprofen orally every 4 hours for 24 hours whether or not they were experiencing pain. A 24-hour supply of ibuprofen was provided to all study patients. Pain was assessed using the Visual Analog Pain Scale with a maximum pain rating of 100. Assessments were done at the time of and 18 hours after discharge. MAIN OUTCOME MEASURE: Postoperative pain 18 and 24 hours after discharge was assessed using a standardized questionnaire in a telephone interview by a registered nurse from the Outpatient Surgical Unit. RESULTS: There was no significant difference in the level of pain experienced by 35 patients who received ketorolac intravenously and 35 who received ibuprofen orally. There was no significant difference between the 2 treatment groups in the amount of pain experienced at discharge and 18 hours after discharge. CONCLUSIONS: Pain relief from ibuprofen, 800 mg, administered orally an hour before laparoscopic hernia repair was not statistically different from that obtained with intravenous ketorolac, 60 mg, administered intraoperatively when comparing the hospital discharge pain score and the mean and highest pain scores 18 hours after discharge. Ibuprofen offers equivalent pain control at a lower cost and reduced potential for adverse drug events compared with intravenous ketorolac in patients having laparoscopic hernia repair. No patient required narcotic supplementation, and pain control was judged satisfactory by all the patients.

Laparoscopic common bile duct exploration: practical application.

Year 1998
Ferguson CM.
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
OBJECTIVE: To evaluate the effectiveness of laparoscopic common bile duct exploration in unselected patients. DESIGN: Consecutive sample. SETTING: Tertiary care general hospital. PATIENTS: Three hundred and two patients with symptomatic cholelithiasis presenting to a single surgeon during a 5-year period. INTERVENTIONS: Laparoscopic cholecystectomy, cholangiography, and common bile duct exploration. MAIN OUTCOME MEASURES: Successful laparoscopic cholecystectomy and common bile duct exploration. RESULTS: Three hundred and two consecutive patients underwent cholecystectomy for symptomatic cholelithiasis; 280 of the procedures were successfully completed laparoscopically. Cholangiography was attempted in 269 patients, was successful in 239, and revealed evidence of choledocholithiasis in 25. Preoperative ultrasonography and liver function tests predicted the presence of common bile duct stones in 24% and 32% of patients, respectively. Seven of the patients with choledocholithiasis presented with biliary colic, 7 with biliary colic and jaundice, 8 with acute cholecystitis (3 with gallbladder perforation), 1 with acute cholecystitis and jaundice, and 2 with gallstone pancreatitis. Four of 5 patients underwent successful transcystic exploration with a biliary Fogarty catheter, 12 of 16 patients underwent successful transcystic choledochoscopy and stone basket extraction, and all 4 attempts at choledochotomy and choledochoscopic stone basket extraction were successful, for a total success rate of 80% with laparoscopic common bile duct exploration. One of the failures was converted to an open procedure, and 4 of the failures had successful postoperative endoscopic retrograde cholangiopancreatography and extraction of stones. CONCLUSIONS: Laparoscopic cholecystectomy and common bile duct exploration is a highly successful procedure for the management of common duct stones in an unselected group of patients. Choledochotomy with choledochoscopy is the preferred method of common bile duct exploration.

Intestinal atresia and stenosis: a 25-year experience with 277 cases.

Year 1998
Dalla Vecchia LK. Grosfeld JL. West KW. Rescorla FJ. Scherer LR. Engum SA.
Department of Pediatric Surgery, James Whitcomb Riley Hospital for Children, Indiana University Medical Center, Indianapolis 46202, USA.
OBJECTIVE: To evaluate the causes, clinical presentation, diagnosis, operative management, postoperative care, and outcome in infants with intestinal atresia. DESIGN: Retrospective case series. SETTING: Pediatric tertiary care teaching hospital. PATIENTS: A population-based sample of 277 neonates with intestinal atresia and stenosis treated from July 1, 1972, through April 30, 1997. The level of obstruction was duodenal in 138 infants, jejunoileal in 128, and colonic in 21. Of the 277 neonates, 10 had obstruction in more than 1 site. Duodenal atresia was associated with prematurity (46%), maternal polyhydramnios (33%), Down syndrome (24%), annular pancreas (33%), and malrotation (28%). Jejunoileal atresia was associated with intrauterine volvulus, (27%), gastroschisis (16%), and meconium ileus (11.7%). INTERVENTIONS: Patients with duodenal obstruction were treated by duodenoduodenostomy in 119 (86%), of 138 patients duodenotomy with web excision in 9 (7%), and duodenojejunostomy in 7 (5%) A duodenostomy tube was placed in 3 critically ill neonates. Patients with jejunoileal atresia were treated with resection in 97 (76%) of 128 patients (anastomosis, 45 [46%]; tapering enteroplasty, 23 [24%]; or temporary ostomy, 29 [30%]), ostomy alone in 25 (20%), web excision in 5 (4%), and the Bianchi procedure in 1 (0.8%). Patients with colon atresia were managed with initial ostomy and delayed anastomosis in 18 (86%) of 21 patients and resection with primary anastomosis in 3 (14%). Short-bowel syndrome was noted in 32 neonates. MAIN OUTCOME MEASURES: Morbidity and early and late mortality. RESULTS: Operative mortality for neonates with duodenal atresia was 4%, with jejunoileal atresia, 0.8%, and with colonic atresia, 0%. The long-term survival rate for children with duodenal atresia was 86%; with jejunoileal atresia, 84%; and with colon atresia, 100%. The Bianchi procedure (1 patient, 0.8%) and growth hormone, glutamine, and modified diet (4 patients, 1%) reduced total parenteral nutrition dependence. CONCLUSIONS: Cardiac anomalies (with duodenal atresia) and ultrashort-bowel syndrome (

Improved survival in congenital diaphragmatic hernia with evolving therapeutic strategies.

Year 1998
Weber TR. Kountzman B. Dillon PA. Silen ML.
Department of Surgery, Saint Louis University Health Sciences Center, and Cardinal Glennon Children's Hospital, MO 63104, USA.
OBJECTIVE: To compare the survival rates for 3 therapeutic eras, each using different treatment strategies for the management of newborns with congenital diaphragmatic hernia (CDH). DESIGN: Retrospective review of all infants with CDH from 1970 through 1997. SETTING: Tertiary care children's hospital. PARTICIPANTS: A total of 203 newborns with CDH. INTERVENTIONS: Extracorporeal membrane oxygenation (ECMO) was performed with arterial and venous cannulation connected to a membrane oxygenatorroller pump perfusion apparatus, using systemic heparinization. Delayed operative therapy involved operative repair 2 to 5 days after birth using preoperative ventilation support only. Since 1970, 203 newborns with CDH were managed in 3 therapeutic eras: era 1 (1970-1983, 102 patients) was immediate CDH repair with postoperative ventilator and pharmacologic support; era 2 (1984-1988, 45 patients) was immediate repair with postoperative ventilator support (18 patients), immediate ECMO with CDH repair on ECMO (4 patients), or immediate repair with postoperative ECMO (23 patients); and era 3 (1989-1997, 56 patients) was immediate ECMO with repair on ECMO (23 patients), immediate repair with postoperative ECMO (9 patients), or delayed (2-5 days) CDH repair (24 patients). MAIN OUTCOME MEASURES: Survival, defined as discharge from the hospital, and morbidity. RESULTS: Survival was 42% (43/102 patients) in era 1, 58% (26/45 patients) in era 2, and 79% (44/56 patients) in era 3 (P

Evaluation of benign vs malignant hepatic lesions with positron emission tomography.

Year 1998
Delbeke D. Martin WH. Sandler MP. Chapman WC. Wright JK Jr. Pinson CW.
Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tenn 37232-2675, USA.
BACKGROUND: In most malignant cells, the relatively low level of glucose-6-phosphatase leads to accumulation and trapping of [18F]fluorodeoxyglucose (FDG) intracellularly, allowing the visualization of increased uptake compared with normal cells. OBJECTIVES: To assess the value of FDG positron emission tomography (PET) to differentiate benign from malignant hepatic lesions and to determine in which types of hepatic tumors PET can help evaluate stage, monitor response to therapy, and detect recurrence. DESIGN: Prospective blinded-comparison clinical cohort study. SETTING: Tertiary care university hospital and clinic. PATIENTS: One hundred ten consecutive referred patients with hepatic lesions 1 cm or larger on screening computed tomographic (CT) images who were seen for evaluation and potential resection underwent PET imaging. There were 60 men and 50 women with a mean (+/-SD) age of 59 +/- 14 years. Follow-up was 100%. INTERVENTIONS: A PET scan using static imaging was performed on all patients. The PET scan imaging and biopsy, surgery, or both were performed, providing pathological samples within 2 months of PET imaging. All PET images were correlated with CT scan to localize the lesion. However, PET investigators were unaware of any previous interpretation of the CT scan. MAIN OUTCOME MEASURES: Visual interpretation, lesion-to-normal liver background (L/B) ratio of radioactivity, and standard uptake value (SUV) were correlated with pathological diagnosis. RESULTS: All (100%) liver metastases from adenocarcinoma and sarcoma primaries in 66 patients and all cholangiocarcinomas in 8 patients had increased uptake values, L/B ratios greater than 2, and an SUV greater than 3.5. Hepatocellular carcinoma had increased FDG uptake in 16 of 23 patients and poor uptake in 7 patients. All benign hepatic lesions (n = 23), including adenoma and fibronodular hyperplasia, had poor uptake, an L/B ratio of less than 2, and an SUV less than 3.5, except for 1 of 3 abscesses that had definite uptake. CONCLUSIONS: The PET technique using FDG static imaging was useful to differentiate malignant from benign lesions in the liver. Limitations include false-positive results in a minority of abscesses and false-negative results in a minority of hepatocellular carcinoma. The PET technique was useful in tumor staging and detection of recurrence, as well as monitoring response to therapy for all adenocarcinomas and sarcomas and most hepatocellular carcinomas. Therefore, pretherapy PET imaging is recommended to help assess new hepatic lesions.

Treatment of advanced gastroesophageal reflux disease with Collis gastroplasty and Belsey partial fundoplication.

Year 1998
Ritter MP. Peters JH. DeMeester TR. Gadenstatter M. Oberg S. Fein M. Hagen JA. Crookes PF. Bremner CG.
Department of Surgery, University of Southern California School of Medicine, Los Angeles 90033-4612, USA.
OBJECTIVE: To examine the factors affecting outcome in patients with advanced gastroesophageal reflux disease. DESIGN: Retrospective analysis. SETTING: University tertiary referral center. PATIENTS: Thirty-seven patients with advanced gastroesophageal reflux disease and no previous antireflux surgery. INTERVENTIONS: Thirty patients underwent Collis gastroplasty for esophageal lengthening and Belsey partial fundoplication. Seven patients with esophageal stricture and global loss of esophageal body motility who underwent primary esophagectomy and reconstruction were used as a comparison group. OUTCOME MEASURES: Symptomatic outcome in all 37 patients was assessed by questionnaire at a median of 25 months (range, 5-156 months) after surgery. In a subset of 11 patients undergoing the Collis-Belsey procedure, outcome was measured using 24-hour pH and results of motility studies. RESULTS: The Collis-Belsey procedure was successful in relieving symptoms of gastroesophageal reflux in 21 (70%) of the 30 patients. The outcome was excellent or good in 16 (89%) of 18 patients who presented with symptoms other than dysphagia, but only in 5 (42%) of 12 patients with dysphagia (P = .01). The outcome was particularly poor if dysphagia was associated with a previously dilated esophageal stricture. Persistent or induced dysphagia was the reason for failure in all but 1 patient. Results of 24-hour esophageal pH studies were returned to normal in 8 (73%) of 11 patients undergoing postoperative evaluation. Contraction amplitudes in the distal esophagus and the prevalence of simultaneous contractions in these segments did not change after the operation. All 7 patients who underwent primary esophagectomy were classified as having an excellent or good outcome and were relieved of their reflux symptoms, including dysphagia. Six of these could eat 3 meals per day and enjoyed an unrestricted diet. CONCLUSIONS: The outcome of the Collis-Belsey procedure in patients with advanced gastroesophageal reflux disease without dysphagia is excellent. It is less so in patients with dysphagia as a preoperative symptom. Esophagectomy can provide a good outcome in patients who have a combination of dysphagia stricture and a profound loss of esophageal motility.

Delayed primary repair of esophageal atresia with tracheoesophageal fistula: is it worth the wait?

Year 1998
Healey PJ. Sawin RS. Hall DG. Schaller RT. Tapper D.
Department of Surgery, University of Washington, and the Children's Hospital and Medical Center, Seattle 998105, USA.
OBJECTIVE: To characterize a successful approach to the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF), significant prematurity with respiratory distress syndrome (RDS), or both, so as to preserve the native esophagus. DESIGN: A review of the medical records and office charts of a cohort of patients with EA and TEF. SETTING: A tertiary care children's hospital affiliated with a major university. PATIENTS: A total of 118 children with EA and TEF admitted from February 1986 through December 1996. All of the patients diagnosed as having EA and TEF during this period were included. INTERVENTION: Of the 118 infants, 88 received primary repair of EA and TEF within 48 hours of birth. An additional 23 children had the TEF divided and a gastrostomy placed secondary to (1) severe RDS and prematurity (n = 6), (2) long-gap EA (gap length > 4 cm or the upper pouch above the thoracic inlet (n = 10), or (3) associated cardiac defects (n = 7). Delayed primary EA repair was done when the RDS resolved or the gap length was 2 cm or less. MAIN OUTCOME MEASURES: Successful anastomosis of native esophagus. Comparison of incidence of gastroesophageal reflux, anastomotic complications, or survival between groups undergoing primary or delayed repair. RESULTS: Primary EA was accomplished in 88 patients. Delayed EA was successfully accomplished in 18 of the 19 surviving patients within 5 months, thereby preserving the native esophagus in all surviving infants. There was no difference in anastomotic complications, gastroesophageal reflux, or survival when the delayed group was compared with those who had a primary repair. CONCLUSIONS: Using delayed EA repair, all children with EA and TEF, regardless of gap length, can have their esophagus preserved. The primary cause of mortality was the association of a severe cardiac anomaly with EA and TEF.