Surgery

Microsatellite instability in sporadic carcinomas of the proximal colon: association with diploid DNA content, negative protein expression of p53, and distinct histomorphologic features.

Forster S. Sattler HP. Hack M. Romanakis K. Rohde V. Seitz G. Wullich B.
Institute of Human Genetics, University of the Saarland, Homburg, Germany.
BACKGROUND: Microsatellite instability (MIN) seems to characterize a particular subset of sporadic colorectal adenocarcinomas with the studies indicating a better clinical outcome for patients with MIN-positive tumors than for those with MIN-negative ones. The goal of this study was to further clarify whether a genotype-specific histomorphology of the right-sided colonic carcinomas can be identified. METHODS: MIN status, DNA content, and p53 protein expression were evaluated in cryoconserved specimens from 20 adenocarcinomas of the proximal colon and correlated to stage, grade, and other histomorphologic features. The study was restricted to tumors of the proximal colon because approximately 90% of all MIN-positive tumors were found in the proximal colon, and differences between right- and left-sided tumors cannot be excluded a priori. RESULTS: By using four microsatellite markers, instability was detected in 35% of the tumors analyzed. The clinicopathologic features in the MIN-positive tumors were found to differ markedly from the MIN-negative tumors in their poorly differentiated histologic pattern, extracellular mucin production, and favorable lymph node and distant metastatic behavior. A marked association was found between MIN positivity and DNA diploid status, as well as negative p53 immunostaining. CONCLUSIONS: The MIN-positive colonic carcinomas were characterized by distinct histomorphologic features that are recognizable at routine diagnostic evaluation. Poorly differentiated adenocarcinomas of the proximal colon, with only a few lymph nodes and no distant metastases at presentation, and lack of p53 accumulation are highly suggestive of being MIN positive. These tumors should be discriminated from the other poorly differentiated carcinomas, because they seem to be associated with an improved prognosis compared with the tumors without microsatellite instability.

Mesenteric arterioportal shunt after hepatic artery interruption.

Iseki J. Noie T. Touyama K. Nakagami K. Takagi M. Ori T. Ooba N. Ito K.
Department of Surgery, Shizuoka General Hospital, Japan.
BACKGROUND: Massive hepatic necrosis from hepatic artery (HA) interruption is a complication after extended pancreatobiliary operation. The effectiveness of a mesenteric arterioportal shunt in preventing liver failure after massive hepatic necrosis was evaluated. METHODS: Of 98 patients who underwent pancreatic or hepatic resection for pancreatobiliary carcinoma between January 1989 and December 1995, six received a mesenteric arterioportal shunt. Clinical and hemodynamic analyses were done retrospectively. RESULTS: The six patients were classified into groups: A, postoperative hepatic arterial occlusion and, B, main HA excision without reconstruction. One patient in group A and three patients in group B had good arterioportal shunt patency and favorable clinical courses. However, fatal hepatic necrosis after ligation of the HA proper occurred in one patient in group A from small portal flow despite a presumed patent shunt. In another patient in group A angiogram revealed shunt occlusion. CONCLUSIONS: A mesenteric arterioportal shunt is beneficial when massive hepatic necrosis has occurred or is expected after main HA interruption under such conditions as postoperative hepatic arterial occlusion or HA excision without reconstruction. The procedure has the advantages of appropriate selection of artery size, a lower abdominal site apart from the primary operative field, and easy shunt closure by transarterial embolization.

Usefulness of three-dimensional computed tomography for anatomic liver resection: sub-subsegmentectomy.

Togo S. Shimada H. Kanemura E. Shizawa R. Endo I. Takahashi T. Tanaka K.
Second Department of Surgery, Yokohama City University School of Medicine, Japan.
BACKGROUND: Precise subtotal hepatectomies based on the vascular anatomy revealed by preoperative three-dimensional computed tomography (3D-CT) were reviewed to examine the usefulness of 3D-CT. METHODS: The clinical records and 3D-CT images of 20 patients with 24 hepatomas less than 50 mm in diameter who underwent hepatectomy for hepatocellular carcinoma and metastatic tumors and the usefulness of 3D-CT were assessed. Couinaud's classification of liver subsegments and Takayasu's classification of sub-subsegments were used as the criteria for the anatomic division. RESULTS: The accuracy in localizing tumors in a small subsegment of the liver was 75% (18 of 24 tumors) for conventional CT and 100% (24 of 24 tumors) for 3D-CT (p < 0.05). 3D-CT images made it possible to perform complete resection confined to the portal unit containing the tumor in patients with poor liver function. This method allowed complete preservation of the circulation of the remnant liver, thus reducing complications. CONCLUSIONS: The 3D-CT technique provides more accurate diagnosis and a realistic virtual image of a tumor's location in the liver and so makes possible the anatomic resection of the liver. Because diagnostic errors could result in such clinical complications as postoperative bile leakage, this is a useful technique for hepatectomy, especially for sub-subsegmentectomy.

Short-term outcome after mesh or shouldice herniorrhaphy: a randomized, prospective study.

Barth RJ Jr. Burchard KW. Tosteson A. Sutton JE Jr. Colacchio TA. Henriques HF. Howard R. Steadman S.
Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756-0001, USA.
BACKGROUND: Retrospective analyses have shown that long-term recurrence rates after Lichtenstein mesh and Shouldice herniorrhaphies are low. Therefore differences in short-term outcome may be important determinants of one's choice of repair. Although proponents of the mesh repair claim that their methods is less morbid, to our knowledge no prospective comparative studies of short-term morbidity have been reported. METHODS: One hundred five adult patients were randomized to undergo either a mesh or Shouldice inguinal hernia repair. Postoperative pain, narcotic use, and time to resumption of usual activities and employment were recorded. Patients were blinded to the type of repair received until all data were collected. RESULTS: There was no difference between the herniorrhaphy methods with respect to postoperative pain, duration of narcotic use, and time to resumption of usual activity and employment. Recovery was rapid for both groups of patients. By 3 days after operation, 50% of patients rated their pain as very mild or less and no longer required narcotic analgesics. Patients in both groups returned to usual activity and work by a median of 9 days after operation. CONCLUSION: Both of these well-established methods can be used to repair inguinal hernias with local anesthetics in an outpatient setting with minimal morbidity. Despite the "tension-free" design of the mesh repair, short-term outcomes of mesh and Shouldice repairs of inguinal hernias do not differ.

Total gastrectomy is not necessary for proximal gastric cancer.

Harrison LE. Karpeh MS. Brennan MF.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
BACKGROUND: Although there is an increasing incidence of proximal gastric cancers in the United States, the appropriate extent of resection for proximal gastric cancer is not known. This study addresses whether the type of operation (total gastrectomy [TG] vs proximal gastrectomy [PG]) affects outcome for proximal gastric adenocarcinoma. METHODS: Review of the prospective gastric database at Memorial Sloan-Kettering Cancer Center from July 1985 to August 1995 identified 391 patients with proximal gastric cancer. Of those patients, 98 underwent curative TG or PG through an exclusively abdominal approach. Patients undergoing esophagogastrectomy (n = 293) were excluded from analysis. Data are expressed as medians and ranges. RESULTS: The length of hospital stay was the same for patients undergoing resection for PG (16.5 days [range 8 to 55]) and for TG (18 days [range 8 to 48]). In addition, hospital mortality rates for PG (6.0%) were similar to those for TG (3.0%). There was no significant difference in tumor differentiation and overall stage between the groups that underwent TG and those that underwent PG. There was no significant difference in time to recurrence between the two operative groups (PG, 15.7 months, versus TG, 18 months). In addition, there was no association between first site of recurrence and type of procedure. The overall 5-year survival rate for proximal gastric cancer was 43% (median survival 46 months), whereas the 5-year survival rate for TG was 41% (median survival 51 months; difference not significant). CONCLUSIONS: The extent of resection for proximal gastric cancer does not affect long-term outcome. TG and PG have similar overall survival rates and time and rate of recurrence, and both procedures can be accomplished safely.

Aggressive surgical approaches to hilar cholangiocarcinoma: hepatic or local resection?

Miyazaki M. Ito H. Nakagawa K. Ambiru S. Shimizu H. Shimizu Y. Kato A. Nakamura S. Omoto H. Nakajima N. Kimura F. Suwa T.
First Department of Surgery, School of Medicine, Chiba University, Japan.
BACKGROUND: It has been reported that surgical excision of hilar cholangiocarcinoma rather than palliative surgical therapy, chemotherapy, or radiotherapy caused prolonged survival in some patients, However, excision is associated with high operative morbidity and mortality rates, particularly when hepatic resection is also performed. The aim of this study was to evaluate the clinical implications of hepatic resection in hilar cholangiocarcinoma. METHODS: The study involved 76 patients with hilar cholangiocarcinoma who were undergoing surgical resections. Twenty-one patients (28%) underwent a combined resection, with reconstruction of the portal vein in 20 patients and reconstruction of the hepatic artery in 7 patients. Sixty-five patients undergoing seven different types of hepatic resection with extrahepatic bile duct resection (BDR) and 11 patients undergoing BDR only were retrospectively compared for background, operative morbidity and mortality, and survival. RESULTS: Curative resection was obtained in 5 of 11 (45%) patients undergoing local resection and in 49 of 65 (75%) patients undergoing hepatic resection (p < 0.05). The surgical morbidity rates were 34% and 27% for hepatic and local resection, respectively. The 30-day mortality and hospital mortality rates were 4.6% and 15% for hepatic resection and 0% and 0% for local resection, respectively. The 5-year survival rate was 26% for all resected patients (76 patients); it was 40% versus 0% for curative versus noncurative resections (p < 0.05). No significant difference in surgical resection rates was revealed between hepatic and local resection among resected and curative resected patients. CONCLUSIONS: Aggressive surgical approaches to obtain curative resections could bring about a better prognosis in hilar cholangiocarcinoma independently of whether hepatic resection or local resection is performed.

Postoperative functional evaluation of pylorus-preserving gastrectomy for early gastric cancer compared with conventional distal gastrectomy.

Imada T. Rino Y. Takahashi M. Suzuki M. Tanaka J. Shiozawa M. Kabara K. Hatori S. Ito H. Yamamoto Y. Amano T.
First Department of Surgery, Yokohama City University, School of Medicine, Japan.
BACKGROUND: Malnutrition, gallbladder dysfunction, dumping syndrome, reflux esophagitis, and gastritis of the remnant stomach are unfavorable sequelae in patients undergoing gastrectomy. Operative procedures should be improved to ensure such patients a satisfactory quality of life. METHODS: After operation, gallbladder function, reflux gastritis, gastric emptying, and caloric intake were evaluated in 20 patients with early gastric cancer undergoing pylorus-preserving gastrectomy (PPG) and 25 patients undergoing conventional distal gastrectomy (CDG). RESULTS: The resting gallbladder area increased significantly after CDG. In contrast, after PPG the gallbladder area showed no significant change and the contraction rate decreased slightly. After CDG, emptying was much more rapid for the first 30 minutes after ingestion of a meal. Although delayed emptying was observed early after PPG, the rate of emptying increased with time. Gastric pH was lower and gastric mucosal injury was milder in patients undergoing PPG. These results are attributed to preserved pyloric function. The caloric intake and changes in body weight after operation were similar in both the CDG and PPG groups. CONCLUSIONS: PPG has advantages over CDG in terms of gallbladder function, the condition of the remnant stomach, and gastric emptying, PPG should be used in carefully selected patients with early gastric cancer to improve their quality of life.

Cytokine-mediated differential induction of hepatic activator protein-1 genes.

Wang S. Evers BM.
Department of Surgery, University of Texas Medical Branch, Galveston, 77555-0533, USA.
BACKGROUND: Tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) increase the synthesis of hepatic acute-phase proteins; these effects appear mediated by activation of transcription factors. The purpose of this study was to determine the effects of TNF-alpha and IL-6 on expression of the jun family of activator protein-1 (AP-1) transcription factors with the human hepatoma cell line HepG2, a well-characterized model of the hepatic acute-phase response. METHODS: HepG2 cells, treated with either TNF-alpha (100 ng/ml) or IL-6 (10 ng/ml), were extracted for RNA and protein (total and nuclear) and analyzed. RESULTS: TNF-alpha increased c-jun and junD mRNA and c-Jun and JunD protein levels, as well as AP-1 binding activity. IL-6 increased c-jun mRNA, c-Jun protein, and AP-1 binding activity but did not affect either junD or junB expression. CONCLUSIONS: TNF-alpha and IL-6 induce a differential pattern of AP-1 expression in HepG2 cells; TNF-alpha increases both c-Jun and JunD, whereas IL-6 stimulates only c-Jun. Neither TNF-alpha nor IL-6 stimulates JunB. Multiple cytokines, released during stress, may act in concert to stimulate the AP-1 proteins, which ultimately culminate in the downstream synthesis of a variety of acute-phase proteins.

Effect of alcohol abuse on polyamine metabolism in hepatocellular carcinoma and noncancerous hepatic tissue.

Kubo S. Tamori A. Nishiguchi S. Kinoshita H. Hirohashi K. Kuroki T. Omura T. Otani S.
Second Department of Surgery, Osaka City University Medical School, Japan.
BACKGROUND: Alcohol abuse is a risk factor for hepatocellular carcinoma (HCC) and the recurrence of HCC after resection. We therefore investigated polyamine metabolism, which is important in cell proliferation, HCC tissue, and noncancerous hepatic tissue. METHODS: In 30 patients who underwent liver resection for HCC, 13 patients had drunk 86 gm or more ethanol per day for at least 10 years (group 1), whereas the remaining 17 patients were nondrinkers or occasional drinkers (group 2). The control subjects were five patients who did not have liver disease or abuse alcohol. Tissue ornithine decarboxylase (ODC) activity and polyamine concentrations were measured. RESULTS: ODC activity in the HCC tissue was significantly higher in group 1 than in group 2. ODC activity in noncancerous tissue was significantly higher in group 1 than in group 2 and the control group. The ratio of spermidine/spermine in the HCC tissue was significantly higher in group 1 than in group 2. The ratio in noncancerous tissue was significantly higher in groups 1 and 2 than in the control group. CONCLUSIONS: Alcohol abuse affects polyamine metabolism, which influences the grade of malignancy of HCC. Hepatic tissue has greater potential for carcinogenesis in patients with chronic liver disease and alcohol abuse than in patients without them.

Abdominal aortic aneurysms and malignant neoplasia: double jeopardy.

Valentine RJ. Pearson AS. McIntire DD. Hagino RT. Turnage RH. Clagett GP.
Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75235-9157, USA.
BACKGROUND: This study was performed to determine whether there is a significant association between abdominal aortic aneurysms (AAAs) and malignancy and to determine the impact of malignancy on late survival in patients with AAA. METHODS: We studied 126 men undergoing AAA repair and compared them with 99 men undergoing aortofemoral bypass (AFB) for occlusive disease and with 100 men undergoing herniorrhaphy during the same period. RESULTS: Fifty-one (40%) patients with AAA, 23 (23%) patients undergoing AFB, and 21 (21%) patients undergoing herniorrhaphy were diagnosed with cancer (p = 0.002). By life table analysis the proportion of subjects remaining cancer free at 5 years was 0.60 +/- 0.05 for AAA, 0.83 +/- 0.04 for AFB, and 0.81 +/- 0.04 for herniorrhaphy (p = 0.004). Multivariate analysis selected four independent risk factors for cancer: presence of AAA (p = 0.003, odds ratio 1.4, confidence interval [CI] 1.2 to 1.7), age (p = 0.001, odds ratio per year 1.1, CI 1.0 to 1.1), smoking (p = 0.04, odds ratio 1.5, CI 1.0 to 2.2), and hypertension (p = 0.04, odds ratio 0.73, CI 0.5 to 1.0). Cancer deaths accounted for 32% of late deaths in patients with AAA, which was not different compared with 26% of late deaths in patients undergoing AFB and 36% of late deaths in patients undergoing herniorrhaphy. Five-year cancer-free survival was 0.44 +/- 0.05 for patients with AAA, 0.64 +/- 0.05 for patients undergoing AFB, and 0.70 +/- 0.05 for patients undergoing herniorrhaphy (p < 0.001, AAA versus herniorrhaphy only). CONCLUSIONS: Cancer is more prevalent in men with AAA than in men undergoing AFB or herniorrhaphy. The presence of AAA appears to be an independent risk factor for cancer. Despite the higher cancer prevalence in patients with AAA, cardiovascular disease accounted for the largest number of late deaths in this series, minimizing differences in cancer-free survival between patients with AAA and patients undergoing AFB.

Preoperative staging of colorectal cancer by a 15 MHz ultrasound miniprobe.

Year 1998
Hamada S. Akahoshi K. Chijiiwa Y. Sasaki I. Nawata H.
Third Department of Internal Medicine, Kyushu University, Fukuoka, Japan.
BACKGROUND: Our objective was to examine the accuracy of a 15 MHz ultrasound miniprobe in the pre-operative staging of colorectal cancer by assessing the depth of tumor infiltration and involvement of pericolonic lymph nodes. METHODS: Thirty-three patients with colorectal cancer who underwent ultrasonography with a miniprobe were studied prospectively. The results of this imaging were compared with the histologic findings of the resected specimens. RESULTS: The accuracy of the miniprobe for depth of invasion (T category) was 82% (27 of 33) for all tumors, 76% (13 of 17) in pT1 cases, and 88% (14 of 16) in pT2 to pT4 cases. The accuracy of the miniprobe for nodal staging (N category) was 87% (26 of 30) overall. The sensitivity was 63% (5 of 8), the specificity was 95% (21 of 22), the positive predictive value was 83% (5 of 6), and the negative predictive value was 88% (21 of 24). CONCLUSIONS: The miniprobe is an accurate method for the preoperative TN staging of colorectal cancer. We recommend its preoperative use because the results may influence the surgical approach.

Hepatic resection for bilobar multicentric hepatocellular carcinoma: is it justified?

Year 1998
Wu CC. Ho WL. Lin MC. Yeh DC. Wu HS. Hwang CJ. Liu TJ. P'eng FK.
Department of Surgery, Taichung Veterans General Hospital, Taiwan.
BACKGROUND: Hepatic resection for multiple hepatocellular carcinomas (HCCs) involving both lobes of the liver is rarely recommended because of high operative risks and low radicality. Thus the justification of hepatic resection for bilobar multicentric HCC remains undefined. METHODS: Two hundred eleven patients with HCC, who underwent curative hepatic resection, were studied retrospectively. The patients were divided into two groups. Group A consisted of 39 patients with bilobar (both sides of Cantlie's line) multicentric HCCs. Group B consisted of 172 patients with HCC with solitary or unilobar lesions. The backgrounds and resectional results of patients in groups A and B were compared. RESULTS: Patients in group A usually required multiple separate liver resections and a longer operative time. However, the operative blood loss, amount of blood transfused, and operative morbidity and mortality rates were not significantly different. Patients in group A showed higher incidences of associated satellite nodules, microscopic vascular invasion, and a lack of capsules. The 6-year disease-free and actuarial survival rates of patients in groups A and B were 30.5% and 41.8% (p = 0.17) and 42.9% and 51.4% (p = 0.12), respectively. For patients in group A the presence of satellite nodules in any resected tumor was the only independent unfavorable feature that influenced the actuarial survival rate after multivariate analysis. CONCLUSIONS: Liver resection is justified for bilobar multicentric HCCs in selected patients, if the tumors can be totally resected. Postoperative adjuvant therapies should be considered when satellite nodules are present in any resected tumor.

Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supranormal oxygen delivery and consumption.

Year 1998
Ueno S. Tanabe G. Yamada H. Kusano C. Yoshidome S. Nuruki K. Yamamoto S. Aikou T.
First Department of Surgery, Kagoshima University School of Medicine, Japan.
BACKGROUND: This study was undertaken to evaluate the response to therapy aimed at achieving supranormal cardiac and oxygen transport variables (cardiac index > than 4.5 L/min/m2, oxygen delivery > 600 ml/min/m2, and oxygen consumption > 170 ml/min/m2) in patients with cirrhosis who have undergone partial hepatectomy and to assess the relationship between those parameters and outcome. METHODS: Thirty-four consecutive patients underwent elective hepatectomy for hepatocellular carcinoma. The postoperative outcomes and hemodynamic and oxygen transport values in 16 patients (group S) who maintained supranormal values were compared with those in 18 patients (group N) treated to maintain normal hemodynamic values. Patients in group S received volume expansion and then, if necessary, dobutamine (3 to 15 micrograms/kg/min) to increase cardiac index, oxygen delivery, and oxygen comsumption simultaneously during the first 12 hours. RESULTS: The hemodynamic targets were reached by 56% of patients in group S during the first 12 hours and 31% during the next 12 hours. Postoperative blood lactate levels at 12 and 24 hours were lower in group S than in group N, and total bilirubin concentrations, hepatic venous oxygen saturation, and arterial ketone body ratio, useful markers of postoperative liver function, also showed more favorable changes in group S than in group N. Postoperative morbidity and mortality rates were not significantly different in the two groups, but the incidence of hyperbilirubinemia and liver failure was much lower in group S than in group N. CONCLUSIONS: These results suggest that fluid therapy aimed at achieving a supranormal pattern by 12 hours after hepatectomy improved the systemic oxygen demand-supply dynamics and hepatic hemodynamics, decreasing the incidence of postoperative hyperbilirubinemia and liver failure in patients with liver cirrhosis.

Congenital diaphragmatic hernia survival and use of extracorporeal life support at selected level III nurseries with multimodality support.

Year 1998
Reickert CA. Hirschl RB. Atkinson JB. Dudell G. Georgeson K. Glick P. Greenspan J. Kays D. Klein M. Lally KP. Mahaffey S. Ryckman F. Sawin R. Short BL. Stolar CJ. Thompson A. Wilson JM.
University of Michigan Medical Center, Ann Arbor, MI 48109-0245, USA.
BACKGROUND: Congenital diaphragmatic hernia (CDH) has been cited to have a mortality rate of 50%. There have been multiple studies at individual institutions demonstrating potential benefits from various strategies including extracorporeal life support (ECLS), delayed repair, and lower levels of ventilator support. There has been no multicenter survey of institutions offering these modalities to describe the current use of ECLS and survival of these infants. In addition, the relationship between the number of patients with CDH managed at an individual institution and outcome has not been evaluated. METHODS: We queried 16 level III neonatal intensive care centers on the use of ECLS and survival of infants with CDH who were treated during 2 consecutive years (1993 to 1995). Data are presented as mean +/- SEM, median, and range. RESULTS: Data were collected on 411 patients. Of these, 71% +/- 8% were outborn and 8% +/- 3% were considered nonviable. Overall survival of CDH infants was 69% +/- 4% (range, 39% to 95%). The survival rate of infants on ECLS was 55% +/- 4%, whereas survival of infants not requiring ECLS was significantly increased at 81% +/- 5% (p = 0.005). The mean rate of ECLS use was 46% +/- 2%. There was no correlation between the number of cases per year at an individual institution and overall survival, ECLS survival, or ECLS use (r = 0.341, 0.305, and 0.287, respectively). There was also no correlation between case volume at an individual institution and ECLS survival (r = 0.271). CONCLUSIONS: The current survival rate and rate of ECLS use in infants with CDH at level III neonatal intensive care units in the United States are 69% +/- 4% and 46% +/- 2%, respectively. There is no correlation between the yearly individual center experience with managing CDH and rate of ECLS use or outcome.

Is laparoscopic cholecystectomy hazardous for gallbladder cancer?

Year 1998
Suzuki K. Kimura T. Ogawa H.
First Department of Surgery, Hamamatsu University School of Medicine, Japan.
BACKGROUND: There have been several case reports of unexpected gallbladder cancer diagnosed after laparoscopic cholecystectomy (LC) being associated with fatal recurrence of cancer in the abdominal wall. Therefore there is a risk that LC might worsen the prognosis of gallbladder cancer. The objective of this study was to examine the frequency of recurrence of cancer in the abdominal wall and the prognosis of patients with unexpected gallbladder cancer diagnosed after LC. METHODS: A clinicopathologic study was performed on 30 patients with postoperatively diagnosed gall-bladder cancer among 3566 patients undergoing LC at 19 institutions. The cumulative survival rate was compared with that reported for gallbladder cancer diagnosed after open cholecystectomy. RESULTS: Recurrence of cancer in the abdominal wall occurred in three patients, and two of them died. The 3-year survival rate was 100% for early gallbladder cancer and 70% for advanced tumors. These results were comparable to the 3-year survival rates for gallbladder cancer diagnosed after open cholecystectomy. CONCLUSIONS: The incidence of recurrence of cancer in the abdominal wall was increased, but the medium-term prognosis was not worsened by laparoscopy. It does not appear necessary to exclude patients with cholecystitis or gallbladder wall hypertrophy from undergoing laparoscopic procedures on the grounds that they might have gallbladder cancer.

Gastric carcinoma with pyloric stenosis.

Year 1998
Watanabe A. Maehara Y. Okuyama T. Kakeji Y. Korenaga D. Sugimachi K.
Department of Surgery, Fukuoka City Hospital, Japan.
BACKGROUND: The surgical outcome of gastric carcinomas with pyloric stenosis and their prognostic factors are sparsely documented. METHODS: A clinicopathologic study of gastric carcinoma with pyloric stenosis (PS group, n = 122) was done and findings were compared with the cases involving the antrum (A group, n = 695). Independent prognostic factors for survival of the patients with PS were determined by Cox's proportional hazard model. RESULTS: There were no differences in age and gender between the two groups. The PS group was characterized by an infiltrating growth pattern and undifferentiated adenocarcinoma. The incidence of serosal invasion, direct invasion into neighboring organs, peritoneal dissemination, lymph node metastasis, and liver metastasis of the PS group was higher than those of the A group (p < 0.01). The resection rate and 5-year survival of the PS group were 78% and 22%, respectively; these values were significantly lower than 98% and 58% of the A group (p < 0.01). Multivariate analyses showed that operative curability, resection of the stomach, liver metastasis, serosal invasion, and histologic type were the independent prognostic factors of the PS group. CONCLUSIONS: In cases of gastric carcinoma with pyloric stenosis, efforts should be made to do a curative operation, but for other patients with poor prognostic factors, intensive surgery and adjuvant therapy should be considered.

Primary pancreatic lymphoma.

Year 1998
Bouvet M. Staerkel GA. Spitz FR. Curley SA. Charnsangavej C. Hagemeister FB. Janjan NA. Pisters PW. Evans DB.
Department of Surgical Oncology, University of Texas, Houston, USA.
BACKGROUND: Primary pancreatic lymphoma is a rare neoplasm that may be confused with pancreatic adenocarcinoma. We reviewed retrospectively our contemporary experience with this disease to define more clearly the clinical presentation of this disease and the proper role for percutaneous fine-needle aspiration biopsy and surgery. METHODS: From 1980 to 1995, 11 patients with primary pancreatic lymphoma were treated at The University of Texas M. D. Anderson Cancer Center. Patient demographics, radiographic studies, fine-needle aspiration biopsy findings, operative procedures, and other treatment data were reviewed. RESULTS: The median age of the 11 patients was 64 years (range, 37 to 74 years). Abdominal pain was the most common symptom at presentation. Five patients had an elevated lactate dehydrogenase level, and only two patients had hyperbilirubinemia. Computed tomography scan demonstrated encasement of the superior mesenteric artery or superior mesenteric-portal vein confluence in six patients. Seven patients underwent computed tomography-guided fine-needle aspiration; five had findings of lymphoma. Two patients underwent distal pancreatectomy and splenectomy, and one underwent pancreaticoduodenectomy. All patients were treated with combination chemotherapy, and seven received radiotherapy. Only two patients have died of disease (12 and 16 months after diagnosis) at a median follow-up time of 67 months. CONCLUSIONS: In the majority of patients, pancreatic lymphoma can be distinguished from pancreatic adenocarcinoma on the basis of symptoms, laboratory and radiographic findings, and fine-needle aspiration biopsy results. Once the diagnosis is established, all patients should undergo systemic chemotherapy followed by involved-field radiotherapy if the tumor has not been resected.

Diagnosis of anomalous pancreaticobiliary junction: value of magnetic resonance cholangiopancreatography.

Year 1998
Sugiyama M. Baba M. Atomi Y. Hanaoka H. Mizutani Y. Hachiya J.
First Department of Surgery, Kyorin University School of Medicine, Tokyo, Japan.
BACKGROUND: Anomalous pancreaticobiliary junction (a long common channel), with or without congenital choledochal cyst, is frequently associated with biliary tract carcinoma. We assessed the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) for patients with anomalous pancreaticobiliary junction (PBJ). METHODS: In 159 adult patients with pancreatobiliary disease, breath-hold (1 to 18 seconds) MRCP was performed according to a half-Fourier acquisition single-shot turbo spin-echo sequence. In all patients the length of the common channel demonstrated by MRCP was compared with that demonstrated by endoscopic retrograde cholangiopancreatography. In 11 patients with anomalous PBJ (the common channel > or = 15 mm on endoscopic retrograde cholangiopancreatography), the diagnostic accuracy of MRCP for associated biliary diseases was evaluated. RESULTS: No complications were encountered in performing MRCP. On MRCP, the length of the common channel was calculated to be 15 mm or longer in nine (82%) of 11 patients with anomalous PBJ. In patients with normal PBJ, MRCP identified PBJ with the channel measuring 0 mm in length. MRCP allowed detailed visualization of congenital choledochal cyst (all seven patients) but failed to depict carcinoma (one patient) and mucosal hyperplasia (five patients) of the gallbladder. CONCLUSIONS: MRCP is a noninvasive and accurate imaging method for diagnosing anomalous PBJ and congenital choledochal cyst.

Treatment of hepatoblastoma: less extensive hepatectomy after effective preoperative chemotherapy with cisplatin and adriamycin.

Year 1998
Seo T. Ando H. Watanabe Y. Harada T. Ito F. Kaneko K. Horibe K. Sugito T. Ito T.
Department of Pediatric Surgery, Nagoya University School of Medicine, Japan.
BACKGROUND: Although the prognosis of hepatoblastoma was improved by the introduction of cisplatin and doxorubicin (Adriamycin) for adjuvant chemotherapy, extensive hepatectomy continues to be the usual practice. We retrospectively reviewed our recent experience with hepatoblastoma to determine whether the new modality of intensive chemotherapy could change the resectability, extent of hepatectomy, operative complications, and prognosis. METHODS: The clinical features of 15 children with hepatoblastoma treated between 1985 and 1995 were reviewed. Intensive chemotherapy was added before surgical resection not only when a tumor was unresectable but also when it was large enough to increase the risk of operative morbidity. RESULTS: There was 100% resectability, and the overall mortality rate was only 6.7%. Fourteen patients have been free of disease for 2 to 12 years. Preoperative chemotherapy enabled resection of six previously unresectable hepatoblastomas. Moreover, hepatic resection tended to be less invasive in several patients whose tumors had been much reduced after preoperative chemotherapy. Intraoperative and postoperative complications were minimal, with a short operative time and small amount of blood loss, especially in the group with delayed primary operation. CONCLUSIONS: The preoperative administration of cisplatin and Adriamycin reduced the tumor size so that a safe hepatectomy could be performed with less blood loss and minimal technical complications. Unnecessary sacrifice of the normal hepatic tissue was avoided by performing the less extensive hepatectomy.

Hepatolithiasis: outcome of cholangioscopic lithotomy and dilation of bile duct stricture.

Year 1998
Yoshida J. Chijiiwa K. Shimizu S. Sato H. Tanaka M.
Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan.
BACKGROUND: Cholangioscopic lithotomy (CSL) for hepatolithiasis, a minimally invasive procedure, has a place in complicated or recurrent hepatolithiasis. CSL itself, however, carries inherent risk for recurrence. We analyzed follow-up data after CSL for primary or repeat hepatolithiasis to determine the frequency of recurrence. METHODS: This retrospective analysis includes 21 patients with hepatolithiasis admitted to the hospital from September 1992 to December 1995 who underwent CSL. Through a percutaneous biliary drainage route, cholangioscopy was inserted to remove calculi with basket forceps or electrohydraulic lithotripter. Stenotic ducts, defined as less than 2 mm in diameter, were dilated with silicone rubber stenting or a balloon dilator. RESULTS: Ten patients were treated for primary hepatolithiasis and 11 for repeat hepatolithiasis. Of the patients with primary hepatolithiasis, one died of complications and the other nine patients underwent complete lithotomy. Among 11 patients who had repeat hepatolithiasis, four had undergone hepatectomy for hepatolithiasis and two previous CSLs; 10 patients (91%) underwent complete lithotomy. During the follow-up, four (40%) of the 10 patients with biliary stenosis at the time of cholangioscopic treatment showed recurrent calculi, whereas all eight patients without stricture had uneventful courses. Of the 19 patients who underwent complete lithotomy, calculi recurred in four (21%), three cases of which recurred less than 1 year after CSL. CONCLUSIONS: Against hepatolithiasis of primary and postoperative repeat cases, CSL can allow complete lithotomy. The bile duct stricture, however, carries a high risk for recurrent calculi; hence, permanent relief of stricture is mandatory.

Treatment of superficial cancer of the esophagus: a summary of responses to a questionnaire on superficial cancer of the esophagus in Japan.

Year 1998
Kodama M. Kakegawa T.
First Department of Surgery, Shiga University of Medical Science, Japan.
BACKGROUND: Histopathologic characteristics and optimal treatment modality for superficial esophageal cancer were reevaluated on the basis of 2418 patients from 143 institutions through a nationwide questionnaire to the members of the Japanese Society for Esophageal Diseases. METHODS: A questionnaire was designed for patients with preoperatively untreated superficial cancer of the esophagus who had undergone either surgical or endoscopic treatment between January 1, 1990, and December 30, 1994. Mucosal cancer and submucosal cancer were divided into three subclasses according to the criteria formulated by the Society. RESULTS: The incidence of positive lymphatic invasion or lymph node metastases tended to increase markedly as cancer infiltrates reached the lamina muscularis mucosa. The majority of the cases with 0-I or 0-III components were submucosal cancer. The indication of endoscopic mucosal resection (EMR) was limited to mucosal 1 and mucosal 2 superficial cancer in 76% of the institutions surveyed. Tumors measuring 2 cm or more in diameter were resected piecemeal in 94% of patients. Complications of EMR, including perforation, stenosis, and hemorrhage, were observed in approximately 6.8% of patients. Almost all patients with mucosal 1 or mucosal 2 cancer are still alive. There was no significant difference in prognosis between mucosal 3 cancer and mucosal 1 or mucosal 2 cancer, but submucosal 1 cancer showed worse prognosis than mucosal cancer. CONCLUSIONS: Local resection of cancer lesions is regarded as the treatment of choice against the superficial esophageal cancers limited to the lamina propria mucosae. Further study is advocated to define the treatment strategy against mucosal 3 or submucosal 1 cancer.

First experience and technical aspects of isolated liver perfusion for extensive liver metastasis.

Year 1998
Oldhafer KJ. Lang H. Frerker M. Moreno L. Chavan A. Flemming P. Nadalin S. Schmoll E. Pichlmayr R.
Department of Abdominal and Transplantation Surgery, Hannover Medical School, Germany.
BACKGROUND: New drugs and modalities for locoregional tumor treatment in recent years may offer new potential for isolated liver perfusion in patients with nonresectable liver tumors. The purpose of this study was to prove the feasibility of arterial isolated liver perfusion and to assess the tolerance of perfusion with high-dose tumor necrosis factor (TNF). METHODS: Twelve patients with extensive liver metastases previously treated unsuccessfully with systemic chemotherapy underwent isolated hyperthermic liver perfusion using a heart-lung machine. High doses of mitomycin were administered in the first six and a combination of TNF and melphalan in the last six patients. RESULTS: No operative death occurred and no direct postoperative liver failure was observed in any patient. In cases of variations of the arterial hepatic blood supply, the perfusion was done through the splenic artery or an angiography catheter. Histologic analysis of tumor biopsy specimens obtained on the first postoperative day revealed major tumor necrosis in 8 of 12 patients. CONCLUSIONS: Isolated arterial perfusion of the liver is a complex surgical procedure that is feasible in patients with anatomic variations of the hepatic artery. The remarkable histologic response to perfusion in several pretreated patients, especially after application of high-dose TNF and melphalan, suggests that this modality is very effective in tumor killing.

Twenty-five years of experience in the surgical treatment of perforation of the ileum caused by Salmonella typhi at the General Hospital of Mexico City, Mexico.

Year 1998
Athie CG. Guizar CB. Alcantara AV. Alcaraz GH. Montalvo EJ.
Emergency Department, General Hospital of Mexico City, Mexico.
BACKGROUND: This work summarizes the experience obtained during 25 years in the management of intestinal perforations caused by Salmonella typhi with a directed resection and anastomosis at the General Hospital of Mexico City. METHODS: A total of 352 cases of perforation of the ileum caused by Salmonella typhi seen during the course of 25 years were studied. Patients were divided into two groups; group A had 236 patients and group B had 116 patients. All patients underwent either conventional resection and anastomosis or primary closure (group A) or directed intestinal resection of 10 cm at each side of the perforation on the basis of anatomopathologic studies with serial sections (group B). RESULTS: Morbidity and mortality for group B were each of 1.72%, significantly lower than the 33.47% morbidity and 7.20% mortality in group A. CONCLUSIONS: Primary closure should be discouraged, even for a single perforation. Instead directed intestinal resection is recommended as elective surgery for all cases of typhoid fever complicated with intestinal perforation, resecting 10 cm at each side of the distal and proximal perforation.

Long-term results of classic antireflux surgery in 152 patients with Barretts esophagus: clinical, radiologic, endoscopic, manometric, and acid reflux test analysis before and late after operation.

Year 1998
Csendes A. Braghetto I. Burdiles P. Puente G. Korn O. Diaz JC. Maluenda F.
Department of Surgery, University of Chile, Jose Joaquin Aguirre Hospital, Santiago, Chile.
BACKGROUND: The classic surgical procedure for patients with Barrett's esophagus (BE) has been either Nissen fundoplication or posterior gastropexy with calibration of the cardia. METHODS: The purpose of our study was to determine late subjective and objective results of these classic surgical techniques in a large number of patients with BE. A total of 152 patients were included in this prospective protocol. RESULTS: There was 1 death (0.7%) after operation. The late follow-up of 100 months demonstrated a high percentage of failures among patients with noncomplicated BE (54%) and an even higher figure in patients with complicated BE (64%). In 15 patients low grade dysplasia appeared at 8 years of follow-up and an adenocarcinoma in 4 patients. Twenty-four-hour pH monitoring demonstrated a decrease in acid reflux into the esophagus, and Bilitec studies also demonstrated a decrease of duodenoesophageal reflux, but in all cases with a higher value than the normal limit. CONCLUSIONS: Classic antireflux surgery in patients with BE results in a high percentage of failures at very late follow-up because it cannot completely avoid acid and duodenal reflux into the esophagus.

Depression of peritoneal fibrinolysis during operation is a local response to trauma.

Year 1998
Holmdahl L. Eriksson E. Eriksson BI. Risberg B.
Department of Surgery, Sahlgrenska University Hospital, Goteborg University, Sweden.
BACKGROUND: Peritoneal fibrinolytic capacity decreases during abdominal operation. This may be a local effect or a part of a generalized response to the procedure. METHODS: Plasma and paired peritoneal biopsy specimens were taken at intervals during abdominal operation, and fibrinolytic components were assayed in plasma and tissue extracts. Values are given as median [interquartile range]. RESULTS: In peritoneal tissue there was a gradual decrease of tissue-type plasminogen activator (tPA) activity, and at 90 minutes of the operation differed significantly from that of the initial sample (1.0 [1.0] ng/mg protein, and 5.1 [6.5] ng/mg protein, respectively, p < 0.05). The tPA activity levels at the wound were significantly lower (1.0 [1.0] ng/mg protein) at 90 minutes compared with a remote peritoneal site (1.8 [1.9] ng/mg protein, p < 0.05). At the wound, the tPA activity correlated significantly with time (r = -0.48, n = 26, p < 0.01). tPA activity and antigen peaked in plasma at 30 minutes (p < 0.05) and 60 minutes (p < 0.05), respectively. Plasminogen activator inhibitor type 1 activity increased in plasma during operation (p < 0.05), but was not detectable in peritoneal samples. CONCLUSIONS: The intraoperative changes in tissue tPA activity were not consistently reflected in plasma samples. These findings suggest that the reduction in peritoneal fibrinolysis during abdominal operation is a local response to trauma.

Surgical results in patients with dual hepatitis B- and C-related hepatocellular carcinoma compared with hepatitis B- or C-related hepatocellular carcinoma.

Year 1998
Chen MF. Jeng LB. Lee WC. Chen TC.
Department of Surgery, Chang Gung University, Chang Gung Memorial Hospital, Taipei, Taiwan.
BACKGROUND: The purpose of our study was to report on the surgical outcomes of patients with hepatocellular carcinoma (HCC) with dual hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and to assess the differences in the surgical results between those patients and the patients with hepatitis B- or hepatitis C-related HCC. METHODS: The operative outcomes of 13 patients with hepatitis B surface antigen (HBsAg)-positive and hepatitis C antibody (HCV Ab)-positive (the BC-HCC group) results, 57 patients with HBsAg-positive and HCV Ab-negative (the B-HCC group) results, and 34 patients with HBsAg-negative and HCV Ab-positive (the C-HCC group) results, who had undergone hepatic resection from 1991 to 1995, were compared. RESULTS: The operative mortality rate within 1 month after operation for patients with BC-HCC was 7.7%. No statistically significant difference was found compared with the patients with B-HCC and C-HCC (5.3% and 5.9%, respectively). The postoperative course of patients with BC-HCC was complicated by liver failure, postoperative ascites, and wound infection in one patient each. Also, no statistically significant difference was found among the groups (23.1%, 22.8%, and 20.5% for patients with BC-HCC, B-HCC, and C-HCC, respectively). The overall 1-, 3-, and 5-year survival rates of patients with BC-HCC in this series were 75%, 50%, and 40%, respectively. The postoperative recurrence rate was 66.7%. No statistically significant differences were found between the various groups of the virus-related HCC on the overall survival rate and disease-free survival rate. CONCLUSIONS: Hepatic resection for HCC in patients with dual HBV and HCV infections was associated with slightly higher operative morbidity and mortality rates, but there were no statistical differences compared with hepatitis B- or C-related HCC regarding the survival and recurrence rates.

Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation.

Year 1998
Girvent M. Maestro S. Hernandez R. Carajol I. Monne J. Sancho JJ. Gubern JM. Sitges-Serra A.
Department of Surgery, Hospital Universitari del Mar, Barcelona, Spain.
BACKGROUND: Emergency operation in the elderly carries a high risk of death. We investigated the incidence of euthyroid sick syndrome (ESS) and associated nutritional and endocrine abnormalities and their relationship to postoperative outcome in this population. METHODS: Sixty-six patients older than 70 years of age requiring emergency operations were assessed before any therapeutic intervention. Values for thyroid hormones, catecholamines, cortisol, interleukin-6, interleukin-1, C-reactive protein, and the Acute Physiology and Chronic Health Evaluation II score were determined. Nutritional assessment was carried out. Mortality rates and duration of hospital stay were related to ESS and albumin concentrations. RESULTS: ESS was diagnosed in 34 patients (51.50%) and was associated with worse Acute Physiology and Chronic Health Evaluation II scores (10.9 vs 8.6; p = 0.004), hypoalbuminemia (34.7 vs 40.8 gm/L; p = 0.0001), lower triceps skinfold (11.8 vs 14.6 mm; p = 0.03), and higher cortisol and norepinephrine levels (937 vs 741 nmol/L [p = 0.04] and 358 vs 250 pg/ml [p = 0.02], respectively), interleukin-6 plasma concentrations (347 vs 113 pg/ml; p = 0.01), death rate (20% vs 0%; p = 0.02), and length of hospital stay (17.2 vs 11.8 days; p = 0.03). A serum albumin level less than 35 gm/L was virtually always associated with ESS. CONCLUSIONS: ESS is highly prevalent in the elderly with acute surgical problems and is associated with poor nutrition, higher sympathetic response, and worse postoperative outcome. The serum albumin level at admission is a specific marker of ESS.

Diarrhea after resection of advanced abdominal neuroblastoma: a common management problem.

Year 1998
Rees H. Markley MA. Kiely EM. Pierro A. Pritchard J.
Department of Haematology/Oncology, Great Ormond Street Hospital for Children NHS Trust, London, U.K.
BACKGROUND: After resection of advanced abdominal neuroblastoma, children may have persistent postoperative diarrhea. Until recently, the magnitude of this problem had not been appreciated. METHODS: To assess the incidence, severity, and management of chronic postoperative diarrhea in these patients, we reviewed the case notes of all children with stage III or IV abdominal and pelvic neuroblastoma who underwent tumor resection in our hospital between January 1985 and September 1996. We classified the severity of diarrhea as follows: mild, less than 3 loose stools per day; moderate, 3 to 5 loose stools per day; and severe, more than 5 loose stools per day and/or urgency, incontinence, or nocturnal diarrhea. RESULTS: Seventy-seven children underwent resection during this period, and 23 (30%) had postoperative diarrhea, classified as mild in 11 patients, moderate in 7, and severe in 5. Dissection around the superior mesenteric and celiac arteries was associated with a significantly higher incidence of diarrhea. Fifteen children (65%) received treatment with loperamide, which reduced but did not abolish symptoms. Twelve children subsequently died of progressive neuroblastoma. Of the 11 surviving children (mean duration of follow-up, 8.4 years), 8 have persistent loose stools. CONCLUSIONS: Diarrhea, probably resulting from disruption of the autonomic nerve supply to the gut during clearance of tumor from the major vessels of the retroperitoneum, is common after resection of advanced abdominal neuroblastoma. Many children require long-term treatment to slow intestinal peristalsis, and a few have severe and unremitting diarrhea. More effective medical management of this complication is needed.

Evidence of survival benefit of extended (D2) lymphadenectomy in western patients with gastric cancer based on a new concept: a prospective long-term follow-up study.

Year 1998
Roukos DH. Lorenz M. Encke A.
Department of Surgery, University Hospital of Frankfurt, Germany.
BACKGROUND: The use of extended (D2) lymph node dissection in gastric cancer achieves better locoregional tumor control than limited (D1) lymphadenectomy, but its influence on survival is controversial. The value of D2 resection is unproven in randomized trials. However, a survival benefit in favor of D2 resection has been shown in reports from some specialized centers. This study was undertaken to assess whether D2 resection improves survival. We evaluated the efficacy of D2 resection on the basis of a new concept that eliminates the stage migration phenomenon. METHODS: D2 resection achieved with a standardized technique in this prospective study included dissection of the perigastric lymph nodes (stations 1 through 6, D1 resection), as well as those at the celiac axis (stations 7 through 11) and at hepatoduodenal ligament (station 12, N2 level). We evaluated survival data of patients with involved nodes at stations 7 through 12 (N2 disease) because these nodes are left behind in a D1 resection. RESULTS: D2 resection resulted in a resection of cure in 31 patients with N2 disease, a 25% (31 of 125) increase of the curative resection compared with a supposed D1 resection. The 5-year survival rate for N2 patients was 17%, which demonstrates the therapeutic benefit of the D2 resection. In patients with pN0 and pN1 disease, the 5-year survival rates were 71% and 53%, respectively. Overall hospital mortality and morbidity were 1.3% (2 of 146) and 33.4% (40 of 146), respectively. CONCLUSIONS: D2 resection can be performed safely and is of therapeutic value in patients with advanced lymph node metastases. Furthermore, the survival data suggest indirectly a possible beneficial effect for patients with node-negative disease (N0) or early node metastases (N1).