Surgical excision of a giant pelvic pseudotumour in a patient with haemophilia A

The development of pseudotumors represents one of the most challenging complications facing physicians who care for patients with hemophilia. The successful removal of the giant pseudotumor described in this case report was achieved by a multidisciplinary team and demonstrates that this approach, albeit associated with significant risk, may be curative.

A prospective study of the mesh-plug hernioplasty

A prospective study of patients with symptomatic inguinal hernias was undertaken to determine the safety and efficacy of the mesh-plug hernioplasty. Between May 1, 1997 and March 1, 1999 a total of 309 mesh-plug hernioplasties were performed on 283 patients. There were 43 recurrent and 26 bilateral hernioplasties. There were 273 men and 10 women ranging in age from 15 to 94 years (mean 47 years). There were 199 indirect, 104 direct, and six femoral hernias. Mean operative time for primary hernioplasty was 26 minutes (range 20-34) and 35 minutes (range 31-40) for recurrent hernioplasty. All procedures were performed as outpatient surgery with mean recovery room time being 45 minutes (range 25-27) for primary hernioplasty. Two hundred sixty-six patients (94%) returned to normal activities within 3 days. All manual laborers (124 patients) returned to work without restriction on postoperative day 14. Only 43 patients (15%) required prescription pain medication. At one year postoperatively 283 patients (100% follow-up) have been examined and no recurrence has been detected. At 2 years postoperatively 135 patients (100% follow-up) have been examined and no recurrence has been detected. The mesh-plug hernioplasty uses a minimum of medical resources, is associated with a small amount of postoperative pain, and has an early return to normal activities and manual labor without a documented early recurrence in this study.

First report of hepatic lobectomy for metastatic carotid body tumor

Hepatic lobectomy for metastatic colon cancer is well accepted, yielding a 30-35% five-year survival with a low mortality of less than 5%. Less commonly is hepatic resection for selected metastasis from other organs. We report here what we believe is the first hepatic lobectomy for a metastatic carotid body tumor. The patient was a 41-year-old white female who presented with a large incapacitating hepatic metastasis and an incidental lung metastasis from a carotid body tumor resected 12 years earlier. The patient underwent left hemihepatectomy and local lymph node dissection at our university. Twenty-one months after the operation the patient is asymptomatic and has no sign of tumor reoccurrence . We discuss here the clinical features, pathophysiology, treatment and the surgical literature of this rare entity. This is yet another example of the effectiveness of hepatic resection for noncolonic metastasis (26 references).

Do angiogenesis and growth factor expression predict prognosis of esophageal cancer?

A retrospective study of surgically resectable esophageal cancers was undertaken to determine the relationship between angiogenesis score and growth factor expression with tumor size, histology, degree of differentiation, depth of invasion, nodal disease, and the presence of Barrett's esophagus. The office and hospital charts of 27 patients who had esophageal resection for carcinoma between 1990 and 1995 at Rush-Presbyterian-St. Luke's Medical Center were reviewed. Data collection included patient demographics, survival, tumor size, histology, differentiation, depth of invasion, nodal metastases, and the presence of Barrett's esophagus. The pathology specimens were immunostained for von Willebrand factor (factor VIII-related antigen). Immunostaining was also performed for vascular endothelial growth factor and transforming growth factor alpha. Twenty normal esophageal specimens served as controls. Angiogenesis score was determined by counting vessels under conventional light microscopy at x200 magnification, and growth factor expression was graded on a scale of 1 to 4. Cancers had higher angiogenesis and growth factor expression than controls (P = 0.01). Patient age, tumor size, histology, differentiation, depth of invasion, and Barrett's esophagus did not correlate with angiogenesis score or tumor growth factor expression. Lymph node status did correlate with both angiogenesis score and growth factor expression (P < or = 0.02). We conclude that high angiogenesis score and growth factor expression correlate with the presence of lymph node metastases. This may help select patients for preoperative radiation and chemotherapy or determine the extent of surgery performed for esophageal carcinoma.

Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas

A retrospective study of patients with surgically resectable adenocarcinoma of the pancreatic head was undertaken to determine which prognostic factors are independently associated with improved survival. Thirty-four men and 41 women (mean age, 61.9 years) had resection for adenocarcinoma of the pancreatic head between 1980 and 1997 at Rush-Presbyterian-St. Luke's Medical Center. Surgical resections included 15 total pancreatectomies, 43 pyloric-preserving procedures, and 17 standard Whipple procedures. Thirty-six patients received adjuvant radiation and/or chemotherapy. Overall median survival was 13 months, with a 5-year survival of 17 per cent. Thirty-day surgical mortality was 1.3 per cent. Significant factors that negatively influenced survival using univariate Kaplan-Meier analysis were: positive resection margin (P = 0.01), intraoperative blood transfusion (P = 0.01), and lymph node metastases (P = 0.01). Presenting signs and symptoms, patient demographics, operative procedure, tumor size, histologic differentiation, and adjuvant therapy did not have a significant impact on survival. Using multivariate Cox regression analysis, the only significant independent factors improving survival were the absence of intraoperative blood transfusion (P = 0.02) and a negative resection margin (P = 0.04). Performing pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas with negative microscopic margins of resection and without intraoperative transfusion significantly improves survival.

Mucin Hypersecreting Intraductal Papillary Neoplasm of the pancreas

Mucin Hypersecreting Intraductal Papillary Neoplasm is a rare neoplasm that arises from ductal epithelial cells. This entity is distinct from the more commonly known Mucinous Cystadenoma or Mucinous Cystadenocarcinoma. Despite this distinction, it has been erroneously categorized with these more common cystic neoplasms. Characteristic clinical presentation, radiographic, and endoscopic findings help distinguish this neoplasm from the cystadenomas and cystadenocarcinomas. Histopathologic identification is not crucial to the preoperative diagnosis. This neoplasm is considered to represent a premalignant condition and, therefore, surgical resection is warranted. Prognosis, following resection, is felt to be curative for the majority of patients. We present two cases of Mucin Hypersecreting Intraductal Papillary Neoplasm and discuss their diagnosis and surgical therapy.

An open, minimally invasive approach to the lumbar spine

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6-10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11-52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5-12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60-330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.

Mechanical, histologic, and biochemical effects of canine rectal formalin instillation

Instillation of 4 percent formalin effectively treats radiation hemorrhagic proctitis; however, little is known regarding its side effects.

PURPOSE

The study contained herein was undertaken to determine rectal compliance and collagen content, mucosal and vascular histologic changes, and kinetics of formalin absorption following instillation.

METHODS

Fifteen mongrel dogs (50-60 pounds) were randomized into five experimental groups according to time elapsed from formalin treatment: control, acute, one week, two weeks, and four weeks. Formalin was instilled in 30-ml aliquots to a total volume of 400 ml. Rectal compliance (closed manometry system) was assessed pre-formalin and post-formalin at the designated time interval. Serum formalin metabolites were determined at time 0, 0.5, 1, and 3 hours. A segment of rectal wall was analyzed for collagen content, mucosal injury, and blood vessel density.

RESULTS

Serum formalin levels peaked within 30 minutes, returning to normal by 3 hours. With the exception of one dog, toxic levels were not reached at any time during the study. No dogs experienced sepsis, fever, or altered gastrointestinal function. Acute and one-week dogs showed mild diffuse proctitis and mucosal slough, which healed within two weeks. Rectal compliance and collagen content were unchanged. Mucosal blood vessels decreased in number early (P = 0.03).

CONCLUSIONS

Instillation of 4 percent formalin in sequential aliquots of a small volume that is kept in contact for a short period of time is safe. Serum formalin levels generally do not reach toxic levels, and the slight elevation in formalin concentration that was seen returns to normal within three hours. Formalin-induced proctitis heals within two weeks, and no long-term changes in rectal compliance or collagen content were seen.

Absorption kinetics of rectal formalin instillation

Formalin instillation has become an accepted treatment of radiation-induced hemorrhagic cystitis and proctitis since the initial report by Brown in 1969 (Med. J. Aust. 1:23, 1969). Although its use is widespread, no studies have been performed to determine the safest, volume or duration of formalin exposure. The purpose of our study was to determine the optimum technique for instillation and the safety margin regarding the maximum time that formalin can be in contact with the rectal mucosa without causing serum toxicity. In a pilot canine study, 4% neutral buffered formalin was instilled into the rectum in 30 ml aliquots for 60 seconds each after which each aliquot was withdrawn; a total volume of 400 ml was used. Our subsequent experiment involved rectal instillation of a single formalin bolus of 100 ml for 1 hour without removal during this time. Formalin metabolites were measured in the blood and urine to assess toxicity. Results indicate that with the latter technique serum formic acid reaches toxic levels within 15 minutes of instillation and may stay elevated for several hours. Metabolites in the urine similarly increase within 15 minutes, lagging only shortly behind the rise in serum levels. Performing formalin instillation in a series of 30 ml aliquots appears to be a safer treatment, as toxic serum levels were not reached and their slight rise above baseline returned to normal within 3 hours.

Pulmonary metastasis from a basal-cell carcinoma of the retroauricular region

Basal-cell carcinoma of the skin is a common facial neoplasm, usually regarded as benign. It is also called basalioma. Distant metastasis is very rare and may involve the brain, lung, and bones. We report a 74-year-old white male who was admitted to our hospital with cough and fever. Chest radiograph revealed an opacity of 2 x 1 cm in diameter in the upper lobe of the right lung. Bronchoscopy and thoracic fine-needle aspiration could not establish a diagnosis. Therefore the patient underwent right thoracotomy and wedge excision of the lesion. Histologic evaluation was consistent with pulmonary metastasis of a facial basal-cell carcinoma. The patient recovered uneventfully from surgery and is well 5 years after the operation. According to the English literature the median survival of patients with metastatic basal-cell carcinoma is 10 months. The clinical features, pathology, and treatment of this rare entity are discussed.

Hepatic resection for metastatic colorectal cancer

One-hundred thirty-one primary hepatic resection for colorectal secondary tumors were performed at Rush-Presbyterian-St. Luke's Medical Center between 1975 and 1993. Perioperative mortality occurred in five patients (3.8%). Twenty-three patients had minor morbidities (18%); major morbidity occurred only in the five patients who died. Curative resections were performed in 107 patients. Overall actuarial survival at 2, 3, and 5 years was 62, 42, and 25 per cent, respectively. Patients with extrahepatic disease (5-year survival, 0% vs 27%; P = 0.049) and positive resection margins (0% vs 30%; P < 0.001) had significantly poorer survival. Among the curative resections, patients who had metachronous hepatic resections did significantly better than those who underwent synchronous colon and hepatic resections (35% vs 13%; P = 0.002). This survival benefit persisted when comparison was restricted to patients with synchronous metastases. Age, sex, race, number of lesions, site of colon primary resection, blood transfusion, disease-free interval, and extent of resection had no effect on survival. All patients who are acceptable surgical risks with potentially resectable metastatic colorectal cancer confined to the liver should undergo exploration. Assessment of resectability should include intraoperative ultrasound in all patients to maximize the probability of tumor clearance.

Intraoperative ultrasound in the management of liver neoplasms

The purpose of this study was to determine the impact of intraoperative ultrasound (IOUS) on the management of patients with neoplasms of the liver. Fifty-nine patients with liver neoplasms (primary, 6; metastatic, 53) and without pre- or intraoperative evidence of extrahepatic disease underwent laparotomy for possible liver resection. Preoperative imaging studies included external ultrasound (n = 12), magnetic resonance imaging (n = 11), and/or computed tomography (n = 57). Intraoperative evaluation on all patients included inspection, bimanual palpation, and ultrasonography. External ultrasound, magnetic resonance imaging, and computed tomography identified all intraoperatively confirmed liver neoplasms in 33, 45, and 67 per cent of cases, respectively. Unsuspected neoplasms were identified in 12 patients (20%) by inspection/palpation and in 19 patients (32%) by IOUS. In eight patients (14%), the occult neoplasms were identified only IOUS, and in one patient the neoplasms were identified only by inspection/palpation. Occult neoplasms identified by IOUS were characterized by small size (less than 2 cm). Findings from the intraoperative evaluation, such as unsuspected neoplasms and vascular proximity or invasion, altered the preoperative plan in 20 (34%) patients. Inspection, and particularly palpation, identifies a number of preoperatively unsuspected liver neoplasms. Intraoperative ultrasound, however, is the most sensitive method for detection of liver neoplasms and influences the operative management in a substantial number of patients.

Integration of surgery in multimodality therapy for esophageal cancer

BACKGROUND

While adding chemotherapy to radiation for the treatment of esophageal cancers has been shown to be beneficial, surgery usually follows treatment or is omitted. In either case, regional control remains problematic. The purpose of this study was to test the feasibility of using chemotherapy and radiation following surgery in the treatment of of esophageal cancer and to assess the impact of this approach on regional control and survival.

PATIENTS AND METHODS

Twenty-five patients with esophageal cancer were treated in a phase I pilot protocol consisting of initial esophagectomy with gastroesophagostomy and subsequent combined chemotherapy and radiation. Chemotherapy consisted of cisplatin given on day 1 and 5-fluorouracil (FU) on days 1-5 by continuous infusion. Radiation therapy was administered in varying fractionation schedules of once or twice daily concomitantly with the chemotherapy. Treatment was repeated every other week for two to four cycles. Median follow-up was 42 months.

RESULTS

Acute toxicities (mucositis and cytopenias) were common but not worse than grade 3. Higher doses of 50 Gy with 2 Gy b.i.d. hyperfractionation caused late complications in four of 10 patients, (two lethal). Control of local disease for all patients was excellent with only two known and two possible local recurrences (16%) but distant metastases were common (46%). Disease-free survival was 58 and 30% at 1 and 2 years, respectively. Survival was 58 and 32% at 1 and 2 years, respectively (median survival, 19 months).

CONCLUSION

The local control rate and survival were better than those in our historical experience with cisplatin and 5-FU chemotherapy and radiation given prior to surgery. A dose-fractionation schedule of < 2 Gy up to a total of 50 Gy b.i.d. is recommended to avoid late adverse effects. The role of surgery will be defined by randomized studies. Better systemic therapy is needed to impact on systemic failure.

Invasive therapy of metastatic colorectal cancer to the liver

Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.

Survival after repeat hepatic resection for recurrent colorectal hepatic metastases

BACKGROUND

This is a retrospective clinical study done to examine survival of patients undergoing repeat hepatic resection for recurrent colorectal hepatic metastases.

METHODS

The records of 131 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resection was performed in 107 of these patients. Thirty-one experienced recurrences confined to the liver. Thirteen (13 of 107, 12%) of them underwent resection and make up the study population.

RESULTS

The eight men (62%) and five women (38%) had a median age of 60 years (range, 32 to 75 years). In 30% of patients recurrence developed near the original resection site. In 70% the recurrences were remote from the original site. The patients underwent a total of six wedge resections, two left lateral segmentectomies, three right lobectomies, and two trisegmentectomies. Average blood loss was 2995 cc; average hospital stay was 17.2 days. Morbidity was 23% (3 of 13); mortality was 8% (1 of 13). Four patients died of recurrent disease, with a mean disease-free survival of 9.7 months (median, 7.5 months; range, 3 to 21 months) and mean total survival of 39 months (median, 24 months; range, 8 to 99 months). One of these patients had a second recurrence resected at month 21 and lived an additional 78 months. Seven patients were alive with no evidence of disease, with a mean follow-up time of 34.9 months (median, 14 months; range, 1 to 186 months). Actual 5-year survival was 23% (3 of 13). Actual disease-free 5-year survival was 15% (2 of 13).

CONCLUSIONS

In properly selected patients morbidity, mortality, and survival after repeat resection are similar to those after initial resection.

Surgical palliation for ductal adenocarcinoma of the pancreas

The short and long term outcomes of operative palliation for unresected ductal adenocarcinoma were evaluated in a critical review of 319 patients from 1972-1990. A total of 154 of 243 operated patients had palliative procedures, including biliary drainage in 86 per cent and combined biliary drainage and gastrojejunostomy in 53 per cent. Overall mortality rate was 13 per cent; one-half of the patients had some complication during their remaining lifetime. Biliary enteric anastomoses provided clinical relief of jaundice in 78 per cent of patients at hospital discharge; jaundice recurred in 16.7 per cent. The overall outcomes of choledochojejunostomy, cholecystojejunostomy, and choledochoduodenostomy were similar and superior to biliary intubation. Choledochojejunostomy was associated with a trend toward longer survival. Gastrojejunostomy did not affect overall results. However, upper gastrointestinal hemorrhage was more frequent when gastrojejunostomy was added to biliary bypass. Late duodenal obstruction developed in 6 per cent of patients initially treated by biliary drainage alone. Mean survival was 8.1 months; one-year survival was 18.2 per cent. Operative palliation for ductal cancer of the pancreas has important morbidity and mortality. Biliary enteric anastomoses provide lifelong relief of jaundice for most patients. Selective, rather than routine, gastrojejunostomy is recommended.

Rapid resolution of necrolytic migratory erythema after glucagonoma resection

A 55-year-old man presented with an 11-year history of necrolytic migratory erythema and glossitis. After the patient's serum glucagon was demonstrated to be elevated, computed tomography scan revealed a mass involving the head of the pancreas. The patient underwent a Whipple-type pancreatico-duodenectomy and his rash resolved completely 6 days after tumor resection. He received no adjuvant treatment. A discussion of the varying theories regarding the pathogenesis and treatment of glucagon-associated necrolytic migratory erythema is presented.

Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients

PURPOSE

Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safety, ability to stop bleeding, and complications associated with therapy.

METHODS

Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient.

RESULTS

In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month.

CONCLUSIONS

Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.

A 15-year review of esophagectomy for carcinoma of the esophagus and cardia

OBJECTIVE

To evaluate the effect of surgical approach and adjuvant therapy on patients with carcinoma of the esophagus and/or cardia.

DESIGN

Retrospective analysis of 157 consecutive patients who underwent esophagectomy.

SETTING

A private university medical center and its affiliated community hospital.

PATIENTS

One hundred twenty men and 37 women (mean age, 61.7 years) with carcinoma of the esophagus and/or cardia that was surgically treated between 1978 and 1993.

INTERVENTIONS

Three approaches were used for resection: Transhiatal esophagectomy (THE) (n = 67), transthoracic esophagectomy (TTE) (n = 71), and abdominal-only esophagectomy (AOE) (n = 19). Sixty-five patients received adjuvant radiotherapy and chemotherapy.

MAIN OUTCOME MEASURES

Surgical mortality, morbidity, and survival and the effect of adjuvant therapy.

RESULTS

The overall surgical mortality rate was 7.6%: 12.7% with the TTE, 4.5% with the THE, and 0% with the AOE approach. A significantly increased incidence of adult respiratory distress syndrome (P < .001) and empyema (P < .001) was seen with the TTE approach. The average intraoperative blood loss (P = .08) and the median intensive care unit stay (P = .26) and hospital stay (P = .40) were decreased with the THE and AOE approaches when compared with the TTE approach without significance. The overall median survival time was 17 months, with a 5-year survival rate of 21%. There was no significant difference in survival by pathologic stage between approaches. The addition of adjuvant therapy did not affect the overall median survival time or the 5-year survival rate. Node-positive patients did benefit from adjuvant radiotherapy and chemotherapy, with increased median survival times from 7 to 15 months and a 5-year survival rate from 0% to 15% (P = .01).

CONCLUSIONS

The THE and AOE approaches have fewer early complications than does TTE. Both THE and TTE have equal long-term survival rates. Adjuvant therapy provides increased survival to node-positive patients with carcinoma of the esophagus and/or cardia.

A prospective comparison of transabdominal preperitoneal laparoscopic hernia repair versus traditional open hernia repair in a university setting

In this study, laparoscopic transabdominal preperitoneal inguinal hernia repair and traditional open inguinal hernia repair were compared in relation to operative time, hospital stay, pain medication use, recovery time, complications, and costs. Elective hernia repairs, 126 in 106 patients, were prospectively followed from January 1991 through September 1993. Seventy-five procedures were performed by laparoscopy and 51 by traditional open approach. Time off work, pain medication use, surgical complications, and hospital stay were all significantly less (p < 0.001) with the laparoscopic approach. Patients in the laparoscopic group returned to work on average 5.5 weeks earlier than patients who underwent traditional herniorrhaphy. The difference in operative times was not statistically significant; however, the difference in the cost of the operations was. In conclusion, laparoscopic inguinal hernia repair offers significantly decreased postoperative pain, shorter hospital stays, faster return to work, fewer complications, and comparable operative times, but at an increased expense for the cost of laparoscopic instrumentation and technology.

Transhiatal stapled esophagojejunostomy without a pursestring suture in patients with previous gastric resection

Previous gastric resection complicates alimentary tract reconstruction after esophagectomy. Colonic interposition is the standard conduit in this circumstance, but has substantial mortality and morbidity, especially important when treatment goals are to provide effective alimentation and minimize hospital stay. This report details the technique of a transabdominal, intrathoracic, stapled esophagojejunostomy created without a pursestring suture, which was used to reconstruct the esophagus in 3 patients who had previously undergone partial gastrectomy. This technique avoids both colon interposition and thoracotomy, thereby minimizing the associated complications.

Recurrent intracranial epithelioid hemangioendothelioma associated with multicentric disease of liver and heart: case report

Epithelioid hemangioendothelioma is an unusual vascular neoplasm with prominent cytoplasmic vacuolization representing primitive lumen formation. A case is presented of this unique vascular neoplasm in a woman with a seizure disorder who had cardiac, hepatic, and recurrent nervous system lesions. To our knowledge, this is the third known case of intracranial epithelioid hemangioendothelioma. Emphasis is placed on the indolent course of this rare neoplasm, with a recommendation for aggressive surgical treatment and diligent follow-up.

The current role of U tubes for benign and malignant biliary obstruction

OBJECTIVE

The recent experience with U tubes at Rush-Presbyterian-St. Lukes Medical Center was reviewed in order to assess their current role in hepatobiliary surgery.

SUMMARY BACKGROUND DATA

Transhepatic intubation by a variety of methods has been used routinely for biliary decompression and inhibition of anastomotic stricture since the 1960s. U tubes were popularized in the early 1970s. However, little has been written about their use and efficacy in recent years. Because of the apparent benefits associated with the use of U tubes versus other stenting techniques, the authors performed this study.

METHODS

The hospital and office charts of all patients who had U tubes placed between 1980 and 1992 were reviewed retrospectively. Between 1980 and 1992, U tubes were placed intraoperatively in 54 patients for biliary decompression and/or stenting. Twelve patients were operated on for benign causes of obstruction. Forty-two patients with malignant tumors underwent surgery for U tube placement in conjunction with or without tumor resection and anastomotic bypass.

RESULTS

There was a 0% operative mortality rate in the benign group. In six patients, the U tube played a major role in the long-term management of their disease processes. None of these patients has had restricture since removal of the tube. In the malignant group, the 30-day operative mortality rate was 12%. After 3 months, marked clinical improvement and complete biliary decompression were achieved, with mean bilirubin levels dropping from 14.0 mg/dL to 1.3 mg/dL. No patients in the malignant group required reoperation for recurrent biliary obstruction after U tube placement.

CONCLUSIONS

The use of U tubes is advocated for biliary decompression and/or anastomotic stenting in patients with benign stricture or resectable malignancy and in patients with nonresectable, malignant biliary obstruction for adequate palliation of intractable jaundice.

Synchronous, metachronous, and multiple hepatic resections of liver tumors originating from primary gastric tumors

BACKGROUND

The role of hepatic resection for noncolorectal gastrointestinal malignancies involving the liver is not well defined. To address this issue we studied our experience with resection of liver tumors arising from primary gastric malignancies.

METHODS

A retrospective study of 195 patients who underwent a total of 207 liver resections identified 12 patients with primary gastric cancer who underwent 16 resections for liver involvement. There were 10 adenocarcinomas and two leiomyosarcomas. We examined the type of hepatic surgery, the status of residual disease, and the primary histologic findings. Morbidity, mortality, and actual survival rates were recorded.

RESULTS

Thirty-day operative mortality was 8.3% (1 of 12). Hospital mortality was 25% (3 of 12). Operative morbidity occurred in three of nine survivors (33%). Synchronous en bloc resection (n = 3) of stomach and liver for adenocarcinoma produced two long-term survivors (no evidence of disease for 10 and 13 years). Mean survival after synchronous discontinuous resection (n = 4) was 8 months (range, 2 to 17 months). Metachronous resection for adenocarcinoma (n = 3) produced one long-term survivor (74 months), and one patient with recurrent leiomyosarcoma underwent a total of five liver resections and survived 64 months.

CONCLUSIONS

For adenocarcinoma, en bloc resection of contiguous liver involvement produced long-term survivors. Synchronous resection of discontinuous metastases did not. Metachronous resection of isolated disease and multiple resections of recurrent isolated disease may have value in carefully selected patients.

Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases

Complications of laparoscopic cholecystectomy were evaluated by a survey of surgical department chairpersons at 4,292 US hospitals. The 77,604 cases were reported by 1,750 respondents. Laparotomy was required for treatment of a complication in 1.2% of patients. The mean rate of bile duct injury (exclusive of cystic duct) was 0.6% and was significantly lower at institutions that had performed more than 100 cases. Bile duct injuries were recognized postoperatively in half of the cases and most frequently required anastomotic repair. Intraoperative cholangiography was practiced selectively by 52% of the respondents and routinely by 31%. Bowel and vascular injuries, which occurred in 0.14% and 0.25% of cases, respectively, were the most lethal complications. Postoperative bile leak was recognized in 0.3% of patients, most commonly originating from the cystic duct. Eighteen of 33 postoperative deaths resulted from operative injury. These data demonstrate that laparoscopic cholecystectomy is associated with low rates of morbidity and mortality but a significant rate of bile duct injury.

The impact of laparoscopic cholecystectomy on the operative experience of surgical residents

The impact of laparoscopic cholecystectomy (LC) on the operative experience of surgical residents was assessed in a series of 787 cholecystectomies. During an initial 18-month period, residents participated in LC as operating surgeon and as first assistant or camera operator in 33% and 97% of cases, respectively. Operative time, cholangiography rate, conversion rate, and complications were not adversely affected by resident operators. Residents performed 87% of concurrent planned open cholecystectomies (OC). In comparison to the 6 months preceding LC: (1) The mean number of resident OCs decreased significantly while the total number of resident cholecystectomies was unchanged; (2) the proportion of OCs performed by PGY5 residents significantly increased at the expense of junior resident cases. LC can be safely integrated into surgical resident training by standard methods as for open procedures. Although resident operative experience has been redistributed, initial experience does not suggest that qualification in open biliary surgery has been compromised.

Major abdominal operations in acquired immunodeficiency syndrome

Twenty-one major abdominal operations performed on 20 patients with Acquired Immunodeficiency Syndrome (AIDS) were reviewed. Fourteen operations were for therapeutic indications, eight were emergent. The array of pathology encountered included opportunistic infection with Mycobacterium avium intracellulare, Cytomegalovirus, Cryptosporidium, abdominal tuberculosis, lymphoma, Kaposi's sarcoma, AIDS-related immune thrombocytopenia, perforated appendicitis and colonic pseudo-obstruction. Hospital mortality was 20 per cent. Major morbidity occurred in 15 per cent of patients and was more common following emergency operations. Preoperative demographic, hematologic, or nutritional parameters examined or the presence of single-organ system dysfunction did not predict outcome. Fifty-three per cent of hospital survivors are alive with a nine-month median postoperative follow-up. It is concluded that major abdominal procedures in patients with AIDS should not be withheld due to fear of excessive morbidity or mortality. General surgeons are involved in the evaluation and treatment of increasing numbers of patients with HIV infection. Appropriate management requires recognition of a wide range of surgical pathology and attention to details of safe intraoperative conduct.

Intraoperative radiation therapy in biliary tract cancer

From 1983 to 1986, nine patients with advanced cancers of the proximal biliary tract were treated with intraoperative electron beam radiation therapy (IORT) following surgical resection or intubation. Five patients also received external beam radiation and four received chemotherapy. Early complications were minimal. Late complications included cholangitis, gastroduodenal ulceration, gastric outlet obstruction and portal vein thrombosis. Symptomatic recurrent or residual disease developed in eight patients with a median disease-free survival of 6 months. Seven patients failed locally; four recurred outside of the intraoperatively radiated field. The longest survivor is free of disease at 40 months; one patient is alive with disease at 30 months. Mean and median survivals were 16.8 months and 13 months respectively with 56 per cent 1-year survival. This was not different from a mean survival of 11 months and 46 per cent 1-year survival observed in 13 concurrent patients treated by external beam +/- 192Ir. Survival of six patients not treated by radiation was only 4.6 months (P = 0.3). Two thirds of patients had good or fair palliation. IORT has theoretical advantages for the treatment of locally advanced biliary cancer; preliminary results suggest useful palliation and potential long-term survival. Complications require ongoing evaluation and superiority to conventional treatment modalities has not been demonstrated.

Surgical intervention for pheochromocytoma

Between 1964 and 1983 at Rush-Presbyterian-St Luke's Medical Center, 30 surgical procedures on 28 patients were performed for pheochromocytoma. In two cases, the tumors were nonresectable. Three patients had malignant pheochromocytomas, and of these, all had recurrences by eight years after surgery. Although the prognosis for patients with malignant pheochromocytomas is not good, the majority of patients have benign tumors and are cured of their disease.

Abdominal emergencies

Acute surgical conditions of the abdomen are heralded by pain, and can occur in patients hospitalized for unrelated reasons. A thorough history and physical examination, aided by certain laboratory and radiographic studies, are essential in making a correct diagnosis.

Pheochromocytoma: operative strategy

We studied 28 patients who had undergone 30 operations for pheochromocytoma since 1964. The tumor types included bilateral, extra-adrenal, malignant, recurrent, and multiple endocrine neoplasia, with 20 tumors confined to the adrenal gland. The preoperative studies used to localize the tumor included ultrasonography, intravenous urography, angiography, and computed tomography. Patients underwent exploratory operations via flank, subcostal, bilateral subcostal, midline, or thoracoabdominal approaches. In one case, that of a recurrence after bilateral adrenalectomy, surgical exploration discovered a tumor that had not been localized during the preoperative workup. Two patients underwent splenectomy because of injury incurred during operative exploration. Our experience suggests that preoperative localization is highly reliable, and therefore the benefits of extensive surgical exploration may be outweighed by its risks. We believe that with the exception of tumors that occur in association with childhood or pregnancy, multiple endocrine neoplastic syndromes, or recurrent disease, a direct approach to the tumor, possibly via the flank, is justified. Our results suggest that exploration of the contralateral adrenal or periaortic area is not so important as to be worth jeopardizing the spleen or other organs by a complex or extensive dissection.

A ten year experience with hepatic resection

The results of our experience have demonstrated that patients who undergo hepatic resection for primary or metastatic carcinomas have survival rates considerably higher than those reported in the literature for patients who do not undergo resection. Morbidity rates as well as survival rates among the patients we studied lie within the reported values of the major institutions. It is certainly clear that, within the past five years, metastatic disease to the liver from a primary carcinoma of the colon and rectum has become a treatable disease. We, therefore, advocate the aggressive approach to carcinoma of the liver and look forward to further advancement in the treatment of this disease.

Combined high-frequency ventilation for management of terminal respiratory failure: a new technique

Seven patients with severe adult respiratory distress syndrome (ARDS) developed terminal respiratory failure and severe hypoxemia (PaO2 below 50 mm Hg) with death imminent despite maximal ventilatory support with intermittent positive-pressure ventilation (IPPV) and positive end-expiratory pressure (PEEP). High-frequency positive-pressure ventilation (HFPPV) was used in these patients for one day at a rate of 250 breaths/min, with slight improvement of PaO2 to a mean of 80 mm Hg. High-frequency oscillatory (HFO) ventilation was used during the second day at a rate of 2000 breaths/min; this provided adequate oxygenation with a mean PaO2 of 244 mm Hg. Nonetheless, during HFO there was progressive CO2 retention and respiratory acidosis (mean PCO2 67 mm Hg). On the third study day, all seven patients were ventilated with combined high-frequency ventilation (CHFV) for a period from 5-21 days. CHFV is based on the administration of HFPPV simultaneously with HFO and provided adequate oxygenation by accelerated gas diffusion and CO2 elimination by convection. PaO2 was maintained during CHFV at a mean of 280 mm Hg. CO2 elimination was adequate with a mean PaCO2 of 32 mm Hg. Cardiac output also was adequately maintained during CHFV. Moreover, CHFV was well tolerated in our patients, allowing them to communicate with their families and nurses. CHFV successfully treated the hypoxemia of respiratory failure in all the patients. However, five patients (71%) died of cardiac arrest as a result of multisystem failure despite adequate oxygenation (PaO2 above 80 mm Hg).

Management of pancreatic abscesses

The records of twenty-one patients treated for pancreatic abscesses were reviewed. Pancreatitis developed following alcohol ingestion, operative procedures, biliary tract disease, ulcers, and undetermined causes. The clinical findings included abdominal pain in 19 patients (90%); fever in 18 (86%); tenderness in 18 (86%); and leukocytosis in 18 (86%). Ultrasonographic examination aided the diagnosis in seven of 11 patients. Computerized tomography was useful in diagnosing eight of ten cases. There were twenty-nine hospital admissions, with a mean length of hospitalization of 76 days per patient. The operative findings varied with extent and duration of underlying pancreatitis. The surgical approach depended on clinical presentation and prior localization of the abscess. Eleven additional operations were performed. Complications included respiratory failure (three patients); fistula formation (five patients); hemorrhage (two patients); renal failure (one patient); and splenic vein thrombosis (one patient). Thirteen patients were treated with hyperalimentation and nine patients had gastrostomy and jejunostomy placed for decompression and feeding. Of 15 patients in whom microbial studies were reviewed, nine patients had polymicrobial infections. Three patients had Candida albicans. There was one death.

Radiation carcinogenesis in man: new primary neoplasms in fields of prior therapeutic radiation

Nine patients are presented in whom new malignant neoplasms developed in fields of prior irradiation. The prior irradiation had been administered to these patients for previously confirmed cancers, lesions suspected of being cancer (but never confirmed as such), and for non-neoplastic disorders. Each of these cases is relatively unique and several present the first association between prior radiation therapy and the subsequent neoplasm or neoplasms which developed.

Bilateral hypernephroma with solitary pancreatic metastasis

A case of bilateral renal carcinoma with an uncommon solitary metastasis is presented. Therapeutic rationale is discussed.

Pneumatosis cystoides intestinalis following jejunoileal by-pass

Four cases of pneumatosis cystoides intestinalis following ileojejunal by-pass in 37 patients are described and the literature reviewed. This complication is usually a self-limited condition, responding to conservative management.

Splenic cysts

Benign non-parasitic cysts of the spleen are very uncommon, with a total of 651 cases having been described in the literature to date. Because of their uncommon nature, and the fact that their symtoms may be vague, a high index of suspicion is necessary if they are to be diagnosed. The therapy of choice is surgical excision by splenectomy and the accompanying cystectomy. The prognosis following such therapy is excellent.

Acute hemorrhagic pancreatitis and pseudocyst due to mumps

This is the first reported case of mumps hemorrhagic pancreatitis in a child, documented at operation, and by rising mumps titers and complicated by a pseudocyst. In severe cases when surgery is indicated, drainage of the lesser sac usually prevents pseudocyst formation. If a pseudocyst occurs, drainage is required to eliminate disabling pain and chronic pancreatitis. Live attenuated mumps vaccine may eliminate this source of pancreatitis from American children in the future.