Should all patients with duodenal adenocarcinoma be considered for aggressive surgical resection?

BACKGROUND: Long-term survival for duodenal adenocarcinoma is inconsistent in the literature, and the biology of duodenal adenocarcinoma is poorly understood. METHODS: One institution's experience with duodenal adenocarcinoma from 1984 to 2005 is reviewed. Clinicopathologic data were analyzed, and overall survival was estimated using Kaplan-Meier curves with log-rank test. RESULTS: Of the 52 patients, 35 (67%) underwent potentially curative surgery; 31 survived the postoperative period and were included in the analysis. Of these, the median survival was 34 months (range 6 to 186 months) compared with 13 months (range 1 to 24 months) for those not undergoing curative surgery (P < or = .001). Clinicopathologic factors favoring long-term survival were tumor size >3.5 cm (P < or = .001) and T-stage < or =4 (P = .014). CONCLUSIONS: Clinicopathologic factors important to survival in duodenal cancer are T4 tumor status and tumor size. Interestingly, larger tumors were less likely to be invasive, and patients with these tumors had improved survival. The biology of this cancer is poorly understood; therefore, aggressive resection for all duodenal adenocarcinomas is recommended for all patients medically fit to undergo resection.

Inguinal hernia is not a sign of colon cancer: results of a prospective screening trial.

BACKGROUND: It has been suggested that patients with an inguinal hernia harbour an increased risk for colorectal cancer. METHODS: In a prospective clinical trial, we compared the prevalence of colonic neoplasms in 100 cases with inguinal hernia and 100 controls without inguinal hernia. The number, size, histology type, and the location of all colorectal lesions found during a screening flexible sigmoidoscopy were recorded. RESULTS: Not a single case of colorectal cancer was detected in the patients with inguinal hernia pending surgical repair. In the asymptomatic control subjects, one Dukes A and one Dukes B1 colon cancer were detected. Polypectomy was performed in 15% and 17% of the case and control subjects, respectively. During a 5-year period following the initial screening procedure, none of the case or control subjects was diagnosed with colon cancer. CONCLUSIONS: The decision for or against performing an endoscopic procedure in a patient with inguinal hernia should be guided by the general principles of screening for colorectal cancer. The mere presence of an inguinal hernia does not automatically increase the risk of colorectal cancer.

Long-term survival of a patient with widespread metastases from Barrett's adenocarcinoma.

Five-year survival of patients with stage 4 Barrett's adenocarcinoma is minimal. Such a patient is presented, alive without evident disease, 7 years after resection of the primary lesion, during which time he drank Peruvian herbal tea.

Pancreaticogastrostomy following pancreaticoduodenectomy: review of 102 consecutive cases.

Disruption of the pancreatic anastomosis with resultant sepsis is the cause of nearly 50% of deaths following pancreaticoduodenectomy (PD). Traditionally, the pancreatic remnant is anastomosed to the jejunum. Pancreaticogastrostomy (PG) was introduced as an alternative by Waugh and Clagett in 1946 and by Park, Mackie, and Rhoads in 1967. The purpose of this retrospective review was to assess the safety of PG at a single institution. Between 1986 and 1998 a total of 102 patients underwent PG following PD. The indications for PD were periampullary carcinoma (n = 89), pancreatitis (n = 7), and miscellaneous (n = 6). Altogether, 80 patients underwent the traditional Whipple procedure and 22 the pylorus-preserving Whipple (PPW) procedure. The PG was performed by a single-layer invagination technique to the posterior gastric wall using interrupted silk sutures. Leaks from the pancreatic anastomosis were detected by measuring amylase in fluid obtained from surgically placed drains. Operative mortality was 3.9% (4/102). The cause of death was uncontrolled upper gastrointestinal hemorrhage, sepsis, pulmonary embolus, and cardiac failure secondary to myocardial infarction. The mean operating time was 6.8 hours. Blood transfusion was given in 43 patients (42%), and the mean amount of the transfusion was 2.6 units. Nonfatal complications occurred in 35 patients (34%), and included leaks from the pancreatic anastomosis in 9 (8.8%), leaks from the biliary-enteric anastomosis in 4 (3.9%), and gastric paresis 7 (6.9%). Other complications included abscess, wound infection, colitis, delirium tremens, and hyperbilirubinemia. Discharge occurred 6 to 47 days (median 12 days) postoperatively and was prolonged in patients suffering from a complication. PD is associated with significant morbidity. PG is a safe alternative to pancreaticojejunostomy for managing the pancreatic remnant.

Long-term nonsurgical management of Barrett's esophagus with high-grade dysplasia.

BACKGROUND & AIMS: Surgical resection of the esophagus is frequently recommended for Barrett's high-grade dysplasia (HGD) without cancer. METHODS: During a 20-year period, patients were diagnosed and observed through an organized surveillance program at the Hines Veterans Affairs Hospital. The program was supported by Hines VA and organized and managed by 2 endoscopists using preestablished endoscopic criteria. RESULTS: Barrett's esophagus was diagnosed in 1099 patients, and 36,251 esophageal mucosal specimens were reviewed. Seventy-nine of 1099 patients (7.2%) initially had HGD (34 prevalent) or subsequently developed HGD (45 incident) without evidence of cancer. Of the 75 HGD patients who remained without detectable cancer after the 1 year of intensive searching, 12 developed cancer (16%) during a mean 7.3-year surveillance period: 11 of the 12 who were compliant were considered cured with surgical or ablation therapy. Cancer did not develop in the remaining 63 HGD patients during the surveillance period. CONCLUSIONS: HGD without cancer in Barrett's esophagus follows a relatively benign course in the majority of patients. In the patients who eventually progress to cancer during regular surveillance, surgical resection is curative. Surveillance endoscopies with biopsy is a valid and safe follow-up strategy for Barrett's patients who have HGD without cancer.

Age is not a contraindication to pancreaticoduodenectomy.

The incidence of pancreatic cancer has increased threefold over the last 40 years with the greatest rate of growth occurring in the elderly. In the past it was suggested that elderly patients tolerated pancreaticoduodenectomy less well than younger patients with higher mortality rates. This single-institution experience examines the question of whether age is a significant factor in relation to morbidity and mortality in patients undergoing pancreaticoduodenectomy. Between 1994 and 1999 outcomes of 122 patients who underwent pancreaticoduodenectomy were reviewed. There were 48 patients 70 years of age and older and 74 patients less than 70 years of age. Both groups were compared with respect to preoperative clinical prognostic determinates and perioperative factors affecting morbidity and mortality. There was no significant difference between the two groups comparing their comorbidities, use of preoperative antibiotics, intraoperative blood loss, or length of hospital stay (11.9 and 10.8 days respectively). The two groups were also similar with regard to pathologic diagnosis with pancreatic adenocarcinoma being the most frequently encountered neoplasm. There was one death in the less-than-70-year-old group and none in the older group. No significant difference in the rate of complications was appreciated. These data demonstrate that pancreaticoduodenectomy can be performed safely in patients 70 years of age and older with morbidity and mortality rates similar to those of younger individuals.

Leiomyosarcoma of the pancreas.

BACKGROUND: This is a single case report of a rare tumour, pancreatic leiomyosarcoma. CASE OUTLINE: A 44-year-old woman presented with a painless epigastric mass, and CT scan showed a cystic lesion of the head of pancreas. An associated epigastric mass was found to be a lipoma. Pancreatoduodenectomy was successfully performed. Pathology revealed leiomyosarcoma of the pancreas. The patient is well and free of disease four years later. DISCUSSION: Leiomyosarcomas of the pancreas can present with abdominal pain, weight loss and abdominal mass. However, a certain number of tumours will be discovered incidentally and may be cystic in nature. This patient had no antecedent history of gallstones or alcohol and underwent a curative resection.

Defining a role for endoscopic ultrasound in staging periampullary tumors.

BACKGROUND: The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients. METHODS: Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients. RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT. CONCLUSIONS: CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.

The increasing problem of unusual pancreatic tumors.

HYPOTHESIS: Patients presenting with a pancreatic mass often have a curable lesion rather than the more common adenocarcinoma. Greater awareness of this among nonsurgeons is necessary. DESIGN: Retrospective case series. SETTING: Tertiary care referral hospital. PATIENTS: All patients who presented with a pancreatic mass during the 8 years from 1990 to 1998 were studied. Patients with a history of chronic pancreatitis, a functioning pancreatic neuroendocrine tumor, or pancreatic adenocarcinoma were excluded. Forty patients were identified, demographic and clinical characteristics recorded, and long-term follow-up obtained. INTERVENTIONS: Therapy included either a Whipple procedure or distal pancreatectomy. Two patients underwent a biliary bypass. MAIN OUTCOME MEASURES: Tumor histology, morbidity, and survival. RESULTS: Three hundred thirty-six patients with a pancreatic mass were treated during this 8-year period. Two hundred ninety-six of these had pancreatic adenocarcinoma. Forty (11.9%) of the 336 patients had other types of pancreatic tumors. Two thirds of these patients were female, with an average age of 57 years. Seventy-five percent of these tumors were either malignant or potentially malignant. In several instances, cystic tumors were diagnosed as inflammatory pseudocysts and managed accordingly. Fourteen (35%) of 40 patients had no symptoms and their tumor was found on a computed tomographic scan performed for another indication. Percutaneous biopsy was performed in 9 patients, of whom 5 were assigned an incorrect diagnosis. There were no operative deaths, although the postoperative complication rate was 23%. CONCLUSIONS: In this series, nearly 12% of patients presenting with a pancreatic mass did not have pancreatic adenocarcinoma, but rather more favorable lesions amenable to operation. Preoperative biopsy should not be carried out. Curative procedures can be safely performed in centers seeing a large number of patients with pancreatic tumors, and the long-term results of extirpation are excellent.

How well do third-year medical students learn key objectives in a case-based surgical lecture series?

Faculty members were asked to list major and minor concepts of their case-based session presented during the 12-week 3rd-year surgical clerkship. After each session, students were queried to list the key concepts presented. Data were collected from two groups: one at the end of an academic year and a second at the beginning of the next academic year. Faculty members listed a median of 10 major and 15 minor concepts. The mean number of matched major concepts ranged from 0.2 to 4, and from 0.2 to 3.4 for minor concepts. In a comparative analysis, the end-of-the-year students listed a higher number of matched concepts for 17 of the 20 sessions than the beginning of the year students (8 sessions reached statistical significance, P < 0.05). The current case-based teaching method is not effective in emphasizing key concepts to students. Reformatting cases to better align with key concepts may be one solution to enhance a student's ability to grasp key concepts. Students at the end of the academic year outperformed those at the beginning of the year. This additional variable needs to be considered by faculty and incorporated into their teaching techniques.

Adenosquamous carcinoma of the pancreas.

BACKGROUND: Adenosquamous carcinoma of the pancreas most probably represents squamous metaplasia of an adenocarcinoma. Metastases are typically an admixture of both elements, but more frequently, adenocarcinoma. METHODS: A review of 102 pancreaticoduodenectomies for masses of the head of the pancreas done between 1994 and 1998 revealed two patients with adenosquamous carcinoma of the pancreas. RESULTS: Both patients underwent successful pancreaticoduodenctomy, but were found to have nodal metastasis. One patient lived 13 mo and the other lived 14 mo with both dying from metastatic disease. CONCLUSION: Adenosquamous carcinoma of the pancreas is a rare tumor, and because its presentation, clinical features, and course are identical to adenocarcinoma of the pancreas, it should be considered in the differential diagnosis for any mass of the head of the pancreas. Survival is poor for these patients. In this series, it was 13 and 14 mo, respectively.

Predictors of axillary lymph node metastasis in T1 breast carcinoma.

This study was designed to determine the predictors of axillary lymph node metastasis in T1a (< or =0.5 cm), T1b (>0.5 cm and < or =1.0 cm), and T1c (>1.0 cm and < or =2.0 cm) breast cancers. The charts of 204 patients who underwent axillary lymph node dissections for T1 breast carcinomas at our institution were reviewed. Of these, 23 (11%) patients had T1a cancers, 55 (27%) patients had T1b cancers, and 126 (62%) patients were diagnosed with T1c lesions. Fifty patients (24.5%) had axillary node metastases. Of those with T1a lesions, one (4.3%) patient had axillary node involvement, compared with 9 (16.4%) patients with T1b and 40 (31.7%) patients with T1c lesions. Nodal involvement was significantly increased in T1c cancer compared with either T1a (odds ratio = 8.24; P < 0.05) or T1b (odds ratio = 2.73; P < 0.05). Similar results were found in tumors with grade 3 nuclear pleomorphism (odds ratio = 10.45 versus grade 1 and 3.46 versus grade 2; P < 0.05). The presence of lymphovascular invasion was also associated with an increased likelihood of nodal involvement (odds ratio = 3.15; P < 0.05). Predictors of axillary lymph node metastasis in T1 breast carcinomas include increasing tumor size, grade 3 nuclear pleomorphism, and the presence of lymphovascular invasion. These predictors may have a role in stratifying patients with T1 breast carcinomas into subgroups that may benefit from less invasive methods of evaluating axillary lymph node status.

Successful nonoperative management of bleeding hepatic artery pseudoaneurysm following pancreaticoduodenectomy.

BACKGROUND/AIMS: To report the management of a hepatic artery pseudoaneurysm presenting 35 days following a Whipple procedure. METHODS: The case study of a patient with a bleeding pseudoaneurysm is presented. RESULTS: Computed tomography demonstrated a pseudoaneurysm which was successfully embolized. CONCLUSIONS: Acute gastrointestinal bleeding from a pseudoaneurysm in the hepatic artery following Whipple procedure can be successfully managed with transcatheter embolization.

Assessing the resectability of pancreatic carcinoma: the value of reinterpreting abdominal CT performed at other institutions.

OBJECTIVE: The purpose of this study was to determine the value of reinterpreting abdominal CT performed at other institutions when assessing the resectability of pancreatic carcinoma. MATERIALS AND METHODS: Fifty-three patients (30 men, 23 women; mean age, 62 years) referred to our tertiary care institution with newly diagnosed pancreatic carcinoma had formally reinterpreted abdominal CT scans and available initial reports. CT was performed at community hospitals (n = 47), university hospitals (n = 4), an outpatient clinic (n = 1), and an imaging center (n = 1); reinterpretation was performed by university radiologists with subspecialty expertise in abdominal imaging. On the basis of the initial and reinterpretation reports, the patients were categorized as having resectable or nonresectable disease. Medicare reimbursement rates were assessed. RESULTS: The initial and reinterpretation reports agreed in 36 (68%) of the 53 patients, with the disease of 16 patients considered resectable and 20 unresectable by both reports. In 17 patients (32%), we found discrepancies between the initial and the reinterpretation reports. All discrepancies involved the initial report indicating resectability and the reinterpretation report consistent with nonresectable disease. Discrepancies were resolved by findings at surgery (n = 9), percutaneous biopsy (n = 3), dedicated pancreatic CT (n = 3), dedicated liver CT (n = 1), and follow-up abdominal CT (n = 1); the reinterpretation reports were correct in 16 (94%) of 17 patients. Reimbursement for outside CT reinterpretation, repeated abdominal CT, and an exploratory laparotomy were estimated at $46.45, $414.47, and $16,996.44, respectively. CONCLUSION: Reinterpretation of outside abdominal CT was valuable for determining pancreatic carcinoma resectability and inexpensive when compared with repeating the CT examination or performing an exploratory laparotomy.

A technique for pancreaticogastrostomy.

A technique for pancreaticogastrostomy is presented. The technique is a one-layer, invaginated anastomosis of the pancreatic remnant to the posterior gastric wall following a Whipple resection of the pancreatic head. Key steps to achieve a successful anastomosis are described. Using this technique, there have been no pancreatic anastomotic leaks in 29 consecutive patients.

The international medical graduate in US academic general surgery.

OBJECTIVES: To identify graduates of medical schools outside of the United States who are on academic general surgical faculties in the United States and to determine their contribution to surgery in the United States. DESIGN: A questionnaire was sent to the departments of general surgery of 128 medical schools and clinics with independent surgical training programs. SETTING: All the departments of surgery affiliated with medical schools and clinics in the United States. PARTICIPANTS: All department chairpersons of the general surgical services in the United States. MAIN OUTCOME MEASURE: To identify graduates of foreign medical schools who had their training in the United States, their area of expertise, and their present positions. RESULTS: One hundred twenty-two (95.3%) of the 128 medical schools and clinics replied to the questionnaire. Of the 122, 108 (88.5%) had at least 1 international medical graduate (IMG) on their faculty; 572 IMGs were identified on the surgical faculty, of which 538 were men and 34 were women. These individuals represent 72 countries or colonies and most continents and regions of the world. Fourteen are or have been department chairpersons. Asia, with 172 medical graduates, contributed the highest number of graduates, followed by North, Central, and South America, with 136 total, and Europe, with 123. India, followed by Canada, South Africa, the United Kingdom, and the People's Republic of China, accounts for a large number of the individuals. The states with the most IMGs were California, 78; New York, 75; and Illinois, 42. CONCLUSIONS: International medical graduates account for 10% of the academic surgical faculty in the United States. These graduates come from all countries and regions of the world. International medical graduates occupy faculty positions commensurate with experience. Fourteen are or have been department chairpersons. Since 1960, there has been an increasing number of appointments of IMGs to faculty of the departments of surgery. The results of this survey suggest that the experience of the IMG in US surgery has been quite favorable.

Fine-needle aspiration of 697 palpable breast lesions with histopathologic correlation.

BACKGROUND: Fine-needle aspiration breast biopsy has been used increasingly as an alternative to excisional biopsy. The purpose of this study is to evaluate the accuracy of fine-needle aspiration with histopathologic confirmation. METHODS: A retrospective study was performed using a computer database over a 5-year period. All women who had had fine-needle aspiration breast biopsy with histopathologic confirmation of the diagnosis were included. Fine-needle aspirations were interpreted as malignant, suspicious, or benign. Histopathologic diagnosis included core-needle biopsy, open excisional biopsy, or mastectomy specimen. RESULTS: A total of 697 patients fulfilled the criteria. Only 5 (0.7%) of the specimens were inadequate for study. There were 401 total malignant fine-needle aspiration diagnoses, with only 3 false-positive specimens. All three were ductal hyperplasia, one from a previously radiated breast. There were 125 suspicious readings; 84 of these were malignant and 41 were false-suspicious specimens. Most of the false-suspicious lesions were fibrocystic disease. Of the 166 lesions interpreted as benign, there were 13 false-negative specimens. The test had a 97% sensitivity, 78% specificity, 92% positive predictive value, and 92% negative predictive value. CONCLUSIONS: Fine-needle aspiration is a sensitive test that can be useful as an adjunct in the diagnosis of breast cancer. "Malignant" and "benign" interpretations are highly predictive but must be used only in the context of other diagnostic modalities. "Suspicious" lesions require further investigation.

Giant antral ulcer: a rare presentation of eosinophilic gastroenteritis--case report and review of the literature.

A 24-yr-old female presented with a giant gastric ulcer and anemia. She suffered from a transient infantile malabsorption syndrome with eosinophilia. The diagnosis of eosinophilic gastroenteritis associated with the gastric ulcer was made by endoscopic biopsy. Ulcer healing was refractory to medical therapy and partial gastrectomy was performed. Histologic examination revealed transmural eosinophilic infiltrates with mast cell infiltrates in the gastric wall. This case illustrates (1) an extremely rare presentation of eosinophilic gastroenteritis--giant, refractory, gastric ulcer; (2) a potential pathogenic role for mast cells in this syndrome; and (3) the chronic and relapsing nature of the syndrome.

Factors influencing bowel function following total abdominal colectomy.

PURPOSE: The purpose of this study was to determine which factors influenced bowel function following total abdominal colectomy. METHODS: Thirty-two patients who had undergone total abdominal colectomy were studied with regard to factors that are classically thought to influence bowel function, namely, residual stump length, transit time, and rectal stump manometry. In a limited subset of patients, anal manometry was done also. RESULTS: Transit time was the best predictor of bowel function following total abdominal colectomy. This was followed by stump length. If transit time was short, then stump length became important in predicting the occurrence of diarrhea following total abdominal colectomy. CONCLUSIONS: Two factors have an important influence on bowel function following total abdominal colectomy: transit time and rectal stump length. Rectal stump length is an anatomic factor that can be controlled by the surgeon. In total abdominal colectomy, rectal stump length of at least 20 cm is necessary if the patient is to have satisfactory postoperative bowel function. This may not always be possible. In these patients, modification of diet to influence transit time and methods to increase rectal compliance will be necessary.