Experience with the Whipple procedure (pancreaticoduodenectomy) in a university-affiliated community hospital.

BACKGROUND: The purpose of this report is to review the current standards of the Whipple pancreaticoduodenectomy and show that excellent results are achievable in a low-volume, university-affiliated community hospital. METHODS: A case series of consecutive patients operated on during the period November 1981 to June 1996 was evaluated retrospectively. Medical records were abstracted for demographic data, clinical presentation, comorbid factors, pathological diagnosis and staging, operative records, perioperative mortality, morbidity, and length of stay. Postoperative follow-up data were obtained from telephone interviews and from the primary referring physicians. RESULTS: A total of 29 patients underwent a pancreaticoduodenectomy procedure during this 15-year period. Twenty-eight patients underwent the standard Whipple resection and 1 patient underwent an extended resection owing to the extent of the disease. The average age was 64 years (range 41 to 82). Comorbid diseases were present in 59% of cases. Jaundice was the main presenting complaint (62%), loss of weight and appetite was present in 34%. The most common indication for this procedure was malignant periampullary disease (83% of cases). Of patients with adenocarcinoma of the pancreas, 67% were stage I and 33% were stage III. The operation lasted an average of 5.5 hours (range 3.5 to 8 h). The mean operative blood loss was 1153 mL (range 250 to 4,000). The median length of stay was 11 days (range 7 to 81). There was 1 operative mortality (3%), and the overall major morbidity rate was 28%. Three patients required reoperation (10%), 2 for intraabdominal hemorrhage and 1 for delayed gastric emptying. The major morbidity was hemorrhage at the gastrojejunostomy site (14%); 2 cases were intraabdominal and 2 were intraluminal. Pancreaticojejunostomy leak occurred in 1 patient, resulting in a localized intraabdominal abscess. Delayed gastric emptying, defined as the need for nasogastric suctioning for more than 10 days postoperatively, occurred in only 1 patient. Overall, an oral diet was tolerated after a median of 6 days (range 4 to 61). Seventy-two percent of patients had no major complications at all, 17% had one major complication, and 10% had two or more major complications. Pancreatic insufficiency was the major long-term complication, developing in about 50% of patients. There were no biliary strictures. The median survival for patients with carcinoma of the pancreas was 21 months and the 5-year survival was 15%. CONCLUSIONS: The above study demonstrates that a complicated procedure like the Whipple pancreaticoduodenectomy can be performed with excellent results in a community hospital. The most important prerequisite is that the surgeon be adequately trained in the procedure. In low-volume hospitals, the case load should be restricted to a minimal number of trained surgeons in order to concentrate the experience.

Persistence of the gallbladder following laparoscopic cholecystectomy: a case report.

Laparoscopic cholecystectomy is the technique of choice for cholecystectomy. No experience with congenital abnormalities of the gallbladder has been reported. We report here the case of a 42-year-old woman who developed recurrent symptoms seven months after laparoscopic cholecystectomy and was found to have the majority of her gallbladder still intact. We speculate that the patient had a bilobate gallbladder as the explanation for the mishap. She subsequently underwent open repeat surgery.

Hepatic resection for primary and metastatic tumors.

Thirty-four hepatic resections were performed on 33 patients. These included 4 trisegmentectomies, 14 lobectomies, 7 segmentectomies, and 9 wedge resections. Twenty patients had metastatic colorectal cancer, 4 had a primary liver tumor, 2 had giant cavernous hemangioma, 1 had metastatic leiomyosarcoma, 5 had various benign lesions including focal nodular hyperplasia, and 1 patient had resection for trauma. Operative morbidity included four subphrenic abscesses, one bile leak, one bile duct injury, one case of cholestasis, and one case of phlebitis. There were no operative deaths. The median survival of the patients with metastatic colorectal cancer was 40 months, and the 5-year actuarial survival rate was 35 percent. Survival rates were not significantly different between patients with a solitary metastasis and those with multiple lesions and was not influenced by size of the metastases. However, survival was significantly better in patients whose primary colorectal lesion was Dukes' B as compared with those whose lesion was Dukes' C. The results indicate that liver resection can be performed safely with acceptable morbidity and improved long-term survival.

Mesenteric panniculitis of the sigmoid colon. Report of two cases.

Mesenteric panniculitis is an extremely rare disease in which the normal fatty architecture of the mesentery is replaced by fibrosis, necrosis, and calcification. Grossly, the mesentery is massively thickened and rubbery, with irregular areas of reddish-brown to pale yellow foci resembling fat necrosis scattered throughout. Microscopically, inflammatory involvement of the fibroadipose tissue shows round cells, foam cells, and giant cells. Macrophages that have ingested fat, also called lipophages, are the hallmark of the diagnosis. One hundred twenty-two cases of mesenteric panniculitis have been described in the literature; only three of these involved the large-bowel mesentery. This paper presents a review of the literature and two new cases that involve exclusively the mesentery of the sigmoid colon.

Hepatic resection for metastases of the colon and rectum.

Hepatic resection is the treatment of choice for a solitary metastatic deposit from a primary carcinoma of the large intestine in the absence of extrahepatic disease. This study was done to evaluate hepatic resection in the treatment of multiple hepatic metastases from carcinoma of the colon and rectum. Sixty-two patients underwent hepatic resection with an over-all operative mortality of 10 per cent, but a recent (1968-1981) mortality of 2 per cent. Three, five and ten year survival rates were 50, 34 and 21 per cent, respectively. No significant differences in survival patterns were noted comparing site (colon versus rectum), time interval from diagnosis of the primary to diagnosis of metastases (synchronous versus metachronous), sex (male versus female), size of the metastatic lesion (less than 5 centimeters versus greater than or equal to 5 centimeters) or number of metastatic lesions (single versus multiple). The pathologic stage of the primary carcinoma of the large intestine significantly (p less than 0.05) influenced survival patterns after hepatic resection with Dukes' B primary tumor having a median survival time of 123 months versus 27 months for patients with Dukes' C primary tumor. Sixty-seven per cent of those with a recurrence did so within the liver. Adjuvant chemotherapy had no demonstrable effect on survival patterns. Further improvement in survival statistics will require more sensitive staging procedures and effective adjuvant therapy, particularly for patients with Dukes' C primary carcinoma of the large intestine.

Primary lymphoma of the liver treated with extended left hepatic lobectomy.

Primary lymphoma of the liver is an extremely rare entity; only five cases have been reported in the English language literature. Presented is a case report of a patient with primary hepatic lymphoma successfully treated by major liver resection. The current management trends are reviewed.

Self-inflicted sigmoid colon perforation. Report of a case.

A rare, if not unique, case of sigmoid colon perforation by a balloon, self-inserted transanally, is described. Mechanical properties of the sigmoid colon make it prone to rupture by pneumatic distention. Management depends on amount of peritoneal contamination, timing, and associated injury. With prompt surgery, isolated traumatic sigmoid colon perforations have a good prognosis.

Second-look laparotomy based on CEA elevations in colorectal cancer.

Second-look laparotomy was performed in 32 patients who had significant CEA elevations following curative resection for adenocarcinoma of the large bowel. All were asymptomatic, with no demonstrable evidence of recurrence on work-up prior to surgery. Five patients developed subsequent CEA elevations after curative resections at second-look surgery and, while remaining asymptomatic, underwent re-exploration. A total of 37 laparotomies were performed. The CEA level at second-look ranged from 5.1--470 ng/ml with a median level of 25 ng/ml, the time delay ranged from 1--20 months with a median of four months, and the rate of CEA elevation ranged from 0.39--49.05 ng/ml in two weeks with a median of 3.17 ng/ml in two weeks. Recurrent disease was documented in 33 (89%) and four patients had negative explorations (11%). Liver metastasis was evident in 18 with seven curative resections, and local-abdominal disease in 15 with nine curative resections, giving a resectability rate of 43% (16/37). Lower CEA levels, shorter time delays to surgery, and slower rates of CEA elevation were directly related to the resectability rate. The follow-up ranged from 2--61 months, with a median of 15 months. Eight patients are alive and well, 8--61 months, 10 patients are alive with disease 10--47 months; and 14 patients are dead of disease 2--37 months following the second-look surgery. These results suggest a definite role for CEA in selecting patients for second-look laparotomy; however, more follow-up is necessary to document prolonged survival.

Adenocarcinoma of the appendix.

Twenty-two cases of appendiceal adenocarcinoma are reviewed. Correct diagnosis was not made preoperatively in any case, and in only 38 per cent of the cases was it made intraoperatively. Thirty-two per cent of the patients had second primary neoplasm, and in more than half of these cases, the neoplasms were most likely concurrent with the appendiceal tumors. The overall five-year survival rate of the 22 patients was 18.7 per cent, with a 43.4 per cent survival rate in the curative resection group. The grade of tumor differentiation was the only significant factor in determining curative resectability and prognosis.

Radiation-induced carcinoma of the rectum.

Carcinomas and sarcomas are known to develop after radiation therapy. A complete review of the literature regarding appearance of carcinoma of the rectum following radiation therapy to the pelvis was undertaken. The average interval between irradiation and diagnosis of the rectal cancer was 15.2 years, the range being from one year, two months to 33 years. We present a case of carcinoma of the rectum arising as two separate primaries 46 years after irradiation for an epidermoid carcinoma of the cervix. There were many pathologic changes related to the radiation therapy.

Pseudo-obstruction of the colon (Ogilvie's syndrome).

Pseudo-obstruction of the colon is an acute abdominal problem that can occur from a variety of causes and multiple organ failures. It is characterized by massive colonic dilatation and a clinical picture suggestive of mechanical large-intestinal obstruction, without any organic obstruction. Decompression should be cautiously attempted with proctoscopy and, possibly, colonoscopy; if these fail, then surgical decompression, usually be a cecostomy, is indicated.

Resected pulmonary metastases from colorectal cancer.

A review of 35 patients who, over an 18-year preiod, underwent excision of pulmonary metastases from colorectal cancer, is presented. The cumulative five-year survival rate was 22 per cent, and this was significantly increased where the primary colonic cancer was Dukes' A or B. No difference in survival was found regarding the disease-free interval and the number of metastatic lesions. The follow-up of patients with colorectal cancer should always include yearly chest x-rays; and when metastases developed in the lungs alone, surgery for their removal is recommended.

Subungual squamous cell carcinoma.

Twelve patients with subungual squamous cell carcinoma were treated at Memorial Sloan-Kettering Cancer Center during a 27-year period. To our knowledge, only 58 cases are reported in the literature. Trauma and chronic infection were predisposing factors in some of the cases, and radiation therapy was a substantive predisposing factor in our series. Disarticulation of the distal phalanx proved effective in most patients.

Hepatic resection for metastasis from colorectal cancer.

Twenty-five patients who had hepatic metastases from carcinomas of the colon and rectum had resection for cure at Memorial Hospital, with a determinate five-year survival rate of 40 per cent, and 10-year survival rate of 28 per cent. Most of the hepatic metastatic lesions were solitary, small, and peripheral, and were treated with simple wedge resection. These favorable results justify an aggressive approach to solitary metastatic lesions in the liver.

Axillary micrometastasis and macrometastasis in carcinoma of the breast.

A retrospective analysis was made of 105 patients with primary operable carcinoma of the breast with positive axillary nodes who had been observed for a 14 year period after radical mastectomy. Patients with micrometastasis alone, especially if only level I is involved, have a good prognosis with 85 and 77 per cent survival rates at ten and 14 years, respectively. No patients had more than three micrometastasis. Patients with four or more positive nodes have a much worse prognosis than do those with three or less positive nodes. Macrometastasis at any level carries a poor prognosis. Since these data show no significant difference between the ten and 14 year survival rates, the ten year survival rate is, therefore, a valid one for long term evaluation of the treatment of carcinoma of the breast.

Hemobilia complicating needle liver biopsy. A case report with arteriographic demonstration.

Massive hemobilia secondary to a needle liver biopsy developed in a 16-year-old boy with Hodgkin's disease. Cholecystectomy and common bile duct drainage failed to control the condition and the patients bled massively; management of the hemobilia was effected with left hepatic artery ligation. A review of the literature is presented, with a brief discussion of the clinical picture, pathophysiology, diagnosis, and management of this condition.