Pancreatic resection combined with intraoperative radiation therapy for pancreatic cancer.

OBJECTIVE: The objective of the study was to analyze a single center's experience in the treatment of pancreatic carcinoma with a combination of pancreatic resection and intraoperative radiation therapy (IORT). SUMMARY BACKGROUND DATA: Pancreatic cancer is the most lethal form of gastrointestinal malignancy. Historically, it carries a 20% 1-year survival and a 5-year survival of 3% to 5%. Since 1987, patients at Thomas Jefferson University Hospital have been offered IORT in an attempt to improve their survival. METHODS: The authors reviewed all patients treated at Thomas Jefferson University Hospital with pancreatic adenocarcinoma from 1987 to 1994. From this population, 14 patients were identified who received IORT in conjunction with curative surgery. Duration of hospital stay, perioperative complications, duration of postoperative ileus, and survival were assessed by retrospective review. RESULTS: Of the 14 patients, 6 were male and 8 were female. Patient median age was 61. Six patients had stage I disease, 2 had stage II, 6 had stage III. Two patients had total pancreatectomy, 2 had distal pancreatectomy, and the remaining had pancreaticoduodenectomy (Whipple resection). Median survival was 16 months with a 15.5% 5-year survival. Postoperative complications, duration of hospital stay, and duration of postoperative ileus were not adversely affected by the addition of IORT when compared to in-house control subjects. CONCLUSIONS: Intraoperative radiation therapy is a useful adjunct to surgical resection as treatment of pancreatic cancer. The authors' data suggested it can prolong median survival and long-term survival without adding significant morbidity.

Improved staging of liver tumors using laparoscopic intraoperative ultrasound.

BACKGROUND: Intraoperative ultrasound has been shown to provide significant assistance in operative staging and management of patients with liver tumors during open surgery. The availability of the 5.0-7.5 Mhz semiflexible ultrasound transducer with gray-scale, color and spectral Doppler capabilities can provide similar information laparoscopically. METHODS: Twenty-four consecutive patients with liver tumors (18 metastatic and six primary), in technically resectable locations determined by a variety of conventional imaging studies, were brought to the operating room. There was no known extrahepatic disease, and there was no recurrence at the primary site in the metastatic subgroup. These patients were evaluated intraoperatively with laparoscopy and intraoperative laparoscopic ultrasound to assess resectability prior to performing a major laparotomy. Laparoscopy was successful in 23 of the patients and in 19 of 23, laparoscopic ultrasound was also employed, using the 5.0-7.5 MHz semiflexible transducer. The use of the open entry technique, selection of alternate entry sites, coupled with expertise in laparoscopic lysis of adhesions, has allowed safe laparoscopic tumor staging. RESULTS: The laparoscopic evaluation was aborted only once due to dense adhesions, despite the fact that 67% of the patients had undergone previous abdominal surgery. There was only one complication: bleeding from a liver biopsy in an unresectable cirrhotic patient, necessitating laparotomy. Laparoscopy and ultrasound together predicted nonresectability in six of eight unresectable patients, all of whom were spared an unnecessary laparotomy. CONCLUSIONS: Laparoscopic ultrasonographic evaluation for the staging of liver tumors should be a prerequisite to definitive laparotomy, with the objective of avoiding unnecessary surgery.

Laparoscopic liver sonography: preliminary experience in liver metastases compared with CT portography.

This study evaluated the ability of laparoscopic ultrasonography to detect, localize, and characterize focal liver masses. Laparoscopic ultrasonography and CT portography of the liver were performed in 13 patients with known or suspected malignancy. Laparoscopic ultrasonography directly influenced surgical management in four (31%) cases; three by detection of small focal masses and one by exclusion of masses suspected on CT portography. Laparoscopic ultrasonography provided guidance for biopsy or added important anatomic information in three cases. Laparoscopic ultrasonography was complementary to CT portography but added no additional information in three cases, and it failed to provide any information in two cases. Laparoscopic ultrasonography was falsely negative in one case. In this preliminary series, laparoscopic ultrasonography assisted surgeons in critical decision-making by either providing important new information, clarifying questionable areas, or complementing CT portography.

Cholangiocarcinoma: clinical significance of tumor location along the extrahepatic bile duct.

PURPOSE: To define the criteria for resection and/or radiation therapy (RT) of extrahepatic bile duct cancer. MATERIALS AND METHODS: Of 81 patients with extrahepatic bile duct cancer treated from 1983 to 1992, those with proximal duct lesions (n = 56) underwent RT and/or resection or palliative care, and those with distal lesions (n = 25) underwent resection with or without RT. Follow-up was available 3-114 months (median, 28 months). RESULTS: Patients with distal bile duct cancer lived longer than patients with proximal bile duct cancer (survival with Kaplan-Meier analysis, 53% vs 13% at 5 years, respectively, P < .01). Median survival in patients with proximal cancer after RT was more than double that without RT (17 months vs 6 months, respectively, regardless of stage [P = .01]); survival was not significantly different after resection. In patients with distal cancer, RT after resection made no significant difference in median survival (68 months). CONCLUSION: Patients with proximal cancer should undergo primary RT, and expectations should be limited. Patients with distal cancer should undergo resection, and RT may not be needed.

Laparoscopic gray-scale and color Doppler US: preliminary animal and clinical studies.

PURPOSE: To evaluate a semiflexible ultrasound (US) transducer inserted through a laparoscopic port to image abdominal structures. MATERIALS AND METHODS: Laparoscopic US with a 9.6-mm-diameter, 5.0-7.5-MHz semiflexible transducer with gray-scale, color, and spectral Doppler capabilities was performed in three miniature swine and in 25 patients with a variety of abdominal abnormalities. RESULTS: This miniature US probe was used to locate normal structures such as blood vessels, allowing the surgeon to decide the best approach for dissection. Color and spectral Doppler US proved especially useful in differentiating vascular from nonvascular structures. The presence or absence of stones in the gallbladder and common bile duct was readily determined. It was possible to detect masses and to provide guidance for their aspiration or biopsy within abdominal organs. In 10 cases (40%), laparoscopic US helped the surgeon make the decision for clinical management and altered the surgical procedures. CONCLUSION: Laparoscopic US was useful in assisting laparoscopic evaluation of abnormalities in the abdomen.

Management of infected pancreatic fluid collections.

Percutaneous drainage of pancreatic collections has recently been advocated as a means of diagnosis of bacterial contamination, for temporizing unstable patients, and as definitive treatment in itself. In order to assess its efficacy, the role of percutaneous drainage of infected pancreatic fluid collections was retrospectively reviewed by a single surgical practice. Seventeen patients were treated over a 5-year period from 1987 to 1992. All patients admitted or referred with a diagnosis of infected peripancreatic fluid collection were included in the review. The group consisted of eleven males and six females; mean age was 55.2 years (range 28 to 70). Patients were stratified into one of two groups based on initial treatment modality. Group A consisted of eight patients treated initially with percutaneous drainage as presumed definitive management. Eight patients in Group B were treated initially with surgical debridement and drainage. APACHE II scores on admission were 5.62 +/- 3.66 for Group A and 9.12 +/- 3.87 for Group B (N.S.). Mean hospital stay was 100 days (range 13-311) for Group A and 71 (range 25-149) for Group B (N.S.). Despite initial percutaneous drainage, six of eight (75%) patients in Group A required operative debridement because of clinical deterioration. APACHE II scores in this subset went from 6.83 +/- 3.43 to 9.83 +/- 5.04 (N.S.) despite a total of 18 preoperative percutaneous procedures (2.25 per patient; range 1-7). The number of complications for this group totaled 15. Five of the six patients with positive cultures from their initial aspiration failed percutaneous drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma of the pancreas: a multimodality approach--a single surgeon's experience (1979-1988).

A retrospective review of a single surgeon's experience with adenocarcinoma of the pancreas was performed. One hundred-one patients were treated over a 10-year period from 1979 to 1988. Seven patients underwent potentially curative resections and 28 patients presented with metastatic (stage IV) disease. Sixty-four patients had locally advanced and unresectable primary lesions. A total of 51 patients received I-125 seed implantation. There was no statistically significant difference in morbidity (33% vs. 30%) or mortality (6% vs. 8%) between patients receiving I-125 implantation and those undergoing palliative surgical procedures without implantation. Operative mortality was highest in patients presenting with stage IV lesions (11%). In those patients with locally advanced and unresectable carcinomas, there was a nonsignificant increase in survival (12.8 mo vs. 10.7 mo) in those receiving intraoperative I-125 implants when compared to those who did not when both groups received postoperative adjuvant chemotherapy and external beam radiotherapy. Based on these encouraging results, it is concluded that I-125 implantation can be performed safely and shows a trend toward improving long-term survivorship in patients with locally advanced pancreatic carcinoma when used in conjunction with chemotherapy and external beam radiation.

Selective arterial stimulation of secretin in localization of gastrinomas.

In two patients with malignant gastrinoma and the Zollinger-Ellison syndrome, we were able to use selective arterial stimulation with secretin as a technique to localize the lesions accurately, allowing resection. The technique of selected arterial secretin stimulation is one of measuring variations in gastrin levels in both the hepatic vein and a peripheral artery at specified times after injection of secretin into a specific artery. When the criteria for localization have been met, one can plot the presence of the gastrinoma within the blood supply of the injected artery and, using angiograms, thus accurately localize the lesion. This method promises to be a valuable additional tumor-localizing procedure, particularly when gastrinomas are extrapancreatic.

Recurrent esophageal carcinoma at thoracotomy incisions: diagnostic contributions of CT.

Three cases of surgical implantation of esophageal carcinoma during esophagogastrectomy are presented. The CT and radiographic appearance is demonstrated. A possible etiology and method for decreasing the risk of surgical spread of tumor are discussed.

Experience with the esophagogastric devascularization procedure.

Twenty-eight consecutive unselected patients were treated for esophageal varices by means of a modified Sugiura procedure between 1978 and 1985. In accordance with Child's classification, 59% were considered as class A, 11% as class B, and 30% as class C. The etiology of the cirrhosis included alcohol abuse (42%), hepatitis (33%), granulomatous disease (7%), and cryptogenic disease (18%). One patient had extrahepatic portal hypertension from unknown causes. The surgical treatment included esophageal and gastric devascularization in all cases. The average operative time was 4 1/2 hours. The average blood replacement during surgery was 8 units. The operative mortality was 32% (2/16 class A, 1/3 class B, and 6/9 class C). Morbidity occurred in 33% of the patients. Significant causes of morbidity and mortality were related to complications of the esophageal transection, which was omitted in the later series. Six of the eighteen patients who survived surgery died later, but only one death was due to presumed recurrent variceal hemorrhage. Significant bleeding occurred in four patients--two due to recurrent varices and two due to peptic ulcer disease. Encephalopathy, which was present preoperatively in two patients, is still manifest but is well controlled. Encephalopathy did not develop in any other patients. At present, the 12 surviving patients have stable liver function.

Intraoperative ultrasound of the liver. An important adjunctive tool for decision making in the operating room.

Forty-nine patients operated on for liver or other pathologic processes were examined intraoperatively with special ultrasound transducers during surgical exploration of the abdomen. Subjects were evaluated because of known or suspected disease of the liver. All patients were examined using sterile technique. Prospective diagnosis and retrospective analysis of data were used. In 55% of subjects, no new information was obtained. In 19%, new information was gathered that changed the surgical approach. In 14% of patients, new information was obtained but it was such that no change in the therapeutic approach was needed. In 12% of patients, although no new information was gathered by the use of intraoperative ultrasound, a change in the surgical approach and management of the patient was still possible because of intraoperative ultrasound. These studies show that the routine use of ultrasound during intraoperative procedures, particularly when involving hepatic structures, is a clinically useful technique. In many instances, it will change the course of management.