Laparoscopic Heller myotomy and fundoplication: findings and predictive value of early postoperative radiographic studies.

BACKGROUND: We describe the findings on esophagography, the frequency and appearance of leaks after laparoscopic Heller myotomy and fundoplication, and the utility of early postoperative studies for predicting clinical outcome. METHODS: Our study group consisted of 40 patients who underwent laparoscopic Heller myotomy and fundoplication in whom radiographic studies were performed during the early postoperative period. The radiographic reports and images were reviewed to determine the esophageal diameter, visualization or nonvisualization of the wrap, and the presence or absence of a leak. The esophageal diameter subsequently was correlated with the clinical findings to determine whether this was a useful parameter for predicting clinical outcome. RESULTS: Two patients (5%) had small, sealed-off leaks on radiographic studies, and four (10%) had pseudo-leaks resulting from trapping of contrast material alongside the fundoplication wrap. Twelve (60%) of 20 patients with a dilated esophagus had esophageal symptoms on short-term follow-up versus three (15%) of 20 with a normal-caliber esophagus (p = 0.008), and five (56%) of nine patients with a dilated esophagus had symptoms on long-term follow-up versus six (43%) of 14 with a normal-caliber esophagus (p = 0.68). CONCLUSION: Radiographic studies are useful for showing leaks after laparoscopic Heller myotomy and fundoplication, but radiologists should differentiate true leaks from trapping of contrast material alongside the fundoplication wrap. The caliber of the esophagus on early postoperative studies is also a useful parameter for predicting short-term clinical outcome in these patients.

Role of videoscopic-assisted techniques in staging malignant diseases.

Preoperative radiographic studies fail to uncover a significant number of patients with unresectable malignancies. Small peritoneal studs of tumor, lymph node involvement, and small liver metastases are common causes of understaging by imaging studies. Videoscopic staging offers a higher degree of accuracy among these patients, with minimal complications and a shorter recovery time than with exploratory laparotomy. The addition of laparoscopic sonography and peritoneal lavage may further increase sensitivity to unresectable disease. Staging videoscopy has been applied to hepatobiliary and gastrointestinal malignancies, pleural and pulmonary tumors, and gynecologic malignancies. The author believes that videoscopic staging will become increasingly common as it is further studied and the best applications are delineated.

Minimally invasive management of low-grade and benign gastric tumors.

BACKGROUND: Benign gastric tumors and tumors of low-grade malignancy can be safely removed laparoscopically. METHODS: Seven patients were considered candidates for laparoscopic resection of gastric tumors. Inclusion criteria included small tumor size (less than 6 cm), exophytic or endophytic tumor morphology, and benign characteristics. Indications for surgical intervention included bleeding, weight loss, and need for tissue diagnosis. Patients ranged in age from 38 to 70. There were five female and two male patients. All patients underwent preoperative upper GI endoscopy. The procedures were performed using a four- or five-port technique. An Endo-GIA (US Surgical Company, Norwalk, Connecticut) was used to amputate those tumors located on the serosal surface of the stomach. Tumors on the mucosal surface were exposed via a gastrotomy, then likewise amputated using an Endo-GIA. The gastrotomy closure was then either hand sewn or stapled. Operating time ranged from 95 to 225 min. RESULTS: Final pathologic diagnoses included lipoma, lymphoma, leiomyoma, and leiomyosarcoma. There was a 28% conversion rate. There were no complications. Length of postoperative stay ranged from 4 to 7 days. There have been no tumor recurrences in 6-38-month follow-up. CONCLUSIONS: Minimally invasive management of benign and low-grade gastric tumors can be performed safely with excellent short- and long-term results.

Consequences of lost gallstone.

Laparoscopic cholecystectomy has become the treatment of choice in the management of calculus gallbladder disease. Intraperitoneal gallstone loss is not uncommon; it occurs in up to 40% of cases. Often, the stones are left unretrieved and are thought to be inconsequential. We present a series of patients who have had serious sequela from gallstones in the peritoneal cavity. We performed a retrospective study of the management of six patients with complications from intraperitoneal gallstones. The patients presented with a variety of complaints, from fevers to pneumonia to a colo-cutaneous fistula. Presentation ranged from immediately postoperatively to 18 months after surgery. Diagnosis included perihepatic abscesses and colo-biliary fistula. General anesthesia was usually necessary for removal of the stones. All patients have resolved following the removal of the gallstones. Our recommendation is to attempt to avoid spillage through careful dissection and retrieve any lost stones. The defect in the gallbladder can be closed with a clip. Whether the procedure should be converted to an open one to retrieve all the stones remains open to debate. The surgeon should be aware of the possible consequences of the lost gallstone.

Hürthle cell carcinoma of the thyroid gland: prognostic factors and results of surgical treatment.

BACKGROUND: Hürthle cell carcinomas of the thyroid are unusual variants of well-differentiated thyroid cancers. Considered more aggressive tumors, their optimal treatment is controversial. Our institution's half century of experience, the largest series to date, includes 40 patients with Hürthle cell carcinomas of 1000 well-differentiated thyroid cancers. METHODS: A retrospective study was carried out on 40 patients. RESULTS: Seventy-two percent were female, with a median age of 53 years. Median follow-up was 9 years. With the AMES risk stratification (age, distant metastasis, capsular extent, tumor size), among the 21 high-risk patients, 10 (48%) had a recurrence or died, with median time to recurrence 3 years (range, 0.5 to 14 years). Of these 10, 5 died of disease, one died of unrelated causes with disease, and 4 are alive with disease. Five recurrences presented as distant metastases. Extent at operation was the strongest predictor of recurrence, occurring in 66% of those with gross extraglandular involvement. CONCLUSIONS: The AMES criteria are useful in predicting recurrence and death. Although more aggressive surgery is appropriate for high-risk patients, in general their outlook remains grim.

Breast cancer in the nineties.

Breast cancer is the most common cancer in women and is the second (after lung cancer) leading cause of cancer deaths in women. Knowledge of breast cancer and its epidemlology, natural course, and response to treatment continue to evolve, making the survival rates for patients with breast cancer more optimistic. Women with breast cancer must decide, in partnership with expert physicians and nurses, what their options are for screening, diagnosis, and treatment. This article provides an overview of options available to women diagnosed with breast cancer.

Ductal carcinoma in situ of the male breast.

BACKGROUND: Ductal carcinoma in situ (DCIS) of the male breast is an uncommon disease, accounting for approximately 7% of all male breast carcinomas. Compared with invasive carcinomas of the breast, the prognosis associated with DCIS in men is excellent; however, clinical features, pathology, and treatment of this disease are not well defined in the literature. METHODS: Records of 23 men with carcinoma of the breast treated at the Lahey Clinic from 1968 to 1991 were reviewed, revealing 4 patients with pure DCIS (17%). The reported management of DCIS in women is discussed in comparison with that of DCIS in men. RESULTS: Of the four patients with DCIS, the presenting complaint was a retroareolar mass in three patients and a bloody nipple discharge in one patient. The pathologic subtype was papillary in one patient and intracystic papillary in three patients. Two patients were treated with partial mastectomy alone. Disease recurred locally as DCIS in both patients, requiring mastectomy at 30 and 108 months. No lymph node metastases were found in the three patients who underwent axillary dissection. All four patients were alive without disease at 133, 120, 36, and 32 months of follow-up, respectively. CONCLUSIONS: Although the sample size was small, our patients and a review of the literature suggest that most DCIS in men is of the papillary type and that mastectomy without axillary dissection is the preferred treatment.

Purification of bovine bone morphogenetic protein by hydroxyapatite chromatography.

Bovine bone morphogenetic protein (bBMP) induces differentiation of mesenchymal-type cells into cartilage and bone. bBMP has an apparent Mr of 18,500 +/- 500 and represents less than 0.001% of the wet weight of bone tissue. A Mr 34,000 protein resembling osteonectin is separated by extraction with Triton X-100. A Mr 24,000 protein and about half of a Mr 22,000 protein are disassociated from bBMP by precipitation in 1.5 M guanidine hydrochloride. Aggregates of bBMP and a Mr 14,000 protein are insoluble in aqueous media; the bBMP becomes soluble when the Mr 14,000 protein is disassociated in 6 M urea and removed from the solution by ultrafiltration. Three separate molecular species with apparent Mrs 18,500, 17,500, and 17,000 are eluted at 0.10, 0.15, and 0.20 M phosphate ion concentrations, respectively, from a hydroxy-apatite column. The Mr 18,500 protein has the amino acid composition of acidic polylpeptide and includes four half-cystine residues; the pI is 4.9-5.1. The Mr 22,000 component is a chromoprotein resembling ferritin. The NH2-terminal amino acid sequence of the Mr 17,500 protein simulates histone H2B. The Mr 17,000 protein may possess calmodulin activity. Aggregates of the Mr 18,500 and other proteins induce formation of large deposits of bone; the Mr 18,500 protein alone is rapidly absorbed and induces formation of small deposits. None of the other proteins induces bone formation.