Chemotherapy and radiation components of neoadjuvant treatment of pancreatic head adenocarcinoma: Impact on perioperative mortality and long-term survival.

BACKGROUND: We compared outcomes of neoadjuvant therapy delivered as chemotherapy-only (Chemo) versus concurrent chemoradiation (ChemoRT) versus chemotherapy followed by radiation (Chemo-ChemoRT) among pancreatic head adenocarcinoma patients receiving pancreaticoduodenectomy. METHODS: National Cancer Data Base cases diagnosed 2006-2011 treated by neoadjuvant therapy and pancreaticoduodenectomy. RESULTS: 1163 pts received neoadjuvant treatment with Chemo (n = 309; 26.6%), ChemoRT (n = 626; 53.8%), or Chemo-ChemoRT (n = 228; 19.6%). Odds of 30-day and 90-day mortality were not influenced by delivery of any neoadjuvant therapy type. Median overall survival for Chemo, ChemoRT, and Chemo-ChemoRT groups were 25.6 (95% confidence interval 23.1-28.7), 22.9 (21.4-24.8), and 26.9 (23.7-29.4) months, respectively. There was no statistically significant difference between Chemo and Chemo-ChemoRT groups (log rank test p = 0.854), while there was significant difference of ChemoRT (p = 0.017 versus Chemo; p = 0.021 versus Chemo-ChemoRT). Multivariate model suggests delivery of concurrent ChemoRT as opposed to neoadjuvant therapy with full dose systemic chemotherapy is associated with shortened survival (aHR = 1.311, p = 0.001). CONCLUSIONS: There is no detectable difference in early outcomes (30-day and 90-day postsurgical mortality) among pancreaticoduodenectomy patients treated with various types of neoadjuvant therapy. Overall survival appears better among patients exposed preoperatively to full dose systemic chemotherapy rather than concurrent chemoradiation only. Further studies with more detailed data sources are needed.

Effect of heated and humidified carbon dioxide gas on core temperature and postoperative pain: a randomized trial.

BACKGROUND: Intraoperative hypothermia is a common event during laparoscopic operations. An external warming blanket has been shown to be effective in preventing hypothermia. It has now been proposed that using heated and humidified insufflation gas can prevent hypothermia and decrease postoperative pain. Therefore, we examined the extent of intraoperative hypothermia in patients undergoing laparoscopic Nissen fundoplication using an upper body warming blanket. We also attempted to determine whether using heated and humidified insufflation gas in addition to an external warming blanket would help to maintain intraoperative core temperature or decrease postoperative pain. METHODS: Twenty patients were randomized to receive either standard carbon dioxide (CO2) gas (control, n = 10) or heated and humidified gas (heated and humidified, n = 10). After the induction of anesthesia, an external warming blanket was placed on all patients in both groups. Intraoperative core temperature and intraabdominal temperature were measured at 15-min intervals. Postoperative pain intensity was assessed using a visual analogue pain scale, and the amount of analgesic consumption was recorded. Volume of gas delivered, number of lens-fogging episodes, intraoperative urine output, and hemodynamic data were also recorded. RESULTS: There was no significant difference between the two groups in age, length of operation, or volume of CO2 gas delivered. Compared with baseline value, mean core temperature increased by 0.4 degrees C in the heated and humidified group and by 0.3 degrees C in the control group at 1.5 h after surgical incision. Intraabdominal temperature increased by 0.2 degrees C in the heated and humidified group but decreased by 0.5 degrees C in the control group at 1.5 h after abdominal insufflation. There was no significant difference between the two groups in visual analog pain scale (5.4 +/- 1.6 control vs 4.5 +/- 2.8 heated and humidified), morphine consumed (27 +/- 26 mg control vs 32 +/- 19 mg heated and humidified), urine output, lens-fogging episodes, or hemodynamic parameters. CONCLUSION: Heated and humidified gas, when used in addition to an external warming blanket, minimized the reduction of intraabdominal temperature but did not alter core temperature or reduce postoperative pain.

Cardiac function during laparoscopic vs open gastric bypass.

BACKGROUND: Hypercarbia and increased intraabdominal pressure during prolonged pneumoperitoneum can adversely affect cardiac function. This study compared the intraoperative hemodynamics of morbidly obese patients during laparoscopic and open gastric bypass (GBP). METHODS: Fifty-one patients with a body mass index (BMI) of 40-60 kg/m2 were randomly allocated to undergo laparoscopic (n = 25) or open (n = 26) GBP. Cardiac output (CO), mean pulmonary artery pressure (MPAP), pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), heart rate (HR), and mean arterial pressure (MAP) were recorded at baseline, intraoperatively at 30-min intervals, and in the recovery room. Systemic vascular resistance (SVR) and stroke volume (SV) were also calculated. RESULTS: The two groups were similar in terms of age, weight, and BMI. Operative time was longer in the laparoscopic than in the open group (p < 0.05). The HR and MAP increased significantly from baseline intraoperatively, but there was no significant difference between the two groups. In the laparoscopic group, CO was unchanged after insufflation, but it increased by 5.3% at 2.5 h compared to baseline and by 43% compared to baseline in the recovery room. In contrast, during open GBP, CO increased significantly by 25% after surgical incision and remained elevated throughout the operation. CO was higher during open GBP than during laparoscopic GBP at 0.5 h and at 1 h after surgical incision (p < 0.05). During laparoscopic GBP, CVP, MPAP, and SVR increased transiently and PAWP remained unchanged. During open GBP, CVP, MPAP, and PAWP decreased transiently and SVR remained unchanged. There was no significant difference in the amount of intraoperative fluid administered during laparoscopic (5.5 +/- 1.6 L) and open (5.6 +/- 1.7 L) GBP. CONCLUSION: Prolonged pneumoperitoneum during laparoscopic gastric bypass does not impair cardiac function and is well tolerated by morbidly obese patients.

Evaluation of core temperature during laparoscopic and open gastric bypass.

BACKGROUND: Intraoperative hypothermia is a common event during open and laparoscopic abdominal surgery. The aim of this study was to compare changes in core temperature between laparoscopic and open gastric bypass (GBP). METHODS: 101 patients with a body mass index (BMI) of 40-60 kg/m2 were randomly assigned to open (n = 50) or laparoscopic (n = 51) GBP. Anesthetic technique was similar for both groups. An external warming blanket and passive airway humidification were used intraoperatively. Core temperature was recorded at preanesthesia, at baseline (after induction) and at 30-min intervals; intra-abdominal temperature was additionally measured at 30-min intervals in a subset of 30 laparoscopic GBP patients. The number of patients who developed intraoperative and postoperative hypothermia (< 36 degrees C) was recorded. Length of operation for both groups and the amount of CO2 gas delivered during laparoscopic operations were also recorded. RESULTS: There was no significant difference between groups with respect to age, gender, mean BMI, and amount of intravenous fluid administered. After induction of anesthesia, core temperature significantly decreased in both groups; 36% of patients in the open group and 37% of patients in the laparoscopic group developed hypothermia. This percentage increased to 46% in the open group and 41% in the laparoscopic group during the operation, and then decreased to 6% in the open group and 8% in the laparoscopic group in the recovery-room. Core temperature increased during the operative procedure to reach 36.5 +/- 0.6 degrees C in the open group and 36.3 +/- 0.5 degrees C in the laparoscopic group at 2.5 hours after surgical incision. Intra-abdominal temperature during laparoscopic GBP was significantly lower than core temperature at all measurement points (p < 0.05). Operative time was longer in the laparoscopic group than in the open group (232 +/- 43 vs 201 +/- 38 min, p < 0.01). Mean volume of gas delivered during laparoscopic GBP was 650 +/- 220 liters. CONCLUSION: Perioperative hypothermia was a common event during both laparoscopic and open GBP. Despite a longer operative time, laparoscopic GBP did not increase the rate of intraoperative hypothermia when efforts were made to minimize intraoperative heat loss.

Hemangiopericytoma of the sciatic notch presenting as sciatica in a young healthy man: case report.

A case of hemangiopericytoma of the sciatic notch presenting with sciatica in a healthy 33-year-old man is presented. Tumors of the sciatic notch are exceedingly rare, and few data pertaining to the entity are found in the literature. A few series have been published on neurogenic tumors of the sciatic nerve, and one series of hemangiopericytomas mentions a case in which the sciatic nerve in the thigh is involved with tumor. To our knowledge, this is the first case in the literature detailing a hemangiopericytoma spanning the sciatic notch. Hemangiopericytomas are well known to neurosurgeons as durally based lesions and have been categorized as a subtype of meningioma. However, hemangiopericytomas are vascular sarcomas that most commonly occur in the pelvis and thigh. A brief discussion of the symptoms of sciatic notch lesions and hemangiopericytomas is included.

Cimetidine and neonatal small bowel adaptation: an experimental study.

Histamine2-blockers are being used more extensively in the pediatric short gut patient as an agent to accelerate small bowel adaptation. Reversal of lipid malabsorption and a direct trophic effect on the intestinal crypt cells have been postulated as the mechanism for the salutary influence of cimetidine. Weanling Sprague-Dawley rats underwent 85% small bowel resection. Controls had repair of a simple ileal transection. Rats received either a fat-defined rat chow only, or chow with high- or low-dose cimetidine, 2% cholestyramine, or cholestyramine/low-dose cimetidine. All animals were killed 2 weeks postresection, and ileal and jejunal sections were examined for changes in villous and crypt morphology. The animals receiving cimetidine showed earlier and more consistent weight gain than resected animals who received no adjunctive treatment. High- and low-dose regimens were equally efficacious. Cimetidine administered alone decreased fecal fat losses, but not when given with cholestyramine. The cimetidine/cholestyramine group showed increased weight gain when referenced to the resection controls despite continuing lipid malabsorption. Villous and crypt lengthening did not correlate with clinical evidence of adaptation. An augmented lymphocytic activity (plasma cell hyperplasia, enlargement Peyer's patches) was present in the hyperplastic ileal segments of the cimetidine-treated rats. Overall immunoreactivity was similar in all study groups. No significant differences in villous morphology or immunologic activity were seen in jejunal segments. The effects of H2-blockers on lipid absorption and intestinal hyperplasia are inadequate to explain the benefits of cimetidine in the short gut patient. Examination of the immunology of the short bowel complex merits further attention in elucidating cimetidine's action in this setting.

Cytoprotective agents in experimental small bowel volvulus.

An accepted experimental model for midgut volvulus was used to produce small bowel strangulation obstruction of 48 hours duration in Sprague-Dawley rats. A 93% perioperative mortality rate resulted after release of the volvulus. Treatment with three cytoprotective agents at the time of volvulus release resulted in the following mortality rates: superoxide dismutase, 89%; ibuprofen, 50%; prostaglandin E1 (PGE1, 11%. The predominant cause of death in all treatment groups was bowel infarction, with a smaller number succumbing to either sepsis or circulatory collapse. Concomitant administration of ephedrine or indomethacin to suppress prostaglandin E1's splanchnic vasodilatory activity did not cause any increase in mortality. A trial of aspirin, to simulate PGE's antiplatelet actions, showed no reduction in mortality when compared with detorsion alone. Prostaglandin E1 and, to a lesser extent, ibuprofen, appear to have cytoprotective effects during reperfusion of bowel compromised by volvulus, independent of their influence on the mesenteric vasculature and thrombogenesis.

Management of experimental pneumothorax in weanling rabbits with the use of fibrin glue sclerosant.

Fibrin glue pleurodesis successfully sealed surgically created pneumothoraxes in 12 (92.3%) of 13 New Zealand white rabbits, an animal model chosen for its similarity to the thoracic configuration of the human neonate. All chest tubes were removed at 24 hours; there were no recurrences. Two rabbits, in whom human cryoprecipitate was used, died of an immunologically mediated pneumonitis. This reaction would not be expected in the human setting. Four months' follow-up revealed nearly total fibrin glue resorption. This "biodegradability" is well suited to the neonate, since alveolar barotrauma, not congenital emphysematous blebs, is the usual initiator of pneumothorax. Time-limited adhesions created by fibrin glue pleurodesis should be adequate for treatment of the acute event, while avoiding persistent pleural adhesions that could interfere with subsequent thoracic surgery or cause long-term deleterious effects on pulmonary function.

Clinical and operative experience with non-Caucasian patients with Crohn's disease.

Fifteen black patients with Crohn's disease were seen during a ten-year period (1975-1985). They represented 11 percent of our experience with Crohn's disease during that time. These patients had an earlier age of onset of Crohn's symptoms than our white patients, and correct diagnosis was delayed for an average of four years. All 15 patients required abdominal surgery, and seven (47 percent) suffered recurrences necessitating additional abdominal operations. The five-year actuarial estimate of probability of reoperation was 77 percent. Extraintestinal manifestations were present in all patients, and six (40 percent) had multiple manifestations. These disease manifestations are more severe than those noted in series that studied predominantly caucasian Crohn's populations, and suggest that Crohn's disease in the black patient is a distinctly aggressive form.