Pancreaticoduodenectomy for metastatic tumors to the periampullary region.

Although operative resection of metastatic lesions to the liver, lung, and brain has proved to be useful, only recently have there been a few reports of pancreaticoduodenectomies in selected cases of metastases to the periampullary region. In this report we present four cases of proven metastatic disease to the periampullary region in which the lesions were treated by pancreaticoduodenectomy. Metastatic tumors corresponded to a melanoma of unknown primary site, choriocarcinoma, high-grade liposarcoma of the leg, and a small cell cancer of the lung. All four patients survived the operation and had no major complications. Two patients died of recurrence of their tumors, 6 and 63 months, respectively, after operation; the other two patients are alive 21 and 12 months, respectively, after operation. It can be inferred from this small but documented experience, as well as a review of the literature, that pancreaticoduodenectomy for metastatic disease can be considered in selected patients, as long as this operation is performed by experienced surgeons who have achieved minimal or no morbidity and mortality with it.

Access problems in laparoscopic cholecystectomy: postoperative adhesions, obesity, and liver disorders.

In the decade since the clinical arrival of laparoscopic cholecystectomy, there have been gratifying improvements in imaging technology and instrumentation, and innovative techniques have evolved. Laboratory-simulator devices are available for basic skills exercises and can at least reasonably mimic the appearance of the gallbladder and some other organs or anatomic regions. Unfortunately, there is no satisfactory method to practice dealing with certain structural abnormalities or disease processes. Because of that, some operations will be particularly difficult and the outcomes will be favorable only with careful planning and capable execution. The experiences and skill level of the surgeon can be enhanced by appropriate mental preparation. As a result, the surgeon will have the opportunity to accomplish the task, both laparoscopically and safely, under circumstances that initially were thought to be inappropriate or impossible for laparoscopy.

Laparoscopic cholecystectomy in pregnancy: a review of published experiences and clinical considerations.

Symptomatic biliary disease during pregnancy may have serious consequences for both the mother and the fetus. Laparoscopic cholecystectomy was felt initially to be contraindicated in pregnancy, but clinical experience accumulated since 1991 has been extremely favorable. Specialists in the areas of anesthesiology, obstetrics and laparoscopic surgery should continue to carefully monitor and analyze practices and outcomes of laparoscopic cholecystectomy during pregnancy. At the present time, there is no consensus regarding several management issues, such as optimal pressure limits for insufflation. Nevertheless, the reported results are quite encouraging and may foretell an improvement in patient care for this special population as dramatic as that achieved by laparoscopic cholecystectomy in others.

Economics of pancreatoduodenectomy in the elderly.

BACKGROUND: Managed care and the increasing percentage of surgical procedures performed in the elderly have renewed the focus on hospital charges and expenditures. The objective of this study was to determine whether septuagenarians and octogenarians accrue more hospital charges or have a higher risk of morbidity and death. METHODS: We retrospectively reviewed the charges and pertinent clinical outcomes data that were available on 70 of the last 100 pancreatoduodenectomies performed at our institution (1989 to 1994). Charges from four cost centers were analyzed and normalized to 1995 dollars by using the Consumer Price Index and Wilcoxon rank sum test. Patients were divided into two groups: group 1, 70 years of age or older (n = 21); group 2, younger than 70 years of age (n = 49). RESULTS: Anesthetic charges were $2657 +/- $835 for group 1 versus $2815 +/- $826 for group 2, which was not a statistically significant difference. Laboratory charges were $4650 +/- $3284 for group 1 versus $5969 +/- $5169 for group 2, which was not a significant difference. Pharmaceutical charges were $5424 +/- $4435 for group 1 versus $9243 +/- $9695 for group 2, which was not a significant difference. Charges for operative units were $6198 +/- $1671 for group 1 versus $7469 +/- $2116 for group 2, p < 0.02. Total charges were $41,180 +/- $20,635 for group 1 versus $50,968 +/- $33,783 for group 2, which was not a significant difference. No difference was noted in morbidity, mortality, length of stay, or survival. CONCLUSIONS: Pancreatoduodenectomy in the elderly can be performed safely without accruing higher cost, increased morbidity, or increased mortality.

The difficult laparoscopy.

As others have emphasized, a progressive and structured training process is necessary to understand and avoid the potential pitfalls of laparoscopy. A surgeon who is poorly trained or has minimal skills and experience finds that many cases are "difficult." Nevertheless, even those with appropriate skill and experience encounter intellectual and technical challenges in laparoscopy. It is also very important to realize that some procedures simply should not be done laparoscopically. A review of 77,604 laparoscopic cholecystectomies documented that more than half the deaths were from technical complications occurring during the procedure. Traditional methods of surgery may have their own characteristics of limitations and morbidity, but in most cases, the old operation might still be a very good one in the face of unfavorable laparoscopic conditions.

Ultrastructural and immunocytochemical features of a case of neuroendocrine carcinoma developing in a prior ileostomy site.

A patient who developed a mixed neuroendocrine carcinoma and adenocarcinoma at the site of a previous long-standing ileostomy is reported. The neuroendocrine features are documented by both ultrastructural and immunocytochemical findings. Carcinoma arising in an ileostomy site is rare but has been recorded in patients with long-standing ileostomies after colectomy for chronic inflammatory bowel disease, as in this patient. Neuroendocrine carcinoma developing in this setting apparently has not been described before, however.

Hepatic artery pseudoaneurysm and hemobilia following laser laparoscopic cholecystectomy. A case report.

This report describes injury to the hepatic artery with pseudoaneurysm formation and hemobilia following the use of laser-assisted dissection to perform laparoscopic cholecystectomy. A 57-year-old woman was referred emergently 2 weeks after laser laparoscopic cholecystectomy with upper abdominal pain, upper gastrointestinal bleeding, and jaundice. A selective hepatic arteriogram showed a right hepatic artery pseudoaneurysm which was embolized. Two weeks later the patient had recurrent hemobilia as the result of blood flow restoration in the pseudoaneurysm and a fistula to the cystic duct remnant. She was treated with two additional embolizations and direct injection of the aneurysm with thrombogenic material. Follow-up at 2 years showed no further recurrence. Since the laser has never been shown to have advantages over electrocautery, its use during laparoscopic cholecystectomy is difficult to justify.

Choledochoduodenostomy. Analysis of 71 cases followed for 5 to 15 years.

To investigate the long-term effectiveness of choledochoduodenostomy (CDD), the experience with 71 patients followed for 5 or more years after CDD was analyzed retrospectively. From 1968 to 1984, 134 patients underwent CDD. Eight patients (6%) died in the immediate postoperative period, 55 left the hospital, 8 of them were lost to follow-up, and 47 were followed but died before 5 years elapsed after CDD. The remaining 71 patients form the data base for this analysis: 38 were followed for more than 5 years, 25 were followed for more than 10 years, and 8 were followed for more than 15 years (mean 12.1 years +/- 1.3 SEM). Choledocholithiasis, chronic pancreatitis, and postoperative stricture were the indications for CDD. Cholangitis was observed in only three patients. The diameter of the common bile duct (CBD) was large in most patients (mean 18 mm +/- 0.9 SEM). These results infer that CDD is effective to treat non-neoplastic obstructing lesions of the distal CBD on a long-term basis and that the presence of a dilated CBD (more than 16 mm) that allows the construction of a CDD more than 14 mm is essential to obtain good results.

Gastric lymphoma.

From 1976 to 1988, 35 patients were treated for Stage IE and Stage IIE primary gastric lymphoma (non-Hodgkin's). Pain and weight loss were the predominant symptoms, physical findings were usually absent and 20 per cent of the patients were anemic. The results of gastrointestinal contrast studies suggested a malignant condition in 75 per cent, but findings were not specific for lymphoma. Endoscopic findings suggested a malignant process in 85 per cent, but the yield for biopsy was only 60 per cent. Of 28 patients undergoing operative exploration, 75 per cent were resectable. Nine patients received postresectional adjuvant therapy. Five had chemotherapy; three, radiotherapy, and one patient, a combination of the two. Primary nonsurgical treatment consisted of chemotherapy in 11, radiotherapy in two and combined therapy in one instance. Three of five recurrences were successfully treated. The five year survival rate was 65 per cent without significant differences between surgical and nonsurgical regimens. Those with tumors smaller than 7 centimeters had a five year survival rate of 100 per cent versus 50 per cent for larger neoplasms. Patients more than 60 years of age appeared to have a more favorable course after surgical therapy compared with those who had nonsurgical treatment. We concluded that endoscopy is a most useful, although limited diagnostic study and since no treatment program is obviously superior, the choice of therapy can be individualized accordingly.

Abdominoperineal resection for rectal carcinoma: perioperative risk factors.

This retrospective review of 37 cases of abdominoperineal resection for adenocarcinoma sought to correlate preoperative clinical characteristics and intraoperative events with the likelihood of subsequent development of specific complications in the postoperative period. Mortality was 3% (1/37), and the complication rate was 76% (28/37), with urologic (49% [18/37]) and pulmonary (30% [11/37]) complications being the most common. Significant perioperative risk factors included a history of cardiac disease, current cardiac medications, diabetes mellitus, an abnormal preoperative electrocardiogram, and extended operation. Factors not associated with an increased risk included age, sex, a history of pulmonary disorders, previous abdominal operations, operative time, and need for transfusions, management of the pelvic peritoneum, or perineal drainage. Such information should reliably identify high-risk patients and therefore should be useful for selecting such patients for palliative or other limited techniques of tumor control.

Total gastrectomy for gastric carcinoma.

We retrospectively analyzed experience with total gastrectomy (TG) for gastric carcinoma in 23 patients. The TNM stage was I in one patient, II in one patient, III in eight patients, and IV in 13. Linitis plastica was found in ten patients. The operation was considered curative in only eight patients (35%). There were 13 complications in eight patients. There were no operative deaths. The survival ranged from three to 36 months. The survival for curative TG was a mean of 21.2 months +/- 3.3 SEM; for palliative TG, mean survival was 10.1 months +/- 1.1 SEM (P less than .001). These results suggest that gastric carcinoma that extensively involves the fundus and/or the corpus continues to be highly lethal, even when these tumors can be resected with a TG. Furthermore, even when the operation is considered "curative" and can be done with little or no operative mortality, the average survival was at best 21 months.

Peritoneovenous shunt for intractable ascites of hepatic, nephrogenic, and malignant causes.

A retrospective analysis of 54 patients with a peritoneovenous shunt inserted to control massive ascites refractory to conventional medical treatment is presented. The cause of ascites was hepatic in 29 patients (Group 1, 54 percent), malignant in 13 (Group 2, 24 percent), and nephrogenic in 12 (Group 3, 22 percent). The peritoneovenous shunt failed in 11 patients (20 percent): 6 in Group 1, 3 in Group 2, and 2 in Group 3. Shunt outflow obstruction (thrombosis) was the principal cause. Systemic sepsis in five patients and variceal hemorrhage in three were the factors responsible for most of the deaths (22 percent). Of the 42 patients who survived operation, the peritoneovenous shunt was effective in controlling the massive ascites in 37 (86 percent). Eight patients (15 percent), four with hepatic and four with nephrogenic ascites, survived 3 years or more without ascites. Removal of at least 50 to 70 percent of ascitic fluid at the time of shunt insertion was considered an important factor in decreasing morbidity and mortality. A peritoneovenous shunt can be effective for a long-term period in controlling massive ascites with an hepatic or nephrogenic cause in a selected group of patients; however, in patients with malignant ascites, although the benefit was substantial in half, the survival period did not exceed 6 months.

The pericholecystic hepatic activity sign in a normal DISIDA study. Case report.

A patient with a normal DISIDA study underwent a laparotomy that revealed acute cholecystitis. Retrospective review of the DISIDA study showed pericholecystic hepatic activity.

Predicting the risk of abdominal disease in Hodgkin's lymphoma. A multifactorial analysis of staging laparotomy results in 255 patients.

There were 425 consecutive patients treated for Hodgkin's disease at this Medical Center from 1943 to 1983. Of these, 255 patients underwent a staging laparotomy and had complete preoperative clinical records. Overall, 35% had a change in stage (24% were upstaged, 11% downstaged). Twenty-nine per cent of clinical stage I patients were upstaged; 31% of stage II patients were upstaged, while less than 1% were downstaged; and four per cent of stage III patients were upstaged while 44% were downstaged. The diagnostic laparotomy yielded involvement in the spleen in 71% of patients with abdominal involvement, in the periaortic lymph nodes in 41%, in the liver in 11%, and the bone marrow in seven per cent. Only 12% of the 135 patients with negative laparotomies subsequently relapsed in the abdomen after a mean follow-up of 4.8 years. A multifactorial analysis was performed to identify dominant factors predicting the risk for abdominal disease. The factors best predicting abdominal involvement in stage I and II patients were: antecedent symptoms (greater than or equal to 2, 1, 0; p less than 0.00001), histological type [nodular sclerosing (NS) less than lymphocyte-predominant (LP) less than mixed cellularity (MC) less than lymphocyte-depleted (LD); p = 0.0009], and sex (females less than males, p = 0.01). The clinical stage (I vs. II), the site of lymphoma presentation, and the age and race of the patient did not have significant predictive value for the risk of abdominal disease after the other factors were accounted for. A mathematical model was derived for identifying dominant prognostic factors for predicting the risk of abdominal disease in an individual patient setting. The lowest risk patients were asymptomatic females with NS histology (6%) or LP histology (8%), while the highest risk patients were men with multiple symptoms and either MC histology (85%) or LD histology (93%). This information can be useful in making clinical decisions in Hodgkin's lymphoma patients, especially those at an increased risk for surgery.