Predicting the likelihood of residual disease in women treated for ductal carcinoma in situ.

BACKGROUND: To identify women at risk for residual disease after excision of ductal carcinoma in situ (DCIS), we assessed the relationship between characteristics of the initial biopsy and the presence of residual DCIS at a subsequent operation. STUDY DESIGN: We identified 134 consecutive "paired" operations from 112 women who had undergone 2 or more operations for DCIS between February 1995 and December 1996. Cancer status of the margins, patient age and leading presentation, tumor subtype and grade, and the presence of multifocal-extensive disease were assessed as potential predictors. RESULTS: Residual DCIS was found in 60 patients (45%): in 2 of 12 patients (17%) with negative margins, in 11 of 36 (31%) with close margins (< 2 mm), in 30 of 52 (58%) with positive margins, and in 17 of 34 patients (50%) with margins of unknown status. Patients with positive or unknown margins were 7.7 and 8.3 times, respectively, more likely to have residual disease than patients with negative margins (95% CI 1.1-59.1; 1.1-66.4). Patients with clinical presentations were 8.0 times more likely to have residual disease than patients who presented with abnormal mammograms (95% CI 2.3-27.6). Multifocal-extensive DCIS was associated with residual disease (adjusted odds ratio [OR] = 7.7, 95% CI 2.9-20.5), as was comedo subtype (OR = 2.7, 95% CI 1.1-6.7). CONCLUSIONS: Positive or unknown biopsy margins, a clinical presentation, multifocal-extensive cancer, and the comedo subtype are associated with higher risk of residual DCIS.

Trends in bile duct injuries from laparoscopic cholecystectomy.

Bile duct injuries are a serious complication of cholecystectomy. Laparoscopic cholecystectomies (LC) were originally associated with an increased incidence of injuries. Patients referred to a tertiary center were reviewed to assess the trends in the number, presentation, and management. Seventy-three patients were referred over a 6-year period with a maximum of 17 patients referred in 1992, but the number has not declined substantially over time. The persistent number of referrals is a consequence of ongoing injuries. One third of injuries were diagnosed at LC, and the use of cholangiography has not increased. The number of cystic duct leaks has not decreased and they represent 25% of all cases. The level of injury has remained unchanged with Bismuth types I and II in 37% and types III and IV in 38%. Excluding patients with cystic duct leaks, 58% were referred after a failed ductal repair. Definitive treatment with biliary stenting was successful in 37%, and 34 patients (47%) required a biliary-enteric anastomosis. Complications occurred in 18 patients (25%) including seven with postoperative stricture or cholangitis. No biliary reoperations have been performed at a mean follow-up of 36 months.

Operations for gastric ulcer: a long-term study.

This study assesses the long-term results of operations for benign gastric ulcers. Three-hundred forty-nine patients operated upon between 1950-1979 have been followed over the past 20 years with a mean and median follow-up of 11.8 and 11.1 years. Fifty-five per cent of the patients had a gastric resection without vagotomy; 19.8 per cent had gastric resection with vagotomy; and 20.3 per cent had vagotomy, pyloroplasty, and wedge excision or biopsy of the ulcer. Operations were selected based on the type of ulcer (Types 1-4), whether the surgeon suspected cancer preoperatively, whether the operations was elective or an emergency, and the age and general health of the patient (presence of significant co-morbid disease). Overall mortality was 6.9 per cent, with a mortality for elective operations 3.6 per cent, and for emergency operations of 32.5 per cent. Age and cardiovascular disease were significant factors in operative mortality and morbidity. All operations were equivalent in long-term results. Excellent to good results were obtained in 92 per cent of patients, with an ulcer recurrence rate of 4 per cent. We conclude that vagotomy, pyloroplasty, and wedge excision or biopsy of a benign gastric ulcer is a comparable operation to a more major gastric resection, with or without vagotomy, in the surgical management of gastric ulcer. The addition of vagotomy to gastric resection does not appear to improve long-term results.

Monoethylglycinexylidide formation as an independent measure of warm hepatic ischemia and reperfusion injury.

An accurate serologic measure of hepatic function would be clinically useful in selecting donors for liver transplantation. An experimental model that incorporates varying lengths of total hepatic warm ischemia with reperfusion injury was utilized to compare serologic parameters and mitochondrial performance of oxidative phosphorylation in predicting hepatocellular injury. Monoethylglycinexylidide (MEGX) formation following bolus intravenous lidocaine injection was found to be significantly decreased (P < 0.0001) at all periods of ischemia when compared to that in nonischemic controls. A serum MEGX level of < 50 micrograms/liter suggested severe hepatic damage. No correlation was found between MEGX level and liver viability as measured by animal survival. Serum transaminase (AST and ALT) levels demonstrated progressive, nonsignificant elevations with increasing length of ischemia (P = 0.0779 at the maximum ischemic time). Polarographic measurements of mitochondrial oxidative phosphorylation did not reveal a significant alteration in subcellular metabolism with prolonged ischemic time. These data highlight the comparative sensitivity of MEGX formation as an early quantitative measurement of hepatocellular injury during warm ischemia, although it was not predictive of organ viability.

Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation. Lessons and prospects.

OBJECTIVE: The 50-year experience with surgery for the treatment of portal hypertension and bleeding varices at the Cleveland Clinic is reviewed. SUMMARY BACKGROUND DATA: A variety of procedures have been used to treat bleeding varices during the past 50 years. These include transesophageal ligation of varices or devascularization of the esophagus and stomach with splenectomy; portal-systemic (total) shunts; distal splenorenal (selective) shunts; endoscopic sclerotherapy; transjugular intrahepatic portal-systemic shunts; and liver transplantation. METHODS: Our experience with these procedures is reviewed in four time periods: 1946 to 1964, 1965 to 1980, 1980 to 1990, and 1990 to 1994. RESULTS: Our use of these procedures has changed as experience and new techniques for managing portal hypertension have evolved. Most ligation--devascularization--splenectomy procedures were performed before 1980; they provide excellent results in patients with normal livers and extrahepatic portal venous obstruction, but a major complication (40-50%) is rebleeding. Total shunts were performed most frequently before 1980; with patient selection, operative mortality was reduced to 8%, control of bleeding was achieved in more than 90%, but the incidence of encephalopathy was high (30%). Selective shunts provide almost equal protection from rebleeding with less post-shunt encephalopathy. We currently use selective shunts for patients with good liver function. Liver transplantation has been used since the mid 1980s for patients with poor liver function and provides good results for this difficult group of patients. CONCLUSIONS: The selection of patients for these procedures is the key to the successful management of portal hypertension.

Partial mastectomy and breast reconstruction. A comparison of their effects on psychosocial adjustment, body image, and sexuality.

BACKGROUND: This retrospective study compared psychosocial adjustment, body image, and sexual function in women who had either breast conservation or reconstruction for early stage disease. METHODS: Questionnaires were completed at a mean of 4 years after surgery by 72 women who had partial mastectomy and 146 women who had immediate breast reconstruction after mastectomy. RESULTS: In general, fewer than 20% of women reported poor adjustment on the domains measured. The two groups did not differ in overall psychosocial adjustment to illness, body image, or satisfaction with relationships or sexual life. There was a specific advantage of partial mastectomy over breast reconstruction in terms of maintaining pleasure and frequency of breast caressing during sexual activity. Women who had undergone chemotherapy had more sexual dysfunction, poorer body image, and more psychological distress. Hormonal therapy and radiation therapy, however, did not measurably affect quality of life. Factors predictive of greater psychosocial distress included a troubled marriage, a poor body image, sexual dissatisfaction, less education, and treatment with chemotherapy. CONCLUSIONS: The choice of local treatment had little psychosexual impact, whereas chemotherapy was associated with long term impairments.

Fascial closure in the management of infected pancreatic necrosis.

Reports have focused on the perceived benefit of a new method of managing pancreatic necrosis and sepsis: leaving the abdomen packed open after debridement, the "marsupialization" technique. We have continued to treat infected pancreatic necrosis with aggressive pancreatic debridement and drainage, closure of the abdomen, and prompt reoperation as often as necessary if further sepsis is identified. We report 52 consecutive patients with infected pancreatic necrosis operated upon between July, 1972 and March, 1990. Postoperative organ failure and APACHE II scoring correlated with survival. Patients with APACHE II scores less than 15 had an operative mortality rate of 4 per cent, whereas patients with scores greater than 15 had a 44 per cent mortality rate. We recognize that no two retrospective series are truly comparable, but in comparison to published reports on the open technique, fascial closure after pancreatic debridement appeared to produce fewer wound complications (only one dehiscence and one incisional hernia) and fewer trips to the operating room.

Long-term results of the surgical management of chronic pancreatitis.

To investigate the long-term results of surgical management of chronic pancreatitis, we reviewed the hospital records of 50 consecutive patients who underwent surgery for chronic pancreatitis between 1975 and 1985. The principal indications for surgery were abdominal pain (100%), pseudocyst (24%), and biliary obstruction (42%). Surgeries included pancreatic duct drainage (56%), distal pancreatic resection (20%), and drainage of a pancreatic pseudocyst (24%). Follow-up averaged 5.2 years (range 5 to 11 years). Reoperation was required in 31 patients during the extended follow-up period. Principal indications for reoperation were abdominal pain (93%), recurrent pancreatic pseudocyst (32%), and uncertainty of the diagnosis of chronic pancreatitis (26%). Subsequent operations included cholecystectomy (35%), pseudocyst drainage (32%), splanchnicectomy (16%), and pancreatic biopsy (16%); and eliminated abdominal pain in 24 patients (83%). The diagnosis of chronic pancreatitis was not revised in any case. At most recent follow-up, 30 patients (60%) were well and without abdominal pain, 12 (24%) experienced intermittent abdominal pain, and one (2%) had continued abdominal pain that required narcotics. Five patients (10%) died of other causes, and two (4%) were lost to follow-up. We conclude that pain, the principal symptom of chronic pancreatitis, can be eliminated or reduced in the majority of patients by appropriate surgical therapy.

Partial mastectomy without radiation is adequate treatment for patients with stages 0 and I carcinoma of the breast.

The treatment of potentially curable carcinoma of the breast has changed from one operation, radical mastectomy, to a flexible approach. At the Cleveland Clinic, we use four types of treatment for primary potentially curable carcinoma of the breast (Stages 0, I and II)--modified radical mastectomy, simple mastectomy, partial mastectomy with postoperative adjuvant radiation therapy and partial mastectomy without radiation therapy. The latter treatment (partial mastectomy without adjuvant radiation) is controversial. We recommend this procedure for patients with T(is) and T1 carcinomas that appear to be localized, without lymph node metastases, Stages 0 and I disease. The overall and disease-free survival rates are similar to those of patients having modified radical or partial mastectomy with radiation. Local recurrence is slightly higher at five years (11.0 percent) as compared with the other procedures, but at ten years, is only 16.1 percent, a figure comparable with patients having partial mastectomy with radiation (14.4 percent). For patients with Stages 0 and I carcinoma of the breast, the addition of postoperative radiation therapy after partial mastectomy seems to be unnecessary.

Removal of trypsin complexed alpha-2 macroglobulin by plasma fractionation.

The aim of this study is to assess in vitro the efficacy of a plasma fractionator to remove trypsin complexed alpha 2MG (alpha-2 macroglobulin) from human plasma in a manner analogous to the reticuloendothelial system (RES). Eval filter type "4A" (Kuraray Co., Osaka, Japan) was chosen as a plasma fractionator. Two and one half liters of bovine trypsin spiked human plasma was perfused in vitro through the fractionator in a single pass mode (n = 5). The concentrations of complexed alpha 2MG, total alpha 2MG, albumin, and IgM were measured before and after fractionation, and the concentration of free alpha 2MG and the sieving coefficients of each solute were calculated. The concentration of the trypsin complexed alpha 2MG measured by ELISA was significantly decreased by fractionation with Eval "4A" from 103.7 +/- 16.7 to 13.8 +/- 8.2 mg/L (reduction of 86.7%). Mean sieving coefficients of each solute were 0.133 +/- 0.079 in complexed alpha 2MG, 0.203 +/- 0.065 in free alpha 2MG, 0.203 +/- 0.065 in total alpha 2MG, 0.770 +/- 0.130 in albumin, and 0.070 +/- 0.010 in IgM. Although in vivo study will be required in patients with acute pancreatitis, in vitro study shows the feasibility of membrane plasma fractionation in eliminating trypsin complexed alpha 2MG.

Breast-conserving surgery: how much is enough?

Breast-conserving operations for the treatment of small, apparently localized invasive breast cancer are now accepted by most surgeons. Still controversial are (1) the size of the primary tumor selected for breast conservation treatment, (2) how much breast tissue must be removed to provide an "adequate" margin to achieve local control, and (3) whether the entire breast needs to be treated by radiation therapy in all patients after adequate partial mastectomy. The results of breast-conserving operations at the Cleveland Clinic are presented and the case for selected, individualized therapy utilizing partial mastectomy without radiation therapy for selected patients with small invasive cancers is made.

Perioperative blood transfusion and survival of breast cancer patients after modified radical mastectomy.

To investigate the effect of perioperative blood transfusion on the survival of patients with breast cancer, the authors reviewed the clinical records of 455 patients who underwent modified radical mastectomy between 1960 and 1979. Thirty-eight patients (8.4%) received blood transfusions. For stage I patients who received perioperative transfusions, 5- and 10-year survival rates were 53% and 47%; for the no-transfusion group, the rates were 93% and 85%. There was also a significant difference in disease-free survival for stage I patients: for the transfusion group, 5- and 10-year survival rates were 47%; for the group not receiving a transfusion, the rates were 89% and 84%. For stage II patients, there was no difference in total or disease-free survival between those who received transfusions and those who did not, and both groups had comparable distribution of nodes.

Role of radiation after operative palliation in cancer of the proximal bile ducts.

Cancer of the proximal bile ducts continues to pose a formidable problem to even the most experienced biliary surgeon. From 1977 through 1985, 51 patients with histologically confirmed proximal bile duct cancers underwent surgical treatment. The lesion was confined to the hilar region in 30 patients; there was extensive hepatic infiltration or distant metastatic disease in 21 patients. One patient underwent resection. Biopsy only was performed in six patients. In the remaining 44 patients, transtumoral dilation and intubation were performed. These 44 patients were further analyzed with regard to how survival was affected by the presence of metastatic disease and by the adjunctive use of radiation therapy. Mean survival in those patients with metastatic disease (n = 16) was 6.1 months, and survival was not improved by the use of postoperative radiation. In the absence of metastatic or advanced local disease, however, the addition of external beam radiation did significantly extend the mean survival from 4.5 to 12.2 months and the median survival from 2.2 to 12.2 months. The operative mortality for the series was 14% and postoperative complications occurred in 18 patients. These findings suggest that the addition of external beam radiation improves survival in patients undergoing palliative treatment of hilar tumors. Further confirmation of the value of radiation awaits prospective investigation.

Indications for gastric bypass in palliative operations for pancreatic carcinoma.

This review was undertaken to determine whether there are specific factors which predict the development of gastric outlet obstruction (GOO) in patients with pancreatic carcinoma. One hundred forty-two patients with biopsy proven pancreatic carcinoma had palliative operations of whom 74 had gastric bypass (GB). Of the 68 who did not, four died after biliary bypass. The 64 patients who remained at risk for GOO are the subject of this report. Seven of those patients developed GOO in the postoperative period and were compared with the 57 who did not. No significant difference was found between the two groups when they were compared on the basis of 20 historic, laboratory, and operative finding criteria. These data indicate that accurate prediction of subsequent GOO is not possible based on available objective data. Because GB creation does not increase operative blood loss, operative time, postoperative stay, or postoperative morbidity, and because prediction of need is difficult, prophylactic GB should be applied very liberally.

Surgery for acute and chronic cholecystitis.

Cholecystostomy and cholecystectomy remain appropriate and effective therapy for acute and chronic cholecystitis. Cholecystectomy is the gold standard against which all alternative methods of treatment of inflammatory biliary stone disease should be judged. The pathogenesis, diagnosis, and surgical treatment of acute and chronic cholecystitis have been described. Techniques of cholecystostomy, cholecystectomy, and intraoperative cholangiography used by the author have been given. Our results and those generally described in the literature indicate that the overall mortality rate for cholecystectomy, in all age groups, is approximately 0.5%. This rate increases slightly in patients with acute cholecystitis and in those over the age of 65 years. Cholecystectomy remains the most effective and the definitive treatment for acute and chronic cholecystitis.