The impact of a laparoscopic colorectal surgeon on the laparoscopic colectomy experience of a single academic center.

BACKGROUND: The objective of this study was to evaluate the impact of a laparoscopic colorectal surgeon (LCRS) on the laparoscopic colectomy experience of a single academic center. METHODS: We performed a retrospective review of case complexity, patient characteristics, operative and preparation time, and trends over time for the LCRS compared to two veteran laparoscopic surgeons (VLS). RESULTS: The LCRS performed 48 of the procedures (83%) and the VLS 10 (17%) for a total of 58 laparoscopic colon cases. The LCRS handled a greater number of complex cases (p = 0.07). For less complex cases, overall operative time differed for the two groups (LCRS = 220 +/- 11 vs VLS = 152 +/- 15 min, p = 0.004). Overall hospital stay was 4.8 +/- 0.6 days (range, 2-33). Minor complications occurred in 12 cases (21%); major complications in occurred in seven cases (12%). Among procedures performed by the LCRS, comparison of the first 24 cases to the second 24 demonstrated that operative and preparation time decreased in the second cohort (all p < 0.05). CONCLUSION: The addition of an LCRS had a significant impact on this center's experience with laparoscopic colectomies in terms of both volume and case complexity.

Radical resection improves survival for patients with pT2 gallbladder carcinoma.

Radical resection (wedge resection of the gallbladder bed and dissection of the hepatoduodenal ligament, portal, and celiac lymph nodes) has been reported to improve survival from pathologic T2 gallbladder carcinoma (pT2 GBCa; invasion through the muscularis without perforation of the serosa). We report our experience and the outcome of patients with pT2 GBCa. Between 1989 and 2000 at Vanderbilt University Medical Center ten patients were found to have pT2 disease after cholecystectomy. The patients had an average age of 64+/-13 years and underwent either radical resection (n = 5) or no further surgical therapy (n = 5). Of the patients who underwent cholecystectomy only, one (20%) is still alive at 27 months and four (80%) died of recurrent GBCa between 6.5 and 21 months. For the patients who underwent radical resection all five are alive at 15 to 83 months with no recurrence. The proportion of patients surviving pT2 GBCa after radical resection was significantly greater than with cholecystectomy alone (P < 0.05). The difference in length of survival between the two groups was also significant (P < 0.05). Morbidity after radical resection was low (pancreatic leak in one patient), and there were no operative mortalities. Radical resection significantly improved survival over cholecystectomy alone for patients with pT2 GBCa. The procedure has low morbidity and mortality rates. Therefore a radical resection operation is indicated for patients with pT2 GBCa.

Bile duct injury following laparoscopic cholecystectomy: a cause for continued concern.

Previous reports suggest that bile duct injuries sustained during laparoscopic cholecystectomy (lap chole) are frequently severe and related to cautery and high clip ligation. We performed a review of patients who sustained bile duct injury from lap chole since 1990 and assessed time to injury recognition, time to referral, Bismuth classification, initial and subsequent repairs, rate of recurrence, and length of follow-up. Seventy-four patients [median age 44 years, 58 of 74 female (78%)] were referred with a bile duct injury after lap chole. The level of injury was evenly divided between the bile duct bifurcation and the common hepatic duct: Bismuth III, IV, and V (40 of 74, 54%) versus Bismuth I and II (34 of 74, 46%). Concomitant hepatic arterial injury was identified in nine (12%) patients. Patients referred early after bile duct injury and requiring operative intervention underwent hepaticojejunostomy at a median of 2 days after referral. After surgical reconstruction at our center there has been an overall success rate of 89 per cent with no need for reintervention. Six (10%) of these patients have required one additional balloon dilatation at a mean follow-up of >24 months. One (2%) patient underwent biliary-enteric revision in follow-up. In patients with bile duct injury, stricture repair without delay was successful in the majority of patients treated in this series. Only one of 64 patients reconstructed at our center has required reoperation; six others have required a single balloon dilatation with subsequent good or excellent results. The majority of patients treated with operative repair at an experienced center can expect good long-term results with rare need for reintervention.

Interspecies differences in hepatic Ca(2+)-ATPase activity and the effect of cold preservation on porcine liver Ca(2+)-ATPase function.

The accumulation of intracellular calcium ([Ca(2+)](i)) caused by ischemia-reperfusion during liver transplantation has been implicated as a factor leading to primary graft nonfunction. Plasma membrane (PM) and endoplasmic reticulum (ER) Ca(2+)-adenosinetriphosphatases (ATPases) are the primary transporters that maintain [Ca(2+)](i) homeostasis in the liver. We hypothesized that the porcine liver is better than the rat liver as a model for the study of human liver Ca(2+)-ATPase activity. We also hypothesized that cold preservation would depress Ca(2+)-ATPase activity in the porcine liver. Pig and rat livers were harvested, and human liver samples were obtained from surgical resection specimens. All were preserved with University of Wisconsin solution, and porcine livers were also preserved on ice for 2 to 18 hours. Ca(2+)-ATPase activity was measured after incubation with (45)Ca(2+) and adenosine triphosphate in the presence of specific Ca(2+)-ATPase inhibitors. Porcine PM and ER Ca(2+)-ATPase activities were 0.47 +/- 0.03 and 1.57 +/- 0.10 nmol of Ca(2+)/mg of protein/min, respectively. This was not significantly different from human liver, whereas rat liver was significantly greater at 2.60 +/- 0.03 and 9.2 +/- 0.9 nmol of Ca(2+)/mg of protein/min, respectively. We conclude that the Ca(2+)-ATPase activity in the pig liver is equivalent to that of human liver, and thus, the pig liver is a better model than the rat liver. Cold preservation studies showed a significant decrease in porcine hepatic PM Ca(2+)-ATPase activity after 4 hours of storage and near-total inhibition after 12 hours. Porcine hepatic ER Ca(2+)-ATPase activity showed a 45% decrease in activity by 12 hours and a 69% decrease by 18 hours. We conclude that cold ischemia at clinically relevant times depresses PM Ca(2+)-ATPase more than ER Ca(2+)-ATPase activity in pig liver homogenates.

Effect of dopamine infusion on hemodynamics after hepatic denervation.

BACKGROUND: . The effects of dopamine (DA) on systemic hemodynamics are better understood than its effects on hepatic hemodynamics, especially after liver denervation occurring during liver transplantation. Therefore, a porcine model was used to study DA's effects on hemodynamics after hepatic denervation. MATERIALS AND METHODS: Fifteen pigs underwent laparotomy for catheter and flow probe placement. The experimental group (n = 7) also underwent hepatic denervation. After 1 week, all pigs underwent DA infusion at increasing doses (3-30 mcg/kg/min) while measuring hepatic parameters [portal vein flow (PVF), hepatic artery flow (HAF), total hepatic blood flow (THBF = HAF + PVF), portal and hepatic vein pressures] and systemic parameters [heart rate (HR), mean arterial pressure (MAP)]. RESULTS: There was a significant increase in HAF from baseline to the 30 mcg/kg/min DA infusion rate (within-subjects P < 0.01), but the differences between the two groups were not significant. PVF and THBF showed large effects (increases) with denervation, but the increase in flow with DA infusion was not present after denervation. Perihepatic pressures were unchanged by denervation or DA. Heart rate differed significantly between the control and denervated animals at baseline, 3, 6, 12 (all P < 0.05), and 30 mcg/kg/min DA (P = 0.10). Control vs denervation MAP at baseline was 100 +/- 4 vs 98 +/- 4 Torr and at 30 mcg/kg/min it was 110 +/- 3 vs 101 +/- 5 mm Hg. CONCLUSIONS: Hepatic flows tended to be higher after denervation. HAF showed similar increases with DA in both control and denervation groups. Increases in PVF and THBF with DA infusion were not present after denervation. HR was significantly decreased and MAP tended to be lower after denervation. The HR and MAP response to DA was similar in both groups. Therefore, both denervation and DA infusion have an effect on systemic and hepatic hemodynamics.

Health-related quality of life after different types of solid organ transplantation.

OBJECTIVE: To describe functional health and health-related quality of life (QOL) before and after transplantation; to compare and contrast outcomes among liver, heart, lung, and kidney transplant patients, and compare these outcomes with selected norms; and to explore whether physiologic performance, demographics, and other clinical variables are predictors of posttransplantation overall subjective QOL. SUMMARY BACKGROUND DATA: There is increasing demand for outcomes analysis, including health-related QOL, after medical and surgical interventions. Because of the high cost, interest in transplantation outcomes is particularly intense. With technical surgical experience and improved immunosuppression, survival after solid organ transplantation has matured to acceptable levels. More sensitive measures of outcomes are necessary to evaluate further developments in clinical transplantation, including data on objective functional outcome and subjective QOL. METHODS: The Karnofsky Performance Status was assessed objectively for patients before transplantation and up to 4 years after transplantation, and scores were compared by repeated measures analysis of variance. Subjective evaluation of QOL over time was obtained using the Short Form-36 (SF-36) and the Psychosocial Adjustment to Illness Scale (PAIS). These data were analyzed using multivariate and univariate analysis of variance. A summary model of health-related QOL was tested by path analysis. RESULTS: Tools were administered to 100 liver, 94 heart, 112 kidney, and 65 lung transplant patients. Mean age at transplantation was 48 years; 36% of recipients were female. The Karnofsky Performance Status before transplantation was 37 +/- 1 for lung, 38 +/- 2 for heart, 53 +/- 3 for liver, and 75 +/- 1 for kidney recipients. After transplantation, the scores improved to 67 +/- 1 at 3 months, 77 +/- 1 at 6 months, 82 +/- 1 at 12 months, 86 +/- 1 at 24 months, 84 +/- 2 at 36 months, and 83 +/- 3 at 48 months. When patients were stratified by initial performance score as disabled or able, both groups merged in terms of performance by 6 months after liver and heart transplantation; kidney transplant patients maintained their stratification 2 years after transplantation. The SF-36 physical and mental component scales improved after transplantation. The PAIS score improved globally. Path analysis demonstrated a direct effect on the posttransplant Karnofsky score by time after transplantation and diabetes, with trends evident for education and preoperative serum creatinine level. Although neither time after transplantation nor diabetes was directly predictive of a composite QOL score that incorporated all 15 subjective domains, recent Karnofsky score and education level were directly predictive of the QOL composite score. CONCLUSIONS: Different types of transplant patients have a different health-related QOL before transplantation. Performance improved after transplantation for all four types of transplants, but the trajectories were not the same. Subjective QOL measured by the SF-36 and the PAIS also improved after transplantation. Path analysis shows the important predictors of health-related QOL. These data provide clearly defined and widely useful QOL outcome benchmarks for different types of solid organ transplants.

Lung allocation in the United States, 1995-1997: an analysis of equity and utility.

BACKGROUND: Waiting time for organ transplantation varies widely between programs of different sizes and by geographic regions. The purpose of this study was to determine if the current lung-allocation policy is equitable for candidates waiting at various-sized centers, and to model how national allocation based solely on waiting time might affect patients and programs. METHODS: UNOS provided data on candidate registrations; transplants and outcomes; waiting times; and deaths while waiting for all U.S. lung-transplant programs during 1995-1997. Transplant centers were categorized based on average yearly volume: small (< or = 10 pounds sterling transplants/year; n = 46), medium (11-30 transplants/year; n = 29), or large (>30 transplants/year; n = 6). This data was used to model national organ allocation based solely on accumulated waiting time for candidates listed at the end of 1997. RESULTS: Median waiting time for patients transplanted was longest at large programs (724-848 days) compared to small and medium centers (371-552 days and 337-553 days, respectively) and increased at programs of all sizes during the study period. Wait-time-adjusted risk of death correlated inversely with program size (365 vs 261 vs 148 deaths per 1,000 patient-years-at-risk at small, medium, and large centers, respectively). Mortality as a percentage of new candidate registrations was similar for all program categories, ranging from 21 to 25%. Survival rates following transplantation were equivalent at medium-sized centers vs large centers (p = 0.50), but statistically lower when small centers were compared to either large- or medium-size centers (p < or = 0.05). Using waiting time as the primary criterion lung allocation would acutely shift 10 to 20% of lung-transplant activity from medium to large programs. CONCLUSIONS: 1) Waiting list mortality rates are not higher at large lung-transplant programs with long average waiting times. 2) A lung-allocation algorithm based primarily on waiting-list seniority would probably disadvantage candidates at medium-size centers without improving overall lung-transplant outcomes. 3) If fairness is measured by equal distribution of opportunity and risk, we conclude that the current allocation system is relatively equitable for patients currently entering the lung-transplant system.

Hepatic cryoablation-induced acute lung injury: pulmonary hemodynamic and permeability effects in a sheep model.

HYPOTHESIS: Hepatic cryoablation of 30% to 35% or more of liver parenchyma in a sheep model results in eicosanoid and nuclear factor-kappaB (NF-kappaB)-mediated changes in pulmonary hemodynamics and lung permeability. SETTING: Laboratory. INTERVENTIONS: At initial thoracotomy, catheters were placed in the main pulmonary artery, left atrium, right carotid artery, and efferent duct of the caudal mediastinal lymph node for subsequent monitoring in adult sheep. After a 1- to 2-week period of recovery, animals underwent laparotomy and left-lobe cryoablation (approximately 35% by volume) with subsequent awake monitoring and on postoperative days 1 to 3. MAIN OUTCOME MEASURES: Cryoablation-induced lung permeability and hemodynamic changes were compared with baseline values in sheep that underwent instrumentation. Similarly handled sheep underwent resection of a similar volume of hepatic parenchyma or had pulmonary artery pressure increases induced by mechanical left atrial obstruction. Activation of NF-kappaB was assessed with electrophoretic mobility shift assay, and serum thromboxane levels were measured with mass spectroscopy. RESULTS: Cryoablation resulted in acutely increased mean pulmonary (20 to 35 cm water) and systemic pressures, which returned to baseline at 24 hours with no change in cardiac output. Serum thromboxane levels increased 30 minutes after cryoablation (9-fold) and returned to baseline at 24 hours. Activation of NF-kappaB was present in liver and lung tissue by 30 minutes after cryoablation. Lung lymph-plasma protein clearance markedly exceeded the expected increase from pulmonary pressures alone, and increased lymph-plasma protein ratio persisted after pulmonary artery pressures normalized. Similar changes were not associated with 35% hepatic resection. CONCLUSIONS: This study demonstrates that 35% hepatic cryoablation results in an acute but transient increase in pulmonary artery pressure that may be mediated by increased thromboxane levels. Increases in pulmonary capillary permeability are not accounted for by pressure changes alone, and may be a result of NF-kappaB-mediated inflammatory mechanisms. These data show that cryosurgery causes pathophysiological changes similar to those observed with endotoxin and other systemic inflammatory stimuli.

The incidence of splenectomy is decreasing: lessons learned from trauma experience.

Over the past decade, splenic preservation has become a well-reported and accepted principle in trauma management. The reasons for splenic preservation may have influenced nontraumatic surgical management as well. To investigate the changing incidence and indications for splenectomy, we conducted a 10-year review of all splenectomies at our institution. During this time, between January 1, 1986, and December 31, 1995, 896 patients underwent splenectomy. Hospital charts and records were examined to determine the etiology and incidence of splenectomy. Indications were classified as: 1) trauma, i.e., performed for blunt or penetrating injury; 2) hematologic malignancy, i.e., therapy or staging of underlying leukemia, Hodgkin's lymphoma, or non-Hodgkin's lymphoma; 3) cytopenia, i.e., treatment of thrombocytopenia, anemia, or leukopenia; 4) iatrogenic, i.e., injury during another procedure; 5) incidental, i.e., required for adjacent organ resection; 6) portal hypertension, i.e., left-sided portal hypertension or during shunting procedure; 7) diagnostic, i.e., uncertainty excluding hematologic malignancy; or 8) other, i.e., miscellaneous indications. Trauma accounted for 41.5 per cent of all splenectomies during this time period, hematologic malignancy 15.4 per cent, cytopenia 15.6 per cent, incidental 12.3 per cent, iatrogenic 8.1 per cent, portal hypertension 2.3 per cent, diagnostic 2.0 per cent, and other 2.7 per cent. Comparing the first and second 5-year time periods, the following increases/decreases in average annual incidence were noted: splenectomy for all indications, -36.9 per cent; trauma, -32.9 per cent; hematologic malignancy, -51.4 per cent; cytopenia, 35.1 per cent; incidental, -35.9 per cent; iatrogenic, -30.2 per cent; diagnostic, +4.9 per cent, and other, -57 per cent. Traumatic injury to the spleen remains the most common indication for splenectomy, but the incidence has decreased dramatically over the past 10 years. Splenectomies for treatment of hematologic malignancies and cytopenia, as well as incidental and iatrogenic splenectomies, have also decreased significantly. Only the incidence of diagnostic splenectomy has remained stable. Although initiated within the field of trauma, the advantages of splenic preservation now appear to be well recognized beyond that field.

Effect of dopamine infusion (3-30 microg/kg/min) on hepatic hemodynamics.

BACKGROUND: While dopamine produces well-characterized dose-dependent effects on systemic hemodynamics, there is a paucity of information regarding its effects on hepatic hemodynamics. Infusion rates above 10 microg/kg/min are reported to produce significant vasoconstriction and impair organ perfusion. Therefore, donors are sometimes considered unsuitable when higher doses of dopamine are in use. The aim of this study was to determine the effect of increasing doses of dopamine on hepatic hemodynamics in a nonanesthetized swine model. MATERIALS AND METHODS: Sixteen pigs were instrumented with indwelling catheters in a peripheral artery, peripheral vein, portal vein, and hepatic vein and flow probes around the portal vein and hepatic artery. After recovery, the following variables were measured 10 +/- 1 days postinstrumentation: hepatic arterial flow (HAF), portal venous flow (PVF), mean systemic arterial pressure (MAP), central venous pressure (CVP), portal venous pressure (PVP), hepatic venous pressure (HVP), heart rate (HR). Recordings were obtained at baseline and subsequently when dopamine was infused at rates of 3, 6, 12, 15, 21, and 30 microg/kg/min increasing at 1-h intervals. RESULTS: HAF and PVF increased linearly over the entire infusion range, to 69 and 13% over baseline, respectively (P < 0.001, P < 0.05). Total hepatic blood flow rose 23% over baseline at the 30 microg/kg/min dosage (P < 0.01). MAP increased linearly 13% over the range 12 to 30 microg/kg/min (P < 0.001). CVP, HVP, and PVP did not change significantly. HR decreased from 12 to 15 microg/kg/min (P < 0.01), then increased from 15 to 30 microg/kg/min (P < 0.05). CONCLUSION: These data show that dopamine infused at dosages of 3-30 microg/kg/min augments HAF, PVF, and THBF and that this effect is linear. These results suggest high-dose dopamine infusion does not disqualify a potential donor liver for transplantation.

Optimal interpretation of FDG PET in the diagnosis, staging and management of pancreatic carcinoma.

UNLABELLED: This study had two purposes: to optimize the semiquantitative interpretation of 18F-fluorodeoxyglucose (FDG) PET scans in the diagnosis of pancreatic carcinoma by analyzing different cutoff levels for the standardized uptake value (SUV), with and without correction for serum glucose level (SUV(gluc)); and to evaluate the usefulness of FDG PET when used in addition to CT for the staging and management of patients with pancreatic cancer. METHODS: Sixty-five patients who presented with suspected pancreatic carcinoma underwent whole-body FDG PET in addition to CT imaging. The PET images were analyzed visually and semiquantitatively using the SUV and SUV(gluc). The final diagnosis was obtained by pathologic (n = 56) or clinical and radiologic follow-up (n = 9). The performance of CT and PET at different cutoff levels of SUV was determined, and the impact of FDG PET in addition to CT on patient management was reviewed retrospectively. RESULTS: Fifty-two patients had proven pancreatic carcinoma, whereas 13 had benign lesions, including chronic pancreatitis (n = 10), benign biliary stricture (n = 1), pancreatic complex cyst (n = 1) and no pancreatic pathology (n = 1). Areas under receiver operating characteristic curves were not significantly different for SUV and SUV(gluc). Using a cutoff level of 3.0 for the SUV, FDG PET had higher sensitivity and specificity than CT in correctly diagnosing pancreatic carcinoma (92% and 85% versus 65% and 61%). There were 2 false-positive PET (chronic pancreatitis, also false-positive with CT) and 4 false-negative PET (all with true-positive CT, abnormal but nondiagnostic) examinations. There were 5 false-positive CT (4 chronic pancreatitis and 1 pancreatic cyst) and 18 false-negative CT (all with true-positive FDG PET scans) examinations. FDG PET clarified indeterminate hepatic lesions or identified additional distant metastases (or both) in 7 patients compared with CT. Overall, FDG PET altered the management of 28 of 65 patients (43%). CONCLUSION: FDG PET is more accurate than CT in the detection of primary tumors and in the clarification and identification of hepatic and distant metastases. The optimal cutoff value of FDG uptake to differentiate benign from malignant pancreatic lesions was 2.0. Correction for serum glucose did not significantly improve the accuracy of FDG PET. Although FDG PET cannot replace CT in defining local tumor extension, the application of FDG PET in addition to CT alters the management in up to 43% of patients with suspected pancreatic cancer.

Acute lung injury after hepatic cryoablation: correlation with NF-kappa B activation and cytokine production.

BACKGROUND: Previous clinical reports have documented multisystem organ injury after hepatic cryoablation. We hypothesized that hepatic cryosurgery, but not partial hepatectomy, induces a systemic inflammatory response characterized by distant organ injury and overproduction of nuclear factor kappa B (NF-kappa B)-dependent, proinflammatory cytokines. METHODS: In this study, rats underwent either cryoablation of 35% of liver parenchyma or a similar resection of left hepatic tissue. Serum tumor necrosis factor-alpha and macrophage inflammatory protein-2 levels and NF-kappa B activation were assessed by electrophoretic mobility shift assay at 30 minutes 1, 2, 6, and 24 hours after either procedure. RESULTS: Cryoablation of 35% of liver (n = 22 rats) resulted in lung injury and a 45% mortality rate within 24 hours of surgery, whereas 7% treated with 35% hepatectomy (n = 15 rats) died during the 24 hours after surgery (P < .05, cryoablation vs hepatectomy). Serum tumor necrosis factor-alpha and macrophage inflammatory protein-2 levels were markedly increased in rats (n = 10 rats) 1 hour after hepatic cryoablation compared with rats that underwent partial hepatectomy (P < .005). We evaluated NF-kappa B activation by electrophoretic mobility shift assay in nuclear extracts of liver and lung after cryosurgery and found that NF-kappa B activation was strikingly increased in the liver but not the lung at 30 minutes and in both organs 1 hour after cryosurgery, and returned to baseline in both organs by 2 hours. In rats undergoing 35% hepatectomy, no increase in NF-kappa B activation was detected in nuclear extracts of either liver or lung at any time point. CONCLUSIONS: These data show that hepatic cryosurgery results in systemic inflammation with activation of NF-kappa B and increased production of NF-kappa B-dependent cytokines. Our data suggest that lung injury and death in this animal model is mediated by an exaggerated inflammatory response to cryosurgery.

Acute pancreatitis after cardiac transplantation and other cardiac procedures: case-control analysis in 24,631 patients.

Previous series have identified an increased risk of developing acute postoperative pancreatitis in heart transplant recipients and other cardiac surgical patients, and some suggest that mortality is significantly increased when pancreatitis occurs in the transplant setting. We conducted a retrospective case-control analysis of adult patients undergoing orthotopic heart transplant or other cardiac procedures from April 1985 through June 1996 at our medical center. Specific risk factors for outcome were assessed including low cardiac output, intra-aortic balloon pump usage, exogenous calcium repletion, immunosuppression, cytomegalovirus infection, cholelithiasis, prior pancreatitis, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. There was a 30-fold increase in the incidence of pancreatitis in the heart transplant group [12 of 394 (3%) vs 27 of 24,237 (0.1%); P < 0.01]. Compared with the nontransplant cardiopulmonary bypass patients, the transplant patients experienced a statistically significant increased incidence of immunosuppression and three or more risk factors. Transplant patients with pancreatitis demonstrated a significant increase in APACHE II scores and the incidence of three or more risk factors compared with their transplant control group. Patients undergoing nontransplant cardiac procedures and developing pancreatitis had significantly increased cross-clamp times, incidence of low cardiac output, APACHE II scores, and incidence of three or more risk factors compared with their nontransplant cohort. In conclusion, there is a significant increase in the incidence of pancreatitis after orthotopic heart transplant compared with other cardiac procedures. Analysis demonstrates the additive effect of multiple individual risk factors. Immunosuppression confers significant additional risk for pancreatitis in the orthotopic heart transplant patient.

Bromfenac (Duract)-associated hepatic failure requiring liver transplantation.

Bromfenac sodium (Duract) is a phenylacetic acid-derived nonsteroidal anti-inflammatory agent introduced in the United States in 1997 and withdrawn in 1998. We describe the first case of fulminant hepatic failure associated with this agent treated successfully with liver transplantation. Similarities to hepatotoxicity with related agents is discussed.

Image-guided surgery: preliminary feasibility studies of frameless stereotactic liver surgery.

BACKGROUND: Liver surgery can be difficult because there are few external landmarks defining hepatic anatomy and because the liver has significant vascularity. Although preoperative tomographic imaging (computed tomography or magnetic resonance imaging) provides essential anatomical information for operative planning, at present it cannot be used actively for precise localization during surgery. Interactive image-guided surgery involves the simultaneous real-time display of intraoperative instrument location on preoperative images (computed or positron-emission tomography or magnetic resonance imaging). Interactive image-guided surgery has been described for tumor localization in the brain (frameless stereotactic surgery) and allows for interactive use of preoperative images during resections or biopsies. HYPOTHESIS: The application of interactive image-guided surgery (IIGS) is feasible for hepatic procedures from a biomedical engineering standpoint. METHODS: We developed an interactive image-guided surgery system for liver surgery and tested a porcine liver model for tracking liver motion during insufflation; liver motion during respiration in open procedures in patients undergoing hepatic resection; and tracking accuracy of general surgical instruments, including a laparoscope and an ultrasound probe. RESULTS: Liver motion due to insufflation can be quantified; average motion was 2.5+/-1.4 mm. Average total liver motion secondary to respiration in patients was 10.8 +/-2.5 mm. Instruments of varying lengths, including a laparoscope, can be tracked to accuracies ranging from 1.4 to 2.1 mm within a 27-m3 (3 X 3 X 3-m) space. CONCLUSION: Interactive image-guided surgery appears to be feasible for open and laparoscopic hepatic procedures and may enhance future operative localization.

Transcatheter arterial chemoembolization as primary treatment for hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) in Western populations has historically been associated with poor survival. METHODS: In this study, we conducted a 7-year retrospective analysis of patients with HCC undergoing transcatheter arterial chemoembolization (TACE) at our institution and examined demographics, outcomes, and complications. RESULTS: During the period of study, 39 patients (25 male [64%], mean age 58 [range 17 to 86]) underwent a total of 78 chemoembolization treatments. During the same time period, an additional 31 patients received supportive care only. The majority of patients had late stage disease (American Joint Committee on Cancer stage III, IVa, or IVb) with no statistical difference noted between the two groups (P = 0.2). However, patients receiving supportive care only had significantly worse hepatic dysfunction by Child's classification (P = 0.005). Twenty-nine patients (74%) had documented cirrhosis, with hepatitis C being the most common cause in 11 of 29 (38%). In patients undergoing TACE, overall actuarial survival was 35%, 20%, and 11% at 1, 2, and 3 years with a median survival of 9.2 months, significantly improved over the group receiving supportive care only (P < 0.0001). Median survival for the group receiving supportive care was less than 3 months. Neither age nor stage had a significant impact on survival. The most common complications of TACE included transient nausea, abdominal pain, vomiting, and fever. CONCLUSIONS: TACE is a safe and effective therapeutic option for selected patients with HCC not amenable to surgical intervention.

Surgical experience with hepatic colorectal metastasis.

The outcome of 134 patients undergoing hepatic resection for colorectal metastasis was studied. Current follow-up was available in 98 per cent of patients, for more than 5 years in 58 patients, and totaling 360 patient-years. Patients (52% male) had an average age of 62 +/- 1 years (standard error of the mean). Time lapse between the primary colon surgery and hepatic resection was a median of 16 months and a mean of 19 +/- 1 months. Thirty-two (24%) were operated on within 6 months for both their primary tumor and hepatic metastasis. Intensive care unit and total hospital length of stay were a median of 1 and 7 days, respectively. Pathology reports demonstrated that on average there were 2.0 +/- 0.1 lesions, with the largest lesion measuring 4.4 +/- 0.2 cm. In 72 per cent of patients, the lesions were found in one lobe only. CEA was elevated in 83 per cent of patients preoperatively and was 60 +/- 11 ng/mL before and 4.0 +/- 0.5 ng/mL after hepatic resection. Patient survival was 81 per cent at 1 year, 50 per cent at 3 years, 36 per cent at 5 years, and 23 per cent at 10 years. Actual 5- and 10-year survival was 22 of 58 (38%) patients and 4 of 21 (19%) patients respectively. Disease-free survival was 58 per cent at 1 year, 27 per cent at 3 years, 16 per cent at 5 years, and 12 per cent at 7 years. Survival was much better for one to four lesions than for five or more lesions (P < 0.01). Several other potential risk factors did not affect survival, including whether the patient received chemotherapy after hepatic resection. There were 36 (43%) patients who recurred with hepatic involvement only, 27 (32%) including hepatic involvement and 21 (25%) with nonhepatic involvement only. There were 15 patients who went on to receive repeat hepatic resections, with a 5-year survival of 74 per cent and disease-free survival of 58 per cent. Hepatic resection provides the best outcome of any form of therapy for selected patients with isolated hepatic metastasis.

Antiperistaltic Roux-en-Y biliary-enteric bypass after bile duct injury: a technical error in reconstruction.

Bilioenteric reconstruction using a Roux limb of jejunum is a well-established surgical option for the reconstruction of the proximal bile duct. Previous studies discussing short- and long-term complications of biliary-enteric anastomosis have focused on technical aspects, such as the use of anastomotic stenting or the level of the biliary tree used. We report two cases of previously unreported complications after hepaticojejunostomy that resulted from a technical error in constructing the Roux limb. Within a 3-month period, two patients were referred to our institution with recurrent cholangitis after biliary reconstruction for injuries sustained during laparoscopic cholecystectomy. Reexploration disclosed major technical flaws in the construction of the Roux limb used for biliary drainage. Antiperistaltic limbs had been constructed in both patients: one from the distal ileum and one from the conventional location in the jejunum. In both cases, isoperistaltic reconstruction of the Roux limbs resolved the recurrent cholangitis. Cholangitis after biliary-enteric bypass can arise from a variety of etiologies and lead to anastomotic narrowing or ineffective drainage of the biliary tree. Review of the literature failed to disclose reports of technically flawed Roux limb construction as a cause of cholangitis. We present these cases to highlight the devastating consequences of antiperistaltic construction of the Roux limb. We hope that by publishing the role of this avoidable error in recurrent cholangitis after biliary-enteric bypass we may help prevent its future occurrence.

18Fluorodeoxyglucose-positron emission tomography in the management of patients with suspected pancreatic cancer.

OBJECTIVE: To assess the accuracy and clinical impact of 18fluorodeoxyglucose-positron emission tomography (18FDG-PET) on the management of patients with suspected primary or recurrent pancreatic adenocarcinoma, and to assess the utility of 18FDG-PET in grading tumor response to neoadjuvant chemoradiation. SUMMARY BACKGROUND DATA: The diagnosis, staging, and treatment of pancreatic cancer remain difficult. Small primary tumors and hepatic metastases are often not well visualized by computed tomographic scanning (CT), resulting in a high incidence of nontherapeutic celiotomy and the frequent need for "blind resection." In addition, the distinction between local recurrence and nonspecific postoperative changes after resection can be difficult to ascertain on standard anatomic imaging. 18FDG-PET is a new imaging technique that takes advantage of increased glucose metabolism by tumor cells and may improve the diagnostic accuracy of preoperative studies for pancreatic adenocarcinoma. METHODS: Eighty-one 18FDG-PET scans were obtained in 70 patients undergoing evaluation for suspected primary or recurrent pancreatic adenocarcinoma. Of this group, 65 underwent evaluation for suspected primary pancreatic cancer. Nine patients underwent 18FDG-PET imaging before and after neoadjuvant chemoradiation, and in eight patients 18FDG-PET scans were performed for possible recurrent adenocarcinoma after resection. The 18FDG-PET images were analyzed visually and semiquantitatively using the standard uptake ratio (SUR). The sensitivity and specificity of 18FDG-PET and CT were determined for evaluation of the preoperative diagnosis of primary pancreatic carcinoma, and the impact of 18FDG-PET on patient management was retrospectively assessed. RESULTS: Among the 65 patients evaluated for primary tumor, 52 had proven pancreatic adenocarcinoma and 13 had benign lesions. 18FDG-PET had a higher sensitivity and specificity than CT in correctly diagnosing pancreatic carcinoma (92% and 85% vs. 65% and 62%). Eighteen patients (28%) had indeterminate or unrecognized pancreatic masses on CT clarified with 18FDG-PET. Seven patients (11%) had indeterminate or unrecognized metastatic disease clarified with 18FDG-PET. Overall, 18FDG-PET suggested potential alterations in clinical management in 28/65 patients (43%) with suspected primary pancreatic adenocarcinoma. Of the nine patients undergoing 18FDG-PET imaging before and after neoadjuvant chemoradiation, four had evidence of tumor regression by PET, three showed stable disease, and two showed tumor progression. CT was unable to detect any response to neoadjuvant therapy in this group. Eight patients had 18FDG-PET scans to evaluate suspected recurrent disease after resection. Four were noted to have new regions of 18FDG-uptake in the resection bed; four had evidence of new hepatic metastases. All proved to have metastatic pancreatic adenocarcinoma. CONCLUSIONS: These data confirm that 18FDG-PET is useful in the evaluation of patients with suspected primary or recurrent pancreatic carcinoma. 18FDG-PET is more sensitive and specific than CT in the detection of small primary tumors and in the clarification of hepatic and distant metastases. 18FDG-PET was also of benefit in assessing response to neoadjuvant chemoradiation. Although 18FDG-PET cannot replace CT in defining local tumor resectability, the application of 18FDG-PET in addition to CT may alter clinical management in a significant fraction of patients with suspected pancreatic cancer.