Patency rates of portal vein/superior mesenteric vein reconstruction after pancreatectomy for pancreatic cancer.

BACKGROUND: Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction. METHODS: From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up. RESULTS: VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16%) or saphenous vein patch (9, 21%); segmental resection with splenic vein division and either primary anastomosis (10, 23%) or internal jugular vein interposition (8, 19%); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7%) or interposition grafting (6, 14%). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9%) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16-238). CONCLUSIONS: Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.

Hepatocellular carcinoma: multimodality management.

BACKGROUND: Hepatocellular carcinoma is one of the most common tumors worldwide. Surgical resection has been the standard treatment but can only be applied to a small percentage of patients. In recent years, several other treatment options, including ablative procedures and transplantation, have been used in patients with hepatocellular carcinoma. METHODS: For 6 years, 110 patients with hepatocellular carcinoma were managed at the Medical College of Wisconsin. Fifty-five patients received only chemotherapy (n = 5) or palliative treatment (n = 50) because of advanced cirrhosis (P <.03) or tumor. Thirty-one patients had tumor ablation with percutaneous ethanol injection, cryoablation, radiofrequency ablation, or arterial chemoembolization. Twenty-eight patients underwent surgical resection (n = 18) or hepatic transplantation (n = 10). Relatively more patients (38%; P <.001) were treated with ablation in the second period of the study (1998-2000). RESULTS: Thirty-day mortality was 3% with ablation and 0% with resection. Median survival was 6 months with no treatment, 27 months with ablation (P <.001), and 35 months with resection (P <.001). Patients who underwent liver transplantation had the longest median survival (53 months). A multivariate analysis suggested that treatment modality (ablation or resection; P <.001) and Child-Pugh classification (P <.01) were the most important factors predicting outcome. CONCLUSIONS: This study suggests that treatment of hepatocellular carcinoma requires multidisciplinary expertise and that ablation and operation can be performed safely. Outcome is influenced most by treatment modality and Child-Pugh classification. Patients in Child-Pugh classes A and B should be treated with ablation, surgical resection, or liver transplantation.

Ablation of liver metastasis: is preoperative imaging sufficiently accurate?

The recent introduction of cryotherapy and radiofrequency ablation of liver metastasis has expanded the indications for treatment. As technology has advanced, a percutaneous approach has been developed. Percutaneous treatment, however, requires accurate preoperative imaging. From 1993 to 1999, 179 patients underwent operative exploration for treatment of suspected hepatic metastases from colorectal carcinoma. One hundred seventy-seven patients were staged by preoperative CT, two patients were staged by MRI, and complete data were available in 176. Hepatic tumor count by preoperative imaging was compared to intraoperative tumor count obtained by inspection, palpation, ultrasonographic examination using a 3.5/7.5 MHz T probe, and careful gross sectioning of the resected specimen. Post hoc analysis was performed on 35 CT scans by two radiologists who specialize in abdominal CT. These radiologists were blinded to the intraoperative findings. Their interpretations were compared to the intraoperative counts and to each other. Thirty-four (19%) of 179 patients were deemed untreatable at operation because of unsuspected overwhelming liver involvement in 11 (6%) or extrahepatic metastases in 23 (13%). For the group, CT was accurate in 80 patients (45%), showed more lesions than were found in 16 (9%), and showed fewer metastases than were found in 80 (45%). When the preoperative scan predicted a solitary metastasis, it was correct in 45 (65%) of 69 patients and underestimated disease in 24 (35%). In the post hoc analysis, the mean numbers of lesions reported by the two radiologists did not differ from the mean number of tumors found; however, the radiologists' counts agreed on 16 (59%) and disagreed on 11 (41%) of the scans. The accuracy of CT decreased with increasing numbers of lesions. Regardless of the type of preoperative imaging, intraoperative findings altered the course of the operation in 96 (55%) of 176 patients. Preoperative imaging is not sufficiently accurate to permit adequate percutaneous treatment of hepatic metastases from colorectal carcinoma.

Postoperative atrial fibrillation in noncardiothoracic surgical patients.

BACKGROUND: Atrial fibrillation is a common arrhythmia whose prevalence increases with age. It is a well-known complication of cardiothoracic surgery, but the incidence and contributing factors to the development of atrial fibrillation in noncardiothoracic surgical patients are less well known. This study was undertaken to investigate the incidence, association with known risk factors, treatment, and outcome of atrial fibrillation in postoperative noncardiac, nonthoracic surgical patients. METHODS: A 2-year retrospective review was performed of all noncardiac, nonthoracic surgical patients that developed atrial fibrillation within 30 days of operation. Incidence, risk factors, treatment and outcome related to the development of this arrhythmia were analyzed. RESULTS: Fifty-one patients developed atrial fibrillation during this study period for an incidence of 0.37%. Most had preexisting cardiac risk factors, a positive fluid balance, or had electrolyte or arterial oxygen saturation abnormalities. Two thirds were discharged home on new cardiac medications, 16% remained in atrial fibrillation, and 12% died. CONCLUSIONS: New onset atrial fibrillation in this group of noncardiothoracic surgical patients is an uncommon problem that is a morbid event associated with significant mortality.

Cryotherapy extends the indications for treatment of colorectal liver metastases.

BACKGROUND: Hepatic resection for colorectal metastases has been established as the best option for patients with 4 or less lesions meeting specified criteria. Recently, the use of intraoperative ultrasound has increased the detection of previously occult liver lesions, and cryotherapy has allowed the treatment of liver lesions in inaccessible areas with less destruction of normal liver in the case of multiple lesions. 14e prospectively performed hepatic resection or cryotherapy to test the hypothesis that more than 4 liver metastases could be safely and successfully treated with improved long-term survival. METHODS: From August 1993 to January 1999, 137 patients with liver metastases from colorectal cancer were treated with hepatic resection or cryotherapy at the Medical College of Wisconsin. Preoperative and postoperative computed tomography scans, intraoperative assessments of lesion number and curability, number of blood transfusions administered, length of stay, complications experienced, and overall survival rates were reviewed. RESULTS: One hundred thirty-seven patients were explored. Treatment consisted of resection alone in 34, cryotherapy alone in 20, both treatments in 52, and no treatment was possible in 31 patients. "Curability" was defined as complete resection or cryotherapy of all identifiable tumor at the conclusion of the operation. A Cox proportional hazards model demonstrated that survival was determined by the destruction of all identifiable metastases (P < . 001) and was not statistically influenced by age, gender type of therapy, or the number of metastases treated. CONCLUSIONS: Surgical treatment of colorectal liver metastases remains the best option for patients with this disease. A key factor in overall survival is the destruction or resection of all identifiable disease and not the number of tumors per se. Using cryotherapy as an addition to the surgical arsenal, patients previously deemed unresectable because of the number of lesions have a chance for long-term survival. This study demonstrates improved long-term survival for "cured" patients with more than 4 metastatic lesions, thereby extending the indications for resection/ablation.

Surgical management of colorectal metastases to the liver: role of resection and cryosurgery.

Long-term results of 41 patients who underwent hepatic resection and early experience with 21 patients treated by hepatic cryosurgery alone or combined with resection for colorectal metastases are presented. Patients treated by resection had three or fewer metastases, no perioperative mortality, and a mean follow-up of 43.5 months. The five-year overall survival is 34% with a median survival of 48 months. By multivariate analysis, only transfusions correlated significantly with survival, but in a negative manner (p = 0.05). A mean of 4.3 units were transfused per patient, though only 25 patients actually received transfusions.

Shock-associated right colon ischemia and necrosis.

Ischemic complications associated with hemorrhagic shock after blunt or penetrating trauma can result in acute renal, pulmonary, or hepatic failure. Less well described is the association between hemorrhagic shock and ischemic necrosis of the right colon, with only 14 cases reported in the literature. Herein, we report three previously healthy young trauma victims with shock-associated right colon necrosis. Each patient suffered a period of hypotension after injury. Diagnosis and operation took place within 2 days of initial injury in all three cases. In each patient, a right colectomy and primary anastomosis was performed without complication. Pathologic examination of the resected specimens showed ischemic necrosis, but no evidence of vascular thrombosis or embolic occlusion of the mesenteric vessels. The etiology of this type of ischemic colitis is not clear, but seems to represent a form of nonocclusive mesenteric ischemia. Knowledge of this disease process will lead to early recognition, prompt treatment, and a satisfactory outcome.

Hand protection.

The traditional purpose of surgical gloves is to prevent transmission of pathogens (usually bacterial) from surgeon to patient. Yet the hand is also the most common site of injury and blood contamination among operating room personnel. Thus, gloves also can protect against transmission of pathogens from patient to surgeon. This article focuses on the value of gloves for hand protection. The current data on such protection derive exclusively from studies that use glove leak and contamination as outcome measures. There are no data that measure protection in terms of actual disease transmission.

How to select and evaluate new products on the market.

New devices and products often promise to protect health-care workers and patients from transmission of viral infections. These need to be evaluated carefully for efficacy, applicability, and cost in an objective, structured manner.

Treatment of Hickman catheter sepsis using antibiotic lock technique.

Antibiotic lock therapy, an alternative treatment for Hickman catheter sepsis, was evaluated in six recipients of prolonged outpatient intravenous therapy. Twenty-two episodes of catheter sepsis were identified, involving coagulase-negative staphylococci (11), gram-negative bacilli (3), gram-positive bacilli (1), yeast (4), and mixed bacteria or fungi (3). In a select group of patients, treatment was successful 92% of the time.

Analysis of pain management in critically ill patients.

We analyzed the adequacy of pain control for 17 trauma patients during the initial part of their stay in the intensive care unit, and assessed reasons for inadequate analgesia, if it occurred. Patients, and physicians, and nurses were interviewed. A verbal pain intensity scale was used to determine whether patients received adequate analgesia. Patients were asked if the pain hindered their activities, and whether they requested pain medication from their caregivers. Caregivers were questioned whether patients received adequate analgesia. Prescribed morphine regimens and the amount of narcotic administered were analyzed. Twenty-seven percent of patients rated pain intensity as moderate and 47% as severe. Ninety-five percent of housestaff and 81% of nurses reported the patients received adequate pain control. Forty-seven percent of the patients who had moderate or severe pain asked their physician for more pain medication, and 65% asked the nurse. Thirteen residents did not order a larger dose of morphine due to concern about respiratory depression or hypotension. Morphine dosages ranged from 1-8 mg intravenously every 1-2 hours as necessary. Nurses administered less than the maximum amount ordered 58% of the time. The mean dosing interval was 2.3 hours. Barriers to adequate pain management were disparity in the perception of pain between patients and caregivers; patients not requesting more analgesia despite despite the presence of moderate to severe pain; and physician and nurse concerns about patients' adverse physiologic response to increased dosages.

Pyoderma fistulans sinifica (fox den disease): a distinctive soft-tissue infection.

Pyoderma fistulans sinifica (PFS, also referred to as fox den disease because its multiple fistulae and sinuses resemble the structure of a fox den) is a distinct chronic infectious disease in which epithelialized tracts form within the subdermal fatty tissue. PFS, which has not been previously described in the English-language literature, must be differentiated from hidradenitis suppurativa, pilonidal sinus, and perianal fistula. The fistulous tracts of PFS are always lined by stratified squamous-cell epithelium but, unlike those of hidradenitis, reach deep into the subcutaneous fat, run epifascially for long distances, and have no relation to skin appendices. We report on 10 men (mean age +/- SD, 36 +/- 5 years) with PFS (mean duration +/- SD, 11 +/- 7 years). Bacterial cultures of affected tissue from these patients yielded a total of 14 facultative and 31 obligate anaerobic species. Treatment consisted of wide en-bloc excision down to the fascia, including all fistulae. Antibiotic therapy temporarily reduced purulent discharge but did not eradicate the infection. Two patients who underwent fistulotomy without wide en-bloc excision developed recurrences.

Care of the trauma patient in the age of the human immunodeficiency virus.

HIV-infected patients will be seen in emergency rooms and trauma centers because the number of infected patients is large and growing. Proper precautions by health care workers are effective in decreasing risk of transmission to a very low level, and, therefore, the fear of HIV should not dissuade the medical profession from giving these individuals proper care. Operative treatments should not be arbitrarily rejected simply because an HIV infection is detected because poor wound healing and infection appear to be much less of a risk than predicted. Unusual infections and intercurrent medical problems may require additional attentiveness to detect their existence and may require more complex treatment regimens to control.

Current patterns of prescribing and administering morphine in trauma patients.

We attempted to characterize the current prescribing practices and administration patterns for intravenous intermittent morphine in trauma patients in a multicenter, open prospective, observational study. The subjects were 141 patients admitted to the surgical intensive care units (ICU) of five United States trauma centers within 12 hours of injury who received intermittent intravenous morphine for pain relief. The study was conducted from April 15, 1992, to February 15, 1993. Data obtained during the first 32 hours of the ICU stay included morphine regimen, doses administered, and time between doses. One hundred sixty-one orders were prescribed by surgeons. The most frequently ordered dose was 2-4 mg and the most frequently ordered interval was every hour as necessary. There was no relationship between the severity of injury and the minimum dose ordered. During the 492 nursing shifts studied, 1257 doses were administered. Of these, 44% were at or below the minimum amount prescribed by the surgeons. Thirty-three percent of the patients received a dose at an interval of more than 3 hours. We concluded that small amounts of narcotic analgesics are given to severely injured patients, and amount ordered is not affected by the severity of injury.

Thoracostomy tubes after acute chest injury: relationship between location in a pleural fissure and function.

OBJECTIVE: The purpose of this study was to determine how often chest tubes placed for acute trauma lie within a pleural fissure and to determine whether an intrapleural location influences outcome. SUBJECTS AND METHODS: Fifty-eight consecutive thoracostomy patients who had 66 chest tubes were studied prospectively. Tube location was determined from frontal and lateral chest radiographs. Outcome measures recorded included the following: duration of thoracostomy drainage, quantity of pleural fluid drained, need for further tubes, length of hospital stay, appearance on last chest radiograph before discharge, and need for surgical intervention. RESULTS: Thirty-eight (58%) of the tubes were placed within a pulmonary fissure, 15 (23%) were posterior, nine (13%) were anterior, and four (6%) were in other locations. We found no significant difference in any of the outcome measures between tubes located in the fissure and other tubes. CONCLUSION: A large percentage of tubes placed for acute chest trauma lie within a pleural fissure. These tubes, however, appear to function as effectively as those located elsewhere in the pleural space.

Pinch-off syndrome: a rare etiology for central venous catheter occlusion.

BACKGROUND: Catheter pinch-off syndrome is a rare and often misdiagnosed complication of tunneled Silastic central venous catheters. Pinch-off syndrome occurs when the catheter is compressed between the first rib and the clavicle, causing an intermittent mechanical occlusion for both infusion and withdrawal. We report its incidence in a large series of catheter insertions and describe the clinical presentation, radiographic findings, and recommended treatment. METHODS: A total of 1457 tunneled Silastic central venous catheters that were inserted using the percutaneous subclavian approach were prospectively studied. Indications for catheter placement included bone marrow transplant, continuous or intermittent chemotherapy, long-term antibiotics, and parenteral nutrition. Catheters were evaluated for clinical presentation of an occlusion relieved by postural changes and radiographic findings of luminal narrowing. RESULTS: Pinch-off syndrome was identified in 16 (1.1%) catheters. Radiographic findings were present in all catheters; clinical findings were present in 15 catheters. Clinical symptoms presented within a median of 2 days after placement (range, 0 to 167 days). Partial or complete catheter transection, a serious sequela of catheter pinch-off syndrome, occurred in 19% of the identified catheters. CONCLUSIONS: (1) Catheter pinch-off syndrome presents clinically as a catheter occlusion related to postural changes; (2) clinical symptomatology should be confirmed radiographically; and (3) catheter removal with a more lateral replacement in the subclavian vein or in the internal jugular vein will avoid a recurrent complication.

Effect of analgesic treatment on the physiological consequences of acute pain.

Physiological responses to acute pain are described, and the effects of different analgesic techniques on these responses are discussed. The body's response to acute pain can cause adverse physiological effects. Pain can impede the return of normal pulmonary function, modify certain aspects of the stress response to injury, and alter hemodynamic values and cardiovascular function. It can produce immobility and contribute to thromboembolic complications. In addition, pain can slow a patient's recovery from surgery and contribute to increased morbidity. Fewer pulmonary complications occur when adequate analgesia is provided through the use of epidural narcotics and local anesthetics, particularly if the injury or surgery involves the lower part of the body. Continuous morphine infusions, intercostal nerve blocks, and transcutaneous electrical stimulation do not alter the frequency of pulmonary complications. The effectiveness of patient-controlled analgesia in reducing postoperative pulmonary complications is still not known. Epidural local anesthetic therapy inhibits the stress response, particularly in operations involving the lower abdomen or extremities; this technique is less effective during major abdominal procedures. Suppression of endocrine-metabolic changes following lower abdominal surgery requires neural block to the fourth thoracic segment. Epidural narcotics partially inhibit the stress response after lower abdominal or extremity surgery but not after upper abdominal or thoracic surgery. Local anesthetics applied to the surgical site, intercostal nerve blocks, and intrapleural and intraperitoneal administration also do not modify the stress response. Adequate analgesia through the use of local anesthetics and narcotics postoperatively generally results in improved cardiovascular function, decreased pulmonary morbidity and mortality, earlier ambulation, and decreased likelihood of deep vein thrombosis. Some data suggest that improved patient outcome occurs with adequate analgesia. Block of afferent and efferent neural pathways by local anesthetics seems to be the most effective analgesic modality in lessening the physiologic response to pain and injury.

Identification of patient-controlled analgesia overdoses in hospitalized patients: a computerized method of monitoring adverse events.

OBJECTIVE: To describe and validate a computer-based quality assurance method that detects narcotic overdoses associated with patient-controlled analgesia (PCA) use. SETTING: Two acute care teaching hospitals. PATIENTS: 4669 patients who received PCA. INTERVENTIONS: The following patient lists were obtained during a two-year period from both hospital information systems: those who received PCA and (1) received naloxone, a narcotic antagonist, (2) were transferred to an intensive care unit, (3) had a cardiac or respiratory arrest, or (4) died. Possible overdoses were defined as patients who appeared on the PCA list and one of the other lists. Charts were reviewed if the patient's name appeared on the PCA and one of the other lists. Patients were judged to have experienced a narcotic overdose if there was an immediate improvement in blood pressure, respiratory rate, or mental status after the administration of naloxone. RESULTS: The search strategy identified 294 possible overdoses in 1499 patients who received PCA. Ten charts were unavailable for review. An actual overdose occurred in 11 patients. The accuracy of the new method was compared with that of the hospitals' present reporting methods. Eleven overdoses were identified by the computer search, but only 6 overdoses were identified in incident and adverse drug reaction reports. CONCLUSIONS: The systematic computer search identified almost twice as many adverse incidents than were reported by the traditional hospital methods.