Prognosis of adenocarcinoma arising in Barrett's esophagus.

BACKGROUND: The rising incidence of adenocarcinoma of the esophagus, as well as its association with Barrett's esophagus, has been reported previously. We report our experience in treating patients with adenocarcinoma arising in Barrett's esophagus. METHODS: A retrospective review was performed of 70 consecutive patients with adenocarcinoma of the esophagus treated between November 1988 and April 1996 with preoperative chemoradiation and resection. Demographics, pathologic features, and survival were compared with patients who developed adenocarcinoma of the esophagus without Barrett's. Statistical analyses was performed using Student's t test, Fisher's exact test, and Kaplan-Meier where appropriate. RESULTS: Thirty-two (46%) patients had adenocarcinoma arising in Barrett's esophagus. During the last 4 years, 72% (23 of 32) of patients with adenocarcinoma had coexistent Barrett's. No differences in patients with or without Barrett's with regard to age, sex, race, tumor location, preoperative chemotherapy, type of operation, or operative stage were observed. Tumors in patients with Barrett's were larger (p = 0.017), had better differentiation (p = 0.002), and were less likely to have a complete response to preoperative chemoradiation (p = 0.05). Actuarial survival, however, was better in the group with associated Barrett's esophagus (p = 0.033). CONCLUSIONS: The incidence of adenocarcinoma of the esophagus arising in Barrett's esophagus appears to be increasing. It may be distinct clinically and biologically from adenocarcinoma of the esophagus that does not develop in association with Barrett's epithelium. Long-term survival was better in our patients with adenocarcinoma associated with Barrett's esophagus.

Repeat hepatic surgery for colorectal cancer metastasis to the liver.

OBJECTIVE: The authors addressed whether a repeat hepatic operation is warranted in patients with recurrent isolated hepatic metastases. Are the results as good after second operation as after first hepatic operation? SUMMARY BACKGROUND DATA: Five-year survival after initial hepatic operation for colorectal metastases is approximately 33%. Because available alternative methods of treatment provide inferior results, hepatic resection for isolated colorectal metastasis currently is well accepted as the best treatment option. However, the main cause of death after liver resection for colorectal metastasis is tumor recurrence. METHODS: Records of 95 patients undergoing initial hepatic operation and 10 patients undergoing repeat operation for isolated hepatic metastases were reviewed for operative morbidity and mortality, survival, disease-free survival, and pattern of failure. The literature on repeat hepatic resection for colorectal metastases was reviewed. RESULTS: The mean interval between the initial colon operation and first hepatic resection was 14 months. The mean interval between the first and second hepatic operation was 17 months. Operative mortality was 0%. At a mean follow-up of 33 +/- 27 months, survival in these ten patients was 100% at 1 year and 88% +/- 12% at 2 years. Disease-free survival at 1 and 3 years was 60% +/- 16% and 45% +/- 17%, respectively. After second hepatic operation, recurrence has been identified in 60% of patients at a mean of 24 +/- 30 months (median 9 months). Two of these ten patients had a third hepatic resection. Survival and disease-free survival for the 10 patients compared favorably with the 95 patients who underwent initial hepatic resection. CONCLUSIONS: Repeat hepatic operation for recurrent colorectal metastasis to the liver yields comparable results to first hepatic operations in terms of operative mortality and morbidity, survival, disease-free survival, and pattern of recurrence. This work helps to establish that repeat hepatic operation is the most successful form of treatment for isolated recurrent colorectal metastases.

A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy.

OBJECTIVE: A meta-analysis of all published clinical trials comparing selective versus routine nasogastric decompression was performed in an attempt to evaluate the need for nasogastric decompression after elective laparotomy. BACKGROUND: Many studies have suggested that routine nasogastric decompression is unnecessary after elective laparotomy and may be associated with an increased incidence of complications. Despite these reports, many surgeons continue to practice routine nasogastric decompression, believing that its use significantly decreases the risk of postoperative nausea, vomiting, aspiration, wound dehiscence, and anastomotic leak. METHODS: A comprehensive search of the English language medical literature was performed to identify all published clinical trials evaluating nasogastric decompression. Twenty-six trials (3964 patients) met inclusion criteria. The outcome data extracted from each trial were subsequently "pooled" and analyzed for significant differences using the Mantel-Haenszel estimation of combined relative risk. RESULTS: Fever, atelectasis, and pneumonia were significantly less common and days to first oral intake were significantly fewer in patients managed without nasogastric tubes. Meta-analysis based on study quality revealed significantly fewer pulmonary complications, but significantly greater abdominal distension and vomiting in patients managed without nasogastric tubes. Routine nasogastric decompression did not decrease the incidence of any other complication. CONCLUSIONS: Although patients may develop abdominal distension or vomiting without a nasogastric tube, this is not associated with an increase in complications or length of stay. For every patient requiring insertion of a nasogastric tube in the postoperative period, at least 20 patients will not require nasogastric decompression. Routine nasogastric decompression is not supported by meta-analysis of the literature.

Recurrent mammary carcinoma after local excision. A segmental problem.

BACKGROUND: The acceptance of local operative therapy for mammary carcinoma has stimulated scrutiny of specific techniques with the goals of minimizing the incidence of local recurrence while optimizing the cosmetic result. Intraductal spread of carcinoma has been established as a major factor in determining the rate of local recurrence after breast-conserving therapy for mammary carcinoma. The relationship of the anatomic location of a recurrent neoplasm to that of the primary tumor is likely to be instructive in evaluating the effectiveness of various proposed approaches to primary excision. METHODS: Using the tumor registry of a tertiary care medical center, the authors reviewed all patients with mammary carcinoma treated with primary local excision during a 9-year period (1984-1992; n = 86), and identified all patients who subsequently experienced local recurrence (n = 5). The pathologic anatomic findings in each case were reviewed carefully and correlated with clinical and mammographic data. RESULTS: The rate of local recurrence in this series was 5.8%, similar to that of Veronesi's "lumpectomy" group (7%). In all five patients, the recurrent lesion was located in the same breast quadrant, along a radius from the nipple to the edge of the breast disc that crossed the site of the initial lesion. CONCLUSION: Local recurrence of mammary carcinoma after breast-conserving operative therapy most often occurs within the same segment; it is therefore proposed that its incidence may be substantially reduced with the use of a primary excision technique (based on normal breast anatomy) that removes en bloc the dominant tumor mass and the associated (possibly diseased) duct system.

Verrucous carcinoma of the esophagus: surgical treatment for an often fatal disease.

Verrucous carcinoma of the esophagus is a very rare esophageal cancer, with only 12 cases reported in the literature. Although this cancer is slow growing and rarely metastasizes, it is associated with a significantly high mortality. Because of the disease's insidious onset and its rarity, diagnosis has often been late, after local invasion has produced significant symptoms. We present the thirteenth reported case of verrucous carcinoma of the esophagus and support resection as the best form of treatment for this disease.

Reverse phasic contractions are present in antiperistaltic jejunal limbs up to twenty-one years postoperatively.

One of the surgical procedures that has been performed to reduce symptoms of dumping is the antiperistaltic jejunal limb (APL). We hypothesized that the polarity of the Phase III activity fronts would be maintained after creation of an APL. To test that hypothesis, water perfused, low compliance intestinal manometry was performed upon four patients with APL, four patients with vagotomy, antrectomy and Roux-en-Y gastrojejunostomy (VARY) and four volunteers. The patients were studied for a minimum of four hours of fasting. Recordings were analyzed by visual inspection by two observers and results are expressed as mean plus or minus standard error of the mean. Statistical analysis was performed with Student's t test. Phase III activity fronts occurred more frequently (1.4 +/- 0.3 per hour) in the patients with a VARY reconstruction than in the volunteers (0.5 +/- 0.5 minute). The duration of Phase II activity was significantly less in the patients with the VARY reconstruction (19.1 +/- 5.1 minutes) than in the volunteers (49.5 +/- 5.2 minutes). Patients with reversed activity fronts showed statistically significant propagation velocity (3.0 +/- 0.6 versus 9.6 +/- 2.0 centimeters per minute) (p < 0.005), but longer Phase III activity fronts (8.0 +/- 0.8 versus 4.9 +/- 0.3 minutes) (p < 0.001) than in the volunteers. Although there were a number of abnormalities identified in the patients with VARY reconstruction, there were no reverse Phase III activity fronts seen in the four patients with APL reconstruction. The polarity of the small intestine is maintained up to 21 years after construction of an antiperistaltic jejunal segment.

Resection of primary hepatic malignant fibrous histiocytoma, fibrosarcoma, and leiomyosarcoma.

Four patients had resection for primary hepatic sarcoma: one with malignant fibrous histiocytoma (MFH), two with poorly differentiated fibrosarcoma, and one with leiomyosarcoma. Age ranged from 40 to 69 years. One patient had a cousin and a grandmother who had died of hepatic tumors. At presentation, all patients had pain; one had tumor rupture, and one had mental changes and hypoglycemia. None had hepatitis or cirrhosis. Results of laboratory evaluation were nonspecific, including normal carcinoembryonic antigen and alpha-fetoprotein levels. Computed tomography showed hypodense masses with enhancement. Angiography showed a hypervascular mass in three patients and an avascular mass in the patient with MFH. Despite large tumors (8 to 32 cm), portal and hepatic veins were not invaded. The pattern of vascularization and lack of venous invasion helps differentiate primary hepatic sarcomas from hepatocellular carcinoma, especially in noncirrhotic patients. All patients had extensive hepatic resections, with one operative death. Immunohistochemical stains of the tumors were positive for vimentin but negative for epithelial markers, differentiating these lesions from other hepatic tumors. The patient with MFH died with recurrence at 10 1/2 months. The patient with the ruptured fibrosarcoma had a second resection and chemotherapy, but died with recurrence at 3 years. The patient with the leiomyosarcoma had a second resection and was disease free at 4 years. Resection of primary hepatic sarcoma is warranted, with potential survival measured in years.

Improved survival with neoadjuvant therapy and resection for adenocarcinoma of the esophagus.

OBJECTIVE: This study sought to determine the impact of preoperative chemotherapy and radiation therapy (neoadjuvant therapy) followed by resection in patients with adenocarcinoma of the esophagus. SUMMARY BACKGROUND DATA: Long-term survival in patients with carcinoma of the esophagus has been poor. An increase in the incidence of adenocarcinoma of the esophagus has been reported recently. METHODS: Fifty-eight patients with biopsy-proven adenocarcinoma of the esophagus treated at this institution from January 1951 through February 1993 were studied. Since 1989, 24 patients were entered prospectively into a multimodality treatment protocol consisting of preoperative cisplatin, 5-fluorouracil (5-FU), and leucovorin with or without etoposide, and concomitant mediastinal radiation (30 Gy). Patients were re-evaluated and offered resection. RESULTS: There were no deaths related to neoadjuvant therapy and toxicity was minimal. Before multimodality therapy was used, the operative mortality rate was 19% (3 of 16 patients). With multimodality therapy, there have been no operative deaths (0 of 23 patients). The median survival time in patients treated before multimodality therapy was 8 months and has yet to be reached for those treated with the neoadjuvant regimen (> 26 months, p < 0.0001). The actuarial survival rate at 24 months was 15% before multimodality therapy and 76% with multimodality therapy. No difference in survival was noted in neoadjuvant protocols with or without etoposide (p = 0.827). CONCLUSIONS: Multimodality therapy with preoperative chemotherapy and radiation therapy followed by resection appears to offer a survival advantage to patients with adenocarcinoma of the esophagus.

Preliminary results with neoadjuvant therapy and resection for esophageal carcinoma.

Between December 1988 and August 1992, 68 patients with adenocarcinoma (n = 39) and squamous carcinoma (n = 29) of the esophagus were entered prospectively in a treatment protocol to receive two cycles of cisplatin, 5-fluorouracil, etoposide, leucovorin, and 3,000 cGy of radiation to the involved esophagus and adjacent mediastinum, followed by resection. There were four deaths during chemotherapy, and 7 patients had a decline in condition or were denied operation. Fifty-six patients have come to operation, and 1 awaits resection. Twenty-two patients had transhiatal esophagectomy and 29 patients had esophagogastrostomy with a combined abdominal and right thoracic approach. Five patients did not undergo resection at operation. There was one hospital death (2%). A complete response to preoperative therapy was seen in 12 patients (21%): 5 of 20 with squamous cancer (25%) and 7 of 36 with adenocarcinoma (19%). Average follow-up is 19 months. Median survival in these patients after entrance in the protocol is 24 months. Actuarial survival at 12, 18, and 24 months is 72% (confidence limits, 66% and 78%), 53% (confidence limits, 46% and 60%), and 51% (confidence limits, 44% and 58%). Significantly better survival was associated with adenocarcinoma (p = 0.041). There is no survival advantage based on complete response to preoperative therapy. This neoadjuvant regimen is effective in patients with squamous carcinoma and adenocarcinoma. These preliminary results demonstrate an improved median and actuarial survival compared with historical controls in 137 patients operated on between 1966 and 1985 at our institution.

Laparoscopic highly selective vagotomy.

Although the prevalence of peptic ulcer disease has not decreased, the number of surgical procedures for definitive treatment of peptic ulcer disease has diminished. While H-2 blockers are effective in healing ulcers, the incidence of recurrence, particularly in patients who have specific risk factors and do not use life-long maintenance therapy, may range from 50-90%. In an attempt to minimize the morbidity of definitive ulcer surgery, this study was undertaken to perform and evaluate highly selective vagotomy performed laparoscopically in the porcine model. Sixteen swine underwent laparoscopic highly selective vagotomy. The acute group (n = 10) underwent immediate celiotomy after the surgery. The chronic group underwent barium studies and celiotomy 6 months following surgery. In 70% of the acute group and 100% of the chronic group, nerve identification and division were accurate. Bleeding, when encountered, could be managed laparoscopically. In the chronic group, the postoperative weight gain was appropriate and barium studies were normal. This paper details the technique and results of laparoscopic highly selective vagotomy in an animal study and shows that this procedure can be safely and accurately performed. Based on this study, a clinical trial, which includes studies of acid production, long-term follow-up, and intraoperative endoscopic Congo red testing has been undertaken on recipients of laparoscopic highly selective vagotomy.

Stratified diagnostic approach to fine needle aspiration of the breast.

The clinical value of fine needle aspiration (FNA) of the breast is enhanced by incorporating into the cytologic diagnosis explicit comments on the level of diagnostic certainty. This stratification of diagnostic certainty is based predominantly on the cytologic features but occasionally also takes into consideration the clinical situation. Strong clinical and mammographic suspicion of mammary carcinoma associated with FNA, diagnostic of typical, intermediate to high-grade mammary carcinoma, warrants proceeding to definitive therapy without further diagnostic studies. False-positive results are virtually eliminated by placing cases with any uncertainty into a "probable" category, which does not support definitive therapy. In addition, oversimplified "benign versus malignant" approaches to FNA diagnoses ignore the heterogeneity of breast masses, with in situ and low-grade carcinomas warranting special clinical management and usually being placed in the "probable" category. Thus, malignant diagnoses are stratified into "definite" and "probable," with only the former supporting definitive therapy. Within our recent series of 1,005 FNAs of the breast, we were able to confirm the diagnosis in all 62 patients with a "definite" carcinoma diagnosis, and only 3 of 25 "probable" cancer diagnoses were benign at tissue biopsy. Thus, false-positive results were successfully avoided in the "definite" category. Furthermore, a much greater incidence of unusual and good prognosis tumor types were identified by the "probable" category. If the clinical setting is relatively suspicious only, a definitive diagnosis of cancer by FNA is rare and not necessary because the clinical question to be addressed is only whether to biopsy. This approach to FNA diagnosis, unlike the oversimplified "benign versus malignant" scheme, provides an approach that is more likely to result in optimal therapy for breast neoplasms, with low-grade or in situ carcinomas requiring special clinical management since these types of cancers are found predominantly in the "probably malignant" category. It also provides additional security against false-positive diagnoses by incorporating clinical level of certainty statements into FNA diagnostic categories, which more closely reflect the diversity and inherent complexity in the appropriate diagnosis and therapy of mammary carcinomas.

Benefit of resection of metastatic gastrinoma in multiple endocrine neoplasia type I.

Although gastrinoma resection is generally advocated for patients with the sporadic form of nonmetastatic Zollinger-Ellison syndrome, there is controversy regarding the surgical management of the gastrinoma among patients with multiple endocrine neoplasia type I (MEN-I). Using strict criteria, to date no biochemical cures of the Zollinger-Ellison syndrome lasting greater than 5 months have been achieved by gastrinoma resection among patients with MEN-I. Whereas resections of hepatic metastases have been performed in patients with sporadic gastrinoma, none have been reported among patients with MEN-I. The current report describes a patient with MEN-I, closely followed up for 30 years, in whom enlargement of pancreatic gastrinoma and development of hepatic gastrinoma was observed to occur over 3 years. After preoperative localization, an 80% pancreatectomy and a left lateral segmentectomy of the liver were performed. Sixteen months after the operation, secretin and calcium provocative testing showed that the patient's fasting gastrin and stimulated plasma gastrin concentrations were normal; also, results of computerized tomographic angiography, selective abdominal angiography, and hepatic venous sampling for gastrin after intra-arterial secretin injection were negative for gastrinoma. By achieving a 16-month cure of gastrinoma, this case shows that an aggressive surgical approach can benefit certain patients with gastrinoma who have MEN-I even in the presence of hepatic metastases.

Management of postgastrectomy syndromes.

There is still much to learn about the cause of postgastrectomy syndromes. Fortunately, most patients can be managed by conservative measures unless a mechanical cause, amenable to operative correction, is found. Thus, it is important to determine the type of postgastrectomy problem that is affecting the patient. In carefully selected patients, remedial operations may ameliorate the patient's symptoms and permit him or her to return to a normal lifestyle. Humoral factors have attracted increasing attention, especially in patients with the dumping syndrome. The somatostatin analogue octreotide has provided relief from the vasomotor and gastrointestinal symptoms of severe dumping but must be given three to four times a day by injection.

Major hepatic resection: an update.

In 1981, we reported a series of 75 major hepatic resections done over a ten-year period; 58 were for hepatic trauma, nine were for benign disease, and eight were for malignant disease. Since that report, the indications for major hepatic resection have changed, with a more conservative approach to hepatic trauma and a more aggressive approach toward hepatic tumors. In this update, we report 88 hepatic resections from Vanderbilt University Hospital and Metropolitan Nashville General Hospital; 32 were for trauma, 25 were for benign disorders, and 31 were for malignant disease. Since 1977, nine adults and four children have had hepatic resection for primary malignant tumors; there were six hepatocellular lesions, three hepatoblastomas, two malignant hemangioendotheliomas, one malignant hepatoma, and one intrahepatic cholangiocarcinoma. At the time of this writing, the four children have survived for 7.3, 6, 6, and 3.8 years (mean 5.7), and all are alive without evidence of recurrence. For the nine adults, survival has averaged 1.7 years, excluding one postoperative death. Three adult patients are alive at this writing, one of whom is a five-year survivor without evidence of disease. Seventeen adults and one child had hepatic resection for metastatic lesions. In the adults, the primary tumor was in the colon in 14 cases and in the small bowel, stomach, and an unknown site in one case each. The one child had a metastatic Wilms' tumor. Survival has averaged two years, with two long-term survivors (nine years). Six patients are alive at this time. Operative mortality for elective resection has decreased from 12% (2/17) in our earlier report to 3% (1/31) in this series, which has encouraged us to assume a more aggressive approach to the resection of malignant primary and metastatic liver tumors.

Tumor seeding from percutaneous biliary catheters.

Percutaneous transhepatic biliary decompression has been used since 1973 as a preoperative surgical adjunct in patients with obstructive jaundice. Tumor seeding along the catheter tract is an unusual complication but it occurred recently in one of our patients who had preoperative biliary drainage for four days. Four months after his pancreaticoduodenectomy, a 2-cm nodule developed at the catheter exit site. This nodule was a metastatic focus of adenocarcinoma similar to his pancreatic tumor. He died 1 month later and at autopsy was found to have numerous metastases along the catheter tract. A review of the world literature found 17 other patients with this complication. Thirteen of the 18 total patients had catheters placed for palliation, while 5 patients underwent preoperative drainage before definitive procedures, and 4 of these patients had undergone "curative" resections. Nine of the 18 patients had biliary obstruction from cholangiocarcinoma, while seven patients had primary pancreatic carcinoma. Positioning of the catheter tip above the obstructing tumor and maintaining the catheter for only a short duration before operation (mean 8 days for resected patients, range 2 to 16 days) did not protect against catheter-related tumor seeding. Patients with suspected malignant obstruction of the biliary tract who may have resectable tumors should not undergo routine preoperative biliary decompression. If, on exploration, the tumor is found to be unresectable, then a palliative bypass may be performed.

Pancreatoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note.

Radical pancreatoduodenectomy for treatment of pancreatic carcinoma has been the surgical standard of care for the past four decades. The recent popularization of pylorus-sparing pancreatoduodenectomy to treat benign pancreatic disease, because of its decreased morbidity and long-term nutritional consequences, has led to the use of this procedure in cases of pancreatic carcinoma. We report recent experience with three patients with pancreatic carcinoma in whom pyloric preservation would have compromised the potential chance for curative resection or compromised palliation because of occult spread of tumor to a region not resected with this new operative approach. Two patients had proximal, microscopic intramural spread of pancreatic adenocarcinoma within the duodenum or antrum--a mode of spread not previously reported with pancreatic carcinoma. Both patients had no other evidence of metastatic involvement, and both would have had positive surgical margins in a pylorus-sparing pancreatoduodenectomy. A third case demonstrates a true submucosal recurrence of pancreatic carcinoma after a pylorus-sparing pancreatoduodenectomy. It is debatable that any case demonstrating intramural spread within the duodenum could be cured with a standard Whipple resection as this may well represent another sign of incurability, like lymphatic or perineural spread, but it is clearly a major potential obstacle to palliation if submucosal recurrences occur as a result of the use of the pylorus-sparing pancreatoduodenectomy in cases of pancreatic cancer. The use of pylorus-sparing pancreatoduodenectomy in resectable pancreatic cancers must be viewed skeptically at this time.

Gastrointestinal tuberculosis: resurgence of an old pathogen.

Thirteen patients with gastrointestinal tuberculosis (GITB) were treated at our hospitals from 1977-1987. Ten of these patients were seen during the last four years. Three patients required operative intervention for management of complications of their disease. This review discusses the presentation, diagnosis, and operative management of GITB. The authors feel that the increasing prevalence of GITB noted in their institution is primarily the result of the growing prevalence of mycobacterium tuberculosis pneumonia across the nation. With the recent influx of patients from areas of endemic tuberculosis and the increasing number of immunosuppressed patients, a surge in the number of patients presenting with GITB is likely to occur in the United States. Surgeons must be conversant with the diverse clinical features and operative management of this disease.

Prolonged use of intravenous isoniazid and rifampin.

We present a case of a 55-year-old woman requiring prolonged therapy with intravenous isoniazid and rifampin secondary to extensive bowel disease. We believe that this is the first U.S. report of a patient receiving both medications by the iv route. After months of therapy the patient has not experienced side effects secondary to this route of administration. We believe that iv isoniazid and rifampin provides a safe alternative method of delivery when clinical situations dictate this route.