Economics of pancreatoduodenectomy in the elderly.

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

Palliative procedures for pancreatic cancer: when and which one?

Pancreatic cancer usually requires palliative rather than curative therapy. Palliative procedures should have low morbidity and mortality, provide a good quality of life, and necessitate minimal hospitalization. The surgeon, endoscopist, and radiologist all play a role in delivering effective palliation to properly selected patients.

Needle-localization biopsy of the breast: impact of a selective core needle biopsy program on yield.

PURPOSE: To determine the effect of a selective core biopsy program on the yield at needle-localization biopsy (NLB) of nonpalpable lesions. MATERIALS AND METHODS: Two hundred consecutive core biopsy samples of the breast were evaluated in an ongoing consecutive series of 1,172 NLB samples. RESULTS: Before implementation of the core biopsy program, the yield at NLB improved from 21% at 100 cases to 35% just before the introduction of core biopsy. After implementation, the yield increased gradually to 55% at 200 cases. The yield in masses increased from 21% at 100 cases to 43% just before the initiation of the core biopsy program and then increased dramatically to 72% at 200 cases. The percentage of small lesions detected did not change with implementation: 88% of invasive cancers measured less than 1.5 cm and 60% measured less than 1 cm in the last 100 cases. CONCLUSION: Appropriate selection of cases for core biopsy can more than double the yield of cancer in NLB samples without a decrease in the percentage of small cancers detected.

Melanoma recurrence surveillance. Patient or physician based?

OBJECTIVE: The authors determined the roles of the physician and the patient in melanoma recurrence detection. METHODS: The University of Alabama Melanoma Registry, consisting of 1475 patients surgically treated for cutaneous melanoma from 1958 to 1984, was searched to find 195 evaluable cases of melanoma recurrence. Patients were grouped by the type of return visit. Group I returned on a previously determined date, whereas group II returned before the scheduled visit. RESULTS: Symptoms of recurrence were present in 90% of group I patients and 93% of group II and correlated with the site of recurrence in more than two thirds of cases. Recurrence sites were local, regional, and distant in 35%, 31%, and 29% of group I, respectively, and 42%, 25%, and 29% of group II. The median interval to recurrence was 24.2 months in group I and 37.7 months in group II (p = 0.059). Median overall survival was 57 months in group I and 62 months in Group II (p = 0.210). CONCLUSIONS: Symptoms are present in 90% of the patients with recurrent melanoma and accurately predict the site of recurrence. Overall survival is not affected by the type of patient return visit.

Preoperative infusional chemoradiation and surgery with or without an electron beam intraoperative boost for advanced primary rectal cancer.

PURPOSE: To compare the multimodality treatment results of surgical resection plus preoperative radiotherapy with concomitant protracted infusion chemotherapy (preop-chemoXRT), with or without an electron beam intraoperative radiotherapy (EB-IORT) boost, in 37 patients having advanced primary rectal cancer, with the results of a protocol using only preoperative radiotherapy (preop-XRT) plus surgical resection in a historic control group of 36 patients. METHODS AND MATERIALS: Thirty-eight patients with tethered T3 or T4 primary rectal cancer were treated with 45 Gy delivered in 25 fractions over 5 weeks plus infusional chemotherapy. Thirty-seven patients underwent surgical resection: 13 (35%) had restorative operations, and the remainder had either abdomino-perineal resection (APR) or pelvic exenteration (PE). Electron beam intraoperative radiotherapy (EB-IORT) was used in doses of 10-20 Gy for 11 patients with adherent pelvic tumor. In the 36 historic control patients, the preop-XRT dose was 45 Gy, and 93% of them had APR or PE. RESULTS: The local recurrence rate was 3% for the preop-chemoXRT group and 33% for the historic control group. The 3-year survival rate for patients treated with preop-chemoXRT plus resection was 82% compared with 62% for the historic control group. Distant metastases occurred more frequently in patients treated with an EB-IORT boost than in patients who were not (64% vs. 19%, p < 0.05), and the overall 3-year survival rate was lower for the former (67% vs. 96%, p < 0.05). Acute and late toxicities were acceptable. CONCLUSIONS: Preop-chemoXRT for advanced primary rectal cancer results in better control of pelvic disease and better overall survival rates than does preop-XRT alone. With preop-chemoXRT, acute chemoradiation toxicity is increased whereas late morbidity is unchanged compared with preop-XRT alone. Local control in patients with areas of residual or clinically adherent disease is improved by the use of EB-IORT; however, patients treated with EB-IORT had poorer survival rates than those treated without EB-IORT.

Colorectal cancer hepatic metastases: the surgeons role.

Liver metastases are not uniformly fatal. A group of patients exists that will benefit from therapy directed at the liver either with surgical resection, intra-arterial chemotherapy or a combination of both. (Fig 2) All patients should be evaluated for the possibility of surgical resection since it can provide a 5-year survival of 25 to 40%, or hepatic arterial infusion therapy since response rates are higher and toxicity lower than systemic chemotherapy. When metastases are discovered simultaneously with the primary tumor, consideration should be given to concomitant treatment of both the primary and the liver if the patient is a suitable operative candidate and the resection will not entail more than a wedge or a left lateral lobe resection. Metastases discovered on follow-up of the primary tumor may be immediately addressed with surgical resection or hepatic artery infusion pump placement if the disease-free interval has been greater than 1-2 years. When the disease free interval has been less than a year, systemic chemotherapy is probably more prudent to allow time for manifestation of extra hepatic disease. If no extra-hepatic metastases become manifested after 6 months of systemic chemotherapy, then regional chemotherapy or resection should be considered. Intrahepatic progression on systemic chemotherapy is not a contraindication to hepatic artery infusion chemotherapy since the metastases may still respond. This approach allows patients manifesting extrahepatic disease while on systemic chemotherapy to be spared an operative procedure.

Automation of environmental ELISAs.

ELISAs for pesticides and herbicides in environmental and agricultural samples are becoming very important in screening applications [1-3]. Traditional chromatographic methods are expensive and results need long turnaround times, making them incompatible with rapid on-site decision making. ELISA methods have been shown to meet or exceed the performance of gas chromatography-they offer rapid low-cost analysis, thereby increasing the frequency of sampling and enhancing data quality. Automated ELISA workstations allow the full benefit of these kits to be realized. Sample preparation, reagent pipetting, incubation, and photometric evaluation can be performed without user intervention. Reliability is increased through the elimination of operator error, better accuracy and precision, and often higher speed. Much larger batch sizes are possible and these systems can provide sample tracking with report generation for documentation requirements. In this paper the manual procedures and ELISA methods are compared and some critical aspects of automating these ELISA kits are discussed.

Locally advanced carcinoma of the colon and rectum involving the urinary bladder.

We reviewed the records of 70 patients who underwent resection of a carcinoma of the colon and rectum with en bloc total cystectomy (36 patients) or partial cystectomy (34 patients) because of tumor directly extending into the urinary bladder. Preoperative genitourinary symptoms were present in 33 of the 70 patients (41.7 percent) and were highly predictive of malignant invasion of the bladder (97.0 percent). Duration of catheter drainage after partial cystectomy correlated with early postoperative bladder function; all 25 patients who had the catheter remain in place at least ten days had normal voiding after catheter removal, while five of nine patients whose catheter was removed before ten days had retention requiring catheter reinsertion (p < 0.01). Urologic complications occurred in two patients after total cystectomy and in three patients after partial cystectomy. There were three postoperative deaths in the total cystectomy group but none after partial cystectomy. Sixty-four patients with negative resection margins had a median survival period of 34 months and a five-year actuarial survival rate of 51.8 percent. In contrast, the median survival period for six patients who had positive margins was 11 months, with no survivors at five years.

Preoperative chemotherapy and radiation therapy for locally advanced primary and recurrent rectal carcinoma. A report of surgical morbidity.

BACKGROUND: Complete surgical resection of locally advanced primary and recurrent rectal cancer is often incomplete. Improved tumor downstaging may improve resection rates and local control if postoperative morbidity is not increased. METHODS: The clinical and pathologic records of 119 patients with locally advanced primary and recurrent rectal carcinoma were reviewed to determine the effect of preoperative chemoradiation on postoperative morbidity compared with a control group treated with external beam radiation therapy alone. Group I (56 patients) was treated with 45 Gy of external beam radiation therapy. Group II (63 patients) received 45 Gy of external beam radiation therapy with continuous-infusion cisplatin, 5-fluorouracil, or both. RESULTS: Forty-one patients (73.2%) in Group I and 48 in Group II (76.1%) underwent surgical resection. Anal-sparing procedures were performed more frequently in Group II (25%) than in Group I (5.3%, P < 0.05). The overall complication rate for Group I was 51% versus 44% for Group II (P < 0.05) or 1.17 complications per patient in Group I and 0.58 complications per patient in Group II. One patient in each group died of treatment-related septic complications. CONCLUSIONS: It was concluded that the addition of chemotherapy to radiation to treat rectal carcinoma does not result in an increased operative morbidity and may contribute to a higher proportion of patients being treated with anal-rectal-conserving surgical procedures.

Discriminability of load heaviness: implications for the psychophysical approach to manual lifting.

The main objective of this study was to investigate human ability to discriminate between different levels of load heaviness in manual lifting. Twelve male college students participated in the laboratory experiment. Twenty-eight sequences of five boxes that weighed from 5 to 64 lbs (2.27-29.1 kg) were used. The subjects were asked to arrange boxes in each sequence in order of the perceived (increasing or decreasing) heaviness, i.e., from lightest to the heaviest box, or from heaviest to the lightest box. The subjects were also asked to assign linguistic descriptors of perceived load heaviness to each box in the sequence, and to indicate the confidence levels regarding correctness of the assigned box order and assignment of linguistic values. The independent variables included magnitude of weight and load differential between the successive weights in a sequence. The number of sequential ordering errors, assignment of linguistic variables, and estimated confidence levels were highly dependent on the load differential and weight range. It was concluded that in order to assure reliable results of the psychophysical approach to determining the values of maximum acceptable weight of lift, the adjustment process for male subjects should require using small weights of at least 4 lbs (1.8 kg) to be added or removed from the lifted box. The results of this study also suggest that the error rate in load discriminability can be controlled below the 10% level, if the relative difference in weight between successive boxes lifted is at least 12%. Given the above findings, it is suggested that usefulness of some of the recommendations for setting safe limits for manual lifting tasks, which were reached based on the psychophysical approach and broadly reported in the past, may need to be carefully re-examined. Finally, this study showed that the Weber fraction for load heaviness over the range of lifted weights from 8.6 to 29.1 kg is between 0.03 and 0.04.

Extended resection for locally advanced colorectal carcinoma.

We reviewed the medical records of 101 patients who underwent extended resection for locally advanced colorectal carcinoma between 1965 and 1989. Preoperative symptoms related to the genitourinary system were present in 46 patients. Malignant invasion of genitourinary structures by colorectal carcinoma was found in 43 of these 46 patients (93%). In contrast, 51% of the patients without such symptoms had malignant invasion of contiguous structures. Preoperative intravenous pyelography, computerized tomographic scans, and cystoscopy correctly predicted the presence or absence of malignant invasion in 89%, 83%, and 87% of patients, respectively. Tumor-positive resection margins had a negative impact on survival (mean survival: 11.4 months). The 5-year actuarial survival rate for the patients who underwent a curative extended resection (margins tumor negative) was 54%. A thorough preoperative evaluation can identify a significant number of patients with colorectal cancer extending into adjacent organs and structures. Such evaluation is vital for operative planning and patient preparation, since an appropriate extended resection can produce long-term local control and patient survival.

Traumatic neuroma of the bile duct causing cholangitis and atrophy of the right hepatic lobe.

Intraluminal traumatic neuromas are an unusual cause of bile duct obstruction. These benign collections of disorganized nerve fibers arise from a bile duct injury during cholecystectomy. Symptoms associated with obstruction or cholangitis may develop decades after the operation. Our patient's neuroma imitated a malignant neoplasm, but the patient has been returned to good health by resection of the right hepatic duct and the atrophic right hepatic lobe.

The prognostic implications of location for scalp melanoma.

The clinical and pathologic records of 95 patients with primary cutaneous melanoma isolated to the scalp and regional lymph nodes treated at the MD Anderson Cancer Center between 1976 and 1985 were reviewed to assess the effect of lesion location on the prognosis of scalp melanoma. The scalp was defined as an area bounded by the supraorbital ridges, superior nuchal line, zygoma, and mastoid, thereby including a large non-hair-bearing area. Patients were grouped according to lesion location: hair-bearing or non-hair-bearing; anterior or posterior to the mid-tragal line; and parietal versus frontal, temporal, or occipital. There was a similar distribution of prognostic factors between the anatomic subsites. Analysis by univariate and multivariate methods demonstrated that, in a hair-bearing area, in an area posterior to the mid-tragal line, or in the parietal region, lesion location was highly predictive of the patient's survival. For example, the 5-year, melanoma-specific survival rate was 65% overall, 86% for patients with lesions located in non-hair-bearing regions and 47% for those with lesions in hair-bearing regions (p = 0.0019).

Use of Dexon Mesh for abdominal partitioning above the peritoneal reflection.

Dexon Mesh (Davis & Geck, Sugarland, TX) was used to partition the abdomen after incomplete resection of a locally advanced left colon cancer. Following surgery, external beam radiotherapy was delivered to the left flank without the risk of radiation enteritis. The technique of abdominal partitioning using Dexon Mesh is described.

Factors influencing the treatment of intra-abdominal abscesses.

Forty-eight consecutive patients with 68 intra-abdominal abscesses who had operative or radiologic attempts at drainage were analyzed. Patients who had radiologic drainage were older and had simple abscesses more often. Simple abscesses were treated successfully in a high percentage of patients using both operation and radiologic drainage. Mortality was higher for patients with complex abscesses, and most of these patients required operative treatment. Successful abscess resolution was eventually achieved in 79 percent of patients.

Preliminary investigation of ion mobility spectrometry after capillary electrophoretic introduction.

Using standard capillary electrophoretic and ion mobility methods, several electrospray interface designs were investigated for the capillary electrophoretic introduction of samples into the ion mobility spectrometer. Of the interfaces investigated, the flow assisted interface and the direct coupled interface showed the most promise. These preliminary experiments were encouraging. The ion mobility spectrometer coupled with a capillary electrophoretic introduction system operated with excellent separation efficiency and ion mobility reproducibility. Using tetrabutylammonium iodide, the number of theoretical plates for the spectrometer was calculated to be 3.10(3) and reduced mobilities were found to be reproducible with a relative standard deviation of 1.43%. Because of the desire to hold the spectrometer as hot as possible, the solvent would often vaporize in the interface, creating an unstable spray and inhomogeneities in the electrophoretic field. More work is needed to improve the spray process which contributed to the overall noise of the system and to eliminate the phenomenon of solvent vaporization which limited the reproducibility of electrophoretic migration times.

Myocardial contusion. When can the diagnosis be eliminated?

The clinical significance of various diagnostic tests and the length of monitoring required for myocardial contusion were evaluated in 172 patients. Cardiac isoenzyme levels, electrocardiograms, and echocardiograms were evaluated. Twenty-eight patients had a documented myocardial contusion based on at least one positive diagnostic study. The majority of positive studies were detected on admission and all positive tests were present within 24 hours. No patients developed positive diagnostic studies after 24 hours and, likewise, no clinical deterioration occurred late or in patients with a negative screening examination. The electrocardiogram and the clinical course were the therapeutic intervention. Cardiac isoenzyme levels had negligible significance on outcome, and the two-dimensional echocardiogram was not particularly valuable as a screening technique, If no abnormality is detected within 24 hours post injury, further investigation or monitoring does not appear warranted.

Coronaspray nebulization and ionization of liquid samples for ion mobility spectrometry.

Ion mobility spectrometry after electrospray nebulization and ionization was investigated as a method for the detection of components dissolved in liquids. While electrosprary operating conditions proved promising, greater sensitivity was achieved when the electric potential applied to the sample introduction needle was increased above breakdown potential and a corona discharge was established. Passing the liquid through the corona discharge established a "coronaspray" that efficiently nebulized and ionized the solvent and analytes. In this initial investigation of coronaspray ion mobility spectrometry (CIMS), ion current as a function of potential, temperature, and liquid flow rate was studied; several IMS spectra were obtained; and a continuous monitoring mode of operation was demonstrated. The results from this study indicated that CIMS has potential as a versatile and sensitive detection method for a variety of analytical procedures involving liquid flowing streams such as flow injection analysis, liquid chromatography, capillary zone electrophoresis, and field flow fractionation.

More is better. Antibiotic management after hemorrhagic shock.

Previous reports suggest that standard antibiotic prophylaxis is ineffective in reducing the incidence of wound infection after hemorrhagic shock. This study investigated the use of larger and longer doses of antibiotic in a model of staphylococcal infection after hemorrhagic shock. Sprague-Dawley rats resuscitated from hemorrhagic shock were injected with either 10(6), 10(8) or 10(10) Staphylococcus aureus subcutaneously. Five treatments were investigated: 1) control (no antibiotic), 2) short-course cefazolin (CEF) (SHORT), 30 mg/kg intraperitoneal (IP), 30 minutes before and 4 hours after inoculation, 3) long-course CEF (LONG), 30 mg/kg IP, 30 minutes before and 4 hours after inoculation, and thereafter, every 8 hours for 3 days, 4) mega-CEF (MEGA) 200 mg/kg IP, 30 minutes before and 4 hours after inoculation, and 5) mega-long CEF (MEGA-LONG), 200 mg/kg IP, 30 minutes before and 4 hours after inoculation, and thereafter, every 8 hours for 3 days. Abscess number, weight, and diameter were measured on Day 7. At the 10(6) inoculum, SHORT was effective in both shocked and unshocked animals. In the 10(10) group, all antibiotic regimens decreased the 100% mortality that followed shock without treatment, but they had little effect on abscess formation. In unshocked rats at the 10(8) inoculum, SHORT was effective in reducing abscess number, diameter, and weight (all p less than 0.05 vs. control). After hemorrhagic shock, SHORT did not decrease abscess frequency, but it did diminish abscess diameter. LONG significantly decreased abscess diameter and abscess weight (both p less than 0.05). After shock, both MEGA and MEGA-LONG reduced abscess number (p less than 0.05 vs. control) and MEGA-LONG was superior to all other regimens at the 10(8) inoculum. These experimental data show that increasing both the dose and duration of antibiotic administration is more effective than standard short-course antibiotic prophylaxis in preventing experimental infection after hemorrhagic shock.