Evaluation of POSSUM for patients undergoing pancreatoduodenectomy.

BACKGROUND: Comparison of operative morbidity rates after pancreatoduodenectomy between units may be misleading because it does not take into account the physiological variable of the condition of the patients. The aim of the present study was to evaluate the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) for pancreatoduodenectomy patients and to look for risk factors associated with morbidity in a high-volume center. METHODS: Between January 1993 and April 2006, 652 patients underwent a pancreatoduodenectomy, 502 of them for malignant disease. POSSUM performance was evaluated by assessing the "goodness-of-fit" with the linear analysis method. RESULTS: Overall, 332 of the 652 patients (50.9%) had one or more complication after pancreatoduodenectomy, and 9 patients (1.4%) died. POSSUM had a significant lack of fit using goodness-of-fit analysis. In multivariate analysis, one statistically significant factor associated with morbidity and not incorporated in POSSUM (P < 0.05) was identified: ampulla of Vater adenocarcinoma (OR = 1.73, 95% CI: 1.07-2.80). CONCLUSIONS: Overall, there is a lack of calibration of POSSUM among patients who undergo pancreatoduodenectomy.

Predicting individual survival after potentially curative esophagectomy for adenocarcinoma of the esophagus or gastroesophageal junction.

INTRODUCTION: Even after potentially curative esophagectomy, the majority of patients with adenocarcinoma of the esophagus or gastroesophageal junction die due to cancer recurrence. To predict individual disease-specific survival, a nomogram has been developed in a high-volume center in the Netherlands. The validity of this nomogram was externally tested in patients treated in another country at a different high-volume institution. METHODS: Clinicopathological data from patients who underwent a macroscopically radical resection in a high-volume center in Leuven, Belgium, were used to validate the original nomogram based on a Cox regression model. Moreover, it was examined whether adjusting the value of the original coefficients of the predictors or adding new predictors would improve the fit of the nomogram in the validation cohort. Calibration was evaluated by comparing the observed survival with the expected survival as predicted by the original nomogram across patients with different risk profiles. The discriminatory ability of the nomogram was determined in the validation cohort, using the concordance index and compared with the original estimate. RESULTS: A total of 382 patients were used in the validation study. The median esophageal cancer-specific survival was 38 months. None of the coefficients re-estimated in the validation cohort differed significantly from the values of the original nomogram. Observed and expected survival curves showed good calibration. Discrimination of the original nomogram was preserved in the validation cohort: the concordance index hardly decreased from 0.77 in the original cohort to 0.76 in the validation cohort. CONCLUSIONS: The nomogram model that was originally developed in a Dutch institute had good individual discriminatory properties and good overall calibration when applied to an independent series of patients. The nomogram was updated using the data from both cohorts to provide even more robust estimates of survival for individual patients. This tool is clinically helpful to supply more reliable prognostic information, to offer tailored follow-up schedules and/or novel therapeutic strategies in subgroups of patients with higher risk of recurrence.

[Evidence-based surgery]. / Chirurgie op basis van wetenschap.

Authority-based surgery is slowly being replaced by evidence-based surgery. New and existing interventions are increasingly being studied in randomised controlled trials (RCTs). RCTs allow not only for comparison of different types of surgical interventions but also for comparison with non-surgical interventions and adjuvant therapies. Surgical RCTs have many methodological limitations, such as inherent difficulties with randomisation and blinding, and ethical limitations in using placebo controls. Choosing appropriate intervention groups, providing adequate training for participating surgeons and ensuring a high volume per surgeon reduces the risk of complications due to inexperience. Unplanned cross-over is a potential source of bias in explanatory RCTs comparing surgical interventions. Conducting a surgical RCT requires good collaboration between large and small hospitals due to organisational complexity, ethical limitations, funding and long term follow-up. Acceptance and implementation of the results from surgical RCTs through evidence-based guidelines depends heavily on local opinion leaders and the training of surgical residents.

Decision making for relaparotomy in secondary peritonitis.

BACKGROUND/AIMS: To provide a qualitative ranking of clinical variables by surgeons that influence their decision for reoperation and to evaluate whether these variables are related to positive findings at relaparotomy. METHODS: Importance in decision making for relaparotomy was evaluated for 21 factors using a 10-point visual analogue scale (VAS). Variables with median VAS scores >5.0 were labeled 'important'. Predictive value for positive findings was evaluated by multivariate analysis. RESULTS: The response rate was 64%. For each variable, a wide range of VAS scores was given. Of variables labeled 'important', a diffuse extent of abdominal contamination (odds ratio, OR 1.9; 95% CI 0.99-3.8; p = 0.052), localization of the infectious focus (upper gastrointestinal tract including small bowel: OR 2.6, 95% CI 0.98-7.0, p = 0.055; colon: OR 2.4, 95% CI 0.93-6.0, p = 0.071), and both low (<3 x 10(9)/l: OR 4.6, 95% CI 1.3-17, p = 0.021) and high (>20 x 10(9)/l: OR 2.2, 95% CI 1.0-4.9, p = 0.042) leukocyte counts independently predicted positive relaparotomy. As a set, these variables had only moderate predictive accuracy (c-statistic 0.69). CONCLUSIONS: There was no consensus among surgeons which variables were important in decision making for relaparotomy. Only three out of ten variables labeled as 'important' were indeed independently predictive, but even as a set had only moderate predictive accuracy.

Analysis of micrometastatic disease in histologically negative lymph nodes of patients with adenocarcinoma of the distal esophagus or gastric cardia.

SUMMARY: Lymphatic dissemination is the most important prognostic factor in patients with esophageal carcinoma. However, the clinical significance of lymph node micrometastases is still debated due to contradictory results. The aim of the present study was to identify the incidence of potentially relevant micrometastatic disease in patients with histologically node-negative esophageal adenocarcinoma and to analyze the sensitivity and specificity of three different immunohistochemical assays. From a consecutive series of 79 patients who underwent a transthoracic resection with extended 2-field lymphadenectomy, all 20 patients with pN0 esophageal adenocarcinoma were included in this study. A total of 578 lymph nodes were examined for the presence of micrometastases by immunohistochemical analysis with the antibodies Ber-EP4, AE1/AE3 and CAM 5.2. Lymph node micrometastases were detected in five of the 20 patients (25%). They were identified in 16 of the 578 lymph nodes examined (2.8%) and most frequently detected with the Ber-EP4 and AE1/AE3 antibody (sensitivity 95% and 79% respectively). In 114 of the 559 negative lymph nodes (20.4%), positive single cells were found that did not demonstrate malignant characteristics. These false-positive cells were more frequently found with the AE1/AE3 staining (specificity of the Ber-Ep4 and AE1/AE3 antibody 94% and 84% respectively). The presence of nodal micrometastases was associated with the development of locoregional recurrences (P=0.01), distant metastases (P=0.01), and a reduced overall survival (log rank test, P=0.009). For the detection of clinically relevant micrometastatic disease in patients operated upon for adenocarcinoma of the distal esophagus or gastric cardia, Ber-EP4 is the antibody of first choice because of its high sensitivity and specificity. Immunohistochemically detected micrometastases in histologically negative lymph nodes have potential prognostic significance and are associated with a high incidence of both locoregional and systemic recurrence. Therefore, this technique has the potential to refine the staging system for esophageal cancer and to help identify patients who will not be cured by surgery alone.

Evaluation of O-POSSUM in predicting in-hospital mortality after resection for oesophageal cancer.

BACKGROUND: The aims of the present study were to validate the Physiological and Operative Severity Score for the enUmeration of Mortality adjusted for oesophagogastric surgery (O-POSSUM). METHODS: Data on patients who underwent potentially curative oesophagectomy in a tertiary referral centre for adenocarcinoma or squamous cell carcinoma of the oesophagus were analysed. The in-hospital mortality predicted by O-POSSUM was compared with the actual value by linear analysis. RESULTS: Twenty-four (3.6 per cent) of 663 patients died in hospital. The observed : predicted ratio for in-hospital mortality was 0.29. The model had a poor fit (P < 0.001). The area under the receiver-operator characteristic curve was 0.60 (95 per cent confidence interval 0.47 to 0.72); P = 0.113). O-POSSUM score was not related to the severity of complications. CONCLUSION: O-POSSUM overpredicted in-hospital mortality threefold and could not identify patients at higher risk of death. O-POSSUM needs substantial modification before it can be used for comparison of treatment outcomes between centres.

Management of solid-pseudopapillary neoplasms of the pancreas: a comparison with standard pancreatic neoplasms.

BACKGROUND: Solid-pseudopapillary neoplasms (SPNs) of the pancreas are increasingly diagnosed, but the exact surgical management in terms of extent of the resection is not well defined. MATERIALS AND METHODS: Patients operated on in our hospital between January 1993 and March 2005 formed the study groups. RESULTS: From 659 consecutive resections for pancreatic neoplasms, 12 female patients (1.8%) with a median age of 21 years who underwent resection for (SPN) are compared with the remaining 647 pancreatic resection patients. Jaundice (SPN 0 versus PR 73%, p < 0.001) and weight loss (SPN 0 versus PR 49%, p = 0.001) occurred significantly less often. Neoplasms were distributed equally among the pancreatic head (SPN 5 out of 12 patients versus PR 88%, p < 0.001) and corpus/tail (SPN 6 out of 12 patients versus PR 8%, p < 0.001). The operative time was significantly shorter (SPN 233 min versus PR 280 min, p = 0.012), and there were significantly fewer complications (SPN 1 of 12 patients versus PR 48%, p = 0.007). The mortality was not different (SPN 0 versus PR 1.6%, p = 1.000), and the hospital stay was significantly shorter (SPN 9 days versus PR 15 days, p = 0.012). The median size of the neoplasms was significantly larger (SPN 6.9 cm versus PR 2.5 cm). The median number of lymph nodes harvested was significantly fewer (SPN 1 versus PR 6, p = 0.001), and lymph node metastases occurred significantly less often (SPN 0 versus PR 64%, p < 0.001). The 5-year survival of SPN patients was 100% and is significantly better compared with survival of patients with pancreatic adenocarcinoma (12%, p < 0.001) and ampulla of Vater adenocarcinoma (22%, p = 0.005). CONCLUSIONS: Patients with solid-pseudopapillary neoplasms of the pancreas present differently and the course of the disease is more benign. These patients can be adequately managed by pylorus-preserving pancreatoduodenectomy or spleen-preserving distal pancreatectomy with excellent early and long-term results.

Predictive factors associated with prolonged chest drain production after esophagectomy.

After esophagectomy, pleural drainage is performed to ensure complete drainage of the pleural cavities. The aim of this study was to detect predisposing factors for prolonged drainage. Patients who underwent transhiatal or extended transthoracic esophagectomy for adenocarcinoma of the distal esophagus or gastroesophageal junction were included. Patients who underwent esophagectomy produced a median total drainage volume of 2477 mL (range 30-14,908). Seventy-five patients needed chest drainage = 7 days (short drainage) while 57 patients needed chest drainage > 7 days (prolonged drainage). Factors associated with prolonged drainage were a transthoracic approach (P < 0.001), a higher volume of blood loss (P = 0.027), a higher number of resected lymphnodes (P = 0.046) and a radical dissection (P = 0.033). Prolonged pleural drainage is associated with a transthoracic approach and is seen more often in patients after a microscopically radical dissection. Prolonged drainage is a sign of adequate dissection on the site of the primary tumor, probably due to the more extensive trauma to the lymphatic vessels in the mediastinum.

Initial and long-term outcome after palliative surgical drainage of 269 patients with malignant biliary obstruction.

AIMS: This study aimed to analyse the current outcome after palliative surgical drainage of malignant biliary obstruction. METHOD: From 1992 to 2003, perioperative parameters and the incidence and indications of readmissions were analysed in 269 patients who underwent a palliative biliary bypass for periampullary carcinoma. RESULTS: Hospital mortality occurred in seven patients and median postoperative stay was 10 days. Anastomotic leakage occurred in three patients and intraabdominal haemorrhage in eight patients. Overall 75 patients experienced a complication. Nine patients underwent a relaparotomy during initial hospital admission. Overall, 142 patients were readmitted, 13 for indications related to the biliary bypass, 11 for surgery-related indications. Twenty-five patients were readmitted for radiochemotherapy, 112 for progressive disease and 23 for indications not related to the disease. Median survival was 7.5 months and the 3-year survival 3%. Survival was significantly lower in patients with metastases and in those who underwent elective bypass for gastric outlet obstruction. CONCLUSION: Current hospital mortality after palliative biliary bypass as well as readmission rates for complications related to the biliary bypass or surgical procedure are low. Surgical biliary bypass is a safe and effective palliative treatment for patients with malignant biliary obstruction.

Original article: New surgical approaches to the Klatskin tumour.

BACKGROUND: Surgical treatment of hilar cholangiocarcinoma (Klatskin tumours) is difficult because of its central location in the liver hilum. Recent developments in surgical techniques have improved the outcome after resection. AIM: To describe the surgical approaches currently applied in our centre and the impact of these strategies on outcome and criteria for resection. METHODS: From 1988 to 2003, 99 consecutive patients underwent resection for hilar cholangiocarcinoma. Patients were analysed for rate of R0 resections in relation with Bismuth classification. Morbidity, mortality and survival were assessed. RESULTS: The rate of hilar resections in combination with (extended) liver resections for type III and IV tumours increased from 24% to 95% in the last 5 years of the study period. Eight patients (8%) had Bismuth type IV tumours. Four of these patients underwent palliative local excisions of the hepatic duct confluence whereas the other four patients underwent hilar resection in combination with partial liver resection, resulting in microscopically radical resections. There was no mortality in this group. Overall postoperative morbidity and mortality were 68% and 10%, respectively. CONCLUSIONS: An aggressive surgical approach consisting of hilar resections combined with partial liver resections including segments 1 and 4, resulted in a higher rate of R0 resections. Even Bismuth type IV tumours may be resectable depending on the biliary anatomy of the hepatic duct confluence.

Results of the combination of open transthoracic esophagectomy with laparoscopic gastric tube formation for esophageal cancer.

BACKGROUND: Postoperative complications after open transthoracic esophagectomy could possibly be reduced if the abdominal phase is performed laparoscopically. The aim of this study was to investigate the feasibility of laparoscopic mobilization of the stomach and gastric tube formation in patients undergoing an open transthoracic esophagectomy for cancer. METHODS: Thirteen patients underwent an open transthoracic esophagectomy with extended en bloc lymphadenectomy combined with laparoscopic gastric tube formation. Clinicopathological data were derived from a prospective database and patient files. RESULTS: The median operation time was 484 min (range 347-573) and the median intraoperative blood loss was 1,500 ml (range 250-3,700). In 2 patients the laparoscopic procedure was converted to a laparotomy because of technical difficulties. Median postoperative stay in the ICU was 3 days (range 1-8) and median hospital stay was 29 days (range 12-104). One patient died in the hospital. Postoperatively 3 patients suffered from anastomotic leakage, 5 from pneumonia and 3 from vocal cord palsy. CONCLUSIONS: The complication rate was high in this series of patients undergoing an open extended transthoracic esophagectomy with laparoscopic mobilization of the stomach and gastric tube formation. Laparoscopic mobilization of the stomach and gastric tube formation are feasible, but need carefully guided testing before this technique can be applied routinely.

Delayed closure of complex duodenal injuries by a Foley balloon catheter duodenostomy.

Less than 5% of abdominal injuries comprise the duodenum. Treatment is complex with high mortality and morbidity rates. These injuries are usually treated surgically and complications frequently occur. Three cases are presented in this communication in which the injury of the duodenum could not be repaired tension-free. In these cases a Foley balloon catheter was used to close the rupture. After a few weeks, patients were fed through the Foley catheter duodenostomy until a fistular track was formed. On removal of the catheter the fistular track closed spontaneously including the perforation of the duodenum.

[Centralisation of pancreatic resection: a systematic review and evaluation in the Netherlands]. / Centralisatie van pancreasoperaties: een systematische review en evaluatie in Nederland.

OBJECTIVE: To analyse the volume-outcome effect of pancreatic surgery by means of a systematic review, and to determine the effect of the ongoing plea for centralisation of pylorus-preserving pancreaticoduodenectomy in the Netherlands. DESIGN: Systematic review and retrospective evaluation. METHOD: A systematic search for studies comparing hospital mortality rates after pancreatic resection in high- and low-volume hospitals was conducted. The studies were independently assessed regarding design, inclusion criteria, threshold value for high and low volume and primary hospital mortality outcome. Data were obtained from the Dutch nation-wide registry on the mortality outcome of pancreaticoduodenectomy in 1994-2003. Hospitals were divided into 4 categories based on the number of pancreaticoduodenectomies performed. The effect of the ongoing plea for centralisation was analysed. RESULTS: Twelve observational studies comprising a total of 19,688 patients were included. Because the studies were too heterogeneous to allow a meta-analysis, a qualitative analysis was performed. The relative risk of dying in a high-volume hospital compared with a low-volume hospital was between 0.07 and 0.76 and was inversely proportional to the arbitrarily defined volume cut-off values. Various analyses conducted over a to-year period in the Netherlands reported mortality rates of 14-17% in hospitals that performed fewer than 5 pancreaticoduodenectomies per year, compared with rates of 0.0-3.50 degrees h in hospitals that performed more than 24 pancreaticoduodenectomies per year. The percentage of patients undergoing surgery in hospitals with a volume less than ro pancreaticoduodenectomies per year was 57% in 2000-2003 (454/792), compared with 65% (280/428) in 1994-1995. CONCLUSION: This systematic review provided evidence of an inverse relationship between hospital volume and mortality after pancreaticoduodenectomy and confirmed the value of centralisation of this procedure in high-volume hospitals. The 10-year-long plea of the Dutch surgical community for quality assessment and, if necessary, centralisation has not resulted in a reduction in mortality rates after pancreatic resection or a change in referral patterns in The Netherlands.

Effects of prolonged intensive care unit stay on quality of life and long-term survival after transthoracic esophageal resection.

OBJECTIVE: There are few prospective data on the effects of prolonged intensive care unit stay on the quality of life and long-term survival of a homogeneous patient population. Therefore, the aims of this prospective study were a) to describe the quality of life in patients after having a transthoracic esophageal resection; and b) to analyze the influences of a prolonged intensive care unit stay on quality of life and survival in patients after esophageal cancer resection who survived to hospital discharge. DESIGN: Prospective study. SETTING: Medical center. PATIENTS: The study population consisted of 109 patients undergoing a transthoracic resection for adenocarcinoma of the middistal esophagus or gastric cardia between April 1994 and February 2000. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A comparison was made between patients staying or=6 days in the intensive care unit and also or=14 days. Quality of life was assessed in all patients by mailed self-report questionnaires at baseline (preoperatively), at 5 wks, and at 3, 6, 9, 12, 18, 24, 30, and 36 months after surgery. Daily physical, emotional, and social functioning was assessed with the generic Medical Outcome Studies Short Form-20. Disease-specific quality of life was measured by an adapted Rotterdam Symptom Check List. Quality of life data were gathered between July 1994 and March 2003. Five of the 109 patients died in the hospital and were excluded from the analysis. All five of them were in the intensive care unit >or=6 days. Of the remaining 104 patients, 92 provided baseline scores. The data of the 92 patients were used for the quality of life analyses. For the clinicopathologic and survival analysis, the data of 104 hospital survivors were used. Patients spent a median of 5.5 days (range 0-71) in the intensive care unit. The Medical Outcome Studies Short Form-20 and the Rotterdam Symptom Check List measurements showed no clear differences in long-term quality of life between patients after a short vs. a prolonged postoperative intensive care unit period. The median overall survival in all patients was 2.0 yrs (range 0.1-8.0). Median overall survival in patients staying in the intensive care unit or=6 days (p = .9, log-rank test). Median overall survival in patients staying in the intensive care unit or=14 days (p = .74, log-rank test). CONCLUSIONS: For patients who survived to hospital discharge after transthoracic esophagectomy, there was no difference in long-term quality of life or survival between those submitted to the intensive care unit for a short period vs. a long period.

Prospective analysis of patients with adenocarcinoma of the gastric cardia and lymph node metastasis in the proximal field of the chest.

BACKGROUND: The extent to which adenocarcinoma of the cardia with lymph node metastasis in the upper mediastinum is amenable to cure by radical surgery is open to debate. It remains unclear whether these relatively distant metastases have an effect on long-term survival. The aim of this study was to identify the incidence of such positive nodes and evaluate their prognostic significance. METHODS: Some 50 patients with adenocarcinoma of the gastric cardia and substantial invasion of the oesophagus (junctional type II), who underwent an extended transthoracic oesophagectomy as part of a prospective randomized trial between 1994 and 2000, were studied. RESULTS: Eleven patients (22 per cent) had lymph node metastasis in the proximal field of the chest. These patients had more positive nodes overall (P = 0.020) and a shorter median survival (P = 0.009) than those without such metastasis. Multivariate analysis identified positive nodes in the proximal field as an independent predictor of poor survival. CONCLUSION: Lymph node metastasis in the proximal field of the chest is common and is an indicator of poor prognosis in patients with adenocarcinoma of the cardia.

Incidence and management of pancreatic leakage after pancreatoduodenectomy.

BACKGROUND: Optimal management of severe pancreatic leakage after pancreatoduodenectomy can reduce morbidity and mortality. Completion pancreatectomy may be adequate but leads to endocrine insufficiency. This study evaluated an alternative management strategy for pancreatic leakage. METHODS: Outcome after disconnection of the jejunal limb, resection of the pancreatic body and preservation of a small pancreatic remnant, performed between 1997 and 2002, was compared with that after completion pancreatectomy performed between 1992 and 1996. RESULTS: Pancreatoduodenectomy was performed in 459 consecutive patients. Pancreatic leakage occurred in 41 patients (8.9 per cent); its incidence did not change over the study period. Non-surgical drainage procedures were performed in 14 patients, of whom one died, and surgical drainage in eight patients, of whom two died. Completion pancreatectomy was performed in nine patients with no deaths. A pancreatic remnant was preserved in ten patients, of whom three died. A remnant tail had to be resected in two patients and three patients still developed endocrine insufficiency ('brittle' diabetes). CONCLUSION: The incidence of pancreatic leakage did not change over the study interval. Preservation of a small pancreatic tail was associated with higher morbidity and mortality rates than those of completion pancreatectomy.

Quality of life after curative or palliative surgical treatment of pancreatic and periampullary carcinoma.

BACKGROUND: Quality of life (QOL) is an important outcome measure after treatment of pancreatic and periampullary carcinoma. The aim of this prospective longitudinal study was to analyse QOL after surgery for resectable pancreatic or periampullary carcinoma. METHODS: Patients with potentially resectable tumours underwent pancreaticoduodenectomy (n = 72) or a double-bypass procedure (n = 42). They were asked to complete a questionnaire before laparotomy and at 2 weeks, 6 weeks, and 3, 6, 9 and 12 months after surgery. Fifty-nine patients completed a shortened questionnaire on a weekly basis. RESULTS: There was a temporary decrease in physical and gastrointestinal functioning after pancreaticoduodenectomy. A similar decrease in QOL was observed after double bypass, as well as decreases in mental functioning and overall QOL. Almost all QOL scores returned to preoperative values by about 3 months after surgery, although only briefly so in patients who had a double-bypass procedure. There were no differences between groups in the terminal stages of disease. A rapid decrease on all QOL scales was observed in the last 8 weeks before death. CONCLUSION: Surgery for pancreatic and periampullary carcinoma was not associated with irreversible impairment or protracted recovery of QOL. The relatively long plateau phase after recovery supports the argument for surgical treatment, including surgical palliation in selected patients.

Survey among surgeons on surgical treatment strategies for secondary peritonitis.

BACKGROUND: There is controversy about performing either a planned relaparotomy (PR) or relaparotomy on demand (ROD) in patients with secondary peritonitis. Subjective factors influencing surgeons in decision making for either surgical treatment strategy have never been studied. METHODS: All 858 surgeons of the Association of Surgeons of The Netherlands were sent a survey with 16 case vignettes simulating peritonitis patients and evaluating the preference for PR or ROD. RESULTS: Sixty-two percent of surgeons responded to the survey. Of the returned surveys, 407 were eligible for evaluation. The responding surgeons had a slight overall preference for the ROD strategy, as shown by the mean overall preference score of 5.2 (range 3.54-6.52, with a maximal score of 7). Gastrointestinal surgeons and surgeons working in regional and smaller hospitals were significantly more in favour of a ROD strategy than their counterparts. Factors significantly influencing the preference towards PR were ischaemia as aetiology and performing a primary anastomosis; as for ROD, it was small bowel as focus, local extent of contamination and the question whether abdominal closure was possible. However, there was a considerable variability in treatment decisions by surgeons. CONCLUSION: The majority of responding surgeons would make a choice for a particular treatment strategy based on peritonitis and surgical treatment characteristics. There was a slight overall preference towards the ROD strategy despite the considerable variability per case vignette.

Surgical management of neoplasms of the ampulla of Vater: local resection or pancreatoduodenectomy and prognostic factors for survival.

BACKGROUND: Neoplasms of the ampulla of Vater have a better 5-year survival than pancreatic and bile duct neoplasms after resection. This study was performed to analyze the outcome after local resection and pancreatoduodenectomy (PD) and to identify predictive factors for survival. METHODS: We used a prospective database to evaluate 145 patients (1992-2002) with a neoplasm of the ampulla of Vater. RESULTS: The median age of the entire cohort was 66 years. Agreement between preoperative biopsies and definite resection specimen was 58% for invasive adenocarcinoma. Local resection was performed in 25 patients, but the operation was adequate therapy in only 16 patients (64%). Subsequent PD (n=9) was performed in the remaining patients because of an R1 resection. Other patients (n=120) underwent an elective PD. Hospital mortality was 4.0% (1/25) after local resection and 5.0% (6/120) after PD. Multivariate analysis revealed that advanced invasion and nodal status were independent predictive factors for survival. The overall 5-year actuarial survival of patients with adenocarcinoma after PD was 37%. CONCLUSIONS: Preoperative biopsies have a poor diagnostic accuracy. Local resection is an adequate surgical treatment for adenomas. In experienced hands, PD is the preferred treatment for patients with adenocarcinoma.

Outcome of patients with esophageal carcinoma and suspicious celiac lymph nodes as determined by endoscopic ultrasonography.

BACKGROUND AND STUDY AIMS: The management of patients with esophageal cancer with malignant celiac lymph nodes (CLNs) is controversial. In this study we evaluated the management and survival of patients with positive CLN findings on endoscopic ultrasonography (EUS) and compared the outcome in surgically treated patients with that of nonsurgically treated patients. PATIENTS AND METHODS: The EUS database of the Academic Medical Center was retrospectively searched for patients with esophageal carcinoma and EUS-positive CLN. Follow-up comprised the review of medical charts and contact with general practitioners. RESULTS: From 1993 through 2000, 78 patients with esophageal carcinoma and suspicious CLN were eligible for inclusion in this study. The median survival of patients with CLN size < 2 cm was 13.5 months vs. 7.0 months for patients with CLN size >2 cm ( P = 0.01). In a multivariate model, CLN size was the only predictive factor for poor patient survival. Of the 78 study patients, 13 underwent a surgical resection and 65 received nonsurgical treatment. The surgical group was significantly younger and all patients in this group had CLN size < 2 cm. The median survival for the surgical group was 13.7 months vs. 13.5 months for the nonsurgical group with CLN size < 2 cm ( P = 0.63). CONCLUSIONS: In this retrospective study, CLN size was a significant predictor for poor survival. The surgically treated patients had a medium-term survival similar to that of nonsurgically treated patients with a CLN size < 2 cm. These findings underline the prognostic value of CLN size in patients with esophageal carcinoma.