Laparoscopic cholecystectomy in patients with early cirrhosis.

Traditionally, cholecystectomy in cirrhotic patients has been reserved for patients with severe biliary disease, because of the high morbidity and mortality in cirrhotic patients undergoing this procedure. Laparoscopic cholecytectomy (LC) was originally contraindicated in cirrhotic patients because of the associated portal hypertension and coagulopathy. This study examined the safety of LC in Child's class A patients.A review was conducted of all patients with cirrhosis who underwent cholecystectomy at our hospital between 1990 and 1998.Fifteen patients with cirrhosis had their gallbladder removed laparoscopically during that time period. All patients were Child's class A. The average age was 59 (range, 36-85). The operative indications included acute cholecystitis (5 patients), biliary pacreatitis (4 patients), biliary colic (5 patients), and cholangitis (1 patients). Six patients had known cirrhosis, and 9 were examined intraoperatively. The average operative time was 105 minutes. None of the patients required a blood transfusion. No intraoperative or postoperative complications occurred. No deaths occurred. Postoperative stay was 3 days or less in all but 3 patients.These results compare favorably to other published studies from outside of the United States. Based on our findings, we believe LC can be performed safely in patients with class A cirrhosis.

Early recognition of hepatic portal vein gas on CT with appropriate surgical intervention improves patient survival.

Historically, hepatic portal vein gas has been linked with a dismal prognosis. However, in the last 3 decades, identification of hepatic portal vein gas has undergone a transition from late recognition on roentgenograms to earlier identification on computed tomography scan. The 5 patients in this case series were found to harbor hepatic portal vein gas identified using computed tomography scan. Eighty percent of the patients had concomitant pathology identified by computed tomography, felt to be the cause of the hepatic portal vein gas. All patients were taken to the operating room for exploration and resection of the offending pathology. All 5 patients survived. We suggest that early recognition using computed tomography scan, with appropriate operative intervention, improves the chance for patient survival when hepatic portal vein gas is identified.

Laparoscopic management of pseudomyxoma peritonei secondary to adenocarcinoma of the appendix.

Pseudomyxoma peritonei is a rare disease in which the abdominal cavity fills with thick mucoid material secondary to either benign or malignant conditions. We discuss a case where pseudomyxoma peritonei secondary to adenocarcinoma of the appendix was diagnosed and managed laparoscopically. The laparoscopic approach allows thorough exploration of the abdomen, as well as irrigation and aspiration of the thick mucinous material using a 10-mm suction cannula and the instillation of mucolytic agents such as 5% dextrose solution. Appendectomy or right hemicolectomy can be performed with minimal disturbance of the anterior abdominal wall, thus minimizing future adhesions as well as possible tumor-cell implantation. Intraperitoneal catheters for chemotherapy can be placed easily through the port sites. These measures offer an alternative to radical peritoneal dissection and can be accomplished during the initial laparoscopic exploration.

Inferolateral retraction reduces the risk of thermal injury to biliary structures.

OBJECTIVES: Do various traction techniques significantly change the anatomic position during laparoscopic cholecystectomy? METHODS: 16 cadaveric liver specimens were dissected and measurements were taken between structures in the triangle of Calot. Measurements were taken while traction was placed on the infidubilum in the inferolateral, cephalad and anatomic positions. Thermal necrosis data was measured one week post-injury in a rat model for Non-contact Yag laser, Quartz, Sapphire tip, and electrocautery. RESULTS: Inferolateral traction provided statistically significant increases in distance (P < 0.01) between the critical biliary structures. The increase in length by cephalad traction on the gallbladder was not statistically significant. Depth of necrosis for the devices were: cautery 1.03 mm, sapphire tip 0.63 mm, non-contact Yag laser 2.13 mm, and bare quartz tip laser 1.05 mm. CONCLUSION: Inferolateral traction produced a statistically significant increase in distance between the critical biliary structures. This was not demonstrated with cephalad traction. We recommend avoiding thermal dissection in the Triangle of Calot due to the thermal devices necrosis depth in relation to the proximity of the biliary structures.

Laparoscopic management of appendiceal intussusception associated with villous adenocarcinoma.

The authors present a case of appendiceal intussusception, a rare finding that can be associated with appendiceal neoplasms. A 74-year-old woman with right lower quadrant abdominal pain was found to have an appendiceal intussusception associated with a villous adenocarcinoma and was managed with a laparoscopic assisted right hemicolectomy. This case is presented along with a review of the symptoms, diagnosis, classification, and appropriate management of this entity via laparoscopy.

Fatty acid composition of the subcutaneous adipose tissue and risk of proliferative benign breast disease and breast cancer.

BACKGROUND: Studies in animals and geographic correlations across populations suggest that fatty acid intake may have a positive relationship with breast cancer risk, but analytic epidemiologic studies of fat intake have been less supportive. Adipose tissue analysis provides a more objective assessment of intakes of fatty acids that are not endogenously synthesized than do the questionnaire survey methods used in many epidemiologic studies. PURPOSE: This case-control study of postmenopausal women was designed to examine the relationship between fatty acid composition of subcutaneous adipose tissue and risk of breast cancer and proliferative benign breast disease. In addition, we examined specific hypotheses that breast cancer risk is negatively associated with long-chain N-3 fatty acid intake, positively associated with trans fatty acid intake, and positively associated with increased intake of polyunsaturated fat together with low intake of antioxidants. METHODS: Aspirates of subcutaneous fat from the buttocks were obtained from 380 women with newly diagnosed stage I or II breast cancer and 176 with proliferative benign breast disease. A total of 397 women who were evaluated for breast abnormalities at the same institutions but did not require breast biopsy or whose biopsy revealed nonproliferative benign breast disease served as the control group. We examined associations between saturated, monounsaturated, polyunsaturated, trans, or long-chain N-3 fatty acids and breast cancer, atypical hyperplasia, or proliferative benign breast disease without atypia. RESULTS: We observed no consistent patterns of association between breast cancer risk and any of the categories of fatty acids or the individual constituent fatty acids in the adipose tissue. Saturated fatty acids were inversely associated with risk of proliferative benign breast disease without atypia but not with atypical hyperplasia or breast cancer. This association was not observed, however, when total fat intake was taken into account. Women with high levels of polyunsaturated fatty acids in adipose tissue and low serum or dietary levels of antioxidants were not observed to be at higher risk of breast cancer. CONCLUSIONS: Using an objective measure of intake, we observed no major associations between polyunsaturated fatty acids, including long-chain N-3 fatty acids and trans fatty acids, and risk of breast cancer or proliferative benign breast disease. IMPLICATIONS: These data do not support the hypothesis that intake of specific fatty acids, particularly polyunsaturated and trans fatty acids, is an important risk factor for malignant or benign breast disease.

Carotenoids, retinol, and vitamin E and risk of proliferative benign breast disease and breast cancer.

We investigated the relationship between serum levels of retinol, beta-carotene, alpha-carotene, lycopene, alpha-tocopherol, and gamma-tocopherol as well as intakes of retinol, carotene, and vitamin E and the risks of breast cancer and proliferative benign breast disease (BBD) in a case-control study of postmenopausal women in the Boston, MA (United States) area. Serum nutrient data were available for 377 women with newly diagnosed stage I or II breast cancer and 173 women with proliferative BBD. Controls were 403 women who were evaluated at the same institutions but did not require a breast biopsy or whose biopsy revealed nonproliferative BBD. We observed no significant associations between serum levels of these micronutrients and risk of proliferative BBD or breast cancer. The risk of breast cancer was decreased among women in the highest quintile of intake of vitamin E from food sources only (odds ratio [OR] for the highest quintile = 0.4, 95 percent confidence interval [CI] = 0.2-0.9; P, trend across quintiles = 0.02) but less so for total vitamin E intake including supplements (OR = 0.7, CI = 0.4-1.3; P, trend = 0.07).

Carcinoid tumors: the relationship between clinical presentation and the extent of disease.

In this study the relationship between the initial clinical presentation and the extent of tumor progression was determined in a group of 31 patients with carcinoid tumors. The proportion of patients with symptomatic tumors was similar to those patients with carcinoid tumors that were incidentally found (55% versus 45%; SE = 0.089). Symptoms were caused by metastatic tumor in nine (30%) of the patients and by local effects of the primary tumor in eight (26%) of the patients. The patients with symptoms had a significantly increased frequency of metastatic disease, even when the symptoms were due to the primary tumor, compared to patients with no symptoms (76% versus 7%; p less than 0.001). Tumor size was related to the presence of symptoms and metastases. Symptoms were most common when the size of the primary tumor was greater than 1.0 cm (p less than 0.005), although the rate of metastases increased when primary tumors were 2.0 cm and larger (p less than 0.01). These results indicate that the presence of symptoms or a primary tumor 2.0 cm or larger are associated with an increased risk of metastatic disease in patients with carcinoid tumors. These patients should be treated with wide resection of the primary tumor and its lymphatic drainage.

Long-term results with primary retroperitoneal tumors.

Primary retroperitoneal tumors represent a variety of lesions, with different treatments and prognoses. Of 182 patients in our study, retroperitoneal tumor was recognized preoperatively in only 39% of them. Sarcomas were most common (43% of patients), followed by lymphomas (23%), benign tumors (11%), undifferentiated malignant tumors (11%), carcinomas (8%), and germ cell tumors (4%). In 81 patients since 1960, the resection rate was 50%. Operative determinants of resectability were pathologic category and grade and extent of tumor. Resection included segments of the gastrointestinal tract (30% of the patients), kidney (25%), and pancreas, bladder, spleen, aorta, and vena cava (for each, 5% or less of the patients). The operative mortality was 6%. Tumor caused late death in 95% of the patients. Pathologic findings were a significant determinant of survival in the 81 patients. For sarcomas, 69% of the patients underwent resection, and the 1- and 5-year actuarial survival rates were 80% and 43%, respectively. Sixty percent of these patients underwent multiple operations. For lymphomas, most patients were treated with radiotherapy and chemotherapy; the 1- and 5-year survival rates were 67% and 35%, respectively. Benign tumors, almost all resected, yielded a 5-year survival rate of 100%. Undifferentiated tumors and carcinomas, most treated with radiotherapy and chemotherapy, had a 1-year survival rate of less than 33%. Other determinants of survival were age, weight loss, grade of tumor, and extent of tumor. Patients who underwent palliative resection had the same survival rate as patients who underwent biopsy alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of pancreatic fistulas.

Conservative management of pancreatic fistulas resulting from trauma, operation for tumor, or operation for pancreatitis has met with variable success. To assess optimal management strategies and outcome, we reviewed the records of 35 patients with external pancreatic fistulas (26 patients), pancreatic ascites (6 patients), or pancreatic pleural effusion (3 patients). Treatment included no operation in 5 patients, oversewing of the fistula in 7 patients, internal drainage in 11 patients, and resection in 12 patients. One (3%) postoperative death occurred. The overall rate of operative success was 83% (25 patients). The incidence of recurrent fistulas was about the same regardless of the procedure. Patients treated successfully without operation did not have pancreatitis as an underlying disease. Patient selection is of great importance in the decision to resect or to drain and is based in part on imaging the pancreatic duct and fistula.

Surgical treatment of biliary cystadenoma. A report of 15 cases.

Mucinous biliary cystadenomas are rare intrahepatic or, less commonly, extrahepatic neoplasms that may produce massive enlargement, hemorrhage, rupture, secondary infection, jaundice, or vena caval obstruction. Radiologic criteria differentiate biliary cystadenomas from more common parasitic or simple cysts. Treatment has included sclerosis, marsupialization, internal drainage, or resection, but without resection the patient is at risk for enlargement, infection, or progression of an unrecognized malignant neoplasm. We report the course of 15 patients who underwent resection for biliary cystadenoma to elucidate the clinical presentation, preoperative evaluation, and surgical treatment. Nine patients had had previous radiologic or surgical intervention other than excision, and complications of sepsis and tumor recurrence had developed. Following complete resection, however, only five postoperative complications were encountered, and no patient experienced recurrence of tumor. Thus, we recommend complete surgical resection as the preferred therapy.

Surgically incurable well-differentiated thyroid carcinoma. Prognostic factors and results of therapy.

A series of 97 consecutive patients with well-differentiated thyroid carcinoma treated between 1941 and 1970 presented with distant metastatic disease or extensive nonresectable local neck disease or had residual carcinoma after thyroid resection. Men 40 years of age or younger and women 50 years of age or younger were considered at low risk for dying of disease; older patients were considered at high risk for dying of disease. Of 17 patients with distant metastatic carcinoma, 40% of younger patients in the low-risk group and 92% of older patients in the high-risk group died. Of 80 patients with unresectable or residual local neck cancer, only 13% of younger patients but 71% of older patients died. Survival related better to risk group classification as defined by age and sex than to any details of disease presentation or management. Treatment was far more successful in patients in the low-risk group.

Gastric mucosal dissection using the Nd-YAG laser synthetic sapphire crystal contact probe. Development of an endoscopic method for the treatment of pancreatic pseudocysts.

A canine gastric-ulcer model was developed to evaluate the safety and effectiveness of the neodymium yttrium-aluminum-garnet (Nd-YAG) laser synthetic sapphire crystal contact probe in intraluminal gastric dissection. The purpose of the study was to assess the potential endoscopic application of the Nd-YAG contact probe in cystogastrostomy for the treatment of selected patients with pancreatic pseudocyst. Seven dogs were used in the study. In the first two dogs, full-thickness linear incisions through the gastric wall demonstrated the Nd-YAG contact probe could be used for a full-thickness gastrostomy dissection. In the other five dogs, gastric ulcers were created by injection of morrhuate sodium (5%). Gastric mucosal dissection with the Nd-YAG contact probe was performed without difficulty. Hemostasis was obtained with either the Nd-YAG contact probe or noncontact fiber, and all areas of dissection and ulcer beds healed within 35 days. The Nd-YAG laser contact endoscopic delivery system appears to be a promising technique for intraluminal dissection.

Pancreatoduodenectomy in the management of chronic pancreatitis.

The records of 73 consecutive patients who underwent pancreatoduodenectomy for chronic pancreatitis between 1960 and 1985 were reviewed. The median size of the pancreatic duct was 5 mm. Two operative deaths (2.7%) occurred early in the series. Eighty-eight percent, 86%, and 79% of the patients had improvement in pain at six months, two years, and five years, respectively. Diabetes was present preoperatively in 25% of patients and postoperatively in 37%, 45%, and 69% of patients at six months, two years, and five years, respectively. Pancreatic enzyme preparations were used preoperatively by 26% of patients; this use increased to 75% by five years. Only four of 17 late deaths could be related to diabetes or malnutrition. In most patients, pancreatoduodenectomy achieves long-term pain improvement and permits return to normal activities. Selection of patients is important to decrease the late morbidity and mortality.

Cystic neoplasms of the pancreas.

From 1963 to 1983, 26 patients with cystic neoplasms of the pancreas were treated at the Lahey Clinic, Burlington, Mass. Cystadenoma (15 patients) was more common than cystadenocarcinoma (11 patients). Preoperative symptoms, such as abdominal pain, were present for as long as 18 years before diagnosis. The mean size of cysts was 7 cm. Distal pancreatectomy, the most common operation, was performed in ten patients. Eight of the 11 patients with cystadenocarcinoma had metastatic disease at the time of surgical exploration. There was one postoperative death (3.8%). Patients with cystadenocarcinoma had an adjusted median survival time after operation of 6.0 months. The long prodrome in many of the cancer patients suggests that benign cystadenomas, particularly of the mucinous type, may undergo malignant degeneration. Benign cystadenoma seems unlikely to recur after adequate resection. Whenever possible, complete excision of cystadenoma and cystadenocarcinoma is the procedure of choice.

Carcinomas arising in cystic conditions of the bile ducts. A clinical and pathologic study.

Thirty patients with cystic disease of the bile ducts operated on between 1965 and 1985 were reviewed. Three patients (10%) had a synchronous adenocarcinoma, and in three patients (10%) a metachronous carcinoma developed for a total incidence of malignancy of 20%. All patients died within 1 year of the diagnosis of malignancy. Of 19 benign cysts available for pathologic examination, one third had proliferative epithelial changes, and in two of these patients a metachronous carcinoma developed. Goblet cell metaplasia was prominent in four patients. This suggests the possibility that dysplastic changes and metaplasia of the epithelium could give rise to carcinoma. Resection of benign cysts of the bile ducts is favored, when feasible, in an attempt to decrease the incidence of malignancy.

Unilateral hepatic duct obstruction.

Experience with unilateral hepatic duct obstruction is limited. We reviewed 33 cases of unilateral hepatic duct obstruction from a total of 500 patients with biliary reconstruction treated between 1965 and 1984. The median age of the patients reviewed was 56 years. The most common cause of unilateral hepatic duct obstruction was operative injury (73 percent of patients). Including operations for unilateral obstruction, patients in the series underwent 131 operations related to biliary tract problems. The most common presentation (73 percent of patients) was fever and pain. Obstruction was more common in the right duct than in the left duct by a ratio of 2:1 (22 patients versus 11 patients). The three types of surgical procedures used were hepaticojejunostomy (17 patients), dilatation and drainage (13 patients), and primary hepatic resection (3 patients). Atrophic hepatic lobes resulting in rotational deformity of the portal structures were resected in six patients with combined hepatic duct and arterial injury. No operative deaths occurred, although 51.5 percent of the patients had postoperative complications. Follow-up studies ranging from 1 to 16 years demonstrated that patients who had hepaticojejunostomy required less frequent reoperation compared with those who had dilatation (36 percent versus 64 percent) and had a lower postoperative mortality rate related to biliary tract problems (7 percent versus 18 percent). We conclude that unilateral hepatic duct obstruction continues to occur most commonly because of operative injury and is best treated by hepaticojejunostomy or by resection of chronically obstructed lobes when possible.

Gastric and small bowel lymphoma.

Despite the vague presentation of gastric and small bowel lymphoma, survival can be achieved by adequate surgical resection of stage I disease. A role still exists for debulking of advanced stage disease by surgical excision. Debulking enhances potential for complete response with chemotherapy, decreases the risk of gastric and small bowel perforation with large exophytic tumors as they necrose with chemotherapy, and prevents gastrointestinal obstruction from limiting patients' ability to receive chemotherapy. All attempts should be made to maintain nutritional support of these patients to allow them an adequate chance of receiving chemotherapy. The increasing frequency of immunodeficiency disorders will continue to produce higher numbers of patients with non-Hodgkin's lymphoma. Awareness of our surgical limitations is important because surgical exploration is frequently the first step. Multimodality therapy of gastric and small bowel lymphoma offers the best chance for successful outcome. Surgical resection should not prevent patients from receiving a complete trial of chemotherapy and radiation if appropriate.

Hyperparathyroidism.

A review of hyperparathyroidism and current controversies in diagnosis and management is presented. Accurate diagnosis by the endocrinologist and an experienced surgeon remain the standards for good surgical results. Hyperparathyroidism is a heterogeneous disease, and therapy must be individualized to each patient. Conservative surgical removal of parathyroid tissue is preferred in most patients.