Hiatal hernia and disorders of the spine: a historical perspective.

Our understanding of esophageal disease and the foregut has evolved over the past 100 years, especially in recent times. Modern diagnostic technologies and new management paradigms have provided progressive insights into the anatomy, physiology, and normal and abnormal function of the esophagus, as well as improving patient care. Yet, the relationship between the esophagus and its close neighbor, the spine, is rarely discussed and likely underappreciated. Anatomic proximity and intertwined pathophysiology led early investigators to postulate relationships between esophageal disease and spinal abnormalities. More recent studies have illustrated a link between spinal disease and hiatal hernias. Objective radiographic measurements of kyphoscoliosis have correlated with increased hiatal hernia formation. Spinal abnormalities and disease of the esophageal hiatus are becoming more common in our aging population, with each carrying significant risk of morbidity and decreased quality of life. Operative planning and subsequent hiatal hernia repair must be undertaken in the context of these spinal abnormalities. A historical review of past publications related to the subject forms the basis for this publication, thus revealing insight and improving our understanding of the association between spinal abnormalities and hiatal hernias.

Analysis of thymectomy for myasthenia gravis in older patients: a 20-year single institution experience.

BACKGROUND: Thymectomy has become recognized as an integral element in the care of the patient with myasthenia gravis. Although the number of elderly patients with myasthenia is substantial, little data exist demonstrating the efficacy and morbidity of thymectomy in this population. STUDY DESIGN: We retrospectively analyzed 126 cervicomediastinal thymectomies performed at a single university hospital from 1980 to 1998. Patients 55 years or older were compared with those less than 55. Efficacy was measured by determining the change in Osserman score, the rate of remission during followup, and the reduction in medication requirements after thymectomy. RESULTS: Older patients (n = 28) had similar Osserman scores (p = 0.8) and similar rates of complete and partial remission as the younger group (n = 98) at a mean +/- SEM followup of 58 +/- 5 months. The two groups did not differ in the number (p = 0.4) and doses of medications used to control myasthenic symptoms after operation. Older age was associated with an increased length of hospitalization (13.8 +/- 3.2 days versus 9.7 +/- 0.6 days, p = 0.05) and a higher incidence of reintubation, and longer ventilatory support (2.6 +/- 1.3 days versus 0.1 +/- 0.1 days, p = 0.001). CONCLUSIONS: Increased age does not alter the outcomes of thymectomy for myasthenia gravis. Older patients can expect to have similar responses and require a similar number of postoperative medications as younger patients, but with a higher short-term morbidity.

Surgical treatment and outcomes in carcinoma of the extrahepatic bile ducts: the University of Rochester experience.

HYPOTHESIS: To our knowledge, few individual surgeons and only a handful of institutions have gained a meaningful experience with the treatment of adenocarcinoma of the extrahepatic bile ducts or cholangiocarcinoma. The purpose of this study was to critically evaluate the experience of a single center in the treatment of these tumors. DESIGN: Retrospective cohort study with a median follow-up of 48 months. SETTING: Department of surgery at a university referral center. PATIENTS: Seventy-seven patients with biopsy-confirmed adenocarcinoma of the extrahepatic bile ducts evaluated and treated between January 1980 and February 1998. MAIN OUTCOME MEASURES: Prognostic variables, resectability rates, morbidity, and survival. RESULTS: Thirty-eight male and 39 female patients were studied (median age, 71 years). Twenty-three patients (30%) underwent curative resections, 32 patients (41%) underwent palliative surgery, and 22 patients (29%) received nonoperative therapies. The 30-day perioperative morbidity rate was 18%, and mortality was 6%. Overall median survival was 11 months; 4 months for patients receiving nonoperative therapy; 8 months for patients receiving palliative surgery; and 72 months for curative resection. Five-year survival rates were 23%, 0%, 10%, and 55%, respectively. Curative resection was the only prognostic variable to have a statistically significant effect on survival. CONCLUSIONS: Curative resection could be achieved in approximately one third of patients who had cholangiocarcinoma, and should be the goal of treatment. Survival is significantly improved in those patients who are considered to have resectable tumors and who undergo removal of all gross disease. Palliative surgical treatments also revealed a survival advantage over nonoperative therapies.

Role of splenectomy in hematologic disorders.

There has been an increase in the indications for splenectomy for hematologic diseases. It is a consequence of expanding the list of disorders and liberalizing the indications for splenectomy for many diseases. Hereditary spherocytosis is the most frequently encountered congenital anemia for which splenectomy is curative. Splenectomy is generally advised for warm antibody acquired hemolytic anemia if conventional medical therapy fails. Idiopathic thrombocytopenic purpura (ITP) remains the most common hematologic disorder for which splenectomy is therapeutic. A variety of thrombocytopenias are improved by splenectomy. The myeloproliferative disorders constitute a spectrum of disease potentially improved by splenectomy, but preoperative management should be modified in this group. Splenectomy in patients with chronic leukemias and lymphomas are often palliative and facilitate chemotherapy. There are no specific requirements preoperatively other than the administration of pneumococcal and Hemophilus influenzae vaccines. Platelets are not administered to patients with ITP. An integral part of the procedure is the search for accessory spleens. The postoperative complication of overwhelming postsplenectomy sepsis must be considered; it occurs more frequently in association with specific basic diseases and can be obviated by appropriate treatment.

Hepatic resection for noncolorectal nonneuroendocrine metastases.

The experience with hepatic resection for metastatic lesions, exclusive of colorectal and neuroendocrine tumors, is anecdotal. The reduction in operative mortality leads to a reconsideration of the subject. A review of the literature suggests a selective approach. There is little improvement to be anticipated for resection of metastases from tumors of the esophagus, stomach, small intestine, or pancreas. Resection of metastases from primary renal cell carcinoma, Wilms' tumor, and adrenocortical carcinoma is indicated. There is little to recommend resection of metastases from gynecologic or breast primary carcinomas. Resection as palliation is to be considered for all lesions, particularly bulky metastases from ocular melanomas.

Hepatic adenoma and focal nodular hyperplasia.

Hepatic adenoma and focal nodular hyperplasia are benign lesions of the liver. The incidence of these conditions has been increasing since 1970. Hepatic adenoma primarily affects young women of childbearing age who have a long history of using oral contraceptives, while focal nodular hyperplasia has a wider age distribution and is not associated with the use of oral contraceptives. The most extensive complication of hepatic adenoma is intratumoral or intraperitoneal hemorrhage, which occurs in 50 to 60 per cent of patients. Patients with focal nodular hyperplasia are usually asymptomatic and rarely experience complications. Hepatic adenoma is distinct from focal nodular hyperplasia both in its clinical behavior and its pathologic features; the two can usually be differentiated radiographically using a combination of radionuclide scanning and angiography. There is a proved association between the use of oral contraceptives and the development of hepatic adenoma; the longer the duration of oral contraceptive use, the more the risk of having hepatic adenoma develop. In addition, users of oral contraceptives who have hepatic adenoma develop are likely to have larger tumors and higher rates of bleeding and rupture than nonusers who have hepatic adenoma develop. Although hepatic adenomas may regress after discontinuation of oral contraceptive use, this is not a consistent finding. In addition, it has now been demonstrated that hepatic adenomas do undergo malignant transformation and that this can be detected by measuring the alpha-fetoprotein level. Focal nodular hyperplasia may be a precursor for fibrolamellar hepatocellular carcinoma. Elective resection of hepatic adenoma has a mortality rate of less than 1 per cent, while the mortality rate with free rupture is 5 to 10 per cent. Because of the relative safety of elective versus emergency resection and the potential for malignant change, the treatment of choice for hepatic adenoma is surgical resection.

PIP: The benign tumors hepatic adenoma and focal nodular hyperplasia are compared in their etiology, differential diagnosis, risk of transformation, and management. Hepatic adenomas range in size from 1-30 cm, averaged 8-10 cm in diameter, contain vacuoles and glycogen, but no Kupfer cells or bile ducts. Adenoma is usually symptomatic, causing pressure or hemorrhage. The risk of developing adenoma is increased with duration of oral contraceptive use, and chance of a larger tumor, a hemorrhage and mortality during pregnancy or surgery is also increased in pill users. Adenoma also occurs in people with Type Ia glycogen storage disease, and is associated with insulin-dependent diabetes. Often stopping oral contraceptives will cause an adenoma to regress. If not, It is best managed by elective resection, with 1% mortality, rather than 5-10% mortality due to spontaneous rupture. Adenomas can progress to adenomatosis, which are inoperable, or malignant transformation. Focal nodular hyperplasia is marked by a stellate scar, sometimes accompanied by hemangioma, but is asymptomatic. It is not increased in oral contraceptive users, but occurs in older women. It can transform to fibrolamellar hepatocellular carcinoma. The 2 benign lesions can be distinguished by radionuclide scanning and angiography. Only fine needle aspiration is advised for biopsy, because of the risk of hemorrhage with adenoma. Focal nodular hyperplasia takes up radionuclide, stains intensely on angiography, and is safe to biopsy percutaneously.

Carcinoma of the parathyroid gland: a 30-year experience.

Eleven patients with parathyroid carcinoma and 186 patients with parathyroid adenoma were seen between 1958 and 1990. Significant differences (p less than 0.01) were found between the two groups in calcium and parathormone levels, lesion size, presence of palpable mass, and severity of clinical presentation. Initial operative management consisted of parathyroidectomy alone in three patients, all of whom experienced recurrence of disease. Of the eight patients who underwent aggressive surgical management (parathyroidectomy and resection of thyroid or thymus), only one experienced recurrence. Three of the four patients with recurrence underwent multiple thoracic and cervical procedures for control of disease; one patient was treated with medical therapy alone. The mean survival in the surgical group was 17 years; the patient treated with medical therapy survived 10 years. In all four patients, however, treatment was palliative rather than curative. We conclude that patients with primary hyperparathyroidism characterized by markedly elevated serum calcium and parathormone, palpable mass, and severe clinical presentation should be suspected of harboring a parathyroid carcinoma. An aggressive initial surgical approach was considered in these patients. This experience emphasizes the importance of aggressive surgical extirpation in reducing disease recurrence and also for palliation and prolongation of life when recurrence does occur.

Insulin inhibits apolipoprotein B secretion in isolated human hepatocytes.

The effect of insulin on apolipoprotein (apo) B secretion was investigated in human hepatocytes. Freshly isolated hepatocytes, prepared by collagenase dispersion of liver specimens, were incubated in serum-free media in the absence and presence of 100 nmol/L insulin for 2 hours. The media was then assayed for apo B content by radioimmunoassay. In hepatocytes incubated without insulin, the secretion of apo B (relative to human low-density lipoprotein [LDL]) was 125 +/- 37 ng/10(6) cells/2 hours. In the presence of insulin, apo B secretion was reduced to 83 +/- 29 ng/10(6) cells/2 hours (34% inhibition, P less than .05). These results using human hepatocytes are consistent with previous data from our laboratory describing insulin-dependent inhibition of apo B secretion in primary cultures of rat hepatocytes and studies by others employing the human-derived hepatoma cell line, Hep G2. We conclude that human hepatic apo B secretion is under insulin control. The role of more chronic insulin exposure requires further investigation.

Recurrent acute pancreatitis caused by ampullary villous adenoma.

Neoplastic lesions of the ampulla of Vater are a rare cause of acute and recurrent pancreatitis. We have recently had the privilege of studying a 58-year-old woman who presented with recurrent pancreatitis. At endoscopic retrograde pancreatography, a mucosal abnormality of the ampulla of Vater was noted and documented to be a villous adenoma. It was resected surgically and the patient has been symptom free. This report documents the ninth patient in the English literature with pancreatitis secondary to a benign neoplasm of the ampulla of Vater. Six of the nine patients have been male. They have ranged in age from 42 to 68 years. Approximately 30% of villous adenomas of the duodenum contain foci of invasive or in situ carcinoma. Villous adenomas of the ampulla of Vater require aggressive therapy. Further, it has been noted that a number of patients with small intestinal neoplasms have concomitant large-bowel polyps.

Hepatic resection.

The current performance and applicability of elective hepatic resection represents an impressive evolution. From removal of tumor-bearing, ill-defined portions of the liver, which is always threatened by the inability to control bleeding, surgery of the liver has progressed to hemostatically controlled dissection of anatomically defined portions of the organ. Accompanying the series of technical refinements that have markedly reduced the mortality and morbidity rates associated with the procedure, there has been an expansion of the indications for hepatic resection.

Diagnostic and therapeutic approaches to pyogenic abscess of the liver.

A review was conducted of 33 patients with pyogenic hepatic abscesses seen during the past seven years to evaluate the effect of roentgenologic refinements on diagnosis and therapy. Cause, bacterial infection and clinical manifestations were determined. An ultrasonogram was positive in 27 of 29 patients; computed tomographic scan was diagnostic in 20 of 23 patients, and radionuclide studies were positive in eight of 13 patients. Abscesses were confined to the right lobe in 19 patients, to the left lobe in six and were diffuse in eight. In the group of patients with abscesses developing from a biliary route, one patient was successfully managed by roentgenologically controlled drainage while three others required subsequent surgical drainage. Five of seven patients in the biliary route category who were treated with primary surgical drainage were permanently cured. Twelve patients had an abscess emanating from the portal route. In five of these, drainage under roentgenologic control was successful. Two patients upon whom the procedure failed subsequently underwent drainage at operation. Five had primary surgical drainage, and two of these died. All nine patients with post-traumatic, cryptogenic abscesses or an abscess evolving from an arterial route were successfully drained surgically. Three patients with multiple or diffuse abscesses were successfully treated by primary hepatic resection. Refined roentgenologic techniques established the diagnosis of pyogenic abscess in almost all instances. Roentgenologically controlled drainage may be therapeutic in some patients, but surgical drainage remains the standard. Resection has been used as primary treatment in selected patients.