bluuebunny/crossref_metadata_2025 huggingface dataset:
The role of hyperthermic perfusion as a first step in the treatment of soft tissue sarcoma of the extremities
Authors: Di Filippo Franco , Calabrò Anna Maria , Cavallari Andrea , Carlini Sandro , Buttini Giovanni Luca , Moscarelli Francesco , Cavaliere Francesco , Piarulli Loredana , Cavaliere Renato
Published: May 2005

Eighty‐six patients with locally advanced, high‐grade soft tissue sarcomas of the extremities were studied prospectively in order to determine the efficacy of hyperthermic perfusion (HP) or hyperthermic antiblastic perfusion (HAP) as the first step of a combined multimodality therapy.

The immediate response was evaluated in terms of tumor regression, and results confirmed the in vivo sensitivity of human sarcomas to the selective antineoplastic action of heat alone or combined with drugs (melphalan, actinomycin D, and cis‐platinum). HAP has been shown to be simpler and safer than HP, and it is now currently routinely employed.

As far as the long‐term cure is concerned, all the patients have been evaluated for functional results, locoregional control, and survival, according to the different treatment schedules.

The first clinical trials employed HP or HAP followed by delayed surgery alone. In 11 of 17 evaluable patients treated with HP, and in 17 of 29 treated with HAP, conservative surgery could be performed. A high incidence of locoregional relapse (24%) occurred, with low overall survival rates: 50.1% and 31.7% at 5 and 10 years after HP plus surgery, and 47.9% after HAP plus surgery at both 5 and 10 years.

The protocol was, therefore, modified to include continuous intraarterial infusion of Adriamycin® (ADR) (17 patients) or radiotherapy (9 patients) before surgery.

The results obtained thus far may be summarized as follows: (a) conservative surgery with functional limb‐salvage was possible in all patients; (b) the percentage of locoregional failure decreased to approximately 12% after HAP + ADR infusion + excision, the 5‐ and 10‐year overall survival rates both being 77.6 %, and the 5‐ and 10‐year disease‐free rates both being 57.8%; (c) no local recurrences occurred in the group treated with HAP + radiotherapy + excision with a 5‐year overall survival rate of 71.5% and a 5‐year disease‐free rate of 50.4%.

In conclusion, the combined multimodality approaches employed appear to have improved both functional results and long‐term cure, even though these must be further confirmed on a larger series of patients.
The economics of general thromboembolic prophylaxis
Authors: Bergqvist David , Jendteg Stefan , Lindgren Björn , Mätzsch Thomas , Persson Ulf
Published: May 2005

The clinical and economic effects of each of 3 alternatives—no prophylaxis, general prophylaxis, and selective treatment—have been assessed in conjunction with 3 types of surgery—general surgery, the subset surgery for cholelithiasis, and elective hip surgery. The costs of thromboembolic and hemorrhagic complications have been calculated from the figures for 28 patients hospitalized at the Department of Surgery, Malmö General Hospital, Malmö, Sweden. The anticipated number of thromboembolic complications—and thus even the number of fatal pulmonary embolisms—can be minimized in all 3 types of surgery by means of general prophylaxis. General prophylaxis with low‐dose heparin is, however, accompanied by the greatest incidence of hemorrhagic complications.

Health care costs are minimized with general prophylaxis in elective hip and general surgery, while no prophylaxis is the best alternative in surgery for cholelithiasis.

From the patient's point of view, general prophylaxis minimizes the duration of thromboembolic disease in general surgery as well as in elective hip surgery. In surgery for cholelithiasis, however, no differences in health loss for the individual are shown between the 2 main alternatives, no prophylaxis and general prophylaxis.

Selective treatment means treatment after diagnosis of thrombosis with some screening method. The alternative selective treatment was the least satisfactory of those 3 studied.
The role of surgery in the management of unusual complications of transcatheter arterial embolization for hepatocellular carcinoma
Authors: Jeng Kuo ‐Shyang , Ching Hsen ‐Jia
Published: May 2005

Transcatheter arterial embolization (TAE) is accepted to be an effective treatment in both resectable and nonresectable hepatoma, which is very prevalent in Taiwan. Two hundred and twenty‐five embolizations of TAE were performed in 137 patients in a 3‐year period. Postembolization syndrome developed in the majority of patients. We analyzed these patients to study the nature and incidence of unusual complications and the surgical role in their managment. In our series, unusual complications, which were rarely reported in the literature, included 13 cases (5.8%) of gastroduodenal bleeding, 2 cases (0.9%) of duodenal perforation, 9 cases (4.0%) of acute pancreatitis with 1 case of gangrenous change, 24 cases (10.7%) of gallbladder infarction with 1 case of perforation, 4 cases (1.8%) of delayed formation of gallstones, 3 cases (1.3%) of hyperuricemia, and 2 cases (0.9%) of hepatoma rupture. Ischemic necrosis of the organs may be attributed to the inadvertent blockade of the gastroduodenal artery, gastric artery, cystic artery, and important collaterals. Inadequate superselectivity, the size of the tumor, regurgitation of embolus, anatomical variations, injury of vessel intima, or pseudoaneurysm formation resulting from previous embolization attempts made the avoidance of complications difficult with this technique. Most of the unusual complications could be managed by conservative treatment, but urgent operation was indicated in the cases of organ perforation. Elective operation was also needed for the delayed formation of gallstones with prominent symptoms. Awareness of the occurrence of these untoward sequelae makes us more careful in the evaluation and long‐term follow‐up of patients following TAE. Surgical intervention plays a selective but important role in the management of these unusual complications.
The role of mammography in the detection of bilateral primary breast cancer
Authors: Tinnemans J. G. M. , Wobbes T. , Hendriks J. H. C. L. , Holland R. , Van Der Sluis R. F. , De Boer H. H. M.
Published: May 2005

The significance of mammography in the detection of contralateral primary breast cancer was evaluated in 55 patients with bilateral breast disease. Fifteen (65%) of 23 patients in the synchronous group and 16 (50%) of 32 patients in the metachronous group had clinically occult carcinoma in the opposite breast. Excluding the 2 malignancies discovered by prophylactic mastectomy, mammography alone was responsible for the detection of 29 (52.7%) nonpalpable, contralateral breast carcinomas. The whole series of 110 malignant breasts comprised 41 nonpalpable carcinomas, of which 12 were noninvasive [ductal carcinoma in situ (7) and lobular carcinoma in situ (5)] and the remaining 29 were invasive carcinomas, either ductal of various types (25) or lobular (4). With regard to the évaluable axillary nodes, 20 (54.1%) of 37 palpable breast cancers and only 3 (11.5%) of 26 nonpalpable breast carcinomas had positive lymph nodes. The multicentricity rate was particularly high in synchronous tumors (70.6%), and in invasive lobular (73.3%) and noninvasive (75%) carcinomas. The favorable 5‐ and 10‐year survival of patients, both in synchronous and metachronous bilateral primary breast cancer, justify that they be treated with aggressive optimism.
Pre‐ and intraoperative localization of insulinomas: Report of 22 observations
Authors: Gianello P. , Gigot J. F. , Berthet F. , Dardenne A. N. , Lambotte L. , Rahier J. , Otte J. B. , Kestens P. J.
Published: May 2005

From a retrospective analysis of 22 cases of pancreatic insulinoma operated in our center, we have determined the predictive value of various pre‐ and intraoperative localization procedures. In 18 patients, solitary insulinomas were localized by selective arteriography (SA) in 55.5% of cases, by transhepatic catheterization with pancreatic venous sampling (THVS) in 64% of cases, but by ultrasonography (US) and computed tomography (CT) in only 11% of cases. The combination of SA and THVS allowed the preoperative localization of the tumor in 83% of cases. Intraoperative palpation, ultrasonography, and blood glucose monitoring localized a single tumor in all cases.

When the insulinomas were multiple, the various preoperative investigations were not reliable. In the 4 cases of multiple insulinoma, various investigations (SA, US, CT, THVS) localized only 8 (28%) tumors of 28. Intraoperative palpation was also unreliable. Only intraoperative ultrasonography and continuous blood glucose monitoring localizeall multiple tumors (the diameter of the smallest tumor was 4 mm). These 2 intraoperative investigations are now the procedures of choice for the detection of small pancreatic insulinomas.
A statistical evaluation of advancement in gastric cancer surgery with special reference to the significance of lymphadenectomy for cure
Authors: Soga Jun , Ohyama Shinichi , Miyashita Kaoru , Suzuki Tsutomu , Nashimoto Atsushi , Tanaka Otsuo , Sasaki Kohichi , Muto Terukazu
Published: May 2005

For the purpose of evaluating recent improvements in gastric cancer surgery, a comparative analysis was made between our previously reported series of 530 curative resection cases in a 10‐year period from 1961 to 1970 (group A) and the present series of 481 curative resection cases in the following 10‐year period from 1971 to 1980 (group B).

During the latter period, curative resections made up 74.7% of all resections (481/644) for gastric cancer, and the 5‐year survival rate was 65.9% (294/446). In group B, a total of 15,512 regional lymph nodes, an average of 32.6 per specimen (30 per specimen in group A and 37.9 per specimen in group C, the last 5 years from 1981 to 1985), were removed at surgery, examined histologically for metastases, and 11.0% were found to be positive. Of 247 patients with advanced, transmural cancers, 80.6% had lymph node metastases. Those with negative nodes showed a 5‐year survival rate of 71.4%, higher than the rate of 63.5% in group A, while those with positive nodes had a 5‐year survival rate of 40.6%, significantly higher (p<0.05) than the 29.9% rate found in group A. The 5‐year survivors with positive nodes in group B made up 72.2% of all 5‐year survivors, this also being significantly higher (p<0.05) than the 58.5% noted in group A. The surgical death rate was 1.0% (5/481) of patients in group B and 1.1% (3/274) in group C.

In the present study, the significance of lymphadenectomy in curative gastric cancer surgery was well documented and the results indicated that curative gastric resection with extensive lymphadenectomy can be safely performed without increasing, but perhaps decreasing, surgical mortality.
Laparoscopic cholecystectomy: Experience of a single surgeon
Authors: Soper Nathaniel J. , Dunnegan Deanna L.
Published: May 2005

Gallbladder removal using laparoscopic techniques has rapidly been adopted by surgeons around the world. Questions have been raised concerning laparoscopic cholecystectomy, including the safety of the operation, its implications for management of common bile duct stones, and the means by which surgeons should be trained. In the present series, 424 patients were referred to a single surgeon for cholecystectomy during a 22‐month period. A traditional open cholecystectomy was performed in 9 patients (2.1%) because of presumed contraindications to laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted in the remaining 415 patients (97.9%). On the basis of preoperative investigations, 19 patients (4.6%) underwent endoscopic retrograde cholangiopancreatography. Endoscopic sphincterotomy and stone extraction were performed in the 13 patients (3.1%) demonstrating choledocholithiasis. Laparoscopic cholecystectomy was converted to an open operation in 8 patients (1.9%) owing to dense adhesions, obscure anatomy, or cholangiographic abnormalities. Laparoscopic cholecystectomy was successfully performed in 407 patients (96%) in 95 ± 2 minutes (mean ± SEM). Surgical trainees were involved in all operations and performed 68% of the procedures under supervision. Cystic duct cholangiograms were obtained selectively in 129 patients (30.4%). Intraoperative complications occurred in 3 patients, including 1 patient with a minor injury to the common bile duct (0.2%). There was no perioperative mortality, and major complications occurred in 6 patients (1.4%). Minor complications were seen in 12 others (2.8%), and one patient required reoperation for a trocar injury to the jejunum. Prolonged follow‐up has revealed one case of asymptomatic retained common bile duct stones (0.2%). Laparoscopic cholecystectomy can therefore be performed in more than 95% of patients with no mortality and minimal morbidity. The operation is safely taught to surgical trainees. Choledocholithiasis may be treated by a combination of endoscopic and laparoscopic techniques. Because of these considerations, laparoscopic cholecystectomy has become the preferred therapy for symptomatic cholelithiasis at our institution.
Laparoscopic choledochoscopy and extraction of common bile duct stones
Authors: Phillips Edward H. , Carroll Brendan J. , Pearlstein A. Randolph , Daykhovsky Leon , Fallas Moses J.
Published: May 2005

Various strategies have been proposed for the treatment of common bile duct stones encountered during laparoscopic cholecystectomy (LC). Eighty‐three patients who had choledocholithiasis discovered during or just prior to LC are included in this study. These patients were treated by various modalities including preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic choledochotomy, transcystic duct‐common bile duct (TCD‐CBD) exploration, and conventional “open” common duct exploration. Sixty‐six patients were successfully treated with TCD‐CBD exploration. They were discharged on average 2.6 days postoperatively and were able to return to normal physical activities within 7 days of discharge. There was minimal morbidity and no mortality. The technique of TCD‐CBD exploration is described in detail. The role of laparoscopic choledochotomy and endoscopic sphincterotomy for management of common duct stones in patients undergoing laparoscopic cholecystectomy appears limited.
Management of groin hernias by laparoscopy
Authors: Ger Ralph , Mishrick Abdallah , Hurwitz Jessica , Romero Carlos , Oddsen Robert
Published: May 2005

The surgical treatment of groin hernias continues to undergo technical modifications. The introduction of minimally invasive surgery had added a possible new dimension, replacing an inguinal approach by laparoscopy. Conceived some 15 years ago, the thesis was subjected to a clinical trial where coincidental abdominal hernial openings were closed at laparotomy. This study was followed by an experimental study at which time the openings were closed laparoscopically. The satisfactory results led to the development of a stapling instrument that could be passed through a cannula at laparoscopy and used to close the abdominal hernial opening. The clinical trial of treating hernias by laparoscopy was originally directed to the management of indirect inguinal hernias, but its use has since been expanded to include treatment of direct, femoral, obturator, incarcerated, recurrent, and bilateral hernias. The laparoscopic anatomy of the inguinal hernia, different from that seen by an inguinal approach, is briefly reviewed. The details of the operative technique are presented, as are the bases of other laparoscopic techniques that have evolved. Thirty‐one hernial orifices have been closed and followed over 18 months. The results appear to be satisfactory in 27 instances. There were early technical failures in 2: One patient developed a recurrence after 5 months, later shown to be due to a sliding hernia; and symptoms of meralgia paresthetica of indeterminate origin appeared in one case. The advantages over the traditional approach are described; the disadvantages of the laparoscopic approach are those of laparoscopy itself and the absence of a long‐term follow‐up.
Laparoscopic colonic procedures
Authors: Franklin Morris E. , Ramos Raul , Rosenthal Daniel , Schuessler William
Published: May 2005

With the advent and general acceptance of laparoscopy as a means of surgically treating intraabdominal disease processes, procedures on organs other than the gallbladder and female genital tract have slowly evolved. After developing basic techniques in an animal model, a clinical series (n=19) of laparoscopic procedures for a variety of colonic lesions was undertaken and is herein presented. It included both malignant and 1 nonmalignant disease processes and has carried an acceptable complication rate and survival. The average age of our patients was 68, and except for two extended postoperative hospitalizations and one death for nonprocedure‐related complications, the patients were generally ready for discharge in less than 96 hours. Our current techniques and indications for laparoscopic colonic surgery are detailed.
Surgical treatment of carcinoma of the hepatic duct confluence: Analysis of 55 resected carcinomas
Authors: Ogura Yoshifumi , Mizumoto Ryuji , Tabata Masami , Matsuda Shinsuke , Kusuda Tsukasa
Published: May 2005

We treated 65 patients with carcinoma of the hepatic duct confluence between 1976 and 1991, 57 (87.7%) of whom were treated surgically; of the 57, 55 (96.5%) underwent resection. Radical resection was performed at a rate of 50.9%. Procedures for these 55 patients included resection of the extrahepatic bile duct plus hepatectomy (n=33; 60.0%), and resection of the duct without hepatectomy (n=22; 40.0%). In addition, the caudate lobe was resected in 28 of these patients, and the portal vein, hepatic artery, or both were resected in 6. The overall operative morbidity was 21.8%; morbidity occurred in 33.3% of patients with hepatectomy, a significantly higher percent than the 4.5% rate in those without hepatectomy (p<0.05). Operative death occurred in only 1.9%. As the depth of cancer invasion in the bile duct wall advanced, the incidence of tumor spread (e.g., lymphatic permeation, venous invasion, perineural invasion, lymph node metastasis) increased significantly. The prevalence of extramural tumor extensions in a transverse direction was higher than that in the longitudinal direction along the bile duct wall; and the distance from the margin of the primary tumor to the site of tumor extensions along the bile duct wall was much longer on the hepatic side than on the duodenal side. Cancer invasion of the caudate lobe was observed in 36.4%, and invasion at the surgical margins was found more frequently in those without hepatectomy than those with hepatectomy. Cumulative 1‐, 3‐, and 5‐year survival rates in patients with hepatectomy were 83.5%, 37.1%, and 23.2%, respectively‐significantly higher than the 44.3%, 18.5%, and 18.5% rates in patients without hepatectomy (p<0.05). Furthermore, cumulative survival rates were higher for hepatectomy patients with resection of the caudate lobe than for those without resection of the caudate lobe. The results indicate that hepatectomy improves prognosis because cancer frequently invades the surgical margins in these tumors, although postoperative morbidity is higher with this procedure. Hence for poor‐risk patients (e.g., the elderly, those with poor hepatic functional reserve), caudate lobectomy with or without hilar hepatectomy may be the procedure of choice.
Extension of surgical indications for hepatocellular carcinoma by portal vein embolization
Authors: Lee Kwang Choon , Kinoshita Hiroaki , Hirohashi Kazuhiro , Kubo Shoji , Iwasa Ryutaro
Published: May 2005

We studied, clinically and experimentally, hypertrophy of the part of the liver not embolized after portal vein embolization (PVE). The subjects of the clinical study were 29 patients with hepatocellular carcinoma (HCC) who underwent embolization of the right first portal branch; 19 patients had cirrhosis, and 10 did not. The volume of the liver was calculated from computed tomograms obtained before PVE and 2 weeks after. In all patients, the volume of the nonembolized (left) lobe increased significantly. For the experimental study, we used male Wistar rats. Normal rats were untreated, and in the other rats cirrhosis was induced with carbon tetrachloride. The portal branch that supplies 70% of the total volume of the liver was embolized. The rats underwent one of four procedures: 70% PVE, 70% portal vein ligation, 70% hepatectomy, or laparotomy only. Rats were killed at different times after surgery, and the livers were removed and weighed. The mitotic index and DNA synthesis were measured in the nonembolized lobe (PVE group), in the lobe not supplied by the ligated branch (ligation group), or in the remaining liver (hepatectomy group). The liver weight, mitotic index, and DNA synthesis were high in the PVE, ligation, and hepatectomy groups for both normal rats and rats with cirrhosis. PVE caused cell proliferation and hypertrophy in the nonembolized part of the liver in the normal rats and even in those with cirrhosis. We concluded that PVE can extend the surgical indications for patients with HCC and underlying cirrhosis.
Total pancreatectomy for ductal adenocarcinoma of the pancreas with special reference to resection of the portal vein and multicentric cancer
Authors: Launois B. , Franci J. , Bardaxoglou E. , Ramee M. P. , Paul J. L. , Malledant Y. , Campion J. P.
Published: May 2005

Between March 1, 1968 and March 1, 1986, 323 patients underwent surgery for cancer of the pancreas or the periampullary region. Extirpative procedures were performed in 91 patients, of whom 51 had ductal carcinoma of the pancreas. Forty‐seven patients had total pancreatectomy, 9 associated with resection of the portal vein and 1 with total gastrectomy. Operative mortality was 15% but fell to zero for the 19 total pancreatectomies performed after 1981. With the introduction of total pancreatectomy, the resectability rate increased from 15% to 32%. Overall mean survival was 14.4 months. Actuarial survival was 42.4% at 1 year, 25.6% at 2 years, 11.9% at 3 years, and 8% at 5 years. Six patients are alive 7, 11, 14, 30, 30, and 73 months, respectively, after operation. Survival was calculated according to the classifications of Hermreck, Tryka and Brooks, and the TNM system. Ductal carcinoma was multifocal in 32% of patients, and 25% had epithelial dysplasia of the pancreatic duct. When portal vein resection was necessary, mean survival was 6.1 months, compared with 18.25 months when it was not performed. We conclude that total pancreatectomy has increased our resectability rate, mainly in patients with tumor spread beyond the usual margins of division for Whipple's procedure. However, the procedure does not appear worthwhile when portal vein resection is necessary or when multicentric cancer or neoplastic emboli are observed in the operative specimen.
Sclerotherapy for emergency variceal hemorrhage
Authors: Terblanche John
Published: May 2005

This report emphasizes the importance of emergency endoscopy in the diagnosis of suspected variceal hemorrhage and reviews the role of sclerotherapy at the time of the initial diagnostic endoscopy. With actively bleeding varices, initial control with vasopressin and/or balloon tube tamponade is preferred. Sclerotherapy has been successfully performed by injecting sclerosants intravariceally, paravariceally, or by a combined technique. The best sclerosant to use and the ideal timing of emergency sclerotherapy is as yet unresolved. Successful results have been achieved in Cape Town with intravariceal injections using the rigid endoscope under general anesthesia and recently with a combined technique using a flexible endoscope without an anesthetic. The rare failures of sclerotherapy should be identified early and treated surgically. Injection sclerotherapy is currently the best management for patients who present with proven continued active variceal bleeding. More extensive procedures are unjustified in patients in whom a simple measure such as sclerotherapy is effective in controlling acute variceal bleeding.
Bleeding esophageal varices
Authors: McDermott William V.
Published: May 2005

Bleeding esophageal varices remain a major problem which has not been solved despite the number of ingenious and imaginative efforts to control and prevent hemorrhage through a variety of surgical, radiologic, pharmacologic, and endoscopic techniques.

A surgically constructed portal systemic shunt still remains the most effective method of permanent control, but the high morbidity and mortality rates have led to efforts to explore other types of therapy. Variations of shunt surgery, such as the selective procedure described by Warren, are promising as are types of portal azygous disconnections and transections.

There has been a revival of endoscopic sclerosis of varices stimulated by the development of more sophisticated equipment. Radiologic obliteration of the coronary vein and other portal systemic collaterals is under evaluation.

In the face of the catastrophic emergency of exsanguinating hemorrhage, balloon tamponade is the most effective means of temporary control prior to definitive therapy in those patients who have not responded to other conservative approaches such as vasopressin or pituitrin. Success is primarily determined by the degree of hepatocellular function, and biochemical evaluations such as amino‐acid tolerance appear to be more predictive than the simpler and widely used Child's classification which has been the yardstick for 3 decades.

In short, the multiplicity of recommended methods of therapy indicates the lack of unanimity and thus the absence of a single universally accepted algorithm for management of this difficult and multifactorial clinical problem.
Injection sclerotherapy for the long‐term management of variceal bleeding
Authors: Westaby David , Williams Roger
Published: May 2005

Injection sclerotherapy for the long‐term management of variceal bleeding is discussed with particular reference to our experience at King's College Hospital. The important questions of which techniques to use, which sclerosing agent to inject, the timing of the first and subsequent treatments, and the periods between follow‐up endoscopic examinations are reviewed. The efficacy of sclerotherapy both with respect to rebleeding and survival are assessed on the basis of 2 completed controlled trials and a third study from which preliminary data are available. A possible role for the prophylatic use of sclerotherapy in selected high‐risk patients is discussed. The complications associated with sclerotherpy are detailed and attention is drawn to the very low mortality rate of the procedure.
Esophageal transection with paraesophagogastric devascularizations (the Sugiura procedure) in the treatment of esophageal varices
Authors: Sugiura Mitsuo , Futagawa Shunji
Published: May 2005

The Sugiura procedure was performed in 671 patients with esophageal varices. Of these, 203 (30%) had prophylactic, 363 (54%) had elective, and 105 (16%) had emergency procedures. Portal hypertension was due to liver cirrhosis in 495‐alcoholic in 52 and cryptogenic in 443‐idiopathic portal hypertension in 100, extrahepatic portal vein occlusion in 39, hepatoma in 23, schistosomiasis in 4, Budd‐Chiari syndrome in 3, and other causes in 7. Operative mortality rate was as follows: emergency, 13.3%; elective, 3.0%; prophylactic, 3.9%; overall, 4.9%. The operative mortality rate by Child's classification was 0% for 244 class A patients, 2% for 251 class B patients, and 16% for 176 class C patients. There were no operative deaths in prophylactic cases of class A and B. The 10‐year actuarial survival rate in patients with liver cirrhosis was 55% in emergency cases, 72% in prophylactic cases, and 72% in elective cases. The similar survival rate in patients without cirrhosis was 90% in emergency cases, 96% in prophylactic cases, and 95% in elective cases. The incidence of recurrent variceal bleeding was only 1.5%, and 5.2% had recurrent varices. There was no postoperative variceal bleeding in prophylactic cases. Five class C patients with suture insufficiency developed empyema and died. Our procedure is safe and effective in controlling esophageal varices and able to prolong the long‐term survival.
Splenic artery and coronary vein occlusion for bleeding esophageal varices
Authors: Del Guercio Louis R. M. , Hodgson W. John B. , Morgan Jean C. , Berman Howard L. , Kinkhabwalla Mahesh N.
Published: May 2005

Fifty consecutive, unselected, endoscopically confirmed patients with bleeding esophageal varices received splenic artery and coronary vein occlusion as their primary treatment. This was accomplished surgically in the first 30 patients and by interventional angiography in the last 20. The in‐hospital mortality rate was 22% and the actuarial 5‐year survival rate was 52%. The incidence of recurrent gastrointestinal bleeding from all causes was 43.6% with a mortality rate of 13%.

The mean decrease in portal pressure was 8.5 cm H2O, and subsequent angiograms in 14 survivors revealed significant increases in the diameter of the proper hepatic artery, and decreases in the diameter of the portal vein. Hepatic function improved in 10 of the 32 Child's class B cirrhotics. The increase in the blood platelets of the survivors was statistically significant when compared with the decline in those who died.

The long‐term results of splenic artery and coronary vein occlusion, performed surgically or angiographically, compare favorably with other methods used to control bleeding esophageal varices.
An update of portal systemic shunting and its complications
Authors: Voorhees Arthur B. , Price John B.
Published: May 2005

A clinical retrospective review of 66 patients with portal hypertension who were surgically treated with portal systemic shunting, during a 6‐year period, is presented. Some broad comparisons can be made with a similar review undertaken in 1970. Portal systemic shunting is currently being performed with less frequency, enjoys less popularity as a primary form of therapy, and is reserved for patients in an advanced stage of the disease. The operative mortality rate has understandably risen to over 30% as a result of the shift toward treating surgically only severely ill patients. The degree of liver function impairment is the most important factor for survival; shunt type plays but a minor role. Portal systemic encephalopathy is probably present in all patients and its severity is determined by numerous variables.
Surgical management of patients with the Budd‐Chiari syndrome
Authors: Sanfey Hilary , Boitnott John K. , Cameron John L.
Published: May 2005

Twelve patients with the Budd‐Chiari syndrome were managed surgically at The Johns Hopkins Hospital over a 10‐year period. Ten patients were female and 2 were male. Nine were white, 2 were black, and 1 was Asian. Three patients had polycythemia vera, one had paroxysmal nocturnal hemoglobinuria, and one was taking estrogens. The diagnosis was confirmed in all 12 patients by liver biopsy and angiography. Five patients had a patent inferior vena cava and underwent a mesocaval shunt. There were 2 hospital deaths in this group. Ascites redeveloped in 1 patient and was controlled with a Le Veen shunt. The remaining 2 patients did well, are ascites free, and have angiographically demonstrated patent shunts. Histological findings in these 2 patients showed the condition of the liver to have improved markedly. Seven of the 12 patients had occlusion of the inferior vena cava due to thrombosis (6) or compression by the enlarged liver (1), and underwent mesoatrial shunts. There were 2 hospital deaths in this group. One late death occurred from liver failure following thrombosis of the entire mesenteric venous system. Ascites redeveloped in another patient and was controlled with a Le Veen shunt. The remaining 3 patients did well and were demonstrated angiographically to have patent shunts. Two of the 3 patients redeveloped ascites at 4 and 10 months postoperatively and required a second mesoatrial shunt. They are now ascites free, with angiographically demonstrated patent shunts 10 months and 12 months, respectively, following their second operation. The follow‐up for the 6 patients still alive ranges from 15 to 74 months.
The distal splenorenal shunt: An update
Authors: Henderson J. Michael , Millikan William J. , Warren W. Dean
Published: May 2005

The distal splenorenal shunt (DSRS), as the prototype for selective variceal decompression, has evolved over the 17 years since its introduction. Attention to detail in the preoperative assessment and perioperative management will minimize morbidity. Reported experience from over 25 centers has shown an average overall operative mortality rate of 9%, shunt patency and bleeding control rates in excess of 90%, encephalopathy in from 0 to 18% of cases, and a 5‐year survival rate between 50 and 60%. Non‐alcoholic cirrhotics (70–80%) have a significantly (p< 0.05) greater 5‐year survival rate than do alcoholic cirrhotics (45%). The 6 prospective randomized trials comparing DSRS to total portal systemic shunts have been conducted primarily in alcoholic cirrhotics; they show no significant difference in survival. Current experience in schistosomiasis and portal vein thrombosis shows selective variceal decompression to be superior to total shunt. Quantitative data prior to and 1 year after DSRS show a fall in liver volume, stabilization of hepatocyte function, and variable change in hemodynamics: alcoholic cirrhotics have a 70% chance of losing portal venous flow, while nonalcoholics maintain portal perfusion. Loss of portal venous flow is associated with a systemic hyperdynamic response in those with poorer hepatocyte function. Splenopancreatic disconnection is currently being studied in an attempt to maintain portal perfusion better and preserve liver volume. We conclude that the DSRS has achieved its pathophysiological goals of preventing recurrent variceal bleeding, while maintaining hepatocyte function. Modifications in management and the operative procedure are evolving from increased understanding of the pathology of the underlying causes of the portal hypertension leading to variceal bleeding.
Factors influencing survival after distal splenorenal shunt
Authors: Zeppa Robert , Hutson Duane G. , Levi Joe U. , Livingstone Alan S.
Published: May 2005

Prospective study of 206 patients treated by distal splenorenal shunts for esophagogastric hemorrhage due to portal hypertension reveals a probability of survival at 6 years of 0.53. The actuarial analyses show a marked difference in survival between alcoholic patients (0.39) and non‐alcoholics (0.68) during the same interval. In the latter group, those patients with stable liver disease had a probability of survival of 0.78.

The leading causes of death for alcoholic patients were liver failure, liver cancer, and trauma. In the nonalcoholic group, there were two leading causes: liver failure and complications of arteriosclerosis.
Surgical treatment of portal hypertension in schistosomiasis
Authors: Raia Silvano , Mies Sergio , Macedo Antonio Luiz
Published: May 2005

Patients with mansonic schistosomiasis and portal hypertension are usually young, with good liver functional reserve, huge splenomegaly, and hypersplenism detectable only by alterations seen in laboratory tests. Patients who are not operated on do not develop portosystemic encephalopathy (PSE). Angiographic alterations are characteristic and totally different from those observed in patients with liver atrophy or cirrhosis. Digestive tract hemorrhage is the most severe complication. The patient with schistosomiasis is, therefore, a good model for the study of the consequences caused by the surgical treatment of portal hypertension. The evaluation, however, of results published in the literature regarding schistosomiasis is practically impossible. In a review of 130 publications referring to 4,516 surgically treated patients, the absence of prospective or retrospective studies with adequate controls was observed, and only 3.2% of the patients were followed for 5 years. According to available data, a total of 29 different surgical techniques has been employed, 81.6% of which are represented by simple splenectomy, esophagogastric devascularization (EGDS), and splenorenal shunt (SRS). Splenectomy was the surgical procedure showing the highest rate of recurrent hemorrhage (54.3%), and the portocaval shunt had the highest PSE incidence (60%). Portosystemic encephalopathy incidence after SRS was 29%. Thus, in view of a lack of objective information, in 1977 our group started a prospective, randomized study comparing the results of the surgical procedures most widely used in our country: selective portal decompression (SPD), EGDS, and SRS. The randomization was interrupted after 94 patients had been operated on (32 SRS, 30 SPD, and 32 EGDS) because of a highly significant PSE incidence in the SRS group. Preliminary results as of January, 1984, refer to an average follow‐up period of 53 months (minimum 29, maximum 77 months). In the SRS group, the late mortality rate was 18.7%, and the incidence of PSE was 31.2%. Among the patients included in this group, 18.7% had arterial hypertension. In the SPD group, late mortality occurred in 10% of the cases, and PSE in 13.3%, while a mild hyperbilirubinemia was seen in 43.3% of patients. Recurrent hemorrhage and ascites had an approximately similar incidence in the 3 groups.
Hepatic secondaries: Minimal tumor and resectable tumor
Authors: Little J. M.
Published: May 2005

Fifteen patients undergoing hepatic resection for secondary tumor, mostly of colonic origin, have been compared to 9 with unresectable secondaries of low volume. There were no statistically significant differences in age or sex distribution between the groups. The Karnovsky index was 90 or better in those with unresectable tumor at the time of laparotomy for diagnosis and staging. Patients undergoing liver resection fared much better than those with unresected disease. Three and five‐year survival rates were both 49%, and there were no operative deaths. No patient in the unresected group has survived for 3 years. The improved prognosis noted in patients undergoing resection of liver metastases does not depend on tumor volume at the time of laparotomy. There is evidence that hepatic resection can influence favorably the prognosis of individual patients.
Surgical management of esophageal diverticula
Authors: Fegiz Gianfranco , Paolini Antonio , De Marchi Carlo , Tosato Filippo
Published: May 2005

The therapy of esophageal diverticula has not yet been defined, even if our knowledge of the functional alterations involved seems to have clarified the pathogenesis of this disease. The objective of this study was to verify the results of surgical therapy carried out following physiopathological criteria.

Out of 49 patients seen with esophageal diverticular disease, 18 had cervical diverticula, 9 had epibronchial diverticula, and 22 had epiphrenic diverticula. Thirty‐one patients had an operation performed: 15 had a diverticulectomy only, 13 had a diverticulectomy with subdiverticular myotomy, and 3 had a subdiverticular or Heller myotomy plus a Nissen procedure. There was no operative mortality. Three patients operated on for epiphrenic diverticula developed an intrathoracic esophageal fistula which healed spontaneously. One patient who had a cervical diverticulectomy developed a recurrence.

Long‐term results in 29 cases were good. In 2 cases the results could be considered as poor (recurrence, persistent dysphagia).

It is concluded that the most effective surgical procedure for esophageal diverticula is to be chosen for each patient on the basis of an accurate preoperative functional study.
Intraoperative irradiation combined with radical resection for cancer of the head of the pancreas
Authors: Hiraoka Takehisa , Watanabe Eiji , Mochinaga Mizuho , Tashiro Seiki , Miyauchi Yoshimasa , Nakamura Ikuo , Yokoyama Ikuzo
Published: May 2005

Since December, 1976, intraoperative irradiation combined with resection for cancer of the head of the pancreas has been used in our clinic to prevent local recurrence. Thirty Gy of the electron beam from a linear accelerator were administered to the operative field including the celiac axis and mesenteric artery following pancreaticoduodenectomy. Results of the combined therapy in 12 patients were compared to results in 12 patients who underwent pancreaticoduodenectomy alone. The combined therapy group compared to pancreaticoduodenectomy alone showed improvement in the 1‐year survival rate, but not in the 2‐year survival rate. Autopsy of 3 paients who underwent the combined therapy did not reveal any involvement of the lymph nodes in the irradiation field. However, there was involvement of the lymph nodes around the aorta from the diaphragm above to the inferior mesenteric artery below (except in the irradiation field). Additionally, there were metastases to the liver in all autopsied patients and recurrence in the pancreatic remnant in 1 patient. In spite of the local effect of irradiation therapy, there was no prolongation of survival. These results suggest that treatment for carcinoma of the head of the pancreas should be intensified toward liver metastases and the lymph nodes around the aorta from the diaphragm above to the inferior mesenteric artery below.
Clinical significance of intraoperative sonography on hepatectomy in primary carcinoma of the liver
Authors: Igawa Sumito , Kinoshita Hiroaki , Sakai Katsuji
Published: May 2005

The development of diagnostic equipment for sonography has not only caused a marked improvement in the preoperative diagnostic rate of primary carcinoma of the liver, but also has enabled us to conduct sonography during operations.

During the past 2 years, intraoperative sonography was used in 41 cases of primary carcinoma of the liver. The main tumor was detected in 39 patients (95.1%), and daughter tumors were detected in 14 (63.6%) out of the 22 who had them. Tumor thrombi in the portal vein were detected in 2 (50%) of the 4 patients in whom they occurred.

Since intraoperative sonography can clearly demonstrate intrahepatic ductal structures, it is useful for identification of hepatic and portal veins and the subsegment containing tumors (by a sonographically guided puncture). Of the various kinds of medical imaging available to us, intraoperative sonography is the final diagnostic procedure used before the last details of the operation are decided.
Long‐term evaluation of patients treated by radical operation for carcinoma of the thoracic esophagus
Authors: Nishihira Tetsuro , Watanabe Toshio , Ohmori Norio , Kitamura Michihiko , Toyoda Tsuneo , Hirayama Katsu , Kawachi Saburo , Kuramoto Jun ‐ichi , Kanoh Tadamichi , Akaishi Takashi , Sekine Yoshito , Kasai Morio
Published: May 2005

During the past 19 years, resection has been performed on 457 (72.9%) of 627 patients with carcinoma of the thoracic esophagus; curative resection was done in 388 patients. Among the 259 (57%) patients who underwent reconstruction through the retromediastinal space, thoracic esophagogastrostomy accounted for 181 and interposition of jejunal segments between the thoracic esophagus and the stomach accounted for 78 patients. Among the 171 (37.4%) patients who underwent reconstruction through the retrosternal space, there were 110 with esophagogastrostomy, 57 with interposition of jejunal segments, and 4 with colonic segments between the esophagus and the stomach. Comparing the reconstructive organs or the reconstructive routes used, there were no significant differences in the incidences of pulmonary complication, leakage, or operative death.

Among the patients who tolerated curative surgery, the 5‐year and 10‐year survival rates were 31% and 23.1%, respectively. Comparing operative procedures, there were no significant differences in survival rates. Reconstruction was also performed in postgastrectomized patients using jejunal segments.

There was a considerable number of complaints of passage failure and reflux esophagitis such as heartburn among patients who underwent esophagogastrostomy performed in the thoracic cavity, even 5 years after surgery.

The performance status of patients in whom jejunal segments were used was better than that of patients in whom gastric tubes were used.
Intrabiliary rupture of the hydatid cyst of the liver
Authors: Dadoukis Johannes , Gamvros Orestis , Aletras Homeros
Published: May 2005

During the last 20 years, 265 patients underwent surgery for liver echinococcosis. Forty‐five (17%) had frank rupture of the hydatid cyst into the intrahepatic bile ducts. The most common clinical manifestations were colicky right hypochondrial pain and obstructive, jaundice accompanied by fever and chills. A correct preoperative diagnosis was made in 35 patients, based mainly on the history, clinical manifestations, and laboratory findings. In the remaining 10 patients, the diagnosis was established at operation. The parasitic cyst was removed and the common bile duct explored in all patients. The latter was usually drained with a T‐tube, except for 3 patients in whom a choledochoduodenostomy was performed. The residual cyst cavity was drained in most patients with a Pezzer catheter and closed following partial pericystectomy. Our results were satisfactory. There was only 1 death due to suppurative cholangitis.
Preoperative radiotherapy in rectal cancer
Authors: Duncan William
Published: May 2005

A review is made of the clinical experience of preoperative radiotherapy in patients with operable cancer of the rectum or rectosigmoid. The randomized clinical trials that have been reported are evaluated. It is concluded that preoperative irradiation using a dose of no less than 34.5 gray in 15 daily fractions [Nominal Standard Dose (NSD) 1,290] can reduce locoregional recurrences and improve disease‐free survival. Doses of this order are not associated with any significant increase of morbidity. The administration of lower doses has not been confirmed to be of any benefit.

It is suggested that patients with fixed or partially fixed cancers of the rectum or rectosigmoid should be selected for preoperative adjuvant radiotherapy. This group has a low probability of undergoing curative resection without adjuvant treatment. Local recurrence is high and survival poor in this group of patients.

Patients with mobile cancer of the rectum should probably proceed to definitive resection and be considered for postoperative radiotherapy (perhaps combined with chemotherapy) if found to have Dukes' stage B or C cancer. This policy also minimizes the probability of irradiating patients with Dukes' A cancer who are unlikely to benefit from such adjuvant treatment.