bluuebunny/crossref_metadata_2025 huggingface dataset:
Stress ulcer disease in the burned patient
Authors: Pruitt Basil A. , Goodwin Cleon W.
Published: May 2005

Stress‐induced ulcers of the stomach and duodenum in massively burned patients, otherwise known as Curling's ulcers, result from a defect in the mucosal barrier to secreted acid. The etiology of this defect is related, at least in part, to mucosal ischemia, which is aggravated by hypotension, sepsis, and hypoxia. Early prophylactic administration of antacids and cimetidine, either singly or in combination, has significantly reduced the occurrence of the life‐threatening complications of these lesions. When preventive measures have failed or have not been utilized and massive bleeding or perforation has occurred, these complications of Curling's ulcer appear to be best treated by gastric resection combined with vagotomy.
Methods of prophylaxis in stress ulcer disease
Authors: Priebe Hans ‐Joachim , Skillman John J.
Published: May 2005

Although infrequent, acute upper gastrointestinal bleeding is potentially life‐threatening for critically ill patients. Gastric erosions can be detected endoscopically in almost all seriously ill patients. Although gastric acid plays a key role in the pathogenesis of acute gastric erosions, mucosal integrity is very much dependent on mucosal permeability, gastric blood flow, the secretory state of the mucosa, and acid‐base balance. Various agents that affect any of these physiological processes such as vitamin A, carbenoxolone, gastrin, vasoactive agents, sodium bicarbonate, and anticholinergic drugs have been used experimentally or clinically in the prevention of stress ulcerations. However, no controlled clinical trials are available. The effectiveness of antacids in the prevention of acute stress ulceration in critically ill patients has been documented in controlled, prospective trials. The effectiveness of the histamine H2‐receptor antagonist cimetidine remains controversial; it is less effective in critically ill patients of the type usually encountered in a respiratory‐surgical intensive care unit but it may be effective in selected groups of patients with head and thermal injury. Prostaglandins have been evaluated increasingly for their cytoprotective effects on the gastric mucosa. Clinical trials are needed to evaluate their effectiveness in the prevention of stress ulcers.
Evaluation of extensive lymph node dissection for carcinoma of the stomach
Authors: Kodama Yoshifumi , Sugimachi Keizo , Soejima Kazuhiko , Matsusaka Toshimitsu , Inokuchi Kiyoshi
Published: May 2005

We compared the results of curative resection for carcinoma of the stomach in 254 patients who underwent simple resection (SR) and 454 patients who underwent extensive regional lymph node dissection (ELD). The 5‐year survival rates of the 2 procedures were significantly different in carcinoma involving the serosa of the stomach; it was 45% in the ELD group and 18% in the SR group (p<0.001). In patients with regional lymph node metastasis we obtained a 5‐year survival rates of 39% and 18% by ELD and SR, respectively (p<0.001). The incidence of metastasis to the secondary lymph nodes, removable only by ELD, was higher in cases with carcinomatous invasion of the deeper layers of the gastric wall, and this may have been the reason why ELD proved to be more effective than SR. ELD is discussed in relation to the site of the primary carcinoma and the extent of lymph node metastasis.
Results of resection of carcinoma of the esophagus and cardia in 196 patients
Authors: Orel Janez J. , Eržen Janez J. , Hrabar Bogomir A.
Published: May 2005

During the period 1962–1976, 196 patients were operated on for carcinoma of the esophagus (51) and cardia (145). In all patients resection with primary esophagogastrostomy or esophagojejunostomy was performed. Metastases involving the regional lymph nodes were found in 54.2% of patients. The early postoperative mortality rate was 21.9%. The most common cause of death was leakage at the esophagogastric anastomosis (46.5% of deaths). Mean survival period was 16.2 months, overall 5‐year survival rate was 18.7%, and 5‐year survival rate excluding early post‐operative mortality was 21.7%. Mean survival period in patients who had resection of the esophagus with negative lymph nodes was 13.5 months and in those with positive nodes was 8.1 months. Mean survival time in patients after resection of the cardia was 19.7 months if nodes were negative and 8.2 months if nodes were positive.

The most frequent cause of late death was advanced cancer and distant metastases. Postoperatively, most patients were able to adopt their previous mode of life. All living patients but 1 are ambulatory, 2/3 perform work that is the same as or easier than that prior to the onset of the illness, they have no difficulty in consuming food, and are physically fit. The most common side effect was heartburn due to reflux esophagitis.
Results of partial and total pancreaticoduodenectomy in 117 patients with chronic pancreatitis
Authors: Gall F. P. , Mühe E. , Gebhardt C.
Published: May 2005

This is a report of 117 pancreaticoduodenectomies performed for chronic pancreatitis, of which 49 were partial and 68 were total. The operative mortality rate of partial pancreaticoduodenectomy was 8.2% and of total pancreatectomy was 20.6%. During a follow‐up period of 6 1/2 years, 76% and 63% of the surgical patients, respectively, continued to drink alcohol as heavily as before. Prior to total pancreatectomy, only 42% of the patients had diabetes. After total extirpation of the organ, all had diabetes and 75% were very difficult to stabilize with insulin, experiencing repeated episodes of hypoglycemic shock. The additional late mortality rate was 20.4% following partial pancreaticoduodenectomy and 19.1% after total resection. After total pancreatectomy, 50% of the late deaths were due to hypoglycemia. After total pancreatectomy, 11% fewer patients were still alive at the end of the follow‐up period than after partial pancreaticoduodenectomy. Total pancreatectomy is justified only in patients who already have diabetes requiring insulin. A new technique is described in which, following resection of the head of the pancreas, the duct system is occluded by injection of a rapidly hardening amino acid solution, leading to atrophy of the excretory pancreas within a few weeks. This procedure has been carried out in 39 patients with a mortality rate of 2.5% and postoperative complications in 7.6%. We believe that the immediate risk of partial pancreaticoduodenectomy in chronic pancreatitis can be decreased markedly and the late results improved by this new technique.
Treatment of bleeding typhoid ulcer of the terminal ileum and cecum
Authors: Eggleston F. C. , Santoshi B.
Published: May 2005

Over a 16‐year period, 12 patients were operated upon for bleeding typhoid ulcers of the terminal ileum or cecum with a mortality rate of 17%. Bleeding typhoid ulcer occurred in 0.8% of patients hospitalized for typhoid fever. Males predominated and 1/2 of the patients were in the third decade of life. If bleeding is massive or persistent, early surgery is advocated.
Benign breast disease: The cost of the service and the cost to the patient
Authors: Baum Michael
Published: May 2005

The patients attending a hospital breast clinic during 1 year have been reviewed to assess the impact and cost of benign conditions. Four of 5 patients referred do not have cancer.

The cost to the patient lies predominantly in anxiety related to the possibility of cancer and, to a lesser extent, in cosmetic damage due to multiple biopsies.

Benign breast disease is a common problem that creates severe anxiety in many women and a heavy burden on an overstretched National Health Service. A policy of reeducating general practitioners when it is safe not to refer may reduce this problem. Cyst aspiration or needle aspiration cytology may reduce the burden to both the patient and the health service, while desensitization of women's groups and women themselves to the needs for breast self‐examination can also reduce this burden.
The endocrine basis of benign breast disorders
Authors: Dogliotti Luigi , Orlandi Fabio , Angeli Alberto
Published: May 2005

There is sound clinical evidence that many benign breast conditions, especially pain, nodularity, and cysts, are likely to have their pathogenesis in hormonal events during reproductive life. Yet the classical theories of persisting hyperestrogenism and luteal progestogen deficiency have not stood up to detailed investigation. Recent work has demonstrated the importance of dynamic hormonal changes and of chronobiological rhythms—daily, menstrual, and seasonal. Recent developments and findings are reviewed to point to the directions in which the basic etiology of these conditions is likely to be discovered.
Radiological evaluation of benign breast disorders
Authors: Gravelle I. H. , Lyons Kathleen
Published: May 2005

The radiological features of common benign conditions of the breast and the radiological procedures used in the investigation of benign breast disorders are presented.
Sclerosing adenosis
Authors: Preece Paul E.
Published: May 2005

The literature regarding sclerosing adenosis has been reviewed. The pathological and radiological aspects of this benign breast condition have been emphasized since they influence clinical practice.

Features of 43 patients diagnosed as having sclerosing adenosis have been reported. Cancer was suspected on mammography in 17, and 25 experienced breast pain. Thus, the lesion is important both as a mimic of malignancy and as a cause of mastalgia. The clinical and radiological features allow the condition to be suspected before biopsy, in which circumstance paraffin histology is greatly preferable to frozen section.
Benign breast disorders in nonwestern populations: Part I—Benign breast disorders in Chinese women
Authors: Alagaratnam Thevakaruna T. , Wong John
Published: May 2005

Experience with benign breast disorders has been analyzed in 3 nonwestern populations: Hong Kong, India, and Northern Nigeria. Similarities to and differences from Western experience are found, but of great interest are notable differences between these populations which, as yet, lack explanation. All show “fibroadenosis” and fibroadenoma as common conditions, but the frequency with which phyllodes tumor is diagnosed varies between different centers in India as well as between different racial groups. Tuberculosis is another interesting example—wide differences in the frequency of breast infection are found although tuberculosis itself is common in all 3 countries. The value of prospective studies was shown when mastalgia was studied in this way in India. Often considered a “Western” affliction, these authors have been able to study 112 cases of mastalgia and found it to be twice as common as cancer as a presentation. These differing experiences between populations have been little explored and must hold promise for unravelling some of the enigmas of benign breast disorders in all countries.
Benign breast disorders in nonwestern populations: Part III‐Benign breast disorders in Northern Nigeria
Authors: Onukak Etim E. , Cederquist Robert A.
Published: May 2005

Experience with benign breast disorders has been analyzed in 3 nonwestern populations: Hong Kong, India, and Northern Nigeria. Similarities to and differences from Western experience are found, but of great interest are notable differences between these populations which, as yet, lack explanation. All show “fibroadenosis” and fibroadenoma as common conditions, but the frequency with which phylloides tumor is diagnosed varies between different centers in India as well as between different racial groups. Tuberculosis is another interesting example—wide differences in the frequency of breast infection are found although tuberculosis itself is common in all 3 countries. The value of prospective studies was shown when mastalgia was studied in this way in India. Often considered a “Western” affliction, these authors have been able to study 112 cases of mastalgia and found it to be twice as common as cancer as a presentation. These differing experiences between populations have been little explored and must hold promise for unravelling some of the enigmas of benign breast disorders in all countries.
Aesthetic surgery for benign disorders of the breast
Authors: Carlson Grant , Bostwick John
Published: May 2005

Those benign breast disorders that are amenable to improvement by aesthetic surgery are discussed from the points of view of indications, techniques, and results.
Extracorporeal lithotripsy and combined surgical procedures in the treatment of renoureteral stone disease: Our experience with 2,955 patients
Authors: Rigatti Patrizio , Francesca Francesco , Montorsi Francesco , Consonni Paolo , Guazzoni Giorgio , Di Girolamo Valerio
Published: May 2005

From May, 1985 to August, 1987, a total of 2,955 patients with renoureteral stone disease presented at our institution and were treated either by extracorporeal lithotripsy alone or combined with percutaneous nephrolithotomy, ureteroscopy, or open surgery. Seventy‐three percent of patients were stone‐free at the 3 month follow‐up date while 22% presented with negative urine culture and small (less than 5 mm) asymptomatic fragments deemed susceptible to spontaneous discharge. The rate of major complications was extremely low (sepsis, 0.03% and major renal bleeding, 1.55%). The application of this multimodal therapeutic strategy allowed successful treatment in almost every case of renoureteral lithiasis with minor iatrogenic damage to the renal parenchyma.
Survival after vagotomy: Results of the Aarhus county vagotomy trial
Authors: Ditlevsen Søren
Published: May 2005

In order to investigate whether the previously found excess mortality in surgically‐treated patients with peptic ulcer might be due partly to the resections employed, a survival analysis was undertaken in 824 patients 8–13 years after different types of vagotomy. These patients had been submitted to selective gastric vagotomy with drainage, selective gastric vagotomy with antrectomy or parietal cell vagotomy with or without drainage for duodenal ulcer, pyloric ulcer, prepyloric ulcer, or combined ulceration during the period from 1972 to 1977.

A statistically significant excessive mortality was found for both sexes in the total material compared to the background population. Analysis of the material, subdivided according to the operative methods employed, revealed a significant excess mortality in men treated with selective gastric vagotomy and antrectomy, whereas the mortality rates were slightly and insignificantly raised in the nonantrectomy groups. No significant difference in the mortality could be demonstrated in relation to the site of the ulcers.

Analysis of the cause‐specific mortality revealed a significantly raised mortality from gastrointestinal diseases, including a significant excessive mortality in the subgroups of benign peptic ulcer and cirrhosis of the liver. Likewise, the death rate from accidents including the subgroup of suicide was significantly increased. The overall mortality from malignancies was insignificantly raised among patients, whereas cancer in the stomach was significantly increased. An increased mortality from cancer in the lungs and pancreas did not reach statistical significance. These findings are in reasonable accordance with other studies. A significantly increased mortality from gastric cancer has been usual, although not a constant finding after gastric resection. This study has shown, as the first substantial series, that gastric cancer rate is increased after vagotomy as well.
Highly selective vagotomy combined with cholecystectomy: Is there an increased risk of diarrhea?
Authors: Schein Moshe
Published: May 2005

The addition of cholecystectomy to truncal vagotomy and a drainage procedure increases the incidence and severity of postvagotomy diarrhea. This study attempts to establish whether diarrhea is more common after highly selective vagotomy (HSV) and cholecystectomy than after HSV alone. The incidence of diarrhea in 729 patients who underwent HSV without cholecystectomy was found to be 8.8% whereas, in 66 patients in whom HSV was combined with cholecystectomy, the incidence of diarrhea was 9.3%. In most patients, the diarrhea was very mild and in none was it severe. We conclude that the addition of cholecystectomy to HSV does not result in an increased incidence of diarrhea.
Central bisegmentectomy of the liver: Experience in 16 patients
Authors: Hasegawa Hiroshi , Makuuchi Masatoshi , Yamazaki Susumu , Gunvén Peter
Published: May 2005

Fourteen patients with hepatocellular carcinoma and mild to moderate liver dysfunction and 2 with metachronous liver metastases from rectal cancers underwent central bisegmentectomy of the liver, i.e., en bloc removal of the left medial and right anterior segments. One patient who had undergone preoperative liver artery embolization died in the hospital. Four patients survived without relapse 6–135 months postoperatively. Eleven patients had recurrent tumors, all in the liver remnant, and 2 also had recurrent tumors in the lungs. Six patients who relapsed died 28–93 months postoperatively. Four were alive with disease at 7–89 months, 1 after a second liver resection 54 months after central bisegmentectomy. Six of the 16 patients survived for 5 years or more. The results are favorable for these advanced tumors, often in the presence of liver dysfunction. The indications, technique, and results are discussed.
Perioperative antibiotic prophylaxis in cardiovascular surgery: A prospective randomized comparative trial of cefazolin versus ceftriaxone
Authors: Soteriou M. , Recker F. , Geroulanos S. , Turina M.
Published: May 2005

With a view of possible reduction in antibiotic dosage, several prospective randomized comparative trials performed in our institution showed that a 4‐day prophylactic antimicrobial regimen with cefazolin was equally effective as a 2‐day prophylaxis with cefuroxime and that the best regimen was equally as effective as a double dose of ceftriaxone prophylaxis in major cardiovascular surgery.

In this prospective randomized comparative study, 1‐day cefazolin prophylaxis (4×0.5 g intravenously) was compared with a single dose of ceftriaxone prophylaxis (2 g intravenously). Of the 900 patients enrolled in the study, 17 were subsequently excluded. Of the remaining 883 patients, 439 were in the cefazolin group and 444 were in the ceftriaxone group. The overall postoperative infection rate was 5.0% in the cefazolin group and 4.5% in the ceftriaxone group.

In view of the almost identical infection rates in both groups, we considered that a single 2 g dose of ceftriaxone offers patients a reliable antimicrobial prophylaxis. The single‐dose prophylaxis has the additional advantage of reducing the dosage administered and the costs of administration.
Tumoral calcinosis
Authors: Prasad V. L. N. , Naresh K. N. , Krishna S. R. Govind , Ananthakrishnan N. , Veliath A. J.
Published: May 2005

Tumoral calcinosis is an interesting clinical entity. It is not uncommon in certain countries. We report our experience with 22 patients with this condition seen over a 7‐year period and review in detail the modalities of clinical presentation, theories of etiogenesis, histological appearances, and treatment modalities.
Thyroxine suppressive therapy of benign solitary thyroid nodules: A prospective randomized study
Authors: Cheung Polly S. Y. , Lee Joseph M. H. , Boey John H.
Published: May 2005

Patients with solitary thyroid nodules that are benign on aspiration biopsy are often treated nonsurgically. To find out if thyroxine therapy is effective, 74 patients were randomized to receive levothyroxine treatment or nothing. There were 8 males and 66 females. Their mean age was 39 years. The mean nodule size was 3.6 cm and the mean nodule duration was 11 months. All patients had normal serum thyroxine and thyroid stimulating hormone (TSH) levels, and positive thyrotropin releasing hormone (TRH) tests. The dose of thyroxine was adjusted until the TRH test was negative. Patients were followed at 6‐month intervals in the first 2 years and yearly thereafter, with measurement of the nodule diameter. The mean follow‐up period was 1.5 years.

In the 37 patients receiving thyroxine therapy, 8 had disappearance of nodules, 6 had greater than 50% reduction in nodule size. In 19, the nodules were unchanged and in 4, the nodules were enlarged. In the 37 patients receiving no drug, 8 had disappearance of nodules, 5 had greater than a 50% reduction in nodule size, 17 had nodules unchanged, and 7 had enlarged nodules (p >0.9). The mean reduction in nodule diameter at various follow‐up periods was greater in the thyroxine group, but the difference did not reach statistical significance. Carcinoma was found in 1 patient in each group and both of them experienced nodule enlargement.

We conclude that an adequate suppressive dose of levothyroxine does not alter the natural course of benign solitary thyroid nodules. An enlargement of the nodule or a change in its consistency should be further investigated to exclude malignancy.
Cancer of the extrahepatic bile duct: A clinicopathologic study of immunohistochemistry for CEA, CA19‐9, and p21
Authors: Yamaguchi Koji , Enjoji Munetomo , Nakayama Fumio
Published: May 2005

A total of 86 patients with extrahepatic bile duct cancer (excluding intraduodenal bile ducts and the ampulla of Vater) selected from 422 patients with cancer of the biliopancreatoduodenal region were studied clinicopathologically. Significant parameters influencing the prognosis include histologic grade of differentiation, lymph node metastasis, perineural invasion, and immunohistochemical demonstration of carcinoembryonic antigen (CEA). Tumor cells had CEA, carbohydrate antigen 19‐9 (CA19‐9),and c‐Ha‐ras p21 antigen (p21) reactants in 75, 58, and 20 patients, respectively, of the 82 patients with bile duct cancer. Four tumors were classified as early bile duct cancers, showing a polypoid mass restricted within the bile duct wall. The patients with such early carcinoma were alive with the postoperative course ranging from 1 1/2 to 7 1/2 years.
The role of ultrasound, percutaneous transhepatic cholangiography, computed tomographic scanning, and magnetic resonance imaging in the preoperative assessment of bile duct cancer
Authors: Okuda Kunio , Ohto Masao , Tsuchiya Yukihiro
Published: May 2005

The diagnosis of bile duct carcinoma currently depends largely on radiographic imaging. Imaging provides certain information that is necessary for determining operability and the proper surgical procedure to be employed. In an early stage of bile duct carcinoma, elevated serum enzymes may be the only abnormality detectable, but once the mass has grown to cause sufficient stenosis along the biliary tract, serum bilirubin starts to rise. Differentiation of intra‐ and extrahepatic cholestases is the primary task of the gastroenterologist. The site and nature of the obstructing lesion must then be determined by means of imaging. This article deals mainly with the diagnosis of dile duct carcinoma through imaging, excluding the endoscopic procedure.
The role of preoperative biliary decompression in the treatment of bile duct cancer
Authors: Yanagisawa Jiro , Ichimiya Hitoshi , Kuwano Nagako , Nakayama Fumio
Published: May 2005

Usefulness of preoperative biliary decompression by percutaneous transhepatic biliary drainage (PTBD) in patients with obstructive jaundice remains controversial. We determined bile and bile acid outputs in patients with complete biliary obstruction following biliary decompression by PTBD. Bile and bile acid outputs correlated well with the decline index of serum bilirubin. Patients with a poor decline index tended to have low bile acid output in spite of high bile output, i.e., secretion of watery bile. Daily bile acid output reflecting daily bile acid synthesis remained low or increased only slowly in almost all cases, indicating that recovery of liver function is considerably delayed. We stress the importance of bile acid output as a function of bile acid synthesis as an index of the recovery of liver function. Although many studies comparing operative intervention alone and PTBD followed by operation have already been carried out, and because of the increasing use and greater safety of a 2‐staged approach with ultrasound‐guided PTBD, the advantages and disadvantages of preoperative PTBD should continue to be reevaluated with respect to technical improvement and a concomitant decrease in complications.
Resection or palliation: Priority of surgery in the treatment of hilar cancer
Authors: Bismuth Henri , Castaing Denis , Traynor Oscar
Published: May 2005

During the past 25 years, 213 patients with hilar cancer have been treated in this unit. One hundred seventy‐eight patients had some form of surgical intervention and 35 were unfit for any surgery. The preoperative and peroperative assessment of the 178 patients having surgery was directed toward identifying tumors which might be suitable for potentially curative resection. On this basis, 18 patients (10.1%) had tumor resection and the remaining 160 patients had a palliative procedure. When possible, some form of surgical bypass procedure was performed to achieve palliation (96 patients) but when this was either impossible or contraindicated, an intubation and drainage procedure was performed (64 patients). There was no operative mortality among the 18 patients having surgical resection (10 having local resection and 8 having hepatic resection). There was a complete disappearance of jaundice in all patients and the mean survival was 53 months with a mean duration of well‐being of 39 months. Among the 96 patients having surgical bypass, the operative mortality rate was 7%, and 20% of these patients had a postoperative complication. There was a complete relief of jaundice in more than 75% of these patients. The average survival time was 9 months with a duration of well‐being of 8 months. Among the 64 patients having intubation and drainage, the operative mortality rate was 30%, and 26% of these patients had postoperative complications. Less than half of these patients experienced a complete relief of jaundice. Although the average survival time was 7 months, the duration of well‐being was usually only 2–4 months. We conclude that surgical resection offers the best possibility of prolonged survival and the best quality of life for suitable patients with hilar cancer. The majority of patients are, however, suitable only for a palliative procedure and the best palliation is achieved by a surgical bypass procedure.
Skeletization resection and central hepatic resection in the treatment of bile duct cancer
Authors: White Thomas Taylor
Published: May 2005

We were able to carry out skeletization resection and central hepatic resection in 24 of 50 patients referred for treatment of Klatskin tumors. Thirteen of the 24 operations were primary. The other 11 patients had 14 prior operations. The average hospital stay was 18.4 days (including work‐up), ranging from 10 to 30 days. There were 3 postoperative deaths. The average survival of patients with lesions 14‐mm in diameter or less was 34 months, while the larger tumors averaged a 9‐month survival. Other factors such as blood vessel invasion, lymph node metastasis, and perineural invasion did not seem to be important in survival. The operative technique utilized is illustrated in this article.
Radical surgery for middle and distal thirds bile duct cancer
Authors: Nakayama Fumio , Miyazaki Kohji , Nagafuchi Kazumitsu
Published: May 2005

A total of 38 patients with middle and distal thirds bile duct cancer treated in our department during a period of 20 years were reviewed and analyzed in respect to the type of operative procedures employed and the long‐term results. The purpose of the study was to evaluate the impact of various recently available modalities for diagnosis and treatment on the prognosis of patients with these malignancies.

The longest mean survival was 22.8 months after resection and the shortest was 3.5 months after intubation. Resectability increased during the course of the study, especially for distal bile duct cancer, and reached 70% in the last 10 years. Either local excision of the bile duct or pancreatoduodenectomy was chosen as a radical operative procedure for middle bile duct cancer, however, curative resection was obtained only by the latter. Pancreatoduodenectomy was the only choice of radical treatment for distal thirds bile duct cancer. Postoperative morbidity decreased during the last 10 years and preoperative biliary decompression significantly improved the postoperative survival time.
Radical resection and liver grafting as the two main components of surgical strategy in the treatment of proximal bile duct cancer
Authors: Pichlmayr Rudolf , Ringe Burckhardt , Lauchart Werner , Bechstein Wolf O. , Gubernatis Gundolf , Wagner Ernst
Published: May 2005

In the treatment of adenocarcinoma of the proximal bile duct, our current strategy is to resect the tumor radically and to offer patients with unresectable tumors the chance of hepatic transplantation, if extrahepatic tumor growth is exluded. Tumor resection is performed by resection of the hilum alone or combined with partial hepatectomy. The latter procedure enables radical treatment of more advanced tumor stages and, eventually, a higher degree of radically is achieved, and is recommended. This concept is based on our experience with 108 patients with proximal bile duct carcinoma operated on between February, 1975 and October, 1986.

In 10 patients, no therapeutic or palliative surgical procedure could be performed during laparotomy because of advanced tumor stage. In 30 patients, various drainage procedures were performed. Fifty‐two patients underwent resection: 25 underwent resection of the hilum only, and 27 underwent resection of the hilum combined with partial liver resection. Twenty‐eight of these resections were classified as curative and 24 as palliative. Sixteen patients with unresectable tumors had hepatic transplantation. In 7 of these patients, extrahepatic tumor growth was already present at the time of liver transplantation.

Median survival times were: laparotomy only, 1 month; drainage procedures, 5 months; total resection, 15 months; curative resection, 23 months; palliative resection, 7 months; liver grafting, 16 months. Seven patients are alive up to 21 months posttransplantation. On the basis of favorable results in our more recent group of patients, liver grafting as the ultimate chance for tumor removal in patients otherwise treatable only by palliative drainage procedures may be justified.
Endoscopic retrograde drainage for bile duct cancer
Authors: Soehendra Nib , Grimm Horst
Published: May 2005

Endoscopic biliary drainage is a palliative measure. It is mainly indicated for inoperable malignant jaundice. Extrahepatic obstructions are suitable for the transpapillary decompression, which may be successful in 80–90% of patients. Morbidity and mortality rates are approximately 5% and 1–2%, respectively. Tumors of the hilum region, which usually already involve the intrahepatic ducts, are less eligible for drainage treatment. In the case of insufficient drainage, cholangitis may occur. A satisfactory decompression can only be achieved if both hepatic ducts are catheterized. Apart from the technique, the long‐term results of the drainage treatment also depend on the consistency of the follow‐up. A regular check of the patients is required because, after an average of 3 months, the biliary stent may be occluded, which is usually followed by cholangitis.
The role of chemotherapy in the treatment of bile duct cancer
Authors: Oberfield Richard A. , Rossi Ricardo L.
Published: May 2005

Cancer of the bile ducts continues to account for about 4,000 deaths yearly in the United States. Resection is often not possible, and overall survival is poor. In view of this, chemotherapy has been employed over the years in the hope of achieving enhanced response rates with increased survival. Despite the limitation of the approach, it does have a role as is indicated by a review of the literature. Systemic chemotherapy, employing such drugs as 5‐fluorouracil (5‐FU) and mitomycin C as single agents and the combination of 5‐FU with adriamycin and mitomycin C (FAM), resulted in a collective response rate of 29% (28 of 97 patients).

Regional infusion chemotherapy may have a special role as a more effective treatment for this disease, which is locally confined for long periods with dissemination only in the later stages. The blood supply to the bile ducts allows a high concentration of such drugs as 5‐FU, floxuridine (FUDR), and mitomycin C to be given over prolonged periods with enhanced response rates. A recent report of biliary sclerosis as a toxic effect from regional infusion by implantable pumps further corroborates the selective action of this treatment. The series from the literature show a collective response rate of 39% (15 of 38 patients) for regional infusion chemotherapy. This article should provide stimulation for further investigation of this method of treatment for bile duct cancer.
Diagnostic and prognostic utility of flow cytometric DNA measurements in follicular thyroid tumors
Authors: Grant Clive S. , Hay Ian D. , Ryan John J. , Bergstralh Erik J. , Rainwater Leslie M. , Goellner John R.
Published: May 2005

Distinguishing cellular follicular adenomas (FA) from minimally invasive follicular carcinomas (FC) continues to plague even experienced thyroid pathologists. DNA ploidy analysis has been promoted as a means of making this differentiation; however, the finding of DNA aneuploidy in FA has caused concern that they may demonstrate potential for malignant behavior or should even be reclassified as low‐grade noninvasive cancers. In histologically‐proven FC, nuclear DNA content has been claimed to have predictive power equivalent to that of all other prognostic factors combined. The aims of the present study, therefore, were to define the DNA ploidy characteristics of FA and FC, to assess the diagnostic potential of cell‐cycle parameters, and, in FC, to investigate the prognostic role of such measurements.

We measured DNA content of 124 tumors (60 FA, 64 FC). DNA pattern was normal (diploid) in 75% of FA and 45% of FC, tetraploid/polyploid (T/P) in 13% of FA and 25% of FC, and aneuploid in 12% of FA and 30% of FC. FC was histologically verified in 39% of DNA normal, 67% of T/P, and 73% of aneuploid tumors. DNA index, S‐phase, G2M, and S‐phase plus G2M were analyzed and were not helpful in differentiating between FA and FC. No patient with FA developed tumor recurrence. In FC (excluding the Hürthle cell variant), no significant differences were found among the 3 DNA ploidy groups with respect to either cancer death or tumor recurrence; however, combining the Hürthle cell variant of follicular carcinomas with pure follicular carcinomas, the presence of distant metastases, DNA aneuploidy, and patient age were the only independently significant prognostic variables. Based on these data, while not valuable for determining the presence of malignancy, DNA ploidy determination is of major prognostic value in follicular carcinomas (including the Hürthle cell variant).
Immunohistochemical reclassification of anaplastic carcinoma reveals small and giant cell lymphoma
Authors: Hölting T. , Möller P. , Tschahargane C. , Meybier H. , Buhr H. , Herfarth C.
Published: May 2005

Thirty‐one cases of thyroid malignancies which were originally classified as anaplastic carcinoma were reexamined immunohistochemically using PAP methods (peroxidase:antiperoxidase) for IgM, IgG, IgA, cytoceratin, calcitonin, lysozyme and alpha‐1‐antitrypsin. The reclassification results were compared with patient data such as clinical symptoms, treatment modalities, and clinical outcome. Postoperative radiotherapy was carried out in more than 80% of cases, chemotherapy in none. Seven of 31 tumors showed a positive staining for IgM (n=4), IgG (n=2), and IgA (n=1) antibodies. All of these cases were negative for epithelial markers. Surprisingly, not only all small cell tumors (n=3) but also 4 tissues with predominantly giant cell areas were among those reclassified as primary malignant lymphoma.
Sporadic unilateral adrenomedullary hyperplasia with hypertension cured by adrenalectomy
Authors: Dralle Henning , Schröder Sören , Gratz Klaus F. , Grote Reinhard , Padberg Barbara , Hesch Rolf D.
Published: May 2005

Adrenomedullary hyperplasia (AMH) with increased urinary excretion of epinephrine is regarded as the earliest adrenal manifestation in familial pheochromocytoma; however, pathogenetic mechanisms and morphogenesis involved in the development of sporadic adrenomedullary diseases are unknown as yet. We present 4 patients with clinical, biochemical, imaging, and morphological findings of sporadic unilateral adrenomedullary hyperplasia cured by unilateral adrenalectomy. All patients were hypertensive with intermittent hypertensive crises, and with increased catecholamine concentrations in urine and serum. Correct unilateral localization was achieved by 123‐I‐BG‐scan (planar and SPECT) (n=2) or cavovenous blood sampling with selective catheterization of both suprarenal veins (n=2). Histomorphometric analyses revealed diffuse adrenomedullary hyperplasia in all 4 specimens with significant increase of relative volume to 17.6% (controls, 8.7%), and of estimated medullary weight to 0.95 g (controls, 0.45 g); corticomedullary ratio (C∶M) was decreased to 5.4 (controls, 11.2). DNA histograms showed euploidy in all cases. In 3 patients, DNA analysis revealed evidence of cell proliferation, but without increase to grade of malignancy indices (0.101–0.523). Adrenalectomy was performed preferentially by a translumbar approach; the operative and postoperative course was uneventful in all 4 patients. Blood pressure without antihypertensive drugs returned to normal in 3 patients, in 1 patient to the upper normal limit.
Clinical significance of associated nodular lesions of the adrenal in patients with aldosteronoma
Authors: Ito Yukio , Fujimoto Yoshihide , Obara Takao , Kodama Takaya
Published: May 2005

Thirty‐seven patients with primary aldosteronism were treated by unilateral total adrenalectomy during a 7‐year period (1981–1987). The 37 patients were classified into 3 groups on the basis of adrenal pathology: unilateral solitary adenoma, 23 cases (group 1); unilateral adenomas, 3 cases (group 2); and adenoma with multiple macro‐ or microscopic nodules, 11 cases (group 3). The preoperative conditions of the patients (age, duration of hypertension, plasma renin activity, plasma aldosterone concentration, and serum potassium concentration), postoperative sequential changes of hormone levels, and outcome of hypertension were compared among the groups in order to determine whether the differences of adrenal pathology would affect the postoperative course. The preoperative parameters excluding age at surgery did not differ significantly among the 3 groups. The mean age in group 3, however, was slightly higher than in groups 1 and 2 (47.8 versus 42.8 versus 42.7 years).

Postoperative hormonal changes were also similar, particularly in groups 1 and 3, staying within the normal range throughout the follow‐up period (mean, 31 months; range, 3–86 months). However, postoperative improvement of hypertension showed marked differences, being significantl retarded in patients with multinodular lesions (group 3), about half of whom remained hypertensive even after 1 year. Nodular lesions other than adenoma(s) were, therefore, thought not to contribute to hormonal excess but to result from intractable hypertension.
Aberrant hormone production from ovarian neoplasms: Strategies for diagnosis and therapy
Authors: Leach Steven D. , LaMorte Annette I. , True Lawrence D. , Flynn Stuart D. , Schwartz Peter E. , Cahow C. Elton , Kinder Barbara K.
Published: May 2005

Syndromes involving peptide or nonsex steroid hormone secretion due to aberrantly located tumors are rare. We report a collected series of 16 patients with ectopic hormone production from ovarian neoplasms, including 3 patients recently encountered at our institution as well as 13 additional cases identified in the recent literature. These tumors included 2 insulin‐producing ovarian carcinoids, 1 ACTH‐producing pituitary adenoma within a benign ovarian cystic teratoma, 2 cortisol‐producing ovarian neoplasms, 8 gastrin‐producing ovarian cystadenomata or cystadenocarcinomata, and 3 thyroxine‐producing ovarian strumal carcinoids. All patients presented with syndromes of hormone excess. Only 62% of all tumors were localized preoperatively. Following ovarian resection, 87% of patients remained disease‐free with a median follow‐up period of 1.5 years. In addition to ovariectomy, 8 additional unnecessary ablative procedures were performed in 7 patients. These included distal pancreatectomy, pancreaticoduodenectomy, adrenalectomy, total gastrectomy, selective vagotomy, and subtotal thyroidectomy. Failure to localize the ovarian neoplasm preoperatively was associated with a significantly higher risk of subsequent unnecessary ablative procedures. Because of the potential for the ovary to act as a source of aberrant hormone secretion, we recommend complete preoperative evaluation of the pelvis in female patients presenting with nonlocalizable endocrine tumors.
Intraoperative and postoperative PTH secretion mode in patients with hyperparathyroidism
Authors: Fischer S. , Flentje D. , Kettelhack C. , Schmidt‐Gayk J. , Buhr H. , Herfarth C.
Published: May 2005

The development of a sensitive 2‐site immunoradiometric assay which detects only intact human PTH (1–84) enabled us to study kinetics of PTH secretion intraoperatively. In a prospective study, we assessed the PTH (1–84) secretion mode intraoperatively in 54 patients with adenomas, in 14 patients with tertiary hyperparathyroidism (HPT), and in 2 patients with persistent HPT. After the removal of adenomatous or hyperplastic tissue, a significant drop of PTH (1–84) concentration was seen. A 50% decrease in the basal PTH concentration was reached significantly earlier for adenomas than for hyperplasias. In the 2 cases with unrevealing neck exploration, the PTH (1–84) concentrations showed hardly any change. The recovery of PTH secretion was studied in 23 patients, 20 of whom had a single adenoma; in 2 cases, a hyperplasia was present and 1 patient showed the clinical signs of a toxic HPT. We found an initial drop of PTH concentration 4 hours postoperatively below the limit of detection and a rapid recovery within 24 hours postoperatively. The PTH concentration values were well within the normal range after 48–72 hours.
Study of intact (1–84) parathyroid hormone secretion in patients undergoing parathyroidectomy
Authors: Davies Charmian , Demeure Michael J. , John Andrew St. , Edis Anthony J.
Published: May 2005

Patterns of intact (1–84) parathyroid hormone (intact PTH) elimination and subsequent recovery of parathyroid function were studied in 12 patients undergoing parathyroidectomy. Nine patients had primary hyperparathyroidism (HPT), with single gland disease in 6 and multiple gland disease in 3. Two patients had subtotal parathyroidectomy for HPT secondary to chronic renal failure and 1 underwent excision of a hyperfunctioning parathyroid autograft. Using a sensitive 2‐site immunochemiluminometric assay, serum intact PTH levels were measured preoperatively, intraoperatively, and postoperatively. A dual phase pattern of hormone clearance was found in 10 of the 12 patients, including the patient undergoing autograft excision. A monoexponential clearance pattern was seen in the remaining 2 patients, both of whom had subtotal parathyroidectomies for multiple gland disease. In the patients with primary HPT due to single gland disease, the early phase of intact PTH clearance had a half‐life (T1/2) of 3.3 (±standard deviation 0.9) minutes and a late T1/2 of 96.4 (±standard deviation 92.7) minutes. Calculation of decay curves and half‐lives for the patients undergoing subtotal parathyroidectomy was more difficult because of the inherent uncertainty in determining time zero. Nevertheless, in all but 2 patients, the clearance pattern was biexponential and the T1/2 measurements were very similar to those encountered in patients with single‐gland disease. In the 2 patients with monoexponential clearance, the T1/2 figures were 86.7 minutes and 26.7 minutes, respectively. In the patients undergoing parathyroidectomy for primary HPT, levels of intact PTH were lowest at 1–3 hours after surgery, recovering to normal in the majority of patients by 18–40 hours.
Gastrinomas: A 42‐year experience
Authors: Kaplan Edwin L. , Horvath Keith , Udekwu Anthony , Straus Francis , Schark Claudia , Ferguson Donald J. , Skinner David B.
Published: May 2005

In 1947, a patient with metastatic islet cell tumor was treated for intractable ulcer disease at the University of Chicago Medical Center. Eight years later, in retrospect, it was recognized that he and another patient had the Zollinger‐Ellison syndrome (ZE). From 1947 until the present, 30 patients with the ZE syndrome have been treated at this institution. Twenty‐one (70%) were male and 9 (30%) were female. Their ages ranged from 24 to 76 years. Most (79%) had abdominal pain, however, melena (42%), hematemesis (33%), and severe diarrhea (35%) were prominent as well. Symptoms were present for a mean of 5.8 years before diagnosis. Over their entire clinical course, duodenal ulcers occurred in 96% of patients, gastric ulcers in 24%, jejunal ulcers in 29%, esophageal ulcers in 6%, and stomal ulcerations in 58%. Eleven (38%) of all gastrinomas were proved to occur in the duodenum; 10 (34%) were pancreatic in origin, including 3 with the MEN I syndrome; 3 (10%) were extrapancreatic and extraduodenal in origin, and no tumor was found in 5 (17%). Each of the 3 patients with MEN I developed a proven pancreatic islet cell carcinoma with metastases as well as hyperparathyroidism and a pituitary lesion.

Of 27 patients who were explored for gastrinoma, tumor was found in 20 (74%). Excluding patients with MEN who had multiple lesions throughout the pancreas, all tumors were found in the “gastrinoma triangle.” Total gastrectomy was performed in 10 (37%) of 27 of all patients who were explored, in 5 (71%) of 7 when no tumor was found, and in only 5 (25%) of 20 when tumor was present. Operative mortality was 15% (4 of 27), but no death has occurred since 1974. Long‐term survival has followed both tumor resection or total gastrectomy in selected individuals (including 1 patient with known multiple liver metastases who is alive 18 years after liver biopsy and total gastrectomy); however, since malignant gastrinomas were present in 46% of all patients (or 57% in whom tumor was found) and since local metastases can sometimes be removed, we favor an aggressive approach to localization and resection when liver metastases or other distant metastases are not found.

Duodenal gastrinomas are particularly favorable for resection for cure. They were malignant in only 36% and their metastases were nodal in each of 4 cases. The major problem is finding them since they are often small and “occult.” All patients with ZE should have duodenoscopy preoperatively and, at operation, a wide duodenotomy with eversion of the duodenal mucosa and careful inspection and palpation should be performed. Above all, surgeons should realize that at least 38% of all gastrinomas may be duodenal in origin. Finally, since the early 1970's when serum gastrin measurements became available, 43% of our patients who were explored have been returned to basal eugastrinemia.