bluuebunny/crossref_metadata_2025 huggingface dataset:
Polytrauma in the elderly
Authors: Marx Axel B. , Campbell Robert , Harder Felix
Published: May 2005

Twenty‐seven patients over 70 years old in a consecutive series of 300 patients (mean age 75.1 years) who had sustained polytrauma were compared to a group of 27 younger patients of that series (mean age 36.1 years) and were matched for similar patterns of injuries. The injury severity scores (ISS) were nearly equal in both groups. The amount of blood transfused, the shock index on arrival, the number of peritoneal lavages performed, and the number of chest drains inserted were similar in both groups. In general, the trauma‐causing injury in the older patients was substantially less severe than in the younger age group. Nearly all fractures were treated operatively in the younger patients, while equivalent fractures in the older group were more often treated conservatively. The greater mortality in the older patients was due to preexisting handicaps, which are disregarded by the ISS. Most of the older patients who survived could be satisfactorily rehabilitated. What causes and what are the injuries of the elderly polytrauma patient? How aggressive should the treatment be and to what degree is rehabilitation of survivors possible?
Acute volvulus of the right colon: An analysis of 69 patients
Authors: Anderson John R. , Welch George H.
Published: May 2005

Sixty‐nine patients with acute volvulus of the right colon have been analyzed; the overall mortality was 19%. Nonviable colon was present in 20 patients; the mortality rate in these patients was 40%. When the cecum is viable, a combination of simple cecopexy and tube cecostomy was as effective as resection in preventing long‐term recurrence. Cecopexy alone was followed by recurrence in 20%. In the presence of cecal perforation or a large area of confluent gangrene, resection with the formation of an ileostomy and a distal mucous fistula is the procedure of choice; resection with primary anastomosis should be avoided. When the gangrene is patchy, resection and primary anastomosis appears to be a safe procedure.
Stress ulceration: The clinical problem
Authors: Lucas Charles E.
Published: May 2005

As the ability to prolong life in severely traumatized patients increased, the incidence of clinically apparent upper gastrointestinal hemorrhage also increased. By 1970, it was recognized that the most common cause of such bleeding was so‐called stress ulceration, consisting of multiple, punctate, superficial erosions, confined initially to the proximal gastric mucosa. “Stress” ulcers develop in association with shock which requires massive transfusion, with certain types of central nervous system injury, with respiratory insufficiency, with acute renal failure, and, most particularly, with sepsis. Active bleeding from “stress” ulcer is usually preceded by a striking increase in the volume and acidity of aspirated gastric content, which is also heavily bile stained. Abnormalities in coagulation are frequently present. The nasogastric tube, per se, does not contribute to “stress” bleeding. Intraoperative endoscopy for diagnosis is of value in selected instances.
The role of histamine and histamine receptors in the pathogenesis and treatment of erosive gastritis
Authors: Gurll Nelson J. , Damianos Aristotle J.
Published: May 2005

Experiments have demonstrated the importance of histamine and intraluminal acid in the pathogenesis of gastric stress erosions. Histamine H2 receptor antagonists were found to protect against stress ulcers and bleeding in experimental animals and in patients at risk. The seriousness of this clinical problem has been almost eliminated by the use of antacids or histamine antagonists designed to reduce intraluminal gastric acidity.
Role of bile acid reflux in acute hemorrhagic gastritis
Authors: Ritchie Wallace P.
Published: May 2005

A model was developed to assess the influence of bile acids on the ability of proximal canine gastric mucosa to maintain an intraluminal pH gradient and to resist acute morphologic injury. It was found that the combination of topical acid, topical bile acid, and mucosal ischemia is acutely and severely ulcerogenic. Lesion severity is a function of the absolute amount of H+; diffusing into the mucosa which is, itself, a function of the intraluminal concentrations of both bile and H+. Morphologic injury is associated with the development of a marked gastric venous acidosis. Bile acid species differ in their capacity to induce lesions. Topical application of bile acids to nonischemic mucosa is not acutely ulcerogenic because a compensatory increase in mucosal blood flow occurs which is proportional to the degree of H+ loss induced. In the present model, steroids are “cytoprotective” by virtue of this mechanism, while histamine H1 and H2 receptor antagonists, either along or in combination, are not. The clinical applicability of these findings is discussed.
Treatment of established stress ulcer disease
Authors: Cheung Laurence Y.
Published: May 2005

All patients who are at risk of developing stress ulcers or who may have stress ulcers without hemorrhage should be treated with vigorous antacid therapy with or without cimetidine to prevent the deeper penetration of these erosions into the larger blood vessels of the submucosa. Bleeding from stress ulcers should be treated initially with iced saline lavage, since this maneuver serves to arrest hemorrhage in most patients. Replacement of blood, treatment of underlying sepsis, avoidance of gastric irritants such as aspirin, and correction of coagulation defects are all important parts of the management program. Endoscopy enables the positive identification of the lesions that are bleeding and provides an opportunity for direct control by electrocoagulation at institutions where this technique is available. Persistent bleeding from acute stress ulcers may be treated with intra‐arterial infusion of vasopressin into the left gastric artery, if trained personnel are present. If all nonsurgical measures fail to control bleeding, then vagotomy, pyloroplasty, and suture ligation of the bleeding site should be performed. Rebleeding after this procedure will require a near total gastrectomy. Surgical mortality rate in these patients exceeds 30%, indicating the lethal nature of this complication and the seriousness of the underlying illness associated with stress ulcers. Therefore, one must combat ongoing illness, such as sepsis, as well as control the massive hemorrhage when established stress ulcer disease is present.
Total and proximal gastrectomy in the treatment of gastric carcinoma: A series of 305 cases
Authors: Inberg Markku V. , Heinonen Reijo , Laurén Pekka , Rantakokko Veikko , Viikari Sauli J.
Published: May 2005

A total of 305 total or proximal gastrectomies for gastric carcinoma were performed in 291 patients. Of the tumors 51.5% were of the intestinal‐type and 35.7% were of the diffuse‐type of carcinoma. Proximal gastrectomy was performed in 68 patients, total gastrectomy in 230, and anastomotic resection in 7. In 25 patients a reresection for recurrent carcinoma was performed. After total gastrectomy the main reconstructive procedures were end‐to‐side esophago‐jejunostomy and Roux‐en‐Y esophagojejunostomy. The hospital mortality rate was 13.4%. The main causes of death were anastomotic leakage and pulmonary embolism. The incidence of leakage was 10.8% and the complication proved fatal in 36.4% of the patients who developed it. After Roux‐en‐Y reconstruction only 8% of the patients with leakage died. After curative operations 27% of the patients survived for over 5 years (relative survival rate of 33%). The 5‐year survival rates for the intestinal‐type and diffusetype of carcinoma were similar, but the 10‐year survival rate for intestinal‐type of carcinoma was significantly better. In our view a relatively high mortality rate after total or proximal gastrectomy has to be accepted when older patients are concerned, and when no other curative procedure is possible on account of the site and extent of invasion of the tumor. However, in cases where radical resection can be achieved by means of subtotal gastrectomy, this method is best. At present, in cases of the diffuse‐type of carcinoma of the corpus, we perform a total gastrectomy instead of subtotal gastrectomy. In the small series of reresections the results were encouraging.
The effect of highly selective vagotomy on canine gastric mucosal blood flow
Authors: Natsikas Nick B. , Konstantaras Christos , Psarrakos Kyriakos P. , Kappas Angelos M. , Lazarides Demetrius P.
Published: May 2005

Gastric mucosal blood flow (GMBF) was studied before and after highly selective vagotomy (HSV) by the pertechnate clearance technique. The studies were done on 24 mongrel dogs (Group A) under general anesthesia. Betazole was used to increase GMBF and gastric secretion (GS), and phenolred solution was used to correct the volume of GS collected by continuous aspiration. In all animals the measurements were done under resting, betazole‐stimulated conditions, and then immediately after HSV. In 12 of the 24 dogs (Group B) the same measurements were done again 2 months later. The findings of the study indicate that betazole‐stimulated GMBF was significantly decreased immediately after HSV (p<0.001). Betazole stimulation resulted in a 6‐fold increase of GMBF from the resting state before HSV, but only a 2‐fold increase 2 months after HSV. GS showed a significant decrease right after HSV without a significant difference (p<0.30) from the resting state. Two months postoperatively GS showed no significant difference from the resting state after betazole stimulation. There was a linear correlation between GMBF and GS before and after HSV but the correlation coefficients were not statistically significant.
An improved microsurgical course for a mixed group of surgeons
Authors: Lee Sun , Diez‐Pardo Juan , Olszewski W. , Rowinski W. , Hirner A. , Brekke Inge , Swedenborg J. , Flatmark U. , Häring A. , Nylander G. , Orloff Marshall J.
Published: May 2005

Although the participants in the various microsurgical courses were of varied backgrounds and experience, and published materials that can serve as an adequate text are limited, the principles of microsurgery can be learned by skilled surgeons determined to become microsurgeons. Fundamental training depends upon the proper text and suitable models for practice under the guidance of a properly trained microsurgeon instructor. In particular, audiovisual aids are of substantial value. Techniques from the fundamental, simple vascular anastomosis to highly sophisticated organ transplantation in rodents may be mastered in a course of several days' duration. A 7‐ to 10‐day course should be repeated annually to enable participants to polish their skills. Further, during an annual course, a half to whole day can be set aside for a microsurgical scientific program to allow exchange of scientific and clinical information, and to stimulate junior participants.
Nonendocrine theories of the etiology of benign breast disease
Authors: Minton John Peter , Abou‐Issa Hussein
Published: May 2005

This article summarizes 15 years of clinical and laboratory studies that have continued the search for a biochemical basis for the development and resolution of symptomatic benign fibrocystic disease. The clinical response to diet modifications is presented along with simultaneous laboratory tissue and serum studies. An ongoing study of the clinical response to complete and total methylxanthine abstention, especially caffeine, is presented in the initial part of the article. Following the clinical observations, is a series of laboratory studies, some of which actually preceded the clinical investigation and, in fact, pointed out that a beneficial clinical response might occur in some women following complete abstention. In the last paragraph, we present current information that may identify which women are susceptible to fibrocystic breast disease development.
The use of ultrasound in benign breast disorders
Authors: Guyer Peter B.
Published: May 2005

The role of ultrasonography in the diagnosis of benign conditions of the breast is presented. The images seen with common benign conditions are illustrated and diagnostic problems are discussed.
Management of breast pain and nodularity
Authors: Maddox Paul R. , Mansel Robert E.
Published: May 2005

The management of mastalgia consists of classification into its various patterns: reassurance, drug therapy for severe cases, and, rarely, surgery. Differentiation into cyclical and noncyclical patterns on a simple pain chart is useful for objective assessment of pain severity and for selection of appropriate drug therapy and subsequent monitoring of response. About 85% of new patients will be satisfied with adequate reassurance, but some 15% will have persistent pain and warrant medical treatment. Only a small number of drugs have been adequately tested in controlled trials and have been demonstrated to be more effective than placebo; these are bromocriptine, danazol, evening primrose oil, and tamoxifen. No ideal agent exists and the choice of drug will depend on efficacy, side effects, and cost.

Noncyclical pain has a lower response rate compared to cyclical mastalgia, but differentiation of a subgroup with chest wall pain leads to an overall 90% response to treatment by local infiltration with steroid and lignocaine. Newer agents such as LHRH agonists are currently undergoing evaluation in double‐blind controlled trials against placebo.

The management of nodularity is based on the clinical differentiation of the normal spectrum of physiological change within the breast (ANDI), requiring simple reassurance, from a true dominant breast nodule that will require excision biopsy to exclude malignancy. When pain and lumpiness coexist, some reduction in overall nodularity (with the use of agents given for mastalgia) may occur.
Fibroadenoma
Authors: Dent David M. , Cant Peter J.
Published: May 2005

The common breast fibroadenoma makes up between one‐third and one‐half of biopsies for benign breast disease. The contemporary view is that it is an abnormality of normal development and involution rather than a neoplasm. Various other benign conditions may be clinically indistinguishable, and histological confirmation was only obtained in 68% of 321 masses thought to be fibroadenomas. Short‐term (13–24 mo) follow‐up of 201 masses, thought to be fibroadenomas on clinical and cytological grounds, showed resolution in 31% and regression in a further 12%, this behavior being more common with single lesions; a further 32% increased in size. There have been no long‐term studies, but it is likely that most regress toward the end of a woman's reproductive years. Aspiration cytology can differentiate malignant from benign disease with great accuracy, but had impaired sensitivity (87%) and specificity (76%) in differentiating fibroadenoma from other benign processes in an analysis of 244 successful aspirates. While these lesions may be safely left in women under 25 years of age, only 19 (27%) of 70 women of this age group chose this option and excision remains the most frequent treatment.
Breast macrocysts
Authors: Hughes Leslie E. , Bundred Nigel J.
Published: May 2005

Clinical macrocysts occur in about 7% of adult women. Modern terminology and understanding of benign breast disorders considers microcysts and macrocysts as specific clinical and pathological entities. The terminology and concepts of fibrocystic disease and its many alternative terms have been discarded.

Cysts arise as an aberration of normal lobular involution (ANDI) associated with active secretion of apocrine epithelium under hormonal stimulation. They are readily managed in most cases by aspiration alone. Multiple recurrent cysts may constitute a considerable nuisance and justify short‐term therapy with danazol. There is increasing evidence that multiple recurrent cysts are associated with a small, but significant increase in breast cancer risk.
Periductal mastitis/duct ectasia
Authors: Dixon J. Michael
Published: May 2005

Periductal mastitis/duct ectasia affects major breast ducts and is poorly understood. A variety of different terms have been used for this condition and these probably reflect different stages in one disease process.

It appears to be responsible for 1–2% of all symptomatic breast conditions. Although the incidence is higher in postmortem studies, much of what is included as so‐called “periductal mastitis” or“duct ectasia” in these studies is duct dilatation, which occurs as part of normal breast involution.

Periductal mastitis appears to be the primary condition with duct ectasia being the outcome. The cause of this periductal mastitis is uncertain, although bacteria, particularly anaerobic organisms, appear to play some role. Clinically, this condition can present with noncyclical mastalgia, nipple discharge, nipple retraction, a subareolar breast mass with or without overlying breast inflammation, a periareolar abscess, or a mammillary fistula.

Antibiotics effective against the organisms isolated from this condition are effective in resolving periareolar inflammation and are useful when combined with surgery in mammillary fistula.
Benign disorders of the male breast
Authors: Webster David J. T.
Published: May 2005

Gynecomastia is the dominating problem of the male breast. Other diseases are rare but mimic the same conditions in women. Gynecomastia may occur at any age either as a primary event, when it is due to a minor hormonal unbalance, or secondary to other pathology (e.g., liver failure) or drugs. Treatment consists of assessment of cause and reassurance. In a minority of patients, treatment with drugs—such as danazol—or surgical resection is indicated.
Benign breast disease in the postmenopausal woman
Authors: Devitt James E.
Published: May 2005

Breast symptoms are surprisingly common in the postmenopausal period, especially (but not only) when taking hormonal therapy. All of the common conditions of the premenopausal period may be seen. Clinical examination is usually easier and more precise in the postmenopausal woman. The importance of accurate clinical observation is stressed, as a diagnosis can usually be made in this way, supplemented by mammography and aspiration cytology where reliable services exist.
Benign breast disorders in nonwestern populations: Part II—Benign breast disorders in India
Authors: Shukla Hari S. , Kumar Sandeep
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.
Management of breast abscesses
Authors: Benson Edward A.
Published: May 2005

Hospital experience of breast abscess is changing as nonpuerperal abscess associated with periductal mastitis assumes increasing importance. Clinical presentation, bacteriology, and management differ notably from acute puerperal abscess, but the latter can still cause severe morbidity.

The standard management of puerperal abscess by incision, breaking down loculi, and dependent drainage may still be used, but the author has shown that an alternative approach—curettage and primary obliteration of the cavity under antibiotic cover—can give equally good results with reduced morbidity.
Noncosmetic operations for benign breast disease
Authors: Hadfield Geoffrey J.
Published: May 2005

The operation of excision of the major duct system of the breast has remained unchanged since it was first designed by Adair and described by Hadfield [1–4], Urban [5], and recently by Preece [6] from Professor Hughes' unit in Cardiff.

Operations for diseases for a single major duct or the whole major duct system, namely subareolar excision of the major ducts of the breast, are discussed. Technical problems are discussed and suggestions are made on ways to avoid these problems. An adequately performed operation should render the patient free from her disease with a good cosmetic result.

Operations for excision of palpable and radiologically detected lesions are described. Since a histological examination is the final arbiter; methods ensuring that the whole lesion is demonstrated, excised, and fully examined are discussed. The medico‐legal aspect of this is of obvious importance.
Reoperation following failed fundoplication
Authors: Siewert J. Rüdiger , Isolauri Jouko , Feussner Hubertus
Published: May 2005

Fifty patients reoperated for failed Nissen fundoplication are presented; 29 patients (group 2) were operated between 1983 and 1988 while 21 patients (group 1) were operated before 1983. In group 1, the “slipped Nissen” had been the most frequent cause of reoperation (48%). In group 2, the most frequent causes for the unsuccessful operation were: (1) partial or total disruption of the fundic wrap (62%), (2) slipping of the fundoplication, giving rise to the telescope phenomenon (21%), and (3) creation of a fundoplication which was too low (10%). Refundoplication was performed in cases where the dissection of the previously formed fundic wrap was possible (42/50=84%). In group 1, three patients were treated by resection of the cardia, one by an Angelchik prosthesis and one by a distal gastric resection with Roux‐en‐Y diversion.

In group 2, fundectomy was performed in one patient; in another, an Angelchik device was inserted, and in a third patient, fundoplication and proximal gastric vagotomy were performed. The results were excellent or good in 66% of patients in group 1 and in 76% of group 2. Operative mortality was 2% and morbidity, 4%.

In conclusion, repeat fundoplication is recommended when reestablishment of the fundic region anatomy is possible during dissection. The operation can usually be performed through an abdominal route. Meticulous preoperative evaluation of the patients including 24‐hour pH measurement and manometry is necessary. Good results of refundoplication should be expected in 66%–76% of patients with recurrent disease.
Severe chronic cephalic pancreatitis: Use of partial duodenopancreatectomy with occlusion of the pancreatic duct in 289 patients
Authors: Gall Franz P. , Gebhardt Christoph , Meister Richard , Zirngibl Hubert , Schneider Michael U.
Published: May 2005

Partial duodenopancreatectomy and occlusion of the remaining ductal system by Ethibloc®to induce rapid exocrine atrophy for treatment of severe chronic cephalic pancreatitis was introduced in our department in January of 1978. Since then, this surgical procedure has been performed in a total of 289 patients. Postoperative morbidity was 12.2%, 5 pancreatic and 3 biliary fistulas occurred. Postoperative mortality was 1% and relapses of pancreatitis occurred in only 2.2% due to incomplete filling of ducts with Ethibloc®. A total of 88.2% of patients became pain‐free and symptomless, 10.8% voiced minor complaints, and 85.9% gained an averaged of 7.8 kg weight postoperatively.

We conclude that Ethibloc®occlusion is highly effective in inducing complete exocrine atrophy, thus abolishing the inflammatory process and preventing relapses of chronic pancreatitis and preserving the endocrine function from further impairment. This was demonstrated by biochemical assays during a 36‐month follow‐up in a prospective study in 23 of 289 patients.

Our results compare favorably with and are superior to results from any other operative procedure for chronic cephalic pancreatitis. We consider partial duodenopancreatectomy combined with Ethibloc®occlusion of the pancreatic duct the procedure of choice in the surgical treatment of severe chronic cephalic pancreatitis.
Surgical anatomy of the hepatic hilum with special reference to the caudate lobe
Authors: Mizumoto Ryuji , Suzuki Hideaki
Published: May 2005

The portal triad around the hepatic hilum, including the caudate lobe, was investigated using 106 adult cadavers. The portal vein showed regular branching at the hepatic hilum. The round ligament was attached mainly to the pars umbilicalis of the left branch of the portal vein (81.3%), especially to its lower portion (64.6%). Typical extrahepatic branching of the hepatic artery was noted in 67% of the cadavers. Intrahepatic branching of the middle and left hepatic arteries showed some variations in 9.4% and 12.5% of the cadavers, respectively. The cystic artery originated from the right hepatic artery in 84.4% of the cadavers, and a dual cystic artery was observed in 30.2%.

An aberrant hepatic duct, previously reported as an accessory hepatic duct, was observed in 9.0% of the cadavers; each entered the common hepatic duct on the right side. With reference to the course of bile duct and hepatic artery, the middle hepatic artery traversed the left main hepatic duct anteriorly in 13.5% of the cadavers, and ran partly in front of the duct in 52.0%. Furthermore, the right hepatic artery or its branches traversed the right main hepatic duct anteriorly in 9.4% of the cadavers and ran partly in front of the duct in 38.5%. The caudate lobe is supplied by both the right and left branches of the portal triad, mainly by the left. The caudate process is mainly supplied by the posterior branches of the portal triad, being continuous with the posterior segment of the liver.
The role of endoscopic retrograde cholangiopancreatography in preoperative assessment of bile duct cancer
Authors: Tanaka Masao , Ogawa Yoshiaki , Matsumoto Shinji , Nakayama Fumio
Published: May 2005

A total of 73 patients with carcinoma of the bile duct (59 patients) or duodenal papilla (14 patients) were reviewed with regard to the role of endoscopic retrograde cholangiopancreatography (ERCP) in preoperative assessment of these diseases. Percutaneous transhepatic cholangiography was preferred in most of the jaundiced patients and ERCP was performed after establishment of percutaneous or operative drainage above the obstruction. Pancreatography obtained in 19 patients with bile duct carcinoma revealed pancreatic invasion in 2 patients, and chronic pancreatitis in 1 patient. Other patients with normal pancreatograms included 2 patients whose initial diagnosis had been pancreatic cancer. The extent of bile duct carcinoma could be determined in 92% of 26 patients who had retrograde cholangiography, whereas it was known preoperatively in only 27% of 33 patients in whom retrograde cholangiography was not obtained. Combined use of antegrade and retrograde cholangiography performed in 13 patients was particularly useful to clearly delineate the lesion. In most of the patients with ampullary carcinoma, biopsy during ERCP confirmed the diagnosis preoperatively; 3 of these patients underwent ERCP with a different diagnosis. Biopsy after sphincterotomy revealed bile duct carcinoma in 2 patients in whom bile duct cancer was not suspected. Complications included 2 cases of cholangitis and 2 cases of mild pancreatitis. ERCP does not provide sufficient information as to the proximal bile duct anatomy and extent of the lesion, which are essential for appropriate surgical treatment. If used with precautions to prevent possible septic complications, however, it is useful in excluding pancreatic diseases by pancreatography, in specifying the distal bile duct, and in observing the duodenum and papilla. The use of several ERCP‐derived techniques such as perendoscopic biopsy, sphincterotomy, and balloon catheter cholangiography substantially increases the diagnostic utility of this procedure.
Extended right hepatic lobectomy, left hepatic lobectomy, and skeletonization resection for proximal bile duct cancer
Authors: Pinson C. Wright , Rossi Ricardo L.
Published: May 2005

Tumors in the proximal third of the bile duct are associated with the lowest rates of resectability and poorest survival of tumors in all locations in the duct. Of 25 patients who underwent resection for tumors located proximally, 3 had extended right hepatic lobectomy, 6 had left hepatic lobectomy, and 16 had skeletonization resection. The operative mortality rate was 4% overall and 0 for patients undergoing hepatic resection. Actuarial survival at 1, 3, and 5 years was 84%, 44%, and 35%, respectively, with almost all patients dying with disease. Survival was longer for patients who had curative resection than for those who had palliative resection. Survival was longer after hepatic lobectomy than after skeletonization resection but was not statistically significant. Survival for the 25 patients who underwent resection compared favorably with the survival of 131 patients treated by strictly palliative procedures, and the quality of life for patients with resection was also improved.

We conclude that aggressive resection for cure is the procedure of choice in selected patients with proximal bile duct cancer, but that it must be performed with low operative mortality. Current patient selection and operative techniques are described.
Bypass procedure for bile duct cancer
Authors: Miyazaki Kohji , Nagafuchi Kazumitsu , Nakayama Fumio
Published: May 2005

In spite of the great advances made in diagnostic procedures and patient management, and the aggressive attitude adopted by most surgeons, a sizable portion of bile duct cancer remains unresectable and should be treated by palliative procedures. We reviewed 93 patients with bile duct cancer treated in our department during the 20‐year period from 1965 to 1984, and found that biliary enteric anastomosis offers the best palliation with acceptable mortality and complication rates and increases length of survival and improves quality of life. For proximal third bile duct cancer, the approach in the plane of the falciform ligament by Bismuth and Corlette and the anastomosis of the duct of the lateral inferior segment, segment III, or anterior inferior segment, segment V, to a Roux‐Y jejunal loop is recommended because of its sufficient size, accessibility, and distance from the tumor. For middle and distal thirds bile duct cancer, hepaticodochojejunostomy (Roux‐Y) is preferred by first transecting the common hepatic or common bile duct and anastomosing it to the Roux‐Y jejunal loop to delay encroachment by the distally located bile duct cancer.
Percutaneous transhepatic endoprosthesis in malignant obstruction of the bile duct
Authors: Yamakawa Tatsuo , Esguerra Ricardo D. , Kaneko Hitoshi , Fukuma Eisuke
Published: May 2005

This article reviews our experience with the use of a prosthetic tube, placed percutaneously across unresectable malignant obstructions of the bile duct, in 23 patients. The tube, which is available in various sizes ranging from 8 to 20 Fr., has multiple side holes that allow adequate biliary drainage. A collar at the external end, positioned at skin level, prevents inward migration of the tube. Occlusion of this end by means of a cap allows internal drainage, while external decompression is made possible by connecting it to a closed‐system drainage bottle. This tube is inserted, under fluoroscopic or choledochoscopic guidance, after dilating the sinus tract established by percutaneous transhepatic biliary drainage.

Relief of obstructive jaundice was achieved in all patients and the mean survival time of the entire group was 6.8 months. In patients with obstruction at the upper third of the bile duct, survival after placement of the tube ranged from 4 to 38 months, with a mean of 12.4 months. We found this method safe even in the weak and elderly, and tube patency was easy to maintain. We advocate its use particularly in patients with unresectable bile duct cancer, in whom biliary decompression is difficult by other procedures.
The role of intraoperative radiation therapy in the treatment of bile duct cancer
Authors: Iwasaki Yoji , Todoroki Takeshi , Fukao Katashi , Ohara Kiyoshi , Okamura Takao , Nishimura Akira
Published: May 2005

Since October, 1976, we have treated a total of 81 patients with bile duct cancer. Fifty of these patients had cancer that originated at and/or infiltrated into the main hepatic ducts. Five patients had cancer on the upper to middle portion, 19 on the middle to intrapancreatic bile duct, and the remaining 7 had diffusely involved tumors. Fifty of the 81 patients underwent resections. Of the 50 patients, 33 received curative or noncurative resection alone, 14 were treated by resection plus intraoperative radiotherapy (IORT), and the remaining 3 received postoperative external irradiation. Thirty‐one of the 81 patients did not undergo tumor resection. Of these, 6 had IORT and 4 underwent external radiotherapy after bile drainage. The remaining 21 underwent bile drainage alone. Curative resection achieved the best cumulative 5‐year survival rate of 59.3%. IORT plus noncurative resection showed a superior 2‐year survival rate of 17,1% compared to 9.0% after noncurative resection alone. Only 1 patient treated by IORT plus bile drainage survived more than 2 years and subsequently died at 34 months.

In the earlier stage of the development of the combination therapy with resection and IORT, severe complications were experienced in 9 patients (so treated), including remarkable obstructive changes of the hepatic arteries. In the later stage, resection plus IORT with a reduced single dose (20 Gy), using a smaller field size (3.7±1.4 cm) and beam energy (7.3±3.0 MeV), did not result in complication and produced 2 long‐term survivors among 5 patients. Fractionated external irradiation (30–40 Gy/4–5 weeks) has been added to the IORT recently. These results indicate that noncurative resection plus IORT in combination with external radiation would improve the prognosis of the patient with advanced bile duct cancer.
Internal radiation for bile duct cancer
Authors: Meyers William C. , Jones R. Scott
Published: May 2005

The clinical course of 27 patients with bile duct cancer who received intraductal exposure to192iridium was reviewed. All patients exhibited evidence of biliary obstruction prior to diagnosis of cancer and all underwent intubation for relief of obstruction either by surgical or radiologic methods. The patients then received either internal irradiation alone or the combination of internal plus external irradiation. The patients lived an average of 11.5 months following internal irradiation and 13.5 months following diagnosis. Patients who received both internal and external irradiation lived longer than those who received internal irradiation alone. The 3 patients who had resection of their primary tumors lived longer than the group as a whole. All patients continued episodes of mild or severe cholangitis following irradiation. The heterogeneity of patient material, pretreatment methods, and lack of controls preclude any statement concerning effectiveness of radiation therapy for bile duct cancer. A few patients may benefit from the therapy, and use of irradiation techniques as an adjuvant modality is worth continued investigation; however, while internal irradiation for local control of proximal bile duct tumors remains theoretically attractive, there remains little evidence of its efficacy.
Treatment and prognosis in bile duct cancer
Authors: Tompkins Ronald K.
Published: May 2005

Over the past 30 years, a total of 165 patients with bile duct cancer have been studied at the University of California at Los Angeles (UCLA), U.S.A. A review of careful retrospective analyses of surgical treatment is presented. The data support a treatment strategy of resection of those tumors which can be grossly removed at operation. Palliation of other patients is best done by biliary‐enteric bypass or operative intubation. The higher morbidity and mortality rates for palliative resections, together with a poorer quality of life in those patients surviving this procedure, argue against resection for palliative purposes.
Primary endoscopic papillotomy (EPT) in patients with stones in the common bile duct and the gallbladder in situ: A 5‐8‐year follow‐up study
Authors: Rosseland Arne R. , Solhaug Jan Helge
Published: May 2005

Seventy‐five patients (mean age, 77 years) with common duct stones and the gallbladder in situ were treated with primary endoscopic papillotomy (EPT) during the period 1976–1979. The endoscopic procedure was successful in all patients, but 4 patients had to be operated on since the common duct stone did not pass.

The complication rate was 13.3% and 1 patient died. One patient was operated on with cholecystectomy within a week after EPT because of progression of his cholecystitis. Another patient was operated on with drainage for perforated liver abscesses and cholecystectomy; she also died 1 week after operation.

In the follow‐up period of 5–8 years, 12 patients were operated on with cholecystectomy: 7 patients because of acute cholecystitis, and 3 patients because of recurrent pain attacks. In 2 patients, the operation was done electively.

Thirty patients died, all from other diseases except 1 patient who died from a gallbladder carcinoma 1 1/2 years after EPT. Three patients were treated conservatively for acute cholecystitis.

After 5 years, 28 patients were still alive with the gallbladder in situ and none had symptoms from the gallbladder. Altogether, 13 (17.3%) patients were treated for acute cholecystitis during the 5–8‐year follow‐up period.
A Comparison of flexible and rigid endoscopy in evaluating esophageal cancer patients for surgery
Authors: Cheung H. C. , Siu K. F. , Wong J.
Published: May 2005

Flexible and rigid esophagoscopy and bronchoscopy were performed in 71 patients with carcinoma of the thoracic esophagus who subsequently underwent surgery; a thoracotomy was performed in 68 patients and the mediastinum examined to assess the extent of disease. Four patients presented with tracheo‐or bronchoesophageal fistulas, 1 of whom also had a thoracotomy. Biopsy confirmation of diagnosis was obtained using flexible esophagoscopy in all patients. In 78% of the patients the fiberscope could negotiate through the tumor and the tumor length was noted, and the distal esophagus, stomach, and duodenum were examined—information otherwise unobtainable using the rigid esophagoscope. The accuracy of flexible and rigid bronchoscopy were comparable in detecting tracheobronchial involvement, but both were insensitive in assessing mediastinal invasion. While other investigations such as computed tomography scan and azygogram may improve the accuracy in evaluating mediastinal disease, whether this would alter the management of patients needs further assessment since, in most patients with bronchoscopic abnormalities, the tumor could still be resected. We conclude that although endoscopy has limitations in the preoperative evaluation of patients with carcinoma of the esophagus, flexible endoscopy is as accurate and, in certain situations, superior to its rigid counterpart and, if available, is the examination of choice.
Preservation of functional aerobic capacity with daily submaximal exercise during intravenous feeding in hospitalized normal man
Authors: Albert James D. , Legaspi Adrian , Horowitz Glenn D. , Kubo Spencer H. , Tracey Kevin J. , Cody Robert J. , Lowry Stephen F.
Published: May 2005

We evaluated the relationship between nutritional status and maximal aerobic capacity in hospitalized normal subjects receiving intravenous nutritional support. In addition, the impact of a daily submaximal exercise regimen on maximal oxygen consumption (VO2 Max) during weight‐stable intravenous feeding (IVF) was quantified. Six normal male volunteers were studied serially in the post‐absorptive state following 3 days of standard enteral feeding, after 10 days of starvation, and after 10 days of intravenous nutritional repletion (group A). Another group of 11 normal subjects were studied post‐absorptively after 3 days of enteral feeding and again after 10 days of weight‐stable IVF (group B). Five of the 11 subjects in group B were randomized to perform 1 hour of daily bicycle exercise at 75 watts during IVF whereas the remaining 6 subjects received IVF without daily exercise.

In group A subjects, VO2 Max (ml min−1 kg−1 ±SE) was 36.2±1.5 after enteral feeding and fell to 32.4±2.6 after 10 days of starvation. VO2 Max remained significantly (p<0.05) less than the enteral study even after 10 days of repletion IVF (28.4±2.9). Group B subjects demonstrated a VO2 Max of 34.1±3.0 at admission and, despite 10 days of weight‐stable IVF, the nonexercised subjects experienced a decrease in VO2 Max to 26.4±2.4 (p<0.05). In contrast, those subjects who received daily exercise during IVF demonstrated a nonsignificant decrease in VO2 Max (31.4±4.6) after 10 days of weight‐stable IVF compared to their admission enteral study.

The data suggest that loss of cardiovascular functional aerobic capacity as determined by maximal oxygen consumption occurs independently of nutritional status and reflects the relative immobilization of hospital confinement. Moreover, 1 hour of bicycle exercise at 40–50 % of admission VO2 Max during IVF diminishes, but does not totally inhibit, the hospital‐acquired loss of aerobic functional capacity.
DNA analysis and parathyroid pathology
Authors: Shenton Brian K. , Ellis Huw , Johnston Ivan D. A. , Farndon John R.
Published: May 2005

The nuclear DNA content of 85 parathyroid glands (4 carcinomas, 39 adenomas, 21 secondary parathyroid hyperplasias, and 21 normal parathyroid glands) were determined by flow cytometric analysis. All normal parathyroid glands, 85% of the adenomas, and 83.3% of the secondary hyperplastic glands had DNA indices within values of 0.85–1.1. Paraffinembedded fixed glands showed less DNA staining than that found with fresh or normal glands. Glands from patients with carcinoma showed DNA indices outside the normal DNA index range. When the percent of nuclei within the G0/G1 phase of the cell cycle was compared between the study groups, highly significant results were found. While patients with secondary hyperplasia showed a similar distribution to the normal glands studied, only 48% of primary adenomas showed over 80% of cells within the G0/G1 region. A clear subgroup of adenomas was defined with more rapidly cycling tetraploid cells, and showing classical adenoma pathology. This group showed negative correlation with gland weight, plasma calcium, and ionized calcium. These findings suggested that a different etiology of the disease process occurs between secondary hyperplasia and parathyroid adenoma. Such abnormal adenomas may form a group worthy of long‐term follow‐up.
Results of reoperations for persistent or recurrent secondary hyperparathyroidism in hemodialysis patients
Authors: Henry Jean‐Francois R. , Denizot Anne , Audiffret Jean , France Georges
Published: May 2005

Among 258 patients operated on for secondary hyperparathyroidism (HPT II) from 1971 to 1988, a total of 33 had one or more reoperations for persistent or recurrent HPT II. These reoperations did not induce any mortality or significant morbidity.

After inadequate parathyroidectomy (25 cases), 15 patients were reoperated. Twelve of these had undergone initial surgery at another institution. Three patients died of causes unrelated to their HPT II. The other 12 patients are disease‐free.

After successful subtotal parathyroidectomy (79 cases), 2 patients (2.5%) had a recurrence 5 and 6 years later, respectively. Currently, the 2 patients remain disease‐free.

After total parathyroidectomy with autotransplantation (152 cases), 16 patients (10.5%) had reoperations on the grafts. The mean time before reoperation was 2 1/2 years. Hypertrophy of grafted fragments was observed in 4 cases (2.6%), but only 2 of these 4 patients were cured by removal of the grafts. Residual parathyroid tissue or a supernumerary gland in the neck or the mediastinum was suspected in 5 patients, but this could not be confirmed because one had already been reoperated on in the neck without success, another still refuses reoperation, and 3 died. In 6 other patients, the recurrence was debatable and HPT II was not confirmed.

In the last 3 patients, the diagnosis was incorrect and aluminium intoxication was proved later.

Results of reoperations for persistent or recurrent HPT II depend, first, on a correct diagnosis. After Successful subtotal parathyroidectomy, reoperations are rare and simple. After total parathyroidectomy and transplantation, it must be kept in mind that recurrences can occur on the grafts and/or on residual tissue in the neck or mediastinum.
Hypoglycemia induced by excessive rebound secretion of insulin after removal of pheochromocytoma
Authors: Akiba Masako , Kodama Takaya , Ito Yukio , Obara Takao , Fujimoto Yoshihide
Published: May 2005

During an 8‐year‐period from 1981 to 1989, a total of 6 of 45 patients with pheochromocytoma developed severe hypoglycemia (plasma glucose, 12–50 mg/dl) 2–4 1/2 hours after removal of the tumor. In order to elucidate the pathogenesis of the hypoglycemic attack, the levels of plasma immunoreactive insulin (IRI) and glucose were sequentially measured at surgery in 10 patients with pheochromocytoma, from the beginning of the operation until usually 5 hours after tumor resection. The same examinations were carried out in 4 patients with primary aldosteronism and 1 patient with Cushing's syndrome as controls. The highest plasma IRI levels observed in the 2 patients with postexcisional hypoglycemia were 174 and 2,081μU/ml and those in the 8 patients without hypoglycemia were 13–222μU/ml (mean, 77), but they were only 14–33μU/ml (mean, 22) in the 5 control patients. The mean of the highest plasma IRI/glucose ratios in the immediate postoperative phase was 1.37±0.87 in the 10 patients with pheochromocytoma but only 0.16±0.04 in the 5 control patients (p<0.01). Review of the clinical data in our series disclosed that patients with higher levels of preoperative urinary epinephrine excretion and those with either diabetes mellitus or impaired glucose tolerance tended to develop postoperative hypoglycemia. These observations suggest that endogeneous insulin secretion is suppressed by increased plasma catecholamines, and that excessive rebound secretion of insulin after removal of a pheochromocytoma is a rather common phenomenon. Intravenous infusion of glucose is necessary and plasma glucose levels should be monitored after resection of a pheochromocytoma.