bluuebunny/crossref_metadata_2025 huggingface dataset:
Limitations of percutaneous transhepatic cholangioscopy in the removal of complicated biliary calculi
Authors: Jeng Kuo‐Shyang , Chiang Hsein‐Jar , Shih Shou‐Chuan
Published: May 2005

To investigate the limitations of percutaneous transhepatic cholangioscopic lithotomy (PTCSL) in the management of retained or reformed biliary calculi, we conducted a retrospective study of 50 patients who had received PTCSL for complicated biliary calculi during a period of 32 months. The calculi were located in the common bile duct (24%), the intrahepatic bile ducts (60%), and in both the common bile duct and intrahepatic bile ducts (16%). The adjunctive techniques in PTCSL included balloon dilatation for the biliary stricture, electrohydraulic lithotripsy (EHL) for crushing large impacted stones, and flushing techniques, biliary spoons, and basket catheters for stone fragmentation and grasping. The overall percutaneous manipulations totaled 221 procedures, including 124 sessions of PTCS.

In each patient, the number of sessions of PTCS varied from 1 to 7. In our series, the main complications of PTCS therapy, rarely reported in the literature, included pain intolerance in 7 cases (14%), minor bleeding in 7 cases (14%), and massive bleeding which needed angiographic diagnosis and therapy for hemostasis in 5 cases (10%). Secondary biliary cirrhosis, severe biliary stricture and angulations, previous shunt surgery, neovascularization surrounding the chronic inflammatory stenotic intrahepatic bile ducts, pseudoaneurysm formation, and coexistent cholangiocarcinoma contributed to the vulnerability of bleeding during manipulations. The complications resulted in treatment failure in 11 patients (22%). We conclude that PTCS is a useful alternative treatment to surgery for biliary calculi, but it has limitations that obviate complete stone clearance.
Segmental colonic resection is an appropriate operation for short skip lesions due to Crohn's disease in the colon
Authors: Allan A. , Andrews H. , Hilton C. J. , Keighley M. R. B. , Allan R. N. , Alexander‐Williams J.
Published: May 2005

Thirty‐six patients have had a segmental colonic resection for Crohn's colitis between 1948 and 1984. There were 2 deaths caused by intraabdominal abscesses present before operation. There were no cases of anastomotic dehiscence in the 29 patients having segmental resection and immediate anastomosis. The reoperation rate at 10 years was 66% (95% confidence interval, 48–84%), the majority of reresections being for recurrent large bowel Crohn's disease.

The 10‐year reoperation rates were higher than after subtotal colectomy and ileorectal anastomosis (53%; 95% confidence interval, 37–69%) performed in a comparable group of patients with colonie Crohn's disease. The difference did not achieve statistical significance. These findings suggest that when a patient with Crohn's disease has a short segment of diseased large bowel, a segmental resection is feasible and safe.
The survival benefit of resection in patients with advanced stomach cancer: The norwegian multicenter experience
Authors: Haugstvedt Trond , Viste Asgaut , Eide Geir Egil , Söreide Odd ,   Members of the Norwegian Stomach Cancer Trial
Published: May 2005

Five hundred three of 1,165 patients with stomach cancer included in a national multicenter study received noncurative treatment. This study elucidates whether a palliative resection offered any survival advantage compared to nonresectional treatment. One hundred eighty‐two (36%) of 503 patients had gastric resection (including total gastrectomy in 64 patients), 70 (14%) had a bypass procedure, and an exploratory laparotomy was carried out in 156 (31%). Seventy‐eight patients (16%) were not subjected to surgery. Resection carried the same postoperative mortality rate as a nonresectional procedure (13% versus 12%). Univariate survival analysis demonstrated that median survival and 1‐ and 2‐year survival rates were significantly higher in resected patients; however, as basic patient characteristics (age, stage, etc.) differed between the 2 main treatment groups, survival and factors affecting survival were analyzed using the Cox proportional hazards model. Given similar age and preoperative weight loss, resection doubled median survival both for stage III disease (9 versus 4.5 mo) and for stage IV disease (6 versus 3 mo) compared to nonresection or no operation. In conclusion, resection seems justified in patients with advanced stomach cancer since a survival benefit is documented.
Surgical approach to early gastric cancer with lymph node metastasis
Authors: Sowa Michio , Kato Yasuyuki , Nishimura Masanori , Kubo Toshiaki , Maekawa Hisashi , Umeyama Kaoru
Published: May 2005

The clinicopathology of our series of patients (n=486) with early gastric cancer was reviewed with special reference to metastasis to the regional lymph nodes. The incidence of lymph node metastasis was 15.8% (19/120) in patients with the protruded type of carcinoma and 11.7% (42/360) in patients with the depressed type of carcinoma. It was especially high in carcinomas of the IIa + IIc type of the former group. The incidence of lymph node involvement was higher in the group with larger tumors (>30 mm) than in the group with smaller tumors (≤30 mm). Metastatic lesions were detected in as many as 25.0% (16/64) of the cases with large tumors (≥50 mm); however, of the 46 cases with small tumors (<10 mm), 1 case had metastases to the nodes of group 1. There were 4 cases of m‐cancer with metastasis to group 1 lymph nodes. Skip metastasis to group 2 lymph nodes was discovered in 4 cases. From these results, we feel that the standard operation for early gastric cancer is R2‐gastrectomy including the complete removal of group 1 and 2 lymph nodes. R1‐gastrectomy or local resection is thought to be sufficient for m‐cancer with a lesion smaller than 10 mm in maximum diameter.
The effects of blood transfusion on the prognosis of patients with gastric cancer
Authors: Kampschöer G. H. M. , Maruyama K. , Sasako M. , Kinoshita T. , van de Velde C. J. H.
Published: May 2005

The effect of perioperative blood transfusion on the survival rate of patients with gastric cancer was studied. One thousand patients with primary gastric cancer, who had curative surgery performed at the National Cancer Center Hospital in Japan from 1976 to 1981, were studied retrospectively. Overall comparison of transfused (n=371) versus nontransfused (n=629) patients by log rank analysis revealed a statistically significant adverse influence of blood transfusion on survival (p=0.0001). Fifty‐seven percent of transfused as compared to 80.8% of nontransfused patients survived for 5 years or more; however, after stratifying patients into stages and applying proportional regression analyses, blood transfusion did not appear to have any effect on prognosis: relative risk ratio, 1.16;p=0.28. Similarly, comparison of patients transfused with more than 600 cc of blood and those transfused with 600 cc of blood or less revealed no statistical difference in survival time.

It is postulated that the possible adverse influence of blood transfusion on the survival of patients with gastric cancer is linked to other prognostic features rather than to the immunologic sequelae of the transfusion itself.
Metabolic basis for management of the septic surgical patient
Authors: Shaw J. H. F. , Koea J. B.
Published: May 2005

The physiologic events accompanying postoperative septic complications in surgical patients represent a coordinated response to bacterial invasion, which is aimed at maintaining the function of key organ systems. When sepsis is prolonged or overwhelming, physiologic dysfunction and multiorgan failure develop. This review outlines the pathophysiologic response to sepsis and correlates it with recent therapeutic advances in the metabolic management of the postoperative septic patient.
Underweight patients and the risks of major surgery
Authors: Windsor John A.
Published: May 2005

The relation between weight loss and the risks of major surgery have been investigated for more than 50 years. It can now be said, with some confidence, that the underweight patient has an increased risk of complications following major surgery. This understanding, however, is based on methods of nutritional assessment that are of limited relevance to hospitalized patients whose malnutrition might be due to sepsis, neoplasia, trauma, or starvation. A consequence is the widespread belief that protein‐energy malnutrition (PEM) has been overemphasized as a surgical risk factor, and that the many nonnutritional risk factors ought to be implicated more often. An argument is made for a fresh approach to nutritional assessment in order to better identify the individual patient who, by virtue of PEM, stands an increased risk of a complicated postoperative course. It is suggested that an evaluation of the impact PEM has on vital physiologic function provides a clinically relevant defect to identify and treat and a means of monitoring response to nutritional intervention.
Perioperative care of the immunocompromised patient
Authors: Yee John , Christou Nicolas V.
Published: May 2005

Immunocompromised patients are increasingly common in modern surgical practice. Challenges related to their care include identifying the determinants of increased risk and selecting the appropriate therapy for individual patients. There are multiple and overlapping causes of immunosuppression in surgical patients that make the interpretation of clinical trials difficult. A clear understanding of these mechanisms guides the physician to choose the immunomodulatory agents that can be used for improving current rates of complication and mortality. The best practical approach to immunocompromised patients involves determining who is at risk, aggressive diagnosis, early therapy, and a high index of suspicion for infectious complications.
Postmastectomy morbidity after combination preoperative irradiation and chemotherapy for locally advanced breast cancer
Authors: Sauter Edward R. , Eisenberg Burton L. , Hoffman John P. , Ottery Faith D. , Boraas Marcia C. , Goldstein Lori J. , Solin Lawrence J.
Published: May 2005

Neoadjuvant therapy for locally advanced breast cancer improves disease control, but the complications of treatment are not well established. The aim of this study was to assess the operative morbidity in 20 consecutive patients with locally advanced, noninflammatory breast cancer treated with preoperative chemotherapy and radiation. Patients received preoperative cyclophosphamide, methotrexate, 5‐fluorouracil, prednisone, and tamoxifen (CMFPT) to maximum response followed by concurrent chemotherapy and radiation to the involved breast and regional lymph nodes. Following modified radical mastectomy, chemotherapy was continued for a total of 10 cycles. Disease progressed in 3 of 20 patients (15%). Seventeen patients underwent mastectomy, 4 (24%) of whom demonstrated a pathologic complete response to chemoradiotherapy. Seven patients (41%) developed wound infections, 2 (12%) necrosis, 5 (29%) delayed healing, 2 (12%) upper extremity lymphedema, and 8 (47%) seromas. Postoperative chemotherapy was delayed in 4 (24%) patients. There was no mortality, and hospitalization was for less than 1 week. Only one patient required readmission. Although this treatment regimen is aggressive with attendant morbidity, complications are easily managed and generally do not delay therapy. Treatment modification to further reduce complications may be indicated.
Logistic regression and discriminant analyses of hepatic failure after liver resection for carcinoma of the biliary tract
Authors: Nagino Masato , Nimura Yuji , Hayakawa Naokazu , Kamiya Junichi , Kondo Satoshi , Sasaki Ryuichiro , Hamajima Nobuyuki
Published: May 2005

Stepwise logistic and discriminant analyses were used to define the risk factors for hepatic failure after liver resection for carcinoma of the biliary tract and to predict this complication. The logistic analysis identified the linear pattern of oral glucose tolerance test, cholangitis, pancreatoduodenectomy, and indocyanine green disappearance rate as the factors most related to hepatic failure among 18 pre‐ and perioperative parameters of the past 84 hepatectomized cases (55 hilar bile duct carcinomas and 29 gallbladder carcinomas). Our discriminant formula using five variables, including the above‐mentioned four plus the liver resection rate, could distinguish the patients with posthepatectomy liver failure (n=25) from those without (n=59) with 86.9% accuracy, 96.0% sensitivity, and 83.1% specificity. The cross‐validation test has confirmed that this model was robust for discriminant analysis. The results of this study show that statistical multifactorial analysis makes possible the preoperative prediction of hepatic failure after liver resection for carcinoma of the biliary tract.
Laparoscopic cholecystectomy: Treatment of choice for cholelithiasis in children
Authors: Vinograd Itzhak , Halevy Ariel , Klin Baruch , Negri Michael , Bujanover Yoram
Published: May 2005

Laparoscopic cholecystectomy is rapidly replacing traditional cholecystectomy as the standard treatment for cholelithiasis and cholecystitis in adults. Over a period of 16 months, 14 children with a clinical diagnosis of cholelithiasis, ranging in age from 4 to 15 years (mean 12.2), were treated. All had symptoms of abdominal pain or vomiting; one had jaundice and recurrent cholecystitis. Five children (35%) had associated metabolic or hemolytic diseases. The 14 children were operated on using the laparoscopic cholecystectomy technique. No operation was converted to open cholecystectomy, but two patients required laparotomy: one because of suspected injury to the common duct, and the other because of non visualization of the gallbladder during laparoscopy. The mean post‐operative hospital stay for the 11 children who underwent only laparoscopic cholecystectomy (one patient also had a simple mastectomy) was 50 hours (range 48–72 hours). All children resumed their normal activities almost immediately after discharge from hospital. No long‐term biliary or other complications were seen in any patient throughout an average follow‐up period of 6.2 months (range 3–16 months). The benefits of this operation in children are obvious: It is safe, effective, and well tolerated.
Colon J‐Pouch rectal reconstruction after total or subtotal proctectomy
Authors: Cohen Alfred M.
Published: May 2005

Multiple stools, urgency, and episodic frequency are common during the first 6 months after proctectomy and coloanal or low colorectal reconstruction. We used an 8‐cm colon J‐pouch in 23 patients and have confirmed that this approach obviates much of this early dysfunction.
Endorectal ultrasonography for staging small rectal tumors: Technique and contribution to treatment
Authors: Detry Roger J. , Kartheuser Alex , Kestens Paul J.
Published: May 2005

Thirty‐one tumors, lying in the lower two‐thirds of the rectum and possibly suitable for local excision, were analyzed by endorectal ultrasonography (EUS) using the Aloka® scanner SSD 520. There were 18 sessile villous adenomas (group I) and 13 invasive cancers 3 cm or less (group II). Preoperative endosonographic staging (uT, uN stages) was compared with the histologic analysis of the specimens (pT, pN) and the possible contribution to therapy was evaluated. In group I, the depth of tumor infiltration was accurately assessed in 89% of cases. Malignant transformation was suspected in 4 cases (uT2) and confirmed postoperatively in 3 cases. In group II, the extent of the tumor was correctly evaluated in 84% of cases. With regard to the overall differentiation between T1 and T2/T3 tumors on one hand, and between T1/T2 and T3 lesions on the other hand, the positive predictive values were 93.3% and 100%, respectively. The negative predictive values were 93.7% and 92.8%. In group II the search for regional lymph nodes was positive in 4 cases and negative in 9 cases. An accuracy rate of 82% (sensitivity 75%, specificity 85%) was estimated by analysis of the specimens and postoperative follow‐up. The exact performance could not be evaluated because a radical resection was not carried out in most cases. EUS was useful for planning the treatment of villous adenomas. A broad full‐thickness excision was carried out without delay for the four uT2 villous tumors, allowing safe margins to be obtained in all cases. Using EUS the choice of local excision was questioned for six small invasive cancers (uT3 and/or uN+), although radical resection was carried out for only two. As high sensitivity could not be achieved when detecting lymphatic metastasis, the choice of limited surgery based on EUS staging requires strict postoperative follow‐up.
Acute temporary laterofixation for treatment of bilateral vocal cord paralyses after surgery for advanced thyroid carcinoma
Authors: Ejnell Hasse , Tisell Lars‐Erik
Published: May 2005

Four patients with breathing obstruction after surgery for advanced thyroid carcinoma were found to have bilateral vocal cord paralysis. They were treated with acute temporary laterofixation of one of the vocal cords. This measure established a stable airway in all the patients and maintained acceptable voices. None of the patients had aspiration problems. After 4 to 7 weeks the nonlaterofixated vocal cord had regained normal function in each patient, and the thread used for the laterofixation could be removed. In the two patients who had anatomically intact recurrent laryngeal nerves bilaterally, the previously laterofixated vocal cords displayed normal movements within another 8 weeks in one patient and 7 weeks in the other patient. This observation demonstrates that a temporary laterofixation can be done without lasting damage to the vocal cord. Acute temporary vocal cord laterofixation is a procedure that has the potential to minimize the morbidity and complications of bilateral vocal cord paralysis, and in most patients it can be done instead of tracheostomy.
Natural history of adenomas
Authors: Eide Tor J.
Published: May 2005

One‐third of individuals over the age of 55 years have single or multiple colorectal adenomas. During a subsequent period of 10 years, 3–5% of adenoma‐bearing individuals will probably develop a carcinoma. The rather low conversion rate from benign to malignant disease indicates that most individuals with adenomas will never develop colorectal carcinoma. More knowledge is required to predict the outcome of the individual adenoma in a given patient. This will probably be obtained by increasing progress within gene technology and through large prospective follow‐up studies of adenoma‐bearing patients.
Diagnosis of familial adenomatous polyposis
Authors: Bülow Steffen
Published: May 2005

Familial adenomatous polyposis (FAP) includes early development of up to thousands of colorectal adenomas and of colorectal adenocarcinoma in all untreated cases. Moreover, a variety of extracolonic manifestations are seen. Proctosigmoidoscopy is used for screening; when adenomas are found, the diagnostic evaluation includes colonoscopy and gastroduodenoscopy. Screening of first degree relatives should start at the age of 10 years, using proctosigmoidoscopy at regular intervals. The recent detection of a specific FAP gene at chromosome 5 and of congenital retinal pigmentations will allow an early preclinical diagnosis in the future. A centralized registration of FAP has resulted in an improved prognosis, and the establishment of international groups will contribute to increased research of this disease.
Other gastrointestinal polyps
Authors: Järvinen Heikki J.
Published: May 2005

Gastrointestinal polyp is a descriptive concept—observation of an elevated broad‐based or stalked lesion which can be defined exactly only when examined histologically. Therefore, all polyps must, in principle, be snared or excised to achieve a final diagnosis. Nonneoplastic polyps or tumor‐like lesions were formerly considered innocent findings with no malignant potential, while neoplastic adenomas with dysplasia are well‐known premalignant lesions. This view of the totally harmless nature of nonneoplastic polyps is no longer true. At least the dominantly inherited juvenile polyposis and Peutz‐Jeghers polyposis syndromes definitely have malignant potential through adenomatous change in the originally hamartomatous lesions. Consequently, juvenile polyposis is best treated with colectomy and ileorectal anastomosis, and repeated multiple polypectomies are now recommended in Peutz‐Jeghers polyposis, in combination with laparotomy when feasible. In addition, hyperplastic gastric polyps may reflect an underlying atrophic gastritis implying increased risk of gastric carcinoid tumors and cancer. Furthermore, even colorectal hyperplastic polyps may undergo adenomatous change, and thus represent, theoretically, a reservoir from which adenomas arise.
Bleeding esophageal varices associated with pancreatic arteriovenous malformation
Authors: Katoh Hiroyuki , Kojima Tetsufumi , Okushiba Shunichi , Shimozawa Eiji , Tanabe Tatsuzo
Published: May 2005

Three cases of bleeding esophageal varices associated with arteriovenous malformation of the pancreas have been observed over the last 7 years. In 1 case, arteriovenous malformation (AVM) was the cause of the portal hypertension; thus, it was considered to be a “primary lesion.” In the other cases, liver cirrhosis was the cause of the portal hypertension, and the AVM, which originally was a minor pathology, became significant as the portal hypertension progressed, thus making it a “secondary lesion.” In the case of a “primary lesion,” resection of the lesion is the preferred treatment for bleeding varices, but our case had multiple lesions, and excision was problematic. In the case of bleeding varices caused by liver cirrhosis, if liver function is normal, surgical treatment of both the varices and the AVM is recommended, while if the liver function is abnormal, repeated sclerotherapy is the best mode of therapy.
Resection of synchronous liver metastases from colorectal cancer
Authors: Vogt P. , Raab R. , Ringe B. , Pichlmayr R.
Published: May 2005

Whereas resection for metachronous liver metastases from colorectal cancer is considered to be a potentially curative approach, little is known about the prognosis after resection of synchronous liver metastases. In the past, these patients usually underwent only palliative therapy. Therefore, we have analyzed the data of 36 patients who underwent curative hepatic resection of synchronous liver metastases from colorectal carcinomas from 1977 to 1987 at the Department of Surgery, Hannover Medical School. In 19 patients, liver resection was combined with colonic resection; in the other 17 patients, hepatic resection was performed after a median interval of 2 months following resection of the primary tumor. No operative mortality was observed in either of the approaches. The median survival time was 28 months for all patients with a median recurrence‐free interval of 13.5 months. Overall 5‐year survival probability for all patients was 20%. There were no significant differences observed between immediate or delayed liver resection (median survival 18 months versus 31 months). Survival rates were not different after resection of solitary versus multiple liver metastases (26 versus 28 months). Twenty‐one of the 36 patients had a recurrence of their liver metastases. In 7 of them, curative liver resection could be performed again. These 7 patients had a significantly improved survival (p<0.05) compared to the residual 14 patients. It is concluded that patients with synchronous liver metastases from colorectal cancer may profit from resection of the primary tumor and liver metastases. Timing of liver resection—immediate versus delayed—obviously has no impact on survival rates.
Body composition in Chinese subjects: Comparison with data from North America
Authors: Jiang Zhu‐ming , Yang Nai‐fa , Chou Chun , Liu Zhen‐hua , Sun Te‐lin , Chen Yuan‐he , Xue Bao‐zhen , Fei Li‐ming , Tseng Hsien‐chiu , Brown Elaine , Scheltinga Marc , Wilmore Douglas W.
Published: May 2005

A multiple tracer dilution method measuring total body water, extracellular water, plasma volume, and red cell volume was used to study body composition. Healthy Chinese subjects were compared to a group of Chinese patients with various newly diagnosed gastrointestinal disorders scheduled for elective operation. Compositional data obtained from these groups showed no significant differences in compartmentalization, suggesting absence of major changes during the early stages of certain gastrointestinal diseases. In addition, healthy Chinese subjects were compared to a group of healthy Americans previously evaluated by similar dilutional methods. In males, body weight (kg) differed considerably (Chinese=62.1±2.0 versus American = 72.5±4.1,p<0.02) and could be explained by alterations in body fat (Chinese=12.4±1.3 versus American=19.2±2.2,p<0.02) and extracellular water (Chinese=14.4±0.5 versus American=16.8±0.8,p<0.02). Functional tissue (“body cell mass”) was similar in the 2 groups which suggested that Chinese have comparable body composition without an additional fat burden.

The multiple tracer technique using deuterium oxide, sodium bromide, Evans dye, and Cr51for body compositional assessment is accurate but expensive and laborious. Therefore, equally precise but more economical bedside methods are needed for routine compositional analysis.
Retroperitoneal drainage in the management of the septic phase of severe acute pancreatitis
Authors: Alberto Villazón S. , Oscar Villazón D. , Francisco Terrazas E. , Ricardo Raña G.
Published: May 2005

Eighteen consecutive patients with sepsis due to surgically confirmed peripancreatic necrosis extending diffusely into the retroperitoneal fat were treated in our hospital from 1980 to 1987. Management consisted of early retroperitoneal debridement of necrotic tissue and drainage through lumbar incisions. Enteral nutrition was implemented in all patients 3–8 days after their first surgery. A total of 40 reoperations were required—an average of 2.6 per patient. Complications included respiratory failure (17), renal failure (4), gastrointestinal bleeding (4), retroperitoneal bleeding (1), and gastrointestinal fistulas (6). Four (22%) of the 18 patients died; the major cause of death was multiple organ failure secondary to sepsis. Before 1980, all patients with severe pancreatitis treated in our hospital died, despite the use of different management techniques. The use of the extraperitoneal route for early debridement of necrotic tissue and to avoid contamination of the peritoneal cavity has substantially reduced the mortality associated with peripancreatic necrosis in our hospital. The mortality in this series of patients (22%) compares very favorably with that reported in studies of similar patients.
Lower esophageal sphincter characteristics and esophageal acid exposure following partial or 360‡ fundoplication: Results of a prospective, randomized, clinical study
Authors: Lundell Lars , Abrahamsson Hasse , Ruth Magnus , Sandberg Nils , Olbe Lars C.
Published: May 2005

In a prospective, randomized, clinical trial, we compared a partial (180–200‡, Toupet) with a total fundoplication (360‡, Rossetti) in the surgical treatment of gastroesophageal reflux disease. Seventy‐one patients entered the trial; 33 were allocated to a partial fundoplication and 38 to a 360‡ fundic wrap. Each patient was investigated prior to as well as 3 and/or 6 months after the operation, including an endoscopic and clinical assessment. Manometry was carried out via a triple lumen catheter and the pressure in the high pressure zone (HPZ) in the distal esophagus was measured as well as the length of the intraabdominal segment by a “station pull‐through” technique. Acid exposure of the esophageal mucosa was evaluated by ambulatory 24‐hour pH measurements.

Acid exposure of the esophageal mucosa was “normalized” by the 2 operations. In addition, the length of the HPZ was increased to a “normal” level by both operations. The pressure of the HPZ was, however, “normalized” only in patients allocated to a Rossetti fundoplication, whereas patients operated on with a partial fundoplication had a significantly lower HPZ pressure (p<0.01). The clinical assessment revealed excellent results in both groups with no significant differences between the 2 operations except for a higher incidence of dysphagia at 3 months after a Rossetti fundoplication (p<0.01), which disappeared during the subsequent 3 months.
Scintigraphic detection of gastric and pancreatic carcinomas with In‐111 ZCE 025 monoclonal antibody
Authors: Abdel‐Nabi Hani H. , Schwartz Alan N. , Wechter Debra G. , Higano Celestia S. , Ortman‐Nabi Judith A. , Unger Michael W.
Published: May 2005

We have evaluated the role of In‐111 anti‐CEA (carcinoembryonic antigen) monoclonal antibody ZCE 025 in 8 patients. Three patients had a confirmed diagnosis of gastric carcinoma. Three had a confirmed diagnosis of pancreatic carcinoma. Two patients had elevated serum levels of CEA with no known primary. Each patient received 5.5 mCi In‐111 ZCE 025 infused at doses of 10–80 mg. Planar and single photon emission computed tomography (SPECT) imaging at 3 and 7 days after infusion detected 9 of 12 known tumor sites and all 5 of the previously identified sites of metastasis. In‐111 ZCE 025 MoAb imaging also found 6 previously unsuspected tumor sites and changed the preoperative evaluation in 50% of the patients studied. It changed the clinical management in 2 patients and established the site of primary involvement in 2 others. There were no clinical or biochemical reactions. In‐111 ZCE 025 monoclonal antibody scintigraphy is a useful adjunct in the evaluation of patients with either gastric or pancreatic carcinoma. It may have a beneficial impact on the surgical decision making in these patients.
Cervicothoracic arterial injuries: Recommendations for diagnosis and management
Authors: George Salem M. , Croce Martin A. , Fabian Timothy C. , Mangiante Eugene C. , Kudsk Kenneth A. , Voeller Guy R. , Pate James W.
Published: May 2005

Management of arterial injuries at the thoracic outlet and neck presents a major challenge to the trauma surgeon; hemorrhagic shock, neurologic deficit, and limb loss are the serious sequelae. Over a 13‐year period, 118 patients with injuries to the innominate, carotid, subclavian, and axillary arteries were evaluated. Most injuries were penetrating (78%). Half of the patients were diagnosed by physical examination and half by angiography. Patients were treated by either primary repair (35%), interposition graft (31%), ligation (8%), or anticoagulation (26%). Two patients required amputations (1 digit, 1 above elbow). Overall mortality was 14%, with 5% due to consequences of hemorrhagic shock, 7% due to cerebral ischemia, and 2% due to other causes. Claviculectomy, median sternotomy, and trap door incisions were routinely used for proximal vascular control and repair. We conclude that liberal use of angiography is indicated in stable patients for penetrating wounds near major arteries, and for blunt injuries associated with neurologic deficits unexplained by computed tomography. Patients with obvious arterial injury should have immediate exploration. Extensile exposure is mandatory for appropriate management. Blunt carotid dissections are generally best managed nonoperatively with anticoagulation.
Hepatectomy for large hepatocellular carcinoma: The optimal resection margin
Authors: Lai Edward C. S. , Ng Irene O. L. , You K. T. , Choi T. K. , Fan S. T. , Mok Francis P. T. , Wong John
Published: May 2005

The necessary resection margin (RM) for cure during hepatectomy for hepatocellular carcinoma (HCC) remains conjectural. From January, 1972 to June, 1988, a total of 96 patients who had complete macroscopic extirpation of their large tumor (≥5 cm in largest diameter) were studied retrospectively to determine the macroscopic distance of RM required to secure histological disease clearance. Positive histological RM, which was found in 31 (32.3%) patients, had significantly compromised both diseasefree survival (p<0.04) and overall survival (p<0.006) of these patients. Among the 65 patients with detailed measurement of macroscopic RM, a significant reduction of residual histological disease was observed when a 0.5 cm margin had been established (p<0.05). Further extension of margin had no additional benefit. The presence of microsatellite (p<0.03) and multiple tumor nodules (p<0.03) was associated with an increased risk of positive histological margins among the 15 pathological parameters evaluated, including macroscopic RM. Since measurement of RM is an unreliable guide, histological confirmation is the only means for establishing the diagnosis of complete tumor clearance. Within safety limits dictated by anatomical factors and severity of underlying cirrhosis, aggressive surgery should be offered for patients with large HCC; however, resection is not advisable unless a 0.5 cm margin can be secured with certainty, especially for multinodular lesions.
Decision making in surgical practice
Authors: Clarke John R.
Published: May 2005

Judgment has been defined as the ability to make correct decisions with uncertain, incomplete, or inconsistent information. Decision analysis is a scientific method of choosing between trade‐offs. This review provides evidence that the model of decision analysis adequately represents clinical problems and that the use of decision analysis can improve clinical judgment. The technique of analyzing decisions using a decision tree model is reviewed. Using the decision tree model, a decision consists of specifying the options, specifying the outcomes associated with each option, assigning probabilities to those outcomes when they are not known with certainty, and assigning values or utilities to those outcomes. Surgical decisions can be described by a limited number of decision trees despite a much larger number of clinical problems. A model of the surgical decision making process, consistent with the analytical decision tree model, details steps useful in clinical decision making. The surgeon determines whether the characteristics of the patient match those of the typical patient with the condition. If so, the standard solution is recommended. If not, the surgeon concentrates on assessing or revising the specific probabilities or utilities that are different. If the best option is suboptimal, consideration is given to more aggressive diagnosis or to a therapy that offers the potential for a better outcome, but at a risk.

The recommendations of surgeons for 6 patient management problems was compared to the analytical solutions using their own subjective estimates of probabilities and utilities. Decision analysis provided a net gain in accuracy in all 6 problems. Decision analysis was also significantly more accurate than the conventional second opinion program.

Evidence exists that decision trees are reasonable models of the clinical trade‐offs involved in surgical judgment. Resolving clinical trade‐off decisions with decision analysis can be shown to be practical and result in improvement in clinical judgment.
A new scoring system for disease intensity in a surgical intensive care unit
Authors: Lehmkuhl Peter , Jeck‐Thole Sabine , Pichlmayr Ina
Published: May 2005

This study of 215 patients in a surgical intensive care unit (ICU) compares the predictive value of a new disease intensity scoring system called the Hanover Intensive System (HIS) with two previously described systems: APACHE (Acute Physiology and Chronic Health Evaluation), and TISS (Therapeutic Intervention Scoring System).

HIS was superior in predicting a lethal outcome at an earlier time than the other methods of scoring. Practical use of this system in clinical decision making was made in timing of reoperation, planning nursing time, and caring for patients following liver transplantation.

It is concluded that an accurate disease intensity scoring system such as HIS is of practical benefit in decision making in a surgical ICU.
Score‐aided decision making in patients with severe liver damage after hepatic transplantation
Authors: Gubernatis Gundolf , Tusch Günter , Ringe Burckhardt , Bunzendahl Hartwig , Pichlmayr Rudolf
Published: May 2005

This article describes how a system of scoring risk factors contributes to deciding whether a patient showing signs of liver failure soon after hepatic transplantation should be treated expectedly or should undergo immediate retransplantation.

Of 78 adult patients receiving a first liver graft, 25 had evidence of severe damage of the graft and were further investigated. Nine had failure due to irreversible initial nonfunction, and 2 of the 9 died before a second graft was available. Seven were retransplanted with 3 long‐term survivors. The other 16 patients showed reversible severe damage and survived without retransplantation.

Since retransplantation for irreversible initial nonfunction is successful only in the first postoperative days, there is an urgent need to identify the degree of the observed damage. We devised a scoring system which identified and weighted factors that were predictable in determining irreversibility. Measurements of highest relevance are transaminases, bile volume, the slope of the enzyme GLDH, and the amount of fresh blood and fresh‐frozen plasma required for support on the day of operation and the following day. Logistic regressional analysis produced a numerical score which was applied to a decision tree and produced probabilities and utilities to indicate whether reoperation is advisable.

We use this scoring system and believe it assists our decisions in the early posttransplant period.
Ultrasonographic screening for abdominal aortic aneurysm: Analysis of surgical decisions for cost‐effectiveness
Authors: Bengtsson Henrik , Bergqvist David , Jendteg Stefan , Lindgren Bjorn , Persson Ulf
Published: May 2005

A mathematic model is created to determine the economic cost per year of anticipated prolongation of life that would result from a program of abdominal ultrasonographic (US) screening for abdominal aortic aneurysm. The protocol involves US screening at age 60,67, and 74 years with additional annual follow‐up US and examination if an aneurysm of less than 40 mm is detected. Larger aneurysms are assumed to be sent for early elective resection. The benefits and risks for a subset of men with symptoms of intermittent claudication (IC) as an additional risk factor of atherosclerosis is calculated for comparison.

Many of the factors on which these calculated costs and benefits are based are approximations and inferences. These include operative mortality for elective and emergent cases, charges for each such condition, cost of US, and anticipated survival following successful aneurysmectomy both with and without concomitant IC. Sensitivity analysis is performed to show how variations in the major parameters alter the outcome of the calculated cost per year of anticipated extension of life.
Prospective scenarios: A method of evaluating new decision tools
Authors: Dudley Hugh A. F. , Brown Simon Paterson , Thomson Jeremy N. , Eckersley J. Rupert
Published: May 2005

Prospective randomized controlled trials are rarely suitable for the evaluation of new decision making techniques. An approach is described in which a cohort of patients is taken down the usual study pathway to the point at which the new technique would be used. Conventional decision rules are then applied and the results recorded. The new technique is then deployed and the cohort reclassified. The logical and statistical justification for this approach is outlined. More rapid (although possibly less pure) analysis of the effect of the new technique is achieved.
Dynamics of bile flow through the human choledochal sphincter following exploration of the common bile duct
Authors: Holdsworth R. J. , Sadek S. A. , Ambikar S. , Cuschieri A.
Published: May 2005

The opening pressure and flow rates through the sphincter of Oddi using the patient's own bile to prime the system were measured daily in 17 patients after cholecystectomy and exploration of the common bile duct. The sequential changes in these parameters were correlated with preoperative serum bilirubin, bile bacteriology, biliary lipid composition, and bile viscosity. The opening pressure fell from an initial value of 17.2±1.9 to 9.1±0.9 cm bile (p<0.01) on the seventh postoperative day, indicating a self‐limiting hold‐up following stone extraction. The low opening pressure after the fifth to sixth day is well below the maximal hepatic secretory pressure and suggests that the bile flow into the duodenum may be continuous after cholecystectomy. The flow rate through the sphincter measured at a fixed pressure head of 30 cm of bile increased from 23.9±3.9 to 40.0±6.1 ml during the same period (p<0.01). Presumably, the latter represents the maximal flow rate of bile through the sphincter of Oddi under physiological conditions. These changes in flow could not be explained by alterations in the bile viscosity during the study period. The increase in flow rate was significant only in the nonjaundiced group and correlated positively with the phospholipid concentration in the bile. There were no significant differences in opening pressure, flow rates, and biliary lipid concentrations between patients with sterile bile and those with positive bile cultures.
Long‐term results of hemostatic gastric suture in the treatment of esophagogastric varices
Authors: Romero‐Torres Raul
Published: May 2005

Portal azygos disconnection, using vein ligatures and a circumferential hemostatic suture of the gastric wall at the level of the upper pole, is a simple and a rapid technique that effectively controls bleeding from esophagogastric varices. Its low mortality rate in emergency cases or poor‐risk patients can be of great benefit to patients who have not responded to conservative therapy, including tamponade and vein sclerosis.

In this article, we conclude that the long‐term results of this operation demonstrate that it can also be used in elective cases, especially in patients with Child's “C” classification. These patients with advanced cirrhosis have a very low survival rate (no more than 5 years) yet they can benefit from this portal disconnection since this procedure does not alter the portal hemodynamics and, consequently, does not induce chronic encephalopathy.
Surgical intervention following fragmentation of gallstones by extracorporeal shock waves
Authors: Teichmann Reinhard K. , Sauerbruch Tilman , Sackmann Michael , Holl Joseph , Paumgartner Gustav , Heberer Georg
Published: May 2005

Five cases of surgical intervention following extracorporeal shock wave lithotripsy (ESWL) of gallbladder and bile duct stones are reported. This represents an incidence of surgical intervention in 1% of patients with gallbladder stones and in 9% of patients with common bile duct stones who underwent ESWL during a two‐and‐a‐half‐year investigation period. There was no mortality. In 2 patients with gallbladder stones and persistent colic after ESWL, elective cholecystectomy was performed. There was no evidence of macroscopic or microscopic damage or bleeding within the wall of the gallbladder. Furthermore, no damage to the liver, common bile duct, duodenum, or stomach was noted. ESWL was applied in 34 patients with common bile duct stones in whom endoscopic sphincterotomy and stone extraction had proved ineffective. Three (9%) of these patients required surgery. In 1 patient, a Dormia basket got stuck and the basket, together with the stone, were removed by choledochotomy. In a second patient, rupture of a juxtapapillary diverticulum occurred 10 days after ESWL and 2 days after endoscopic extraction of stone fragments. At laparotomy, the retroperitoneum was drained. In a third patient with gallbladder and common bile duct stones, acute cholecystitis developed after lithotripsy of common bile duct stones. Cholecystectomy was performed and a t‐tube was inserted in the bile duct. In all patients, the postoperative course was uneventful. In our experience, ESWL is a safe procedure with no mortality and an infrequent need for surgical intervention.
Colorectal carcinomas: Diagnostic implications of their changing frequency and anatomic distribution
Authors: Ghahremani Gary G. , Dowlatshahi Kambiz
Published: May 2005

This retrospective review included 1,694 consecutive cases of colorectal carcinoma diagnosed at the University of Chicago Medical Center during a 25‐year period (1960 through 1984). The number and percentage of tumors occurring within 7 anatomic segments of the large bowel were determined. The statistical data for a recent 5‐year interval were then compared with those of the 2 preceding decades. There was a 10.2% increase in the frequency of cancers originating in the cecum or ascending colon, while rectal and rectosigmoid carcinomas declined by 15.8% during the same study period. These data provide further evidence for a progressive left‐to‐right shift in cancer distribution within the colon during the past quarter century. Currently, the most proximal and distal 20–25 cm segments of the large bowel (cecum or ascending colon versus rectum and rectosigmoid) each harbor approximately 25% of the tumors. Therefore, the classic medical teaching that over 50% of colorectal cancers would be detectable by digital examination and/or proctosigmoidoscopy is no longer accurate. This documented increase in proximal colon cancers and redistribution of lesions within various large bowel segments indicate the growing importance of barium enema and colonoscopy as the optimal techniques for detection of colorectal neoplasms.
Surgical complications of typhoid fever: Enteric perforation
Authors: Santillana Miguel
Published: May 2005

Typhoid fever remains a prevalent disease in developing nations as the result of adverse socioeconomic factors. The most frequent complication, and principal cause of mortality, is perforation of the terminal ileum. This report presents our experience with 96 patients surgically treated at Cayetano Heredia University Hospital in Lima, Peru from 1972 to 1986. The clinical characteristics and the diverse surgical procedures utilized in the management of these patients are reviewed.
Surgical complications of ascariasis
Authors: Ochoa Bernardo
Published: May 2005

Over the past 25 years (1963–1988), a total of 311 children under 12 years of age were admitted to the Pediatric Surgical Service of the San Vicente de Paúl University Hospital, Medellín, Colombia, with complications resulting from infection withEntamoeba histolyticaorAscaris lumbricoides.In this group, the abdominal complications produced by ascariasis numbered 145, and included intestinal obstruction (n = 107), perforation of the appendix (n = 10), and migration of the parasite to the biliary tree or to the peritoneal cavity (n = 28). Evaluation of the living conditions of a significant subgroup of our patients confirms that intestinal parasitism is an endemic condition prevailing in nations that exhibit deep social and economic imbalance, where large sectors of the population remain deprived of the basic services of education, health, housing, and recreation.

Massive infestation in children may give rise to grave complications that demand expert surgical care. Third World surgeons practicing in general hospitals that take care of patients of low economic capacity are usually familiar with the diagnosis and management of this pathology; surgeons who practice in the industrialized nations will only occasionally face such problems. The greater mobility of today's societies and the rather massive migrations that take place in current times have resulted in an increasing incidence of these entities in the hospital populations of the large urban centers of these nations. It is for the surgeons practicing in such centers that the information presented herein may be of greater value.