bluuebunny/crossref_metadata_2025 huggingface dataset:
Radiolabeled Sentinel Node Biopsy: Collaborative Trial with the National Cancer Institute
Authors: Krag David N. , Harlow Seth , Weaver Donald , Ashikaga Taka
Published: October 2003

The objective of this study was to maximize the success rate of sentinel node (SN) localization in breast cancer patients with the tracer that demonstrated the highest initial success during a preliminary evaluation. Altogether, 145 patients with operable invasive breast cancer and clinically negative lymph nodes were studied. Technetium 99m (99mTc)‐sulfur colloid was injected into the breast parenchyma surrounding the invasive cancer or the biopsy cavity. Variable volumes of tracer, amounts of 99mTc, and duration of time between injection and surgery were evaluated. A hand‐held gamma detector was used at surgery to locate and guide resection of all radioactive sentinel nodes (SNs), including those that were extraaxillary. A conventional lymphadenectomy was then performed in all cases. Based on previous studies, unfiltered sulfur colloid provided a higher success rate of SN identification than the other tracer types. Further evaluation with 99mTc‐sulfur colloid demonstrated that increased volume increased the success rate of SN identification. An injection volume of 8 ml resulted in a success rate of 98%. SNs were not exclusively located in the axilla: In 8.6% of cases SNs were removed from an internal mammary location. The overall accuracy of patients with SNs resected was 98.4%, and the false‐negative rate was 4.4%. It was concluded that (1) unfiltered 99mTc‐sulfur colloid at a volume of 8 ml resulted in a high success rate for SN identification; (2) a significant number of the SNs were extraaxillary in location; and (3) the accuracy of the SNs for determining whether regional metastases had occurred was high. The U.S. National Cancer Institute is funding a randomized phase III clinical trial to evaluate SN resection compared to conventional axillary lymphadenectomy in clinical node‐negative breast cancer patients. Major endpoints of this trial include long‐term regional control and survival.
Natural History of Liver Metastasis of Gastroenteropancreatic Neuroendocrine Tumors: Place for Chemoembolization
Authors: Proye C.
Published: October 2003

Hepatic metastases of gastroenteropancreatic tumors are observed in at least 10% of cases at presentation and in 85% of cases after 20 years of follow‐up. They are slow‐growing; and there is a 5‐year life expectancy that varies between 13% and 60% depending of the degree of differentiation, with occasional survival of more than 20 years. Curative liver resection is the best treatment, with a 4‐year survival rate of 73%, but this is possible in only 10% of cases. Chemoembolization is indicated for nonresectable multiple bilobar metastases: 87% of patients respond, half with tumor reduction and the other half with diminution of the symptoms of hypersecretion. The mean survival is 2 years; complete remission of more than 2 years is exceptional. The technique can be repeated but is not without risks, with a possible postembolization syndrome lasting up to 10 days and subsiding spontaneously, without indication for operation. Therefore one lobe only should be embolized at a session. It is not impossible that chemoembolization increases the occurrence of lung metastases. It is only a palliative method but with great functional benefit for patients with hypersecreting tumors.
Cryoablation, Percutaneous Alcohol Injection, and Radiofrequency Ablation for Treatment of Neuroendocrine Liver Metastases
Authors: Siperstein Allan E. , Berber Eren
Published: October 2003

Neuroendocrine liver metastases are associated with slow clinical progression, prolonged patient survival, and symptoms of hormone oversecretion. Although surgical resection is the gold standard of treatment, most of the patients are not candidates for resection, and the 5‐year survival of patients with neuroendocrine liver metastases is 11% to 40%. Cryotherapy, percutaneous alcohol injection, and radiofrequency thermal ablation are among the alternative regional treatment options available for these patients. The current role of these treatment options for neuroendocrine liver tumors are discussed in this review. Cryosurgery is the classic technique for local tumor destruction, mostly performed with open surgery. There has been limited experience with percutaneous alcohol injection for neuroendocrine liver metastasis. Radiofrequency thermal ablation is a relatively new modality that can be performed percutaneously or laparoscopically, and encouraging results have been obtained with it for treatment of neuroendocrine liver metastases.
Treatment of Hepatic Metastases from Gastroenteropancreatic Neuroendocrine Tumors: Role of Liver Transplantation
Authors: Ringe Burckhardt , Lorf Thomas , Döpkens Karen , Canelo Ruben
Published: October 2003

The role of liver transplantation in malignancy has been discussed, but controversially, over the past two decades. This is particularly true for hepatic metastases from neuroendocrine tumors, which have a wide variety of primary tumor localizations, morphologic types, functional activities, and clinical presentations. Despite generally slow tumor progression, the prognosis is often unpredictable. Total hepatectomy and liver replacement has been offered primarily to patients with nonresectable metastases and symptomatic disease. The results from retrospective single and multicentric analyses show that most liver recipients experience significant palliation despite tumor recurrence, and in some patients long‐term cure can be achieved. The existing data emphasize the importance of proper selection and timing for this approach.
Nonsurgical Treatment of Advanced Malignant Neuroendocrine Pancreatic Tumors and Midgut Carcinoids
Authors: Skogseid Britt
Published: October 2003

Neuroendocrine enteropancreatic tumors are relatively uncommon and present variable biologic and clinical features. Surgery at early disease stages is currently the only available cure. Evidenced‐based medicine and consensus on systemic treatment of advanced malignant disease is virtually nonexistent, and the various available therapeutic regimens should be considered primarily palliative. Symptomatic treatment of patients with endocrine functioning tumors, however, is of utmost importance and leads to extensive prolongation of survival. Biotherapy by means of somatostatin analogs and interferon‐α facilitates symptomatic control and offers stabilization of tumor progression for extended periods of time. Pancreatic endocrine tumors metastatic to the liver frequently respond to chemotherapy by means of a significant reduction in tumor volume. Programs including streptozotocin and 5‐fluorouracil or doxorubicin are generally regarded as first line treatment for pancreatic endocrine tumors with liver metastases, whereas midgut carcinoid tumors often are resistant to systemic chemotherapy. Treatment attempts in patients with the latter disease may rather include interferon‐α and somatostatin analogs. Somatostatin receptor‐targeted radiotherapy is still investigational. Repeated surgical intervention including various debulking procedures should be considered here and in patients with advanced neuroendocrine pancreatic tumors and midgut carcinoids requiring systemic antitumor treatment.
Minimally Invasive Video‐assisted Parathyroidectomy: Multiinstitutional Study
Authors: Lorenz Kerstin , Miccoli Paolo , Monchik John M. , Düren Mete , Dralle Henning
Published: October 2003

Unilateral and minimally invasive parathyroidectomies with endoscopic and video‐assisted technique have been introduced. Most of these procedures utilize preoperative localization and intraoperative monitoring of parathyroid hormone. There are only a few reports on these procedures. The objective of this study was to evaluate video‐assisted parathyroidectomy (MIVAP) for surgery in patients with primary hyperparathyroidism (pHPT). From February 1997 to June 1999 a series of 123 consecutive patients with pHPT at four surgical centers were evaluated. The patients' ages ranged from 18 to 77 years (median 50 years). Preoperatively, sestamibi scintigraphy and ultrasonography for localization were performed for all patients. Selection criteria for a MIVAP procedure excluded patients with negative localization, suspicion of multiglandular disease (MGD) or thyroid malignancy, a large thyroid mass, and prior surgery or irradiation to the neck. MIVAP was performed with a 1.5 cm suprasternal incision; the operation was then done through this incision with a 30 degree 5 mm endoscope and microsurgical instruments with brief CO2 insufflation for adenoma identification. We then proceeded with an open technique through the small incision under video‐assistance. Intraoperative monitoring of intact parathyroid hormone (iPTH) assays was used in all patients. Among the 123 patients in whom MIVAP was attempted, the procedure was accomplished in 109 (89%). Conversion to conventional cervicotomy was required in 14 (11%) patients because of failed localization, failure of the iPTH level to fall appropriately, or technical problems. There was no persistent or recurrent HPT during the 3 to 12‐month follow‐up. Oral calcium replacement for symptomatic hypocalcemia postoperatively was given in 7 (6%) cases. A unilateral transient laryngeal nerve palsy, resolving within 6 months postoperatively, occurred in two (2%) patients. The median hospital stay was 1.5 days (range 0.5–5.0 days). This study showed the feasibility of MIVAP as an alternative surgical treatment for pHPT in a selected group of patients. Further studies are necessary to evaluate the efficacy and rationale of MIVAP compared to other techniques for parathyroidectomy in pHPT patients.
Association between Residual Thyroid Carcinoma and Diffuse Hepatic Uptake of 131I following Radioiodine Ablation in Postoperative Total Thyroidectomy Patients
Authors: Tatar Fatma Atalay , Morita Eugene , Ituarte Philip H.G. , Cavalieri Ralph R. , Duh Quan‐Yang , Price David C. , Siperstein Allan E. , Clark Orlo H.
Published: October 2003

In patients with differentiated thyroid cancer (DTC) total or near‐total thyroidectomy, postoperative 131I ablation, and thyroid suppression therapy are reported to be associated with fewer recurrences than other treatments. Many patients with DTC after total thyroidectomy and radioablation therapy have diffuse hepatic uptake of radioiodine, and its clinical importance is debated. Some investigators report that diffuse liver uptake correlates with uptake in the thyroid bed or the presence of metastatic thyroid cancer somewhere in the body, whereas others note no such correlation. The purpose of this research was to determine the clinical importance of diffuse hepatic uptake of radioiodine after 131I ablative therapy in patients with DTC. We retrospectively reviewed 141 posttherapy scans done in 118 patients with DTC. Patients had had total thyroidectomy and were hypothyroid when serum thyroglobulin (Tg) levels were obtained, and they were treated with 30 to 200 mCi of 131I. Scans were performed 3 to 21 days after radioablation therapy. Information was collected regarding the patients' age and gender, the interval between the ablation therapy and scan, uptake of radioiodine, serum thyroglobulin level, thyroid‐stimulating hormone (TSH) level, thyroglobulin antibodies, TNM classification, mortality, and recurrence. Diffuse liver uptake was classified from 0 to 4 depending on hepatic brightness. Radioiodine scans were done to determine whether there was uptake in the thyroid bed or elsewhere. Statistical analyses included analysis of variance and Kaplan‐Meier survival analysis. Diffuse hepatic uptake was observed (grades 1–4) in 96.4% of the patients; thus 3.6% had no hepatic uptake. There was no significant association between liver uptake and the uptake in the thyroid bed, the dose of 131I administered for ablation therapy, thyroglobulin levels, age, stage of the disease, presence of local or distant metastases, recurrence, or survival. Diffuse hepatic uptake was therefore not associated with residual normal thyroid or metastases as suggested by some but not all previous investigators.
Posterior Retroperitoneoscopic Adrenalectomy: Lessons Learned within Five Years
Authors: Walz Martin K. , Peitgen Klaus , Walz Markus V. , Hoermann Rudolf , Saller Bernhard , Giebler Reiner M. , Jockenhövel Friedrich , Philipp Thomas , Broelsch Christoph E. , Eigler Friedrich W. , Mann Klaus
Published: October 2003

Posterior retroperitoneoscopic adrenalectomy is one of the new endoscopic methods in endocrine surgery. In a prospective clinical study 142 posterior retroperitoneoscopic adrenalectomies (72 right, 70 left) were performed in 130 patients (52 males, 78 females, age 49.1 ± 14.9 years). Indications were primary adrenal tumors (unilateral, n= 118; bilateral, n= 2), adrenal metastases (n= 2), and bilateral ACTH‐dependent hyperplasias (n= 10). Tumor size ranged from 0.5 to 7.0 cm (mean 2.7 ± 1.4 cm). Partial adrenalectomies were performed in 39 patients. Conversion to open posterior adrenalectomy was necessary in five patients and seven procedures (5%). Intraoperative and postoperative complications were minor and occurred in 5% and 13%, respectively. Mortality was zero. Operating time was 101 ± 39 minutes (range 35–285 minutes) and depended on tumor type (pheochromocytoma versus others; p < 0.01), tumor size (< 3 vs. ≥ 3 cm; p < 0.05), gender (p < 0.05), and extent of resection (partial versus complete, p < 0.05. Twenty‐three adrenalectomies (17%) were performed within 1 hour or less. Blood loss was 54 ± 72 ml. Consumption of analgesics was low (mean 6 mg piritramide postoperatively). Median duration of hospitalization was 3 days. Posterior retroperitoneoscopic adrenalectomy is a safe method that has become a standard procedure in endocrine surgery.
Achalasia and Esophageal Cancer: Incidence, Prevalence, and Prognosis
Authors: Brücher Björn Lucas Dietrich Maria , Stein Hubert Jakob , Bartels Holger , Feussner Hubert , Siewert Jörg Rüdiger
Published: October 2003

Reported incidence rates of carcinoma in patients with achalasia and the prevalence of achalasia in patients with esophageal cancer vary widely in the literature. The prognosis of an “achalasia‐carcinoma” is generally considered poor, although systematic studies assessing the incidence, prevalence, and prognosis of patients with “achalasia‐carcinoma” are scant. We investigated the incidence of esophageal cancer in a large series of patients with known achalasia, assessed the prevalence of achalasia in patients presenting with esophageal cancer, and evaluated the prognosis of these patients compared to that of patients with esophageal cancer without achalasia. Between 1982 and 1998 a total of 124 patients with primary achalasia were treated and followed at our department. During the same time period 1366 patients presented with esophageal cancer (879 esophageal squamous cell carcinomas, 487 adenocarcinomas). Of the 124 patients with primary achalasia, 4 developed a carcinoma during a mean follow‐up of 5.6 years (i.e., an incidence of one carcinoma per 173.6 patient‐years of follow‐up). Altogether, 13 of 879 patients (1.5%) presenting with esophageal squamous cell carcinoma and 1 of 487 patients (0.2%), presenting with esophageal adenocarcinoma had a history of primary achalasia. Seven patients with achalasia‐carcinoma (50%) had early‐stage disease (stage I, IIA, or IIB). There was no difference in the prognosis of patients with resected achalasia‐carcinoma versus those with esophageal carcinoma but no achalasia. Thus in our population of patients with long‐standing achalasia the risk for developing an esophageal cancer was increased about 140‐fold over that of the general population. With liberal use of surveillance, carcinoma could often be detected at an early stage in these patients, with a prognosis that was not worse than that of patients with squamous cell esophageal cancer but no achalasia.
Surgery for Abdominal Metastases of Cutaneous Melanoma
Authors: Gutman Haim , Hess Kenneth R. , Kokotsakis John A. , Ross Merrick I. , Guinee Vincent F. , Balch Charles M.
Published: October 2003

The objective of this study was to support our hypothesis that surgical resection of abdominal metastases of melanoma, regardless of symptomatology, could provide prolonged palliation and improved survival. We performed a retrospective chart review at M.D. Anderson Cancer Center. A series of 251 melanoma patients (stages I, II, or III at registration) who developed intraabdominal metastases during follow‐up were studied. Altogether, 96 patients underwent 119 laparotomies; 51 underwent endoscopic or percutaneous procedures; and 116 patients were treated medically. Surgery was associated with a median survival of 11 months, significantly longer than that with other treatment (p < 0.001). Tumor was extirpated during 37% of the first laparotomies, and in an additional 33% very good palliation was achieved with incomplete resection. Tumor extirpation was associated with 10‐month symptom‐free survival (SFS), significantly longer than that with any other approach (p < 0.0001). In the nonsurgically treated patients, good palliation was achieved in 8% to 17% of patients with no complete response. The median SFS after surgery was 5 months, but 23% of patients were symptom‐free more than 12 months; 87 patients with minimal symptoms; and 72 severely symptomatic patients underwent surgery. Complete resection was feasible in 42% and 34%, respectively. Surgery was associated with 12 months median survival in both groups. There was a significant survival benefit from surgery in patients with gastrointestinal (GI) tract metastases in contrast to those who had non‐GI metastases. For the 96 surgically treated patients, a time interval of more than 4 years between diagnosis of the primary lesion and the abdominal recurrence predicted decreased risk of death (p= 0.038). The 30‐day postoperative complication and mortality rates were 19.0% and 3.3%, respectively. Complete surgical resection of melanoma metastases in the abdomen is associated with median and symptom‐free survival benefits. Symptomatic and asymptomatic patients benefit equally, especially if abdominal metastases appear more than 4 years after the initial diagnosis and do not involve non‐GI viscera. Less than complete resection can provide durable palliation.
Adrenal locidentaloma
Authors: Brunt L. Michael , Moley Jeffrey F.
Published: October 2003

Because of the frequent use of computed tomography and other abdominal imaging modalities, clinicians more frequently see the incidentally discovered, clinically silent adrenal mass. Most adrenal incidentalomas should be evaluated for hormonal activity and assessed for their risk of malignancy. Adrenalectomy is indicated for hyperfunctioning tumors and for any potential primary malignant adrenal lesion. Nonfunctioning cortical adenomas<4 to 5 cm in size should be followed clinically and radiographically. Laparoscopic adrenalectomy has been used increasingly as the preferred approach in patients who require surgical resection whereas open adrenalectomy is reserved for patients with large, malignant tumors. The indications for adrenalectomy in patients with nonfunctioning adrenal tumors should not be liberalized because of the laparoscopic approach.
Cytotoxic treatment of adrenocortical carcinoma
Authors: Ahlman Håkan , Khorram‐Manesh Amir , Jansson Svante , Wängberg Bo , Nilsson Ola , Jacobsson Carl‐Erik , Lindstedt Sven
Published: October 2003

Adrenocortical carcinoma (ACC) is a rare, aggressive tumor that is often detected in an advanced stage. Medical treatment with the adrenotoxic drug mitotane has been used for decades, but critical prospective trials on its role in residual disease or as an adjuvant agent after surgical resection are still lacking. The concept of a critical threshold plasma level of the drug must be confirmed in controlled studies. Because individual responsiveness cannot be predicted, the use mitotane is still advised for nonresectable disease. In case of Cortisol or other steroid overproduction, several drugs (e.g., ketoconazole or aminoglutethimide) may be used. Chemotherapy with single agents (e.g., doxorubicin or cisplatin) have been disappointing, with low response rates (< 30%) and a short response duration. Part of this refractoriness may be explained by the fact that ACC tumors express the multidrug‐resistance gene MDR‐1. Chemotherapy with multiple agents has been tested in smaller series and has resulted in significant side effects. The best results were achieved by the combination of etoposide, doxorubicin, and cisplatin associated with mitotane, achieving a response rate of 54%, including individual complete responses. To be able to make progress in treating advanced ACC disease, adjuvant multicenter trials must be encouraged. When mitotane‐based therapies are used, monitored drug levels are mandatory.
Gushing syndrome doe to ectopic adrenocorticotropic hormone secretion
Authors: Aniszewski Jaroslaw P. , Young William F. , Thompson Geoffrey B. , Grant Clive S. , van Heerden Jon A.
Published: October 2003

Gushing syndrome (CS) caused by ectopic adrenocorticotropic hormone (ACTH) production (EA) poses major challenges diagnostically by mimicking the pituitary‐dependent form of CS and therapeutically by producing severe, life‐threatening hypercortisolemia. This retrospective follow‐up study describes the clinical characteristics and course of EA in a large referral center. Computer‐based cross‐index codes for EA, CS, and bilateral adrenalectomy were used to identify patients treated at the Mayo Clinic between 1956 and 1998. EA was confirmed in 106 patients. Gender distribution showed a slight female predominance (61:45). Bronchial carcinoid was the most frequent cause of EA (25%), followed by islet cell cancer (16%), small‐cell lung carcinoma (11%), medullary thyroid cancer (8%), disseminated neuroendocrine tumor of unknown primary source (7%), thymic carcinoid (5%), pheochromocytoma (3%), disseminated gastrointestinal carcinoid (1%), and other tumors (8%). No tumor was found in 16% of patients. Altogether, 28 patients were managed medically, and the others underwent curative tumor resection (13 patients) or bilateral adrenalectomy (65 patients). Surgically treated patients had longer survival, but this was most likely affected by treatment bias. The diagnoses of CS and ACTH‐secreting neoplasm were usually concurrent, although, there were remarkable cases in which the two conditions were diagnosed several years apart. Curative resection of the tumor producing EA was possible in a small proportion of patients (12%). When curative resection is not possible, patients who are reasonable surgical candidates are likely to benefit from adrenalectomy. Additional experience with bilateral laparoscopic adrenalectomy should increase the number of patients who benefit from adrenal‐directed surgery.
Primary aldosteronism: Are we diagnosing and operating on too few patients?
Authors: Gordon Richard D. , Stowasser Michael , Rutherford John C.
Published: October 2003

Many cases of potentially curable primary aldosteronism are currently likely to be diagnosed as essential hypertension unless screening tests based on suppression of renin are carried out in all hypertensive patients. More than half of the patients with primary aldosteronism detected in this way have normal circulating potassium levels, so measurement of potassium is not enough to exclude primary aldosteronism. When primary aldosteronism is diagnosed, fewer than one‐third of patients are suitable for surgery as initial treatment, but this still represents a significant percentage of hypertensive patients. After excluding glucocorticoid‐suppressible primary aldosteronism, adrenal venous sampling is essential to detect unilateral production of aldosterone and diagnose angiotensin‐responsive aldosterone‐producing adenoma. One cannot rely on the computed tomography scan. If all hypertensive patients are screened for primary aldosteronism and the workup is continued methodically in those with a positive screening test, patients with unilateral overproduction of aldosterone who potentially can be cured surgically are not denied the possibility of cure.
Genetic background of adrenocortical tumor development
Authors: Kjellman Magnus , Larsson Catharina , Bäckdahl Martin
Published: October 2003

The increasing occurrence of incidentally discovered benign adrenocortical tumors has become a clinical dilemma because of the difficulties in differentiating them from their malignant counterpart. Adrenocortical tumors are associated with familial cancer syndromes such as the Beckwith‐Wiedemann syndrome, the Li‐Fraumeni syndrome, the Carney complex, multiple endocrine neoplasia type 1, congenital adrenal hyperplasia, and the McCune‐Albright syndrome. Genetic events are known to take place on the chromosomal and gene level in sporadic adrenocortical tumors.
Secretin and pancreatic islet biood flow in anesthetized rats: Increased insulin secretion with no augmentation of blood perfusion
Authors: Carlsson Per‐Ola , Jansson Leif
Published: October 2003

Secretin is a stimulator of both endocrine and exocrine secretions of the pancreas, and we aimed to evaluate its effects on splanchnic blood flow in rats with a microsphere technique. Anesthetized rats were infused with secretin (0.5 or 2.0 µg/kg body weight/hr) for 10 minutes. Some animals were normoglycemic, whereas other received a glucose injection 3 minutes before blood flow measurements. Secretin did not affect serum insulin concentrations in normoglycemic animals but consistently led to higher insulin concentrations in the hyperglycémie rats. Total pancreatic blood flow was increased by the highest secretin dose in normoglycemic animals, whereas no effects were seen in the hyperglycémie rats. Administration of glucose caused a pronounced increase in islet and fractional islet blood flow in saline‐infused animals. Secretin affected neither islet nor fractional blood flow in normoglycemic or hyperglycémie rats. Glucose administration increased duodenal blood flow in animals infused with saline and both duodenal and colonie blood flow in rats given the lowest dose of secretin. No effects on either colonie or duodenal blood perfusion were seen in animals infused with the highest dose of secretin. Secretin mainly affects blood flow to the whole pancreas and not that of the islets. Furthermore, glucose‐induced insulin release can be achieved without a simultaneous increase in islet blood flow; that is these two events may be dissociated from one another.
Early imaging of integration response to polypropylene mesh in abdominal Wall by environmental scanning electron microscopy: Comparison of two placement techniques and correlation with tensiometric studies
Authors: Ferrando José M. , Vidal José , Armengol Manuel , Huguet Pedro , Gil Javier , Manero José M. , Planell José A. , Segarra Alfonso , Schwartz Simón , Arbos María A.
Published: October 2003

The repair of incisional hernias has taken advantage of the strength provided by prosthetic mesh grafts, but the best position for inserting the materials has not been conclusively established. Environmental scanning electron microscopy (ESEM) provides imaging of bio‐logic samples with minimal manipulation. We used ESEM for early imaging of the integration response to polypropylene meshes placed in two anatomic positions in the abdominal wall and correlated results with tensiometric studies. Two macroporous polypropylene prostheses were implanted in a rat model—one on the abdominal aponeurotic layer and one on the peritoneal surface—without creating a wall defect. Studies were performed over implantation intervals of 7, 15, and 30 days in strips obtained from the polypropylene fiber‐receptor repair tissue interface. Microscopic appearance, tensile strength, percent elongation, and stiffness were evaluated. Meshes implanted on the abdominal aponeurotic layer showed better early tissue incorporation (higher collagen deposition, capillary density, cell accumulation) and increased tensile strength, reflecting tighter anchorage to the abdominal wall. The percent elongation increased from day 7 to day 30 after implantation, mainly in the deep stratum. The ESEM images correlated well with biomechanical results, indicating the potential of this technique as a powerful, effective tool for use in wound‐healing studies.
Clinical analysis and literature review of massive Duodenal diverticular bleeding
Authors: Yin Wen‐Yao , Chen Hwa‐Tzong , Huang Shih‐Ming , Lin Hsien‐Hong , Chang Tzu‐Ming
Published: October 2003

A duodenal diverticulum (DD) appears in 2.5% of upper gastrointestinal (UGI) examinations and up to 22% of endoscopie retrograde cholangiopancreaticographies (ERCP) and autopsies. Most of these patients are asymptomatic, but the lesion is occasionally associated with bleeding, inflammation, perforation, obstruction of the duodenum or biliary‐pancreatic duct (or both), fistula formation in the bile duct, and bezoar formation inside the diverticulum. A total of 816 patients have undergone ERCP examination at our institution since January 1987, and 100 (12.25%) of them have DD. Seven (7%) patients presented with bloody or tarry stools from massive UGI bleeding followed by shock. Only two could be diagnosed by UGI endoscopy preoperatively. The lesions were demonstrated in angiographie studies in another four cases. However, only one was correctly interpreted and one required reoperation after a correct repeat endoscopie finding. The lesions in the other two patients were identified by thorough exploration during laparotomy. The remaining case was diagnosed by intraoperative endoscopy via pyloroduodenotomy. Six underwent surgical intervention, and one was successfully treated by expectant treatment. Three (50%) had leakage from the duodenotomy but recovered uneventfully with conservative treatment. In conclusion, we believe that DD bleeding is more frequent than usually thought. A high index of suspicion should be raised in cases of UGI bleeding when more obvious and common causes have been excluded by routine endoscopy. Aggressive but careful endoscopie examination combined with accurate angiography can help us diagnose most of the cases preoperatively. Diverticulectomy is an effective surgical procedure, though it is associated with a considerable leakage rate. The morbidity is minimal if we can identify the lesion earlier and evacuate the lesion without delay.
Laparoscopic management of bile duct and bowel injury during laparoscopic cholecystectomy
Authors: Kwon A.‐Hon , Inui Hiroyuki , Kamiyama Yasuo
Published: October 2003

Accidentai injuries to the bile duct and bowel are significant risks of laparoscopic surgery and sometimes require conversion to open surgery. Although some of the injuries related to laparoscopic cholecystectomy can be managed by endoscopic techniques, laparoscopic surgery is not yet sufficiently perfected. We investigated the efficacy of laparoscopic management combined with endoscopic tube or stent insertion in cases of bile duct and bowel injuries during laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted on 1,190 consecutive patients between April 1992 and June 1999. The first 70 patients underwent only preoperative intravenous infusion cholangiography (IVC), and the remaining 1,120 patients were subjected to both preoperative IVC and intraoperative cholangiography. We experienced 16 cases of bile duct injury (1.4%). Five patients with circumferential injuries of the bile duct were converted to open surgery for biliary reconstruction. The other 11 patients with partial laceration injuries of the bile duct and biliary leakage from the cystic duct underwent a laparoscopic simple closure technique. In 10 of these patients, an endoscopic tube or stent was inserted on the day after surgery to facilitate biliary decompression and drainage. Bowel injuries occurred in seven patients (0.6%). Three intestinal injuries were due to careless technique, and two duodenal injuries and two intestinal injuries were related to dense adhesions. All of these injuries were successfully repaired using laparoscopic techniques, auto‐suturing devices, or extracorporeal suturing via the umbilical incision. No postoperative complications were identified. We concluded that the biliary injury site could be closed with a laparoscopic technique so long as the biliary injury was not circumferential. Bowel injuries also could be repaired laparoscopically.
Hyperamylasemia and subclinical pancreatitis after cardiac surgery
Authors: Ihaya Akio , Muraoka Ryusuke , Chiba Yukio , Kimura Tetsuya , Uesaka Takahiko , Morioka Koichi , Matsuyama Katsuhiko , Tsuda Takeshi , Nara Masafumi , Niwa Hiroyuki
Published: October 2003

Hyperamylasemia after cardiac surgery is common but typically causes no clinical concern because it consists mainly of the salivary isoenzyme. In this study we evaluated the incidence, source, and time course of postoperative hyperamylasemia with special attention to the possibility of subclinical pancreatitis. In 88 patients prospectively tested for serum amylase and lipase concentrations, elastase 1 activity, and amylase isoenzyme characteristics, 57 (64%) showed hyperamylasemia during the early postoperative period. In most cases early hyperamylasemia was not of pancreatic origin, but two patients were diagnosed with subclinical pancreatitis. Among the last 23 patients, 5 of 10 patients with early hyperamylasemia exceeding 1000 IU/L showed late hyperamylasemia on the seventh postoperative day, when it represented mainly the pancreatic isoenzyme. Lipase concentrations and elastase 1 activities were elevated in these cases. Late hyperamylasemia following cardiac surgery may be of pancreatic origin and indicative of subclinical pancreatitis, even if early hyperamylasemia was of salivary origin.
Histologic factors affecting prognosis following hepatectomy for intrahepatic cholangiocarcinoma
Authors: Uenishi Takahiro , Hirohashi Kazuhiro , Kubo Shoji , Yamamoto Takatsugu , Hamba Hiroyuki , Tanaka Hiromu , Kinoshita Hiroaki
Published: October 2003

Long‐term survival following hepatectomy for intrahepatic cholangiocarcinoma has been poor, and specific factors influencing survival are unclear. In a retrospective study we sought to determine prognostic factors related to survival in these patients. In 28 patients who underwent hepatic resection for intrahepatic cholangiocarcinoma, we investigated the relations of several histologic factors to patient survival by univariate and multivariate analyses. No deaths occurred during the first 30 days. Median and mean survival times following hepatectomy were 409 and 935 days, respectively. The respective survival rates at 1, 3, and 5 years were 57%, 27%, and 27%. Resection margin status, intrahepatic metastasis, lymph node involvement, and lymphatic invasion were significant predictors of outcome. In a multivariate analysis using the Cox proportional hazards model, only lymphatic invasion independently predicted survival. Curative resection with clear margins was found to prolong survival after surgery. Hepatectomy for intrahepatic cholangiocarcinoma without lymphatic invasion offers hope for long‐term survival.
Transanal endoscopic microsurgical excision of rectal tumors: Indications and results
Authors: Demartines Nicolas , von Flüe Marcus O. , Harder Felix H.
Published: October 2003

Transanal endoscopic microsurgery (TEM) allows local excision of rectal tumors located 4 to 18 cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. The aim of this prospective, descriptive study was to analyze the currently accepted indications for TEM and to evaluate the use of this procedure for treating rectal cancer. Over a 4‐year period 50 patients aged 31 to 86 years (mean 64 years) underwent TEM for treatment of rectal tumors located 12 cm above the anal verge (range 4–18 cm). The local complication rate was 4%. Altogether, 76% of lesions were benign, and 24% were T1 and T2 tumors. Of 12 cancer cases, 4 required reoperation by total mesorectal resection; the other 8 are currently under follow‐up management. Over the follow‐up period of 30.6 months (range 11–54 months) the recurrence rate of T1 tumors was 8.3%. TEM is a minimally invasive surgical technique that may benefit a small, specific population of patients with rectal tumors. Compared with conventional transanal resection, TEM provides superior exposure of tumors higher up in the rectum (i.e., up to 18 cm from the anal verge). The greater precision of resection combined with low morbidity (10%, relative to that of anterior resection) and short duration of hospitalization (5.5 days) make this technique a reliable and in some cases more effective surgical approach than laparotomy and low anterior resection.
Colonic J‐pouch function at six months versus straight coloanal anastomosis at two years: Randomized controlled trial
Authors: Ho Yik‐Hong , Seow‐Choen Francis , Tan Margaret
Published: October 2003

The colonic J‐pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra‐low anterior resection, but there are few studies with long‐term follow‐up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2‐year period. Forty‐two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 ± 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 ± 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 ± 2.8 vs. 49 ± 1.4/week; p<0.05) and less soiling at passing flatus (38% vs. 73.7%; p<0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 ± 0.4 vs. 8 ± 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p<0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J‐pouch.
Evaluation of risk of splenosis during laparoscopic splenectomy in rat model
Authors: Espert Joan Josep , Targarona Eduard M. , Bombuy Ernest , Setoain Josep , Visa Josep , Trias Manuel
Published: October 2003

Laparoscopic splenectomy (LS) is an alternative to open surgery. However, there is a theoretic risk of splenosis and abdominal cavity dissemination of splenic cells if the splenic capsule is broken, as seen by experimental evidence of tumoral cell mobilization by the pneumoperitoneum. We evaluated the features of splenosis after splenectomy operated via an open approach or under laparoscopic control in an experimental model in the rat. A total of 65 Sprague‐Dawley rats were distributed in seven groups that included the open approach, CO2 pneumoperitoneum LS, or wall lift LS with or without a splenic graft. Splenic function was evaluated 90 day later through (1) scintigraphy with Tc‐labeled heat‐damaged erythrocytes; (2) determination of circulating “pitted” cells; and (3) analysis of the distribution of splenic pulp in the peritoneal cavity. Scintigraphy did not show viable residual tissue in any group after splenectomy; splenic activity in the splenic fossa was observed in 40% of the animals with grafts. Splenectomy increased the “pit” cell count, but it was reduced to normal values with a splenic graft. Necropsy showed normal splenic tissue in the splenic fossa in 100% of animals with a graft. Abdominal implants were observed significantly more frequently after CO2 LS than after the open surgery or a wall lift LS (80% vs. 20% vs. 30%; p<0.05). In addition, trocar site implants were observed with CO2 LS (n=3) or wall lift LS (n=2), whereas there were no implants in the wound in the open group. We conclude that in an experimental rat model the pneumoperitoneum may facilitate abdominal splenosis after LS if the splenic capsule is ruptured or if splenic tissue spills compared with surgery without gas (open or laparoscopic).
Surgical management of pectus carinatom: 30 years’ experience
Authors: Fonkalsrud Eric W. , Beanes Steven
Published: October 2003

Pectus carinatum is an uncommon malformation that is often more symptomatic than the appearance suggests, and one that physicians often do not refer for surgical correction. Hospital records of 90 patients who underwent repair of pectus carinatum deformities between 1970 and 2000 were reviewed. During the same period another 445 patients underwent repair of excavatum deformities. Minimal deformity was observed before the age of 10 years for 81 of 90 patients; only 7 of the 90 underwent repair before age 11 years. AH patients were symptomatic; 84 had exertional dyspnea and exercise limitation, 52 had frequent respiratory infections, 24 had asthma, and 38 had chest discomfort. The mean pectus severity score (width of chest divided by the distance between the sternum and spine) was 1.73 (the normal chest is 2.56). The type of repair varied with the type of deformity, consisting of subperiosteal resection of the deformed cartilages, transverse osteotomy of the anterior sternum with insertion of a cartilage wedge, and support with a steel strut for 4 to 6 months in 76 of 90. There were no deaths within 1 year after the repair. Complications included hypertrophic scar (n=13), wound seroma (n=5), pleural effusion (n=3), and pneumothorax (n=2). The mean blood loss was 78 ml, and the mean hospital stay was 2.6 days. With a mean follow‐up of 12.8 years, all patients experienced alleviation of respiratory symptoms and chest discomfort and diminished exercise limitation; 88 of 90 patients experienced a very good to excellent long‐term result. One patient required reoperation. Pectus carinatum often causes more severe respiratory symptoms and exercise limitation than is generally recognized. Repair in 90 patients with carinatum deformities has resulted in marked clinical improvement in all patients, with low morbidity and short hospitalization.
Silent Cerebral Infarction: Risk Factor for Stroke Complicating Carotid Endarterectomy
Authors: Fürst Heinrich , Hartl Wolfgang H. , Haberl Roman , Berger Hermann , Meimarakis Georgios , Lauterjung Lutz , Schildberg Friedrich W. , Warlow Charles P.
Published: October 2003

“Silent” cerebral infarction is found in 20% to 30% of patients with significant internal carotid artery (ICA) disease. Our purpose was to determine whether such “silent” cerebral infarction in the operated carotid territory represents a risk factor for stroke during and immediately after carotid endarterectomy. Over 5 years we followed a cohort of 663 patients with symptomatic and asymptomatic ICA stenosis who were consecutively scheduled for surgery. The stenosis was more than 70% in patients with transient ischemic attacks and more than 95% in asymptomatic stenosis patients. All patients underwent preoperative computed tomography to determine the frequency, extent, and location of any “silent” cerebral infarction. Patients were grouped by the absence or presence of infarction in the operated carotid territory. Among the entire cohort, 20 patients had a major perioperative stroke (3.0%). All deaths were stroke‐related. No intracranial bleeding occurred. Major stroke occurred in four (0.8%) patients without appropriate “silent” cerebral infarction, compared with 16 (8.8%) with an appropriate “silent” cerebral infarct (p < 0.001). After adjustment for confounding co‐variables (e.g., gender, presence of preoperative symptoms, and age), “silent” cerebral infarction was found to be the only independent predictor of perioperative major stroke for symptomatic and asymptomatic stenosis (overall adjusted relative risk 11.5, 95% confidence interval 3.8–34.9, p < 0.0001). Patients with “silent” cerebral infarction seem to be at increased risk of perioperative stroke. Consequently, preoperative cerebral imaging is important for risk classification.
Hypertonic Saline in Hydatid Disease
Authors: Kayaalp Cuneyt , Balkan Mujdat , Aydin Cenk , Ozgurtas Taner , Tanyuksel Mehmet , Kirimlioglu Vedat , Akoglu Musa , Oner Koksal , Pekcan Mesut
Published: October 2003

The objective of this study was to determine the scolicidal effects of saline in different concentrations using different exposure times and to examine whether hypertonic saline can be used to irrigate the abdomen when there is a free intraperitoneal perforation of hydatid disease. Various concentrations of saline solutions (0.09%, 3.0%, 6.5%, 10%, 15%, 20%, 25%, 30%) were added to concentrated echinococcus granulosus sediments for the following times: 1, 2, 3, 4, 5, 10, 15, 30, 45, and 60 minutes. Normal (0.09%), 3.0%, and 6.5% saline resulted in high viability ratios after 60 minutes' exposure. Complete lethality for 10%, 15%, 20%, 25%, and 30% saline occurred at the end of 75, 10, 6, 3, and 3 minutes, respectively. During the second part of the study, 20 Sprague‐Dawley rats were used for abdominal saline irrigation in four groups: 30% NaCl for 3 minutes; 20% NaCl for 6 minutes; intravenous isotonic dextrose water and furosemide plus 30% NaCl irrigation for 3 minutes; the same prophylactic therapy plus 20% NaCl irrigation for 6 minutes. Sodium and chloride values rose significantly (20–30%) shortly after hypertonic saline irrigation in each group (p < 0.01). Support with isotonic dextrose and furosemide before irrigation did not have any beneficial effect on biochemical values or mortality. The 24‐ and 48‐hour mortality rates were 70% and 90%, respectively. These studies illustrate that the scolicidal effect of hypertonic saline is limited in low concentrations, but an increase in the concentration can augment its adverse effects. Peritoneal irrigation with hypertonic saline should be avoided for intraabdominal perforated hydatid disease. Therefore, we concluded that hypertonic saline is not a good scolicidal agent to prevent recurrence of hydatid disease.