bluuebunny/crossref_metadata_2025 huggingface dataset:
Genetic Markers of Survival and Liver Recurrence after Resection of Liver Metastases from Colorectal Cancer
Authors: Crowe Philip J. , Yang Jia‐Lin , Berney Christophe R. , Erskine Catherine , Ham John M. , Fisher Richard , Russell Pamella J.
Published: October 2003

A significant number of patients with liver metastases from colorectal cancer (CRC) achieve 5‐year survival after liver resection. Increased expression of genetic markers in the primary tumor are known to predict outcome after colonic resection, but the predictive value of such markers after resection of hepatic metastases is unknown. The objective of this study was to evaluate whether DNA content and multiple genetic markers, separately or expressed together, can predict patient outcome (liver recurrence and survival) after resection of hepatic metastases. We studied the paraffin‐embedded liver tissue of 71 consecutive patients who had undergone a potentially curative resection of hepatic metastases from CRC. Using DNA flow cytometry and immunohistochemical staining techniques we determined the DNA content and the level of co‐expression of seven tumor‐associated proteins: proliferating cellular nuclear antigen (PCNA), epidermal growth factor receptor (EGFr), p53, c‐erbB‐2, H‐ras, c‐myc, and nm23. Three endpoints (liver recurrence, cancer specific, overall survival) were correlated with these tumor markers. The 5‐year overall survival of the group was 31.2%. There was no correlation detected between the DNA aneuploidy and overall or cancer‐specific survival. Similarly, expression of the individual tumor‐associated proteins did not predict survival. Patients whose tumors co‐expressed multiple markers had survivals similar to those whose tumors expressed fewer markers. However, a significant difference in hepatic recurrence was found between the p53‐positive and p53‐negative patients (p= 0.007), with marker‐negative tumors having decreased recurrence. In conclusion, this study demonstrates that the DNA content and genetic markers c‐myc, c‐erbB‐2, EGFr, H‐ras, p53, PCNA, and nm23 do not predict survival after potentially curative resection of hepatic metastases from CRC. However, the immunoreactivity of p53 may be an important marker of local recurrence in the liver, which may be useful if re‐resection of metastatic liver tumors is considered a viable management option in this disease.
Pancreatectomy Combined with Superior Mesenteric‐portal Vein Resection for Adenocarcinoma in Pancreas
Authors: Shibata Chikashi , Kobari Masao , Tsuchiya Takashi , Arai Kousuke , Anzai Ryouichi , Takahashi Masanori , Uzuki Miwa , Sawai Takashi , Yamazaki Tadashi
Published: October 2003

The aims of this study were to investigate morbidity, mortality, and survival of patients with ductal adenocarcinoma of the pancreas who underwent pancreatectomy without (group 1) or with (group 2) en bloc portal vein resection and to study the degree of carcinoma invasion of the portal vein in group 2. The medical records of 46 and 28 patients in groups 1 and 2, respectively, were reviewed. In addition, the degree of invasion of the wall of the portal vein was categorized histologically into three types: type I, transmural invasion involving the intima; type II, invasion of the wall of the vein without intimal involvement; and type III, compression of the wall of the vein by surrounding carcinoma without true invasion. The morbidity and mortality in group 1 (26% and 4%) were not different from those in group 2 (32% and 4%). Similarly, there was no difference in survival between the two groups. Survival tended to vary directly with the depth of invasion of the wall of the portal vein: type I 6.8 ± 1.9 months; type II 15.3 ± 6.4 months; type III 20.6 ± 13.0 months. These findings suggest that en bloc resection of the pancreas and the portal vein does not increase mortality and morbidity after pancreatectomy; survival after en bloc resection was similar to that of patients not requiring portal vein resection. Combined resection of the pancreas with the portal vein could be an option in the treatment of pancreatic cancer with direct invasion of the portal vein.
Head Injury in the United Kingdom
Authors: Kay Andrew , Teasdale Graham
Published: October 2003

This paper reviews aspects of head injury management and research in the United Kingdom (UK). We discuss evidence about the scale and etiology of head injury in Britain and how this information has supported a triage‐based approach, incorporating risk analysis. A Cohesive organization based upon nationally accepted,
yet regionally flexible head injury management guidelines is important.
Research in the United Kingdom has clarified the effect of head injury on the brain and how this can be reduced. This clarification follows from improved understanding of the neurobiology of injury, of secondary damage and recovery, and information gained from new techniques aimed at investigating events in patients. Outcome is an important perspective and we highlight the increasing focus upon recovery and the extent of disability after so called mild head injury. Although we retain a UK perspective, comparisons with aspects of European head injury emphasize the increasing importance of an international approach in the future.
Biliary Strictures: Classification Based on the Principles of Surgical Treatment
Authors: Bismuth Henri , Majno Pietro E.
Published: October 2003

The classification of biliary strictures used at Hôpital Paul Brousse is based on the lowest level at which healthy biliary mucosa is available for anastomosis. The classification is intended to help the surgeon choose the appropriate technique for the repair. Type I strictures, with a common duct stump longer than 2 cm, can be repaired without opening the left duct and without lowering the hilar plate. Type II strictures, with a stump shorter than 2 cm, require opening the left duct for a satisfactory anastomosis. Lowering the hilar plate is not always necessary but may improve the exposure. Type III lesions, in which only the ceiling of the biliary confluence is intact, require lowering the hilar plate and anastomosis on the left ductal system. There is no need to open the right duct if the communication between the ducts is wide. With type IV lesions the biliary confluence is interrupted and requires either reconstruction or two or more anastomoses. Type V lesions are strictures of the hepatic duct associated with a stricture on a separate right branch, and the branch must be included in the repair. Although this classification is intended for established strictures, it is commonly used to describe acute bile duct injuries. The surgeon must be aware, however, that the established stricture is generally one level higher than the level of the injury at the original operation.
Surgical Treatment of Iatrogenic Lesions of the Proximal Common Bile Duct
Authors: Gazzaniga Gian Massimo , Filauro Marco , Mori Lorenzo
Published: October 2003

Between January 1979 and September 1999 a series of 96 patients were operated on at our institution for iatrogenic biliary injuries, and among them 62 involved the proximal biliary tract. Injuries, according to the Strasberg classification, were type E2 in 18 patients, type E3 in 29 patients, and type E4 in 15 patients. The most frequent primary surgical procedures were laparoscopic cholecystectomy in 27 of the 62 patients (43.6%) and open cholecystectomy in 30 patients (48.3%). Previous repair had been attempted in 25 patients (40.3%). A total of 58 cholangiojejunostomies were performed. Repair had been performed directly, and a T‐tube had been left in the main bile duct in four patients with E2 Strasberg lesions. Postoperative death occurred in four patients (6.4%). Outcome was graded as excellent, good, or poor depending on clinical symptoms, liver function tests, and the need for reintervention due to anastomotic stricture. The final outcome was evaluated in 54 patients. The mean follow‐up was 5.9 ± 0.3 years, with the longest follow‐up 10.2 years. Following our first repair 49 of the 54 patients (90.7%) had excellent results, 1 (1.9%) had good results, and 4 (7.4%) had poor results. None of the patients who underwent immediate or early repair had complications. Diagnostic and therapeutic courses are given on the basis of the type of lesion and the timing of repair. We emphasize the importance of timing (i.e., carrying out surgical repair as soon as possible) and of cholangiojejunostomy reconstruction in respect to defined technical principles. Moreover, we believe that repair treatment at a hepatobiliary center with multidisciplinary competence greatly influences the final long‐term outcome.
Complications of Hepatectomy for Hilar Cholangiocarcinoma
Authors: Nagino Masato , Kamiya Junichi , Uesaka Katsuhiko , Sano Tsuyoshi , Yamamoto Hideo , Hayakawa Naokazu , Kanai Michio , Nimura Yuji
Published: October 2003

We retrospectively reviewed postoperative complications in 105 patients with hilar cholangiocarcinoma who underwent hepatectomy at Nagoya University Hospital from January 1990 through March 1999. Of the 105 subjects, 97 (92.4%) underwent resection of two or more Healey's segments of the liver. Combined portal vein resection was performed in 33 (31.4%) patients and pancreatoduodenectomy in 10 (9.5%). Twenty (19.0%) patients had no postoperative complications, another 39 (37.1%) patients had minor complication(s) only, and the remaining 46 (43.8%) developed major complication(s). The morbidity rate reached as high as 81.0%. Major complications required relaparotomy in 11 (10.5%) patients. Of the 46 patients with major complication(s) 36 recovered; the remaining 10 patients died of liver failure with other organ failure(s) or of intraabdominal bleeding 12, 14, 18, 21, 57, 75, 75, 87, 93, or 134 days after surgery. Thus the 30‐day mortality was 3.8% and the overall mortality 9.5%. Pleural effusion was the most frequent complication found in 66 (62.9%) patients, followed by wound sepsis in 39 (37.1%), and then liver failure in 29 (27.6%). Liver failure developed in 16.7% of 48 patients with less than 50% liver resection and in 36.8% of 57 patients with 50% or more resection (P < 0.05). Other organ failures, including renal, respiratory, gastrointestinal, and hematologic failures, developed as a sign of multiple organ failure following liver failure in most patients or preceding liver failure in a few patients. None of the six patients with four or more organ failures survived. Hepatectomy for hilar cholangiocarcinoma is risky owing to impaired hepatic functional reserve in jaundiced patients and the technical difficulty associated with hepatobiliary resection. Our goal is to reduce mortality to less than 5% while keeping a high resectability rate (above 80%).
Complications of Biliary Tract in Liver Transplantation
Authors: Testa Giuliano , Malagò Massimo , Broelsch Christoph E.
Published: October 2003

Bile duct leaks and stenosis, although greatly reduced in their incidence, still play a major role in early and late graft loss. Their pathogenesis is multifactorial, being related to graft quality, ischemia time, arterial blood flow, and, of course, technical mishaps. The diagnosis and treatment of biliary complications is nowadays a joint effort among surgeons, interventional radiologists, and gastroenterologists. The correct algorithm in obtaining a fast diagnosis and the correct therapeutic approach are necessary to save the graft, avoid retransplantation or recipient death. Although this may seem to be a simple and basic concept, it assumes tremendous importance in liver transplantation in which the differential diagnosis between biliary and arterial complications or graft rejection and malfunctioning is often a difficult one.
Complications following Repair of Extrahepatic Bile Duct Injuries after Blunt Abdominal Trauma
Authors: Rodriguez‐Montes Jose A. , Rojo Esther , García‐Sancho Martín Luis
Published: October 2003

Extrahepatic bile duct traumatic injuries are extremely rare and their treatment is difficult and with several controversies. The aim of this study was to offer some more clinical information on their surgical repair and outcome. We present seven patients with extrahepatic biliary tract lesions after blunt abdominal trauma, (isolated gallbladder lesions were excluded) four males and three females from 23 to 51 years of age (mean age 35.1 years). All patients had suffered high‐energy blunt abdominal trauma and presented associated injuries, mostly liver trauma and lung contusions. Six gallbladder lesions and six common bile duct injures were identified; a right hepatic duct laceration and a left hepatic duct transection were also present. Injuries were treated either with primary repair or with duct‐jejunal anastomoses with Roux‐en‐Y reconstruction. Principal complications were postoperative anastomotic leakage (1 case) and recurrent cholangitis (3 cases) with or without stricture. Not‐diagnosed injuries caused substantial morbidity. We prefer and recommend the use of primary repair in partial ruptures with no significant tissue loss and biliary‐enteric anastomoses in large injuries and complete transections because they offer the best long‐term drainage with less risk of stricture formation than end‐to‐end anastomoses. We defend the use of long duration (6 to 9 months) transanastomotic stents.
Incidence, Risk Factors, and Prevention of Biliary Tract Injuries during Laparoscopic Cholecystectomy in Switzerland
Authors: Krähenbühl Lukas , Sclabas Guido , Wente Moritz N. , Schäfer Markus , Schlumpf Rolf , Büchler Markus W.
Published: October 2003

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) which may result in patient disability or death are reported to occur more frequently when compared to open surgery. The aim of this nationwide prospective study beyond the laparoscopic learning curve was to analyze the incidence, risk factors, and management of major BDI. During a 3‐year period (1995–1997) 130 items of all LC data were collected on a central computer system from 84 surgical institutions in Switzerland by the Swiss Association of Laparoscopic and Thoracoscopic Surgery and evaluated for major BDIs. Simple biliary leakage was excluded from analysis. There were 12,111 patients with a mean age of 55 years (3–98 years) enrolled in the study. The overall BDI incidence was 0.3%, 0.18% for symptomatic gallstones, and 0.36% for acute cholecystitis. In cases of severe chronic cholecystitis with shrunken gallbladder, the incidence was as high as 3%. Morbidity and mortality rates were significantly increased in BDIs. BDI was recognized intraoperatively in 80.6%, in 64% of cases by help of intraoperative cholangiography. Immediate surgical repair was performed laparoscopically (suture or T‐drainage) in 21%; in 79%, open repair (34% simple suture, 66% Roux‐en‐Y reconstruction) was needed. The BDI incidence did not decrease during the last 7 years. In 47%, BDIs were caused by experienced laparoscopic surgeons, perhaps because they tend to operate on more difficult patients. In conclusion, the incidence of major BDIs remains constant in Switzerland at a level of 0.3%, which is still higher when compared to open surgery. However, most cases are now detected intraoperatively and immediately repaired which ensures a good long‐term outcome. For preventing such injuries, exact anatomical knowledge with its variants and a meticulous surgical dissecting technique especially in case of acute inflammation or shrunken gallbladder are mandatory.
Treatment of Common Bile Duct Injuries during Laparoscopic Cholecystectomy: Endoscopic and Surgical Management
Authors: Csendes Attila , Navarrete Claudio , Burdiles Patricio , Yarmuch Julio
Published: October 2003

The increase of laparoscopic cholecystectomy has resulted in an increase of bile duct injuries. The purpose of this article is to define the types of injury, their occurrence and frequency, and their management by endoscopic and surgical techniques. Three investigations were included in the present study. 1. A 3‐year retrospective study among 29 hospitals with 25,007 laparoscopic cholecystectomies. 2. An 8‐year prospective study at our institution of 6488 patients. 3. A prospective endoscopic study of 94 patients with injuries and strictures of the common bile duct (CBD) after laparoscopic cholecystectomy. A special classification for bile duct injuries was developed. Among 25,007 patients from 29 hospitals, a total of 74 lesions were detected with an incidence of 0.29%. At our institution, 20 cases were seen (0.29%) with type I, II, and III injuries. The 94 cases managed by endoscopic procedure were submitted to endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, with placement of several stents 5 to 10 F during 8 months. The results of this procedure have been excellent to good in 76% of the cases up to 3 years of follow‐up. According to our previous and present experience, bile duct injuries after laparoscopic procedure are two times higher than after open procedure. The best treatment is the prevention of these injuries by careful surgical technique. If they occur, the best moment to repair them is during surgery. If they are noticed after the operation, endoscopic or surgical procedures can be employed.
Surgical Therapy of Iatrogenic Lesions of Biliary Tract
Authors: Ahrendt Steven A. , Pitt Henry A.
Published: October 2003

Iatrogenic injuries of the biliary tract have increased in incidence over the past decade with the introduction of laparoscopic cholecystectomy. Although a number of factors have been identified with a higher risk of injury (male gender, complicated gallstone disease, aberrant anatomy) and a number of technical steps have been emphasized to avoid these injuries, the incidence of bile duct injuries has reached a steady‐state at least double the rate observed with open cholecystectomy. Most patients sustaining a bile duct injury are recognized in the weeks following laparoscopic cholecystectomy. Careful preoperative preparation should include control of sepsis by draining any bile collections or fistulas and complete cholangiography. Long‐term results are best achieved in specialized hepatobiliary centers performing biliary reconstruction with a Roux‐en‐Y hepaticojejunostomy. Success rates over 90% have been reported from several centers to date with intermediate follow‐up.
Information Age Technologies for Surgeons: Overview
Authors: Satava Richard M.
Published: October 2003

This overview summarizes the revolutionary changes that are occurring in medicine today and looks beyond medicine to the other disciplines of science that contribute to the overall revolution of the Information Age. The concept of "information equivalent," representing real objects within a computer as information, is explained. The application of today's emerging information technologies is divided into the components of patient care‐diagnosis, consultation, treatment, and education‐and illustrations are given of how information sciences are changing the practice of surgery.
Objective Psychomotor Skills Assessment of Experienced, Junior, and Novice Laparoscopists with Virtual Reality
Authors: Gallagher Anthony G. , Richie Karen , McClure Neil , McGuigan Jim
Published: October 2003

Objective assessment of psychomotor skills in surgery is now a priority; however, this assessment is difficult to achieve because of measurement difficulties associated with the reliability and validity of assessing surgical skills in vivo and in the laboratory. In this study virtual reality (VR) was used to overcome these problems in the objective psychomotor assessment of senior, junior, and novice laparoscopists. Twelve experienced laparoscopic surgeons (performed >50 Minimal Access Surgery (MAS)
procedures), 12 inexperienced laparoscopic surgeons (<10 MAS procedures), and 12 laparoscopic novices (no MAS procedures)
participated in the study. Each subject completed all six tasks of the Minimally Invasive Surgical Trainer; Virtual Reality (MIST VR). In comparison to the other groups, experienced laparoscopic surgeons performed the tasks significantly (p < 0.01) faster,
had a lower error rate, were more economic in their movement of surgical instruments and in the use of diathermy. As a group they also showed greater consistency in their performance. MIST VR distinguished between the three groups of laparoscopists. VR provides a useful objective assessment tool for evaluating psychomotor skills for laparoscopic surgery.
Surgical Education and Surgical Simulation
Authors: Satava Richard M.
Published: October 2003

The science of virtual reality provides an entirely new opportunity in the area of simulation of surgical skills using computers for training, evaluation, and eventually certification. A taxonomy of the types of simulators is proposed based upon the level of complexity of the task which is being simulated.
These tasks are precision placement, simple manipulation, complex manipulation, and integrated procedure. Representative simulators in each category are illustrated and discussed in the context of their contribution to the education and training of a surgeon. The importance of a curriculum is to give content to the role of simulators as another advanced tool for education. Simulators must be integrated into a comprehensive curriculum and not considered as a stand‐alone system.
The current accomplishments as well as challenges are discussed.
Nonoperative Treatment of Blunt Splenic Injury
Authors: Uranüs Selman , Pfeifer Johann
Published: October 2003

A spleen‐preserving program was implemented at the author's institution during the mid‐1980s using a five‐part injury‐grading scale that is similar and comparable to the AAST classification. Since that time, all patients with splenic injuries admitted to the Department of Surgery at the Karl‐Franzens University Hospital in Graz, a level I trauma center, have been prospectively evaluated with respect to splenic preservation. Analysis of the relation of the severity of organ injury to the use of nonoperative management showed that degree I or II injuries were treated nonoperatively, whereas degree III and IV injuries were usually treated with adhesives, partial resection, or mesh splenorrhaphy; only degree V injuries almost always required splenectomy. With increasing experience in nonoperative management of splenic injuries the initial criteria have become less rigid, and there is now a tendency to attempt it in patients who formerly would have undergone surgery.
Grade IV Renal Injuries: Evaluation, Treatment, and Outcome
Authors: Santucci Richard A. , McAninch Jack M.
Published: October 2003

Of our last 2483 renal trauma patients, 113 had grade IV injuries. In most the mechanism was a penetrating injury (60%: 30% gunshot, 30% stab wounds). Associated injuries were common (80%) and hospital stays prolonged, averaging 16 days. Most of the patients (70%) required transfusion, some massively (average volume 4.4 liters, range 0‐30 liters). Surprisingly, not all patients with grade IV renal injuries had gross hematuria: 25% had microhematuria, and 4% had neither microscopic nor gross hematuria. Computed tomography (CT) diagnosed the injury correctly in 100% of the patients in whom it was performed; when CT was not available, "one‐shot" intraoperative intravenous pyelography (IVP) demonstrated grossly abnormal findings in 90%. Renal exploration was performed in 78%, resulting in 69% renorrhaphy and 9% nephrectomy rates in our 113 patients. Almost all those with penetrating trauma required exploration (97%), whereas only 50% of those with blunt trauma did so. The overall complication rate and kidney‐specific complication rate did not differ significantly between patients who were observed and those who underwent surgery. Complications rates were similar in grade IV renal laceration patients and grade III patients. Delayed complications after hospital discharge were not seen, although follow‐up was rare in this inner‐city trauma population. Among the 21% of patients in whom postoperative nucleotide renal function scans were available, function was generally good (average 36%). Only patients who underwent concomitant vascular repair had poor function (below 20%).
Pelvic Fracture and Associated Urologic Injuries
Authors: Brandes Steven , Borrelli Joseph
Published: October 2003

Successful management of patients with major pelvic injuries requires a team approach including orthopedic,
urologic, and trauma surgeons. Each unstable pelvic disruption must be treated aggressively to minimize complications and maximize long‐term functional outcome. Commonly associated urologic injuries include injuries of the urethra, corpora cavernosa (penis), bladder, and bladder neck. Bladder injuries are usually extraperitoneal and result from shearing forces or direct laceration by a bone spicule. Posterior urethral injuries occur more commonly with vertically applied forces,
which typically create Malgaigne‐type fractures. Common complications of urethral disruption are urethral stricture, incontinence, and impotence. Acute urethral injury management is controversial, although it appears that early primary realignment has promise for minimizing the complications. Impotence after pelvic fracture is predominantly vascular in origin, not neurologic as once thought.
Removal of Mediators by Continuous Hemofiltration in Septic Patients
Authors: Hoffmann Johannes N. , Faist Eugen
Published: October 2003

Continuous hemofiltration currently represents standard renal replacement therapy in critically ill patients. Because higher ultrafiltration rates are related to better survival rates in experimental and clinical studies and hemofiltration results in fewer cardiovascular side effects than does conventional hemodialysis, the use of inflammatory mediator removal by this extracorporeal procedure has emerged. This article reviews clinically relevant principles of compound transport and the experimental and clinical effects of hemofiltration during sepsis. Hemofiltration did not have a major impact on plasma concentrations of prominent inflammatory cytokines (tumor necrosis factor‐a and interleukins
1b, 6, and 8) and seems therefore not to be able to counterbalance endogenous cytokine production despite considerable cytokine removal in the filtrate. Contradictory results in the literature are discussed under the viewpoint of membrane‐related sieving coefficients and plasma cytokine measurement. A significant reduction in plasma anaphylatoxin concentrations by hemofiltration is associated with impressive immunomodulatory and cardiodepressive ultrafiltrate effects. Thus far,
however, the use of hemofiltration for nonrenal indications remains experimental and is not supported by controlled clinical trials. Modern strategies of blood purification that may be associated with a high degree of effectiveness for mediator removal (high‐volume hemofiltration and heparin‐induced extracorporeal lipoprotein‐fibrinogen precipitation) are discussed.
Clinical Impact of Continuous Renal Replacement Therapy on Multiple Organ Failure
Authors: Dunham C. Michael
Published: October 2003

Because continuous renal replacement therapy (CRRT) may enhance inflammatory mediator removal, this review assesses its impact on multiple organ failure (MOF). Regarding MOF with acute renal failure (ARF), the overall mortality of 2313 CRRT patients
(43 studies) was 62.8% compared with 59.1% (p = 0.046) in 961 intermittent hemodialysis (IHD) patients (12 other studies). Of 13 CRRT studies with an IHD comparison group, 3 showed that the groups had a similar risk, but IHD mortality was higher; 1
noted that CRRT had lower mortality (risk not stated); and 4 showed similar mortality and greater CRRT risk. Aggregate mortality was IHD
69.5% and CRRT 63.9% (p = 0.02). Of the six studies with matched groups (age and APACHE II scores), IHD mortality was higher (70.9% vs. 60.1%, p = 0.01). CRRT pulmonary gas exchange, hemodynamic instability, azotemia control, fluid overload, and nutritional support were better. Regarding MOF without ARF, of 14 CRRT studies (14.5 patients per study), only 4 had comparison groups. Patient conditions were as follows: acute respiratory distress syndrome, six studies; sepsis, three studies;
septic shock, two studies; pancreatitis, one study; critically ill patients, one study; and cardiac surgery with respiratory failure, one study. Of the three studies with a control group, the mortality was the same. There was minimal evidence that CRRT improved pulmonary gas exchange or hemodynamic instability. For MOF patients with ARF, there is compelling evidence that CRRT provides better survival than IHD and more improvement in pulmonary gas exchange, hemodynamic instability,
azotemia control, fluid overload, and nutritional support. In patients with MOF and no renal failure, there is little evidence that CRRT enhances survival, oxygenation, or perfusion. Controlled trials demonstrating a CRRT benefit are necessary before CRRT can be recommended for MOF without ARF.
Survival‐associated Histologic Spreading Modes of Operable Intrahepatic, Peripheral‐type Cholangiocarcinomas
Authors: Namieno Tsutomu , Koito Kazumitsu , Takahashi Masatoshi , Une Yoshie , Yamashita Kenichiro , Shimamura Tsuyoshi
Published: October 2003

We investigated survival‐associated histologic and metastatic spreading modes of intrahepatic, peripheral‐type cholangiocarcinomas resected to contribute to surgical control of the tumor. Previous results have been mostly obtained from autopsies, reflecting the terminal status of patients. We clinicopathologically reviewed the resected 20 intrahepatic, peripheral‐type cholangiocarcinomas and investigated the histologic findings of resected specimens and medical records to assess spreading modes along with patients' survival. The carcinoma cells superficially spread in the ductal epithelium in 75%, infiltrated along Glisson's system and migrated multidirectionally in 100%, and permeated the vascular network in 80%. The cumulative survival rate significantly related to vascular permeation, extrahepatic metastases, and lymphatic, neural, and nodal involvement but not to ductal spread, tumor size (cutoff size 5 cm), or intrahepatic metastases by the log‐rank test. The patients with lymphatic, neural, or nodal involvement died early after surgery. Practically, only vascular permeation was identified as a significant independent variable for survival using multivariate analysis. Peripheral cholangiocarcinomas spread mainly in three modes: ductal spread, infiltration along Glisson's system, and vascular permeation. In the practically operable cases, vascular permeation is closely related to survival, and intrahepatic metastasis may be surgically controlled to some degree.
Clinical Decision‐making, Ultrasonography, and Scores for Evaluation of Suspected Acute Appendicitis
Authors: Zielke Andreas , Sitter Helmut , Rampp Thomas , Bohrer Thomas , Rothmund Matthias
Published: October 2003

Diagnosing acute appendicitis (aA) remains difficult. This study evaluated the utility of ultrasonography (US) compared to clinical decision‐making alone and scoring systems to establish the indication for laparotomy in patients in whom aA was suspected. The prospectively documented data of 2209 patients admitted for suspicion of aA, who underwent US by one of 12 surgeons, formed a database in which the diagnostic and procedural performance of clinical decision‐making, US, two scoring systems (Ohmann and Eskelinen scores), and clinical algorithms taking account of clinical and either US findings or score results, were retrospectively evaluated. The results of either modality were correlated with final diagnoses obtained by laparotomy in 696 patients, of whom 540 had aA (prevalence 24.45%) and follow‐up data in the remainder. US had the highest specificity (97%, compared to 93% for the Ohmann and Eskelinen scores and 94% for the clinical evaluation and algorithms) and lowest overall rate of false‐positive findings (negative laparotomy rate 7.6%). The scores were accurate in refuting the diagnosis of aA but otherwise not superior to US. The best overall diagnostic and procedural results were obtained with the algorithms that combined the results of either US or the Ohmann score with clinical evaluation, which produced the most favorable numbers of negative laparotomies, potential perforations, and missed cases of aA. US is the diagnostic standard of reference for patients with a possible diagnosis of aA. It yields diagnostic results superior to those of scoring systems and provisional clinical evaluation. However, the benefits of US by ultrasonographically trained surgeons are only fully appreciated within the context of clinical algorithms. The joint evaluation of score results and clinical evaluation may deliver information of similar accuracy.
Pancreaticogastrostomy following Pancreaticoduodenectomy: Review of 102 Consecutive Cases
Authors: O'Neil Stephen , Pickleman Jack , Aranha Gerard V.
Published: October 2003

Disruption of the pancreatic anastomosis with resultant sepsis is the cause of nearly 50% of deaths following pancreaticoduodenectomy (PD). Traditionally, the pancreatic remnant is anastomosed to the jejunum. Pancreaticogastrostomy (PG) was introduced as an alternative by Waugh and Clagett in 1946 and by Park, Mackie, and Rhoads in 1967. The purpose of this retrospective review was to assess the safety of PG at a single institution. Between 1986 and 1998 a total of 102 patients underwent PG following PD. The indications for PD were periampullary carcinoma (n= 89), pancreatitis (n= 7), and miscellaneous (n= 6). Altogether, 80 patients underwent the traditional Whipple procedure and 22 the pylorus‐preserving Whipple (PPW) procedure. The PG was performed by a single‐layer invagination technique to the posterior gastric wall using interrupted silk sutures. Leaks from the pancreatic anastomosis were detected by measuring amylase in fluid obtained from surgically placed drains. Operative mortality was 3.9% (4/102). The cause of death was uncontrolled upper gastrointestinal hemorrhage, sepsis, pulmonary embolus, and cardiac failure secondary to myocardial infarction. The mean operating time was 6.8 hours. Blood transfusion was given in 43 patients (42%), and the mean amount of the transfusion was 2.6 units. Nonfatal complications occurred in 35 patients (34%), and included leaks from the pancreatic anastomosis in 9 (8.8%), leaks from the biliary‐enteric anastomosis in 4 (3.9%), and gastric paresis 7 (6.9%). Other complications included abscess, wound infection, colitis, delirium tremens, and hyperbilirubinemia. Discharge occurred 6 to 47 days (median 12 days) postoperatively and was prolonged in patients suffering from a complication. PD is associated with significant morbidity. PG is a safe alternative to pancreaticojejunostomy for managing the pancreatic remnant.
Hemodynamic Response of Modified Fluid Gelatin Compared with Lactated Ringer's Solution for Volume Expansion in Emergency Resuscitation of Hypovolemic Shock Patients: Preliminary Report of a Prospective, Randomized Trial
Authors: Wu Jackson Jer‐kan , Huang Mu‐Shun , Tang Gau‐Jun , Kao Wei‐Fong , Shih Hsin‐Chin , Su Cheng‐Hsi , Lee Chen‐Hsen
Published: October 2003

The objective of this study was to compare the cardiac and hemodynamic responses to a rapid infusion of 1000 ml of modified fluid gelatin (group A) or 1000 ml of lactated Ringer's solution (group B) in emergency room patients suffering from shock. This prospective, randomized, open, noncrossover study was performed at a medical center university hospital in a surgical resuscitation room in the emergency department. The subjects were 34 patients with either hypovolemic or neurogenic shock who were admitted to the emergency room. A resuscitation protocol according to Advanced Trauma Life Support (ATLS) with an additional central venous line or Swan‐Ganz catheters for hemodynamic monitoring was used. Physical parameters and hemodynamic variables were measured at baseline and 15 minutes, 30 minutes, and 1 hour after the infusion of each fluid. In both groups the mean arterial blood pressure (MAP), systolic and diastolic pressure, central venous pressure (CVP), and pulmonary artery occlusion pressure (PAOP) increased significantly. The CVP and PAOP increased significantly more in the modified fluid gelatin resuscitation group. In patients with traumatic or neurogenic shock due to acute volume deficiency, there was significantly better hemodynamic improvement, judged by CVP and PAOP measurements using the modified fluid gelatin for volume replacement than with lactated Ringer's solution during the first hour of resuscitation.
Determination of the Immunoglobulin E Postoperative Variation as a Measure of Surgical Injury
Authors: Navarro‐Zorraquino Marta , Lozano Ricardo , Deus Javier , Pastor Cristina , Larrad Luis , Tejero Eloy , Román Javier , Palacios María J. , Torcal Javier , Salinas José C.
Published: October 2003

The aim of this study was to ascertain postoperative changes in immunoglobulin E (IgE) in patients undergoing different types of surgery and the possible correlation with the duration and type of surgery. Evidence suggests that surgery induces a predominant activation pattern through the T‐helper‐2 (Th2) cell pathway, increasing interleukins (IL‐4, IL‐5, IL‐10, IL‐13), inhibiting Th1 cell activation, and promoting B and Th2 cell activation. IgE production may indicate predominant Th2 pathway activation and may be a more persistent and easily measurable postoperative marker than IL‐6 for measuring surgical trauma. Altogether, 180 patients undergoing different types of surgery for nonneoplastic and nonparasitic diseases were studied. All patients received the same type of anesthesia. Before surgery and on the first (1PO) and 7th (7PO) postoperative days we determined in peripheral blood the CD3, CD4, CD8, CD16, and CD19 cell percentages; IL‐1, IL‐2, IL‐4, IL‐6, and tumor necrosis factor (TNF) levels; and the IgA, IgG, IgM, total IgE, C3, C4, and CIC levels. On 1PO, all variables decreased except IgE, IL‐1, IL‐2, IL‐4, IL‐6, CIC, and CD19. Only IgE, IL‐6, and CD19 increases showed a significantly statistical (ss) difference regarding preoperative values (0.01, 0.05, 0.001, respectively). Relations between the IL‐4 and IgE increases (p < 0.01) and between the IgG decrease and IgE increase (p < 0.001) were found. On 7PO, only IgE was increased (p < 0.001). The IgE increase correlated with surgical trauma intensity (p < 0.05). We concluded that IgE increases during the early postoperative period, correlating with surgical injury intensity. The increase in the IgE level may be detected 24 hours after surgery and during the first 7 postoperative days depending on the type of surgery.
Systolic and Diastolic Properties and Myocardial Blood Flow in the Heterotopically Transplanted Rat Heart during Acute Cardiac Rejection
Authors: Szabó Gábor , Bátkai Sándor , Dengler Thomas J. , Bährle Susanne , Stumpf Nicole , Notmeyer Winfried , Zimmermann Rainer , Vahl Christian F. , Hagl Siegfried
Published: October 2003

The aim of the study was to characterize the course of systolic and diastolic function, myocardial blood flow, and histologic changes during acute rejection in a model of heterotopic transplantation in rats. For this purpose isogenic Lewis‐to‐Lewis and allogenic DA (Dark Agouti)‐to‐Lewis rat cardiac transplants were studied 1 hour and 1, 3, and 5 days, respectively, after heterotopic intraabdominal transplantation. Myocardial tissue blood flow (MBF) was assessed by the hydrogen‐clearance method. An implanted balloon was used to measure pressure–volume relations in the transplanted heart. Myocardial water content was determined at the end of the experiments, and histologic examinations were performed. The MBF recovered during the first day postoperatively in both groups and decreased again in the allogenic group after 3 and 5 days (p < 0.05); it remained stable in the isogenic group. Myocardial relaxation was already prolonged in the allogenic group after 3 days and deteriorated further. Left ventricular end‐diastolic pressure progressively increased in the allogenic group, whereas it remained unchanged in the isogenic group up to 5 days. After recovery from ischemia, the left ventricular peak systolic pressure was stable in the isogenic group for the entire further observation period, but it significantly decreased in the allogenic group after 5 days (p < 0.05). Myocardial water content showed a significant increase in the allogenic group compared to that in the isogenic group after 5 days. In the allogenic group histologic examination confirmed mild to moderate rejection after 3 days and severe acute rejection after 5 days. Thus, after recovery from ischemia, mild to moderate cardiac rejection was associated with reduced MBF and impaired relaxation. In a typical sequence, generation of edema and impaired diastolic compliance were terminally followed by systolic dysfunction during severe rejection.
Patterns of Recurrence after Resection of Colorectal Liver Metastases: Prediction by Models of Outcome Analysis
Authors: Lise Mario , Bacchetti Stefano , Da Pian Pierpaolo , Nitti Donato , Pilati Pierluigi
Published: October 2003

Various series have reported similar survival and recurrence rates after resection of colorectal liver metastases (CRLM). If outcomes were predictable, indications for surgery could be improved. This hypothesis was tested in 135 consecutive patients with CRLM who underwent “curative” resection from 1977 to 1997. Among the 132 patients available for follow‐up, three groups were identified on the basis of outcome: (1) survival of more than 5 years disease‐free (n= 32; 24%); (2) diffuse recurrences within the first 6 months (n= 24; 18%); and (3) discrete recurrences for which reresection was performed (n= 16; 12%). As our results are similar to those reported in the literature, we assumed that about 50% of patients with resectable lesions have recognizable patterns of recurrence. At multivariate analysis, factors significant for disease‐free survival (DFS) were the percentage of liver invasion, metastases to lymph nodes at the primary site, number of metastases, preoperative glutamic pyruvic transaminase (GPT) level, and type of liver resection. On the basis of the relative risk (RR) expressed by significant prognostic factors, a score model was developed, and three prognostic groups were defined: Group A, with the best prognostic score, included 23 of 32 (72%) patients who survived more than 5 years, and that with the worst prognostic score (group C) included 22 of 24 (92%) patients with early diffuse recurrences. Extreme (especially unfavorable) outcomes can therefore be predicted. By using improved models of outcome analysis, many patients could be spared surgery as first‐line treatment, and stratification criteria could be worked out for future trials.
Early Soft Tissue Coverage after Complex Foot Trauma
Authors: Brenner Peter , Rammelt Stefan , Gavlik Johann Marian , Zwipp Hans
Published: October 2003

Complex foot injuries require early and durable soft tissue coverage to reduce infection rates and fibrosis, thereby improving the functional outcome. Definitive wound closure with tissue transfer was achieved as an emergency procedure within 24 hours in 2 of 28 cases, as urgent revision within 72 hours in 9 of 28 cases, and as early revision within 120 hours in 15 of 28 patients. To evaluate the global foot function the Maryland Foot Score was applied to 17 of 28 patients at the 1‐year follow‐up. The mean score was 74.2 (of 100) points, indicating “good” to “sufficient” foot function. The outcome was superior compared with a series of 18 consecutive open calcaneus fractures with delayed soft tissue coverage (64.4 points). These results were confirmed with a modified Merle d'Aubigné Score. The overall infection rate could be lowered to 7.1% after complex foot injuries with early soft tissue coverage compared to 26 open calcaneus fractures (19.2%). Functional scores allow a reasonable overall assessment of the results, but they are centered on subjective criteria. Thus they must be viewed in conjunction with radiologic and biometric factors as well as criteria valuable for plastic reconstruction, such as two‐point discrimination and durability. Unfortunately, emergency flap procedures are still rare in foot surgery, although they permit primary stable osteosynthesis even with complex foot trauma. The foot should gain the same functional rank as the hand with respect to acute or emergency flap procedures to avoid further complications.
Coexisting Chronic Lymphocytic Thyroiditis and Papillary Thyroid Cancer Revisited
Authors: Kebebew Electron , Treseler Patrick A. , Ituarte Philip H.G. , Clark Orlo H.
Published: October 2003

The effect of chronic lymphocytic thyroiditis (CLT) on the behavior of papillary thyroid cancer (PTC) remains unclear. In recent studies the presence of CLT in patients with PTC was reported to be associated with a lower recurrence rate and an improved survival rate. Furthermore, patients with PTC and tumor infiltrating lymphocytes (TILs) have been reported to have lower recurrence rates and a lower frequency of distant metastases. Because of these and other observations, a tumor immune response in PTC has been suggested. The aim of our study was to determine: (1) the relative frequency of CLT in PTC; (2) the prognostic significance of CLT in patients with PTC; and (3) if TIL occurs independently or in association with CLT. A 10‐year retrospective study of patients who underwent initial thyroidectomy for PTC from 1986 to 1996 was completed. The extent of thyroid lymphocytic infiltration was determined within the tumor, surrounding the tumor, and in the distant parenchyma by two independent observers blinded to the clinical data. Dense focal/diffuse lymphoid aggregates throughout the thyroid gland were diagnostic of CLT and when present within or surrounding the tumor were designated TILs. A total of 136 patients with PTC (typical and follicular variant of PTC histologic subtypes) were identified with a mean follow‐up of 4.4 years and a 8% mortality rate at 10 years. Thirty percent of the patients with PTC had coexisting CLT, and 65% of these patients with CLT had positive anti‐thyroglobulin antibodies. Patients with coexisting CLT and PTC were younger (p < 0.05), more likely to be female (p < 0.05), and more likely to have multicentric tumors (p < 0.001) compared to patients without CLT. Only 5% of patients had TILs without CLT, but 82.5% of patients with CLT had TILs identified (p < 0.0001). By univariate analysis CLT, age, gender, stage of PTC, tumor multicentricity, and tumor size were significant prognostic factors. Only age and TNM stage of PTC remained independent prognostic factors by multivariate analysis. We found a similar frequency (30%) of coexisting CLT and PTC as reported by others; but, more importantly, the presence of TILs primarily occurred in association with CLT. The presence of CLT in patients with PTC correlated with an improved prognosis. It was not an independent prognostic factor, however, and was not associated with a lower recurrence rate or a lower frequency of distant metastasis.