bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical treatment of adenomas
Authors: Nicholls R. John
Published: May 2005

Surgical treatment of adenomas may become necessary when the base of the polyp is too wide for snaring, increasing the risk of incomplete removal or perforation of the bowel wall. Suspicion of malignancy may also indicate surgery. Multiple adenomas not controlled by snare polypectomy can be treated by colectomy. The different approaches of surgical treatment are described.
Follow‐up after polypectomy
Authors: Winawer Sidney J.
Published: May 2005

Progress in understanding the biology, natural history, and relationship to colorectal cancer has provided the basis for a rational approach to patients with adenomas. Pathological assessment of polyps is essential for initial management; only adenomas require search for synchronous neoplasia. A finding of a 30%–50% synchronous rate has been observed. After clearing of the colon of all adenomas, follow‐up examination will reveal a 30%–50% rate of metachronous adenomas, but usually with unimportant pathology. Patients with no special concerns at initial polypectomy can have surveillance at intervals of approximately 3 years, while those with an incompletely cleared colon, numerous polyps, or large sessile or malignant adenomas need individualized surveillance. Working guidelines can be provided at this time pending observations in ongoing trials. It is expected but not yet proven that control of colonic adenomas will reduce the incidence and mortality from colorectal cancer. Further research into the biology of adenomas and cancer will undoubtedly provide a clear understanding of susceptibility for colorectal adenomas and more selective control strategies.
Intervention studies in adenoma patients
Authors: Armitage Nicholas C. M.
Published: May 2005

There is considerable evidence that most colorectal carcinomas arise in preexisting adenomas. It also appears that there may be a considerable influence of diet in the genesis and growth of adenomas. This evidence is discussed and the current dietary intervention studies in humans are reviewed.
Treatment of carcinoma in adenomas
Authors: Muto Tetsuichiro , Sawada Toshio , Sugihara Kenichi
Published: May 2005

Invasive carcinomas in polyps removed during endoscopy are described. Most of them can be treated adequately by polypectomy alone, but some need additional surgical treatment. Incomplete excision, poorly‐differentiated carcinoma, and lymphatic invasion are associated with increased risk of residual carcinoma and lymph node metastases, making colorectal resection more attractive; however, in elderly patients and poor‐risk patients, the risks of surgery should be balanced against the possible advantage of curative surgery. Rectal polyps may be large but sphincter preservation can usually be achieved by different types of local excision. Recently described flat adenomas may contain carcinoma, but may also be treated by polypectomy using snare or hot biopsy.
Management of acute volvulus of the sigmoid colon: A new approach by percutaneous deflation and colopexy
Authors: Salim Aws S.
Published: May 2005

Forty‐one consecutive patients with acute sigmoid volvulus were prospectively randomized into 2 groups to compare percutaneous deflation prior to emergency tube decompression followed electively by colopexy with banding (n=20) versus emergency tube decompression followed electively by sigmoid colectomy (n=21). Of 21 patients subjected to tube decompression, the procedure was successful in 15 (71%). Emergency sigmoid colectomy was done in the remaining 6 patients and 3 of them died postoperatively. Percutaneous deflation enabled all patients (n=20) to have successful tube decompression without complications. Two of the patients (13%) who underwent elective sigmoid colectomy died postoperatively and another 2 developed wound infections, whereas colopexy by banding caused no mortality and only 1 patient (5%) developed a wound infection. Disconnection of the intravenous line, consumption of solid food, and discharge from the hospital were each effected at significantly (p <0.001) earlier postoperative times with colopexy than with sigmoid colectomy. Both of these elective procedures were equally effective in preventing recurrence of the volvulus. During 1 year of follow‐up, colopexy was not observed to cause any abdominal pain or alteration in bowel habits.

This study shows that percutaneous deflation of acute sigmoid volvulus is a rapid and safe method which enables successful sigmoidoscopic decompression with avoidance of emergency surgery and its high mortality rates. The study also shows that colopexy by banding is a simple elective procedure which overcomes the limitations of mesenteropexy and resectional surgery.
Sequential abdominal reexploration with the zipper technique
Authors: Cuesta M. A. , Doblas M. , Casta∼neda L. , Bengoechea E.
Published: May 2005

Frequently, several multiple abdominal reexplorations are needed in patients with acute necrotizing hemorrhagic pancreatitis (ANP) or with persistent intraabdominal sepsis (PIAS). Residual undrained necrotic and septic foci lead to multiple organ failure. To provide wide‐open drainage of the abdominal cavity, since 1985 we have performed sequential abdominal reexploration with the zipper technique (SARZT) in 24 patients.

Apache II score was used to evaluate expected mortality. In the pancreatic necrosis group, with a mean Apache II score of 31, the expected and the observed mortality were 70% and 29%, respectively. In the PIAS group, with a mean Apache II score of 30, the expected and observed mortality were 60 and 28%, respectively. These results are attributed to the sequential reexploration of the abdominal cavity that permits excision and drainage of necrotic and septic foci.
Primary jejunoileal tumors: A review of 45 cases
Authors: Desa L. A. J. , Bridger J. , Grace P. A. , Krausz T. , Spencer J.
Published: May 2005

We reviewed 45 patients who underwent surgery for primary jejunoileal tumors over a 15‐year period. There were 16 benign and 29 malignant tumors, which included 13 lymphomas, 7 adenocarcinomas, 7 carcinoid tumors, and 2 leiomyosarcomas. Eighteen patients, 13 of whom had benign tumors, presented with intestinal bleeding and 5 tumors were found incidentally at laparotomy. Benign lesions were more frequently sited in the jejunum while malignant lesions were more common in the ileum (p<0.001). Lesions presenting with hemorrhage were more likely to be benign than malignant (p<0.001) and were more commonly sited in the jejunum than in the ileum (p<0.05). Visceral perforation (31%), intestinal obstruction (21%), and an abdominal mass (17%) were other presenting features in patients with malignant tumors. In spite of a wide variety of investigations, the correct diagnosis was reached preoperatively in only 31% of patients. Surgical management included either limited bowel resection or segmental resection with regional lymphadenectomy. Operative mortality was 13% and morbidity was 36%. Actuarial 5‐year survival for all malignant tumors was 24%, being 64% at 5 years for carcinoid tumors, 20% at 30 months for adenocarcinomas, and 10% at 42 months for lymphomas. These results reemphasize the need for a high index of suspicion and early laparotomy in patients with obscure intestinal symptoms if the prognosis of small bowel tumors is to improve.
Falls in hemoglobin saturation during ERCP and upper gastrointestinal endoscopy
Authors: Al‐Hadeedi S. , Leaper D. J.
Published: May 2005

Fiberoptic endoscopy is practiced everyday in the field of gastroenterology and, for diagnostic purposes, carries a risk of complications and an estimated mortality of 1∶5,000, which is multiplied several times during interventional procedures. Half of these complications have a cardiopulmonary origin which may be anticipated by the use of pulse oximetry to measure hemoglobin saturation (SaO2).

We studied 132 patients undergoing diagnostic or procedural endoscopic retrograde cholangiopancreatography (ERCP) under sedation, and 51 undergoing esophagogastroduodenoscopy (EGD) without sedation. In the ERCP group, SaO2fell from 95.7±2.4% (mean ±standard deviation) to 88.9±6.4% (p<0.001) with a corresponding rise in pulse from 95±19 to 116±18/min (p<0.001) followed by recovery. The largest falls followed positioning of the endoscope (rather than following administration of the sedative or the procedure), particularly during introduction of the endoscope within 1 minute of administering diazemuls (diazepam). The EGD group also had a fall in SaO2(97.3±1.9% to 93.9±3.3%,p<0.001), although the patients were younger and undergoing shorter examinations. Again, the largest falls occurred 1 minute after introduction of the endoscope.

In subgroups of patients undergoing ERCP, analysis of respiratory patterns using spectral techniques and electrocardiogram during endoscopy (n=25), or peripheral perfusion using transcutaneous oximetry and laser Doppler velocimetry (n=12) was undertaken. No correlations were found in relation to changes in SaO2.

The cause of the fall in SaO2during endoscopy is multifactorial. It is known to be related to a fall in blood pressure and, although we could not demonstrate any obvious change in peripheral perfusion, this may still be occurring and affecting pulse oximetry readings which are less accurate in poor perfusion states. We recommend its use, however, during endoscopy and, after intravenous sedation, it might be safer to wait 2 minutes and document that the SaO2is satisfactory before introducing the endoscope.
Surgical treatment of severe postshunt hepatic encephalopathy
Authors: Dagenais Michel H. , Bernard Denis , Marleau Denis , Morgan Stephen , Tassé Daniel , Wassef Ramsès , Villeneuve Jean‐Pierre , Pomier‐Layrargues Gilles , Willems Bernard , Lavoie Pierre
Published: May 2005

Hepatic encephalopathy is a major complication of portal‐systemic shunts with an incidence ranging up to 52%. A small fraction of these patients are refractory to medical therapy. Shunt ligation and colonic procedures are the main surgical approaches. The goal of the latter is to diminish the colonic absorption of nitrogenous substances which are involved in the pathophysiology of hepatic encephalopathy. Six patients, whose average age was 55.7±2.6 years, were operated for severe postshunt encephalopathy requiring 4.3±0.9 admissions for a total duration of 76±26 days over 1–11 years. One patient had undergone a splenoral shunt and 5 had a portacaval shunt. One ligation of the shunt and 5 colon exclusions were performed. The average postoperative hospital stay was 21.5±3.9 days. The mean follow‐up was 47±20 months. The patient with the shunt ligation remains free of encephalopathy 94 months after the procedure and has not bled from his esophageal varices. Among the 5 colon exclusion patients, there were 1 death and 3 complications. Three patients were completely relieved of their hepatic encephalopathy. One of those 3 died of a subarachnoid hemorrhage 28 months after the surgery. The fourth still needs medication to control a persistent, although improved, encephalopathy that required 2 further hospitalizations. Colon exclusion is a useful intervention in very selected cases. It has a lower operative mortality than total colectomy and the advantage over shunt ligation of not reestablishing hypertension in the portal system.
Prospective randomized double‐blind trial of branched chain amino acid enriched versus standard parenteral nutrition solutions in traumatized and septic patients
Authors: Vente Johannes P. , Soeters Peter B. , von Meyenfeldt Maarten F. , Rouflart Margriet M. J. , van der Linden Cees J. , Gouma Dirk J.
Published: May 2005

The addition of branched chain amino acids (BCAA) to total parenteral nutrition (TPN) solutions of balanced aminoacid composition has been reported to result in improved nitrogen balance, preservation of plasma protein levels, and improved immune function; however, only a few large clinical studies have been performed, yielding conflicting results. We, therefore, studied in a prospective, randomized double blind trial, the effects of BCAA enrichment of an otherwise isonitrogenous and isocaloric TPN solution on plasma protein levels in 101 traumatized and septic patients.

TPN‐derived nitrogen intake was similar in both study groups. Nitrogen balances in the BCAA group (n=49) were not different from those in the standard group (n=52). Plasma total protein levels increased significantly in the standard group resulting in a significant difference between study groups on day 7. Pre‐albumin levels increased significantly in the BCAA group and in the standard group. The number of neutrophils (rods) was significantly lower in the standard group compared to the BCAA group on day 7. Lymphocytes increased significantly in the standard group as did the number of platelets, resulting in a significant difference between study groups on day 7.

We conclude that BCAA enrichment of standard TPN solutions does not result in more efficient nitrogen metabolism in septic or traumatized patients.
Complicated pneumothorax: Short‐ and long‐term results of endoscopic fibrin pleurodesis
Authors: Hauck Herwig , Bull Philippe G. , Pridun Nestor
Published: May 2005

Complicated pneumothorax is defined as a recurrent or persistent air leak in the pleural interspace beyond 5 days despite adequate tube drainage. Up to now, this disorder could only be corrected by open thoracotomy. Endoscopic fibrin pleurodesis is shown to be a method that could obviate, in most cases, the need for thoracotomy. In the last 6 years, 138 of 153 patients presenting with complicated spontaneous pneumothorax were treated with this method. The fibrin sealant consists of 2 components: fibrinogen, factor XIII, and albumin dissolved in aprotinin (3,000 KIU/ ml), and a thrombin calcium chloride solution, which is applied through the working channel of a thoracoscope and vaporized with nitrous oxide. In this observation period, 6 (4.4%) recurrences were observed, which were subsequently treated with thoracotomy; a second attempt at fibrin pleurodesis was not undertaken. In all cases, endoscopic sealing was followed by prompt reexpansion of the collapsed lung. Long‐term follow‐up was satisfactory, pulmonary function tests showed no signs of restrictive dysfunction, and pleural fibrosis was not observed on x‐ray as reported in other modes of treatment. Following these results, it is concluded that this method is useful in cases of persistent, therapy‐resistant, complicated spontaneous pneumothorax; its effects are durable and it has a low rate of recurrence. It produces a physiological healing process without damage to the pleura.
Unresolved surgical issues in the management of patients with Zollinger‐Ellison syndrome
Authors: Norton Jeffrey A. , Jensen Robert T.
Published: May 2005

In the last 10 years, there have been a number of major advances that have markedly changed the management of patients with Zollinger‐Ellison syndrome. These advances have been described recently in a number of excellent reviews [1–3]. After reading each of these reviews, including our own, one is left generally with the impression that most of the important problems and particularly those involving surgery in the treatment of this disease have been resolved; however, in considering the possible problems to address in protocols in the coming years in our patients with Zollinger‐Ellison syndrome followed at the National Institutes of Health, it became apparent to us that not only will surgery play an increasingly important role in the management of this disease, but that there are a number of major questions in which various aspects involving surgery are not resolved. Furthermore, resolution of a number of these areas will have applicability to the surgical treatment of other islet cell tumors. The purpose of this article is to call attention to these questions with the hope that other investigators may also consider these and specifically attempt to address some of these issues in the surgical treatment of Zollinger‐Ellison syndrome in prospective studies.
Methods of decision analysis: Protocols, decision trees, and algorithms in medicine
Authors: Greep J. M. , Siezenis L. M. L. C.
Published: May 2005

Algorithms, decision trees, and protocols are defined and explained since they constitute an accepted part of clinical decision analysis and application to clinical care. Algorithms are particularly useful for common clinical problems where uncertainties are unlikely. Decision trees are helpful when—as usually occurs in difficult clinical decisions—there are problems in probability. Clinical protocols, which, at best, are based on algorithms and decision trees, provide instruction of how to best treat a patient given the strict definitions of the clinical problem. These techniques are, in essence, merely graphic representations of a logical scientific approach to clinical problems. Criticisms of these techniques center on their rigidity and the automatic unthinking cookbook medicine they might sponsor. It is concluded that if these techniques are wisely designed and, even more importantly, wisely administered with an understanding flexibility, they can lead to both economy and patient benefit.
Cost‐effective diagnostic test sequencing
Authors: Eiseman B. , Jones R. , McClatchey M. , Borlase B.
Published: May 2005

Proper diagnostic test selection and logical sequencing can minimize cost without compromising care. This study analyzes the logic for sequencing tests either in series (one after another) or in parallel (simultaneously). A model is created using 2 diagnostic tests for 2 diseases. Tests are assumed to have perfect performance characteristics.

Factors involved in cost‐effective test sequencing include cost of each test, test performance characteristics, per diem hospital charge, and the clinician's prior probability of the suspected diagnosis based on history, physical examination, and previous laboratory data. At a given point of clinical suspicion, cost‐effective sequencing strategy should shift. In general, a cheap test can effectively be used in parallel even at low diagnostic probabilities; an expensive test should, in general, be used in series only when there is a high prior probability of diagnosis. High per diem hospitalization costs—such as for a patient in the intensive care unit—favor in parallel testing.

Clinical acumen and suspicion of diagnosis (prior probability) primarily direct cost‐effective diagnostic test sequencing. Decision analysis of diagnostic test sequencing represents a technique for making cost‐effective decisions for sequencing and, thereby, minimizing costs while achieving optimal patient care.
Subjectivity in decision making: Common problems and limitations
Authors: Ravitch Michael M.
Published: May 2005

Subjectivity is an inescapable part of the diagnostic and decision making process. Limitations on memory are compensated for by invoking “diagnoses” as devices for managing information during diagnosis. Thus, large amounts of information can be stored as confirmations and departures from the diagnostic hypotheses. Well‐documented limitations in probabilistic reasoning interfere with diagnosis and patient management. Uncommon diagnoses may be invoked inappropriately. Misconceptions of chance may lead to erroneous conclusions about health care. Most perplexing is that physicians attempting to incorporate patient preference in decision making are confronted with problems of subjective inconsistencies in patient valuation of outcomes of health care. The major problems of quantification and analysis are amenable to management through education, computing, and better patient data management. Problems of utility elicitation will require further research.
Decision analysis in surgical education
Authors: Elstein Arthur S.
Published: May 2005

Surgical education can no longer be considered adequate if limited to description of surgical diseases and methods of management. Due to the growth in numbers of surgical diagnostic and therapeutic procedures, the surgeon of the future will find it increasingly necessary to understand the principles by which algorithms are constructed and by which individualized decisions should be made. Several systematic approaches for assisting clinical decision makers have been developed. Decision analysis is particularly appealing because it is flexible and readily adapted to a wide range of clinical situations. It explicitly guides the decision maker in determining the crucial variables in a clinical decision, and permits both objective data and personal preferences to play a part in decision making. Because it provides for personal estimates and preferences, decision analysis is not dehumanizing, even though it is quantitative, explicit, and mathematically rigorous. Topics for a series of seminars or case conferences are suggested. Decision analysis should be part of the intellectual preparation of every clinician.
Theoretical surgery: A new specialty in operative medicine
Authors: Lorenz Wilfried , Rothmund Matthias
Published: May 2005

Theoretical surgery is defined as a nonoperative decision analysis and clinical and basic research supporting system for surgery. It developed to meet the needs of academic surgeons to coordinate communication with basic science disciplines.

This article summarizes the development of this idea at the University of Marburg where theoretical surgery has reached departmental and institutional proportions. Its objectives and methods are described. Central to its operation are permanent working teams of 2 clinical surgeons, 1 basic scientist (theoretical surgeon), 1–2 technicians, and 1–2 students focusing on one problem in a joint interdisciplinary manner. Decision analysis with classification methods and the creation of decision trees and algorithms are central to the operation of this experiment.

Lessons learned from this academic experiment and the accomplishments during the past 20 years are summarized on 3 levels of efficacy: performance, changing strategies, and outcome.
Repeated hepatic ischemia as a treatment for carcinoid liver metastases
Authors: Persson Bo G. , Nobin Anders , Ahrén Bo , Jeppsson Bengt , Månsson Bertil , Bengmark Stig
Published: May 2005

Hepatic ischemia has been used in the treatment of bilobar malignant carcinoid tumors in the liver. Hepatic artery ligation, hepatic dearterialization, and embolization with nondegradable micromaterial have been followed by collateral formation and are associated with a high complication rate. To reduce this, an implantable vascular occluder permitting intermittent occlusion of the hepatic artery was used in 3 patients with bilateral malignant carcinoid in the liver, with high urinary excretion of 5‐hydroxyindoleacetic acid (5‐HIAA). Following a thorough dearterialization of the liver and division of all attachments, except for the hepatic artery, portal vein, and common duct, the vascular occluder was placed around the hepatic artery and connected to an implantable subcutaneous port. The hepatic artery was occluded by injecting a few milliliters of saline into the port and flow was released by withdrawal of the same amount of saline. Two patients had an anomalous blood supply to the right lobe and the arterial branch was transposed to the proper hepatic artery. One patient had the hepatic artery regularly occluded for 16 hours at 4–6 week intervals. Two patients managed to do the occlusions by themselves at home for 1 hour twice daily. Two patients had a normalization of the urinary excretion of 5‐HIAA after 4 and 9 months. On follow‐up with computed tomographic scanning, tumor regression was noted in one, however, there was no change in the other. The third patient has already had a 75% reduction of urinary excretion of 5‐HIAA after 2 months of treatment. This new technique has the advantage of being performed on repeated occasions and on an ambulant basis over a long period of time.
Hepatic abscess
Authors: Donovan Arthur J. , Yellin Albert E. , Ralls Philip W.
Published: May 2005

Hepatic abscess—amebic or pyogenic—can be diagnosed with great accuracy by either ultrasonography or computed tomographic (CT) scanning. Ultrasound is the modality of choice and will detect almost 100% of abscesses. Confirmation of a diagnosis of amebic liver abscess is made by the indirect hemagglutination test that should be positive in almost 100% of cases. Cultures of pus from the abscess and from the blood must be obtained in cases of pyogenic liver abscess. A positive culture of pus from the abscess has been achieved in 90% of cases. Ultrasound or CT guidance is utilized in aspiration of a hepatic abscess.

In the treatment of an amebic liver abscess, metronidazole is the amebicide of choice. Open drainage is contraindicated. For cases that fail to respond to therapy with amebicides, closed drainage guided by CT or ultrasound is performed. Secondary bacterial infection of an amebic liver abscess is an extremely rare event.

The identification and determination of the antibiotic sensitivity of organisms responsible for pyogenic liver abscess is a crucially important step. Unless a celiotomy is necessary to correct an intraabdominal process or the abscess is extremely large, the initial treatment of pyogenic liver abscess is a 2 week course of appropriate antibiotics followed by a 1 month course of oral antibiotics. The majority of pyogenic liver abscesses will respond to such treatment. If drainage of a pyogenic abscess is required, the preferable technique is with a percutaneous CT‐ or ultrasound‐directed catheter. Open surgical drainage should be reserved for those cases in which a celiotomy is required for other purposes or for the patient who has failed a course of appropriate antibiotic therapy and closed percutaneous drainage is not feasible.

The mortality for treatment of amebic liver abscess should be approximately zero and for pyogenic liver abscess should be less than 10%.
Portal hypertension in mansonic schistosomiasis
Authors: Raia Silvano , Mies Sergio , Alfieri Fernando
Published: May 2005

Mansonic schistosomiasis is an endemic disease in Brazil, with an estimated 10–12 million people infested. Among its clinical manifestations, the hepatosplenic form causes portal hypertension which, in turn, brings about severe digestive hemorrhage, the most serious complication of the disease. Normally, the patients are young, and have hepatosplenomegaly, hypersplenism without clinical manifestations, and slightly reduced hepatic function. The angiographic findings are characteristic, differing from those of hepatic cirrhosis.

In Brazil, the definitive treatment for gastrointestinal hemorrhage is surgery, which should be done under elective conditions whenever possible. During a short period of time, known as the “risk period” (the time between the hemorrhagic episode and the surgery), propranolol has been used to prevent further bleeding. Surgical treatment is indicated only after the first episode, and never on a prophylactic basis.

In 1977, a prospective, randomized trial was begun in order to assess the delayed results of the 3 surgical operations most widely used in this country. The study was interrupted after 94 patients had been operated on due to the high incidence of encephalopathy in the group who underwent classical splenorenal shunt. After a follow‐up of at least 60 months and, at most, 130 months, the results showed that classical splenorenal shunt caused encephalopathy in 39.3% of the cases and distal splenorenal shunt in 14.8%. None of those submitted to esophagogastric devascularization with splenectomy developed encephalopathy. The 3 procedures showed similar rates of hemorrhagic recurrence.
Surgery of chagasic megacolon
Authors: Cutait Daher E. , Cutait Raul
Published: May 2005

Chagas' disease is an endemic clinical entity caused byTrypanosoma cruzi,a parasite that is transmitted to humans by the hematophagic Triatominae insects. It affects several million persons in Latin America, mostly in Brazil, Argentina, Chile, Paraguay, and Bolivia. Megacolon, the most common complication of intestinal trypanosomiasis, results in severe constipation, for which surgery is indicated. A variety of procedures have been proposed for the correction of this disabling condition including sigmoidectomy, abdominal rectosigmoidectomy, left colectomy, and subtotal colectomy. On long‐term follow‐up, however, these operations have proved to be inadequate in a significant number of cases, apparently due to preservation of the dyskinetic rectum which continues to act as a functional obstacle to the progression of the fecal bolus. On the other hand, pull‐through operations, which include the removal of all or almost all of the dyskinetic rectum, or the exclusion of the rectum, as in the Duhamel‐Haddad operation, have been demonstrated to be superior.

The abdominoperineal endoanal pull‐through resection with delayed colorectal anastomosis and the Duhamel‐Haddad operation are the most accepted procedures in Brazil and other Latin American countries; their technical details are illustrated. Functional results are satisfactory. Anal continence is normal in the vast majority of cases and sexual disturbances are rare. Routine treatment of 2 main complications—fecaloma and volvulus of the sigmoid colon—are discussed.
Surgical complications of Chagas' disease: Megaesophagus, achalasia of the pylorus, and cholelithiasis
Authors: Pinotti Henrique Walter , Felix Valter Nilton , Zilberstein Bruno , Cecconello Ivan
Published: May 2005

Three surgical complications of Chagas' disease—megaesophagus, achalasia of the pylorus, and cholelithiasis—were evaluated within the framework of the experience acquired in the management of 840 cases of megaesophagus—722 in the nonadvanced stage of the disease and 118 with advanced disease (dolichomegaesophagus).

In the group of the 722 patients with nonadvanced disease, achalasia of the pylorus was present in 140 (19.4%), and in the total of 840 patients, uncomplicated cholelithiasis without chagasic involvement of the gallbladder and/or papilla was observed in 58 (6.9%).

The 722 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy performed at the level of the anterior esophagogastric junction, combined with an antireflux valvuloplasty procedure. We recorded no mortality, and 95% excellent and good results in long‐term follow‐up. On the other hand, dolichomegaesophagus required esophageal resection with reconstruction by means of an esophagogastroplasty placed in the esophageal bed. The mortality rate was 4.2% (5/118); the main postoperative complications were pleural effusion (22%) and fistulas of the esophagogastric anastomosis (8.4%). Postoperatively, the patients adapted well to their new anatomy and gained weight. Achalasia of the pylorus was confirmed by delayed gastric emptying time. This entity was managed by concomitant antropyloromyectomy without mortality. Cholelithiasis was managed by cholecystectomy and radiologic exploration of the bile ducts.
Endemic goiter and endemic thyroid disorders
Authors: Gaitan Eduardo , Nelson Norman C. , Poole Galen V.
Published: May 2005

The primary role of iodine deficiency in goitrogenesis and the prevention and treatment of endemic goiter by iodine supplementation is firmly established. Unfortunately, implementation of iodine prophylaxis programs has met with considerable technical and socioeconomic difficulties. Besides, lack of knowledge concerning some of the other causative factors of endemic goiter has prevented development of appropriate measures for its complete eradication in those areas where goiter persists in spite of prolonged and adequate iodine supplementation. At present, no less than 5% of the world's population have goiters and associated disorders, resulting in a public health and socioeconomic problem of major proportions. Seventy‐five percent of people with goiter live in less developed countries where iodine deficiency is prevalent. Goiter prevalence rates of more than 50% and the highest frequency of severe cases of iodine deficiency disorders, namely, cretinism, congenital hypothyroidism, and various degrees of impairment of growth and mental development are found in endemic areas with extreme iodine deficiency. Goiters are usually multinodular and of very large size, producing, on occasion, signs of compression that require surgery. Recurrence rates are as high as 25–30% and second surgery accounts for 16% of all thyroidectomies. Unfortunately, most of these goiters occur in areas with highly restricted medical and surgical facilities. Twenty‐five percent of people with goiters live in more developed countries where goiter continues to occur in certain areas despite iodine prophylaxis. Iodine‐sufficient goiters are associated with autoimmune thyroiditis, hypothyroidism, hyperthyroidism, and thyroid carcinoma. Goiter is of considerable surgical significance in iodine‐sufficient endemic areas and, to a lesser degree, in nonendemic areas where it is called “sporadic” goiter. Recurrence rates of iodine‐sufficient goiter are 10–19% following thyroidectomy. Since most of these goiters grow by mechanisms other than increased thyrotropin (TSH) stimulation, treatment with suppressive doses of L‐thyroxine is inefficient and, because of possible complications, not recommended. Although Graves' hyperthyroidism is not directly related to endemic goiter, it does relate adversely with ingestion or administration of iodine. At present, Graves' disease is treated with131I or antithyroid drugs in more than 90% of the cases. The incidence rates of papillary, follicular, and anaplastic thyroid carcinomas appear to be related to endemic goiter and iodine supplementation, with surgery being required in essentially all of these cases.
Fulminant amebic colitis
Authors: Aristizábal Humberto , Acevedo Jairo , Botero Mario
Published: May 2005

Amebiasis is the acute and chronic disease produced byEntamoeba histolytica,an entity which occurs in endemic fashion in many of the tropical and subtropical areas of the world, capable of affecting diverse organs of the body, especially the colon. Amebiasis has different clinical forms of presentation, varying from the asymptomatic carrier state to severe, although not frequent, fulminant or necrotizing colitis, characteristically associated with high morbidity and mortality. We hereby report a series of 50 adult patients with fulminating amebic colitis managed at our institution between January, 1971 and July, 1989, with a global mortality of 60%. Early diagnosis, treatment with effective antiamebic agents—specifically metronidazole—and opportune aggressive surgical intervention have resulted in better survival rates. We had no survivors prior to 1970; our current survival rate is still a dismal 40%, indicating the very severe nature of the disease.
The epidemiology of gastric cancer
Authors: Correa Pelayo
Published: May 2005

The etiology of gastric carcinoma, especially its “epidemic” or “intestinal” type is reviewed. The prevailing etiologic hypothesis, based on the selective targeting of etiologic agents in different points of the chain of causation, is described. Support for the hypothesis is updated, based on descriptive and analytical epidemiologic studies as well as on recently obtained laboratory and experimental evidence. Primary and secondary prevention measures are briefly discussed.
Necrotizing lesions of soft tissues: A review
Authors: Patiño José Félix , Castro Daniel
Published: May 2005

Necrotizing lesions of the soft tissues are grave entities not infrequently seen in daily surgical practice. They may occur with epidemic proportions after natural disasters, representing a serious challenge to the surgeon since they are characteristically associated with high mortality rates unless an early diagnosis is made and prompt aggressive surgical management is initiated. Necrotizing fasciitis is the currently accepted generic term to encompass into a single category the diverse syndromes of progressive gangrenous infections of the skin and subcutaneous tissues. Necrotizing fasciitis must be viewed as a clinical entity rather than a specific type of infection: it is a clinical infection most commonly caused by a mixed aerobic/anaerobic synergistic polymicrobial combination. Zygomycetes may appear as major causal organisms (mucormycosis) and they should be actively searched for. Initial diagnosis of necrotizing fasciitis is established through the characteristic physical signs, Gram stain, and, in some doubtful cases, through frozen‐section tissue biopsy. Aggressive and urgent radical debridement is the key to survival, combined with widespectrum antibiotic therapy.
Necrotizing soft tissue lesions after a volcanic cataclysm
Authors: Patiño José F. , Castro Daniel , Valencia Alvaro , Morales Pedro
Published: May 2005

A volcanic cataclysm of major proportions, the fourth largest in terms of total casualties in the history of mankind, wiped out the town of Armero, Colombia, in 1985 resulting in over 23,000 deaths and 4,500 wounded. Among the hundreds of survivors who were transferred to hospitals in the capital city of Bogotá, there was as overwhelming number who developed necrotizing fasciitis. These patients constitute, perhaps, the single largest group of this type of lesions in the recorded literature. Thirty‐eight patients with well established necrotizing fasciitis were identified at 4 selected hospitals in Bogotá; 8 of them presented with zygomycetic infection (mucormycosis), a highly lethal entity. Many additional cases were treated at other hospitals in Bogotá and several cities in Colombia. The main clinical features of these 38 patients affected by necrotizing fasciitis are reviewed, with special emphasis on the patients with mucormycosis. Patients with necrotizing fasciitis had an overall mortality rate of 47.7%; patients with mucormycosis, 80%. A plea is made for an early diagnosis, utilizing tissue sampling and microbiological studies, so that prompt and radical treatment can be instituted. This is especially pertinent in situations of natural disasters resulting in massive numbers of casualties and seriously injured survivors.
Recurrent pyogenic cholangitis: Current management
Authors: Fan S. T. , Choi T. K. , Wong J.
Published: May 2005

Successful treatment of recurrent pyogenic cholangitis depends on the ability to delineate the pathology of the entire biliary system and to eradicate all stones, strictures, and destroyed liver segments. Recent advances in imaging techniques and stone fragmentation technology have been applied successfully in the management of this condition. Apart from direct cholangiography and ultrasonography, valuable information can be obtained from computed tomography which is particularly helpful in patients with recurrent disease after previous biliary surgery. Application of electrohydraulic lithotripsy in this disease solves the problem of difficult stone retrieval due to large size, impaction behind relative strictures and inside angulated segmental bile ducts. Together with construction of a hepaticocutaneous jejunostomy serving as a permanent access to the bile duct, it is anticipated that the incidence of recurrence and reoperation in the future can be reduced.
The role of oxygen‐derived free radicals in the management of venous (varicose) ulceration: A new approach
Authors: Salim Aws S.
Published: May 2005

This double blind controlled study examined whether oxygen‐derived free radicals interfere with the healing of venous ulceration occurring on the medial side of the leg for the first time. Graduated compression bandages exerting a mean ankle pressure of 42.1±0.3 mmHg and a mean pressure of 17.3±0.2 mmHg just below the knee healed 70% of ulcers within 12 weeks (n=44). Addition of the radical scavengers allopurinol (n=45) or dimethyl sulfoxide (n=44) to the compression bandages (daily application of the powder for 7 days, then once weekly applications to the end of the study at 3 months) significantly (p< 0.01) stimulated the healing of venous ulceration relative to controls when studied 4, 8, and 12 weeks after commencing treatment. After 3 months of treatment, allopurinol healed 93% and dimethyl sulfoxide healed 95% of the venous ulcers. The results suggest that oxygen‐derived free radicals are directly implicated in the mechanism of venous ulceration and are responsible for its persistence. Scavenging such radicals stimulates the healing of ulceration.
Staging for M Disease
Authors: Winton Timothy L.
Published: May 2005

The presence of distant metastatic disease (M disease) in non‐small‐cell cancer patients is associated with a poor prognosis, and surgical resection at the primary site is contraindicated. Careful preoperative evaluation to identify the subset of patients presenting with M disease is essential in order to avoid unnecessary surgery. Current indications for the use of diagnostic techniques and the methods utilized to detect metastatic disease at the commonest sites encountered in patients with non‐small‐cell carcinoma, including the pleura, central nervous system, liver, adrenal glands, and skeletal system, are discussed.
Staging of bronchogenic carcinoma
Authors: Herman Stephen J.
Published: May 2005

Both computed tomography (CT) and magnetic resonance imaging (MRI) can provide important information not obtainable by chest radiography regarding staging of patients with bronchogenic carcinoma. However, while CT and MRI can both detect enlarged mediastinal nodes, this only approximately indicates tumor involvement. For example, enlarged nodes do not necessarily contain tumor, so biopsy is necessary before declaring the patient inoperable. As well, normal‐sized nodes may contain tumor, and whether mediastinoscopy is required in such situations is controversial. Similarly, neither MRI nor CT is highly accurate in detecting mediastinal or chest‐wall involvement, although certain specific features can occasionally be highly predictive of invasion.
Invasive staging of the mediastinum
Authors: Johnston Michael R.
Published: May 2005

Les résultats de la résection chirurgicale des cancers du poumon (excepté les cancers à petites cellules) sont bien corrélés avec le stade de la maladie. S'il existe des métastases régionales, il est essentiel de bien évaluer l'état médiastinal avant de proposer une exérèse chirurgicale. Bien qu'il existe plusieurs méthodes d'imagerie moderne, reconnues comme extrêmement efficaces dans l'évaluation de l'extension locorégionale, il persiste des erreurs lorsqu'on prend en compte seulement la taille des ganglions lymphatiques du médiastin pour prédire l'existence de l'envahissement métastatiques ou non. Pour cette raison, la plupart des chirurgiens thoraciques exigent des biopsies réglées et systématiques des ganglions avant d'opérer, surtout lorsque l'imagerie met en évidence des adénopathies médiastinales. Les études de traitement adjuvant conduites actuellement par les groupes d'études multicentriques dans le Continent Nord‐Américain exigent à présent un tel “staging mini‐invasif “. On établit ensuite une carte “métastatique” des différents ganglions lymphatiques du médiastin afin d'y adapter la thérapeutique. Dans le choix interviennent également l'expérience et le savoir du chirurgien, le site de la tumeur primitive et le degré d'extension tumorale locorégionale. L'évaluation du médiastin peut être faite avec un minimum de morbidité et fournit un maximum de renseignements pour le pronostic. Ceci est capital pour bien expliquer aux patients l'attitude thérapeutique qu'on leur propose.
Extended resection for higher‐stage non‐small‐cell lung cancer
Authors: Luketich James D. , Van Raemdonck Dirk E. , Ginsberg Robert J.
Published: May 2005

This report reviews the results of extended surgical resection for advanced lung cancer (stage IIIa, IIIb, IV) reported in the Anglo‐American literature between 1980 and 1993. Complete resection of stage IIIa (T3) tumors with minimal or no nodal involvement resulted in a 5‐year survival approaching 40%. Ipsilateral mediastinal nodal involvement (N2) lowered 5‐year survival to 10–15% and to near 0% if bulky disease was present. Historically, resection of stage IIIb disease has failed to improve survival. Radiation therapy has decreased local recurrence in advanced‐stage disease but has not improved survival.

Preliminary results have recently been reported using induction chemotherapy or chemoradiotherapy followed by resection in subsets of patients with stage IIIa and IIIb disease. Induction chemotherapy for bulky N2 (IIIa) disease resulted in major response rates of up to 77% and a 5‐year survival of up to 26% after complete resection. Preliminary results of resection of stage IIIb tumors following induction chemotherapy have achieved 2‐year survivals of 40%. Metastatic lung cancer (stage IV) with disseminated disease remains virtually incurable with poor response rates to chemotherapy. However, resection of isolated brain metastases (M1 disease) resulted in a 5‐year survival near 25%. Resection of other sites of isolated metastatic disease including the adrenal gland is under investigation.

The major prognostic factor in these studies has been the ability to completely resect all tumor. To improve resectability rates, induction therapy and radical resections are being combined more frequently. The increased morbidity and mortality of these aggressive approaches requires careful patient selection.
Neoadjuvant and adjuvant therapy in the management of locally advanced non‐small‐cell lung cancer
Authors: Jaklitsch Michael T. , Strauss Gary M. , Sugarbaker David J.
Published: May 2005

The role of adjuvant therapy in non‐small‐cell lung cancer continues to be defined. We review the most recent major reports of adjuvant trials. Three large randomized trials of postoperative chemotherapy and/or radiation therapy for stage I and II patients have noted improvement trends in median and long‐term survival. Two large preoperative phase II trials for stage III A patients have reported high response and surgical resectability rates for preoperative combinations of radiation and chemotherapy, but without significant improvement in survival. In general, most of these protocols require months to complete, and not all patients are able to withstand the associated toxicity. The field of adjuvant therapy is continuing to develop; some of the strategies of ongoing protocols are reviewed.
Postoperative chemotherapy for resected non‐small‐cell lung cancer
Authors: Crump Michael
Published: May 2005

Surgical resection is the treatment of choice for patients with stage I and stage II non‐small‐cell lung cancer (NSCLC—squamous cell, adenocarcinoma, and large‐cell carcinoma). Distant recurrence is an important cause of death after complete surgical resection, occurring in 30–60% of patients. Postoperative adjuvant chemotherapy has been studied for over three decades in randomized controlled trials but is not considered standard therapy for this group of patients. The use of multidrug regimens including cisplatin has produced a prolongation of disease‐free survival, but until recently no overall survival benefit has been shown. A new generation of studies is now warranted, employing the more active combinations identified in the 1980s or incorporating one of the many promising new agents being tested in NSCLC. The use of improved supportive care measures, such as the new serotonin receptor antagonist antiemetics, is required to increase compliance with chemotherapy in this group of patients. With this approach, the real goal of adjuvant system chemotherapy—to increase the number of patients actually cured of their cancer—may be attained in early stage NSCLC.