bluuebunny/crossref_metadata_2025 huggingface dataset:
Multidisciplinary management of cancer of the anus
Authors: Nigro Norman D.
Published: May 2005

Anal margin cancers are treated by local excision, with radical surgery reserved only for invasive cancers or those associated with fistula or condylomata. Squamous cell cancers of the anal canal have been treated by abdominoperineal resection regardless of cell type. Radiation therapy alone has been advocated by some, and we initiated a study using a combination of radiation, chemotherapy, and surgery. This study includes 104 patients treated from December, 1971, to July, 1983. Routine abdominoperineal resection was discontinued by us in 1975 because chemoradiation therapy eliminated the primary lesion in 5 of the first 6 patients. In the series, gross tumor disappeared in 97 patients after chemoradiation therapy. Radical operation was done routinely in 24 patients, for residual disease in 7, and for recurrent disease in 7 others. There were 21 deaths of which 13 were due to cancer of the anal canal. Large primary lesions and recurrent local disease account for the majority of deaths due to cancer. The 5‐year survival rate is projected to be 83%, with 65 patients followed for at least 5 years. Under our current regimen only 16 of the 38 patients would have had radical surgery. Chemoradiation therapy is advocated for all patients with squamous cell cancer of the anal canal and for invasive cancers of the anal margin. Patients with large (6–8 cm) primary cancers and those with recurrent disease should have additional chemoradiation therapy and/or abdominoperineal resection of the rectum.
Intraportal chemotherapy in colorectal carcinoma as an adjuvant modality
Authors: Metzger U. , Mermillod B. , Aeberhard P. , Gloor F. , Bissat A. , Egeli R. , Laffer U. , Martinoli S. , Mueller W. , Schroeder R. , Weber W. ,   the Swiss Group for Clinical Cancer Research (SAKK)
Published: May 2005

Liver metastases of colorectal origin arise from malignant cells entering the portal venous circulation. Four hundred sixty patients from 7 participating institutions have been entered in a prospective randomized trial to assess the value of adjuvant portal venous infusion to prevent liver metastases following curative colorectal cancer surgery. By preoperative randomization, patients were assigned to surgery alone (control arm) or to portal liver infusion with 5‐fluorouracil (5‐FU) (500 mg/m2 daily × 7, continuous infusion during the first 7 postoperative days) and mitomycin C (10 mg/m2, 24 hours postoperatively as a 2‐hour infusion). A portal venous catheter was placed through any side branch of the mesenteric venous system during laparotomy for the primary tumor. Using the transabdominal route, there have been no catheter‐related complications. Despite a large cumulative dose of 5‐FU given during the immediate postoperative period, the systemic side effects were minimal. Overall hospital mortality in this study was 1.85% and was not influenced by the adjuvant treatment. This rate is considerably lower than that reported by previous multicenter trials and by the surgical literature, and it indicates an advance in surgical technique and pre‐/postoperative patient management in this type of elective surgery.

Three hundred seventy‐eight patients (187 controls, 191 infusion patients) are completely evaluable for recurrence and survival. After a median follow‐up of 24 months, 43 recurrences have been observed in the control group and 34 in the infusion group (p<0.05). Liver metastases were present in 18 control patients and in 14 infusion patients. Twenty‐five patients in the control group and 18 patients in the infusion group died of recurrent disease. Due to the low number of recurrences in this study, it is too early to draw survival conclusions.

Several controlled trials using adjuvant portal infusion are in progress. They also showed the feasibility of this approach and they suggested that adjuvant cytotoxic liver infusion may reduce the incidence of liver metastases without significantly increasing morbidity and mortality. It is too early, however, to recommend adjuvant portal infusion outside a clinical trial setting and such treatment should still be restricted to well‐designed prospective protocols.
Intraoperative radiotherapy in carcinoma of the stomach and pancreas
Authors: Abe Mitsuyuki , Shibamoto Yuta , Takahashi Masaji , Manabe Tadao , Tobe Takayoshi , Inamoto Takashi
Published: May 2005

Clinical results of intraoperative radiotherapy (IORT) in carcinoma of the stomach and the pancreas are reported. In carcinoma of the stomach, 101 patients were treated by IORT and 110 patients were treated by operation alone. The 5‐year survival rates of patients treated by IORT were 87.2% for Stage I, 83.5% for Stage II, 62.3% for Stage III, and 14.7% for Stage IV. On the other hand, the 5‐year survival rates of patients treated by operation alone were 93.0% for Stage I, 61.8% for Stage II, 36.8% for Stage III, and 0% for Stage IV. It has been demonstrated that IORT has definite effects on locally advanced gastric cancer.

In carcinoma of the pancreas, a total of 110 patients with locally advanced disease were entered into the pilot study. Forty‐nine patients were treated by IORT (group 1), 20 patients were treated by IORT followed by external beam radiotherapy (group 2), and 41 patients were treated by operation alone (group 3). The median survivals were 5.5 months for group 1, 12.0 months for group 2, and 5.5 months for group 3. The pilot study suggests that a combined IORT and external beam treatment may provide better survival time than can be achieved by IORT without external beam radiotherapy or by operation alone for locally advanced pancreatic cancer.
The concept of immunochemosurgery in gastric cancer
Authors: Kim Jin ‐Pok
Published: May 2005

To evaluate the effectiveness of adjuvant immunochemotherapy in advanced adenocarcinoma of the stomach, patients who had undergone radical subtotal gastrectomy for stage III gastric carcinoma were randomized to receive immunochemotherapy or not. For immunotherapy,Streptococcus pyogenes preparation (picibanil) was given intramuscularly every week, and for chemotherapy, either MFC (mitomycin C, 5‐fluorouracil, and cytosine arabinoside) regimen or FME (5‐fluorouracil and methyl‐CCNU) regimen was given. Immunotherapy was started at the fourth or fifth postoperative day and chemotherapy was started at the eighth to tenth postoperative day.

To evaluate the immune status of patients, various immune parameters such as 1‐chloro‐2, 4‐dinitrobenzene (DNCB) test, T‐lymphocyte count, PHA‐ and concanavalin‐A‐stimulated lymphoblastogenesis, and antibody‐dependent cellular cytotoxicity (ADCC) activity were checked before surgery and 3–4 months postoperatively.

One hundred and thirty‐eight patients were chosen for study during a 5‐year period. Seventy‐four patients received postoperative immunochemotherapy and 64 patients received no further anticancer therapy following their operation. All patients had been followed for at least 5 years since they underwent surgery. Survival rate and immune status were compared between the 2 groups. Patient characteristics and preoperative values for the immune status of the 2 groups were similar to each other.

The 5‐year survival rate of the postoperative immunochemotherapy group was 44.6%, whereas that of the surgery alone group was 23.4%. The difference is statistically significant (p<0.05). All the postoperative values of immune parameters showed more favorable data in the postoperative immunochemotherapy group.

Postoperative immunochemotherapy is no longer adjuvant, but is an essential systemic therapy to prolong patient survival and cure disease. This author proposes to use the termimmunochemosurgery instead of “surgery and adjuvant immunochemotherapy” for gastric cancer.
Adjuvant chemotherapy in gastric cancer
Authors: Schlag Peter
Published: May 2005

The results of adjuvant chemotherapy trials in gastric cancer are less favorable in European and Anglo‐American countries than in Japan. The majority of findings in Western countries leads to the conclusion that the routine application of adjuvant chemotherapy for gastric cancer cannot be recommended. The therapeutic benefit reported in Japanese studies is possibly due to the fact that chemotherapy is started intraoperatively or during the immediate postoperative period in Japan as opposed to the procedure in the majority of Western countries. The effectiveness of adjuvant chemotherapy may be improved by intraperitoneal drug administration because peritoneal seedings and lymph node metastases are the major cause of treatment failure after curative gastric cancer surgery. Since the efficacy of adjuvant chemotherapy is influenced by the responsiveness of cancer cells to cytotoxic agents, preoperative chemotherapy could improve the selection of patients for subsequent postoperative adjuvant treatment trials in the future.
Rationale and indications for limited surgery in breast cancer: Current data
Authors: Veronesi Umberto
Published: May 2005

A limited number of clinical trials have been performed in the last 20 years to test the validity of techniques for preserving the breast in patients with a mammary carcinoma. From the trials published, a number of conclusions can be formulated: (a) quadrantectomy, axillary dissection, and radiotherapy for small tumors is a procedure as safe as the Halsted mastectomy in terms of local, regional, and distant recurrences, and long‐term survival (Milan trial, Villejuif trial); (b) limited resection plus axillary dissection without radiotherapy exposes the patients to a high risk of local recurrences (NSABP trial); and (c) large resection without axillary dissection and with inadequate radiotherapy will increase the risk of axillary recurrences (Guy's Hospital trial). Whether the increase of local/regional recurrences will decrease the long‐term survival rates (Guy's Hospital) or will not influence the survival (NSABP) must be clarified.

The main problems to be faced by future trials are: the extent of the surgical act (limited excision versus extensive resection, axillary dissection versus no dissection, total axillary dissection versus axillary sampling), the type of radiotherapy (immediate versus delayed, whole breast versus limited direct field, boost versus no boost, regional nodes irradiation versus no nodal irradiation), the comparison with other forms of surgery providing good cosmetic results (conservative treatments versus total mastectomy plus immediate reconstruction), the size of primary tumor to be submitted to conservation procedures, and the pathologic patterns requiring differentiated conservative technique (lobular carcinoma in situ, intraductal noninfiltrating carcinoma, Paget's disease, and minimal carcinoma).
Surgical strategies in locoregional recurrences of gastrointestinal carcinoma
Authors: Herfarth C. , Schlag P. , Hohenberger P.
Published: May 2005

In contrast to the more standardized treatment of primary gastrointestinal cancers, the therapeutic concept in locoregional recurrences requires very individualized approaches. In most patients cure cannot be obtained and those patients who are cured are cured only by combining surgery with adjunctive treatment modalities.

In recurrences of colorectal cancer, tumor biological factors limit surgical efforts. In about 50% of the patients, generalized tumor spread is present at the time of diagnosis of a local relapse. More than 75% of the patients present with symptoms thus calling into question the effect of routine follow‐up examinations. The percentage of patients operated on for cure has only slightly increased during the past 25 years. In our series the rate is 26.4%. These patients benefit most, showing a median survival time of 19 months compared to 13 months in nonradical procedures and 6–8 months in palliative interventions. Nodal status of the primary tumor is very important: 27% of the patients with N0 could be re‐resected compared to only 13% with N1 histological findings.

In gastric cancer, the chance for cure in locoregional recurrences is minimal since the removal of the draining lymph nodes at the primary operation leads to generalized peritoneal carcinomatosis in almost all patients. Only in recurrences in the gastric stump should secondary resection be radical. Less than 10% of patients undergo resection for gastric cancer recurrence. Since even explorative laparotomy yields a high operative mortality, inoperable situations should be identified preoperatively by imaging procedures.

Since encouraging approaches in the treatment of recurrences are lacking, adjuvant pre‐, intra‐, and postoperative chemo‐ and radiotherapy at the time of resection of the primary tumor should be evaluated in controlled trials.
Rationale and indications for perfusion in liver tumors: Current data
Authors: Schwemmte K. , Link K. H. , Rieck B.
Published: May 2005

Since Novermber, 1981, 50 patients (predominantly those with metastases of colorectal carcinomas) have been treated in our clinic by an isolated regional chemotherapy on an average of 9 months after the primary operation. The mortality rate was 8%.

The cytostatic drugs applied alone or in combination were 5‐fluorouracil (5‐FU) (300–1,250 mg) and mitomycin C (5–50 mg) in 46 patients, and 5‐FU, mitomycin C, and cisplatin (50 mg) in 4 patients. The course of the disease was observed in 41 patients. The median survival was 14 months, 24 months in 11 patients still living, and 12.5 months in those patients who died. An additional treatment with cycles of an intraarterial infusion therapy seeemed to extend the survival time (7.5 months without additional treatment, 18 months with additional treatment). Nine (22%) of 41 patients had a complete remission, and 28 (68%), a partial remission. Lung metastases and/or local tumor recurrences arose in 40% of the patients with secondary liver tumors.

We consider the very high cytostatic drug concentrations in the infusion circuit and the additional perfusion of the portal vein to be the advantages of isolated liver perfusion (ILP). Certainly, this therapy can be applied only once, and ILP must be completed by another means of treatment.
The use of ultrasound during spinal cord surgery
Authors: Rubin Jonathan M. , Chandler William F.
Published: May 2005

Intraoperative spinal ultrasonography is now considered an indispensable tool in many operations on the spine and spinal cord. Using ultrasonography, surgeons can now easily find and evaluate lesions within the spinal cord, dural sac, and along the ventral margin of the vertebral column during operations. Syrinxes, intra‐ and extramedullary tumors, hematomas, bone fragments, bullet fragements, cysts, and discs can be easily located and treated under ultrasonic guidance. In this article, we described the techniques used in peforming this procedure, normal anatomy, and images of various types of pathologic lesions.
The use of high‐resolution ultrasound to locate parathyroid tumors during reoperations for primary hyperparathyroidism
Authors: Kern Kenneth A. , Shawker Thomas H. , Doppman John L. , Miller Donald L. , Marx Stephen J. , Spiegel Allen M. , Aurbach Gerald D. , Norton Jeffrey A.
Published: May 2005

In a previous report we compared intraoperative ultrasound (IOUS) to preoperative ultrasound (US) in 25 consecutive patients undergoing reoperations for primary hyperparathyroidism. We demonstrated the superior effectiveness of IOUS to image abnormal parathyroid glands compared to US, and a 50% reduction in operative time resulting from this superior imaging capability. The present study extends these comparisons of preoperative imaging techniques to include computed tomography (CT) and technetium/thallium scintigraphy (Tc/Tl) in an updated series of 39 patients undergoing reoperative parathyroid surgery.

All 39 patients underwent successful reoperations for either parathyroid adenoma (34 patients), parathyroid hyperplasia (4 patients), or parathyroid carcinoma (1 patient). IOUS was more effective than preoperative US, CT scan, or Tc/Tl scintigraphy in imaging 41 abnormal glands in these 39 patients. IOUS was not dependent on size or anatomic location of an abnormal gland for successful imaging. Abnormal glands in unusual locations, such as intrathyroidal adenomas or undescended adenomas, were imaged accurately with IOUS. Multiglandular disease was detected by IOUS, with correct imaging of 3 hyperplastic glands in a single patient; no other imaging technique was able to identify more than 1 abnormal gland in any patient. No imaging study (including IOUS restricted to the neck alone) was able to identify accurately a mediastinal parathyroid adenoma (1 patient).

A clinical decision analysis revealed that IOUS had the highest sensitivity and positive predictive value of any imaging study. IOUS is thus a tool to be used by the surgeon in reoperations for parathyroid disease to facilitate dissection and identification of abnormal glands. When positive, IOUS can help the surgeon proceed quickly and easily to the location of abnormal tissue.
The application of operative ultrasound immediately following carotid endarterectomy
Authors: Lane Rodney J. , Ackroyd Nigel , Appleberg Michael , Graham John
Published: May 2005

One hundred and seventy‐five carotid bifurcations have been scanned using intraoperative ultrasonic imaging. The technique is simple, reproducible, rapid, and reliable. Intimal flaps, clamp stenoses, residual plaques, and platelet accumulations were detected by this method. Most technical defects occurred in the external carotid artery (12%), and it is recommended that significant lesions remaining in this vessel should be removed. Defects in the internal carotid artery and common carotid artery were much less common (7%) and most of these were quite small, not requiring reopening. In fact, only 2% required reopening. In 1% of patients there were defects detected that led to stroke, which would have been removed on present criteria. Although there were other causes of stroke, technical error remains an immediately reversible source of postoperative stroke that can be avoided by the use of operative ultrasonic imaging. Long‐term minor defects, as followed by noninvasive tests, rarely became significant and bore no relationship to the development of restenosis.
The use of two‐dimensional color Doppler sonography during the surgical management of aortic dissection
Authors: Omoto Ryozo , Takamoto Shinichi , Kyo Shunei , Yokote Yuji
Published: May 2005

To examine the clinical significance of two‐dimensional color flow mapping during the surgical management of aortic dissection, we reviewed 18 aortic dissections at Saitama Medical School. In all 18 patients (100%), intraoperative color flow mapping offered total visualization of dissecting aortic aneurysm, confirmation of entry, and flow dynamics in true and false lumina. In 4 patients (22%), the preoperative angiographical diagnoses erred on the extent of the dissection (2 patients) and on the location of entry (2 patients) and were corrected by intraoperative color flow mapping. These color flow results changed the planned operative procedure. The effect of aortic valvuloplasty in the patients with coexisting significant aortic regurgitation was assessed prior to chest closure in 4 patients. Small leakage from the anastomosis line was imaged in 5 patients (28%). Additional sutures were placed in 2 of the patients to stop the leakages. In the other 13 patients (72%), no leakages from the anastomosis line were seen. In some situations when localization of origin of intimal flap is unclear preoperatively, identification of entry by intraoperative color flow mapping is most valuable for precise planning of surgical procedure. The immediate evaluation of repaired valve prior to chest closure may allow the cardiac surgeon to be more aggressive in salvaging native valves. In conclusion, intraoperative color flow mapping can be a valuable new tool to provide information which may significantly improve the surgical management in aortic dissection.
The use of operative ultrasound in surgery of primary liver tumors
Authors: Bismuth Henri , Castaing Denis , Garden O. James
Published: May 2005

Operative ultrasound was evaluated in 77 patients submitted for surgery of primary liver tumors over a 3‐year period. Preoperative ultrasonography, computed tomography, and selective hepatic arteriography were performed in all patients before 79 surgical interventions. Peroperative ultrasonography provided additional information to that obtained from preoperative investigations in 26 cases (33%). This information modified the intended surgical procedure in 21 cases and, in 10 patients, subsegmental resection was facilitated by ultrasonically guided cannulation of the portal venous branch.

Operative ultrasonography provides more detailed information about liver tumors and their topography than can be obtained by intensive preoperative investigations. This information may avoid unnecessary trial dissection of apparently operable tumors and enables more precise and limited resection of those lesions shown to be resectable by operative ultrasonography.
The use of operative ultrasound as an aid to liver resection in patients with hepatocellular carcinoma
Authors: Makuuchi Masatoshi , Hasegawa Hiroshi , Yamazaki Susumu , Takayasu Kenichi , Moriyama Noriyuki
Published: May 2005

In October, 1979, a new operative probe for liver surgery was developed. Since then, 386 patients who received laparotomy for hepatectomy underwent intraoperative ultrasonography. Of these, 245 patients had hepatocellular carcinoma (HCC), and 152 patients had tumors less than 5 cm in diameter. In these 152 patients, intraoperative sonography detected 198 of a total of 203 small HCC's (sensitivity: 99%), whereas the sensitivity of preoperative ultrasound, angiography, and computed tomography was 89.3%, 84.1%, and 89.6%, respectively. Intraoperative ultrasound had a much higher sensitivity in detecting daughter nodes as well as intraheptic metastasis, but slightly lower specificity in differentiating malignant nodules from benign lesions. Intraoperative sonography revealed 70% of tumor thrombi, while ultrasound and angiography disclosed only 21%. In patients with small HCC associated with liver cirrhosis, 65% had invisible and nonpalpable tumors.

Intraoperative ultrasonography led to the development of new liver‐sparing hepatectomy procedures: systematic subsegmentectomy and hepatectomies which preserve the inferior right hepatic vein. Systematic subsegmentectomy was performed on 96 patients. Survival rates after this procedure in 58 patients with small HCC were 53.6±17.7% at 3 years and 47.9±19.1% at 5 years, which was much better than that of patients who received partial hepatectomy.

Intraoperative ultrasonography was indispensable in liver surgery, not only for diagnosis of the tumor spread in the liver, but also as a direct guide for hepatectomy.
The systematic use of operative ultrasound for detection of liver metastases during colorectal surgery
Authors: Boldrini Giuseppe , de Gaetano Anna Maria , Giovannini Ivo , Castagneto Marco , Colagrande Corrado , Castiglioni Giancarlo
Published: May 2005

Intraoperative ultrasonography of the liver was routinely performed during 86 elective surgical procedures for the treatment of primary colorectal malignancies, in search of intrahepatic metastatic deposits. Results were compared to preoperative diagnostic procedures and to direct evaluation of the liver at laparotomy. Different diagnostic modalities showed a definite scatter in the number of reported space‐occupying hepatic lesions.

Solitary liver metastases were visualized in 6 patients by preoperative hepatic ultrasonography and in 5 patients by abdominal computed tomographic (CT) scan and by the operating surgeon at laparotomy; intraoperative ultrasonography disclosed solitary lesions in 8 patients. Multiple metastases were visualized in 10 patients by preoperative ultrasonography, in 11 by CT scan, and in 13 at laparotomy; intraoperative ultrasonography disclosed multiple lesions in 13 patients. Furthermore, operative hepatic sonography allowed the detection of an increased number of non‐neoplastic intraparenchymal lesions, promptly recognizing their solid or liquid nature.

As a result of the systematic use of operative sonography for liver scanning during colorectal surgery, previously undetected neoplastic nodules as well as lesions escaping even the most accurate direct examination at surgery, were easily visualized.
The use of intraoperative sonography in endocrine tumors of the pancreas
Authors: Klotter H. J. , Rückert K. , Kümmerle F. , Rothmund M.
Published: May 2005

Intraoperative ultrasound (IOUS) was performed in 21 patients with 22 endocrine tumors of the pancreas. Seventeen patients suffered from an organic hyperinsulinism, 4 had Zollinger‐EUison syndrome. One patient with an insulinoma had a pancreatic‐polypeptide‐producing adenoma (PPoma) as a second tumor. Fifteen of the insulinomas investigated by IOUS were visible and palpable. In 2 patients no tumor was found during initial operation. At reoperation 1 tumor was detected by IOUS only, the reoperation in the other patient is planned. The PPoma was an incidental finding during IOUS.

In 4 patients with Zollinger‐Ellison Syndrome, 1 gastrinoma was localized in the pancreas and 2 in the duodenal wall by palpation. In 1 patient we found no gastrinoma by either surgical exploration or by IOUS. In 1 of the positive cases the tumor was demonstrable by IOUS. In the other patient it was too small for imaging. Two of these patients had liver metastases, which could be demonstrated by IOUS only. We conclude that IOUS should be performed routinely in operations for pancreatic APUDomas.
The ultrasonic detection of insulinomas during surgical exploration of the pancreas
Authors: Angelini Licinio , Bezzi Mario , Tucci Gianfranco , Lirici Marco M. , Candiani Francesco , Rubaltelli Leopoldo , Tremolada Carlo , Tamburrano Guido , Fegiz Gianfranco
Published: May 2005

The sensitivity of preoperative imaging was evaluated for the localization of insulinomas in 2 series of 54 and 17 patients, respectively. In the first series, diagnosis was obtained with ultrasonography (US) in 14.8%, with computed tomographic (CT) scan in 60%, and with arteriography and/or angio CT scan in 75% of patients. In the second series, US, CT scan, and arteriography were performed preoperatively showing a sensitivity of 53% of one or more of the imaging techniques. The last 17 patients all underwent intraoperative pancreatosonography, and the insulinoma was localized in each.

Considering the high reliability of intraoperative ultrasonography, and the high costs and low benefits of other current diagnostic techniques, a new management plan is suggested for patients with a definite laboratory diagnosis of insulinoma.
The use of high‐resolution intraoperative ultrasound to localize gastrinomas: An initial report of a prospective study
Authors: Cromack Douglas T. , Norton Jeffrey A. , Sigel Bernard , Shawker Thomas H. , Doppman John L. , Maton Paul N. , Jensen Robert T.
Published: May 2005

We evaluated the use of high‐resolution, real‐time, B‐mode, intraoperative ultrasound (IOUS) compared to simple manual palpation to localize gastrinomas during laparotomies in 10 consecutive patients with Zollinger‐Ellison syndrome (ZES). All patients had clear biochemical evidence of ZES, and patients with metastatic gastrinoma identified preoperatively were excluded. Preoperative localization studies including ultrasound, computed tomography, and selective arteriography localized gastrinoma in 3 patients. Transhepatic portal venous sampling (PVS) for gastrin localized gastrin gradients to the pancreatic head region in 8 patients, and found no significant gastrin gradient in 2 patients. Gastrinomas were found at laparotomy and proven pathologically in 6 patients. Four patients had gastrinomas in the pancreatic head area as predicted by PVS; however, one patient had a tumor in the pancreatic tail and another in the jejunal wall. Palpation was the most sensitive intraoperative method to localize a gastrinoma (100% sensitivity). IOUS correctly imaged 3 gastrinomas (50% sensitivity). Palpation had 1 false‐positive finding (80% specificity) and IOUS had 2 false‐positive findings (60% specificity). All palpable masses that were also sonolucent on IOUS proved to be gastrinomas (3 patients). Thus, a combined positive finding raised the specificity and positive predictive value to 100%. We conclude that IOUS has utility in explorations for gastrinomas. Although not as sensitive or specific as palpation, IOUS can confirm, noninvasively, a suspicious palpable nodule. If IOUS fails to image a palpable nodule, our results suggest that the surgeon should still attempt to resect the nodule.
The use of operative sonography in carcinoma of the pancreas
Authors: Plainfosse M. C. , Bouillot J. L. , Rivaton F. , Vaucamps P. , Hernigou A. , Alexandre J. H.
Published: May 2005

We studied 22 patients who underwent surgery for suspected pancreatic carcinoma. One individual was found to have a normal pancreas and one mass was finally diagnosed as chronic pancreatitis. Accurate diagnoses were made preoperatively in 63% of our patients. All masses were palpated intraoperatively. Operative ultrasonography confirmed these findings and the absence of a mass in the patient with a normal pancreas. Operative sonography (OS) revealed 2 previously undetected lesions and permitted 2 biopsies of lesions under its guidance. It was helpful in diagnosing 18% of lesions. In evaluating the spread of pancreatic carcinoma, OS was very helpful in 32% of our patients and moderately helpful in 18%. OS thus helped to direct surgical management in 50% of our patients, by providing information that limited dissection in patients with unresectable spread or permitted resection to proceed in the absence of evidence of unresectability.
The use of ultrasound during surgery for complications of pancreatitis
Authors: Sigel Bernard , Machi Junji , Kikuchi Toshiyuki , Anderson Kenneth W. , Horrow Mindy , Zaren Howard A.
Published: May 2005

Ultrasound imaging is a useful diagnostic procedure during operations for complications of pancreatitis. The most common of such procedures are for drainage of pancreatic pseudocysts, abscesses, and obstructed pancreatic ducts. Operative ultrasound proved to be helpful in 71.7% of these operations. In addition to diagnosing and better defining abnormalities for drainage, operative ultrasound is able to detect previously unsuspected associated pathological conditions such as a second pseudoeyst. Knowledge of such associated lesions may permit their management at the primary operation.
The detection of gastric and esophageal tumor extension by high‐resolution ultrasound during surgery
Authors: Machi Junji , Takeda Jinryo , Kakegawa Teruo , Yamana Hideaki , Fujita Hiromasa , Kurohiji Toshihiko , Yamashita Yuichi
Published: May 2005

High‐resolution ultrasound with 7.5‐MHz instruments was employed to detect tumor extension during 30 gastric and 25 esophageal cancer operations. With 5 echo layers, which corresponded to histologie structures of the stomach wall, operative ultrasound diagnosed intramural tumor spread more accurately than operative palpation. Thirteen of 14 early gastric cancers including 8 nonpalpable cancers were precisely localized by operative ultrasonography. In addition, lateral extension of tumor along the stomach wall was correctly diagnosed by operative ultrasound in 26 of 30 cancers, while palpation was correct in 14 of 30 cancers. For esophageal cancer, extramural local invasion, particularly to vessels, was accurately detected by operative ultrasound. Three of 25 esophageal cancers had histological invasion of the aorta. Preoperative imaging methods showed 1 false‐negative and 2 false‐positive results in determining the aortic invasion. Operative ultrasound had no false results. Lymph nodes that were unrecognized at preoperative studies, nodes that were nonpalpable prior to tissue dissection, and nodes as small as 3 mm in size could be depicted by ultrasonography during gastroesophageal operations. The present results indicate that high‐resolution operative ultrasound may be a valuable technique for the detection of gastric and esophageal cancer extension during surgery.
Adenosine: A new antihypertensive agent during pheochromocytoma removal
Authors: Gröndal Staffan , Bindslev Lars , Sollevi Alf , Hamberger Bertil
Published: May 2005

Severe hypertension and cardiac arrhythmias are well known problems during surgical removal of pheochromocytoma. This is due to extremely high circulating catecholamines during tumor manipulation. In this study, peroperative blood pressure control was obtained by the infusion of adenosine, which antagonized cardiovascular effects of catecholamines. During operation of 10 patients, none had systolic blood pressure exceeding 200 mm Hg or any cardiac arrhythmias despite extremely high plasma catecholamine levels. A mean blood pressure of 120–150 mm Hg was maintained in all patients. Peroperative use of adenosine seems to be a most effective compound for hemodynamic control during pheochromocytoma surgery.
The effect of subtotal thyroidectomy on Graves' ophthalmopathy
Authors: Levitt Michael D. , Edis Anthony J. , Agnello Ross , McCormick Clement C.
Published: May 2005

Nineteen unselected patients undergoing subtotal thyroidectomy (STT) for Graves' disease were submitted to thorough ophthalmologic assessment before and after (mean, 10 mo) thyroid surgery. All clinical examinations were performed by the same observer and findings were scored according to the American Thyroid Association (“NOSPECS”) classification. Orbital computed tomography (CT) scans were performed in all patients prior to surgery and again at follow‐up if the initial scan was abnormal or if there was evidence of clinical deterioration; all CT scans were viewed by the same individual. There was evidence of infiltrative ophthalmopathy at some stage in the course of observation in 17 (89%) of the 19 patients.

No predictable ocular response to STT was apparent. Ophthalmic status was noted to improve in 6 patients, to remain unchanged in 7 patients, and to progressively deteriorate in 6 patients. This unpredictable pattern was seen irrespective of the severity of preexisting ocular involvement. The absence of any consistent or predictable ocular response to STT strongly suggests that thyroidectomy does not influence the natural course of Graves' ophthalmopathy. We believe that the presence of evolving or stable ophthalmopathy, even if severe, should not be regarded as a contraindication to STT in Graves' disease.
Changing concepts of islet cell dysplasia in neonatal and infantile hyperinsulinism
Authors: Thomas C. G. , Cuenca R. E. , Azizkhan R. G. , Underwood L. E. , Carney C. N.
Published: May 2005

Neonatal and infantile hypoglycemia due to insulin excess has been associated with a spectrum of anatomic changes, i.e., nesidioblastosis, endocrine cell dysplasia, islet cell hyperplasia, and adenomatosis. The mechanism of hyperinsulinemia in these patients has been attributed to: (a) an increase in islet cell mass, (b) abnormal islet cell architecture with alternation in paracrine function, (c) imbalance of alpha, beta, and delta cell secretion, and (d) a regulatory defect of insulin secretion. Morphometric, immunocytochemical, and electron microscopy studies have not substantiated an increase in endocrine cell mass in many patients. Nesidioblastosis is believed to be a normal phase of fetal development of the pancreas rather than a pathologic entity. A regulatory defect in insulin storage and release is the best explanation of hyperinsulinism in these patients.

We report experience with 165 neonates and infants including 6 of our own collected during the last decade. Subtotal pancreatectomy (79–90%) was carried out as the initial operative procedure in 76% of patients. Twenty‐eight percent required a second operation of near‐total to total pancreatectomy. Eleven percent required a third procedure. A near‐total pancreatectomy (95–98%) was performed as the initial operation in 24% of the patients. Five percent of these patients required a second operation.

There is a clear advantage of performing an extensive pancreatectomy (95–98%) at the initial operative procedure. In the 40 patients so treated, the incidence of mental retardation was 12.5% and seizures, 2.5%. Ten percent required diazoxide for further management, and 7.5% required insulin on a long‐term basis. Mortality was 2.5%. In our report, covering experience from 1934 to 1971, the mortality was 8.3% and mental retardation, 52%.
Epidermal growth factor receptor on human thyroid neoplasms
Authors: Masuda Hiroyuki , Sugenoya Akira , Kobayashi Shinya , Kasuga Yoshio , Iida Futoshi
Published: May 2005

Morphological observation of epidermal growth factor receptor (EGF‐R) was attempted for human thyroid neoplasms, and the results were evaluated compared with the various histological types.

Thirty‐four malignant tumors, 24 benign tumors, 7 adenomatous goiters, and 7 normal thyroid tissues obtained at surgery were subjected to this study. They were fixed in 10% formalin solution, embedded in paraffin. After sectioning at 4μm, immunohistochemical staining by avidin‐biotin‐peroxidase complex technique was performed employing anti‐human EGF‐R monoclonal antibody.

Both normal thyroid tissues and benign adenomas showed no apparent immunoreactive staining. The majority of the malignant tumors, however, demonstrated dark brown reaction products indicating location of EGF‐R on the cell surface, cytoplasm, and nuclear envelope. Medullary and anaplastic carcinomas were stained more intensively than papillary and follicular carcinomas. In adenomatous goiter, the immunoreactive products were occasionally observed on the follicular cells of some limited areas, whereas its staining pattern was different from the malignant neoplasms.

The correlative study between UICC classification of thyroid tumors and EGF‐R staining in the papillary carcinoma revealed a higher frequency of positive staining in cases of multifocal metastasis.
Deaths due to differentiated thyroid cancer: A 46‐year perspective
Authors: Harness Jay K. , McLeod Michael K. , Thompson Norman W. , Noble Walter C. , Burney Richard E.
Published: May 2005

From 1940 to 1986, a total of 798 patients were treated for differentiated thyroid carcinoma. One hundred and seventy‐two patients died during the follow‐up period: 42 (24.4%) patients from thyroid cancer, 14 (8.1%) from other causes with extensive thyroid cancer present, 75 (43.6%) with no thyroid cancer, and 41 (23.8%) with an unknown status of thyroid cancer.

Of the 42 patients dying due to thyroid cancer, 15 were male and 27, female. Mean age at diagnosis was 48.3±17.7 years with one‐third of patients age 45 or younger at the time of the initial diagnosis. The primary tumors were large (>4 cm) and 59.5% of the patients had local invasion and/or cervical metastasis. Distant metastases were present in 9 (21.4%) patients at the time of diagnosis.

Surgical therapy included total thyroidectomy (72.1%) and limited or radical neck dissection (69.4%). Radioactive iodine (131I) was used to treat residual cancer and/or distant metastasis in 73.8% of the patients. External radiation therapy was used to treat locally advanced or recurrent disease in 52.3% of the patients.

Distant metastases and local recurrence were identified earlier in patients with follicular thyroid cancer whose survival time and disease‐free interval were significantly shorter (p<0.001) than that of patients with papillary neoplasms. However, the survival and disease‐free intervals were often very long in both papillary and follicular thyroid cancer deaths.

Onset of differentiated thyroid cancer before the age of 40 years does not preclude serious sequelae and death. Since no known histopathologic features can consistently predict outcome, we continue to advocate aggressive treatment of all patients with differentiated thyroid cancer.
Ionized calcium in monitoring effective parathyroidectomy: A preliminary report
Authors: Rosen Irving B. , Pollard Alan
Published: May 2005

This study set out to determine the validity of a laboratory technique that might provide the surgeon with an indication of effective parathyroidectomy before the patient leaves the operating room. Seventeen patients with a firm diagnosis of primary hyperparathyroidism established by conventional criteria (11 adenoma and 6 hyperplasia) came to operative treatment. During operation, interval blood sampling was carried out for duplicate determination of ionized calcium using the Radiometer ICA 1 Analyzer, which also measures pH and corrects ionized calcium to a pH of 7.4. Samples, usually 6 in number or more, were collected about every 20 minutes throughout operation. The times of parathyroid sampling or excision were noted and correlated with ionized calcium levels.

Twelve of the 17 patients showed a marked decline in ionized calcium levels 40–120 minutes following presumptive effective parathyroidectomy. If measured on site, these results would have been available before the patient's departure from the operating room. All these patients achieved eucalcemia. In 5 patients, there was no significant decline in ionized calcium. Four of these patients became eucalcemic, the fifth patient showed a marked decrease in total serum calcium, but not to normal levels. Three control patients showed no evidence of alteration in ionized calcium.

This study should be construed as preliminary, but does provide a basis for continued investigation. While it is apparent that a lack of decline of intraoperative ionized calcium does not exclude cure, the occurrence of such a decline provides strong evidence of curative parathyroidectomy. This technique, if confirmed by further work, permits a rapid, reliable, simple measure which would be available to most hospitals.
Pancreatic endocrine functions in long‐term survivors after pancreatoduodenectomy: Special reference to reversibility of insulin and glucagon secretion
Authors: Miyata Masahiko , Yamamoto Takayoshi , Hamaji Masayasu , Izukura Masaaki , Nakamura Masahiro , Taketani Hiroshi , Nakao Kazuyasu , Kawashima Yasunaru
Published: May 2005

The number of long‐term survivors of pancreatectomy for cancer is increasing. This study was conducted in patients with periampullary cancer to elucidate the serial change in the pancreatic endocrine functions before and after resection of the head of the pancreas. The pancreatic A and B cell functions were determined by the responses of plasma glucagon and insulin to arginine infusion. For serial comparison, the maximum response and integrated increment of plasma glucagon and insulin were calculated in each patient. There were no significant differences in these parameters between the patients (n=36) before the operation and normal controls (n=18). Early after pancreatoduodenectomy (mean, 6.4 weeks), each parameter was significantly less than its corresponding preoperative value and also less than the value in the normal controls. In the long‐term survivors (mean, 20.1 months after the surgery; n=12) among these 36 patients, these parameters showed no significant changes compared with the early postoperative values and were still significantly less than both the preoperative values and the normal control values. We, thus, conclude that pancreatic A and B cell functions are preserved long‐term after pancreatoduodenectomy in patients with periampullary cancer.
Emergency department thoracotomy following injury: Critical determinants for patient salvage
Authors: Timothy Baxter B. , Moore Ernest E. , Moore John B. , Cleveland Henry C. , McCroskey Brian L. , Moore Frederick A.
Published: May 2005

The role of emergency department (ED) thoracotomy in resuscitation of the moribund trauma patient remains ill‐defined. The purpose of this article is to analyze our experience during the past decade in order to elucidate prognostic features enabling a more cost‐effective application of this heroic measure.

Injury mechanism in the 632 ED thoracotomies performed in our trauma consortium consisted of blunt (BLT) in 50%, gunshot wounds (GSW) in 35%, and stab wounds (SW) in 15%. Mean patient age was 31 years, and 76% were men. Twenty‐nine (5%) of the patients were ultimately discharged alive from the hospital. Outcome was analyzed on the basis of physiologic status at presentation to the ED: group I, n=481 (76%), presented without signs of life (SL); group II, n=38 (6%), presented with SL (pupillary response), but without vital signs (VS); and group III, n=113 (18%), presented with VS. Survival without SL was 10% of SW, 1% of GSW, and 1% of BLT. When VS were present, patient salvage was 32% following SW, 15% following GSW, and 5% after blunt trauma. Five of 15 survivors without SL had irreversible cerebral damage; whereas, 13 of the 14 survivors with VS had no permanent neurologic sequelae.

This experience underscores the rationale for selective application of ED thoracotomy done for postinjury resuscitation; functional salvage of the blunt trauma victim arriving lifeless is nil while nearly one‐third of patients in extremis from a thoracic SW can be returned to their preinjury state.
Preoperative imaging versus intraoperative localization of tumors in adult surgical patients with hyperinsulinemia: A multicenter study of 338 patients
Authors: Proye C. , Boissel P.
Published: May 2005

Three hundred thirty‐eight patients with organic hypoglycemia were referred to French‐speaking surgeons during an 18‐year period (1965–1983). Two hundred sixty‐eight (79%) of these patients proved to have benign tumors (12 multiple), 37 (11%) had carcinoma, and 11 (3%) had “hyperplasia.” Of the remaining 22 patients, 9 (2%) were not operated, 12 (4%) underwent negative pancreatic explorations, and 1 (0.3%) was misdiagnosed.

The use of preoperative localization studies (computed tomographic scan, arteriography, ultrasound, and transhepatic portal sampling) were successful in 195 (62%) of 315 patients.

Intraoperative diagnostic studies (blood sugar and insulin assays) in peripheral and portal blood, and intraoperative ultrasound were positive in 86% (265/305) of patients.
Percutaneous transhepatic gallstone removal by nephroscopic technique in a case of cholelithogenous liver abscess
Authors: Janetschek Günther , Aufschnaiter Martin , Bodner Ernst
Published: May 2005

In a patient with intrahepatic bile duct obstruction in the right lobe due to a retained stone, we succeeded in removing the calculus with a nephroscope through a percutaneous transhepatic puncture after a failed surgical attempt to extract the stone.
Multiple neuroectodermal abnormalities in pheochromocytoma patients
Authors: Jansson Svante , Tisell Lars ‐Erik , Hansson Göran , Stenström Gunnar
Published: May 2005

A series of 80 consecutive pheochromocytoma patients operated on from 1956 to 1985 were investigated for other neuroectodermal abnormalities. Such abnormalities were found in 23 (29%) patients. Medullary thyroid carcinoma was the most common associated neuroectodermal abnormality followed by von Recklinghausen's neurofibromatosis. Other abnormalities were intracranial tumors, midgut carcinoid, and parathyroid hyperplasia. All 6 patients with multiple pheochromocytomas had other neuroectodermal abnormalities. In the total series, the 14 patients with hereditary disease had multiple neuroectodermal abnormalities (MNA). Hypertension occurred significantly less often in MNA patients (p<0.05). All the MNA patients had benign adrenal pheochromocytoma. In 7 of 9 normotensive patients, pheochromocytoma was suspected because of the presence of other neuroectodermal abnormalities. None of these 9 patients had any cardio‐ or cerebrovascular complications, but these occurred in 22% of the hypertensive patients. No patient in the series died from pheochromocytoma, but 4 of 5 deceased MNA patients died as a result of their associated neuroectodermal disease. During the last decade, 40% of the pheochromocytoma patients had MNA diagnosed compared to 20% during the previous period. An increased observation for other neuroectodermal abnormalities in pheochromocytoma patients and for pheochromocytoma in patients with neuroectodermal abnormalities should lead to earlier diagnosis and a better prognosis for the patients concerned.