Showing papers in "World Journal of Surgery in 1996"

Role of the Gut in Multiple Organ Failure: Bacterial Translocation and Permeability Changes

Abstract: It is clear that increased gut permeability and bacterial translocation play a role in multiple organ failure (MOF). Failure of the gut barrier remains central to the hypothesis that toxins escaping from the gut lumen contribute to activation of the host's immune inflammatory defense mechanisms, subsequently leading to the autointoxication and tissue destruction seen in the septic response characteristic of MOF. However, the role of the gut is more than that of a sieve, which simply allows passage of bacteria and endotoxin from the gut lumen to the portal or systemic circulation. It appears, in addition, that the translocation of bacteria and endotoxin may lead to local activation of the immune inflammatory system and the local production of cytokines and other immune inflammatory mediators. These intestinally derived mediators may then exacerbate the systemic inflammatory response and potentially lead to a further increase in gut permeability. A vicious cycle of increased intestinal permeability, leading to toxic mediator release, resulting in a further increase in gut permeability is generated. Additionally, the systemic and local inflammatory cells that become activated in the gut contribute to the systemic response characteristic of the sepsis syndrome and MOF. Thus even if the immune inflammatory system, rather than the gut, is the "motor of" MOF, the gut remains one of the major pistons that turns the motor.

Ingested Foreign Bodies of the Gastrointestinal Tract: Retrospective Analysis of 542 Cases

Abstract: n = 379) were jail inmates at the time of ingestion, 22.9% ( n = 124) had a history of psychosis, and 7.2% ( n = 39) were alcoholics or denture-wearing elderly subjects. Most foreign bodies passed spontaneously (75.6%; n = 410). Endoscopic removal was possible in 19.5% ( n = 106) and was not associated with any morbidity. Only 4.8% ( n = 26) required surgery. Of the latter, 30.8% ( n = 8) had long gastric FBs with no tendency for distal passage and were removed via gastrotomy; 15.4% ( n = 4) had thin, sharp FBs, causing perforation; and 53.8% ( n = 14) had FBs impacted in the ileocecal region, which were removed via appendicostomy. Conservative approach to FB ingestion is justified, although early endoscopic removal from the stomach is recommended. In cases of failure, surgical removal for gastric FBs longer than 7.0 cm is wise. Thin, sharp FBs require a high index of suspicion because they carry a higher risk for perforation. The ileocecal region is the most common site of impaction. Removal of the FB via appendicostomy is the safest option and should not be delayed more than 48 hours.

Gastric carcinoids and neuroendocrine carcinomas: pathogenesis, pathology, and behavior.

Abstract: The goal of this study was to provide information of prognostic value for gastric endocrine tumors. A total of 205 gastric endocrine tumors have been studied: 193 well differentiated tumors [2 gastrin cell tumors, 191 enterochromaffin-like (ECL) cell tumors] and 12 poorly differentiated carcinomas. Subtyping of ECL cell tumors (carcinoids) resulted in 152 associated with chronic atrophic gastritis (CAG) (type 1); 12 associated with hypertrophic gastropathy (HG) due to Zollinger-Ellison syndrome with multiple endocrine neoplasia type I (type 2), and 27 with no specific association (type 3, sporadic). Type 1 cases occurred most often in female (108 of 152), elderly (mean 63 years) patients, with no tumor-related death at an overall mean follow-up of 53 months. The 12 type 2 cases were equally distributed between the sexes (six of each), with a mean age of 45 years; there was one tumor-related death (49 months after diagnosis) and an overall mean survival of 84 months. Type 3 cases were mostly in men (20 of 27), with a mean age of 55 years; there were seven tumor-related deaths at a mean follow-up of 28 months. Poorly differentiated neuroendocrine carcinomas were observed in elderly patients (mean 63 years, range 41-76 years) of both sexes, with nine tumor-related deaths and a mean survival of 7 months. It was concluded that correct clinicopathologic subtyping may predict the clinical behavior of gastric endocrine tumors.

Update on the Mechanisms of Immune Suppression of Injury and Immune Modulation

Abstract: Major trauma results in massive impairment of immunologic reactivity, the clinical consequence of which consists in the high susceptibility of the traumatized individual toward serious infection. Whereas parts of the immune system are stimulated within a systemic, nondiscriminant, excessive whole-body inflammation, other functions within the complex of cell-mediated immunity (CMI) are dramatically paralyzed. Immune abnormalities in the aftermath of trauma occur in a sequence of states of cellular activation and within a complex order of events that is not yet well understood. Traumatic stress is causing disintegration of the intact monocyte (Mphi)-T cell interaction, which is associated with profound changes in Mphi forward-regulatory capacities and substantial depression of T cell function. Extensive tissue destruction results in the generation of numerous stimuli, such as phagocytosis, immune complexes, complement split products, and endo- and exotoxins, all of which contribute to excessive Mphi activation. Mphi then rapidly produce and release prostaglandin E2 (PGE2), a powerful endogenous immune suppressant. PGE2 is an inhibitor of T cell mitogenesis, interleukin 2 (IL-2) production, and IL-2 receptor expression; and it has a massive impact on the quality of B cell antibody synthesis. Most importantly, PGE2 represents an important cofactor for the induction of T-helper lymphocyte (TH) activity toward the TH2 direction. TH2 cells are associated with the synthesis of immunosuppressive cytokines, such as IL-4 and IL-10. Although immunosuppressive substrates are inhibitory for TH1 cells-the functional carriers of CMI-they support TH2 activity, which predisposes the host to develop infection. The endogenous ability of the organism to survive overwhelming trauma is insufficient and requires major exogenous support. Immune modulatory interventions, depending on the immune abnormalities seen in the traumatized host, should be started as early as possible after trauma in a preventive fashion to protect against organ tissue destruction. Ideally, it should protect all cellular host defense compartments from hyperactivation as well as from exhaustion. We do believe that only a combination of drugs can effectively control the posttraumatic dyshomeostasis of the various cell systems.

Gut Ischemia, Oxidative Stress, and Bacterial Translocation in Elevated Abdominal Pressure in Rats

Abstract: The purpose of this experimental study was to investigate whether the increased intraabdominal pressure due to gas insufflation creates intestinal ischemia leading to oxygen free radical production and bacterial translocation. A group of 88 rats were studied, 40 of which were subjected to a 15 mmHg pressure pneumoperitoneum for 60 minutes, with the following parameters being studied: mean arterial pressure after carotid catheterization; intestinal microcirculation by means of the laser-Doppler technique; gut metabolic activity (O2 extraction) by blood sampling from portal vein and carotid artery; intestinal, hepatic, splenic, and lung free radical production (malondialdehyde); and bacterial translocation toward the mesenteric lymph nodes, liver, and spleen at 3 and 18 hours after pneumoperitoneum deflation. The mean arterial pressure exhibited no alterations, whereas the jejunal mucosa microcirculation was significantly decreased (p = 0.0001), as was the gut metabolic activity (p = 0.025). Malondialdehyde was increased in gut mucosa (p = 0.0002), liver (p = 0.02), spleen (p = 0.03), and lung (p = 0.017). Bacterial translocation toward the mesenteric lymph nodes (p = 0.002), spleen (p = 0.002), and liver (p = 0.05) was increased in the 3-hour group; in the 18-hour group bacteria were not found in mesenteric lymph nodes but were in liver (p = 0.008) and spleen (p = 0.035). It is concluded that elevated intraabdominal pressure in the rat leads to intestinal ischemia, oxygen free radical production, and bacterial translocation. These results must be reproduced in humans and their clinical significance clarified.

Laparoscopic versus open appendectomy: prospective randomized trial.

Abstract: A prospective randomized trial comparing laparoscopic appendectomy with open appendectomy in patients with a diagnosis of acute appendicitis was conducted between October 1992 and April 1994. Of the 158 patients randomized, 7 patients were excluded because of protocol violations (conversion to laparotomy in 4, appendix not removed in 3). The 151 patients randomized to either a laparoscopic (n = 79) or an open appendectomy (n = 72) showed no difference in sex, age, American Society of Anesthesiology (ASA) rating, or previous abdominal surgery. The histologic classification of normal, catarrhal, inflamed, suppurative, and gangrenous appendicitis was not different between the two groups. Conversion from laparoscopic to open appendectomy was necessary in seven patients (9%) who had advanced forms of appendiceal inflammation. When compared to open appendectomy the laparoscopic group had a longer median operating time (63 minutes versus 40 minutes), fewer wound infections (2% versus 11%), less requirement for narcotic analgesia, and an earlier return to normal activity (median 7 days versus 14 days). There was no difference in morbidity, and both groups had a median time to discharge of 3 days. Laparoscopic appendectomy is as safe as open appendectomy; and despite the longer operating time, the advantages such as fewer wound infections and earlier return to normal activity make it a worthwhile alternative for patients with a clinical diagnosis of acute appendicitis.

Posterior Retroperitoneoscopy as a New Minimally Invasive Approach for Adrenalectomy: Results of 30 Adrenalectomies in 27 Patients

Abstract: Posterior retroperitoneoscopic adrenalectomy is a new mini- mally invasive method. It represents an alternative to conventional open procedures and laparoscopic techniques. Between July 1994 and Novem- ber 1995 a total of 30 retroperitoneoscopic adrenalectomies were per- formed on 27 patients. In 24 patients, unilateral tumors were seen (size 1-7 cm): seven Cushing adenomas,five Conn adenomas, seven pheochro- mocytomas, four hormonally inactive tumors, one cyst. Three patients suffered from Cushing syndrome with bilateral adrenal gland hyperpla- sias (two inoperable pituitary gland tumors, one bronchial carcinoid with ACTHsecretion).Theoperationswerecarriedoutinproneposition.After balloon dilatation of the retroperitoneum and creation of a pneumoperi- toneum the preparation of the adrenal gland was performed via three trocar sites positioned below the 12th rib. Twenty-five adrenalectomies were completed endoscopically, and five times (among four patients) conversion to the conventional posterior technique was necessary. The average operating time of complete endoscopic adrenalectomies was 124 minutes (45-225 minutes); blood loss was 10 to 120 ml. With minimal need for postoperative analgesia (average dosage 7.9 mg of piritramide), mobilization and adequate food uptake were possible on the day of operation. The posterior retroperitoneoscopic adrenalectomy is a rela- tively fast, safe method, with the advantages of the posterior open approach and minimally invasive surgery. It therefore represents an important addition to adrenal gland surgery.

Improved survival of patients with papillary thyroid cancer after surgical microdissection.

Abstract: A total of 195 patients had surgery for papillary thyroid cancer. The mean age at operation was 50 years. A microdissection technique was used for total thyroidectomy and lymph node clearance. Postoperative radioiodine tests showed no uptake or an uptake close to the background activity in 77% of the examined patients. By counting the lymph nodes removed at surgery we were able to check on the quality of the lymph node dissection. Men had a higher incidence (70%) of lymph node metastases than women (45%). Only 4% of the patients had radioiodine ablation of the thyroid remnant. The median follow-up time was 13 years. None of the patients below 45 years of age at surgery died of thyroid cancer. In the older age group eight patients died of thyroid cancer at a mean age of 75 years. Five of those who died of a thyroid carcinoma had distant metastases at diagnosis. Among patients with resectable disease, three (1.6%) died of thyroid cancer, all of whom had lived for more than 17 years after surgery. Hence longer follow-up is needed before we know the final mortality in our series. The results suggest that surgical technique and strategy can positively influence the survival of patients with papillary thyroid cancer.

Laparoscopic Cholecystectomy for Acute Cholecystitis: Is It Really Safe?

Abstract: p < 0.0001). Significantly more adhesions (20% versus 8%), more blood loss (48% versus 19%), a higher incidence of bile spillage (28% versus 12%), and lost stones (19% versus 8%) were encountered in patients with acute cholecystitis. Common bile duct (CBD) injuries were also more frequent in that group (5.5% versus 0.2%;p = 0.005). The rate of conversion to open surgery was higher than with routine LCs (13% versus 4%). There were two deaths in the routine LC group and none in the acutely inflamed group. There was no difference in postoperative pain intensity or postoperative fatigue according to visual analog scale measurements. Patients with acute cholecystitis stayed only 1 day longer (median 4 days versus 3 days) in hospital. The quality of life scores indicate return to almost normal values by the 14th postoperative day. Long-term follow-up (1–3 years) did not reveal any delayed clinical adverse effects. In summary, LC for inflamed gallbladders has a higher conversion rate than LC for routine symptomatic gallbladders. If successfully performed, it has definite benefit for the patient in terms of better postoperative recovery. The trade-off is that the risk of CBD injury is significantly higher.

Pattern of organ failure following severe trauma.

Abstract: Multiple organ failure (MOF) is considered to be the leading cause of death after severe trauma. Although there is extensive literature on MOF, little is known about the pattern, sequence, and onset of this clinical syndrome. The first goal of this clinical study was to define MOF; the second was to assess the typical onset, sequence, and pattern of MOF; and the third was to define certain risk factors for the development of MOF in 342 multiple trauma patients. Patients with an Injury Severity Score (ISS): > 20 (mean 35.7) were included. Three well established MOF scoring methods were used to give strict definitions of MOF: 11.4% of the total patient population developed MOF, and 88.6% did not. Respiratory failure was most frequent in patients developing MOF (74.4%), and these patients had the highest mortality rate (65.5%) compared to patients with failure of other organ systems (liver, cardiovascular system). Generally, the lung is the first organ to fail after injury (failure after 3.7 +/- 2.8 days). Significant renal failure and the need for dialysis decreased to < 5%; other signs of organ dysfunction (gastric, central nervous system) are difficult to verify. Typical risk factors for the development of MOF after severe trauma are the severity, type, and distribution of injury as well as the indicators of prolonged hemorrhagic shock (elevated lactate levels). The main therapeutic efforts, therefore, should be the effective treatment of traumatic hemorrhagic shock during the initial phase, adequate resuscitation, optimal oxygenation, and early surgical treatment.

Clinical spectrum and outcome of functional extraadrenal paraganglioma.

Abstract: Functioning extraadrenal paragangliomas represent more than 10% of all pheochromocytomas, occur at diverse anatomic locations, and are said to have a higher malignancy rate than intraadrenal pheochromocytomas. Sixty-six patients had surgery for catecholamine-producing paragangliomas between 1952 and 1992. Median follow-up was 8.8 years. Median age was 40 years (11-67 years); the male/female ratio was 29:37. Familial disease occurred in 9 patients (13.6%), and 10 patients (15.2%) also developed adrenal pheochromocytoma. Solitary paragangliomas occurred in 52 patients: 46 abdominal, 4 thoracic, and 2 head and neck. Fifty-three tumors developed in 14 patients with multiple paragangliomas: 38 abdominal and 15 thoracic. Of 28 patients with solitary tumors undergoing localization studies over the past 10 years accurate localization was achieved in 27. There was one operative death; 15 patients had persistent disease; and 50 were cured postoperatively. Of those cured, nine developed recurrence, disease-free survival being 86%, 80%, and 80% at 5, 10, and 20 years. Metastatic disease was found in 14 patients (21%), 7 of whom have died. An additional 10 patients (15%) had locally invasive disease, of whom 4 have died. Cause-specific survivals at 5, 10, and 20 years were 90%, 83%, and 72%. Risk factors for death from pheochromocytoma were tumor size > 5 cm (p = 0.0002), metastatic disease (p = 0.001), and tumor invasion (p = 0.0023). Cause-specific survival for patients with tumors > 5 cm was 59% at 15 years compared to 100% among patients with tumors 5 cm and the occurrence of invasive or metastatic disease are strong predictors of outcome. Most tumors are abdominal, and imaging is highly successful for localization.

Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism.

Abstract: Unilateral neck exploration (UNE) is a controversial approach to the treatment of primary hyperparathyroidism (PHP), and most surgeons favor bilateral neck exploration. The aim of this study was to assess the value of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of urinary cyclic AMP (UcAMP) or 1-84 PTH in 200 patients undergoing unilateral neck exploration under local anesthesia. Conditions for UNE were (1) a presumed solitary adenoma detected by ultrasonography, (2) no thyroid disease, and (3) no family history of PHP or multiple endocrine neoplasia. Patient's consent was obtained for conversion to bilateral exploration according to surgical and biologic findings. Sensitivity of ultrasonography was 92.5%. Sestamibi scintigraphy, performed in 70 patients, was less sensitive than ultrasonography (80%). Persistent PHP was accurately detected by intraoperative measurement of UcAMP or 1-84 PTH in all cases. At follow-up, 96.0% of the patients were cured either after unilateral neck exploration only (90.5%), or after conversion into bilateral exploration. Ultrasonography and intraoperative measurement of 1-84 PTH allow unilateral neck exploration with excellent results in a selected group of patients with PHP.

Laparoscopic Approach to Pheochromocytoma: Hemodynamic Changes and Catecholamine Secretion

Abstract: This study compares the outcome of laparoscopic adrenalectomy (LpA) in 23 patients using CO2 insufflation with the outcome of this procedure in another 8 patients with pheochromocytoma (7 unilateral, 1 bilateral) using helium for pneumoperitoneum. The adrenal lesions in the first group included nonfunctional adenoma (n = 3), aldosterone adenoma (n = 11), Cushing's adenoma (n = 6), and Cushing's disease (n = 3). The latter patients were compared with a third group of 8 patients with pheochromocytoma undergoing conventional transabdominal adrenalectomy (CTA). With both procedures, intraoperative changes in plasma catecholamine levels were studied during pheochromocytoma removal and the changes correlated with intraoperative cardiovascular derangements. LpA was successfully performed in 95% of patients with adrenal lesions and in 100% of patients with pheochromocytoma. There was no significant difference in laparoscopic adrenalectomy for pheochromocytoma compared to that for other adrenal lesions in terms of operative time, blood loss, hospital stay, analgesic requirements, and return to normal activity. The outcome was less favorable in pheochromocytoma patients undergoing CTA. The largest increase of catecholamine levels in pheochromocytoma patients occurred during tumor manipulation with both LpA (17.4-fold for epinephrine and 8.6-fold for norepinephrine) and CTA (34.2-fold for epinephrine and 13.7-fold for norepinephrine), but cardiovascular instability was associated only with CTA. LpA may become the technique of choice for surgical removal of adrenal lesions and may also become the preferred method for removing pheochromocytoma.

Clonal analysis of nodular parathyroid hyperplasia in renal hyperparathyroidism

Abstract: Although it is well known that chronic renal failure induces parathyroid hyperplasia, the pathogenesis and development of this parathyroid lesion in this disease are poorly understood. Histopathologically, there is progression from diffuse to nodular hyperplasia, and each nodule consists of a single cell type with aggressive proliferative potential. Pathophysiologic and clinical investigations have suggested that neoplastic tumors may emerge from nodular hyperplasia. In this study the clonality of parathyroid tissue in nodular and diffuse hyperplasia in renal hyperparathyroidism was analyzed by a method based on restriction fragment length polymorphism of the X chromosome-linked phosphoglycerokinase gene and on random inactivation of the gene by methylation. DNA of peripheral lymphocytes was screened in 43 women undergoing parathyroidectomy for advanced renal hyperparathyroidism, and 10 of these patients appeared to be heterozygous. Fourteen specimens from these patients were available for clonal analysis. The analysis showed that all four specimens of diffuse hyperplasia were polyclonal, whereas all seven specimens from nodules in nodular hyperplasia and all three samples representing parathyroid tissue removed from forearm because of graft-dependent recurrence were revealed to be monoclonal. It is likely that the clonal origin of each nodule is independent. These results suggest that in renal hyperparathyroidism parathyroid glands initially grow diffusely and polyclonally, and then the cells in the nodules are later transformed monoclonally and proliferate aggressively. From the present study it can be concluded that nodular hyperplasia represents monoclonal parathyroid neoplasia, which might explain why patients with nodular hyperplasia in renal hyperparathyroidism are refractory to medical treatment, requiring parathyroidectomy. To prevent recurrences, nodular hyperplastic tissue should not be left at surgery.

Metastatic Endocrine Tumors: Medical Treatment, Surgical Resection, or Liver Transplantation

Abstract: We reviewed our experience with 34 patients with metastatic endocrine tumors (METs) who were treated by different modalities. Eight patients were treated by chemotherapy or chemoembolization because of stable disease or surgical contraindications. Seventeen patients underwent curative or cytoreductive surgical resection. Nine patients received grafts based on the following criteria: no extrahepatic spread on imaging workup and nonresectable symptomatic metastatic disease. Of the eight medically treated patients, the five patients with initial stable clinical condition are alive 32 to 56 months after referral. Of the 17 patients treated by liver resection, 13 are alive 6 to 108 months after surgery, and 7 are disease-free. After curative resection, the 5-year actuarial survival and disease-free survival rates were 62% and 52%, respectively. Of the nine grafted patients, three patients grafted for carcinoid tumor are alive at 15, 24, and 62 months, one of whom has a late recurrence. Our results indicate that therapeutic indications for METs should be based on age, clinical symptoms, histologic type, and tumor extension: Patients with stable MET may benefit from surgical restraint; liver resection in patients with aggressive MET may provide good long-term palliation and possibly cure one-third of the patients; liver transplantation should be restricted to young patients with nonresectable carcinoid MET but remains a high-risk operation because of previous surgery and chemoembolization.

Incidence of Regional Recurrence Guiding Radicality in Differentiated Thyroid Carcinoma

Abstract: p < 0.0001). Similar results could be achieved for follicular thyroid cancer, showing statistical significance with regard to operative procedure ( p < 0.009). Our experience demonstrates a positive correlation of regional tumor recurrence with increasing tumor stage for both histologic tumor types. The high rate of regional recurrence justifies a more radical approach, including neck dissection at the initial operation. The impact on survival, however, must be proved by further evaluation.

Anterior Approach for Difficult Major Right Hepatectomy

Abstract: In selected patients with huge right hepatic tumors that had infiltrated the surrounding structures, injudicious mobilization of the liver before transection, as in the conventional manner, may result in excessive bleeding, prolonged ischemia from rotation of the hepatoduodenal ligament, and spillage of cancer cells into the systemic circulation. Alternatively, the "anterior" approach, which involves initial completion of the parenchymal transection before the right hepatic lobe is mobilized, can be adopted for these patients with difficult right hepatic tumors. After hilar control of the inflow vessels, liver parenchyma was transected using an ultrasonic dissector until the anterior surface of the inferior vena cava is exposed. The right hepatic lobe is then mobilized laterally by securing all venous tributaries, including the right hepatic vein. The prospective data of 25 patients who had major right hepatectomy using the "anterior" approach were compared with data from 34 patients who had their operation performed in the conventional manner. Despite the facts that larger tumors (p < 0.004), more extrahepatic structures (p < 0.05), and the caudate lobes (p < 0.03) were resected, the amount of perioperative blood transfusion, fluid replacement, and outcome between the two groups of patients were comparable. There were three hospital deaths, among which one could be attributed to an intraoperative catastrophe during hepatectomy using the conventional approach. The "anterior" approach is a safe, effective option for selected patients undergoing complicated major right hepatectomy.

Early Risk Factors for Postinjury Multiple Organ Failure

Abstract: Epidemiologic studies, based on retrospective data from heterogeneous populations with poor control of confounders, led early investigators to conclude that infection was the overriding risk factor for multiple organ failure (MOF). More recent studies have convincingly shown that MOF frequently occurs in the absence of infection. Consequently, we have shifted our research focus away from the traditional infectious models of MOF to the newer "one-hit" and "two-hit" inflammatory models. Clinically, we have chosen to study trauma patients because they are a relatively homogeneous group with a low incidence of common confounders. Trauma also permits a clear distinction between the first insult and the outcome, both temporally and with respect to the definition criteria. In this review we discuss the background, rationale, and our initial attempts to use indicators of the first insult (i.e., tissue injury quantification and clinical signs of shock) and indicators of the host response (i.e., systemic inflammatory response syndrome) to predict MOF early after injury.

Importance of the Duodenal Passage and Pouch Volume after Total Gastrectomy and Reconstruction with the Ulm Pouch: Prospective Randomized Clinical Study

Abstract: p < 0.01), higher body weight, and better physiologic regulation of gastrointestinal hormones; moreover, they developed (in contrast to all other reconstruction types) no pathologic glucose tolerance. Our conclusion is that all patients with a postoperative life expectancy of at least 6 months (i.e., tumor stages UICC I and II) should undergo pouch reconstruction with preservation of the duodenal passage.

Mediators of injury and inflammation.

Abstract: Mediators play a key role in the development of systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome, and multiple organ failure of vital organs. In this short review, we update our knowledge on these mediator networks. First, we summarize the stimuli that occur during severe trauma (intraoperative stress), including polymorphonuclear neutrophil-derived tissue-damaging substances, complement activation products, and adherence molecules such as selectins. The gut in shock is discussed as an important intermediate step in the transition from noninfectious to infectious SIRS. Second, we describe the mediators, including cytokines, nitric oxide, phospholipase A2, platelet-activating factor, and procoagulatory substances, that are released during sepsis. The release of mediators depends primarily on the severity of the trauma, shock, or sepsis and secondarily on the activation of the various cascades of mediators during posttraumatic/postoperative complications. The mediators are thus of decisive importance regarding the intensity of organ damage and the outcome.

Islet Cell Carcinoma of the Pancreas

Abstract: n = 11) followed by glucagonoma ( n = 6) and insulinoma ( n = 4) were the most common functioning tumors. In the patients undergoing a laboratory study, 67% of the nonfunctioning tumors had elevated peptide hormone levels. Potentially curative resections were performed in 17 patients (26%), palliative procedures in 35 (55%), and exploratory laparotomy alone in 12 (19%). One patient (2%) died within 30 days after operation. Symptomatic improvement was achieved in 96% of patients with a mean duration of 22 months. Three- and five-year survivals were 66% and 49%, respectively. In patients with curative resection, the disease-free survival at 3 years was 53% (95% CI: 32–86%). The presence of diffuse hepatic metastases was a predictor of poor survival at 3 years (74% versus 58%; p = 0.05); there was no statistically significant difference in survival between functioning and nonfunctioning groups ( p > 0.1). Although curative resection for ICC is rare, meaningful palliation can be achieved in most patients with rare mortality and acceptable morbidity.

Peritoneal Carcinomatosis from Adenocarcinoma of the Colon

Abstract: Peritoneal carcinomatosis is a major cause of surgical treatment failure in patients with colorectal cancer. In the past patients with this condition have had a lethal outcome. In this study, 64 consecutive patients were treated by the cytoreductive approach, which involved surgery to maximally resect all cancer in the abdomen and pelvis, early postoperative intraperitoneal chemotherapy with 5-fluorouracil (5-FU) and mitomycin C, and three cycles of adjuvant intraperitoneal 5-FU with systemic mitomycin C. The clinical features that may affect prognosis were assessed and critically analyzed statistically. Peritoneal implant size of < 5 cm present in the abdomen and pelvis at the time of exploration correlated with a good prognosis (p < 0.0001), as did complete cytoreduction with tumor removed to nodules < 2.5 mm (p < 0.0001). Involvement of only one or two of the five abdominopelvic regions, compared to three or more regions, was a significant determinant of prognosis (p < 0.0001). Finally, a mucinous histologic type correlated adversely with prognosis when compared to intestinal-type adenocarcinomas (p < 0.001). These data suggest that patients with small-volume peritoneal seeding from colon cancer should be treated with cytoreductive surgery and aggressive regional and systemic chemotherapy in an attempt to achieve long-term disease-free survival.

Prospective randomized comparison of open versus laparoscopic appendectomy in men.

Abstract: A prospective, randomized trial was performed to compare open appendectomy with laparoscopic appendectomy in men with a clinical diagnosis of acute appendicitis. Sixty-four patients with a median age of 25 years (range 18-84 years) were randomized to open appendectomy (n = 31) or laparoscopic (n = 33) appendectomy. Of the 64 men, 56 (87.5%) had appendicitis (27 open, 29 laparoscopic procedures). The mean operating times were 50.6 +/- 3.7 minutes (+/- SEM) for open and 58.9 +/- 4.0 minutes for laparoscopic appendectomy (p = 0.13). Five (15%) patients randomized to laparoscopic appendectomy had an open operation. The mean postoperative hospital stay was significantly longer for open appendectomy (3.8 +/- 0.4 days) than for laparoscopic appendectomy (2.9 +/- 0.3 days) (t = 2. 05,df = 62,p = 0.045). The complication rate after open appendectomy (25.8%) was not significantly different from that after laparoscopic appendectomy (12.1%). There was a single postoperative death due to a pulmonary embolus in the laparoscopic group and a single death due to cardiac and renal failure in the open group. The mean time to return to normal activities was significantly longer following open appendectomy (19.7 +/- 2.4 days) than after laparoscopic appendectomy (10.4 +/- 0.9 days), (t = 3.75,df = 49,p = 0.001). In conclusion, laparoscopic appendectomy in men has significant advantages in terms of a more rapid recovery compared to open appendectomy. There were no significant disadvantages to laparoscopic appendectomy compared to open appendectomy.

Low-Molecular-Weight Heparin versus Warfarin for Prevention of Recurrent Venous Thromboembolism: A Randomized Trial

Abstract: A group of 105 consecutive patients with venographically proved major acute deep vein thrombosis (DVT) were randomized in an open prospective study to evaluate the comparative efficacy and safety of a fixed dose of subcutaneous low-molecular-weight heparin (LMWH) and warfarin for the prevention of recurrent venous thromboembolism. Four patients developed venographically proved recurrent DVT during the 3 months of treatment: three in the LMWH group and one in the warfarin group. Nonfatal pulmonary embolism occurred in two patients in the LMWH group and in one in the warfarin group. Five of the 55 patients (10%) in the warfarin group and none of the 50 patients in the LMWH developed bleeding complications (two-tailed Fisher exact test, p = 0.06). A preliminary assessment of the costs indicated that treatment with LMWH was less expensive by Pounds 900 per patient than warfarin. In conclusion, the fixed daily dose of LMWH and the adjusted dose of warfarin therapy were of similar efficacy in preventing recurrence of DVT. However, warfarin therapy, despite strict laboratory control, is associated with more frequent side effects and is expensive. Another study with a higher dose of LMWH is recommended.

Surgical management for carcinoid tumors of small bowel, appendix, colon, and rectum.

Abstract: Carcinoid tumors occur most frequently in the gastrointestinal tract. Despite their ability to produce hormones, most of the midgut and hindgut carcinoids covered in this study are clinically silent, and the diagnosis is often not made before emergency surgery or evaluation for liver metastases. Because the rate of lymph node involvement and the prognosis of carcinoid tumors depend on their site and size, surgery refers to these two factors too. Lymph node metastases are most commonly found with small bowel carcinoids (20-45%), providing the rationale for an extended resection including the adjacent lymph node drainage area. Carcinoid tumors of the appendix 2 cm should be treated by right hemicolectomy because of their approximately 30% risk of lymph node metastases. Resection should always be done for carcinoid tumors of the colon resection as for adenocarcinomas. Rectal carcinoids 2 cm a standard cancer resection should be performed provided distant metastases are absent. In general, the younger the patient or the larger the primary tumor, the more aggressive the treatment should be.

Thyroid cancer detected by ultrasound-guided fine-needle aspiration biopsy.

Abstract: n = 55) (e.g., small cancers with or without benign lesions or cancers associated with Hashimoto’s thyroiditis or Graves’ disease); and (2) palpable cancers with insufficient cell material for analysis ( n = 44) (e.g., cystic carcinoma and cancers with calcified lesions. UG-FNAB is a powerful technique for detecting microcancers, cystic carcinomas, cancers associated with benign nodules, Hashimoto’s thyroiditis, or coarse calcifications.

Laparoscopic Colorectal Surgery: Ascending the Learning Curve

Abstract: n = 5), hemorrhage ( n = 6), intraabdominal abscess ( n = 4), prolonged ileus ( n = 4), wound infection ( n = 2), anastomotic leak ( n = 1), aspiration ( n = 1), cardiac arrhythmia ( n = 1), upper intestinal bleeding ( n = 1), and postoperative small bowel obstruction ( n = 1). There were no deaths. When divided into three equal, consecutive groups, the patients in the early ( n = 33) and intermediate ( n = 33) groups had a significantly higher complication rate (42% and 27%, respectively), than those in the late group ( n = 34, 12%; p < 0.05). The complication rate in each group was also directly related to the number of TACs performed (18 in the early, 13 in the intermediate, and 5 in the late group). The overall complication rate in TAC cases was significantly higher (42%) when compared to that of all other procedures (segmental resection 9%, nonresectional 12%; p < 0.01). The mean operating time was 4 hours (2.5–6.5 hours) for TAC, 2.5 hours (1.5–5.5 hours) for segmental colonic resection, and 1.6 hours (1.0–2.5 hours) for the nonresectional procedures. The length of ileus was 3.5 days (2–7 days) after TAC, 3 days (2–7 days) after the segmental resections, and 2 days (1–4 days) after the nonresectional procedures. The mean hospital stay was 7.3 days (2–40 days): 8.4 (5–40), 7.0 (4–12), and 6.8 (2–11) days for the TAC, segmental resection, and nonresectional procedures, respectively. We conclude that the feasibility of laparoscopic colorectal surgery has been well established. The morbidity associated with laparoscopic colorectal surgery correlates with a steep learning curve but is also related to the type of procedure. TAC is associated with a higher complication rate than are other laparoscopic colorectal procedures.

Total Pancreatectomy for Cancer of the Pancreas: Is It Appropriate?

Abstract: During the late 1960s total pancreatectomy was advocated on theoretic grounds as an operation superior to subtotal (Whipple) resection in patients with pancreatic cancer. There are, however, no prospective randomized studies and only few institutional comparisons between the two operations. The aim of the present paper was to report the clinical outcome of total and subtotal pancreatectomy, respectively, in a consecutive series of patients with exocrine pancreatic cancer. The short- and long-term results of 89 consecutive patients who underwent total pancreatectomy (1959-1984) for pancreatic cancer were retrospectively compared with a similar group of 36 patients who had a subtotal pancreatectomy (1985-1992) for the same diagnosis. The clinical characteristics were on the whole similar in the two groups. Postoperative mortality and morbidity, the amount of intraoperative bleeding, operation time, reoperation rate, postoperative days in the intensive care unit, and duration of hospital stay were statistically significantly increased after total pancreatectomy. The 5-year survival rate was lower after total pancreatectomy when hospital deaths were included in the analysis. At multivariate analysis total pancreatectomy adversely influenced long-term survival compared to subtotal resection, as did positive lymph nodes and poor histologic differentiation. Better early and long-term results were found after subtotal than after total pancreatectomy in patients with exocrine pancreatic cancer. Although the two operations were done during different time periods, we believe the results suggest that total pancreatectomy cannot be recommended as a routine treatment for this patient group.

Pathology and nomenclature of human gastrointestinal neuroendocrine (carcinoid) tumors and related lesions.

Abstract: The pathology and nomenclature of the neuroendocrine cell proliferations in the gut are reviewed. The neoplastic lesions are discussed within the light of a new classification system that attempts to consider the morphologic, functional, and biologic features of the tumors.

Clinical development of human polymerized hemoglobin as a blood substitute.

Abstract: Although the efficacy of hemoglobin-based oxygen carriers was established more than 60 years ago, all prior clinical trials have demonstrated significant toxicity characterized by renal dysfunction, gastrointestinal distress, and systemic vasoconstriction. The mechanisms of these toxicities now appear to be understood. Tetrameric forms of the hemoglobin molecule extravasate from the circulation and interact with endothelium-derived relaxing factor, leading to unopposed vasoconstriction. Although numerous efforts are under way to chemically modify the native tetramer, it is likely that all tetrameric forms of the hemoglobin molecule will continue to extravasate. We have focused on developing a polymerized form of hemoglobin that is virtually free of unreacted tetramer. The development and characterization of this polymerized pyridoxylated hemoglobin solution (Poly SFH-P) is described. Clinical trials have been completed successfully in volunteers and are now under way to assess the safety and efficacy of Poly SFH-P as a clinically useful red blood cell substitute for treatment of acute blood loss in the setting of trauma and surgery.