Transthoracic versus extrathoracic esophagectomy: mortality, morbidity, and long-term survival

Extrathoracic esophagectomy for carcinoma is an acceptable substitute for transthoracic resection if it can be shown to have comparable or superior safety and no adverse effect on long-term survival. To test this hypothesis, we employed extrathoracic esophagectomy in 30 consecutive patients with carcinoma of the esophagus from January, 1978, to July, 1984. During this period, 65 comparable patients underwent transthoracic resection through a left thoracotomy for lower esophageal lesions or a right thoracotomy and laparotomy for upper thoracic lesions. Only patients with carcinoma limited to the gastric cardia were excluded from the study. Overall morbidity was higher in the extrathoracic than in the transthoracic group (13 of 30 or 43.3% versus 15 of 65 or 23.1%; p = 0.05), but the differences in hospital mortality (4 of 65 or 6.2% for the transthoracic group versus 4 of 30 or 13.3% for the extrathoracic group) and duration of hospital stay (17.4 +/- 11.7 days for the transthoracic group versus 20.5 +/- 13.4 days for the extrathoracic group) were not statistically significant. Considering all patients who either died or sustained a postoperative complication, we found significant differences favoring transthoracic resection in those subgroups of patients who were able to undergo primary reconstruction at the time of resection (12 of 57 or 21.1% versus 15 of 28 or 53.6%; p = 0.004), those with advanced Stage III lesions (11 of 47 or 23.4% versus 12 of 20 or 60%; p = 0.006), those with tumor of the lower esophagus (8 of 35 or 22.9% versus 6 of 10 or 60%; p = 0.04), and those with tumor that could be resected through a left thoracotomy (2 of 18 or 11.1% versus 17 of 30 or 56.7%; p = 0.002). Actuarial survival curves for all transthoracic and extrathoracic resections and separate analysis for Stage I and Stage III tumors revealed no statistically significant differences between these two techniques.     

Primary non-Hodgkin's lymphoma of the main hepatic duct junction

A rare case of primary non-Hodgkin's lymphoma of the main hepatic duct junction is reported. A 71-year-old man was admitted for treatment of obstructive jaundice. Radiological examination revealed stenosis of the main hepatic duct junction. Biliary drainage was not necessary because total bilirubin decreased spontaneously. A left hepatic and caudate lobectomy, combined with resection of bile ducts and lymph node dissection, was performed with the preoperative diagnosis of cholangiocarcinoma of the main hepatic duct junction. Macroscopic examination of the resected specimen revealed tumorous growth in the main hepatic duct junction. Histological and immunochemistry findings disclosed a mucosaassociated lymphoid tissue (MALT) lymphoma. The patient received three courses of combination chemotherapy [cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP)], and there was no evidence of recurrence 45 months after the surgery. Although primary non-Hodgkin's lymphoma of the main hepatic duct junction is extremely rare and difficult to diagnose preoperatively, aggressive surgery followed by chemotherapy, as here, is a possible curative option.     

Carcinoma of the junction of the main hepatic ducts

Patients with carcinoma of the hepatic duct junction often present the surgeon with a difficult problem. If at all possible radical surgery may be performed either as a resection of the tumour and an anastomosis according to Roux-en-Y or a resection of the left or right hepatic lobe together with the obliterated hepatic duct or ducts. The present series consists of 17 patients treated for cancer of the hepatic duct junction during the period 1965-1974 with a follow-up period of at least five years. The surgical treatment given included a radical procedure in 8 cases, a palliative procedure in 7 cases and in 2 cases surgery of the hepatic ducts was not possible. Radical procedures included 4 patients with a resection of the left hepatic lobe and 4 patients with resection of the left and right hepatic ducts and anastomosis according to Roux. A mean survival time of 22.8 months was reached when a radical operation was attempted with a longest survival time of 8 years. A palliative procedure gave a mean survival time of 2.0 months. These figures indicate that a careful selection of patients for an attempt of radical surgery could be made since removal of the tumour gives a more effective palliation, often a longer survival time and an improvement of quality of life.     

Middle pancreatectomy: indications, short- and long-term operative outcomes

OBJECTIVE: To evaluate the indications, perioperative, and long-term outcomes of a large cohort of patients who underwent middle pancreatectomy (MP). SUMMARY BACKGROUND DATA: MP is a parenchyma-sparing technique aimed to reduce the risk of postoperative exocrine and endocrine insufficiency. Reported outcomes after MP are conflicting. METHODS:: Patients who underwent MP between 1990 and 2005 at the Massachusetts General Hospital and at the University of Verona were identified. The outcomes after MP were compared with a control group that underwent extended left pancreatectomy (ELP) for neoplasms in the mid pancreas. RESULTS: A total of 100 patients underwent MP. The most common indications were neuroendocrine neoplasms, serous cystadenoma, and branch-duct IPMNs. Comparison with 45 ELP showed that intraoperative blood loss and transfusions were significantly higher for ELP. The 2 groups showed no differences in overall morbidity, abdominal complications, overall pancreatic fistula, and grade B/C pancreatic fistula rate (17% in MP and 13% in ELP), but the mean hospital-stay was longer for MP patients (P = 0.005). Mortality was zero. In the MP group, 5 patients affected by IPMNs had positive resection margins and 3 had recurrence. After a median follow-up of 54 months, incidence of new endocrine and exocrine insufficiency were significantly higher in the ELP group (4% vs. 38%, P = 0.0001 and 5% vs. 15.6%, P = 0.039, respectively). CONCLUSIONS: MP is a safe and effective procedure for treatment of benign and low-grade malignant neoplasms of the mid pancreas and is associated with a low risk of development of exocrine and endocrine insufficiency. MP should be avoided in patients affected by main-duct IPMN.     

Acute subdural hematoma: morbidity, mortality, and operative timing

Traumatic acute subdural hematoma remains one of the most lethal of all head injuries. Since 1981, it has been strongly held that the critical factor in overall outcome from acute subdural hematoma is timing of operative intervention for clot removal; those operated on within 4 hours of injury may have mortality rates as low as 30% with functional survival rates as high as 65%. Data were reviewed for 1150 severely head-injured patients (Glasgow Coma Scale (GCS) scores 3 to 7) treated at a Level 1 trauma center between 1982 and 1987; 101 of these patients had acute subdural hematoma. Standard treatment protocol included aggressive prehospital resuscitation measures, rapid operative intervention, and aggressive postoperative control of intracranial pressure (ICP). The overall mortality rate was 66%, and 19% had functional recovery. The following variables statistically correlated (p less than 0.05) with outcome; motorcycle accident as a mechanism of injury, age over 65 years, admission GCS score of 3 or 4, and postoperative ICP greater than 45 mm Hg. The time from injury to operative evacuation of the acute subdural hematoma in regard to outcome morbidity and mortality was not statistically significant even when examined at hourly intervals although there were trends indicating that earlier surgery improved outcome. The findings of this study support the pathophysiological evidence that, in acute subdural hematoma, the extent of primary underlying brain injury is more important than the subdural clot itself in dictating outcome; therefore, the ability to control ICP is more critical to outcome than the absolute timing of subdural blood removal.     

Elective and emergency hepatic resection. Determinants of operative mortality and morbidity.

To determine the reasons for improved mortality and morbidity rates after major hepatic resection, five variables were analyzed retrospectively in 300 patients operated on over a 27-year period: (1) the indication for surgery, (2) the surgical approach, (3) the urgency with which surgery was performed, (4) the nature of the surgical procedure, and (5) the experience of the surgeon. The operative mortality rate decreased from 19% between 1962 and 1979 to 9.7% between 1980 and 1988 (p less than 0.05). The operative mortality rates for patients undergoing resection for benign hepatic neoplasms was 3.4%; for metastatic tumors, 6.3%; for primary hepatic malignancies, 19%; and for trauma, 33%. Fifty-seven percent of operations before 1980 were performed through a thoracoabdominal exposure as compared with 19% after 1980. Overall a thoracoabdominal exposure of the liver was associated with a 20% mortality rate as compared with 8.6% for operations with abdominal exposure of the liver (p less than 0.02). Elective operations accounted for 65% of hepatic resections before 1980, as compared with 90% after 1980, and were associated with an 8.8% mortality rate as compared with 30.7% for urgent and emergency operations (p less than 0.001). Segmental and wedge resections were associated with a 5.3% mortality rate as compared with 14.7% for major hepatic resections (p less than 0.05), but this difference did not affect overall operative mortality rates because there was no change in the proportion of major hepatic resections after 1980. Surgical experience was not a determinant of operative mortality or morbidity rates in elective operations. Although there was no reduction in the complication rate after 1980, there was a reduction in postoperative stay from 26 days before 1980 to 16 days after 1980 (p less than 0.001). A reduction in the incidence of postoperative sepsis and a change in its management was associated with improved operative mortality rates.     

Surgery of central lung embolism: indications, mortality and early morbidity

Between 1979 and 1988 massive pulmonary embolism (PE) was treated surgically in 36 patients with extracorporeal circulation (ECC). Circulation was stable in 11 patients and unstable in 25; in this group 9 had previous resuscitation because of cardiac arrest. There were 7/36 early deaths (19%); 5 of those patients had to be resuscitated prior to surgery. Deaths were caused mainly by cerebral edema or hemorrhage. Significant complications occurred in 8 patients (28%). Diagnoses of PE was made clinically in most cases; confirmation by echocardiography was useful. Pulmonary angiography was made in patients with uncertain diagnosis and stable circulation. Operation is indicated in patients with unstable circulation and proved central PE; it is advisible in patients with embolism of the main pulmonary artery or its major branches. Hospital mortality is very high when the patient has to be resuscitated preoperatively; in this group surgery should be performed only in younger patients with a short period of resuscitation. Interruption of the inferior vena cava should be performed to prevent recurrent PE.     

Bilateral nephrectomy before transplantation: indications, surgical approach, morbidity and mortality

Forty patients with end-stage renal failure, who had undergone simultaneous bilateral native nephrectomy before a subsequent renal transplant operation, were reviewed with particular reference to the indications and surgical approach for bilateral nephrectomy and to the complications of the procedure. The main indications for bilateral nephrectomy are hypertension resistant to medical therapy, persistent symptomatic renal infection, severe renal protein loss and occasionally polycystic kidneys or bilateral renal tumours. In this consecutive series of 40 patients both kidneys were removed because of chronic pyelonephritis with reflux (n = 28), glomerulonephritis with reflux (n = 9) and uncontrolled hypertension (n = 3). Surgical morbidity was less in patients who had bilateral nephrectomy performed through bilateral vertical lumbotomy incisions. There was no surgical mortality.     

Completion pneumonectomy: factors affecting operative mortality and cardiopulmonary morbidity

BACKGROUND: The purpose of this report is to analyze preoperative and perioperative factors affecting operative mortality and cardiopulmonary morbidity after a completion pneumonectomy. METHODS: We retrospectively reviewed all patients who underwent completion pneumonectomy from January 1985 through September 1998 at the Mayo Clinic in Rochester, MN. Factors affecting operative mortality and postoperative morbidity and were analyzed using univariate and multivariate analysis. RESULTS: There were 115 patients (73 men and 42 women), with a median age of 64 years (range, 12 to 83 years). Indication for pneumonectomy was benign disease in 57 patients (49.6%), lung cancer in 51 (44.3%) and metastatic disease in 7 (6.1%). There were 24 deaths (mortality 20.9%, 95% CI 13.9% to 29.4%). Mortality for patients undergoing completion pneumonectomy for benign disease, lung cancer, and metastatic cancer was 26.3%, 17.6%, and 0%, respectively (p = 0.24). Factors adversely affecting mortality with univariate analysis included advanced age (p = 0.004), preoperative corticosteriod use (p = 0.01), decreased preoperative diffusion capacity of lung to carbon monoxide (p = 0.01), intraoperative blood transfusion (p = 0.04), and excessive crystalloid infusion within the first 12 hours (p = 0.01) and 24 hours (0.03) postoperatively, respectively. Factors adversely affecting mortality with multivariate analysis included advanced age (p = 0.001), preoperative corticosteriod use (p = 0.002), and low preoperative hemoglobin (p = 0.02). Cardiopulmonary complications occurred in 72 patients (63.7%). Factors adversely affecting morbidity with univariate analysis included benign disease (p = 0.002), decreased preoperative diffusion capacity of lung to carbon monoxide (p = 0.04), bronchial stump reinforcement (p = 0.0001), and excessive crystalloid infusion within the first 12 hours (p = 0.006) and 24 hours (p = 0.02) postoperatively, respectively. Factors adversely affecting morbidity with multivariate analysis included advanced age (p = 0.005) and bronchial stump reinforcement (p = 0.001). CONCLUSIONS: Multiple factors adversely affect operative mortality and cardiopulmonary morbidity after completion pneumonectomy. Although completion pneumonectomy remains a high-risk procedure, especially for benign disease, it still should be considered a treatment option in selected patients.     

Elective pneumonectomy: factors associated with morbidity and operative mortality.

We have retrospectively reviewed hospital records of 197 consecutive patients undergoing pneumonectomy for neoplastic disease between 1985 and 1990 to identify predictors of outcome. Seventeen of the 197 patients died during their hospital stay (8.6%; 95% confidence intervals, 6.7% to 11.2%). The most significant predictors of in-hospital mortality were presence of coexisting medical conditions (p less than 0.001), respiratory function tests showing an obstructive picture with a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.55 (p less than 0.001), 24-hour fluid replacement of more than 3 L (p less than 0.05), postoperative pulmonary edema (p less than 0.001), respiratory tract infection with positive sputum culture (p less than 0.01), postoperative renal failure (p less than 0.001), and cardiac arrhythmias (p less than 0.001). There were 232 postoperative management, problems occurring in 197 patients. The most significant predictors of postoperative morbidity were continued cigarette smoking up to the time of operation (p less than 0.05), perioperative blood loss or more than 2 L (p less than 0.05), and infusion of more than 3 L of fluid in the first 24 hours (p less than 0.05). Although retrospective analyses must be interpreted with caution, this study has identified preoperative and perioperative factors associated with in-hospital morbidity and mortality after pneumonectomy.     

Elective pulmonary lobectomy: factors associated with morbidity and operative mortality

Periodic review of clinical results is essential to ensure that high-quality patient care is maintained. To that end, we reviewed the morbidity and operative mortality in a consecutive series of 369 pulmonary lobectomies performed between January 1, 1970, and December 31, 1983. There were 251 male and 118 female patients with a mean age of 50.6 years. The thirty-day operative mortality was 2.2% (8/369), with 6 of these deaths related primarily to respiratory insufficiency. Two hundred twenty-four postoperative management problems occurred in 151 patients and included arrhythmia, air leak, pneumothorax, respiratory difficulties, postoperative bleeding, pleural effusion, wound infection, myocardial infarction, pulmonary embolus, empyema, bronchial stump leak, and lobar gangrene. Multiple factors were related to the occurrence of postoperative morbidity and mortality using both chi-square analysis to examine each individual item and discriminant analysis to evaluate their interaction. Chi-square tabulation showed no difference in the occurrence of major postoperative complications (p greater than 0.05) related to the side of operation, an abnormal preoperative electrocardiogram, a forced vital capacity of 2.8 liters or less, a one-second forced expiratory volume (FEV1) of less than 1.7 liters, an oxygen tension of less than 60 mm Hg, or the seniority of the surgeon (resident versus attending). An increased number of complications (p less than 0.05) was found in male patients, in patients operated on for carcinoma, and in patients older than 60 years. Stepwise discriminant analysis included FEV1 as a significant predictor of postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)     

医源性胆胰结合部损伤

医源性胆胰结合部损伤指在治疗和检验过程中引起胆总管、主胰管汇合部位的损伤,虽然发生率较低,但其处理不当时常给患者带来极大痛苦,甚至危及患者生命。为此,本文阐述了引起医源性胆胰结合部损伤的原因、早期诊断及防治措施。一、医源性胆胰结合部损伤的原因开腹下胆总管探查术和内镜括约肌切开术(EST)是导致胆胰结合部损伤的两大主要医源性因素。①开腹下胆总管探查术:主要是胆总管探查术时Bakes探条的暴力性操作引起胆胰汇合部损伤,特别是近年来纷纷开展胆道手术的基层医院,在胆总管下端通过受阻时,未经术中胆道造影或胆道镜检查,采用…     

Breast carcinoma in the elderly patient: an assessment of operative risk, morbidity and mortality

Of 711 patients with histologically proven carcinoma of the breast, 94 patients aged 65 years or older were treated primarily by operation. The long-term survival was comparable to that in the general population with breast cancer despite a high percentage of noncancer death from intercurrent disease. Surgical therapy appropriate for the stage of disease can be performed with acceptable morbidity and mortality. Elderly patients often present with advanced disease but should not be denied the benefits of surgical palliation strictly on the basis of age.     

Cervical spine fractures in the elderly: morbidity and mortality after operative treatment

Purpose

Although there are currently many different strategies and recommendations in the therapy of cervical spine fractures in elderly patients, there are still no generally accepted treatment algorithms. The aim of the present study was to analyze the morbidity, mortality, and outcome of operated cervical spine injuries in the elderly.

Methods

This study presents a retrospective review of 69 patients aged 65 years or older admitted to our level I trauma center with cervical spine injury, who had undergone surgical treatment. The data were acquired by analysis of the hospital inpatient enquiry system and radiological review.

Results

The ratio between male and female patients was 37:32. The average age of the patients was 76 years (ranging from 65 to 96 years) for males and 80 years (ranging from 66 to 93 years) for females. Injury to the cervical spine was caused by low-energy trauma in 71 % and high-energy trauma in 29 %, respectively. 55.1 % sustained isolated cervical spine injuries, 39.1 % injuries to two adjacent vertebrae, 2.9 % injuries to three adjacent vertebrae, and 2.9 % an odontoid fracture combined with associated fracture(s) in non-contiguous vertebra(e). Isolated spine injury level was dominated by C2 (47.8 %). The most common site for injuries to two adjacent vertebrae was observed at C6/C7 (14.5 %). The morbidity included cerebral complications, respiratory complications, Clostridium difficile-associated disease, heart failure, and acute renal failure. Operative complications included dislocation/malposition, neurovascular lesions, wound infection, and transient swallowing difficulty. The mortality rate at 3 months was 26.1 %, with an in-hospital mortality of 21.7 %. Age was associated with mortality at 3 months. A cervical fracture-induced neurological deficit was documented in 26.1 %, resulting in a mortality of 44.4 % (8/18). Twenty-seven of 33 patients living at home/nursing home at the time of injury returned to their home/nursing home after their hospitalization. The overall outcome was predominantly related to age and the severity of neurological deficit.

Conclusions

In elderly patients with cervical spine fractures, the hospital course is complicated by medical issues and early mortality rates are significant. Therefore, treatment strategies should be carefully individualized to the patients and their comorbidities.     

Circadian aspects of post‐operative morbidity and mortality

It has been well established that there exists a circadian concentration of cardiovascular, cerebrovascular and cardiopulmonary events. The aim was to describe aspects of circadian variation in relation to cardiovascular, cerebrovascular and thromboembolic diseases and to describe the literature concerning post‐operative circadian disturbances. We also present the literature concerning circadian variation in post‐operative morbidity and mortality. PubMed and the Cochrane database were searched for papers using a combination of ‘circadian,’‘surgery,’‘post‐operative,’‘mortality’ and ‘morbidity.’ Eleven relevant studies were found, and seven of these were excluded due to the use of time of surgery and not time of morbidity or mortality as the main variable. The results from the four articles showed a circadian distribution of morbidity and mortality that mimics the one seen without surgery. There is a peak incidence of myocardial ischemia, fatal thromboembolism and sudden unexpected death in the morning hours. A circadian variation exists in post‐operative morbidity and mortality. The observed circadian variation in post‐operative morbidity and mortality may warrant a chronopharmacological approach to patients in the perioperative period. The underlying pathophysiological mechanisms should be the focus for future studies.     

Predictors of operative morbidity and mortality in gastric cancer surgery

BACKGROUND: The aim of this study was to identify factors that predict morbidity and mortality in gastric cancer surgery. METHODS: Data on 719 consecutive patients who underwent operations for gastric cancer at Seoul National University Hospital between January and December 2002 were reviewed. RESULTS: Overall morbidity and mortality rates were 17.4 per cent (125 patients) and 0.6 per cent (four patients) respectively, and the rates of surgical and non-surgical complications were 14.7 per cent (106 patients) and 3.3 per cent (24 patients). Morbidity rates were higher in patients aged over 50 years (odds ratio (OR) 1.04 (95 per cent confidence interval (c.i.) 1.02 to 1.06)), when the gastric tumour was resected with another organ (36 per cent for combined resection versus 15.4 per cent for gastrectomy only; OR 3.25 (95 per cent c.i. 1.76 to 6.03)) and when gastrojejunostomy was used for reconstruction after subtotal gastrectomy (17.0 per cent for Billroth II versus 9.5 per cent for Billroth I; OR 2.00 (95 per cent c.i. 1.05 to 3.79)). Only three patients (2.8 per cent) with a surgical complication underwent reoperation, two for adhesive obstruction and one for intra-abdominal bleeding. CONCLUSION: Age, combined resection and Billroth II reconstruction after radical subtotal gastrectomy were independently associated with the development of complications after gastric cancer surgery.