Combined biliary and gastric bypass procedures as effective palliation for unresectable malignant disease

Background: Although endoscopic treatment of jaundice is increasingly used in the palliation of unresectable malignant disease, surgical bypass still has a role to play in this setting. This study aimed to reappraise the short‐term and long‐term results of combined biliary/gastric bypass (hepaticojejunostomy and gastrojejunostomy) as palliation for unresectable malignant disease. Methods: All patients undergoing simultaneous biliary and gastric bypass procedures for unresectable malignant disease between August 2000 and January 2006 were identified and outcomes reviewed. Results: One hundred and two patients underwent open surgical biliary drainage procedures for palliation of malignant disease. Underlying malignant disease included pancreatic carcinoma (n = 88), duodenal adenocarcinoma (n = 6) and distal cholangiocarcinoma (n = 3). Thirty‐one of the patients underwent a planned palliative bypass procedure, the remainder being carried out after unresectable disease was identified at laparotomy. Postoperative mortality and morbidity rates were higher in the group undergoing planned bypass. During follow up, two patients developed recurrent jaundice that required transhepatic stenting and two patients developed late gastric outlet obstruction requiring refashioning of the gastrojejunostomy. Conclusion: Combined surgical biliary and gastric bypass achieved effective palliation of jaundice and gastric outlet obstruction until death in >95% of patients in this series. It remains first‐line therapy in patients identified as having unresectable disease at laparotomy.     

Is unplanned return to the operating room a useful quality indicator in general surgery?

HYPOTHESIS: To test our hypothesis that unplanned return to the operating room (OR) is a useful quality indicator, we examined how often and for what reasons patients go back to the OR in a broad-based general surgery practice. DESIGN AND SETTING: Prospective cohort study at a rural tertiary care center. PATIENTS: Consecutive series of 3044 patients undergoing general surgery procedures in the OR between September 1, 1998, and March 31, 2000. Information about all postoperative adverse events occurring before discharge or within 30 days (whichever was longer) was collected prospectively. Unplanned return to the OR was defined as any secondary procedure required for a complication resulting directly or indirectly from the index operation. MAIN OUTCOME MEASURES: Unplanned return to the OR, mortality, and hospital charges. RESULTS: Overall, 107 (3.5%) had an unplanned return to the OR. A relatively small number of inpatient procedures accounted for a disproportionate share of unplanned reoperations, including colon resection (18% of total reoperations), renal transplant (9%), gastric bypass (6%), and pancreatic resection (6%). As expected, hospital charges were markedly higher for patients with unplanned returns to the OR. Reoperation was also associated with higher mortality rates; statistically significant increases were noted for pancreatic resection (33% vs 3.7%; P =.04), esophagogastrectomy (100% vs 4.2%; P =.002), and laparoscopic Nissen fundoplication (50% vs 0%; P =.01). Overall, 91 reoperations (85%) were for complications occurring at the original surgical site, including those related to an anastomosis (n = 16), surgical wound (n = 21), infection (n = 16), bleeding (n = 12), and other (n = 26). CONCLUSIONS: Unplanned returns to the OR occur across a broad spectrum of general surgical procedures and carry significant implications. Because they most often reflect problems related to the procedure itself, reoperation rates may be useful for monitoring quality across hospitals and for identifying opportunities for quality improvement locally.     

Laparoscopic gastric and biliary bypass: a single-center cohort prospective study

PURPOSE: Relief of gastric outlet and distal biliary obstruction may be accomplished by open surgery or by minimally invasive techniques including endoscopic and laparoscopic approaches. We examined the feasibility and safety of laparoscopic gastric and biliary bypass in all patients with malignant and benign disease requiring surgical relief of obstructive symptoms. MATERIALS AND METHODS: Patients with benign duodenal stricture or inoperable malignancy underwent therapeutic laparoscopic bypass surgery. Prophylactic gastric or biliary bypass was added in selected patients with nonmetastatic malignancy. RESULTS: Twenty-eight patients (17 of them female) with a median age of 67 years (range, 26-81 years) underwent 29 laparoscopic bypass procedures for malignant (n = 23) or benign (n = 6) disease. One patient who underwent a Roux-en-Y gastrojejunostomy for non-steroidal anti-inflammatory drug induced ulcer disease developed stenosis of the stoma that required laparoscopic refashioning 2 months later, accounting for the 29th procedure reported herein in 28 patients. Surgery included the construction of a single gastric (n = 16) or biliary (n = 5) bypass or a double bypass (n = 8), and an additional prophylactic bypass in 5 of 23 cancer patients (21.8%). All procedures were completed laparoscopically. The median operative time was 90 minutes (range, 60-153 minutes) and mean postoperative hospital stay was 4 days (range, 3-6 days). Complications developed following 4 procedures (13.8%) and 1 patient died (3.4%). No complications occurred in patients with prophylactic bypass. One patient required laparoscopic revision of the gastroenterostomy 2 months postoperatively, for benign disease. No recurrence of obstructive symptoms was observed in cancer patients during follow-up. CONCLUSION: Laparoscopic bypass surgery for distal biliary and gastric obstruction in patients with benign or malignant disease results in low morbidity and mortality and short postoperative hospital stay. The addition of prophylactic bypass in patients with nonmetastatic unresectable malignancy appears safe and effective.     

The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life

OBJECTIVE: To evaluate the effect of a prophylactic gastrojejunostomy on the development of gastric outlet obstruction and quality of life in patients with unresectable periampullary cancer found during explorative laparotomy. SUMMARY BACKGROUND DATA: Several studies, including one randomized trial, propagate to perform a prophylactic gastrojejunostomy routinely in patients with periampullary cancer found to be unresectable during laparotomy. Others suggest an increase of postoperative complications. Controversy still exists in general surgical practice if a double bypass should be performed routinely in these patients. METHODS: Between December 1998 and March 2002, patients with a periampullary carcinoma who were found to be unresectable during exploration were randomized to receive a double bypass (hepaticojejunostomy and a retrocolic gastrojejunostomy) or a single bypass (hepaticojejunostomy). Randomization was stratified for center and presence of metastases. Patients with gastrointestinal obstruction and patients treated endoscopically for more than 3 months were excluded. Primary endpoints were development of clinical gastric outlet obstruction and surgical intervention for gastric outlet obstruction. Secondary endpoints were mortality, morbidity, hospital stay, survival, and quality of life, measured prospectively by the EORTC-C30 and Pan26 questionnaires. It was decided to perform an interim analysis after inclusion of 50% of the patients (n = 70). RESULTS: Five of the 70 patients randomized were lost to follow-up. From the remaining 65 patients, 36 patients underwent a double and 29 a single bypass. There were no differences in patient demographics, preoperative symptoms, and surgical findings between the groups. Clinical symptoms of gastric outlet obstruction were found in 2 of the 36 patients (5.5%) with a double bypass, and in 12 of the 29 patients (41.4%) with a single bypass (P = 0.001). In the double bypass group, one patient (2.8%) and in the single bypass group 6 patients (20.7%) required (re-)gastrojejunostomy during follow-up (P = 0.04). The absolute risk reduction for reoperation in the double bypass group was 18%, and the numbers needed to treat was 6. Postoperative morbidity rates, including delayed gastric emptying, were 31% in the double versus 28% in the single bypass group (P = 0.12). Median postoperative length of stay was 11 days (range 4-76 days) in the double versus 9 days (range 6-20 days) in the single bypass group (P = 0.06); median survival was 7.2 months in the double versus 8.4 months in the single bypass group (P = 0.15). No differences were found in the quality of life between both groups. After surgery most quality of life scores deteriorated temporarily and were restored to their baseline score (t = -1) within 4 months. CONCLUSIONS: Prophylactic gastrojejunostomy significantly decreases the incidence of gastric outlet obstruction without increasing complication rates. There were no differences in quality of life between the two groups. Together with the previous randomized trial from the Hopkins group, this study provides sufficient evidence to state that a double bypass consisting of a hepaticojejunostomy and a prophylactic gastrojejunostomy is preferable to a single bypass consisting of only a hepaticojejunostomy in patients undergoing surgical palliation for unresectable periampullary carcinoma. Therefore, the trial was stopped earlier than planned.     

Comparison of superficial femoral vein and saphenous vein as conduits for mesenteric arterial bypass

PURPOSE: Gangrenous bowel, intraabdominal sepsis, and previous failed mesenteric bypass are indications for use of an autogenous conduit for mesenteric arterial reconstruction. Saphenous vein (SV) is often used as the autogenous conduit of choice, but it may be prone to graft stenosis or occlusion. Recent experience with superficial femoral vein (SFV) suggests that it is an excellent alternative conduit for major arterial reconstruction. The purpose of this study was to compare the outcomes of SV and SFV for mesenteric arterial bypass. METHODS: During a 7-year period, 26 patients underwent 43 mesenteric arterial bypass procedures with autogenous conduit. SV was used for 23 bypasses (53%), and SFV was used for 20 bypasses (47%). Indications for revascularization included chronic mesenteric ischemia (n = 15; 58%), acute mesenteric ischemia (n = 9; 35%), and mycotic aneurysm of the paravisceral aorta (n = 2; 7%). Three patients (11%) underwent revascularization with SV grafts and two patients (8%) with SFV grafts after previous failed mesenteric bypass. RESULTS: The 30-day mortality rate was 15%. Three deaths occurred after SV bypass for acute mesenteric ischemia, and one death occurred after a SFV bypass for a ruptured paravisceral mycotic aneurysm. Twenty-two surviving patients were followed for a mean of 31 +/- 6 months. Three of 11 patients (27%) who survived after SV bypass had recurrent mesenteric ischemia develop (acute, n = 1; chronic, n = 2) from graft thrombosis at a mean interval of 32 +/- 22 months after surgery. No patient had recurrent symptoms develop after SFV bypass. One of the three patients with SV graft failure died of acute mesenteric ischemia, and the other two patients underwent successful bypass with SFV. Symptomatic graft failure was significantly more likely to occur in patients receiving SV grafts compared with SFV grafts (P <.05). CONCLUSION: SFV yields acceptable clinical outcomes for mesenteric arterial bypass compared with SV. SFV is a viable alternative to SV when autogenous conduit is indicated for mesenteric arterial reconstruction.     

Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease

OBJECTIVE: Atheromatous aortic disease is a risk factor for excessive mortality and stroke in patients undergoing coronary artery bypass grafting. Outcomes of off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass in patients with severe atheromatous aortic disease were compared by propensity case-match methods. METHODS: Routine intraoperative transesophageal echocardiography identified 985 patients undergoing isolated coronary artery bypass grafting with severe atheromatous disease in the aortic arch or ascending aorta. Off-pump coronary artery bypass grafting was performed in 281 patients (28.5%). Propensity matched-pairs analysis was used to match patients undergoing off-pump coronary artery bypass grafting (n = 245) with patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. RESULTS: Univariate analysis revealed decreased hospital mortality (16/245, 6.5% vs 28/245, 11.4%; P =.058) and stroke prevalence (4/245, 1.6% vs 14/245, 5.7%; P =.03) in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass. Freedom from any postoperative complication was higher in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass (226/245, 92.2% vs 196/245, 80.0%; P <.001). Multivariable analysis of preoperative risk factors showed that increased hospital mortality was associated with coronary artery bypass grafting with cardiopulmonary bypass (odds ratio = 2.7; P =.01), fewer grafts (P =.05), acute myocardial infarction (odds ratio = 11.5; P <.001), chronic obstructive pulmonary disease (odds ratio = 2.4; P =.03), previous cardiac surgery (odds ratio = 10.2, P =.05), and peripheral vascular disease (odds ratio = 2.1; P =.05). Cardiopulmonary bypass was the only independent risk factor for stroke (odds ratio = 3.6, P =.03). At 36 months' follow-up, comparable survival was observed in the off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass groups (74% vs 72%). Multivariable analysis revealed that renal disease (P <.001), advanced age (P <.001), previous myocardial infarction (P =.03), and lower number of grafts (P =.02) were independent risks for late mortality. CONCLUSIONS: Patients with severe atherosclerotic aortic disease who undergo off-pump coronary artery bypass grafting have a significantly lower prevalence of hospital mortality, perioperative stroke, and overall complications than matched patients who underwent coronary artery bypass grafting with cardiopulmonary bypass. Routine intraoperative transesophageal echocardiography identifies severe atheromatous aortic disease and directs the choice of surgical technique.     

An analysis of cost and clinical outcome in palliation for advanced pancreatic cancer

BACKGROUND: The optimal palliative method for patients with unresectable pancreatic cancer remains controversial. METHODS: A retrospective chart review evaluated patients who underwent exploration for presumed resectable pancreatic cancer. Cost-based analysis was performed using relative value units (RVUs) that included the initial surgical procedure and any additional procedure required to achieve satisfactory palliation. RESULTS: Of 96 patients (1993--2002), 6% had biliary bypass, 42% had duodenal bypass, 40% had double bypass, and 13% had no procedure with equivalent clinical outcomes. If biliary bypass was not initially performed, there was a significant incidence of biliary complications before definitive endoscopic stenting (P=.01). If duodenal bypass was not initially performed, 11% developed duodenal obstruction (P=.04). Total RVUs was highest for a double bypass and lowest for no initial surgical palliative procedure. CONCLUSIONS: Although surgical bypass procedures at initial exploration provide durable palliation, these procedures are associated with greater costs.     

Surgical palliation of unresectable periampullary adenocarcinoma in the 1990s

Background: Advances in the nonoperative staging and palliation of periampullary carcinoma have dramatically changed the management of this disease. Currently, surgical palliation is used primarily for patients found to be unresectable at the time of laparotomy performed for the purpose of determining resectability.

Study Design: A review of all patients undergoing operative management for periampullary adenocarcinoma at a single, high-volume institution was performed. The review focused on patients found to be unresectable who, therefore, underwent surgical palliation.

Results: Between December 1991 and December 1997, 256 patients with unresectable periampullary adenocarcinoma were operatively palliated. During the same time period, 512 patients underwent pancreaticoduodenectomy (PD) for periampullary carcinoma. Sixty-eight percent of patients were unresectable secondary to liver metastases or peritoneal metastases, and 32% were deemed unresectable because of local vascular invasion. Of the 256 patients, 51% underwent double bypass (hepaticojejunostomy [HJ] and gastrojejunostomy [GJ]), 11% underwent HJ alone, 19% underwent GJ alone, and 19% did not undergo any form of bypass. Celiac block was performed in 75% of patients.

Palliated patients were significantly younger, with a mean age of 64.0 years compared with 65.8 years in the resected group (p = 0.04). Gender and race distributions were similar in the 2 groups, with 57% of palliated patients and 55% of resected patients being men (p = NS) and 91% of patients in each group being Caucasian (p = NS). Palliative procedures were performed with a mortality rate of 3.1%, compared to 1.9% in those successfully resected (p = NS). Those undergoing operative palliation had a significantly lower incidence of postoperative complications when compared with those undergoing pancreaticoduodenectomy (22% versus 35%, p < 0.0001) and had significantly shorter lengths of stay (10.3 days versus 14.8 days, p < 0.0001). As expected, palliated patients had a significantly poorer prognosis, with 1-, 2- and 4-year survivals of 25%, 9%, and 6% (median 6.5 months), respectively, compared with 75%, 47%, and 24% in their resectable counterparts (median 21 months, p < 0.0001).

Conclusions: Surgical palliation continues to play an important role in the management of periampullary carcinoma. In this high-volume center, 33% of patients undergoing operative management of this disease were unresectable. Surgical palliation can be accomplished with acceptable perioperative mortality (3.1%) and morbidity (22%), with excellent longterm results.     

Palliation for esophageal carcinoma

Fifty-three patients with carcinoma of the esophagus treated since 1972 are reviewed. Eighteen unresectable patients with distant metastases or pulmonary insufficiency were treated with irradiation or with esophageal or gastrostomy tubes plus irradiation. There were 5 early deaths, and only 3 patients survived more than three months. Six patients underwent bypass. Three died in the hospital, and 1 lived three months. None compled a course of irradiation or gained weight. The remaining 29 patients, who did not differ clinically from the bypass group, underwent resection for palliation or cure. There were 5 hospital deaths. Twenty patients lived more than three months and 7 of these more than one year. Two of them apparently were cured. These data indicate that the only effective means of increasing the duration of survival for esophageal carcinoma is resection with immediate reconstruction.     

Bypass surgery for unresectable oesophageal cancer: early and late results in 124 cases

The early and late results of bypass surgery in 124 patients with unresectable oesophageal cancer are reported. Patients were grouped according to the extent of disease: group A, tumour localized to the oesophagus where severe pulmonary disease contra-indicated oesophagectomy (n = 9); group B, tumour less than or equal to 10 cm in length with mediastinal invasion (n = 81); group C, tumour greater than 10 cm in length with mediastinal invasion and/or fixed malignant lymph nodes (n = 33). Extent of disease was not recorded in one patient. The operative mortality was 4 per cent but 9 other patients died in hospital (hospital mortality, 11 per cent). Mortality was increased in patients undergoing colon bypass and in those with a large tumour load but these differences failed to reach statistical significance. The most frequent complication was neck sepsis, secondary to leakage from the proximal end of the excluded oesophagus. Eighty-nine per cent of the survivors could eat a normal, unrestricted diet on discharge and eighty-two per cent of survivors had complete and lasting relief from dysphagia. Median survival after bypass was 5 months but survival was significantly improved by radiotherapy to the tumour (P less than 0.001). Gastric bypass with radiotherapy is indicated in patients with extra-oesophageal spread of malignancy and in patients with tumours localized to the oesophagus who are unfit for resection. Bypass surgery may be contra-indicated in patients with a primary tumour greater than 10 cm in length and/or fixed lymph node metastases because mortality is increased and survival after operation is short.     

Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia

OBJECTIVE: To evaluate the authors' experience with gastric transposition as a method of esophageal replacement in children with congenital or acquired abnormalities of the esophagus. SUMMARY BACKGROUND DATA: Esophageal replacement in children is almost always done for benign disease and thus requires a conduit that will last more than 70 years. The organ most commonly used in the past has been colon; however, most series have been fraught with major complications and conduit loss. For these reasons, in 1985 the authors switched from using colon interpositions to gastric transpositions for esophageal replacement in infants and children. METHODS: The authors retrospectively reviewed the records of 41 patients with the diagnoses of esophageal atresia (n = 26), corrosive injury (n = 8), leiomyomatosis (n = 5), and refractory gastroesophageal reflux (n = 2) who underwent gastric transposition for esophageal replacement. RESULTS: Mean +/- SE age at the time of gastric transposition was 3.3 +/- 0.6 years. All but two transpositions were performed through the posterior mediastinum without mortality or loss of the gastric conduit despite previous surgery on the gastric fundus in 8 (20%), previous esophageal operations in 15 (37%), and previous esophageal perforations in 6 (15%) patients. Complications included esophagogastric anastomotic leak (n = 15, 36%), which uniformly resolved without intervention; stricture formation (n = 20, 49%), all of which no longer require dilation; and feeding intolerance necessitating jejunal feeding (n = 8, 20%) due to delayed gastric emptying (n = 3), feeding aversion related to the underlying anomaly (n = 1), or severe neurological impairment (n = 4). No redo anastomoses were required. CONCLUSIONS: Gastric transposition reestablishes effective gastrointestinal continuity with few complications. Oral feeding and appropriate weight gain are achieved in most children. Therefore, gastric transposition is an appropriate alternative for esophageal replacement in infants and children.     

Surgical and endoscopic palliation of esophageal carcinoma

We reviewed the records of 732 patients with advanced esophageal carcinoma to determine the efficacy of palliative therapy. Palliative resection was performed in 156 patients. Hospital mortality was 9.6%, 1-year survival was 29.1%, and median survival was 7.8 months. Excellent or good palliative results were obtained in 78% of operative survivors. Bypass procedures were performed in 49 patients: hospital mortality was 20.4%, with a median survival of 6.2 months. Excellent or good palliative results were obtained in 71% of operative survivors. Intubation of the tumor was performed in 254 patients. Thirty-day mortality was 10.2%, and median survival was 4.0 months. No patient received excellent palliation. Neodymium:yttrium-aluminum-garnet laser therapy or photodynamic therapy was performed in 50 patients. No procedure-related deaths were recorded, and median survival was 4.1 months. Excellent or good results were obtained in 83% of patients. Lesser procedures were performed in 106 patients, and 117 had only staging examinations. Although surgical palliation of esophageal cancer with resection or bypass provides good results, the cost is high. Improvements in palliative results require reduction in operative mortality, increased accuracy of preoperative staging, continuing use of laser therapy, and increased use of chemotherapy alone or in combination with radiotherapy and operation.     

Surgical palliation for pancreatic cancer. The 25-year experience of a single reference centre

BACKGROUND: In spite of dynamic development of modern diagnostic and therapeutic methods, the long-term results of surgical therapy in pancreatic cancer are still unsatisfying. The aim of this study was to analyse long-term results of surgical palliation for pancreatic cancer in a pancreatic surgery centre. METHODS: We performed a retrospective analysis of 418 patients who underwent non-resective, palliative procedures for pancreatic cancer between 1975 and 1999. In order to compare two consecutive periods of time, the patients were divided in 2 groups; group I treated from 1975 to 1990 (n = 204), and group II from 1991 to 1999 (n = 214). RESULTS: Of all patients qualified for surgery, 281 (67.2 %) underwent surgical bypass, 107 (25.6 %) laparotomy, and in 30 cases surgical intervention was limited to implantation of endoprosthesis. A significant tendency towards double (i. e. biliary and gastric) anastomosis was observed (32.3 % vs. 74.8 %; p < 0.01) in patients who underwent bypass procedures. The postoperative morbidity was 16.3 %. The postoperative mortality rate was 5.7 % and significantly (p < 0.01) decreased from 10.3 % (group I) to 1.4 % (group II). No differences neither in mortality nor morbidity related to the type of performed surgery were found. The mean time of hospital stay was 15.5 +/- 6.9 days and showed no differences related to the type of intervention. Jaundice or symptoms of gastric outlet obstruction were observed in 16 % of patients in the follow-up period and concomitantly performed biliary and gastric bypasses were associated with the lowest rate of the late gastrointestinal obstruction (4 %). The median survival time was 169 days and only 4 % of patients survived 12 months. The univariate analysis of prognostic factors showed that location and stage of the tumour, the type of surgical intervention and bypass procedure influenced 1-year survival. The multivariate analysis using Cox proportional hazard model proved that only stage and location of the tumour had independent prognostic value. CONCLUSION: Surgical palliation for pancreatic cancer can be performed with acceptable morbidity and mortality rates. For tumours located in the head and body of the pancreas combined biliary and gastric bypass should be preferred. For cancers located in the tail of the pancreas gastric bypass should be performed routinely. Because surgical palliation can prevent gastric outlet obstruction by gastroenterostomy, endoscopic biliary stenting should be only performed in patients with pancreatic head cancers and simultaneous evidence of distal metastases as well as in older patients with high comorbidity.     

Palliative surgery for unresectable pancreatic and periampullary cancer: a reappraisal

This study aimed to reappraise short-term and long-term results of palliative biliary and gastric bypass surgery in patients with unresectable pancreatic head carcinoma found at explorative laparotomy. We retrospectively analyzed 83 consecutive patients whose pancreatic head carcinoma appeared unresectable at laparotomy (vascular involvement [57%], liver metastases [24%], distant metastatic lymph nodes [11%], peritoneal implants [8%]) and who underwent palliative surgical concomitant biliary and gastric bypass. Postoperative mortality and morbidity rates were 4.8% and 26.5%, respectively. Postoperativedelayed gastric emptying occurred in 9 patients (10%). Antecolic (46%) and retrocolic (54%) gastrojejunostomies did not differ for the duration of nasogastric suction, the delay of oral intake, and the incidence of delayed gastric emptying. Mean hospital stay was 16 +- 8 days. Median survival was 9 months (range 1–44). Late cholangitis occurred in 2 patients (2.4%) treated medically. One recurrent jaundice required transhepatic stenting 9 months from surgery. Four late gastric outlet obstructions occurred (4.8%) with a mean delay of 8 months from surgery. These data demonstrate that, in patients with unresectable pancreatic head carcinoma at laparotomy, palliative concomitant biliary and gastric bypass in a single procedure is safe and long-term efficient. This strategy remains to be compared to endoscopic palliation in this setting.     

Colonic interposition after esophagectomy for cancer

HYPOTHESIS: The use of colonic interposition in esophageal replacement after esophagectomy for cancer results in similar morbidity, mortality, and long-term outcome compared with gastric transposition. DESIGN: Prospectively collected database on patients with esophageal cancer from January 1, 1982, through December 31, 2000. SETTING: Academic university hospital department of surgery. PATIENTS: We compared 42 patients who underwent colonic interposition (colon group) with 959 patients who underwent gastric transposition (stomach group) after esophagectomy. MAIN OUTCOME MEASURES: Morbidity, mortality, and long-term survival. RESULTS: Greater blood loss (median, 1000 vs 700 mL; P<.001) and longer operation duration (median, 270 vs 225 minutes; P<.001) were encountered in the colon group. We found no difference in cardiopulmonary complications, but we found significantly greater incidences of anastomotic leakage (14.3% vs 3.9%; P =.007) and intra-abdominal septic complications (9.5% vs 0.2%; P<.001) in the colon group. Conduit ischemia developed in 5 patients (0.5%) in the stomach group, 3 of whom underwent successful staged reconstruction with colon. One patient (2.4%) in the colon group was found to have conduit ischemia and died. Hospital mortality rates included 7 patients (16.7%) from the colon group and 102 (10.6%) from the stomach group (P =.21). These figures improved to 0 and 27 (5.5%), respectively, in the second half of the study period (P>.99). Median survival was 12.8 and 10.4 months in the stomach and colon groups, respectively (P =.4). CONCLUSIONS: Colonic interposition is a more complex procedure with increased morbidity, compared with gastric transposition. Overall mortality and survival, however, were similar to those for gastric transposition.     

Results of coronary artery bypass grafting in end-stage renal disease

We examined the results of coronary artery bypass grafting (CABG) in patients with end-stage renal disease and symptomatic ischemic heart disease who had significant arteriosclerotic narrowing of one or more coronary vessels between 1970 and 1984. Twenty-four such patients underwent bypass grafting, 20 dialysis patients and four who had been transplanted. Bypass grafting completely or partially relieved symptoms in 83%. The hospital mortality associated with this surgery for the 20 dialysis patients was 20% compared with a lower overall hospital mortality for bypass grafting in nondialysis patients of 1.3%. Greater hospital mortality was noted for patients over age 60 undergoing bypass grafting, 33.3% v 1.9% in nondialysis patients. In this study, the most significant factor associated with mortality was older age. We conclude that bypass grafting has an acceptable mortality in younger end-stage renal disease patients anticipating or having had renal transplantation, but it is associated with a high hospital mortality in older dialysis patients.     

Substernal gastric bypass of the excluded esophagus--results of an ill-advised operation

Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma was proposed as a method of providing maximum patient comfort with minimum morbidity. Our results with this operation in 37 patients are reviewed and indicate that the procedure carries unacceptable complication and mortality rates. Among our patients, there have been nine (24%) hospital deaths, seven (19%) anastomotic leaks, and six (17%) disruptions of the divided distal thoracic esophagus. Major postoperative complications have occurred in 59% of these patients. Only 15 (54%) of the 28 survivors were discharged swallowing within 3 weeks of operation, and 10 (36%) required hospitalization for 1 month or longer after operation. The average survival time in those leaving the hospital alive has been only 5.9 months. Only seven patients (25% of the survivors) have achieved good palliation with the bypass procedure. It is concluded that substernal gastric bypass of the excluded thoracic esophagus is too much of an operation for patients with unresectable tumors who have a life expectancy of only several months.     

Calcium antagonists are associated with reduced mortality after cardiac surgery: a propensity analysis

OBJECTIVES: Observational studies have questioned the effectiveness of perioperative calcium channel blockers but failed to correct for selection biases. We therefore performed a prospective observational cohort study of the effects of calcium channel blockers on cardiac surgical mortality. A propensity score technique was used for risk adjustment. METHODS: We identified 6619 patients who underwent nontransplant cardiac surgery at the Toronto General Hospital (Toronto, Ontario, Canada) between May 1999 and December 2001. Propensity scores for calcium channel blocker use were constructed for the entire sample and for the subgroup (n = 5222) that underwent coronary artery bypass grafting. The calcium channel blocker adjusted odds ratio for in-hospital mortality after cardiac surgery was determined by using multiple logistic regression and propensity matched-pairs analyses. A subgroup analysis was performed for patients who underwent coronary artery bypass grafting: the calcium channel blocker adjusted odds ratio for mortality was determined by using propensity score matched-pairs analyses. RESULTS: Calcium channel blockers were associated with significantly reduced cardiac surgical mortality after adjustment with both multiple logistic regression (odds ratio, 0.56; 95% confidence interval, 0.33-0.94; P =.028) and propensity score matched-pairs analyses (odds ratio, 0.56; 95% confidence interval, 0.32-0.98; P =.042). Calcium channel blockers were also associated with reduced mortality (odds ratio, 0.48; 95% confidence interval, 0.23-0.98; P =.044) among patients who underwent coronary artery bypass grafting. CONCLUSIONS: After adjustment for baseline differences, calcium channel blockers were associated with significantly reduced mortality after cardiac surgery. This benefit also extends to the subgroup that underwent coronary artery bypass grafting. A large randomized controlled trial of perioperative calcium channel blockers is therefore warranted.     

Intraaortic balloon pumping in patients undergoing coronary artery bypass grafting

Beneficial effect of preoperative intraaortic balloon pumping (IABP) treatment in high-risk patients who had open heart surgery have been demonstrated. The purpose of this study is to determine the impact of preoperative IABP use on survival in high-risk patients undergoing coronary artery bypass grafting (CABG). METHODS: Two hundred seventy-seven consecutive patients having CABG at our institution were reviewed. Patients having an IABP were identified retrospectively and grouped into one of 3 groups as follows. Group A (n = 14): preoperative IABP for high-risk urgent or elective cases. Group B (n = 26): preoperative IABP for emergency cases. Group C (n = 6): unplanned intraoperative or postoperative IABP. RESULTS: Forty-six patients had an IABP (16.6% of total). Parsonnet score in group B was significantly higher (p < 0.05). Length of operation for group C was significantly longer (p < 0.05). Overall hospital mortality in the total group of 277 cases was 4.2%. Hospital mortality was 7.1% in group A, 7.7% in group B, and 50% in group C. Hospital mortality in group C was significantly higher (p < 0.01). CONCLUSIONS: The beneficial effect of preoperative treatment with IABP in high-risk patients undergoing CABG was confirmed. This approach resulted in a significantly lower hospital mortality.     

Salvage esophagectomy for recurrent tumors after definitive chemotherapy and radiotherapy.

OBJECTIVES: Some patients and oncologists choose to treat localized esophageal cancer with definitive chemotherapy and radiation therapy rather than surgery. A subset of these patients have local relapse without distant metastases and therefore have no other curative intent treatment option but salvage esophagectomy. METHODS: We reviewed our experience with salvage esophagectomy from 1987 to 2000 at M.D. Anderson Cancer Center (n = 13, salvage after chemotherapy and radiotherapy group) and compared the data with those of patients receiving esophagectomy in a planned fashion 4 to 6 weeks after preoperative chemotherapy and radiation therapy (n = 99, preoperative chemotherapy and radiotherapy group). RESULTS: Increases in morbidity were seen after resection in the salvage after chemotherapy and radiotherapy group relative to the preoperative chemotherapy and radiotherapy group: mechanical ventilation (9.0 days vs 3.3 days, P =.08), intensive care unit stay (11.2 days vs 5.1 days, P =.07), hospital stay (29.4 days vs 18.4 days, P =.03), and anastomotic leak rates (5/13 [39%] vs 7/99 [7%], P =.005). Operative mortality (within 30 days) also tended to be increased statistically nonsignificantly (2/13 [15%] vs 6/99 [6%], P =.2). Salvage esophagectomy resulted in long-term survival (25% 5-year survival) in a subset of patients. Improved survival after salvage esophagectomy was associated with early pathologic stage (T1 N0, T2 N0), prolonged time to relapse, and R0 surgical resection. CONCLUSION: Patients who undergo salvage esophagectomy for relapse of tumor after definitive chemoradiation therapy have increased morbidity, mortality, and hospital use relative to patients undergoing planned esophagectomy after preoperative chemoradiation. Nevertheless, long-term survival can be achieved in this group, and such treatment should be considered for carefully selected patients at an experienced center.