Limited survival in patients with carcinomatosis from foregut malignancies after cytoreduction and continuous hyperthermic peritoneal perfusion

Peritoneal carcinomatosis is a frequent mode of metastasis in patients with gastric, duodenal, or pancreatic cancer. Survival in this setting is short and therapeutic options are limited. This analysis examines the outcomes of 18 patients treated with operative cytoreduction and continuous hyperthermic peritoneal perfusion. Eighteen patients (6 males and 12 females) with gastric (n = 9), pancreatic (n = 7), or duodenal (n = 2) cancer were treated on protocol. Patients underwent optimal cytoreduction (complete gross resection, 11; minimal residual disease, 7) and a 90-minute perfusion with cisplatin. Clinical parameters and tumor and treatment characteristics were analyzed. Survival curves were estimated using the Kaplan-Meier method. Procedures included gastrectomy (n = 8), pancreaticoduodenectomy (n = 3), and hemicolectomy (n = 2). After cytoreduction, patients had no evidence of residual disease (n = 11), fewer than 100 implants less than 5 mm (n = 1), more than 100 implants between 5–10 mm (n = 3), or multiple implants with greater than 1 cm (n = 3). Five patients received a postoperative intraperitoneal dwell with 5-fluorouracil and paclitaxel. There was one perioperative mortality, and complications occurred in 10 patients. The median progression-free survival was 8 months (mean, 10 months; range, 1–47 months) with a median overall survival of 8 months (mean, 18 months; range, 1–74 months). In this cohort, peritoneal perfusion with cisplatin used to treat foregut malignancies has a high incidence of complications and does not significantly alter the natural history of the disease. Investigation of novel therapeutic approaches should be considered. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

Laparoscopic nissen fundoplication for treating reflux in lung transplant recipients

Gastroesophageal reflux disease may contribute to pulmonary injury and the development of bronchiolitis obliterans syndrome in lung transplant patients. As a result, such individuals are increasingly likely to undergo corrective gastrointestinal surgery. The present study collected outcome data for 28 lung transplant patients with documented reflux who underwent an uncomplicated laparoscopic Nissen fundoplication at our institution. The results were compared to data from 63 nontransplant reflux patients who had undergone the procedure over the same time period. All Nissen fundoplications were conducted by the same surgeon. There were no intraoperative or perioperative deaths in either patient group. Operative parameters did not differ but the postoperative hospital stay was significantly greater for the lung transplant patients (P < 0.05). Seven transplant patients (25%) were readmitted within 30 days compared to two readmissions (3.2%) in the reflux group. Five transplant patients (17.9%) have died, all from pulmonary complications; on average, death occurred 15.5 months after the Nissen surgery. There have been no deaths in the reflux group. These data indicate that laparoscopic Nissen fundoplication can be performed on lung transplant recipients to treat reflux. The average hospital stay is longer and there are more frequent readmissions in this population, but this does not appear to be due to any Nissen-related morbidity. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation). Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Pancreas-sparing duodenectomy is effective management for familial adenomatous polyposis

Duodenal adenocarcinoma remains the leading cause of cancer death in familial adenomatous polyposis patients following colectomy. Stratification based on Spigelman’s criteria provides a means for determining therapy. Spigelman stage IV patients have been selected for pancreas-sparing duodenectomy. Twentyone patients underwent resection between 1992 and 2004, with a mean age of 58 ±11 years. The mean time from colectomy to duodenectomy was 27 ±13 years. Invasive cancer was found in the distal duodenum in one patient. Operative time averaged 327 ±61 minutes with a mean blood loss of 503 ± 266 ml. There was no mortality, and eight patients (38%) had 14 complications: six (29%) with delayed gastric emptying, four (19%) with biliary/pancreatic anastomotic leak, one with pancreatitis, and one with wound infection. There were two reoperations: one for delayed gastric emptying and one for an early biliary leak. Mean length of stay was 15 ±10 days. Two late complications occurred: a stomal ulcer and an intestinal obstruction at 48 and 24 months, respectively. Mean follow-up was 79 months (range, 3–152 months). Two patients developed polyps in the advanced jejunal limb and were endoscopically treated. Pancreassparing duodenectomy represents a definitive treatment for advanced duodenal polyposis and can obviate the need for pancreaticoduodenectomy. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

Frequency With Which Surgeons Undertake Pancreaticoduodenectomy Continues to Determine Length of Stay,Hospital Charges,and In-Hospital Mortality

Introduction This study was undertaken to determine changes in the frequency of, volume of, and outcomes after pancreaticoduodenectomy 6 years after a study denoted that, in Florida, the frequency and volume of pancreaticoduodenectomy impacted outcome. Methods Using the State of Florida Agency for Health Care Administration database, the frequency and volume of pancreaticoduodenectomy was correlated with average length of hospital stay (ALOS), in-hospital mortality, and hospital charges for identical periods in 1995–1997 and 2003–2005. Results Compared to 1995–1997, 88% more pancreaticoduodenectomy was performed in 2003–2005 by 6% fewer surgeons; the majority of pancreaticoduodenectomies were conducted by surgeons doing <1 pancreaticoduodenectomy every 2 months. In-hospital mortality rate did not decrease from 1995–1997 to 2003–2005 (5.1 to 5.9%); in-hospital mortality rate increased for surgeons undertaking <1 pancreaticoduodenectomy every 2 months (5.5 to 12.3%, p < 0.01). For 2003–2005, frequency with which pancreaticoduodenectomy is conducted inversely correlates with ALOS (p = 0.001), hospital charges (p = 0.001), and in-hospital mortality (p = 0.001). Conclusions In Florida, more pancreaticoduodenectomies are carried out by fewer surgeons. Mortality has not decreased because of surgeons infrequently performing pancreaticoduodenectomy. Most pancreaticoduodenectomies are still undertaken by surgeons who conduct pancreaticoduodenectomy infrequently with greater lengths of stay, hospital costs, and in-hospital mortality rates. To an even greater extent than previously documented, patients are best served by surgeons frequently performing pancreaticoduodenectomy. Presented at the 2007 Annual Meeting of the American Hepato-Pancreato-Biliary Association, April 19–22, 2007, Las Vegas, Nevada.     

Recurrent Pyogenic Cholangitis with Hepatolithiasis—The Role of Surgical Therapy in North America

Purpose To determine role of surgical intervention for Recurrent Pyogenic Cholangitis with hepatolithiasis at a North American hepatobiliary center. Methods Retrospective analysis of 42 patients presenting between 1986 and 2005. Results Mean age is 54.3 years (24–87). Twenty-seven patients (64%) underwent surgery, after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous intervention in 19/27 patients. Surgical procedures were: 10 common bile duct explorations with choledochojejunostomy and a Hutson loop and 17 hepatectomies (10 with, 7 without Hutson loop). Liver resection was indicated for lobar atrophy or stones confined to single lobe. Operative mortality was zero; complication rates for hepatectomy and common bile duct exploration were comparable (35% vs. 30%). Median follow-up was 24 months (3–228). Of 21 patients with Hutson loops, only seven (33%) needed subsequent loop utilization, with three failures. At last follow-up, 4/27 (15%) surgical patients had stone-related symptoms requiring percutaneous intervention, compared to 4/11 (36%) surviving nonoperative patients. Cholangiocarcinoma was identified in 5/42 (12%) patients; four were unresectable and one was an incidental in-situ carcinoma in a resected specimen. Conclusion Surgery is a valuable part of multidisciplinary management of recurrent pyogenic cholangitis with hepatolithiasis. Hepatectomy is a useful option for selected cases. Hutson loops are useful in some cases for managing stone recurrence. Cholangiocarcinoma risk is elevated in this disease. Presented at the 2007 Annual Meeting of the American Hepato-Pancreatico-Biliary Association, Las Vegas, Nevada, April 22, 2007.     

Minimally invasive esophagectomy for cancer: laparoscopic transhiatal procedure or thoracoscopy in prone position followed by laparoscopy?

Background Minimally invasive esophagectomy is rapidly emerging as a suitable surgical alternative to the open technique. This retrospective comparative study aimed to compare two minimally invasive techniques for esophagectomy: transhiatal laparoscopy with intrathoracic or cervical anastomosis (group A) and right thoracoscopy in prone position followed by laparoscopy and left cervicotomy (group B) performed by the same surgeon (G.B.C.). The operative time, perioperative blood loss, intensive care and total hospital stays, peri- and postoperative morbidity, in-hospital mortality, number of lymph nodes dissected, and survival were the outcome measures. Methods Between April 1999 and August 2005, 24 patients (group A) and 15 patients (group B) underwent minimally invasive esophagectomy for cancer in the authors’ department. Their median age was 61 years in group A and 61 years in group B. Preoperatively, the endoscopic location of the tumor was in the upper third in 2 cases (1 vs 1), the middle third in 11 cases (7 vs 4), and the lower third in 26 cases (16 vs 10). Two patients in each group received neoadjuvant chemo- and radiotherapy. One patient (group A) and two patients (group B) received only neoadjuvant chemotherapy, and three patients (group A) received only neoadjuvant radiotherapy. Results The median operative time was 300 min (range, 240–420 min) in group A and 377 min (range, 240–540 min) in group B (nonsignificant difference [NS]). The median perioperative bleeding was 325 ml (range, 100–800 ml) in group A and 700 ml (range, 100–2,400 ml) in group B (NS). The perioperative complications included one splenectomy in each group and one conversion to thoracotomy in group B. The postoperative medical complications totaled three in group A and six in group B. The postoperative surgical complications included one hemoperitoneum, one pneumothorax, five anastomotic leaks, and two recurrent laryngeal nerve paralyses in group A and two tracheal necroses, four anastomotic leaks, one colic fistula, and three recurrent laryngeal nerve paralyses in group B. The median intensive care unit (ICU) stay was 5 days (range, 2–70 days) for group A and 5 days (range, 1–180 days) for group B (NS). The median hospital stay was 12 days (range, 7–98 days) for group A and 14 days (range, 7–480 days) for group B (p = 0.05). The early mortality rate was 0%. All the specimens were free of disease. The median number of mediastinal/periesophageal lymph nodes was 3 (range, 1–10) for group A and 4 (range, 2–13) for group B (NS), and the median number of celiac/perigastric lymph nodes was 11 (range, 2–31) for group A and 10 (range, 3–22) for group B (NS). After a median follow-up period of 42.4 months (range, 2–84 months) for group A and 19.1 months (range, 1.5–34 months) for group B, 12 patients in group A died after a median period of 22 months (range, 2–55 months), and 7 patients in group B died after a median time of 15 months (range, 1.5–23 months). Conclusions This retrospective comparative study showed that minimally invasive esophagectomy performed by thoracoscopy in the prone position is comparable with laparoscopic transhiatal esophagectomy in terms of the significant postoperative and survival outcomes. Paper presented at the Annual Meeting of the Society of American Gastrointestinal Endoscopic Surgeons, (SAGES), Las Vegas, Nevada, 19–22 April 2007.     

Bariatric surgery at the extremes of age

The safety and efficacy of bariatric surgery in adolescents and especially in Medicare population have been challenged. Our aim was to determine short-term (30-day) and long-term outcomes of bariatric surgery in patients ⩾60 years and ⩽18 years old. Query of our 20-year bariatric surgery database identified 155 patients ⩾60 years and 12 patients ⩽18 years. We determined morbidity and mortality rates and sent a questionnaire to all surviving patients; 127 of 139 survivors ⩾60 years and all 12 adolescents returned the questionnaire (92%) at a mean of 5 years (range 1–19 years). For patients ⩾60 years, 30-day mortality was 0.7%, serious morbidity delaying discharge was 14%, and 5-year mortality was 5%. At a mean of 5 years, body mass index (BMI in kg/m²) decreased from a mean (±SEM) of 46±1 to 33±1 with a 51% resolution of weight-related comorbidities and an 89% subjective overall satisfaction rate. In patients ⩽18 years, all with serious comorbidities, there were no deaths and no serious complications. BMI decreased from 55 (range 39–74) to 36 (range 27–53) at 4 years (range 1–8 years). Resolution of weight-related comorbidities was 82%, and satisfaction with outcome was 83%. Thirty-day hospital mortality (<1%) and 5-year mortality (5%) were much lower than reported previously in the senior population, with acceptable morbidity and importantly, with satisfactory outcomes. Bariatric surgery is safe and effective at high volume centers for patients with morbid obesity at both extremes of age. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, May 20–25, 2005.     

Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors

Myogenic neoplasms of the stomach are the most common submucosal mass. Their natural history is indeterminate, and surgical resection is advised regardless of size. These lesions have typically required open resection, but a variety of laparoscopic techniques have been described. We report results of endoscopically guided, laparoscopic intragastric resection. Fourteen lesions have been excised in 13 patients in the last 3.5 years. There were eight women and five men with a mean age of 57 years (range 34—72). All patients were asymptomatic, and no lesions had mucosal ulceration. Eight lesions were located at the gastroesophageal junction, two each at the incisura and posterior body, and one each in the fundus and anterior wall of the corpus. All lesions were predominantly intraluminal, and three were transmural. The diagnosis of a myogenic lesion was confirmed by endoscopic ultrasound in eight patients. The laparoscopic/endoscopic technique included two or three, 2 or 5 mm intragastric trocars; endoscopic suture passage and specimen removal; and laparoscopic intragastric suture repair of the gastric defect. The mean operative time was 186 minutes. The mean size of the resected specimens was 3.8 cm (range 1.5-7.0). There was no mitotic activity on histopathology, and all were considered pathologically benign. The median length of stay was 3.8 days (range 3–8). There was no mortality or operative morbidity. At a mean follow-up of 16.2 months (range 1–32) there has been no local recurrences. A combined laparoscopic/endoscopic intragastric resection is most appropriate for intraluminal, benign-appearing submucosal lesions of the proximal stomach. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (poster presentation).     

Intramedullary Kirschner wire (K-wire) fixation of femoral fracture in children

Purpose The aim of this study was to evaluate the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of femoral shaft fracture in children. Methods We report the results of intramedullary K-wires nailing in 178 children with a mean age of 7.7 years (range, 4–14 years) from 2000 to 2005, retrospectively. A total of 184 diaphyseal femoral fractures were treated with both antegrade and retrograde nailing using the same principles of elastic stable intramedullary nailing (ESIN). The patients were followed for 12 months on average (range, 6–24 months). Results No major complication (limb length discrepancy >15 mm, non-union, avascular necrosis, knee joint stiffness) occurred during the observation period. All fractures healed within 7.1 weeks on average (range, 5–12 weeks). Associated injuries were seen in 16.9% of the cases. All but seven fractures were reduced by closed manipulation. Early mobilization and weight bearing was allowed. Intramedullary K-wires were removed after an average of 4.8 months (range, 3–12 months) without any complications. Conclusions In children, intramedullary fixation by using standard K-wires provides effective treatment for the diaphyseal femoral fracture that has excellent clinical results. Each intramedullary K-wire costs US $5, which adds a cost effective advantage to this method of treatment.     

An initial evaluation of pelvic floor function and quality of life of bladder exstrophy patients after ureterosigmoidostomy

Classic bladder exstrophy is characterized by displaced pelvic floor musculature and significant skeletal and genitourinary defects. A paucity of data exist evaluating long-term pelvic floor function in exstrophy patients after ureterosigmoidostomy. This study is an initial attempt to evaluate the prevalence of urofecal incontinence, pelvic organ prolapse, and overall quality of life in patients who have had ureterosigmoidostomies. Fifty-two individuals who underwent ureterosigmoidostomy between 1937 and 1990 were identified through the Ureterosigmoidostomy Association and the Johns Hopkins bladder exstrophy database and mailed questionnaires approved by the Institutional Review Board (Johns Hopkins). Data were analyzed with SigmaStat 3.0 (SPSS, Inc., Chicago, IL). Eighty-three percent of the subjects responded, with a mean age of 44.4 years (range, 14–73 years) and mean of 40.9 years (range, 14–65 years) after ureterosigmoidostomy. Prevalence of daily urinary and fecal incontinence was 48% (n = 20) and 26% (n = 11), respectively, whereas the prevalence of weekly combined urofecal incontinence was 63% (n = 27). The incidence of pelvic organ prolapse in this cohort was 48% (n = 20). In these patients, a significant risk of urofecal incontinence and pelvic organ prolapse exists. Long-term follow-up studies are needed to understand the role of pelvic floor musculature in this complex birth defect. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–19, 2005 (poster presentation).     

Positive VEGF Immunostaining Independently Predicts Poor Prognosis in Curatively Resected Gastric Cancer Patients: Results of a Study Assessing a Panel of Angiogenic Markers

Angiopoietin-2 (Ang-2) and vascular endothelial growth factor (VEGF) contribute to gastric cancer aggressiveness by up-regulating the expression of proteases. We evaluated the expression and the prognostic significance of angiogenic factors and proteases in 148 patients with R0-resected gastric cancer. Expression of VEGF, Ang-2, cyclooxygenase-2 (COX-2), urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1, matrix metalloproteinases (MMP)-1 and -9 were assayed by immunohistochemistry. After a mean of 63 ± 4 months, 81 out of 148 patients had died due to disease. The probability of being free of recurrence was 62, 48, and 42% at 2, 5, and 10 years, respectively. Single bivariate analysis identified VEGF, Ang-2, COX-2, PAI-1, and MMP-9 expression, along with several clinicopathological parameters (grade of curability, lymph node ratio, pTNM, pT, pN), as variables associated with both decreased disease-specific survival and recurrence. On multivariate analysis, after adjusting for significant clinical covariables, positive VEGF immunostaining was the primary prognostic factor, and no other tumor marker variable could add any significant improvement for the prediction, for both disease-specific survival (p = 0.001; HR, 3.27; 95% CI, 1.76 to 6.10) and tumor recurrence (p = 0.002; HR, 2.81; 95% CI, 1.48 to 5.35). Our study suggests that VEGF alone may be clinically useful for establishing therapeutic decisions in gastric cancer patients. Presented in part at the 41st Annual Meeting of the American Society of Clinical Oncology, Orlando, Fl, May 13–17, 2005 (poster presentation). óscar Vidal, Antonio Soriano-Izquierdo, contributed equally to this work.     

The Survival Benefit to Patients with Positive Sentinel Node Melanoma After Completion Lymph Node Dissection May Be Limited to the Subgroup with a Primary Lesion Breslow Thickness Greater Than 1.0 and Less Than or Equal to 4 mm (pT2–pT3)

Background  The survival benefit of sentinel node biopsy is still controversial. The aim of our study was to assess the overall survival (OS; calculated both from the date of primary tumor excision and lymph node dissection) data from two large groups of AJCC 2002 stage-III cutaneous melanoma patients—after completion lymph node dissection (CLND after positive sentinel node biopsy) and after therapeutic LND (TLND for clinically/cytologically detected regional lymph node metastases). Materials and Methods  We analyzed the outcomes for 544 consecutive patients, who underwent CLND (47.4%; 258 patients) or TLND (52.6%; 286 patients) at one institution between December 1994 and January 2005. There were no significant differences between the two groups in terms of age and gender distribution and in the parameters of the primary tumor. Median follow-up time was 36 months (range 6–110 months). Results  We found no significant differences in OS (from the date of primary tumor excision) between CLND and TLND patients in the groups with primary tumor thicknesses of 1.0 mm or less or greater than 4.0 mm (pT1 and pT4); however, in patients with thicknesses greater than 1.0 mm and 4.0 mm or less (in subgroups pT2 and pT3), we found significantly better OS for CLND than for TLND patients—CLND: median OS not reached, 5-year OS was 57.2% (95%CI: 44.4–70.1%); TLND: median OS 42.1 months, 5-year OS was 37.9% (95%CI: 26.5–49.2%) (P = 0.0006). In the entire CLND and TLND groups, the median OS and 5-year OS rates were 60.5 months and 52.5% (95%CI: 45.6–61.5%) and 38.2 months and 39.5% (95%CI: 32.7–46.5%), respectively. Based on multivariate analysis, we have found that in the CLND group the important factors negatively influencing OS (from the date of lymphadenectomy) are: male gender, features of primary tumor (higher Breslow thickness and presence of ulceration) and features of nodal metastases (extracapsular invasion and number of involved nodes). In the TLND group, however, the negative prognostic factors are: male gender and features of nodal metastases (extracapsular invasion and number of involved nodes) without the impact of primary tumor characteristics. Conclusion  The results of the study demonstrate that the survival benefit after positive sentinel node biopsy with subsequent CLND is probably limited only to the subgroup of patients with primary tumor thicknesses not larger than 4 mm and not less than 1 mm when compared with lymph node dissection of palpable nodes. The primary tumor features have no impact on survival after lymphadenectomy performed for clinically involved nodes. The study was presented as an oral presentation during the 61^st Annual Cancer Symposium of the Society of Surgical Oncology; March 13–16, 2008, Chicago, IL.     

Prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: Seven-year follow-up

Laparoscopic Nissen fundoplication and proton pump inhibitor (PPI) therapy are both established treatments for gastroesophageal reflux disease (GERD). We have performed a prospective randomized study comparing these two treatments and now have long-term follow-up data. Between July 1997 and August 2001, 183 patients in Norwich took part in a randomized controlled trial comparing laparoscopic Nissen fundoplication and PPI therapy for the treatment of GERD. In October 2005, patients were followed up and asked to complete a reflux symptom questionnaire. Ninety-one patients were randomized to have surgery and 92 to have optimized PPI therapy. After 12 months, those who had been randomized to PPI were offered the opportunity to have surgery. Fifty-four patients went on to have antireflux surgery; the remaining 38 did not. In all three groups, there was a significant improvement in symptom score after the initial 12 months (P<0.01; Mann-Whitney U test). However, those who later had surgery despite having had optimal PPI treatment beforehand experienced further symptomatic improvement (P<0.01) at long-term follow-up (median 6.9 years, range, 4.3–8.3). Both optimal PPI therapy and laparoscopic Nissen fundoplication are effective treatments for GERD. However, surgery offers additional benefit for those who have only partial symptomatic relief whilst on PPIs. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006 (oral presentation).     

Long-term results of conventional myotomy in patients with achalasia: A prospective 20-year analysis

Myotomy has proved to be an efficient primary therapy in patients with achalasia, especially in younger patients (<40 years of age). The results of laparoscopic myotomy cannot be finally assessed, on account of the shorter postoperative follow-up. Thus, there are considerable data regarding intermediate-term outcomes after laparoscopic myotomy. The aim of our study was a 20-year analysis of the conventional cardiomyotomy as the underlying basis assessing the results of minimal-invasive surgery. Within 20 years (September 1985 through September 2005), 161 operations for achalasia were performed in our clinic. Enrolled in this study were 108 patients with a conventional, transabdominal myotomy in combination with an anterior semifundoplication (Dor procedure) and a minimal follow-up of 6 months. All patients were prospectively followed and, in addition to radiologic and manometric examinations of the esophagus, the patients were asked for their clinical symptoms by structured interviews in 2-year intervals. The median age at the time of surgery was 44.5 (range, 14–78) years, and 72.2% of the patients were males. The median length of the preoperative symptoms was 3 years (3 months to 50 years), and the postoperative follow-up was 55 (range, 6-206) months. In 70 (64.8%) patients, a pneumatic dilation had been performed. The preoperative Eckardt score of 6 (range, 2–12) could be reduced to 1 (range, 0–4) after myotomy (P<0.0001). Consequently, with 97.2% of all patients, a good-to-excellent result was achieved in the long-term follow-up, corresponding to a clinical stage I-II. Postoperatively, 69 patients (63.9%) gained weight. The radiologically measured maximum diameter of the esophagus decreased from preoperatively 45 (range, 20–75) mm to postoperatively 30 (range, 20–60) mm, while the minimum diameter of the cardia increased from 3.4 (range, 1–10) mm to 10 (range, 5–15) mm. The resting pressure of the lower esophageal sphincter could be reduced from 28.4 (range, 9.4–56.0) mm Hg to 8.6 (range, 3.0–22.5) mm Hg. Conventional myotomy leads in the long run with high efficiency to an improvement of the symptoms evident in achalasia. These results may be regarded as the basis for assessment of the minimal-invasive procedure.     

Outcome of carpal tunnel decompression: the influence of age,gender, and occupation

The aim of this study was to investigate the effect of age, gender, and occupation on the outcome of carpal tunnel decompression. A total of 479 patients (342 females, 137 males) with a mean age of 56 years undergoing 608 carpal tunnel decompressions were prospectively studied. Outcome was assessed using the Brigham Hospital carpal tunnel questionnaire at two weeks pre-operatively and six months post-operatively. Cases were divided into four age categories (less than 40 years of age, 40–59, 60–79, and over 80 years of age) and two occupation (repetitive and non-repetitive) groups. The mean differences for both the symptom-severity and functional-status scores amongst the four age categories were similar and no significant difference was found. The mean differences for both the symptom-severity and functional-status scores between females and males and the two occupation groups were similar and no significant differences were found. The majority of the patient’s symptoms improved following carpal tunnel decompression. However, we found no influence of age, gender, or occupation on the outcome of carpal tunnel decompression in our series of patients.     

Surgical Management of Hepatocellular Adenoma: Take It or Leave It?

Background  Hepatocellular adenoma (HA) is a rare benign tumor of the liver. Surgical resection is generally indicated to reduce risks of hemorrhage and malignant transformation. We sought to evaluate clinical presentation, surgical management, and outcomes of patients with HA at our institution. Methods  We performed a retrospective review of 41 patients who underwent surgical resection for HA between 1988 and 2007. Results  Thirty-eight patients were women, and the median age at presentation was 36 years (range, 19–65 years). The most common clinical presentation was abdominal pain (70%) followed by incidental radiological finding (17%). Twenty-two patients had a history of oral contraceptive use. Median number of HA was one (range, 1–3). There were 32 open cases (3 trisectionectomy, 15 hemihepatectomy, 7 sectionectomy, 4 segmentectomy, and 3 wedge resection), and 9 laparoscopic cases (1 hemihepatectomy, 5 sectionectomy, 1 segmentectomy, and 2 wedge resection). The median estimated blood loss was 225 mL (range, 0–3400 mL). The median length of stay was 6 days (range, 1–15 days). Surgical morbidities included pleural effusion requiring percutaneous drainage (n = 2), pneumonia (n = 1), and wound infection (n = 1). There was no perioperative mortality. Twelve patients had hemorrhage from HA. Hepatocellular carcinoma was observed in two patients with HA. Median follow-up was 23 months (range, 1–194 months), at which time all patients were alive. Conclusion  In view of 29% hemorrhagic and 5% malignant complication rates, we recommend surgical resection over observation if patient comorbidities and anatomic location of HA are favorable. A laparoscopic approach can be safely used in selected cases. Presented at Society of Surgical Oncology 61st Annual Cancer Symposium, Chicago, Illinois, March 13–16, 2008.     

The influence of positive peritoneal cytology on survival in patients with pancreatic adenocarcinoma

The American Joint Committee on Cancer (AJCC) staging system for pancreatic adenocarcinoma classifies positive peritoneal cytology as stage IV disease. Data are limited with respect to the prevalence of positive peritoneal cytology and its influence on survival in patients with resectable, locally advanced, and metastatic disease. Four hundred sixty-two patients underwent staging laparoscopy for pancreatic adenocarcinoma between January 1995 and December 2005. Kaplan-Meier survival comparisons were performed to evaluate the significance of positive peritoneal cytology on overall survival (OS) in resected patients and patients with locally advanced and metastatic disease. Of the 462 patients, 47% (217/462) underwent a pancreatic resection. The 21% (95/462) with locally advanced disease and 32% (150/462) with metastatic disease did not undergo resection. Peritoneal cytology was positive in 17% (77/462), and was associated with stage of disease (metastatic, 37%; locally advanced, 11%; resected, 5%; P=0.01). Positive cytology was not associated with OS in patients with metastatic disease or locally advanced disease, but was in resected patients (median, 16 months vs. 8 months; P<0.001). Node-positive disease was present in 8 of 10 patients resected with positive cytology (2 years OS, 12% positive cytology vs. 23% negative; P=0.006). In this study, patients who underwent resection in the presence of positive peritoneal cytology and absence of other identifiable metastatic disease had a similar survival as other patients with stage IV disease. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006 (poster presentation).     

Microwave ablation of hepatic tumors using dual-loop probes: Results of a phase I clinical trial

Hepatic tumors are a common cause of death worldwide. However, few patients are candidates for resection at the time of presentation. Microwave ablation is a viable alternative available for these patients. To date, only straight antennas are used for microwave ablation. Recently, a prototype loop-shaped microwave antenna was developed that, in animal studies, more effectively kills tumors. For this study, the dualprobe lesions were created by placing the probes in both tumors and normal livers. Lesions were created with 60 watts applied power for 5–7 minutes. The livers were sectioned and stained for viability. The average ablation volume was 63.9 ±8.7 cm³. Microwave ablation with the loop probes results in complete tumor kill at the ablation/tumor interface, and adjacent to surrounding blood vessels. In addition, vessels within the ablation/tumor interface failed to show viable cells. The shape of the lesions was not distorted by proximity to blood vessels. The advantages of this configuration over conventional straight probes include the ability to encircle a tumor, deliver large amounts of precisely targeted microwave energy to the tumor, and spare normal liver outside the loop. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

Benchmarking hospital outcomes for laparoscopic adjustable gastric banding

Background Since the Food and Drug Administration (FDA) approval of laparoscopic adjustable gastric bands (LAGB) in June 2001, the number LAGB procedures performed in the United States has increased exponentially. This study aimed to benchmark the authors’ initial hospital experience to FDA research trials and evidence-based literature. Methods Over a 2-year period, 87 consecutive patients with a mean age of 43 years (range, 21–64 years) and a body mass index of 45.6 kg/m² (range, 35–69 kg/m²) underwent an LAGB procedure at the authors’ institution. The authors conducted a retrospective review of the outcomes including conversion, reoperation, mortality, perforation, erosion, prolapse, port dysfunction, excess weight loss, and changes in comorbidities, then compared the data with published benchmarks. Results Gender, age, and body mass index were comparable with those of other series. Perioperative adverse events included acute stoma obstruction (n = 1) and respiratory complications (n = 2). Delayed complications included gastric prolapse (n = 4) and port reservoir malposition (n = 4). Five bands were explanted. The mean follow-up period was 14 months (n = 79). The mean percentage of excess weight loss was 30% (range, 4.7–69%) at 6 months, 41% (range, 9.6–82%) at 12 months, and 47% (range, 14–92%) at 24 months. Comorbidities resolved included diabetes (74%), hypertension (57%), gastroesophageal reflux disease (55%) and dyslipidemia (38%). Conclusions The short-term outcomes for LAGB were comparable with published benchmarks. With adequate weight loss, most patients achieve significant improvement in obesity-related illnesses. With new bariatric accreditation standards and mandates required for financial reimbursement, hospitals will need to demonstrate that their clinical outcomes are consistent with best practices. The authors’ early experience shows that LAGB achieves significant weight loss with low mortality and morbidity rates. Despite a more gradual weight loss, most patients achieve excellent weight loss with corresponding improvement of comorbidities within the first 2 years postoperatively. Poster Presentation at Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Annual Meeting, Dallas, TX 2006     

Comparison of responsiveness of the Japanese Society for Surgery of the Hand version of the carpal tunnel syndrome instrument to surgical treatment with DASH, SF-36, and physical findings

Background The Japanese Society for Surgery of -the Hand version of the Carpal Tunnel Syndrome Instrument (CTSI-JSSH), which consists of two parts — one for symptom severity (CTSI-SS) and the other for functional status (CTSI-FS) — is a self-administered questionnaire specifically designed for carpal tunnel syndrome. The responsiveness of the CTSI-JSSH was compared with that of the JSSH version of the Disability of Arm, Shoulder, and Hand questionnaire (DASH), the official Japanese version of the 36-Item Short Form Health Survey (SF-36, version 1.2), and physical examinations to elucidate the role of the CTSI-JSSH for evaluating patients with carpal tunnel syndrome. Methods Preoperatively, a series of 60 patients with carpal tunnel syndrome completed the CTSI-JSSH, DASH, and SF-36. Results of physical examinations, including grip strength, pulp pinch, and static two-point discrimination of the thumb, index, and long fingers, were recorded. Three months after carpal tunnel release surgery the patients were asked to fill out the same questionnaires, and the physical examinations were repeated. The responsiveness of all the instruments was examined by calculating the standardized response mean (SRM) and effect size (ES). Correlation coefficients were calculated between questionnaire change scores and patient satisfaction scores as well as between the CTSI change scores and those of the DASH and SF-36. Results The largest responsiveness was observed in the CTSI-SS (SRM/ES: −1.00/−1.08) followed by the CTSI-FS (−0.76/−0.63), and bodily pain subscale of SF-36 (SF-36-BP, 0.45/0.55), and the DASH (−0.46/−0.47). Only the change scores of the CTSI-SS had significant correlation with patient satisfaction (r = 0.34, P < 0.01). An absolute value of Spearman's correlation coefficient of >0.5 was observed between the change scores of the CTSI-SS and the DASH, the CTSI-SS and the SF-36-BP, the CTSI-FS and the DASH, and the DASH and the SF-36-BP. Conclusion The CTSI-JSSH was proven to be more sensitive to clinical changes after carpal tunnel release than the other outcome measures and should be used to evaluate patients with carpal tunnel syndrome who speak Japanese as their native language.