Treatment of instrumental perforation of esophageal malignancy by transhiatal esophagectomy

Perforation of esophageal malignancy secondary to instrumentation is an uncommon but catastrophic complication. Esophageal perforation at the site of an obstructing esophageal malignancy precludes simple operative repair and mandates esophageal resection with reestablishment of gastro-intestinal tract continuity. In the past the standard surgical approach has involved transthoracic esophageal resection via thoracotomy. We have successfully treated four patients with perforated esophageal neoplasms by transhiatal esophagectomy and cervical esophagogastrostomy, thus avoiding thoracotomy in high-risk patients. We consider transhiatal esophagectomy an advantageous alternative in the management of selected cases of instrumental esophageal perforation adjacent to an esophageal malignancy.     

Survival after gastric adenocarcinoma resection: Eighteen-year experience at a single institution

Gastric adenocarcinoma is the second leading cause of cancer death worldwide. In Western series, survival rates vary widely and are generally lower than those reported from Eastern series. We performed a retrospective analysis of cases operated on at the Johns Hopkins Hospital over the past 18 years and collected data on demographics, tumor characteristics, pathologic stage, treatment methods, complications, survival time, and other relevant factors. Survival according to stage of disease, Lauren tumor type, tumorlocation,time period, andadministration of adjuvant therapy wasanalyzed, andresultswerecompared with those of other Western series. During this period, 436 patients with gastric adenocarcinoma underwent resection. We have shown a statistically significant association between survival and margin status, stage of disease, and Lauren tumor type. Overall 5-year survival was 26%, and 5-year survival after R0 resection was 33%. No significant difference was detected between survival and tumor location, time period of treatment, or administration of adjuvant therapy. Analysis of various Western series reveals major differences between the cohorts under study, such as stage of disease, extent of resection, tumor type, and tumor location. Many of the reported differences among Western series may be due to cohort differences, such as stage of disease, extent of resection, tumor type, and tumor location.     

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a combined endoscopic-operative technique for removing the gallbladder. Patients with symptomatic gallstones are eligible for this procedure. Contraindications include pregnancy, acute cholangitis, advanced cholecystitis, acute pancreatitis, peritonitis, significant bleeding disorder, portal hypertension, and a prior major upper abdominal operation. The procedure does require experience and specialized training. It is guided by an endoscope, camera, and video monitor, and is performed through four cannulas. The gallbladder is dissected from the hepatic bed under observation on a monitor. The possible complications are bleeding, injury to the common bile duct, and technical problems, such as perforation of the gallbladder. The length of the hospital stay and the postoperative recovery time are markedly shortened compared with standard cholecystectomy. The procedure has an advantage over stone dissolution and biliary lithotripsy in that the gallbladder is removed, and additional or continued treatment is not necessary. This procedure offers sufficient advantages to the patient that it will likely become a standard for qualified abdominal surgeons.     

Image-directed percutaneous biopsies with a biopsy gun

Core tissue for histologic study is believed by many pathologists to be more diagnostic than material from needle aspiration. Recently, a biopsy "gun" has been introduced, which simplifies core biopsies. With this device, 182 biopsies of multiple anatomic sites were performed with ultrasonic, computed tomographic, and fluoroscopic guidance and 18-gauge needles. High-quality histopathologic specimens were obtained in 177 of the biopsies, and diagnostic target tissue was obtained in 167. Only three significant complications occurred: one bleeding complication that required transfusion and two cases of pneumothorax that necessitated placement of chest tubes. The biopsy gun eliminated the disjointed movements of conventional "skinny" needle biopsies, and none of the samples demonstrated significant "crush" artifact or obscuring blood, problems that are commonly associated with manual biopsy techniques. Patient discomfort was decreased with this system compared with that of manual biopsies, and the total procedure time was reduced. Because of these distinct advantages, the authors now use the biopsy gun exclusively for all percutaneous biopsies and recommend that other institutions consider the use of this biopsy method.     

Assessment of the Long-Term Impact of Pancreatoduodenectomy on Health-Related Quality of Life Using the EORTC QLQ-PAN26 Module

Annals of Surgical Oncology - Long-term pancreatoduodenectomy (PD) survivors have previously reported favorable quality of life (QoL). However, there has been a paucity of studies utilizing...     

Osteosarcomatosis

A review of the 690 cases of osteosarcoma in the radiographic file of the Armed Forces Institute of Pathology revealed 29 cases of "osteosarcomatosis" (multiple skeletal sites of osteosarcoma). Fifteen of these patients were 18 years old and under and manifested rapidly appearing, usually symmetric, sclerotic metaphyseal lesions. The remaining 14 patients were more than 18 years old and had fewer, asymmetric sclerotic lesions. In most patients (28 of 29), a radiographically dominant skeletal tumor was seen. Pulmonary metastases occurred in the majority of patients and were detected at the same time as the bone lesions. These 29 patients were studied with regard to demographic data and skeletal distribution and radiographic appearance of their lesions. As a result of the findings, a metastatic origin from a primary dominant osteosarcoma is favored over a multifocal origin as the basis for osteosarcomatosis. Osteosarcomatosis is more commonly encountered in the mature skeleton than has been previously recognized.