Gamma probe guided biopsy of the sentinel node in malignant melanoma: a multicentre study.

Sentinel lymph node biopsy was attempted in 336 patients with clinically node-negative cutaneous melanoma. All patients were injected with technetium-99m labelled radiocolloid, with 108 patients simultaneously receiving vital blue dye for sentinel node identification. Sentinel lymph nodes were identified in 329 patients, giving a technical success rate of 97.9%. Metastatic disease was identified in 39 (11.9%) of the patients in whom sentinel nodes were found. Patients with negative sentinel nodes were observed and patients with positive sentinel nodes underwent comprehensive lymph node dissection. The presence of metastatic disease in the sentinel nodes and primary tumour depth by Breslow or Clark levels were joint predictors of survival based on Cox proportional hazards modelling. Disease recurrences occurred in 26 (8.8%) patients with negative sentinel lymph nodes, with isolated regional recurrences as the first site in 10 (3.4%). No patients with Clark level II primary tumours were found to have positive sentinel nodes or disease recurrences. One patient with a thin (<0.75 mm) Clark level III primary had metastatic disease in a sentinel node. Patients with metastases confined to the sentinel nodes had similar survival rates regardless of the number of nodes involved.

Parietal cell vagotomy for bleeding duodenal ulcers.

From January 1978 to December 1985, 22 parietal cell vagotomies for bleeding peptic ulcers were performed at the Charleston Area Medical Center. Twenty of these operations were done for acute bleeding with an overall complication rate of 27 per cent. There was only one operative mortality, and these results coincide with those of the world literature. Follow-up ranges from 1 month to 6 years with an average of 2 and one half years. Seventy-eight per cent of our patients had a good result defined as either Visick class I (ten patients) or Visick class II (four patients). All of the patients, with the exception of the one mortality, had control of the bleeding. Therefore, the authors believe parietal cell vagotomy should be considered in the treatment of acute bleeding peptic ulcer disease.

The value of sequential peritoneal profile in blunt abdominal trauma.

The performance of a laparotomy in hemodynamically stable patients with hemoperitoneum is based on the need to assess and control hemorrhage and to repair injuries assumed to be significant. This premise could be ignored in selected circumstances if injuries requiring intervention can be recognized early and with reasonable certainty. It is believed that a combination of traditional clinical parameters in conjunction with a modified and sequential lavage technique and a standard analysis of the effluent to include endotoxin, amylase, and corrected white blood cell determinations could increase the diagnostic accuracy in blunt abdominal trauma to permit safe observation of selected patients. Using this approach, 32 trauma victims with gross intraperitoneal blood were treated nonoperatively with no complications. In addition, four patients had gastrointestinal-pancreatic injuries detected in less than 12 hours despite negative clinical signs and red cell lavage counts.

The potential value of endotoxin-amylase detection in peritoneal lavage fluid.

Widespread acceptance of Limulus Amoebocyte Lysate testing in clinical situations has been elusive. The results obtained in this series of 38 patients seem to support the contention that the amylase-endotoxin complex can be of value in detecting rapidly and with reasonable sensitivity the presence of pancreatic injury and gastrointestinal perforations. A corrected WBC count appears to add diagnostic possibilities to the technique. Despite the promising evidence detailed in this paper, further studies are required to establish the true sensitivity/specificity of the test. Its validity and utility could be assessed rapidly if traumatologists who routinely perform lavage would utilize this method and report their findings.

Breast Cancer Cells in the Blood: A Pilot Study.

The goal of this pilot study was to determine in patients with operable breast cancer the incidence of breast cancer cells present in the blood, the clearance rate after surgical resection of the primary tumor, and the incidence of patients with persistent cancer cells in the blood after the primary tumor was removed. Twenty-one patients with operable breast cancer had 15 ml venous blood obtained twice prior to surgery and after surgery at 2, 4, 8, 12, 24, and 48 hours and also on days 7 and 14. Immunomagnetic selection of malignant cells was performed on each sample. Cells were then fixed on slides and immunocytochemistry performed on the collected cells. Cells that had a rosette of magnetic beads, cytoplasmic staining for keratin, and malignant morphology were counted as breast cancer cells. Eighteen of 19 of patients had cancer cells detected in at least one of the two blood samples preceding surgical removal of the primary tumor. The incidence of cancer cells in the blood of patients rapidly declined during the 48 hours postsurgery. The incidence of cancer cells in the blood remained stable in approximately 30% of patients to 14 days. The majority of breast cancer patients in this pilot study (even with small tumors and negative nodes) had detectable cancer cells in the blood prior to resection of the primary tumor. These findings justify further investigation. Successful application of this methodology may serve as a powerful indicator of which patients need systemic adjuvant therapy, the effectiveness of systemic adjuvant therapy, tumor recurrence, and early detection of breast cancer.

Long term follow-up of prophylactic caval clipping.

120 high risk patients who underwent prophylactic inferior vena cava clipping were retrospectively evaluated to determine the incidence of post clipping leg swelling and pulmonary embolism. Each one of those patients had at least two criteria for the clipping. These criteria of high risk factors were precisely identified. There were two patients who had postoperative pulmonary embolism but none of them was fatal, i.e. less than two per cent. Two patients developed severe leg swelling (less than two per cent) and six had mild leg swelling (less than six per cent). Prophylactic inferior vena cava clipping is a safe and effective mean to prevent post-operative pulmonary embolism.

Laparoscopic pelvic lymph node dissection.

Traditionally, cancer of the prostate has been staged by digital exam, ultrasound, CT scan, bone scan, prostatic acid phosphatase (PAP), and prostate specific antigen (PSA) determinations. These methods commonly lead to understaging, resulting in surgical or radiation therapy of questionable benefit. Pathologic staging, even though reliable and accurate, requires laparotomy with its associated morbidity and lengthy hospitalization/recovery period. Following national trends, we have recently introduced the technique of Laparoscopic Pelvic Lymph Node Dissection (LPND) at our institution. In July 1990 we performed the first LPND at CAMC (Memorial Division). This report details our experience with the first three patients treated in this manner and suggest that the procedure can be performed safely, effectively, and with a significant reduction in morbidity, thus allowing the surgeon to obtain an adequate specimen for pathologic staging. Possible cost containment, minimal discomfort, and little scarring are other advantages that appeal to both patients and surgeons alike.

Laparoscopic cholecystectomy.

In recent months, the technique of Laparoscopic Laser Cholecystectomy (LLC) was introduced at our institution. A small series is presented here involving 14 patients, seven of whom underwent LLC and seven in which a "mini-lap" cholecystectomy was performed. Symptomatic cholelithiasis was the indication for surgery in all cases, and operative cholangiograms were employed in 12 patients. Comparisons are made regarding length of hospitalization, recovery time and operative time. An improved recovery period is indeed demonstrated with LLC allowing return to normal activities and employment much sooner than with an open cholecystectomy. We suggest that, though some prudence and caution is advised, this appears to be a safe and feasible adjunct in the treatment of cholelithiasis.

Leiomyomas of the rectum and anal canal: report of six cases and review of the literature.

Since 1872, 168 rectal leiomyomas have been reported in the world literature. Their incidence, therefore, is very low. It is estimated that one leiomyoma may be seen for every 2,000 or more rectal tumors. Those leiomyomas located in the anal canal and sphincter are the rarest. A case is reported here that appears to be the eleventh in such a location. The incidence of these lesions is highest between the ages of 40 and 59 years. Most patients have a combination of symptoms rather than a single one, the most frequent of these being the presence of a mass, bleeding, and constipation. Almost always, the chain of events that leads to the diagnosis starts when the tumor is discovered by digital examination of the rectum. The lack of reliable criteria of malignancy and the marked tendency to recur shown by these tumors are the two main problems the surgeon faces when selecting the operative procedure to be used. We believe that those tumors with an original size of 5 cm or more in largest diameter are the ones that have shown the highest tendency to recur, mostly as sarcomas. Therefore it is thought that these lesions should be treated radically from the beginning, especially when they recur. More adequate follow-up studies are needed.

Laparoscopic Ripstein procedure.

An endolaparoscopic technique to perform a proctopexy is reported. This procedure appears to be ideally suited for this approach and, furthermore, it can be performed safely and effectively. Long-term predictions of morbidity, mortality and recurrence rates cannot yet be made, but those parameters might not be different from what would be expected with the open approach.

Hand-assisted laparoscopic splenectomy.

A method of performing a laparoscopic splenectomy with the aide of intraabdominal manipulation is described. We believe that this is a versatile technique that compares quite favorably with a pure cannula approach. It is likely that this approach is safer because vascular control can readily be assured by the intraabdominal operator. It is also less costly because it is more rapid than a procedure done solely by cannula techniques. Moreover, it is reproducible by an experienced general surgeon. The results appear equal in terms of access morbidity and hospitalization time to those seen with a purely laparoscopic approach. Experience with 21 splenectomies is described and compared with 20 others performed by the traditional open approach.

Blunt pelviperineal injuries. An expanded role for the diverting colostomy.

The combination of blunt pelvic and perineal injuries is relatively uncommon but carries with it a high morbidity and mortality. A colostomy with distal wash-out plays a significant role in the prophylaxis of septic complications, even in the absence of recognizable colorectal trauma. Among 14 patients with this type of injury, there were six deaths (42 per cent). Three patients died initially because of hemorrhage, and three late deaths were due to sepsis. Two of these patients had no colostomy, and one had a diversion without wash-out. The indications for proximal diversion should be broadened to include an expanded view of the perineum, herein presented.

Prophylactic inferior vena cava clipping in colonic surgery.

Incidental prophylactic inferior vena cava clipping (IVCC) has been used in 30 patients undergoing colonic operations. The results obtained compare quite favorably with other methods of preventing postoperative pulmonary embolism (PE). This procedure would be justified in patients with a postoperative PE risk greater than 5 to 10 per cent. Practical criteria to identify this group of patients are presented, and the value of utilizing a risk profile is emphasized. There is no mortality from the procedure itself, and the morbidity was limited to lower-extremity edema in three patients who otherwise could have been expected to develop PE. The edema lasted two months in one patient and cleared rapidly in the other two. Attesting to the procedure's effectiveness, there were no cases of recurrent PE. Caval partition is an appealing mode of prophylaxis in high-risk patients because of its safety, efficacy, and permanence.

Laparoscopic staging laparotomy with intra-abdominal manipulation.

We describe a method for performing laparoscopic staging laparotomy. We believe this minimally invasive approach can ease the transition between purely open and laparoscopic surgery, and it is applicable to a variety of intra-abdominal problems. The results are comparable to those of a standard staging laparotomy, with improvement in access morbidity and decreased hospitalization time.

Colonic surgery. The splenic connection.

Colonic resections, particularly those that require mobilization of the splenic flexure, occasionally will lead to injury of the spleen. Under these circumstances, the abdominal surgeon has traditionally considered incidental splenectomy to be the only safe alternative. Currently, a better understanding of splenic physiology and its role in sepsis prevention has reversed this trend. These efforts to preserve splenic function have resulted in various options available to the surgeon, herein reviewed. The results obtained in 36 general surgical patients with splenic injuries suggest that the salvage of the spleen is a safe alternative. In situations where salvage is impossible, the surgeon can resort to omental autotransplantation of the removed spleen, a recently described technique of appealing simplicity. The results obtained with this procedure in 23 other patients are presented.

The sentinel node in breast cancer--a multicenter validation study.

BACKGROUND: Pilot studies indicate that probe-guided resection of radioactive sentinel nodes (the first nodes that receive drainage from tumors) can identify regional metastases in patients with breast cancer. To confirm this finding, we conducted a multicenter study of the method as used by 11 surgeons in a variety of practice settings. METHODS: We enrolled 443 patients with breast cancer. The technique involved the injection of 4 ml of technetium-99m sulfur colloid (1 mCi [37 MBq]) into the breast around the tumor or biopsy cavity. "Hot spots" representing underlying sentinel nodes were identified with a gamma probe. Sentinel nodes subjacent to hot spots were removed. All patients underwent a complete axillary lymphadenectomy. RESULTS: The overall rate of identification of hot spots was 93 percent (in 413 of 443 patients). The pathological status of the sentinel nodes was compared with that of the remaining axillary nodes. The accuracy of the sentinel nodes with respect to the positive or negative status of the axillary nodes was 97 percent (392 of 405); the specificity of the method was 100 percent, the positive predictive value was 100 percent, the negative predictive value was 96 percent (291 of 304), and the sensitivity was 89 percent (101 of 114). The sentinel nodes were outside the axilla in 8 percent of cases and outside of level 1 nodes in 11 percent of cases. Three percent of positive sentinel nodes were in nonaxillary locations. CONCLUSIONS: Biopsy of sentinel nodes can predict the presence or absence of axillary-node metastases in patients with breast cancer. However, the procedure can be technically challenging, and the success rate varies according to the surgeon and the characteristics of the patient.