Intraoperative electron beam irradiation for patients with unresectable pancreatic carcinoma.

Since 1978 we have used electron beam intraoperative radiation therapy (IORT) to deliver higher radiation doses to pancreatic tumors than are possible with external beam techniques while minimizing the dose to the surrounding normal tissues. Twenty-nine patients with localized, unresectable, pancreatic carcinoma were treated by electron beam IORT in combination with conventional external radiation therapy (XRT). The primary tumor was located in the head of the pancreas in 20 patients, in the head and body in six patients, and in the body and tail in three. Adjuvant chemotherapy was given in 23 of the 29 patients. The last 13 patients have received misonidazole (3.5 mg/M2) just prior to IORT (20 Gy). At present 14 patients are alive and 11 are without evidence of disease from 3 to 41 months after IORT. The median survival is 16.5 months. Eight patients have failed locally in the IORT field and two others failed regionally. Twelve patients have developed distant metastases, including five who failed locally or regionally. We have seen no local recurrences in the 12 patients who have been treated with misonidazole and have completed IORT and XRT while 10 of 15 patients treated without misonidazole have recurred locally. Because of the shorter follow-up in the misonidazole group, this apparent improvement is not statistically significant. Fifteen patients (52%) have not had pain following treatment and 22 (76%) have had no upper gastrointestinal or biliary obstruction subsequent to their initial surgical bypasses and radiation treatments. Based on the good palliation generally obtained, the 16.5-month median survival, and the possible added benefit from misonidazole, we are encouraged to continue this approach.

Complications of intercostal nerve blocks performed under direct vision during thoracotomy: a report of two cases.

Intrathoracic intercostal nerve block is a well-described procedure used to provide postoperative pain relief following thoracotomy. The two cases described present possible complications secondary to such blocks and suggest that the routine use of intrathoracic intercostal nerve blocks should be discouraged.

The role of surgery on ambulatory patients in one teaching hospital.

The development of a program of one-day surgery for ambulatory patients in one hospital was stimulated by overloaded operating room facilities and a long waiting list of patients for hospital admission. This concept has received enthusiastic reception by the surgical staff and the number of operations has increased to over 7,500 per year. All of the surgical specialty services use the surgical day care unit, although the number of cases suitable for ambulatory surgical treatment varies greatly on the various services. There have been no deaths and about 1% of patients have been admitted to the hospital from the surgical day care unit for a variety of reasons that are summarized.

Effects of pentolinium on blood sugar and serum potassium concentrations during anaesthesia and surgery.

Blood surgar and serum potassium (K+) concentrations were measured before, during and 60 min after surgery in two groups of 10 non-diabetic patients during nitrous oxide/halothane/tubocurarine anaesthesia. In the control group the arterial pressure was maintained within the patients' normal ranges, while in the study group pentolinium was administered i.v. (average 22 mg per patient) to achieve and maintain a mean arterial pressure of 50 mm Hg (+/-10 SEM). In the normotensive group the blood sugar concentration increased markedly and significantly during surgery and in the early postoperative period while the serum K+ concentration was essentially unchanged. In the hypotensive group pentolinium produced a striking modification of the surgery-induced hyperglycaemic response (but not to hypoglycaemic values) as well as a small but significant decrease in serum K+ concentration. The observed increase in the blood sugar concentration may be part of the autonomic response to surgical stress. Two mechanisms can explain the reduction in serum K+ concentration: (1) decreased hepatic glycogenolysis and (2) attenuation of the suppressive effect of adrenaline on insulin release, both effects being secondary to the ganglion-blocking property of pentolinium. These results are in contrast to the widely held belief that ganglion-blocking drugs cause hypoglycaemia.