Bioelectrical impedance in the clinical evaluation of liver disease.

Liver disease is often characterized by an accumulation of excess body water as ascites, edema, or both. It was our purpose, using bioelectrical impedance analysis (BIA), to measure total body water (TBW) and extracellular water (ECW) in 35 patients with end-stage liver disease, including those undergoing orthotopic liver transplantation and, in 15 of these patients, to compare these values with measurements of TBW by deuterium oxide and of ECW by bromide dilutions. Poor correlation of TBW derived from BIA with TBW by deuterium dilution was found (r = 0.36, P = 0.35). In 19 patients, in whom TBW and ECW were not measured by dilution studies, 158 BIA measurements were taken for determining TBW. In 15 orthotopic liver transplantation patients with various amounts of fluid overload, a modest correlation was found between short-term weight change and BIA (r = 0.38, p = 0.001). In patients with fluid overload not exceeding 25% of ECW, ECW correlated with reactance (r = -0.96, P = 0.0025). TBW and ECW were covariant (r = 0.68, P = 0.01). In three patients with cirrhotic ascites, impedance measurements were taken with source electrodes on the hand and foot and detector electrodes on the abdomen during paracentesis of 8-11 L. Calculated volume of ascites correlated with measured volume (r = 0.99, P = 0.001). Segmental electrode placement and parallel impedance measurements were effective in determining ascites fluid volume.

Liver transplantation in a patient with sickle cell anemia.

Orthotopic liver transplantation in a patient with sickle cell disease presents many new challenges to the transplant team. We describe the case of a 47-year-old patient with sickle cell disease and hepatitis C virus-induced cirrhosis who required liver transplantation.

Role of pancreatoduodenectomy in the management of primary duodenal wall gastrinomas in patients with Zollinger-Ellison syndrome.

BACKGROUND: The role of pancreatoduodenectomy in the surgical management of duodenal wall gastrinomas (DWGs) has not been well established. Recently DWGs have been recognized with increasing frequency, and several reports have emphasized that pancreatoduodenectomy can now be performed with a low operative morbidity and mortality for other conditions. The purpose of this study was to determine the indications, safety, and efficacy of pancreatoduodenectomy in the treatment of DWGs. METHODS: Forty-five patients with Zollinger-Ellison syndrome were evaluated and surgically treated between 1960 and 1991; 15 (33%) of these had primary DWGs. RESULTS: Pancreatoduodenectomy was considered necessary for curative resection in six patients. Two of these patients had multiple gastrinomas as part of multiple endocrine neoplasia type 1 syndrome and underwent tumor excisions and total gastrectomy; both died of tumor-related complications (survival, 8.5 and 12 years). A third patient did not consent to pancreatoduodenectomy, underwent total gastrectomy and tumor excision, and also died of tumor-related complications (survival, 10 years). The remaining three patients underwent pancreatoduodenectomy. After pancreatoduodenectomies were performed, these three patients became and remained eugastrinemic with normal results from secretin stimulation tests (mean follow-up, 7.5 years). CONCLUSIONS: In patients with DWGs and Zollinger-Ellison syndrome, pancreatoduodenectomy should be considered the treatment of choice whenever complete tumor excision is not possible by a lesser procedure.

Selective surgical management of correctable hypergastrinemia.

Sixty patients with surgically correctable hypergastrinemia were treated between 1960 and 1988. Provocative testing was used when available to select appropriate operations. Sources of hypergastrinemia included antral G cell hyperplasia (AGCH) (17), pancreatic gastrinomas (14), duodenal gastrinomas (11), multiple gastrinomas in patients with type I multiple endocrine neoplasia (MEN I) (five), lymph node gastrinomas (four), and the source not found in nine patients. Eugastrinemia was achieved by resection in 17 of 17 patients with AGCH, nine of 11 patients with duodenal gastrinomas, three of four patients with lymph node gastrinomas, zero of 14 patients with pancreatic gastrinomas, zero of five patients with MEN I, and zero of nine patients in whom the source was not found. Hepatic metastases developed in 11 patients with pancreatic gastrinomas, two patients with MEN I, one patient with duodenal gastrinomas, and one patient with lymph node gastrinomas. One patient in whom the source of the hypergastrinemia was not found developed hepatic metastases, and seven required total gastrectomy. This experience suggests the following: (1) that patients with AGCH, duodenal gastrinomas, or lymph node gastrinomas can usually be rendered eugastrinemic by resection; (2) that patients with pancreatic gastrinomas, whether sporadic or familial (MEN I), are rarely cured by resection and frequently develop hepatic metastases; and (3) that patients in whom the source of the hypergastrinemia is not identified and removed frequently require total gastrectomy, but antroduodenectomy should be considered because it may uncover an occult duodenal microneurogastrinoma or may correct AGCH.

Pancreatogastrostomy: a safe drainage procedure after pancreatoduodenectomy.

The purpose of this study was to evaluate the role of pancreaticogastrostomy as an alternative method of restoring pancreaticointestinal continuity after pancreaticoduodenectomy. Since 1975, 45 patients have undergone pancreaticogastrostomy after pancreaticoduodenectomy at our institution. Pancreaticoduodenectomy was performed for pancreatic carcinoma (24 patients), ampullary carcinoma (8 patients), duodenal carcinoma (4 patients), common bile duct carcinoma (4 patients), pancreatic islet cell carcinoma (1 patient), trauma (1 patient), extensive colon carcinoma (1 patient), chronic pancreatitis (1 patient), and gastroduodenal artery aneurysm (1 patient). There was one operative death, for an overall operative mortality rate of 2%, and seven patients had major postoperative complications, for an overall morbidity rate of 15%. No pancreatic anastomotic leaks or other complications related to the pancreaticogastrostomy occurred. Twenty-four patients have died of recurrent carcinoma, with a mean survival of 25 months (range, 5 to 66 months), and 20 patients are alive and well, with a mean follow-up of 27 months (range, 2 to 106 months). Eight of these patients are alive 2 or more years after operation and four do not have exocrine pancreatic insufficiency. This experience confirms that pancreaticogastrostomy is a safe method of pancreatic drainage after pancreaticoduodenectomy and suggests that it may have technical advantages and therefore merits more widespread application.

Zollinger-Ellison syndrome. A new look at regression of gastrinomas.

Of 44 patients with the Zollinger-Ellison syndrome treated at our institution, nine appeared to have undergone "regression" of their gastrinomas. Six of the nine patients had sporadic gastrinomas and became permanently eugastrinemic following excision of nodal metastases and total gastrectomy (n = 4), antrectomy (n = 1), or pancreatoduodenectomy (n = 1) (mean survival, 13 years). The other three patients had Zollinger-Ellison syndrome as part of the multiple endocrine adenopathy type 1 syndrome and became temporarily eugastrinemic after total gastrectomy (mean survival, 11 years). Occult submucosal duodenal-wall microgastrinomas (mean size, 3.0 mm) were found to have been serendipitously excised in four patients. Long-term follow-up of these nine patients, as well as of six other patients described in the literature, demonstrates that excision of occult duodenal-wall gastrinomas provides a plausible explanation for the phenomenon of apparent regression of primary gastrinomas and the eugastrinemia that may follow total gastrectomy.

Nonoperative treatment of biliary tract disease.

The rise of minimally invasive surgical techniques during the past 20 years has been one of the more dramatic developments in modern medicine. Minimally invasive procedures are now widely accepted for treatment of diseases involving many different organ systems. Minimally invasive procedures may be more common and more accepted in the treatment of diseases of the biliary tract than in any other area. The development of laparoscopic cholecystectomy serves as a benchmark for minimally invasive procedures, and it is now the standard of care for the treatment of cholelithiasis. Today, not only is laparoscopic cholecystectomy one of the most common operations performed in the United States, but many new techniques have been developed that allow minimally invasive treatment of a variety of biliary tract diseases. The development of nonoperative techniques for treatment of biliary tract disease has accompanied the rapid developments in minimally invasive surgical techniques. This article describes the nonoperative treatment of biliary tract disease.

Gastrointestinal neuroendocrine tumors.

It has been said that with the description of the Zollinger-Ellison syndrome in 1955, the clinical era of gastrointestinal endocrinology was inaugurated. Since that time, a virtual explosion of investigations, both basic and clinical, has occurred in which as many as 19 gastroenteropancreatic neuroendocrine cells have been identified and as many as 40 of their humoral products have been discovered. The pharmacologic and physiologic functions of some of these amines and peptides have been clearly identified and account for the clinical presentations of the various clinical syndromes so far described. However, the physiologic functions of many others remain to be elucidated. The interest in gastroenteropancreatic neuroendocrine tumors arising from these cells has markedly increased in recent years as a result of the creation of precise biochemical techniques to confirm the diagnosis and the refinement of localization techniques that allow for the identification of previously occult tumors. Therefore, the recognition and treatment of gastroenteropancreatic neuroendocrine tumors has improved so that an ever-increasing number of patients are diagnosed early and surgically treated before metastases occur. There are still more identified gastroenteropancreatic neuroendocrine cells and humoral products than there are recognized neoplasms and syndromes; continued investigation is essential. Undoubtedly, newer treatment modalities will continue to be created for chemotherapy and receptor modulation, but early surgical excision remains the cornerstone of successful treatment today.

Pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms in elderly patients.

Forty-two patients (age range: 70 to 86 years) underwent pancreaticoduodenectomy between 1970 and 1990 for carcinomas of the pancreas (23), ampulla (8), common bile duct (5), duodenum (5), or islet cells (1). After resection, reconstruction was done by either pancreaticojejunostomy (13) or pancreaticogastrostomy (25); four patients had total pancreatectomy. The mean duration of operation was 5 hours, the mean blood loss was 2,200 mL, the mean transfusion requirement was 4 units of blood, and mean length of hospitalization was 22 days. There were no leaks or other complications related to the pancreatic anastomoses. Six (14%) major complications occurred including two (5%) operative deaths. Mean survival was 42 months (range: 2 to 219 months) for the entire group and 35 months for patients over the age of 80. This experience suggests: (1) pancreaticoduodenectomy can be performed with low operative morbidity and mortality in elderly patients, and advanced age should not be considered a contrainindication to this potentially curative procedure; (2) pancreaticogastrostomy is a safe and easy alternate method of reconstruction; and (3) prolonged survival is possible for elderly patients following pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms.

Characteristics of duodenal wall gastrinomas.

Fifteen patients with duodenal wall gastrinomas (DWGs) and the Zollinger-Ellison syndrome have been treated since 1960. In 6 of 11 patients, DWGs were recognized at operation and totally excised. In four patients, the tumor was subsequently found in the proximal duodenum of the surgical specimens. In 12 patients, DWGs were single and lymph node metastases were present in 8. In three patients, DWGs were multiple and lymph node metastases were present in two. All DWGs were submucosal and all were located in the first or second portions of the duodenum except one found in the fourth portion. Tumor size ranged from 1 to 15 mm, and nine were less than 5 mm. Of 12 patients with single DWGs, 9 have remained eugastrinemic after resection (mean follow-up: 5.5 years). None of the patients with multiple DWGs became eugastrinemic after surgery. DWGs are characteristically single, small or microscopic, submucosal, located in the proximal duodenum, rarely metastasize to the liver, and are usually curable by surgical resection.

Characteristics of cystic neoplasms of the pancreas and results of aggressive surgical treatment.

Twenty-one patients with pancreatic cystic neoplasms (PCNs) were treated from 1970 to 1991. Their mean age was 54 years (range: 30 to 78 years), and 15 (71%) were women. Symptoms were present for a mean of 18 months (range: 5 to 60 months) and included pain (95%), abdominal mass (52%), weight loss (38%), and jaundice (14%). Nine patients had had previous operations and were either misdiagnosed or incorrectly treated; another seven patients had preoperative misdiagnoses of pseudocysts. There were six (29%) serous cystadenomas and two (10%) mucinous cystadenomas. These were treated by excision (n = 2), distal pancreatectomy (n = 5), or pancreatoduodenectomy (n = 1). No recurrence or malignant degeneration occurred during the mean follow-up of 9 years (range: 1 to 19 years). There were 13 (62%) patients with mucinous cystadenocarcinomas. Of these 13 patients, 3 had unresectable tumors, underwent palliative procedures, and died at 4, 7, and 9 months, respectively. Ten patients underwent pancreatoduodenectomy (n = 4), distal (n = 4) pancreatectomy, or total (n = 2) pancreatectomy: 1 died of recurrence (survival: 8 months), and the remaining 9 patients had a mean survival of 6 years (range: 2 to 20 years) without recurrence. This experience suggests that patients with PCNs have a good prognosis and are curable if the cysts are diagnosed early and completely resected.

Diagnostic peritoneal lavage in acute peritonitis.

Fifty patients were studied prospectively to determine the value of diagnostic peritoneal lavage in the evaluation of acute peritonitis. Forty-five patients had a clinical diagnosis of acute peritonitis based on physical findings, and 5 patients were normal control subjects. All lavages were performed with an open technique in the operating room prior to laparotomy. Lavage fluid was analyzed for white and red blood cell counts, the differential, amylase, protein, bilirubin, and pH. Results were analyzed by multiple logistic regression. Thirty-two of the 45 patients with clinical peritonitis had the diagnosis confirmed at laparotomy. A white blood cell count in the lavage fluid greater than or equal to 200 cells/mm3 was associated with a 99% probability of peritonitis.

The role of transjugular intrahepatic portosystemic shunts in the management of patients with end-stage liver disease.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to successfully treat complications of portal hypertension; however, not all reports have been favorable. METHODS: Forty patients underwent 41 attempts to place a TIPS. All patients but 1 had a Wallstent placed. RESULTS: Thirty-nine procedures (95%) were successful. Thirty-one patients were treated for gastrointestinal bleeding, and 9 for refractory ascites. The average fall in portal pressure was 13.7 +/- 0.9 mm Hg. Major postprocedure complications included 4 deaths. Minor problems included liver capsular perforation, fever, self-limited bleeding, and a pseudoaneurysm. Follow-up evaluation revealed that by 5 months, 50% of the shunts developed a portal-venous-to-right-atrial pressure gradient requiring balloon dilatation or a new stent. The 1-year actuarial patient survival was 72%. Eighteen patients were candidates for orthotopic liver transplantation (OLT) and 5 have been transplanted. CONCLUSIONS: TIPS may be best used for stabilization, prior to OLT or as a temporizing measure prior to elective shunt surgery.

Improving resectability and survival in patients with primary duodenal carcinoma.

Of 35 patients with primary duodenal carcinoma (PDC), 13 were treated between 1960 and 1974 (group I) and 22 between 1975 and 1990 (group II). PDCs were found in the first 5 portions of the duodenum (14%), second 18 (51%), third 8 (23%), and fourth 4 (12%). Five patients (38%) in group I were deemed to have unresectable disease compared with only one patient (5%) in group II. Eight patients (62%) in group I underwent resection by either pancreatoduodenectomy (4) or segmental resection (4), and 20 patients (95%) in group II had pancreatoduodenectomy (17) or segmental resection (3). Operative mortality was 31% in group I and 0% in group II. Mean survival was 7 months (range: 0 to 22 months) in group I and 48 months (range: 6 to 218 months) in group II. None of the patients in group I survived for 2 years, whereas the 5-year survival for patients in group II was 62%. This experience suggests that resectability, operative mortality, and survival in patients with PDCs have improved markedly in recent years.

Gastric pacing is a new surgical treatment for gastroparesis.

BACKGROUND: Gastroparesis is a chronic gastric motility disorder affecting mostly young and middle-aged women who present with nausea, abdominal pain, early satiety, vomiting, fullness, and bloating. METHODS: From April 1998 to September 2000, 25 patients underwent gastric pacemaker placement. All had documented delayed gastric emptying by a radionucleotide study. Nineteen patients had diabetic gastroparesis, 3 had developed postsurgical gastroparesis, and 3 had idiopathic gastroparesis. Baseline and postoperative follow-ups were done by a self-administered questionnaire on which the patients rated the severity and frequency of nausea and vomiting. Gastric emptying times were also followed up using a radionucleotide technique. RESULTS: Both the severity and frequency of nausea and vomiting improved significantly at 3 months and was sustained for 12 months. Gastric emptying time was also numerically faster over the 12-month period. Three of the devices have been removed. One patient died of causes unrelated to the pacemaker 10 months postoperatively. CONCLUSIONS: After placement of the gastric pacemaker, patients rated significantly fewer symptoms and had a modest acceleration of gastric emptying.

Significance of lymph node metastases in patients with pancreatic cancer undergoing curative resection.

BACKGROUND: Recent reports suggest an improved survival following resection for patients with pancreatic carcinoma. However, the prognosis for patients with lymph nodes metastases remains uncertain. The purpose of this study was to determine if the presence of lymph node metastases significantly alters survival in patients with otherwise potentially curable pancreatic carcinoma. PATIENTS AND METHODS: Between 1970 and 1995, 401 patients with pancreatic adenocarcinoma, including 327 patients with pancreatic head tumors, were evaluated and treated. RESULTS: One hundred (31%) patients underwent pancreatoduodenectomy. Operative mortality was 3% and morbidity was 22%. Median survival for 97 patients discharged from the hospital following resection was 14 months (range 2 to 293). The estimated 1-, 2-, and 5-year survivals were 61%, 43%, and 20%, respectively. Median survival was 11.5 months (range 2 to 87) for patients with positive lymph nodes (n = 56) and 24 (range 0 to 293) months for patients with negative lymph nodes (n = 41; P = 0.0003). Ten patients (10%) survived longer than 5 years, and 9 (90%) of them had negative lymph nodes. Elderly patients (> or = 70 years) had a median survival twice as long as younger patients (24 versus 12 months, P = 0.03). CONCLUSIONS: Lymph node metastases are found in 56% of patients undergoing resection. Pancreatoduodenectomy can be performed with low operative mortality in patients of all ages. It offers good palliation for patients with lymph nodes metastases and encouraging long-term survival rates as well as a chance for cure in patients with negative lymph nodes.

Is the role of transjugular intrahepatic portosystemic shunts limited in the management of patients with end-stage liver disease?

BACKGROUND: Transjugular intrahepatic portosystemic shunts (TIPS) are an established method for the treatment of the complications of portal hypertension. Recent reports have suggested that TIPS require frequent follow-up and may interfere with orthotopic liver transplantation (OLT). METHODS: Retrospective chart review was performed of ultrasound studies, angiographic studies, and complications of the first 100 patients treated consecutively with TIPS from February 1992 through October 1995. RESULTS: Ninety-seven patients had functional TIPS. Thirty-one percent of patients treated emergently survived, significantly less than the 96% survival of elective patients. Fifty percent of the shunts were found to require angioplasty by 5 months. Seventeen patients treated with OLT did well, without intraoperative bleeding problems, and are alive. CONCLUSIONS: The TIPS method treats successfully the complications of portal hypertension but requires careful follow-up. The technique may be used prior to OLT. For non-OLT candidates, the cost effectiveness of TIPS versus surgical shunting remains in question.

The role of pancreatojejunostomy in patients without dilated pancreatic ducts.

OBJECTIVE: To determine the safety and efficacy of longitudinal pancreatojejunostomy in patients with chronic pancreatitis and intractable pain who do not have a markedly dilated pancreatic duct. BACKGROUND: Ductal decompression by side-to-side, longitudinal pancreatojejunostomy has become the operation of choice for patients with chronic pancreatitis and intractable pain when the pancreatic duct is markedly dilated. However, markedly dilated pancreatic ducts are found in less than 40% of patients with disabling pain. PATIENTS AND METHODS: Twenty-eight consecutive patients with intractable pain from chronic pancreatitis, most of whom had minimal or no dilation of the pancreatic duct, were treated with side-to-side, longitudinal pancreatojejunostomy between 1970 and 1993. RESULTS: There were 18 (64%) males and 10 (36%) females. The mean age was 41 years (range 11 to 72). The etiologies for chronic pancreatitis were alcohol (82%), gallstones (7%), trauma (7%), and familial trait (4%). Intractable pain was present for a mean of 4 years (range 0.5 to 12). Thirteen patients (46%) were dependent on narcotics prior to surgery. Twenty-five patients (89%) had minimal (< 8 mm) or no dilation of the pancreatic duct and 3 (11%) had markedly dilated pancreatic ducts (> 10 mm). All experienced complete pain relief in the immediate postoperative period. Twenty-four patients (86%) have remained free of pain after a mean follow-up of 3.5 years (range 1 to 8). CONCLUSIONS: In patients with chronic pancreatitis and intractable pain, small pancreatic duct size should not be considered a contraindication to side-to-side, longitudinal pancreatojejunostomy.

Significance of tumor spread in adenocarcinoma of the ampulla of Vater.

Twenty-eight patients with ampullary carcinoma were treated between 1965 and 1988: 22 underwent pancreaticoduodenectomy with 1 operative death (5 percent), 1 had local excision, 3 had bypass, and 2 were not explored. Of the 21 patients who survived pancreaticoduodenectomy, 4 had tumor confined to the ampulla, 7 had tumor extending into the duodenum, and 10 had tumor invasion beyond the duodenum. Nine of these patients had positive lymph nodes and 12 had negative lymph nodes. The patient who had local excision was disease-free at last follow-up 104 months postoperatively. Each of the three bypassed patients died of tumor progression within 15 months. The estimated 5-year survival rate for resected patients was 60 percent and was independently related to lymph node metastases (p = 0.031) and to tumor size (p = 0.039). This experience suggests that long-term survival is possible in patients with lymph node metastases or invasive tumors extending beyond the duodenal wall and that curative pancreaticoduodenectomy can be performed with a low operative mortality; therefore, aggressive surgical resection is recommended for all patients with ampullary carcinoma.

Thrombolytic therapy for catheter-related thrombosis.

Thrombosis of the central venous system (CVT) occurs in 20% to 30% of patients with indwelling catheters. This complication is usually treated with anticoagulation, extremity elevation, and catheter removal. Thirty-eight patients with CVT at our institution were treated with thrombolytic therapy to rapidly resolve symptoms and avoid removal of the catheters. Complete clot lysis occurred in 36 of 38 patients (95%) within 1 to 5 days (mean: 2.4 days). Symptoms resolved with clot resolution. Thrombolytic therapy detected stenoses in 22 patients. Angioplasty was successful in 64% of these patients. Five catheters were removed. Complications occurred in six patients: nonfatal pulmonary embolus, three bleeding episodes, pain with infusion of urokinase, and an episode of septic phlebitis. This experience suggests that thrombolytic therapy is safe, rapidly resolves symptoms of thrombosis, uncovers anatomic abnormalities amenable to angioplasty, and allows central venous catheters to remain in place despite central venous thrombosis.