Controlled open lesser sac drainage for pancreatic abscess.

Recent studies suggest that morbidity and mortality in patients with pancreatic abscess can be lessened if controlled open lesser sac drainage (COLD) is performed rather than traditional closed drainage (CD). To determine whether the outcome of patients treated by COLD was more favorable, 81 consecutive patients with pancreatic abscess managed surgically between 1966 and 1985 were studied. COLD, consisting of initial wide debridement of the abscess cavity, open packing, suction drainage, repeated operative pack changes, and lavage was used in 17 patients and CD in 64 patients. Age, sex, etiology of pancreatitis, and radiographic and laboratory findings were similar between treatment groups. However, the number of patients with overt systemic sepsis and those at increased risk of death based on Ranson signs associated with the predisposing episode of pancreatitis were greater in the COLD group than in the CD group (100% vs. 61%, and 92% vs. 44%, respectively; p less than or equal to 0.05 for both). Overall mortality in COLD and CD patients was 18% and 44%, respectively (p less than 0.05). However, in patients at increased risk of death (positive Ranson signs greater than or equal to 3), mortality after COLD and CD was 18% and 70%, respectively (p less than 0.05). Controlled open drainage may be the treatment of choice in patients with pancreatic abscess precipitated by severe pancreatitis (Ranson signs greater than or equal to 3) and associated with overt systemic sepsis.

Primary hyperparathyroidism in patients with multiple endocrine neoplasia syndromes. Surgical experience.

Forty-five patients with biochemically documented primary hyperparathyroidism as part of multiple endocrine neoplasia syndrome types 1 or 2 were surgically treated from 1960 through 1980. Hyperplasia occurred in 69% of the patients, single adenoma in 27%, and double adenomas in 4%. All but two patients with hyperplasia underwent subtotal parathyroidectomy. In this group, the cure rate was 93% and the incidence of permanent postoperative hypoparathyroidism 23%. In the adenoma group, treatment included excision of the adenoma and biopsy of at least one other gland. The cure rate was 76%, with no postoperative hypoparathyroidism. Analysis of patients with persistent hyperparathyroidism suggested that failure to recognize multiple gland disease was the principal cause of postoperative hypercalcemia. In view of the high incidence of hypocalcemia after subtotal parathyroidectomy, approximately 500 mg of tissue should be cryopreserved to allow transplantation should hypocalcemia ensue postoperatively.

The surgical management of medullary thyroid carcinoma.

Medullary carcinoma of the thyroid may occur in three patient groups: multiple endocrine neoplasia, type 2b (MEN2b), MEN2a, and sporadic. The prognosis is best in MEN2a and worst in MEN2b. Multicentric disease occurs in approximately 90% of patients in the MEN groups and in 20% of the patients in the sporadic group. The minimal surgical procedure advocated is total thyroidectomy with dissection of the central compartment nodes. When neck dissection is performed, there appears to be no advantage in resecting the internal jugular vein or the sternomastoid muscle. Primary relatives of all patients with medullary carcinoma should be screened by measurement of plasma immunoreactive calcitonin to identify C-cell disease in a generally unsuspecting group/reservoir and because it results in earlier diagnosis, which leads to a less extensive surgical procedure and a higher percentage of patients with a disease-free state.

Adrenal surgery: trends during the seventies.

Surgical experience with adrenal disease from 1970 to 1979 was reviewed in 315 patients. The pathologic conditions that were encountered were hypercortisolism (74 patients), hyperaldosteronism (46 patients), adrenocortical carcinoma (35 patients), pheochromocytoma (77 patients), and nonfunctioning adenoma (47 patients). In addition, 5 patients with metastatic lesions, 14 with cysts, and 4 with myelolipoma were surgically treated. The accuracy of localizing adrenal lesions increased from about 50 percent to almost 100 percent during the decade studied. The increase was due mainly to the introduction of computerized tomography, the most important advance in the management of adrenal disease. The present study shows that adrenal surgery can be performed with low morbidity and mortality. Operative deaths were confined to patients with malignant disease or increased secretion of cortisol or catecholamines. Only patients with adrenocortical carcinoma (2 year survival probability, 34 percent) or hypercortisolism due to cortical hyperplasia (5 year survival probability, 76 percent) had significantly decreased survival.

Staging laparotomy in Hodgkin's disease: Mayo Clinic experience.

Between 1967 and 1979, 316 patients with Hodgkin's disease underwent staging laparotomy. Histologic examination demonstrated lymphocyte predominance in 40 (12.7%) patients, nodular sclerosis in 178 (56.3%), mixed cellularity in 80 (25.3%), and lymphocyte depletion in seven (2.2%); results in 11 (3.5%) patients were considered unclassifiable. There were no deaths. Major complications occurred in 7.9% and required reoperation in 1.9%. Pathologic stage differed from clinical stage in 111 (35.1%) patients. In 90 (28.5%) patients, the stage advanced; in 21 (6.6%) patients, the stage was reduced; and in five (1.6%) patients, the histologic subtype was changed. Stage changes occurred in 40% of those with lymphocyte predominance, in 27.5% with nodular sclerosis, in 46.3% with mixed cellularity, and in 85.7% with lymphocyte depletion. The reliability of staging laparotomy for the determination of appropriate treatment favors its continued use.

Pheochromocytoma: current status and changing trends.

From 1971 through 1980, 106 patients underwent operations for pheochromocytoma. Twelve patients had a pheochromocytoma as a manifestation of the multiple endocrine neoplasia type 2 syndrome. Twenty patients were found to have extra-adrenal paragangliomas. Fifteen patients (14%) had malignant tumors; eight of these tumors were encountered in the group with extra-adrenal lesions. The cumulative survival probability at 5 years was 53%. Determination of urinary metanephrines and vanillylmandelic acid were the most sensitive diagnostic aids, with accuracy rates of 95% and 89%, respectively. In recent years, the measurement of fractionated urinary and plasma catecholamine levels has greatly increased the diagnostic accuracy. Preoperative localization of pheochromocytoma has improved during the last decade. Nephrotomography, selective angiography, and venous sampling have essentially been abandoned in favor of computed tomography. With an accuracy of more than 90%, computed tomography represents the major step forward in the overall management of pheochromocytoma during the past decade.

Total pancreatectomy for ductal adenocarcinoma of the pancreas. Mayo Clinic experience.

This review reveals that, once again, surgical therapy of ductal adenocarcinoma of the pancreas has been thwarted, probably by the inherent biologic aggressiveness of this particular malignancy. The operative mortality rate (greater than 10 percent) coupled with the 5 year survival rate of 2.3 percent is eloquent testimony to this. Multicentric disease occurred in one third of the patients, whereas extrapancreatic spread was found in half of the resected specimens. At 1 year, the only statistically favorable determinants were multicentricity and female sex. The main bonus of total pancreatectomy appears to be the elimination of pancreatojejunal anastomosis with its lethal complications.

The surgical management of bleeding stress ulcers.

The series included 52 patients with acute bleeding stress ulcers of the stomach and duodenum seen at the Mayo Clinic during a 25-year period. All patients underwent operation for control of massive bleeding that was unresponsive to intensive medical therapy. All ulcers were superficial and occurred during clinically stressful circumstances. No patient had a history or findings suggestive of pre-existing peptic ulcer disease or imbibation of ulcerogenic substances. Overall operative mortality was 54%, and this rate seemed to be related to multiple factors acting together; patients with multiple predisposing stress factors and those requiring large transfusion volumes (greater than 17 total units) were at greatest risk of death. Fifty-two patients underwent 60 operative procedures for control of hemorrhage. Of the 60 procedures, 23 (38%) failed to prevent rebleeding. Of the 28 patients who died, six (21%) died of hemorrhage and five (18%) died of hemorrhage as one of many contributing factors. Of eight different procedures performed, near-total to total gastrectomy was the single procedure that was most effective in controlling hemorrhage. The authors support the selection of rapid intervention and generous extirpative surgery once intensive medical measures fail to control hemorrhage.

Truncal vagotomy and resection in the treatment of duodenal ulcer.

A retrospective analysis was conducted of 466 patients who underwent elective truncal vagotomy with antrectomy or hemigastrectomy for chronic duodenal ulcer. The postoperative (30-day) mortality was 1.1%. In 412 of 466 patients (88.4%), follow-up was obtained, and in 290 patients alive at the writing of this paper, the mean follow-up was 17.1 years; the remaining 54 patients (11.6%) were lost to follow-up. The overall ulcer recurrence rate was 0.7%. Severe postoperative sequelae--postvagotomy diarrhea and postgastrectomy dumping--were uncommon--0.7% and 1.0% of patients, respectively. The combination of truncal vagotomy and gastric resection is a viable alternative in the surgical treatment of chronic duodenal ulcer disease and is the authors' operation of choice for most such patients.

Annular pancreas: May Clinic experience from 1957 to 1976 with review of the literature.

From a review of 266 cases reported in the literature and data on 15 other patients operated on a the Mayo Clinic for symptomatic, annular pancreas, the following three conclusions can be made. First, annular pancreas is an uncommon congenital anomaly, often not becoming symptomatic until late life. Second, complicating congenital and acquired disorders must be recognized it patients are to be properly prepared for surgery. Sometimes associated problems may be recognized, whereas the annular pancreas may be overlooked. The change of this happening is decreased by methodical inspection of the entire abdomen, especially all segments of the duodenum, because annuli can occur in any segment and can be partially or completely circumferential. Third, while there is no single operative procedure of choice, published experience militates against any direct attack on the offending annulus.

The surgical management of malignant lesions of the pancreas.

Over the past 20 years, carcinoma of the pancreas has increased in incidence by 20 percent. In spite of this marked increase, there continues to be controversy in some areas regarding the proper surgical management of ductal lesions. To date, there have been 122 total pancreatectomies performed at the Mayo Clinic; 63 of these were performed for carcinoma of the pancreas. Among 21 patients treated by total pancreatectomy since 1975, there was one operative death for an overall operative mortality of 4.7 percent. During the same period of time, when 34 patients underwent partial pancreatectomy of the Whipple type, there were three postoperative deaths with an operative mortality of 8.8 percent. The three patients that expired following performance of the Whipple procedure did so as a result of leakage at the anastomosis between the pancreas and the jejunum. Endocrine and exocrine pancreatectomy management have not been a particular problem. Conclusions can be drawn that total pancreatectomy for carcinoma of the pancreas is an acceptable procedure.

Cancer of the parathyroid glands.

Hyperfunctioning parathyroid carcinoma is a relatively rare endocrine tumor, accounting for approximately 1% of all cases of primary hyperparathyroidism. The diagnosis is suspected when the tumor is large, parathyroid hormone (iPTH) levels are high, and a palpable tumor is present in the neck. Patients who have recurrence of hyperparathyroidism several months after surgical treatment should be suspected of having a recurrent or persistent parathyroid carcinoma. At operation, a large invasive tumor is usually found. The fibrous, inflammatory-like reaction is the most characteristic indication of malignancy. Even in tumors with minimal invasiveness, the possibility of a carcinoma should be considered if the tumor has mitotic activity and a monotonous instead of a pleomorphic cellular population. If the surgeon can recognize the possibility of parathyroid malignancy and adequately treat the patient during the initial operation, more gratifying results should be obtained.

Splenectomy in myeloid metaplasia.

Between 1960 and 1977, 50 patients with agnogenic myeloid metaplasia were splenectomized. Twenty-five of 26 patients with painful splenomegaly, 4 of 9 patients with refractory hemolytic anemia, 4 of 10 patients with refractory thrombocytopenia, and 4 of 4 patients with portal hypertension showed significant benefit from the procedure. There were five immediate postoperative deaths. Four of these deaths occurred early in our series of splectomies for myeloid metaplasia before 1970. Only one death has occurred in the last 21 patients operated on. Survival following splenectomy averaged 25.5 mo.

A clinicopathologic study of 21 cases of pancreatic cystadenocarcinoma.

Cystadenocarcinomas are rare tumors of the pancreas. They are half as common as their benign counterpart--the cystadenoma. A review of 21 cases, including eight reported since 1963, revealed that most patients presented with upper abdominal pain and a large palpable upper abdominal mass. All patients had evidence of malignant degeneration occurring in a mucous cystadenoma. None had evidence of a serious cystadenoma. Grading revealed a predominance of low-grade tumors: 20 of the 21 lesions were grade 1 or 2. Cystadenocarcinomas were slightly more frequent in the head of the pancreas. Four patients had metastasis. Complete excision by distal or total pancreatectomy or Whipple pancreaticoduodenectomy is recommended. The five year survival after complete excision is 68%, and for patients with grade 1 lesions, and five year survival is 64%.

Urologic aspects of vesicoenteric fistulas.

The classic symptoms of pneumaturia and fecaluria were not present in many of 100 patients (male to female ratio of 2.4) with vesicoenteric fistulas who presented with fever, abdominal mass or cystitis. There was a urinary tract infection in 95 per cent of the patients studied but only 29 per cent had a mixed infection. Roentgenographic studies suggested a fistula in 18 to 35 per cent of those studied but cystoscopy was singularly the most successful diagnostic technique (79 per cent). Inflammatory bowel disease in 63 per cent and colorectal adenocarcinoma in 16 per cent were the most common etiologic factors. Bladder carcinoma was the cause in only 5 per cent. Treatment consisted of single or multistage surgical repair of fecal diversion in 95 operable patients, with gratifying results, and of expectant management in the 5 inoperable patients.