Proximal gastrojejunal reconstruction after pancreaticoduodenal resection.

Introduction. Reconstruction by proximal gastrojejunostomy, and distal biliary and pancreatic anastomoses is infrequently used after resection of the head of the pancreas because of fear of fistulas and cholangitis. Pancreaticoduodenectomy is being performed more frequently for cystic malignant and premalignant lesions. Because of this there is a need for endoscopic visualization and biopsy of the residual pancreatic duct, since multi-centricity is characteristic of some of these malignancies. Since endoscopic access of the bile duct and pancreatic duct is difficult and unsuccessful in 50-70% after B II or Roux Y reconstruction, we prospectively studied the merit and complications (early and late) of proximal gastrojejunal (PGJ) reconstruction after pancreaticoduodenal resection. Material and Methods. Thirty nine consecutive, non-radomized patients underwent pancreaticoduodenectomy and PGJ reconstruction over 14 mos. There were 21 males and 18 females. Results. 7 patients with IPMN have undergone repeat CT scanning for surveillance, with 3 requiring repeat EUS and ERCP. There were no technical difficulties accessing the pancreas or the pancreatic duct, supporting the PGJ reconstruction. Conclusion. Proximal gastrojejunal reconstruction following pancreaticoduodenal resection may be safely done with similar morbidity to traditional pancreaticojejunal reconstructions. PGJ reconstruction may be of greater value when direct visual access to the bile duct or pancreatic duct is necessary, and should be considered when doing resection for mucinous cysts or IPMN of the head of the pancreas.

Renal cell cancer without a renal primary.

Renal cell carcinoma has been increasing in incidence over the past two decades. Men are affected more than women and metastatic disease at presentation occurs in up to one third of patients. Metastasis can occur to virtually any organ, and involvement of multiple organs is not uncommon. To date, no reports have been found of metastatic disease without a renal primary. We present a case of renal cell cancer initially presenting as a subcutaneous mass with subsequent pancreatic and parotid gland metastases in absence of a primary renal source.

Motion-induced blindness in normal observers.

Cases in which salient visual stimuli do not register consciously are known to occur in special conditions, such as the presentation of dissimilar stimuli to the two eyes or when images are stabilized on the retina. Here, we report a striking phenomenon of 'visual disappearance' observed with normal-sighted observers under natural conditions. When a global moving pattern is superimposed on high-contrast stationary or slowly moving stimuli, the latter disappear and reappear alternately for periods of several seconds. We show that this motion-induced blindness (MIB) phenomenon is unlikely to reflect retinal suppression, sensory masking or adaptation. The phenomenology observed includes perceptual grouping effects, object rivalry and visual field anisotropy. This is very similar to that found in other types of visual disappearance, as well as in clinical cases of attention deficits, in which partial invisibility might occur despite the primary visual areas being intact. Disappearance might reflect a disruption of attentional processing, which shifts the system into a winner-takes-all mode, uncovering the dynamics of competition between object representations within the human visual system.

Pancreatic cancer: the bigger picture.

Despite accurate diagnosis, better radiologic techniques, and safer surgery, long-term survival after surgical therapy for pancreatic cancer is disappointing. Median survival following pancreaticoduodenal resection is 12 to 15 months independent of surgical expertise, hospital size, or technical factors. Subsets of favorable tumors and longer survival times after surgery have been defined and include: small tumor size and low-grade lesions, tumor-free margins, and absence of nodal, venous, or perineural invasion; however, long-term survivors of pancreatic cancer may have none of these favorable features, and their tumors commonly manifest the most adverse tumor prognostic features. The converse that small-sized, histologically favorable tumors result in long-term survivors, also is not true. Five-year survival rates average 5% or less after all resections. In a large series in which 118 pancreatic resections were performed in 684 evaluated patients over a 6-year period, there were 12 5-year survivors, 5 of whom died in the sixth year. A report of 10-year survivors after surgery numbered 13 patients. The best actual 5-year survival rate was reported by Trede et al. Of the 37, 5-year survivors from a cohort of 118 patients, more than half died of cancer. This far exceeds any other actual survival rate and may be explained by a smaller tumor size. Farnell et al reported a 5-year survival rate difference (i.e., actuarial survival) in a subset of 174 resected patients with adenocarcinoma without perineural or duodenal invasion and with negative nodes (23% versus 6.8%), respectively. An impressive, large series of 616 patients with resected adenocarcinoma of the pancreas who underwent PDR (85%), distal pancreatectomy (9%), and total pancreatectomy (6%), has been reported. The mortality rate was 2.1%, and postoperative complications occurred in 30%. The five-year survival rate was 15%. The author's best result was observed among 20 initially "unresectable" patients who were treated with chemoradiation therapy, followed by tumor extirpation. Among the 18 surgical survivors there are seven five-year survivors, three of whom are in their tenth year of survival. They are discussed in the article by Cooperman et al ("Long-term Follow-up...") elsewhere in this issue.

Long-term follow-up of twenty patients with adenocarcinoma of the pancreas: resection following combined modality therapy.

Long-term follow-up of 5 or more years in 20 patients with initially unresectable cancer of the pancreas that responded to chemoradiation therapy is detailed in this article. All patients underwent resection. Seven or 18 surgical survivors are alive 50 or more months.

Assessment of instability of the long head of the biceps tendon by MRI.

OBJECTIVE: To determine whether MRI can identify instability of the long head of the biceps tendon (LBT) in the rotator interval. DESIGN AND PATIENTS: A retrospective review was carried out of 19 patients, all arthroscopically examined, nine of whom had surgically confirmed instability of the LBT. RESULTS: A LBT perched on the lesser tuberosity correctly indicated all nine cases of instability with one false positive. In six of seven cases where the LBT was oval in shape, no instability of the biceps tendon existed, whereas LBT instability was present in eight of 12 patients with a flat long head of the biceps tendon. In seven of eight acutely angled intertubercular sulci there was no instability of the LBT while eight of 11 obtusely angled sulci were associated with LBT instability. By consensus impression, instability of the LBT could be determined with 67% sensitivity, 90% specificity, 86% positive predictive value, and 75% negative predictive value. CONCLUSIONS: A flat LBT perched on the lesser tuberosity with an obtusely angled intertubercular sulcus suggests the diagnosis of instability of the LBT in the correct clinical setting.

Computed tomography for pancreatic diseases.

CT has evolved over 24 years as an effective cross-sectional imaging modality for benign and malignant pancreatic diseases. Multiphase helical scanners with rapid infusion of intravenous contrast medium allow for the delineation of pancreatic parenchymal, arterial, and venous studies with identification of malignant and benign lesions. Therapeutic applications abound, and CT drainage of postoperative fluid collections, pseudocysts, and abscesses will have an increasing role in the new millennium.

An overview of pancreatic pseudocysts: the emperor's new clothes revisited.

The diminished role of surgery and increased role of nonoperative interventional therapy for pancreatic pseudocysts is discussed. The natural history supports prolonged observation for most asymptomatic pseudocysts.

Surgical treatment of pancreatic pseudocysts.

The surgical treatment of pancreatic pseudocysts (PC) has a less important role now that endoscopic and radiologic intervention can effectively treat PC. Surgery may be needed to correct the underlying cause--usually an obstructed or disrupted pancreatic duct.

Surgery and chronic pancreatitis.

It is hoped that, in this millennium, chronic pancreatitis will be diagnosed earlier in the course of the disease process. Improved axial imaging of the pancreatic duct and pancreatic parenchyma will diminish the need for other invasive tests. Surgical procedures are directed at pancreatic duct decompression or resection of the pancreas (head, body or tail) or, infrequently, total pancreatectomy. Pain relief in 75% to 90% is the general rule, with diabetes developing subsequently in as many as 33% of patients. Surgery for chronic pancreatitis is effective in correcting sequelae of pancreatic fibrosis. Endoscopic stenting of the pancreatic and bile duct is used more frequently today. Until their place is ascertained, careful performance of surgery will continue to be a mainstay of treatment.

Surgery and pancreas divisum: a dwindling role?

Pancreas divisum has generated varying enthusiasm regarding operative intervention. Applying similar principles to divisum surgery as for the surgical treatment of chronic pancreatitis will yield a better outcome than using subjective symptoms.

Current surgical therapy for carcinoma of the pancreas.

Despite progress in treating many solid tumors, pancreatic cancer continues to be a grave illness. Each year, >29,000 new cases of adenocarcinoma of the pancreas are diagnosed in the United States. Of these patients, only 10-20% have resectable tumors and 25,000 patients (83%) die within 12 months of diagnosis. Until recently, surgery has been the only "effective" therapy available for select patients. Historically, the operative mortality after radical pancreatic resection has been variable, ranging 1-30%, and is both operator- and institution-dependent. Even with a safe and complete surgical resection, the actual 5-year survival after surgery alone is essentially zero, although rates up to 5% have been reported. Despite what would appear to be a dismal outlook, slow progress has occurred in the operative and postoperative care of patients with pancreatic cancer. Advanced imaging techniques and laparoscopy have limited the number of unnecessary laparotomies, and novel adjuvant and neoadjuvant chemotherapy approaches have yielded promising results. This review will summarize the recent literature concerning the surgical therapy and trends in the treatment of carcinoma of the pancreas from 1990 to 1999.

Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma. An outcomes trial.

BACKGROUND: Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted. METHODS: Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split-course RT plus 5-fluorouracil, streptozotocin, and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2). RESULTS: Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment. CONCLUSIONS: Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT-FSP.

Magnetic resonance imaging findings in anterolateral impingement of the ankle.

OBJECTIVE: To demonstrate the MR imaging findings of anterolateral impingement (ALI) of the ankle. DESIGN AND PATIENTS: Nine patients with a history of ankle inversion injury and chronic lateral ankle pain were imaged with MR imaging, and the findings correlated with the results of arthroscopy. Three additional patients with clinically suspected ALI of the ankle were also included. Ankle MR imaging studies from 20 control patients in whom ALI was not suspected clinically were examined for similar findings to the patient group. RESULTS: MR imaging findings in the patients with ALI included a soft tissue signal mass in the anterolateral gutter of the ankle in 12 of 12 (100%) cases, corresponding to the synovial hypertrophy and soft tissue mass found at arthroscopy in the nine patients who underwent arthroscopy. Disruption, attenuation, or marked thickening of the anterior talofibular ligament was seen in all cases. Additional findings included signs of synovial hypertrophy elsewhere in the tibiotalar joint in seven of 12 patients (58%) and bony and cartilaginous injuries to the tibiotalar joint in five of 12 (42%). None of the control patients demonstrated MR imaging evidence of a soft tissue mass in the anterolateral gutter. CONCLUSIONS: ALI of the ankle is a common cause for chronic lateral ankle pain. It has been well described in the orthopedic literature but its imaging findings have not been clearly elucidated. The MR imaging findings, along with the appropriate clinical history, can be used to direct arthroscopic examination and subsequent debridement.

Nutritional and metabolic aspects of pancreatic cancer.

Most patients with pancreatic cancer suffer from a variety of severe metabolic and nutritional disturbances. Despite this fact, the role of perioperative nutritional support for these patients remains controversial. This review highlights the results of randomized prospective clinical trials, and meta-analyses that have addressed this issue. The 'current opinion' put forth in this discussion is based on these reviews, and on personal observations in treating more than 500 patients.

Stereoscopic transparency: a test for binocular vision's disambiguating power.

It has been suggested that to resolve ambiguities implicit in binocular perception of complex visual scenes, the brain adopts a continuity constraint assuming that disparities change smoothly with eccentricity. Stereoscopic transparency is characterized by abrupt changes of binocular disparity across retinal locations. The focus of the present study is how the brain uses the continuity constraint in the perception of stereoscopic transparency despite the presence of abrupt disparity changes. Observers viewed random-dot stereograms of overlapping transparent plane and cylindrical surfaces and had to distinguish between two orientations of the cylindrical surface under conditions of strictly controlled depth fixation. Surprisingly, maximal dot density of the transparent plane at which perception is still veridical dramatically decreases as depth separation between the surfaces grows. Persistence of this relationship, when binocular matching processes at each surface are separated to on and off brightness channels, suggests at least two stages in the underlying computation binocular matching and inter-surface interactions. We show that these phenomena cannot be accounted for by either higher severity of matching with high dot densities or the ability of the denser surface to pull vergence to its depth. We also measure contrast sensitivity and near-far symmetry of the underlying mechanism and propose a model of competitive interactions between dissimilar disparities.

Pancreatic calcification in an 18-yr-old patient following gallstone pancreatitis and recurrent pseudocysts.

Most authors believe that biliary pancreatitis rarely progresses to chronic pancreatitis. Here, we present a case of an 18-yr-old white male with a history of gallstone pancreatitis and pancreatic pseudocyst resulting in radiographic and pathologic evidence of pancreatic calcification over a 16-mo period.

Combined modality therapy for stage II and stage III pancreatic carcinoma.

PURPOSE: To study the outcome achieved with three-drug chemotherapy and split-course external-beam radiotherapy as a treatment for unresectable stage II and III pancreatic carcinoma. PATIENTS AND METHODS: Radiotherapy was given in three cycles of 2 Gy/d on days 1 to 5 and 8 to 12 (total dose, 54 Gy) concurrently with fluorouracil (FU) 1,000 mg/m2/d by continuous infusion for 4.5 days, streptozocin (STZ) 300 mg/m2 on days 1, 2, and 3 and cisplatin (P) 100 mg/m2 on day 3 of each every-28-day cycle. Subsequent treatment consisted of leucovorin (LV) 200 mg/m2 and FU 600 to 1,000 mg/m2 every 14 days. RESULTS: The median survival time for the 35 patients was 15 months and 26% of patients were alive at 24 months. Fifteen patients (42.8%) had objective responses to therapy. Six (17%) had a complete response (CR). Three of nine patients with partial responses (PRs) achieved a radiographic CR within the next 3 months. Nine patients underwent attempts at surgical resection: five were resected (median survival time, 31 months; range, 12.8 to 44.7+), two had no residual disease found at complete resection, and three others also had a complete resection. Of four others who could not be resected, three underwent intraoperative radiotherapy and one had occult metastatic disease. Of primary tumors, 91% did not produce either back pain or local gastrointestinal complications for 2 years. The rates of severe side effects were stomatitis 15%, anemia 14%, granulocytopenia 6%, and thrombocytopenia 6%. CONCLUSION: Palliation and survival compare favorably with other series, including many surgical series. The response findings encourage studies of both unresectable and (as neoadjuvant therapy) resectable tumors.

Safety, efficacy, and cost of pancreaticoduodenal resection in a specialized center based at a community hospital.

OBJECTIVE: To determine whether pancreaticoduodenal resection (PDR) for benign and malignant disease can be performed safely, efficiently, and economically at a 50-bed community hospital. DESIGN: Retrospective review of 39 consecutive PDRs performed in an 18-month period. Indications for surgery, length of hospital stay, complications, and patient charges were analyzed. SETTING: A suburban 50-bed community hospital. PATIENTS: Thirty-nine patients (15 male and 24 female) referred for PDR for benign and malignant disease. MAIN OUTCOME MEASURES: Mortality and morbidity rates, length of hospital stay, care, and cost. RESULTS: Of 39 patients who underwent PDRs, 1 patient (2.6%) died of myocardial infarct. Intraoperative blood transfusions were required by 3 patients (8%). The mean postoperative hospital stay was 11 days. Twenty-four patients (62%) were discharged by day 11. Fifteen patients (38%) were hospitalized 11 to 24 days. Complications in 10 patients (28%) included pancreatic or biliary fistula (n = 6), upper gastrointestinal tract bleeding (n = 1), partial wound dehiscence (n = 1), bacteremia (n = 1), and pneumonia (n = 1). No patient required reoperation. Three patients were rehospitalized within 1 month. Mean patient charges were $21,864, and mean reimbursements were $19,669. CONCLUSIONS: Pancreaticoduodenal resection can be accomplished with low morbidity and mortality rates and a short stay at a community hospital. Thorough preoperative investigations to exclude unresectable lesions must precede every PDR for malignant disease. Mortality and morbidity rates in this series were similar to those for patients with similar diagnoses who were operated on in academic centers. Cost for and length of hospital stay of these 39 patients were significantly lower than those in other reported series.

Endoscopic management of cholangitis: critical review of an alternative technique and report of a large series.

OBJECTIVE: To assess the outcome of endoscopic techniques as the solitary treatment modality for the complete management of ascending, bacterial cholangitis, compared with results of radiological and surgical methods as historical controls. METHODS: Endoscopic techniques were used to decompress bile ducts obstructed by stones (898 patients) or stenosis (49 patients). Endoscopic sphincterotomy (ES) was performed in 839 patients, and either 7-Fr straight stents (79), or nasobiliary tubes (29), were utilized as initial therapy in 108 patients. Of these latter patients, 68 subsequently underwent ES and stone removal, 17 had ES, lithotripsy, and stone removal, 18 were left with stents in place, and 5 were lost to follow-up. Follow-up was conducted by direct patient contact, by telephone, or through the referring physicians. RESULTS: All patients were managed by endoscopic techniques. There were four deaths (0.42%) in the first 30 days (none before 2 wk); no deaths were related to the procedures but were attributed to intercurrent medical problems. Two patients underwent surgery: one pancreatitis, one perforation. Complications were infrequent, occurring in 6% of patients. Bleeding occurred in 3%, pancreatitis in 2.8%, and perforation 0.2%. CONCLUSIONS: Endoscopic management of cholangitis is as effective as surgical or radiological methods for managing bacterial cholangitis, a potentially fatal syndrome, but ERCP and ES have been shown to be safer. Endoscopy is the preferred index technique both for establishing a definitive diagnosis and providing therapy.