A pilot study of chronomodulated infusional 5-fluorouracil chemoradiation for pancreatic cancer.

BACKGROUND: Dose limiting acute toxicity from chemoradiation for pancreatic cancer occurs in 15% -20% of patients treated with post-operative adjuvant therapy. Reported here is a pilot study using chronomodulated infusional 5-fluorouracil (5-FU) chemoradiation (CIC) for pancreatic cancer, a treatment designed to reduce normal tissue toxicity and maintain efficacy, with specific evaluation of acute and late morbidity, patterns of disease progression, and survival. PATIENTS AND METHODS: Twenty-three patients with adenocarcinoma of the pancreas were treated with 5-FU CIC between January 1997 and September 1999. The median age was 64, and there were 9 males and 14 females. Six patients were considered unresectable and seventeen others were treated post-operatively. The median external beam irradiation dose was 50.4 Gy. 5-FU infusion was given five days per week (300 mg/m2/d) and the median total dose was 8.4 g/m2. The chronomodulated 5-FU infusion consists of a low basal infusion rate for 16 hours followed by an eight-hour escalating-deescalating infusion peaking at 10 p.m. All patients were followed from the time of initial diagnosis until last follow-up or death; the median follow-up was 16 months. RESULTS: No RTOG grade 3 or 4 hematologic toxicity occurred. Twelve of seventeen patients treated postoperatively have been controlled locally, and seven patients have no evidence of disease. The median survival is 28 months and one-year actuarial survival is 88% in the group of resected patients. The 6 patients treated for unresectable disease have a median survival of 13 months. CONCLUSIONS: Acute toxicity of 5-FU CIC appears to be less frequent and less severe than that reported with flat infusional or bolus 5-FU based chemoradiation used for adjuvant post-operative therapy for pancreatic cancer. This method may warrant further examination, as it may be attractive for the elderly or those who cannot tolerate the toxicity associated with standard post-operative treatment protocols.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway.

OBJECTIVE: To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied. METHODS: During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared. RESULTS: After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings. CONCLUSIONS: Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Intern call schedules and their relationship to sleep, operating room participation, stress, and satisfaction.

BACKGROUND: The ideal resident call schedule remains unknown. This study assessed the impact of different call schedules on intern performance and education. METHODS: A year-long, prospective, observational study of first-year residents in a surgery training program was performed with use of intern sleep/operative logs and questionnaires, and faculty questionnaires. RESULTS: Compared with interns taking call every third or fourth night (and cross-covering a separate service), interns taking call every other night reported the greatest amount of fatigue and stress, the lowest satisfaction, and the fewest operative cases. Errors in patient care were not different between schedules. Multivariate analysis revealed that operative participation was inversely related to frequency of night call and level of fatigue post call, stress was related to fatigue while off call and service census, and overall satisfaction was associated with infrequency of call and operative cases performed. Faculty reported more errors by interns cross-covering other services and less operating room participation by interns taking call every other night. CONCLUSIONS: No single resident schedule optimally balances patient care and resident education and satisfaction. All 3 patterns of call studied are acceptable; specific decisions regarding the allocation of house staff manpower should be flexible and dependent on individual service and educational needs.

Tumor-induced osteomalacia and symptomatic looser zones secondary to mesenchymal chondrosarcoma.

Tumor-induced osteomalacia is a rare clinical entity that is associated with soft-tissue or skeletal tumors. We present a case report of a patient with a chest wall mesenchymal chondrosarcoma who presented with bone pain. The patient had skeletal changes in the femoral neck and fibula consistent with osteomalacia and laboratory values suggesting phosphate diabetes. The patient was treated with tumor resection and phosphate supplementation with reversal of the signs and symptoms of osteomalacia. Tumor-induced osteomalacia is vitamin-D-resistant and often reversed by complete removal of the tumor. Most commonly, the causative tumors are of vascular, mesenchymal, or fibrous origin. The osteomalacia is associated with bone pain, muscle weakness, and radiographic changes. Tumor-induced humoral factors have been implicated in causing the osteomalacia, but the definite etiology has yet to be determined. Current treatment includes complete tumor resection and electrolyte supplementation.

Gastrointestinal recovery following laparoscopic vs open colon surgery.

BACKGROUND: We prospectively studied the recovery of gastrointestinal motility in patients undergoing laparoscopic (LAP, n = 7) or open (OPEN, n = 7) colon resections. METHODS: At operation, bipolar recording electrodes were placed on the proximal and distal antrum, the proximal site of the colonic anastomosis, and the rectosigmoid for postoperative myoelectric recordings. RESULTS: Shorter postoperative hospitalization and earlier resumption of a regular diet of the LAP group just barely failed to achieve significant differences when compared with the OPEN group (p = 0.091, p = 0.050, respectively). There were no differences between groups for slow wave frequency, amplitude, or dysrhythmias in the antrum, nor for return of discrete (DERA) and continuous (CERA) electrical response activity in the colon. Percentage of slow waves with spike activity tended to increase with passage of time postoperatively in both groups. There was a significant difference between POD 3 and 7+ in the LAP group (p < 0.05). However, there were no significant differences in the percentage of slow waves with spike activities between groups on any postoperative day. CONCLUSIONS: The potential benefits of using a laparoscopic approach to colon resection are not clearly confirmed by these data. While such an approach may possibly result in shorter hospitalization, it appears to offer at best only modest increases in the rapidity of recovery of gastrointestinal function.

Intraoperative fine needle aspiration of pancreatic and extrahepatic biliary masses.

Intraoperative fine needle aspiration (IFNA) of masses of the pancreas and extrahepatic biliary system provides a method of rapid tissue diagnosis with a much lower complication rate than either wedge or large bore needle biopsies. Few series include IFNA of extrahepatic biliary system masses in their analyses. We retrospectively evaluated all IFNA of pancreatic, extrahepatic biliary and ampullary masses at the University of Virginia from March 1981 to December 1991 to assess the diagnostic accuracy of this procedure. Ninety-nine IFNA were performed--75 of the pancreas, 17 of the extrahepatic biliary system and seven of the ampulla. All aspirations were performed with direct visualization or palpation of the tumor, or both, using several passes with a 22 gauge needle. A diagnostic "positive" or "negative" reading was rendered in 90 of 99 IFNA. Carcinoma was confirmed by positive tissue diagnosis or clinical course consistent with cancer. Benign disease was confirmed by negative pathologic factors from a resected specimen or confirmatory clinical course of at least 18 months. Diagnosis was confirmed by these criteria in 82 patients. Thirty-four of 43 patients with confirmed carcinoma of the pancreas had positive cytologic factors by IFNA. Three pancreas IFNA were deemed as "suspicious" and six as "unsatisfactory." Two patients with "suspicious" findings had pathologically confirmed well-differentiated carcinoma. Carcinoma of the ampulla and extrahepatic biliary tract was detected by IFNA in 17 of 18 confirmed patients. The overall sensitivity of positive or negative IFNA in this series in 90 percent, with 100 percent specificity and 92 percent accuracy. IFNA has a positive predictive value of 100 percent and negative predictive value of 74 percent. We conclude that IFNA is a highly accurate diagnostic procedure and represents the preferred technique of obtaining an intraoperative tissue diagnosis in masses of the pancreas, extrahepatic biliary tract and ampulla. Positive IFNA may definitively guide surgical decision-making; however, we caution that negative IFNA cannot be relied on definitively to exclude the diagnosis of carcinoma.

Intraoperative endoscopic electrohydraulic lithotripsy of pancreatic stones.

Two male patients with complications associated with chronic pancreatitis are described. In each patient, preoperative examinations revealed a large stone obstructing the main duct in the head of the pancreas. Lateral pancreaticojejunostomy was performed to relieve pain and prevent further attacks of pancreatitis. During each operation, the stone was fragmented under direct visual control with the use of a flexible choledochoscope and a contact electrohydraulic lithotriptor. The stone was removed and ductal flow through the head of the pancreas was reestablished. Our experience shows that endoscopic electrohydraulic lithotripsy facilitates operative removal of pancreatic stones deeply located in the head of the pancreas.

A re-appraisal and modification of the Lauritzen technique of microvascular anastomoses.

Twenty arterial anastomoses were performed in ten Sprague-Dawley rats, utilising a modification of the Lauritzen technique which was being re-evaluated because of its apparent simplicity and high patency rate. In 90% of the anastomoses performed patency was confirmed one week after operation. Histological examination at this time revealed neo-endothelialisation across the anastomotic site. It is clear that this technique is a very efficient method of anastomosing vessels of similar size in the experimental animal where tension is not a problem and should be considered for use in suitable cases in man.