Rationale for the combination of cryoablation with surgical resection of hepatic tumors.

Only 5% to 10% of metastatic and primary liver tumors are amenable to surgical resection. Hepatic cryoablation has increased the number of patients who are suitable for curative treatment. The aim of this study was to evaluate survival and intrahepatic recurrence in patients treated with cryoablation and resection. From June 1994 to July 1999, thirty-eight surgically unresectable patients underwent a total of 42 cryoablative procedures for 65 malignant hepatic lesions. Twenty patients underwent cryoablation alone, and 18 patients were treated with a combination of resection and cryoablation, with a minimum of 18 months' follow-up. The 38 patients had the following malignancies: primary hepatocellular carcinoma (n = 8) and metastases from colorectal cancer (n = 21), neuroendocrine tumors (n = 3), ovarian cancer (n = 3), leiomyosarcoma (n = 1), testicular cancer (n = 1), and endometrial cancer (n = 1). Patients were evaluated preoperatively with spiral CT scans and intraoperatively with ultrasound examinations for lesion location and cryoprobe guidance. Local recurrence was detected by CT. Major complications included bleeding in three patients and acute renal failure, transient liver insufficiency, and postoperative pneumonia in one patient each. Two patients (5%) died during the early postoperative interval; mean hospital stay was 7.1 days. Median follow-up was 28 months (range 18 to 51 months). Overall survival according to Kaplan-Meier analysis was 82%, 65%, and 54% at 12, 24, and 48 months, respectively. Forty-eight-month survival was not significantly different between those patients undergoing cryoablation alone (64%) and those treated with a combination of resection and cryoablation (42%). Disease-free survival at 45 months was 36% for patients undergoing cryoablation plus resection compared to 25% for those undergoing cryoablation alone. Local recurrences were detected at five cryosurgical sites, for a rate of 12% overall (5 of 42), 11% (2 of 18) for patients in the cryoablation plus resection group, and 12% (3 of 24) for those in the cryoablation alone group. For patients with colorectal metastases, survival was 70% at 30 months compared to 33% for hepatocellular cancer and 66% for other types of tumors. Patients with tumors larger than 5 cm or numbering more than three did not have significantly decreased survival. Cryoablation of hepatic tumors is a safe and effective treatment for some patients not amenable to resection. The combination of cryoablation and resection results in survival comparable to that achieved with cryoablation alone.

Current management of esophageal variceal bleeding.

Recent trends in the clinical management of bleeding esophageal varices include a shift away from endoscopic variceal sclerotherapy toward endoscopic variceal ligation. The excellent efficacy of the latter and its lower complication rate favor its increased use. Similarly, the minimally invasive nature of the TIPS procedure and its successful implementation by invasive radiologists have further reduced the need for surgical shunts in general, as well as when endoscopic intervention has failed. A multidisciplinary approach toward evaluation and treatment of variceal hemorrhage can be expected to improve the outcomes of these patients. More selective application of each of the therapies, either alone or in combination with other modalities, leads to improved results, as recently demonstrated by a series comparing outcomes of surgical shunts when used alone or as a preface to liver transplantation.

The changing spectrum of treatment for variceal bleeding.

OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. SUMMARY BACKGROUND DATA: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS. RESULTS: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.

Shunt surgery during the era of liver transplantation.

OBJECTIVE: The indications for and the results of portosystemic shunts done in the authors' institution since initiation of a liver transplant program 10 years ago were reviewed. SUMMARY BACKGROUND DATA: With the widespread availability of liver transplantation as definitive treatment of chronic liver disease, the role of shunts in the overall management of variceal bleeding needs to be redefined. METHODS: Seventy-one variceal bleeders with cirrhosis who received a shunt (82% distal splenorenal shunts) because of sclerotherapy failure or because endoscopic treatment was not indicated were reviewed retrospectively. In 44 patients with well-preserved hepatic reserve, the shunt was used as a long-term bridge to transplantation (shunt group 1). The remaining 27 patients with shunts were not transplant candidates mainly because of uncontrolled alcoholism or advanced age (shunt group 2). Survival of both shunt groups was compared to that of 180 adult patients with a history of variceal bleeding who underwent transplantation soon after referral. RESULTS: Because of their more advanced liver disease, the liver transplant group had a higher operative mortality rate (19%) than did either of the shunt groups (5% and 7%, respectively) (p < 0.02). Kaplan-Meier survival analysis showed better survival in shunt group 1 (seven patients thus far transplanted) than in either the liver transplant group or shunt group 2 during the early years and superior survival of shunt group 1 and the liver transplant group as compared to shunt group 2 during the later years of the analysis. Only two patients from shunt group 1 have died of late postoperative hepatic failure without benefit of liver transplantation. CONCLUSIONS: A shunt may serve as an excellent long-term bridge to liver transplantation in patients with well-preserved hepatic reserve. Shunt surgery still plays an important role in treatment of selected patients with variceal bleeding who are not present or future transplant candidates.

Transabdominal esophagogastric devascularization as treatment for variceal hemorrhage.

BACKGROUND: During the past 18 years we have used a selective operative approach for variceal bleeders in whom endoscopic sclerotherapy failed or sclerotherapy was not indicated. Esophagogastric devascularization with splenectomy has been reserved for unshuntable patients and for those in whom a shunt was deemed inadvisable. The purposes of this study are to describe the surgical procedure technique and indications for esophagogastric devascularization and to report its long-term results. METHODS: Thirty-two patients who underwent either a limited (n = 9) or extensive (n = 23) esophagogastric devascularization procedure without esophageal transection for variceal bleeding were retrospectively reviewed. Common indications were thrombosis of all splanchnic veins (n = 12), distal splenorenal shunt thrombosis (n = 7), generalized portal hypertension with isolated splenic vein thrombosis (n = 5), and symptomatic splenomegaly or severe hypersplenism (n = 6). Eighteen patients (56%) had cirrhosis, eleven (34%) received an emergency operation, and eighteen (56%) bled from gastric varices. RESULTS: Three patients with Child's class C disease undergoing emergency surgery died during the early postoperative interval. Rebleeding occurred in nine surviving patients (31%) and was the cause of death in three. Rebleeding rates for the limited and extensive devascularization procedures were 50% and 24%, respectively. Only one of 11 patients with diffuse splanchnic venous thrombosis without liver disease has died. The 5-year survival rate of patients with liver disease was 51%. Only two patients experienced postoperative encephalopathy. CONCLUSIONS: When used in selected patients, esophagogastric devascularization without esophageal transection is a reasonably effective alternative to shunt surgery.

Cystic adenomatoid malformation involving an entire lung in a 22-year-old woman.

Congenital cystic adenomatoid malformation is an uncommon cause of respiratory distress in infants and is a rare entity in adults. Presentation in older patients is that of recurrent pulmonary infections. Usually a single lobe is involved. This report describes congenital cystic adenomatoid malformation involving the entire right lung in a 22-year-old woman presenting with gastrointestinal bleeding due to cavernous transformation of the portal and splenic veins.

Cricopharyngeal dysfunction in Parkinson's disease: role in dysphagia and response to myotomy.

We report five patients with Parkinson's disease and dysphagia who were found, by radiological and manometric evaluation, to have evidence of cricopharyngeal dysfunction, which included the presence of a Zenker's diverticulum in two. Cricopharyngeal myotomy was performed in four patients with excellent and sustained improvement in swallowing. We conclude that cricopharyngeal function should be carefully evaluated in patients with Parkinson's disease and dysphagia and that surgical treatment should be considered in appropriate cases.

Glucagon, stress, and portal hypertension. Plasma glucagon levels and portal hypertension in relation to anesthesia and surgical stress.

Glucagon has been proposed as the mediator of splanchnic hyperemia in portal hypertension. Employing an assay specific for pancreatic glucagon, we reevaluated the relationship between this peptide and portal hypertension in the portal vein (PV)-stenosed rat model addressing, in particular, the effects of anesthesia and surgical stress. Plasma glucagon levels were similar in sham-operated and portal hypertensive rats: glucagon, sham vs PV stenosed: 110.7 +/- 17.1 pmol/liter vs 140.6 +/- 23.3 pmol/liter (NS). Furthermore, plasma levels of glucagon and the related peptide VIP were not significantly influenced by anesthesia or surgical stress, and levels remained similar under all conditions in sham-operated and PV-stenosed animals. We conclude that pancreatic glucagon is not elevated in the PV-stenosed rat; differences between these results and those describing hyperglucagonemia in this model cannot be explained on the basis of a differential response to stress but may reflect differences in glucagon assay system.

Emergency shunt. Role in the present management of variceal bleeding.

OBJECTIVE: To evaluate the results of selective and nonselective emergency portosystemic shunts in patients with acute variceal hemorrhage. DESIGN: Retrospective review. SETTING: University medical center and Veterans Affairs medical center. PATIENTS: Forty-two consecutive patients who underwent emergency portosystemic shunts from 1978 through 1994. All patients had chronic liver disease (29 [69%] had alcoholic cirrhosis) and half had Child's class C disease. Sixteen patients were actively bleeding at the time of surgery, and 26 had bled within 48 hours. Twenty-two patients underwent a nonselective shunt and 20 underwent a distal splenorenal shunt. The percentages of patients with Child's class C disease and with active bleeding at the time of surgery were significantly higher in the nonselective shunt group. MAIN OUTCOME MEASURES: Operative mortality; early postoperative rebleeding, shunt patency, encephalopathy, and ascites; and long-term survival. RESULTS: Operative mortality rates were higher in patients with Child's class C disease (43% [9/21]) than in patients with Child's class A or B disease (9% [2/21]) and were higher in patients with active bleeding (all of whom underwent nonselective shunt) (44% [7/16]) than in patients who underwent distal splenorenal shunt (10% [2/20]). All shunts were patent after surgery, and no patient had rebleeding during the early postoperative interval. Early postoperative ascites and encephalopathy rates were similar after nonselective shunt and distal splenorenal shunt. Long-term survival was superior in the lower-risk distal splenorenal shunt group. CONCLUSIONS: Even though more effective nonoperative treatments are now available, emergency portosystemic shunt remains an important option for selected patients with acute variceal hemorrhage. When bleeding can be temporarily controlled by nonoperative means, distal splenorenal shunt is an effective and safe emergency procedure. The mortality rate remains high for patients with Child's class C disease undergoing protal decompression.

Pancreatic complications after distal splenorenal shunt.

Pancreatic complications after the distal splenorenal shunt have not been commonly recognized. Between January 1978 and June 1993, 154 patients underwent a distal splenorenal shunt, and 11 patients (7%) developed pancreatic complications, of which 4 had pancreatitis alone, and 7 developed pancreatitis-related complications. Etiology of cirrhosis, Child's classification and timing of surgery were not predictive of pancreatic complications. Eight patients (5%) were found to have chronic pancreatitis at the time of surgery, and four of these patients (50%) developed pancreatic complications following distal splenorenal shunt. Eleven early postoperative deaths in our series resulted in an overall operative mortality rate of 7%. Of these eleven patients, 6 (55%) had postoperative pancreatic complications. The operative mortality rate of patients who developed pancreatic complications (55%) after distal splenorenal shunt was significantly greater than that of patients who did not develop pancreatic complications (3%), P < .001. When compared with patients without pancreatitis, those with pancreatitis had significantly greater incidences of complete or partial portal vein thrombosis (55% v 20%, P < .02), severe ascites (64% v 13%, P < .001), and encephalopathy (45% v 3%, P < .001). We reach the following conclusions: (1) although not a frequent complication after distal splenorenal shunt in general, pancreatitis was commonly present in early postoperative deaths and was most likely a major contributor to the demise of those patients; (2) survivors with postdistal splenorenal shunt pancreatitis had a markedly increased morbidity rate; and (3) pancreatic complications after distal splenorenal shunt are more likely to occur in patients with pre-existing chronic pancreatitis.

Pancreaticoduodenectomy for suspected but unproven malignancy.

BACKGROUND: Pancreaticoduodenectomy is an accepted surgical option for certain benign conditions and biopsy proven cancer. Whether this procedure should be performed when malignancy of the pancreas and periampullary region is suspected but not confirmed represents a fairly common intraoperative dilemma. PATIENTS AND METHODS: Sixty-seven patients who had undergone pancreaticoduodenectomy during a 15-year period were evaluated retrospectively. RESULTS: The indications for resection were symptomatic benign conditions (n = 10, 15%), proven pancreatic or periampullary cancer (n = 37, 55%), and suspected but unproven malignancy (n = 20, 30%). The patients with suspected malignancy ranged in age from 27 to 73 years. Common findings in this group were abdominal pain (75%), jaundice (70%), weight loss (65%), and alcohol use (45%). There were 14 pancreatic and 6 ampullary masses. Biopsies obtained preoperatively (n = 15) and intraoperatively (n = 11) were nonconfirmatory. Postoperatively 9 patients (45%) were found to have tumors, including 6 pancreatic adenocarcinoma, 2 duodenal adenocarcinoma, and 1 islet cell tumor. Six of the 8 adenocarcinomas (75%) were stage I. Seven patients were alive 11 to 108 months later. The most common benign diagnosis was pancreatitis. There were 8 complications and 1 death. CONCLUSIONS: Pancreaticoduodenectomy performed based on suspicion alone frequently reveals malignancy. Immediate and long-term outcomes are acceptable. These findings justify a continued aggressive approach to suspected pancreatic and periampullary malignancy.

Effects of portal vein stenosis and superior mesenteric vein ligation on mesenteric venous pressure and porta-systemic shunting in the rat.

We studied the relative contributions of splanchnic congestion and porta-systemic shunting to the maintenance of experimental portal venous hypertension. Three groups of rats were prepared: portal vein-stenosed, superior mesenteric vein-ligated and sham operated. Though elevated in both operated groups compared to controls, mesenteric venous pressure was highest in the portal vein-stenosed animals (PV vs SMV vs Sham: 19.6 +/- 1.3 vs 15.6 +/- 0.7 vs 13 +/- 0.6; p < .05 PV and SMV vs Sham, and PV vs SMV) despite the presence of 50% porta-systemic shunting in the portal vein-stenosed animals. Shunting was negligible in the other two groups. Peripheral plasma glucagon and vasoactive intestinal peptide (VIP) levels were similar in all three groups. We conclude that mesenteric congestion alone plays a minor role in the pathogenesis of portal hypertension, which may instead be related to the porta-systemic shunting of vasoactive substances other than glucagon and VIP.

Benign mediastinal teratoma masquerading as a large multiloculated effusion.

Benign mediastinal teratomas are uncommon germ cell tumors often discovered while still asymptomatic. Almost all arise in the anterosuperior mediastinal compartment, and most symptoms, when present, result from compression of adjacent structures. We report a case of a large teratoma arising from the anterior mediastinum that presented a confusing clinical picture of a multiloculated pleural effusion. It was successfully treated by surgical excision, with no long-term recurrence.

Practice environment and resident operative experience.

An important aspect of resident training is a graduated increase in responsibility and experience. The level of resident participation in operative procedures is influenced by many factors. Our aim was to determine the effect of the practice environment and staff perception of required surgical skills on the assignment of resident operative responsibility. Questionnaires were sent to 100 surgeons affiliated with the Department of Surgery at the University of Nebraska Medical Center, and the completion rate was 72%. Data were collected on the practice environment of the surgeons and their perception of appropriate resident level and required skills for performance of 20 common general surgery procedures. Surgeons in private practice (n = 34) and affiliated hospitals (n = 15) were more likely to assign cases to higher level residents than those at the University Hospital (n = 23) (mean: 3.0 +/- 0.5 and 3.0 +/- 0.3 versus 2.7 +/- 0.3 years, P < 0.05). Surgeons more than 15 years out of training (n = 28) were more likely to assign a higher level resident to procedures than those (n = 44) more recently trained (3.1 +/- 0.5 versus 2.7 +/- 0.3 years, P < 0.05). Surgeons who worked regularly with residents (n = 44) were more likely to assign a lower level resident to a given procedure (2.8 +/- 0.3 versus 3.1 +/- 0.5 years, P < 0.05). Multivariate analysis, however, found that only time since training was an important factor in the assignment of responsibilities. Laparoscopic procedures caused the greatest disagreement and were more likely to be assigned to higher level residents than the corresponding open procedures (hernia repair 3.3 +/- 0.1 versus 1.2 +/- 0.1 and cholecystectomy 3.2 +/- 0.1 versus 2.0 +/- 0.9 years, P < 0.05). Anatomy (46%) and judgment (36%) were most commonly considered the important surgical factors in determining operative responsibility. However, there was no correlation between assignment of operative responsibility and the perception of required skills for each surgeon. Thus staff perception of the appropriate resident level to perform general surgery procedures is more heavily influenced by factors in the practice environment than surgical aspects of the procedure.

Surgical management of acute variceal hemorrhage.

The advent of more effective nonoperative therapies, mainly endoscopic variceal sclerosis, has decreased the need for emergency surgery for control of acute variceal hemorrhage. In centers where it is available, nonoperative portal decompression by transjugular intrahepatic portosystemic shunting (TIPS) is likely to have a further impact. When acute or chronic sclerotherapy fails or when bleeding is secondary to gastric varices or portal hypertensive gastropathy, emergency surgery may be life-saving and should be done promptly before worsening hepatic functional decompensation develops. Child's class C liver disease is not a contraindication to emergency surgery; many patients who fail nonoperative attempts at control of bleeding are of this risk status. The most commonly utilized emergency procedures are portacaval and interposition mesocaval shunts, both of which are effective, and esophageal transection, which is associated with a higher incidence of late rebleeding. An emergency distal splenorenal shunt is appropriate for selected patients who are not actively bleeding at the time of surgery. TIPS is the preferred alternative for acute or chronic endoscopic sclerotherapy failures who are candidates for liver transplantation within the succeeding 6 to 12 months.