High-dose preoperative external beam and intraoperative irradiation for locally advanced pancreatic cancer.

PURPOSE: To analyze results of high-dose preoperative external beam irradiation followed by surgical exploration and intraoperative radiation therapy in patients with unresectable pancreatic cancer. METHODS AND MATERIALS: From December 1983 through December 1990, 27 patients with primary unresectable but localized pancreatic adenocarcinoma received high-dose (50 to 54 Gy) external beam irradiation with or without concomitant bolus 5-fluorouracil followed by surgical exploration and intraoperative electron beam irradiation (20 Gy) at the Mayo Clinic. RESULTS: Local control was achieved in 21 of 27 (78%) patients. Actuarial local control at 1, 2, and 5 years was 86%, 68%, and 45%, respectively. In 19 (70%) of the 27 patients, distant metastasis developed, and peritoneal or liver progression (or both) was found in 14 (52%). The actuarial distant metastasis rate at 2 and 5 years was 69% and 83%, respectively. Median survival from the date of diagnosis was 14.9 months. Actuarial 2- and 5-year overall survival was 27% and 7%, respectively. These survival rates are higher (p = 0.001) than the 6% and 0% actuarial 2- and 5-year survival observed in 56 patients who underwent intraoperative radiation therapy followed by postoperative high-dose external beam treatment at our institution. CONCLUSION: Administering the full component of external beam irradiation before exploration and intraoperative radiation therapy may be more appropriate because it allows better patient selection. Unfortunately, altered patient selection was not effective in decreasing the relative risk of abdominal failure. Because effective systemic chemotherapy does not currently exist, whole abdominal irradiation alone or in combination with chemotherapy warrants evaluation.

Intraoperative and external beam irradiation +/- 5-FU for locally advanced pancreatic cancer.

Because of the poor local control rates obtained with external beam irradiation +/- chemotherapy for locally advanced pancreatic cancer, our institution has used intraoperative radiation therapy (IORT) with electrons to deliver a single "boost" dose of radiation in 52 patients with biopsy-proven adenocarcinoma (primary, unresectable-49; primary, residual-2; and recurrent, unresectable-1). Patients received 4500-5000 rad of fractionated external beam irradiation and an IORT dose of 1750 rad (2 patients) or 2000 rad (50 patients). Acute and chronic tolerance have been acceptable. Documented local progression within either the external beam or IORT fields has been infrequent (3 of 42 evaluable patients or 7%), but there has been little, if any, change in median or long-term survival from that seen in external beam series. This is probably because of a high incidence of liver and peritoneal metastases with pancreatic cancer. A phase II pilot trial, which combines upper or total abdominal irradiation and infusion 5-FU with tumor nodal irradiation plus IORT, is in progress in our institution to evaluate tolerance and the relative incidence of abdominal failures.

Analysis of failure following curative irradiation of gallbladder and extrahepatic bile duct carcinoma.

Twenty patients with carcinoma of the gallbladder (GB-4 patients) or extrahepatic bile ducts (EHBD-16 patients) received radiation therapy with curative intent between January, 1980 and December, 1982. All 20 received 4500-5000 rad in 180-200 rad fractions to the tumor and regional lymph nodes. A 1000 to 1500 rad external beam boost was delivered in 180-200 rad fractions in 10 patients who received external beam alone or concomitant 5-Fluorouracil (5-FU). Three of the four GB and 5 of the 16 EHBD patients received a transcatheter boost with 192-Iridium (192Ir) to a dose of 2000-2500 rad calculated at a 0.5-0.1 cm radius. An additional 2 patients with EHBD lesions received an intraoperative electron (IORT) boost of 1500-2000 rad in one fraction calculated to the 90% isodose. Survival and patterns of failure were analyzed by site and treatment method. All four patients with GB carcinoma are dead of disease at 5 1/2, 6, 9 and 10 months from the date of diagnosis respectively. Three of the four developed diffuse peritoneal carcinomatosis. Five of the 16 patients with EHBD carcinoma are alive with a median follow-up of 18 months (range 6-23 months). Four of the 5 patients received a transcatheter 192Ir or IORT boost and all are without evidence of disease. Four of 9 patients who had a subtotal resection with transection of tumor, dilatation of the bile ducts with probes or curettement of the bile ducts developed either diffuse peritoneal carcinomatosis (3 patients) or a recurrence in the surgical scar (2 patients). Local failure was documented in 3 of the nine patients treated with external beam alone +/- 5-FU, and has been documented in one of the seven patients who received an IORT or transcatheter 192Ir boost. Further experience is necessary to determine whether this aggressive treatment will result in long-term disease-free survival in these patients.

External beam and intraoperative electron irradiation for locally advanced soft tissue sarcomas.

PURPOSE: Intraoperative irradiation with electrons was used in conjunction with external beam irradiation and maximal surgical resection in 20 patients with locally advanced soft tissue sarcomas or desmoids. This manuscript presents results with regard to tolerance of treatment and its impact on tumor control and survival. METHODS AND MATERIALS: Ten patients presented with previously untreated primary sarcomas and 10 at the time of local recurrence (two had recurrent desmoid tumors). Tumor location was retroperitoneal in 19 and in the low anterior neck in one. A partial or gross total resection was performed prior to the external beam or intraoperative component of irradiation in every patient, but all had positive resection margins. Patients received 4500-6000 cGy of fractionated, external beam irradiation and an IORT dose of 1000-2000 cGy. Chemotherapy was given only at the time of disease progression. RESULTS: Fourteen of 20 patients (70%) were alive; 11 (55%) were free of disease (4/10 primary, 7/10 recurrent), but 1 required hemipelvectomy for salvage. Progression within the intraoperative irradiation field was documented in only 1 patient (5%) and within the external beam field in 3/20 (15%). Blood born distant metastasis occurred in 5 patients (25%) and peritoneal seeding in 1 (5%). The distant failure incidence by grade was 1/8 (13%) for Grades 1, 2 and 5/12 (42%) for Grades 3, 4. Only 1 patient (5%) developed a > or = severe neuropathy, and small bowel obstruction requiring exploration also occurred in a single patient. CONCLUSION: In view of acceptable tolerance and the high current rate of local tumor control, in spite of incomplete surgical resections, further evaluation of intraoperative irradiation as a component of treatment is indicated for locally advanced primary and recurrent soft tissue sarcomas.

Scrotal reconstruction for giant inguinal hernias.

A case of inguinal hernia with massive scrotal enlargement is presented. Walking and voiding had become extremely difficult for the patient; only one testicle could be palpated, and the penis could not be delivered from the scrotal mass. Surgical reduction of the massive hernia was accomplished. The right testis with its spermatic cord had to be sacrificed; the left one was normal, although the cord was elongated. The main bulk of the enlarged scrotum was excised, and a neoscrotum was created from perineal skin; orchiopexy on the left was carried out. Healing has been uneventful.

Splenic abscess--the importance of early diagnosis.

Intrasplenic abscess is an uncommon but potentially lethal condition. Successful management of patients with this complication is facilitated by early diagnosis. The salient clinical features, the diagnostic approaches, and the results of treatment in a group of 19 patients are presented. Splenic abscess was diagnosed ante mortem in two-thirds of the patients but preoperatively in only one-third. When the diagnosis of splenic abscess was made, treatment with splenectomy and antibiotics was associated with a 17% mortality. A high degree of clinical alertness, an awareness of the predisposing clinical conditions, and an aggressive diagnostic approach are emphasized as being essential for an early diagnosis and effective treatment of splenic abscess.

Mesenteric angiofollicular lymph node hyperplasia (lymphoid hamartoma) with nephroitc syndrome.

In an 18-year-old woman who presented with the nephrotic syndrome and an abdominal mass, removal of a benign mesenteric lymphoid tumor was associated with remission of the nephrotic syndrome without further recurrence (30 month follow-up). Biopsies of both kidneys showed a minimal-change glomerular lesion. Clinical and pathologic characteristics of angiofollicular lymph node hyperplasia and its possible relationship to the nephrotic syndrome are discussed.

Radical pancreatoduodenectomy--a procedure to be abandoned?

Radical pancreatoduodenectomy, or Whipple's procedure, has gradually fallen into disrepute during the past decade. This loss of popularity has resulted from excessive postoperative mortality and morbidity due to inherent technical difficulties, the dismal long-term survival when the procedure is done for adenocarcinoma of the pancreas, and the current enthusiasm for total pancreatectomy. Our objective was to assess the technical aspects of the Whipple procedure as they relate to subsequent morbidity and mortality. Conclusions are drawn from the evaluation of 146 consecutive patients who underwent this procedure between 1970 and 1979 for either benign (10 patients) or malignant (136 patients) diseases of the pancreas and periampullary region. The postoperative mortality was 4.1%. Significant morbidity occurred in 34% of patients, and early reoperation was required in 7.5% of these patients. The median postoperative hospital stay was 19 days. The relatively low postoperative mortality indicates that inherent technical difficulties of the Whipple procedure can be overcome and supports its continued use in carefully selected patients. The persistent high morbidity and the rather poor long-term results following treatment of certain pancreatic malignancies place individual surgical judgment and technical expertise at a premium when ever this classic operation is contemplated.

Proximal gastric vagotomy. Initial experience.

Proximal gastric vagotomy was performed in 223 patients with chronic duodenal ulceration between 1973 and 1977. The follow-up ranged from 6 to 78 months with a mean of 39 months. There was no operative mortality. Adverse postoperative sequelae, including delayed gastric emptying, dumping, diarrhea, and reflux gastritis, were seen in less than 3% of patients. Ulcers recurred in 11 patients (4.9%). We conclude that proximal gastric vagotomy is an effective, safe, and satisfactory operation for chronic duodenal ulcer over the short term.

Choledochal cysts in adults: clinical management.

The surgical management of 29 adults with choledochal cysts is reviewed with emphasis on clinicopathologic features, long-term postoperative results (mean 9.1 years), and factors affecting outcome. Clinical symptoms were characterized by abdominal pain, jaundice, and cholangitis. Coexistent hepatobiliary pathologic findings were more complex and frequent than those that occur in children and included cystolithiasis or cholelithiasis, pancreatitis, malignancy, cirrhosis with portal hypertension, and intrahepatic abscess. Associated pathologic findings and cyst type (type I-22, II-1, III-2, IVA-4) determined the operative approach. In patients with type I or IVA cysts, results of cyst excision were excellent in five of seven patients but results of cystenterostomy were excellent in only seven of 19 patients. The high prevalence of pancreatitis (33%) and cyst-associated malignancy (28%) were major causes of treatment failure. Cyst excision with Roux-en-Y hepaticojejunostomy is recommended as the treatment of choice for adults to eliminate pancreatitis by pancreaticobiliary disconnection and possibly to reduce the risk of malignancy.

Closure of abdominal incisions with subcutaneous catheters.

Five hundred patients who underwent a variety of major abdominal operations had primary closure of their abdominal incisions. The technique of closure included the use of catheters in the subcutaneous space with suction, except when an antibiotic solution was being instilled every 8 hours of the first 9 days after operation. The rate of postoperative wound infection in these 500 patients, a group which included 140 patients who had contaminated or dirty wounds, was 0.8 percent. Infection developed in only one (0.47 percent) of the 211 patients who underwent major colon procedures. No significant side-effects of treatment were observed.

Prognostic factors in pancreatic abscess.

Pancreatic abscess is a highly lethal sequela of pancreatitis. The purpose of this study was to identify clinical and laboratory factors associated with the antecedent episode of pancreatitis or at the time of manifestation of a pancreatic abscess and factors related to its treatment that might have prognostic significance. The records of 66 consecutive patients with pancreatic abscess seen between 1966 and 1980 were reviewed. Factors adversely affecting survival included: severity of precipitating pancreatitis (p less than 0.03); sepsis and pulmonary dysfunction (p less than 0.05); and persistent postoperative sepsis (p less than 0.001). All four patients who were treated nonsurgically died. Of 62 patients treated surgically, 80% experienced serious complications, 31% required reoperations, and 40% died. No single surgical procedure, including marsupialization, proved to be superior. Surgical drainage offers the only possibility of survival for patients with pancreatic abscess. More thorough elimination of all focuses of infection is required, however, to reduce the high morbidity and mortality rates associated with persistent postoperative sepsis.

Colovesical and rectovesical fistulas.

Colovesical or rectovesical fistulas develop because of a congenital abnormality, a traumatic incident, or an underlying disease, such as inflammation or cancer. Inflammation, either diverticulitis or Crohn's disease, was the cause of fistula in 73 (67%) of 109 patients with colovesical or rectovesical fistulas seen at the Mayo Clinic, Rochester, Minn, between 1965 and 1980. Sixty-six of the 73 patients had colovesical fistulas, and 64% of them underwent resection and anastomosis in one stage. Cancer of the cervix, prostate, bladder, colon, or rectum was responsible for 27 fistulas, equally divided between colovesical and rectovesical types. Only seven (26%) could be treated by one-stage anterior resection. Fifteen patients required fecal diversion with or without resection of bowel. At follow-up, 80 patients were alive; only two (one with prostatic cancer and one with cervical cancer) had recurrence of fistula.

Radiation hazard to operating room personnel during operative cholangiography.

During operative cholangiography, the surgeon and other operating room personnel are exposed to scattered radiation and its potential hazards. It was determined that a surgeon standing at the side of the patient during cholangiographic filming would receive 3.2 mR per film. Exposure would be only 0.5 mR per film if the surgeon stepped back 75 cm (2.5 ft) from the patient. This simple measure would reduce the monthly exposure of a surgeon who performs four cholangiograms per week from approximately 205 to 32 mR. The use of the new electronic video-disc recording systems and lead aprons can substantially reduce the amount of radiation exposure related to fluoroscopy. The prudent surgeon, recalling that no level of radiation may be totally safe, should use techniques that provide maximal protection for himself and all operating room personnel during performance of operative cholangiography.

Postoperative intussusception in the adult: a previously unrecognized entity?

The records of all adults with intussusception seen at the Mayo Clinic from 1955 to 1978 were reviewed. Of the 73 patients, 25 had intussusception either during the immediate postoperative period (20 patients) or after recent abdominal surgery (five patients). Clinical features in the adult closely resembled the well-recognized entity of postoperative intussusception in children. Etiologic factors likely represented the formation of intra-abdominal adhesions, presence of suture lines, use of long intestinal tubes, or abnormalities in motor activity during the postoperative period. Surgical treatment usually required reduction of the intussusception and lysis of all accompanying adhesions. Resection was required only when reduction was impossible, intestinal viability was questioned, or the intussusception stemmed from an oversewn blind intestinal stump. No patient had a recurrence. Postoperative intussusception represents an entity different from the usual intussusception presenting de novo in the adult.

Chronic pancreatitis. Results of Whipple's resection and total pancreatectomy.

The aim of our study was to determine the success of radical pancreatic resection in relieving the pain of chronic pancreatitis. From 1974 to 1985, 30 consecutive patients underwent radical pancreatic resection for the treatment of debilitating pain (15 underwent Whipple's resection and 15 underwent total pancreatectomy). Patients were not randomized but were subjected to the procedure deemed indicated for their clinical presentation; thus, the two groups were not strictly comparable. There was no operative mortality; major morbidity occurred in three patients (20%) in each group (four patients experienced anastomotic bile leak and two experienced abdominal sepsis). Following Whipple's resection, mean follow-up was 6.2 years (range, 1.5 to 12.1 years). Complete pain relief occurred in eight patients (53%) and significant relief in an additional four (27%). Endocrine insufficiency developed in six patients and exocrine insufficiency in eight. Following total pancreatectomy, mean follow-up was 9.1 years (range, 2.1 to 13.1 years). Complete pain relief occurred in only four patients (27%) and significant relief in an additional six (40%). Significant pain persisted in about 33% of patients after total pancreatic resection. We concluded that radical pancreatic resection can be performed safely in patients with chronic pancreatitis but with gratifying results in only 67% to 80% of patients. Whipple's resection may be preferable for disease located primarily in the head of the gland.

Closure of abdominal incisions with subcutaneous catheters. A prospective randomized trial.

A preliminary report from our institution suggested that closure of abdominal incisions with subcutaneous, closed-suction catheters intermittently irrigated with antibiotic resulted in decreased wound infection rates. To test this hypothesis, a prospective, randomized, controlled trial was undertaken to compare the results of primary closure, subcutaneous catheter irrigated with saline or antibiotic, and subcutaneous catheter alone. During the two-year trial, 3,282 incisions (type II, III, or IV) were analyzed. Subcutaneous catheter placement alone or with antibiotic or saline irrigation was not superior to primary closure for type II or III incisions. A trend favoring subcutaneous catheter and antibiotic irrigation was observed for type IV incisions. This finding suggests that further clinical trials designed to assess the role of subcutaneous catheter placement and antibiotic irrigation in decreasing wound infection rates are warranted in type IV incisions.

Starch peritonitis and its prevention.

Commercially available surgical gloves contain a derivative of cornstarch and peritonitis induced by particles of starch shed from gloves can be a serious complication of abdominal surgery. Five documented and two suspected cases of this condition are known to have occurred at this institution during a recent 12-month period, when 4,965 intra-abdominal procedures were performed. Clinical features included fever, migratory abdominal pain, and ileus. Treatment with corticosteroids proved effective. Studies of the effectiveness of operating room precautions used to eliminate starch contamination indicated that these precautions do not eliminate the problem completely. Preliminary experience with the use of sodium bicarbonate as a substitute for cornstarch derivatives to "lubricate" surgical gloves has proved promising in eliminating the hazard of starch peritonitis.

Radical resection for carcinoma of the ampulla of Vater.

One hundred four consecutive patients who underwent radical resection for ampullary cancer between 1965 and 1989 were retrospectively reviewed. Frequent clinical findings included jaundice (67%), significant (greater than 10%) weight loss (42%), and anemia (27%). Eighty-seven patients (84%) underwent a subtotal pancreatectomy, and 17 patients (16%) underwent a total pancreatectomy. The postoperative mortality was 5.7% (six patients), and reoperation for postoperative complications was required in six patients. The 5- and 10-year survival rates were 34% and 25%, respectively. Eight patients died of tumor recurrence more than 5 years after resection. Patient survival was significantly impaired by microscopic lymphatic invasion, regional nodal metastasis, tumor grade, and the epithelium of origin. In a multivariate analysis, only microscopic lymphatic invasion significantly reduced patient survival. Radical resection for ampullary cancer can be performed with a low morbidity and mortality and should remain the procedure of choice for ampullary carcinoma.

Complications following pancreaticoduodenectomy. Current management.

From 1980 to 1989, 279 patients underwent pancreaticoduodenectomy at a single institution with a postoperative mortality of 4%. The aim of this study was to determine incidence, origin, and present management strategy of early complications following this operation. Significant morbidity occurred in 46% of the patients, including delayed gastric emptying (23%), pancreaticojejunal anastomotic leak (17%), intra-abdominal sepsis (10%), biliary-enteric anastomotic leak (9%), gastrointestinal tract bleeding (5%), and intra-abdominal hemorrhage (3%). Complications were associated with advanced age, prolonged operations, and increased operative blood loss. Most complications were managed nonoperatively. Mortality was increased when a reoperation was required, a biliary-enteric leak occurred, or an intra-abdominal abscess developed. Pancreaticoduodenectomy continues to carry a high postoperative morbidity; however, operative mortality is low, and management of complications has been made simpler with more sophisticated, nonoperative therapeutic options.