Results of an aggressive surgical approach to gastric carcinoma during a twenty-three-year period.

The early work of Dr. William Longmire with total gastrectomy for gastric carcinoma prompted us to initiate an aggressive surgical approach to gastric carcinoma in 1960: in curative resections radical total gastrectomy with hepaticoceliac-left gastric arterial node dissection was to be performed for tumors involving the entire stomach or upper two thirds and radical 80% to 90% subtotal gastrectomy with similar node dissection for tumors located in the antrum. During a 23-year period 213 patients with confirmed gastric carcinoma were studied. Celiotomy was performed in 192: advanced gastric cancer was found in 185 and seven had early gastric cancer. In only 80 patients could resections for "cure" be done. In 31 patients who underwent total or extended total gastrectomy the operative mortality rate was 9.6%, and life table survival curves show a better survival rate than in 49 patients treated by subtotal gastrectomy, with an operative mortality rate of 16.3%. The study shows the urgent need for diagnosis of early gastric cancer by gastroscopic screening of adults at risk and the meager salvage by radical resection in advanced disease.

Pancreatoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note.

Radical pancreatoduodenectomy for treatment of pancreatic carcinoma has been the surgical standard of care for the past four decades. The recent popularization of pylorus-sparing pancreatoduodenectomy to treat benign pancreatic disease, because of its decreased morbidity and long-term nutritional consequences, has led to the use of this procedure in cases of pancreatic carcinoma. We report recent experience with three patients with pancreatic carcinoma in whom pyloric preservation would have compromised the potential chance for curative resection or compromised palliation because of occult spread of tumor to a region not resected with this new operative approach. Two patients had proximal, microscopic intramural spread of pancreatic adenocarcinoma within the duodenum or antrum--a mode of spread not previously reported with pancreatic carcinoma. Both patients had no other evidence of metastatic involvement, and both would have had positive surgical margins in a pylorus-sparing pancreatoduodenectomy. A third case demonstrates a true submucosal recurrence of pancreatic carcinoma after a pylorus-sparing pancreatoduodenectomy. It is debatable that any case demonstrating intramural spread within the duodenum could be cured with a standard Whipple resection as this may well represent another sign of incurability, like lymphatic or perineural spread, but it is clearly a major potential obstacle to palliation if submucosal recurrences occur as a result of the use of the pylorus-sparing pancreatoduodenectomy in cases of pancreatic cancer. The use of pylorus-sparing pancreatoduodenectomy in resectable pancreatic cancers must be viewed skeptically at this time.

Perforated gastric ulcers. A plea for management by primary gastric resection.

One hundred one patients with perforated gastric ulcers have been treated at our institution during the past three decades. Ninety-one patients underwent operative repair, with a 24% mortality. A reduction in mortality and complications was realized when primary gastric resection, rather than patch closure, was performed. This could not be explained by selection bias, as risk factor prevalence was equally distributed between these two groups. We conclude that primary gastric resection, with or without vagotomy, is the procedure of choice for repair of perforated gastric ulcers. Only intraoperative hemodynamic instability should limit operative selection to a faster, less definitive procedure.

Persistent hepatic hydrothorax after peritoneojugular shunt.

Hepatic hydrothorax causes serious respiratory morbidity and is difficult to cure. Evacuation of ascites via peritoneojugular shunt should eliminate the source of the pleural fluid. However, this technique is not infallible. Obtaining pleurodesis by chemical or mechanical means may be necessary. Two cases were successfully treated with pleurectomy and tube thoracostomy, respectively.

Remedial operation for alkaline reflux gastritis and associated postgastrectomy syndromes.

Alkaline reflux gastritis is being recognized with increasing frequency after operations that ablate the pylorus as a true sphincter. Medical management is generally ineffective for patients with severe reflux gastritis, but Roux-en-Y diversion of bile and of pancreatic and intestinal secretions provides gratifying results. We studied 100 patients who underwent remedial operation. Roux-en-Y gastrojejunostomy or Tanner's vs Roux-19 procedure gave good to excellent results in most of the 73 patients followed up for from one to six years. Reflux gastritis can occur in association with other postgastrectomy disorders. Fifteen patients with reflux gastritis also had severe dumping or postvagotomy diarrhea. Good to excellent results were obtained in most of these patients by Roux-en-Y diversion combined with an antiperistaltic jejunal segment.

Colorectal carcinoma in pregnancy.

Colorectal carcinoma in pregnancy is rare. The symptoms frequently are masked by the symptoms associated with normal pregnancy, resulting in delayed diagnosis. Based on our experience with five patients and review of the literature, we developed a management regimen that takes an aggressive approach to tumor excision, yet maintains the pregnancy and fertility if possible. The prognosis is poor for most patients because the stage of the tumor is usually advanced at the time of diagnosis. The key to improved survival, as with all cancers, is early diagnosis and treatment.

Acute perforated duodenal ulcer. An evaluation of surgical management.

The surgical management of acute perforated duodenal ulcer has been evaluated in 360 patients. Simple closure was done in 254 patients, with a mortality of 6.7%, a morbidity of 21%, and an average hospital stay of 11.9 days. In 106 patients (29%) who underwent definitive operation for treatment of duodenal ulcer disease at time of perforation, the mortality was 2.8%, the morbidity was 15%, and the average hospital stay was nine days. Follow-up studies of simple closure in patients with no previous ulcer symptoms showed that 72% of the patients remained asymptomatic; in patients with previous ulcer symptoms, only 23% were asymptomatic. Definitive operation for acute perforation is indicated in good-risk patients who have a history of ulcers. Parietal cell vagotomy and simple closure was used in four patients with excellent early results.

Barrett's esophagus. A surgical entity.

During a ten-year period, endoscopy demonstrated acid-peptic esophagitis in 439 patients. Forty of these patients (9.1%) had Barrett's esophagus. Adenocarcinoma was present in the columnar epithelium in 15 (37.5%) of the patients with Barrett's esophagus. Hiatal hernias, with symptoms of heartburn, dysphagia, stricture, and ulceration, were found in more than 75% of the patients with Barrett's esophagus. We developed a treatment algorithm. Patients with symptomatic reflux esophagitis should undergo endoscopy with biopsy. If Barrett's esophagus is diagnosed, an antireflux procedure should be performed, preferably a proximal gastric vagotomy with Nissen's fundoplication. Follow-up examination by endoscopy with biopsy and cytology should be performed every six months. Indications for early esophagectomy include progression of cellular dysplasia, carcinoma in situ, and a non-healing Barrett's ulcer following an antireflux procedure. Our data support an aggressive surgical treatment of patients with Barrett's esophagus.

Surgical treatment of popliteal artery injuries.

Twenty-seven patients with injury to the popliteal artery and associated structures were operated on during the past 15 years. There was no operative or hospital deaths. The limb salvage rate was 56%; the amputation rate was 44%. Those patients with penetrating injuries were found to have a much better salvage rate (85%) than those with blunt trauma (29%). Preoperative arteriography and immediate repair of the popliteal artery by either end-to-end anastomosis or a vein graft is advocated for these patients. Popliteal vein injuries should be repaired when possible by lateral suture or end-to-end anastomosis. Fasciotomy is advocated on a selected basis.

Pleomorphic adenoma of the cervical esophagus: a rare tumor.

Pleomorphic adenoma of the esophagus is a rare tumor: less than 10 cases have been reported. These pleomorphic neoplasms are sessile and arise in the submucosal glands of the esophagus. Described in this report is the long-term follow-up of an additional case, in which the resection was reinforced with a pectoralis major muscle wrap.

Prognosis of adenocarcinoma arising in Barrett's esophagus.

BACKGROUND: The rising incidence of adenocarcinoma of the esophagus, as well as its association with Barrett's esophagus, has been reported previously. We report our experience in treating patients with adenocarcinoma arising in Barrett's esophagus. METHODS: A retrospective review was performed of 70 consecutive patients with adenocarcinoma of the esophagus treated between November 1988 and April 1996 with preoperative chemoradiation and resection. Demographics, pathologic features, and survival were compared with patients who developed adenocarcinoma of the esophagus without Barrett's. Statistical analyses was performed using Student's t test, Fisher's exact test, and Kaplan-Meier where appropriate. RESULTS: Thirty-two (46%) patients had adenocarcinoma arising in Barrett's esophagus. During the last 4 years, 72% (23 of 32) of patients with adenocarcinoma had coexistent Barrett's. No differences in patients with or without Barrett's with regard to age, sex, race, tumor location, preoperative chemotherapy, type of operation, or operative stage were observed. Tumors in patients with Barrett's were larger (p = 0.017), had better differentiation (p = 0.002), and were less likely to have a complete response to preoperative chemoradiation (p = 0.05). Actuarial survival, however, was better in the group with associated Barrett's esophagus (p = 0.033). CONCLUSIONS: The incidence of adenocarcinoma of the esophagus arising in Barrett's esophagus appears to be increasing. It may be distinct clinically and biologically from adenocarcinoma of the esophagus that does not develop in association with Barrett's epithelium. Long-term survival was better in our patients with adenocarcinoma associated with Barrett's esophagus.

Esophageal perforation: an increasing challenge.

Esophageal perforation continues to be a challenge. The overall incidence is rising even though iatrogenic perforations are decreasing. With early diagnosis followed by prompt surgical treatment, most patients can be expected to survive. Roentgenographic contrast studies demonstrated a perforation in all but 1 of our patients who had this examination and should be used early in patients suspected of having an esophageal perforation. The mortality rate is directly related to the interval between perforation and initiation of treatment. Nonoperative treatment, even for cervical esophageal perforations, is not advocated. An aggressive approach, consisting of closure of the perforation and adequate drainage, is indicated for both diagnosis and surgical treatment.

Preliminary results with neoadjuvant therapy and resection for esophageal carcinoma.

Between December 1988 and August 1992, 68 patients with adenocarcinoma (n = 39) and squamous carcinoma (n = 29) of the esophagus were entered prospectively in a treatment protocol to receive two cycles of cisplatin, 5-fluorouracil, etoposide, leucovorin, and 3,000 cGy of radiation to the involved esophagus and adjacent mediastinum, followed by resection. There were four deaths during chemotherapy, and 7 patients had a decline in condition or were denied operation. Fifty-six patients have come to operation, and 1 awaits resection. Twenty-two patients had transhiatal esophagectomy and 29 patients had esophagogastrostomy with a combined abdominal and right thoracic approach. Five patients did not undergo resection at operation. There was one hospital death (2%). A complete response to preoperative therapy was seen in 12 patients (21%): 5 of 20 with squamous cancer (25%) and 7 of 36 with adenocarcinoma (19%). Average follow-up is 19 months. Median survival in these patients after entrance in the protocol is 24 months. Actuarial survival at 12, 18, and 24 months is 72% (confidence limits, 66% and 78%), 53% (confidence limits, 46% and 60%), and 51% (confidence limits, 44% and 58%). Significantly better survival was associated with adenocarcinoma (p = 0.041). There is no survival advantage based on complete response to preoperative therapy. This neoadjuvant regimen is effective in patients with squamous carcinoma and adenocarcinoma. These preliminary results demonstrate an improved median and actuarial survival compared with historical controls in 137 patients operated on between 1966 and 1985 at our institution.

Reverse phasic contractions are present in antiperistaltic jejunal limbs up to twenty-one years postoperatively.

One of the surgical procedures that has been performed to reduce symptoms of dumping is the antiperistaltic jejunal limb (APL). We hypothesized that the polarity of the Phase III activity fronts would be maintained after creation of an APL. To test that hypothesis, water perfused, low compliance intestinal manometry was performed upon four patients with APL, four patients with vagotomy, antrectomy and Roux-en-Y gastrojejunostomy (VARY) and four volunteers. The patients were studied for a minimum of four hours of fasting. Recordings were analyzed by visual inspection by two observers and results are expressed as mean plus or minus standard error of the mean. Statistical analysis was performed with Student's t test. Phase III activity fronts occurred more frequently (1.4 +/- 0.3 per hour) in the patients with a VARY reconstruction than in the volunteers (0.5 +/- 0.5 minute). The duration of Phase II activity was significantly less in the patients with the VARY reconstruction (19.1 +/- 5.1 minutes) than in the volunteers (49.5 +/- 5.2 minutes). Patients with reversed activity fronts showed statistically significant propagation velocity (3.0 +/- 0.6 versus 9.6 +/- 2.0 centimeters per minute) (p < 0.005), but longer Phase III activity fronts (8.0 +/- 0.8 versus 4.9 +/- 0.3 minutes) (p < 0.001) than in the volunteers. Although there were a number of abnormalities identified in the patients with VARY reconstruction, there were no reverse Phase III activity fronts seen in the four patients with APL reconstruction. The polarity of the small intestine is maintained up to 21 years after construction of an antiperistaltic jejunal segment.

Management of postgastrectomy syndromes.

There is still much to learn about the cause of postgastrectomy syndromes. Fortunately, most patients can be managed by conservative measures unless a mechanical cause, amenable to operative correction, is found. Thus, it is important to determine the type of postgastrectomy problem that is affecting the patient. In carefully selected patients, remedial operations may ameliorate the patient's symptoms and permit him or her to return to a normal lifestyle. Humoral factors have attracted increasing attention, especially in patients with the dumping syndrome. The somatostatin analogue octreotide has provided relief from the vasomotor and gastrointestinal symptoms of severe dumping but must be given three to four times a day by injection.

Carcinoids and the carcinoid syndrome.

The many manifestations of carcinoids will continue to puzzle and intrigue surgeons. Because these are dynamic tumors which produce multiple hormones with many potential side effects, an aggressive surgical debulking of them is advocated. Even in the presence of metastatic disease, some long-term survival can be anticipated. The most debillitating aspect of this tumor to the patient is the carcinoid syndrome. The symptoms occur erratically and are often not well controlled by presently available medication. Although metastatic disease present at diagnosis is most commonly seen with jejunoileal carcinoids, colorectal carcinoids appear to be the most lethal tumors. However, they are rarely associated with the symptoms of carcinoid syndrome. Carcinoids may often be associated with other types of tumors, some of which are known to produce their own hormones. Survival of the patients seems to be related to their other tumor type rather than the primary carcinoid. The clinician should be aware of the strong association of carcinoids with peptic ulcer disease. The ulcer diathesis is probably related to ectopic histamine production and can usually be controlled by cimetidine and antacids, although surgical intervention may be required.

Stratified diagnostic approach to fine needle aspiration of the breast.

The clinical value of fine needle aspiration (FNA) of the breast is enhanced by incorporating into the cytologic diagnosis explicit comments on the level of diagnostic certainty. This stratification of diagnostic certainty is based predominantly on the cytologic features but occasionally also takes into consideration the clinical situation. Strong clinical and mammographic suspicion of mammary carcinoma associated with FNA, diagnostic of typical, intermediate to high-grade mammary carcinoma, warrants proceeding to definitive therapy without further diagnostic studies. False-positive results are virtually eliminated by placing cases with any uncertainty into a "probable" category, which does not support definitive therapy. In addition, oversimplified "benign versus malignant" approaches to FNA diagnoses ignore the heterogeneity of breast masses, with in situ and low-grade carcinomas warranting special clinical management and usually being placed in the "probable" category. Thus, malignant diagnoses are stratified into "definite" and "probable," with only the former supporting definitive therapy. Within our recent series of 1,005 FNAs of the breast, we were able to confirm the diagnosis in all 62 patients with a "definite" carcinoma diagnosis, and only 3 of 25 "probable" cancer diagnoses were benign at tissue biopsy. Thus, false-positive results were successfully avoided in the "definite" category. Furthermore, a much greater incidence of unusual and good prognosis tumor types were identified by the "probable" category. If the clinical setting is relatively suspicious only, a definitive diagnosis of cancer by FNA is rare and not necessary because the clinical question to be addressed is only whether to biopsy. This approach to FNA diagnosis, unlike the oversimplified "benign versus malignant" scheme, provides an approach that is more likely to result in optimal therapy for breast neoplasms, with low-grade or in situ carcinomas requiring special clinical management since these types of cancers are found predominantly in the "probably malignant" category. It also provides additional security against false-positive diagnoses by incorporating clinical level of certainty statements into FNA diagnostic categories, which more closely reflect the diversity and inherent complexity in the appropriate diagnosis and therapy of mammary carcinomas.

Current management of carcinoma of the anus and perianus.

Malignant lesions of the anus and perianus account for 2.4% of malignant cancers of the colon, rectum, and anus. Based on our experience with 56 patients as well as a review of the recent literature, the following recommendations are made: Bowen's disease, Paget's extramammary disease, basal cell, and perianal epidermoid carcinomas arise in the perianus, rarely metastasize, and may be managed by wide local excision. Cloacogenic transitional cell (basaloid squamous carcinoma) and the more common epidermoid anal canal tumors require abdominoperineal resection with wide perineal excision. Therapeutic groin dissection is indicated if the inguinal nodes are or become the site of metastases, but prophylactic groin dissection is not indicated. The five-year survival for epidermoid carcinoma of anus treated by abdominoperineal resection ranges from 40 to 58%. Improvement in survival rate will require early recognition by the patient and early diagnosis and treatment by the physician. Delay in diagnosis occurs because cancer is not considered frequently enough as a possible cause for the patient's symptoms.

Surgical management of esophageal perforation.

The recognition and management of esophageal perforation remain a problem. Diagnostic and treatment delays are common, and controversy continues regarding approaches to surgical intervention. Overall survival has increased with improved adjunctive modalities; however, morbidity and mortality remain high. A total of 115 consecutive cases of nonmalignant esophageal perforation were reviewed. There were 69 thoracic, 27 cervical, and 19 abdominal perforations. Etiology of the perforations was iatrogenic in 65 patients, traumatic in 28, and spontaneous perforation in 22. Symptoms included pain (71%), fever (51%), dyspnea (24%), and crepitus (22%). Contrast roentgenography was used in 78 patients and demonstrated the perforation in all but two patients. All but 20 patients had operations. In the last decade, the survival rate was 11.4 per cent for patients treated within 24 hours of perforation. Survival significantly improved in the last 10 years because of hyperalimentation, cardiopulmonary monitoring, and better antibiotic coverage. Treatment of choice is primary closure with drainage, regardless of the duration of the perforation. In selected patients who have cervical esophageal perforation, nonoperative management has a role.

Crohn's disease of the esophagus.

In 1932 Crohn, Ginzburg, and Oppenheimer described a distinct pathologic and clinical entity characterized by a chronic inflammatory process of unknown etiology involving the terminal ileum. Since then, Crohn's disease has been recognized in all portions of the alimentary canal from mouth to anus. Crohn's disease of the esophagus is a rare process. Such a patient is reported with a review of the literature. A review of the English literature reveals reports of 20 patients with Crohn's disease of the esophagus. One-third of these patients had regional enteritis requiring resection. Esophageal stricture, stenosis, or fistula were frequent complications requiring resection. Regional esophagitis is difficult to distinguish from carcinoma, frequently leads to esophagitis, and is associated with a higher mortality rate than Crohn's disease in other portions of the alimentary tract.