Is stenting necessary for a successful pancreatic anastomosis?

The effect of stenting on pancreaticojejunostomy has not been studied in a prospective randomized trial. In 34 dogs, the left pancreatic lobe was anastomosed to a Roux-Y jejunal limb using a two-layer mucosa-to-mucosa technique. In one group (n = 12), the anastomosis was constructed over a 3F polytetrafluoroethylene (PTFE) stent, and the stent was left in situ. A second group (n = 12) had the stent removed at the completion of the anastomosis. A control group (n = 10) had the anastomosis constructed without a stent. After 1 month, autopsies were performed, and anastomoses were examined for evidence of leak, occlusion, or stenosis. No anastomotic leaks occurred when a stent was used, whereas one (10%) occurred when no stent was used. No occlusions occurred in the two groups with stents, but two (20%) occurred in the no-stent group. Stenosis rates were 0% in the stent-in group, 25% in the stent-out group, and 30% in the no-stent group. Although no comparisons were statistically significant, there was a trend. Anastomoses performed over a stent, whether or not the stent was left in situ, had lower rates of leak, occlusion, and stenosis. We believe, but cannot prove, that a stent improves anastomotic integrity and patency by facilitating exact placement of mucosal sutures.

Preoperative visceral angiography alters intraoperative strategy during the Whipple procedure.

To determine the importance of preoperative visceral angiography prior to pancreaticoduodenectomy, all Whipple procedures performed between 1985 and 1991 at the Virginia Mason Medical Center were retrospectively reviewed. During this period, 77 pancreaticoduodenectomies were performed for both neoplastic disease (n = 54, 70%) and chronic pancreatitis (n = 23, 30%). Sixty-four preoperative angiograms were obtained, of which 39 (61%) were abnormal findings. Thirty percent (19 of 64) of the angiograms revealed a significant vascular abnormality that required specific preoperative or intraoperative measures that might not have been performed without knowledge of these findings. Examples include celiac axis revascularization for celiac occlusion, hepatic artery preservation for replaced vessels, preoperative embolization for pseudoaneurysm or arteriovenous fistula, and splenectomy for splenic vein thrombosis. Because of the high percentage of significant findings requiring an intraoperative or preoperative technical change, we recommend the use of angiography in order to diminish morbidity in all patients preparing to undergo pancreaticoduodenectomy.

Benefits and safety of hepatic resection for colorectal metastases.

BACKGROUND: Metastatic colorectal carcinoma to the liver is a potentially curable disease. The purpose of this study was to determine the safety and efficacy of hepatic resection for metastatic colorectal carcinoma. METHODS: One hundred twenty-one consecutive hepatic resections in 110 patients with metastatic colorectal cancer between January 1978 and September 1998 performed by a single surgeon were reviewed. RESULTS: The actuarial 5-year survival for all patients in the series was 46%. Of the patients operated on before 1993, the actual 5-year survival was 43% and actual disease-free 5-year survival was 28%. The actual 10-year survival was 27%, and of all patients operated on in the last 20 years, 48% are alive today. When comparing initial regional lymph node status, the 5-year survival was 54% for the patients with negative lymph nodes and 40% for patients with positive nodes. Only 18% of patients required a perioperative blood transfusion, and the median length of stay was 7 days. There were complications in 34% of cases, and the operative mortality was 4%. CONCLUSIONS: Hepatic resection for metastatic colon cancer is safe, and significant longevity and cure can be obtained after resection.

Management and long-term follow-up of hepatic cysts.

PURPOSE: To provide an algorithm for the management of hepatic cysts through an analysis of our series over 16 years. METHOD: We reviewed the surgical management and outcome of patients with hepatic cysts between 1984 and 2000 at a single institution. Data were collected by chart review, telephone interview, and follow-up hepatic ultrasonography. RESULTS: Forty-four patients (36 females, 8 males) underwent a total of 46 operations for hepatic cysts (mean size 12.0 +/- 5.2 cm) with a mean follow-up of 5.1 +/- 4.0 years. We treated 28 simple cysts, 4 polycystic liver disease (PCLD), 7 cystadenomas, 2 hydatid cysts, 1 cystadenocarcinoma, 1 endometrioma, and 1 hepatic foregut cyst. Operations included simple drainage, wide unroofing (open and laparoscopic), and hepatic resection. Four patients experienced a symptomatic recurrence after definitive treatment; 3 of these patients had PCLD. Four of the 7 patients with cystadenomas had undergone previous operations that required subsequent definitive resection without a recurrence. CONCLUSIONS: The preoperative distinction between simple cysts and cystadenomas/cystadenocarcinomas can be difficult, yet the management is different. Unroofing is a safe and effective operation for patients with simple cysts. Patients with PCLD frequently have recurrences. Cystadenomas should be completely resected owing to the likelihood of recurrence after partial excision and the risk of eventual cystadenocarcinoma. We present a treatment algorithm for the preoperative evaluation and management of hepatic cysts based on the largest number of patients with the longest follow-up reported to date.

MR in the diagnosis of bone tumours.

Forty-two patients with benign as well as malignant bone tumours or with tumour-like lesions of bone were evaluated using MR tomography. The appropriate choice of examination parameters is an essential prerequisite for the adequate visualisation and the definitive verification of the presence of a tumour. By means of its multi-planar display, MR provides definite advantages in the determination of tumour localisation and extension as well as in differentiating intra-tumoural haemorrhage from surrounding, non-involved tissue. In addition, the clear delineation of neighbouring structures such as muscular compartments and blood vessels achieved in MR can be useful in the planning of an eventual surgical approach. This new technique has proved itself superior to other available imaging modalities in the differentiation of residual or recurrent tumour from post-operative changes. A characterisation of the nature or histology of a suspicious lesion on the basis of relaxation-times or signal intensities, however, is not yet possible.

Interaction of artificial metallic objects with biosusceptometric measurements.

In human subjects, metallic objects cause distortions of the magnetic fields used by magnetic resonance imaging (0.5 - 3.0 T) or by SQUID biomagnetic liver susceptometry (0.1 - 30 mT) and may lead to artifacts in the measurement of the relaxation rate or the magnetic susceptibility. In biosusceptometry, the measured signal will depend not only on the magnetic susceptibility of the object, but also on its distance to the sensor assembly, and in case of ferromagnetic objects, on the direction of its remanent field. The magnetic susceptibility of a vascular access port-a-cath and of surgical clips have been measured by a SQUID biosusceptometer. Additionally, the impact from port-a-caths and dental braces on liver iron concentration (LIC) measurements was measured in vivo with respect to their radial distance from the gradiometer center axis. For the port-a-cath, a mean magnetic volume susceptibility of (83.5 +/- 0.3).10(-6) SI-units was found, which may be compared with the magnetic susceptibility of titanium at room temperature of (180 +/- 2).10(-6) SI demonstrating the absence of ferromagnetic contamination. At a radial distance of 5 cm from the gradiometer center axis, the voltage amplitude is similar to the signal generated by a normal liver. Modern surgical clips have nearly no impact on LIC measurements. However, dental braces although further away from the center axis, often superimpose the signal even from an iron overloaded liver. Depending on the Ni-content, these objects reveal ferromagnetic properties and contribute in first order with a one parameter reciprocal distance function to the measured liver iron signal.

[Pelvic chondroma]. / Beckenchondrom.

Chondroma as a cartilage forming tumor ist localized in up to 50% of the cases in the small bones of the hands and feet, where it is considered a benign tumor. The closer the localization is towards the trunk, the more probable is potential malignancy. The problem is discussed describing two cases with chondroma of the pelvis, which developed into chondrosarcoma. As there could not be achieved any therapeutical success with radiation and chemotherapy, therapy must consist in excochleation, i.e. en-bloc-resection, special alloarthroplasty or hemipelvectomy. The more radical and the sooner the operation is performed, the higher is the chance of survival.

[The congenital club foot]. / Der angeborene Klumpfuss.

The congenital clubfoot of infancy to-day is curable in 90% of cases. Aim of the treatment is normalization of form, function and growth. With combined therapy according to Imhäuser optimal results are possible: 1. Immediately after birth--depending on the general condition of the newborn--reposition of all components without the talipes equinus component; plastercasts are changed frequently till the third or fourth month of life; 2. surgical development of the heel; calcaneal equinus is corrected by elongating the tendocalcaneus combined with arthrolysis of the ankle joint; 3. intensive clinical treatment by physiotherapy; 4. ambulant orthopedic controls at regular intervals till the end of skeletal growth.

[Normal findings and pathological changes of the patellar ligament in the computer tomogram]. / Normalbefunde und pathologische Veränderungen des Ligamentum Patellae im Computertomogramm.

In the computer tomogram, the normal patellar ligament appears as a flat band with an average density of 110 HE. After trauma and also after chronic overloading, the cross-section increases, whereas the density decreases. CT is superior to conventional x-ray diagnosis and to sonography in respect of detecting and differentiating of circumscript changes in the patellar ligament.

[Pharmacokinetics of rifampicin in gastrectomized persons (author's transl)]. / Zur Pharmakokinetik von Rifampicin bei Patienten mit Operationen nach Billroth II.

A laboratory method was developed whereby the presence of Rifampicin in the blood is determined microbiologically by means of a diffusion test. The organism used was Sarcina lutea. The tests established that the Rifampicin levels in the blood of pylorogastrectomized persons were significantly higher then they were in a normal control group. The daily changes in the Rifampicin levels were simulated and checked by analogue computer. The findings indicated that the increased absorption in gastrectomized persons cannot be due to accelerated passage and that it is presumably attributable to chemical and physical factors. The results are analysed statistically and summarized in graphs.

[Meniscus ganglia. Diagnosis and differential diagnosis]. / Meniskusganglien Diagnose und Differentialdiagnose.

3% of isolated meniscectomies were performed on patients with cysts of the meniscus. The etiology is not yet fully elucidated. The problems in clinical and radiological diagnosis are discussed using the examples of two operatively verified cases. In computerized tomography the density values of these lesions range from 20 to 35 Hounsfield units thus allowing specific diagnosis. Localization and extent of the cyst can be shown exactly by computerized tomography.

[Malignant bone tumors of the pelvis and of the extremities--in conventional radiography, arteriography and computed tomography (author's transl)]. / Maligne Knochentumoren des Beckens und der Extremitäten. Konventionelle Radiographie, Arteriographie und Computertomographie.

Bone tumors of the extremities are usually diagnosed by conventional radiography. A good angiogram may render information not only about intra- and extraosseous extension of the tumor, but often also about the biological dignity. CT is usually not necessary, especially since it is sometimes difficult to define the extraosseous borders of these extremity tumors with this method. In bone tumors of the pelvis, however, neither conventional radiography nor angiography render reliable information about the extent of the tumor, which CT is very well able to do. Therefore CT is primarily indicated for evaluation of bone tumors in this region. Angiography is done only for preoperative evaluation of the vascular architecture or for potential therapeutic embolisation.

Laparoscopic live donor nephrectomy: a comparison with the conventional open approach.

PURPOSE: Laparoscopic live donor nephrectomy is an emerging technique that has not yet gained widespread acceptance in the transplant community due to perceived technical difficulties. However, the potential advantages of decreasing donor morbidity, decreasing hospital stay and improving convalescence while producing a functional kidney for the recipient may prove to enhance living related renal transplantation. We report our early experience with laparoscopic live donor nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 50 consecutive laparoscopic nephrectomies performed from October 1998 to May 2000 and compared them with 50 consecutive open donor nephrectomies, which served as historical controls. RESULTS: Donor age, donor sex and number of HLA mismatches did not differ statistically in the 2 groups. In the laparoscopic and open nephrectomy groups mean followup was 109 and 331 days (p = 0.0001), mean operative time was 234 and 208 minutes (p = 0.0068), mean estimated blood loss was 114 and 193 ml (p = 0.0001), and mean hospital stay was 3.5 and 4.7 days (p = 0.0001), respectively. Average renal warm ischemia time was 2.8 minutes in the laparoscopic nephrectomy group. Serum creatinine did not differ statistically in the 2 groups preoperatively or postoperatively at days 1 and 5, and 1 month. The rate of recipient ureteral complications in the laparoscopic and open nephrectomy groups was 2% (1 of 50 cases) and 6% (3 of 50), respectively (not significant). CONCLUSIONS: Laparoscopic live donor nephrectomy is an attractive alternative to open donor nephrectomy. Laparoscopic nephrectomy results in less postoperative discomfort, an improved cosmetic result and more rapid recovery for the donor with equivalent functional results and complications.

Intranuclear undulating membranous structures in cells of a human parosteal osteosarcoma.

Large numbers of paracrystalline undulating membranous structures (UMS) were observed in the nuclei of dense cells in a human parosteal osteosarcoma. The electron-dense walls of the structures were 15-20 nm thick, and circular profiles had an outer diameter of 60-70 nm and an inner diameter of 25-30 nm. The UMS-containing cell nuclei displayed a number of other characteristic features, including vermicellar bodies, large numbers of interchromatin granules, and prominent perichromatin granules. The possible significance of these features is discussed.