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Background: The optimal resection for pancreatic neck cancer is challenging in clinical practice because we could dissect by pancreaticoduodenectomy or distal pancreatectomy. The purpose of this study was to evaluate the effectiveness of lymph node dissection and to help determine the optimal surgical treatment for pancreatic neck cancer., Methods: We retrospectively evaluated 462 patients with pancreatic cancer who underwent curative-intent pancreatectomy between 2012 and 2022, 35 of whom had pancreatic neck cancer without preoperative radiologic gastroduodenal artery contact. We analyzed the clinicopathological characteristics, lymph node metastasis stations, and the efficacy index of lymph node dissection, which was calculated by multiplying the frequency of lymph node metastasis to each station by the 5-year survival rate of patients with positive lymph nodes at each station., Results: The lymph node station with the greatest rate of metastasis was #11p (28.6%), followed by #8 (17.1%), #14 (14.3%), #13 (14.3%), #17 (9.5%), and #6 (4.8%). The efficacy indices of lymph node dissection were 14.3 for #11, 4.76 for #13, and 8.57 for #14. There were no significant differences in 5-year recurrence-free survival and 5-year overall survival between patients undergoing pancreaticoduodenectomy and those undergoing distal pancreatectomy (23.7% vs 54.7%, P = .142; 29.9% vs 51.1%, P = .179, respectively). Univariate survival analysis showed that tumor size ≥2 cm was associated with poor prognosis (hazard ratio, 3.842, P = .009)., Conclusions: PD with #11p lymph node dissection is preferable to DP in terms of survival benefit for pancreatic neck cancer with lymph node metastasis., Competing Interests: Conflict of Interest/Disclosure The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Prothymosin-alpha and ERp57 were previously identified as markers for gastric metaplasia in a mouse model of Helicobacter-induced gastric metaplasia and neoplasia. In this paper we assess whether the expression of these putative biomarkers in humans is correlated with gastric metaplasia and adenocarcinoma and clinical outcomes., Methods: Eight tissue microarrays, containing 749 paraffin-embedded tissue cores from 164 gastric cancer patients, were stained for prothymosin-alpha and ERp57 by horseradish peroxidase immunohistochemical techniques. The proportion of stained cells per core was quantitated using the Ariol SL-50 automated image analysis system., Results: Prothymosin-alpha stained a significantly higher percentage of nuclei in cancer and metastases compared with normal gastric mucosa. ERp57 staining was significantly decreased in cancer and metastases compared with both normal gastric mucosa and metaplasias. ERp57 expression also correlated with greater depth of tumor invasion and advanced stage of disease. Kaplan-Meier survival analysis determined that tumors with the highest quartile of ERp57 expression were statistically associated with longer postoperative survival. A Cox proportional hazard analysis showed that maintenance of ERp57 expression was associated with longer postoperative survival., Conclusions: These results suggest that although prothymosin-alpha is overexpressed in gastric adenocarcinoma, it is not associated with alterations in survival. In contrast, loss of ERp57 expression correlated with more aggressive disease and could provide useful prognostic information for gastric cancer patients.

Background: The objectives of this paper are to describe the shortcomings of current techniques for treatment of preauricular sinus (PAS) and to introduce a new surgical technique. PAS is a common congenital abnormality. Usually these lesions are asymptomatic. However, some patients complain of discharge and/or (recurrent) infections, and require excision. Surgical treatment of PAS is characterized by high recurrence rates. This paper describes a single institution's experience with the operative management of PAS and introduces a new technique., Methods: Data on PAS procedures were collected from a retrospective review of patients' charts and interviews by questionnaire of all patients treated operatively for PAS in the Leiden University Medical Centre from 1984 to 2003., Results: Thirty-nine patients (21 male, 18 female) with PAS underwent 40 procedures for PAS. These procedures included 17 classic operations (in 16 patients) and the "inside-out technique" in 23 patients. In the patient group treated "classically," 2 patients developed a recurrence; one underwent successful reoperation; the other patient has been lost to follow-up. Another patient developed wound breakdown postoperatively, resulting in an ugly scar. Two patients had postoperative infections requiring treatment. Neither recurrences nor complications requiring treatment occurred in the group who underwent the inside-out technique., Conclusions: The inside-out technique provides an easy solution for patients with PAS. However, further study on a larger patient group is necessary.

Background: The purpose of this paper was to review my evolving experience with local/regional anesthesia in an outpatient setting., Methods: Two hundred three consecutive patients during a 9-year period who chose to undergo thyroid operation under regional/local anesthesia were reviewed. Early discharge was offered to patients who were observed for 6 hours without neck swelling and who had no surgical reasons for delaying discharge., Results: In group A there were 2 patients who were given inhalation anesthesia during operation compared with none in groups B and C. The average length of stay in group A was 0.49 days, 0.55 days in group B, and 0.24 days in group C. Eighty-five percent of the patients whose operation began before 1300 hours were discharged within 6 hours versus only 50% of those operated on later in the day. Forty-seven percent of patients in group A, 65% of group B, and 77% of patients in group C were discharged within 6 hours of operation. On the basis of previous experience with general anesthesia, discharge time is not significantly influenced by the type of anesthesia chosen. There were no readmissions to the hospital, but 2 episodes of postoperative bleeding required reoperation. Survey showed that 95% of patients rated the level of pain equivalent or less severe than dental procedures under local anesthesia, and all patients would choose local again., Conclusions: These data suggest that thyroidectomy can be performed with the patient under local/regional anesthesia, with low morbidity and high patient satisfaction. Most patients can be discharged within 6 to 8 hours, and these discharges were not associated with readmissions.

Background: Surgical correction of rectovaginal and complicated anal-perineal fistulas has been associated with high rates of complications and failure of repair., Methods: This paper reports on 107 patients treated during the past 10 years by endorectal advancement flap repair. Ninety-two percent of the patients were women with mean age of 38 years (range, 20 to 71 years). Seventy-one had low rectovaginal, 28 had anterior anal-perineal, and 8 had posterior anal-perineal fistulas. The causes were obstetric injury, 48; cryptoglandular abscess-fistula, 31; Crohn's disease, 24; and trauma or after operation, 4. The technique completely preserves the sphincter muscle, covers the internal opening of the fistula tract with healthy rectal wall, and provides counter drainage to aid healing., Results: No deaths occurred in the series. Persistent or recurrent fistula occurred in 17 patients (16%). Nine patients whose initial operation failed underwent a secondary successful operation. Continence status was unchanged in 80%, improved in 18%, and was unknown in two patients who still had intestinal flow diversion. Recurrence of the fistula did not result in destruction of the sphincter mechanism in those patients who underwent simultaneous reconstructive operation., Conclusions: The endorectal advancement flap repair successfully treated 93% of the complicated anorectal fistulas, avoiding fecal diversion and improving, not injuring, sphincter function.

Background: Completion thyroidectomy can most accurately be described as reexploration of the neck to remove the contralateral thyroid lobe. This procedure has commonly been performed when the histopathologic condition of the ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Because of a definitely increased risk of complications with completion thyroidectomy, avoiding its routine use is important. The purpose of this paper is to define the specific indications for completion thyroidectomy., Methods: Over the past 9 years, we have performed 400 thyroidectomies; the patients ranged in age from 18 to 88 years. Although we have routinely used preoperative needle biopsy and intraoperative frozen section, decisions regarding the extent of thyroidectomy have been based on the gross findings at operation, taking into consideration such prognostic factors as patient age, tumor grade and size, the presence of extracapsular spread or distant metastasis, and associated risk factors. The minimal procedure for solitary thyroid nodule has been lobectomy with isthmusectomy. If the contralateral lobe is grossly normal, lobectomy with isthmusectomy has also been the maximal operation in most of patients. Very few specific indications exist for removal of the opposite lobe., Results: Only three patients underwent completion thyroidectomy. All three patients had aggressive follicular carcinoma requiring radioactive iodine ablation, and all were referred after the initial surgery. We have not performed completion thyroidectomy on any of the patients on whom we initially operated., Conclusions: The most common indication considered for completion thyroidectomy is a frozen section diagnosis of a benign follicular adenoma that is subsequently changed on permanent pathologic condition to follicular carcinoma based on the presence of capsular and/or vascular invasion. However, if minimal invasion has occurred, no difference exists in survival related to the extent of the thyroidectomy. Local recurrence in the contralateral lobe occurs in less than 10% of the time. Because completion thyroidectomy carries more risks, it should be avoided in most patients when possible. The definitive decision should be made during the initial operation based on gross findings, prognostic factors, and frozen section, and this plan should only be changed to mandate completion thyroidectomy in select circumstances.

Thrombosis of the aorta in the neonate is a potentially catastrophic event. The incidence of this problem has increased concomitantly with the widespread use of umbilical artery catheters in the management of infants who are critically ill. The natural history and appropriate management of this complication has not been well established. This is due in part to the wide spectrum of presentations and lack of consensus regarding its classification. Aortic thrombosis may vary from deposition of a fibrin sheath surrounding the length of an umbilical artery catheter to aggregates of nonocclusive thrombus within the aorta or to complete occlusion of the aorta and concomitant occlusion of its main branches. The reported treatments recommended for this problem have ranged from supportive care only to mandatory surgical intervention in all cases. This spectrum of advocated therapies has resulted in considerable confusion regarding the proper management of this problem. This paper presents two cases of neonatal aortic thrombosis: one case was treated medically and the other case was treated with surgical intervention. We review these cases and the current literature, with specific attention directed towards highlighting the critical elements involved in formulating a reasonable approach to the management of neonatal aortic thrombosis. In addition, we offer an algorithm for management of these patients according to the degree of aortic thrombosis, severity of systemic manifestations, and the general condition of each individual patient.

This paper describes an en bloc total abdominal evisceration (TAE) technique that has been used successfully in 81 consecutive multi-organ procurements in donors ranging from 2.5 to 85 kg. Preliminary dissection performed by the surgeon and physician's assistant averaged 30 to 45 minutes before aortic cross-clamping. Removal of all abdominal organs (liver, kidneys, pancreas, bowel) en bloc averaged 16 to 24 minutes after aortic cross-clamping, depending on the speed of the thoracic procurement. Organ grafts were preserved with the University of Wisconsin preservation solution. Total procurement time for the removal of the liver, pancreas, and kidneys averaged 1.5 to 2.25 hours. Because all vascular anomalies were easily recognized ex vivo, vascular reconstruction was possible, so that all donors could potentially provide for combined liver, pancreas, and kidney transplantation. In the TAE group, primary liver graft nonfunction was 1.2% (1/81 grafts), which is less than the non-TAE liver graft nonfunction rate of 7% (7/99 grafts); this is statistically significant (p less than 0.05). Also, the incidence of fresh frozen plasma support after liver transplantation in the TAE group (2/81 transplantations) was lower than the non-TAE group (9/99 transplantations) (p less than 0.05). The overall liver recipient survival rate was 87% (non-TAE; 78/94 recipients; TAE; 65/70 recipients). Kidney-graft initial function has been similar in both the TAE and non-TAE groups. All pancreas tissue was histologically normal, and extraction of viable islet cells (average, 3600 islets per gram pancreas) was possible with yields similar to standard pancreatic (average, 379 islets per gram pancreas) harvest techniques. Preliminary experience with combined liver and whole-organ pancreas transplantations has been encouraging, with immediate discontinuation of intraoperative insulin during transplantation.

William Halsted and Rudolph Matas were two of the most distinguished surgeons in American medicine. Although their personalities were completely opposite, they enjoyed a long and devoted friendship. This is of historical interest in that Halsted opened his nonprofessional life to a very few other men. During their relationship a fairly continuous corresponsence was maintained. This paper will examine their friendship through an analysis of their personal letters, the majority of which have never been published. Their contents reveal a unique alliance, and provide futher information on the world of American surgery as it existed during the first part of this centrury.

An increase in the left ventricular end-diastolic pressure (LVEDP), resulting from the intravenous administration of blood, a colloid solution, or a crystalloid solution, was accompanied by an increase in both the inner:outer left ventricular wall flow ratio and the diastolic myocardial tissue pressure gradient. With a normal left ventricular end-diastolic pressure, the normal inner:outer flow ratio was just above unity and the minimum diastolic myocardial tissue pressure in the subepicardium was twice as high as in the subendocardium. When the left ventricular end-diastolic pressure was raised, the subepicardial tissue pressure rose earlier and to a higher degree than the subendocardial; thus a gradient which encourages subendocardial flow was increased. This paper correlates the changes in diastolic myocardial tissue pressure and in inner:outer flow ratios which occurred when eight dogs were transfused with blood, seven with colloid, and seven with lactated Ringer's solution. Regional diastolic myocardial tissue pressure was measured by the flow-cessation technique and regional flow by radioactive microspheres. The gradient in diastolic myocardial tissue pressure, which is a major contributory factor to adequate subendocardial perfusion under normal conditions, is of even greater importance when LVEDP is raised.

A new method for arresting uncontrollable intercostal hemorrhage is presented. It consists of selective transcatheter embolization of the bleeding artery, either by pieces of gel foam or autologous blood clots. In the patient presented in this paper, the hemorrhage was identified and successfully controlled by embolizing the bleeding artery. Thoracotomy was unnecessary, and there were no complications related to the procedure.

Pulmonary sequestration occurs when some disturbance produces a cystic mass of nonfunctioning lung tissue which lacks normal communication with the tracheobronchial tree. In most cases the sequestered pulmonary tissue receives its blood supply from anomalous systemic vessels. This paper considers 15 children, 11 boys and four girls, ranging in age from one day to 14 years, with ten extralobar sequestrations and five intralobar pulmonary sequestrations. Although roentgenographic examination of the chest may suggest the diagnosis, conclusive diagnosis can only be obtained by arteriography and/or surgical exploration. Arteriography is strongly advocated in all cases, not only for its diagnostic value, but for its preoperative localization of the aberrant blood vessels that are the major technical concern to the surgeon.

This paper presents a cost analysis for herniorrhaphies as they are currently performed, as compared with a new plan. The current system utilizes hospital postoperative care. The new plan involves a different utilization of hospital facilities, personnel, drugs, supplies, and postoperative home care. Costs are considerably reduced under this new proposal. Projections reveal that implementation of the new plan with the same level of present expenditures could eliminate 75 percent of the present backlog of hernias over a 10 year time period. Although the cost and disease estimates derive from an experimental study conducted at the Universidad del Valle, Cali, Colombia, this model can help meet population health care needs in any country or geographic region by basing the system of services and facilities on epidemiologically derived disease prevalence and incidence rates.

The English-language literature, from 1952 to 1979, was surveyed for all papers concerned with vascular trauma penetrating wounds of the neck, or carotid injuries in particular, and all valid, first-hand, adequately detailed cases of carotid arterial trauma were abstracted. The valid, first-hand, adequately detailed cases of carotid arterial trauma were abstracted. The current status of all our own hospital survivors who had been treated for carotid artery injuries was also established to add needed longitudinal perspective. In all, 722 cases were available for analysis. The mean age was 28 years, and the overall mortality rate was 21%. One hundred and eighty-six patients presented with severe neurological deficits. If they underwent arterial repair, 34% were better; if they had a carotid ligated, or were not treated surgically, only 14% improved (P = 0.01). Shock or coma, independently, were significantly ominous (P less than 0.001), but there was no evidence to support coma as a contraindication to restoring arterial continuity. Similarly, in the patients with preoperative neurological deficits, no data could be found to substantiate the contention that prompt arterial repair would yield better results than delayed repair. Follow-up status at 1 year was available for only 40 cases from the results than delayed repair. Follow-up status at 1 year was available for only 40 cases from the entire literature. Assessment of our own patients, at a mean of 4.6 years after injury, uncovered multiple, persistent neurological defects, one stenotic arterial repair, two aneurysms, and an arteriovenous fistula.

The association of neurofibromatosis and pheochromocytoma is well recognized; more recently, attention has been drawn to links between neurofibromatosis, pheochromocytoma, and ampullary somatostatin-rich carcinoid. Because of this association, the duodenum was explored during a recent laparotomy for resection of bilateral pheochromocytoma in a patient with von Recklinghausen's disease. A clinically unsuspected ampullary tumor was discovered; this proved to be in part a ganglioneuroma and in part a somatostatin-rich carcinoid. This paper presents full details of this carefully investigated and documented case and reviews the recent advances in this field. These studies lead us to conclude that: the clinical association of neurofibromatosis, pheochromocytoma, and D cell carcinoids ("somatostatinomas") of the ampullary region is confirmed; this association may be more common than has been previously thought, and the duodenum should be carefully examined in any patient with neurofibromatosis who undergoes laparotomy for pheochromocytoma.

The technique presented in this paper is based on the authors' previous observations in which they found that artificial decrease of blood flow to a portion of the heart muscle leads to an immediate and proportional drop in the regional myocardial temperature. It appeared to the authors as a logical next step to apply the thermographic camera to a monitor and to record such changes in the human patient during coronary surgery and to use the data to draw conclusions applicable to regional blood supply and to blood flow through surgically inserted vein grafts. They found that, on the normothermic heart, there were well-identifiable "cold" patches corresponding with areas of impaired coronary circulation. By infusion of blood to the ischemic myocardium through individual release of the bypass grafts, the thermogram responded by immediate appearance of "warm" spots corresponding with the areas supplied by the grafts. Even more dramatic demonstration of graft patency and outline of the area supplied by the graft could be performed by injecting cold saline solution into the grafted saphenous veins. In the author's experience this most interesting new method proved to be a useful tool in coronary surgery both as an adjunct in delineating ischemic areas and in proving the patency and efficiency of the grafts inserted.

Following "vein stripping" for varicosities, two patients were referred to our service for evaluation of arterial insufficiency of the lower extremities. Both patients had had surgical interruption of the femoral arterial system which required reconstruction. This paper emphasizes the importance of understanding surgical anatomy and presents the techniques of successful surgical management of both cases.

Emergency hemipelvectomy (HP) is a rare procedure. Only three incidents have been previously reported. This paper describes six additional cases, analyzes our results, and sets forth criteria for patient selection. There were five men and one woman. The median age was 38.5 years. Primary underlying diseases were sarcoma (three cases), peripheral vascular disease (one), deep vein thrombosis (one), and drug abuse (one). Life-threatening peripelvic sepsis and hemorrhage were indications for emergency HP. All six patients had multiple procedures prior to definitive HP. Four classical and two modified HPs were performed. The mean operative time was 3.5 hours, the mean blood loss 2292 ml. There were no intraoperative complications. The median duration of hospitalization was 56 days. Five of six patients were saved. Life-threatening peripelvic sepsis or hemorrhage associated with tumor recurrence, radiation, or failed vascular reconstruction is an indication for emergency HP. Neither age nor physical condition should be a deterrent. The patient should not be allowed to advance to a premorbid state before HP is considered, although concomitant intra-abdominal disease is a contraindication. HP is recommended in lieu of hip disarticulation. We anticipate that the need for emergency HP will increase as limb salvage procedures for extremity sarcomas and dysvascular disease become more frequent.

Traditional efforts in the law schools to improve interprofessional communication between the medical and legal professions have been confined to abstract case studies and other academic materials, sometimes augmented with visits and demonstrations by physicians in the classroom. This paper describes one approach to broaden the prespective of law students during their training by permitting them to experience directly the atmosphere of the teaching hospital and the sociology of surgery practice in that environment. The experiment has proved beneficial to the young members of both professions.

The expanded polytetrafluoroethylene (PTFE) graft (Gore-tex) is the most frequently used synthetic graft when an alternative to autologous saphenous vein is required. Early results have been encouraging. In the present paper we report on 6 years of results from 153 above-knee (AK) femoropopliteal bypass grafts, 74 below-knee (BK) femoropopliteal bypass grafts, and 54 femorotibial/peroneal bypass grafts. The main indication for the vascular reconstruction was severe ischemia. Preventive antibiotics were given to 95% of the patients. Minimum observation time was 1 year after implantation. There was no operative death. Graft infection was seen in less than 5% of patients. The 6-year cumulative limb salvage rate was 87% for patients with severe ischemia in the AK femoropopliteal bypass group, 59% for those in the BK femoropopliteal bypass group, and 57% for those in the femorotibial/peroneal bypass group. The graft patency rate was 88% at 2 years and 78% at 6 years for the AK femoropopliteal bypass group, for whom the operative indication was disabling claudication, and 81% and 68%, respectively, when the indication for the vascular procedure was severe ischemia. The cumulative graft patency rate was 53% and 43% at 2 and 6 years, respectively, after implantation of BK femoropopliteal bypass grafts and 43% and 39% for femorotibial/peroneal bypass procedures. The expanded PTFE (Gore-tex) graft seems therefore to be a good alternative when an autologous vein is not available, even for reconstructions well below the knee joint.