Search

Advanced colon adenomas are commonly treated with colectomy, which is associated with substantial morbidity and mortality. Novel endoscopic resection techniques have been described, including endoscopic mucosal resection (EMR) and endoscopic submucosal resection (ESR), which demonstrate promise in treating these neoplasms without colectomy. We performed a retrospective review of patients with advanced adenomas who were referred to a colorectal surgeon for evaluation for resection over 4 years. 40 of 46 (87%) of these patients underwent a successful endoscopic resection. 10 of 46 (21.6%) patients ultimately underwent an operation for a variety of reasons: inability to resect endoscopically (n = 6), invasive cancer on the excised specimen (n = 2), complication of procedure (n = 1), colectomy after polyp recurrence (n = 1). Our study demonstrates EMR and ESD offers an alternative to colectomy in appropriately selected patients with a high success rate. As more surgeons learn advanced endoscopic techniques, there is potential to decrease colectomy rates in benign disease.

It has been well established that hepatocellular carcinomas (HCCs) accumulate [18F]fluorodeoxy-glucose (FDG) to varying degrees; this is thought to be due to differing amounts of FDG-6-phosphatase activity. The purpose of this study was to evaluate the impact of FDG imaging on the management of patients diagnosed with hepatocellular carcinoma. We conducted a retrospective review of the clinical data of 91 consecutive patients diagnosed with HCC who underwent FDG-positron emission tomography (PET) imaging between August 1993 and March 2001. The patients were divided into two groups. In Group one 67 of 91 (74%) patients were evaluated for proven but untreated hepatic lesions using PET. In Group two the remaining 24 patients (26%) were referred for evaluation of HCC recurrence but did not have prior PET. The FDG images were acquired with two dedicated PET tomographs [Siemens ECAT 933, CTI (Knoxville, TN) and GE Advance, General Electric Medical Systems (Milwaukee, WI)] one hour after the intravenous administration of 10 mCi of FDG. Tumor biopsy or resection specimens were available for review from 34 patients and were evaluated for histologic grade, presence of cirrhosis, tumor necrosis, and intratumoral fibrosis. In group one 43 of 67 (64%) of the HCCs accumulated FDG. Sixteen of the 43 patients in whom FDG was accumulated had multiple subsequent FDG-PET scans either for monitoring therapy or for detection of recurrence. FDG-PET imaging had an impact on the management of 20 of these patients: by guiding the biopsy at the metabolically active site of a large necrotic tumor (one), by identifying distant metastases (five), by monitoring the response to treatment with hepatic chemoembolization and guiding additional regional therapy (12), and by detecting recurrence (two). In group two recurrence and/or metastases were demonstrated with FDG-PET imaging in six of 24 (25%) patients, three of whom had multiple subsequent FDG-PET scans to monitor their treatment. Higher histopathologic grade and intratumoral fibrosis but not necrosis or cirrhosis correlated with PET positivity. In this study only 64 per cent of HCCs accumulated FDG. Despite this limitation FDG-PET imaging remains a useful tool in the diagnosis and treatment of HCC. FDG-PET imaging had a clinically significant impact in 26 of 91 (28%) patients with HCC. This includes detection of unsuspected metastatic disease in high-risk patients—including liver transplant candidates—and monitoring response to hepatic-directed therapy. FDG-PET should be considered as part of the workup and management of selected patients with HCC.

In a prospective controlled trial hemostatic effectiveness of a novel collagen-based composite (CoStasis®) was compared with a collagen sponge applied with manual pressure at diffusely bleeding sites after surgical tumor resection. The proportion of subjects achieving complete cessation of bleeding within 10 minutes (i.e., hemostatic success) and the time to “complete hemostasis” were determined at raw surgical sites after tumor resection among 23 experimental and 30 control subjects. There was a similar distribution in tumor types (e.g., benign vs malignant) evaluated between treatment groups. A significantly greater proportion of experimental subjects achieved complete hemostasis within 10 minutes of observation compared with controls [23 of 23 (100%) vs 21 of 30 (70%); P = 0.003]. The median time required to achieve complete hemostasis was more than three times longer for subjects treated with the collagen sponge compared with subjects treated with CoStasis® (243 vs 78 seconds; P = 0.0001). Approximately 80 per cent of experimental subjects achieved complete hemostasis within 2 minutes compared with only 35 per cent of controls. There were no adverse events related to the experimental treatment in this study. These results support the use of this novel hemostatic agent to control diffuse surgical site bleeding after tumor resection at diverse anatomical locations.

Bile leaks occur in up to 27 per cent of liver transplant patients after biliary reconstruction. Synthetic sealants have not been investigated for these biliary procedures. We performed a randomized controlled study to evaluate a novel absorbable polyethylene glycol/collagen bio-polymer sealant (CT3™ Surgical Sealant) after incomplete end-to-end choledochocholedochostomy (CDCD) in pigs. Pigs (n = 18) underwent transection of the common bile duct and incomplete CDCD over a T-tube, leaving a one-sixth circumferential defect anteriorly. Animals were randomly assigned to treatment (CDCD with sealant, n = 9) or control (no sealant, n = 9). Drains were used to monitor leak volume and bilirubin (bili) concentration. Cholangiography was performed on postoperative day 3. Leaks were defined as drain bili/serum bill > 3, total drain output > 10 mL/kg, and/or extravasation on cholangiography. Animals sacrificed at 3 and 8 weeks (n = 4 and n = 5 from each group, respectively) underwent pathologic examination of the CDCD site. Statistical methods included Student's t test, χ2, linear regression, and analysis of variance procedures. The control group had a higher drain output rate over the first 4 postoperative days than the treatment group ( P < 0.05, analysis of variance). Five of nine (56%) control and one of nine (11%) treatment animals had a bile leak ( P < 0.05, χ2). There was no major inflammatory response to the sealant versus controls. We conclude that CT3 is effective in decreasing biliary leaks in an incomplete CDCD porcine model with no major adverse pathologic changes. This sealant should be considered for trials for biliary reconstruction in humans.

Radical resection (wedge resection of the gallbladder bed and dissection of the hepatoduodenal ligament, portal, and celiac lymph nodes) has been reported to improve survival from pathologic T2 gallbladder carcinoma (pT2 GBCa; invasion through the muscularis without perforation of the serosa). We report our experience and the outcome of patients with pT2 GBCa. Between 1989 and 2000 at Vanderbilt University Medical Center ten patients were found to have pT2 disease after cholecystectomy. The patients had an average age of 64 ± 13 years and underwent either radical resection (n = 5) or no further surgical therapy (n = 5). Of the patients who underwent cholecystectomy only, one (20%) is still alive at 27 months and four (80%) died of recurrent GBCa between 6.5 and 21 months. For the patients who underwent radical resection all five are alive at 15 to 83 months with no recurrence. The proportion of patients surviving pT2 GBCa after radical resection was significantly greater than with cholecystectomy alone ( P < 0.05). The difference in length of survival between the two groups was also significant ( P < 0.05). Morbidity after radical resection was low (pancreatic leak in one patient), and there were no operative mortalities. Radical resection significantly improved survival over cholecystectomy alone for patients with pT2 GBCa. The procedure has low morbidity and mortality rates. Therefore a radical resection operation is indicated for patients with pT2 GBCa.

Previous reports suggest that bile duct injuries sustained during laparoscopic cholecystectomy (lap chole) are frequently severe and related to cautery and high clip ligation. We performed a review of patients who sustained bile duct injury from lap chole since 1990 and assessed time to injury recognition, time to referral, Bismuth classification, initial and subsequent repairs, rate of recurrence, and length of follow-up. Seventy-four patients [median age 44 years, 58 of 74 female (78%)] were referred with a bile duct injury after lap chole. The level of injury was evenly divided between the bile duct bifurcation and the common hepatic duct: Bismuth III, IV, and V (40 of 74, 54%) versus Bismuth I and II (34 of 74,46%). Concomitant hepatic arterial injury was identified in nine (12%) patients. Patients referred early after bile duct injury and requiring operative intervention underwent hepaticojejunostomy at a median of 2 days after referral. After surgical reconstruction at our center there has been an overall success rate of 89 per cent with no need for reintervention. Six (10%) of these patients have required one additional balloon dilatation at a mean follow-up of >24 months. One (2%) patient underwent biliary-enteric revision in follow-up. In patients with bile duct injury, stricture repair without delay was successful in the majority of patients treated in this series. Only one of 64 patients reconstructed at our center has required reoperation; six others have required a single balloon dilatation with subsequent good or excellent results. The majority of patients treated with operative repair at an experienced center can expect good long-term results with rare need for reintervention.

Over the past decade, splenic preservation has become a well-reported and accepted principle in trauma management. The reasons for splenic preservation may have influenced nontraumatic surgical management as well. To investigate the changing incidence and indications for splenectomy, we conducted a 10-year review of all splenectomies at our institution. During this time, between January 1, 1986, and December 31, 1995, 896 patients underwent splenectomy. Hospital charts and records were examined to determine the etiology and incidence of splenectomy. Indications were classified as: 1) trauma, i.e., performed for blunt or penetrating injury; 2) hematologic malignancy, i.e., therapy or staging of underlying leukemia, Hodgkin's lymphoma, or non-Hodgkin's lymphoma; 3) cytopenia, i.e., treatment of thrombocytopenia, anemia, or leukopenia; 4) iatrogenic, i.e., injury during another procedure; 5) incidental, i.e., required for adjacent organ resection; 6) portal hypertension, i.e., left-sided portal hypertension or during shunting procedure; 7) diagnostic, i.e., uncertainty excluding hematologic malignancy; or 8) other, i.e., miscellaneous indications. Trauma accounted for 41.5 per cent of all splenectomies during this time period, hematologic malignancy 15.4 per cent, cytopenia 15.6 per cent, incidental 12.3 per cent, iatrogenic 8.1 per cent, portal hypertension 2.3 per cent, diagnostic 2.0 per cent, and other 2.7 per cent. Comparing the first and second 5-year time periods, the following increases/decreases in average annual incidence were noted: splenectomy for all indications, -36.9 per cent; trauma, -32.9 per cent; hematologic malignancy, -51.4 per cent; cytopenia, 35.1 per cent; incidental, -35.9 per cent; iatrogenic, -30.2 per cent; diagnostic, +4.9 per cent, and other, -57 per cent. Traumatic injury to the spleen remains the most common indication for splenectomy, but the incidence has decreased dramatically over the past 10 years. Splenectomies for treatment of hematologic malignancies and cytopenia, as well as incidental and iatrogenic splenectomies, have also decreased significantly. Only the incidence of diagnostic splenectomy has remained stable. Although initiated within the field of trauma, the advantages of splenic preservation now appear to be well recognized beyond that field.

Previous series have identified an increased risk of developing acute postoperative pancreatitis in heart transplant recipients and other cardiac surgical patients, and some suggest that mortality is significantly increased when pancreatitis occurs in the transplant setting. We conducted a retrospective case-control analysis of adult patients undergoing orthotopic heart transplant or other cardiac procedures from April 1985 through June 1996 at our medical center. Specific risk factors for outcome were assessed including low cardiac output, intra-aortic balloon pump usage, exogenous calcium repletion, immunosuppression, cytomegalovirus infection, cholelithiasis, prior pancreatitis, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. There was a 30-fold increase in the incidence of pancreatitis in the heart transplant group [12 of 394 (3%) vs 27 of 24,237 (0.1%); P < 0.01]. Compared with the nontransplant cardiopulmonary bypass patients, the transplant patients experienced a statistically significant increased incidence of immunosuppression and three or more risk factors. Transplant patients with pancreatitis demonstrated a significant increase in APACHE II scores and the incidence of three or more risk factors compared with their transplant control group. Patients undergoing nontransplant cardiac procedures and developing pancreatitis had significantly increased cross-clamp times, incidence of low cardiac output, APACHE II scores, and incidence of three or more risk factors compared with their nontransplant cohort. In conclusion, there is a significant increase in the incidence of pancreatitis after orthotopic heart transplant compared with other cardiac procedures. Analysis demonstrates the additive effect of multiple individual risk factors. Immunosuppression confers significant additional risk for pancreatitis in the orthotopic heart transplant patient.

The outcome of 134 patients undergoing hepatic resection for colorectal metastasis was studied. Current follow-up was available in 98 per cent of patients, for more than 5 years in 58 patients, and totaling 360 patient-years. Patients (52% male) had an average age of 62 ± 1 years (standard error of the mean). Time lapse between the primary colon surgery and hepatic resection was a median of 16 months and a mean of 19 ± 1 months. Thirty-two (24%) were operated on within 6 months for both their primary tumor and hepatic metastasis. Intensive care unit and total hospital length of stay were a median of 1 and 7 days, respectively. Pathology reports demonstrated that on average there were 2.0 ± 0.1 lesions, with the largest lesion measuring 4.4 ± 0.2 cm. In 72 per cent of patients, the lesions were found in one lobe only. CEA was elevated in 83 per cent of patients preoperatively and was 60 ± 11 ng/mL before and 4.0 ± 0.5 ng/mL after hepatic resection. Patient survival was 81 per cent at 1 year, 50 per cent at 3 years, 36 per cent at 5 years, and 23 per cent at 10 years. Actual 5- and 10-year survival was 22 of 58 (38%) patients and 4 of 21 (19%) patients respectively. Disease-free survival was 58 per cent at 1 year, 27 per cent at 3 years, 16 per cent at 5 years, and 12 per cent at 7 years. Survival was much better for one to four lesions than for five or more lesions (P < 0.01). Several other potential risk factors did not affect survival, including whether the patient received chemotherapy after hepatic resection. There were 36 (43%) patients who recurred with hepatic involvement only, 27 (32%) including hepatic involvement and 21 (25%) with nonhepatic involvement only. There were 15 patients who went on to receive repeat hepatic resections, with a 5-year survival of 74 per cent and disease-free survival of 58 per cent. Hepatic resection provides the best outcome of any form of therapy for selected patients with isolated hepatic metastasis.

Bilioenteric reconstruction using a Roux limb of jejunum is a well-established surgical option for the reconstruction of the proximal bile duct. Previous studies discussing short- and long-term complications of biliary-enteric anastomosis have focused on technical aspects, such as the use of anastomotic stenting or the level of the biliary tree used. We report two cases of previously unreported complications after hepaticojejunostomy that resulted from a technical error in constructing the Roux limb. Within a 3-month period, two patients were referred to our institution with recurrent cholangitis after biliary reconstruction for injuries sustained during laparoscopic cholecystectomy. Reexploration disclosed major technical flaws in the construction of the Roux limb used for biliary drainage. Antiperistaltic limbs had been constructed in both patients: one from the distal ileum and one from the conventional location in the jejunum. In both cases, isoperistaltic reconstruction of the Roux limbs resolved the recurrent cholangitis. Cholangitis after biliary-enteric bypass can arise from a variety of etiologies and lead to anastomotic narrowing or ineffective drainage of the biliary tree. Review of the literature failed to disclose reports of technically flawed Roux limb construction as a cause of cholangitis. We present these cases to highlight the devastating consequences of antiperistaltic construction of the Roux limb. We hope that by publishing the role of this avoidable error in recurrent cholangitis after biliary-enteric bypass we may help prevent its future occurrence.

Attempts at improving anastomoses have included the development of stapling techniques. Our purpose was to evaluate arcuate-legged clipped versus standard sutured anastomoses of the hepatic artery (HA), portal vein (PV), and bile duct in a porcine liver transplantation model. Two groups of pigs were studied intraoperatively and 1 day after liver transplantation. A control group underwent sutured anastomosis of PV and HA with polypropylene and of bile duct with polydioxanone (n = 8). An experimental group underwent anastomoses with arcuate-legged clips (n = 8). We analyzed the time to perform anastomosis and flows before and at various time points after anastomosis. In addition, patency and histology of the anastomoses were evaluated 1 day after operation, including a fibrin-thrombosis score, medial injury, and inflammation score. Times to complete HA and PV anastomoses were not different between clipped and sutured groups. However, the time was shorter to complete bile duct anastomosis with clips than with sutures (6.3 ± 1.1 minutes and 13.3 ± 2.0 minutes, respectively). Flows through HA anastomoses were not different between groups, but flow through the PV was higher in clipped compared with sutured anastomosis (P = 0.06). Patency was 100 per cent with no leaks for all three anastomoses in both groups. Histologic data were similar between vascular anastomotic groups. Sutured bile duct anastomoses revealed mild smooth muscle injury in 75 per cent whereas clipped bile duct anastomoses displayed no smooth muscle injury. We conclude that arcuate-legged clipped anastomosis represents a viable option to sutured anastomoses of the PV, HA, and bile duct anastomoses. Bile duct anastomoses were completed in less than half the time and with less tissue damage documented histologically.

It has been well established that hepatocellular carcinomas (HCCs) accumulate [18F]fluorodeoxyglucose (FDG) to varying degrees; this is thought to be due to differing amounts of FDG-6-phosphatase activity. The purpose of this study was to evaluate the impact of FDG imaging on the management of patients diagnosed with hepatocellular carcinoma. We conducted a retrospective review of the clinical data of 91 consecutive patients diagnosed with HCC who underwent FDG-positron emission tomography (PET) imaging between August 1993 and March 2001. The patients were divided into two groups. In Group one 67 of 91 (74%) patients were evaluated for proven but untreated hepatic lesions using PET. In Group two the remaining 24 patients (26%) were referred for evaluation of HCC recurrence but did not have prior PET. The FDG images were acquired with two dedicated PET tomographs [Siemens ECAT 933, CTI (Knoxville, TN) and GE Advance, General Electric Medical Systems (Milwaukee, WI)] one hour after the intravenous administration of 10 mCi of FDG. Tumor biopsy or resection specimens were available for review from 34 patients and were evaluated for histologic grade, presence of cirrhosis, tumor necrosis, and intratumoral fibrosis. In group one 43 of 67 (64%) of the HCCs accumulated FDG. Sixteen of the 43 patients in whom FDG was accumulated had multiple subsequent FDG-PET scans either for monitoring therapy or for detection of recurrence. FDG-PET imaging had an impact on the management of 20 of these patients: by guiding the biopsy at the metabolically active site of a large necrotic tumor (one), by identifying distant metastases (five), by monitoring the response to treatment with hepatic chemoembolization and guiding additional regional therapy (12), and by detecting recurrence (two). In group two recurrence and/or metastases were demonstrated with FDG-PET imaging in six of 24 (25%) patients, three of whom had multiple subsequent FDG-PET scans to monitor their treatment. Higher histopathologic grade and intratumoral fibrosis but not necrosis or cirrhosis correlated with PET positivity. In this study only 64 per cent of HCCs accumulated FDG. Despite this limitation FDG-PET imaging remains a useful tool in the diagnosis and treatment of HCC. FDG-PET imaging had a clinically significant impact in 26 of 91 (28%) patients with HCC. This includes detection of unsuspected metastatic disease in high-risk patients-including liver transplant candidates-and monitoring response to hepatic-directed therapy. FDG-PET should be considered as part of the workup and management of selected patients with HCC.

In a prospective controlled trial hemostatic effectiveness of a novel collagen-based composite (CoStasis) was compared with a collagen sponge applied with manual pressure at diffusely bleeding sites after surgical tumor resection. The proportion of subjects achieving complete cessation of bleeding within 10 minutes (i.e., hemostatic success) and the time to "complete hemostasis" were determined at raw surgical sites after tumor resection among 23 experimental and 30 control subjects. There was a similar distribution in tumor types (e.g., benign vs malignant) evaluated between treatment groups. A significantly greater proportion of experimental subjects achieved complete hemostasis within 10 minutes of observation compared with controls [23 of 23 (100%) vs 21 of 30 (70%); P = 0.003]. The median time required to achieve complete hemostasis was more than three times longer for subjects treated with the collagen sponge compared with subjects treated with CoStasis (243 vs 78 seconds; P = 0.0001). Approximately 80 per cent of experimental subjects achieved complete hemostasis within 2 minutes compared with only 35 per cent of controls. There were no adverse events related to the experimental treatment in this study. These results support the use of this novel hemostatic agent to control diffuse surgical site bleeding after tumor resection at diverse anatomical locations.

Bile leaks occur in up to 27 per cent of liver transplant patients after biliary reconstruction. Synthetic sealants have not been investigated for these biliary procedures. We performed a randomized controlled study to evaluate a novel absorbable polyethylene glycol/collagen biopolymer sealant (CT3 Surgical Sealant) after incomplete end-to-end choledochocholedochostomy (CDCD) in pigs. Pigs (n = 18) underwent transection of the common bile duct and incomplete CDCD over a T-tube, leaving a one-sixth circumferential defect anteriorly. Animals were randomly assigned to treatment (CDCD with sealant, n = 9) or control (no sealant, n = 9). Drains were used to monitor leak volume and bilirubin (bili) concentration. Cholangiography was performed on postoperative day 3. Leaks were defined as drain bili/serum bill3, total drain output10 mL/kg, and/or extravasation on cholangiography. Animals sacrificed at 3 and 8 weeks (n = 4 and n = 5 from each group, respectively) underwent pathologic examination of the CDCD site. Statistical methods included Student's t test, chi2, linear regression, and analysis of variance procedures. The control group had a higher drain output rate over the first 4 postoperative days than the treatment group (P0.05, analysis of variance). Five of nine (56%) control and one of nine (11%) treatment animals had a bile leak (P0.05, chi2). There was no major inflammatory response to the sealant versus controls. We conclude that CT3 is effective in decreasing biliary leaks in an incomplete CDCD porcine model with no major adverse pathologic changes. This sealant should be considered for trials for biliary reconstruction in humans.

Radical resection (wedge resection of the gallbladder bed and dissection of the hepatoduodenal ligament, portal, and celiac lymph nodes) has been reported to improve survival from pathologic T2 gallbladder carcinoma (pT2 GBCa; invasion through the muscularis without perforation of the serosa). We report our experience and the outcome of patients with pT2 GBCa. Between 1989 and 2000 at Vanderbilt University Medical Center ten patients were found to have pT2 disease after cholecystectomy. The patients had an average age of 64+/-13 years and underwent either radical resection (n = 5) or no further surgical therapy (n = 5). Of the patients who underwent cholecystectomy only, one (20%) is still alive at 27 months and four (80%) died of recurrent GBCa between 6.5 and 21 months. For the patients who underwent radical resection all five are alive at 15 to 83 months with no recurrence. The proportion of patients surviving pT2 GBCa after radical resection was significantly greater than with cholecystectomy alone (P0.05). The difference in length of survival between the two groups was also significant (P0.05). Morbidity after radical resection was low (pancreatic leak in one patient), and there were no operative mortalities. Radical resection significantly improved survival over cholecystectomy alone for patients with pT2 GBCa. The procedure has low morbidity and mortality rates. Therefore a radical resection operation is indicated for patients with pT2 GBCa.

Over the past decade, splenic preservation has become a well-reported and accepted principle in trauma management. The reasons for splenic preservation may have influenced nontraumatic surgical management as well. To investigate the changing incidence and indications for splenectomy, we conducted a 10-year review of all splenectomies at our institution. During this time, between January 1, 1986, and December 31, 1995, 896 patients underwent splenectomy. Hospital charts and records were examined to determine the etiology and incidence of splenectomy. Indications were classified as: 1) trauma, i.e., performed for blunt or penetrating injury; 2) hematologic malignancy, i.e., therapy or staging of underlying leukemia, Hodgkin's lymphoma, or non-Hodgkin's lymphoma; 3) cytopenia, i.e., treatment of thrombocytopenia, anemia, or leukopenia; 4) iatrogenic, i.e., injury during another procedure; 5) incidental, i.e., required for adjacent organ resection; 6) portal hypertension, i.e., left-sided portal hypertension or during shunting procedure; 7) diagnostic, i.e., uncertainty excluding hematologic malignancy; or 8) other, i.e., miscellaneous indications. Trauma accounted for 41.5 per cent of all splenectomies during this time period, hematologic malignancy 15.4 per cent, cytopenia 15.6 per cent, incidental 12.3 per cent, iatrogenic 8.1 per cent, portal hypertension 2.3 per cent, diagnostic 2.0 per cent, and other 2.7 per cent. Comparing the first and second 5-year time periods, the following increases/decreases in average annual incidence were noted: splenectomy for all indications, -36.9 per cent; trauma, -32.9 per cent; hematologic malignancy, -51.4 per cent; cytopenia, 35.1 per cent; incidental, -35.9 per cent; iatrogenic, -30.2 per cent; diagnostic, +4.9 per cent, and other, -57 per cent. Traumatic injury to the spleen remains the most common indication for splenectomy, but the incidence has decreased dramatically over the past 10 years. Splenectomies for treatment of hematologic malignancies and cytopenia, as well as incidental and iatrogenic splenectomies, have also decreased significantly. Only the incidence of diagnostic splenectomy has remained stable. Although initiated within the field of trauma, the advantages of splenic preservation now appear to be well recognized beyond that field.

Previous series have identified an increased risk of developing acute postoperative pancreatitis in heart transplant recipients and other cardiac surgical patients, and some suggest that mortality is significantly increased when pancreatitis occurs in the transplant setting. We conducted a retrospective case-control analysis of adult patients undergoing orthotopic heart transplant or other cardiac procedures from April 1985 through June 1996 at our medical center. Specific risk factors for outcome were assessed including low cardiac output, intra-aortic balloon pump usage, exogenous calcium repletion, immunosuppression, cytomegalovirus infection, cholelithiasis, prior pancreatitis, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. There was a 30-fold increase in the incidence of pancreatitis in the heart transplant group [12 of 394 (3%) vs 27 of 24,237 (0.1%); P0.01]. Compared with the nontransplant cardiopulmonary bypass patients, the transplant patients experienced a statistically significant increased incidence of immunosuppression and three or more risk factors. Transplant patients with pancreatitis demonstrated a significant increase in APACHE II scores and the incidence of three or more risk factors compared with their transplant control group. Patients undergoing nontransplant cardiac procedures and developing pancreatitis had significantly increased cross-clamp times, incidence of low cardiac output, APACHE II scores, and incidence of three or more risk factors compared with their nontransplant cohort. In conclusion, there is a significant increase in the incidence of pancreatitis after orthotopic heart transplant compared with other cardiac procedures. Analysis demonstrates the additive effect of multiple individual risk factors. Immunosuppression confers significant additional risk for pancreatitis in the orthotopic heart transplant patient.

Bilioenteric reconstruction using a Roux limb of jejunum is a well-established surgical option for the reconstruction of the proximal bile duct. Previous studies discussing short- and long-term complications of biliary-enteric anastomosis have focused on technical aspects, such as the use of anastomotic stenting or the level of the biliary tree used. We report two cases of previously unreported complications after hepaticojejunostomy that resulted from a technical error in constructing the Roux limb. Within a 3-month period, two patients were referred to our institution with recurrent cholangitis after biliary reconstruction for injuries sustained during laparoscopic cholecystectomy. Reexploration disclosed major technical flaws in the construction of the Roux limb used for biliary drainage. Antiperistaltic limbs had been constructed in both patients: one from the distal ileum and one from the conventional location in the jejunum. In both cases, isoperistaltic reconstruction of the Roux limbs resolved the recurrent cholangitis. Cholangitis after biliary-enteric bypass can arise from a variety of etiologies and lead to anastomotic narrowing or ineffective drainage of the biliary tree. Review of the literature failed to disclose reports of technically flawed Roux limb construction as a cause of cholangitis. We present these cases to highlight the devastating consequences of antiperistaltic construction of the Roux limb. We hope that by publishing the role of this avoidable error in recurrent cholangitis after biliary-enteric bypass we may help prevent its future occurrence.

The outcome of 134 patients undergoing hepatic resection for colorectal metastasis was studied. Current follow-up was available in 98 per cent of patients, for more than 5 years in 58 patients, and totaling 360 patient-years. Patients (52% male) had an average age of 62 +/- 1 years (standard error of the mean). Time lapse between the primary colon surgery and hepatic resection was a median of 16 months and a mean of 19 +/- 1 months. Thirty-two (24%) were operated on within 6 months for both their primary tumor and hepatic metastasis. Intensive care unit and total hospital length of stay were a median of 1 and 7 days, respectively. Pathology reports demonstrated that on average there were 2.0 +/- 0.1 lesions, with the largest lesion measuring 4.4 +/- 0.2 cm. In 72 per cent of patients, the lesions were found in one lobe only. CEA was elevated in 83 per cent of patients preoperatively and was 60 +/- 11 ng/mL before and 4.0 +/- 0.5 ng/mL after hepatic resection. Patient survival was 81 per cent at 1 year, 50 per cent at 3 years, 36 per cent at 5 years, and 23 per cent at 10 years. Actual 5- and 10-year survival was 22 of 58 (38%) patients and 4 of 21 (19%) patients respectively. Disease-free survival was 58 per cent at 1 year, 27 per cent at 3 years, 16 per cent at 5 years, and 12 per cent at 7 years. Survival was much better for one to four lesions than for five or more lesions (P0.01). Several other potential risk factors did not affect survival, including whether the patient received chemotherapy after hepatic resection. There were 36 (43%) patients who recurred with hepatic involvement only, 27 (32%) including hepatic involvement and 21 (25%) with nonhepatic involvement only. There were 15 patients who went on to receive repeat hepatic resections, with a 5-year survival of 74 per cent and disease-free survival of 58 per cent. Hepatic resection provides the best outcome of any form of therapy for selected patients with isolated hepatic metastasis.

Attempts at improving anastomoses have included the development of stapling techniques. Our purpose was to evaluate arcuate-legged clipped versus standard sutured anastomoses of the hepatic artery (HA), portal vein (PV), and bile duct in a porcine liver transplantation model. Two groups of pigs were studied intraoperatively and 1 day after liver transplantation. A control group underwent sutured anastomosis of PV and HA with polypropylene and of bile duct with polydioxanone (n = 8). An experimental group underwent anastomoses with arcuate-legged clips (n = 8). We analyzed the time to perform anastomosis and flows before and at various time points after anastomosis. In addition, patency and histology of the anastomoses were evaluated 1 day after operation, including a fibrin-thrombosis score, medial injury, and inflammation score. Times to complete HA and PV anastomoses were not different between clipped and sutured groups. However, the time was shorter to complete bile duct anastomosis with clips than with sutures (6.3 +/- 1.1 minutes and 13.3 +/- 2.0 minutes, respectively). Flows through HA anastomoses were not different between groups, but flow through the PV was higher in clipped compared with sutured anastomosis (P = 0.06). Patency was 100 per cent with no leaks for all three anastomoses in both groups. Histologic data were similar between vascular anastomotic groups. Sutured bile duct anastomoses revealed mild smooth muscle injury in 75 per cent whereas clipped bile duct anastomoses displayed no smooth muscle injury. We conclude that arcuate-legged clipped anastomosis represents a viable option to sutured anastomoses of the PV, HA, and bile duct anastomoses. Bile duct anastomoses were completed in less than half the time and with less tissue damage documented histologically.

Hepatocellular carcinoma (HCC) in Western populations historically has been associated with poor survival. In this study, we conducted a 7-year retrospective analysis of patients evaluated at our institution with HCC to determine the effects of newer treatment strategies on outcome. During the period of study, 117 patients [86 (74%) male; mean age, 59 years (range, 16-85)] were evaluated with treatment as follows: surgical resection in 22 (19%), chemoembolization with or without systemic chemotherapy in 40 (35%), systemic treatment alone in 16 (13%), orthotopic liver transplantation in 8 (7%), and supportive care only in 31 (26%). Sixty-nine patients (59%) had documented cirrhosis, with hepatitis C being the most common cause in 27 of 69 (39%). In patients receiving no treatment, median survival was just under 3 months, with only two 1-year survivors. Patients with orthotopic liver transplantation had 1-, 2-, and 3-year survival rates of 87, 87, and 58 per cent compared with 69, 52, and 43 per cent in surgically resected patients. Survival after chemoembolization was 35, 20, and 11 per cent at 1, 2, and 3 years, whereas survival after systemic chemotherapy was 30 and 15 per cent at 1 and 2 years, respectively. One-year survival was improved in noncirrhotic patients compared with cirrhotics (47% vs 29%; P0.05) but was no different in patients younger than 55 years compared with older patients (38% vs 38%). When possible, surgical treatment strategies offer superior survival.

Bronchobiliary fistula is an uncommon but remarkable complication after hepatic resection. The case reported illustrates the clinical presentation and preferred initial management of these fistulae. A 61-year-old white male underwent two wedge resections for colorectal metastases to the liver with removal of a portion of the right diaphragm. Four years later, he developed obstructive jaundice secondary to tumor recurrence in the porta hepatis, which required endoscopic stent placement, radiation, and chemotherapy. Almost 2 years later, he developed frank biliptysis. Percutaneous transhepatic cholangiography (PTC) revealed occlusion of the common hepatic duct stent and a bronchobiliary fistula. With adequate reestablishment of common duct drainage, the patient rapidly improved and was discharged free of symptoms. Bronchobiliary fistulae are rare complications of hepatic resection that can present from days to years after operation. Endoscopic retrograde cholangiopancreatography and PTC are the diagnostic studies of choice and offer the possibility of therapeutic intervention. Although large series in the literature emphasize the surgical management of bronchobiliary fistulae, the reoperative procedures tend to be complicated, with a significant morbidity and mortality. Nonsurgical interventions via endoscopic retrograde cholangiopancreatography or PTC are more recently notably successful when resolution of a distal biliary obstruction is accomplished. Only after aggressive attempts at nonoperative, interventional techniques have failed should operative approaches be entertained.

The formation of gallstones around surgical clips after cholecystectomy is a rare complication, with only seven reported cases in the English literature since its initial description in 1979. Three other cases report clip migration into the common bile duct and obstruction. We report a recent experience with "clip cholelithiasis." A 78-year-old female, 16 years following cholecystectomy, presented with a several-month history of colicky abdominal pain worsened by meals, and a 1 week history of jaundice, anorexia, nausea, and vomiting. An abdominal ultrasound demonstrated dilatation of the biliary tree without visible choledocholithiasis. Endoscopic retrograde cholangiopancreatography demonstrated a 1.5-cm radiolucent stone in the common bile duct containing a central surgical clip. She was successfully treated with endoscopic sphincterotomy and stone retrieval. The first report of clip cholelithiasis occurred in 1979. Six additional cases have been reported as well as three cases of clip migration without stone formation into the common bile duct. The incidence of clip cholelithiasis may increase in frequency with the increased use of metallic clips during laparoscopic cholecystectomy. The occurrence of cholelithiasis around inert metals is rare and may be prevented using absorbable clips; however, stone formation is also reported around absorbable materials.

The liver plays a central role in carbohydrate metabolism and glucose homeostasis; therefore, the rapid recovery of glucose homeostasis after liver transplantation (LT) is important. The purpose of this study was to evaluate hepatic and whole-body glucose production (WBGP) on postoperative day 1 after LT using a combination of arteriovenous differences and radioisotope techniques. Two groups of female commercially bred pigs with an average body weight of 31.9 +/- 1.4 kg were studied. A control group (n = 6) underwent laparotomy. A transplanted group (n = 6) was submitted to LT. All pigs were instrumented with catheters placed in the carotid artery and the hepatic, portal, and jugular vein, and flow probes were placed around the hepatic artery and portal vein. WBGP was measured by a primed constant infusion of 3-[3H]glucose 1 day postoperatively. Plasma glucose was 89 +/- 6 versus 98 +/- 7 mg/dL in the control and transplanted groups, respectively. WBGP was increased by 42 per cent in the transplanted group (2.54 +/- 0.17 vs 3.62 +/- 0.39 mg/kg.min), but the net hepatic glucose output was not different between the control and the transplanted groups (1.53 +/- 0.28 vs 1.68 +/- 0.31 mg/kg.min). These results demonstrate that net hepatic glucose output was not different between the control and transplanted pigs, suggesting that LT does not compromise the ability of the liver to produce glucose. However, the WBGP was increased by 42 per cent in the transplanted group, suggesting either a significant contribution from another organ or a significant intrahepatic utilization of glucose.

Inapparent gallbladder carcinoma discovered by histologic examination following 1 per cent of cholecystectomies generates a difficult clinical problem. There is evidence that radical resection can prolong survival, especially for locally advanced (or = PT2, according to the Union International Centre Cancer pathologic T classification) lesions. Case reports of recurrence at port sites after laparoscopic cholecystectomy add another aspect to the management difficulty. A 64-year-old woman underwent laparoscopic cholecystectomy for biliary colic. Histologic evaluation revealed an incidental adenocarcinoma, stage pT3. Radical resection with curative intent occurred 11 days later, including mesohepatectomy, skeletonization resection of the common bile duct with en bloc lymph node dissection, and bilateral Roux-en-Y hepaticojejunostomies. There was no tumor identified in the re-excision specimen (T3N0M0). At 7-month follow-up, the patient presented with nodules in the right subcostal area and in the periumbilical incision. Positron emission tomography demonstrated carcinoma at both sites. Biopsy confirmed metastatic gallbladder carcinoma. This case emphasizes the significance of tumor seeding at port sites during laparoscopy. An open technique is indicated if carcinoma is suspected. To avoid dissemination of unsuspected carcinoma during routine laparoscopic procedures, isolation techniques must be applied. The benefit of radical resection was clearly thwarted in this case, and resection of port sites at the time of reoperation is warranted. Finally, positron emission tomography scan is useful in delineating the recurrence of gallbladder carcinoma and its extent.

Healthcare reform has mandated scrutiny of the fiscal aspects of patient care as well as medical outcomes. Therefore, we reviewed our experience with 50 liver transplant recipients from a multidisciplinary collaborative transplant team. From February 1991 to July 1994, of 175 patients referred, 75 were formally evaluated for transplantation; 56 (76%) of these patients were accepted for transplantation; 50 patients underwent 53 transplants. Operative mortality of 6 per cent, retransplantation rate of 6 per cent, 6-month actuarial survival of 88 per cent, 1-year survival of 86 per cent, and the 2 and 3-year survival of 83 per cent were unchanged over time. Quality of life evaluated by the Karnofsky Performance Status was a mean of 55 pretransplant, 72 at 3 months, 79 at 6 months, 84 at 1 year, 88 at 2 years, and 95 at 3 years, demonstrating improved general health and functional rehabilitation after transplantation. Psychosocial Adjustment to Illness Scale scores demonstrated significant improvement following transplantation, improving most dramatically in the vocation environment, domestic environment, and sexual relationship domains. Postoperative length of stay has declined with an average of 28 days in 1991, 22 days in 1992, 19 days in 1993, and 14 days in 1994. Average total hospital, organ procurement, and physician charges for the transplantation hospitalization was $165,000. Average 91-92 hospital charges were $154,000 and were reduced in 93-95 to $103,000 (P.05). We found that charges and length of stay decreased over time, while the outcome and quality of patient care was maintained. We believe the collaborative practice, case management, and revised patient care protocols are responsible.

Although adenoma and focal nodular hyperplasia (FNH) are both benign liver lesions, adenomas are associated with a risk of rupture and malignant degeneration. This had led to the general recommendation of resection of adenomas. However, FNH rarely ruptures or becomes malignant, and a nonoperative approach has been adopted by most hepatobiliary centers when the diagnosis of FNH can be made with reasonable certainty. There are only two previous reports of rupture of FNH in the English literature; we present a third case of FNH with spontaneous rupture and hemorrhage. An 18-year-old healthy Caucasian woman presented with sudden onset of severe RUQ pain. She had never been pregnant, nor used oral contraceptive agents, and had not sustained major trauma. Her abdominal exam revealed RUQ tenderness on palpation. Hepatic biochemical tests, CBC, and coagulation tests were normal. Her hematocrit of 44% fell to 31% over 48 hours. CT scan revealed right anterior lobe and left medial segment hypodense liver lesions (4-5 cm) as well as hemoperitoneum and angiography revealed hypervascular lesions. At laparotomy, two tan fibrous subcapsular masses were excised. Pathology showed a central stellate scar in both lesions with several nodules surrounding the central scar on microscopic section, characteristic of FNH. There was evidence of hemorrhage in one lesion. Significant symptoms are an indication for resection of FNH lesions. However, most patients with FNH are asymptomatic and have a normal physical exam. The natural history of these lesions is enigmatic, and the indications for surgery are still evolving. This report emphasizes that a small risk of rupture clearly exists.(ABSTRACT TRUNCATED AT 250 WORDS)

The vast majority of biliary tract disease is correlated with calculi, and the diagnosis of biliary disease is made simpler when calculi are detected. There are good screening studies for the detection of calculi; however, a reproducible objective test for biliary tract disease in the absence of gallstones has been lacking. Occult biliary tract disease should be considered when symptoms typical of biliary tract disease are present, gallstones cannot be demonstrated, and other diseases have been ruled out. This is characteristically a diagnosis of exclusion, with only the subjective criteria of pain relief to validate surgical intervention. Recently, we have used a nuclear medicine test that simulates the gallbladder response to normal postprandial physiologic stress, to study in an objective fashion the gallbladder function of a group of patients who have symptoms typical of biliary tract disease, but no demonstrable calculi. We have found that the CCK DISIDA study has correlated well with occult pathology. The experience at Easton Hospital has confirmed that the CCK augmented DISIDA scan with calculation of ejection fraction is a reasonably accurate study, with a sensitivity of 88% in detecting previously suspected but undemonstrable pathology in this selected population. This corresponds closely to the observed finding that the pathology reports of 77% of the resected gallbladders noted some abnormality. Of further interest is the long term symptomatic relief achieved in 85% of the patients available for follow up interviews, including a symptomatic benefit in eight of the 11 patients with a normal pathology report.(ABSTRACT TRUNCATED AT 250 WORDS)

A retroesophageal right subclavian artery, the most common congenital aortic arch abnormality, is an unusual cause of dysphagia in adults. The embryologic abnormality of the aortic arch is involution of the fourth vascular arch, along with the right dorsal aorta, leaving the seventh intersegmental artery attached to the descending aorta. This persistent intersegmental artery assumes a retroesophageal position as it proceeds out of the thorax into the arm. Since compression of the esophagus by this right subclavian artery may produce dysphagia, the term "dysphagia lusoria" ("dysphagia by freak of nature"), has been used to describe the symptom complex. The presence of an aneurysm of the artery or Kommerell's diverticulum at its aortic origin is more likely to produce symptoms from esophageal compression. This case presents a middle aged adult with an associated Kommerell's diverticulum and dysphagia. Surgical correction was used to relieve his symptoms and to correct the diverticulum of the proximal right subclavian artery. The embryologic changes that occur are discussed in detail.

Recent advances in elective treatments for gallbladder (GB) gallstones (GS) provide so many options that we may be entering a new therapeutic era. Many of the 20 million Americans with GS are asymptomatic and do not need any treatment unless they are diabetic or cirrhotic, have a porcelain gallbladder, or can have an incidental cholecystectomy while undergoing an elective abdominal operation for other reasons. Therapy is required for significantly symptomatic gallstones and for complications of GS. With the development of so many options for nonoperative treatments, some predicted these would eclipse surgical cholecystectomy as the gold standards. However, such therapies are palliative and leave a "guilty" gallbladder in situ in the presence of lithogenic bile, circumstances inviting the recurrence of GS. The few selected patients for whom a general anesthetic represents an inordinate risk should be considered for biliary lithotripsy or percutaneous cholecystolithotomy, both of which can be done without anesthesia. When anesthesia does not present a risk, laparoscopic cholecystectomy, which incurs minimal disruption of a patient's normal function, has returned cholecystectomy to its position as the therapeutic gold standard for cholelithiasis. Complicated biliary anatomy or disease may dictate the need for traditional open cholecystectomy. However, most patients and referring physicians are demanding laparoscopic cholecystectomy even as this technique is evolving. Its risk for common bile duct injury is uncertain.

Ischemic colitis, or more properly colonic ischemia, became a clear clinical entity in the past 25 years. Yet, early diagnosis of this disease with its various presentations remains a difficult task. A 10-year review at our hospital identified 38 patients with colonic ischemia for comparison with the authors' previous experience and with data from the literature. Several important factors emerge: (1) Twice as many cases occurred after operations (34% in this series vs. 16% in the past), probably because fewer and fewer spontaneous cases were hospitalized. (2) Sixteen patients required operative intervention for colonic ischemia with a mortality of 62 per cent, while those treated nonoperatively had a mortality of 14 per cent. Seven of eight postoperative patients who required a second operative procedure for their colonic ischemia died. A high clinical suspicion is necessary in the postoperative patient, as colonic ischemia appears to be more severe among these patients. Moreover, the high incidence of associated cardiovascular disease indicates that early diagnosis, as well as monitoring of the "at-risk" patient, is needed for improvement in survival to occur. New monitoring methods, such as tonometry, may help accomplish this goal.

At least 10 extracorporeal shockwave lithotripters are under investigation in the United States for treatment of biliary stone disease. Few reports, however, have documented the potential side effects of this new treatment method. In this study, we performed a series of acute and chronic studies in dogs exposed to varying numbers of shockwaves directed at the gallbladder wall via a transthoracic or transabdominal targeting approach. When shockwaves were directed transthoracically, pulmonary hemorrhagic contusions were found which were sometimes large in size. When a transabdominal approach was used, however, only focal areas of hemorrhage were found in the gallbladder wall and adjacent liver with no alterations in postlithotripsy pancreatic or liver enzymes, and normal cholecystokinin-octapeptide stimulated oral cholecystograms were obtained 6 days after treatment. Biliary shockwaves appear to cause few side effects under normal conditions but should be used with caution in patients with potential bleeding disorders. Until further studies are performed, lung tissue should be avoided in the shockwave beam path during treatment.