RESUMEN
BACKGROUND: A modified technique for mesh-plug hernioplasty is a long-term, safe and efficacious treatment for primary unilateral inguinal herniorrhaphy. METHODS: Prospective analysis of 2,038 patients who underwent primary unilateral hernioplasty from 1997 to 2005 at a private university medical center. A modified technique using a mesh-plug was performed under local anesthesia with intravenous sedation. The modified technique consisted of placing the mesh plug into the preperitoneal space and suture fixation of the plug using the inner petals. The main outcome measures were Surgical morbidity, postoperative recovery, hernia recurrence, and chronic pain. RESULTS: There were 1,265 indirect and 773 direct hernias. Mean operative time was 28 min; mean recovery room time, 47 min. A total of 1,936 (95%) returned to normal activities within 3 days. Only 367 patients (18%) required prescription pain medication. Nine patients (0.4%) have been treated for chronic pain. No mesh infections or mesh migration have occurred. Three recurrences (0.15%) have been detected with a 99% follow-up over 2-10 years (mean 72 months). CONCLUSION: The modified mesh-plug hernioplasty is a safe and efficacious treatment option for the primary unilateral inguinal hernia patient.
Asunto(s)
Hernia Inguinal/cirugía , Mallas Quirúrgicas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios/instrumentación , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/epidemiología , Estudios Prospectivos , Recurrencia , Seguridad , Técnicas de Sutura , Resultado del TratamientoRESUMEN
The development of pseudotumors represents one of the most challenging complications facing physicians who care for patients with hemophilia. The successful removal of the giant pseudotumor described in this case report was achieved by a multidisciplinary team and demonstrates that this approach, albeit associated with significant risk, may be curative.
Asunto(s)
Hemofilia A/complicaciones , Neoplasias Pélvicas/cirugía , Pelvis/cirugía , Abdomen/patología , Adulto , Coagulantes/administración & dosificación , Factor VIII/administración & dosificación , Hemofilia A/tratamiento farmacológico , Humanos , Infusiones Parenterales , Masculino , Grupo de Atención al Paciente , Pelvis/patología , Resultado del TratamientoRESUMEN
A prospective study of patients with symptomatic inguinal hernias was undertaken to determine the safety and efficacy of the mesh-plug hernioplasty. Between May 1, 1997 and March 1, 1999 a total of 309 mesh-plug hernioplasties were performed on 283 patients. There were 43 recurrent and 26 bilateral hernioplasties. There were 273 men and 10 women ranging in age from 15 to 94 years (mean 47 years). There were 199 indirect, 104 direct, and six femoral hernias. Mean operative time for primary hernioplasty was 26 minutes (range 20-34) and 35 minutes (range 31-40) for recurrent hernioplasty. All procedures were performed as outpatient surgery with mean recovery room time being 45 minutes (range 25-27) for primary hernioplasty. Two hundred sixty-six patients (94%) returned to normal activities within 3 days. All manual laborers (124 patients) returned to work without restriction on postoperative day 14. Only 43 patients (15%) required prescription pain medication. At one year postoperatively 283 patients (100% follow-up) have been examined and no recurrence has been detected. At 2 years postoperatively 135 patients (100% follow-up) have been examined and no recurrence has been detected. The mesh-plug hernioplasty uses a minimum of medical resources, is associated with a small amount of postoperative pain, and has an early return to normal activities and manual labor without a documented early recurrence in this study.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/instrumentación , Hernia Femoral/cirugía , Hernia Inguinal/cirugía , Mallas Quirúrgicas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Procedimientos Quirúrgicos Ambulatorios/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Estudios Prospectivos , Recurrencia , Seguridad , Mallas Quirúrgicas/efectos adversos , Técnicas de Sutura , Factores de Tiempo , Resultado del TratamientoRESUMEN
A retrospective study of surgically resectable esophageal cancers was undertaken to determine the relationship between angiogenesis score and growth factor expression with tumor size, histology, degree of differentiation, depth of invasion, nodal disease, and the presence of Barrett's esophagus. The office and hospital charts of 27 patients who had esophageal resection for carcinoma between 1990 and 1995 at Rush-Presbyterian-St. Luke's Medical Center were reviewed. Data collection included patient demographics, survival, tumor size, histology, differentiation, depth of invasion, nodal metastases, and the presence of Barrett's esophagus. The pathology specimens were immunostained for von Willebrand factor (factor VIII-related antigen). Immunostaining was also performed for vascular endothelial growth factor and transforming growth factor alpha. Twenty normal esophageal specimens served as controls. Angiogenesis score was determined by counting vessels under conventional light microscopy at x200 magnification, and growth factor expression was graded on a scale of 1 to 4. Cancers had higher angiogenesis and growth factor expression than controls (P = 0.01). Patient age, tumor size, histology, differentiation, depth of invasion, and Barrett's esophagus did not correlate with angiogenesis score or tumor growth factor expression. Lymph node status did correlate with both angiogenesis score and growth factor expression (P < or = 0.02). We conclude that high angiogenesis score and growth factor expression correlate with the presence of lymph node metastases. This may help select patients for preoperative radiation and chemotherapy or determine the extent of surgery performed for esophageal carcinoma.
Asunto(s)
Biomarcadores de Tumor/metabolismo , Carcinoma/metabolismo , Factores de Crecimiento Endotelial/metabolismo , Neoplasias Esofágicas/metabolismo , Linfocinas/metabolismo , Neovascularización Patológica/metabolismo , Factor de Crecimiento Transformador alfa/metabolismo , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Esófago de Barrett/etiología , Esófago de Barrett/metabolismo , Carcinoma/complicaciones , Carcinoma/patología , Carcinoma/cirugía , Neoplasias Esofágicas/complicaciones , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esofagectomía , Femenino , Humanos , Metástasis Linfática/fisiopatología , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Estadísticas no Paramétricas , Análisis de Supervivencia , Factor A de Crecimiento Endotelial Vascular , Factores de Crecimiento Endotelial Vascular , Factor de von Willebrand/metabolismoRESUMEN
Hepatic lobectomy for metastatic colon cancer is well accepted, yielding a 30-35% five-year survival with a low mortality of less than 5%. Less commonly is hepatic resection for selected metastasis from other organs. We report here what we believe is the first hepatic lobectomy for a metastatic carotid body tumor. The patient was a 41-year-old white female who presented with a large incapacitating hepatic metastasis and an incidental lung metastasis from a carotid body tumor resected 12 years earlier. The patient underwent left hemihepatectomy and local lymph node dissection at our university. Twenty-one months after the operation the patient is asymptomatic and has no sign of tumor reoccurrence . We discuss here the clinical features, pathophysiology, treatment and the surgical literature of this rare entity. This is yet another example of the effectiveness of hepatic resection for noncolonic metastasis (26 references).
Asunto(s)
Tumor del Cuerpo Carotídeo/cirugía , Hepatectomía , Neoplasias Hepáticas/cirugía , Adulto , Tumor del Cuerpo Carotídeo/diagnóstico por imagen , Tumor del Cuerpo Carotídeo/secundario , Femenino , Humanos , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/secundario , Tomografía Computarizada por Rayos XRESUMEN
A retrospective study of patients with surgically resectable adenocarcinoma of the pancreatic head was undertaken to determine which prognostic factors are independently associated with improved survival. Thirty-four men and 41 women (mean age, 61.9 years) had resection for adenocarcinoma of the pancreatic head between 1980 and 1997 at Rush-Presbyterian-St. Luke's Medical Center. Surgical resections included 15 total pancreatectomies, 43 pyloric-preserving procedures, and 17 standard Whipple procedures. Thirty-six patients received adjuvant radiation and/or chemotherapy. Overall median survival was 13 months, with a 5-year survival of 17 per cent. Thirty-day surgical mortality was 1.3 per cent. Significant factors that negatively influenced survival using univariate Kaplan-Meier analysis were: positive resection margin (P = 0.01), intraoperative blood transfusion (P = 0.01), and lymph node metastases (P = 0.01). Presenting signs and symptoms, patient demographics, operative procedure, tumor size, histologic differentiation, and adjuvant therapy did not have a significant impact on survival. Using multivariate Cox regression analysis, the only significant independent factors improving survival were the absence of intraoperative blood transfusion (P = 0.02) and a negative resection margin (P = 0.04). Performing pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas with negative microscopic margins of resection and without intraoperative transfusion significantly improves survival.
Asunto(s)
Adenocarcinoma/mortalidad , Neoplasias Pancreáticas/mortalidad , Adenocarcinoma/cirugía , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía , Pronóstico , Análisis de SupervivenciaRESUMEN
Mucin Hypersecreting Intraductal Papillary Neoplasm is a rare neoplasm that arises from ductal epithelial cells. This entity is distinct from the more commonly known Mucinous Cystadenoma or Mucinous Cystadenocarcinoma. Despite this distinction, it has been erroneously categorized with these more common cystic neoplasms. Characteristic clinical presentation, radiographic, and endoscopic findings help distinguish this neoplasm from the cystadenomas and cystadenocarcinomas. Histopathologic identification is not crucial to the preoperative diagnosis. This neoplasm is considered to represent a premalignant condition and, therefore, surgical resection is warranted. Prognosis, following resection, is felt to be curative for the majority of patients. We present two cases of Mucin Hypersecreting Intraductal Papillary Neoplasm and discuss their diagnosis and surgical therapy.
Asunto(s)
Adenocarcinoma Papilar/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Adenocarcinoma Papilar/cirugía , Anciano , Cistadenocarcinoma/diagnóstico , Cistoadenoma/diagnóstico , Diagnóstico Diferencial , Femenino , Humanos , Neoplasias Pancreáticas/cirugíaRESUMEN
A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6-10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11-52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5-12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60-330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.
Asunto(s)
Vértebras Lumbares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos , Fusión Vertebral/métodos , Adolescente , Adulto , Pérdida de Sangre Quirúrgica , Niño , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Dispositivos de Fijación Ortopédica , Complicaciones Posoperatorias , Espacio Retroperitoneal/cirugía , Estudios Retrospectivos , Fusión Vertebral/instrumentaciónRESUMEN
UNLABELLED: Instillation of 4 percent formalin effectively treats radiation hemorrhagic proctitis; however, little is known regarding its side effects. PURPOSE: The study contained herein was undertaken to determine rectal compliance and collagen content, mucosal and vascular histologic changes, and kinetics of formalin absorption following instillation. METHODS: Fifteen mongrel dogs (50-60 pounds) were randomized into five experimental groups according to time elapsed from formalin treatment: control, acute, one week, two weeks, and four weeks. Formalin was instilled in 30-ml aliquots to a total volume of 400 ml. Rectal compliance (closed manometry system) was assessed pre-formalin and post-formalin at the designated time interval. Serum formalin metabolites were determined at time 0, 0.5, 1, and 3 hours. A segment of rectal wall was analyzed for collagen content, mucosal injury, and blood vessel density. RESULTS: Serum formalin levels peaked within 30 minutes, returning to normal by 3 hours. With the exception of one dog, toxic levels were not reached at any time during the study. No dogs experienced sepsis, fever, or altered gastrointestinal function. Acute and one-week dogs showed mild diffuse proctitis and mucosal slough, which healed within two weeks. Rectal compliance and collagen content were unchanged. Mucosal blood vessels decreased in number early (P = 0.03). CONCLUSIONS: Instillation of 4 percent formalin in sequential aliquots of a small volume that is kept in contact for a short period of time is safe. Serum formalin levels generally do not reach toxic levels, and the slight elevation in formalin concentration that was seen returns to normal within three hours. Formalin-induced proctitis heals within two weeks, and no long-term changes in rectal compliance or collagen content were seen.
Asunto(s)
Formaldehído/toxicidad , Recto/efectos de los fármacos , Administración Rectal , Animales , Colágeno/análisis , Adaptabilidad , Perros , Formaldehído/sangre , Formaldehído/farmacocinética , Hemorragia Gastrointestinal/tratamiento farmacológico , Mucosa Intestinal/efectos de los fármacos , Mucosa Intestinal/fisiología , Manometría , Proctitis/inducido químicamente , Proctitis/tratamiento farmacológico , Traumatismos por Radiación/tratamiento farmacológico , Recto/metabolismo , Recto/patología , Recto/fisiologíaRESUMEN
Basal-cell carcinoma of the skin is a common facial neoplasm, usually regarded as benign. It is also called basalioma. Distant metastasis is very rare and may involve the brain, lung, and bones. We report a 74-year-old white male who was admitted to our hospital with cough and fever. Chest radiograph revealed an opacity of 2 x 1 cm in diameter in the upper lobe of the right lung. Bronchoscopy and thoracic fine-needle aspiration could not establish a diagnosis. Therefore the patient underwent right thoracotomy and wedge excision of the lesion. Histologic evaluation was consistent with pulmonary metastasis of a facial basal-cell carcinoma. The patient recovered uneventfully from surgery and is well 5 years after the operation. According to the English literature the median survival of patients with metastatic basal-cell carcinoma is 10 months. The clinical features, pathology, and treatment of this rare entity are discussed.
Asunto(s)
Carcinoma Basocelular/secundario , Neoplasias de Cabeza y Cuello/patología , Neoplasias Pulmonares/secundario , Anciano , Carcinoma Basocelular/cirugía , Humanos , Neoplasias Pulmonares/cirugía , Masculino , Neumonectomía , PronósticoRESUMEN
Formalin instillation has become an accepted treatment of radiation-induced hemorrhagic cystitis and proctitis since the initial report by Brown in 1969 (Med. J. Aust. 1:23, 1969). Although its use is widespread, no studies have been performed to determine the safest, volume or duration of formalin exposure. The purpose of our study was to determine the optimum technique for instillation and the safety margin regarding the maximum time that formalin can be in contact with the rectal mucosa without causing serum toxicity. In a pilot canine study, 4% neutral buffered formalin was instilled into the rectum in 30 ml aliquots for 60 seconds each after which each aliquot was withdrawn; a total volume of 400 ml was used. Our subsequent experiment involved rectal instillation of a single formalin bolus of 100 ml for 1 hour without removal during this time. Formalin metabolites were measured in the blood and urine to assess toxicity. Results indicate that with the latter technique serum formic acid reaches toxic levels within 15 minutes of instillation and may stay elevated for several hours. Metabolites in the urine similarly increase within 15 minutes, lagging only shortly behind the rise in serum levels. Performing formalin instillation in a series of 30 ml aliquots appears to be a safer treatment, as toxic serum levels were not reached and their slight rise above baseline returned to normal within 3 hours.
Asunto(s)
Formaldehído/farmacocinética , Recto/metabolismo , Administración Rectal , Animales , Modelos Animales de Enfermedad , Perros , Formaldehído/administración & dosificación , Mucosa Intestinal/metabolismo , Mucosa Intestinal/patología , Proyectos Piloto , Recto/patologíaRESUMEN
The purpose of this study was to determine the impact of intraoperative ultrasound (IOUS) on the management of patients with neoplasms of the liver. Fifty-nine patients with liver neoplasms (primary, 6; metastatic, 53) and without pre- or intraoperative evidence of extrahepatic disease underwent laparotomy for possible liver resection. Preoperative imaging studies included external ultrasound (n = 12), magnetic resonance imaging (n = 11), and/or computed tomography (n = 57). Intraoperative evaluation on all patients included inspection, bimanual palpation, and ultrasonography. External ultrasound, magnetic resonance imaging, and computed tomography identified all intraoperatively confirmed liver neoplasms in 33, 45, and 67 per cent of cases, respectively. Unsuspected neoplasms were identified in 12 patients (20%) by inspection/palpation and in 19 patients (32%) by IOUS. In eight patients (14%), the occult neoplasms were identified only IOUS, and in one patient the neoplasms were identified only by inspection/palpation. Occult neoplasms identified by IOUS were characterized by small size (less than 2 cm). Findings from the intraoperative evaluation, such as unsuspected neoplasms and vascular proximity or invasion, altered the preoperative plan in 20 (34%) patients. Inspection, and particularly palpation, identifies a number of preoperatively unsuspected liver neoplasms. Intraoperative ultrasound, however, is the most sensitive method for detection of liver neoplasms and influences the operative management in a substantial number of patients.
Asunto(s)
Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Colorrectales/diagnóstico por imagen , Neoplasias Colorrectales/patología , Hepatectomía , Humanos , Periodo Intraoperatorio , Laparotomía , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
One-hundred thirty-one primary hepatic resection for colorectal secondary tumors were performed at Rush-Presbyterian-St. Luke's Medical Center between 1975 and 1993. Perioperative mortality occurred in five patients (3.8%). Twenty-three patients had minor morbidities (18%); major morbidity occurred only in the five patients who died. Curative resections were performed in 107 patients. Overall actuarial survival at 2, 3, and 5 years was 62, 42, and 25 per cent, respectively. Patients with extrahepatic disease (5-year survival, 0% vs 27%; P = 0.049) and positive resection margins (0% vs 30%; P < 0.001) had significantly poorer survival. Among the curative resections, patients who had metachronous hepatic resections did significantly better than those who underwent synchronous colon and hepatic resections (35% vs 13%; P = 0.002). This survival benefit persisted when comparison was restricted to patients with synchronous metastases. Age, sex, race, number of lesions, site of colon primary resection, blood transfusion, disease-free interval, and extent of resection had no effect on survival. All patients who are acceptable surgical risks with potentially resectable metastatic colorectal cancer confined to the liver should undergo exploration. Assessment of resectability should include intraoperative ultrasound in all patients to maximize the probability of tumor clearance.
Asunto(s)
Neoplasias Colorrectales/patología , Hepatectomía , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/cirugía , Femenino , Humanos , Periodo Intraoperatorio , Neoplasias Hepáticas/diagnóstico por imagen , Neoplasias Hepáticas/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia , UltrasonografíaRESUMEN
BACKGROUND: While adding chemotherapy to radiation for the treatment of esophageal cancers has been shown to be beneficial, surgery usually follows treatment or is omitted. In either case, regional control remains problematic. The purpose of this study was to test the feasibility of using chemotherapy and radiation following surgery in the treatment of of esophageal cancer and to assess the impact of this approach on regional control and survival. PATIENTS AND METHODS: Twenty-five patients with esophageal cancer were treated in a phase I pilot protocol consisting of initial esophagectomy with gastroesophagostomy and subsequent combined chemotherapy and radiation. Chemotherapy consisted of cisplatin given on day 1 and 5-fluorouracil (FU) on days 1-5 by continuous infusion. Radiation therapy was administered in varying fractionation schedules of once or twice daily concomitantly with the chemotherapy. Treatment was repeated every other week for two to four cycles. Median follow-up was 42 months. RESULTS: Acute toxicities (mucositis and cytopenias) were common but not worse than grade 3. Higher doses of 50 Gy with 2 Gy b.i.d. hyperfractionation caused late complications in four of 10 patients, (two lethal). Control of local disease for all patients was excellent with only two known and two possible local recurrences (16%) but distant metastases were common (46%). Disease-free survival was 58 and 30% at 1 and 2 years, respectively. Survival was 58 and 32% at 1 and 2 years, respectively (median survival, 19 months). CONCLUSION: The local control rate and survival were better than those in our historical experience with cisplatin and 5-FU chemotherapy and radiation given prior to surgery. A dose-fractionation schedule of < 2 Gy up to a total of 50 Gy b.i.d. is recommended to avoid late adverse effects. The role of surgery will be defined by randomized studies. Better systemic therapy is needed to impact on systemic failure.
Asunto(s)
Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Neoplasias Esofágicas/terapia , Adenocarcinoma/cirugía , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/cirugía , Cisplatino/administración & dosificación , Terapia Combinada , Supervivencia sin Enfermedad , Neoplasias Esofágicas/cirugía , Esofagectomía , Estudios de Factibilidad , Femenino , Fluorouracilo/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Dosificación RadioterapéuticaRESUMEN
Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.
Asunto(s)
Neoplasias Colorrectales/patología , Hepatectomía/métodos , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Criocirugía , Humanos , Hígado/diagnóstico por imagen , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/mortalidad , Factores de Riesgo , Tasa de Supervivencia , UltrasonografíaRESUMEN
BACKGROUND: This is a retrospective clinical study done to examine survival of patients undergoing repeat hepatic resection for recurrent colorectal hepatic metastases. METHODS: The records of 131 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resection was performed in 107 of these patients. Thirty-one experienced recurrences confined to the liver. Thirteen (13 of 107, 12%) of them underwent resection and make up the study population. RESULTS: The eight men (62%) and five women (38%) had a median age of 60 years (range, 32 to 75 years). In 30% of patients recurrence developed near the original resection site. In 70% the recurrences were remote from the original site. The patients underwent a total of six wedge resections, two left lateral segmentectomies, three right lobectomies, and two trisegmentectomies. Average blood loss was 2995 cc; average hospital stay was 17.2 days. Morbidity was 23% (3 of 13); mortality was 8% (1 of 13). Four patients died of recurrent disease, with a mean disease-free survival of 9.7 months (median, 7.5 months; range, 3 to 21 months) and mean total survival of 39 months (median, 24 months; range, 8 to 99 months). One of these patients had a second recurrence resected at month 21 and lived an additional 78 months. Seven patients were alive with no evidence of disease, with a mean follow-up time of 34.9 months (median, 14 months; range, 1 to 186 months). Actual 5-year survival was 23% (3 of 13). Actual disease-free 5-year survival was 15% (2 of 13). CONCLUSIONS: In properly selected patients morbidity, mortality, and survival after repeat resection are similar to those after initial resection.
Asunto(s)
Neoplasias Colorrectales/mortalidad , Neoplasias Colorrectales/patología , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/cirugía , Adulto , Anciano , Pérdida de Sangre Quirúrgica , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Hepáticas/secundario , Masculino , Persona de Mediana Edad , Recurrencia , Reoperación , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
The short and long term outcomes of operative palliation for unresected ductal adenocarcinoma were evaluated in a critical review of 319 patients from 1972-1990. A total of 154 of 243 operated patients had palliative procedures, including biliary drainage in 86 per cent and combined biliary drainage and gastrojejunostomy in 53 per cent. Overall mortality rate was 13 per cent; one-half of the patients had some complication during their remaining lifetime. Biliary enteric anastomoses provided clinical relief of jaundice in 78 per cent of patients at hospital discharge; jaundice recurred in 16.7 per cent. The overall outcomes of choledochojejunostomy, cholecystojejunostomy, and choledochoduodenostomy were similar and superior to biliary intubation. Choledochojejunostomy was associated with a trend toward longer survival. Gastrojejunostomy did not affect overall results. However, upper gastrointestinal hemorrhage was more frequent when gastrojejunostomy was added to biliary bypass. Late duodenal obstruction developed in 6 per cent of patients initially treated by biliary drainage alone. Mean survival was 8.1 months; one-year survival was 18.2 per cent. Operative palliation for ductal cancer of the pancreas has important morbidity and mortality. Biliary enteric anastomoses provide lifelong relief of jaundice for most patients. Selective, rather than routine, gastrojejunostomy is recommended.
Asunto(s)
Adenocarcinoma/cirugía , Cuidados Paliativos , Neoplasias Pancreáticas/cirugía , Adenocarcinoma/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Gastrostomía , Humanos , Yeyunostomía , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/mortalidad , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
A 55-year-old man presented with an 11-year history of necrolytic migratory erythema and glossitis. After the patient's serum glucagon was demonstrated to be elevated, computed tomography scan revealed a mass involving the head of the pancreas. The patient underwent a Whipple-type pancreatico-duodenectomy and his rash resolved completely 6 days after tumor resection. He received no adjuvant treatment. A discussion of the varying theories regarding the pathogenesis and treatment of glucagon-associated necrolytic migratory erythema is presented.
Asunto(s)
Eritema/etiología , Glucagonoma/complicaciones , Neoplasias Pancreáticas/complicaciones , Eritema/patología , Glositis/etiología , Glucagonoma/patología , Glucagonoma/cirugía , Humanos , Masculino , Persona de Mediana Edad , Necrosis , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Piel/patologíaRESUMEN
PURPOSE: Our goal was to evaluate use of topical (4 percent) formalin in management of radiation-induced hemorrhagic proctitis, refractory to other methods of treatment. Specifically, we wished to determine its safety, ability to stop bleeding, and complications associated with therapy. METHODS: Sixteen patients with radiation-induced hemorrhagic proctitis were treated with topical (4 percent) formalin. All had been previously treated with conservative regimens such as cautery, topical steroids, or laser, but these had failed. Five-hundred milliliters (ml) of a 4 percent formalin solution was instilled into the rectum in 50-ml aliquots. Each aliquot was kept in contact with rectal mucosa for approximately 30 seconds. Treatments were performed under local anesthesia in nine patients, sedation only in four, spinal in two, and general in one patient. RESULTS: In 12 patients, bleeding stopped after a single formalin instillation; in 3, bleeding was considerably reduced but continued sporadically. One patient required three treatments before bleeding stopped. Four patients developed postoperative anal pain, of which one also had significant tenesmus and reduced capacity. Of these four patients, only two had significant anal pain and fissures that lasted longer than one month. CONCLUSIONS: Topical (4 percent) formalin is safe and effective in treatment of radiation-induced hemorrhagic proctitis. A single treatment will stop bleeding in 75 percent of patients.
Asunto(s)
Formaldehído/uso terapéutico , Hemorragia Gastrointestinal/etiología , Proctitis/tratamiento farmacológico , Traumatismos por Radiación/tratamiento farmacológico , Administración Rectal , Anciano , Anciano de 80 o más Años , Femenino , Formaldehído/administración & dosificación , Formaldehído/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Proctitis/complicaciones , Proctitis/etiología , Traumatismos por Radiación/complicaciones , Resultado del TratamientoRESUMEN
OBJECTIVE: To evaluate the effect of surgical approach and adjuvant therapy on patients with carcinoma of the esophagus and/or cardia. DESIGN: Retrospective analysis of 157 consecutive patients who underwent esophagectomy. SETTING: A private university medical center and its affiliated community hospital. PATIENTS: One hundred twenty men and 37 women (mean age, 61.7 years) with carcinoma of the esophagus and/or cardia that was surgically treated between 1978 and 1993. INTERVENTIONS: Three approaches were used for resection: Transhiatal esophagectomy (THE) (n = 67), transthoracic esophagectomy (TTE) (n = 71), and abdominal-only esophagectomy (AOE) (n = 19). Sixty-five patients received adjuvant radiotherapy and chemotherapy. MAIN OUTCOME MEASURES: Surgical mortality, morbidity, and survival and the effect of adjuvant therapy. RESULTS: The overall surgical mortality rate was 7.6%: 12.7% with the TTE, 4.5% with the THE, and 0% with the AOE approach. A significantly increased incidence of adult respiratory distress syndrome (P < .001) and empyema (P < .001) was seen with the TTE approach. The average intraoperative blood loss (P = .08) and the median intensive care unit stay (P = .26) and hospital stay (P = .40) were decreased with the THE and AOE approaches when compared with the TTE approach without significance. The overall median survival time was 17 months, with a 5-year survival rate of 21%. There was no significant difference in survival by pathologic stage between approaches. The addition of adjuvant therapy did not affect the overall median survival time or the 5-year survival rate. Node-positive patients did benefit from adjuvant radiotherapy and chemotherapy, with increased median survival times from 7 to 15 months and a 5-year survival rate from 0% to 15% (P = .01). CONCLUSIONS: The THE and AOE approaches have fewer early complications than does TTE. Both THE and TTE have equal long-term survival rates. Adjuvant therapy provides increased survival to node-positive patients with carcinoma of the esophagus and/or cardia.