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BACKGROUND: While elective lymph node dissection (ELND), adjuvant radiation therapy and sentinel lymph node biopsy have all been advocated in the routine management of primary cutaneous melanoma arising in the head and neck, the optimal management has not been defined. METHODS: We have reviewed our experience of 273 patients with primary melanoma of the head and neck entered into a prospective database at the University of Colorado Health Sciences Center (UCHSC) from 1978 through 1998 and contrasted this with other reports in the literature. RESULTS: A total of 168 patients were identified that received their initial management at UCHSC and had no clinical evidence of distant disease. Only nine patients (5%) underwent ELND, and no patients received adjuvant radiation therapy. The local recurrence rate and 5-year melanoma specific survival, according to Breslow thickness, were similar to centers where adjuvant radiation therapy or ELND are routinely performed. Our preliminary experience and a review of the literature suggests that the technique of sentinel lymph node biopsy is an accurate and low risk procedure that provides valuable prognostic information useful in the further management of these patients. CONCLUSIONS: There is no clear indication that either ELND or adjuvant radiation therapy impacts on the outcome of patients with primary melanoma of the head and neck. Sentinel lymph node biopsy, in appropriate cases, is becoming the standard of care.

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BACKGROUND: Routine endocrine screening of idiopathic gynecomastia has been advocated, but may not be cost effective. We carried out a cost-benefit analysis of this approach. METHODS: A retrospective study (1992 to 1997) of 87 adult males with symptomatic gynecomastia was performed. RESULTS: Thirty-four (39%) patients had extrinsic causes; 53 (61%) were considered idiopathic. Forty-five idiopathic cases underwent endocrine testing: beta human chorionic gonadotropin alone, 16; and beta human chorionic gonadotropin, LH, estradiol, testosterone+/-testicular ultrasound, 29. One (2%) occult Leydig cell testicular tumor was detected. Forty-four patients had normal studies and remain well after local excision. CONCLUSION: Routine endocrine evaluation of idiopathic gynecomastia is rarely productive; such testing is best done selectively.

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BACKGROUND: The incidence of intrathyroidal parathyroid glands remains controversial. The purpose of this study was to determine the incidence in a series of patients with hyperparathyroidism. METHODS: Three hundred nine patients underwent parathyroidectomy. Patients were divided into two groups: uniglandular disease versus hyperplasia. RESULTS: Eighteen of 309 patients (6%) had abnormal intrathyroidal parathyroid glands. The incidence was 3% (7 of 222) in patients with uniglandular disease versus 15% (11 of 73) in those with hyperplasia. With a mean follow-up of 54 months, 12 patients are eucalcemic, 5 have persistent hypocalcemia, and 1 has recurrent hypercalcemia. There were no recurrent laryngeal nerve injuries. CONCLUSIONS: These data suggest that an intrathyroidal adenoma is an uncommon cause of failure, whereas abnormal intrathyroidal parathyroid tissue may be a more common cause of failure in patients with hyperplasia.

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BACKGROUND: Exposure for open cholecystectomy entails lateral, caudal traction on the gallbladder infundibulum, which results in opening the angle between the cystic and hepatic ducts. Laparoscopic cholecystectomy (LC), as initially described, is done with cephalad traction on the gallbladder. We hypothesized LC exposure technique narrows the angle between the cystic and hepatic ducts, placing them at increased risk of injury. METHODS: Twenty-three patients had routine LC. Cystic duct cholangiography (IOC) was done with a flexible 5-Fr catheter via a percutaneous introducer placed anterior to the gallbladder. Exposure of Calot's triangle was maintained with cephalad traction on the gallbladder fundus. IOC was repeated after allowing the organ to assume the anatomic position. The cholangiograms were inspected for significant differences, and the angle of the cystic to the hepatic duct (CDHD) was measured by a blinded radiologist. RESULTS: The mean angle of the cystic to hepatic duct was 30 degrees +/- 19 degrees in the IOCs taken with cephalad traction on the gallbladder fundus vs 59 degrees +/- 22 degrees, P < 0.001, in the cholangiograms taken without traction. A filling defect at the cystic-hepatic duct junction was present in 39% of IOC taken with traction vs none without traction. The intrahepatic ducts were seen in all films without traction, whereas the intrahepatic ducts were not visualized in 13% of IOCs taken with traction. CONCLUSIONS: From these data we conclude (1) extra-hepatic biliary ducts may be at increased risk of injury during LC because of the exposure technique and (2) imaging bile ducts in the anatomic position may convey misleading information about the relative location of important structures. Optimal exposure for dissection of Calot's triangle should utilize a second clamp on the infundibulum with lateral, caudal traction.

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BACKGROUND: Standard ilioinguinal node dissection for melanoma has substantial cost and morbidity. Beginning in 1988, we modified the procedure in hopes of reducing side effects without compromising survival. PATIENTS AND METHODS: Dissection was standard except for preservation of saphenous vein and femoral sheath and omission of sartorius muscle transfer. To date, 19 patients with recurrent melanoma in the groin have had the procedure, 6 for N1 disease and 13 for N2, M1 metastases. RESULTS: Average hospital stay was 4.5 days (range 3 to 7). Postoperative edema occurred in 1 (5%) patient. Disease-free survival at 40 months was 66% for N1 disease and 26% for N2, M1 metastases. CONCLUSION: Modified ilioinguinal node dissection appears to reduce cost and morbidity of treating recurrent melanoma in the groin without compromising survival.

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Ultrasonography has many clinical applications and can be done with both extra- and intracorporeal techniques. Miniaturization of ultrasound transducers has opened the way for intracorporeal use of ultrasound at laparoscopy. The principles of ultrasonography are presented. Laparoscopic intracorporeal ultrasound (LICU) has proven to be useful in the differential diagnosis of liver tumours. In one series, 75 of 85 patients had positive identification of a suspected liver tumour with laparoscopic ultrasound examination. LICU has also been useful for delineation of hepatobiliary anatomy during laparoscopic cholecystectomy in both animal models and patients having cholecystectomy. LICU may detect useful anatomic information prior to dissection of the cystic duct and is accurate in detecting common bile duct stones. LICU may also be useful in the preoperative staging of pancreatic malignancy. Laparoscopic intracorporeal ultrasound may find practical application in other areas as experience evolves.

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The purpose of this study was to compare laparoscopic intracorporeal ultrasound (LICU) examination of the biliary duct system with cholangiography for delineation of duct anatomy and determination of presence or absence of ductal calculi. Thirty-one patients had LICU examination of the extrahepatic bile ducts after exposure of the gallbladder but prior to dissection of the cystic duct. After LICU examination, cystic duct dissection and cholangiography were done. Evaluation of duct anatomy and decision for duct exploration were based on findings of both tests. All patients had successful LICU examination and 30 had successful cholangiography. Duct size as determined by LICU corresponded precisely with cholangiography. LICU provided useful anatomical information in two patients with aberrant anatomy and detected cholangiogram. LICU aids in delineation of biliary duct anatomy and accurately determines presence or absence of duct calculi.

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Late recurrence of malignant melanoma is uncommon but appears to be a growing problem. It is unclear whether late recurrence has a better prognosis than early recurrence. Since the answer may influence treatment, we compared recurrence sites and subsequent survival in 35 patients with disease-free intervals of 72 to 240 months (median: 127 months) with 35 case-controls who had relapse at 4 to 56 months (median: 26.7 months). The distribution of recurrence sites in early relapse was 66% in regional nodes or soft tissue and 34% in distant soft tissue or viscera. In late relapse, this distribution was 49% in regional nodes or soft tissue and 51% in distant soft tissue or viscera (no significant differences). Median survival for patients with early and late recurrences in regional nodes or soft tissue was 26 and 44 months, respectively (no significant differences); 5-year survival was 27% and 33%, respectively (no significant differences). Median survival was similar for early or late relapse in distant soft tissue or viscera (8 and 10 months, respectively), as was 5-year survival (0% and 6%, respectively). These results suggest that the metastatic pattern and survival after recurrence are similar for patients with early and late recurring melanoma.

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We used polymerase chain reaction DNA amplification methods for the detection and typing of genital human papillomaviruses in paraffin-embedded tissue sections of five patients with anorectal squamous cell carcinoma and 22 patients with colonic adenocarcinoma. The cases were further tested by in situ hybridization with biotin-labeled probes specific for human papillomavirus types 6/11, 16/18, and 31/33/35. By polymerase chain reaction, human papillomavirus DNA was demonstrated in all of the cases of anorectal squamous cell carcinoma and in none of the cases of colonic adenocarcinoma for which analyzable DNA was available. Tumor cell nuclei stained for human papillomavirus DNA by in situ hybridization in four of the five cases of squamous cell carcinoma and in none of the cases of colonic adenocarcinoma. We conclude that human papillomavirus types usually associated with malignant transformation are uniformly present in anorectal squamous cell carcinoma but are absent from adenocarcinoma of the colon.

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Thirty-four patients with suspected common bile duct stones were randomized to undergo endoscopic cholangiography and stone removal prior to open cholecystectomy or to have open cholecystectomy, operative cholangiography, and common bile duct exploration. Sixteen underwent the first protocol, and 18 the second. Analysis of the ability to clear stones from the common bile duct, morbidity, mortality, hospital stay, length of operation, and hospital cost showed no difference in outcome between patients treated by either method. These data suggest there is neither an advantage nor a disadvantage to treating patients with suspected duct stones by precholecystectomy endoscopic cholangiography and stone removal.

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Carbon dioxide laser incisions are reported to be less painful, less bloody, and less prone to seroma formation and to heal better than scalpel or electrosurgical incisions. We compared all three modalities in a prospective randomized study of cholecystectomy incisions. Time required for the incision and incisional blood loss was less with electrosurgery than with the carbon dioxide laser or scalpel. Postoperative pain and wound healing, however, were the same for all three techniques. The carbon dioxide laser appears to offer no advantage over conventional means of making a standard incision.

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Duodenal perforation resulting from endoscopic sphincterotomy (ES) is a serious complication with a high mortality. Diagnosis is often problematic and the optimum treatment is controversial. Eight proven perforations occurred following 441 ES at University of Colorado Hospital, a rate of 1.8 per cent. Physical and laboratory findings were of little diagnostic value, whereas plain abdominal radiographs showed evidence of perforation in 86 per cent. All patients were operated on promptly after diagnosis of perforation. Delay in diagnosis of perforation beyond 24 hours in six patients was associated with a high morbidity and two deaths. Analysis of published series confirmed that delay in diagnosis and delay in operation after perforation were associated with a higher mortality rate than early diagnosis with or without operation. We recommend operative intervention in all patients with clinical evidence of perforation following ES.

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Pelvic exenteration has a high complication rate due, in large part, to the extensive raw surfaces and dead space it creates. Numerous techniques have been used to control this space and line these surfaces, but none, to date, has proven to be a reliable solution. We investigated the use of continent ileocolonic urinary reservoirs as a new "flap" to fill and line the pelvis in 17 patients, and found that our historical complication rate of 44% for pelvic exenteration was reduced to 18%. These reservoirs appear to be an improved method of managing the post-exenteration pelvis.

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Survival of ovarian adenocarcinoma patients depends on the size of the largest residual nodule at the end of debulking surgery. The argon beam coagulator (ABC) delivers radiofrequency current traveling in a beam of argon gas which facilitates tumor destruction and hemostasis. We used the ABC as an aid to cytoreduction in seven consecutive patients with stage III/IV ovarian cancer. Despite extensive disease, optimal debulking was achieved in all seven patients: four (57%) had no gross residual cancer; three had residual nodules of 2-3 mm. The ABC facilitated tumor destruction on the diaphragm, bowel wall and mesentery, presacral space, ureters, vagina, and iliac vessels. In addition, the ABC was used to "sterilize" surgical margins such as the vaginal cuff and rectosigmoid colon anastomoses. Five patients are currently alive, four disease free, with mean survival of 33 months since diagnosis. The ABC enables debulking of ovarian cancer in sites inaccessible to conventional resection.

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This study compared operative gastrostomy (OG) (by surgeons) with endoscopic gastrostomy (PEG) (by physicians) in a prospective randomized fashion to determine whether one technique was superior. PEG (Sachs-Vine) and OG (Stamm) were done using local anesthesia. Patients were assessed for complications, mortality, tube function, and cost. Groups were equally matched for indications and underlying disease. Fifty-seven had OG and 64 had attempted PEG. Complications occurred in 26% of OG patients and 9% died. Complications occurred in 25% of PEG patients and 12% died. Tube feeding was initiated in both groups within a mean of 29 (24 to 72) hours of the gastrostomy placement. OG cost $1675 and PEG $979 to perform. Twenty-one PEG patients required endoscopic tube change which raised their total cost to $1574. We conclude there is no difference between OG (using local anesthesia) and PEG with regard to morbidity, mortality, or tube function. The endoscopic technique does appear to have economic advantage.

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Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85,526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.

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Between 1980 and 1987, we operated on 23 patients (16 men and 7 women) with fixed rectal cancer. Two patients had primary tumours. Twenty-one patients had recurrent disease (anterior resection, 8; abdominoperineal resection, 13). Eighteen patients had prior irradiation (40 Gy to 120 Gy). Resection was possible in 20 patients (16 for cure and 4 for palliation). Operations included extended proctectomy (n = 4), standard pelvic exenteration (n = 4), and sacropelvic exenteration (n = 12). One (5%) patient died postoperatively and five (25%) others had significant postoperative complications. With a follow-up time of 1 to 48+ months (median, 18 months), nine patients are dead of disease (operative death included), four are living with disease, two are dead free of disease, and eight (50% of those undergoing curative resection) are living free of disease. The results suggest that resection of fixed rectal cancer is feasible in many patients and of potential long-term benefit to approximately 50% of those in whom curative resection is possible.

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