Donald C. McIlrath

Surgical management of intussusception in the adult.

Controversy concerning the appropriate surgical management of intussusception in the adult prompted review of the Mayo Clinics experience with this uncommon entity. During the last 23 years, 48 patients had documented intussusception: 24 instances of intussusception originating in the small intestine and 24 instances of intussusception originating in the colon. Two-thirds of the colonic intussusceptions were associated with primary carcinoma of the colon. Only one-third of the intussusceptions of the small intestine were harbingers of malignancy, and 70% of these lesions were metastatic. Because of these findings, we advocate resection of intussusceptions of the colon without initial surgical reduction, in order to minimize the operative manipulation of a potential malignancy. In the patient with intussusception of the small intestine, an associated primary malignancy is uncommon. Initial reduction, followed by limited surgical resection, is the preferred treatment. Surgical resection without reduction is favored only when an underlying primary malignancy is clinically suspected.

External beam versus intraoperative and external beam irradiation for locally advanced pancreatic cancer

One hundred fifty‐nine patients with unresectable but localized pancreatic cancer, as defined at exploratory laparotomy, were treated at the Mayo Clinic between February 1974 to April 1985. Postoperative therapy consisted of 4000 to 6000 cGy external beam irradiation (XRT) alone in 122 patients or 4500 to 5500 cGy XRT in combination with an intraoperative electron boost in 37. In addition, 132 (both groups) received 5‐fluorouracil (5‐FU) chemotherapy. Local control (LC) at 1 year was 82% with XRT + intraoperative radiation therapy (IORT) versus 48% with XRT and 66% versus 20% at 2 years respectively (P < 0.0005). Due to the high incidence of hematogenous and/or peritoneal spread in both groups (abdominal failure in 54 and 56% of patients at risk), the decreased frequency of local progression did not translate into an improved survival. Neither median nor long‐term survival of the two treatment groups (XRT versus XRT + IORT) was statistically different (median 12.6 months versus 13.4 months, P = 0.25). With tumor arising in the head of the pancreas, survival at 2 years was 18% as opposed to 0% for other locations (P < 0.01). On the basis of a Cox multivariate analysis, no other treatment or prognostic factor significantly altered survival. Until the problem with systemic failure (usually abdominal) can be resolved, the median and long‐term survival of patients with pancreatic carcinoma is likely to remain unchanged. Since IORT appears to improve local control, we will continue to utilize IORT in phase 1,2 studies which also attempt to decrease the incidence of abdominal failures. Even with IORT + XRT combinations, the incidence of local progression is excessive and radiation dose modifiers need to be evaluated.

Bowel perforation in steroid-treated patients.

Gastrointestinal perforation in patients receiving glucocorticosteroid (GCS) therapy has been reported to have mortality rates as high as 100%. From 79 patients seen during a nine-year period, three groups were formed according to GCS dosage: group 1 (steroid perioperative coverage), group 2 (low-dose steroids, prednisone < 20 mg daily), and group 3 (high-dose steroids, prednisone ≥ 20 mg daily). Of 11 clinical presentation factors, only abdominal tenderness was consistently present in group 3. The mean delay from onset of symptoms to treatment for group 3 was 8.3 days and was in marked contrast to that for group 1 or 2, 1.7 and 2.2 days, respectively (p < 0.005). Mortality increased from 11.8% in group 1 to 13.3% in group 2 to 85% in group 3. High-dose GCS therapy decreased the clinical expression of peritonitis to the point that recognition and, therefore, treatment of gastrointestinal perforation were markedly delayed. In a patient receiving high-dose GCS, a high degree of clinical suspicion must accompany any new abdominal discomfort, and aggressive diagnostic efforts should be made to establish the cause. If abdominal pain persists, surgical exploration should be considered.

High-dose preoperative external beam and intraoperative irradiation for locally advanced pancreatic cancer

PURPOSE To analyze results of high-dose preoperative external beam irradiation followed by surgical exploration and intraoperative radiation therapy in patients with unresectable pancreatic cancer. METHODS AND MATERIALS From December 1983 through December 1990, 27 patients with primary unresectable but localized pancreatic adenocarcinoma received high-dose (50 to 54 Gy) external beam irradiation with or without concomitant bolus 5-fluorouracil followed by surgical exploration and intraoperative electron beam irradiation (20 Gy) at the Mayo Clinic. RESULTS Local control was achieved in 21 of 27 (78%) patients. Actuarial local control at 1, 2, and 5 years was 86%, 68%, and 45%, respectively. In 19 (70%) of the 27 patients, distant metastasis developed, and peritoneal or liver progression (or both) was found in 14 (52%). The actuarial distant metastasis rate at 2 and 5 years was 69% and 83%, respectively. Median survival from the date of diagnosis was 14.9 months. Actuarial 2- and 5-year overall survival was 27% and 7%, respectively. These survival rates are higher (p = 0.001) than the 6% and 0% actuarial 2- and 5-year survival observed in 56 patients who underwent intraoperative radiation therapy followed by postoperative high-dose external beam treatment at our institution. CONCLUSION Administering the full component of external beam irradiation before exploration and intraoperative radiation therapy may be more appropriate because it allows better patient selection. Unfortunately, altered patient selection was not effective in decreasing the relative risk of abdominal failure. Because effective systemic chemotherapy does not currently exist, whole abdominal irradiation alone or in combination with chemotherapy warrants evaluation.

Total gastrectomy for advanced cancer. A worthwhile palliative procedure

Subtotal gastric resection usually provides the best palliation in advanced gastric cancer; however, if total gastrectomy (TG) is required there is doubt about its benefit. The authors reviewed 53 consecutive patients undergoing TG for advanced gastric adenocarcinoma between 1980 and 1989. Indications for TG were tumor location in 30% and extent of tumor in 70%, including nine patients (17%) with linitis plastica. Four patients (8%) died postoperatively, and six patients required reoperation for postoperative complications. The median postoperative hospital stay was 13 days. The median survival was 19 months, and 13 patients (24%) lived for more than 2 years. The quality of life was graded in survivors as good in 59%, satisfactory in 28%, and poor in 13% of patients. It was concluded that TG is a worthwhile procedure for selected patients, even in the presence of advanced disease, providing prolongation of good quality of life with low morbidity and mortality.

Spectrum and management of major complications of laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the most prevalent method of treating uncomplicated, symptomatic cholelithiasis in the United States and elsewhere. As experience with this procedure grows, certain pitfalls are becoming apparent. Since October 1990, we have treated 22 patients for major injuries incurred during laparoscopic cholecystectomy, including 15 women and 7 men (range: 23 to 85 years). One patient had previous upper abdominal surgery; no other patient had any relative contraindication to laparoscopic surgery. The most frequent site of injury (19 patients) was the extrahepatic biliary tract. There was one fatal duodenal perforation. All but two patients whose injuries went unrecognized at laparoscopy were symptomatic during the immediate postoperative period. The biliary injuries included complete transection of the common hepatic or common bile duct in 10 patients, complete ductal occlusion in 3, a cystic duct stump leak in 2, and a partially retained gallbladder with a contained intraperitoneal bile leak in 2. The site and extent of biliary injuries were delineated with transhepatic or endoscopic retrograde cholangiography. Reconstruction or repair of the biliary tract was accomplished with Roux-en-Y hepaticojejunostomy or cholangiojejunostomy in 11 and 1 patients, respectively, completion cholecystectomy in 2, and temporary transhepatic stenting, primary choledochocholedochostomy, and primary choledochorrhaphy over a T-tube in 1 patient each. One patient with a cystic duct stump leak was managed successfully with endoscopic sphincterotomy, whereas another required operative ligation. Laparoscopic injuries during cholecystectomy can lead to serious morbidity and mortality, thus emphasizing the need for adequate training and credentialing for surgeons and for a heightened clinical awareness of the potential complications, their long-term sequelae, and how to avoid them.

Analysis of failure following curative irradiation of gallbladder and extrahepatic bile duct carcinoma

Twenty patients with carcinoma of the gallbladder (GB-4 patients) or extrahepatic bile ducts (EHBD-16 patients) received radiation therapy with curative intent between January, 1980 and December, 1982. All 20 received 4500-5000 rad in 180-200 rad fractions to the tumor and regional lymph nodes. A 1000 to 1500 rad external beam boost was delivered in 180-200 rad fractions in 10 patients who received external beam alone or concomitant 5-Fluorouracil (5-FU). Three of the four GB and 5 of the 16 EHBD patients received a transcatheter boost with 192-Iridium (192Ir) to a dose of 2000-2500 rad calculated at a 0.5-0.1 cm radius. An additional 2 patients with EHBD lesions received an intraoperative electron (IORT) boost of 1500-2000 rad in one fraction calculated to the 90% isodose. Survival and patterns of failure were analyzed by site and treatment method. All four patients with GB carcinoma are dead of disease at 5 1/2, 6, 9 and 10 months from the date of diagnosis respectively. Three of the four developed diffuse peritoneal carcinomatosis. Five of the 16 patients with EHBD carcinoma are alive with a median follow-up of 18 months (range 6-23 months). Four of the 5 patients received a transcatheter 192Ir or IORT boost and all are without evidence of disease. Four of 9 patients who had a subtotal resection with transection of tumor, dilatation of the bile ducts with probes or curettement of the bile ducts developed either diffuse peritoneal carcinomatosis (3 patients) or a recurrence in the surgical scar (2 patients). Local failure was documented in 3 of the nine patients treated with external beam alone +/- 5-FU, and has been documented in one of the seven patients who received an IORT or transcatheter 192Ir boost. Further experience is necessary to determine whether this aggressive treatment will result in long-term disease-free survival in these patients.

External beam and intraoperative electron irradiation for locally advanced soft tissue sarcomas

PURPOSE Intraoperative irradiation with electrons was used in conjunction with external beam irradiation and maximal surgical resection in 20 patients with locally advanced soft tissue sarcomas or desmoids. This manuscript presents results with regard to tolerance of treatment and its impact on tumor control and survival. METHODS AND MATERIALS Ten patients presented with previously untreated primary sarcomas and 10 at the time of local recurrence (two had recurrent desmoid tumors). Tumor location was retroperitoneal in 19 and in the low anterior neck in one. A partial or gross total resection was performed prior to the external beam or intraoperative component of irradiation in every patient, but all had positive resection margins. Patients received 4500-6000 cGy of fractionated, external beam irradiation and an IORT dose of 1000-2000 cGy. Chemotherapy was given only at the time of disease progression. RESULTS Fourteen of 20 patients (70%) were alive; 11 (55%) were free of disease (4/10 primary, 7/10 recurrent), but 1 required hemipelvectomy for salvage. Progression within the intraoperative irradiation field was documented in only 1 patient (5%) and within the external beam field in 3/20 (15%). Blood born distant metastasis occurred in 5 patients (25%) and peritoneal seeding in 1 (5%). The distant failure incidence by grade was 1/8 (13%) for Grades 1, 2 and 5/12 (42%) for Grades 3, 4. Only 1 patient (5%) developed a > or = severe neuropathy, and small bowel obstruction requiring exploration also occurred in a single patient. CONCLUSION In view of acceptable tolerance and the high current rate of local tumor control, in spite of incomplete surgical resections, further evaluation of intraoperative irradiation as a component of treatment is indicated for locally advanced primary and recurrent soft tissue sarcomas.

Analysis of failure after curative irradiation of extrahepatic bile duct carcinoma

Thirty-four patients with subtotally resected or unresectable carcinoma of the extrahepatic bile ducts received radiation therapy; a minimum of 45 Gy (external beam) to the tumor and regional lymph nodes ± 5-fluorouracil (5-FU). Seventeen patients received an external beam boost of 5 to 15 Gy to the tumor, and a specialized boost was used in the remaining 17 patients (iridium-192 transcatheter seeds in 10 and intraoperative radiation therapy [IORTJ with electrons in seven). The median time to death in all 34 patients was 12 months (range, 4 to 98 months). The only patients who survived longer than 18 months were those either with gross total or subtotal resection before external irradiation (2 of 6) or who received specialized boosts (192Ir, 3 of 10; IORT, 3 of 7). Local failure was documented in 9 of 17 patients who received external beam irradiation alone ± 5-FU, 3 of 10 patients who received an 192Ir boost, and 2 of 6 patients who received an IORT boost with curative intent.

Scrotal Reconstruction for Giant Inguinal Hernias

Giant inguinal hernias require special consideration for repair of the abdominal wall. The associated greatly thickened, enlarged scrotum should be discarded and a neoscrotum should be reconstructed from the uninvolved perineal-scrotal skin. A cloverleaf design flap is used for this reconstruction.