Duane G. Hutson

Radical resection of periampullary tumors in the elderly: evaluation of long-term results.

Increasingly, patients of advanced age are coming for evaluation of periampullary tumors. Although several studies have demonstrated the safety of resecting periampullary tumors in older patients, few long-term survival data have been reported. Between 1983 and 1992 various periampullary masses were resected in 70 patients over age 65 (range 65–87 years). Total pancreatectomy was performed in 11 patients, and 59 patients underwent pancreaticoduodenectomy. The mean duration of hospitalization was 17 ± 15 days. Major complications occurred in 27 patients (39%), and operative mortality rate was 8.5%. Overall median survival was 24 months; and 5-year survival was 25%. Perioperative outcome was compared in patients aged 65 to 74 years and in patients ≥75 years old. The older age group required longer periods in the surgical intensive care unit postoperatively, but the long-term survival was similar in the two age groups. Radical resection with the intent to cure periampullary tumors is safe in selected patients of advanced age, and long-term survival is in the range of expected survival for younger patients with the same tumors.

The comparative survivals of alcoholics versus nonalcoholics after distal splenorenal shunt.

Survival after distal splenorenal shunt is appreciably better in nonalcoholic patients than in alcoholics. This increase in survival does not appear to be dependent upon the state of biochemical liver function or the severity of changes in liver histology since these latter were similar for both groups. We suggest that the poorer survival of alcoholics may be related to continuing alcohol toxicity, and that a possible reason for the failure to demonstrate this difference in survival after portacaval shunts may be due to the harmful effects of total portal diversion on the liver.

Balloon dilatation of biliary strictures through a choledochojejuno-cutaneous fistula

The problem of recurrent strictures following repair for bile duct injuries or in patients with sclerosing cholangitis is well recognized. For the most part, the recurrent problems have required repeated operations. The possibility of controlling the recurrent strictures by dilatation has been postulated, but repeated dilatations obviously require simple access to the entire biliary tree. We have found that stomatization of the afferent limb of a choledochojejunostomy or hepaticojejunostomy provides ready access to the biliary tree through which strictures can be readily traversed and dilated. Our early results with this procedure suggest that long-term patency can be expected following dilatation of these strictures.

Hemodynamic contrasts between selective and total portal-systemic decompression.

Hemodynamic Contrasts Between Selective and Total Portal-Systemic Decompression Atef Salam;W. Warren;James LePage;Manuel Viamonte;Duane Hutson;Robert Zeppa; Annals of Surgery

New techniques for interruption of gastroesophageal venous blood flow.

Enlarged gastroesophageal veins were successfully obliterated in 41 patients using embolization with modified autogenous clots and/or Gelfoam, balloon occlusion, iatrogenic perivenous hematoma, sclerosing agents (Sotradecol and Keflin), or a combination of these methods. Thirteen patients were actively bleeding when studied, and the site of bleeding was detected in 4. Surgical exploration of 16 patients and autopsy study of 5 showed persistent obliteration ranging between three weeks and seven months. No major complications requiring reparative surgery were encountered. Gelfoam soaked with Sotradecol is the preferred agent because it provides persistent obliteration of the embolized veins. Patients who are acutely bleeding or have done so previously are candidates for selective obliteration of the gastroesophageal veins.

The effect of the distal splenorenal shunt on hypersplenism.

Twenty-four patients with leukopenia and/or thrombocytopenia improved these deficiencies after distal splenorenal shunts. The average white blood cell count for 23 neutropenic patients increased by an average 1000 cells/cu.mm p less than .01. The average platelet count for 13 thrombocytopenic patients increased by more than 40,000, p less than .02. Analysis of the data showed that patients older than 50 years, with a history of alcoholic liver disease and sinusoidal hypertension greater than 15mm Hg were most likely to correct leukocyte and platelet defects after distal splenorenal shunts.

Percutaneous dilatation of biliary strictures through the afferent limb of a modified roux-en-y choledochojejunostomy or hepaticojejunostomy

BACKGROUND This report is a 13-year prospective evaluation of percutaneous balloon dilatation of benign biliary strictures through the subcutaneous or subfascially positioned afferent limb of a choledocho or hepaticojejunostomy in 30 patients. DATA SOURCE Twenty-seven strictures developed after a common duct injury sustained at the time of cholecystectomy, two after hepatectomy reconstruction for trauma and one following a gastrectomy. Twelve injuries (40%) were recognized at operation. Of the 18 patients where the injury was unrecognized at the time of operation, 8 had not been reoperated at the time of referral, 7 had late repairs by the referring physician, and 3 had late repairs at our institution. The follow-up is 1 to 13 years. RESULTS There has been 1 late death and 6 patients are lost alive. The jejunal-limb was accessed 50 times with two minor and no major complications. There have been two parajejunal hernia repairs, but there have not been any reoperations for recurrent biliary strictures. CONCLUSIONS Benign biliary strictures can be effectively managed by repeat balloon dilatations thru the afferent limb of a choledocho or hepaticojejunostomy, thus eliminating the need for repeat surgical interventions.

Percutaneous transhepatic cholangiography utilizing the Chiba University needle

Percutaneous transhepatic cholangiography with the Chiba University needle has been performed in 42 patients with cholestasis. The examination was successful in 100% of patients with dilated intrahepatic bile ducts and in 89% of those with normal-size ducts. Complications were minimal. The results of this study suggest that PTC with the Chiba needle is superior to the current conventional methods. The patients with intrahepatic cholestasis, which often simulates extrahepatic biliary obstruction, were spared an unnecessary laparotomy.

A longitudinal study of tryptophan involvement in hepatic coma

Previous cross-sectional studies have demonstrated that hepatic coma is associated with abnormally high levels of plasma free tryptophan. Establishment of a more definitive relationship between this biochemical abnormality and hepatic coma requires an evaluation of biochemical changes in individual patients as they undergo alterations in the function of their central nervous systems. The present report is an evaluation of tryptophan and substances believed to influence its entry into the brain in six patients whose clinical status progressed from hepatic coma to complete recovery. Consistent significant decreases in plasma free tryptophan and free fatty acids were demonsrated to occur as the patients recovered. No consistent changes, however, were found in the plasma levels of the amino acids which have been reported to compete with tryptophan for transport across the blood-brain barrier, except for leucine which was significantly decreased in all six patients upon recovery from coma. Assay of lumbar cerebrospinal fluid for both tryptophan and the serotonin metabolite, 5-hydroxyindoleacetic acid (5-HIAA), showed no consistent changes as the patients recovered from hepatic coma.

The fate of esophageal varices following selective distal splenorenal shunt.

Esophagographic evaluation of the fate of esophageal varices after distal splenorenal shunt was obtained. The radiologistobserver was blinded as to the surgical status of the films under study. The results indicate that varices are likely to persist after surgery. However, the sizes of the varices are clearly diminished following selective distal splenorenal shunt. The incidence of post-operative bleeding has been low, 3.7% (2/54) or one episode for each 441 months of postoperative survival.