Fang-Ku P'eng

PROSPECTIVE COMPARISON OF DIAGNOSTIC PERITONEAL LAVAGE, COMPUTED TOMOGRAPHIC SCANNING, AND ULTRASONOGRAPHY FOR THE DIAGNOSIS OF BLUNT ABDOMINAL TRAUMA

From January through December 1990, a prospective study comparing the accuracy of diagnostic peritoneal lavage (DPL), abdominal computed tomographic (CT) scanning, and abdominal ultrasonographic (US) scanning was carried out. Patients with stable vital signs following their initial resuscitation coupled with equivocal physical examination findings received both CT and US scanning. A DPL was then done. If any of these three examinations produced positive findings, a laparotomy was done and the surgical findings were compared with the results of the diagnostic studies. Fifty-five patients were studied (44 men, 11 women), with a mean age of 43 years and a mean ISS of 18.5 +/- 10.5. The sensitivity, specificity, and accuracy were 100%, 84.2%, and 94.5% for DPL, 97.2%, 94.7%, and 96.4% for CT scanning, and 91.7%, 94.7%, and 92.7% for US scanning. Problems do exist in identifying isolated small intestinal perforations with ultrasonography. Since more and more trauma centers are using ultrasonography in the emergency department as a screening method in the management of patients with blunt abdominal trauma, it is important to avoid overestimating its capability. Frequent re-evaluation of the patients condition, repeat ultrasonographic scans, diagnostic peritoneal lavage, and CT scanning are complementary and important in the diagnosis of blunt abdominal trauma.

Factors Influencing Postoperative Morbidity, Mortality, and Survival After Resection for Hilar Cholangiocarcinoma

UNLABELLED OBJECTIVE; Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patients survival also were re-evaluated. SUMMARY BACKGROUND DATA Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis. METHODS The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival. RESULTS There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that co-existent hepatolithiasis and lower serum asparate aminotransferase levels (<90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin > or = 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin > or = 10 mg/dL, curative resection, and histologic type as the three most significant independent variables. CONCLUSIONS Surgical resection provides the best survival for hilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3 g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well-differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.

Surgical mortality, survival, and quality of life after resection for gastric cancer in the elderly.

Abstract. Although there were some studies on clinicopathologic characteristics, operative morbidity, and mortality in elderly patients with gastric cancer, no reports have specifically focused on survival and quality of life after resection. A total of 433 patients aged ≥ 65 years (1987–1994) who underwent gastric resection for gastric adenocarcinoma were studied. Two groups were considered: patients aged 65 to 74 years and those > 74 years. Most of the patients (78.1%) had advanced diseases, and nearly half (41.3%) had associated chronic disease(s). Resections with curative intention were performed in 362 patients (83.6%). The overall operative morbidity rate was 21.7% and mortality rate 5.1%. Although operative procedures were similar in both groups, patients aged >74 years had a higher mortality rate than those aged 65 to 74 years (10.1% vs. 3.5%; p= 0.034). Age and extent of gastric resection were two independent factors negatively affecting mortality. The cumulative survival rates for patients who underwent curative resection were 86.2%, 72.4%, 67.2%, 62.9%, and 60.0% at 1, 2, 3, 4, and 5 years, respectively. Nearly all patients (96%) after surgery had normal work and daily activities. Some patients appeared to lack energy (16%) or experienced a period of anxiety or depression. There was no statistical difference in survival and quality of life assessed by the Spitzer index after curative resection between the two groups. Therefore resection with curative intention can be performed for the elderly with acceptable morbidity and mortality rates, possible long-term survival, and good quality of life, but a limited operation should be considered in the very elderly patients.

Relative prevalence of gallstone diseases in Taiwan : a nationwide cooperative study

For many years, it has been said that Taiwan has the highest relative prevalence of hepatolithiasis among the Asian countries. To confirm this, and to reevaluate the chronological changes regarding gallstone disease in Taiwan, a retrospective nationwide cooperative study was conducted in this country. A total of 17,182 patients from 28 medical centers are included in this survey. A gradual increase during the past 20 years in gallstone prevalence with a concomitant decrease of choledocholithiasis and hepatolithiasis are well demonstrated. Both nutritional and environmental factors are involved in these changes. With respect to hepatolithiasis, Taiwan continues to have the highest prevalence among Asian countries, and 20% may be the average figure for the whole country.

Relation of number of positive lymph nodes to the prognosis of patients with primary gastric adenocarcinoma.

BACKGROUND--No nodal grouping category of gastric cancer has been universally accepted for the grading of the effectiveness of therapeutic regimens. AIMS--To establish an appropriate nodal grouping as a forecaster of distant disease and test its validity as a determinant in survival. PATIENTS--Five hundred and ten patients who underwent curative resections for gastric cancer were studied. METHODS--Retrospectively analyse the prognostic significance of the number of metastatic lymph nodes. RESULTS--A total of 17 176 lymph nodes with an average of 34 per specimen were removed, of which 2811 (16%) showed metastases. Among the 510 patients, 287 (56%) had lymph node metastases, with an average of 9.8 per metastatic case. The survival of all patients was related to their nodal status, an abrupt decrease in survival was seen between 0 and 1 and 4 compared with 5 or more modes while little difference in survival existed among 1, 2, 3, and 4, and among 5, 6, 7, and 8 positive nodes. Multivariate analysis showed that the number of positive nodes (1-4, 5-8 versus > or = 9; relative risk 2.2) and depth of cancer invasion (three levels; relative risk 1.9) were independently correlated with survival. The current nodal stage was not a prognostic factor. CONCLUSIONS--Gastric cancer patients with 0, 1 to 4, 5 to 8, and > 9 positive nodes may represent four appropriate prognostic groups and should be adopted for classification of nodal stage in gastric cancer.

Quality of Life of Patients with Gastric Adenocarcinoma after Curative Gastrectomy

Abstract. Quality of life (QOL) was evaluated in 162 patients having radical gastrectomy for cancer. The results showed that more than half of the patients had a good appetite; they consumed a normal diet and a normal volume of food. Approximately 60% of the patients had weight loss of more than 5 kg. Patients who underwent a total gastrectomy had poor tolerance of normal food and frequent eating and body weight loss versus those who had a subtotal gastrectomy. Patients who underwent Billroth II reconstruction after a distal subtotal gastrectomy lost more body weight than those with a Billroth I anastomosis. The extent of lymphadenectomy did not influence the QOL. Patients under 65 years of age had a better QOL. Nearly all patients had normal work and daily living activities. Some patients appeared to lack energy or had a period of anxiety or depression. These data indicate that radical gastrectomy can be performed with an acceptable QOL for a potentially curable gastric carcinoma.

Hepatic resection of hepatocellular carcinoma in cirrhotic livers : Is it unjustified in impaired liver function ?

BACKGROUND Resection for hepatocellular carcinoma in patients with cirrhosis and impaired liver function is usually unjustified because of higher surgical risks and poorer long-term prognosis. METHODS A retrospective comparison of the background and resectional results of patients with cirrhosis and hepatocellular carcinoma was carried out between those with preoperative indocyanine green 15-minute retention rate of 20% or greater (group A, impaired function group, n = 36) and those with indocyanine green 15-minute retention rate of 10% or less (group B, normal function group, n = 34). RESULTS The group A patients had significantly lower serum albumin level and higher serum bilirubin level, longer prothrombin time, higher incidence of associated esophageal varices, and poorer Childs classifications for cirrhosis. Although the tumor diameter in both groups was similar (A, 6.9 versus B, 7.1 cm; p = 0.94), the resected liver amount in group B was greater (227.4 versus 473.2 gm; p = 0.038) because of a greater extent of liver resection (p < 0.001) and a wider surgical margin (0.34 versus 1.85 cm; p < 0.0001). The amount of operative blood loss and blood transfusion, operative morbidity, and operative mortality were not different between the two groups. The pathologic characteristics and staging were also comparable. The 5-year disease-free and actuarial survival rates of groups A and B were 30.9% and 29.6% (p = 0.16) and 45.2% and 33.4% (p = 0.11), respectively. CONCLUSIONS If the amount of resected nontumorous liver parenchyma could be reduced, resection of hepatocellular carcinoma in selected patients with cirrhosis and impaired liver function is still justified in spite of a narrow surgical margin.

Prognostic significance of surgical margin in hepatocellular carcinoma resection: an analysis of 165 Childs' A patients.

The clinical significance of the width of the surgical margin in the resection of hepatocellular carcinoma (HCC) has yet to be clarified.

Prognostic indicators for survival after curative resection for patients with carcinoma of the stomach

This study aims to determine prognosticindicators among patient-, tumor-, and treatmentrelatedfactors of gastric cancer patients. A total of 510patients who underwent curative gastric resection were studied. Univariate analysis of patient-relatedfactors showed a significantly lower survival inpatients with a history of obstruction, hypoalbuminemia,and anemia. Tumor-related factors including gross appearance, location, and size of tumor; depthof cancer invasion; level, number, and frequency oflymph node metastasis; stromal reaction and tumor growthpattern; and histological classification allsignificantly affected survival. Surgical treatment relatedfactors such as total or distal subtotal gastrectomy,extent of lymphadenectomy, and combined resection ofadjacent organ(s) showed a statistically significant adverse influence on survival. Multivariateanalysis identified only four tumor-related factors— number of metastatic lymph nodes, depth ofcancer invasion, stromal reaction, and gross appearanceof the tumor — as independently affectingsurvival. These findings suggest that only fourtumor-related factors were prognostic indicators inpatients with gastric cancer.

Sex hormone receptors in gastric cancer

Gastric adenocarcinoma that originates from mucosal tissue invades submucosa, muscle, and serosa in different stages. The level of progesterone receptors (PgR), estrogen receptors (ER), and androgen receptors (AdR) in the superficial part of gastric cancer tissues (CAs) from 16 patients was determined and compared with that of the corresponding normal gastric mucosal tissues (NLm). There were PgR in all CAs (100%) with values that ranged from 20.5 to 548.4 fmol/mg protein. Eight CAs (50%) had ER values that ranged from 6.8 to 325.1 fmol/mg protein. AdR was found in two CAs with values of 14.7 and 16.4 fmol/mg protein. In NLm, 15 (93.8%) had PgR values that ranged from 7.3 to 473.2 fmol/mg protein and ten (62.5%) had ER values that ranged from 0.9 to 87.9 fmol/mg protein. AdR were present in two NLm with values of 1.5 and 73.5 fmol/mg protein. There was no statistical difference in levels of PgR and ER between CAs and NLm. There were PgR in all gastric cancers and in 93.8% of NLm. The results suggest that gastric mucosa may be the target tissues for progesterone action. Furthermore, the lack of correlation between the levels of ER and PgR in gastric cancer tissue suggests that the PgR in gastric cancers are probably estrogen independent.