J. A. Van Heerden

Long-term survival after resection for ductal adenocarcinoma of the pancreas. Is it really improving?

ObjectiveThe authors review their recent experience with resected pancreatic ductal adenocarcinoma. Summary Background DataDuctal adenocarcinoma of the pancreas has traditionally had a 5-year survival rate less than 10% after curative resection. Recently, several groups have reported markedly improved 5-year survival rates (approaching 25%) for patients undergoing curative resection. MethodsInstitutional experience with 186 consecutive patients (1981–1991) with pathologic diagnoses of ductal adenocarcinoma undergoing pancreatic resection was reviewed. Histologic specimens of all 3-year survivors (n = 31) were re-reviewed by two pathologists, one internal and one external; nonductal pancreatic cancers then were excluded. ResultsAfter histologic re-review, 12 patients did not have ductal adenocarcinoma, leaving a total of 174 patients for analysis (102 men, 72 women; mean age 63 years, range 34–82 years). Mean followup was 22 months (range 4–109). Classical pancreaticoduodenectomy was performed in 71%, pylorus-preserving resection in 9%, and total pancreatectomy in 20%. Hospital mortality was 3%. Twenty-eight patients (16%) had macroscopically incomplete resections; 98 (56%) had lymph node metastases within the resected specimens, and 21 patients (12%) had extensive perineural invasion. Overall actuarial 5-year survival was 6.8%. Five-year survival was greater for nodenegative versus node-positive patients (14% vs. 1%, p< 0.001), and for smaller (<2 cm) versus larger tumors (20% vs. 1%, p< 0.001). The 5-year survival for the subset of patients with negative nodes and no perineural or duodenal invasion (69 patients) was 23% (p< 0.001). Mean survival of the 12 excluded patients was 53 ± 7 months compared with 17.5 ± 1 months in the 174 patients with ductal pancreatic cancer. ConclusionsFive-year survival for patients undergoing pancreatic resection for lesions deemed to be clinically “curable” intraoperatively and histologically reviewed/confirmed to be ductal adenocarcinoma of the pancreas is approximately 7%. Survival is greater (23%) in the subset of patients with negative

Perioperative blood transfusion and determinants of survival after liver resection for metastatic colorectal carcinoma.

The authors reviewed their institutional experience with liver resection for metastatic colorectal carcinoma to (1) determine whether perioperative blood transfusion affects survival; (2) identify prognostic determinants; and (3) estimate the patient requirement for a prospective randomized trial designed to demonstrate efficacy of liver resection. Two hundred eighty consecutive patients treated by potentially curative liver resection between 1960 and 1987 were included. Data were obtained for all but 10 patients for at least 5 years after operation or through 1990. Actuarial survival curves related to potential prognostic determinants were analyzed with the log-rank test. Overall, survival was 47 ± 3% at 3 years and 25 ± 3% at 5 years, including 4% 60-day operative mortality rate. Eighty-one patients who did not receive blood 7 days before to 14 days after operation had 60 ± 6% 3-year and 32 ± 6% 5-year survival compared with 40 ± 4% and 21 ± 3% survival rates for 183 patients who received at least one unit (p = 0.03, operative deaths excluded). Extra-hepatic disease (p = 0.015), extrahepatic lymph node involvement (p = 0.002), satellite configuration of multiple metastases (p = 0.0052), and initial detection by abnormal liver enzymes (p = 0.0005) were associated with poor survival rates. Synchronous presentation of metastatic and stage B primary disease was associated with a favorable prognosis (p = 0.003). The requirement for a prospective randomized trial estimated by an exponential survival model would be 36, 74, 168, or 428 patients if 5-year survival without resection were 1, 5, 10, or 15%. We conclude that (1) perioperative blood transfusion may be adversely associated with survival; (2) extrahepatic disease, extrahepatic lymph node involvement, satellite configuration, and initial detection by clinical examination or a liver enzyme abnormality portend a poor prognosis; and (3) a prospective randomized trial of liver resection is impractical because of the large patient requirement, at least by a single institution.

Long-term course of patients with persistent hypercalcitoninemia after apparent curative primary surgery for medullary thyroid carcinoma

Thirty-one patients with persistent hypercalcitoninemia after seemingly adequate primary operation for medullary thyroid carcinoma (MTC) were followed for a mean period of 11.9 years after operation. Ten patients had sporadic MTC and the remaining patients were members of families with multiple endocrine neoplasia (MEN)--either MEN 2A (15 patients) or MEN 2B (six patients). Overall 5- and 10-year survival rates were 90% and 86%, respectively. Only four patients died at the completion of the study: two of MTC and two of unrelated causes. Eleven patients (35.5%) underwent surgical re-exploration after demonstration of recurrent disease clinically or radiologically. In no patient did the calcitonin level return to normal after re-exploration. The presence of more than three metastatic nodes at the time of initial operation was a statistically significant (p = 0.003) predictor for disease recurrence. Factors approaching statistical significance were patients younger than age 35 (p = 0.06) and the percentage of cells in the S phase of cell division (0.07). This data supports a conservative surgical philosophy in the management of the patient with persistent hypercalcitoninemia after resection of MTC.

The spectrum of serous cystadenoma of the pancreas. Clinical, pathologic, and surgical aspects.

Serous cystadenoma of the pancreas is a rare lesion thought to be almost invariably benign. Since 1978, 211 cases have been reported in the literature. Some have been recognized by computed tomography (CT) when small and asymptomatic. The authors have reviewed their experience with 40 patients (median follow-up of 1.9 years, maximum of 22.2 years) from 1936 to 1991. One third (13) were asymptomatic, of whom eight (20%) were discovered intraoperatively. Of those 20 who had CT, an unequivocal preoperative diagnosis was reached in none. Needle biopsy proved accurate in two patients. Endoscopie retrograde cholangiopancreatography (ERCP) and biopsy were performed with diagnostic success on one occasion. Three patients presented acutely. The tumor was resected in 90%, with an operative mortality rate of 10%. Enucleation of the tumor without formal anatomic pancreatectomy necessitated reoperation for complications in four of eight patients. Survival after successful resection paralleled expected survival. Serous cystadenoma may be associated with von Hippel-Lindau syndrome. The current role for conservative management remains questionable because of our current inability to reliably differentiate many of these benign neoplasms from malignant cystic neoplasms of the pancreas.

Major hepatic resections for metastatic colorectal cancer.

In 1973, our study of patients with resectable hepatic metastases from colorectal cancer compared survival of 60 patients who had metastases removed with survival of 60 patients with similar lesions that had been biopsied only. We concluded that excision of small, apparently solitary metastatic lesions could be justified on the basis of the low operative risk and prolonged survival. However, the risks and benefits of resection of larger metastatic lesions could not be determined by that earlier study, because only seven of those patients had lesions so large as to require major hepatic resection. Therefore, to evaluate size as a determinant of prognosis after resection, we added to those 7 patients 27 others who were managed since 1973 by major hepatic resection of larger metastases. There were two hospital deaths. Of the 32 surviving patients, 82% lived one year or more, 77% 18 months or more, 58% two years or more, and 41% three years or more postoperatively. Three patients are living 10–22 years after resection. We conclude from a critical analysis of the duration and quality of life of surviving patients that at least 20% and perhaps 30% of these patients were benefited by major hepatic resection of their large hepatic metastasis.

The surgical aspects of insulinomas.

The clinical diagnosis of insulinoma rests on the demonstration of VVhipples triad (symptoms of hypoglycemia, low circulating glucose and prompt relief of symptoms after glucose administration). Biochemically, the association of an increased value of immunoreactivc insulin with a low glucose value is diagnostic of insulin-mediated hypoglycemia. Angiographie localization of these tumors is accomplished in more than 90% of cases. The pathologic changes are usually due to a single adenoma, for which surgical cnucleation is the procedure of choice. Malignancy and persistent hypoglycemia occur in slightly less than 10% of cases and can be fairly successfully managed by diazoxide and streptozotocin.

Mediastinal parathyroid tumors: experience with 38 tumors requiring mediastinotomy for removal.

Most hyperfunctioning parathyroid tumors situated in the mediastinum can be removed by means of a cervical approach. However, a few tumors, because of their location deep in the chest, require mediastinotomy for removal. These tumors are probably derived from parathyroid glands that have developed from the third branchial pouch. Between 1942 and 1980, 38 such tumors were removed at the Mayo Clinic, using a sternum-splitting procedure. With one exception, the patients had undergone previous parathyroid exploration. Almost all of the patients had significant complications of primary hyperparathyroidism (HPT). Thirty-seven patients (97%) were cured after removal of their mediastinal parathyroid tumors, but postoperative chest complications were encountered in eight patients (21%), and eight have permanent hypoparathyroidism. Six patients had selective arteriography, two had selective thyroid venous sampling and parathyroid hormone assay, and 13 had mediastinal computed tomography in an attempt to localize tumors before operation. The anatomic locations of the tumors at operation were variable, but the vast majority (68%) were in or near the thymus.

Elective colon and rectal surgery without nasogastric decompression: a prospective, randomized trial

Nasogastric (NG) decompression after colorectal surgery is practiced commonly. Our aim was to determine whether routine NG decompression benefitted patients undergoing this type of surgery. Five hundred thirty-five patients were randomized prospectively to either NG decompression or no decompression. Stratification was by type of operation and patient age. Excluded were patients who had emergency surgery with peritonitis, extensive fibrous adhesions, enterotomies, previous pelvic irradiation, intra-abdominal infection, pancreatitis, chronic obstruction. prolonged operating times, or difficult endotracheal intubation. Two hundred seventy-four patients received NG decompression (Salem sump, Argyle Co., Division of Sherwood Medical, St. Louis, MO) and two hundred sixty-one did not. There were 33 protocol violations included in the 535 patients. Patients who were not decompressed experienced significantly more abdominal distention, nausea, and vomiting than did those patients who were. Moreover, 13% required subsequent NG decompression as opposed to a reinsertion rate of 5% for patients routinely decompressed. The mean length of hospitalization for both groups was 11 days. There were no significant differences in nasopharyngeal or gastric bleeding, inability to cough effectively, respiratory infections, wound disruptions, reoperation, and wound infection rates (5%) between the two groups. We conclude that even though there is an increase in the rate of minor symptoms of nausea, vomiting, and abdominal distention, routine nasgastric decompression is not warranted after elective colon and rectal surgery.

Gastrointestinal anastomoses. Factors affecting early complications.

A retrospective review of gastric and colonic anastomoses during a recent 12-month period was performed at the Mayo Clinic. One hundred sixty-nine patients had gastroduodenal or gastrojejunal anastomoses (Group I). Five hundred nineteen patients had ileocolonic or ileorectal (222) and colocolonic or colorectal (297) anastomoses (Group II). Major anastomotic complication rates for Group I patients were: leaks, 1% hemorrhage, 2% and stenosis or obstruction, 2%. Reoperations and deaths secondary to anastomotic complications during the postoperative period were 2% and 0.6%, respectively. Corresponding rates for Group II were 2%, 1%, and 4%, with reoperative and anastomotic death rates of 1% and 0. 2%, respectively. In Group I patients, length of operation had a significant effect (p < 0.01) on anastomotic complications. In Group II patients, a significant increase in complications was related to the presence of obstruction (p < 0. 001), recent weight loss (> 10 pounds) (p < 0.02), malignancy (p < 0. 04), and sepsis (p < 0.05).

Sexual dysfunction following proctocolectomy and abdominoperineal resection.

Sexual dysfunction after rectal excision was studied in 45 male patients who were less than 50 years of age. Of 25 patients having had proctocolectomy, one (4%) was impotent, while three (15%) of 20 patients having had abdominoperineal resection were impotent. Two patients in the abdominoperineal group reported no ejaculation with normal potency and sensation of orgasm. The age of the patient and the extent of dissection seemed to be the two main factors concerned with sexual dysfunction after rectal excision.