James V. Sitzmann

Trends in long-term survival following liver resection for hepatic colorectal metastases

ObjectiveTo examine trends in outcomes of patients undergoing resection at a single tertiary care referral center over a 16-year period. Summary Background DataHepatic resection is considered the treatment of choice in selected patients with colorectal metastasis confined to the liver. Although a variety of retrospective studies have demonstrated improvements in short-term outcomes in recent years, changes in long-term survival over time are less well-established. MethodsData from 226 consecutive patients undergoing potentially curative liver resection for colorectal metastases between 1984 and 1999 were analyzed. Actuarial survival rates related to prognostic determinants were analyzed using the log-rank test. ResultsThe median survival for the entire cohort was 46 months, with 5- and 10-year survival rates of 40% and 26% respectively. Ninety-three patients operated on between 1984 and 1992 were found to have an overall survival of 31% at 5 years, compared to 58% for the 133 patients operated on during the more recent period (1993–1999). Both overall and disease-free survival were significantly better in the recent time period compared with the earlier period on both univariate and multivariate analyses. Other independent factors associated with improved survival included number of metastatic tumors ≤ 3, negative resection margin, and CEA < 100. Comparisons were made between time periods for a variety of patient, tumor and treatment-related factors. Among all parameters studied, only resection type (anatomical versus nonanatomical), use of intraoperative ultrasonography, and perioperative chemotherapy administration differed between the early and recent time periods. ConclusionsLong-term survival following liver resection for colorectal metastases has improved significantly in recent years at our institution. Although the reasons for this survival trend are not clear, contributing factors may include the use of newer preoperative and intraoperative imaging, increased use of chemotherapy, and salvage surgical therapy.

Pancreaticoduodenectomy for cancer of the head of the pancreas: 201 patients

ObjectiveThis single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas. Summary of Background DataIn recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%. MethodsTwo hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date. ResultsThe overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections: n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, <800 mL intraoperative blood loss, <2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection.

Improved hospital morbidity, mortality, and survival after the Whipple procedure.

Between 1969 and 1986, 88 patients had a Whipple resection for adenocarcinoma of the pancreas (N = 50), ampulla (N = 19), distal bile duct (N = 10), and duodenum (N = 9). Forty-nine patients were men, 39 were women, and the mean age was 58 years (range: 34-84 years). The patients were divided into two groups on the basis of two different time periods: those operated on from 1969 to 1980 (N = 41) and those operated on from 1981 to 1986 (N = 47). There were no significant differences between the two groups in terms of mean age, sex distribution, duration of symptoms before presentation, or mean weight loss. Likewise, preoperative laboratory data were similar for both groups of patients. In addition, mean tumor size for patients with pancreatic cancer (3.5 cm vs. 3.2 cm) and patients with nonpancreatic periampullary cancer (1.9 cm vs. 2.2 cm) was similar in both groups, as was the incidence of positive lymph nodes. Among the 41 patients operated on during the first period, hospital morbidity and mortality rates were 59% and 24%, respectively. In contrast, hospital morbidity and mortality rates were 36% and 2%, respectively, among the 47 patients operated on during the recent period. During the recent period, more Whipple procedures were performed each year (7.8 vs. 3.4) and by fewer surgeons (3.4 operations/surgeon vs. 1.9 operations/surgeon). In addition, between 1981 and 1986, there were fewer total pancreatectomies (9% vs. 39%), fewer vagotomies (26% vs. 76%), and more pyloric-preserving procedures (30% vs. 0) performed compared with the earlier period. During the recent period, mean operative time (7.8 vs. 9.0 hours), mean estimated blood loss (1694 vs. 3271 mL), and mean intraoperative blood replacement (3.6 vs. 6.3 units) were all significantly less than in the earlier period. These findings suggest that the recent decline in operative morbidity and mortality may be due to fewer surgeons performing more Whipple resections in less time and with less blood loss. The actuarial 5-year survival rate for the 38 patients with nonpancreatic periampullary cancer was 34%. Surprisingly, the actuarial 5-year survival rate among the 50 patients with pancreatic cancer was 18%. Moreover, in the absence of positive lymph node involvement, the 5-year actuarial survival rate among patients with pancreatic cancer was 48%. No explanation is obvious for the improvement in survival among patients with pancreatic cancer.

Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer

Eighty-nine patients with carcinoma of the head of the pancreas underwent pancreaticoduodenectomies. The actuarial 5-year survival for all 89 patients was 19%, with a median survival of 11.9 months. The 81 hospital survivors were analyzed in an effort to determine factors influencing long-term survival. Negative lymph nodes and the absence of blood vessel invasion both favored long-term survival. The strongest predictive factor was negative lymph node status with a median survival of 55.8 months, compared with 11 months with lymph nodes involved with tumor (p less than 0.05). Blood transfusions were also predictive, with patients receiving two or fewer units having a median survival of 24.7 months, compared with 10.2 months for those receiving three or more units (p less than 0.05). The most important determinant of long-term survival after pancreaticoduodenectomy for pancreatic cancer is biology of the tumor (lymph node status, blood vessel invasion). However, performance of the resection (units of blood transfused) also appears to be an important factor influencing survival.

The catecholamine, cortisol, and hemodynamic responses to mild perioperative hypothermia. A randomized clinical trial.

BackgroundUnintended hypothermia occurs frequently during surgery and may have adverse effects on the cardiovascular system. Although the mechanisms responsible for the cardiovascular manifestations of hypothermia are unclear, it is possible that they are sympathetically mediated. In this prospectiv

Septic and technical complications of central venous catheterization. A prospective study of 200 consecutive patients.

The results of central venous catheterization for total parenteral nutrition were prospectively evaluated in 200 consecutive patients. All catheters were fabricated of polyurethane tubing inserted by the Seldinger technique. Two hundred sixty-three lines were inserted in 200 patients for a total of 4103 days. Major complications occurred in 2.3% patients. Twenty-four per cent of catheters were associated with suspected sepsis; of these, 52% were removed directly and 48% were changed over a guidewire. The total catheter sepsis rate was 5.7%. The incidence of sepsis correlated with the number of attempts to insert the line and with positive skin cultures. These data indicate that: use of the Seldinger technique to insert nonthrombogenic flexible catheters results in lower technical morbidity; the incidence of established infection is much lower than the incidence of suspected sepsis; guidewire change may be performed without risk to the patient or interruption of therapy; sepsis rates can be decreased by reducing the number of attempts to catheterize the subclavian vein; and sepsis rates correlate with positive skin cultures at the insertion site.

Should hepatic resections be performed at high-volume referral centers?☆

Recent studies have demonstrated the relationship between clinical outcomes of complex surgical procedures and provider volume. Hepatic resection is one such high-risk surgical procedure. The aim of this analysis was to determine whether mortality and cost of performing hepatic resection are related to surgical volume while also examining outcomes by extent of resection and diagnosis, variables seen with this procedure. Maryland discharge data were used to study surgical volume, length of stay, charges, and mortality for 606 liver resections performed at all acute-care hospitals between January 1990 and June 1996. One high-volume provider accounted for 43.6% of discharges, averaging 40.6 cases per year. In comparison, the remainder of resections were performed at 35 other hospitals, averaging 1.5 cases per year. Data were stratified into these high- and low-volume groups, and adjusted outcomes were compared. The mortality rate for all procedures in the low-volume group was 7.9% compared to 1.5% for the high-volume provider (P <0.01, relative risk = 5.2). No overall differences were observed between low- and high-volume providers in total hospital charges. When analyzing by procedure type and diagnosis, lower mortality was seen in the high-volume center for both minor and major resections, as well as resections for metastatic disease. It was concluded that hepatic resection can be performed more safely and at comparable cost at high-volume referral centers.

Perioperative Predictors of Morbidity Following Hepatic Resection for Neoplasm A Multivariate Analysis of a Single Surgeon Experience with 105 Patients

ObjectiveFactors that predict mortality or morbidity risk in consecutive hepatic resections for neoplasm were examined, with controlled variables of surgical technique and experience. Summary Background DataHepatic resection has become the therapy of choice for the management of metastatic or primary neoplasms of the liver. Although mortality for this procedure has steadily decreased, associated morbidity remains high. MethodsOne hundred five patients undergoing hepatic resection for malignancy over a 4-year period by a single surgeon to identify preoperative, intraoperative, or postoperative predictors of morbid outcomes were studied. Variables were analyzed using multiple regression in a stepwise, logistic model. ResultsSixty-day hospital mortality was 2.8%, with morbidity occurring in 33%. A significant preoperative predictor of morbidity was serum billrubin (p > 0.005). Notably, preoperative renal function, or medical illness, did not increase morbid risk. Operative variables increasing risk included extent of resection, blood loss, and operative time (p > 0.005). ConclusionsComplex hepatic resection can be performed with low mortality, and serum bilirubin is the single most powerful predictor of postoperative complication.

Multivariate determinants of early postoperative oxygen consumption in elderly patients. Effects of shivering, body temperature, and gender.

Background Previous investigators have proposed that postoperative shivering may be poorly tolerated by patients with cardiopulmonary disease because of the associated significant increase in total-body oxygen consumption. However, the often-quoted 300-400% increase in oxygen consumption with shivering was derived from relatively few studies performed in a small number of younger persons specifically selected on the basis of clinically recognizable shivering. We hypothesized that the average elderly postoperative patient has a shivering response that is associated with a relatively small increase in total-body oxygen consumption.

Increased endothelial nitric oxide synthase activity in the hyperemic vessels of portal hypertensive rats

BACKGROUND/AIM Portal hypertension is characterized by splanchnic hyperemia due to a reduction in mesenteric vascular resistance. Mediators of this hyperemia include nitric oxide. This is based on several reports indicating a marked splanchnic hyporesponsiveness in portal hypertension to vasoconstrictor stimuli both in vitro and in vivo, and a subsequent reversal using specific inhibitors of nitric oxide synthase. The objective of this study was to determine firstly whether the functional activity and/or expression of nitric oxide synthase is altered in portal hypertensive vasculature and secondly which isoenzyme form was responsible for the preferential response to nitric oxide blockade in these animals. METHODS We compared nitric oxide synthase functional activity in the hyperemic vasculature of sham and portal hypertensive rats (following partial portal vein ligation). Nitric oxide synthase activities were determined by measuring the conversion of L-arginine to citrulline using ion-exchange chromatography and the amount of immunodetectable nitric oxide synthase in sham and portal hypertensive vessels was determined by Western blot. RESULTS Ca(2+)-dependent nitric oxide synthase activity was significantly elevated (p < 0.05) in portal hypertensive particulate fractions from the superior mesenteric artery, thoracic aorta and portal vein. Vascular tissue cGMP levels and plasma nitrite levels were both significantly elevated in portal hypertension. Immunodetection with specific antisera raised against the inducible nitric oxide synthase demonstrated a lack of induction within the hyperemic vasculature. Immunodetection with antisera against endothelial nitric oxide synthase showed a significant increase in portal hypertensive portal vein only. These results demonstrate enhanced calcium-dependent nitric oxide synthase activity in portal hypertension hyperemic vessels concurrent with elevated tissue cGMP levels. CONCLUSION We conclude that enhanced endothelial nitric oxide synthesis may in part contribute to the hyperdynamic circulation of portal hypertension.