John A. Ryan

Catheter complications in total parenteral nutrition. A prospective study of 200 consecutive patients.

Abstract The complications related to central venous catheters for total parenteral nutrition were prospectively evaluated in 200 patients. Catheter sepsis was defined as an episode of sepsis, for which no anatomic locus could be identified, that resolved on removal of the catheter. The insertion of 355 catheters for 4492 days led to complications involving 4 per cent of the catheters and 6 per cent of the patients. Catheter sepsis was associated with 7 per cent of catheters and occurred in 11 per cent of patients. Eight cases of superior-vena-cava thrombosis and three of pulmonary embolism were found in 34 autopsied patients. Catheters used with strict aseptic technic were complicated by a sepsis rate of 3 per cent as compared to one of 20 per cent when breaks in the protocol were observed (p = 0.01). Thus, total parenteral nutrition can be employed with an acceptable risk, provided catheter care is according to protocol. (N Engl J Med 290:757–761, 1974)

Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections

Eighteen patients with active pancreatic ductal disruptions, including 14 with definable fluid collections, were treated with transpapillary pancreatic duct drains or stents. Twelve of these patients had undergone a previous percutaneous or surgical pancreatic drainage procedure or both, and 8 had long-term drainage tubes in chronic fistulous tracts. Transpapillary catheters could be placed across the ductal disruption or directly into the fluid collection in each case, and 16 of 18 patients had resolution of the disrupted pancreatic duct. Twelve of 14 fluid collections resolved. Complications were limited to mild exacerbation of pancreatitis symptoms in 2 patients and 2 patients who developed subsequent stent occlusion leading to recurrent pancreatitis (1 patient) or recurrent duct blowout with pseudocyst (1 patient). Nine patients had variably significant ductal changes attributable to pancreatic duct stents. At a median follow-up of 16 months, 7 patients ultimately required surgery for ongoing pancreatic pain or residual/recurrent fluid collection. The transpapillary treatment of ongoing pancreatic ductal disruption with or without fluid collection has the potential to obviate surgery in some patients, change an urgent surgical procedure into an elective one, or even assist the surgeon in the performance of intraoperative pancreatography. Further study of this technique appears warranted and must be placed into the perspective of current therapies.

Intraductal neoplasms of the pancreas

BACKGROUND Since 1980 a group of pancreatic tumors have been termed intraductal papillary mucinous tumors (IPMT). Because these tumors occupy an intraductal position they are demonstrated by pancreatography to reside in the main pancreatic duct (MPD) or side branch ducts (SBD). Lesions of IPMT result in abdominal pain or pancreatitis symptoms because mucin production or papillary growth results in ductal obstruction. Only 104 cases had been reported in the literature by 1996 but more are being presented in abstract form. We reviewed our own 33 cases to assist defining operative decision-making criteria. METHODS All cases of IPMT between 1989 and 1997 were reviewed for clinical presentation, anatomy by endoscopic retrograde cholangiopancreatography and computed tomography, histologic findings, and long-term outcomes. RESULTS Our cases were older (65 years) and presented with disease centered mainly in the head of the gland. Clinical presentation was epigastric pain (82%), pancreatitis (56%), weight loss (36%), diabetes (27%), and jaundice (9%). Operations were pancreatectomy in 31 (Whipple n = 15, total n = 5, distal n = 10, local n = 1), bypass only (n = 1), and no operation (n = 1). Malignancy was found in 14 of 33 (42%). Factors significantly associated (P <0.05 Fisher exact test) with malignancy were history of alcohol abuse or death from disease. Jaundice or presence in both MPD and SBD approached a significant association with malignancy but not abdominal pain, weight loss, diabetes, preoperative serum elevations of amylase, SGOT, CA-19-9, or CEA; diffuse MPD dilation, gland region, gross mucus in ducts or filling defects, cytology, calcifications, or a pancreatic mass. In 31 resected patients after a follow-up of 37 months (1 to 103) death had occurred in 6 of 13 malignant cases and 0 of 18 with benign disease. Three-year actuarial survival was 82% (all) and 56% (malignant). Symptom recurrence after resection was found in 6 of 31 at a mean of 13 months postoperatively and was associated with death from disease (P <0.05) or presence of pain preoperatively. CONCLUSION Malignancy is common with IPMT and is more likely to be present with the clinical history of alcohol abuse or jaundice and if the tumor involves both the MPD and the SBD. The prognosis after resection is better than pancreatic cancer but the 19% recurrence of symptoms was equally seen with benign or malignant cases owing to residual disease in pancreatic remnants. The amount of resection should be extensive in patients likely to have malignancy (alcohol, jaundice, MPD+SBD). In those likely to redevelop symptoms, ie, those with preoperative pain, a careful assessment should be made via imaging studies for extent of disease.

Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography

We assessed the accuracy of dynamic contrast-enhanced computed tomography (CT) in the diagnosis and staging of 213 patients with pancreatic carcinoma and compared it with the accuracy of angiography and surgery. A correct CT diagnosis of pancreatic carcinoma was made in 207 of 213 (97%) patients. Tumors were located in the pancreatic head in 64%, the body in 22%, and the tail in 10%, and enlarged the pancreas diffusely in 4%. CT staged 25 (12%) patients as having potentially resectable tumors and 188 (88%) as having unresectable tumors on the basis of local extension (72%), contiguous organ invasion (43%), vascular invasion (82%), and distant metastases (50%). Compared with angiography in 60 patients, CT detected vascular invasion missed on angiography in 20%, and angiography detected invasion missed by CT in 5%. In these latter cases, other CT criteria of unresectability were present, and angiography provided no significant staging information. Compared with surgery in 71 patients, CT accurately predicted unresectable tumors in 100% of patients and resectable tumors in 72% of patients. Eleven of the patients with CT-resectable tumors underwent resection. Median survival was 22.7 months, with four patients alive at a median of 15.5 months postoperatively. Palliative resections were performed in six patients, and median survival was 14.4 months.

Nutritional benefits of immediate postoperative jejunal feeding of an elemental diet

Positive nitrogen balance and preservation of body weight and total proteins were demonstrated in 26 patients undergoing extensive upper gastrointestinal operations who were randomized to receive elemental diet by a needle catheter jejunostomy. Infusions were started immediately after operation and continued for 10 days. In 26 patients receiving enteral feedings and 22 intravenous control patients, mean cumulative 10 day nitrogen balance was +11.7 +/- 5.4 and -44.7 +/- 6.5 g, respectively (p = 0.0001). Enterally fed patients lost only 0.02 +/- 0.5 kg of weight compared with 3.8 +/- 0.3 kg in control patients. The only complications were diarrhea in 34 percent of the study patients and one broken catheter. It is probable that the nitrogen and body weight preservation provided by enteral hyperalimentation equals or exceeds that demonstrated for total parenteral nutrition in postoperative patients.

Hyperalimentation as primary therapy for inflammatory bowel disease

Abstract In a series of thirteen patients with regional enteritis, granulomatous colitis, and ulcerative colitis, hyperalimentation was carried out with additional forms of therapy. The response in the group with regional enteritis and granulomatous colitis suggests the hyperalimentation may be of value as primary therapy. One patient with partial small bowel obstruction secondary to a stenotic segment avoided operation as the segment became dilated after three weeks of therapy. In ulcerative colitis total parenteral nutrition appears to be more of a supportive nature, as persistent bleeding necessitated operation in three of four patients.

Hyperalimentation in inflammatory bowel disease.

The effect of total parenteral nutrition on a group of thirty-four patients with inflammatory bowel disease over the past three and a half years was reviewed. Only patients in whom medical management had failed were included. Patients in whom the decision for surgery had been made and who were treated with total parenteral nutrition in an effort to prepare them for surgery were excluded. Of the group with Crohns disease, those patients with small bowel involvement appeared to fare best; surgery was avoided in approximately 70 per cent of these admissions. Crohns disease with colonic involvement had a less favorable prognosis, and 43 per cent of these patients underwent operation. Parenteral nutrition does not appear to affect the course of ulcerative colitis, as almost all patients in the group were treated by colectomy.

Surgical versus endoscopic management of common bile duct stones.

The charts of all patients with common bile duct (CBD) stones admitted to Virginia Mason Medical Center between January 1, 1981 and July 31, 1986 were reviewed to define current methods of management and results of operative versus endoscopic therapy. Two hundred thirty-seven patients with CBD stones were treated. One hundred thirty patients had intact gallbladders. Of these patients, 76 (59%) underwent cholecystectomy and common bile duct exploration (CBDE) while 54 (41%) underwent endoscopic papillotomy (EP) only. Of the 107 patients admitted with recurrent stones after cholecystectomy, all but five were treated with EP. The overall mortality rate was 3.0%. Complications, success, and death rates were all similar for CBDE and EP, but the complications of EP were often serious and directly related to the procedure (GI hemorrhage, 6; duodenal perforation, 5; biliary sepsis, 4; pancreatitis, 1). Patients undergoing EP required significantly shorter hospitalization than those undergoing CBDE. Multivariate analysis showed that age greater than 70 years, technical failure, and complications increased the risk of death, regardless of procedure performed. Twenty-one per cent of those undergoing EP with gallbladders intact eventually required cholecystectomy. The conclusion is that the results of EP and CBDE are similar, and the use of EP has not reduced the mortality rates of this disease.

Benefits and safety of hepatic resection for colorectal metastases

BACKGROUND Metastatic colorectal carcinoma to the liver is a potentially curable disease. The purpose of this study was to determine the safety and efficacy of hepatic resection for metastatic colorectal carcinoma. METHODS One hundred twenty-one consecutive hepatic resections in 110 patients with metastatic colorectal cancer between January 1978 and September 1998 performed by a single surgeon were reviewed. RESULTS The actuarial 5-year survival for all patients in the series was 46%. Of the patients operated on before 1993, the actual 5-year survival was 43% and actual disease-free 5-year survival was 28%. The actual 10-year survival was 27%, and of all patients operated on in the last 20 years, 48% are alive today. When comparing initial regional lymph node status, the 5-year survival was 54% for the patients with negative lymph nodes and 40% for patients with positive nodes. Only 18% of patients required a perioperative blood transfusion, and the median length of stay was 7 days. There were complications in 34% of cases, and the operative mortality was 4%. CONCLUSIONS Hepatic resection for metastatic colon cancer is safe, and significant longevity and cure can be obtained after resection.

Management and long-term follow-up of hepatic cysts

PURPOSE To provide an algorithm for the management of hepatic cysts through an analysis of our series over 16 years. METHOD We reviewed the surgical management and outcome of patients with hepatic cysts between 1984 and 2000 at a single institution. Data were collected by chart review, telephone interview, and follow-up hepatic ultrasonography. RESULTS Forty-four patients (36 females, 8 males) underwent a total of 46 operations for hepatic cysts (mean size 12.0 +/- 5.2 cm) with a mean follow-up of 5.1 +/- 4.0 years. We treated 28 simple cysts, 4 polycystic liver disease (PCLD), 7 cystadenomas, 2 hydatid cysts, 1 cystadenocarcinoma, 1 endometrioma, and 1 hepatic foregut cyst. Operations included simple drainage, wide unroofing (open and laparoscopic), and hepatic resection. Four patients experienced a symptomatic recurrence after definitive treatment; 3 of these patients had PCLD. Four of the 7 patients with cystadenomas had undergone previous operations that required subsequent definitive resection without a recurrence. CONCLUSIONS The preoperative distinction between simple cysts and cystadenomas/cystadenocarcinomas can be difficult, yet the management is different. Unroofing is a safe and effective operation for patients with simple cysts. Patients with PCLD frequently have recurrences. Cystadenomas should be completely resected owing to the likelihood of recurrence after partial excision and the risk of eventual cystadenocarcinoma. We present a treatment algorithm for the preoperative evaluation and management of hepatic cysts based on the largest number of patients with the longest follow-up reported to date.