John L. Sawyers

A prospective study to determine the efficacy of antibiotics in acute pancreatitis.

This study is a double “blind” prospective evaluation of the efficacy of antibiotics (Ampicillin) in the treatment of acute alcohol-induced and idiopathic pancreatitis. Fifty-eight patients with acute pancreatitis were randomly divided into antibiotic and non-antibiotic treatment groups. The two groups were comparable clinically at the onset of the study and other than for antibiotics received identical therapy. The patients without antibiotics had a clinical course equal or slightly more favorable than the antibiotic treatment group in all parameters examined. These data indicate that prophylactic use of Ampicillin is not indicated in patients with routine acute alcohol-induced or idiopathic pancreatitis. The role of prophylactic antibiotics in patients with pancreatitis related to biliary calculi and those with more severe varieties of acute hemorrhagic or necrotizing pancreatitis remains to be more clearly defined.

Living related kidney donors: a 14-year experience

Living related donor (LRD) nephrectomies are controversial due to the risks to the donor and improved cadaveric graft survival using cyclosporine A. Between December 22, 1970, and December 31, 1984, 1096 renal transplants were performed at a single institution, 314 (28.6%) from LRD. The average age was 34.3 years (range: 18-67); none had preoperative hypertension. All nephrectomies were performed transabdominally. Major perioperative complications occurred in 22 (7.0%). These include wound infections (3.5%), pancreatitis (1.0%), injuries to spleen (1.0%) or adrenal gland (0.3%) requiring removal, pneumonitis (0.6%), ulnar nerve palsy (0.6%), femoral artery thrombosis after arteriogram (0.3%), pulmonary embolus (0.3%), and upper pole infarct of contralateral kidney (0.3%). There are six known deaths in this series, none of which were related to the operation. Major late complications were seen in 50 (20.0%) of 250 patients followed for 6 to 175 months (mean 53.1 months). These included definite hypertension (5.6%), suture granuloma (4.4%), incisional hernia (3.6%), proteinuria (2.4%), bowel obstruction (2.0%), nephrolithiasis (1.2%), wound infection (0.4%), scrotal hydrocele (0.4%), and chronic pancreatitis (0.4%). While the risk of hypertension appears to increase as the interval from donation increases, no cases of renal failure after donation have been noted, and negligible proteinuria among those followed long-term has been seen in this series. It is felt that living related kidney donation is justified when the relative is sincerely motivated and well informed prior to donation.

Cefoxitin versus erythromycin, neomycin, and cefazolin in colorectal operations. Importance of the duration of the surgical procedure.

Perioperative parenteral cefoxitin was compared with oral erythromycin, neomycin and parenteral cefazolin in a prospective, double-blind, randomized evaluation of 119 patients undergoing colorectal operations. Patients receiving cefoxitin had a higher wound infection rate than patients receiving erythromycin-neomycin-cefazolin (12.5% v 3.2%, respectively, p = .06). A direct correlation existed between the duration of the operation and the infection rate. Cefoxitin prophylaxis was as effective as erythromycin-neomycin-cefazolin in patients undergoing surgical procedures of 4 hours or less (infection rates of 4.8% and 4.0%, respectively). However, for surgical procedures lasting more than 4 hours, 5 of 14 patients (37.5%) receiving cefoxitin developed a wound infection v 0 of 13 patients receiving erythromycin-neomycin-cefazolin (p < .05). It is speculative as to whether frequent two-gram doses of cefoxitin given during the operation would provide prophylaxis equivalent to erythromycin-neomycin-cefazolin.

Management of adult choledochal cysts.

A review of the English literature reveals a total of 1,337 patients with choledochal cysts. Improved diagnostic techniques to visualize the billary system are demonstrating an increasing number of unsuspected choledochal cysts in adult patients. Either choledochal cysts remain clinically silent until adulthood or may develop in later life. Experience is reported with adult patients having type I, II, III, and IV choledochal cysts. Type I cysts are preferably managed by excision but cyst anatomy may necessitate choledochoenteric drainage. Type II cysts are treated by excision except for those located within the pancreatic portion of the common bile duct. These are best managed by transduodenal cystoduodenostomy. The type III cyst (choledochocele) should be excised carefully, identifying and preserving the common bile and pancreatic ducts. Type IV cysts include a combination of any one of the first three types of cyst plus the presence of intrahepatic cyst or cysts. Treatment of these cysts is dictated by the type and location of the extrahepatic cyst. Since choledochal cysts are being recognized with increased frequency in adults, surgeons need to be aware of the diagnostic and treatment modalities available for each type of biliary cyst.

Surgical Management of Reflux Gastritis

Reflux gastritis is now recognized with increasing frequency as a complication following operations on the stomach which either remove, alter, or bypass the pyloric phincter mechanism. The entity may occasionally occur as a result of sphincter dysfunction in the patient who has not undergone prior gastric surgery. The diagnosis is made on the basis of symptoms (postprandial pain, bilious vomiting and weight loss), gastroscopic examination with biopsy and persistent hypochlorhydria. Remedial operation for correction of reflux is indicated in the presence of persistent symptoms when conservative measures fail. Only operative procedures which divert duodenal contents from the stomach or gastric remnant are effective. Both the isoperistaltic jejunal segment (Henley loop) and the Roux-en-Y diversion have been effective as remedial operations for reflux gastritis and merit greater awareness by gastroenterologists and surgeons. Our choice is the Roux-en-Y because of its technical simplicity and lower morbidity rate.

Improved survival with neoadjuvant therapy and resection for adenocarcinoma of the esophagus.

ObjectiveThis study sought to determine the impact of preoperative chemotherapy and radiation therapy (neoadjuvant therapy) followed by resection in patients with adenocarcinoma of the esophagus. Summary Background DataLong-term survival in patients with carcinoma of the esophagus has been poor. An increase in the incidence of adenocarcinoma of the esophagus has been reported recently. MethodsFifty-eight patients with biopsy-proven adenocarcinoma of the esophagus treated at this institution from January 1951 through February 1993 were studied. Since 1989, 24 patients were entered prospectively into a multimodality treatment protocol consisting of preoperative cisplatin, 5-fluorouracil (5-FU), and leucovorin with or without etoposide, and concomitant mediastinal radiation (30 Gy). Patients were re-evaluated and offered resection. ResultsThere were no deaths related to neoadjuvant therapy and toxicity was minimal. Before multimodality therapy was used, the operative mortality rate was 19% (3 of 16 patients). With multimodality therapy, there have been no operative deaths (0 of 23 patients). The median survival time in patients treated before multimodality therapy was 8 months and has yet to be reached for those treated with the neoadjuvant regimen (> 26 months, p < 0.0001). The actuarial survival rate at 24 months was 15% before multimodality therapy and 76% with multimodality therapy. No difference in survival was noted in neoadjuvant protocols with or without etoposide (p = 0.827). ConclusionsMultimodality therapy with preoperative chemotherapy and radiation therapy followed by resection appears to offer a survival advantage to patients with adenocarcinoma of the esophagus.

Comparative studies of the clinical effects of truncal and selective gastric vagotomy.

Abstract A prospective randomized clinical study was carried out in 145 patients to compare the effects of truncal and selective gastric vagotomy. Evaluation of results of vagotomy have been at regular follow-up intervals from six to thirty months. Selective gastric vagotomy appears to be significantly superior to truncal vagotomy in achieving complete vagal denervation of the stomach. The clinical benefits of preserving hepatic and celiac vagal innervation were not impressive.

Current status of conventional (open) cholecystectomy versus laparoscopic cholecystectomy.

For the past century, open cholecystectomy has been the conventional method, or gold standard, for the treatment of patients with symptomatic gallstones. First performed in France in 1987, laparoscopic cholecystectomy was introduced in the United States in 1988. During the past 5 years, laparoscopic

Preliminary results with neoadjuvant therapy and resection for esophageal carcinoma

Between December 1988 and August 1992, 68 patients with adenocarcinoma (n = 39) and squamous carcinoma (n = 29) of the esophagus were entered prospectively in a treatment protocol to receive two cycles of cisplatin, 5-fluorouracil, etoposide, leucovorin, and 3,000 cGy of radiation to the involved esophagus and adjacent mediastinum, followed by resection. There were four deaths during chemotherapy, and 7 patients had a decline in condition or were denied operation. Fifty-six patients have come to operation, and 1 awaits resection. Twenty-two patients had transhiatal esophagectomy and 29 patients had esophagogastrostomy with a combined abdominal and right thoracic approach. Five patients did not undergo resection at operation. There was one hospital death (2%). A complete response to preoperative therapy was seen in 12 patients (21%): 5 of 20 with squamous cancer (25%) and 7 of 36 with adenocarcinoma (19%). Average follow-up is 19 months. Median survival in these patients after entrance in the protocol is 24 months. Actuarial survival at 12, 18, and 24 months is 72% (confidence limits, 66% and 78%), 53% (confidence limits, 46% and 60%), and 51% (confidence limits, 44% and 58%). Significantly better survival was associated with adenocarcinoma (p = 0.041). There is no survival advantage based on complete response to preoperative therapy. This neoadjuvant regimen is effective in patients with squamous carcinoma and adenocarcinoma. These preliminary results demonstrate an improved median and actuarial survival compared with historical controls in 137 patients operated on between 1966 and 1985 at our institution.

Management of postgastrectomy syndromes

There is still much to learn about the cause of postgastrectomy syndromes. Fortunately, most patients can be managed by conservative measures unless a mechanical cause, amenable to operative correction, is found. Thus, it is important to determine the type of postgastrectomy problem that is affecting the patient. In carefully selected patients, remedial operations may ameliorate the patients symptoms and permit him or her to return to a normal lifestyle. Humoral factors have attracted increasing attention, especially in patients with the dumping syndrome. The somatostatin analogue octreotide has provided relief from the vasomotor and gastrointestinal symptoms of severe dumping but must be given three to four times a day by injection.