John W. Braasch

Pyloric and gastric preserving pancreatic resection. Experience with 87 patients.

Eighty-seven patients with neoplasm (57 cases), pancreatitis (28 cases), or benign biliary obstruction (2 cases) were treated with pyloric preserving pancrcatectomy with two postoperative deaths, neither due to abdominal complications. About 50% of patients had delay in recovery of gastrointestinal function. Six and seven patients had clinically significant biliary and pancreatic fistulas, respectively, with some patients having both. Complications required 16 reoperations. Marginal ulcer was suggested by endoscopy or barium study in five patients, three of whom were successfully managed by a medical regimen. In the other two patients, exploration failed to demonstrate an ulcer or jejunitis. In most patients, long-term gastrointestinal function was judged to be excellent based on weight gain and lack of digestive symptoms. Pyloric function and gastric motility were evaluated by abdominal scanning using indium 111 and technetium 99m. Gastric emptying of liquids and solids was normal. Estimations of enterogastric reflux showed a moderate difference between normal subjects and pancreatectomy patients. Cancer-free survival was comparable to that after the standard Whipple procedure.

Management of Hilar Cholangiocarcinoma: Comparison of an American and a Japanese Experience

ObjectiveTo compare the experience and outcome in the management of hilar cholangiocarcinoma at one American and one Japanese medical center. Summary Background DataControversies surround the issues of extent of resection for hilar cholangiocarcinoma and whether the histopathology of such cancers are similar between patients treated in America and in Japan. MethodsRecords were reviewed of 100 patients treated between 1980 and 1995 at the Lahey Clinic in the United States, and of 155 patients treated between 1977 and 1995 at Nagoya University Hospital in Japan. Selected pathologic slides of resected cancers were exchanged between the two institutions and reviewed for diagnostic concordance. ResultsIn the Lahey cohort, there were 25 resections, 53 cases of surgical exploration with biliary bypass or intubation, and 22 cases of percutaneous transhepatic biliary drainage or endoscopic biliary drainage without surgery. In the Nagoya cohort, the respective figures were 122, 10, and 23. The overall 5-year survival rate of all patients treated (surgical and nonsurgical) during the study periods was 7% in the Lahey cohort and 16% in the Nagoya cohort. The overall 10-year survival rates were 0% and 12%, respectively. In patients who underwent resection with negative margins, the 5- and 10-year survival rates were 43% and 0% for the Lahey cohort and 25% and 18% for the Nagoya cohort. The surgical death rate for patients undergoing resection was 4% for Lahey patients and 8% for Nagoya patients. Of the patients who underwent resection, en bloc caudate lobectomy was performed in 8% of the Lahey patients and 89% of the Nagoya patients. Histopathologic examination of resected cancers showed that the Nagoya patients had a higher stage of disease than the Lahey patients. ConclusionsIn both Lahey and Nagoya patients, survival was most favorable when resection of hilar cholangiocarcinoma was accomplished with margin-negative resections. Combined bile duct and liver resection with caudate lobectomy contributed to a higher margin-negative resection rate in the Nagoya cohort.

Considerations that lower pancreatoduodenectomy mortality

To aid in case selection for pancreatoduodencetomy and to gain information on the technical management of this operation and its complications, records of 279 patients who were treated for neoplasm or pancreatitis by this procedure between the years 1957 and 1975 were reviewed. The overall operative mortality was 12.5 per cent and was 10.7 per cent for the years 1969 throught 1974. The use of vagotomy did not prevent postoperative bleeding from the stomach, and the use of a stent did not make a statistically significant difference in morbidity or mortality. Postoperative hemorrhage is an ominous complication and is best treated conservatively until blood loss cannot be replaced. Preoperative serum bilirubin levels above 20 mg/100 ml indicate a two-stage operative procedure as does the presence of right upper quadrant sepsis. The resection of malignant disease of the duodenum and lower bile duct is followed by a high mortality and requires total pancreatectomy if a satisfactory pancreatojejunostomy cannot be constructed.

Biliary carcinoma: A review of 109 cases☆

One hundred nine patients operated on for bile duct carcinoma were reviewed. Herein, we reported 83 proximal duct tumors, 12 mid-duct tumors, and 14 distal third tumors. Resectability was 10 percent, 33 percent, and 100 percent, respectively, with an operative mortality of 0 percent, 25 percent, and 23 percent. The median survival time and 5 year survival rate for these resected groups were 21 months and 25 percent for proximal duct tumors, 8 months and 0 percent for mid-duct tumors, and 16 months and 20 percent for distal third tumors. Eighty-three patients were treated with strictly palliative procedures with an operative mortality of 19 percent, an adjusted median survival rate of 10.9 months, and a 5 year survival rate of 0. The 2 and 5 year survival rates of patients with well-differentiated tumors were 73 percent and 15 percent, respectively, whereas for patients with poorly differentiated lesions, it was 6 percent and 0. Although most patients require palliative decompressive procedures, resection should be attempted whenever possible. It is expected that nonoperative techniques will have an increased role in the treatment of poor-risk patients or those who have unresectable disease.

Surgical management of nonparasitic cystic liver disease

We report clinical features, surgical management, recurrences, and follow-up study of 12 patients with simple hepatic cyst, 11 patients with polycystic liver disease, and 19 patients with cystadenoma who were surgically treated over a 25-year period. The median age of patients was 48 years, and 37 women and 5 men were in the series. The most common presenting symptom and physical finding were chronic abdominal pain and tenderness in the right upper quadrant. The most commonly associated disease was polycystic kidney disease, which was an associated finding in 5 of the 11 patients with polycystic liver disease (45%). The most valuable diagnostic studies in all groups were computed tomography and ultrasonography. The location of the disease was bilobar in patients with polycystic liver disease, with a right lobe predominance in 18% of patients. The right lobe was also predominant in 83% of patients with simple hepatic cyst and 58% of patients with cystadenoma. Of all solitary cystic lesions in the left lobe, 75% of them were cystadenomas. Of the 66 surgical procedures performed, aspiration was associated with a failure rate of 100%; partial excision, a failure rate of 61%; and total excision and liver resection, a failure rate of 0%. Orthotopic liver transplantation was performed in three patients and was associated with two early deaths. Partial excision relieved symptoms in three patients (43%) with polycystic liver disease. Total excision, enucleation, or liver resection with cyst(s) is the treatment of choice for non-parasitic cystic lesions of the liver.

Ductal drainage or resection for chronic pancreatitis

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunosotomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.

Carcinomas arising in cystic conditions of the bile ducts. A clinical and pathologic study.

Thirty patients with cystic disease of the bile ducts operated on between 1965 and 1985 were reviewed. Three patients (10%) had a synchronous adenocarcinoma, and in three patients (10%) a metachronous carcinoma developed for a total incidence of malignancy of 20%. All patients died within 1 year of the diagnosis of malignancy. Of 19 benign cysts available for pathologic examination, one third had proliferative epithelial changes, and in two of these patients a metachronous carcinoma developed. Goblet cell metaplasia was prominent in four patients. This suggests the possibility that dysplastic changes and metaplasia of the epithelium could give rise to carcinoma. Resection of benign cysts of the bile ducts is favored, when feasible, in an attempt to decrease the incidence of malignancy.

A technique of biliary tract reconstruction with complete follow-up in 44 consecutive cases

Forty-four consecutive stricture repairs by one surgeon with long-term follow-up study are reported. Sutured anastomoses were performed in 39 patients. Essentials of the sutured repair include minimal dissection of the proximal duct, a one-layer anastomosis, mucosa-to-mucosa apposition, and a preference for hepaticojejunostomy with a T-tube stent. Eighty-six per cent of the patients treated by this technique achieved satisfactory results. This technique is the procedure of choice for repair of biliary stricture

Pyloric and gastric preservation with pancreatoduodenectomy

Pyloric and gastric-preserving pancreatic resection was performed in 35 patients with no mortality. Twenty-seven patients were followed for at least 8 months postoperatively and are reported herein in detail. This variation in the Whipple procedure is associated with a satisfactory weight gain after operation for benign disease, does not produce the usual postgastrectomy digestive symptoms, and so far jejunal or anastomotic ulceration has not been a problem. We believe this variation of the Whipple procedure is the operation of choice for benign disease and for certain types of periampullary malignant growth.

Pancreatic abscess. A critical analysis of 113 cases.

Abstract Pancreatic abscess has continued to defy the best efforts in diagnosis and treatment and has remained a serious and often fatal complication. Few surgeons have had sufficient experience to recognize this serious complication, to evaluate its ramifications, and to develop adequate surgical technics in its management. Surgeons at the Lahey Clinic have accumulated a large experience in pancreatic abscess, 113 cases to date, which represents the largest series in the literature. A review of these cases was made in an effort to define diagnostic, therapeutic, and prognostic parameters that are of importance in management. Clinical features, usefulness of various diagnostic modalities, etiologic factors, bacteriologic features, complications of the abscess, operative findings, effectiveness of various forms of treatment, and results of follow-up study are analyzed. The increased survival rate and relatively smooth course of the majority of patients in this series are believed to be due to a timely, aggressive surgical approach, with wide debridement and sump drainage and liberal use of supportive measures, such as feeding jejunostomy, gastrostomy, colloid infusion, and enteral and parenteral hyperalimentation, all of which have been found useful and, indeed, sometimes essential in successful management.