Michael J. Jacobs

The value of intraoperative ultrasound during hepatic resection compared with improved preoperative magnetic resonance imaging

BACKGROUNDnPatients with colorectal metastases confined to the liver may be cured by resection. Combined bimanual palpation and intraoperative ultrasound (IOUS) augment the detection of colorectal hepatic metastases. The importance of IOUS in the surgical management of hepatic tumors has been demonstrated and should arguably be considered the final diagnostic procedure.nnnOBJECTIVEnTo determine the relevance of routine IOUS prior to hepatic resection compared with improved preoperative Magnetic resonance imaging (MRI).nnnPATIENTS AND METHODSnEighty patients with metastatic colorectal adenocarcinoma underwent hepatic resection between 1998 and 2001. The IOUS results were compared with preoperative MRI, bimanual palpation, and resection histopathology. The preoperative surgical plan was compared with the surgical procedure performed. Data were retrospectively analyzed.nnnRESULTSnIOUS provided additional useful information not available preoperatively for 37 (47%) patients, including the identification of subcentimetre metastatic lesions, characterization of the lesion, and the anatomy of the hepatic vasculature. The preoperative surgical plan was changed secondary to the IOUS findings alone in 14/80 (18%) patients. IOUS did not provide any additional useful information for 43 (53%) patients. A correlation was demonstrated between the preoperative diagnosis, intraoperative findings, and resection histopathology.nnnCONCLUSIONnAccurate diagnostic studies facilitate critically decisive actions during planned hepatic resection(s). The current findings suggest that IOUS provide the most useful additional information for hepatic lesions, despite recent improvements in preoperative MRI scanning. Furthermore, routine IOUS should be employed during hepatic resection for colorectal metastases.

Prognostic factors in primary adenocarcinoma of the small intestine: 13-year single institution experience

BackgroundAdenocarcinoma of the small bowel is a relatively rare malignancy as compared to the other malignancies of the gastrointestinal tract. Nonspecific presentation and infrequent occurrence often leads to a delay in diagnosis and consequent poor prognosis. Various other factors are of prognostic importance while managing these tumors.MethodsThe medical records of a total of 27 patients treated for adenocarcinoma of the small bowel at Providence Hospital and Medical Centers from year 1990 through 2003 were reviewed retrospectively. Data were analyzed using SPSS software (version 10.0; SPSS, Inc., Chicago, IL). Survival analyses were calculated using the Kaplan Meier method with the log rank test to assess the statistical significance. The socio-demographics (age, gender) were calculated using frequency analyses.ResultsThe patients included nine males and eighteen females with a median age at diagnosis of 62 years. Only 48% of the patients had an accurate preoperative diagnosis while another 33% had a diagnosis suspicious of small bowel malignancy. None of the patients presented in stage 1. The cumulative five-year survival was 30% while the median survival was 3.3 years. There was no 30-day mortality in the postoperative period in our series.ConclusionThe univariate analysis demonstrated that tumor grade, stage at presentation, lymph nodal metastasis and resection margins were significant predictors of survival.

Total laparoscopic pancreaticoduodenectomy.

Total laparoscopic pancreaticoduodenectomy may be a viable alternative to the standard Whipple procedure, offering the potential of a decreased length of stay, quick recovery, and improved quality of life.

Pancreatic schwannoma: literature review.

Pancreatic schwannoma is a rare neoplasm. Accurate preoperative diagnosis remains difficult, but computed tomography (CT) scanning and magnetic resonance imaging (MRI) help to establish the diagnosis, and definitive diagnosis requires immunohistochemical examination. Cystic pancreatic schwannomas should be considered in the differential diagnosis of cystic neoplasms and pseudocysts. Simple enucleation may be adequate for pancreatic schwannoma. In this report, we examine a case of benign pancreatic schwannoma in a 56-year-old woman. She was being evaluated for an ovarian teratoma, and an 8-cm cystic mass was incidentally found in the head of the pancreas. She underwent a pylorus preserving Whipple procedure with bilateral oopherectomy. Only 37 cases have been reported in the English literature. We present a thorough review with an emphasis on the clinical presentation, diagnostic modalities, and treatment options in the management of this rare clinical entity.

Lipomatous pseudohypertrophy of the pancreas: a clinicopathologically distinct entity.

Objectives: Owing to the challenges in obtaining pancreatic biopsies, pancreatic resection for presumed malignancy is often performed without histological confirmation. As a result, benign lesions are sometimes surgically removed. One such condition, which is poorly defined in the literature, is referred to as lipomatous pseudohypertrophy (LPH) of the pancreas. Methods: Five cases of LPH were analyzed. Results: Four patients underwent surgical resection, 3 of which were diagnosed preoperatively by radiology as having ductal adenocarcinoma. The fourth case was correctly interpreted by magnetic resonance imaging as LPH, but the patient underwent resection because of the intractable pain due to pancreatitis. The fifth patient has been placed on watchful waiting. Two tumors were in the pancreatic head, one in the tail, one in the uncinate process, and one demonstrated diffuse involvement. Microscopically, they were characterized as having normal lipocytes without lipoblasts or inflammation. Within the adipose tissue, scattered microscopic foci of pancreatic parenchyma could be seen. Conclusion: Lipomatous pseudohypertrophy of the pancreas is a distinct entity characterized by localized/diffuse replacement of pancreatic parenchyma with mature adipose tissue. It forms a pseudotumor that may be difficult to distinguish clinically from pancreatic adenocarcinoma. This entity should be considered when evaluating patients with a new diagnosis of a hypodense pancreatic neoplasm on imaging.

Interferon receptor alpha/beta is associated with improved survival after adjuvant therapy in resected pancreatic cancer

AIMnInterferons (IFNs) are known to have antiproliferative and immunoregulatory activities that are modulated through specific cell surface ligands, known as IFN-alpha, -beta, and -gamma receptors. The presence of these receptors and their impact on response to adjuvant therapy in patients with pancreatic cancer has not been determined.nnnPATIENTS AND METHODSnSlides were prepared from 46 patients with pancreatic adenocarcinoma. Immunohistochemistry (IHC) was subsequently used to determine the expression of IFN- alpha/beta receptor-chain 2 (IFN-alpha/betaR) and IFN-gamma receptor-chain 1 (IFN-gammaR). The correlation between IFN receptor expression, tumor characteristics, and the overall patient response to adjuvant therapy were determined analytically.nnnRESULTSnThe IHC performed for pancreatic adenocarcinoma demonstrated a high IFN-alpha/betaR expression in 4% (2/46) of patients, moderate expression in 20% (9/46) of patients, and faint or no expression in 76% (35/46) of patients. IHC confirmed a high expression of IFN-gammaR in 52% (24/46) of patients, moderate expression in 35% (16/46) of patients, and faint or no expression in the remaining 13% (6/46) of patients. Thirty-two (69.7%) patients received adjuvant therapy. Clinicopathological survey did not demonstrate any significant correlation between IFN-alpha/betaR and IFN-gammaR expression with regard to tumor size, vascular invasion, perineural invasion, lymph node metastases, or stage of disease. Use of adjuvant therapy was associated with increased survival in patients with IFN-alpha/betaR-positive tumors compared with patients with IFN-alpha/betaR-negative tumors (24 months versus 14.7 months in log rank test, p=0.012). The expression of IFN-gammaR, however, had no impact on patient survival (20 months vs 17 months; p=0.656, log rank test).nnnCONCLUSIONnIFN-alpha/betaR is associated with improved survival for patients with resectable pancreatic cancer who received adjuvant therapy.

Comparison between staple and vessel sealing device for parynchemal transection in laparoscopic liver surgery in a swine model

BACKGROUNDnAdvancements in technology have allowed laparoscopic surgery to expand into advanced procedures such as liver resection; however, the transection method is debatable. This study was designed to evaluate the feasibility and outcome of laparoscopic liver resection comparing the vessel sealing device (VSD) versus endomechanical stapling devices for parenchymal transection in a swine model.nnnMATERIALS AND METHODSnLaparoscopic left hepatectomy was performed in two groups (n=7 in each group) comparing the stapler device with the VSD. The cut surfaces of the liver were evaluated for bleeding and biliary leakage at the time of the operation and 1 week later. The animals were sacrificed 1 week after the operation to determine hemorrhage and bile leakage, and to allow histological evaluation of the liver. Serum liver enzymes were checked before, after, and 1 week postoperatively.nnnRESULTSnNo evidence of biliary leakage or hemorrhage was noted at the time of the operation and 1 week later for both groups. There was a trend toward an increase in blood loss in the stapled group compared with LigaSure (40+/-16.4 cc vs 17+/-3.7 cc, p>0.05). There was also a trend toward shorter transection time in the stapled group compared with the LigaSure group (15+/-4.1 min vs 21.8+/-5.3, p>0.05). The instrument cost was significantly higher in the stapled group (720+/-110 vs 400+/-50; p<0.05). There was no difference in serial liver enzymes and liver histopathology in the two groups.nnnCONCLUSIONSnThe VSD and endomechanical stapler can be safely and effectively used for parenchymal transection during laparoscopic liver resection. However, using endomechanical staplers is associated with an increase in cost.

Benefits of surgical experience in a third-world country during residency.

PURPOSEnCompletion of a United States surgical residency enables the graduate to provide service in most populated areas. Graduates are technically well trained and efficient in performing most surgeries. United States-based teaching facilities are generally furnished with technically advanced supplies and equipment. Access to financial reserve is also available. Surgery in third-world countries, however, can be challenging. These countries, particularly in the outskirts, lack supplies and innovation, such as advanced equipment, medication, and personnel. Compounding the problem, patients tend to have advanced pathology and diminished financial means.nnnMETHODSnThe United States-based surgical team annually collaborated with a medical mission to provide service to a rural community of the Dominican Republic. A senior-level surgery resident accompanied the surgeon. Surgical supplies were donated and brought with the team. The average number of cases performed was approximately 37 per week. All procedures were performed for symptomatic pathology. All patients were preoperatively screened and evaluated for comorbidities.nnnRESULTSnNo immediate complications occurred. Local physicians provide long-term follow-up. Pediatric procedures were not performed secondary to lack of postoperative resources.nnnCONCLUSIONSnSurgical experience is beneficial to the recipient community and the resident surgeon. The extent of pathology and lack of resources enforces efficiency and broadens skills. This opportunity can potentially prepare surgeons for the growing need of rural surgery.

Protective effect of methylprednisolone on warm ischemia-reperfusion injury in a cholestatic rat liver.

BACKGROUNDnCholestasis has been identified as a risk factor for oxidative stress, and it potentially enhances after ischemic-reperfusion injury. The aim of this study was to evaluate the role of methylprednisolone on warm ischemia-reperfusion injury in the presence of cholestasis.nnnMETHODSnA reversible cholestatic rat model was created. After 7 days, rats received 30 mg/kg of intravenous methylprednisolone 2 hours before ischemia, followed by 30 minutes of ischemia. Rats were euthanized 24 hours after ischemia. Serum aspartate aminotransferase and interleukin-6 were measured, and the liver was harvested for histology and myeloperoxidase estimation.nnnRESULTSnMethylprednisolone had a protective effect, with a statistically significant decrease in aspartate aminotransferase (P=.01) and a trend toward decreased levels of interleukin-6 (P=.07). Histology showed a significant difference in architectural distortion (P=.01), cytoplasmic vacuolation (P=.01), and nodular hepatocellular necrosis (P=.04).nnnCONCLUSIONSnMethylprednisolone attenuated the ischemic-reperfusion injury in the presence of cholestasis and can be considered for clinical use in the presence of cholestasis.

Analysis and implications of changing hepatopancreatobiliary (HPB) case loads in general surgery residency training for HPB surgery accreditation

OBJECTIVEnThis study was conducted to determine whether residents are receiving enough hepatopancreatobiliary (HPB) training during general surgery residencies to exclude the necessity of pursuing formal fellowships in HPB surgery.nnnMETHODSnTrends in HPB surgery training were examined using Accreditation Council for Graduate Medical Education (ACGME) operative log data for the academic years 1999/2000 to 2009/2010.nnnRESULTSnOf 800,000 HPB operations performed annually in the USA, the proportion of HPB procedures performed by general surgery residents increased from 15% (122,007) to 18% (143,000) between the periods under study. Numbers of pancreatic, liver and biliary procedures performed by graduating general surgery residents increased by 47% (from 8185 to 12,006), 31% (from 7468 to 9765), and 14% (from 106,354 to 121,239), respectively. The mean number of operations undertaken by a graduating resident increased from 8.3 to 11.5 (38% increase) for pancreatic surgeries, from 7.6 to 9.4 (24% increase) for liver surgeries, and from 107.5 to 116.6 (8% increase) for biliary surgeries. Total numbers of complex pancreatic, liver and biliary procedures increased by 91% (from 4768 to 9129) and 24% (from 6649 to 8233), and decreased by 29% (from 6581 to 4648), respectively.nnnCONCLUSIONSnThe overall trend shows an increase in the number of HPB procedures undertaken by graduating general surgery residents. The mean number of procedures exceeds ACGME requirements, but falls short of association guidelines. However, certain residents exceed International Hepato-Pancreato-Biliary Association (IHPBA) fellowship requirements for total and complex procedures during residency. Consideration should be given to those residents to allow them to bypass fellowship training provided that they meet other IHPBA standards.