Romano Delcore

Significance of lymph node metastases in patients with pancreatic cancer undergoing curative resection

BACKGROUND Recent reports suggest an improved survival following resection for patients with pancreatic carcinoma. However, the prognosis for patients with lymph nodes metastases remains uncertain. The purpose of this study was to determine if the presence of lymph node metastases significantly alters survival in patients with otherwise potentially curable pancreatic carcinoma. PATIENTS AND METHODS Between 1970 and 1995, 401 patients with pancreatic adenocarcinoma, including 327 patients with pancreatic head tumors, were evaluated and treated. RESULTS One hundred (31%) patients underwent pancreatoduodenectomy. Operative mortality was 3% and morbidity was 22%. Median survival for 97 patients discharged from the hospital following resection was 14 months (range 2 to 293). The estimated 1-, 2-, and 5-year survivals were 61%, 43%, and 20%, respectively. Median survival was 11.5 months (range 2 to 87) for patients with positive lymph nodes (n = 56) and 24 (range 0 to 293) months for patients with negative lymph nodes (n = 41; P = 0.0003). Ten patients (10%) survived longer than 5 years, and 9 (90%) of them had negative lymph nodes. Elderly patients (> or = 70 years) had a median survival twice as long as younger patients (24 versus 12 months, P = 0.03). CONCLUSIONS Lymph node metastases are found in 56% of patients undergoing resection. Pancreatoduodenectomy can be performed with low operative mortality in patients of all ages. It offers good palliation for patients with lymph nodes metastases and encouraging long-term survival rates as well as a chance for cure in patients with negative lymph nodes.

Transhiatal versus transthoracic esophagectomy for adenocarcinoma of the distal esophagus and cardia

BACKGROUND Transhiatal esophagectomy is a popular method of resection because of its reported lower morbidity and mortality and similar survival rates compared to transthoracic esophagectomy. A review of recent experience with these two procedures for resection of distal esophageal and cardia adenocarcinoma is reported. METHODS From 1988 to 1994, 48 patients with adenocarcinoma of the distal esophagus and gastric cardia were resected with intent to cure, 32 by transhiatal esophagectomy (group 1) and 16 by transthoracic esophagectomy (group II). The two groups were comparable in terms of patient demographics, preoperative risk factors, tumor stage, tumor differentiation, and involvement of resection margins (all not significant [NS]). RESULTS There was no significant difference in median intensive care unit stay, median hospital stay, incidence of postoperative anastomotic leak, and stricture. Respiratory complications were higher in group I (41% versus 6%, P = 0.01). Hospital mortality was not significantly different for the two groups (group I 3.1% versus group II 0%, NS). Actuarial 5-year survival rates (Kaplan-Meier) were 12% for group I and 39% for group II (NS). CONCLUSIONS These results suggest that when compared with transhiatal esophagectomy, the transthoracic approach is at least as safe, has comparable complication and survival rates, and remains an acceptable procedure for resection of adenocarcinomas of the distal esophagus and gastric cardia.

The role of pancreatojejunostomy in patients without dilated pancreatic ducts

OBJECTIVE To determine the safety and efficacy of longitudinal pancreatojejunostomy in patients with chronic pancreatitis and intractable pain who do not have a markedly dilated pancreatic duct. BACKGROUND Ductal decompression by side-to-side, longitudinal pancreatojejunostomy has become the operation of choice for patients with chronic pancreatitis and intractable pain when the pancreatic duct is markedly dilated. However, markedly dilated pancreatic ducts are found in less than 40% of patients with disabling pain. PATIENTS AND METHODS Twenty-eight consecutive patients with intractable pain from chronic pancreatitis, most of whom had minimal or no dilation of the pancreatic duct, were treated with side-to-side, longitudinal pancreatojejunostomy between 1970 and 1993. RESULTS There were 18 (64%) males and 10 (36%) females. The mean age was 41 years (range 11 to 72). The etiologies for chronic pancreatitis were alcohol (82%), gallstones (7%), trauma (7%), and familial trait (4%). Intractable pain was present for a mean of 4 years (range 0.5 to 12). Thirteen patients (46%) were dependent on narcotics prior to surgery. Twenty-five patients (89%) had minimal (< 8 mm) or no dilation of the pancreatic duct and 3 (11%) had markedly dilated pancreatic ducts (> 10 mm). All experienced complete pain relief in the immediate postoperative period. Twenty-four patients (86%) have remained free of pain after a mean follow-up of 3.5 years (range 1 to 8). CONCLUSIONS In patients with chronic pancreatitis and intractable pain, small pancreatic duct size should not be considered a contraindication to side-to-side, longitudinal pancreatojejunostomy.

Outcome of lymph node involvement in patients with the Zollinger-Ellison syndrome.

Prognosis of gastrinoma patients with metastases to lymph nodes only is uncertain, and the true nature of isolated nodal gastrinomas remains controversial. The purpose of this study was to determine the outcome of such patients and whether nodal gastrinomas may occur as primary lesions. Eleven patients with nodal involvement but without hepatic metastases are reported (mean follow-up of 129 months). Primary gastrinomas were located in the duodenum in seven (Group 1) and not identified in four (Group 2). In Group 1, five patients remained eugastrinemic after excision of all gross tumors and gastrectomy (n = 4) or pancreaticoduodenectomy (n = 1), one patient had residual disease and died of other causes (survival of 88 months), and one patient had MEA-I syndrome with multiple gastrinomas (follow-up of 126 months). In Group 2, three patients became eugastrinemic after nodal excision and total gastrectomy (mean follow-up of 212 months) and may represent primary nodal gastrinomas, and in one patient, liver metastases developed and the patient died. Four deaths occurred in a 27-year period, but only one was tumor-related. There was no significant difference in 20-year survival rates between the two groups (85% vs. 75%). It is concluded that 1) lymph node gastrinomas are usually metastatic from primary duodenal lesions, 2) although rare, nodal gastrinomas may occur as primary lesions, and 3) in the absence of hepatic metastases, lymph node gastrinomas, whether primary or metastatic, have a good prognosis and should not deter aggressive surgical treatment.

Liquid chromatographic monitoring of CSF metabolites

The determination of neurotransmitter metabolites in small animal CSF can provide an index of in vivo transmitter release in brain structures near ventricles. The metabolite analyses have most often used ventricular perfusion with radiolabeling for detection sensitivity. These methods have been thoroughly reviewed recently a. This note describes a new approach. High performance liquid chromatography (LC) coupled with electrochemical detection has ample sensitivity and the separation capabilities to directly analyse biogenic amines and their metabolites in ventricular CSF samples as small as 2-5/zl. A rapid, one-step analysis for the simultaneous determination of homovanillic acid (HVA), dihydroxyphenylacetic acid (DOPAC) and 5-hydroxyindoleacetic acid (5-HIAA) in such samples is described herein. The method can be used directly to follow in vivo release of dopamine (DA) and serotonin (5-HT) metabolites with drug and other brain stimulations. Samples (2-10 #1) are removed by microsyringe via an indwelling ventricular cannula and can be taken before, during, and after stimulation. With only acidification to prevent air oxidation, the samples are directly injected onto an LC column for quantitative readout. The analyses are directly representative of the metabolite concentrations in the ventricle at the time of sampling since they do not involve the dilution and time integration of collected perfusates. On the other hand, the discrete sampling may measure local inhomogeneities or gradients in ventricular concentrations. The new technique is not particularly useful for lateral ventricle monitoring in rat since only 1 or 2 samples per hour can safely be removed from the restricted ventricular volume. It appears ideally suited to rabbits and should work well with cats, a favored preparation for in vivo release studies. The LC method with electrochemical detection has been thoroughly described for catecholamine analysesL Identical equipment is used except anion resin columns and a different eluent serve to separate the acid metabolites. The choice of LC para-

Characteristics of cystic neoplasms of the pancreas and results of aggressive surgical treatment

Twenty-one patients with pancreatic cystic neoplasms (PCNs) were treated from 1970 to 1991. Their mean age was 54 years (range: 30 to 78 years), and 15 (71%) were women. Symptoms were present for a mean of 18 months (range: 5 to 60 months) and included pain (95%), abdominal mass (52%), weight loss (38%), and jaundice (14%). Nine patients had had previous operations and were either misdiagnosed or incorrectly treated; another seven patients had preoperative misdiagnoses of pseudocysts. There were six (29%) serous cystadenomas and two (10%) mucinous cystadenomas. These were treated by excision (n = 2), distal pancreatectomy (n = 5), or pancreatoduodenectomy (n = 1). No recurrence or malignant degeneration occurred during the mean follow-up of 9 years (range: 1 to 19 years). There were 13 (62%) patients with mucinous cystadenocarcinomas. Of these 13 patients, 3 had unresectable tumors, underwent palliative procedures, and died at 4, 7, and 9 months, respectively. Ten patients underwent pancreatoduodenectomy (n = 4), distal (n = 4) pancreatectomy, or total (n = 2) pancreatectomy: 1 died of recurrence (survival: 8 months), and the remaining 9 patients had a mean survival of 6 years (range: 2 to 20 years) without recurrence. This experience suggests that patients with PCNs have a good prognosis and are curable if the cysts are diagnosed early and completely resected.

Improving resectability and survival in patients with primary duodenal carcinoma

Of 35 patients with primary duodenal carcinoma (PDC), 13 were treated between 1960 and 1974 (group I) and 22 between 1975 and 1990 (group II). PDCs were found in the first 5 portions of the duodenum (14%), second 18 (51%), third 8 (23%), and fourth 4 (12%). Five patients (38%) in group I were deemed to have unresectable disease compared with only one patient (5%) in group II. Eight patients (62%) in group I underwent resection by either pancreatoduodenectomy (4) or segmental resection (4), and 20 patients (95%) in group II had pancreatoduodenectomy (17) or segmental resection (3). Operative mortality was 31% in group I and 0% in group II. Mean survival was 7 months (range: 0 to 22 months) in group I and 48 months (range: 6 to 218 months) in group II. None of the patients in group I survived for 2 years, whereas the 5-year survival for patients in group II was 62%. This experience suggests that resectability, operative mortality, and survival in patients with PDCs have improved markedly in recent years.

Pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms in elderly patients

Forty-two patients (age range: 70 to 86 years) underwent pancreaticoduodenectomy between 1970 and 1990 for carcinomas of the pancreas (23), ampulla (8), common bile duct (5), duodenum (5), or islet cells (1). After resection, reconstruction was done by either pancreaticojejunostomy (13) or pancreaticogastrostomy (25); four patients had total pancreatectomy. The mean duration of operation was 5 hours, the mean blood loss was 2,200 mL, the mean transfusion requirement was 4 units of blood, and mean length of hospitalization was 22 days. There were no leaks or other complications related to the pancreatic anastomoses. Six (14%) major complications occurred including two (5%) operative deaths. Mean survival was 42 months (range: 2 to 219 months) for the entire group and 35 months for patients over the age of 80. This experience suggests: (1) pancreaticoduodenectomy can be performed with low operative morbidity and mortality in elderly patients, and advanced age should not be considered a contrainindication to this potentially curative procedure; (2) pancreaticogastrostomy is a safe and easy alternate method of reconstruction; and (3) prolonged survival is possible for elderly patients following pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms.

Thrombolytic therapy for catheter-related thrombosis.

Thrombosis of the central venous system (CVT) occurs in 20% to 30% of patients with indwelling catheters. This complication is usually treated with anticoagulation, extremity elevation, and catheter removal. Thirty-eight patients with CVT at our institution were treated with thrombolytic therapy to rapidly resolve symptoms and avoid removal of the catheters. Complete clot lysis occurred in 36 of 38 patients (95%) within 1 to 5 days (mean: 2.4 days). Symptoms resolved with clot resolution. Thrombolytic therapy detected stenoses in 22 patients. Angioplasty was successful in 64% of these patients. Five catheters were removed. Complications occurred in six patients: nonfatal pulmonary embolus, three bleeding episodes, pain with infusion of urokinase, and an episode of septic phlebitis. This experience suggests that thrombolytic therapy is safe, rapidly resolves symptoms of thrombosis, uncovers anatomic abnormalities amenable to angioplasty, and allows central venous catheters to remain in place despite central venous thrombosis.

Significance of tumor spread in adenocarcinoma of the ampulla of vater

Twenty-eight patients with ampullary carcinoma were treated between 1965 and 1988: 22 underwent pancreaticoduodenectomy with 1 operative death (5 percent), 1 had local excision, 3 had bypass, and 2 were not explored. Of the 21 patients who survived pancreaticoduodenectomy, 4 had tumor confined to the ampulla, 7 had tumor extending into the duodenum, and 10 had tumor invasion beyond the duodenum. Nine of these patients had positive lymph nodes and 12 had negative lymph nodes. The patient who had local excision was disease-free at last follow-up 104 months postoperatively. Each of the three bypassed patients died of tumor progression within 15 months. The estimated 5-year survival rate for resected patients was 60 percent and was independently related to lymph node metastases (p = 0.031) and to tumor size (p = 0.039). This experience suggests that long-term survival is possible in patients with lymph node metastases or invasive tumors extending beyond the duodenal wall and that curative pancreaticoduodenectomy can be performed with a low operative mortality; therefore, aggressive surgical resection is recommended for all patients with ampullary carcinoma.