Ronald K. Tompkins

Primary sclerosing cholangitis: results of an aggressive surgical approach.

Traditional management of patients with primary sclerosing cholangitis (PSC) has included steroids and/or choledochotomy plus prolonged T-tube drainage. The authors have not been convinced, however, that either of these therapies significantly influence the course of the disease. Therefore, a more aggressive surgical approach was adopted that included performance of a choledochoenteric anastomosis in all patients with PSC who had either (1) a major area of extrahepatic blockage, or (2) primary involvement of the extrahepatic bile ducts. Using this approach, 17 of 22 patients (77%) managed surgically at the UCLA Medical Center from 1974 through 1980 have undergone a choledochoenteric anastomosis. Of these 17 patients, 13 (77%) have had an excellent or good result following surgery. Four patients whose disease was confined to the common bile duct have all had excellent results (mean follow-up 49.3 months since surgery). In addition, 18 of the entire group of 22 patients (82%) are still alive, a mean of 52.2 months after operation and 64.7 months following establishment of the diagnosis. These results in 22 patients encourage the authors to continue to pursue an aggressive surgical approach for patients with primary sclerosing cholangitis.

Primary sclerosing cholangitis. A heterogenous disease

The clinical, radiologic and pathologic features of 37 patients diagnosed as having primary sclerosing cholangitis (PSC) were reviewed. Sixty-two per cent were men, and 35% had ulcerative colitis. The patients demonstrated considerable variability in their natural history and pathology. It appeared that they could be divided into four fairly distant groups (1) sclerosing cholangitis affecting primarily the distal common bile duct; (2) sclerosing cholangitis occurring soon after an attack of acute necrotizing cholangitis; (3) chronic diffuse sclerosing cholangitis; and (4) chronic diffuse sclerosing cholangitis associated with inflammatory bowel disease. It is suggested that the patients in these groups may have different etiologies, may respond to different treatment regimes, and may have different prognoses.

Primary adenocarcinoma of the duodenum: analysis of survival

A survival analysis of 24 patients with primary adenocarcinoma of the duodenum managed at UCLA, Los Angeles, California, U.S.A. was made with reference to their pathological findings. Pancreaticoduodenectomy as a curative procedure was performed in 15 patients with 2 deaths postoperatively. Palliative surgery with either segmental duodenal resection (4 patients) or gastrojejunostomy (5 patients) had no complications. Metastatic disease to the paraduodenal nodes in close proximity of the duodenum, and distant regional nodes around the celiac axis, paraaortic region, and mesentery occurred frequently (63.6%). The extent of nodal disease significantly affected the survival of these patients (p=0.016). When the disease was confined to the paraduodenal nodes, the median survival was 16.47 months, which was less than that for those patients without nodal secondaries (median survival, 42 months) but much better than that for those who had metastasized to distant regional nodes (median survival, 5.97 months). The depth of transmural neoplastic penetration was also probably of prognostic importance since it correlated significantly with the extent of metastatic lymph nodes (p=0.04). Regardless of the paraduodenal nodal status, pancreaticoduodenectomy should be attempted for all patients with primary duodenal adenocarcinoma when careful examination has excluded regional nodal involvement and systemic dissemination.RésuméLa survie de 24 patients ayant un adénocarcinome primitif du duodénum traité à lUniversité de Californie à Los Angeles a été analysée selon lhistologie. Une duodénopancréatomie céphalique a été réalisée dans un but curatif chez 15 patients avec 2 morts postopératoires. La chirurgie palliative consistait en une résection duodénale segmentaire (4 cas) ou une gastroentérostomie (5 cas) sans complication immédiate. Les ganglions lymphatiques paraduodénaux, coliques, para-aortiques et mésentériques étaient analysés dans 63.6% des cas. Lenvahissement ganglionnaire influençait de façon significative la survie (p=0.016). Lorsque lenvahissement intéressait seulement les ganglions paraduodénaux, la survie médiane était de 16.47 mois, inférieure à celle des patients sans envahissement ganglionnaire (survie médiane, 42 mois), mais meilleure que celle des patients avec envahissement des ganglions régionaux à distance (survie médiane, 5.97 mois). La profondeur de latteinte néoplasique pariétale était dune importance pronostique capitale car elle était en corrélation significative avec latteinte des ganglions lymphatiques (p=0.04). Quel que soit létat ganglionnaire paraduodénal, il faut essayer de réaliser une duodénopancréatectomie céphalique chez tout patient avec un adénocarcinome primitif du duodénum si lon peut exclure lenvahissement ganglionnaire régional ou la dissémination systémique.ResumenSe efectuó un análisis de supervivencia en los 24 pacientes con adenocarcinoma primario del duodeno manejados en la Universidad de California de Los Angeles entre julio de 1954 y septiembre de 1986, mediante el análisis retrospectivo de las historias clinicas y con el propósito de determinar la modalidad más apropiada de terapia quirúrgica en esta entidad.La pancreaticoduodenectomía como procedimiento curativo fue realizada en 15 pacientes con 2 muertes postoperatorias; cirugía paliativa con resección duodenal segmentaria (4 pacientes) o gastroyeyunostomía (5 pacientes) fue realizada sin complicaciones. Se observó enfermedad metastásica a los ganglios paraduodenales de la vecindad inmediata y a los más distantes ganglios ubicados alrededor del tronco celíaco, la región paraaórtica, y el mesenterio, con elevada frecuencia (63.6%) y el grado de la invasión ganglionar demostró afectar en forma significativa la supervivencia de estos pacientes (p=0.016). Cuando la enfermedad permaneció confinada a los ganglios paraduodenales, la supervivencia media fue 16.47 meses, inferior a la de los pacientes sin ganglios afectados (supervivencia media, 42 meses), pero bastante mejor que la de los pacientes con ganglios distales afectados (supervivencia media, 5.97 meses). La profundidad de la penetración transmural del neoplasma también parece tener importancia en cuanto al pronóstico y exhibió correlación significativa con el grado de metástasis ganglionares (p=0.04). Sin consideración del estado ganglionar paraduodenal, se debe intentar la pancreatoduodenectomía en todo paciente con adenocarcinoma primario del duodeno una vez que un examen meticuloso haya excluído la presencia de extensión ganglionar regional o diseminación sistémica.

Serum alpha1-fetoglobulin in a patient with hepatic metastases from bronchogenic carcinoma

A patient with bronchogenic carcinoma with metastases to the liver was found to have α1-fetoglobulin in his serum. The presence of this protein in the serum of adults was believed to be specific for hepatoma or testicular teratoblastoma; however, 4 recent cases were reported in which α1-fetoglobulin was present in patients with gastric carcinoma and hepatic metastases. As a result of these cases the strict specificity of α1-fetoglobulin and its ability to distinguish between primary and secondary hepatic tumors must be questioned.

Amino terminal fragments of human progastrin from gastrinoma

Two peptides which copurified from a human gastrinoma were found to correspond to the amino acid sequence deduced for the amino terminal portion of human and porcine progastrin. The sequence of peptide A is Ser-Trp-Lys-Pro-Arg-Ser-Gln-Gln-Pro-Asp-Ala-Pro-Leu-Gly-Thr-Gly-Ala-Asn- Arg-Asp-Leu-Glu-Leu which is identical to an amino terminal portion of human progastrin. The sequence of peptide. B is identical to that of peptide A except it is missing the first five amino acids. If peptide A corresponds to the amino terminus of progastrin, the signal peptidase cleaves at an Ala-Ser bond.

The surgical treatment of pancreatic disease

Periampullary carcinoma and chronic pancreatitis are the most frequent indications for operations on the pancreas.Exploration and resection by pancreaticoduodenectomy is the preferred method of treatment for carcinoma of the periampullary region when the malignancy is localized to this area and when it does not invade the superior mesenteric vein. A direct anastomosis of the remaining pancreatic duct to the side of the jejunum is performed when possible. Total pancreatectomy has been utilized for extensive carcinomas of the pancreas and for early lesions with an essentially normal pancreatic parenchyma to avoid the hazards of the pancreaticojejunal anastomosis.Chronic pancreatitis has been treated by various operative procedures. Duct stenosis and calculi, fibrosis and inflammation, and occasional pseudocyst formation commonly occur in the head of the gland. This area seems to act as a site of origin and perpetuation of the disease process. Proximal pancreatic resection by pancreaticoduodenectomy is being performed more frequently with anastomosis of five to 15 per cent of the pancreatic tail to the jejunum. Diabetes may be prevented and some external pancreatic enzyme function may thereby be preserved.In any pancreaticoduodenectomy, preservation of the entire stomach and first portion of the duodenum and intact pylorus should be considered. Preliminary observations suggest that the presence of an intact stomach and a functioning pylorus tend to lessen the digestive disturbances following this resection.After total pancreatectomy, further efforts should be made to extract and regraft the patients viable islet of Langerhans cells from the excised pancreas. A reliable method of restoring insulin production would extend the use of total pancreatectomy for both malignant and benign pancreatic disease.

Treatment and prognosis in bile duct cancer

Over the past 30 years, a total of 165 patients with bile duct cancer have been studied at the University of California at Los Angeles (UCLA), U.S.A. A review of careful retrospective analyses of surgical treatment is presented. The data support a treatment strategy of resection of those tumors which can be grossly removed at operation. Palliation of other patients is best done by biliary-enteric bypass or operative intubation. The higher morbidity and mortality rates for palliative resections, together with a poorer quality of life in those patients surviving this procedure, argue against resection for palliative purposes.RésuméUne analyse rétrospective soignée du traitement chirurgical de 165 malades atteints dun cancer des canaux biliaires et opérés à UCLA, au cours des 30 dernières années est présentée par lauteur. Cette analyse lui permet de définir la stratégie à suivre pour réséquer les tumeurs qui peuvent être extirpées presque totalement par la chirurgie. Dans les autres cas le traitement relève de la constitution dune dérivation bilio-digestive ou de lintubation transtumorale chirurgicale. Les taux élevés de la mortalité et de la morbidité des résections palliatives allant de pair avec une pauvre qualité de la survie sinscrivent contre ce genre dintervention.ResumenSe realizó un cuidadoso análisis retrospectivo del tratamiento quirúrgico en 165 pacientes con cáncer del canal biliar manejados en la Universidad de California de Los Angeles, Estados Unidos, en el curso de los pasados 30 años. Los datos obtenidos dan apoyo a la estrategia terapéutica de resección de aquellos tumores que pueden ser totalmente removidos mediante la operación, pero la resección paliativa de cánceres altos de la vía biliar, con o sin resección hepática, aparece asociada con mayores tasas de morbilidad y mortalidad operatoria y no resulta en mejor supervivencia que la observada con intubación biliar. La mejor paliación en estos casos se obtiene mediante derivación bilioentérica o intubación operatoria. Las mayores tasas de morbilidad y mortalidad de las resecciones paliativas, junto con una más pobre calidad de la vida de los pacientes que sobreviven el procedimiento, son argumenta suficiente en contra de la resección con propósitos paliativos solamente.Over the past 30 years, a total of 165 patients with bile duct cancer have been studied at the University of California at Los Angeles (UCLA), U.S.A. A review of careful retrospective analyses of surgical treatment is presented. The data support a treatment strategy of resection of those tumors which can be grossly removed at operation. Palliation of other patients is best done by biliary-enteric bypass or operative intubation. The higher morbidity and mortality rates for palliative resections, together with a poorer quality of life in those patients surviving this procedure, argue against resection for palliative purposes. Une analyse rétrospective soignée du traitement chirurgical de 165 malades atteints dun cancer des canaux biliaires et opérés à UCLA, au cours des 30 dernières années est présentée par lauteur. Cette analyse lui permet de définir la stratégie à suivre pour réséquer les tumeurs qui peuvent être extirpées presque totalement par la chirurgie. Dans les autres cas le traitement relève de la constitution dune dérivation bilio-digestive ou de lintubation transtumorale chirurgicale. Les taux élevés de la mortalité et de la morbidité des résections palliatives allant de pair avec une pauvre qualité de la survie sinscrivent contre ce genre dintervention. Se realizó un cuidadoso análisis retrospectivo del tratamiento quirúrgico en 165 pacientes con cáncer del canal biliar manejados en la Universidad de California de Los Angeles, Estados Unidos, en el curso de los pasados 30 años. Los datos obtenidos dan apoyo a la estrategia terapéutica de resección de aquellos tumores que pueden ser totalmente removidos mediante la operación, pero la resección paliativa de cánceres altos de la vía biliar, con o sin resección hepática, aparece asociada con mayores tasas de morbilidad y mortalidad operatoria y no resulta en mejor supervivencia que la observada con intubación biliar. La mejor paliación en estos casos se obtiene mediante derivación bilioentérica o intubación operatoria. Las mayores tasas de morbilidad y mortalidad de las resecciones paliativas, junto con una más pobre calidad de la vida de los pacientes que sobreviven el procedimiento, son argumenta suficiente en contra de la resección con propósitos paliativos solamente.

Surgical research publication in a selection of research and surgical speciality journals

BACKGROUNDnA prior study revealed a paucity of surgical research in the 5 top-rated general surgery journals for 1998. The hypothesis of the current study was that a large amount of surgical research was published in other journals.nnnMETHODSnIn all, 15 research journals and 9 surgery specialty journals were reviewed for basic research, funded clinical studies, randomized clinical trials, and drug trials. The funding sources and the surgeons role were recorded. The findings were compared with research published in the previously studied 5 journals in 1998 and 2005.nnnRESULTSnOf 6,016 papers in the research and surgery specialty journals, 19% were research, of which 76% were basic research. Funding from 1,101 sources was provided to 825 studies (70%). Seventy-four percent of funded studies were basic research. Government was the source for 46% of grants, private for 41%, and industry for 13%. A surgeon was the sole or senior author in 72% of studies. A total of 1,172 research articles were published in the research and surgery specialty journals in 1998. In comparison, 369 research papers were published in the general surgery journals in 1998 and 306 papers were published in 2005. With respect to the type of research, there were 896 basic research papers in the research and specialty journals in 1998, 200 such papers in the general surgery journals in 1998, and 164 in 2005. There were 87 randomized trials in the research and the surgery specialty journals in 1998, 46 such papers in the general surgery journals in 1998, and 29 in 2005.nnnCONCLUSIONnA 3-fold greater volume of surgical research and more than a 4-fold greater volume of basic research was found in the research and the surgical specialty journals than in the general surgical journals in 1998, and this margin is increased when compared with the data for 2005. Consideration of only the general surgical journals greatly underestimates the surgical research being conducted.

Gastrointestinal Hormones in Clinical Disease: Recent Developments

With the advent of radioimmunoassay and immunocytochemical methods, the peptides of the gastrointestinal tract have been identified and measured. Gastrinoma and insulinoma syndromes have been wall characterized. The pancreatic cholera syndrome and some of the evidence that the major manifestations of this disease may be mediated by vasoactive intestinal peptide have been re-examined. Pancreatic polypeptide seems to be an ideal peptide for study of vagal-cholinergic mechanisms that regulate hormone release; it also appears to be a tumor marker for several types of pancreatic endocrine tumors, particularly those of pancreatic cholera. Secretin and cholecystokinin are important regulators of pancreatic exocrine secretion and have been used to test pancreatic function, but there is little evidence that they account for clinical disease. Glucagon-secreting tumors produce a clinical syndrome of diabetes mellitus and distinctive skin lesions, which can be cured by tumor resection. Hormone-secreting tumors may provide insight into normal gut physiology.

The surgical journal of the future: how will it appear?

Not since the invention of the printing press in 1440 by Johannes Gutenberg has there been such a revolution in the methods of dissemination of knowledge as is now being seen in the electronic media. The time-honored printed journal is becoming obsolete and open-access electronic journals and other technological innovations are rapidly reshaping the field of scientific publication. This paper will explore some of the forces driving these changes and what lies in store for the surgical journal of the future.