William P. Longmire

Decreased morbidity and mortality after pancreatoduodenectomy

In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.

Resection of the liver for colorectal carcinoma metastases. A multi-institutional study of long-term survivors.

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to 1-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primarycarcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized.

Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost

Despite recent advances in perioperative support care, surgery for obstructive jaundice is still associated with significant morbidity and mortality. For this reason, preoperative percutaneous transhepatic drainage (PTD) has been recommended for these patients. This method of management, however, has only been supported by retrospective and nonrandomized studies. Therefore, a prospective, randomized study was performed to determine the effect of preoperative PTD on operative mortality, morbidity, hospital stay, and hospital cost. Thirty-day mortality was 8.1% among 37 patients undergoing preoperative PTD, compared to 5.3% for 38 patients who went to surgery without preoperative drainage. Overall morbidity was also slightly, but not significantly, higher in patients who underwent preoperative PTD (57% versus 53%). However, total hospital stay was significantly longer (p < 0.005) in the PTD group (31.4 days versus 23.1 days). The cost of this excess hospitalization and the PTD procedure at our university medical center was over

Surgical palliation for pancreatic cancer. The UCLA experience.

8000 per patient. The authors conclude that preoperative PTD does not reduce operative risk but does increase hospital cost and, therefore, should not be performed routinely.

Prognostic Factors in Bile Duct Carcinoma: Analysis of 96 Cases

We reviewed the records of 340 patients with a tissue diagnosis of pancreatic cancer treated at UCLA Medical Center between 1973 and 1988. Sixty-one patients underwent pancreatic resection (group 1), 173 had some form of surgical palliation (group II), and 106 had neither (group III). The diagnosis was made 1 to 2 months more quickly in the last 8 years of the review than in the first 8 years, but the effect of early diagnosis on curability was negligible. Biliary obstruction was best treated by cholecystojejunostomy or choledochojejunostomy, which were equally effective. Anastomoses to the jejunum were safer and more effective than were those to the duodenum for the relief of biliary obstruction. Gastrojejunostomy should be performed prophylactically as well as therapeutically. It was effective and safe in both settings. Surgical palliation for pancreatic cancer was generally effective and was associated with an operative mortality rate of less than 10%. However morbidity was high, with significant complications occurring in one third of cases.

Factors influencing outcome in patients with postoperative biliary strictures

A computerized analysis of prognostic variables was performed in 96 proven cases of extrahepatic bile duct carcinoma treated over a 24-year period at IJCI.A. Forty-nine percent of the lesions were in the upper third of the bile ducts and 47% of these were resected, for an operative mortality rate of 23% and a maximum survival rate of 4.5 years. Palliative procedures in this region were associated with a 16% mortality rate and maximum survival rate of three years. The patients whose lesions were in the middle third suffered no operative mortality rate for resection or palliation and had a 12% five-year survival rate, with the longest survivor lasting 11 years. In the lower third lesions, 67% were resected hy Whipples procedures, for an 8% mortality rate and a five-year survival rate of 28% extending to nine years. Resection of these difficult carcinomas offers the best hope of survival but must be weighed against the high operative mortality risk in those lesions located in the hilar region

Carcinoma of the pancreas and periampullary region.

We reviewed our experience from 1955 to 1979 with benign postoperative biliary strictures to determine which factors were associated with a favorable outcome. Patients operated on from 1970 to 1979 were significantly more likely (p less than 0.01) to achieve a good result (86 percent) than were patients undergoing surgery between 1955 and 1969 (68 percent). An inverse correlation (r = -0.96, p less than 0.05) was present between the number of previous repairs and the percentage of good results. Patients referred without a previous repair were most likely to achieve a good result (86 percent). Roux-Y jejunal reconstructions were associated with the best results (p less than 0.01). In recent years Silastic transhepatic stents were used in 20 patients with hilar strictures; 18 (90 percent) achieved good results. Patients stented for the shortest period (less than 1 month) were less likely to achieve a good outcome than those stented for longer periods (p less than 0.025). Patients with difficult hilar strictures who were stented for more than 9 months were more likely to have a good result if a changeable Silastic transhepatic stent was employed (p less than 0.01). This analysis suggests that early referral, Roux-Y jejunal reconstruction, judicious use of Silastic transhepatic stents, and prolonged stenting of hilar strictures will improve the outlook in patients with postoperative biliary strictures.U

Hepatic Surgery Trauma, Tumors and Cysts

Over a 21 year period, 245 cases of cancer of the pancreas were operated upon and followed-up at UCLA Hospital. A further 34 cases of periampullary tumor were treated by partial or total pancreatectomy. Apparent clearance of tumors at the time of pancreaticoduodenectomy that was confirmed by subsequent histopathology resulted in a patient survival time of 20.3 months as compared with a figure of 12.9 months when the pathological examination revealed tumor in a resection margin, although the surgeon believed that excision had been complete at the time of the operation. Frozen section examination of resection margins is therefore mandatory. The result of performing a pancreaticoduodenectomy in which tumor was seen to be left behind was a survival time of only 6.8 months, which is similar to the survival time of 6.2 months following a palliative biliary bypass. Pancreaticoduodenectomy in patients over the age of 70 resulted in an average survival of only 7.6 months. Of patients having a palliative biliary bypass alone, 13% required subsequent reoperation to bypass distressing duodenal obstruction. A duodenal bypass should therefore be a routine concomitant of a biliary bypass. Total pancreatectomy with duodenectomy for pancreatic cancer gave an increased average survival of 26 months, and it is likely that the frequency of performance of this operation will increase.

Cancer of the stomach. Review of consecutive ten year intervals.

Surgery is not a single applied science. It is the application of many sciences to the management of disease and injury.

Factors in management of acute cholangitis.

Records were reviewed for all patients who underwent primary treatment for adenocarcinoma of the stomach at two UCLA hospitals between 1956 and 1975. Division of the data into two, ten-year time periods reveals a pattern of unchanging presentation and pathologic characteristics which probably accounts for the unaltered response to operative therapy. The consistency of certain prognostic findings justifies a surgical approach in which extensive resections are only selectively employed.