Classification of neuroendocrine carcinomas of the gastrointestinal tract.
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Gastrointestinal Neoplasms↗
Biomedical subjects
D J Deziel
Publications and source records attributed to D J Deziel.
Laparoscopic general surgery: state of the art.
The rapid acceptance of laparoscopic cholecystectomy into surgical practice has been followed by the extension of laparoscopic treatment to many other surgical problems. While the role of laparoscopic surgery for some conditions is now well established, its applicability in other situations requires further evaluation. This review summarizes our current understanding of the laparoscopic management of common surgical disorders involving the gallbladder and bile ducts, groin hernias, appendix, colon, stomach, and esophagus.
Cholecystectomy, Laparoscopic↗
Laparoscopic liver biopsy in patients with coagulopathy, portal hypertension, and ascites.
The safety, reliability, and technique of laparoscopic liver biopsy were evaluated in 22 consecutive patients with coagulation abnormalities who were considered high risk for standard percutaneous liver biopsy. Fifty-eight biopsies were performed in 15 men and seven women. All patients had a prolonged prothrombin time (> 13.5 seconds), bleeding time (> 9 minutes), or thrombocytopenia (< 100,000 TH/UL). Ten patients (45%) had more pronounced coagulation abnormalities defined as a prolonged PT > 2.5 seconds or < or = 30% control, platelet count < 50,000 TH/UL, or bleeding time twice normal. Thirteen patients (59%) had both thrombocytopenia and a prolonged PT. Ascites was present in 19 patients (86%) and portal hypertension in 16 (73%). Laparoscopic liver biopsy was performed under general anesthesia, most commonly using two trocar sites and an open laparoscopic technique. Hemostasis was most effectively obtained by application of direct pressure and topical gelfoam and thrombin. A postoperative drop in hemoglobin of > or = 1 gm per cent occurred in four patients. One patient required laparotomy for postoperative bleeding and was the only patient requiring transfusion of red blood cells. Other complications included two minor ascitic leaks, one small subcapsular hematoma, and one wound infection. In conclusion, laparoscopic liver biopsy can be performed safely and reliably in patients with conditions contraindicating percutaneous biopsy.
Adult↗
Evaluation of the postoperative stomach and duodenum.
Patients who undergo a gastric or duodenal operation present challenging problems to the physician. Currently, gastric or duodenal operations are performed to correct peptic ulcer disease and its complications, resect benign or malignant masses, and control obesity. Indications for surgery in patients with peptic ulcer disease include hemorrhage, perforation, obstruction, ulcer intractability, and the inability to exclude malignancy in a gastric ulcer. Neoplasms of the stomach and duodenum require resection, depending on their benign or malignant nature, their location, the extent of disease, and the underlying physiologic status of the patient. Most clinically significant gastroduodenal masses are malignant and require formal anatomic resection, usually with distal or total gastrectomy. Stapling procedures have been shown to be effective in reducing excess body weight with creation of a small gastric pouch to restrict the outlet and cause early satiety, decreased caloric intake, and weight loss. Reliable radiologic findings depend on a thorough understanding of the complex anatomic and physiologic alterations that occur after surgery and familiarity with appropriate techniques of examination. With this background, complications unique to the surgical procedure as well as general complications found in all postoperative patients with be detected quickly and accurately.
Contrast Media↗
Complications of cholecystectomy. Incidence, clinical manifestations, and diagnosis.
Both open cholecystectomy and laparoscopic cholecystectomy are highly safe and effective procedures for the treatment of patients with symptomatic cholelithiasis. Today, adverse outcomes after open cholecystectomy are largely limited to elderly patients with co-morbid conditions and complicated biliary tract disease. Although infrequent, major biliary complications still occur and have been slightly more common in the initial experience with laparoscopic cholecystectomy. Diagnosis of these potentially serious problems is founded on recognition of their early clinical manifestations and accurate cholangiographic definition on which definitive therapy is predicated.
Biliary Tract Diseases↗
Appearances of the postoperative alimentary tract.
In summary, patients who have had alimentary tract operations are looked upon by most radiologists as a travail rather than a challenge. This article has reviewed common operations and has given some definite guidelines to ensure accurate radiologic diagnoses of patients who have had even complicated alimentary tract surgery.
Digestive System↗
Synchronous, metachronous, and multiple hepatic resections of liver tumors originating from primary gastric tumors.
BACKGROUND: The role of hepatic resection for noncolorectal gastrointestinal malignancies involving the liver is not well defined. To address this issue we studied our experience with resection of liver tumors arising from primary gastric malignancies. METHODS: A retrospective study of 195 patients who underwent a total of 207 liver resections identified 12 patients with primary gastric cancer who underwent 16 resections for liver involvement. There were 10 adenocarcinomas and two leiomyosarcomas. We examined the type of hepatic surgery, the status of residual disease, and the primary histologic findings. Morbidity, mortality, and actual survival rates were recorded. RESULTS: Thirty-day operative mortality was 8.3% (1 of 12). Hospital mortality was 25% (3 of 12). Operative morbidity occurred in three of nine survivors (33%). Synchronous en bloc resection (n = 3) of stomach and liver for adenocarcinoma produced two long-term survivors (no evidence of disease for 10 and 13 years). Mean survival after synchronous discontinuous resection (n = 4) was 8 months (range, 2 to 17 months). Metachronous resection for adenocarcinoma (n = 3) produced one long-term survivor (74 months), and one patient with recurrent leiomyosarcoma underwent a total of five liver resections and survived 64 months. CONCLUSIONS: For adenocarcinoma, en bloc resection of contiguous liver involvement produced long-term survivors. Synchronous resection of discontinuous metastases did not. Metachronous resection of isolated disease and multiple resections of recurrent isolated disease may have value in carefully selected patients.
Adenocarcinoma↗
Neuroendocrine carcinomas of the stomach: a clinicopathologic evaluation.
BACKGROUND: The purpose of this study was to determine by immunocytochemistry the relative incidence and clinicopathologic characteristics of neuroendocrine carcinomas of the stomach. METHODS: Sections from paraffin blocks from 81 patients who had undergone resection of carcinomas of the stomach were immunostained with a battery of neuroendocrine differentiation markers and with A-80, a marker of exocrine differentiation. The clinical and pathologic data of the 12 patients diagnosed with neuroendocrine carcinomas of the stomach were analyzed. RESULTS: The 10 men and two women ranged from 53 to 81 years of age (median, 69 years). Procedures performed included distal subtotal gastrectomy in eight patients and total gastrectomy in four patients. Pathologic stages were stage I, one patient; stage III, four patients; and stage IV, seven patients. Metastatic sites included regional nodes, 11 patients; liver, four patients; and bone, one patient. Adjunct treatment included multiagent chemotherapy plus radiotherapy, four patients; and only radiotherapy, one patient. Eleven patients died of disease 1 to 27 months after diagnosis with an overall median survival of 15 months. Three groups of neuroendocrine carcinomas were identified based on immunostaining patterns. These included pure neuroendocrine carcinomas, two patients; neuroendocrine carcinomas with occasional exocrine cells, three patients; and mixed neuroendocrine-exocrine carcinomas, seven patients. CONCLUSIONS: (1) The relative incidence of neuroendocrine differentiation in carcinomas of the stomach is higher than is generally recognized. (2) Neuroendocrine gastric carcinomas behave aggressively and display numerous structural and functional similarities with their colonic, extrahepatic biliary tract, and pulmonary counterparts.
Aged↗
Clinical results of piezoelectric gallstone lithotripsy.
The safety and efficacy of piezoelectric extracorporeal shockwave lithotripsy in the treatment of symptomatic gallbladder stones were evaluated in 53 consecutively treated patients. All treatments were performed as outpatients without anesthesia; over 95 per cent of 109 treatments were performed without analgesia or sedation. Ursodeoxycholic acid was administered post-treatment. Seventy per cent of patients had multiple sessions. Cumulative stone-free rates of 38 per cent at 6 months, 65 per cent at 12 months, and 75 per cent at 15 months were achieved. There was no difference in eventual stone clearance between patients with single stones less than 20 mm diameter, single stones greater than or equal to 20 mm diameter, or multiple (two or three) stones, although patients with single smaller stones required significantly fewer total shocks to become stone-free (P = .02). Stone clearance correlated with estimated stone volume. Biliary pain occurred in 62 per cent of patients after treatment but ceased in stone-free patients. Biliary complications of pancreatitis (7.5%) and choledocholithiasis (3.8%) were successfully treated by endoscopic papillotomy. Nonbiliary complications were virtually nonexistent. Three patients (5.7%) had elective cholecystectomy. Results indicate that piezoelectric lithotripsy is a safe, minimally painful treatment that, in conjunction with oral bile acids, can produce stone-free rates of 75 to 100 per cent in selected patients.
Adult↗
Neuroendocrine differentiation and prognosis of extrahepatic biliary tract carcinomas.
From 1980 to 1987, 35 patients underwent exploratory surgery for carcinomas of the extrahepatic biliary tract (EBT). Samples from 28 of these tumors (15 gallbladder, 13 bile duct) were assessed by immunohistochemical analysis for exocrine and/or neuroendocrine differentiation. Seven patients were excluded from the study because of insufficient available specimen or loss to follow-up. Paraffin sections were immunostained for neuroendocrine differentiation markers: neuron-specific enolase (NSE), chromogranin-A, synaptophysin, serotonin, somatostatin, substance-P, and glucagon. Additional sections were also stained with monoclonal antibody A-80 that recognizes a glycoprotein related to exocrine differentiation. The tumors were reclassified on the basis of immunophenotyping data: (I) pure exocrine carcinoma (n = 8); (II) predominantly exocrine carcinoma with occasional neuroendocrine cells (n = 9); (III) mixed exocrine-neuroendocrine carcinoma (n = 4); (IV) pure neuroendocrine (n = 2); and (V) predominantly neuroendocrine with occasional exocrine cells (n = 5). Survival time among the two pure neuroendocrine (group IV) and five predominantly neuroendocrine carcinomas (group V) was significantly less than the survival time of patients from the other groups (2.6 +/- 2.2 months vs 13.5 +/- 12.3 months; p = 0.015). No difference was noted between groups in extent of disease, treatment rendered, or location of tumor (bile duct vs gallbladder). This study indicates that (1) the incidence of neuroendocrine differentiation in cancers of the EBT is higher than generally recognized, (2) carcinomas of the EBT may be phenotypically reclassified on the basis of immunohistochemical analysis, and (3) the presence of pure or predominant neuroendocrine differentiation in carcinomas of the EBT is associated with shorter survival time than carcinomas with pure or predominant exocrine differentiation (or mixed exocrine and neuroendocrine factors).
Biliary Tract Neoplasms↗
Appendiceal Kaposi's sarcoma: a cause of right lower quadrant pain in the acquired immune deficiency syndrome.
These case reports describe two patients with acquired immune deficiency syndrome (AIDS) who presented with acute right lower quadrant pain. Appendiceal involvement with Kaposi's sarcoma accounted for the clinical presentation, and was confirmed histologically. This association emphasizes the diagnostic confusion that may be caused by acute abdominal conditions in the AIDS population. Abdominal pain may result from AIDS-related or unrelated processes; appropriate operative intervention requires recognition of the various diagnostic possibilities.
Abdominal Pain↗
Major abdominal operations in acquired immunodeficiency syndrome.
Twenty-one major abdominal operations performed on 20 patients with Acquired Immunodeficiency Syndrome (AIDS) were reviewed. Fourteen operations were for therapeutic indications, eight were emergent. The array of pathology encountered included opportunistic infection with Mycobacterium avium intracellulare, Cytomegalovirus, Cryptosporidium, abdominal tuberculosis, lymphoma, Kaposi's sarcoma, AIDS-related immune thrombocytopenia, perforated appendicitis and colonic pseudo-obstruction. Hospital mortality was 20 per cent. Major morbidity occurred in 15 per cent of patients and was more common following emergency operations. Preoperative demographic, hematologic, or nutritional parameters examined or the presence of single-organ system dysfunction did not predict outcome. Fifty-three per cent of hospital survivors are alive with a nine-month median postoperative follow-up. It is concluded that major abdominal procedures in patients with AIDS should not be withheld due to fear of excessive morbidity or mortality. General surgeons are involved in the evaluation and treatment of increasing numbers of patients with HIV infection. Appropriate management requires recognition of a wide range of surgical pathology and attention to details of safe intraoperative conduct.
Abdominal Pain↗
Intraoperative radiation therapy in biliary tract cancer.
From 1983 to 1986, nine patients with advanced cancers of the proximal biliary tract were treated with intraoperative electron beam radiation therapy (IORT) following surgical resection or intubation. Five patients also received external beam radiation and four received chemotherapy. Early complications were minimal. Late complications included cholangitis, gastroduodenal ulceration, gastric outlet obstruction and portal vein thrombosis. Symptomatic recurrent or residual disease developed in eight patients with a median disease-free survival of 6 months. Seven patients failed locally; four recurred outside of the intraoperatively radiated field. The longest survivor is free of disease at 40 months; one patient is alive with disease at 30 months. Mean and median survivals were 16.8 months and 13 months respectively with 56 per cent 1-year survival. This was not different from a mean survival of 11 months and 46 per cent 1-year survival observed in 13 concurrent patients treated by external beam +/- 192Ir. Survival of six patients not treated by radiation was only 4.6 months (P = 0.3). Two thirds of patients had good or fair palliation. IORT has theoretical advantages for the treatment of locally advanced biliary cancer; preliminary results suggest useful palliation and potential long-term survival. Complications require ongoing evaluation and superiority to conventional treatment modalities has not been demonstrated.
Adenocarcinoma↗
Management of bile duct cysts in adults.
In 31 adult patients with bile duct cysts seen at the Lahey Clinic (Burlington, Mass) during a 20-year period, the median age at time of initial therapy at Lahey Clinic was 34 years. Abdominal pain was the most common presenting symptom, followed by jaundice and fever. The 31 patients underwent a total of 86 biliary tract procedures, of which 37 were performed at Lahey Clinic. Internal drainage was the most common operation, but it frequently resulted in recurrent symptoms requiring reoperation. Cyst excision was associated with a significantly lower incidence of recurrent cholangitis and need for reoperation and was not associated with increased operative mortality. Cystic disease was frequently associated with other hepatobiliary diseases. Biliary carcinoma occurred in five (16%) of our patients, and late deaths from biliary-related disease occurred in seven patients (22%). When technically possible, cyst excision is the treatment of choice.
Adolescent↗
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 pancreatectomy 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.
Adenocarcinoma↗
The frequency response of the canine choledochoduodenal junction.
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Ampulla of Vater↗
Avoiding laparoscopic complications.
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Abdominal Injuries↗