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L William Traverso

Publications and source records attributed to L William Traverso.

At least 19 recordsLinked to original sources
PubMed2006

The usefulness of drain data to identify a clinically relevant pancreatic anastomotic leak after pancreaticoduodenectomy?

Pancreatic anastomotic leak (leak) remains a persistent problem after pancreaticoduodenectomy (PD). Recent reports indicate a mean occurrence of 10% with a range of 2%-28% of patients. However, valid comparisons for these studies cannot be made because the definition of leak is variable, and many patients deemed to have a leak are not sick. The aim of this study was to determine the meaning of the volume and amylase content of the effluent from surgical drains by comparing these values to actual clinical outcomes. From January 1996 to July 2002, 207 consecutive patients underwent PD. We considered a leak to be present if greater than 30 ml/day of drainage was observed from drains and if that drainage contained an amylase-rich fluid (greater than 5X serum) on or after postoperative day (POD) 5. Cases were then divided into three groups-no leak, chemical leak only (leak but asymptomatic), and a clinical leak group (leak that required therapeutic intervention, reoperation, readmission, or prolonged length of stay). Then the drainage volume and its amylase concentration for every postoperative day were compared between the three groups. There were no operative or hospital deaths, and the mean length of stay (LOS) was 11.2 +/- 6.1 days. Prolonged LOS was set at greater than 17 days (one standard deviation beyond the mean LOS for all cases). Leak was observed in 14% of cases (n = 29) and the patients were subsequently divided into these groups: no leak (n = 178), chemical leak only (n = 12), and clinical leak (n = 17). Surprisingly, the daily drain amylase values did not differ between the chemical leak group and the clinical leak group. The daily volume of drainage on POD 5-8 for the clinical leak group was significantly greater than the volumes of the other two groups, so that a combination of greater than 200 ml/day of drainage on POD 5 with an amylase greater than 5X serum had a positive predictive value (PPV) of 84% and a negative predictive value (NPV) of 99% for a clinically relevant leak. We used broad criteria from drainage effluent to include as many potential leaks as possible. This broad definition of leak selected 14% of the PD patients as having a leak; within this group, all of the clinical complications of leak occurred. By increasing the volume criteria from greater than 30 ml per day to greater than 200 ml per day, the PPV was increased from 59% to 84% while keeping NPV at 99%. Drain data based on the volume and amylase criteria of this study may be useful for early detection of a leak that will have clinical impact. This study's criteria for leak may be a good definition to design a clinical trial.

Adolescent↗
PubMed2006

Exocrine function following the whipple operation as assessed by stool elastase.

What impact does pancreaticoduodenectomy (PD) have on exocrine function? Does the pancreatic anastomosis remain patent? When stool elastase became available for testing in November 2001, we began preoperative assessment and then increasingly employed postoperative measurements. From December 2001 until March 2006, 182 patients underwent PD by the same surgeon. Preoperative stool elastase was measured in 138 (76%) patients and was repeated postoperatively at 3 +/- 1 month, 12 +/- 2 months, and 24 +/- 3 months. At the same time periods, an abdominal CT scan was used to assess patency of the pancreatic anastomosis as implied by pancreatic duct dilation in the remnant (dilation = duct >3 mm or, if duct dilated preoperatively, then duct that failed to decrease in size). All cases were reconstructed with duct-to-mucosa pancreaticojejunostomy. Stool elastase was expressed as normal (>200 microg/gram stool), moderately reduced (100-200 microg/gram), or severely reduced (<100 microg/gram). Preoperative stool elastase values were "normal" in 78% (pancreatic cancer 32% normal vs. all other groups >78%; P < or = 0.001). As compared with preoperative values, the percent of cases with reduced elastase levels at 3 months, 1 year, and 2 years postoperatively was 48%, 73%, and 50%, respectively. The CT scans at the time of the 69 stool elastase measurements after PD showed pancreatic duct dilation in the pancreatic remnant in 9 of 69 (9%) stools but was not more frequent in the group with decreased elastase. Based on cases elastase, one third of patients about to have PD will have exocrine insufficiency, an observation most common among the patients with pancreatic cancer (68%). Stool elastase levels are further depressed in the majority of cases after PD from parenchymal loss because we could not implicate an occluded pancreatic anastomosis. These results suggest that, after PD, exocrine supplementation should be given to all patients with pancreatic cancer, especially those with impending adjuvant therapy. To further improve the long-term results after PD, each surgeon should assess the effect of their own type of pancreaticoenteric technique on exocrine function.

Exocrine Pancreatic Insufficiency↗
PubMed2006

Pancreatic anastomotic leak after the Whipple procedure is reduced using the surgical microscope.

BACKGROUND: Pancreatic anastomotic leakage (Leak) is the most common major complication after pancreaticoduodenectomy (PD). In this study we tested the hypothesis that better vision would improve the technical performance of this anastomosis and result in a lower Leak rate. METHODS: A retrospective review of 266 consecutive patients who underwent PD with pancreaticojejunostomy between 1996 and 2003 was carried out. In the first 196 patients we had used an end-to-side, internally-stented, duct-to-mucosa pancreaticojejunostomy aided by surgical Loupes at 2.5x magnification (Loupes group). In the next 70 patients we substituted the surgical microscope at 12.5x for the surgical Loupes (microscope group). Risk factors associated with Leak were determined for all 266 cases and then the outcomes for each group were compared. RESULTS: Leak was observed in 11.7% of patients (31 of 266). Uni- and multivariate analysis showed 3 independent risk factors for Leak: (1) male gender (odds ratio [OR], 3.10); (2) a pancreatic duct size of less than or equal to 3 mm (OR, 7.75); and (3) not using the microscope (OR, 7.43). The Leak rate in the Loupes group was 15% (29 of 196) and in the microscope group 2.9% (2 of 70, P = .008). The mean hospital length of stay was longer in the Loupes group (11.3 days) as compared to the microscope group (9.0 days, P < .001). In the high-risk subset for Leak with duct size less than or equal to 3 mm (n = 147), the Leak rate was 23% in the Loupes group vs 4.2% in the microscope group (P = .027). CONCLUSION: The enhanced vision provided by the surgical microscope allowed precise construction of the anastomosis resulting in a significant decrease in Leak, particularly when a patient was at risk for Leak, ie, pancreatic duct less than or equal to 3 mm.

Adult↗
PubMed2006

Pancreatic necrosis: paradigm of a multidisciplinary team.

Although we recommend the team approach for the treatment of pancreatic necrosis, we cannot support our method with evidence-based medicine. The few reports available (presented in this article) suggest an improvement by avoiding surgery in many cases and with a low mortality. Two important prerequisites are necessary to begin this team method. First is the assembly of a team, which requires years of recruitment using influence and leadership at centers of expertise in the treatment of pancreatic necrosis. Second, and possibly just as difficult as team assembly, is the design and use of a common algorithm that allows the reporting of data supported with the "power of n."

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2006

Solid serous adenoma of the pancreas: a rare variant within the family of pancreatic serous cystic neoplasms.

We report the third case of a solid serous adenoma of the pancreas, a rare variant of tumor within the family of pancreatic serous cystic neoplasms. This asymptomatic tumor presented in a 66-year-old man during imaging for another problem. Computed tomography of the abdomen demonstrated a 3.5-cm hypervascular mass in the head of the pancreas. A pylorus preserving pancreaticoduodenectomy was performed. Histological examination demonstrated a neoplasm identical to a serous cystadenoma-glycogen-rich cuboidal or polygonal cells with finely granulated eosinophilic or clear cytoplasm. More often, the neoplasm contained solid areas and tubules but no microcysts. Periodic acid Schiff's-glycogen staining was positive in some cells, turning negative after diastase was applied. Immunostaining was positive for CK7, CK8, neuron specific enolase, and MUC6. The microscopic findings of a solid neoplasm of cuboidal cells rich in glycogen and the immunostaining listed associate this tumor with the previously 2 reported cases of solid serous adenoma. All 3 reported cases thus far have proven to be benign lesions by pathological examination. Because clinical follow-up is reported only in the present case, caution should be exercised in declaring the solid serous adenoma of the pancreas as a benign lesion.

Aged↗
PubMed2005

Outcomes following resection of invasive and noninvasive intraductal papillary mucinous neoplasms of the pancreas.

BACKGROUND: Since any intraductal papillary mucinous neoplasm (IPMN) is at least premalignant, avoiding conversion to invasion by pancreatic resection should provide a survival advantage-but how much? METHODS: We reviewed 100 cases of IPMN that were resected. Survival was compared between 3 groups: noninvasive IPMN (n = 75), invasive IPMN (n = 25), and invasive ductal adenocarcinoma (n = 24), the latter matched by tumor-node-metastasis (TNM) stage to the IPMN invasive group. RESULTS: The 5-year disease-specific survival was significantly better for the noninvasive IPMN group (100%) than the invasive IPMN group (46%). Tumor recurrence was infrequent with noninvasive IPMNs (1.3% benign IPMN). Recurrence was common in the invasive IPMN group (46%). Even the subgroup with stage 1 disease had a 25% recurrence of malignancy. Survival curves were not different (P = .11) between the cases matched by stage for those with invasive IPMN cases versus cases with ductal adenocarcinoma. CONCLUSION: Patients with the invasive form of IPMN will have a similarly poor survival as those with ductal adenocarcinoma. In patients thought to have a benign IPMN, these lesions should be removed to avoid conversion to invasive cancer and to preserve the opportunity for the more favorable prognosis observed in this study.

Adenocarcinoma, Mucinous↗
PubMed2005

Pancreatic necrosectomy: definitions and technique.

Pancreatic necrosis implies a permanent condition in which a portion of the pancreas loses its blood supply. This condition is irreversible, yet many cases of "necrosis" will, after recovery, culminate in a patient with a normal pancreas by computed tomography or endoscopic retrograde cholangiopancreatography. The problem is in our definitions. An understanding of this disease through its related definitions is required before judgment deems "necrosectomy to be appropriate." These definitions are of pancreatic ductal disruption, peripancreatic fluid collections, pseudocyst, pancreatic abscess, and pancreatic necrosis. The technique of necrosectomy removes mature "necrosum" and is described in this article. Once necrosectomy is completed, the surgeon still depends on the continued support of interventional radiology through regular exchange of large-bore pancreatic drains. In our institution, many of these drain sites are placed at some time before necrosectomy. Once the team method has been implemented, the following improved outcomes will result--lowered need for necrosectomy and single digit mortality.

Biopsy, Needle↗
PubMed2004

Useful benchmarks to evaluate outcomes after esophagectomy and pancreaticoduodenectomy.

BACKGROUND: Multiple publications have suggested that outcomes after complex operations are better at high-volume centers. However, of all the potential "outcomes" to measure, only mortality has been studied extensively. The broadest difference in mortality between low- and high-volume centers has been measured after esophagectomy (EG) and pancreaticoduodenectomy (PD). If a low-volume center recorded high mortality, then a broader set of outcomes beyond mortality would be useful for self-assessment. METHODS: Two single-surgeon prospective databases for outcomes of EG and PD were reviewed in a multispecialty clinic within a tertiary-referral, resident-training hospital. Between January 1996 and December 2002, 174 consecutive patients underwent EG performed by 1 surgeon (25 cases/y), and 232 consecutive patients underwent PD performed by another surgeon (34 cases/y). We measured hospital and 30-day mortality rate, mean operation time (OR time), mean estimated intraoperative blood loss (EBL), mean length of stay (LOS), and the anastomotic leak rate. These outcomes were compared with those of recently published cases for EG and PD. RESULTS: Mortality for both operations was zero. After EG, OR time was 394 minutes (literature = 336), EBL was 204 mL (literature = 964), transfusion rate was 3.5% (literature = 34%), LOS was 11.1 days (literature = 16.6), leak was 2.9% (literature = 9.1%), and reoperation was 1.7% (literature = not stated). After PD, OR time was 450 minutes (literature = 431), EBL was 382 mL (literature = 1,183), transfusion rate was 7.3% (literature = not stated), LOS was 11.2 days (literature = 17.8), leak was 6.5% (literature = 9.9%), and reoperation was 0.4% (literature = 3.8%). CONCLUSIONS: These 2 single-surgeon series provide benchmarks to help better define acceptable outcomes after EG and PD. This assessment demonstrated lower mortality and LOS in a high-volume surgical practice. These outcomes are not associated with OR time but with lower EBL, less need for transfusion, and lower need for reoperation. Anastomotic leaks occurred in both series; however, this was not associated with mortality because of early recognition and the use of nonsurgical minimally invasive techniques. If mortality is high at a low-volume center, then the additional benchmarks of this study, in addition to mortality and LOS, could be used to lower mortality through self-assessment by identifying specific outcomes that need improvement.

Adolescent↗
PubMed2004

The Virginia Mason approach to localized pancreatic cancer.

This article describes the approaches presently employed at Virginia Mason Medical Center for treatment of localized pancreatic cancer, including preoperative staging, operative intervention, incorporation of adjuvant therapy, and supportive care.

Academic Medical Centers↗
PubMed2003

Interferon-based adjuvant chemoradiation therapy after pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: Patients with cancer who undergo pancreaticoduodenectomy (PD) followed by radiation and 5-fluorouracil (5-FU) therapy have experienced median overall survival from 18 to 24 months and an actuarial 2-year overall survival from 34% to 48%. We previously reported an 84% 2-year survival using a novel adjuvant chemoradiation protocol that included alpha interferon. This report describes the continued observations regarding this methodology with longer follow-up and more than twice the number of patients as the original report. METHODS: From July 1995 to May 2002, 43 patients with adenocarcinomas in the pancreatic head underwent PD at our institution. The mean age was 62 years (range 29 to 77) and 60% were men. Final pathologic findings were stage I (2%), II (12%), III (72%), and IVa (14%) while 84% had positive lymph nodes (average number of nodes positive was 3.2 nodes, (range 0 to 13). Tumor extended through the capsule of the surgical specimen in 70%. These patients then received our investigational protocol consisting of external-beam irradiation at a dose of 4,500 to 5,400 cGy (25 fractions over 5 weeks) and three-drug chemotherapy: continuous infusion 5-FU (200 mg/m(2) daily, days 1 to 35), weekly intravenous bolus cisplatin (30 mg/m(2) daily, days 1,8,15,22,29), and subcutaneous alpha, interferon (3 x 10(6) units, days 1 to 35). This chemoradiation was followed by continuous infusion 5-FU (200 mg/m(2) daily, weeks 9 to 14 and 17 to 22). Chemoradiation was generally initiated between 6 and 8 weeks after surgery. RESULTS: All patients completed radiation therapy. There were no deaths due to chemoradiation but 42% were hospitalized during chemoradiation, virtually all due to gastrointestinal toxicity. With a mean follow-up time of 31.9 months, 67% of the patients are alive. Therefore, the median survivorship has not been reached. Actuarial overall survival for the 1-, 2-, and 5-year periods was 95% (confidence interval [CI] = 91% to 98%), 64% (CI = 56% to 72%), and 55% (CI = 46% to 65%), respectively. CONCLUSIONS: This follow-up report further suggests overall survival may be improved for patients with adenocarcinoma in the pancreatic head using an adjuvant interferon-based chemoradiation protocol. These results are obtained despite a high incidence of node involvement and advanced tumor stage. From this limited patient series, the actuarial 2-year and 5-year overall survival rates suggest a potential for improved long-term survival. Further study of this regimen in a multiinstitutional setting is needed.

Actuarial Analysis↗
PubMed2003

Mucus is a predictor of better prognosis and survival in patients with intraductal papillary mucinous tumor of the pancreas.

The aim of our study was to examine the case histories of patients with intraductal papillary mucinous tumor (IPMT) treated with resection to determine predictors of prognosis. Between 1989 and 2000, all patients treated with pancreatic resection for IPMT (n = 63) were analyzed. The diagnosis of IPMT was made using the surgical specimen and the World Health Organization definition. Predictors were determined using univariate and multivariate analysis. The pathologic findings were benign (n = 30), carcinoma in situ (CIS; n = 5), and invasive carcinoma (n = 28). After univariate analysis, predictors of malignancy (invasive plus CIS) were jaundice (odds ratio = 10.32), elevated serum CA19-9 (odds ratio = 15.0), any abnormal liver function test (odds ratio = 7.69), and p53 overexpression. The only predictor of benign disease was gross mucus observed during endoscopy (odds ratio = 4.35). After multivariate analysis, predictors of malignancy were any abnormal liver function test (odds ratio = 5.09) and p53 overexpression, whereas the only predictor of benign disease was still gross mucus (odds ratio = 5.88). Actuarial 3- and 5-year survival for benign disease was 95% and 83% and for malignant disease 52% and 44%, respectively (P = 0.0048). Survival curves also favored p53-negative tumors vs. p53-positive tumors (P = 0.0055). In the 33 patients with malignant disease (mean follow-up time = 35 months), the presence of gross mucus was a predictor of prolonged survival after univariate and multivariate analysis (odds ratio = 4.34 and 4.55, respectively), whereas alcohol abuse was a predictor of poor survival (odds ratio = 3.41 and 3.60, respectively). Gross mucus observed during endoscopy is a predictor of benign IPMT and, within the group with malignant IPMT; the presence of gross mucus was associated with better survival. Survival was also strongly associated with either benign IPMT or negative staining for p53 overexpression.

Adenocarcinoma, Mucinous↗
PubMed2003

Use of self-expandable metallic stents in benign GI diseases.

BACKGROUND: The self-expandable metallic stent is of proven benefit in patients with malignant disease; however, its use in patients with benign disease is not well established. There are few data available regarding long-term complications and outcomes with use of self-expandable metallic stents in benign disease and virtually none regarding attempted removal once the acute problem is resolved. METHODS: Thirteen patients who had a self-expandable metallic stent placed for benign GI disorders were included in a retrospective analysis. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. RESULTS: Thirteen patients (7 women, 6 men; mean age 67 years, range 34-84 years) had one or more self-expandable metallic stents placed for benign disease and were followed for a mean of 3.4 years (3 weeks to 10 years). Of the 13 patients, 8 had esophageal stents, 4 biliary stents, and 1 had dual stents placed in the pancreaticobiliary tree. Complications developed in 8 (62%) patients; 4 (31%) ultimately died, either from the primary disease process (3) or from stent-related complications (1). CONCLUSIONS: Self-expandable metallic stent placement is effective treatment for benign esophageal leaks, providing the stent can be removed. It also may be used in either the esophagus or biliary tree in patients who are poor candidates for surgery and short expected survival. However, a self-expandable metallic stent should not be placed in a patient with a benign GI disorder who has a significant life expectancy and is a good candidate for surgery.

Adult↗
PubMed2003

Percutaneous embolization of the pancreatic duct with cyanoacrylate tissue adhesive in disconnected duct syndrome.

Traditionally, patients with chronic end-pancreatic fistulas caused by pancreatic necrosis have been treated with long-term percutaneous catheter drainage and/or surgical procedures such as resection or open drainage. With surgical treatment, the endocrine and exocrine functions of the removed pancreatic segment are sacrificed. Surgery in this patient population presents additional risks because of the inflammatory changes of pancreatitis and associated venous thromboses. The authors devised a method of percutaneous embolization of the pancreatic duct in a patient with catheter-dependent pancreatic fistula who wished to avoid surgery. The procedure was performed under fluoroscopic guidance with use of a microcatheter and wire system to access the duct, which was embolized with opacified n-butyl cyanoacrylate tissue adhesive. After 1 year of surveillance, the patient remains symptom-free. There has been no need for replacement of the drainage catheter and no further intervention has been performed.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed2002

Long-term biliary function after reconstruction of major bile duct injuries with hepaticoduodenostomy or hepaticojejunostomy.

HYPOTHESIS: Normal biliary function can be achieved after reconstruction for major bile duct injuries using either hepaticoduodenostomy (HD) or Roux-en-Y hepaticojejunostomy (HJ). DESIGN: Retrospective analysis of consecutive patients requiring biliary enteric reconstructions from February 1, 1993, through January 1, 2002, for bile duct injuries. SETTING: Academic multispecialty referral clinic. PATIENTS: Twenty-seven consecutive patients were evaluated who underwent biliary enteric reconstruction for bile duct injury caused during cholecystectomy. Patients were reconstructed either by HD (18 patients) or HJ (9 patients). INTERVENTIONS: Patients' medical records were reviewed and long-term evaluations were obtained via telephone questionnaire by 2 separate observers (R.J.M. and F.T.L.). Biliary function was evaluated in all using symptoms and liver function test results. Cholangiography was obtained, if indicated clinically. These were reviewed for stricture or dilatation. Any biliary interventions were recorded. MAIN OUTCOME MEASURES: Comparison of long-term biliary function after HD vs HJ reconstructions. RESULTS: All patients were contacted after a median postoperative time of 54 months. Excellent or good results were observed for biliary function in 25 (92%) of the 27 patients. These results were obtained regardless of the type of reconstruction-HD (18 patients) or HJ (9 patients). CONCLUSIONS: We found biliary function to be normal at more than 4 years after biliary-enteric reconstruction for bile duct injury. When surgically feasible, we prefer HD to HJ.

Adult↗
PubMed2002

Should bilateral inguinal hernias be repaired during one operation?

BACKGROUND: We tested the hypothesis that performing an open tension-free bilateral inguinal hernia repair at one operation would have similar outcomes as performing an open tension-free unilateral repair. METHODS: In our prospective study of 243 patients who underwent inguinal hernia repair, 197 were unilateral (UL) and 46 were simultaneous bilateral (SBL). Prospectively the surgeon completed a standardized form during the first postoperative visit. Long-term follow-up was obtained by telephone interview. RESULTS: Respectively for UL versus SBL: age 56 +/- 16 years versus 60 +/- 12 years, regional anesthesia 93% versus 94%, operating room time 76 +/- 22 minutes versus 114 +/- 21 minutes (P < 0.05), and operating room costs $1,513 versus $1,793. Also observed were nonsignificant differences in overnight admissions 9.6% versus 4.3%, wound infection 0% versus 2.2%, number of days of narcotic pain pills taken 3.5 +/- 2.7 versus 3.3 +/- 2.2, postoperative day first left home 2.4 +/- 1.6 versus 2.8 +/- 1.7, postoperative day drove car 4.6 +/- 2.1 versus 5.0 +/- 2.3. Telephone contact was made in 62% after a follow-up period of 28 +/- 17 months. Recurrences were observed in 6 of 151 (4.0%): UL 4.2% and SBL 3.0%. CONCLUSIONS: We believe a tension-free technique allows bilateral inguinal hernias to be repaired during one operation with similar outcomes as a unilateral tension-free repair and less cost than a sequential bilateral repair.

Adult↗