Preoperative localization tests [sonography, computed tomography, angiography, percutaneous transhepatic portal venous sampling for insulin radioimmunoassay (PTP)] have a sensitivity of 60% to 90% in cases of organic hyperinsulinism. In all publications, however, the sensitivity of intraoperative localization, 75% to 100%, is distinctly higher. With the exception of PTP, all tumors that can be identified by preoperative localization can also be detected using palpation or intraoperative sonography. Preoperative localization diagnosis is therefore not absolutely necessary prior to primary operation in the case of organic hyperinsulinism. It is requested by many surgeons because: (1) only a few clinics have extensive experience with patients with an organic hyperinsulinism; (2) only a few clinics have extensive experience with intraoperative sonography; (3) the accuracy of palpation is improved following appropriate preoperative localization; and (4) in rare cases, the results of a PTP influence the operative procedure.

Humans↗

PubMedDate not supplied

Value of tumor localization in patients with insulinoma.

Based on our patient material, preoperative localization of insulinoma was correct with sonography in 13 (61.9%) of 21 patients, with computed tomography in 3 (21.4%) of 14 patients, with computed tomography with bolus injection of contrast medium in 11 (73.3%) of 15 patients, with angiography in 20 (66.6%) of 30 patients, and with percutaneous transhepatic portal vein catheterization with selective measurement of insulin in 10 (76.9%) of 13 patients. Intraoperatively, 40 (95.2%) of 42 insulinomas were palpable and 12 of 16 insulinomas were identified during intraoperative sonography. Although 95.2% of the insulinomas can be palpated, we would support additional diagnostic localization since it may improve the reliability of palpation.

Adenoma, Islet Cell↗

PubMedDate not supplied

Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis.

Subfascial elimination of incompetent perforating veins is the most effective therapeutic principle in the treatment of trophic skin disorders associated with varicosis. A recently developed endoscopic technique allows accurate sectioning of perforating veins with direct observation of the veins and minor trauma. From November 1986 to July 1991 endoscopic sectioning of perforating veins was performed in 72 patients (103 legs). The most frequently transected perforating veins were Cockett's veins (n = 219), 24 cm perforating veins (n = 83), and Boyd's perforating veins (n = 82). Postoperative delayed wound healing was observed in 3 (2.9%) legs with pronounced trophic skin disorders in the lower extremities. Two patients complained of dysesthesia in the area of distribution of the sural nerve. Further complications recorded were extended subcutaneous hematoma in 6 (5.8%) legs and postoperative dysesthesia in the area of distribution of the saphenous nerve in 10 (9.7%) legs. At follow-up examination (mean 27 months postoperatively) clinical investigation and Doppler sonography showed newly formed incompetent perforating veins in only 2 lower legs. Radiography at follow-up revealed one incompetent Dodd's perforating vein in 1 leg, which was the starting point of pronounced recurrent varicosis in the lower leg. After an average follow-up of greater than 2 years, we recorded the occurrence of new varices in 9 lower legs. Staging of chronic venous incompetence showed an upward trend ranging from change to a more favorable stage to complete cure. Findings were unchanged in only 10% of the patients. There was no case of postoperative aggravation.

Adult↗

PubMedDate not supplied

Diagnosing and staging of pancreatic carcinoma-what is necessary?

The aim of the present prospective observational study was to diagnose and stage pancreatic carcinoma with a minimum of diagnostic procedures. Our experiences in 307 patients with a histologically confirmed pancreatic carcinoma show that for diagnosing pancreatic carcinoma sonography and computed tomography are sufficient in 95% of the cases. The combination of both has a sensitivity equal to that of endoscopic retrograde cholangiopancreatography (ERCP; 96.8 vs. 98.7%; n.s., chi2 test). ERCP is only indicated in cases with negative sonography and computed tomography, and suspicion of pancreatic cancer. For tumor staging, the routine performance of angiography cannot be recommended in view of the fact that although it provides greater sensitivity for the evaluation of an infiltration of the portal vein (80% for angiography vs. 22% for sonography or computed tomography), it is associated with a lower positive predictive value (56.4 vs. 68 and 72%) which results in a lower accuracy. Despite recent advantages in diagnostic technology, less than 50% of unresectable tumors were identified preoperatively at a 10% false-positive rate. The major reason for unresectability is infiltration into the mesenteric axis, which cannot be identified laparoscopically. Laparoscopy or percutaneous biopsy is recommended only in the presence of a tumor with suspicion of distant metastasis detected by radiological imaging and requiring histological confirmation. In conclusion, sonography and computed tomography as the only diagnostic images are sufficient for diagnosing and staging of pancreatic carcinoma in more than 95% of the patients. Only a small number of patients needs further diagnostic procedures.

Adult↗

PubMedDate not supplied

Value of quantitative DNA analysis in endocrine tumors of the pancreas.

BACKGROUND: The diagnosis of malignancy can be difficult in endocrine tumors of the pancreas. Moreover prognostically relevant factors are not available. The aim of this study was to evaluate retrospectively whether the DNA distribution pattern can differentiate between benign and malignant pancreatic endocrine tumors and secondly whether the DNA content of tumor cells gives prognostic information. METHOD: Image cytometry of paraffin-embedded tumor material of 42 pancreatic endocrine tumors. RESULTS: In 27 benign endocrine pancreatic tumors (25 insulinomas, 2 benign nonfunctioning endocrine tumors) we could differentiate between 6 diploid, 15 hypotriploid and 6 triploid DNA histograms. In 15 malignant endocrine tumors of the pancreas we could differentiate between 1 diploid, 1 hypotriploid, 9 triploid and 4 hypertriploid tumors. All 4 patients with a hypertriploid tumor died as a consequence of their disease in contrast to only 1 patient with a diploid, hypotriploid or triploid tumor even in case of a nonradical resection. CONCLUSION: With the help of quantitative DNA measurement a differentiation between malignant and benign endocrine pancreatic tumors is not possible even if the risk of malignancy increases with the DNA content. The DNA content of malignant endocrine pancreatic tumors has an influence on the long-term survival. Hypertriploid tumors have a statistically significantly worse prognosis than diploid, hypotriploid or triploid tumors.

Adenoma↗

PubMedDate not supplied

Beta 1 integrin expression in adenocarcinoma of Barrett's esophagus.

BACKGROUND/AIMS: In vitro and in vivo studies did not show that beta 1 integrin expression is associated with malignant transformation or that it is of prognostic value in some malignant tumors. There are no data on the expression or prognostic value of beta 1 integrins in adenocarcinoma of Barrett's esophagus. METHODOLOGY: We assessed the expression pattern and the prognostic impact of beta 1 integrins in paraffin-embedded specimens of 41 patients with adenocarcinoma of Barrett's esophagus by immunochemistry. At the time of investigation, neither histomorphological parameters nor the survival time were known. RESULTS: There was no correlation between histomorphological parameters and the expression of beta 1 integrins. The expression of beta 1 integrins had no influence on long- term survival. There was a relationship between the prognosis and the following histopathological parameters: pT, pN and pM category, the UICC stage, the presence of lymphangiosis, and the DNA content of the tumor cells. CONCLUSIONS: The preliminary results obtained in this study did not show that the expression of beta 1 integrins was of prognostic value in patients with adenocarcinoma of Barrett's esophagus. Further studies in a larger number of patients are required to confirm the results obtained in this investigation.

Adenocarcinoma↗

PubMedDate not supplied

Is age a risk factor for major pancreatic surgery? An analysis of 300 resections.

BACKGROUND/AIMS: The aim of this study was to analyze if age alone is a risk factor in major pancreatic surgery. METHODOLOGY: From September 1, 1985 to December 31, 1997, 806 patients underwent surgery for malignant and benign diseases of the pancreas in a prospective case control study performed at the Department of Surgery, Johannes Gutenberg University Hospital Mainz. In 228 patients (men: n = 139; women: n = 89; mean age: 61 years; range: 23-83 years) we performed partial (n = 178) or total (n = 50) pancreaticoduodenectomy, which was combined with portal vein resection in 16 cases. Left pancreatic resection was carried out in 72 patients (men: n = 40; women: n = 32; mean age: 65 years; range: 28-86 years). RESULTS: Surgical complications after pancreaticoduodenectomy occurred in 22.1% of patients < or = 70 years and in 30.2% of patients > 70 years, however, less than half of them had severe complications ranging below 50%. General complications developed in 16.1% of patients < or = 70 years and in 27.9% of patients > 70 years (p < 0.001). The mortality rates 30 and 90 days after surgery were 3.2% (< or = 70 years) and 2.3% (> 70 years), and 6.0% (< 70 years) and 6.9% (> 70 years), respectively. Regression analysis showed the following factors to exert an independent influence on mortality: Pre-operative serum bilirubin, the diameter of the pancreatic duct, intra-operative blood loss and the occurrence of surgical and nonsurgical complications. Age did not exert an independent influence on the prognosis of either morbidity or mortality. However, general complications developed significantly more often in elderly patients. After left pancreatic resection surgical complications developed in 29.3% (< or = 70 years) and 21.4% (> 70 years) of patients, however the rate of severe complications was below 10%. General complications occurred in 10.3% (< or = 70 years) and 28.6% (> 70 years) (p < 0.001). Mortality rates 30 and 90 days after operation were 1.7% (< or = 70 years) and 14.2% (> 70 years), and 3.4% (< or = 70 years) and 14.2% (> 70 years) (p = n.s.), respectively. Regression analysis showed the intra-operative blood loss to exert an independent influence on post-operative morbidity and mortality. Age had no independent influence on either morbidity or mortality. CONCLUSIONS: Results obtained by this study show that, although general complications develop significantly more often in elderly patients, age is not an independent risk factor for post-operative mortality after major pancreatic resection. Factors of importance in improving the outcome of this operation include the experience of the surgeon in selecting patients eligible to undergo the procedure, his operative skills in performing major pancreatic resections, as well as better anticipation and management of post-operative complications.

Adult↗

PubMedDate not supplied

Liver resection for breast cancer metastases.

BACKGROUND/AIMS: The prognosis of patients with hepatic metastases (HM) from breast cancer receiving no treatment is extremely poor. Results of systemic and regional chemotherapy as well as other treatment modalities, such as immunotherapy or hormonal therapy, are disappointing in this group of patients, with median survival rates hardly exceeding 1 year. METHODOLOGY: We performed a retrospective analysis of patients undergoing resection of isolated HM from breast cancer to determine the morbidity, mortality and prognosis following this procedure. RESULTS: Fifteen female patients underwent liver resection between September 1985 and April 1997. Two patients had synchronous and 13 patients had metachronous HM. The mean number of HM was 3.3 (1-9) (bilobar in 6 patients) with a mean diameter of 5.3 cm (2-11 cm). The following resections were performed: wedge resection (4), left lateral segmentectomy (2), right hemihepatectomy (3), left hemihepatectomy (1), extended right hemihepatectomy (3) and extended left hemihepatectomy (2). There was no hospital mortality. Morbidity (transient hepatic failure (n=2) and intra-operative hemorrhage necessitating splenectomy (n=1)) occurred in 3 patients. Median follow-up was 12 (1-88) months. Six patients developed recurrent liver disease; 2 relapsed elsewhere. Six of these 8 patients died. Overall median survival following liver resection was 57 months with 1-, 2- and 3-year survival rates of 100%, 71.4% and 53.6% respectively. CONCLUSIONS: Liver resection is a viable treatment option for selected patients with isolated HM from breast cancer that can be performed safely. It should be considered in individual patients if the operative risk is low, if no extrahepatic disease is present and provided a complete resection with clear margins is technically feasible.

Adult↗

PubMedDate not supplied

Prognostic factors following liver resection for hepatic metastases from colorectal cancer.

BACKGROUND/AIMS: We aimed to identify prognostic factors that may allow better patient selection for liver resection for colorectal liver metastases. METHODOLOGY: A retrospective analysis of the files of 120 patients undergoing liver resection for colorectal metastases between 9/85 and 12/96 was performed. Survival and disease-free survival were calculated, and a uni- and multivariate analysis for the prognostic impact of various perioperative factors on survival was performed. RESULTS: Perioperative morbidity and mortality were 28.3% and 5.8% respectively. Median overall survival was 30 months with a 5-year survival rate of 31%. Radicality was the prime prognostic determinant. In patients with R0-resection, a liver metastasis of > 3.5 cm in diameter was the only independent factor associated with an adverse prognosis. CONCLUSIONS: Liver resection for colorectal liver metastases should be attempted if complete resection with clear margins is feasible and may be especially beneficial in patients with small (< or = 3.5 cm) lesions.

Adult↗

PubMedDate not supplied

The impact of clinical types of disease manifestation on the risk of early postoperative recurrence in Crohn's disease.

BACKGROUND/AIMS: Surgery for Crohn's disease is frequently followed by symptomatic recurrence, which in up to 40% requires reoperation within 6 years. Whilst there is evidence that postoperative medical prophylaxis can be efficient, the results of clinical trials are inconsistent regarding the achieved benefit for the patient. Several parameters have been claimed to indicate an increased intrinsic risk of early surgical recurrence. METHODOLOGY: Patient charts of 287 patients who had undergone abdominal surgery for Crohn's disease were reviewed. Mean follow-up was 4.4 years. Recurrence-free intervals were calculated by the Kaplan-Meier method. A uni- and multivariate analysis was conducted to assess the impact of possible indicators of the need of repeated surgery. RESULTS: Patients with fistulizing type of symptoms, extraintestinal manifestations, corticosteroid treatment or male gender experienced significantly earlier reoperation. Recurrent disease, histologic evidence of inflamed resection margins, patient's age at the time of primary diagnosis and operation and the presence of epitheloid granulomas did not show significant influence on recurrence-free intervals. CONCLUSIONS: We conclude that the natural course of disease after intestinal resection in patients with one or more of these risk factors tends towards earlier recurrence requiring surgical intervention. The risk factors identified in this trial may be useful for patient stratification for randomized trials on the efficacy of medical prophylaxis.

Adult↗

PubMedDate not supplied

Relevant factors in the prognosis of ductal pancreatic carcinoma.

Because it is important to assess relevant prognostic factors when deciding which patients will profit from pancreatic resection and which will not, 484 patients with ductal pancreatic carcinoma who were operated on between 1 January 1978 and 31 December 1987 in the Department of General and Abdominal Surgery of Mainz Medical School were studied retrospectively. Prognostically favourable factors were: a history of 8 weeks or less, the presence of jaundice, the absence of back pain, a well to moderately differentiated carcinoma, a tumour less than 3 cm in diameter, a preoperative CA19-19 value of less than 400 U/ml, and no sign of lymph node metastases or other metastatic spread. Only 19 patients (3.9%) satisfied these criteria. Our objective is to now check these results in a prospective study with a larger number of patients and, in addition, to compare the quality of life of patients who were treated by resection with that of those who received palliative treatment.

Adolescent↗

PubMedDate not supplied

The electrostimulation test for intraoperative control of vagotomy.

A prospective randomized study was made of the Burge-Vane intraoperative electrostimulation test (EST) following selective proximal vagotomy for duodenal ulcer. Histologically proven nerve fibres were demonstrated by EST in 6 of 50 patients. The postoperative acid values and the ulcer recurrence rate were compared in these 50 patients and in 50 who did not undergo EST. The postoperative acid values did not differ significantly between these two groups. Ulcer recurred in 16% of the EST and 14% of the non-EST group during 6-8 year follow-up. Use of EST thus did not influence the results in this trial.

Adult↗

PubMedDate not supplied

Predictive value of ASA classification for the assessment of the perioperative risk.

To assess the predictive value of the ASA classification for morbidity and mortality during the whole time of post-operative hospitalization, data of 2248 patients undergoing elective surgery were analyzed prospectively. The incidence of post-operative morbidity, considering surgical as well as non-surgical complications, rose from 3.9% in ASA class I to 33.7% in ASA class IV. No patient died in ASA I, whereas 7.2% died in ASA IV. Furthermore, the ASA classes corresponded with the postoperative outcome of the patients, taking into account both the length of stay at the ICU and the postoperative hospitalization. The duration at the ICU increased an average of 0.1 to nearly 4 days and hospitalization from 11.8 to 27.3 in ASA classes I and IV, respectively. The results were confirmed considering separated groups with a different operative stress and risk. ASA-classification is also of conceivable value in estimating the perioperative risk and should therefore be considered prior to surgical intervention.

Adult↗