Abstract: ObjectiveThe authors documented the localization and frequency of lymphatic spread in squamous cell carcinoma of the thoracic esophagus and evaluated the influence of radical systematic lymph node dissection on patient survival.Summary Background DataFrom accumulated surgical experience, it was sugg

Abstract: ObjectiveAnatomic variations in the hepatic arteries were studied in donor livers that were used for orthotopic transplantation.Summary Background DataVariations have occurred in 25% to 75% of cases. Donor livers represent an appropriate model for study because extrahepatic arterial anatomy must be

Abstract: OBJECTIVE. The authors determined the role of Candida colonization in the development of subsequent infection in critically ill patients. DESIGN. A 6-month prospective cohort study was given to patients admitted to the surgical and neonatal intensive care units in a 1600-bed university medical center. METHODS. Patients having predetermined criteria for significant Candida colonization revealed by routine microbiologic surveillance cultures at different body sites were eligible for the study. Risk factors for Candida infection were recorded. A Candida colonization index was determined daily as the ratio of the number of distinct body sites (dbs) colonized with identical strains over the total number of dbs tested; a mean of 5.3 dbs per patient was obtained. All isolates (n = 322) sequentially recovered were characterized by genotyping using contour-clamped homogeneous electrical field gel electrophoresis that allowed strain delineation among Candida species. RESULTS. Twenty-nine patients met the criteria for inclusion; all were at high risk for Candida infection; 11 patients (38%) developed severe infections (8 candidemia); the remaining 18 patients were heavily colonized, but never required intravenous antifungal therapy. Among the potential risk factors for candida infection, three discriminated the colonized from the infected patients--i.e., length of previous antibiotic therapy (p < 0.02), severity of illness assessed by APACHE II score (p < 0.01), and the intensity of Candida spp colonization (p < 0.01). By logistic regression analysis, the latter two who were the independent factors that predicted subsequent candidal infection. Candida colonization always preceded infection with genotypically identical Candida spp strain. The proposed colonization indexes reached threshold values a mean of 6 days before Candida infection and demonstrated high positive predictive values (66 to 100%). CONCLUSIONS. The intensity of Candida colonization assessed by systematic screening helps predicting subsequent infections with identical strains in critically ill patients. Accurately identifying high-risk patients with Candida colonization offers opportunity for intervention strategies.

Abstract: OBJECTIVE: The open Nissen fundoplication is effective therapy for gastroesophageal reflux disease. In this study, the outcomes in 198 patients treated with the laparoscopic Nissen fundoplication was evaluated for up to 32 months after surgery to ascertain whether similar positive results could be obtained. SUMMARY BACKGROUND DATA: To ensure surgical success, patients were required to have mechanically defective sphincters on manometry and increased esophageal acid exposure on 24-hour pH monitoring. The patients either had severe complications of gastroesophageal reflux disease or had failed medical therapy. These requirements have been found to be necessary to ensure a successful surgical outcome. METHODS: The disease was complicated by ulceration (46), stricture (25) and Barrett's esophagus (33). Patients underwent standard Nissen fundoplications identical in every detail to open procedures except that the procedures were carried out by the laparoscopic route. RESULTS: Perioperative complications included gastric or esophageal perforation (3), pneumothorax (2), bleeding (2), breakdown of crural repair (2) and periesophageal abscess (1). The only mortality occurred from a duodenal perforation. Six patients required conversion to the open procedure. The median hospital stay was 3 days. One hundred patients were observed for follow-up for 6 to 32 months (median 12 months), with outcomes similar to the open Nissen fundoplication. Further surgery was required for two patients who had recurrent gastroesophageal reflux and one who developed an esophageal stricture. Ninety-seven percent are satisfied with their decision to have the operation. CONCLUSIONS: The laparoscopic Nissen fundoplication can be carried out safely and effectively with similar positive results to the open procedure and with all of the advantages of the minimally invasive approach.

Abstract: Objective This study analyzed the incidence and timing of biliary tract complications after orthotopic liver transplantation (OLTx) in 1792 consecutive patients. These results were then compared with those of previously reported series. Finally, recommendations were made on appropriate management strategies. Summary background data Technical complications after OLTx have a significant impact on patient and graft survival. One of the principal technical advances has been the standardization of techniques for biliary reconstruction. Nonetheless, biliary complications still occur. A 1983 report from the University of Pittsburgh reported biliary complications in 19% of all transplants, and an update in 1987 reported biliary complications in 13.2% of transplants. Methods The medical records of all patients who underwent liver transplantation and were hospitalized between January 1, 1988 and July 31, 1991 were reviewed. The case material consisted of the medical records of 217 patients treated for 245 biliary complications. Results Primary biliary continuity was established by either choledochocholedochostomy over a T-tube (C-C, n = 129) or a Roux-en-Y choledochojejunostomy with an internal stent (C-RY, n = 85). The overall incidence for biliary complication in this large series was 11.5%. Strictures (n = 93) and bile leak (n = 58) were the most common complications (69.6%). Most biliary complications (n = 143, 66%) occurred within the first 3 months after surgery. In general, leaks occurred early, and strictures developed later. Bile leaks were equally frequent in both C-C and C-RY (27.1% and 25.9%, respectively); strictures were more common after a C-RY type of reconstruction (36.4% and 52.9%, respectively). Twenty-one patients died, an incidence of 9.6%. Fifteen of the 21 biliary-related deaths were among patients treated for rejection before the recognition of biliary tract pathologic findings. Conclusions Progress has been made on improving the results of biliary reconstruction after OLTx. Nonetheless, patients continue to experience biliary complications after OLTx, and these complications cause considerable loss of grafts and life. If significant additional improvement in patient and graft survival are to be obtained, the technical performance of OLTx must continue to improve.

Abstract: BackgroundMissense germ-line mutations in the RET protooncogene are associated with multiple endocrine neoplasia type 2A (MEN 2A). Detection of these mutant alleles in kindred members predicts disease inheritance and provides the basis for preventative thyroidectomy.MethodsA polymerase chain reactio

Abstract: Operations which alter gastrointestinal function, but which do not require the removal of an organ or part of an organ, seem ideally suited to being undertaken laparoscopically. Fundoplication falls firmly into this category. The procedure was first reported in 1991 by Dallemagne who divided the short gastric vessels in performing the technique. The authors feel justified in calling their technique a Nissen fundoplication, as the anterior wall of the stomach is used without dividing the short gastric vessels as first described by Nissen.

Abstract: OBJECTIVE: The authors determined whether Meckel's diverticulum, discovered incidentally at operation, should be removed. SUMMARY BACKGROUND DATA: It is not clear from the medical literature whether the risk of an incidental Meckel's diverticulectomy is greater than the risk of leaving the diverticulum in place. METHODS: The authors used the medical experience of Olmsted County, Minnesota residents for the period 1950 to 1992 to answer the question. RESULTS: During the period, 58 residents developed Meckel's complications that required diverticulectomies. The incidence of complications was 87 per 100,000 person-years, and the lifetime risk (to 80 years of age) of developing them was 6.4%. The risks were similar throughout the period and at all ages of life, but were greater among men (124 per 100,000 person-years) than women (50 per 100,000 person-years, p < 0.05). Diverticulectomies for complications carried an operative mortality and morbidity of 2% and 12% and a cumulative risk of long-term postoperative complications of 7%, whereas incidental diverticulectomies done in 87 residents during the period carried corresponding rates of only 1%, 2%, and 2%, respectively. CONCLUSIONS: Meckel's diverticula discovered incidentally at operation should be removed for most patients, regardless of age.

Abstract: OBJECTIVE: The aims of this study were to analyze the natural history of patients with pseudomyxoma peritonei (PMP), evaluate clinical and pathologic variables as prognostic indicators, and review the authors' experience with different treatments SUMMARY BACKGROUND DATA: PMP is an unusual form of intra-abdominal neoplasm that presents with large amounts of extracellular mucin Diffuse peritoneal spread occurs in most patients with PMP, and distant metastasis is infrequent Debulking surgery, radiation therapy (radioisotope and external beam), and chemotherapy (both intraperitoneal and systemic) have all been advocated for optional patient management, but the variability of patients studied, the small patient numbers, and the prolonged course of this disease make the evaluation of results difficult METHODS: Fifty-six patients were treated for PMP at the Mayo Clinic between 1957 and 1983 The data were collected retrospectively Univariate (log-rank test) and multivariate (Cox regression model) analyses were performed for disease recurrence and patient survival RESULTS: Most patients with PMP had carcinomas of the appendix (52%) or ovary (34%) All gross tumor could be removed only in the 34% of patients with limited disease Although tumor progression occurred in 76% of patients, the 1-, 5-, and 10-year survival rates were 98%, 53%, and 32%, respectively Adverse predictors of patient survival included weight loss (p = 0001), abdominal distention (p = 0004), use of systemic chemotherapy (p = 0005), diffuse disease (p = 0038), and invasion of other organs (p = 004) Intraperitoneal chemotherapy (p = 0009) and radioisotopes (p = 00043) both were effective in prolonging the recurrence time of symptomatic PMP CONCLUSIONS: Although PMP is an indolent disease, aggressive surgical debulking followed by intraperitoneal radioisotopes and/or chemotherapy should be considered because of the diffuse peritoneal involvement

Abstract: OBJECTIVE: This study defined negative outcomes of solid organ transplantation, proposed a new classification of complications by severity, and applied the classification to evaluate the results of orthotopic liver transplantation (OLT). SUMMARY AND BACKGROUND DATA: The lack of uniform reporting of negative outcomes has made reports of transplantation procedures difficult to interpret and compare. In fact, only mortality is well reported; morbidity rates and severity of complications have been poorly described. METHODS: Based on previous definition and classification of complications for general surgery, a new classification for transplantation in four grades is proposed. Results including risk factors of the first 215 OLTs performed at the University of Toronto have been evaluated using the classification. RESULTS: All but two patients (99%) had at least one complication of any kind, 92% of patients surviving more than 3 months had grade 1 (minor) complications, 74% had grade 2 (life-threatening) complications, and 30% had grade 3 (residual disability or cancer) complications. Twenty-nine per cent of patients had grade 4 complications (retransplantation or death). The most common grade 1 complications were steroid responsive rejection (69% of patients) and infection that did not require antibiotics or invasive procedures (23%). Grade 2 complications primarily were infection requiring antibiotics or invasive procedures (64%), postoperative bleeding requiring > 3 units of packed red cells (35%), primary dysfunction (26%), and biliary disease treated with antibiotics or requiring invasive procedures (18%). The most frequent grade 3 complication was renal failure, which is defined as a permanent rise in serum creatinine levels > or = twice the pretransplantation values (11%). Grade 4 complications (retransplantation or death) mainly were infection (14%) and primary dysfunction (11%). Comparison between the first and last 50 OLTs of the series indicates a significant decrease in the mean number of grade 1 and 2 complications. This was partially a result of better medical status of patients at the time of transplantation. Using univariate and multivariate analyses of risk factors, the best predictor of grade 1 complications was donor obesity; for grade 2 complications, the best predictor was a donor liver rewarming time of > 90 minutes, and for grade 3 and 4 complications, the best predictor was the APACHE II scoring system and donor cardiac arrest. CONCLUSIONS: Standardized definitions and classifications of complications of transplantation will allow us to better evaluate and compare results of transplantation among centers and over time, and better compare effectiveness of new therapies. Orthotopic liver transplantation still is a procedure with high morbidity that requires careful analysis of risk factors to optimize selection of patients and organ sharing.

Abstract: ObjectiveThe authors sought to determine whether intensive follow-up improves 5-year survival rates in patients with colorectal cancer who were operated on for cure.Summary Background DataIntensive follow-up of patients with colorectal cancer is still controversial. The present uncertainty in regard

Abstract: Objective The study was undertaken to correct or reaffirm current recommendations based on old observations of doubtful validity because of their lack of routine colonoscopy, scintigraphy, or angiography. Background Patterns of bleeding were derived from transfusion records of 78 patients admitted 106 times for lower gastrointestinal bleeding with no detectable cause other than colon diverticula. Result Bleeding stopped spontaneously in 82 of 108 episodes and in 66 of 67 patients requiring less than four units of transfusion on any day. When four or more units were required in a day, 25 of 42 patients required emergency surgery. When a bleeding site was identified and removed, only 1 of 25 patients bled again from another divertculum. After discharge without surgery, 28 of 73 began to bled again. After “blind” colectomy and ileoproctostomy, four of seven patients developed leaks or abscesses, and two died. Conclusions Bleeding stopped spontaneously in 75% of episodes and in 99% of patients requiring less than four units of transfusion per day. Bleeding continued in 25% of episodes and in most patients who required four or more units per day. Bleeding sites of those patients who continued to bleed were shown by scintigraphy or angiography. When a bleeding diverticulum is removed, rebleeding is rare. “Blind” resection is unsafe.

Abstract: OBJECTIVE: The aim of this investigation was to determine the prognostic variables and optimal surgical procedure for patients with adenocarcinoma of the appendix. SUMMARY BACKGROUND DATA: Primary adenocarcinoma of the appendix is a rare malignancy that constitutes less than 0.5% of all gastrointestinal neoplasms. However, the prognostic factors and the preferred surgical procedure and outcome are poorly understood. METHODS: The authors reviewed their institutional experience from 1976 to 1992 in treating 94 consecutive patients with primary adenocarcinoma of the appendix. Patients with carcinoid tumors or those in whom the diagnosis of primary cecal cancer could not be ruled out were excluded from the study. RESULTS: Fifty-two (55%) patients had the mucinous variety, of which 22 had pseudomyxoma peritonei; the other 45% had the colonic and adenocarcinoid types of tumor. The most common presentation was that of acute appendicitis. Interestingly, in no patients was the correct diagnosis made before surgery, and it was entertained intraoperatively in only 30 patients (32%). The cure 5-year survival rate was 55%, but it varied with stage (A, 100%; B, 67%; C, 50%; and D, 6%; p < 0.01) and with grade (I, 68%, and III, 7%; p < 0.01). Patients with the mucinous type had a better prognosis than those with the colonic type (p < 0.01). The survival rate was superior after right hemicolectomy versus appendectomy alone (68% vs. 20%, p < 0.001). Right hemicolectomy performed as a secondary procedure resulted in the upstaging of 38% of the patients' tumors. A second primary malignancy occurred in 33 patients (35%), of which 17 were located in the gastrointestinal tract. CONCLUSIONS: Primary adenocarcinoma of the appendix should be treated by right hemicolectomy, even if it is a secondary procedure. Surveillance for synchronous or metachronous tumors, especially in the gastrointestinal tract, is warranted.

Abstract: OBJECTIVE: The authors determined the most useful predictors of common bile duct (CBD) stones as diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent laparoscopic cholecystectomy (LC) METHODS: Prospective and retrospective collection of historical, biochemical and ultrasonographic data was used Receiver operating characteristics curve analysis was used to determine optimal biochemical cut-off values Multivariate analysis using logistic regression with generation of the best model identifying independent predictors of CBD stones also was employed Prospective validation of the model was performed on an independent group of patients RESULTS: Endoscopic retrograde cholangiopancreatographies were performed before LC in 106 patients, and after LC in 33 Only four of ten clinical variables evaluated independently predicted the presence of CBD stones The optimal model predicted a 94% probability of CBD stones in a patient older than 55 years of age who presented with an elevated bilirubin (over 30 mumol/L) and positive ultrasound findings (a dilated CBD, and a CBD stone seen on ultrasound) This model was validated prospectively in a subsequent series of 49 patients in which the probability of CBD stone was only 8% when all four predictors were absent CONCLUSIONS: The identified independent clinical predictors of a CBD stone helps select a population of symptomatic gallstone bearers who benefit most from cholangiographic assessment

Abstract: OBJECTIVE: The objective of this study was to evaluate the benefit of an aggressive approach to gallbladder carcinoma on long-term survival. SUMMARY BACKGROUND DATA: Recent studies have shown that an aggressive surgical treatment of bile duct carcinoma can be associated with a surprising long-term survival. However, recent data on gallbladder carcinoma are not available. METHODS: Data were obtained from a questionnaire sent to 73 institutions in France, Europe, and overseas, and they were analyzed retrospectively. The review included an analysis of patient sex and age, associated hepatobiliary diseases, symptoms and signs, diagnostic tests, operative management, pathology reports, and survival. RESULTS: Seventy-eight per cent of the patients were women, and 22% were men (p 70 years) had a higher operative risk (p 60 months; T1 to T2, > 22 months, and T3 to T4, 2 to 8 months). No differences were observed among the different surgical procedures adopted. CONCLUSIONS: No progress has been made in the last 10 years in the treatment of gallbladder malignancies.

Abstract: ObjectiveThe authors determined whether there was an advantage to laparoscopic appendectomy when compared with open appendectomy.Summary/Background DataThe advantages of laparoscopic appendectomy versus open appendectomy were questioned because the recovery from open appendectomy is brief.MethodsFro

Abstract: Objectives The authors examined the impact of adjuvant total parenteral nutrition after major pancreatic resection for malignancy. Summary background data Previous studies have suggested a benefit to perioperative nutritional support for patients undergoing major gastrointestinal surgery. Methods A prospective, randomized study was conducted using patients who had undergone a major pancreatic resection with randomization on postoperative day one to either receive or not receive adjuvant total parenteral nutrition. Results No benefit could be demonstrated by the use of adjuvant parenteral nutrition in this setting. Complications were significantly greater in the group receiving total parenteral nutrition. These complications tended to be those associated with infection. Conclusions Routine applications of postoperative parenteral nutrition to patients undergoing major pancreatic resection for malignancy cannot be recommended. Further studies are required to determine the reason that infectious complications in these patients are increased.

Abstract: OBJECTIVE: Analysis of a staged management scheme for initial and definitive management of acute abdominal wall defects is provided. METHODS: A four-staged scheme for managing acute abdominal wall defects consists of the following stages: stage I--prosthetic insertion; stage II--2 to 3 weeks after prosthetic insertion and wound granulation, the prosthesis is removed; stage III--2 to 3 days later, planned ventral hernia (split thickness skin graft [STSG] or full-thickness skin and subcutaneous fat); stage IV--6 to 12 months later, definitive reconstruction. Cases were evaluated retrospectively for benefits and risks of the techniques employed. RESULTS: Eighty-eight cases (39 visceral edema, 27 abdominal sepsis, 22 abdominal wall resection) were managed during 8.5 years. Prostheses included polypropylene mesh in 45 cases, polyglactin 910 mesh in 27, polytetrafluorethylene in 10, and plastic in 6. Twenty-four patients died from their initial disease. The fistula rates associated with prosthetic management was 9%; no wound-related mortality occurred. Most wounds had split thickness skin graft applied after prosthetic removal. Definitive reconstruction was undertaken in 21 patients in the authors' institution (prosthetic mesh in 12 and modified components separation in 9). Recurrent hernias developed in 33% of mesh reconstructions and 11% of the components separation technique. CONCLUSIONS: The authors concluded that 1) this staged approach was associated with low morbidity and no technique-related mortality; 2) prostheses placed for edema were removed with fascial approximation accomplished in half of those cases; 3) absorbable mesh provided the advantages of reasonable durability, ease of removal, and relatively low cost--it has become the prosthesis of choice; and 4) the modified components separation technique of reconstruction provided good results in patients with moderate sized defects.

Abstract: Objective To decrease the operative time for parathyroidectomy in patients with hypercalcemic (primary) hyperparathyroid disease, a combination of preoperative localization of a parathyroid tumor with an effective nuclear scan (scintigram) and intraoperative monitoring of parathyroid hormone (quick parathyroid hormone measurement) to ensure excision of all hyperfunctioning tissue was studied. Summary Background Data For many years, persistent hypercalcemia after parathyroidectomy (3% to 10%) has been constant and is usually due to the surgeon's failure to remove all hyperfunctioning glands. A marked decrease in parathormone level after excision of a single large gland predicts operative success and a return to normal calcium levels

Abstract: BACKGROUND. The presence or absence of lymph node metastases in patients with malignant melanoma is the most powerful prognostic factor for predicting survival. If regional nodal metastases are found, the 5-year survival for the patient decreases approximately 50%. If the presence or absence of regional nodal metastases will determine which patients receive formal dissections or which patients enter adjuvant trials, then a technique is needed to accurately screen lymph node samples for occult disease. Routine histopathologic examination routinely underestimates the number of patients with metastases. This study was initiated to develop a highly sensitive clinically applicable method to detect micrometastases by examining lymph nodes for the presence of tyrosinase messenger RNA (mRNA). The hypothesis was that if mRNA for tyrosinase is found in the lymph node preparation, that finding is good evidence that metastatic melanoma cells are present. METHODS. The assay is accomplished using the combination of reverse transcription and double-round polymerase chain reaction (RT-PCR). The amplified samples are examined on a 2% agarose gel and tyrosinase cDNA is seen as a 207 base pair fragment. Lymph node preparations from 29 patients who were clinically stage I and II and undergoing elective node dissections were analyzed both by standard pathologic staining and RT-PCR. RESULTS. Eleven of 29 lymph node (38%) samples from 29 patients with intermediate thickness melanoma were pathologically positive. Nineteen of the 29 lymph node preparations (66%) were RT-PCR-positive, and these included all of the pathologically positive samples, so that the false-negative rate was 0. In a spiking experiment, one SK-Mel-28 melanoma cell in a background of one million normal lymphocytes could be detected, thus indicating the sensitivity of this method. In addition, analysis by restriction enzyme mapping showed that the amplified 207-bp PCR product produced is part of the tyrosinase gene sequence. CONCLUSION. The RT-PCR method is an extremely sensitive, reproducible, and efficient technique for the identification of micrometastases in patients with melanoma and could be widely applicable. If clinical correlation is obtained, staging of the melanoma patient becomes more accurate, and treatment becomes more standardized and rational, because all those patients who have evidence of nodal disease can be identified so that they may benefit from more extensive surgery (formal node dissections) or adjuvant therapies. Based on these results, RT-PCR could be a powerful tool to detect micrometastatic melanoma.

Abstract: OBJECTIVE: This review updates the surgeon about the cellular, matrix, and growth factor components of scarless fetal wound repair. SUMMARY BACKGROUND DATA: Fetal skin wound healing is characterized by the absence of scar tissue formation. This unique repair process is not dependent on the sterile, aqueous intrauterine environment. The differences between fetal and adult skin wound healing appear to reflect processes intrinsic to fetal tissue, such as the unique fetal fibroblasts, a more rapid and ordered deposition and turnover of tissue components, and, particularly, a markedly reduced inflammatory infiltrate and cytokine profile. Scarless fetal wounds are relatively deficient in the inflammatory cytokine, transforming growth factor beta (TGF-beta). In contrast, the fibrosis characteristic of adult wound repair may be associated with TGF-beta excess. Recent experimental studies suggest that specific anti-TGF-beta therapeutic strategies can ameliorate scar formation in adult wound repair and fibrotic diseases. Inhibitors of TGF-beta may be important future drugs to control scar. CONCLUSIONS: Based on the scarless fetal wound repair model, a number of ways in which the matrix and cellular response of the healing adult wound might be manipulated to reduce scarring are reviewed.

Abstract: Objective This study evaluated the impact of aggressive surgery on survival in patients with carcinoma of the thoracic esophagus. Summary Background Data Prognostic value of lymph-node status for patients with esophageal carcinoma was emphasized, although it is currently under debate whether extensive lymph node dissection improves survival. Methods Two hundred ninety-five patients with thoracic esophageal carcinoma were admitted to Kagoshima University Hospital from December 1982 to December 1990. Esophagectomy was performed on 244 (82.7%) of these patients; 106 of whom underwent three-field lymphadenectomy (bilateral cervical, mediastinal, and abdominal regions) were analyzed regarding lymph-node status, tumor recurrence, and the effect of prognostic factors on survival using Cox's proportional hazards model. Results Hospital mortality and morbidity were 10.4% (11/106) and 65.1%, respectively. Seventy-eight patients (73.6%) had nodal involvement, including 49 patients with abdominal lymph-node metastases and 46 patients with recurrent nerve-node metastases. Five-year survival rates were 54.5% for 16 patients with a solitary nodal metastasis, 30.3% for stage III, 17.4% for stage IV, and 7.2% for 28 patients with six or more metastatic nodes. The most frequent sites of recurrence were the upper mediastinal region and the lung – its incidence increased significantly as the number of positive nodes increased. The most unfavorable prognostic factors included regional or recurrent nerve-node metastasis and patient age of more than 71 years. Conclusions Three-field lymphadenectomy, including especially the removal of bilateral recurrent nerve nodes in the cervical region, is essential for improving the survival of patients with carcinoma of the upper two thirds of the thoracic esophagus.

Abstract: ObjectiveThis evaluated the long-term outcome after endoscopic thoracic sympathectomy (ETS) from below D1 to D4, using a single-site access technique for primary hyperhidrosis of the upper limbs.Summary Background DataPrimary hyperhidrosis of the upper limbs is a distressing and often socially disab

Abstract: Objective This study investigated the influence of the fetal environment on the healing characteristics of adult skin. Summary Background Data The remarkable ability of the fetus to heal without scarring is poorly understood. The unique qualities of fetal wound healing may be caused by the fetal environment, the fetal tissues, or a combination of both. There are numerous differences between the prenatal and postnatal environments that may play a role in the unique fetal response to injury. Methods Full-thickness adult sheep skin was transplanted onto the backs of 60-day-gestation fetal lambs (term, 145 days of gestation). The adult skin grafts were thus perfused by fetal blood and bathed in amniotic fluid. Previous work has demonstrated that, before midgestation, fetal lambs do not reject allogeneic skin grafts. Forty days later (100 days of gestation), incisional wounds were made on both the adult skin graft and the adjacent fetal skin. The wounds were harvested 14 days postwounding and analyzed by both light microscopy and immunohistochemical testing using antibodies to collagen types I, III, and VI. Results The wounds in the adult skin grafts healed with scar formation. This observation contrasts strongly with the scarless healing of the incisional fetal skin wounds. Conclusions This study suggests that scarless fetal skin healing properties are intrinsic to fetal skin and are not primarily the result of the fetal environment.

Abstract: ObjectiveThe authors introduce a simple six-step infiltration technique that results in satisfactory local anesthesia and prolonged postoperative analgesia, requiring a maximum of 30 to 40 mL of local anesthetic solution.Summary Background DataFor the last 20 years, more than 12,000 groin hernia rep

Abstract: OBJECTIVE: The authors sought to identify prognostic factors in the management of extremity soft tissue sarcoma. SUMMARY BACKGROUND DATA: The surgical management of soft tissue sarcoma has evolved because of advances in therapy, resulting in increased limb preservation and quality of life. However, identifying a subset of patients most likely to benefit from adjuvant chemotherapy has been difficult to achieve. METHODS: A retrospective analysis of a prospective data base of 182 patients with extremity sarcomas from 1970 to 1992 was performed. RESULTS: A histologic diagnosis of Ewing's sarcoma, synovial sarcoma, and angiosarcoma was associated with a 13-fold increased risk of death compared with liposarcoma, fibrosarcoma, and malignant peripheral nerve sheath histologic types after having adjusted for the other prognostic factors (p < 0.001). In addition to histologic type, high-grade sarcomas (p = 0.018), sarcomas greater than 10 cm in size (p = 0.006), and age at diagnosis (p = 0.016) were found to be important prognostic factors for survival but not for local recurrence. For the first time to their knowledge, the authors showed that mean mitotic activity has prognostic value after having adjusted for other prognostic factors, such as grade (p = 0.005). The only prognostic factors predictive for local recurrence were whether the patient presented with locally recurrent disease (p = 0.0001) or had microscopically positive margins (p = 0.052). CONCLUSIONS: The use of mitotic activity along with grade, size, histologic type, and age at diagnosis is prognostic for survival in extremity soft tissue sarcoma. The use of an objective pathologic feature, such as mean mitotic activity, is also useful in selecting patients for future systemic neoadjuvant or adjuvant trials and primary therapy.

Abstract: ObjectiveThe authors assessed the impact of gastrinoma resection on the subsequent development of hepatic metastases in Zollinger-Ellison syndrome.Summary Background DataThe symptoms of acid hypersecretion can be controlled medically in Zollinger-Ellison syndrome with high-dose pharmacologic therapy

Abstract: Operation Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts. Patient Material The operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24,26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification. Assessment Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal—Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate—Vicodin weekly, daily; and major—meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily. Results Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperativety and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively. Conclusions The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.