Biomedical subjects

H Obertop

Publications and source records attributed to H Obertop.

At least 109 records · Page 6Linked to original sources

PubMed1999

Local resection of biliopancreatic cancer.

Biliopancreatic tumors that are potentially amenable to local resection include proximal bile duct tumors (Klatskin tumors), mid-choledochal duct tumors and tumors arising from the papilla of Vater. This paper reviews our experience in the AMC, with local resection of these conditions. From 1983-1997, 112 patients underwent surgical resection of a carcinoma of the hepatic duct confluence (Klatskin tumor). Local resection was undertaken in 80 patients (52 patients with type I and II tumors, and 28 patients with type III tumors) whereas in 32 patients with type III tumors, hilar resection was performed with liver resection. Negative surgical margins were achieved in 10 patients after local resection of type I and II tumors (19.2%), in 1 patient after local resection of a type III tumor (3.6%), and in 5 patients after hilar resection and liver resection (15.6%). Middle-third carcinomas of the extra-hepatic biliary tract are less common than proximal or distal bile duct tumors. From 1993-1998, 12 patients underwent resection of a mid-choledochal duct carcinoma. In 8 patients, local resection was performed and in 4 patients, subtotal pancreatoduodenectomy (PPPD) because of the close relationship of the tumor and the pancreas. Four patients had negative surgical margins, 2 after local resection (25%) and 2 after PPPD (50%). Although accepted for villous adenomas located in the ampulla, local resection for ampullary carcinoma is controversial. Nine patients underwent local resection of a presumed adenoma that proved to be an ampullary carcinoma. In 4 patients with T1 tumors, resection of the carcinoma was locally complete (44%). Additional PPPD was performed in 6 patients, including the 4 patients with complete local resections, showing no residual tumor at the previous site of excision, but, lymphnode metastases in two resection specimens (both of patients with presumed T1 tumors). Hence, local resection of a T1 ampullary carcinoma might result in tumor free margins, but does not deal with (usually retropancreatic) lymphnode metastases. In conclusion, local resection is applicable to Klatskin type I and II tumors. Local resection may be considered in the proximally located, mid-choledochal duct carcinomas but, when located closer to the pancreas, PPPD is the preferred treatment. For ampullary adenomas, local resection is feasible unless frozen section examination raises suspicion on a malignancy. Local resection of even limited ampullary carcinomas is not advisable because of lymphatic dissemination of the tumor and consequently, inadequate clearance.

Adolescent↗

PubMed1999

Complications after resection of biliopancreatic cancer.

During the past decade the mortality after pancreaticoduodenectomy decreased to 0-4% in centers with experience. The morbidity however remains high although a decrease has also been demonstrated. Leakage of the pancreatic anastomosis is the most severe complication associated with a high mortality reported between 8-40%. Resection of the pancreatic remnant is the most radical treatment but unfortunately associated with insulin dependent diabetes. Subtotal resection of the pancreas tail seems an alternative. The incidence of postoperative bleeding is decreasing in particular bleeding from ulcers. Bleeding from a pseudoaneurysm (2%) is leading to a high mortality up to 50% and early aggressive intervention is mandatory. Delayed gastric emptying is reported between 20-30%, the pathophysiology is still unknown but postoperative intra-abdominal complications proved to be a risk factor. It is now evident that mortality is strongly related with hospital experience and regionalization reduced overall mortality. These findings are arguments to favour centralization of surgery for biliopancreatic cancer.

Anastomosis, Surgical↗

PubMed1999

Surgical palliative treatment in bilio-pancreatic malignancy.

Most patients with bilio-pancreatic malignancy are no candidate for curative resection and will need palliative treatment. Palliation in these patients is focussed on relief symptoms such as obstructive jaundice, duodenal obstruction and pain. It has been suggested that non surgical treatment (stenting) is the optimal palliation for patients with short survival and surgical bypass for those surviving more than 6 months. Unfortunately valid criteria for estimating survival are not available except for metastases. A prognostic score chart to predict survival probabilities for 3,6 and 9 months after diagnosis has been developed. The use of this prognostic score chart may help clinicians to select optimal palliative treatment for individual patients. Surgical biliary drainage can be performed by a simple cholecystoenterostomy; a choledochoduodenostomy or a choledocho/hepaticojejunostomy with Roux-Y jejunal limb reconstruction. The present data available in the literature do not give sufficient guidance to make a well deliberated selection between the different types of bypass surgery but choledochojejunostomy is generally preferred. Gastroentero-stomy is performed routinely during the biliary bypass procedure in our institution because gastric outlet obstruction has been described between 9-21% of the patients who underwent only a surgical biliary bypass but there is still controversy. Recently it was also suggested that there is an indication to perform palliative resections. No results are available to justify resections as a debulking procedure.

Biliary Tract Neoplasms↗

PubMed1998

[Gastroesophageal reflux disease: pathophysiology, diagnosis and drug therapy].

The principal mechanism leading to gastro-oesophageal reflux is an increased frequency of transient lower oesophageal sphincter relaxations; other factors are oesophageal hypersensitivity to gastric juice, hiatus hernia, and possible duodenal reflux. Patients with classical symptoms such as heartburn and regurgitation may be treated pharmaceutically combined with life style counselling. If the symptoms have not improved after 6 to 12 weeks, endoscopical examination is performed and, if necessary, 24-hour pH monitoring, barium radiographing and manometry. In the case of atypical symptoms such as dysphagia, laryngitis, asthma and chest pain, there is more reason to pursue diagnostic testing. In patients with dysphagia endoscopy is indicated to exclude malignancy. Drug treatment can be subdivided into antacids, H2 receptor antagonists, cytoprotective agents, prokinetics and proton pump inhibitors. In general practice a step-up approach to treatment is preferable, while for specialist treatment a stepdown approach is more (cost-)effective. Drawbacks of medical treatment are considerable frequency of recurrence of oesophagitis, persistence of regurgitation in 'volume refluxers' and controversial data on the possible development of (pre)malignant lesions of oesophagus and stomach. Surgical treatment is a good alternative for patients with persistent severe regurgitation during medical therapy and for young patients who prefer surgery to lifelong medication. Patients with Barrett's oesophagus should undergo regular endoscopic biopsy surveillance.

Anti-Ulcer Agents↗

PubMed1998

Clinical decision making in Barrett's oesophagus can be supported by computerized immunoquantitation and morphometry of features associated with proliferation and differentiation.

Grading of dysplasia in Barrett's oesophagus has a therapeutic impact, but subjective grading is associated with substantial observer variation. Quantitative pathological methods could help to achieve a more accurate and reproducible diagnosis. In the present study, the immunoquantitation of p53 and Ki67 and the morphometric analysis of features associated with proliferation and differentiation were evaluated for this purpose. In slides of 35 oesophagectomy specimens, 73 areas that displayed either no dysplasia (ND), low-grade dysplasia (LGD), high-grade dysplasia (HGD), or intramucosal carcinoma (ImCa) were initially considered. Agreement on double blind examination by two experienced pathologists was reached in 58 areas, which were used as the 'learning set'. The 15 areas of disagreement were used as a second set. In the univariate analysis, the most significant differences in the learning set were found for Ki67, p53, stratification index (SI), mean nuclear area, and volume. Further multivariate analysis showed that for discrimination between ND and LGD, the combination of Ki67 and SI resulted in 94 per cent correctly classified areas. Likewise, for the discrimination between LGD and HGD, Ki67 and SI were the most powerful combination (again, 94 per cent of areas classified correctly). The discrimination between HGD and ImCa with any combination of the quantitative parameters never exceeded 80 per cent correct classification. The addition of p53 was of no value in improving the discrimination of ND vs. LGD, or of LGD vs. HGD. In the 15 original disagreement areas of the initial set of 73, three of the five ND/LGD areas could be uniquely classified as either ND or LGD by Ki67 and SI. Moreover, three of the four LGD/HGD disagreement areas could be uniquely classified with the combination of Ki67 and SI as either LGD or HGD. We conclude that the quantitative assessment of cytometric and morphometric features associated with proliferation and differentiation (especially Ki67 and SI) can be a valuable adjunct tool for clinical decision making in Barrett's oesophagus.

Barrett Esophagus↗

PubMed1998

Prognostic value of cell proliferation (Ki-67 antigen) and nuclear DNA content in clinically resectable, distal bile duct carcinoma.

BACKGROUND: The aim of this study was to investigate the prognostic value of cell proliferation (Ki-67 antigen) and DNA content in patients resected for distal bile duct carcinoma (DBDC). METHODS: Formalin-fixed tumor specimens of 35 patients with resected DBDC and a long-term clinical follow-up were analyzed. MIB-1 antibody was used for Ki-67 antigen detection to determine the proportion of proliferating cells. DNA content was measured using flow cytometry. RESULTS: A significant correlation was found between a low MIB-1 index (<20%) and survival (P <.05). Of the 35 tumor specimens, 34 specimens were evaluable by flow cytometry: 22 carcinomas were diploid (65%), and 12 were aneuploid (35%). The median DNA index of aneuploid tumors was 1.36 (range, 1.09 to 1.76). No correlation of DNA-ploidy with survival time was found. CONCLUSION: In contrast to DNA-ploidy pattern, Ki-67 antigen expression showed prognostic significance in resectable DBDC. A Ki-67 positive ratio of > or =20% was associated with decreased survival time.

Adult↗

PubMed1998

Warm flush at 37 degrees C following cold storage attenuates reperfusion injury in preserved rat livers.

Pretransplant rinse solutions have been shown to reduce reperfusion injury in cold-stored liver grafts, especially at the nonparenchymal level in sinusoidal endothelial cells (SEC). In this study, different rinse temperatures were tested in a rat liver preservation model. Livers were washed out in situ via the portal vein with cold (4 degrees C) University of Wisconsin (UW) solution, and after hepatectomy (t0), were stored for 8, 16, or 24 h of cold ischemia time (CIT). After storage, livers were flushed with UW solution at either 4 degrees C, 20 degrees C, or 37 degrees C and reperfused for 90 min (37 degrees C). Control livers were reperfused at t0 without preflush. Levels of hyaluronic acid (HA), purine nucleoside phosphorylase (PNP), AST, and LDH were measured in the reperfusion medium. Bile production was monitored during reperfusion. At the end of reperfusion, liver biopsies were taken for enzyme hystochemistry (5'-nucleotidase and LDH). After 8-h CIT and a flush at 4 degrees C, a release of endogenous HA (-7%) was observed, whereas uptake of exogenous HA occurred after the 20 degrees C flush (2%, P = NS) and after the 37 degrees C flush (24%, p < 0.001). HA release occurred at all three preflush temperatures after the 16-h CIT but was significantly lower when flushed at 37 degrees C (-10%) that at 4 degrees C and 20 degrees C (-64% and -17%, respectively, p = 0.05). After the 24-h CIT, the release of endogenous HA increased in the 4 degrees C and 20 degrees C preflush groups, but not in the 37 degrees C group. Levels of PNP and AST increased until the 24-h CIT in all groups but were significantly lower after preflush at 37 degrees C. Release of LDH did not increase with increasing periods of cold storage in any of the flush series. Compared to control livers, mean bile production during reperfusion was significantly decreased following preflush at 4 degrees C or 37 degrees C after all periods of CIT. No differences in mean bile production could be demonstrated in the three preflush groups after any period of CIT. LDH activity in liver tissue was best preserved after the 8 and 16-h CIT in combination with the 37 degrees C preflush, indicating less hepatocellular damage. In conclusion, in cold stored rat livers flushed at 37 degrees C before reperfusion, SEC and hepatocellular damage is attenuated.

Adenosine↗

PubMed1998

The prognosis of esophageal carcinoma staged irresectable (T4) by endosonography.

BACKGROUND: Endosonography is an accurate preoperative staging technique for esophageal carcinoma. We retrospectively investigated a cohort of patients with carcinoma of the esophagus or gastric cardia that was endosonographically staged to be irresectable and studied whether their survival was influenced by the treatment received. STUDY DESIGN: Between April 1992 and July 1995, 654 patients were referred for endosonographic staging. We retrospectively searched our database for patients staged T4 and collected followup. Kaplan-Meier survival and Cox proportional hazards model were used to study the effect of treatment and various other factors on survival. RESULTS: Fifty-one patients (median age, 62 years; range, 44-87; 37 male) were staged T4 by endosonography. Followup was collected of all patients. Explorative surgery was chosen in 24 patients (47%), and the tumor was resected in 13 patients. Median survival in the surgical group was 9.67 months (95% confidence interval [CI] 6.03, 13.31) and 7.06 months (95% CI: 5.68, 8.44) in the nonsurgical group (not significant). Patients with infiltration in the respiratory tract had a 2.5 times higher risk of death than patients without (adjusted hazard ratio: 2.54; 95% CI: 1.30, 4.96). CONCLUSIONS: Patients staged irresectable by endosonography (T4 stage) have a very poor prognosis, regardless of further therapy. Survival of this group of patients was not influenced by surgery.

Adult↗

PubMed1998

Postoperative weight gain after standard Whipple's procedure versus pylorus-preserving pancreatoduodenectomy: the influence of tumour status.

BACKGROUND: Recent reports suggest a better postoperative weight gain after pylorus-preserving pancreatoduodenectomy (PPPD) compared with standard pancreatoduodenectomy (PD). Factors that could also influence postoperative weight gain, such as tumour-positive resection margins and tumour recurrence, have not been taken into account in these studies. The aim of this prospective study was to evaluate weight gain in the first 15 months after PD or PPPD and to investigate the influence of other tumour-related factors. METHODS: From 1991 to 1995, 140 patients underwent subtotal pancreatoduodenectomy; 125 patients underwent resection for malignant disease of the pancreatic head region (56 had PD and 69 PPPD). Patients' weights were evaluated in the pre-illness phase, before operation and during four postoperative phases (at 3, 7, 11 and 15 months). Weight was calculated as a percentage of the pre-illness weight. Patients were subdivided according to tumour status: PD with positive and PD with negative tumour status; PPPD with positive and PPPD with negative tumour status. Tumour-positive status was defined as either microscopically tumour-positive resection margins or radiologically or cytologically proven tumour recurrence within 2 years of surgery. RESULTS: Five patients died during the hospital stay (PD, four; PPPD, one) (overall mortality rate 4 per cent). There was no difference in overall weight gain between patients having PD and PPPD. There was, however, a difference in patients with positive and negative tumour status for PD (P = 0.0003) and PPPD (P< 0.0001). CONCLUSION: There is only a minimal difference in postoperative weight gain between patients having PD and PPPD. Differences in postoperative weight gain are related more to positive resection margins and tumour recurrence than to the type of resection.

Adult↗

PubMed1998

Follow-up after inguinal hernia repair. Questionnaire compared with physical examination: a prospective study in 299 patients.

OBJECTIVE: To assess the value of a written questionnaire in the follow-up of patients after inguinal hernia repair. DESIGN: Prospective study. SETTING: University and two district hospitals. The Netherlands. SUBJECTS: 314 patients with 362 inguinal hernias. MAIN OUTCOME MEASURES: Correlation between answers to questionnaire and clinical examination in the diagnosis of recurrent hernias. RESULTS: 13/24 recurrences (54%) after a mean follow-up of 33 months with a follow-up rate of 93% were not diagnosed by the questionnaire. CONCLUSION: Follow-up after hernia repair must be by physical examination.

Adolescent↗

PubMed1998

The vascularization of a gastric tube as a substitute for the esophagus is affected by its diameter.

The stomach is used for reconstruction of the upper gastrointestinal tract after esophageal resection for cancer. The whole stomach can be used, but also a wide or narrow gastric tube can be constructed. Short-term functional results are superior after use of a narrow tube. Healing of the cervical esophagogastrostomy can be impaired, leading to leakage and stricture. The decreased vascularization at the site of the anastomosis may be one reason. It was hypothesized that the quality of the vascularization of the gastric tube, used as a substitute for the oesophagus after esophagectomy, depends on its diameter. The vascularization of postmortem specimens was studied using angiography. Whole stomachs (3), wide (3) and narrow gastric tubes (3) were constructed. In a patient with an anastomotic stricture of a narrow tube with a cervical esophagogastrostomy vascularisation was evaluated by angiography. After infusion of contrast through the supplying arteries, the whole stomachs and wide gastric tubes showed adequate vascularization, whereas the narrow gastric tube showed poor vascularization especially at the site of the anastomosis. In narrow gastric tubes, the right gastroepiploic artery was the only feeding artery. In the patient's angiography, a limited contrast visualization of the proximal end of the gastric tube could be demonstrated. Although a narrow gastric tube is favoured by some surgeons, the use of whole stomach or a type of gastric tube with preservation of the right gastric artery may lead to a better anastomotic healing.

Adult↗

PubMed1998

Cytology of peritoneal lavage performed during staging laparoscopy for gastrointestinal malignancies: is it useful?

OBJECTIVE: To evaluate the potential benefit of cytology of the peritoneal lavage obtained during diagnostic laparoscopy for staging gastrointestinal (GI) malignancies. SUMMARY BACKGROUND DATA: Peritoneal lavage is a simple procedure that can be performed during laparotomy for GI tumors. Tumor cells in the lavage fluid are thought to indicate intraperitoneal tumor seeding and to have a negative effect on survival. For this reason, peritoneal lavage is frequently added to diagnostic laparoscopy for staging GI malignancies. METHODS: Patients who underwent peritoneal lavage during laparoscopic staging for GI malignancies between June 1992 and September 1997 were included. Lavage fluids were stained using Giemsa and Papanicolaou methods. Cytology results were correlated with the presence of metastases and tumor ingrowth found during laparoscopy and with survival. RESULTS: Cytology of peritoneal lavage was performed in 449 patients. Tumor cells were found in 28 patients (6%): 8/87 with an esophageal tumor, 2/32 with liver metastases, 11/72 with a proximal bile duct tumor, 7/236 with a periampullary tumor, and none in 7 and 15 patients with a primary liver tumor or pancreatic body or tail tumor, respectively. In 19 of the 28 patients (68%) in whom tumor cells were found, metastatic disease was detected during laparoscopy, and 3 of the 28 patients had a false-positive (n = 1) or a misleading positive (n = 2) lavage result. Therefore, lavage was beneficial in only 6/449 patients (1.3%); in these patients, the lavage result changed the assessment of tumor stage and adequately predicted irresectable disease. Univariate analysis showed a significant survival difference between patients in whom lavage detected tumor cells and those in whom it did not, but multivariate analysis revealed that these survival differences were caused by metastatic or ingrowing disease. CONCLUSION: Cytology of peritoneal lavage with conventional staining should no longer be performed during laparoscopic staging of GI malignancies because it provides an additional benefit in only 1.3% of patients and has limited prognostic value for survival in this group of patients.

Gastrointestinal Neoplasms↗

PubMed1998

Impact of endoscopic biopsy surveillance of Barrett's oesophagus on pathological stage and clinical outcome of Barrett's carcinoma.

BACKGROUND: The efficacy of endoscopic biopsy surveillance of Barrett's oesophagus in reducing mortality from oesophageal cancer has not been confirmed. AIMS: To investigate the impact of endoscopic biopsy surveillance on pathological stage and clinical outcome of Barrett's carcinoma. METHODS: A clinicopathological comparison was made between patients who initially presented with oesophageal adenocarcinoma (n = 54), and those in whom the cancer had been detected during surveillance of Barrett's oesophagus (n = 16). RESULTS: The surveyed patients were known to have Barrett's oesophagus for a median period of 42 months (range 6-144 months). Prior to the detection of adenocarcinoma or high grade dysplasia, 13 to 16 patients (81%) were previously found to have low grade dysplasia. Surgical pathology showed that surveyed patients had significantly earlier stages than non-surveyed patients (p = 0.0001). Only one surveyed patient (6%) versus 34 non-surveyed patients (63%) had nodal involvement (p = 0.0001). Two year survival was 85.9% for surveyed patients and 43.3% for non-surveyed patients (p = 0.0029). CONCLUSIONS: The temporal course of histological progression in our surveyed patients supports the theory that adenocarcinoma in Barrett's oesophagus develops through stages of increasing severity of dysplasia. Endoscopic biopsy surveillance of Barrett's oesophagus permits detection of malignancy at an early and curable stage, thereby potentially reducing mortality from oesophageal adenocarcinoma.

Adult↗

PubMed1998

Intrahepatic tissue pO2 during continuous or intermittent vascular inflow occlusion in a pig liver resection model.

BACKGROUND: Temporary vascular inflow occlusion of the liver (clamping of the hepatic pedicle) can prevent massive blood loss during liver resections. In this study, intrahepatic tissue pO2 was assessed as parameter of microcirculatory disturbances induced by ischemia and reperfusion (I/R) in the liver following continuous (Cnt) or intermittent (Int) clamping in a hemihepatectomy model in the pig. METHODS: Pigs (20-34 kg) were divided into 2 groups: I/R without hemihepatectomy (-HH; n = 10) and I/R with hemihepatectomy (+HH; n = 8). Ischemia during 90 min was Cnt or Int (6 sequential periods of 12 min of ischemia and 3 min of reperfusion), followed by 120 min of reperfusion. Intrahepatic pO2 histograms (polarographic pO2 needle electrode) were constructed before ischemia, at the end of 90 min of ischemia and after 120 min of reperfusion, along with assessment of plasma AST, ALT and LDH. Bile production was monitored continuously. RESULTS: Cumulative frequency distribution curves (CFDC) after 120 min of reperfusion in the Cnt-HH group were not different from preischemic CFDC (means +/- SEM), whereas in the Int-HH group a left shift occurred indicating more hypo(non)perfused liver areas (pO2 < 10 mm Hg: 2.6 +/- 1.2 and 41.0 +/- 17.5% in Cnt-HH and Int-HH; p < 0.01). In the Cnt+HH group, a left shift in the CFDC occurred. In the Int+HH group, a left and a right shift occurred simultaneously, indicating both hypo(non)- and hyperperfused (shunting) liver areas (pO2 < 10 mm Hg: 4.0 +/- 2.7 and 9.6 +/- 8.5%, n.s., and pO2 > 60 mm Hg: 2.0 +/- 2.0 and 17.3 +/- 6.4%, p = 0.015, in Cnt+HH and Int+HH). Plasma AST, ALT and LDH levels were not increased after 120 min of reperfusion, except for AST in Cnt+HH and Int+HH (from 54.6 +/- 14.0 to 270.4 +/- 42.8 U/l, p < 0.01, and from 47.8 +/- 9.4 to 176.5 +/- 55.9 U/l, n.s.). Bile production (percentage of mean preischemic value) during 120 min of reperfusion was significantly reduced in the Int-HH group, as compared to the Cnt-HH group (57.0 and 117.0% after 120 min of reperfusion, p = 0.002). In Cnt+HH and Int+HH, bile production was significantly reduced (33.3 +/- 20.0%, p = 0.05, and 38.5 +/- 7.9%, p = 0.007); however it was not different between the two groups. CONCLUSIONS: (1) Intrahepatic tissue pO2 as indicator of microvascular perfusion is a parameter of early I/R injury; (2) continuous vascular inflow occlusion resulted in less microcirculatory disturbances, when compared to intermittent occlusion.

Alanine Transaminase↗

PubMed1997

[Complications, hospital mortality and survival following partial pancreaticoduodenectomy].

OBJECTIVE: To analyse hospital mortality, complications and survival of patients after subtotal pancreaticoduodenectomy in the Academic Medical Centre, Amsterdam, the Netherlands, 1983-1996. DESIGN: Partly retrospective (1983-August 1987), partly prospective (September 1987-1996). METHOD: Patient characteristics, indication for surgery, postoperative complications, mortality and survival of patients who underwent subtotal pancreaticoduodenectomy were recorded in a computer database. Patients were subdivided into three groups (1983-September 1992; October 1992-1994; 1995-September 1996) to analyse the influence of change in surgical technique and the increase of experience. RESULTS: From 1983-to September 1996, 312 consecutive patients underwent a subtotal pancreaticoduodenectomy. Hospital mortality decreased from 4.9% to 1.4% in the last period (1995-1996). The complication rate decreased from 60% to 41%. The hospital stay decreased from median 24 days to 16 days. The actualized 5-year survival analysed for patients operated from 1983-to September 1992 was 31%. Patients with ampullary tumours had a 5-year survival of 50%. The 5-year survival of patients with bile duct and pancreatic carcinoma was 24% and 15% respectively. CONCLUSIONS: Subtotal pancreaticoduodenectomy can be performed safely with a low mortality (< 2%) in specialised centres. The morbidity is still substantial (40%). The survival is mainly dependent on type of tumour and patient selection and is approximately 50% for patients with ampullary tumours. The pylorus preserving procedure has become the standard operation.

Adult↗

PubMed1997

[Hospital experience and hospital mortality following partial pancreaticoduodenectomy in The Netherlands].

OBJECTIVE: To analyse the effect of hospital experience on mortality after subtotal pancreaticoduodenectomy in the Netherlands. DESIGN: Retrospective evaluation. METHOD: Information on hospital mortality and pancreatic resection in 1994 and 1995 in the Netherlands was obtained from the National Medical Register. Subanalysis was carried out of surgical mortality by age and hospital experience. RESULTS: Approximately 50% of the pancreaticoduodenectomies in the Netherlands were performed in hospitals with limited experience (< 5 procedures per year). Hospital mortality was higher in small-volume hospitals than in hospitals with experience (> 25 procedures per year): in 1994 17.2 and 0% and in 1995 14.6 and 2.9%, respectively (p < 0.05). Mortality was higher in patients older than 70 years compared with patients younger than 55 (p < 0.05). CONCLUSION: There was a correlation between mortality after pancreaticoduodenectomy and hospital experience. Therefore these procedures should be performed in centres with experience.

Adult↗

PubMed1997

[Barrett esophagus and Barrett carcinoma].

The incidence of Barrett carcinoma has increased almost six-fold in the last 20 years. Barrett oesophagus is defined as the presence of metaplastic columnar epithelium in the oesophagus in continuity with the gastric mucosa. It is regarded as an acquired abnormality, developed as a result of chronic (duodenal) gastro-oesophageal reflux. It is especially the intestinal type of columnar epithelium that has a greatly enhanced risk of malignant degeneration. It is advisable that patients with a Barrett oesophagus should regularly be examined endoscopically, with extensive tissue biopsy. Presence of Barrett epithelium without dysplasia or with only moderate dysplasia does not in itself constitute an indication for supplementary treatment. Major dysplasia constitutes an indication for prophylactic resection. In the treatment with curative intention of Barrett carcinoma, surgery is the therapy of first choice.

Adenocarcinoma↗

PubMed1997

The efficacy of laparoscopic staging in patients with upper gastrointestinal tumors.

BACKGROUND: The major advantage of diagnostic laparoscopy for patients with a gastrointestinal tumor is the prevention of unnecessary explorative laparotomies. However, it is doubtful whether this procedure also prevents late laparotomies that are necessary for palliative treatment during follow-up. METHODS: From January 1992 to July 1995, 233 consecutive patients with gastrointestinal malignancies underwent laparoscopy and laparoscopic ultrasonography after routine diagnostic procedures had shown potential curative disease. RESULTS: After diagnostic laparoscopy, laparotomy was not performed in 21% of all patients (47 of 226) because of histologically proven, unresectable, mainly metastatic disease; 6% had esophageal tumors (4 of 64 patients), 43% had liver tumors (10 of 23), 43% had proximal bile duct tumors (9 of 21), 15% had periampullary tumors (17 of 111), and 43% had pancreatic body and tail tumors (3 of 7). Nonoperative palliation was successful in all patients. However, late laparotomies were necessary in 7 of these 47 patients (15%): 5 patients with periampullary tumors and 2 patients with proximal bile duct tumors. All 7 patients underwent a surgical bypass, most due to duodenal obstruction, 1 to 13 months after diagnostic laparoscopy. CONCLUSIONS: In this study, diagnostic laparoscopy may have prevented unnecessary laparotomies for exploration or palliation in 18% of all patients (40 of 226). The procedure is of doubtful benefit for patients with esophageal tumors because the current findings show that only 6% of explorative laparotomies could be prevented. In patients with periampullary tumors, the initial benefit was 15%, but the risk of a late laparotomy is relatively high (30%).

Bile Duct Neoplasms↗