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J Coleman

Publications and source records attributed to J Coleman.

At least 55 records · Page 3Linked to original sources
PubMed1999

The plasticity of human telomeres demonstrated by a hypervariable telomere repeat array that is located on some copies of 16p and 16q.

Human telomeres are composed of tandem arrays of TTAGGG repeats with many variant repeats at the proximal ends. Comparison of the interspersion of variant and TTAGGG repeats between alleles can be used to study telomere instability, but the difficulty in identifying chromosome-specific sequences close to the start of autosomal telomeres has hampered such investigations. A chromosome end, including a telomere and adjacent sequence, that is polymorphic for its presence or absence in unrelated individuals has been identified. The telomere-adjacent DNA shows strong homology (92-99%) to sequences, including two expressed sequence tags, that are usually located in subterminal regions of human chromosomes but not adjacent to telomeres. Since this chromosome end arose, it has relocated at least once. In Caucasians, it forms the telomere of approximately 6% of 16q and 2% of 16p chromosome arms. The mechanism of relocation is unknown but must have involved the telomere-adjacent DNA rather than the telomere itself, as copies on 16p and 16q share the same telomere-adjacent sequence. The interspersion patterns of TTAGGG with TGAGGG, TTGGGG and non-amplifying repeat sequences revealed extensive allelic variation, such that 47 different alleles were observed among the 50 alleles mapped. Closely related alleles differ by small changes in copy number at blocks of adjacent like repeats, as seen at the Xp/Yp pseudoautosomal telomere. Such differences are compatible with a model in which the majority of mutations arise by intra-allelic mechanisms, in individuals hemizygous for a single copy of the chromosome end.

Base Sequence↗
PubMed1999

Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome.

OBJECTIVE: This prospective, randomized, single-institution trial was designed to evaluate the end points of mortality, morbidity, and survival in patients undergoing standard versus radical (extended) pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy). SUMMARY BACKGROUND DATA: Numerous retrospective reports and one prospective randomized trial have suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection may improve long-term survival for some patients with pancreatic and other periampullary adenocarcinomas. Many of these previously published studies can be criticized for their retrospective and nonrandomized designs, for the inclusion of nonconcurrent control groups, and for their small numbers. METHODS: Between April 1996 and December 1997, 114 patients with periampullary adenocarcinoma were enrolled in an ongoing, prospective, randomized trial at The Johns Hopkins Hospital. After intraoperative verification of completely resected periampullary adenocarcinoma, the patients were randomized to receive either a standard pancreaticoduodenectomy (removing only the peripancreatic lymph nodes en bloc with the specimen) or a radical pancreaticoduodenectomy (standard resection plus distal gastrectomy and retroperitoneal lymphadenectomy). All pathology specimens were reviewed and categorized. The postoperative morbidity, mortality, and short-term outcomes were examined. RESULTS: Of the 114 patients randomized, 56 underwent a standard pancreaticoduodenectomy and 58 a radical pancreaticoduodenectomy. The two groups were statistically similar with regard to age and gender, but there was a higher percentage of white patients in the radical group. All the patients in the radical group underwent distal gastric resection, whereas 86% of the patients in the standard group underwent pylorus preservation. The mean operative time in the radical group was 6.8 hours, compared with 6.2 hours in the standard group. There were no significant differences between the two groups with respect to the intraoperative blood loss, transfusion requirements, location of primary tumor, mean tumor size, positive lymph node status, or positive margin status. There were three deaths in the standard group and two in the radical group. The complication rates were 34% for the standard group and 40% for the radical group. Patients undergoing radical resection had a higher incidence of early delayed gastric emptying but had similar rates of other complications, such as pancreatic fistula, wound infection, intraabdominal abscess, and need for reoperation. The mean total number of lymph nodes resected was higher in the radical group. Of the 58 patients in the radical group, only 10% had metastatic carcinoma in the resected retroperitoneal lymph nodes, and none of those patients had the retroperitoneal nodes as the only site of lymph node involvement. The 1-year actuarial survival rate for patients surviving the immediate postoperative periods was 77% for the standard resection group and 83% for the radical resection group. CONCLUSIONS: These data demonstrate that radical pancreaticoduodenectomy (with the addition of a distal gastrectomy and extended retroperitoneal lymphadenectomy to a standard pancreaticoduodenectomy) can be performed with similar morbidity and mortality to standard pancreaticoduodenectomy. However, the survival data are not sufficiently mature and the numbers of patients enrolled are not adequate to allow firm conclusions to be drawn regarding survival benefit.

Adenocarcinoma↗
PubMed1999

Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial.

OBJECTIVE: This prospective, randomized, single-institution trial was designed to evaluate the role of prophylactic gastrojejunostomy in patients found at exploratory laparotomy to have unresectable periampullary carcinoma. SUMMARY BACKGROUND DATA: Between 25% and 75% of patients with periampullary cancer who undergo exploratory surgery with intent to perform a pancreaticoduodenectomy are found to have unresectable disease. Most will undergo a biliary-enteric bypass. Whether or not to perform a prophylactic gastrojejunostomy remains unresolved. Retrospective reviews of surgical series and prospective randomized trials of endoscopic palliation have demonstrated that late gastric outlet obstruction, requiring a gastrojejunostomy, develops in 10% to 20% of patients with unresectable periampullary cancer. METHODS: Between May 1994 and October 1998, 194 patients with a periampullary malignancy underwent exploratory surgery with the purpose of performing a pancreaticoduodenectomy and were found to have unresectable disease. On the basis of preoperative symptoms, radiologic studies, or surgical findings, the surgeon determined that gastric outlet obstruction was a significant risk in 107 and performed a gastrojejunostomy. The remaining 87 patients were thought by the surgeon not to be at significant risk for duodenal obstruction and were randomized to receive either a prophylactic retrocolic gastrojejunostomy or no gastrojejunostomy. Short- and long-term outcomes were determined in all patients. RESULTS: Of the 87 patients randomized, 44 patients underwent a retrocolic gastrojejunostomy and 43 did not undergo a gastric bypass. The two groups were similar with respect to age, gender, procedure performed (excluding gastrojejunostomy), and surgical findings. There were no postoperative deaths in either group, and the postoperative morbidity rates were comparable (gastrojejunostomy 32%, no gastrojejunostomy 33%). The postoperative length of stay was 8.5+/-0.5 days for the gastrojejunostomy group and 8.0+/-0.5 days for the no gastrojejunostomy group. Mean survival among those who received a prophylactic gastrojejunostomy was 8.3 months, and during that interval gastric outlet obstruction developed in none of the 44 patients. Mean survival among those who did not have a prophylactic gastrojejunostomy was 8.3 months. In 8 of those 43 patients (19%), late gastric outlet obstruction developed, requiring therapeutic intervention (gastrojejunostomy 7 patients, endoscopic duodenal stent 1 patient; p < 0.01). The median time between initial exploration and therapeutic intervention was 2 months. CONCLUSION: The results from this prospective, randomized trial demonstrate that prophylactic gastrojejunostomy significantly decreases the incidence of late gastric outlet obstruction. The performance of a prophylactic retrocolic gastrojejunostomy at the initial surgical procedure does not increase the incidence of postoperative complications or extend the length of stay. A retrocolic gastrojejunostomy should be performed routinely when a patient is undergoing surgical palliation for unresectable periampullary carcinoma.

Adenocarcinoma↗
PubMed1999

Bile duct injuries in laparoscopic cholecystectomy: nursing perspective.

The advent of laparoscopic cholecystectomy brought a new approach with many advantages to patients for the treatment of symptomatic gallstones. What was not anticipated was an increase in bile duct injuries as a major complication of this new technique. The advanced practice nurse (APN) must understand the technical aspects of a laparoscopic cholecystectomy and routine perioperative care, because this knowledge provides a basis to recognize signs and symptoms of potential postoperative problems characteristic of a bile duct injury. The APN may be the initial healthcare provider who examines a patient or who is contacted by the patient with reports of symptoms that must be heeded and acted on. The APN responds to the patient by providing symptom management, initiating and coordinating care, and alerting the healthcare team. The APN at a specialty center may also be the consistent member of the healthcare team caring for a patient through nonoperative management and operative repair of the bile duct injury. Knowledge of the spectrum of bile duct injuries, their various manifestations, diagnostic tests, nonoperative management, and complex surgical repair is necessary for the APN to educate patients, coordinate care along the continuum, and support a patient with a bile duct injury. The medicolegal aspect of bile duct injury during laparoscopic cholecystectomy is also a topic the APN may encounter that requires thoughtful consideration and response. The recognition of subtle postoperative symptoms of a laparoscopic cholecystectomy may mean the difference between early diagnosis of and intervention in a minor injury or a major complication.

Bile Ducts↗
PubMed1999

Clinical pathway implementation improves outcomes for complex biliary surgery.

BACKGROUND: Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center METHODS: Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible. RESULTS: From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05). CONCLUSIONS: These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.

Academic Medical Centers↗
PubMed1999

Controlling malaria transmission with genetically-engineered, Plasmodium-resistant mosquitoes: milestones in a model system.

We are developing transgenic mosquitoes resistant to malaria parasites to test the hypothesis that genetically-engineered mosquitoes can be used to block the transmission of the parasites. We are developing and testing many of the necessary methodologies with the avian malaria parasite, Plasmodium gallinaceum, and its laboratory vector, Aedes aegypti, in anticipation of engaging the technical challenges presented by the malaria parasite, P. falciparum, and its major African vector, Anopheles gambiae. Transformation technology will be used to insert into the mosquito a synthetic gene for resistance to P. gallinaceum. The resistance gene will consist of a promoter of a mosquito gene controlling the expression of an effector protein that interferes with parasite development and/or infectivity. Mosquito genes whose promoter sequences are capable of sex- and tissue-specific expression of exogenous coding sequences have been identified, and stable transformation of the mosquito has been developed. We now are developing the expressed effector portion of the synthetic gene that will interfere with the transmission of the parasites. Mouse monoclonal antibodies that recognize the circumsporozoite protein of P. gallinaceum block sporozoite invasion of mosquito salivary glands, as well as abrogate the infectivity of sporozoites to a vertebrate host, the chicken, Gallus gallus, and block sporozoite invasion and development in susceptible cell lines in vitro. Using the genes encoding these antibodies, we propose to clone and express single-chain antibody constructs (scFv) that will serve as the effector portion of the gene that interferes with transmission of P. gallinaceum sporozoites.

Aedes↗
PubMed1999

Outpatient laparoscopic cholecystectomy: patient and nursing perspective.

Outpatient laparoscopic cholecystectomy has become nearly mandatory in the current health care economic environment. This study determined the opinions of patients and their nurses regarding disability and pain after laparoscopic cholecystectomy. Using a 14-point questionnaire, 32 consecutive patients who underwent inpatient LC were surveyed. The nurses caring for these patients were surveyed with a nine-point questionnaire. Seventy-one percent of patients believed that they could not have been discharged the day of surgery; the nurses reported that 81% of the patients could not have gone home. Nausea and vomiting were common. Pain was rated as 9 or 10 in 19% of patients. Nurses reported that 56% of postoperative patients were not receptive to discharge teaching. Morning (16) versus afternoon (16) procedures were not different. Successful programs of outpatient LC must: 1) ensure adequate home support because patient capability will be limited, 2) optimize pain control, 3) minimize nausea and vomiting, and 4) deliver patient education preoperatively.

Ambulatory Surgical Procedures↗
PubMed1998

The heart rate-corrected QT interval of conscious beagle dogs: a formula based on analysis of covariance.

Three frequently used and cited formulas used to rate correct the QT interval (Bazett's, Fridericia's, and Van de Water's) were compared and ranked using a large population-based cohort of beagle dogs (99 males and 99 females). In addition, analysis of covariance was used to derive a flexible method to rate correct the QT.interval for heart rate. The method is flexible in that it utilizes pretest or control data to determine the degree of correction. In addition, it can also be used to evaluate whether treatment alters the association between heart rate and QT. Specifically, pretest QT (unadjusted) and heart rate data were used to estimate coefficients in the linear regression log(QT) = alpha + beta log(HR). The estimated slope (beta) from the pretest data was used to heart rate correct the QT interval in the formula log(QT)ca = log(QT) - beta *[log(HR - log(HRm)]. The term "log(HRm)" is included to standardize QTca to a reference value, either a fixed value or an average heart rate for the data set being analyzed. These formulas were retrospectively compared under a typical toxicity study paradigm with a class III antiarrhythmic agent (L-768,673) that selectively prolongs the QT interval by blocking the slow activating component of the delayed rectifying potassium channel (lks). Based on their ability to dissociate the effects of heart rate on the QT interval, the formulas received the following ranking: Covariate Adjustment (preferred) = Van De Water's > Fridericia's > Bazett's (not recommended). Analysis of covariance based on pretest or control data is preferred for moderate to large studies where there are adequate data for estimation of the slope parameter beta, the investigator does not have sufficient control over HR, or treatment alters the association between HR and the QT interval. Conversely, for smaller studies a fixed rate adjustment formula from the literature (such as Van de Water's or Fridericia's equations) may be preferable since the bias from using a fixed formula is likely to be smaller than the variance resulting from estimating beta from a small sample.

Acetamides↗
PubMed1998

Use of a free bladder mucosal graft for simple repair of vesicovaginal fistulae.

The aim of this paper is to describe a simple, fast, and effective method for repair of difficult vesicovaginal fistulae by means of a free bladder mucosal graft. Six patients with high, large, multiple, or recurrent vesicovaginal fistulae were treated using a free bladder mucosal graft. Three patients underwent "early" repair (less than 3 months from time of injury) and 3 "late" repair (more than 6 months from time of injury). Via a suprapubic cystotomy, the mucosa of the fistulous tract was debrided without any attempt to excise the tract or close the bladder or vaginal defects. A free bladder mucosal graft was harvested from an unaffected portion of the bladder and placed over the fistulous tract, and mucosal approximation was made using interrupted 5-0 chromic stay sutures. The donor urothelial defect was allowed to re-epithelialize. A Foley catheter, suprapubic tube, and vaginal packing were left in place. Five patients noted an immediate result, with no evidence of leakage, and the suprapubic tube was removed by week 3. One patient required prolonged catheter drainage, and the tube was successfully removed by week 6. This patient had undergone irradiation. All patients remain dry at follow-up, which ranges from 2 to 6 years. We describe a simple and effective method for transabdominal vesicovaginal fistula repair, involving minimal mobilization, decreased dissection, and no need for rotational or interposition flaps, obviating the need to open the peritoneum. A free bladder mucosal graft can be used regardless of the individual anatomy or proximity to the ureteral orifices, because it can easily be tailored. This technique represents an important repair of difficult, recurrent, or multiple vesicovaginal fistulae.

Female↗
PubMed1998

Primary sclerosing cholangitis: resect, dilate, or transplant?

OBJECTIVE: The current study examines the results of extrahepatic biliary resection, nonoperative endoscopic biliary dilation with or without percutaneous stenting, and liver transplantation in the management of patients with primary sclerosing cholangitis (PSC). SUMMARY BACKGROUND DATA: Primary sclerosing cholangitis is a progressive inflammatory disease leading to secondary biliary cirrhosis. The most effective management of sclerosing cholangitis before the onset of cirrhosis remains unclear. METHODS: From 1980 to 1994, 146 patients with PSC were managed with either resection of the extrahepatic bile ducts and long-term transhepatic stenting (50 patients), nonoperative endoscopic biliary dilation with or without percutaneous stenting (54 patients), medical therapy (28 patients), and/or liver transplantation (21 patients). RESULTS: Procedure-related morbidity and mortality rates were similar between surgically resected and nonoperatively managed patients. In noncirrhotic patients, the serum bilirubin level was significantly (p < 0.05) reduced from preoperative levels (8.3+/-1.5 mg/dL) 1 (1.7+/-0.4 mg/dL) and 3 (2.7+/-0.9 mg/ dL) years after resection, but not after endoscopic or percutaneous management. For noncirrhotic PSC patients, overall 5-year survival (85% vs. 59%) and survival until death or transplantation (82% vs. 46%) were significantly longer (p < 0.05) after resection than after nonoperative dilation with or without stenting. For cirrhotic patients, survival after liver transplantation was longer than after resection or nonoperative dilation with or without stenting. Five patients developed cholangiocarcinoma, including three (6%) of the nonoperatively managed patients but none of the resected patients. CONCLUSIONS: In carefully selected noncirrhotic patients with PSC, resection and long-term stenting remains a good option. Patients with cirrhosis should undergo liver transplantation.

Adolescent↗
PubMed1998

Three-dimensional ultrasonographic telepresence.

We have developed a three-dimensional ultrasound telepresence system for remote consultation. Three-dimensional ultrasound data-sets can be acquired by relatively unskilled operators. The data are stored in the remote unit and then transmitted to a consultant equipped with a similar unit. A telepresence pointing device enables the consultant to re-slice that data-set in any plane. During the study period, 72 volumetric scans of male and female volunteers aged 18-45 years were performed in Bosnia. Field users of limited ultrasound experience (most with less than 30 min of training) were able to acquire volumetric scans, send volume data and interact with remote consultants over standard communications lines at distances of up to 20,000 km. Communications links from 9.6 to 1500 kbit/s were used. Technical limitations included lack of motion data, lack of colour data, scan artefacts and increased scan-to-diagnosis time. However, our preliminary experience indicates that this technique may eventually prove to be a useful adjunct to telesonography. Further studies of the technique are needed to determine its value in the broader clinical setting.

Adolescent↗
PubMed1997

Reconstruction of partial laryngopharyngectomy defects.

As our contributors to this section have pointed out, there are at present two main methods of reconstructing defects of the pharynx and cervical esophagus: free jejunal transfer (FJT) and tubed radial forearm flap. The advantage of the FJT is that it is a tube, thus limiting the enteric suture lines to proximal and distal. The radial forearm flap requires not only the proximal and distal suture lines but a long longitudinal suture line to create the tube. This increase the possibility for fistula formation. The controversy surrounding this case concerns what to do with a remaining mucosal strip after a subtotal laryngectomy. Traditional reconstructive principles would dictate that normal tissue should not be sacrificed, but some would argue that the remaining mucosa should be sacrificed to allow for use of a FJT. The other alternative would be use of a radical forearm skin flap tubed to 270 degrees. At the University of Texas M. D. Anderson Cancer Center, we preferentially use the FJT for almost all defects and would probably have sacrificed the remaining mucosal strip in this particular case. We have used skin flaps to patch pharyngeal defects and prevent stricture in a number of cases. This is usually done however when the remaining pharyngeal mucosa approaches 50% or greater. Although we do not routinely use the tubed radial forearm flap because of the increased rate of fistula formation, there are some definite indications for its use. The first important indication is in patients in whom speech rehabilitation is desired or indicated. The skin flap provides a stiffer resonating chamber for the speech production and does not have the peristalsis or the mucus production associated with the jejunal flap. Another indication for use of radial forearm flap would be when there is a contraindication to celiotomy, ie, patients with hepatic cirrhosis and associated ascites or other abdominal conditions precluding abdominal exploration. In this situation, avoiding an intra-abdominal procedure would limit operative morbidity. In conclusion, one should use whichever procedure obtains a healed wound and re-establishes continuity of the upper gastrointestinal tract. In our hands, retention of the remaining mucosal segment would not be critical in this particular case and in fact would present a hindrance to use of the FJT.

Carcinoma, Squamous Cell↗
PubMed1997

Initial experience with an absorbable laparoscopic ligation clip.

BACKGROUND: Laparoscopic surgery requires secure and safe methods of ligation and haemostasis. This study evaluated the efficacy of an absorbable ligation clip with a novel compression closure mechanism. METHODS: A new compression-closure absorbable clip was compared with currently available absorbable and non-absorbable clips used in a variety of laparoscopic procedures in 12 centres worldwide. RESULTS: At follow-up to 3 months after the procedure, no complications specific to the use of the compression-closure clip were detected. Operator satisfaction with the clip was high, with criticism directed at its relatively large size. CONCLUSION: This new clip is as safe and effective as presently available metal and absorbable clips in providing haemostasis and securing tubular structures.

Adolescent↗
PubMed1997

Cloning and expression of two human lysophosphatidic acid acyltransferase cDNAs that enhance cytokine-induced signaling responses in cells.

Lysophosphatidic acid (LPA) and phosphatidic acid (PA) are two phospholipids involved in signal transduction and in lipid biosynthesis in cells. LPA acyltransferase (LPAAT), also known as 1-acyl sn-glycerol-3-phosphate acetyltransferase (EC 2.3.1.51), catalyzes the conversion of LPA to PA. In this study, we describe the isolation and characterization of two human cDNAs that encode proteins possessing LPAAT activities. These two proteins, designated here as LPAAT-alpha and LPAAT-beta, contain extensive sequence sequence similarities to microbial or plant LPAAT sequences. LPAAT-alpha mRNA was detected in all tissues with highest expression in skeletal muscle whereas LPAAT-beta was expressed predominantly in heart and liver tissues. Expression of these two cDNAs in an Escherichia coli strain with a mutated LPAAT gene (plsC) complements its growth defect and shifts the equilibrium of cellular lipid content from LPA to PA and other lipids. Overexpression of these two cDNAs in mammalian cells leads to increased LPAAT activity in cell-free extracts using an in vitro assay that measures the conversion of fluorescently labeled LPA to PA. This increase in LPAAT activity correlates with enhancement of transcription and synthesis of tumor necrosis factor-alpha and interleukin-6 from cells upon stimulation with interleukin-1beta, suggesting LPAAT overexpression may amplify cellular signaling responses from cytokines.

Acyltransferases↗
PubMed1997

Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management.

OBJECTIVE: The authors provide the results of follow-up evaluation after combined surgical and radiologic management of 89 patients with major bile duct injuries during laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: The incidence and mechanism of injury of major bile duct injuries during laparoscopic cholecystectomy has been clearly defined. Furthermore, a number of series have described the management of these injuries by surgical, endoscopic, and radiologic techniques with excellent short-term results. Long-term follow-up data, however, are lacking in the management of these injuries. METHODS: Data were collected prospectively on 89 patients treated at a single institution with major bile duct injuries after laparoscopic cholecystectomy managed between July 1, 1990, and July 1, 1996. Patients referred with injuries underwent early percutaneous transhepatic cholangiography and biliary drainage. Based on the cholangiographic appearance and clinical situation, patients were managed by either percutaneous balloon dilatation or surgical reconstruction with a Roux-en-Y hepaticojejunostomy with transanastomotic stenting. Follow-up was obtained by personal interview during October 1996. RESULTS: Two patients died without an attempt at definitive therapy. Both deaths were caused by sepsis and multisystem organ failure present at the time of transfer to the authors' institution. The remaining 87 patients were managed initially by either balloon dilatation (N = 28) or surgical reconstruction (N = 59). Ten patients have not completed treatment and still have biliary stents in place. Evaluation of 25 patients completing treatment after balloon dilatation (mean follow-up, 27.8 months) showed a success rate of 64%. Evaluation of 52 patients completing treatment after surgical reconstruction (mean follow-up, 33.4 months) showed a success rate of 92%. All failures were managed successfully by either surgical reconstruction or balloon dilatation. CONCLUSIONS: Major bile duct injuries can be managed successfully by combined surgical and radiologic techniques. This series provides, for the first time, significant follow-up on a large number of patients with overall success rates of 64% after balloon dilatation and 92% after surgical reconstruction. The combination of surgery and balloon dilatation resulted in a successful outcome in 100% of patients treated.

Adult↗
PubMed1997

Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival. A prospective, single-institution experience.

OBJECTIVE: This study was designed to evaluate prospectively survival after pancreaticoduodenectomy for pancreatic adenocarcinoma, comparing two different postoperative adjuvant chemoradiation protocol to those of no adjuvant therapy. SUMMARY BACKGROUND DATA: Based on limited data from the Gastrointestinal Tumor Study Group, adjuvant chemoradiation therapy has been recommended after pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancrease. However, many patients continue to receive no such therapy. METHODS: From October 1991 through September 1995, all patients with resected, pathologically confirmed adenocarcinoma of the head, neck, or uncinate process of the pancreas were reviewed by a multidisciplinary group (surgery, radiation oncology, medical oncology, and pathology) and were offered three options for postoperative treatment after pancreaticoduodenectomy: 1) standard therapy: external beam radiation therapy to the pancreatic bed (4000-4500 cGy) given with two 3-day fluorouracil (5-FU) courses and followed by weekly bolus 5-FU (500 mg/m2 per day) for 4 months; 2) intensive therapy: external beam radiation therapy to the pancreatic bed (5040-5760 cGy) with prophylactic hepatic irradiation (2340-2700 cGy) given with and followed by infusional 5-FU (200 mg/m2 per day) plus leucovorin (5 mg/m2 per day) for 5 of 7 days for 4 months; or 3) no therapy: no postoperative radiation therapy or chemotherapy. RESULTS: Pancreaticoduodenectomy was performed in 174 patients, with 1 in-hospital death (0.6%). Ninety-nine patients elected standard therapy, 21 elected intensive therapy, and 53 patients declined therapy. The three groups were comparable with respect to race, gender, intraoperative blood loss, tumor differentiation, lymph node status, tumor diameter, and resection margin status. Univariate analyses indicated that tumor diameter < 3 cm, intraoperative blood loss < 700 mL, absence of intraoperative blood transfusions, and use of adjuvant chemoradiation therapy were associated with significantly longer survival (p < 0.05). By Cox proportional hazards survival analysis, the most powerful predictors of outcome were tumor diameter, intraoperative blood loss, status of resection margins, and use of postoperative adjuvant therapy. The use of postoperative adjuvant chemoradiation therapy was a predictor of improved survival (median survival, 19.5 months compared to 13.5 months without therapy; p = 0.003). The intensive therapy group had no survival advantage when compared to that of the standard therapy group (median survival, 17.5 months vs. 21 months, p = not significant). CONCLUSIONS: Adjuvant chemoradiation therapy significantly improves survival after pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancreas. Based on these survival data, standard adjuvant chemoradiation therapy appears to be indicated for patients treated by pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancreas. Intensive therapy conferred no survival advantage over standard therapy in this analysis.

Adenocarcinoma↗