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Biomedical subjects

K D Lillemoe

Publications and source records attributed to K D Lillemoe.

At least 19 recordsLinked to original sources
PubMed2006

Evaluation of suspected bile duct injuries.

The proper diagnosis and appropriate treatment are paramount in ensuring a satisfactory outcome after a bile duct injury associated with laparoscopic cholecystectomy. Immediate recognition of a bile duct injury during laparoscopic cholecystectomy can allow proper treatment at that time, averting difficult complications that could occur in the postoperative period should the injury be missed. Unfortunately, most bile duct injuries are not recognized at the time of laparoscopic cholecystectomy. An appropriate level of suspicion followed by prompt and complete evaluation should result in accurate delineation of the biliary anatomy, which is essential for directing appropriate surgical reconstruction.

Bile Duct Diseases↗
PubMed2004

Surgical techniques for pancreatic cancer.

Surgical resection of pancreatic adenocarcinoma offers the only chance for long-term cure. Over the past 2 decades significant advances have been made in both the surgical techniques and the perioperative care of patients with pancreatic cancer. The operative management of pancreatic cancer involving the head, neck, and uncinate process consists of 2 phases: first, assessing tumor resectability and then, if the tumor is resectable, completing a pancreaticoduodenectomy and restoring gastrointestinal continuity. In this article, we describe our current techniques for resection of pancreatic cancer, review operative palliation for unresectable cancer, and discuss several controversies in the operative management of pancreatic cancer including: 1) the role of extended lymphadenectomy, 2) pylorus preservation and 3) pancreaticojejunostomy versus pancreaticogastrostomy for pancreatic duct reconstruction.

Carcinoma↗
PubMed2001

Do medical school surgical rotations influence subspecialty choice?

BACKGROUND: A comprehensive exposure to general surgery is essential for medical students pursuing careers in surgery. Occasionally, students applying for surgical residency positions must choose a subspecialty field prior to starting their residency training. Often, this decision is heavily based on their experience on various surgical clerkships. MATERIALS AND METHODS: To determine if surgical clerkships influence subspecialty choice, we surveyed medical students who interviewed for general surgery training over a 2-year period at The Johns Hopkins Hospital. RESULTS: Of 211 surveys sent, 146 were returned (66%). The mean age of the students was 26 +/- 0 years with 21% being female. Students anticipating subspecialization in cardiothoracic, plastic, pediatric, and transplant surgery saw significantly more operations in their respective fields. Similar trends were seen in vascular surgery and surgical oncology. Despite the apparent differences in exposure to subspecialty operations, all students saw equal numbers of hernia repairs and laparoscopic cholecystectomies. CONCLUSIONS: While medical students pursuing careers in surgery have equal exposure to general surgery, their anticipated subspecialty field highly correlated with their operative exposure to that field. Thus, medical school surgical rotations appear to highly influence subspecialty choice.

Adult↗
PubMed2001

Novel allogeneic granulocyte-macrophage colony-stimulating factor-secreting tumor vaccine for pancreatic cancer: a phase I trial of safety and immune activation.

PURPOSE: Allogeneic granulocyte-macrophage colony-stimulating factor (GM-CSF)-secreting tumor vaccines can cure established tumors in the mouse, but their efficacy against human tumors is uncertain. We have developed a novel GM-CSF-secreting pancreatic tumor vaccine. To determine its safety and ability to induce antitumor immune responses, we conducted a phase I trial in patients with surgically resected adenocarcinoma of the pancreas. PATIENTS AND METHODS: Fourteen patients with stage 1, 2, or 3 pancreatic adenocarcinoma were enrolled. Eight weeks after pancreaticoduodenectomy, three patients received 1 x 10(7) vaccine cells, three patients received 5 x 10(7) vaccine cells, three patients received 10 x 10(7) vaccine cells, and five patients received 50 x 10(7) vaccine cells. Twelve of 14 patients then went on to receive a 6-month course of adjuvant radiation and chemotherapy. One month after completing adjuvant treatment, six patients still in remission received up to three additional monthly vaccinations with the same vaccine dose that they had received originally. RESULTS: No dose-limiting toxicities were encountered. Vaccination induced increased delayed-type hypersensitivity (DTH) responses to autologous tumor cells in three patients who had received >or= 10 x 10(7) vaccine cells. These three patients also seemed to have had an increased disease-free survival time, remaining disease-free at least 25 months after diagnosis. CONCLUSION: Allogeneic GM-CSF-secreting tumor vaccines are safe in patients with pancreatic adenocarcinoma. This vaccine approach seems to induce dose-dependent systemic antitumor immunity as measured by increased postvaccination DTH responses against autologous tumors. Further clinical evaluation of this approach in patients with pancreatic cancer is warranted.

Adenocarcinoma↗
PubMed2001

Occupational exposure to pesticides and pancreatic cancer.

BACKGROUND: An increased risk of exposure to pesticides for pancreatic cancer has been suggested in a number of epidemiologic studies. METHODS: Cases (N = 484), aged 30-79 years, were diagnosed in 1986-1989. Controls (N = 2,095) were a random sample of the general population. Information on usual occupation and potential confounding factors was obtained. A job-exposure matrix (JEM) approach was used to estimate the level of occupational exposure to pesticides. RESULTS: A significant trend in risk with increasing exposure level of pesticides was observed, with ORs of 1.3 and 1.4 for low and moderate/high exposure levels, respectively. Excess risks were found for occupational exposure to fungicides (OR = 1.5) and herbicides (OR = 1.6) in the moderate/high level after adjustment for potential confounding factors. An increased risk for insecticide exposure was disappeared after adjustment for fungicide and herbicide exposures. Results of our occupation-based analysis were consistent with those from the JEM-based analysis. CONCLUSIONS: Our results suggest that pesticides may increase risk of pancreatic cancer, and indicate the need for investigations that can evaluate risk by specific chemical exposures. Published 2001 Wiley-Liss, Inc.

Adult↗
PubMed2001

Intraductal papillary mucinous neoplasms of the pancreas: an increasingly recognized clinicopathologic entity.

OBJECTIVE: To assess the authors' experience with intraductal papillary mucinous neoplasms of the pancreas (IPMNs). SUMMARY BACKGROUND DATA: Intraductal papillary mucinous neoplasms of the pancreas are being recognized with increasing frequency. METHODS: All patients who underwent pancreatic resection for an IPMN at the Johns Hopkins Hospital between January 1987 and December 2000 were studied. The data were compared with those of 702 concurrent patients with infiltrating ductal adenocarcinoma of the pancreas not associated with an IPMN resected by pancreaticoduodenectomy. RESULTS: In the 13-year time period, 60 patients underwent pancreatic resection for IPMNs, with 40 patients undergoing resection in the past 3 years. Mean age at presentation was 67.4 +/- 1.4 years. The most common presenting symptom in patients with IPMNs was abdominal pain (59%). Most IPMNs were in the head of the pancreas or diffusely involved the gland, with 70% being resected via pancreaticoduodenectomy, 22% via total pancreatectomy, and 8% via distal pancreatectomy. Twenty-two patients (37%) had IPMNs with an associated infiltrating adenocarcinoma. In a subset of IPMNs immunohistochemically stained for the Dpc4 protein (n = 50), all of the intraductal or noninvasive components strongly expressed Dpc4, whereas 84% of associated infiltrating cancers expressed Dpc4. The 5-year survival rate for all patients with IPMNs (n = 60) was 57%. CONCLUSION: Intraductal papillary mucinous neoplasms represent a distinct clinicopathologic entity being recognized with increasing frequency. IPMNs are clinically, histologically, and genetically disparate from pancreatic ductal adenocarcinomas. The distinct clinical features, the presumably long in situ or noninvasive phase, and the good long-term survival of patients with IPMNs offer a unique opportunity for early diagnosis, curative resection, and further studies of the molecular genetics and natural history of these unusual neoplasms.

Adenocarcinoma, Mucinous↗
PubMed2000

Intensified adjuvant combined modality therapy for resected periampullary adenocarcinoma: acceptable toxicity and suggestion of improved 1-year disease-free survival.

PURPOSE: (1) To determine the toxicity of an intensified postoperative adjuvant regimen for periampullary adenocarcinoma (pancreatic and nonpancreatic) utilizing concurrent 5-fluorouracil (5-FU), leucovorin (LV), dipyridamole (DPM), and mitomycin-C (MMC) combined with split-course locoregional external beam radiotherapy (EBRT) to 50 Gy. This was followed by 4 cycles of the same chemotherapy as adjuvant therapy. (2) To determine preliminary estimates of the overall and disease-free survival associated with the use of this regimen. (3) To compare the toxicities and early survival results of patients treated with the current regimen to those of patients who completed our prior trial of concurrent chemoradiation infusion with 5-FU/LV chemotherapy and regional nodal and prophylactic hepatic irradiation. METHODS: Postpancreaticoduodenectomy, patients received every 4 weeks bolus administration of 5-FU, (400 mg/m(2)), and LV, (20 mg/m(2), Days l-3), DPM (75 mg p.o., 4 times per day, Days 0-3, and every 8 weeks), MMC, (10 mg/m(2); maximum of 20 mg, Day l during EBRT). This was followed by 4 months of the same chemotherapy, beginning 1 month following the completion of EBRT. EBRT consisted of split-course 5000 cGy/20 fractions with a 2-week planned rest after the first 10 fractions (2500 cGy). RESULTS: From 4/96 to 6/99, 45 patients were enrolled and treated. Their experience constitutes the basis of this analysis. There were 29 patients with pancreatic cancer and 16 with nonpancreatic periampullary cancer. Seventeen patients had tumors of 3 cm or more, and 39 patients had at least 1 histologically involved lymph node. Thirteen patients had a histologically positive margin of resection. The mean time to start of treatment was 63 days following surgery. During chemoradiation therapy there were no Grade 3 or worse nonhematologic toxicities and 47% Grade 3 or Grade 4 hematologic toxicities of short duration. Following chemoradiation, during chemotherapy treatment only, there was one Grade 3 hepatic and one Grade 3 pulmonary toxicity which was nondebilitating (2% each case) and 42% Grade 3 or 4 hematologic toxicity. There were 2 episodes of neutropenic fever requiring admission and no treatment-related mortalities. One patient developed a mild case of HUS, which responded to standard management. One patient developed persistent shortness of breath (nondebilitating), and another patient had occasional dyspnea on exertion, both occurring after all therapy. The majority of patients complained of increased fatigue (Grade 1-2), greatest during the combined therapy and improving post all treatment. As of 6/23/99, 20 of 45 patients have relapsed, 13 in the liver. Twelve patients have died. Median follow-up for surviving patients is 14.3 months. Disease-free survival at 12 months following surgery is 66% (as compared to 25% in our prior study), and the median disease-free survival is 17 months (as compared to 8. 3 months in our prior study). Median survival has not yet been reached, but will be greater than 17 months. CONCLUSION: With a 14.3-month median follow-up, acute toxicity has been acceptable and manageable. Observed relapses were seen 9-13 months following surgical resection. Early survival analysis suggests a trend toward increased median disease-free survival (8.3 vs. 17 months), especially for patients with nonpancreatic periampullary adenocarcinoma.

Adenocarcinoma↗
PubMed2000

Surgery for hilar cholangiocarcinoma: the Johns Hopkins approach.

Carcinoma of the hepatic duct confluence is the most common site of bile duct malignancies. Significant progress has been made in recent years in the diagnosis and treatment of this disease. The diagnosis is generally made in the jaundiced patient with contrast-enhanced spiral computed tomography (CT) scanning followed by cholangiography. Percutaneous transhepatic cholangiography is favored over endoscopic retrograde cholangiography in that it better defines the proximal extent of the tumor involvement and allows placement of percutaneous transhepatic catheters. The preoperative placement of stents facilitates the surgical management, as well as decompressing the obstructed biliary tree. The operative technique at The Johns Hopkins Hospital involves resection of the hepatic confluence and reconstruction over Silastic stents. In patients in whom the hilar cholangiocarcinoma extends along either the right or left hepatic duct into the hepatic parenchyma, appropriate hepatic lobectomy is performed. A recent review of the Johns Hopkins experience has demonstrated that 67% of cholangiocarcinomas are located in the perihilar location. Fifty-six percent of these patients were resectable for potential cure. Of the 109 resected patients, 4 patients (3.6%) died secondary to complications of sepsis. In the 109 patients with resected perihilar tumors, the 1-, 3-, and 5-year survival was 68%, 30% and 11%, respectively. The median survival was 19 months. The addition of hepatic lobectomy did not alter the survival rate. Negative margins and negative lymph node status were associated with improved survival. Postoperative adjuvant radiation therapy did not provide benefit to patients with resected perihilar carcinoma.

Baltimore↗
PubMed2000

Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma?

BACKGROUND: Pancreatic lymphoma is a rare neoplasm. The role of surgical resection in curing this disease is poorly defined. STUDY DESIGN: From March 1983 to July 1997, eight patients with stage I or II primary pancreatic lymphoma were identified and retrospectively reviewed. All patients received chemotherapy, five patients received radiotherapy, and three patients also underwent surgical resection. A review of the published pancreatic lymphoma experience in the English-language literature was also undertaken. RESULTS: Three patients underwent pancreaticoduodenectomy with successful resection of the lymphoma and are disease free at 64, 62, and 53 months followup. Five patients were treated with nonresectional therapy. Three are disease free at 128, 51, and 24 months. Two patients died of disease at 9 and 37 months. A review of the pancreatic lymphoma experience in the English-language literature identified 122 cases of pancreatic lymphoma. Fifty-eight of these cases represented stage I or II lymphoma, which was treated without surgical resection with a 46% cure rate. Fifteen patients who had surgical resection for localized disease have been reported with a 94% cure rate. CONCLUSIONS: Based on both our single institution experience and the literature, it is suggested that surgical resection may play a beneficial role in the treatment of localized pancreatic lymphoma, although selection factors cannot be absolutely excluded.

Adult↗
PubMed2000

General surgery and fellowship training: opinions of surgical intern applicants and fellowship directors.

BACKGROUND: Given the pressures that exist today to modify surgical training programs, this study was undertaken to ascertain the opinions of surgical intern applicants and fellowship program directors with regard to the length of surgical training. METHODS: Surveys were sent to fourth-year medical students who were applying for categorical surgical training during a 2-year period at a single university medical center and to fellowship program directors in 6 surgical subspecialties. RESULTS: Ninety-three percent of the applicants planned to pursue fellowship training. Sixty-eight percent of the applicants did not feel that 5 years of general surgery are necessary before beginning a fellowship. Seventy-one percent of the applicants indicated that they would be willing to "short track" into a subspecialty to reduce training time. Virtually all fellowship directors in pediatric surgery (94%), transplantation surgery (94%), and oncologic surgery (100%) felt that 5 years of general surgery training are necessary before entering a fellowship. Significantly fewer fellowship directors in vascular surgery (53%), cardiothoracic surgery (30%), and plastic surgery (17%) felt that 5 years of general surgery are essential before beginning a fellowship (P < or = .001). CONCLUSIONS: For some general surgery subspecialties, a shortened, integrated training program may be desirable from the point of view of both trainees and fellowship directors. Vascular, cardiothoracic, and plastic surgery appear to be those subspecialties that are most amenable to such programs.

Data Collection↗
PubMed2000

Quality of life and outcomes after pancreaticoduodenectomy.

OBJECTIVE: To assess the quality of life (QOL) and functional outcome of patients after pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Pancreaticoduodenectomy is gaining acceptance and is being performed in increasing numbers for various malignant and benign diseases of the pancreas and periampullary region. There is a general impression that pancreaticoduodenectomy can severely impair QOL and alter normal activities. Only a few small studies have evaluated QOL after pancreaticoduodenectomy. METHODS: A standard QOL questionnaire was sent to 323 patients surviving pancreaticoduodenectomy who had undergone surgery at The Johns Hopkins Hospital between 1981 and 1997. Thirty items on a visual analog scale were categorized into three domains: physical (15 items), psychological (10 items), and social (5 items). Scores are reported as a percentile, with 100% being the highest possible score. The same QOL questionnaire was also sent to laparoscopic cholecystectomy patients and healthy controls. A separate component of the questionnaire asked about functional outcomes and disabilities. RESULTS: Overall QOL scores for the 192 responding pancreaticoduodenectomy patients in the three domains (physical, psychological, social) were 78%, 79%, and 81%, respectively. These QOL scores were comparable to those of the 37 laparoscopic cholecystectomy patients and the 31 healthy controls. The pancreaticoduodenectomy patients were subgrouped into chronic pancreatitis, other benign disease, pancreatic adenocarcinoma, and other cancers. Patients who underwent resection for chronic pancreatitis and pancreatic adenocarcinoma had significantly lower QOL scores in the physical and psychological domains compared with the laparoscopic cholecystectomy patients and the healthy controls. Common problems after pancreaticoduodenectomy were weight loss, abdominal pain, fatigue, foul stools, and diabetes. CONCLUSIONS: This is the largest single-institution experience assessing QOL after pancreaticoduodenectomy. These data demonstrate that as a group, patients who survive pancreaticoduodenectomy have near-normal QOL scores. Many patients report weight loss and symptoms consistent with pancreatic exocrine and endocrine insufficiency. Most patients have QOL scores comparable to those of control patients and can function independently in daily activities.

Adenocarcinoma↗
PubMed2000

Does prophylactic octreotide decrease the rates of pancreatic fistula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial.

OBJECTIVE: To evaluate the endpoints of complications (specifically pancreatic fistula and total complications) and death in patients undergoing pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Four randomized, placebo-controlled, multicenter trials from Europe have evaluated prophylactic octreotide (the long-acting synthetic analog of native somatostatin) in patients undergoing pancreatic resection. Each trial reported significant decreases in overall complication rates, and two of the four reported significantly lowered rates of pancreatic fistula in patients receiving prophylactic octreotide. However, none of these four trials studied only pancreaticoduodenal resections, and all trials had high pancreatic fistula rates (>19%) in the placebo group. A fifth randomized trial from the United States evaluated the use of prophylactic octreotide in patients undergoing pancreaticoduodenectomy and found no benefit to the use of octreotide. Prophylactic use of octreotide adds more than $75 to the daily hospital charge in the United States. In calendar year 1996, 288 patients received octreotide on the surgical service at the authors' institution, for total billed charges of $74,652. METHODS: Between February 1998 and February 2000, 383 patients were recruited into this study on the basis of preoperative anticipation of pancreaticoduodenal resection. Patients who gave consent were randomized to saline control versus octreotide 250 microg subcutaneously every 8 hours for 7 days, to start 1 to 2 hours before surgery. The primary postoperative endpoints were pancreatic fistula, total complications, death, and length of hospital stay. RESULTS: Two hundred eleven patients underwent pancreaticoduodenectomy with pancreatic-enteric anastomosis, received appropriate saline/octreotide doses, and were available for endpoint analysis. The two groups were comparable with respect to demographics (54% male, median age 66 years), type of pancreaticoduodenal resection (60% pylorus-preserving), type of pancreatic-enteric anastomosis (87% end-to-side pancreaticojejunostomy), and pathologic diagnosis. The pancreatic fistula rates were 9% in the control group and 11% in the octreotide group. The overall complication rates were 34% in the control group and 40% in the octreotide group; the in-hospital death rates were 0% versus 1%, respectively. The median postoperative length of hospital stay was 9 days in both groups. CONCLUSIONS: These data demonstrate that the prophylactic use of perioperative octreotide does not reduce the incidence of pancreatic fistula or total complications after pancreaticoduodenectomy. Prophylactic octreotide use in this setting should be eliminated, at a considerable cost savings.

Aged↗
PubMed2000

Postoperative bile duct strictures: management and outcome in the 1990s.

OBJECTIVE: To describe the management and outcome after surgical reconstruction of 156 patients with postoperative bile duct strictures managed in the 1990s. SUMMARY BACKGROUND DATA: The management of postoperative bile duct strictures and major bile duct injuries remains a challenge for even the most skilled biliary tract surgeon. The 1990s saw a dramatic increase in the incidence of bile duct strictures and injuries from the introduction and widespread use of laparoscopic cholecystectomy. Although the management of these injuries and short-term outcome have been reported, long-term follow-up is limited. METHODS: Data were collected prospectively on 156 patients treated at the Johns Hopkins Hospital with major bile duct injuries or postoperative bile duct strictures between January 1990 and December 1999. With the exception of bile duct injuries discovered and repaired during surgery, all patients underwent preoperative percutaneous transhepatic cholangiography and placement of transhepatic biliary catheters before surgical repair. Follow-up was conducted by medical record review or telephone interview during January 2000. RESULTS: Of the 156 patients undergoing surgical reconstruction, 142 had completed treatment with a mean follow-up of 57.5 months. Two patients died of reasons unrelated to biliary tract disease before the completion of treatment. Twelve patients (7.9%) had not completed treatment and still had biliary stents in place at the time of this report. Of patients who had completed treatment, 90. 8% were considered to have a successful outcome without the need for follow-up invasive, diagnos tic, or therapeutic interventional procedures. Patients with reconstruction after injury or stricture after laparoscopic cholecystectomy had a better overall outcome than patients whose postoperative stricture developed after other types of surgery. Presenting symptoms, number of stents, interval to referral, prior repair, and length of postoperative stenting were not significant predictors of outcome. Overall, a successful outcome, without the need for biliary stents, was obtained in 98% of patients, including those requiring a secondary procedure for recurrent stricture. CONCLUSIONS: Major bile duct injuries and postoperative bile duct strictures remain a considerable surgical challenge. Management with preoperative cholangiography to delineate the anatomy and placement of percutaneous biliary catheters, followed by surgical reconstruction with a Roux-en-Y hepaticojejunostomy, is associated with a successful outcome in up to 98% of patients.

Adolescent↗
PubMed2000

Surgical treatment of biliary tract infections.

Despite major advances in surgical and nonsurgical therapy, biliary tract infections remain a significant cause of morbidity and mortality. The two classic biliary tract infections most commonly encountered are acute cholecystitis (either calculous or acalculous) and acute cholangitis. In addition, bile leakage associated with bile duct injuries during laparoscopic cholecystectomy has become a problem not infrequently encountered by surgeons. Acute calculous cholecystitis results from a combination of mechanical, biochemical, and infectious mechanisms, initiated by stone impaction in the cystic duct. After instituting empiric antibiotics, early laparoscopic cholecystectomy should be performed. Although conversion to open cholecystectomy is more common than in chronic cholecystitis, there appears to be no increased morbidity or mortality in that setting. Acute acalculous cholecystitis usually occurs in critically ill patients and may present both a diagnostic and therapeutic dilemma. Aggressive management, however, is warranted, both because of the critical nature of illness in these patients and the high incidence of perforation. Percutaneous cholecystostomy is indicated, particularly in high-risk patients both for diagnosis and treatment. Acute cholangitis results from a combination of bactibilia and biliary obstruction. The majority of patients can be successfully managed with intravenous antibiotics and fluid resuscitation. In those patients in whom initial management is not successful, biliary drainage, which is best accomplished nonoperatively, should be instituted. There is a very limited role for early surgical intervention in acute suppurative cholangitis. Biliary leaks resulting in bile "peritonitis" or bilomas are common sequelae of laparoscopic bile duct injury. Although surgeons may feel it is necessary to operate urgently, delineation of the proximal biliary anatomy via percutaneous transhepatic cholangiography and biliary stent placement is the appropriate first step in management. This procedure will usually control the bile leak and allow delineation of the anatomy and opportune timing of definitive reconstruction.

Acute Disease↗