Eighty-seven patients with neoplasm (57 cases), pancreatitis (28 cases), or benign biliary obstruction (2 cases) were treated with pyloric preserving pancreatectomy with two postoperative deaths, neither due to abdominal complications. About 50% of patients had delay in recovery of gastrointestinal function. Six and seven patients had clinically significant biliary and pancreatic fistulas, respectively, with some patients having both. Complications required 16 reoperations. Marginal ulcer was suggested by endoscopy or barium study in five patients, three of whom were successfully managed by a medical regimen. In the other two patients, exploration failed to demonstrate an ulcer or jejunitis. In most patients, long-term gastrointestinal function was judged to be excellent based on weight gain and lack of digestive symptoms. Pyloric function and gastric motility were evaluated by abdominal scanning using indium 111 and technetium 99m. Gastric emptying of liquids and solids was normal. Estimations of enterogastric reflux showed a moderate difference between normal subjects and pancreatectomy patients. Cancer-free survival was comparable to that after the standard Whipple procedure.
From July 2, 1971 to April 1, 1985, 47 patients (median age 63 years) with renal cell cancer extending into the renal vein or inferior vena cava were evaluated and treated. Two-thirds of the tumors occurred in men and three-fourths were found in the right kidney. Of the 44 patients operated on 35 had no evidence of preoperative metastatic disease at operation. The patients were divided into ideal, favorable and unfavorable subgroups. The adjusted 5 and 10-year survival rates in the former 2 groups (32 patients) were 68.8 and 60.2 per cent, respectively. In contrast, 12 patients with nodal involvement or metastases had an adjusted median survival time of 1.2 years with no survival extending beyond 4.8 years. We believe that an extended operation for renal cell cancer with involvement of the vena cava is warranted and provides reasonable long-term survival in properly selected patients.
The natural history of Barrett's esophagus, particularly the prevalence and incidence of malignant changes in it, remains controversial. Furthermore the prognosis of surgically treated patients with carcinoma in Barrett's esophagus has not been elucidated fully. To examine these and other issues, the records of 65 patients with carcinoma in Barrett's esophagus presenting at the Lahey Clinic Medical Center from January 1973 to January 1989 were reviewed. During this period, 241 patients with documented Barrett's esophagus were seen, for a prevalence of carcinoma of 27%. Adenocarcinoma in Barrett's esophagus accounted for 30% of the surgically treated carcinomas of the thoracic esophagus during this period. All but four of these patients were men. Symptoms of chronic reflux were present in less than one half of the patients and dysphagia was often the presenting symptom. In eight patients the carcinoma was discovered on routine surveillance endoscopy, and in four patients progression of disease from benign columnar epithelium to dysplasia to carcinoma was documented. Tumors developed in six patients who had undergone previous antireflux surgery, and in four other patients a second carcinoma developed in residual Barrett's epithelium after a previous resection. Of the 65 patients, 61 (94%) were considered to have operable disease, all of whom underwent resection. Two patients (3.3%) died within 30 days of operation. The resected specimens were staged as follows: stage 0, 4; stage I, 10; stage II, 17; stage III, 25; stage IV, 4. Of the resected specimens, 73% showed areas of dysplasia adjacent to the tumor. The overall adjusted actuarial 5-year survival rate was 23.7%. The 3-year survival rate was 100% for patients with stage 0 carcinoma, 85.7% for patients with stage I carcinoma, 53.6% for patients with stage IIA carcinoma, 45% for patients with stage IIB carcinoma, 25.2% for patients with stage III carcinoma, and 0% for patients with stage IV carcinoma. The premalignant nature of Barrett's esophagus requires endoscopic surveillance to detect early carcinoma because symptoms often occur late or are absent. Antireflux surgery does not protect against the development of carcinoma. All of the Barrett's epithelium must be resected because a second carcinoma may develop in residual columnar epithelium. Severe dysplasia should be considered an indication for resection. Although operability and resectability rates are high, long-term survival is not. Early detection is mandatory if long-term survival is to be achieved.
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