No abstract

From 1969 to 1983 a total of 1918 patients with colorectal cancer were treated by curative resection. One hundred twenty one patients in this group had multivisceral organ involvement, necessitating extended multivisceral radical resection. Tumor infiltration was proven histologically in 55 percent, while 45 percent had inflammatory adherence to the attached organ only. Postoperative mortality was 12 percent. Dukes' A and B stages were present in 57 percent. The five-year survival rate (postoperative mortality included) was 54 percent for patients with inflammatory adherence, 49 percent for patients with tumor infiltration resected en bloc without tumor tears of rupture, and 17 percent when the surgeon inadvertently had torn or cut into tumor tissue during resection.

Despite the overall poor prognosis of gallbladder carcinoma, it appears that, in resectable lesions, an aggressive surgical approach promises improvement in survival rates. Radical treatment of gallbladder carcinoma is based on a detailed knowledge of the lymphatic, venous, direct, and intraductal modes of spread of gallbladder carcinoma. Customized therapy of gallbladder carcinoma takes staging into consideration: if one is dealing with gallbladder carcinoma with macroscopic liver infiltration (T3 or T4), or with a pre- or intraoperatively diagnosed gallbladder carcinoma with an unknown depth of infiltration, an en bloc resection of the gallbladder with adjacent liver segments IVb and V, perhaps including IV, as well as a dissection of the hepatoduodenal ligament should be performed. If the carcinoma is missed intraoperatively at the time of cholecystectomy for other indications, in the presence of a T2 gallbladder carcinoma in proximity to the liver bed, reoperation with dissection of the hepatoduodenal ligament and resection of liver segments IVb and V should be performed. In the presence of T1 gallbladder carcinoma, simple cholecystectomy is adequate. This concept is based on our experience with 113 patients with gallbladder carcinoma who underwent treatment in our department from January, 1970 to June, 1989. Sixty-seven percent of the gallbladder carcinomas were resected, 30% for cure and 37% palliatively. In 33%, the operation was limited to an exploratory laparotomy or a palliative operation, or no operation was performed. Of the curatively resected carcinomas (n = 34), 7 were Stage I, 7 Stage II, 9 Stage III, and 11 Stage IV.(ABSTRACT TRUNCATED AT 250 WORDS)

The term early colorectal carcinoma is used for an infiltrating carcinoma with submucosal spread, but no involvement of the muscle coat (muscularis propria). Our experience with 249 such tumours is reported. Lymph node metastases were detected in only 3% of 130 patients subjected to classical surgery. Early colorectal carcinoma represents a cancer stage with an excellent prognosis (age-corrected 10-year survival rate 100%). The survival rates after limited therapeutic procedures (endoscopic polypectomy, local surgical excision, segmental/tubular resection) or after classical radical surgery do not differ significantly provided that certain selection criteria are strictly observed.

This is a report of 117 pancreaticoduodenectomies performed for chronic pancreatitis, of which 49 were partial and 68 were total. The operative mortality rate of partial pancreaticoduodenectomy was 8.2% and of total pancreatectomy was 20.6%. During a follow-up period of 61/2 years, 76% and 63% of the surgical patients, respectively, continued to drink alcohol as heavily as before. Prior to total pancreatectomy, only 42% of the patients had diabetes. After total extirpation of the organ, all had diabetes and 75% were very difficult to stabilize with insulin, experiencing repeated episodes of hypoglycemic shock. The additional late mortality rate was 20.4% following partial pancreaticoduodenectomy and 19.1% after total resection. After total pancreatectomy, 50% of the late deaths were due to hypoglycemia. After total pancreatectomy, 11% fewer patients were still alive at the end of the follow-up period than after partial pancreaticoduodenectomy. Total pancreatectomy is justified only in patients who already have diabetes requiring insulin. A new technique is described in which, following resection of the head of the pancreas, the duct system is occluded by injection of a rapidly hardening amino acid solution, leading to atrophy of the excretory pancreas within a few weeks. This procedure has been carried out in 39 patients with a mortality rate of 2.5% and postoperative complications in 7.6%. We believe that the immediate risk of partial pancreaticoduodenectomy in chronic pancreatitis can be decreased markedly and the late results improved by this new technique.

Partial duodenopancreatectomy and occlusion of the remaining ductal system by Ethibloc to induce rapid exocrine atrophy for treatment of severe chronic cephalic pancreatitis was introduced in our department in January of 1978. Since then, this surgical procedure has been performed in a total of 289 patients. Postoperative morbidity was 12.2%, 5 pancreatic and 3 biliary fistulas occurred. Postoperative mortality was 1% and relapses of pancreatitis occurred in only 2.2% due to incomplete filling of ducts with Ethibloc. A total of 88.2% of patients became pain-free and symptomless, 10.8% voiced minor complaints, and 85.9% gained an averaged of 7.8 kg weight postoperatively. We conclude that Ethibloc occlusion is highly effective in inducing complete exocrine atrophy, thus abolishing the inflammatory process and preventing relapses of chronic pancreatitis and preserving the endocrine function from further impairment. This was demonstrated by biochemical assays during a 36-month follow-up in a prospective study in 23 of 289 patients. Our results compare favorably with and are superior to results from any other operative procedure for chronic cephalic pancreatitis. We consider partial duodenopancreatectomy combined with Ethibloc occlusion of the pancreatic duct the procedure of choice in the surgical treatment of severe chronic cephalic pancreatitis.

In 597 patients with adenocarcinoma or mucinous adenocarcinoma of the rectum, the prognosis after radical resection for cure was investigated. Staging according to the fourth edition of the UICC TNM Classification showed a good correlation to prognosis. By multivariate analysis, various additional independent prognostic factors could be demonstrated. The individual additional prognostic factors are partly of significance in some pTNM defined stages and substages, but not in others. In order to obtain the most detailed knowledge of prognostic factors after radical resection for cure, multivariate analysis of prognostic factors in colorectal carcinoma must be performed not only in separate colonic and rectal groups, but also separately for each of the individual pTNM defined stages and substages.

In the area of radical surgical treatment of gastric carcinoma, extended or multiorgan resection is--as is systematically extended lymph node dissection--becoming increasingly important. One indication for extended gastrectomy is intramural or transmural infiltration of neighboring organs or the gross presence of metastatic involvement of the lymph nodes associated with the celiac trunk, splenic artery, or splenic hilum. Because the mortality rate associated with extended gastrectomy is hardly any higher than that for nonextended gastrectomy, the indication for the former may be generously applied. The prognostically most unfavorable case is histologic evidence of transmural infiltration of neighboring organs (pT4). Multiorgan resection with improved systematic extension of lymph node dissection is of greatest benefit to patients with inflammatory adhesion of the stomach to neighboring organs or pN2 lymph node metastases. Intramural infiltration of the esophagus can be treated by including the thoracic part of the esophagus in the gastric resection done via an abdominothoracic approach, ensuring an appropriate margin of clearance, with no significant worsening of the prognosis.