Citations

AbstractThe experiences of 206 patients who underwent palliative operations for advanced gastric carcinoma have been reviewed to evaluate the effect of treatment. Gastroenterostomy for obstruction alleviates vomiting for most patients, but significant palliation followed operation in only 1/3 of cases. The procedure was accomplished with an acceptable mortality rate, and the average period of postoperative hospitalization was 13 days. The results of palliative partial gastrectomy for patients having obstructive symptoms preoperatively were only slightly better than those following gastroenterostomy. Approximately 1/3 of the patients lived in relative comfort for more than a year. The poor progress of 6 patients who received total gastrectomy supports the opinion that total gastrectomy is not a satisfactory palliative operation. Palliative esophagogastrectomy for patients with dysphagia gave results similar to, or possibly better than, palliative resections for distal lesions. Although the results following the use of prostheses for inoperable malignant stricturing of the esophagogastric junction were disappointing, the procedure had significant advantages when compared with the marked limitations and disadvantages of jejunostomy and the transient relief afforded by transesophageal dilatation. Review of the records of patients who had had a feeding jejunostomy confirmed the general opinion that this procedure seldom is indicated in the management of advanced gastric carcinoma.

AbstractOperation for gastric carcinoma should be undertaken in the presence of known or probable carcinoma of the stomach, in the absence of clear contraindications. These contraindications include serious disease elsewhere (such as cardiac insufficiency, advanced pulmonary disease, and pronounced renal failure), definite objective evidence of distant metastases, and evidence of local extension beyond the point of resectability. To deny a patient the potential benefits of exploratory laparotomy is to eliminate the chance of cure. After thorough exploration of the abdomen, curative resection of gastric cancer involves radical subtotal gastrectomy for lesions restricted to the distal 2/3 of the stomach, and total gastrectomy with splenectomy for lesions in the upper 1/3. When there is local extension of the cancer, resection of adjacent organs should be performed if it appears that the growth can be completely removed. When curative resection is not possible, palliative resection or gastroenterostomy is often indicated to relieve symptoms.

AbstractThree hundred and eighty‐four consecutive patients with primary hyperparathyroidism (HPT) were surgically treated at a single institution during the 2 year period 1983 through 1984. Two patients were found to have benign familial hypocalciuric hypercalcemia and a single patient had parathyroid carcinoma. In the remaining 379 patients, the cure rate was 99.5%, the operative mortality 0.3%, persistent vocal cord paralysis 0.8%, and permanent hypocalcemia 0.3%. This data supports a liberal policy regarding cervical exploration in patients with HPT and questions any policy of observation without surgical intervention.

AbstractWith few exceptions, proctocolectomy is the treatment of choice for patients with chronic ulcerative colitis. The method by which patients are offered control of bowel function postoperatively, however, is more controversial. Traditionally, proctocolectomy is accompanied by a conventional Brooke ileostomy and control of enteric effluent provided by an external appliance. Today, several alternatives are available, such as Kock's continent ileostomy and the ileoanal anastomosis. The results of both are generally good. The functional outcome of these procedures is, however, not always uniform and not all patients are candidates for such alternatives. Conventional ileostomy, therefore, remains the standard surgical approach; Brooke ileostomy is the one procedure which is applicable to any patient regardless of age, body habitus, type of disease, or other medical problems. It is the aim of this article to summarize important principles of surgical technique and of stomal care, to detail the functional results and physiologic consequences of standard ileostomy, and to document the impact of ileostomy on quality of life. Finally, the current and future role of ileostomy in the era of surgical alternatives will be discussed.

AbstractAn account is given of the evolution of proctocolectomy with construction of a pelvic ileal pouch and an ileoanal anastomosis, which has probably become the most popular elective operation at the present time for ulcerative colitis. The technique favored by the author for this procedure is described and the results obtained in 422 cases at the Mayo Clinic are analyzed, with 188 of them analyzed in detail. Outstanding issues regarding technical methods and outcome are discussed.

AbstractAt the Mayo Clinic, 103 patients with primary malignant lymphoma of the thyroid have been diagnosed and treated through 1978. This study examines the clinical findings in the 57 new cases seen since the last review in 1966; pathology and survival are evaluated for the series as a whole, including the 46 patients reported previously. Age and sex patterns were unchanged since the earlier review; thyroid lymphoma tended to occur in middle‐ to older‐aged women, and patients typically presented with a fairly rapidly enlarging, painless, and firm thyroid mass. The most common histologic subtype of lymphoma encountered was diffuse large cell (diffuse histiocytic). Hashimoto's disease was found in 36% of the pathologic specimens available for review. Follow‐up was completed for all patients up to 1979. Age, sex, and histologic subtype of tumor did not appear to be significant determinants of prognosis. Patients in whom the lymphoma was confined to the thyroid (intrathyroidal type) had a better overall 5‐year survival rate (86%) than those in whom tumor invaded soft tissues surrounding the hyroid or involved regional cervical nodes (38% for the extrathyroidal type). Almost all of the patients who had intrathyroidal tumors underwent surgical resection before irradiation. However, 3 of the 5 patients in this group who were treated by radiotherapy alone survived more than 5 years. There were approximately equal numbers of patients with the extrathyroidal type of lymphoma who were treated either by radiotherapy combined with surgical resection or by radiotherapy alone. The one form of therapy was just as effective as the other.

AbstractIdentification of multiple clinical and pathologic prognostic factors in differentiated thyroid cancer has permitted some degree of risk stratification. However, these clinical indices fail to distinguish potential intrinsic differences in tumor virulence. The nm23 gene has been identified as a potential metastasis suppressor gene that is homologous to nucleoside diphosphate kinases. Studies in human breast cancer have shown a significant inverse correlation between nm23 levels and nodal involvement/tumor recurrence. Given the possible clinical utility of a marker of metastatic potential in the management of thyroid carcinoma, we examined 34 thyroid neoplasms and a human medullary thyroid cancer (MTC) cell line (TT) for nm23 expression. Normalized nm23 expression was assessed by Northern analysis of tumor RNA. nm23 Expression (tumor expression/TT cell expression, mean ±SE) was 1.14 ±0.15* in MTCs (n =5), 0.70 ±0.10* in follicular cancers (n=6), 0.51 ±0.11 in papillary cancers (n=19), and 0.31 ±0.03 in follicular adenomas (n=4) (*p< 0.05 when compared to adenomas). Within histologicgroups, we found no correlation between nm23 expression and nodal involvement or distant métastases. Our results indicate that thyroid neoplasms of different histologies express varying levels of the nm23 transcript. Although nm23 expression seems diminished in metastatic breast cancer, it appears not to be the case in metastatic thyroid cancer. The nm23 gene may therefore have different roles in the evolution and metastases of different neoplasms.