Poor Surgical Risk Research Articles

Hepatocellular carcinoma: treatment with a combination therapy of transcatheter arterial embolization and percutaneous ethanol injection.

In an attempt to obtain complete tumor necrosis in large hepatocellular carcinoma (HCC) lesions, the authors studied the clinical and histologic findings of a new combination therapy, percutaneous ethanol injection (PEI) with transcatheter arterial embolization (TAE) (pretreatment with TAE and subsequent PEI) in 15 patients with a single, large (3.0-9.0 cm in diameter), encapsulated lesion of HCC. Two weeks after TAE, PEI was performed under ultrasound guidance. A total of four to 11 injections were administered at a rate of one injection twice a week. During the follow-up period (range, 7-23 months), all lesions were reduced in size and no evidence of HCC was present at contrast material-enhanced computed tomography or angiography in nine of 11 patients who did not subsequently undergo surgery. Six patients had a follow-up of 1 year or more, for a 1-year survival rate of 100%. Four patients subsequently underwent surgical resection; complete necrosis of the tumor was observed in all four. The authors conclude that a combination of PEI and TAE is an appropriate treatment for patients with large, encapsulated HCC lesions who are poor surgical risks.

Case Studies: The Noncompliant Substance Abuser

The Noncompliant Substance Abuser JR is a combative, young white female who presents in the Emergency Room disoriented, with a fever, chills, and a cough productive of yellow sputum. She complains of chest pain and shortness of breath. JR is well known to the medical staff. She has had three previous admissions with endocarditis and interrupted her clinical course on two of those admissions by leaving the hospital against medical advice. On her most recept previous admission, her mitral valve was replaced with a porcine prosthesis. She also tested HIV positive (but was and remains asymptomatic for AIDS). JR's social history includes occasional prostitution, IV substance abuse (cocaine), and needle-sharing. Although JR had been referred repeatedly to the substance abuse shelter, she refused counseling. With a diagnosis of pneumonia, Staphylococcus aureus bacteremia, and a mitral valve vegetation and mild insufficiency, JR is placed on appropriate IV antibiotics and hospitalized. On the third hospital day, JR is much improved. She is calmer, less combative, and seems resigned to the clinical course as outlined to her by her attending physician (four to six weeks of IV antibiotic therapy). On hospital day 10 JR has a low-grade fever but otherwise feels much improved. She begins to show signs of irritability. She quarrels with her medical resident and nurse about the necessity of remaining in the hospital. On hospital day 11 JR objects to receiving medical direction from the medical resident and demands to see her real doctor. The attending physician is called. JR tells him that she can't stand being confined to the ward. She says that she feels well enough for discharge. The attending points out that the growth on her prosthetic heart valve, while reduced in size, remains. He explains that the bacteria growing in her blood is especially dangerous and that a more extended clinical course is medically indicated. He warns JR that she risks death if she cuts off her clinical course prematurely. JR trivializes his warnings, saying, I'm under a death sentence anyhow. On day 12, JR walks out against medical advice. Two days later, JR again presents to the Emergency Room with a fever, shortness of breath, and a rapid heart rate. A repeat echocardiogram shows worsened mitral valve incompetence and heavier regurgitation. Replacement of the prosthetic valve is recommended. JR's attending physician points out the contraindications of JR's poor surgical risk status and her record for recidivism. A consultation with the hospital ethics committee is sought. After a thorough review, the committee offers the opinion that it would not be unethical to replace JR's damage heart valve. Surgery is scheduled. JR tolerates surgery better than expected. Her course of antibiotics is resumed. In hope of achieving better compliance, JR is fitted with a PRN adapter (an indwelling catheter permitting direct IV access) and given instructions for self-administering her antibiotics at home. On the fifteenth day after surgery, JR is discharged, scheduled for a follow-up clinical appointment in two days. JR misses her appointment. Four weeks after discharge, JR presents yet again in the Emergency Room, with a fever and shortness of breath. Clinical signs indicate that her second valve replacement has failed. (JR admits to using the PRN adapter for cocaine). An echocardiogram shows heavy mitral regurgitation and a perivalvular abscess. She is growing Pseudomonas aeruginosa in her blood. JR demands another valve, saying it would violate her civil rights to be refused. Would it be wrong to refuse her? COMMENTARY Patients like JR frustrate doctors and nurses no end. These patients are pejoratively referred to as dirtballs, especially by residents. Sometimes attending physicians tell their residents that the best they can hope for in caring for such a patient is to learn how to insert a subclavian line when her blood pressure drops. …

Medical management of benign prostatic hyperplasia

Medical management of clinical BPH is a reality. The only effective nonsurgical treatment now recommended is aimed at relieving the dynamic component of clinical BPH. Pharmacologic treatment using alpha-adrenoceptor antagonists may be used appropriately to manage patients with prostatism who are poor surgical risks but who could benefit from reduced sympathetic tone. In addition, alpha blockers are used to relieve acute retention, and to prevent retention when increased sympathetic discharge is expected. Thus far, nonsurgical therapy aimed at reducing the mechanical obstruction associated with BPH by prostatic size reduction has failed to produce consistent objective improvement. However, several drugs are now being investigated and may be effective for reducing prostatic size in patients with BPH. Clinical trials are complicated by a number of factors, especially very variable symptoms. Moreover, reduction in prostatic size induced by drugs is not permanent and regrowth occurs with drug withdrawal, necessitating chronic treatment. Ideally, future research should be aimed at the prevention of BPH at an early age. However, this presupposes a better understanding of the pathogenesis of BPH. BPH may not be a single, variable disease but a family of diseases with a number of predictable clinical courses. In the future, we should pay particular attention to histologic variability, to see if in fact different pathologic forms of BPH follow different clinical patterns. If urologists are to keep their predominant position in managing the patient with BPH, they will have to keep informed of medical treatment trials and of potential alternative treatment strategies to prostatectomy.

The Malignant Polyp - When to Operate: The St. Mark’s Experience

The world literature on malignant polyps suggests that those removed endoscopically with recognized favorable histological features for conservative management have excellent prognoses without surgery. Many sessile or 'uncertainly removed' malignant polyps after endoscopic polypectomy also show no evidence of residual cancer, suggesting that referral for surgical resection is not invariably in the best interests of elderly or poor surgical risk patients. St Mark's experience of five year follow-up of 62 patients with malignant polyps judged 'completely excised' showed three cancer-related deaths (of uncertain primary) in 78- to 81-year-old patients. Of 18 patients with malignant polyps 'incompletely excised,' seven had no cancer found at surgery, 10 were well without surgery and one died from carcinomatosis following delayed surgery. These generally encouraging results are further evidence that 'knee jerk surgery' for malignant polyps is inappropriate.

Choledochoscopic electrohydraulic lithotripsy and lithotomy for stones in the common bile duct, intrahepatic ducts, and gallbladder.

Choledochoscopic lithotomy with the aid of electrohydraulic lithotripsy was performed in 40 patients, including 16 patients with choledocholithiasis, 15 with hepatolithiasis, and 9 with cholecystolithiasis. As a route for the choledochoscopy, a T-tube tract, external cholecystostomy, or jejunal limb of hepaticojejunostomy was used in nine patients, while percutaneous transhepatic biliary drainage followed by dilatation of the track was established in 31 patients. The largest cholesterol stone measured 55 mm by 33 mm and the largest bilirubinate stone measured 52 mm by 37 mm. The stones were disintegrated in all but one patient in whom choledochoscopic access to a gallstone was difficult due to deformity of the gallbladder. Complete removal of the stones was achieved in 38 of 39 patients. In a patient with hepatolithiasis, small stones located deep in inaccessible branches of the intrahepatic duct remained unremovable. There were no serious complication. Minor complications occurred, including bleeding from the bile duct mucosa in four patients and postprocedure chills and fever in three. Choledochoscopic lithotomy with electrohydraulic lithotripsy is efficient and useful to remove biliary calculi in patients who are poor surgical risks.

Perkutane Cholezystostomie in der Behandlung der akuten Cholezystitis des Risikopatienten

Percutaneous cholecystostomy was performed in 17 poor surgical risk patients. 16 patients developed acute acalculous cholecystitis postoperatively in the intensive care unit, 1 patient had an acute cholecystitis with calculi. Diagnostic imaging using CT and US was specific for acute cholecystitis in 58% only. Percutaneous cholecystostomy was the definitive treatment in 69% of the patients. Additional cholecystectomy was required in 3 patients with complicated cholecystitis, in 1 patient with bile leakage after catheter dislocation and in 1 patient with gallbladder calculi. 3 patients died, 2 of them from reasons unrelated to the gallbladder disease. Radiology-guided percutaneous cholecystostomy performed by a transhepatic approach is a safe and effective procedure for acute cholecystitis in high-risk patients.

Fatal hemorrhage from an arterio-portal-peritoneal fistula after percutaneous liver biopsy

Exsanguinating hemorrhage complicated a percutaneous needle biopsy in a 64-yr-old woman with a probable collagen vascular disease. Angiography performed before Gelfoam embolization demonstrated a hepatic arterio-portal venous-peritoneal fistula, a lesion not previously described, to be a cause of the hemorrhage. Although surgery remains the treatment of choice, the role of selective hepatic arteriography and Gelfoam embolization in patients with serious hemorrhage who are poor surgical risks needs evaluation.

Clinical Features and Outcome in 68 Cases of Aneurysmal Subarachnoid Hemorrhage without Aneurysm Repair

The authors studied the clinical features and outcome at 6 months in 191 patients with subarachnoid hemorrhage (SAH) from ruptured aneurysms. Aneurysm repair (AR) was undertaken in 123 cases (64.4%). In the non-AR group (n = 68), 48.5% of the patients were 70 years of age or older, compared with 12.2% in the AR group. The duration from onset to admission was less than 3 hours in 48 non-AR cases (70.6%) and in 42 AR cases (34.1%). Among non-AR patients, 63.2% were Hunt and Hess grade IV or V, whereas the figure for AR patients was only 14.7%. By 6 months after SAH, 94.1% of non-AR patients had died, and the remainder were vegetative or severely disabled. In contrast, only 15.4% in the AR group died, and over 50% showed good recovery. The large majority of non-AR patients were treated conservatively because they were judged to be poor surgical risks and, among these patients, nearly one half were elderly. In the 10 elderly patients considered good surgical candidates, vasospasm was the most common reason (70%) for not performing AR.

Percutaneous cholecystolithotomy

We have successfully removed gallstones percutaneously from the gallbladders in two poor surgical risk patients using the standard equipment and the principles of percutaneous nephrolithotomy. No complication occurred in either patient. A brief review of percutaneous gallstone extraction is presented.

Ultrasonically and fluoroscopically guided therapeutic percutaneous catheter drainage of the gallbladder

Percutaneous gallbladder drainage was performed in 16 poor surgical risk patients; 13 had acute cholecystitis, 1 had cholangitis and septicemia, 1 had undergone removal of a gallbladder calculus, and 1 had pancreatic carcinoma with bile duct occlusion. Catheterization and drainage of the gallbladder succeeded primarily in all patients. Catheter dislodgement occurred within 24 h in 1 patient without any side effects. One 87-year-old patient died 14 h after the insertion of the catheter from reasons unrelated to the drainage procedure. Percutaneous removal of gallbladder calculi failed in 3 patients, 2 of whom had been successfully treated for cholecystitis by catheter drainage. Percutaneous gallbladder drainage is a fast, low-risk, inexpensive procedure well suited for the treatment of acute, poor surgical risk patients.

Small hepatocellular carcinoma: percutaneous alcohol injection--results in 23 patients.

Twenty-three patients with hepatocellular carcinoma less than 4.5 cm in diameter (32 lesions) were treated with a percutaneous injection of ethyl alcohol performed with ultrasound (US) guidance. No complications or sequelae occurred after 271 treatments. All lesions were smaller after 6-27 months follow-up. No evidence of hepatocellular carcinoma was present at fine-needle biopsy or contrast material-enhanced computed tomography (CT). No viable tumor cells were detected in four patients who subsequently underwent surgery. The 1-year survival rate of 12 patients was 91.7%. From these data, it can be concluded that percutaneous alcohol injection (PAI) is an appropriate first-line treatment for patients with small hepatocellular carcinoma lesions who are poor surgical risks. Given the risk of new nodular lesions occurring on resected livers and the risk of perioperative mortality, PAI might even be considered an alternative to surgery.

Results of endocavitary irradiation of early rectal tumors.

At the C. G. F. Leclerc, Dijon, 91 early rectal tumors were treated with intracavitary contact radiotherapy alone or in combination with interstitial brachytherapy. The median age of the patients was 70 years. Most of them were referred because of poor surgical risk. Preservation of the sphincter was obtained in 85% (77/91). The actuarial local relapse-free survival rate at 5 years was 74% (67/91). No significant difference was seen between the 72 adenocarcinomas and 19 villous adenomas (p = 0.12). For the middle rectum the rate was 94% compared to 54% for the upper and 77% for the lower rectum. Anterior primaries fared better than posterior and lateral tumors (100%, 63%, and 67% respectively). After salvage therapy the local control rate raised to 91% (83/91). The clinical and endoscopic staging system of Dijon was of prognostic significance: T1A adenocarcinomas (purely exophytic tumors of less than 3 cm) had a better 5-year local relapse-free survival rate (97%) than T2A, T1B or T2B (p less than 0.01).

Inoperable adenocarcinoma of endometrium: radiation therapy.

Between 1960 and 1979, 41 patients with adenocarcinoma of the endometrium who were poor surgical risks were treated with radiation therapy at the University of Iowa. Local tumor control was achieved in 78% of the patients, 5% manifested complications, and 46% survived 5 years ("uncorrected" 5-year survival rate). Intercurrent disease was the major cause of death (54%), and intrauterine recurrence (22%) was the most frequent recurrence. Intraperitoneal spread (12%) occurred as commonly as hematogenous metastases (12%). Three of nine local failures occurred after 5 years. Local control rates correlated well with clinical stage, and the survival rates correlated well with the stage and grade of the tumor. Local tumor control was achieved in 95% of patients who received greater than 7,000 mg-h intracavitary radium, compared with 63% of patients treated with less than 7,000 mg-h.

Percutaneous Management of Renal Pelvic Tumors: A Treatment Option in Selected Cases

Nine patients with renal pelvic transitional cell carcinomas were selected for treatment with percutaneous resection because of a solitary kidney (3), bilateral synchronous disease (1), renal insufficiency (1), poor surgical risk (2) or preoperative evidence of a single, low grade, superficial tumor (2). Eight patients underwent second-look procedures 2 to 28days postoperatively, at which time 6 received neodymium:YAG laser irradiation. Supplemental intracavitary therapy through the nephrostomy tube was given in 6 patients (mitomycin C in 1 and bacillus Calmette-Guerin in 5). Of those patients 2 had third-look procedures. Five patients remain free of recurrence with a followup of 3 to 28 months (mean 9.5 months). In the other 4 patients there was recurrent disease in the renal pelvis (3) or reappearance of positive cytology studies (1) 4 to 5 months postoperatively. Extrarenal tumor recurrence was not observed. Percutaneous surgery provided adequate information to assess tumor architecture, grade, invasiveness and multifocality, and the presence of contiguous mucosal abnormalities, which, along with positive cytology and a history of or concurrent tumors in other segments of the urinary tract, increased the likelihood of tumor recurrence. Second-look procedures appeared to be useful to assess the effectiveness of the initial procedure and to remove any residual disease. Our results suggest that percutaneous surgery can provide results similar to those of an open conservative operation, although further investigation is needed to determine the ultimate place of this technique.

Combined therapies for squamous-cell carcinoma of the esophagus, a Southwest Oncology Group Study (SWOG-8037).

Conservative treatment of esophageal cancer with radiation therapy has afforded few long-term survivors. In order to improve outcome, patients with locoregional disease were treated using a combined modality approach. Patients were treated with chemotherapy consisting of a 96-hour continuous infusion of 5-fluorouracil (5-FU), 1,000 mg/m2/d, days 1 to 4 and days 29 to 32; cisplatin 75 mg/m2, day 1 and 29; and radiation 3,000 rad, days 1 to 19. In the absence of progressive disease, patients underwent esophagectomy. One hundred twenty-eight patients were registered of whom 113 were eligible and 106 were evaluable. Toxicity included gastrointestinal (GI) symptoms, mucositis, and myelosuppression. One hundred two patients completed chemoradiotherapy. Following its completion, 11 patients refused surgery, six were considered poor surgical risks, and 14 had progressive disease. Of the remaining 71 patients, 16 had unresectable disease, 13 had residual disease which was incompletely resected, 24 had disease which could be completely resected, and 18 were without disease on pathologic examination. The overall operability rate was 63% and the overall resectability rate, 49%. Surgical mortality was 11%. Eighty-nine of 113 eligible patients have died, with a median survival of 12 months and a 2-year survival of 28%. The median postsurgical survival for all 71 patients was 14 months and was 32 months for those patients attaining complete remission (CR). Combined modality therapy remains an investigational approach. Attempts should be directed at increasing response rate to initial therapy. A randomized comparison between combined modality treatment and radiation therapy is necessary to definitively determine the usefulness of this more aggressive approach.

Current Management of the Patient with Autonomously Functioning Nodular Goiter

Autonomously functioning thyroid nodules (AFTNs) are presumably independent of TSH for growth and function and appear "hot" on scintiscan because they selectively concentrate radionuclide to a greater extent than the remaining thyroid gland, which is controlled by the normal TH-TSH feedback mechanism. Such autonomously functioning tissue may occur in "patchy" areas, as a solitary nodule, or as multiple nodules (classic Plummer's disease), with the mass of hyperfunctioning tissue and the related secretion of thyroid hormones determining whether the patient is euthyroid or hyperthyroid. Important diagnostic tests include a 99mTc thyroid scan, T4 RIA, T3 uptake, FTI, TSH RIA, and occasionally T3 RIA ("T3 thyrotoxicosis"). Solitary autonomous nodules in adult patients characteristically progress slowly over many years, with toxicity rarely developing in nodules less than 2.5 cm in diameter and occurring primarily in nodules 3 cm or larger and in older patients. The decision to treat a solitary nodule depends upon the size and degree of function of the nodule and the patient's age. Surgery and radioactive iodine are effective therapies. Hyperfunctioning thyroid nodules in children and adolescents (under age 18) have a more rapidly progressive course than those in adults and should be treated by thyroid lobectomy at the time of diagnosis. Subtotal thyroidectomy is the preferred treatment for most patients with toxic multinodular goiter, because it achieves prompt control of the hyperthyroidism and removes the goiter. Radioiodine therapy and long-term antithyroid drug therapy are alternative forms of treatment for patients who are poor surgical risks or who develop recurrent hyperthyroidism following thyroid surgery.

Endoscopic Control of Major Ulcer Bleeding

Emergency surgery for bleeding ulcer still carries a significant risk. Moreover, most patients with major ulcer bleeding are poor surgical risks. Non-surgical methods that are safe and reliably control major bleeding are therefore much warranted. The most promising of various non-operative methods under investigation seems to be endoscopic application of heat delivered by laser, heater probe, or electrocoagulation. In the present study monopolar electrocoagulation with a wet probe reliably controlled major ulcer bleeding in 51 (66%) of 77 patients hemodynamically assessed as requiring emergency surgery. The endoscopic success rate in patients with gastric or duodenal ulcer was 76% and 56%, respectively. It was particularly high (87%) in 23 patients, 17 of whom fulfilled clinical criteria of having stress ulcers. The mortality rate in patients with endoscopically controlled bleeding did not differ from that in 190 patients with spontaneous cessation of ulcer bleeding (8% and 6%, respectively), none of which exsanguinated.

Radiation therapy in the conservative management of cancers of the low rectum and anal canal.

Radiotherapy has gained a prominent place in the management of cancer of the rectum and anus. In 221 cases of epidermoid carcinoma of the anal canal not involving more than three quarters of the circumference of the anal canal or the vaginal mucosa combined external beam using 60 Cobalt (30 Gy over 19 days) with an iridium implant boost (10-20 Gy) 2 months later resulted in a 5-year survival rate of 65%. Ninety percent of patients had normal anal function. A series of 281 patients with "early" adenocarcinoma of the rectum was treated by intracavitary irradiation (50 Kv energy, 100-150 Gy in 3-4 applications over 6 weeks). They were selected as being confined to the bowel wall without evidence of lymphadenopathy or anaplasia. Five-year survival and local recurrence rates were 78% and 5% respectively. A further series of 64 patients with more extensive "intermediate" type adenocarcinoma of the lower third of the rectum selected on the basis of age and poor surgical risk were treated by external beam 60 Cobalt irradiation (30 Gy over 12 days) followed by intracavitary and 192 iridium inplant after a two month interval. Of 44 patients treated more than 3 years previously the local control rate was 79.5% and survival 83%. These results suggest that radiotherapy might be applied to more extensive rectal carcinomas which otherwise would require total rectal excision.

Indications for different modes of surgical therapy in medically refractory ventricular arrhythmias.

Fifty-one adult patients were referred for surgical treatment during the time period from July 1980 to November 1985. The average age was 59 +/- 6 years (19-70 years). All patients had symptomatic ventricular tachycardia that was refractory to standard or experimental drug therapy. On the basis of patient condition, site of arrhythmia, ventricular function, and extent of coronary disease, 21 patients were classed as good risk (GR) while 30 patients were thought to represent a poor surgical risk (PR). Thirty-two patients (15 GR, 17 PR) underwent electrophysiologic guided endocardial resection of arrhythmic foci. The hospital mortality was 12% (4/32), and two additional patients died late. All deaths were in poor risk patients. Recurrent arrhythmia was the primary cause of death in only one patient. Nineteen patients have required automatic internal cardioverter defibrillation (AICD) or chronic burst pacing (BP) with an implantable radiofrequency stimulator, with no operative mortality. AICD implantation was chosen for 13 drug refractory patients who were either poor surgical risk and/or had a tachycardia rate above 130 beats/minute with multiple scars or a multifocal tachycardia. Six additional patients who had tachycardia less than 130 beats/minute and whose arrhythmia could be safely terminated with BP had radiofrequency stimulator implantation. The one late death in this group was in a medically noncompliant patient. On the basis of this experience, we feel that map-guided endocardial resection should be offered to all good risk patients with a single scar and unifocal tachycardia who are refractory to medical treatment. This operation should be considered in all patients who have frequent, life-threatening attacks of tachycardia of any sort on maximum drug therapy. The remainder can be well managed with an AICD if their tachycardia rate is greater than 130 beats/minute or with BP using a radiofrequency stimulator.

Transgastric esophageal bougienage via a feeding gastrostomy

Peroral bougienage of the esophagus is effective for the dilation of most esophageal strictures. In some patients, the stenosis may be so severe that neither dilator nor guide wire can pass. Previously, surgical therapy has been necessary to relieve the stenoses in such patients; however, the patients frequently are poor surgical risks because of their nutritional status and advanced age. We have developed a technique of bougienage through a feeding gastrostomy, which has allowed the successful endoscopic treatment of two such patients.