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Background: The extent of lymph node dissection for patients with gastroesophageal carcinoma remains controversial. We sought to examine the perioperative risk and survival outcomes in a large Western series of patients undergoing limited (D0/D1) vs extended (D1+/D2) lymphadenectomy (LAD) for gastroesophageal carcinoma., Study Design: Clinicopathologic and treatment factors for 520 patients with gastroesophageal carcinoma undergoing potentially curative resection at a single institution from 1995 to 2017 were analyzed for their impact on perioperative morbidity and mortality, lymph node yield, and overall survival., Results: A total of 362 (70%) patients underwent D0/D1 LAD and 158 (30%) underwent D1+/D2 LAD. Median follow-up was 3.1 years. Patients undergoing D1+/D2 LAD were more likely to have distal tumors, to undergo distal/subtotal/total gastrectomy, and to undergo operation at a more contemporary time than patients undergoing D0/D1 LAD. The median number of lymph nodes examined and the percentage of patients with 16 or more lymph nodes examined was 16 and 53%, respectively, in the D0/D1 group vs 27 and 89%, respectively, in the D1+/D2 group. There were no differences in the rates of major complications (16.6% vs 14.6%) or operative mortality (2.8% vs 0.6%) between the D0/D1 and D1+/D2 groups, respectively. Patients undergoing D1+/D2 LAD had significantly improved overall survival (hazard ratio 0.74; p = 0.035) compared with those undergoing D0/D1 LAD on univariate analysis, but this survival benefit disappeared when controlling for the time period of operation., Conclusions: Gastrectomy with extended (D1+/D2) LAD can be performed safely at a high-volume Western center, and it improves nodal yield significantly and ensures accurate pathologic staging., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.) more...

Objective: To examine the surgical indications and clinical outcomes of a large cohort of patients with necrotizing pancreatitis., Summary Background Data: Mortality after debridement for necrotizing pancreatitis continues to be inordinately high. The clinical experience with patients who underwent uniform surgical treatment for necrotizing pancreatitis at the Massachusetts General Hospital over a 15-year period is described., Methods: Retrospective review of 167 patients with necrotizing pancreatitis who required intervention and were treated with single stage debridement and a closed packing technique. Particular emphasis was placed on the indication for surgery and the presence of infected necrosis. Multiple logistic regression models were used to identify predictors of mortality., Results: The primary preoperative indication for operation was infected necrosis (51%), but intraoperative cultures proved that 72% of the entire cohort was infected. The rate of reoperation was 12.6%, and 29.9% of patients required percutaneous interventional radiology drainage after initial debridement. Overall operative mortality was 11.4% (19/167), but higher in patients who were operated upon before 28 days (20.3% vs. 5.1%, P = 0.002). Other important predictors of mortality included organ failure > or =3 (OR = 2.4, P = 0.001), postoperative intensive care unit stay > or =6 days (OR = 15.9, P = 0.001), and female gender (OR = 5.41, P = 0.02)., Conclusions: Open, transperitoneal debridement followed by closed packing and drainage results in the lowest reported mortality and reoperation rates, and provides a standard for comparing other methods of treatment. A negative FNA does not reliably rule out infection. The clinical status of the patients and not proof of infection should determine the need for debridement. more...

This report summarizes the experience with 144 choledochoscopic examinations performed in the course of 499 common bile duct explorations for stones. Routine choledochoscopy added 15--20 minutes to the operation and caused no complications. In 24% of the patients, additional stones were discovered with the choledochoscope after completion of routine bile duct exploration. In spite of this, the incidence of retained stones found postoperatively remained 4%, with or without choledochoscopy. The factors contributing to the failure of choledochoscopy, thus far, to prevent all retained stones are identified as inexperience of surgeons learning to perform biliary endoscopy, failure to scan the biliary tree systematically and thoroughly (including the left hepatic duct), and failure to reach the duodenum with the choledochoscope, meaning failure to see the lower segment of the common duct and ampullary orifice. With a modicum of experience and attention to detail, it should be possible to reduce considerably further the number of retained stones. more...