Dimitrios N. Papachristou

A retrospective study was made of 41 patients treated for gastric myosarcoma to identify prognostic factors that influence results. The adjusted five- and ten-year survival rates were 56% and 43% respectively, with no significant difference between leiomyosarcoma and malignant leiomyoblastoma. A histopathologic grade of malignancy could be assigned to each tumor according to the degree of hypercellularity, nuclear abnormality, mitotic rate and other characteristics. High histopathologic grade, large tumor size (greater than 5 cm diameter) and invasion of adjacent organs adversely affected prognosis. Five-year survival after curative treatment was: 100% (9/9) for small tumors, of which six were treated by wedge gastric resection; 67% (8/12) for large tumors, mostly after subtotal gastrectomy; and 0% for tumors that invaded adjacent organs, despite extended resections. It is concluded that the management of gastric myosarcomas can be planned according to these prognostic factors and that multimodal therapy of tumors with adverse factors warrants consideration.

Intrahepatic dissection in ablative liver surgery can be accomplished easily and safely with a jet of normal saline generated by a standard agricultural electric sprayer. The jet washes away the intrahepatic parenchyma leaving the ducts and vessels undamaged and easily controlled during dissection. The technique, applied in 45 lobectomies in the dog and in 4 liver resections in man, reduced blood loss.

The incidence of pancreatic fistula in a series of 178 pancreatic resections was 25 per cent and was influenced by the type of pancreatectomy, the management of the remaining pancreas and the size of the pancreatic duct. Thus, fistulas appeared in 52 per cent of patients undergoing pancreatoduodenectomy as compared to only 7 per cent of those undergoing distal pancreatectomy (P less than 0.001). Ligation of the pancreatic, duct in pancreatoduodenectomy led to a 70 per cent incidence; the incidence was 33 per cent if the pancreas was anastomosed to the jejunum instead (P less than 0.001). Fistulas were rare in patients who had dilated pancreatic ducts. Fistulas, once they were established, were rarely influenced by treatment. One out of 5 patients developing pancreatic fistula died, while fistulas were responsible for half of the operative deaths. The study indicated that pancreatojejunostomy is safe in the presence of ductal dilatation; it does not, however, protect from fistula if the pancreatic duct is normal. It also indicated that radiation of the pancreatic remnant in selected patients with persistent fistulas might be a useful therapeutic alternative.

Wide excision of primary malignant melanoma en bloc with regional lymphadenectomy decreases the incidence of regional recurrence as compared with a discontinuous dissection. The more extensive soft tissue defect of the incontinuity procedure is of concern since major lymphatics are often ablated from the ankle region up to the aortic bifurcation. This problem was studied in 81 currently living patients, all of whom had been operated upon for primary melanoma located below the distal thigh. Measurable lymphedema was found in 64% who had had the incontinuity procedure and 69% in the discontinuity group. The incidence of advanced lymphedema (greater than two inches) was 23% and 36%, respectively. All patients with advanced edema had been operated upon more than 3 years ago. Eighty per cent of patients operated upon more than 5 years ago had lymphedema. Wound complications had occurred in 41% of the patients in the incontinuity group and 42% in the discontinuity group, but this did not affect the incidence of edema. The clinical findings are readily explainable on the basis of lymphangiographic data.