Should We Deny Surgery for Malignant Hepato-Pancreatico-Biliary Tumors to Elderly Patients?

Malignant hepato-pancreatico-biliary (HPB) tumors have their highest incidence within the sixth to eighth decades of life. The aging of the world population has resulted in a dramatic increase in the number of elderly patients considered for resection of malignant HPB tumors. Because elderly patients are more likely to have more co-morbidities, cognitive impairment, and decreased life expectancy, the benefit and appropriateness of these procedures must be scrutinized for geriatric patients. Therefore, many surgeons have compared the perioperative and long-term outcome of hepatic and pancreatic resections for elderly and younger patients. In most series the elderly population was defined by an age of 70 years or older. The results demonstrate that hepatic resection for hepatocellular carcinoma and colorectal liver metastases can be safely performed in well-selected elderly patients with long-term outcome comparable to younger patients. Similar findings are also reported for pancreatic resection in elderly patients with either ampullary or pancreatic cancer. Although the survival benefit of pancreatico-duodenectomy is limited in all age groups, the absence of competitive therapy justifies this procedure as the sole curative option in younger as well as older patients. Data on resection of gallbladder cancer and hilar bile duct cancer in the elderly are sparse, but there is evidence from large series on resection of these types of tumors that advanced age per se is not a risk factor for reduced outcome. Therefore, surgical options should not be denied to elderly patients with a malignant HPB tumor, and the evaluation should include surgeons expert in HPB surger

Reaching union families: collective identity, union advantages and the American ethos

The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file.Title from title screen of research.pdf file (viewed on January 10, 2008)Includes bibliographical references.Thesis (M.A.) University of Missouri-Columbia 2007.Dissertations, Academic -- University of Missouri--Columbia -- Sociology.The present study examines the beliefs of union family members. Through analysis of qualitative interviews with union members and their wives and adult children, I investigate three main themes: 1) the benefits of unions, 2) the relations between corporations and unions, and 3) subscription to the American ethos. Generally speaking, I found that all participants focused on lifestyle and consumption advantages to union membership. Many also noted the fringe benefits associated with union coverage such as health insurance and job security. Moreover, many of the participants cite the ongoing struggle for power between unions and corporations. In addition, while most of the participants profess a strong belief in individualism and the ability of individuals to make it on their own in American society, there is also a tendency to articulate a moderate sense of collective identity and the importance of structural constraints on economic opportunity

"State of the Art” in Liver Resection and Living Donor Liver Transplantation: A Worldwide Survey of 100 Liver Centers

Background: New strategies have been developed to expand indications for liver surgery. The objective was to evaluate the current practice worldwide regarding critical liver mass and manipulation of the liver volume. Methods: A survey was sent to 133 liver centers worldwide, which focused on (a) critical liver volume, (b) preoperative manipulation of the liver mass, and (c) use of liver biopsy and metabolic tests. Results: The overall response rate to the survey was 75%. Half of the centers performed more than 100 resections per year; 86% had an associated liver transplant program. The minimal remnant liver volume for resection was 25% (15-40%) in cases of normal liver parenchyma and 50% (25-90%) in the presence of underlying cirrhosis. The minimal remnant liver volume for living donors was 40% (30-50%), whereas the accepted graft body weight ratio was 0.8 (0.6-1.2). Portal vein occlusion to manipulate the liver volume before resection was performed in 89% of the centers. Conclusions: Limits of liver volume and the current practice of liver manipulation before resection were comparable among different centers and continents. The minimal remnant liver volume in normal liver was 25%, and more than 80% of the centers performed portal vein occlusio

Contrast-enhanced MR cholangiography with Gd-EOB-DTPA in patients with liver cirrhosis: visualization of the biliary ducts in comparison with patients with normal liver parenchyma

The purpose of this study was to assess the quality of biliary duct visualization using Gd-EOB-DTPA-enhanced magnetic resonance cholangiography (EOB-MRC) in patients with liver cirrhosis. Forty adult patients with liver cirrhosis (cirrhosis group) and 20 adult individuals with normal liver parenchyma (control group) underwent EOB-MRC using T1-weighted GRE imaging up to 180min after Gd-EOB-DTPA administration. Two observers assessed the visualization of each biliary structure and the overall anatomical visualization of the biliary tree. Child-Pugh, MELD score and laboratory findings were compared. The grade of visualization for each evaluated biliary structure was statistically different in the two groups (P = 0.004 to <0.001). The overall EOB-MRC quality was rated as sufficient for anatomical visualization of the biliary tree in all individuals of the control group 20min after Gd-EOB-DTPA application, but in only 16/40 patients (40%) of the cirrhosis group within 30min after application. Analysis of the ROC curves revealed that the cut-off values, for non-sufficient visualization of the biliary tree 20min after Gd-EOB-DTPA application, were MELD scores ≥11 and total serum bilirubin levels ≥30 μmol/l. Consecutively, EOB-MRC in patients with liver cirrhosis resulted in a decreased or even non-visualization of the biliary tree in a substantial percentage of patient

Prospective intraindividual comparison between respiratory-triggered balanced steady-state free precession and breath-hold gradient-echo and time-of-flight magnetic resonance imaging for assessment of portal and hepatic veins

The purpose of this study was to compare respiratory-triggered balanced steady-state free precession (bSSFP) with breath-hold contrast-enhanced dynamic two-dimensional (2D) gradient-echo (GRE) and time-of-flight (TOF) magnetic resonance imaging (MRI) for portal and hepatic vein visualization and assessment of portal and hepatic venous variants. Sixty patients with liver disease underwent nonenhanced bSSFP and contrast-enhanced GRE, bSSFP, and TOF imaging. Contrast-to-noise ratios (CNRs) for portal and hepatic veins were measured. Two readers rated the quality of portal and hepatic vein visualization on a 5-point Likert scale. The diagnostic performance of each MRI series in the detection of portal and hepatic venous variants was assessed in 40/60 patients who also underwent contrast-enhanced multidetector-row computed tomography (MDCT). CNRs for portal and hepatic veins were highest on contrast-enhanced bSSFP images. Image quality of portal and hepatic veins was rated higher for nonenhanced bSSFP than for contrast-enhanced GRE (p<0.03) and TOF (p<0.003) and higher for contrast-enhanced than for nonenhanced bSSFP (p<0.003). Compared with MDCT, portal and hepatic venous variants were identified with an accuracy of 99% on bSSFP images, with an excellent interobserver agreement (κ=0.97). Compared with MDCT, presence of surgically important portal and hepatic venous anatomical variants can be predicted with high accuracy on bSSFP image

A Quarter Century Experience in Liver Trauma: A Plea for Early Computed Tomography and Conservative Management for all Hemodynamically Stable Patients

Background: Advances in diagnostic imaging and the introduction of damage control strategy in trauma have influenced our approach to treating liver trauma patients. The objective of the present study was to investigate the impact of change in liver trauma management on outcome. Methods: A total of 468 consecutive patients with liver trauma treated between 1986 and 2010 at a single level 1 trauma center were reviewed. Mechanisms of injury, diagnostic imaging, hepatic and associated injuries, management (operative [OM] vs. nonoperative [NOM]), and outcome were evaluated. The main outcome analysis compared mortality for the early study period (1986-1996) versus the later study period (1997-2010). Results: 395 patients (84%) presented with blunt liver trauma and 73 (16%) with penetrating liver trauma. Of these, 233 patients were treated with OM (50%) versus 235 with NOM (50%). The mortality rate was 33% for the early period and 20% for the later period (odds ratio 0.19; 95% CI 0.07-0.50, P=0.001). A significantly increased use of computed tomography (CT) as the initial diagnostic modality was observed in the late period, which almost completely replaced peritoneal lavage and ultrasound. There was a significant shift to NOM in the later period (early 15%, late 63%) with a low conversion rate to OM of 4.2%. Age, degree of hepatic and head injury, injury severity, intubation at admission, and early period were independent predictors of mortality in the multivariate analysis. Conclusions: Integration of CT in early trauma-room management and shift to NOM in hemodynamically stable patients resulted in improved survival and should be the gold standard management for liver traum

Numerical Measure of a Complex Matrix

International audienceWe introduce a natural probability measure over the numerical range of a complex matrix A ∈ M n (C). This numerical measure µ A can be defined as the law of the random variable X ∈ C when the vector X ∈ C n is uniformly distributed on the unit sphere. If the matrix A is normal, we show that µ A has a piecewise polynomial density f A , which can be identified with a multivariate B-spline. In the general (nonnormal) case, we relate the Radon transform of µ A to the spectrum of a family of Hermitian matrices, and we deduce an explicit representation formula for the numerical density which is appropriate for theoretical and computational purposes. As an application, we show that the density f A is polynomial in some regions of the complex plane which can be characterized geometrically, and we recover some known results about lacunas of symmetric hyperbolic systems in 2 + 1 dimensions. Finally, we prove under general assumptions that the numerical measure of a matrix A ∈ M n (C) concentrates to a Dirac mass as the size n goes to infinity