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Exploratory laparotomy for staging in Hodgkin's disease
Exploratory Laparotomy for Staging in Hodgkin’s Disease Diagnostic Yield versus Operative Morbidity
MAJ Melvin D. Smith, MC, USAF, Lackland COL Gerald Klebanoff, MC, USAF, Lackland
Air Force Base, Texas Air Force Base, Texas
COL William T. Kemmerer, MC, USAF, Lackland
Air Force Base, Texas
Among recent approaches to effect more accurate staging of Hodgkin’s disease is surgical staging with splenectomy and abdominal lymph node and liver biopsy. In many centers, operative staging is a well accepted procedure, affording an additional opportunity for the therapist to “tailor” the treatment to the individual patient. Two questions arise, however: Does the patient, because of the basic disease process, represent a greater operative risk than does the average surgical patient? Further, are the results of surgical staging helpful enough to warrant that risk? Enright et al [1] have reported that six of their sixty-eight patients subjected to the staging procedure suffered postoperative complications, although there were no deaths in this series. Glatstein et al [Z] reported that the incidence of major complications was very low, but added that one of every three patients did have postoperative fever and basilar atelectasis. Our experience at Wilford Hall USAF Medical Center was initiated with the occurrence of several complications, arousing the suspicion that the operative morbidity might outweigh the over-all value of the staging procedure. As a result, this prospective study of postoperative complications was undertaken.
From the General Surgery Service, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas. Reprint requests should be addressed to Dr Klebanoff, General Surgery Service, Wilford Hall USAF Medical Center, Lackland Air Force Base. Texas 78236. Presented at the Twenty-Fourth Annual Meeting of the Southwestern Surgical Congress, Albuquerque, New Mexico, May l-4. 1972.
Volume 124, December 1972
Material and Methods Between November 1969 and September 1971, seventy surgical staging procedures for Hodgkin’s disease were performed. Sixty-eight of these were performed by the resident house staff. The choice of incision was left to the preference of the principal surgeon, but usually was an upper abdominal midline incision. The splenectomy, liver biopsy, and lymph node biopsies were performed as previously described [1,2]. Drains were not used, nor were antibiotics used routinely. The most commonly occurring complications observed with any abdominal procedures were evaluated: intraabdominal, incisional, pulmonary, and genitourinary. Fever as an isolated finding was noted because of its frequent occurrence without demonstrable cause. It is defined here as a sustained postoperative temperature elevation of 101°F or greater for several days. These complications were studied in reference to age, sex, preoperative clinical stage, and histologic findings. Results Thirty-seven patients (52.8 per cent) had complications. Twenty of these thirty-seven patients had complications in the “unexplained fever” category, leaving a more reasonable complication rate of 24.6 per cent. (Table I.) There were no fatalities. Our youngest patient was twelve years old, and the oldest, fifty-three. Forty-five patients were from twenty to twenty-nine yea.rs of age and 92 per cent of the complications occurred in these patients. There were fifty-three male (75.7 per cent) and seventeen female patients. (Table II.) Twenty-four of the seventy patients had disease which was clinically staged III or IV preoperatively.
811
Smith, Klebanoff,
TABLE I
and Kemmerer
Surgically Determined Stage of Disease in Thirty-Seven of Seventy Patients with Hodgkin’s Disease at Wilford Hall Medical Center (November 1969-September 1971) Stage I
Complication
A
Stage
3
0 10
4
Decade 10-19 20-29 30-39 40-49 50-60
812
11 1
2 1
Stage IV B
A
Remission Total
B
a
6 1
;
10
2
70
a
2
1 1
2 6 3 9
.
3 4 7
1 1
3 3 6
Of these twenty-four, disease in eleven was downstaged to I and II after the operation. Of the forty-six patients with clinical stage I and II disease, ten had change of staging to III and IV after the surgical staging procedure. Thus, twenty-one of seventy patients had disease which had been clinically staged erroneously. With the exception of “unexplained fever,” pulmonary complications were the largest single group of complications. Seven patients had relatively minor basilar atelectases, and aspiration occurred at the time of extubation in one, necessitating steroids and antibiotics. The three genitourinary complications consisted of urinary retention, two cases of which required more than forty-eight hours of catheter drainage. Three patients had wound infections. One case occurred in a patient with clinically staged IA disease that remained IA after surgical staging. The other two cases occurred in patients with clinically staged IIB disease, both of which were surgically upstaged to IVB disease. The one case of intraabdominal infection was a pancreaticocutaneous fistula occurring in a patient with stage IVB disease who had massive retroperitoneal nodal involvement. There was one patient who received a small lacera-
Age by
A
II I
.
Genitourinary Wound Intra-abdominal Other Subtotal Unexplained fever Total
TABLE I I
Stage
A
B 19
Total number of patients Complication Pulmonary
II
Age and Sex Distribution Compared to Complications in Seventy Cases of Hodgkin’s Disease Number
Number
of Complication
of Male Patients
1 20 6 2 1
4 34 11 3 1
Number of Complications 0 5 0 2 0
Number of Female Patients 2
ii 1 3 0
Total 1 I6 25145 6112 416 l/l
.
.
1
3 6 9
1
1 3 4
tion of the inferior vena eava intraoperatively, and one who was found to have an incisional hernia five days postoperatively. Unexplained fever developed postoperatively in a relatively. larger number of patients whose disease was placed preoperatively in the clinical substage “B” or as symptomatic Hodgkin’s disease. This relationship of preoperative symptoms with postoperative fever seemed to be closer than the relationship of surgical stage and fever. (Table I.) Ten per cent of the patients with disease in substage “A” developed unexplained fever postoperatively, whereas 18.6 per cent of the patients with disease in substage “B” developed the fever. Patients in whom biopsy specimens were interpreted as histologically free of disease appeared to have a higher incidence of complications. (Table III.) In contrast to this, however, it is of interest to note that two of the three patients who had wound infections had histologically positive liver, spleen, and lymph node biopsies. Comments
Nonfatal complications occurred in thirty-seven of our first seventy patients subjected to laparotomy for staging of Hodgkin’s disease. Complications in twenty of these thirty-seven were in the “unexplained fever” category, leaving a more reasonable rate of 24.6 per cent. Ninety-two per cent of the time complications occurred in patients in the twenty to twenty-nine year old group and notwithstanding the basic process of the Hodgkin’s disease, this group was otherwise very healthy. This fact, no doubt, aided in their rapid recovery. As noted by previous investigators, basilar atelectasis was mild to moderate and lasted only a few days [2]. The rate and degree of atelectasis in this group of patients were certainly not greater than those we observed in patients
The American Journal of Surgery
Staging in Hodgkin’s
TABLE I I I
Disease
Comparison of Thirty-Seven Postoperative Complications with Histologic Interpretation of Spleen, Liver, and Lymph Node Biopsies Liver
Spleen Positive Complication Pulmonary Urinary tract Wound infection Intra-abdominal Other
infection
Tear in inferior vena cava Incisional hernia Unexplained fever Total
Negative
Positive
(26)
(42)
(12)
2 0 2 1
6 3 1 0
0 1 9 15
Negative
Positive
Negative
(55)
(29)
(41)
1 0 2 1
7 3 1 0
3 1 2 1
5 2 1 0
1 0 11
0 0 3
1 1 17
0 0 7
1 1 13
22
7
30
14
23
undergoing splenectomy for other reasons or in those with upper abdominal incisions for any operative procedure. Aspiration pneumonitis resulted at the time of extubation in one patient and was recognized at that time, and treatment was initiated promptly. This complication cannot be related to the primary disease process. Urinary retention occurred in three of the seventy patients (4.3 per cent) and this simply was an inability of the patient to void spontaneously within our allotted time of six to eight hours postoperatively. The volume with catheterization was greater than 400 ml in two of the patients, and thus drainage was maintained. We can in no way attribute this small incidence to the presence of Hodgkin’s disease. In their review of immunologic aspects of cancer, Sophocles and Nadler [3] report that patients with Hodgkin’s disease are often unable to “muster” a delayed hypersensitivity response. It is of interest that two of the three cases of wound infection occurred in patients whose disease was staged IV by biopsy. This, admittedly, is a small percentage, but close observation of this relationship is in order. One instance of pancreaticocutaneous fistula occurred in a patient who obviously had stage IV disease at the time of laparotomy with findings of gross liver involvement, enlarged spleen, and greatly enlarged matted nodes throughout the retroperitoneum. The tail of the pancreas was injured during splenectomy and repaired, and appropriate drainage was employed. The case of damaged inferior vena cava is not, strictly speaking, a postoperative complication for it was repaired successfully intraoperatively. It is mentioned here to emphasize that such things can and do occur, but obviously should be recognized and repair immediately carried out. Unexplained fever, although not literally a complication, was bothersome in that an exhaustive search
Volume 124. December 1977
Lymph Nodes
had to be carried out before it could be ascribed to Hodgkin’s disease. None of the patients who had preoperative temperature elevations was included in this category. This “complication” was seen in 28.6 per cent of the cases and occurred in a ratio of 2 to 1 in the symptomatic (B) to asymptomatic (A) substages, supporting our belief that this is a manifestation of the basic disease process, precipated by the surgical insult. These patients all were normothermic by the fifth to seventh postoperative day. All patients were able to be placed on a specific therapeutic regimen for Hodgkin’s disease during the second postoperative week. When compared to the occurrence of complications of splenectomy performed for hematologic disorders and other splenic diseases, our experience is favorable [4-61. To date no patient has had gram-positive bacteremia or other serious infections as reported by others [7l, with a follow-up period as long as two and a half years. Conclusions
The postoperative morbidity of our first seventy patients undergoing staging procedures for Hodgkin’s disease at the Wilford Hall Medical Center is presented. There was no postoperative mortality. Nonfatal complications occurred in 24.6 per cent of the patients and consisted mainly of mild to moderate basilar atelectasis, urinary retention and cystitis, and easily controlled wound infection. There was one case of pancreaticocutaneous fistula occurring in a patient with stage IV disease. To date there have not been any complications of septicemia, subphrenic abscess, or thrombosis. This study was undertaken to help allay the fears of the surgeon who performs laparotomy for staging purposes in Hodgkin’s disease. We found that the
Al.?
Smith,
Klebanoff,
morbidity pitalization
and Kemmerer
is not prohibitive and that prolonged has not been the rule.
hos-
References 1. Enright LP, Trueblood HW. et al: The surgical diagnosis of abdominal Hodgkin’s disease. Surg Gynec Obsfet 130: 853.1970. 2. Glatstein E, et al: The value of laparotomy and splenectomy in the staging of Hodgkin’s disease. Cancer 24: 709, 1969. 3. Sophocles A, Nadler S: Immunologic aspects of cancer. Sorg Gynec Obstet 133: 321, 1971. 4. Devlin HB, et al: Elective splenectomy for primary hematologic and splenic disease. Surg Gynec Cbstet 130: 273, 276,197O. 5. O’Brien PH, et al: Splenectomy for hypersplenism in malignant lymphoma. Arch Sorg 101: 348, 1970.
814
6. Schwartz SI, et al: Splenectomy for hematologic disorders. Arch Surg 101: 338, 1970. 7. Donaldson S, Moore M: Pneumococcal septicemia in lymphoma patients after splenectomy. Cancer Res 19: 491, 1971. 8. Schwartz S, Adams JT, B&man AW: Splenectomy for hematologic disorders. Curr Prob Surg p 38, May 1971. 9. Geller W: Diagnosis and treatment of Hodgkin’s disease. Hosp Med 4: 6, 1968. 10. Johnson RE: Is staging lapatotomy routinely indicated in Hodgkin’s disease. Ann intern Med 75: 459, 1971. 11. Stiver G: Letters to the editor. Ann intern Med 76: 670, 1972. 12. Schwartz SI: Personal communication. 13. Rosenberg SA: ‘A critique of the value of laparotomy and splenectomy in the evaluation of patients with Hodgkin’s disease. Cancer Res 31: 1737, 1971. 14. Tubiana M: Summary of informal discussion on staging procedures in Hodgkin’s disease. Cancer Res 31: 1751, 1971.
The American Journal of Surgery
MAJ Melvin D. Smith, MC, USAF, Lackland COL Gerald Klebanoff, MC, USAF, Lackland
Air Force Base, Texas Air Force Base, Texas
COL William T. Kemmerer, MC, USAF, Lackland
Air Force Base, Texas
Among recent approaches to effect more accurate staging of Hodgkin’s disease is surgical staging with splenectomy and abdominal lymph node and liver biopsy. In many centers, operative staging is a well accepted procedure, affording an additional opportunity for the therapist to “tailor” the treatment to the individual patient. Two questions arise, however: Does the patient, because of the basic disease process, represent a greater operative risk than does the average surgical patient? Further, are the results of surgical staging helpful enough to warrant that risk? Enright et al [1] have reported that six of their sixty-eight patients subjected to the staging procedure suffered postoperative complications, although there were no deaths in this series. Glatstein et al [Z] reported that the incidence of major complications was very low, but added that one of every three patients did have postoperative fever and basilar atelectasis. Our experience at Wilford Hall USAF Medical Center was initiated with the occurrence of several complications, arousing the suspicion that the operative morbidity might outweigh the over-all value of the staging procedure. As a result, this prospective study of postoperative complications was undertaken.
From the General Surgery Service, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas. Reprint requests should be addressed to Dr Klebanoff, General Surgery Service, Wilford Hall USAF Medical Center, Lackland Air Force Base. Texas 78236. Presented at the Twenty-Fourth Annual Meeting of the Southwestern Surgical Congress, Albuquerque, New Mexico, May l-4. 1972.
Volume 124, December 1972
Material and Methods Between November 1969 and September 1971, seventy surgical staging procedures for Hodgkin’s disease were performed. Sixty-eight of these were performed by the resident house staff. The choice of incision was left to the preference of the principal surgeon, but usually was an upper abdominal midline incision. The splenectomy, liver biopsy, and lymph node biopsies were performed as previously described [1,2]. Drains were not used, nor were antibiotics used routinely. The most commonly occurring complications observed with any abdominal procedures were evaluated: intraabdominal, incisional, pulmonary, and genitourinary. Fever as an isolated finding was noted because of its frequent occurrence without demonstrable cause. It is defined here as a sustained postoperative temperature elevation of 101°F or greater for several days. These complications were studied in reference to age, sex, preoperative clinical stage, and histologic findings. Results Thirty-seven patients (52.8 per cent) had complications. Twenty of these thirty-seven patients had complications in the “unexplained fever” category, leaving a more reasonable complication rate of 24.6 per cent. (Table I.) There were no fatalities. Our youngest patient was twelve years old, and the oldest, fifty-three. Forty-five patients were from twenty to twenty-nine yea.rs of age and 92 per cent of the complications occurred in these patients. There were fifty-three male (75.7 per cent) and seventeen female patients. (Table II.) Twenty-four of the seventy patients had disease which was clinically staged III or IV preoperatively.
811
Smith, Klebanoff,
TABLE I
and Kemmerer
Surgically Determined Stage of Disease in Thirty-Seven of Seventy Patients with Hodgkin’s Disease at Wilford Hall Medical Center (November 1969-September 1971) Stage I
Complication
A
Stage
3
0 10
4
Decade 10-19 20-29 30-39 40-49 50-60
812
11 1
2 1
Stage IV B
A
Remission Total
B
a
6 1
;
10
2
70
a
2
1 1
2 6 3 9
.
3 4 7
1 1
3 3 6
Of these twenty-four, disease in eleven was downstaged to I and II after the operation. Of the forty-six patients with clinical stage I and II disease, ten had change of staging to III and IV after the surgical staging procedure. Thus, twenty-one of seventy patients had disease which had been clinically staged erroneously. With the exception of “unexplained fever,” pulmonary complications were the largest single group of complications. Seven patients had relatively minor basilar atelectases, and aspiration occurred at the time of extubation in one, necessitating steroids and antibiotics. The three genitourinary complications consisted of urinary retention, two cases of which required more than forty-eight hours of catheter drainage. Three patients had wound infections. One case occurred in a patient with clinically staged IA disease that remained IA after surgical staging. The other two cases occurred in patients with clinically staged IIB disease, both of which were surgically upstaged to IVB disease. The one case of intraabdominal infection was a pancreaticocutaneous fistula occurring in a patient with stage IVB disease who had massive retroperitoneal nodal involvement. There was one patient who received a small lacera-
Age by
A
II I
.
Genitourinary Wound Intra-abdominal Other Subtotal Unexplained fever Total
TABLE I I
Stage
A
B 19
Total number of patients Complication Pulmonary
II
Age and Sex Distribution Compared to Complications in Seventy Cases of Hodgkin’s Disease Number
Number
of Complication
of Male Patients
1 20 6 2 1
4 34 11 3 1
Number of Complications 0 5 0 2 0
Number of Female Patients 2
ii 1 3 0
Total 1 I6 25145 6112 416 l/l
.
.
1
3 6 9
1
1 3 4
tion of the inferior vena eava intraoperatively, and one who was found to have an incisional hernia five days postoperatively. Unexplained fever developed postoperatively in a relatively. larger number of patients whose disease was placed preoperatively in the clinical substage “B” or as symptomatic Hodgkin’s disease. This relationship of preoperative symptoms with postoperative fever seemed to be closer than the relationship of surgical stage and fever. (Table I.) Ten per cent of the patients with disease in substage “A” developed unexplained fever postoperatively, whereas 18.6 per cent of the patients with disease in substage “B” developed the fever. Patients in whom biopsy specimens were interpreted as histologically free of disease appeared to have a higher incidence of complications. (Table III.) In contrast to this, however, it is of interest to note that two of the three patients who had wound infections had histologically positive liver, spleen, and lymph node biopsies. Comments
Nonfatal complications occurred in thirty-seven of our first seventy patients subjected to laparotomy for staging of Hodgkin’s disease. Complications in twenty of these thirty-seven were in the “unexplained fever” category, leaving a more reasonable rate of 24.6 per cent. Ninety-two per cent of the time complications occurred in patients in the twenty to twenty-nine year old group and notwithstanding the basic process of the Hodgkin’s disease, this group was otherwise very healthy. This fact, no doubt, aided in their rapid recovery. As noted by previous investigators, basilar atelectasis was mild to moderate and lasted only a few days [2]. The rate and degree of atelectasis in this group of patients were certainly not greater than those we observed in patients
The American Journal of Surgery
Staging in Hodgkin’s
TABLE I I I
Disease
Comparison of Thirty-Seven Postoperative Complications with Histologic Interpretation of Spleen, Liver, and Lymph Node Biopsies Liver
Spleen Positive Complication Pulmonary Urinary tract Wound infection Intra-abdominal Other
infection
Tear in inferior vena cava Incisional hernia Unexplained fever Total
Negative
Positive
(26)
(42)
(12)
2 0 2 1
6 3 1 0
0 1 9 15
Negative
Positive
Negative
(55)
(29)
(41)
1 0 2 1
7 3 1 0
3 1 2 1
5 2 1 0
1 0 11
0 0 3
1 1 17
0 0 7
1 1 13
22
7
30
14
23
undergoing splenectomy for other reasons or in those with upper abdominal incisions for any operative procedure. Aspiration pneumonitis resulted at the time of extubation in one patient and was recognized at that time, and treatment was initiated promptly. This complication cannot be related to the primary disease process. Urinary retention occurred in three of the seventy patients (4.3 per cent) and this simply was an inability of the patient to void spontaneously within our allotted time of six to eight hours postoperatively. The volume with catheterization was greater than 400 ml in two of the patients, and thus drainage was maintained. We can in no way attribute this small incidence to the presence of Hodgkin’s disease. In their review of immunologic aspects of cancer, Sophocles and Nadler [3] report that patients with Hodgkin’s disease are often unable to “muster” a delayed hypersensitivity response. It is of interest that two of the three cases of wound infection occurred in patients whose disease was staged IV by biopsy. This, admittedly, is a small percentage, but close observation of this relationship is in order. One instance of pancreaticocutaneous fistula occurred in a patient who obviously had stage IV disease at the time of laparotomy with findings of gross liver involvement, enlarged spleen, and greatly enlarged matted nodes throughout the retroperitoneum. The tail of the pancreas was injured during splenectomy and repaired, and appropriate drainage was employed. The case of damaged inferior vena cava is not, strictly speaking, a postoperative complication for it was repaired successfully intraoperatively. It is mentioned here to emphasize that such things can and do occur, but obviously should be recognized and repair immediately carried out. Unexplained fever, although not literally a complication, was bothersome in that an exhaustive search
Volume 124. December 1977
Lymph Nodes
had to be carried out before it could be ascribed to Hodgkin’s disease. None of the patients who had preoperative temperature elevations was included in this category. This “complication” was seen in 28.6 per cent of the cases and occurred in a ratio of 2 to 1 in the symptomatic (B) to asymptomatic (A) substages, supporting our belief that this is a manifestation of the basic disease process, precipated by the surgical insult. These patients all were normothermic by the fifth to seventh postoperative day. All patients were able to be placed on a specific therapeutic regimen for Hodgkin’s disease during the second postoperative week. When compared to the occurrence of complications of splenectomy performed for hematologic disorders and other splenic diseases, our experience is favorable [4-61. To date no patient has had gram-positive bacteremia or other serious infections as reported by others [7l, with a follow-up period as long as two and a half years. Conclusions
The postoperative morbidity of our first seventy patients undergoing staging procedures for Hodgkin’s disease at the Wilford Hall Medical Center is presented. There was no postoperative mortality. Nonfatal complications occurred in 24.6 per cent of the patients and consisted mainly of mild to moderate basilar atelectasis, urinary retention and cystitis, and easily controlled wound infection. There was one case of pancreaticocutaneous fistula occurring in a patient with stage IV disease. To date there have not been any complications of septicemia, subphrenic abscess, or thrombosis. This study was undertaken to help allay the fears of the surgeon who performs laparotomy for staging purposes in Hodgkin’s disease. We found that the
Al.?
Smith,
Klebanoff,
morbidity pitalization
and Kemmerer
is not prohibitive and that prolonged has not been the rule.
hos-
References 1. Enright LP, Trueblood HW. et al: The surgical diagnosis of abdominal Hodgkin’s disease. Surg Gynec Obsfet 130: 853.1970. 2. Glatstein E, et al: The value of laparotomy and splenectomy in the staging of Hodgkin’s disease. Cancer 24: 709, 1969. 3. Sophocles A, Nadler S: Immunologic aspects of cancer. Sorg Gynec Obstet 133: 321, 1971. 4. Devlin HB, et al: Elective splenectomy for primary hematologic and splenic disease. Surg Gynec Cbstet 130: 273, 276,197O. 5. O’Brien PH, et al: Splenectomy for hypersplenism in malignant lymphoma. Arch Sorg 101: 348, 1970.
814
6. Schwartz SI, et al: Splenectomy for hematologic disorders. Arch Surg 101: 338, 1970. 7. Donaldson S, Moore M: Pneumococcal septicemia in lymphoma patients after splenectomy. Cancer Res 19: 491, 1971. 8. Schwartz S, Adams JT, B&man AW: Splenectomy for hematologic disorders. Curr Prob Surg p 38, May 1971. 9. Geller W: Diagnosis and treatment of Hodgkin’s disease. Hosp Med 4: 6, 1968. 10. Johnson RE: Is staging lapatotomy routinely indicated in Hodgkin’s disease. Ann intern Med 75: 459, 1971. 11. Stiver G: Letters to the editor. Ann intern Med 76: 670, 1972. 12. Schwartz SI: Personal communication. 13. Rosenberg SA: ‘A critique of the value of laparotomy and splenectomy in the evaluation of patients with Hodgkin’s disease. Cancer Res 31: 1737, 1971. 14. Tubiana M: Summary of informal discussion on staging procedures in Hodgkin’s disease. Cancer Res 31: 1751, 1971.
The American Journal of Surgery