Milk of calcium cholelithiasis in children.

Milk of calcium bile is uncommon and occurs mainly in the adult population. The authors report on 2 children, each having a distinct clinical history and presentation, and each with milk of calcium bile/calculi possessing differing chemical composition and highly notable gross morphology. J Pediatr Surg 36:644-647.

Pediatric recipients of three or more hepatic allografts: results and technical challenges.

BACKGROUND/PURPOSE: Children who require a liver transplant at an early age risk chronic allograft rejection (CAR) and other causes of allograft loss. Multiple retransplants may be required for long-term patient survival. The authors evaluate this approach based on our results and technical difficulties. METHODS: Charts of 7 children who received 3 or more liver transplants from 1989 to the present were reviewed retrospectively. RESULTS: A total of 151 children required liver transplantation at our institution since 1989. Of these, 4 boys and 3 girls (mean age, 6.2 years; range, 3 to 14 years) have received 3 or more allografts. The etiology of liver failure for the penultimate allograft was CAR (n = 6) and hepatic artery thrombosis (HAT; n = 1). Five cases required modification of portal vein or hepatic artery anastomoses. Two patients with vena caval strictures required supradiaphragmatic vena caval reconstruction. The original Roux-en-Y limb was adequate for biliary reconstruction in all cases. Five children currently are alive (survival rate, 71%) with good graft function having had a mean follow-up of 23 months (range, 2 to 48 mos.). CONCLUSIONS: The operative procedure for the multiple hepatic transplant child is challenging. The transplant team must be prepared for intraoperative issues such as extended organ ischemia time during hepatectomy, extensive blood loss, and potential need for creative organ revascularization techniques. Overall, multiple retransplant results are good and justify the use of multiple allografts.

Laparoscopic management of peptic ulcer disease.

Laparoscopic surgery has heralded a new era for the operative management of peptic ulcer disease. With a mean hospital stay of 3.5 days,22 a recurrence rate of 4% to 11%,1,3 and a morbidity from dumping and diarrhea of 1% to 2%,21 laparoscopic proximal gastric vagotomy can truly provide a good alternative to medical therapy. Despite the high cost of medical care and surgical equipment, a laparoscopic vagotomy should be cost effective compared with life-long pharmacologic management of peptic ulcer disease. Several different operative procedures have been discussed, with similar outcomes. The surgeon has a choice of several approaches, depending on his or her training and level of skill. As surgeons gain experience with laparoscopic surgery, we are able to offer consistently good results with low recurrence rates and negligible morbidity and mortality. Minimally invasive surgery has rekindled the operative treatment of peptic ulcer disease.

Effects of reconstituted high-density lipoprotein in persistent gram-negative bacteremia.

Reconstituted high-density lipoproteins (rHDL) have been shown bind bacterial LPS and reduce its toxic effects. Since the effect of rHDL on LPS in vitro cannot be directly extrapolated to the in-vivo picture of Gram-negative septic shock, we have investigated the effects of rHDL in a rabbit model of Gram-negative bacteremia. Rabbits were anesthetized, ventilated, and invasively monitored for 6 hours. Escherichia coli (4 x 10(9) CFU/kg) were infused over 2 hours in rabbits given rHDL (75 mg/kg) before the bacterial challenge. Antibiotics were not used in this model. The bacterial infusion resulted in a bacteremia that persisted until the end of the study. The sepsis-induced TNF peak was significantly lowered by rHDL treatment (10 +/- 3 ng/mL in rHDL treated versus 33 +/- 5 in controls, P = 0.001). Blood pressure, although not statistically significant, tended to be higher in the rHDL group. Acidosis was significantly attenuated up to 3 hours after the beginning of the bacterial challenge (7.39 +/- 0.05 versus 7.27 +/- 0.05 in controls, P = 0.041). rHDL treatment produced some transient beneficial effects in this model of persistent Gram-negative bacteremia. Additional studies, investigating the effects of rHDL in combination with antibiotics, are warranted.

Protective effects of reconstituted high-density lipoprotein in rabbit gram-negative bacteremia models.

Reconstituted high-density lipoproteins (rHDLs) have the ability to bind bacterial lipopolysaccharide and to reduce its endotoxin activity in vitro and in vivo. The aim of the present studies was to investigate the therapeutic potential of rHDL in bacteremia models. Gram-negative sepsis was induced in anesthetized rabbits by intravenous infusion of Escherichia coli organisms (4 x 10(9) CFU/kg infused over 2 hours) and treated with appropriate antibiotics. rHDL or placebo was infused either before (prophylaxis) or 1 hour after (therapy) the beginning of the bacterial challenge. In the control groups, the bacterial challenge resulted in transient bacteremia, high plasma levels of lipopolysaccharide, secretion of TNF, and symptoms of sepsis, including hypotension and acidosis. rHDL had no influence on blood bacterial counts; however, plasma lipopolysaccharide levels were significantly reduced. Peak plasma TNF concentrations were reduced after prophylactic but not after therapeutic rHDL administration. Both prophylactic and therapeutic rHDL improved clinical outcome: acidosis was significantly attenuated and blood pressure tended to be higher in the rHDL groups. No effects of rHDL were seen in a similar model of gram-positive sepsis induced by the infusion of Staphylococcus aureus.

Reconstituted high-density lipoprotein reduces LPS-stimulated TNF alpha.

Reconstituted high-density lipoprotein (rHDL), an artificial lipoprotein consisting of apolipoprotein A-I and phosphatidylcholine (1:150, molar ratios) dose-dependently reduces lipopolysaccharide (LPS)-induced tumor necrosis factor-alpha (TNF) production in in vitro, ex-vivo, and in-vivo model systems. In an in-vitro whole blood assay, rHDL (1 mg/ml) added concomitantly with LPS increased cellular resistence to LPS stimulation approximately 1000-fold. Even with extremely high levels of LPS (10 micrograms/ml), rHDL > or = 0.5 mg/ml caused > 50% decrease in TNF production. Preincubation of rHDL with LPS was not required for activity. rHDL (> or = 1 mg/ml) reduced TNF production by 50% even when added to cultures 2 hr after their stimulation with LPS (10 micrograms/ml). In an ex-vivo study, rabbits were infused with rHDL at doses of 25, 50, and 75 mg/kg. Blood was drawn and stimulated with LPS ex vivo and bioactive TNF was assessed using the L929 cytotoxicity assay. Fifteen minutes after rHDL infusion, there was a significant difference in ex-vivo-induced TNF activity between groups (750 +/- 160, 170 +/- 40, 80 +/- 30, 60 +/- 30 pg TNF/ml, for the control, 25, 50, and 75 mg/kg rHDL dose groups, respectively; P < 0.0001). The duration of ex-vivo TNF inhibition was dependent on the dose of rHDL. Even at 2 hr, rHDL showed a pronounced TNF inhibition (control: 950 +/- 120 pg TNF/ml; 75 mg/kg: 140 +/- 60 pg TNF/ml). Further studies showed that a prophylactic infusion of rHDL diminished LPS-induced TNF production in a rabbit endotoxemia model.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of technetium-99m-sestamibi localization on operative time and success of operations for primary hyperparathyroidism.

Intraoperative identification of abnormal parathyroid glands during initial neck exploration for primary hyperparathyroidism is challenging and may require extensive dissection of the neck and mediastinum. We, therefore, evaluated the impact of preoperative localization with Technetium-99m-sestamibi (Tc-99m-sestamibi) and Iodine-123 radionuclide subtraction imaging on operative time and success of initial operation for primary hyperparathyroidism. From January 1989 to September 1992, 42 patients underwent neck exploration for primary hyperparathyroidism; 21 patients underwent neck exploration without preoperative radionuclide scanning, and 21 patients were operated upon following radionuclide Tc-99m-sestamibi localization. In the control group, pathologic exam revealed 15 patients had solitary adenomas, and six patients had diffuse hyperplasia. In the Tc-99m-sestamibi group, 16 patients had solitary adenomas, four had diffuse hyperplasia, and one had multiple adenomas. Analysis of patient demographic data revealed no differences between the control group and the Tc-99m-sestamibi group in mean age (56 vs 59 years), mean intact PTH levels (249 vs 234 pg/mL), mean total calcium (11.3 vs 12.0 mg/dL), and mean ionized calcium (6.19 vs 6.28 mg/dL). Comparison of operative data revealed no differences between groups in the mean number of parathyroid glands identified and biopsied per patient (3.1 vs 3.3), the mean largest diameter of the resected adenomas (19.6 vs 20.0 mm), and the number of patients requiring thymectomy, thyroid resection, retroesophageal exploration, mediastinal exploration, or carotid sheath exploration. The operative success rate was 90 per cent for the control group versus 100 per cent for the Tc-99m-sestamibi group.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective comparison of technetium-99m-sestamibi/iodine-123 radionuclide scan versus high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands in patients with previously unoperated primary hyperparathyroidism.

Surgery for primary hyperparathyroidism is successful in 95% of patients, but ectopic glands and anatomic variations in location are causes of surgical failure. The radionuclide imaging agent, technetium (Tc)-99m-sestamibi, in conjunction with subtraction iodine-123 scanning, is a new method of preoperative localization of abnormal parathyroid glands. In a study approved by the Institutional Review Board, 22 patients with primary hyperparathyroidism underwent preoperative evaluation with high-resolution ultrasonography and Tc-99m-sestamibi/I-123 radionuclide scanning for attempted localization of abnormal parathyroid glands. Results of Tc-99m-sestamibi scanning and ultrasound were correlated with surgical and pathologic findings. Of 22 patients, 16 had a solitary parathyroid adenoma, 1 had a double adenoma, and 5 had diffuse parathyroid hyperplasia. The Tc-99m-sestamibi/I-123 radionuclide scan preoperatively identified a solitary adenoma in 14 of 16 patients (sensitivity: 88%). However, when the data were analyzed retrospectively along with surgical and pathologic findings, the Tc-99m-sestamibi scan correctly localized all parathyroid adenomas for a sensitivity of 100%. The one patient with a double adenoma had a localization image consistent with two enlarged glands. All patients with diffuse parathyroid hyperplasia had Tc-99m-sestamibi imaging consistent with diffuse hyperplasia, although delineation of individual enlarged glands was not possible. High-resolution ultrasound identified 11 of 16 parathyroid adenomas (sensitivity: 69%). The patient with a double adenoma had a negative ultrasound. Ultrasound was less accurate in five patients with diffuse hyperplasia: one scan was completely negative, two scans revealed only one enlarged gland, and two scans revealed two enlarged glands. The Tc-99m-sestamibi/I-123 subtraction radionuclide scan is more sensitive than high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands. Tc-99m-sestamibi/I-123 radionuclide scanning may be more useful than ultrasonography to the surgeon in the preoperative localization of abnormal parathyroid glands.