Percutaneous cervical oesophageal cannulation in the dog for the performance of prolonged oesophageal pH and manometric studies.

Traditional methods for obtaining oesophageal access in experimental animals are unsuitable for prolonged (24 h) oesophageal pH evaluation, a procedure that is commonly employed in the assessment of human patients suspected of having gastroesophageal reflux disease. In the present study, we describe a six-year experience with a technique of percutaneous oesophagostomy for the performance of serial 24 h oesophageal pH and manometric studies involving 62 dogs and a total of 208 oesophageal cannula placement procedures. The results indicate a considerable improvement over previously described techniques with respect to simplicity of surgical technique, associated morbidity, oesophagostomy management, animal conditioning, and avoidance of chemical and excessive physical restraints in animals undergoing oesophageal pH and manometric evaluation.

Laparoscopic adrenalectomy for pheochromocytoma. A comparison to aldosteronoma and incidentaloma.

BACKGROUND: Laparoscopic adrenalectomy is a safe and effective treatment for most surgical diseases of the adrenal gland. However it has been suggested that catecholamine effects associated with pheochromocytoma render the laparoscopic approach a more challenging and a more morbid procedure. The purpose of this study was to compare the operative characteristics and outcomes of laparoscopic adrenalectomy for pheochromocytoma to those of aldosteronoma and incidentaloma. METHOD: Patient records and operative reports were retrospectively reviewed for demographics, diagnoses, operative management, and outcomes for patients undergoing laparoscopic adrenalectomy between June 1994 and July 2002 at two academic medical centers. A total of 74 patients were included and analyzed by diagnosis. Differences were considered statistically significant at p < 0.05. RESULTS: Twenty-eight patients with pheochromocytoma, 27 with aldosteronoma, and 19 with incidentally discovered nonfunctioning adrenal masses underwent laparascopic adrenalectomy. Patients undergoing resection for pheochromocytoma trended toward more operative blood loss (150 ml) compared to aldosteronoma (88 ml) and incidentaloma (75 ml). Eight patients were converted to an open procedure for a 10.8% conversion rate. The mean operative time was 171 min and there was a 10.8% perioperative complication rate. The mean hospital stay was 3.4 days. These results were not statistically significant between diagnostic groups. CONCLUSION: Despite concern about increased operative times and morbidity associated with pheochromocytoma, our experience supports that laparoscopic adrenalectomy may be performed as safely as, and achieve outcomes similar to, those for other diseases.

Tumor necrosis factor alpha gene expression in human peritoneal macrophages is suppressed by extra-abdominal trauma.

BACKGROUND: Trauma is believed to activate immunocytes but paradoxically also increases the risk of intraperitoneal infection. OBJECTIVE: To investigate these events by evaluating changes in the cytokine control networks of human peritoneal macrophages (PM phi) early after trauma. DESIGN: Case-control study comparing cytokine messenger RNA (mRNA) expression by PM phi from patients with extra-abdominal trauma with that of both peripheral blood mononuclear cells (PBM) and PM phi obtained from healthy individuals. SETTING: Level I trauma center and basic science laboratory in a university hospital center. PATIENTS: Six patients with polytrauma (Injury Severity Score, > or = 15) with clinically negative diagnostic peritoneal lavages performed on routine indications at admission to the emergency department and six healthy age- and sex-matched individuals undergoing inguinal herniorrhaphy under local anesthesia. INTERVENTIONS: Peritoneal macrophages were isolated from diagnostic peritoneal lavages in trauma patients. Identical lavages were performed through the hernia sac in the control group. MEASUREMENTS: Cellular RNA was assayed for tumor necrosis factor alpha (TNF-alpha), interleukin-1 beta, IL-6, and IL-10 message by semiquantitative reverse-transcription polymerase chain reaction. RESULTS: Normal PM phi expressed high levels of TNF-alpha mRNA relative to PBM, but expression of the other proinflammatory cytokines was equivalent to that of PBM. Peritoneal macrophage expression of TNF-alpha mRNA was markedly (64-fold) decreased after trauma (P < .001), when PBM expression of IL-10 mRNA was increased (P = .03). CONCLUSIONS: Human PM phi constitutively show high levels of TNF-alpha message expression, and this is down-regulated by polytrauma. This might constitute a functionally "primed" state. If so, TNF-alpha down-regulation might contribute to functional PM phi suppression after systemic injury.

Human peripheral mononuclear cells do not show proinflammatory patterns of cytokine transcription in early trauma: a preliminary report.

Injury has been hypothesized to cause inflammation through systemic release of lipopolysaccharide and pro-inflammatory cytokines, but this has proved difficult to demonstrate in humans. We looked for evidence of an inflammatory pattern of cytokine gene expression by peripheral blood mononuclear cells (PBM) in six polytraumatized patients (ISS = 25 +/- 8) upon ER admission, and in six matched healthy controls. PBM tumor necrosis factor (TNF)-alpha, interleukin (IL)-1 beta, IL-4, IL-6, IL-10, and interferon (IFN)-gamma message was assessed by semi-quantitative reverse-transcription polymerase chain reaction. No increase in expression of any of the pro-inflammatory cytokines (tumor necrosis factor-alpha, IL-1 beta, or IL-6) was found after trauma, and IFN-gamma tended to decrease. Of the immunosuppressive cytokines, IL-10 expression increased 5-fold (p < .05) but no change in IL-4 was discerned. This pattern is fundamentally different from the cytokine expression patterns expected with sepsis or exposure to lipopolysaccharide. These findings are inconsistent with the occurrence of systemic endotoxemia and subsequent global immunocyte activation early after trauma.