Periodontal and peri-implant diseases: identical or fraternal infections?

Peri-implant diseases (peri-implantitis and peri-implant mucositis) are bacterially driven infections. Peri-implantitis leads to aggressive bone resorption and eventual loss of the implant. Traditionally, peri-implantitis was regarded as microbially similar to periodontitis, and translocation of periodontal pathogens into the peri-implant crevice was considered as a critical factor in disease causation. However, evidence is emerging to suggest that the peri-implant and periodontal ecosystems differ in many important ways. The purpose of this review is to examine the evidence supporting microbial congruence and discordance in these two communities. Current evidence suggests that osseointegrated implants truly create unique microenvironments that force microbial adaptation and selection. Further studies that revisit the "microbial reservoir" hypothesis and identify species that play an etiologic role in peri-implant disease and examine their transmission from teeth are needed.

Laparoscopic choledochojejunostomy and gastrojejunostomy in a porcine model.

BACKGROUND: Surgical extirpation remains the only known curative treatment for cancer of the pancreas. Because of locally advanced or metastatic tumor, up to 80% of patients are unresectable at the time of initial diagnosis [13]. Other investigators previously have suggested that laparoscopy before laparotomy aids in the diagnosis of unresectable pancreatic cancer in a fair number of patients even after negative computed tomography scans [3, 17]. Many surgeons are reluctant to incorporate laparoscopy into the workup of patients with cancer of the pancreas because of the frequent need for surgical bypass in the management of either biliary tract obstruction or gastric outlet obstruction [9, 13]. Previous studies have demonstrated the feasibility of laparoscopic cholecystojejunostomy combined with gastrojejunostomy in a porcine model, as well as the individual accomplishment of laparoscopic choledochojejunostomy. The purpose of this study was to document the feasibility of performing laparoscopic choledochojejunostomy with gastrojejunostomy. METHODS: Under general anesthesia, seven pigs underwent laparoscopic choledochojejunostomy and gastrojejunostomy using an intracorporeal hand-sutured technique. RESULTS: The mean operating time ranged from 150 to 450 min. All the animals recovered completely from the operation and had patent anastomoses at the time of necropsy. One pig died of gastric bleeding on postoperative day 13, and two animals had intraabdominal fluid collections discovered at the time of necropsy. CONCLUSIONS: These results suggest that synchronous laparoscopic bypass of biliary and gastric outlet obstruction is feasible, and can be performed in a manner similar to that used in open operations. We believe this lends support to the argument promoting laparoscopy in the evaluation of pancreatic cancer.

Cost comparison of endoscopic stenting vs surgical treatment for unresectable cholangiocarcinoma.

BACKGROUND: Total lifetime costs of endoscopic vs surgical treatment for obstructive jaundice due to cholangiocarcinoma are difficult to assess. The purpose of this study was to compare total costs in these two groups, including all treatment and retreatments. METHODS: This retrospective study identified patients with biopsy-proven cholangiocarcinoma treated this decade with either endoscopic biliary stenting or surgical biliary-enteric bypass with or without resection. Outcomes and hospital charges were recorded. Ten matched control patients were compared from each group. Costs included those for cost of repeat endoscopy in the endoscopic group and for the management of recurrent obstructive jaundice in the surgical group. RESULTS: The groups were similar in age and gender ratio. The surgical approach was frequently for cure; therefore, surgical patients were by and large at an earlier stage of their disease than those in the endoscopic group. Mean survival for the endoscopic group was 19 months vs 16.5 months for the surgical group. The median total lifetime cost for surgical therapy was $60,986 vs $24,251 for endoscopic therapy. CONCLUSION: Endoscopic therapy is an effective palliative therapy for unresectable cholangiocarcinoma. Endoscopic therapy for this entity costs significantly less than surgical treatment. The cost benefit of endoscopic stenting over standard surgical bypass in the management of patients with unresectable cholangiocarcinoma, when considered along with its minimally invasive approach, makes this the procedure of choice for palliative therapy.

Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries.

BACKGROUND: Nonoperative management is now regarded as the best alternative for the treatment of patients with complex blunt liver injuries. However, some patients still require surgical treatment for complications that were formerly managed with laparotomy and a combination of image-guided studies. METHODS: We reviewed the medical records of 15 patients who had complex blunt liver injuries that were managed nonoperatively and in which biliary peritonitis developed. RESULTS: Delayed laparoscopy was performed 2-9 days after admission in patients with extensive liver injuries. All 15 patients had developed local signs of peritonitis or a systemic inflammatory response. Laparoscopy was indicated to drain a large retained hemoperitoneum (eight patients), bile peritonitis (four patients), or an infected perihepatic collection (three patients). Laparoscopy was successful in all patients, and there was no need for further interventions. CONCLUSION: The data indicate that as more patients with complex liver injuries are treated nonoperatively and the criteria for nonoperative management continue to expand, more patients will need some type of interventional procedure to treat complications that historically were managed by laparotomy. At this point, laparoscopy is an excellent alternative that should become part of the armamentarium of the trauma surgeons who treat these patients.

Persistent occurrence of bradycardia during laparoscopic cholecystectomies in low-risk patients.

BACKGROUND/AIMS: A debate has arisen about the use of carbon dioxide to distend the abdomen because of certain negative effects on venous return to the heart, and declining cardiac output. We previously reported 4 cases of bradycardia that occurred during 725 laparoscopic cholecystectomies. Now, we describe 6 cases of bradycardia that occurred in a 1-year period (May 31, 1997 to June 1, 1998) during CO(2) pneumoinsufflation at the beginning of planned, elective laparoscopic cholecystectomies. These patients appeared not to be at any special cardiac risk. To determine the frequency, and possible underlying common denominators, we reviewed the laparoscopic cholecystectomies. METHODS: We completely reviewed the patients' records to find any common denominators. Also, we calculated the frequency of bradycardia during laparoscopic cholecystectomies. RESULTS: Six patients experienced bradycardia during laparoscopic cholecystectomies. None had known cardiac disease or symptoms. These cases occurred during the year's 127 laparoscopic cholecystectomies (4.7% approximately). There were no common denominators between the patients. CONCLUSIONS: Although cardiac changes were noted during laparoscopic gynecologic surgery approximately 20 years ago, only in the last few years have cardiovascular changes been noted during laparoscopic cholecystectomies. Surgeons should be prepared to encounter such cardiovascular changes even with low-risk patients as it appears that bradycardia is a persistent occurrence during laparoscopic cholecystectomies.

DNA flow cytometry does not predict 5- or 10-year recurrence rates for T1-2 node-negative breast cancer.

BACKGROUND: A small proportion of T1 or T2 node-negative breast cancer tumors will recur in patients by 5 years, and more by 10 years. Results of recent studies have suggested improvement in overall survival with administration of adjuvant chemotherapy to all patients. More sensitive and specific methods are needed to identify patients at highest risk for recurrence who might benefit most from adjuvant therapy, saving others from unnecessary treatment. Some investigators have suggested DNA flow cytometry as a method to discriminate patients at greatest risk for recurrence. HYPOTHESIS: DNA flow cytometry has predictive value for breast cancer recurrence in node-negative patients. METHODS: The cancer registry of a medium-sized university-affiliated hospital was used to identify patients with T1-2 N0 M0 breast cancer treated with a uniform surgical approach and no adjuvant therapy who had completed at least 5 years of follow-up or had recurrence. Flow cytometric analysis was performed on paraffin-embedded specimens. RESULTS: Of 115 patients, 92 (80%) had disease-free survival without recurrence and 23 (20%) had recurrence. Comparison of diploid and nondiploid tumors for likelihood of recurrence revealed no association (P = .79). Furthermore, the DNA index and S-phase fraction were not significantly different between recurrent and nonrecurrent groups. CONCLUSIONS: The likelihood of recurrence of small node-negative breast cancers after mastectomy cannot be accurately predicted on the basis of DNA flow cytometric analysis. Traditional methods for determining risks-such as nuclear and histological grade, lymph node status, and tumor size-seem to be more useful. Sentinel lymph node biopsy techniques may increase the detection of micrometastases.

Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery.

Interventional endoscopic techniques have been indespensible in almost every area of modern surgery. As surgeons, we need to continue to advance our skills in these areas if we expect to continue to be involved in these aspects of patient care.

Bile duct carcinoma: trends in treatment in the nineties.

Surgical resection provides the only known chance of cure for cholangiocarcinoma, and even then the 5-year survival is only 10 to 20%, and only one-third of patients are resectable for cure at the time of diagnosis. In recent years we have had considerable experience with endoscopic stenting to palliate common bile duct cancers. This has prompted us to evaluate our results for both endoscopic and surgical treatment of cholangiocarcinoma. From January 1990 through June 1999, we reviewed our endoscopic retrograde cholangiopancreatography registry and the hospital records for patients we treated for cholangiocarcinoma. Fifty patients were identified: 45 with cholangiocarcinoma and five with gallbladder cancer (who were excluded). The surgical group consisted of 16 patients: in 14 patients, resection for cure was possible whereas two had palliative procedures. There was one mortality (6%) and the median survival was 16 months. There have been no long-term surgical survivors, but 2 patients are alive at 24 months. We treated 29 patients with advanced disease with endoscopic stents (the endoscopic group) mainly for relief of obstructive jaundice. Six of 29 patients in the endoscopic group were critically ill and died in less than 4 weeks, whereas 23 patients who were in better condition survived for a mean of 10 months (range 2-84 months). We conclude that for common duct bile cancer surgical resection remains the treatment of choice but is applicable in only 30 to 35 per cent of cases. Endoscopic stenting effectively relieves jaundice and can provide long-term palliation comparable with surgical bypass; 12 of 29 patients in our endoscopic group survived 12 months or longer, and one is alive at 84 months after initial stenting.

Endoscopic treatment of distal bile duct stricture from chronic pancreatitis.

BACKGROUND: Endoscopic placement of biliary stents is an effective initial treatment for jaundice and cholangitis caused by common bile duct (CBD) strictures secondary to chronic pancreatitis; however, the role of endoscopic treatment for long-term management of these strictures is less clear. In 1992, we designed a protocol of balloon dilatation and stenting for > or =12 months. This study evaluates endoscopic therapy as a definitive long-term treatment for these strictures. We have treated 25 patients with this protocol. METHODS: All patients had an endoscopic sphincterotomy, balloon dilatation of the stricture, and then placement of a polyethylene stent (7-11.5 F). Stents were exchanged at 3-4-month intervals to avoid the complications of clogging and cholangitis. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stent. RESULTS: The length of the CBD strictures ranged from 8 to 40 mm. Within days of stenting, all patients achieved relief of jaundice and cholestasis. Complications consisted of six episodes of cholangitis and nine episodes of pancreatitis. There were no deaths. Twenty of the 25 patients are now stent-free after an average stenting period of 13 months (range, 3-28). To date, there has been no recurrence of stricture, for a mean of 32 months. Three patients still have stents in place, and two patients required operation--one for persistent stricture and recurrent cholangitis after 8 months of stenting, and one for a mass in the head of the pancreas that was thought to be cancer. CONCLUSIONS: Our results indicate that these strictures will respond and dilate after a course of stenting in 80% of patients, with an acceptable morbidity. Although these are medium-term results at 32 months, we would expect most recurrences within the 1st year following stent removal. In some cases, stenting is necessary for >12 months. Thus, the data suggest that endoscopic stenting provides definitive treatment in most patients with CBD stricture due to chronic pancreatitis and may be considered a viable alternative to standard surgical bypass.

Endoscopic drainage of the pancreatic pseudocyst.

BACKGROUND: Pancreatic pseudocyst is a common complication of chronic pancreatitis occurring in 20% to 40% of cases. Pseudocysts can be treated by endoscopic cystenterostomy or transpapillary drainage, percutaneously with computed tomography guidance or operatively. METHODS: A total of 36 endoscopic pancreatic pseudocyst drainage procedures were performed in 29 patients with 34 pseudocysts. Eighty percent presented with chronic pain, 25% had recurrent pancreatitis, and approximately one half of the patients had either gastric outlet obstruction or a palpable abdominal mass. RESULTS: Thirty-six endoscopic drainage procedures were performed, 27 cystenterostomies and 9 transpapillary drainages. Endoscopic treatment achieved complete resolution of the pseudocyst in 24 of 29 patients (83%), and the other 5 (17%) eventually required surgery. Two patients required distal pancreatectomy because of their pancreatic pathology, 2 cystgastrostomies for persistence of the pseudocyst, and 1 external drainage of an infected pancreatic cyst. The mean follow-up after the initial drainage was 16 months. There were no deaths attributed to the procedures and no complication that required surgery. Only 1 nonadherent pseudocyst (cystadenoma) required immediate operation after attempted endoscopic drainage. CONCLUSIONS: The conclude that endoscopic drainage of pancreatic pseudocysts can be both safe and effective, and definitive treatment. It should be considered as an alternative option before standard surgical drainage in selected patients.

Subcutaneous access ports with fenestrated catheters for improved management of recurrent pleural effusions.

Repeated percutaneous thoracentesis can involve serious complications, such as pneumothorax or infection. Alternatives such as placement of chest tubes or pleurodesis have their own potential complications. Creative options such as pleuroperitoneal shunting and video thoracoscopy have previously been used to avoid the disadvantages of repeated percutaneous thoracentesis. This paper describes an easy and effective method for managing these patients without repeated percutaneous thoracentesis. A port is inserted that can be accessed percutaneously and immediately for needed aspirations. We have successfully performed this procedure on 6 patients. Our hope is that the easy access using a short needle into the port aperture will allow the thoracentesis to be performed by appropriately instructed and supervised paramedical personnel. Also, with fewer postprocedure chest radiographs or hemothoraceses, future benefits from this procedure could include cost effectiveness.

Untoward cardiac changes during CO2 insufflation in laparoscopic cholecystectomies in low-risk patients.

In the past decade, laparoscopic cholecystectomy has become the gold standard treatment for gallbladder disease. A debate has arisen about using CO2 to distend the abdomen because of negative effects on venous return to the heart and declining cardiac output. Some authors have supported the use of pulmonary artery catheters for intraoperative monitoring while others have recommended gasless techniques to avoid these negative effects for high-risk patients. In this study, four cases of bradycardia and/or asystole during CO2 pneumoinsufflation at the beginning of planned, elective laparoscopic cholecystectomies are described. These patients were ASA category II, without history of cardiac disease. To determine the frequency and any underlying common denominators, we analyzed these laparoscopic cholecystectomies. Each patient experienced bradycardia shortly after the start of the laparoscopic cholecystectomy. None had known cardiac disease or symptoms. Two were on antihypertensive medications, and one had experienced an episode of unexplained bradycardia 6 years earlier. These cases occurred during 725 laparoscopic cholecystectomies (0.6% approximately). Using the senior author's conversion rate of 10% to open cholecystectomies, the entire group would be approximately 800, and the risk of bradycardia upon induction of CO2 is 4 per 800, or 0.5%. Although cardiovascular changes were noted during laparoscopic gynecologic surgery approximately 20 years ago, only in the last few years have cardiovascular changes been reported during laparoscopic cholecystectomies. This study reviews four cases of bradycardia during CO2 insufflation in patients that were considered to be low-risk. Surgeons should be prepared to encounter such cardiovascular changes even with low-risk patients.

Kinevac-assisted cholescintigraphy as an accurate predictor of chronic acalculus gallbladder disease and the likelihood of symptom relief with cholecystectomy.

Thirty patients with chronic upper abdominal pain and no evidence of cholelithiasis were entered into this study. All had negative ultrasonography of the gallbladder, and most had a host of other negative investigations. These patients were referred to a surgeon to evaluate the possibility of atypical biliary colic associated with chronic acalculous cholecystitis. All patients underwent cholecystokinin-stimulated cholescintigraphy and were offered cholecystectomy if the ejection fraction was less than 35 per cent. Of the 30 patients, 27 (90%) had pathologically abnormal gallbladders. Follow-up averaged over 1 year (13.2 mo), and relief of symptoms occurred in 28 (94%). The authors conclude that in appropriately selected patients with symptoms of biliary colic (typical or atypical) and no evidence of cholelithiasis, a cholecystokinin-stimulated cholescintigram is a significant help in predicting not only which patients have gallbladder disease, but also how likely cholecystectomy is to result in an improvement in their symptoms.

Can general surgeons perform colonoscopy safely?

The purpose of the current study was to review the safety of colonoscopy performed by nonfellowship-trained general surgeons. To address this issue, we reviewed more than 1,000 consecutive diagnostic and therapeutic colonoscopies and recorded the complications. This was a multi-institutional study involving seven general surgeons, none of whom had had formal fellowship endoscopic training. Perforation was confirmed by laparotomy, bleeding was defined as that requiring hospitalization and/or transfusion, and cardiopulmonary arrest was self-explanatory. There was one perforation in the diagnostic group and none in the therapeutic group, for a rate of 0.10% overall and 0.12% in diagnostic colonoscopy. There were no instances of bleeding or cardiac arrest. This complication rate of 1 per 1,025 colonoscopic procedures by general surgeons compares favorably with that previously reported by other specialties (p less than 0.001). We conclude that postgraduate endoscopy fellowship is not necessary for general surgeons to become safe colonoscopists.

Peroral enteroscopic removal of a retained percutaneous transhepatic guidewire from the jejunum using a colonoscope.

Several authors have described the ability to perform small-intestine endoscopy with long, flexible fiberscopes. A peroral colonoscope has been used for small-bowel enteroscopy and biopsy. A pediatric colonoscope for jejunoscopy has been described. Herein we report a patient undergoing percutaneous transhepatic decompression for the extrahepatic biliary obstruction in whom the guidewire broke and was lost in the liver. The proximal end of the wire was within the liver, while the distal end exited the ampulla and lay within the upper jejunum. Utilizing a peroral approach with the flexible pediatric colonoscope, we recovered the guidewire without advancing it further into the jejunum, where it may have been lost and have necessitated a celiotomy.

Pitfalls in the role of standardized preadmission laboratory screening for ambulatory surgery.

We conducted a one-year retrospective analysis to determine the effect of a standardized preadmission screening (PAS) program on the cancellation rate of ambulatory surgery. Patients were divided into two groups. Group One patients had selective PAS lab work based on history and physical examination. Group Two patients underwent a standardized PAS consisting of history, physical examination, biochemical profile, complete blood count, and urinalysis. Patients in both groups received a prothrombin/partial thromboplastin time (PT/PTT) if one anticoagulation therapy, an electrocardiogram (EKG) with age greater than 40 years, and a chest X ray with age greater than 50 years. We found that the frequency of surgery cancellation before and after instituting a standardized PAS remained the same (6.9% vs 6.4%); furthermore, only 38.5 per cent of the cancellations in Group One and 16.4 per cent in Group Two were due to laboratory, EKG, or chest X-ray results. The rest were due to intercurrent illness, scheduling conflicts, and other uncontrollable factors. A closer analysis of Group Two shows that of 4,058 standardized preadmission screens performed, 4,015 (99%) were normal; only 43 (1%) had abnormal results that led to cancellation of ambulatory surgery. Similarly, 99.93 per cent of all EKGs and 99.97 per cent of all chest X-rays performed in both groups were normal, having no influence on operational performance or patient management. We suggest that selective use of laboratory and diagnostic studies, in conjunction with a thorough history and physical examination, is as effective as a standardized PAS in identifying patients at risk for ambulatory surgery.(ABSTRACT TRUNCATED AT 250 WORDS)