Nesidioblastosis coexisting with islet cell tumor and intraductal papillary mucinous hyperplasia.

A coexisting of intraductal papillary mucinous hyperplasia (IPMH) and islet cell tumor with nesidioblastosis of the pancreas in a 51-year-old man is reported. All of the clinical data indicated an insulinoma. A distal pancreatectomy was performed. A discrete mass measuring 1.9 x 2.0 cm was grossly identified in the tail of the pancreas. There were no other gross lesions. An islet cell tumor with nesidioblastosis was confirmed by immunostains and ultrastructural study. In addition, an IPMH was found that involved mainly branches of the pancreatic duct. The islet cell tumor and IPMH were topographically separated; however, there was a histologically intimate relationship between the nesidioblastosis and the IPMH. These findings indicate that the IPMH may have derived from autocrine and paracrine influences on the existing duct epithelial cells. To the best of our knowledge, this is the first report of nesidioblastosis coexisting with islet cell tumor and IPMH.

Trends in cardiac morbidity and mortality after endoluminal abdominal aortic aneurysm repair; discussion 999-1000.

HYPOTHESIS: The adverse cardiac event rate following endoluminal abdominal aortic aneurysm (EAAA) repair has decreased as experience in performing the procedure has increased. Aneurysm complexity affects the rate of adverse cardiac events. DESIGN AND PATIENTS: Data from 173 consecutive patients undergoing EAAA repair from 2 successive periods were compared. There were 82 patients in the early group (group 1) and 91 patients in the later group (group 2). MAIN OUTCOME MEASURES: Myocardial infarction, congestive heart failure, unstable angina, major dysrhythmias, death. RESULTS: The cardiac event rate was 8.5% for group 1 vs 16.5% for group 2 (P =.16). Predictors of adverse cardiac events on multivariate analysis were the use of 4 or more graft extensions (P =.04), female sex (P =.01), and number of Eagle risk factors (P<.001). There were 2 postoperative deaths (2.4%) in group 1 and 4 (4.4%) in group 2 (P =.7). CONCLUSIONS: Following EAAA repair: (1) adverse cardiac events were found to correlate with use of 4 or more graft extensions, female sex, and the number of Eagle risk factors; (2) cardiac morbidity and mortality remain significant despite greater experience and improved technology; and (3) operative mortality remains acceptably low.

Simplified admission criterion for predicting severe complications of gallstone pancreatitis.

HYPOTHESIS: Simple admission criteria (white blood cell count, > or =14. 5 x 10(9)/L; blood urea nitrogen level, > or =4.3 mmol/L [> or =12 mg/dL]; heart rate, > or =100 beats per minute; and serum glucose level, > or =8.3 mmol/L [> or =150 mg/dL]) are better predictors of severe complications of gallstone pancreatitis than an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 5 or greater, a modified Imrie (Glasgow) score of 3 or greater, and a biliary Ranson score of 3 or greater. DESIGN: A prospective consecutive case study. SETTING: A university-affiliated, urban, public hospital. PATIENTS: Ninety-two consecutive patients (77 women and 15 men, aged 18 to 76 years [mean age, 39 years]) with gallstone pancreatitis. Seventy-seven patients were Hispanic. MAIN OUTCOME MEASURES: Major local and systemic complications requiring intensive care unit care, and death. RESULTS: Fourteen patients (15%) had severe complications with a mortality of 2%. On univariate analysis, a white blood cell count of 14.5 x 10(9)/L or more (P =.03), a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) (P<.001), an APACHE II score of 5 or greater (P =.008), a modified Imrie score of 3 or greater (P<.001), and a biliary Ranson score of 3 or greater (P =.03) were statistically associated with the development of severe complications; whereas a blood urea nitrogen level of 4.3 mmol/L or more (> or =12 mg/dL) and a heart rate of 100 beats per minute or more were not. On multivariate analysis, only a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) was predictive of adverse events (P<. 001). CONCLUSIONS: Glucose level (> or =8.3 mmol/L [> or =150 mg/dL]) is the best single admission predictor of severe complications of gallstone pancreatitis and is superior to an APACHE II score of 5 or greater, a modified Imrie score of 3 or greater, and a biliary Ranson score of 3 or greater.

Patterns of recurrence in anal canal carcinoma.

HYPOTHESIS: The initial modality of treatment of anal canal carcinoma (ACC) influences the pattern of recurrence of disease. DESIGN: A retrospective analysis comparing patterns of recurrence in patients with ACC undergoing either surgery or chemoradiotherapy as their initial therapeutic intervention. Anal margin cancers and adenocarcinomas were excluded. SETTING: A university-affiliated urban medical center. PATIENTS: Eighty-one patients were given a diagnosis of ACC between February 1, 1952, and December 31, 1998. Fifty-one (63%) of the patients initially underwent surgery: abdominoperineal resection in 38 patients (75%) and local excision in 13 patients (25%). Chemoradiotherapy was the initial therapeutic intervention in 30 patients (37%). MAIN OUTCOME MEASURES: The patterns of recurrence (local vs distant disease) and survival were compared between the group that underwent palliative surgery (hereafter referred to as the surgical group) and the group that received chemoradiotherapy (hereafter referred to as the chemoradiotherapy group). RESULTS: The mean follow-up was 40 months. Local recurrence occurred in 7 patients (14%) in the surgical group vs 7 patients (23%) in the chemoradiotherapy group (P =.46). Using Kaplan-Meier actuarial analysis, local recurrence rates for the surgical and chemoradiotherapy groups at 1 year were 0% and 6%, respectively (P =.32), and at 5 years were 17% and 36%, respectively (P =.02). The average (+/-SD) time to local recurrence in the surgical group was 23 +/- 0.7 months and for the chemoradiotherapy group 16 +/- 2.9 months (P =.27). Five (71%) of the 7 patients with local recurrences in the chemoradiotherapy group underwent salvage abdominoperineal resection with 100% disease-free survival at a mean follow-up of 35 months. When patients presenting with metastatic disease were excluded, distant recurrences developed in 7 patients (16%) in the surgical group and 2 (7%) in the chemoradiotherapy group (P =.31). Actuarial 5-year distant recurrence rates for the surgical and chemoradiotherapy groups were 26% and 19%, respectively (P =.65). Five-year survival was 42% in the surgical group and 74% in the chemoradiotherapy group (P =.01). CONCLUSION: There was a higher rate of local recurrence in patients with ACC treated with chemoradiotherapy vs surgical resection as the initial therapeutic intervention. However, when this occurred, abdominoperineal resection was effective salvage therapy and was associated with a 100% disease-free survival at 3 years. Therefore, chemoradiotherapy is justified as the initial treatment for ACC and has an overall 5-year survival that is significantly higher than that attained with initial surgical treatment.

Extrahepatic biliary obstruction due to post-laparoscopic cholecystectomy biloma.

BACKGROUND: Jaundice presenting after cholecystectomy may be the initial manifestation of a serious surgical misadventure and requires rigorous diagnostic pursuit and therapeutic intervention. Biloma is a well recognized postcholecystectomy complication that often accompanies biliary ductal injury. CASE REPORT: A 23-year-old female underwent laparoscopic cholecystectomy for symptomatic gallstones and three weeks postoperatively developed painless jaundice. Radiographic and endoscopic studies revealed a subhepatic biloma causing extrinsic compression and obstruction of the common hepatic duct. RESULTS: Percutaneous catheter drainage of the biloma combined with endoscopic sphincterotomy successfully relieved the extrahepatic biliary obstruction and resolved the intrahepatic ductal leak responsible for the biloma. CONCLUSION: Although heretofore undescribed, postcholecystectomy jaundice due to extrahepatic bile duct obstruction caused by biloma may occur and can be successfully treated by means of standard radiologic and endoscopic interventions.

Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate gallstone pancreatitis: a prospective randomized trial.

OBJECTIVE: To determine whether endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) stone extraction should be performed routinely before surgery or'selectively after surgery in patients with mild to moderate gallstone pancreatitis. SUMMARY BACKGROUND DATA: The role and timing of ERCP in mild to moderate gallstone pancreatitis remains controversial. Routine preoperative ERCP identifies persisting CBD stones but carries risks of complications and may delay definitive care. Selective postoperative ERCP, performed only if a CBD stone is seen on intraoperative cholangiography (IOC), avoids unnecessary ERCP but risks unsuccessful stone extraction. METHODS: A prospective, randomized study of consecutive patients with gallstone pancreatitis was conducted. Using previously determined criteria, patients with acute cholangitis or necrotizing pancreatitis were excluded. Patients considered at high risk for persisting CBD stones (CBD size > or =8 mm on admission ultrasound, serum total bilirubin > or = 1.7 mg/dL, or serum amylase > or = 150 U/L on hospital day 4) were randomly assigned to routine preoperative ERCP followed by laparoscopic cholecystectomy, or laparoscopic cholecystectomy with selective postoperative ERCP and endoscopic sphincterotomy only if a CBD stone was present on IOC. Primary end points were costs, length of hospital stay, and the combined treatment failure rates (failure of diagnostic ERCP and IOC, complications of ERCP and endoscopic sphincterotomy, and complications of surgery). RESULTS: One hundred fifty-four consecutive patients with gallstone pancreatitis were evaluated prospectively for study eligibility. Sixty patients met the randomization criteria. Thirty patients were randomized to routine preoperative ERCP and 29 patients to selective postoperative ERCP (1 patient refused). Age, admission laboratory values, and APACHE II and Imrie scores were similar in both groups. By protocol, ERCP was performed in all patients in the preoperative ERCP group. In the postoperative ERCP group, ERCP was necessary in only 7 of 29 patients (24%). Mean hospital stay was significantly longer in the routine preoperative ERCP group (11.7 days) than in the selective postoperative ERCP group (9.0 days). Mean total cost was higher in the preoperative ERCP group ($9,426) than in the postoperative ERCP group ($7,798). The combined treatment failure rate was 10% in both groups. CONCLUSIONS: In patients with mild to moderate gallstone pancreatitis without cholangitis, selective postoperative ERCP and CBD stone extraction is associated with a shorter hospital stay, less cost, no increase in combined treatment failure rate, and significant reduction in ERCP use compared with routine preoperative ERCP.

Fibrin glue reduces intra-abdominal adhesions to synthetic mesh in a rat ventral hernia model.

Postoperative intra-abdominal adhesions are associated with significant morbidity and mortality. In this study, the effect of topical fibrin glue (FG) on adhesion formation in a rat model was investigated. Forty Sprague-Dawley male rats underwent midline laparotomy. Bilateral peritoneal-muscular abdominal wall defects were created and then replaced with premeasured soft tissue Goretex patches. Rats were randomized to FG sprayed over the patches or to a control group. Two observers blinded to the randomization assessed the severity of adhesions to the patch by scoring the density of adhesions (grades 0-3) and the percentage of the patch area covered by adhesions (0-100%). The mean percentage of the patch covered by adhesions was 32.8 +/- 6.1 per cent for the FG group versus 57.9 +/- 6.7 per cent for the control group (P < 0.01). The mean density of adhesions for the FG group was 0.95 (+/-0.17) versus 2.0 (+/-0.21) for the control group (P = 0.001). Topical FG reduces the severity and density of intra-abdominal adhesions in a rat model.

Correlation between admission laboratory values, early abdominal computed tomography, and severe complications of gallstone pancreatitis.

BACKGROUND: Our previous study demonstrated that Balthazar grade D or E pancreatitis on early abdominal computed tomography (CT) scan correlated with severe complications of gallstone pancreatitis (GP). OBJECTIVE: To compare the efficacy of individual admission laboratory criteria, multiple criteria scoring systems and CT scan for predicting severe complications of GP. METHODS: Consecutively admitted patients with GP underwent selective early CT scanning (<72 hours). All patients were prospectively monitored for severe complications. RESULTS: Of the 66 patients studied, 21 (32%) did not undergo for early CT scanning and underwent cholecystectomy with no complications. Forty-five patients (68%) had an early abdominal CT scan. Of the 12 patients with grade E pancreatitis, 6 (50%) developed severe complications versus only 2 of 33 (6%) with grade A to D pancreatitis (P = 0.002). A significant correlation was found between admission white blood cell count > or =14.5 x 10(9)/L and grade E pancreatitis on early CT scan (P = 0.002). However, admission glucose > or =150 mg/dL was the best predictor of complications (sensitivity 100%, negative predictive value 100%). CONCLUSION: Although Balthazar grade E on early CT scan correlates with severe complications of GP, admission glucose > or =150 mg/dL has a better sensitivity and negative predictive value, is quicker to use, and is more cost-effective as a prognostic indicator.

Surgical management of gastrointestinal bleeding.

Severe gastrointestinal bleeding has historically been a clinical problem primarily under the purview of the general surgeon. Diagnostic advances made as the result of newer technologies, such as fiberoptic and video endoscopy, selective visceral arteriography, and nuclear scintigraphy, have permitted more accurate and targeted operations. More importantly, they have led to safe, effective nonoperative therapeutic interventions that have obviated the need for surgery in many patients. Today, most gastrointestinal bleeding episodes are initially managed by endoscopic or angiographic control measures. Such interventions are often definitive in obtaining hemostasis. Even temporary cessation or attenuation of massive bleeding in an unstable patient permits a safer, more controlled operative procedure by allowing an adequate period of preoperative resuscitation. Despite the less frequent need for surgical intervention, traditional operative approaches, such as suture ligation, lesion or organ excision, vagotomy, portasystemic anastomosis, and devascularization procedures, continue to be life-saving in many instances. The proliferation of laparoscopic surgery has fostered the application of minimally invasive techniques to highly selected patients with gastrointestinal bleeding. Intraoperative endoscopy has greatly facilitated the accuracy of laparoscopic surgery by endoscopic localization of bleeding lesions requiring excision. It is anticipated that the evolving technologies pertinent to the diagnosis and management of gastrointestinal bleeding will continue to promote collaboration and cooperation between gastroenterologists, radiologists, and surgeons.

Endovascular vs open abdominal aortic aneurysm repair: a comparison of cardiac morbidity and mortality.

HYPOTHESIS: Adverse cardiac event rates following endovascular abdominal aortic aneurysm (EAAA) and open abdominal aortic aneurysm (OAAA) repair are similar. We also hypothesized that the Eagle criteria (Q wave on electrocardiogram, diabetes, angina, congestive heart failure, age >70 years, and ventricular ectopy) are useful predictors of cardiac events in patients undergoing EAAA repair. DESIGN: Prospective (patients undergoing EAAA repair) and retrospective (patients undergoing OAAA repair). SETTING: Public teaching and Veterans Affairs medical centers. PATIENTS: Eighty-three EAAA and 63 OAAA repairs. MAIN OUTCOME MEASURES: Myocardial infarction, congestive heart failure, and cardiac death. RESULTS: Patients with EAAA were older (73 vs 68 years, P=.003). There were no differences in the mean number of Eagle criteria (1.2 vs 1.3), cardiac event rates (6% vs 4.8%), or mortalities (3.6% vs 4.8%). Within the EAAA group, congestive heart failure (P=.005) and Q wave on electrocardiogram (P=.006) were the only predictors of cardiac events. CONCLUSIONS: Patients undergoing OAAA and EAAA repair had similar cardiac event rates and mortality. In patients undergoing EAAA repair, history of congestive heart failure and Q wave on electrocardiogram were predictors of cardiac events.

Cardiac morbidity and operative mortality following lower-extremity amputation: the significance of multiple Eagle criteria.

The ability of the Eagle criteria (age >70 years, angina, diabetes, Q wave on EKG, history of congestive heart failure) to predict adverse cardiac events following major vascular surgery has previously been demonstrated. However, the utility of these criteria for lower-extremity amputation is not well established. To determine the value of the Eagle criteria for predicting cardiac morbidity and operative mortality following major lower-extremity amputation, we reviewed 214 consecutive procedures performed at two institutions over a 3-year period. Mean age was 62.7 years and 85% of the patients were male. Diabetes was the most frequent Eagle criterion (74%). The mean number of Eagle criteria was 1.6. Fifty-six percent of the amputations were below the knee, 24% were above the knee, and 20% were guillotine. On multivariate regression analysis, the presence of two or more Eagle criteria (16% vs. 4%, p = 0.04) and decompensated heart failure (39% vs. 7%, p = 0.003) were predictive of adverse cardiac events. The only predictor of postoperative mortality was the presence of two or more Eagle criteria (15% vs. 4%, p = 0.004). Our evaluation of the results of this study led us to conclude that patients requiring major lower-extremity amputation for major vascular disease who have multiple Eagle criteria or decompensated congestive heart failure are at high risk for adverse cardiac events and postoperative death. These findings should be used to guide perioperative cardiac evaluation and therapy.

Fibrin glue reduces the severity of intra-abdominal adhesions in a rat model.

BACKGROUND: The purpose of this study was to determine whether fibrin glue inhibits intra-abdominal adhesions. METHODS: Twenty rats underwent midline laparotomy. To maximize adhesions, bilateral peritoneal muscular defects were created and covered with polypropylene mesh sewn with a braided suture. The bowel was abraded with dry gauze. Rats were randomized to either fibrin glue (FG) sprayed over the mesh or to control (no further treatment) groups. At 1 week, the adhesion density (graded 0 to 3), the percentage of the patch covered by adhesion (0% to 100%), and adhesion type were recorded. RESULTS: The mean adhesion density was 1.45+/-0.33 for FG versus 2.8+/-0.11 for controls (P = 0.001). The mean percentage of adhesions was 36+/-9.9 for the FG group and 94+/-3.7 for controls (P = 0.0002). Bowel or solid organs were adherent to the patch in 6 of 20 (30%) in the FG group versus 12 of 20 (70%) in controls (P = 0.057). CONCLUSIONS: Topical fibrin glue reduces the density and severity of intra-abdominal adhesions in a rat model.

Osteitis fibrosa cystica with renal parathyroid hormone resistance: a review of pseudohypoparathyroidism with insight into calcium homeostasis.

Pseudohypoparathyroidism is a group of diseases characterized by renal resistance to parathyroid hormone. The patients typically have the bony manifestations of hyperparathyroidism, while being hypocalcemic. Pseudohypoparathyroidism has further been subdivided into types Ia, Ib, Ic, and II. Mutations involving any number of domains of the parathyroid hormone receptor, adenylate cyclase, or G proteins may alter the cellular response to parathyroid hormone. This wide range of possible sites of mutation may explain the heterogeneous biochemical, skeletal, and physical phenotypes associated with the various types of pseudohypoparathyroidism. We describe a patient with pseudohypoparathyroidism who was successfully treated with total parathyroidectomy and gland autotransplantation. The complexities of parathyroid hormone cellular interactions and calcium homeostasis are discussed. Pseudohypoparathroidism is an unusual disease; however, it provides an elegant model for studying problems of calcium balance.

Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones.

OBJECTIVE: The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC). METHODS: A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained. RESULTS: Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones. CONCLUSION: In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.

The outcome of research training during surgical residency.

BACKGROUND/PURPOSE: The exposure to research during residency is currently an integral part of most academic surgical training programs. In this study, graduates of two surgical programs were surveyed to characterize their research experience and to determine the effects on their careers. METHODS: Between 1975 and 1990, 86 and 61 residents completed general surgical training programs at UCLA Medical Center and at Harbor-UCLA Medical Center, respectively. An anonymous survey was sent to each graduate regarding his research experience and current practice. RESULTS: Of the graduates who spent 2 years in research, 47% now hold academic positions, compared with 23% for those who spent less than 2 years (P = .18). When the graduates were segregated according to their desire to enter the laboratory, 49% of graduates who requested research time hold academic positions, whereas only 13% of those who would not request research are in academic positions (P = .01). CONCLUSIONS: Residents who strongly desire a period of research during surgical residency are also more productive in the laboratory. This information should be considered in selecting residents for research training in the current era of academic budget restriction and managed health care.

Gastrinoma before Zollinger and Ellison.

BACKGROUND: The 1955 landmark publication by Zollinger and Ellison characterized the gastrinoma syndrome and presented a hypothesis for the pancreatic endocrine origin of the gastric hypersecretion and dramatic ulcer diathesis. METHODS: A detailed review of the literature was conducted to ascertain the clinical and pathologic spectrum of gastrinoma reported prior to the definition of the Zollinger-Ellison syndrome. RESULTS: In addition to the 2 patients presented by Zollinger and Ellison, 6 published reports of gastrinoma patients were referenced in their manuscript. An additional 6 patients were described by the 5 discussants of the presented paper. Thorough review of the literature has yielded 4, and possibly 6, additional cases of gastrinoma published between 1908 and 1952. CONCLUSION: Despite experience with a sizeable number of gastrinoma patients, it was left to Zollinger and Ellison to define the association between the islet cell tumor, its peptide hormone, and the clinical manifestations of severe gastric hypersecretion. Their seminal contribution served as the defining moment for the field of gastrointestinal endocrinology.

Early computed tomography is rarely necessary in gallstone pancreatitis.

The role of early CT scanning in acute gallstone pancreatitis remains ill defined. The purpose of our study was to: 1) determine whether our previously identified admission prognostic factors for gallstone pancreatitis [white blood cell (WBC) count > or = 14.5 x 10(9)/L, blood urea nitrogen (BUN) > or = 12 mmol/L, Acute and Chronic Health Evaluation II score > or = 5, glucose > or = 150 mg/dL, and heart rate > or = 100 beats/min)] correlate with the severity of pancreatic inflammation on CT scan, and 2) to determine the utility of early CT scanning in the management of gallstone pancreatitis. Admission clinical and laboratory variables were collected prospectively. Early CT scan findings were graded using the Balthazar scoring system and subgrouped into mild-moderate (Balthazar grades A-C) or severe (grades D and E) by a radiologist blinded to the patients' clinical status. Ninety-seven patients underwent surgery during their initial hospitalization without preoperative CT scanning. Four had operative complications (4%). Forty-two patients underwent early CT scan (grade A, 19%; B, 5%; C, 21%; D, 10%; and E, 45%), but only four (all grade E) had surgery delayed because of necrotizing pancreatitis, abscess, or pseudocyst. All four had persistent abdominal pain. There was one (2.5%) operative complication in the CT group and no deaths. Admission WBC count > or = 14.5 x 10(9)/L and BUN > or = 12 mmol/L correlated with severe pancreatitis (grades D and E) on CT (P < .05). We conclude that in patients with gallstone pancreatitis, 1) admission WBC count > or = 14.5 x 10(9)/L and BUN > or = 12 mmol/L correlate with the severity of pancreatic inflammation on CT scan, and 2) CT scan findings rarely influence management decisions and CT is therefore unnecessary, except in the minority of patients with objective indications of severe or unresolving pancreatitis.