Dynamic CT for parathyroid disease: are multiple phases necessary?

BACKGROUND AND PURPOSE: A 4D CT protocol for detection of parathyroid lesions involves obtaining unenhanced, arterial, early, and delayed venous phase images. The aim of the study was to determine the ideal combination of phases that would minimize radiation dose without sacrificing diagnostic accuracy. MATERIALS AND METHODS: With institutional review board approval, the records of 29 patients with primary hyperparathyroidism who had undergone surgical exploration were reviewed. Four neuroradiologists who were blinded to the surgical outcome reviewed the imaging studies in 5 combinations (unenhanced and arterial phase; unenhanced, arterial, and early venous; all 4 phases; arterial alone; arterial and early venous phases) with an interval of at least 7 days between each review. The accuracy of interpretation in lateralizing an abnormality to the side of the neck (right, left, ectopic) and localizing it to a quadrant in the neck (right or left upper, right or left lower) was evaluated. RESULTS: The lateralization and localization accuracy (90.5% and 91.5%, respectively) of the arterial phase alone was comparable with the other combinations of phases. There was no statistically significant difference among the different combinations of phases in their ability to lateralize or localize adenomas to a quadrant (P = .976 and .996, respectively). CONCLUSIONS: Assessment of a small group of patients shows that adequate diagnostic accuracy for parathyroid adenoma localization may be achievable by obtaining arterial phase images alone. If this outcome can be validated prospectively in a larger group of patients, then the radiation dose can potentially be reduced to one-fourth of what would otherwise be administered.

A comparison of the haemostatic effect of Vivostat patient-derived fibrin sealant with oxidised cellulose (Surgicel) in multiple surgical procedures.

AIM: To evaluate the haemostatic properties of Vivostat patient-derived fibrin sealant in a broad range of surgical procedures. METHOD: In a prospective, randomised, multicentre, clinical study, typical surgical wounds of 69 patients (cardiothoracic, general, obstetric and gynaecologic, and vascular), requiring intervention to control bleeding, were treated with either Vivostat-derived sealant (n = 35) or Surgicel (n = 34) as required and the time taken to arrest bleeding was assessed. RESULTS: Compared with Surgicel, the mean time to haemostasis of Vivostat-derived sealant was significantly shorter (1.6 vs. 3.3 min, p < 0.0001) and more patients were successfully treated (i.e. no additional haemostatic measures required; 94 vs. 65%, p = 0.003). CONCLUSION: Vivostat-derived sealant is a more reliable and rapidly effective surgical haemostat than Surgicel.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway.

OBJECTIVE: To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied. METHODS: During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared. RESULTS: After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings. CONCLUSIONS: Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Impaired insulin secretion and increased insulin sensitivity in familial maturity-onset diabetes of the young 4 (insulin promoter factor 1 gene).

Diabetes resulting from heterozygosity for an inactivating mutation of the homeodomain transcription factor insulin promoter factor 1 (IPF-1) is due to a genetic defect of beta-cell function referred to as maturity-onset diabetes of the young 4. IPF-1 is required for the development of the pancreas and mediates glucose-responsive stimulation of insulin gene transcription. To quantitate islet cell responses in a family harboring a Pro63fsdelC mutation in IPF-1, we performed a five-step (1-h intervals) hyperglycemic clamp on seven heterozygous members (NM) and eight normal genotype members (NN). During the last 30 min of the fifth glucose step, glucagon-like peptide 1 (GLP-1) was also infused (1.5 pmol x kg(-1) x min(-1)). Fasting plasma glucose levels were greater in the NM group than in the NN group (9.2 vs. 5.9 mmol/l, respectively; P < 0.05). Fasting insulin levels were similar in both groups (72 vs. 105 pmol/l for NN vs. NM, respectively). First-phase insulin and C-peptide responses were absent in individuals in the NM group, who had markedly attenuated insulin responses to glucose alone compared with the NN group. At a glucose level of 16.8 mmol/l above fasting level, GLP-1 augmented insulin secretion equivalently (fold increase) in both groups, but the insulin and C-peptide responses to GLP-1 were sevenfold less in the NM subjects than in the NN subjects. In both groups, glucagon levels fell during each glycemic plateau, and a further reduction occurred during the GLP-1 infusion. Sigmoidal dose-response curves of glucose clearance versus insulin levels during the hyperglycemic clamp in the two small groups showed both a left shift and a lower maximal response in the NM group compared with the NN group, which is consistent with an increased insulin sensitivity in the NM subjects. A sharp decline occurred in the dose-response curve for suppression of nonesterified fatty acids versus insulin levels in the NM group. We conclude that the Pro63fsdelC IPF-1 mutation is associated with a severe impairment of beta-cell sensitivity to glucose and an apparent increase in peripheral tissue sensitivity to insulin and is a genetically determined cause of beta-cell dysfunction.

The effect of clinical pathway implementation on total hospital costs for thyroidectomy and parathyroidectomy patients.

Clinical pathways have long been used to guide the delivery of patient care in varied practice settings. There is little information in the literature to document the effectiveness of pathway implementation in general surgical populations. This study reports the effect of clinical pathway implementation in two general surgical patient groups, thyroidectomy and parathyroidectomy. Clinical pathways were implemented to serve patients undergoing thyroidectomy and parathyroidectomy surgery. The effects of both clinical pathways on total hospital costs, length of hospitalization, variances, and outcomes were collected and evaluated from July 1998 through July 1999. These data were compared to data from the previous year. The average length of stay for parathyroidectomy patients decreased from 2.4 to 1.5 days (P = 0.26) for pathway patients as compared to prepathway patients. The average cost per case decreased from $5071 to $4291 (P = 0.50) for parathyroidectomy pathway versus prepathway patients. The average length of stay decrease for thyroidectomy patients was 1.4 to 1.2 (P = 0.16) for the pathway to prepathway comparison. The average cost per case decrease was minor at $4117 to $4111. Pharmacy costs and laboratory utilization were effectively reduced. Perioperative costs rose dramatically during this period, operating room/central sterile supply cost per case rose 12 per cent, anesthesia supply cost per case rose 15 per cent, and surgical pathology costs increased 110 per cent overall for both patient groups. Clinical pathway implementation has allowed us to reduce or maintain total hospital costs in the face of rising perioperative costs. We conclude that implementation of these clinical pathways has allowed us to improve consistency with which we deliver care while maintaining the quality of patient outcomes and reducing the costs of care and length of hospital stay.

Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy.

OBJECTIVE: To determine whether infiltrating lobular carcinoma (ILC) is associated with high positive-margin rates for single-stage lumpectomy procedures, and to define clinical, mammographic, or histologic characteristics of ILC that might influence the positive-margin rate, thereby affecting treatment decisions. SUMMARY BACKGROUND DATA: Infiltrating lobular cancer represents approximately 10% of all invasive breast carcinomas and is often poorly defined on gross examination. METHODS: A group of 47 patients with biopsy-proven ILC undergoing breast-conservation therapy (BCT) at the University of Virginia Health Sciences Center between 1975 and 1999 was compared with a group of 150 patients with infiltrating ductal cancer undergoing BCT during the same time period. The pathology of the lumpectomy specimen was reviewed for each patient to confirm surgical margin status. Office and surgical notes as well as mammography reports were examined to determine whether the lesions were deemed palpable before and during surgery. Patients were stratified according to age, family history, tumor size, tumor location, and histologic features of the tumor. RESULTS: The incidence of positive margins was greater in the ILC group compared with the infiltrating ductal cancer group. Patient age, family history, and preoperative palpability of the tumor did not correlate with surgical margin status. Of the mammographic features identified, including spiculated mass, calcifications, architectural distortion, and other densities, only architectural distortion predicted positive surgical margin status. Tumor grade, tumor size, lymph node status, and receptor status were not predictive of surgical margin status. CONCLUSIONS: For patients with ILC, BCT is feasible, but these patients are at high risk of tumor-positive resection margins (51% incidence) after the initial resection. Only the mammographic finding of architectural distortion was identified as a preoperative marker reliably identifying a subgroup of ILC patients at especially high risk for a positive surgical margin. For all patients with ILC considering BCT, careful counseling about the potential need for a second procedure to treat the positive margin should be included in the treatment discussion.

Preoperative evaluation and predictive value of fine-needle aspiration and frozen section of thyroid nodules.

BACKGROUND: We sought to evaluate the predictive value of preoperative fine-needle aspiration (FNA) on surgical decision making by evaluating the final pathologic diagnosis and comparing it to the preoperative diagnosis. Further, we wished to calculate the predictive accuracy of each of several types of preoperative FNA diagnosis. STUDY DESIGN: A retrospective chart review of 151 thyroid resections between July 1990 and April 1996 at the University of Virginia was undertaken. The mean age was 45 years (range, 11 to 85 years). Preoperative laboratory values, presenting symptoms, imaging studies, and predictive values of preoperative FNA and intraoperative frozen section were analyzed. RESULTS: Symptomatology was poorly predictive of a benign versus malignant postoperative final pathologic diagnosis. Sensitivity, specificity, and accuracy of frozen section versus FNA was 86% versus 86%; 99% versus 93%, and 96% versus 92%, respectively, if the reading "cancer" or "suspicious" were predicted as positive for malignancy and "benign" or "follicular" were predicted as negative for malignancy. If only the reading "cancer" was predicted as positive for malignancy and only "benign" was predicted as negative for malignancy, sensitivity and specificity for FNA were 100% and 96%, respectively, and 100% and 99%, respectively, for frozen section. Forty-nine "follicular" lesions obtained by preoperative FNA resulted in 46 benign diagnoses after surgical resection. CONCLUSIONS: The use of preoperative FNA is a powerful diagnostic tool in the hands of skilled pathologists. There is increasing evidence that intraoperative frozen section adds little to intraoperative decision making in patients diagnosed with thyroid cancer by preoperative FNA. Less definitive interpretations decrease the sensitivity, specificity, and accuracy of the FNA diagnosis.

Association of breast cancer with the finding of atypical ductal hyperplasia at core breast biopsy.

OBJECTIVE: The purpose of the study is to evaluate the prevalence of occult breast carcinoma in surgical breast biopsies performed on nonpalpable breast lesions diagnosed initially as atypical ductal hyperplasia (ADH) by core needle biopsy. BACKGROUND: Atypical ductal hyperplasia is a lesion with significant malignant potential. Some authors note that ADH and ductal carcinoma in situ (DCIS) frequently coexist in the same lesion. The criterion for the diagnosis of DCIS requires involvement of at least two ducts; otherwise, a lesion that is qualitatively consistent with DCIS but quantitatively insufficient is described as atypical ductal hyperplasia. Thus, the finding of ADH in a core needle breast biopsy specimen actually may represent a sample of a true in situ carcinoma. METHODS: Between May 3, 1994, and June 12, 1996, image-guided core biopsies of 510 mammographically identified lesions were performed using a 14-gauge automated device with an average of 7.5 cores obtained per lesion. Atypical ductal hyperplasia was found in 23 (4.5%) of 510 lesions, and surgical excision subsequently was performed in 21 of these cases. In these 21 cases, histopathologic results from core needle and surgical biopsies were reviewed and correlated. RESULTS: Histopathologic study of the 21 surgically excised lesions having ADH in their core needle specimens showed seven (33.3%) with DCIS. CONCLUSIONS: In the authors' patient population, one third of patients with ADH at core biopsy have an occult carcinoma. A core needle breast biopsy finding of ADH for nonpalpable lesions therefore warrants a recommendation for excisional biopsy.

General surgical complications can be predicted after cardiopulmonary bypass.

OBJECTIVE: The authors review the general surgical complications of cardiopulmonary bypass, including newer procedures such as heart and lung transplantation, to identify patients at higher risk. SUMMARY BACKGROUND DATA: Although rare, the general surgical complications of cardiopulmonary bypass are associated with high mortality. The early identification of patients at increased risk for these complications may allow for earlier detection and treatment of these problems to reduce mortality. METHODS: A retrospective review was performed of 1831 patients undergoing cardiopulmonary bypass from 1991 to 1993. This was done to identify factors that significantly contributed to an increased risk of general surgical complications. RESULTS: Factors associated with an increased risk of general surgical complications included prolonged cardiopulmonary bypass (p < 0.005) and intensive care unit stay (p < 0.002), occurrence of arrhythmias (p < 0.001), use of inotropic agents (preoperatively or postoperatively p < 0.001), insertion of the intra-aortic balloon pump (preoperatively p < 0.005, postoperatively p < 0.001), use of steroids (p < 0.001), and prolonged ventilator support (p < 0.001). Multivariate analysis identified use of the intra-aortic balloon pump (p < 0.001) as the strongest predictor of the general surgical complications of cardiopulmonary bypass. A variety of factors not contributing significantly to an increased risk also were identified. CONCLUSIONS: Factors indicative of or contributing to periods of decreased end-organ perfusion appear to be significantly related to general surgical complications after cardiopulmonary bypass.

Circulating dihydroxyphenylglycol and norepinephrine concentrations during sympathetic nervous system activation in patients with pheochromocytoma.

Although increased plasma norepinephrine (NE) concentrations mediate vasoconstriction during episodic hypertension and hypertensive crises in patients with pheochromocytoma (Pheo), the precise origin of this circulating NE (tumor or sympathetic nerves) is not known. Dihydroxyphenylglycol (DHPG), a deaminated metabolite of NE, is formed principally in sympathetic nerve endings. Under basal conditions, plasma NE and DHPG concentrations correlate closely, and during sympathetic nervous system activation, both plasma NE and DHPG concentrations increase. This observation suggests that plasma DHPG concentrations may reflect the source of circulating NE (tumor or sympathetic nerves) during hypertensive episodes in patients with Pheo. Plasma NE and DHPG concentrations were measured simultaneously, and the NE/DHPG ratio was calculated in seven patients with Pheo during 20 min of sympathetic nervous system activation (treadmill exercise) before and after surgical resection of the tumor. Age- and sex-matched normal subjects were also studied. Exercise resulted in a significant increase in plasma NE and DHPG concentrations in patients with Pheo and in normal subjects (Pheo: basal NE, 1827 +/- 639; peak NE, 3016 +/- 769 pg/mL (P = 0.02); normal subjects: basal NE, 266 +/- 27; peak NE, 1166 +/- 197 pg/mL (P = 0.01); Pheo: basal DHPG, 1521 +/- 280; peak DHPG, 2313 +/- 252 pg/mL (P = 0.007); normal subjects: basal DHPG, 870 +/- 50; peak DHPG, 1630 +/- 180 pg/mL (P = 0.01)]. The NE/DHPG ratio increased with exercise in normal subjects (basal, 0.30 +/- 0.02; peak, 0.83 +/- 12; P = 0.005), but did not change in patients with Pheo (basal, 1.22 +/- 0.32; peak, 1.54 +/- 0.27). Exercise also increased plasma NE and DHPG concentrations and the NE/DHPG ratio in five patients studied after surgical resection of the tumor. Systolic blood pressure and heart rate increased significantly during exercise in all three study groups. The increase in plasma NE and HDPG concentrations during exercise-induced sympathetic nervous system stimulation in patients with Pheo is similar to that in normal subjects and may indicate that the sympathetic nervous system plays an important role in the pathogenesis of hypertension and hypertensive crises in patients with Pheo.

Hyperinsulinemia after pancreatic transplantation. Prediction by a novel computer model and in vivo verification.

OBJECTIVE: The authors evaluated systemic venous insulin release as a cause of the hyperinsulinemia (HNS) associated with pancreatic transplantation (PTX) with respect to the mechanism and metabolic consequences. SUMMARY BACKGROUND DATA: Many investigators believe the postoperative anatomy associated with common PTX techniques to be the sole cause of the two- to threefold posttransplantation HINS. However, this concept remains to be conclusively proved and characterized quantitatively. METHODS: The authors used three approaches to achieve their objectives. First, a computer model was generated based on established data concerning blood flow and tissue insulin extraction to determine whether it was mathematically possible for HINS to be caused by systemic insulin release. Second, HINS clamps were applied to normal dogs using the Andres clamp technique to quantify the in vivo differences in peripheral insulin levels and the metabolic consequences of systemic versus portal insulin infusion. Third, prolonged insulin half-life was evaluated as a possible mechanism of HINS from systemic insulin release by determination of biexponential rates of plasma disappearance from an endogenous pulse of insulin in surgically induced dog models of systemic and portal insulin release. RESULTS: First, the computer model calculated a 1.4- to 2.9-fold increase in peripheral venous insulin levels with systemic versus portal insulin release, verifying mathematically the concept of HINS resulting from systemic insulin release. Second, the actual systemic insulin infusion produced a 1.3- to 1.4-fold increase in peripheral venous insulin levels compared with portal infusion (p < 0.05). No significant differences in hepatic glucose output, total glucose disposal, or glucose infusion requirements were seen. Third, although the basal insulin level was twofold higher in the surgically induced animal models with systemic insulin release (p < 0.003), there were no differences in biexponential insulin clearance parameters. CONCLUSIONS: The HINS produced by systemic insulin release did not significantly alter glucose metabolism and was not the result of altered peripheral insulin clearance parameters. In vivo systemic venous insulin infusion studies produce HINS, but not to the degree calculated by mathematic modeling or that occurs after clinical PTX, making it likely that other factors also play a role in the HINS after PTX.

Intraoperative fine needle aspiration of pancreatic and extrahepatic biliary masses.

Intraoperative fine needle aspiration (IFNA) of masses of the pancreas and extrahepatic biliary system provides a method of rapid tissue diagnosis with a much lower complication rate than either wedge or large bore needle biopsies. Few series include IFNA of extrahepatic biliary system masses in their analyses. We retrospectively evaluated all IFNA of pancreatic, extrahepatic biliary and ampullary masses at the University of Virginia from March 1981 to December 1991 to assess the diagnostic accuracy of this procedure. Ninety-nine IFNA were performed--75 of the pancreas, 17 of the extrahepatic biliary system and seven of the ampulla. All aspirations were performed with direct visualization or palpation of the tumor, or both, using several passes with a 22 gauge needle. A diagnostic "positive" or "negative" reading was rendered in 90 of 99 IFNA. Carcinoma was confirmed by positive tissue diagnosis or clinical course consistent with cancer. Benign disease was confirmed by negative pathologic factors from a resected specimen or confirmatory clinical course of at least 18 months. Diagnosis was confirmed by these criteria in 82 patients. Thirty-four of 43 patients with confirmed carcinoma of the pancreas had positive cytologic factors by IFNA. Three pancreas IFNA were deemed as "suspicious" and six as "unsatisfactory." Two patients with "suspicious" findings had pathologically confirmed well-differentiated carcinoma. Carcinoma of the ampulla and extrahepatic biliary tract was detected by IFNA in 17 of 18 confirmed patients. The overall sensitivity of positive or negative IFNA in this series in 90 percent, with 100 percent specificity and 92 percent accuracy. IFNA has a positive predictive value of 100 percent and negative predictive value of 74 percent. We conclude that IFNA is a highly accurate diagnostic procedure and represents the preferred technique of obtaining an intraoperative tissue diagnosis in masses of the pancreas, extrahepatic biliary tract and ampulla. Positive IFNA may definitively guide surgical decision-making; however, we caution that negative IFNA cannot be relied on definitively to exclude the diagnosis of carcinoma.

Laparoscopic versus traditional appendectomy for suspected appendicitis.

We compared the results of concurrently performed laparoscopic versus open appendectomy as treatments for suspected acute appendicitis. The 68 laparoscopic procedures resulted in 62 appendectomies, 47 by the laparoscopic (LA) technique and 15 by the open (LO) technique. Another 54 patients underwent open appendectomy (OA). Significantly more females underwent laparoscopy (LA and LO: 52% versus OA: 33%, p = 0.047). Operative duration was shortest for OA (81 +/- 3 minutes), which was shorter than for LO (108 +/- 7 minutes), but not different than LA (86 +/- 6 minutes). The postoperative length of stay was not different for LA (3.5 +/- 0.5 days) compared with OA (5.9 +/- 1.6 days) or LO (4.8 +/- 1.3 days). One death occurred in the OA group. Wound complication rates were not significantly different for LA (4.3%) compared with OA (9.4%) and LO (13.3%). Overall complication rates were lower for LA (10.6%) and OA (18.9%) compared with LO (46.7%, p < 0.01). Median hospital cost for LO ($10,425) was higher (p < 0.02) than for either LA ($5,899) or OA ($5,220). When appendicitis was not present, definitive confirmation of pathology was achieved in 9 of 18 patients undergoing LA versus 4 of 14 patients having OA (p = not significant). We conclude that when laparoscopy and laparoscopic appendectomy can be performed, the procedure is safe and produces results comparable with those of open appendectomy without significant overall cost differences.

Intraoperative urinary cyclic AMP monitoring in primary hyperparathyroidism.

OBJECTIVE: This study examined the utility of intraoperative urinary cyclic 3'5' adenosine monophosphate (UcAMP), an indicator of parathyroid (PTH) hormone end-organ activity, as a "biochemical frozen section," signaling the real-time resolution of PTH hyperactivity during surgery for primary hyperparathyroidism. SUMMARY BACKGROUND DATA: The unsuccessful initial neck exploration for primary hyperparathyroidism, leaving the patient with persistent hyperfunctioning parathyroid tissue, results in part from the surgeon's inability intraoperatively to correlate a gland's gross appearance and size estimation with physiologic function. Preoperative imaging, intraoperative imaging, and intraoperative histologic/cytologic surveillance have not resolved this dilemma. METHODS: Twenty-seven patients underwent a prospective intraoperative UcAMP monitoring protocol. The patients all had a clinical diagnosis of primary hyperparathyroidism and an average preoperative serum calcium of 12.0 +/- 0.3 mg/dl. UcAMP was assayed intraoperatively using 20-minute nonequilibrium radioimmunoassay providing real-time feedback to the operating team. RESULTS: All patients had an elevated UcAMP confirming PTh hyperactivity at the beginning of the procedure. One patient, subsequently found to have an supernumerary ectopic adenoma, had four normal glands identified intraoperatively, and his intraoperative UcAMP values corroborated persistent hyperparathyroidism, the UcAMP of the remaining 26 patients decreased from 7.0 +/- 1.1 to 2.7 +/- 0.7 nm.dl GF (p < .00005) after complete adenoma excision, and they remain normocalcemic. The protocol provided useful and relevant information to the operating team, and aided in surgical decision-making, in 10 of the 27 cases (37%). CONCLUSION: Intraoperative biochemical surveillance with ucAMP monitoring reliably signals resolution of PTH hyperfunction. It is a useful adjunct to the surgeon's skill, judgment, and experience in parathyroid surgery.

Successful paratopic pancreas transplantation: a report of three cases with venous portal drainage and enteric exocrine drainage.

Pancreatic transplantation is able to produce euglycemia in patients with Type I diabetes mellitus. Current surgical techniques utilize revascularization of the graft through the recipient iliac vessels and drainage of the exocrine pancreatic secretions through a duodenal conduit into the bladder. We describe a technique utilized in 3 patients whereby venous pancreatic drainage is into the portal venous circulation via the proximal splenic vein. The exocrine pancreatic secretions are drained into the proximal jejunum via a side-to-side donor duodenum to proximal small bowel anastomosis. Results and complications of this technique are presented. Potential short-term and long-term advantages and disadvantages of this technique are discussed. Our early experience suggests that paratopic pancreatic transplantation with venous drainage into the portal vein and exocrine drainage into the proximal jejunum is both feasible and desirable.

Laparoscopic cholecystectomy in the obese patient.

The authors' experience with laparoscopic cholecystectomy (LC) in obese (O, n = 96) and morbidly obese (MO, n = 27) patient groups was compared with that in the normal weight (NW, n = 174) group of patients as well as the whole group (WG). There were no operative deaths. There were no significant differences between groups for any of the following: successful intraoperative cholangiography (WG, 52.2%; NW, 52.9%; O, 51.1%; MO, 55.6%), conversion to open cholecystectomy (WG, 9.6%; NW, 9.2%; O, 10.4%; MO, 11.1%), incidence of major complications (WG, 4.1%; NW, 3.4%, O, 5.2%; MO, 0%), incidence of minor complications (WG, 7.4%, NW, 7.5%; O, 6.3%; MO, 3.7%), and length of hospitalization after successful LC (WG, 1.25 days; NW, 1.31 days; O, 1.16 days; MO, 1.13 days). Duration of operation did not differ except LC in the MO group (136.4 +/- 6.9 minutes) was longer when compared with NW patients (123.0 +/- 2.9 minutes, p less than 0.05). The authors conclude LC is a safe and effective treatment for obese patients with symptomatic cholelithiasis.

Pancreas transplantation. An initial experience with systemic and portal drainage of pancreatic allografts.

Pancreas transplantation has evolved dramatically since its introduction in 1966. As new centers for transplantation have developed, the evaluation of complications associated with pancreas transplantation has led to advances in surgical technique. Furthermore, surgical alterations of the pancreas resulting from transplantation (systemic release of insulin and denervation) are of unproven consequence on glucose metabolism. Since 1988, the authors have performed 21 transplants (16 combined pancreas/kidney, 3 pancreas alone, which includes 1 retransplantation, 1 pancreas after previous kidney transplant, and 1 "cluster") in 20 patients aged 18 to 49 years; mean, 35 +/- 1 years. Overall patient survival is 95%. Three pancreatic grafts failed within the first year because of technical failure; one additional pancreas was lost to an immunologic event on postoperative day 449, for an overall pancreatic graft survival of 81%. No renal grafts were lost. To evaluate causes of graft failure, demographic data were compared, which included age and sex of the donor and the recipient, operative time, intraoperative blood transfusion, and ischemic time of the graft. No statistically significant differences were found between groups except for ischemic time (11.7 +/- 6.4 hours for the technical success group versus 19.8 +/- 3.7 hours for the technical failure group; p less than 0.05 by unpaired Student's t test). Quadruple immunosuppression was used, which included prednisone, cyclosporine, azathioprine, and antilymphoblast globulin. A mean of 1.2 (range, 0 to 3) rejection episodes per patient occurred. Mean hospital stay was 24 +/- 11 days. Surgical and infectious complications were evaluated by comparing the technical success (TS) group (n = 17) with the technical failure (TF) group. Surgical complications in the TS group revealed a mean of 1.3 episodes per patient, whereas the TF group had 3.7 episodes per patient. The TS also had a reduced incidence of infectious complications compared with the TF (1.7 versus 4.3 episodes per patient). Cytomegalovirus was common in both groups, accounting for 11 infectious episodes, and occurred on a mean postoperative day of 38. Mean postoperative HbA1C levels dropped to 5 +/- 1% from 11 +/- 3%. The authors developed a new technique that incorporates portal drainage of the pancreatic venous effluent in three recipients. Preoperative metabolic studies disclosed a mean fasting glucose of 211 +/- 27 mg/dL and a mean stimulated glucose value of 434 +/- 41 mg/dL for all patients; the mean fasting insulin was 23 +/- 4 microU/mL.(ABSTRACT TRUNCATED AT 400 WORDS)