Reoperation following Pancreaticoduodenectomy.

Introduction. The literature on reoperation following pancreaticoduodenectomy is sparse and does not address all concerns. Aim. To analyze the incidence, causes, and outcome of patients undergoing reoperations following pancreaticoduodenectomy. Methods. Retrospective analysis of 520 consecutive patients undergoing pancreaticoduodenectomy from May 1989 to September 2010. Results. 96 patients (18.5%) were reoperated; 72 were early, 18 were late, and 6 underwent both early and late reoperations. Indications for early reoperation were post pancreatectomy hemorrhage in 53 (68%), pancreatico-enteric anastomotic leak in 10 (13%), hepaticojejunostomy leak in 3 (3.8%), duodenojejunostomy leak in 4 (5%), intestinal obstruction in 1 (1.2%) and miscellaneous causes in 7 (9%). Patients reoperated early did not fare poorly on long-term follow up. Indications for late reoperations were complications of index surgery (n = 12), recurrence of the primary disease (n = 8), complications of adjuvant radiotherapy (n = 3), and gastrointestinal bleed (n = 1). The median survival of 16 patients reoperated late without recurrent disease was 49 months. Conclusion. Early reoperations following pancreaticoduodenectomy, commonly for post pancreatectomy hemorrhage, carries a high mortality due to associated sepsis, but has no impact on long-term survival. Long-term complications related to pancreaticoduodenectomy and adjuvant radiotherapy can be managed successfully with good results.

Characterization of two human genes encoding acyl coenzyme A:cholesterol acyltransferase-related enzymes.

The enzyme acyl coenzyme A:cholesterol acyltransferase 1 (ACAT1) mediates sterol esterification, a crucial component of intracellular lipid homeostasis. Two enzymes catalyze this activity in Saccharomyces cerevisiae (yeast), and several lines of evidence suggest multigene families may also exist in mammals. Using the human ACAT1 sequence to screen data bases of expressed sequence tags, we identified two novel and distinct partial human cDNAs. Full-length cDNA clones for these ACAT related gene products (ARGP) 1 and 2 were isolated from a hepatocyte (HepG2) cDNA library. ARGP1 was expressed in numerous human adult tissues and tissue culture cell lines, whereas expression of ARGP2 was more restricted. In vitro microsomal assays in a yeast strain deleted for both esterification genes and completely deficient in sterol esterification indicated that ARGP2 esterified cholesterol while ARGP1 did not. In contrast to ACAT1 and similar to liver esterification, the activity of ARGP2 was relatively resistant to a histidine active site modifier. ARGP2 is therefore a tissue-specific sterol esterification enzyme which we thus designated ACAT2. We speculate that ARGP1 participates in the coenzyme A-dependent acylation of substrate(s) other than cholesterol. Consistent with this hypothesis, ARGP1, unlike any other member of this multigene family, possesses a predicted diacylglycerol binding motif suggesting that it may perform the last acylation in triglyceride biosynthesis.

Ureteroscopic management of intrarenal calculi.

PURPOSE: To determine its potential role in stone therapy, we evaluated our experience with the ureteroscopic removal of intrarenal calculi in 100 patients. We review the indications, techniques, stone-free and overall success rates, and complications. MATERIALS AND METHODS: From July 1994 to December 1996 ureteroscopic stone removal was attempted in 100 patients a mean of 52 years old who had renal calculi. Indications for treatment included concurrent ureteral stones in 56 cases, and failed extracorporeal shock wave lithotripsy, medical or percutaneous management as well as obesity and anatomical anomalies. There were 2 or more calculi in the affected kidney in 68 patients and stones greater than 6 mm. in 67. Treatment of intrarenal calculi was performed with flexible ureteroscopes, a laser or electrohydraulic lithotriptor and endoscopic graspers. The number and size of calculi were noted in each patient. Stone-free and overall success rates defined as 1 residual fragment less than 3 mm. were noted at 1 and 3-month followup visits. RESULTS: The overall success rate was 89%. Ureteroscopic treatment of intrarenal calculi resulted in a 77% stone-free rate. Of the 23 patients with residual calculi 12 (52%) had a single residual fragment less than 3 mm. The targeted stone was removed or fragmented in 98 patients (98%) and no ureteral calculi remained postoperatively. As expected, the number and size of the original stones inversely correlated with the success rate. There were no intraoperative complications, and only 3 urinary tract infections and 3 fevers were noted postoperatively. CONCLUSIONS: The use of smaller diameter ureteroscopes, better working instruments and more effective lithotriptors allow calculi in all parts of the collecting system to be engaged and treated. Success rates throughout the whole collecting system are comparable to if not better than those of extracorporeal shock wave lithotripsy and percutaneous approaches.