Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review.

Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.

Pancreatic resection in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study.

BACKGROUND: Pancreatectomy is a high-risk, technically demanding operation associated with substantial perioperative morbidity and mortality. This study aims to describe the 30-day morbidity and mortality for pancreatectomy and to compare outcomes between private-sector and Veterans Affairs hospitals using multiinstitutional data. STUDY DESIGN: This is a retrospective review of patients who underwent pancreatic resection for neoplasia at private-sector (PS) and Veterans Affairs (VA) hospitals participating in the National Surgical Quality Improvement Program Patient Safety in Surgery Study in fiscal years 2002 to 2004. The variables reviewed were demographics, preoperative medical conditions, intraoperative variables, and outcomes. Using logistic regression to control for differences in patient comorbidities, 30-day mortality and morbidity rates between PS and VA hospitals were compared. RESULTS: A total of 1,069 patients underwent pancreatectomy for neoplasia at 97 participating hospitals. Six hundred ninety-two patients were treated at PS hospitals and 377 at VA hospitals. The average number of patients treated at each hospital was 11.0, with a range of 1 to 83 during the 3-year study period. There were 842 patients who underwent pancreaticoduodenectomy (CPT 4815x) and 227 who underwent distal/subtotal pancreatectomy (CPT 4814x). Significant differences were observed between PS patients and VA patients with regard to comorbidities and patient demographics. The 30-day unadjusted morbidity rate was 33.8% overall, 42.2% at VA hospitals versus 29.1% at PS hospitals (p < 0.0001). Unadjusted and adjusted odds ratio (OR) for postoperative morbidity comparing VA with PS hospitals was 1.781 (95% CI, 1.369-2.318) and 1.581 (95% CI, 1.064-2.307). The 30-day unadjusted operative mortality rate was 3.8% overall, 6.4% at VA hospitals and 2.5% at PS hospitals (p = 0.0015). Unadjusted and adjusted OR for postoperative mortality was 2.909 (95% CI, 1.525-5.549) and 2.533 (95% CI, 1.020-6.290), respectively. Similar outcomes were observed when looking at pancreaticoduodenectomy (CPT 4815x) when analyzed independent of other types of pancreatic resections. CONCLUSION: Pancreatectomies are high-risk operations with substantial perioperative morbidity and mortality. Risk-adjusted outcomes for patients treated at PS hospitals were found to be superior to those for patients treated at VA hospitals in the study.

Reducible poly(amido ethylenediamine) for hypoxia-inducible VEGF delivery.

Delivery of the hypoxia-inducible vascular endothelial growth factor (RTP-VEGF) plasmid using a novel reducible disulfide poly(amido ethylenediamine) (SS-PAED) polymer carrier was studied in vitro and in vivo. In vitro transfection of primary rat cardiomyoblasts (H9C2) showed SS-PAED at a weighted ratio of 12:1 (polymer/DNA) mediates 16 fold higher expression of luciferase compared to an optimized bPEI control. FACS analysis revealed up to 57+/-2% GFP positive H9C2s. The efficiency of plasmid delivery to H9C2 using SS-PAED was found to depend upon glutathione (GSH) levels inside the cell. SS-PAED mediated delivery of RTP-VEGF plasmid produced significantly higher levels of VEGF expression (up to 76 fold) under hypoxic conditions compared to normoxic conditions in both H9C2 and rat aortic smooth muscle cells (A7R5). Using SS-PAED, delivery of RTP-VEGF was investigated in a rabbit myocardial infarct model using 100 mug RTP-VEGF. Results showed up to 4 fold increase in VEGF protein expression in the region of the infarct compared to injections of SS-PAED/RTP-Luc. In conclusion, SS-PAED mediated therapeutic delivery improves the efficacy of ischemia-inducible VEGF gene therapy both in vitro and in vivo and therefore, has potential for the promotion of neo-vascular formation and improvement of tissue function in ischemic myocardium.

Anti-inflammatory effects of PPAR-gamma agonists directly correlate with PPAR-gamma expression during acute pancreatitis.

Peroxisome proliferator-activated receptors (PPARs) are ligand-inducible transcription factors that regulate cellular energy and lipid metabolism. PPAR-gamma agonists also have potent anti-inflammatory properties through down-regulation of early inflammatory response genes. The role of PPAR-gamma in acute pancreatitis has not been adequately examined. In this study, we determined the effect of PPAR-gamma agonists on the severity of pancreatitis and sought to correlate PPAR-gamma expression in pancreatic acinar cells and the severity of acute pancreatitis in vivo. Acute pancreatitis was induced in mice by hyperstimulation with the cholecystokinin analog, cerulein. PPAR-gamma agonists were administered by intraperitoneal injection 15-30 minutes before induction of pancreatitis (pretreatment) or at various times after induction of pancreatitis (treatment). Pancreata and serum were harvested over the course of 24 hours. Serum amylase activity and glucose levels were measured. Pancreata were used for histological evaluation as well as protein and mRNA analysis. Pretreatment of mice with the PPAR-gamma agonists 15-deoxy-Delta12, 14-prostaglandin J(2), or troglitazone significantly reduced the severity of pancreatitis in a dose-dependent manner. This reduction was indicated by reduced serum amylase activity and histological damage (leukocyte infiltration, vacuolization, and necrosis). Although cerulein decreased PPAR-gamma expression in the pancreas, pretreatment with agonists maintained PPAR-gamma expression early in acute pancreatitis. The expression of PPAR-gamma inversely correlated with pancreatitis severity and expression of the proinflammatory cytokines, interleukin-6, and tumor necrosis factor-alpha. Treatment with troglitazone after the induction of pancreatitis reduced serum amylase activity. The results suggest that PPAR-gamma plays a direct role in the inflammatory cascade during the early events of acute pancreatitis. Our data are the first to demonstrate that PPAR-gamma agonists represent a promising therapeutic strategy for acute pancreatitis.

Trends in research support and productivity in the changing environment of academic surgery.

BACKGROUND: We hypothesized that the changing environment of academic surgery has resulted in a decrease in surgical research funding and basic surgical research productivity of academic departments of surgery. MATERIALS AND METHODS: Trends in National Institutes of Health (NIH) grants to Departments of Medicine and Surgery were analyzed from 1992 to 1999. To assess trends in research productivity, selected basic science journals were screened from 1988 to 1999 for the number of basic research publications where authors cited affiliation with a Department of Medicine or Surgery. RESULTS: NIH funding to Schools of Medicine increased 5.9% per year from 1992 to 1999. Funding to Departments of Medicine increased 21.1% per year, whereas funding to Surgery increased 3.1% per year. As a percentage of total funding to medical schools, NIH funding to Departments of Surgery declined slightly and funding to Departments of Medicine increased 1% per year. The number of grants awarded to Schools of Medicine and Departments of Surgery and Medicine remained constant from 1992 to 1999. The number of publications in basic science journals trended up for both Departments of Surgery and Departments of Medicine. As a percentage of departmental totals, Departments of Surgery publications increased by 9.5% yearly and Departments of Medicine increased 1.5% per year. CONCLUSION: Support for basic surgical research has been static. Despite static grant support, basic research productivity has increased for Departments of Surgery. Basic surgical research remains an integral part of academic surgery department activity.