Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices.

INTRODUCTION: Achalasia is a primary motility disorder of the esophagus that is treated most effectively with operative myotomy. Excellent outcomes with laparoscopic myotomy and fundoplication are well known. Heller myotomy utilizing a computer-enhanced (robotic) laparoscopic platform allows for a more precise dissection by utilizing the superior optics of a 3-dimensional camera and greater degrees of freedom provided by robotic instrumentation. How this affects outcome and quality of life is unknown. METHODS: We assessed patients' health perceptions using a standardized, validated, health-related, disease-specific quality-of-life metric. Sixty-one consecutive patients undergoing laparoscopic or robotic myotomy over a 6-year period were evaluated prospectively. All operations were performed using intraoperative manometric and endoscopic guidance and all except 5 patients had a fundoplication. The effects of the operation on health-related quality of life were evaluated with the Short Form (SF-36) Health Status Questionnaire and a disease-specific gastroesophageal reflux disease activity (GERD) activity index (GRACI) preoperatively and postoperatively. All patients completed the questionnaire at both time points. Patient scores were compared using 2-way repeated measures analyses of variance followed by the Tukey test. Operative time, estimated blood loss, duration of stay, intraoperative complication, and postoperative complications were analyzed. RESULTS: Thirty-seven patients had laparoscopic and 24 patients had robotic Heller myotomy. There was an increase in SF-36 overall evaluation of health postoperatively compared with preoperatively in both groups (P < .05). The robotic myotomy patients had better SF-36 Role Functioning (emotional) and General Health Perceptions (P < .05) compared with the laparoscopic group. The GRACI showed an equivalent improvement in severity of symptoms in both groups (P < .05). Operative time was 287 +/- 9 minutes for laparoscopic cases and 355 +/- 23 minutes for robotic cases. Estimated blood loss and duration of stay were not different between groups. There were 3 operative esophageal perforations (8%) during laparoscopic myotomy and all were repaired immediately. There were no perforations or operative complications in the robotic group. Neither group had any additional complications. CONCLUSIONS: Minimally invasive operative myotomy improves functional status and overall evaluation of health in patients with achalasia. Robotic myotomy had no intraoperative esophageal perforations compared with an 8% intraoperative rate during laparoscopic myotomy. Heller myotomy with partial fundoplication using a robotic platform appears to be a more precise and safer operation than laparoscopic myotomy with improved quality-of-life indices postoperatively compared with laparoscopic myotomy with fewer complications; this suggests that, in skilled hands, the robotic platform may be safer, with improved quality-of-life outcomes.

Synthesis and biological properties of 4-norleucine-neuropeptide Y; secondary structure of neuropeptide Y.

Neuropeptide Y (NPY) is a 36 amino acid peptide amide isolated from porcine brain. The NPY analog, 4-norleucine-NPY was synthesized by a solid-phase method and purified to homogeneity in 20% yield by reverse-phase chromatography. Investigation of the biological properties indicated that the analog is an agonist of NPY. Secondary structural analyses revealed that NPY and the analog exhibited predominantly alpha-helical and beta-sheet structures, respectively; however, experiments in trifluoroethanol indicated that the analog has the potential of assuming an alpha-helical structure. Based on circular dichroism (CD), Raman spectroscopy and Chou-Fasman analyses, a model has been proposed for the secondary structure of NPY.

Comparison of distal and proximal splenorenal shunts: a ten-year experience.

BACKGROUND: This study evaluated the effectiveness of distal (DSRS) versus the central or proximal (PSRS) splenorenal shunts in the elective treatment of bleeding varices. METHODS: A series of 48 patients with portal hypertension and established variceal bleeding were randomized to undergo PSRS or DSRS. Preoperative evaluation included endoscopic examination, angiography, serum amino acid profile, liver chemistry studies, and neurologic evaluation. Any patient with significant ascites and hepatofugal flow underwent PSRS shunt procedures; the remainder were randomized prospectively. RESULTS: Between 1979 and 1989, 29 patients underwent PSRS and 19 underwent DSRS. The mean length of follow-up was 48 months. The groups were equivalent with regard to age, gender, child's class, number of preoperative bleeds, and cause of disease. No difference was found in any of the factors measured. In particular there were no differences in the operative mortality rate (17% PSRS; 11% DSRS), 5-year survival rate (52% PSRS; 52% DSRS), rebleeding (34% PSRS; 32% DSRS), shunt occlusion (7% PSRS; 11% DSRS), development of individual episodes of postoperative encephalopathy (28% PSRS; 26% DSRS), chronic postoperative encephalopathy (17% PSRS; 11% DSRS), or mean branched-chain/aromatic amino acid ratios (PSRS = 0.88 +/- 0.05; DSRS = 0.66 +/- 0.05). CONCLUSIONS: The results do not support the contention that DSRS is associated with either greater survival or less encephalopathy than PSRS.

Proximal jejunal and biliary effects on the enteroinsular axis.

The objective of this study was to investigate the roles of the proximal jejunum and endogenous bile within the proximal jejunum on the enteroinsular axis. Twelve Sprague-Dawley rats underwent proximal jejunal bypass, 11 rats underwent Roux-en-Y cholangiojejunostomies, and 12 rats underwent sham operations. After 3 months, oral glucose tolerance tests were performed in unanesthetized animals and venous blood was collected for plasma glucose and insulin measurements. The surgical procedures did not significantly affect the basal glucose and insulin levels compared with sham-operated animals. The insulin response in rats with excluded proximal jejunal segments was inhibited. The decreased insulinogenic index seen in these animals indicates a possible diabetogenic effect of this procedure. An oral glucose challenge resulted in significant hyperinsulinemia, with an increased insulinogenic index in animals that had undergone Roux-en-Y cholangiojejunostomies. These findings suggest that bile is a potential mediator in the proximal jejunal involvement in the enteroinsular axis.

Long-term evaluation of extended thymectomy with anterior mediastinal dissection for myasthenia gravis.

BACKGROUND: Thymectomy for the treatment of myasthenia gravis (MG) is well established. The extent of resection, however, remains a source for debate. Outcomes for newer surgical techniques need to be compared to more extensive procedures. METHODS: A retrospective review was done of 64 consecutive patients who underwent transsternal thymectomy with extended anterior mediastinal dissection for MG between 1979 and 2000 and who were operated on by a single surgeon. RESULTS: Fifty-six patient charts were available, providing 58 operative procedures. Three patients had died of unrelated causes. The mean age of symptom onset was 36.0 +/- 2.5 years, with a mean duration of 3.3 +/- 0.5 years until surgery was undertaken. The mean length of follow-up was 6.8 +/- 0.8 years. Operative procedures were associated with a 10.3% major morbidity rate and no mortality. Drug-free remission was achieved in 50.0% of the patients, and symptoms were absent or improved in 76.8% of the patients. Patients followed up long-term (>10 years) achieved the greatest remission rate (71.4%) and symptomatic improvement (85.7%). After thymectomy, the mean dosages of prednisone and Mestinon decreased by 69.3% and 58.8%, respectively. CONCLUSIONS: Extended thymectomy provides excellent overall symptom improvement, which is enhanced over time. This review provides a basis for long-term comparison with other less invasive and perhaps less extensive procedures.

Addition of glucagon to total parenteral nutrition (TPN) prevents hepatic steatosis in rats.

Hepatic steatosis is one of the two principal hepatic complications of total parenteral nutrition (TPN), the other being cholestasis. While the cause is uncertain, an excess of carbohydrate calories in rats leads to an elevated portal insulin/glucagon (I/G) molar ratio, periportal fatty infiltration, and increased total hepatic lipid content. Insulin causes fatty acid biosynthesis, whereas glucagon causes hepatic release and inhibition of fatty acid synthesis. Thus we attempted to add glucagon to lower the I/G to see if this would affect the degree of hepatic fatty infiltration by encouraging hepatic fat mobilization. Adult rats (n = 21) received internal jugular catheters; Group 1 (n = 7) was given saline solution (3 ml/h) and chow ad libitum; Group 2 (n = 7), 25% dextrose-base (D25W) TPN solution; Group 3 (n = 7), D25W TPN + 33 micrograms/100 gm/day glucagon. At 7 days portal and peripheral venous blood samples were drawn for insulin and glucagon radioimmunoassay and blood glucose determination; livers were removed for histologic study and lipid determination. Blood glucose did not differ in any group. Hepatic lipid and peripheral and portal venous I/G were increased and periportal fatty infiltration was extensive in Group 2, whereas hepatic lipid and I/G were decreased and periportal fatty infiltration was absent in glucagon-infused rats (Group 3). An abnormally high I/G ratio in portal blood elicited by high-glucose TPN may be responsible, at least in part, for hepatic steatosis. By increasing hepatic lipid export, addition of glucagon to TPN may play a major role in decreasing hepatic steatosis.

Laparoscopic splenectomy by the lateral approach: a safe and effective alternative to open splenectomy for hematologic diseases.

BACKGROUND: The purpose of this study was to compare the clinical outcomes and expense of laparoscopic splenectomy by the lateral approach with open splenectomy for the treatment of hematologic diseases. METHODS: Medical records of 20 matched patients undergoing open splenectomy and lateral approach laparoscopic splenectomy were retrospectively reviewed detailing perioperative course, clinical outcome, and hospital charges. RESULTS: Patients undergoing laparoscopic splenectomy (n = 10) experienced longer anesthesia (324 versus 176 minutes; p < 0.05) and operative times (261 versus 131 minutes; p < 0.05) than those undergoing open splenectomy (n = 10). No difference was noted in both intraoperative and postoperative packed red blood cells transfused. Laparoscopic splenectomy resulted in a shorter duration of nasogastric decompression (1.2 versus 2.6 days), more rapid resumption of normal oral intake (1.9 versus 4.4 days), and earlier hospital dismissal (3.0 versus 5.8 days). Although hospital charges were not significantly higher in the laparoscopic group ($17,071.00 versus $13,196.00; p > 0.05), operative charges were always significantly higher. CONCLUSIONS: When compared with open splenectomy, lateral approach laparoscopic splenectomy allows a more rapid return of normal gastrointestinal function and shorter hospital stay. The operative expense of laparoscopic splenectomy is significantly higher; however, the overall hospital expense is not. If costs can be decreased, the lateral approach laparoscopic splenectomy will be the preferred operative approach.

Management of myasthenia gravis by extended thymectomy with anterior mediastinal dissection.

BACKGROUND: Thymectomy has continued to gain acceptance as definitive treatment for myasthenia gravis. Because of the nature of thymic embryology with scattered rests throughout the anterior mediastinum, we advocate a transsternal thymectomy with extended anterior mediastinal dissection. METHODS: A series of 48 patients with myasthenia gravis treated by thymectomy between 1979 and 1991 were reviewed. RESULTS: The mean length of duration of disease from onset to operation was 48.7 +/- 11.3 months, and the mean length of follow-up was 51.6 +/- 6.5 months. The operation was associated with a 21% morbidity rate (4% major morbidity) with no deaths. Forty-five patients (94%) have improved, requiring decreased medication. The overall drug-free remission rate was 42%. Of the 20 patients in remission, three had thymomas and four had hyperplastic glands. All of the patients who achieved drug-free remission were classified as Osserman's I or II. CONCLUSIONS: An aggressive surgical approach to myasthenia gravis can result in a high percentage of overall improvements and drug-free remissions. The best results are achieved in patients with lower-stage disease. Therefore transsternal extended thymectomy for myasthenia gravis appears to be the procedure of choice and should be advocated as soon as the diagnosis is made and the patient stabilized.

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis.

BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.

Use of omeprazole in the management of giant duodenal ulcer: results of a prospective study.

BACKGROUND: Giant duodenal ulcer (GDU) is generally thought to require surgical intervention. Proton pump inhibitors have beneficial effects in peptic ulcer disease, but their role in GDU disease is unknown. We examined the use of omeprazole in GDU management. METHODS: Twenty-eight patients were diagnosed with GDU. One patient required immediate operative intervention. The remaining 27 were placed on omeprazole (40 mg daily). When ulcer healing was documented by endoscopy, the patients were placed on oral histamine-2 receptor antagonist therapy. RESULTS: Of the 28 study patients, 20 (71.4%) did not require operative intervention, and 8 (28.6%) required operation for ulcer complications. Of the 15 patients with adherent clot or a visible vessel at initial endoscopy, 7 (46.7%) required operative intervention, as compared with 1 (7.7%) of the 13 patients without a visible vessel or adherent clot. This difference was statistically significant (P < .05). Twenty-three patients underwent antral biopsy and/or enzyme-linked immunosorbent assay for Helicobacter pylori, and 9 (39.1%) had a positive result. CONCLUSIONS: Omeprazole is effective in the treatment of GDU disease. An adherent clot or a visible vessel at endoscopy indicates a higher likelihood of complications requiring operation. The relatively low H pylori infection rate, as compared with other peptic ulcer disease, may indicate a different pathophysiology in GDU.

The pull-through procedure: technical factors in influencing outcome, with emphasis on pouchitis.

BACKGROUND: The purpose of the study was to review those features that we believed to be critical to the successful performance of the ileal pouch-anal anastomosis, or pull-through, procedure, and specifically the complication of pouchitis. METHODS: The charts of 205 patients who successfully underwent ileal pouch-anal anastomosis procedure were reviewed. No follow-up was available in five patients; therefore, the basis of this report and its analysis was based on 200 consecutive procedures in which at least two of the three surgeons participated. Particular emphasis was placed on continence, particularly nighttime continence. The incidence of pouchitis, either a single episode or intermittent episodes, was surveyed. Particular attention was paid to the level of rectal mucosectomy and anastomosis at the top of the columns of Morgagni, thus retaining the transitional zone. RESULTS: Only 5% of patients were incontinent in the absence of pouchitis. Twenty-five patients (13%) wore a pad at night, but only nine (5%) wore a pad during the day. Of those patients with pouchitis, 6% (12) have had a single episode and 12% (23) were intermittently on medication. Therapy of pouchitis was usually carried out with ciprofloxacin 500 mg by mouth everyday or twice a day. CONCLUSIONS: Ileal pouch-anal anastomosis is an excellent procedure, provided technical details are adhered to. Satisfactory outcome with respect to nighttime continence can be achieved with rectal mucosectomy with minimal manipulation and retaining the transitional epithelium, performing the pouch anastomosis at the top of the columns of Morgagni. The incidence of pouchitis is disappointing but need not be inhibiting of either patients or carrying out this life-saving procedure in patients with ulcerative colitis and familial polyposis.

Differential expression of intestinal and splenic cytokines after parenteral nutrition.

OBJECTIVE: To determine the effect of parenteral nutrition (PN) on the expression of message for inflammatory cytokines in the spleen and different segments of the intestine. DESIGN: Randomized controlled trial. PARTICIPANTS: Eleven adult male Sprague-Dawley rats weighing 250 to 300 g. INTERVENTIONS: All rats underwent central venous cannulation and were randomized to two groups. Group 1 (n = 6) received saline solution infusion and chow ad libitum; group 2 (n = 5) received lipid-free PN with no oral feeding. After 7 days, the animals were killed and the spleens and segments of small and large intestine were removed. MAIN OUTCOME MEASURES: The expression of message for tumor necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6), and IL-1 in the spleen and intestine was determined using a semiquantitative reverse transcription polymerase reaction. Splenic macrophages were isolated and cultured for 24 hours with and without lipopolysaccharide. Production of TNF-alpha and IL-6 was determined by bioassay followed by enzyme-linked immunosorbent assay. RESULTS: After 7 days of infusion, messenger RNA (mRNA) expression for TNF-alpha, IL-1, and IL-6 was increased in the jejunum (P < .05), and TNF-alpha mRNA and IL-6 mRNA expression was decreased in the spleen (P < .01) of PN-fed animals when compared with saline/chow controls. In addition, TNF-alpha mRNA expression was increased in the cecum (P < .05), IL-1 mRNA expression was increased in the ileum (P < .05), and IL-6 mRNA expression was increased in the cecum (P < .05) and Peyer's patches (P < .007) in the PN-fed animals. Production of TNF-alpha and IL-6 by splenic macrophages was decreased following PN infusion in both lipopolysaccharide-treated and untreated cultures (P < .05). CONCLUSIONS: Infusion of lipid-free PN induces a differential mRNA expression for inflammatory cytokines in the spleen and intestine with an overall up-regulation of the expression of inflammatory cytokines in the intestine and a down-regulation in the spleen. These data provide evidence that the regulatory mechanisms for cytokine production are different in the intestine and the spleen. Further study is needed to elaborate the mechanism of this differential expression following lipid-free PN infusion.

Lipid-free total parenteral nutrition and macrophage function in rats.

Certain lipids are immunosuppressive when used for nutritional support, while other lipids and nutritional additives may enhance immunologic function. We hypothesized that total parenteral nutrition (TPN) may be immunosuppressive irrespective of lipids. Twenty-four rats underwent central vein catheterization and received either intravenous saline solution and oral chow or TPN alone. At 7 or 14 days, the animals were killed. Splenic and bone marrow macrophages were isolated and cultured in either M199 medium alone or were stimulated with Escherichia coli lipopolysaccharide. The supernatants were tested for prostaglandin E2 and C3. The splenic prostaglandin E2 levels were significantly higher in the TPN group following lipopolysaccharide stimulation at 7 days but not at 14 days. Administration of TPN to rats, even without lipids, may be immunosuppressive through the release of prostaglandin E2 from splenic macrophages following a septic challenge. This effect appears to be abolished after 14 days of TPN infusion.

Radioimmunoassay to determine postprandial changes in plasma neuropeptide Y levels in awake dogs.

A specific, precise and sensitive double-antibody radioimmunoassay for Neuropeptide Y (NPY) has been developed. There was no appreciable cross-reactivity with the structurally related peptides, peptide YY (PYY) and pancreatic polypeptide (PP). The minimum detectable plasma NPY level was 3 nM. Application of radioimmunoassay to canine models revealed that portal and systemic NPY levels increased significantly following a standard meal.

Management of giant duodenal ulcer.

Giant duodenal ulcer is a variant of peptic ulcer that is 2 cm in diameter or greater and essentially replaces the duodenal bulb. Diagnosis by upper gastrointestinal series is often missed, due to the large size of the ulcer, which causes it to look like a scarred duodenal bulb or duodenal diverticulum. This study reviews our experience with 32 patients who presented with giant duodenal ulcer between 1963 and 1982. Seventy-five percent of the patients were men between 30 and 81 years of age (mean age 59 years). Gastrointestinal hemorrhage was a presenting symptom in 75 percent of the patients and free perforation in 9 percent. Diagnosis was made by upper gastrointestinal series (24 patients), and endoscopy (11 patients), alone or in combination. Three patients were diagnosed at surgery and one at necropsy. Mean size of the ulcer was 3.5 cm in diameter, range 2 to 6 cm. Twenty-four patients were initially managed medically (mean length of treatment 41 months), with 2 deaths (hemorrhage) and 20 recurrences (83 percent). Twenty-seven operations were required in 25 patients. In 17 of the 25, medical treatment had failed. Seven of these patients required emergency surgery. Eight patients were managed primarily by surgery, of whom five presented emergently. There were three deaths in the surgical group after emergency surgery. In two of these patients, medical treatment had failed. There were no deaths among the elective surgery group. Twenty-five of the 27 operative procedures were definitive, acid-reducing operations (15 vagotomy and antrectomy and 10 vagotomy and drainage). Two patients underwent emergency exploration and oversewing of a giant perforated ulcer alone, and both patients required subsequent surgery because of symptoms. The results indicate that giant duodenal ulcer should be primarily surgically managed and that an acid-reducing procedure should be performed during primary surgery. These patients do very poorly with medical therapy, and the mortality rate is increased if emergency surgery is required for hemorrhage. Medical treatment alone is associated with a high morbidity (92 percent). Should operation be required, a definitive acid reduction operation is the procedure of choice.

Transduodenal sphincteroplasty and transampullary septotomy for primary sphincter of Oddi dysfunction.

We examined 29 patients without stone disease or pancreatic ductal ectasia who underwent transduodenal sphincteroplasty and transampullary septotomy for symptoms of biliary colic or pancreatitis. The combination of biliary symptoms and a fibrotic ampulla of Vater portends a favorable surgical outcome in virtually all such patients. Patients with pancreatitis did worse overall, perhaps due to the existence of unappreciated subclinical parenchymal disease not related to sphincter dysfunction. Although endoscopic retrograde cholangiography was sensitive in demonstrating abnormalities of the pancreaticobiliary system, its specificity as a predictor of good results was poor. It seems prudent to temper one's enthusiasm for sphincteroplasty in the patient with pancreatitis, whereas patients with biliary symptoms, the postcholecystectomy syndrome, or both will usually benefit significantly from this procedure.

Addition of lipid to total parenteral nutrition prevents hepatic steatosis in rats by lowering the portal venous insulin/glucagon ratio.

Hepatic steatosis in rats is associated with an infusion of excessive carbohydrate calories. Previous work from this laboratory suggested that this is associated with an elevated portal insulin/glucagon molar ratio (I/G) and is reversed by parenteral glucagon administration. Although hepatic steatosis is not related to essential fatty acid deficiency, addition of lipid to total parenteral nutrition (TPN) has been reported as being protective against the development of hepatic steatosis. Therefore, we propose that lipid may exert its salutary effect via an alteration of the I/G ratio. To test this hypothesis, adult rats (seven per group) received internal jugular catheters: group 1, saline (3 mL/h) plus chow ad libitum; group 2, 25% dextrose base TPN; group 3, 17% dextrose base TPN + 2.5% lipid; group 4, 25% dextrose base TPN + 2.5% lipid. At 7 days, portal and peripheral venous blood was drawn for insulin and glucagon radioimmunoassay and liver function tests; livers were removed for histology and lipid content determination. Panlobular vacuolization, on histology, and lipid content were excessive in group 2, and the portal I/G was increased because of elevated portal insulin. In contrast, portal venous insulin and I/G did not increase, and hepatic steatosis was absent in groups 3 and 4. The results suggest that the addition of lipid to TPN in rats decreases the portal insulin level and lowers the portal I/G, and thereby prevents hepatic steatosis.

Effect of enteral feeding on hepatic steatosis induced by total parenteral nutrition.

This study was designed to test the hypothesis that deprivation of enteral feeding contributes to the development of total parenteral nutrition (TPN)-induced hepatic dysfunction and that alterations of gut hormones are involved in its pathogenesis. Twenty-one adult Sprague-Dawley rats were randomized into three groups: group 1 received chow feeding ad libitum (288 kcal/kg per day); group 2 received dextrose-based TPN (320 +/- 5 kcal/kg per day); and group 3 received TPN (315 +/- 15 kcal/kg per day) plus chow feeding ad libitum (74 +/- 1 kcal/kg per day). After 7 days, portal blood was assayed for insulin, glucagon, gastrin, peptide YY, secretin, and vasoactive intestinal polypeptide; systemic blood for determination of liver function tests and serum lipid analysis. Liver biopsies were taken for histology and staining for fat, and the remainder of the livers were removed for tissue lipid analysis. TPN induced striking hepatic steatosis with prominent histologic changes and accumulation of lipids, mainly triglycerides and cholesterol ester, in the liver. Addition of enteral feeding to TPN-treated animals significantly reduced the histologic changes as well as lipid accumulation in the liver. Portal plasma levels of gastrin and peptide YY were reduced in animals maintained on TPN alone, with no change in secretin or vasoactive intestinal polypeptide levels. Enteral supplementation increased peptide YY levels in group 3, but not to normal, while gastrin secretion remained decreased. The serum triglyceride levels were decreased in both TPN groups; no differences were detected in the serum cholesterol levels or liver function tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Addition of glucagon to lipid-free total parenteral nutrition reduces production of prostaglandin E2 by stimulated splenic macrophages.

Sepsis is a major complication of total parenteral nutrition (TPN). Impaired immunity has been suggested as being responsible for TPN-related sepsis, but it is unknown how the immune system is affected by TPN. We recently found that administration of lipid-free TPN resulted in an increase in prostaglandin E2 (PGE2) release by stimulated splenic macrophages. This observation suggested that TPN may impair immunity through the prominent immunosuppressive effects of PGE2. In the present study, we tested the hypothesis that addition of glucagon to TPN solution may protect against the immunosuppressive effect of TPN by modifying PGE2 secretion. Adult, male Sprague-Dawley rats (n = 18) underwent jugular vein cannulation: group 1 (n = 7) received intravenous saline and chow ad libitum; group 2 (n = 6) received TPN (80 mL/24 h); and group 3 (n = 5) received TPN (80 mL/24 h) plus glucagon (100 micrograms/24 h). After 10 days, spleens were removed and splenic macrophages were isolated and cultured for 24 h in plain M199 medium (nonstimulated) or in medium containing Escherichia coli lipopolysaccharide (5 micrograms/mL) (stimulated). PGE2 release was determined by enzyme-linked immunosorbent assay. There were no differences in PGE2 release between the groups of nonstimulated cells, but when stimulated with lipopolysaccharide, the macrophages from the TPN rats (group 2) released more PGE2 (81.68 +/- 25.99 ng/2.5 x 10(6) cells) than the control group (16.04 +/- 3.26 ng/2.5 x 10(6) cells). The release of PGE2 was normalized in the TPN animals treated with glucagon (15.71 +/- 3.33 ng/2.5 x 10(6) cells). This difference was significant, with p < .05 by Tukey's test after analysis of variance.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of endoscopic and laparoscopic training practices in surgical residency programs.

BACKGROUND: The ability to adequately train surgical residents in flexible and rigid endoscopy has become a difficult challenge for program directors. The American Board of Surgery requires residents to be familiar in these procedures but the methods for training have not been well defined nor formally outlined. The goals of this study were to evaluate resident experience in flexible endoscopy and laparoscopy and to investigate the specific methods used by surgical programs for the training of residents. METHODS: A survey was created by the authors and the Resident Education Committee of the Society of American Gastrointestinal Endoscopic Surgeons and was mailed to all program directors in general surgery in the United States based on the data base of the Association of Program Directors in Surgery (APDS). RESULTS: Ninety-six of 283 surveys were returned (33.9%). The surgeon played a greater role in flexible endoscopic training in 1998 as compared to 1988 (p=0.002). When analyzed by type of institution, community programs showed a similar trend but this was not seen in academic programs. Formal endoscopy rotations existed in 60% of programs but flexible endoscopy (5.2%) and laparoscopy (10.4%) fellowships were uncommon. No significant differences in the number of advanced laparoscopic procedures performed were found between academic and community programs. The presence of a laparoscopic fellow did not significantly decrease the number of cases per resident. CONCLUSION: According to our survey, surgery departments have a greater impact on flexible endoscopic training in 1998 than in 1988. This is likely due to the creation of formal endoscopy rotations and the hiring of fellowship trained endoscopic instructors. In addition, community programs have been able to provide adequate experience in both basic and advanced laparoscopic techniques as compared to academic programs. As with flexible endoscopy, however, formal laparoscopic rotations may be necessary to allow more intensive experience for each resident.