Primary non-complicated midline ventral hernia: overview of approaches and controversies.

Umbilical hernias and epigastric hernias are some of the most common hernias in the world. Umbilical and epigastric hernia defects can range from small (<1 cm) to very large/complex hernias, and treatment options should be tailored to the clinical situation. Repair techniques include open, laparoscopic, and robotics options, each with advantages and disadvantages. A mesh-based repair is indicated in most cases due to having fewer associated recurrences. Overall outcomes are favorable following umbilical and epigastric hernia repairs; however, some patients have chronic complaints mostly related to recurrences. This report is an overview of available techniques for repair of umbilical and epigastric hernias. It also discusses ongoing controversies related to umbilical and epigastric hernia repairs, the limitations of available literature, and the need for future research.

Ventral hernia repair in patients with abdominal loss of domain: an observational study of one institution's experience.

PURPOSE: Abdominal wall hernias are a common problem. The success of abdominal wall reconstruction decreases with increasing hernia size. This study summarizes the outcomes of one surgeon's experience using a "sandwich" technique for hernia repair in patients with loss of abdominal domain. METHODS: We reviewed our ventral hernia repair (VHR) experience from 2008 to 2015 among patients with loss of domain, as defined by a hernia defect greater than 300 cm2. The percent of herniation through the defect, defined by a hernia sac-to-abdominal cavity volume ratio, was measured on preoperative CT scans by four independent reviewers and averaged. Outcomes were compared among those with giant ventral hernias (hernia sac-to-abdominal cavity volume >30%) and those with smaller defect ratios. RESULTS: Over the study period, 21 patients underwent VHR. In 17 patients (81%), a "sandwich" technique was utilized. Ten patients had hernia sac-to-abdominal cavity defects less than 30%, and 11 had defects greater than 30%. Preoperative characteristics were similar in both groups with the exception of a higher ASA score in those with giant ventral hernias and more Ventral Hernia Working Group Grade 3 hernias in those without giant ventral hernias. Postoperative outcomes were similar in both groups. There were no mortalities. There were two recurrences (18%) in the giant VHR group and none in the smaller defect group (p = 0.16). Surgical site occurrences were noted in 48% of patients and did not differ between giant and non-giant VHR groups (50 vs 45%, p = 0.84). Average postoperative length of stay was significantly longer in the giant VHR group (31 vs. 17 days, p = 0.03). CONCLUSIONS: Our results suggest that the "sandwich" technique for VHR is a safe and durable method to restore abdominal wall integrity in those with LOD, even in patients with giant ventral hernias.

Creation of a novel risk score for surgical site infection and occurrence after ventral hernia repair.

BACKGROUND: Complex ventral hernia repair (VHR) is a common surgical operation but carries a risk of complications from surgical site infections (SSI) and occurrences (SSO). We aimed to create a predictive risk score to identify patients at increased risk for SSO or SSI within 30 days of surgery. METHODS: Data were prospectively collected on all patients undergoing VHR between January 2008 and February 2015 by a single surgeon. Multivariable logistic regression was used to identify independent factors predictive of SSO and SSI. Significant predictors of SSO and SSI were assigned point values based on their odds ratios to create a novel risk score, the Hopkins ventral hernia repair SSO/SSI risk score; predicted and actual rates of outcomes were then compared using weighted regression. RESULTS: During the study period, 362 patients underwent open VHR. Thirty-day SSO and SSI occurred in 18.5 and 10% of patients, respectively. After risk adjustment, ASA class ≥3 (1 point), operative time ≥4 h (2 points), and the absence of a postoperative wound vacuum dressing (1 point) were predictive of 30-day SSO. Predicted risk of SSO utilizing this scoring system was 9.7, 19.4, 29.1, and 38.8% for 1, 2, 3, and 4 points (AUC = 0.73). For SSI, operative time ≥4 h (1 point) and the lack of a wound vacuum dressing (1 point) were predictive. Predicted risk of SSI based on this scoring system was 12.5% for 1 point and 25% for 2 points (AUC = 0.71). Actual vs. predicted rates of SSO and SSI correlated strongly for risk model with a coefficient of determination (R 2) of 0.92 and 0.91, respectively. CONCLUSION: The novel Hopkins ventral hernia repair risk score accurately predicts risk of SSO and SSI after complex VHR. Further studies using a prospective randomized controlled trial will be needed to further validate our findings.

Effect of hernia size on operative repair and post-operative outcomes after open ventral hernia repair.

BACKGROUND: Ventral hernia repair (VHR) is a commonly performed operation, but analysis of patient outcomes based upon hernia size is lacking. We sought to identify differences in operative repair and post-operative morbidity and mortality after open VHR based on hernia defect size. METHODS: Patient and operative data were retrospectively reviewed on all patients undergoing open incisional VHR between January 2008 and February 2015 by a single surgeon at the Johns Hopkins Hospital. Patient variables were described by means for continuous variables and percentages for discrete variables, with differences between groups calculated by Chi-squared analysis. RESULTS: During the study period, 228 patients underwent open VHR during which intraoperative defect size was measured. Patients were split into four groups based upon defect size: less than 200 cm2, 200-300 cm2, 301-400 cm2, and over 400 cm2. Patients with large defects were more likely to present with a recurrent hernia (P = 0.007) and trended towards a history of wound infections (P = 0.07). Operative time was significantly longer as defect size increased (P < 0.001). Component separation was most frequently used in patients with defects 200-300 cm2 in size (P = 0.001), in whom primary closure was most likely to occur. While mesh was used in almost all patients, the specific location (overlay only, underlay only, or overlay with underlay) depended on hernia size (P < 0.001). Mean length of stay increased with defect size (P < 0.001). Larger defect size was associated with increased 30-day morbidity (P = 0.03) but not readmission (P = 0.53), recurrence (P = 0.99), or mortality (P = 0.99). CONCLUSION: Hernia defect size affects operative time and surgical technique for repair of a ventral hernia. Larger defect size is associated with increased post-operative morbidity and length of stay but not readmission, recurrence, or mortality. Hernia size greater than 400 cm2 should not be a limitation to operative repair.

A validated, risk assessment tool for predicting readmission after open ventral hernia repair.

BACKGROUND/PURPOSE: To present a validated model that reliably predicts unplanned readmission after open ventral hernia repair (open-VHR). STUDY DESIGN: A total of 17,789 open-VHR patients were identified using the 2011-2012 ACS-NSQIP databases. This cohort was subdivided into 70 and 30% random testing and validation samples, respectively. Thirty-day unplanned readmission was defined as unexpected readmission for a postoperative occurrence related to the open-VHR procedure. Independent predictors of 30-day unplanned readmission were identified using multivariable logistic regression on the testing sample (n = 12,452 patients). Subsequently, the predictors were weighted according to ß-coefficients to generate an integer-based Clinical Risk Score (CRS) predictive of readmission, which was validated using receiver operating characteristics (ROC) analysis of the validation sample (n = 5337 patients). RESULTS: The rate of 30-day unplanned readmission was 4.7%. Independent risk factors included inpatient status at time of open-VHR, operation time, enterolysis, underweight, diabetes, preoperative anemia, length of stay, chronic obstructive pulmonary disease, history of bleeding disorders, hernia with gangrene, and panniculectomy (all P < 0.05). ROC analysis of the validation cohort rendered an area under the curve of 0.71, which demonstrates the accuracy of this prediction model. Predicted incidence within each 5 risk strata was statistically similar to the observed incidence in the validation sample (P = 0.18), further highlighting the accuracy of this model. CONCLUSION: We present a validated risk stratification tool for unplanned readmissions following open-VHR. Future studies should determine if implementation of our CRS optimizes safety and reduces readmission rates in open-VHR patients.

The effect of TISSEEL fibrin sealant on seroma formation following complex abdominal wall hernia repair: a single institutional review and derived cost analysis.

PURPOSE: The authors evaluated the ability of a fibrin sealant (TISSEEL™: Baxter Healthcare Corp, Deerfield, IL, USA) to reduce the incidence of post-operative seroma following abdominal wall hernia repair. METHODS: We performed a 4-year retrospective review of patients undergoing abdominal wall hernia repair, with and without TISSEEL, by a single surgeon (FEE) at The Johns Hopkins Hospital. Demographics, surgical risk factors, operative data and 30-day outcomes, including wound complications and related interventions, were compared. The quantity and cost of Tisseel per case was reviewed. RESULTS: A total of 250 patients were evaluated: 127 in the TISSEEL group and 123 in the non-TISSEEL control group. The average age for both groups was 56.6 years (P = 0.97). The majority of patients were female (TISSEEL 52.8%, non-TISSEEL 56.1%, P = 0.59) and ASA Class III (TISSEEL 56.7%, non-TISSEEL 58.5%, P = 0.40). There was no difference in the average defect size for both groups (TISSEEL 217 ± 187.6 cm(2), non-TISSEEL 161.3 ± 141.5 cm(2), P = 0.36). Surgical site occurrences occurred in 18.1% of the TISSEEL and 13% of the non-TISSEEL group (P = 0.27). There was a trend towards an increased incidence of seroma in the TISSEEL group (TISSEEL 11%, non-TISSEEL 4.9%, P = 0.07). A total of $124,472.50 was spent on TISSEEL, at an average cost of $995.78 per case. CONCLUSIONS: In the largest study to date, TISSEEL™ application offered no advantage for the reduction of post-operative seroma formation following complex abdominal hernia repair. Moreover, the use of this sealant was associated with significant costs.

Phase I trial of radiation dose escalation with concurrent weekly full-dose gemcitabine in patients with advanced pancreatic cancer.

PURPOSE: The primary objective of this phase I trial was to determine the maximum-tolerated dose of radiation that could be delivered to the primary tumor concurrent with full-dose gemcitabine in patients with advanced pancreatic cancer. PATIENTS AND METHODS: Thirty seven patients with unresectable (n = 34) or incompletely resected pancreatic cancer (n = 3) were treated. Gemcitabine was administered as a 30-minute intravenous infusion at a dose of 1,000 mg/m(2) on days 1, 8, and 15 of a 28-day cycle. Radiation therapy was initiated on day 1 and directed at the primary tumor alone, without prophylactic nodal coverage. The starting radiation dose was 24 Gy in 1.6-Gy fractions. Escalation was achieved by increasing the fraction size in increments of 0.2 Gy, keeping the duration of radiation constant at 3 weeks. A second cycle of gemcitabine alone was intended after a 1-week rest. RESULTS: Two of six assessable patients experienced dose-limiting toxicity at the final planned dose level of the trial (42 Gy in 2.8-Gy fractions), one with grade 4 vomiting and one with gastric/duodenal ulceration. Two additional patients at this dose level experienced late gastrointestinal toxicity that required surgical management. CONCLUSION: The final dose investigated (42 Gy) is not recommended for further study considering the occurrence of both acute and late toxicity. However, a phase II trial of this novel gemcitabine-based chemoradiotherapy approach, at a radiation dose of 36 Gy in 2.4-Gy fractions, is recommended on the basis of tolerance, patterns of failure, and survival data.

Burnout among American surgeons.

BACKGROUND: The long-term consequences of stress on the surgeon are unknown. One manifestation of stress is burnout. The purpose of this study was to measure the prevalence of burnout in actively practicing American surgeons. METHODS: The Maslach Burnout Inventory and a questionnaire of our own design were sent to 1706 graduates of various University of Michigan surgical residencies (1222) and members of the Midwest Surgical Association (484). The response rate was 44%. Responses from 582 actively practicing surgeons were the sample used for analysis. RESULTS: Thirty-two percent of actively practicing surgeons showed "high" levels of emotional exhaustion, 13% showed "high" levels of depersonalization, and 4% showed evidence for low personal accomplishment. Younger surgeons were more susceptible to burnout (r = -0.28, P <.01). Burnout was not related to caseload, practice setting, or percent of patients insured by a health maintenance organization. Important etiologic factors were a sense that work was "overwhelming" (r = 0.61, P <.01), a perceived imbalance between career, family, and personal growth (r = -0.56), P <.01), perceptions that career was unrewarding (r = -0.42, P <.01), and lack of autonomy or decision involvement (r = -0.39, P <.01). A strong association was noted between burnout elements and a desire to retire early (r = 0.50, P <.01). CONCLUSIONS: Burnout is an important problem for actively practicing American surgeons. These data could be used to modify existing surgical training curricula or as an aid to surgical leadership when negotiating about the surgical work environment.

Doctor-patient communication in surgery: attitudes and expectations of general surgery patients about the involvement and education of surgical residents.

BACKGROUND: Education is a major function of academic medical centers. At these teaching institutions residents provide a substantial amount of care on medical and surgical services. The attitudes of patients about the training of surgical residents and the impact of residents on patients' perceptions of care in a surgical setting are unknown. STUDY DESIGN: Patients admitted to the gastrointestinal surgery service completed a 30-item survey designed for this study. Patients included in the study underwent operations and had a postoperative inpatient hospital stay. We analyzed patients' answers to determine frequency and correlations among answers. RESULTS: Two hundred patients participated in the study during a 7-month period between July 1999 and January 2000. A majority of patients were comfortable having residents involved in their care (86%) and felt it was important to help educate future surgeons (91%). Most did not feel inconvenienced by being at a teaching hospital (71%) and felt they received extra attention there (74%). Patients were more willing to participate in resident education if they expected to have several physicians involved in their care, felt that they received extra attention, or if the teaching atmosphere did not inconvenience them. Despite the stated willingness of patients to help with surgical resident education, 32% answered that they would not want residents doing any of their operation. CONCLUSIONS: Surgical resident education is well received and considered important by patients. Patient orientation to the resident education process is vital to patients' perceptions of care and may render patients more willing to participate in educational activities.

Hereditary chronic pancreatitis: implications for surgical treatment and follow-up.

Hereditary pancreatitis is an uncommon cause of chronic pancreatitis in Western society. It should be suspected when chronic pancreatitis presents in young adults. The diagnosis is made when chronic pancreatitis is present in several members of the same family who are determined not to have other risk factors for chronic pancreatitis. Molecular research focusing on mutations in the trypsinogen gene has uncovered the genetic defects associated with hereditary pancreatitis, and this knowledge has suggested the possible pathophysiologic mechanism of this disease. Because patients with hereditary pancreatitis develop their disease early in life they are very likely to require treatment for complications. As in patients with chronic pancreatitis of other etiologies those with hereditary pancreatitis should be treated medically for acute exacerbations. When complications occur or when the disease causes intractable pain surgery is recommended. Surgical therapy is tailored to the patient's pancreatic anatomy based on endoscopic retrograde cholangiopancreatography or CT scan. The two patients described in this report underwent successful longitudinal pancreaticojejunostomy (Puestow procedure) with good results. Finally it has been shown that patients with hereditary pancreatitis are at increased risk for developing pancreatic adenocarcinoma. Although not widely used pancreatic cancer screening programs have been suggested for surveillance of these patients.

Safety and long-term durability of completion gastrectomy in 81 patients with postsurgical gastroparesis syndrome.

Postsurgical gastroparesis syndrome (PGS) is characterized by postcibal nausea and vomiting and is associated with functional gastric dysmotility. Patients frequently present with marked weight loss and malnutrition requiring hospitalization and prolonged parenteral nutrition. Typically, these patients fail to respond to prokinetic agents. Gastric reoperations are frequent and usually unsuccessful. Near-completion gastrectomy (NCG) has proved useful in small series of patients, but long-term follow-up has been lacking. The purpose of this study is to assess the safety and durability of NCG in a large group of patients with PGS. Eighty-one patients with documented PGS who failed to respond to prokinetic drug therapy were treated with NCG over an 11-year period. NCG was standardized with a 55-cm Roux-en-Y reconstruction. Patients were evaluated by a retrospective chart review and a prospective phone interview that compared pre- and postoperative health status based on a standardized severity of symptoms score. There were no operative deaths or complications related to the anastomosis. Average patient follow-up was 56.1 months (range, 2-142 months). Fifteen patients died of unrelated causes, and 14 patients were lost to follow-up. The remaining 52 patients showed a significant overall decrease in severity of symptoms score largely due to reduction in gastrointestinal symptoms and to a smaller but significant reduction in systemic symptoms. Nearly 80 per cent of patients reported long-term relief of symptoms. NCG is the procedure of choice for carefully selected patients with documented. Low morbidity and durable results can be anticipated in the majority of patients.

Dual-phase helical CT of nonfunctioning islet cell tumors.

PURPOSE: The aim of this study was to evaluate the utility of dual-phase imaging in the assessment of nonfunctioning islet cell tumors (NFITs). METHOD: Six patients with histologically and biochemically proven NFIT were evaluated by arterial and portal venous dual-phase helical CT. Scan delay was 20 s for the arterial phase and 70 s for the portal phase. Each phase was assessed by consensus reading and specifically evaluated for tumor conspicuity, hepatic metastases, vascular encasement by tumor, and presence of lymphadenopathy. RESULTS: Overall, tumor conspicuity was greater in the arterial phase (5/6) than in the portal venous phase (1/6) with a mean tumor/normal pancreas attenuation difference of 31.8 HU in the arterial phase compared with 19.2 HU in the portal venous phase. The arterial phase detected a total of 17 liver metastases compared with 9 seen in the portal phase. Lymph node enlargement was noted in three patients, which, although visible in both phases, was more easily discernible in the arterial phase. Venous encasement by tumor was better evaluated on the delayed portal venous phase than the arterial phase. CONCLUSION: Dual-phase helical CT scanning leads to improvement in the detection and staging of NFITs.

Dual-phase helical CT of nonfunctioning islet cell tumors.

PURPOSE: The aim of this study was to evaluate the utility of dual-phase imaging in the assessment of nonfunctioning islet cell tumors (NFITs). METHOD: Six patients with histologically and biochemically proven NFIT were evaluated by arterial and portal venous dual-phase helical CT. Scan delay was 20 s for the arterial phase and 70 s for the portal phase. Each phase was assessed by consensus reading and specifically evaluated for tumor conspicuity, hepatic metastases, vascular encasement by tumor, and presence of lymphadenopathy. RESULTS: Overall, tumor conspicuity was greater in the arterial phase (5/6) than in the portal venous phase (1/6) with a mean tumor/normal pancreas attenuation difference of 31.8 HU in the arterial phase compared with 19.2 HU in the portal venous phase. The arterial phase detected a total of 17 liver metastases compared with 9 seen in the portal phase. Lymph node enlargement was noted in three patients, which, although visible in both phases, was more easily discernible in the arterial phase. Venous encasement by tumor was better evaluated on the delayed portal venous phase than the arterial phase. CONCLUSION: Dual-phase helical CT scanning leads to improvement in the detection and staging of NFITs.

Treatment of cirrhotic rats with epidermal growth factor and insulin accelerates liver DNA synthesis after partial hepatectomy.

Prevention of postoperative hepatic failure is important after hepatic resection. In patients with cirrhosis, impaired liver function and regenerative capacity after major hepatic resection are associated with increased morbidity and mortality. In this study, a combination of epidermal growth factor (EGF) and insulin were used as hepatotrophic factors in an attempt to stimulate DNA synthesis after 70% hepatectomy (HTX). Regenerative capacity was evaluated in normal and cirrhotic rat liver by measuring DNA synthesis in vivo. Micronodular liver cirrhosis was established by the simultaneous oral administration of CCl4 and phenobarbital. Epidermal growth factor plus insulin was injected subcutaneously immediately after and 12 h after HTX or sham operation was performed. Rats were killed 24 h after the operation and liver regeneration was estimated by [3H]-thymidine incorporation into DNA as well as an autoradiographic nuclear labelling index. Hepatectomy increased [3H]-thymidine incorporation significantly in both normal and cirrhotic rats. In cirrhotic rats, [3H]-thymidine incorporation after HTX was significantly lower than in normal rats and administration of a combination of EGF and insulin after HTX enhanced [3H]-thymidine incorporation. In conclusion, DNA synthesis 24 h after HTX is decreased in cirrhotic rats compared with normal rats and EGF supplementation with insulin accelerates DNA synthesis in hepatectomized cirrhotic rats. The data suggest that administration of combinations of exogenous hepatotrophic factors may play a useful role in the treatment of cirrhotic patients undergoing major hepatic resection.

Multimodality staging optimizes resectability in patients with pancreatic and ampullary cancer.

Few patients with pancreatic cancer have resectable disease at the time of diagnosis, and a variety of nonsurgical techniques are available to provide effective palliation of jaundice and pain. Accurate preoperative staging is essential to identify patients with unresectable disease, thereby minimizing unnecessary surgery. Currently used diagnostic tests include contrast-enhanced computerized tomography (CT), visceral angiography, endoscopic ultrasound, and laparoscopy, but their utility remains controversial. To evaluate the accuracy of these various diagnostic tests, 30 consecutive patients with histologically proven pancreatic or ampullary adenocarcinoma treated between 1992 and 1996 were evaluated. All 30 patients had contrast-enhanced CT and laparoscopy, 22 patients (73%) had visceral angiography, and 16 patients (53%) had endoscopic ultrasound. Individual and combined predictive values of resectability and unresectability as well as the sensitivities and specificities were determined for all diagnostic tests and compared with intraoperative findings. When CT, visceral angiography, and laparoscopy were combined, the predictive values of resectability and unresectability were 75 and 90 per cent, respectively, with a sensitivity of 75 per cent and a specificity of 90 per cent. Therefore, the combined use of selected diagnostic tests proved more effective than any single diagnostic test for accurately staging patients with pancreatic head and ampullary cancers and should be considered to minimize unnecessary surgery.

Surgery for primary and metastatic colorectal cancer.

Carcinoma of the colon and rectum currently ranks as the second leading cause of death from cancer in the United States. Surgery remains the cornerstone of treatment for colorectal cancer but has inherent limitations imposed by the biology and stage of the tumor and its location. Ultimately, 50% of patients who undergo curative resection develop local, regional, or widespread recurrence. These statistics have remained relatively constant over several decades despite improved methods of early diagnosis and surgical treatment but may change as new multimodality treatment regimens are developed and clinically evaluated. This article summarizes the surgical management of colorectal cancer and discusses issues pertaining to postoperative surveillance and the diagnosis and management of local or widespread cancer recurrence.

The changing role of surgery for sclerosing cholangitis.

Primary sclerosing cholangitis is a chronic cholestatic disease that may ultimately progress to hepatic parenchymal dysfunction and death from premature liver failure. Symptomatic patients should undergo radiological evaluation to exclude secondary causes of cholangitis and to evaluate the extent and location of biliary ductal disease. A percutaneous liver biopsy is advisable in any patient with clinical or biochemical evidence of cirrhosis. Patients with diffuse ductal involvement should initially receive medical treatment, preferably in a center conducting prospective clinical trials. Liver transplantation should be considered the initial procedure in primary sclerosing cholangitis patients with diffuse ductal involvement, complications of cirrhosis or deteriorating liver function. Nontransplant procedures should be restricted to symptomatic patients with a dominant extrahepatic stricture. In properly selected patients, effective and durable palliation of symptoms can be anticipated with biliary enteric drainage. Many currently available techniques obviate the need for longterm transanastomotic stenting, thus minimizing the risk of recurrent cholangitis and the need for repeated tube changes. These patients may also be candidates for percutaneous or endoscopic balloon cholangioplasty. Liver transplantation should also be considered in patients with a dominant stricture and histologic evidence of biliary cirrhosis or hepatic deterioration following a nontransplant procedure.

Preferential suppression of insulin-stimulated proliferation of cultured hepatocytes by somatostatin: evidence for receptor-mediated growth regulation.

The role of somatostatin (SS-14) in the regulation of rat liver regeneration was examined by using thymidine incorporation into hepatocyte DNA labeled with tritiated thymidine, a nuclear-labeling index, and the binding of 125I-tyr11-SS-14 to hepatocytes isolated at various times after partial hepatectomy. The data demonstrated no suppressive effect of SS-14 on insulin and glucagon-stimulated thymidine incorporation into hepatocyte DNA as early as 2 h after partial hepatectomy. These data were substantiated by a nuclear labeling index studies. At 2 h, 125I-tyr11-SS-14 binding to its specific sites on isolated hepatocytes was undetectable. There was a time-dependent increase in binding of 125I-tyr11-SS-14 to hepatocytes obtained at various times after partial hepatectomy. There was a significant decrease in the number of binding sites after partial hepatectomy as determined by Scatchard analysis. The data were supported by autoradiography analysis of affinity labeled 125I-tyr11-SS-14-binding protein complex followed by SDS-PAGE. SS-14 also inhibited intracellular cAMP in hepatocytes obtained at 18 h after hepatectomy. The data are consistent with the hypothesis that SS-14 participates via its own receptor in the regulation of the liver regeneration.

Are traditional prognostic criteria useful in pancreatic abscess?

Pancreatic abscess remains a potentially lethal disease. Efforts to relate outcome to the severity of associated pancreatitis or the type of surgical drainage employed have yielded conflicting results. This study was designed to test the validity of traditional prognostic criteria in the clinical setting of pancreatic abscess and to determine whether the technique of surgical drainage employed correlated with survival. The records of 40 consecutive patients with pancreatic abscess were reviewed. In each case the diagnosis was confirmed by operation. Prognostic factors analyzed included number of Ranson criteria, etiology, type, and number of microorganisms isolated, extent of abscess, time to diagnosis and operation, and technique of surgical drainage. Of the 11 Ranson criteria evaluated, only an elevation in blood urea nitrogen > 5 mg/dl correlated with decreased survival (p < 0.001). Polymicrobial abscesses (three or more organisms) resulted in a higher mortality than abscesses where fewer than three organisms were isolated (45.4 vs 13.8%; p < 0.05). Intraperitoneal extension of the abscess was associated with an increased mortality rate compared to those confined to the retroperitoneum (57.1 vs 15.2%; p < 0.01). In patients requiring unplanned reexploration, mortality was significantly increased (42.9 vs 11.5%; p < 0.05). The technique of surgical drainage employed (open versus closed) did not influence overall mortality (23.5 vs 21.7%; p = NS). Extent of disease at operation, polymicrobial abscess, reexploration for persistent or recurrent disease, and deterioration in renal function were all predictive of increased mortality in cases of pancreatic abscess.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired phorbol ester-induced hepatocyte proliferation in cirrhosis.

Cirrhotic livers are considered to regenerate less actively than normal livers after hepatic resection. Little is known about the mechanisms responsible for impaired capacity of regeneration in cirrhotic liver. In the present study, we investigated the effect of phorbol ester on hepatocyte proliferation in healthy and cirrhotic hepatocytes, using one of the phorbol esters, 12-O-tetradecanoyl-phorbol-13-acetate (TPA), which has a direct effect on activation of protein kinase C (PKC). Cirrhosis was established by the administration of carbon tetrachloride and phenobarbital to rats. Healthy and cirrhotic hepatocytes were isolated from Wistar male rats by a two-step collagenase perfusion technique. DNA synthesis was estimated by [3H]thymidine incorporation into DNA and by autoradiographic nuclear labeling index. [3H]Thymidine incorporation was measured 24 hr after hepatocytes were stimulated by appropriate reagents. TPA (50 nM) stimulated [3H]thymidine incorporation in healthy hepatocytes (control vs TPA, 991 +/- 247 vs 2569 +/- 766 mean +/- SEM cpm/microgram DNA; P < 0.05), whereas TPA (50 nM) failed to stimulate in cirrhotic hepatocytes (control vs TPA, 1144 +/- 184 vs 1304 +/- 187 cpm/microgram DNA; NS). Staurosporine, a specific PKC inhibitor, suppressed [3H]thymidine incorporation in TPA-stimulated healthy hepatocytes (806 +/- 263 cpm/microgram DNA; P < 0.05); however, it had no effect on cirrhotic hepatocytes (1295 +/- 180 cpm/microgram DNA; NS). An autoradiographic nuclear labeling index exhibited the same results with [3H]thymidine incorporation. We conclude that TPA stimulates hepatocyte proliferation in healthy rat hepatocytes but has no effect on cirrhotic hepatocytes.