Do Drains Contribute to Pancreatic Fistulae? Analysis of over 5000 Pancreatectomy Patients.

INTRODUCTION: Conflicting evidence exists from randomized controlled trials supporting both increased complications/fistulae and improved outcomes with drain placement after pancreatectomy. The objective was to determine drain practice patterns in the USA, and to identify if drain placement was associated with fistula formation. METHODS: Demographic, perioperative, and patient outcome data were captured from the most recent annual NSQIP pancreatic demonstration project database, including components of the fistula risk score. Significant variables in univariate analysis were entered into adjusted logistic regression models. RESULTS: Of 5013 pancreatectomy patients, 4343 (87%) underwent drain placement and 18% of patients experienced a pancreatic fistula. When controlled for other factors, drain placement was associated with ducts < 3 mm, soft glands, and blood transfusion within 72 h of surgery. Age, obesity, neoadjuvant radiation, preoperative INR level, and malignant histology lost significance in the adjusted model. Drained patients experienced higher readmission rates (17 vs. 14%; p < 0.05) and increased (20 vs. 8%; p < 0.01) pancreatic fistulae. Fistula was associated with obesity, no neoadjuvant chemotherapy, drain placement, < 3 mm duct diameter, soft gland, and longer operative times. Drain placement remained independently associated with fistula after both distal pancreatectomy (OR = 2.84 (1.70, 4.75); p < 0.01) and pancreatoduodenectomy (OR = 2.29 (1.28, 4.11); p < 0.01). CONCLUSIONS: Despite randomized controlled clinical trial data supporting no drain placement, drains are currently placed in the vast majority (87%) of pancreatectomy patients from > 100 institutions in the USA, particularly those with soft glands, small ducts, and perioperative blood transfusions. When these factors are controlled for, drain placement remains independently associated with fistulae after both distal and proximal pancreatectomy.

HIV-1 Tat protein directly induces mitochondrial membrane permeabilization and inactivates cytochrome c oxidase.

The Trans-activator protein (Tat) of human immunodeficiency virus (HIV) is a pleiotropic protein involved in different aspects of AIDS pathogenesis. As a number of viral proteins Tat is suspected to disturb mitochondrial function. We prepared pure synthetic full-length Tat by native chemical ligation (NCL), and Tat peptides, to evaluate their direct effects on isolated mitochondria. Submicromolar doses of synthetic Tat cause a rapid dissipation of the mitochondrial transmembrane potential (ΔΨ(m)) as well as cytochrome c release in mitochondria isolated from mouse liver, heart, and brain. Accordingly, Tat decreases substrate oxidation by mitochondria isolated from these tissues, with oxygen uptake being initially restored by adding cytochrome c. The anion-channel inhibitor 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS) protects isolated mitochondria against Tat-induced mitochondrial membrane permeabilization (MMP), whereas ruthenium red, a ryanodine receptor blocker, does not. Pharmacologic inhibitors of the permeability transition pore, Bax/Bak inhibitors, and recombinant Bcl-2 and Bcl-XL proteins do not reduce Tat-induced MMP. We finally observed that Tat inhibits cytochrome c oxidase (COX) activity in disrupted mitochondria isolated from liver, heart, and brain of both mouse and human samples, making it the first described viral protein to be a potential COX inhibitor.

Chronic hypobaric hypoxia increases isolated rat fast-twitch and slow-twitch limb muscle force and fatigue.

Chronic hypoxia alters respiratory muscle force and fatigue, effects that could be attributed to hypoxia and/or increased activation due to hyperventilation. We hypothesized that chronic hypoxia is associated with phenotypic change in non-respiratory muscles and therefore we tested the hypothesis that chronic hypobaric hypoxia increases limb muscle force and fatigue. Adult male Wistar rats were exposed to normoxia or hypobaric hypoxia (PB=450 mm Hg) for 6 weeks. At the end of the treatment period, soleus (SOL) and extensor digitorum longus (EDL) muscles were removed under pentobarbitone anaesthesia and strips were mounted for isometric force determination in Krebs solution in standard water-jacketed organ baths at 25 °C. Isometric twitch and tetanic force, contractile kinetics, force-frequency relationship and fatigue characteristics were determined in response to electrical field stimulation. Chronic hypoxia increased specific force in SOL and EDL compared to age-matched normoxic controls. Furthermore, chronic hypoxia decreased endurance in both limb muscles. We conclude that hypoxia elicits functional plasticity in limb muscles perhaps due to oxidative stress. Our results may have implications for respiratory disorders that are characterized by prolonged hypoxia such as chronic obstructive pulmonary disease (COPD).

Safety of high doses of urokinase and reteplase for acute ischemic stroke.

BACKGROUND AND PURPOSE: ET is considered in selected patients with AIS with persistent arterial occlusion after receiving IVT. Limited data exist on the safety of IA high doses of UK and RT for ET. We investigated any correlation between IA doses of UK or RT and safety outcomes in patients who underwent ET. MATERIALS AND METHODS: We identified all patients from our stroke registry who received UK or RT for ET from 1998 to 2008. Demographics, baseline National Institutes of Health Stroke Scale scores, recanalization rates, rates of attempted MT, mortality, SICH, and discharge modified Rankin Scale scores were collected. RESULTS: Of 197 patients; 72 received UK and 125 received RT. More than 90% of patients in both groups had received prior IVT. The median IA dose of UK was 200,000 U (range, 25,000-1,500,000 U) and of RT was 2 mg (range, 1-8 mg). Concurrent MT was attempted in 59.7% of UK-treated patients and 72.0% of RT-treated patients, with SICH rates of 4.2% and 8.0%, respectively. Logistic regression adjusting for prior IVT and MT revealed no correlation between SICH and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .94) or RT (OR, 0.803; 95% CI, 0.48-1.33; P = .39). There was no correlation between mortality and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .51) or RT (OR, 1.048; 95% CI, 0.77-1.42; P = .75). CONCLUSIONS: High IA doses of UK and RT may be safe when given with or without MT in patients with AIS despite receiving a full dose of intravenous recombinant tissue plasminogen activator. These results need prospective validation.

The effect of transcatheter injections on cell viability and cytokine release of mononuclear cells.

BACKGROUND AND PURPOSE: Several studies suggest that various types of cellular therapies enhance recovery after stroke in animal models. IA-based delivery of cells to the brain is under investigation for stroke, but it is unknown whether cells are injured as a result of being injected through a catheter or exposed to iodinated contrast medium or solutions containing heparin. MATERIALS AND METHODS: We assessed the effect of catheterization with the Excelsior SL-10 catheter or exposure to heparin or iodine contrast on human bone marrow MNCs. Viability and cell injury were assessed by trypan blue exclusion, caspase-3 activity, and lipid peroxidation. Cellular function of MNCs was assessed by their production and release of VEGF, IL-10, and IGF-1. RESULTS: Flow rates of 10 million cells from 0.5 to 2 mL/min did not alter MNC viability; however, 5 mL/min of MNCs did reduce viability by 19%. Iodine and low-dose heparin exposure did not affect cell viability; however, high-dose heparin was cytotoxic. Catheter delivery at 2 mL/min did not affect levels of VEGF, IL-10, or IGF-1. CONCLUSIONS: MNCs do not appear to be damaged by heparin, iodine contrast, and the Excelsior SL-10 catheter at flow rates up to 2 mL/min. However, higher flow rates did reduce viability, and high-dose heparin did cause cell death.

Effects of chronic hypobaric hypoxia on contractile properties of rat sternohyoid and diaphragm muscles.

1. Chronic hypoxia occurs in a variety of circumstances, including respiratory disease and exposure to altitude, and is known to affect respiratory muscle structure. However, little is known about its effects on respiratory muscle contractile properties. 2. Rats were exposed to normoxia (n = 16) or hypobaric hypoxia (n = 16; barometric pressure 450 mmHg) for 6 weeks. Contractile properties were measured in isolated sternohyoid and diaphragm muscles in warmed, oxygenated Krebs' solution. Isometric twitch and tetanic tension, contraction time, half-relaxation time and tension-frequency relationship were determined using field stimulation with platinum electrodes. Fatigue was induced by stimulation at 40 Hz with 300 msec trains of 0.5 Hz for 5 min. 3. Chronic hypoxia had no effect on bodyweight, but did increase haematocrit. Chronic hypoxia increased specific force development in both muscles and increased sternohyoid fatigue. Chronic hypoxia had no effect on contractile kinetics in either muscle, but shifted the tension-frequency relationship to the left in the diaphragm. 4. Therefore, chronic hypoxia alters rat respiratory muscle force and fatigue, either due to the direct effects of hypoxia or to increased muscle activation.

Vein grafting of tunical incisions in the treatment of Peyronie's disease.

The effectiveness of vein grafting of tunical incisions of Peyronie's plaques in straightening the penis, with preservation of normal erectile function is evaluated. Eighteen patients with Peyronie's disease were surgically treated with a vein patch graft technique to correct their penile curvature. Transverse relaxing incisions were made on the tunica albuginea where a curvature was identified by an artificial erection. A vein graft from the saphenous vein was sewn into the defect created by relaxing incisions. If there was evidence of a residual curvature after the vein grafts were sewn in, a plication of the contralateral surface of the tunica albuginea was performed. The saphenous vein grafting alone was sufficient to straighten the penis 90 to 100% in 50% of patients. Of twelve patients who were potent preoperatively, one required postoperatively an occasional intracorporeal injection to maintain erection. Two of the impotent men regained their potency postoperatively. None of the patients lost sensation in the glans or shaft of the penis. Penile shortening was reported in three patients. No decrease in the penis rigidity was noted. Patients were discharged within 5 days of the procedure. There were no immediate complications. Fifteen of our sixteen followed patients resumed intercourse in eight weeks. We found that plaque incision in the venous grafting is much easier than the other incisional and excisional procedures described in the literature, and may lead to successful correction of penile deformity without compromising potency, penile length and sensitivity.

Management of posttraumatic posterior urethral disruption.

We reviewed our experience with 17 cases of posterior urethral disruption due to traumatic pelvic injuries. In all cases, a suprapubic cystostomy was performed at first. For blunt injuries, urethroplasty was delayed for 6 months in average. For most of the penetrating injuries (3/4), we performed immediate debridement and primary repair. Resulting bulbous or membranous strictures less than 3 cm long were treated with one-stage perineal excision-reanastomosis urethroplasty. Membranous strictures longer than 3 cm were managed with a combined transpubic-perineal repair, while bulbous defects longer than 3 cm were treated with a scrotal pedicled island flap. The overall restricture rate was 25%. Those having had initial repeated urethrotomies displayed a 100% restenosis rate. Incontinence rate was 12.5% Erectile dysfunction occurring in 42% of our patients is a sequela of the pelvic injury and was found to be directly related postoperatively to its presence at the time of surgery.

[Augmentation cystoplasty and intermittent catheterization in neurogenic bladder]. / Cystoplastie d'augmentation et cathétérisme intermittent dans les vessies neurogènes.

An enterocystoplasty was done on 17 paraplegic adults patients (Beit Chahab Hospital for Handicapped) with hyperreflexic neurogenic bladder secondary to an accident of the supra-sacral medulla. These patients were incontinent, had urinary tract infections, vesico-renal reflux or autonomic dysreflexia. Detubularized ileum was used in 16 cases and sigmoid in one. Ureteral reimplantation was performed on one patient; implantation of an artificial urinary sphincter for one patient and an injection of a periurethral Teflon paste was also done for one patient. After 16 months of follow-up all patients are continent on self intermittent catheterization. The upper urinary tract is stable or improved. No autonomic dysreflexia. Thirteen patients have an asymptomatic untreated bacteriuria.

[Echocardiographic study of 4 cases of dilatation of the sinus of Valsalva]. / Etude échocardiographique de 4 cas de dilatation du sinus de Valsalva.

Four cases of dilatation of the sinus of Valsalva with or without rupture were studied by echocardiography before surgical correction. In three cases the dilatation affected the right anterior sinus with rupture into the right atrium or ventricle. In the other case dilatation of the right anterior sinus dissecting the interventricular septum was associated with an aneurysm of the left anterior sinus dissecting the free wall of the left ventricle.

[Critical study of echocardiography in mitral cardiopathies]. / Etude critique de l'échocardiogramme dans les cardiopathies mitrales.

The importance of the echocardiogram in a study of mitral disorders has been analysed by examining 107 echocardiograms set against a clinical examination, an investigation of haemodynamic function (57), left-sided angiography (42), and/or examination at the time of operation (40). This study confirms the great diagnostic value of the echocardiographic findings in mitral stenosis (56 patients): the amplitude DE, the slope EF, the percentage of mid-diastolic closure, the echo from the valves, and the dimension of the left atria (P less than 0.001). This association remains valid if there is mitral incomptence as well as stenosis, or if there is also an aortic lesion, provided all the parameters are used. The degree of stenosis of the mitral orifice cannot be determined with sufficient certainty to allow surgical exploration to be undertaken solely on echocardiographic results, however the patients are selected (sinus rhythm, absence of calcification, mobile valve...). The echocardiographic diagnosis of the 17 cases of mitral incompetence was incomplete (except for rupture of the chords); the volume of the regurgitation is poorly appreciated.