Amino acid alcohols: growth inhibition and induction of differentiated features in melanoma cells.

The effects of a series of D- and L-amino acid alcohols on the proliferation and phenotypic expression of B16 mouse melanoma cells were evaluated. B16 melanoma cells were incubated for different time intervals in the presence of D- or L-phenylalaninol (PHE), D- or L-alaninol (AL), D- or L-leucinol (LE), L-histidinol (HIS), L-tyrosinol (TYR) and L-methioninol (MET). All agents, including the D or L configuration, induced an anti-proliferative effect, although of considerably different magnitude. D-PHE was the most active growth inhibitor. The growth inhibitory effects were accompanied by phenotypic alterations, which included morphological changes and enhancement in the activities of NADPH cytochrome c reductase and tau-glutamyl transpeptidase. These phenotypic alterations correlated with the growth inhibitory effects of the different agents and seem to reflect a higher differentiated state.

Laparoscopic vs conventional autopsy. A promising perspective.

OBJECTIVE: To analyze the sensitivity and specificity of laparoscopic autopsy when compared with the ulterior performance of conventional postmortem examination. DESIGN: Consecutive sampling, case-series study. SETTING: A general community referral medical center and the local institute of forensic medicine. PARTICIPANTS: A consecutive sample of 25 fresh cadavers (< 24 hours old) of victims of vehicle accidents, gunshot wounds, and in-hospital deaths. INTERVENTIONS: After insufflation with carbon dioxide, laparoscopy of the abdominal cavity and inspection of the retroperitoneal area was accomplished. Following, a conventional postmortem examination was performed and the findings of both procedures were recorded, compared, and analyzed. MAIN OUTCOME MEASURES: Prior to the beginning of the study, it was hypothesized that laparoscopic autopsy would reach an overall sensitivity and specificity of at least 85% and enable accurate inspection of the abdominal cavity and retroperitoneum in the search for the trauma-related cause of death in trauma victims or the cause of death for in-hospital patients. RESULTS: There was a 100% correlation of both procedures in all accidental cases. The sensitivity of laparoscopic autopsy was 93% for intra-abdominal lesions, with an overall sensitivity of 91%. For the retroperitoneal area, the sensitivity was 58%. The sensitivity for the retroperitoneum dropped, owing to an intrarenal tumor and an extraperitoneal rectal tear in the small sample of inhospital deaths. The specificity of laparoscopic autopsy reached 94%. CONCLUSIONS: Laparoscopic autopsy is accurate and easy to perform. It is highly sensitive for intra-abdominal abnormalities, especially in trauma victims. Laparoscopic autopsy is minimally invasive and not disfiguring, rendering it easier to accept among mourning families. It should be strongly considered when consent for a conventional autopsy is lacking.

The risk of cholecystectomy for acute cholecystitis in diabetic patients.

In order to evaluate the risk of acute cholecystitis in diabetic patients, we analyzed 2,700 consecutive cholecystectomies, 566 of which were performed in the presence of acute cholecystitis. Of these patients 123 had diabetes mellitus (DM) and 433 had no diabetes (ND). The aim of this study was to establish the comparative risks in the two groups. We found that diabetics are more likely to be operated on in the acute stage of their disease (22% vs. 12%). The DM group had a higher rate of septic bile, gangrenous changes and perforations of the gallbladder wall. The morbidity rate was higher in the DM group (21% vs. 9%), and mortality was slightly higher in the DM group. The degree of additional operative risk does not in our view justify recommending cholecystectomy in diabetic patients with asymptomatic gallstones. Early surgery however, is highly recommended in diabetics with symptomatic gallstones and acute cholecystitis.

Primary hyperparathyroidism due to mediastinal parathyroid adenoma.

Of the 90 cases of primary hyperparathyroidism surgically treated in our department over the last decade (1975-1985), ten cases had a mediastinal parathyroidal adenoma. In only two of these patients was a median sternotomy required for excision of the mediastinal adenoma. Three of the ten patients underwent the initial operation in other institutions, having undergone a previous neck exploration. There were seven males and three females, ages ranging from 41-68 years. Six patients had nephrolithiasis, four had both renal stones and bone disease and two had peptic ulcer disease. One of them was operated on as an emergency because of hyperparathyroidism crisis with calcium levels of 15/16 mg%. Four patients were asymptomatic and had hypercalcemia detected by SMA screening. The calcium level ranged from 11.5-16.2 mg%. The phosphorus ranged from 1.6-2.8 mg% with a mean of 2.0 mg%. All ten patients had plasma PTH determination by radioimmunoassay, the values ranged from 1.5-3 times normal. In seven of the ten cases, the mediastinal parathyroid adenoma was localized within the thymus, the other three were adjacent to the great vessels, two to the aortic arch and one to the pulmonary artery-size ranging from 1.2-5.4 cm. Preoperative localization techniques: venous sampling in four cases; technetium scanning in three cases. No preoperative localization techniques were used in the other three cases. There was no mortality nor other significant postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective antibiotic prophylaxis in biliary surgery.

Wound infections and septic complications are among the most frequent complications of biliary surgery. Such complications frequently occur in patients with infected bile. The presence of infected bile is predictable and can be expected in patients defined as high-risk patients. Short-term perioperative antibiotic prophylaxis was shown to be effective on an unselective basis by several authors. In this study of 231 consecutive biliary procedures, antibiotic prophylaxis was used on a selective basis in high-risk patients only. The high-risk patients were 55% of the entire group. Perioperative prophylaxis was given for 24 hours using four gentamicin injections starting two hours prior to anesthesia. Selective prophylaxis was shown to be highly effective reducing the wound infection rate to 3.5% in this group, compared to 12.5% in a similar group without prophylaxis. The selective use of prophylaxis was shown to be highly cost-effective as compared to the group without prophylaxis as well as reported groups of unselective prophylaxis in biliary surgery.

Clinical significance of choledochal diameter and hyperbilirubinemia in acute cholecystitis.

Persistent choledochal stones as well as negative choledochal explorations lead to increased morbidity and expense in surgery for acute cholecystitis. In an attempt to establish more precise criteria for the presence of CBD stones, 300 consecutive emergency cholecystectomies were studied and computer analyzed. Precise determination of the choledochal diameter and preoperative bilirubin levels permit a very accurate estimation of the probable presence of choledochal stones. On the basis of this information, more than 50% of patients can be classified in the low risk group, in which operative cholangiography can be omitted with minimal risk when technical difficulties are encountered, and choledochotomy may be avoided when cholangiography is unclear.

Age profiles of benign gallbladder disease in 2,000 patients.

Hospital charts and operative notes on 2,000 consecutive cholecystectomies performed between 1965-1984 for benign gallbladder disease were reviewed and computer analyzed. Patients were divided into five age categories (1-29, 30-49, 50-69, 70-79, 80 years and above). Fifteen variables were examined for each age category, including total number, sex, presenting symptoms (jaundice, acute cholecystitis, pancreatitis), intraoperative findings (presence of stones, common bile duct width and stones), operative procedures, bile cultures, histology, postoperative course and mortality. In addition to critically assessing performance and permitting comparison with other series, this age-related analysis suggests the following conclusions: The female predominance in age category 1 diminishes in categories 4 and 5. Acute cholecystitis and suppurative cholangitis occur in 44% of age category 5, compared to 14-24% in other age categories. Intraoperative fluorocholangiography is mandatory; common bile duct stones were found in 14% of age category 1. Age category 2 seems to be the group least susceptible to choledochal pathology. Acalculous cholecystitis is closely related to gangrenous changes, especially (almost selectively) in age categories 4 and 5. The frequency of infected bile rises with age, and is found in 90% of patients in age category 5. Mortality from operations for benign gallbladder disease is ten times higher in patients over 70 years of age compared to younger patients. An ultrasonographic study should be performed before any major laparotomy, especially in the aged, in order to diagnose silent stones, and prepare the patient for concomitant cholecystectomy. Elective cholecystectomy in age categories 4 and 5 is still accompanied by high mortality rates.

Multifactorial analysis of prognostic factors in emergency abdominal surgery in patients above 80 years. Analysis of 154 consecutive cases.

Patients above 80 have been the most rapidly growing group in the surgical department. The number of major laparotomies in this segment of the population has grown by 15% in the last two decades and is expected to grow by another 100% by the end of the century. The principal aim of the study was to identify by multifactorial analysis the combination of factors predictive of mortality in abdominal emergencies in this age group. A computer-held data base established by the Authors in 1978 was used to register all relevant information in 1327 major laparotomies performed in patients above 70. Of the base of 1327 patients, 219 (16.5%) were above 80. Of this group, 154 cases (70.3%) underwent emergency procedures and are the focus of this study. The principal conclusions of the Authors are as follows: A. The main differences between the two age groups 70-79 (Group A) and above 80 (Group B) are as follows: 1. Emergency laparotomies are much more frequent in Group B (70% versus 33%). 2. The overall mortality is over two and a half times as high (21.4% versus 8%). 3. The diagnostic profile and the mix of cases is different with an increased number of intestinal obstructions and malignancies in Group B. B. Unifactorial analysis of postoperative mortality disclosed the following factors associated with increased mortality: 1. Vital System Category III (Table 6-A). 2. Presence of generalized peritonitis or gangrenous bowel. 3. Presence of widespread malignant disease. 4. Belonging to the following diagnostic groups: carcinoma of pancreas, mesenteric thrombosis. 5. Age 85 or above.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitivity to new generation of antibiotics in biliary surgery.

The treatment of septic complications of cholecystectomy patients requires special attention. In a prospective study of 1009 consecutive cholecystectomy patients (including all acute and elective patients, excluding cases of malignancy), we routinely took cultures from the cystic duct and the gallbladder, and checked the strain for sensitivity. Positive cultures were found in 31.4% of the series, the most frequent bacteria being E. coli (50.3%). The aminoglycosides and the second and third generations of cephaloridins were found more specific for the strains that were cultured. While the new cephaloridins are the first choice for prophylaxis, the combination of aminoglycosides with ampicillin is to be preferred from the medical and cost effective standpoint while the aim is therapeutic.

Multifactorial analysis of prognostic factors in major abdominal surgery in patients over 80.

OBJECTIVE: The principle aim of the study was to identify by multifactorial analysis the combination of factors predictive of mortality after major laparotomy in patients over 80 years old. DESIGN: A computer held data base established by the authors in 1978 was used to register all relevant information of all major laparotomies performed in patients above 80. RESULTS: Unifactorial analysis of mortality disclosed the following factors associated with increased postoperative mortality: 1. Age 85 or more; 2. ASA fitness status 4 or 4; 3. Emergency procedure; 4. Presence of advanced malignant disease; 5. Diagnostic group 5 or 9 (mesenteric occlusion, pancreato biliary malignancy). Multifactorial analysis disclosed low mortality (2.5%) in cases with no gravity factors and very high mortality (above 70%) in those with 3 or more gravity factors.

The role of percutaneous transhepatic cholecystostomy in the management of acute cholecystitis in high-risk patients.

A method recently developed that may be an appropriate solution for high-risk patients with acute cholecystitis is percutaneous sonography-guided cholecystostomy. We report our experience in 10 high-risk elderly patients with clinical and sonographic diagnosis of acute cholecystitis. Immediate regression and resolution of septic symptoms was achieved in all cases. One patient was operated on as soon as his clinical condition stabilized, with uneventful postoperative recovery. The other nine were considered inoperable; of these, two were readmitted within a few months with recurrence of symptoms who underwent surgery, with a long and complicated postoperative course. The only complication we observed was temporary septicemia in one patient immediately after completion of the procedure. In view of these findings, we consider percutaneous transhepatic cholecystostomy an effective and safe method of treatment for acute cholecystitis in critically ill patients. However, this procedure should be regarded as a preliminary measure only, to render the patient more suitable for a formal cholecystectomy. We report our results and discuss technical and principal matters concerning percutaneous transhepatic cholecystostomy in the light of the current literature.