RESUMEN
PURPOSE: The reported conversion rates for minimally invasive distal pancreatectomy (MIDP) range widely from 2 to 38%. The identification of risk factors for conversion may help surgeons during preoperative planning and patient counseling. Moreover, the impact of conversion on outcomes of MIDP is unknown. METHODS: A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR). The PubMed, Cochrane, and Embase databases were searched for studies concerning conversion to open surgery in MIDP. RESULTS: Of the 828 studies screened, eight met the eligibility criteria, resulting in a combined dataset including 2592 patients after MIDP. The overall conversion rate was 17.1% (range 13.0-32.7%) with heterogeneity between studies associated with the definition of conversion adopted. Only one study divided conversion into elective and emergency conversion. The main indications for conversion were vascular involvement (23.7%), concern for oncological radicality (21.9%), and bleeding (18.9%). The reported risk factors for conversion included a malignancy as an indication for surgery, the proximity of the tumor to vascular structures in preoperative imaging, higher BMI or visceral fat, and multi-organ resection or extended resection. Contrasting results were seen in terms of blood loss and length of stay in comparing converted MIDP and completed MIDP patients. CONCLUSION: The identified risk factors for conversion from this study can be used for patient selection and counseling. Surgeon experience should be considered when contemplating MIDP for a complex patient. Future studies should divide conversion into elective and emergency conversion.
Asunto(s)
Laparoscopía , Neoplasias Pancreáticas , Procedimientos Quirúrgicos Robotizados , Humanos , Pancreatectomía , Neoplasias Pancreáticas/cirugía , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Animal studies have increasingly highlighted the role of macrophages in the development of delayed gastric emptying. However, their role in the pathophysiology of human gastroparesis is unclear. Our aim was to determine changes in macrophages and other cell types in the gastric antrum muscularis propria of patients with diabetic and idiopathic gastroparesis. METHODS: Full thickness gastric antrum biopsies were obtained from patients enrolled in the Gastroparesis Clinical Research Consortium (11 diabetic, 6 idiopathic) and 5 controls. Immunolabeling and quantitative assessment was done for interstitial cells of Cajal (ICC) (Kit), enteric nerves protein gene product 9.5, neuronal nitric oxide synthase, vasoactive intestinal peptide, substance P, tyrosine hydroxylase), overall immune cells (CD45) and anti-inflammatory macrophages (CD206). Gastric emptying was assessed using nuclear medicine scintigraphy and symptom severity using the Gastroparesis Cardinal Symptom Index. RESULTS: Both diabetic and idiopathic gastroparesis patients showed loss of ICC as compared to controls (Mean [standard error of mean]/hpf: diabetic, 2.28 [0.16]; idiopathic, 2.53 [0.47]; controls, 6.05 [0.62]; P=.004). Overall immune cell population (CD45) was unchanged but there was a loss of anti-inflammatory macrophages (CD206) in circular muscle (diabetic, 3.87 [0.32]; idiopathic, 4.16 [0.52]; controls, 6.59 [1.09]; P=.04) and myenteric plexus (diabetic, 3.83 [0.27]; idiopathic, 3.59 [0.68]; controls, 7.46 [0.51]; P=.004). There was correlation between the number of ICC and CD206-positive cells (r=.55, P=.008). Enteric nerves (PGP9.5) were unchanged: diabetic, 33.64 (3.45); idiopathic, 41.26 (6.40); controls, 46.80 (6.04). CONCLUSION: Loss of antral CD206-positive anti-inflammatory macrophages is a key feature in human gastroparesis and it is associates with ICC loss.
Asunto(s)
Complicaciones de la Diabetes/metabolismo , Gastroparesia/metabolismo , Lectinas Tipo C/metabolismo , Macrófagos/metabolismo , Lectinas de Unión a Manosa/metabolismo , Antro Pilórico/metabolismo , Receptores de Superficie Celular/metabolismo , Adulto , Complicaciones de la Diabetes/patología , Sistema Nervioso Entérico/metabolismo , Femenino , Fibrosis , Gastroparesia/patología , Humanos , Células Intersticiales de Cajal/metabolismo , Células Intersticiales de Cajal/patología , Masculino , Receptor de Manosa , Persona de Mediana Edad , Antro Pilórico/patología , Adulto JovenRESUMEN
BACKGROUND: There is increasing evidence for specific cellular changes in the stomach of patients with diabetic (DG) and idiopathic (IG) gastroparesis. The most significant findings are loss of interstitial cells of Cajal (ICC), neuronal abnormalities, and an immune cellular infiltrate. Studies done in diabetic mice have shown a cytoprotective effect of CD206+ M2 macrophages. To quantify overall immune cellular infiltrate, identify macrophage populations, and quantify CD206+ and iNOS+ cells. To investigate associations between cellular phenotypes and ICC. METHODS: Full thickness gastric body biopsies were obtained from non-diabetic controls (C), diabetic controls (DC), DG, and IG patients. Sections were labeled for CD45, CD206, Kit, iNOS, and putative human macrophage markers (HAM56, CD68, and EMR1). Immunoreactive cells were quantified from the circular muscle layer. KEY RESULTS: Significantly fewer ICC were detected in DG and IG tissues, but there were no differences in the numbers of cells immunoreactive for other markers between patient groups. There was a significant correlation between the number of CD206+ cells and ICC in DG and DC patients, but not in C and IG and a significant correlation between iNOS+ cells and ICC in the DC group, but not the other groups. CD68 and HAM56 reliably labeled the same cell populations, but EMR1 labeled other cell types. CONCLUSIONS & INFERENCES: Depletion of ICC and correlation with changes in CD206+ cell numbers in DC and DG patients suggests that in humans, like mice, CD206+ macrophages may play a cytoprotective role in diabetes. These findings may lead to novel therapeutic options, targeting alternatively activated macrophages.
Asunto(s)
Diabetes Mellitus Tipo 1/complicaciones , Gastroparesia/patología , Células Intersticiales de Cajal/patología , Macrófagos/patología , Estómago/patología , Adulto , Recuento de Células , Femenino , Gastroparesia/etiología , Gastroparesia/inmunología , Humanos , Lectinas Tipo C , Macrófagos/inmunología , Receptor de Manosa , Lectinas de Unión a Manosa , Persona de Mediana Edad , Receptores de Superficie Celular , Estómago/inmunologíaRESUMEN
Identification of markers of enteric neurons has contributed substantially to our understanding of the development, normal physiology, and pathology of the gut. Previously identified markers of the enteric nervous system can be used to label all or most neuronal structures or for examining individual cells by labeling just the nucleus or cell body. Most of these markers are excellent but have some limitations. Transmembrane protein 100 (TMEM100) is a gene at locus 17q32 encoding a 134-amino acid protein with two hypothetical transmembrane domains. TMEM100 expression has not been reported in adult mammalian tissues but does appear in the ventral neural tube of embryonic mice and plays a role in signaling pathways associated with development of the enteric nervous system. We showed that TMEM100 messenger RNA is expressed in the gastrointestinal tract and demonstrated that TMEM100 is a membrane-associated protein. Furthermore TMEM100 immunoreactivity was restricted to enteric neurons and vascular tissue in the muscularis propria of all regions of the mouse and human gastrointestinal tract. TMEM100 immunoreactivity colocalized with labeling for the pan-neuronal marker protein gene product 9.5 (PGP9.5) but not with the glial marker S100ß or Kit, a marker of interstitial cells of Cajal. The signaling molecule, bone morphogenetic protein (BMP) 4, was also expressed in enteric neurons of the human colon and co-localized with TMEM100. TMEM100 is also expressed in neuronal cell bodies and fibers in the mouse brain and dorsal root ganglia. We conclude that TMEM100 is a novel, membrane-associated marker for enteric nerves and is as effective as PGP9.5 for identifying neuronal structures in the gastrointestinal tract. The expression of TMEM100 in the enteric nervous system may reflect a role in the development and differentiation of cells through a transforming growth factor ß, BMP or related signaling pathway.
Asunto(s)
Sistema Nervioso Entérico/metabolismo , Tracto Gastrointestinal/metabolismo , Proteínas de la Membrana/metabolismo , Animales , Especificidad de Anticuerpos , Proteína Morfogenética Ósea 4/metabolismo , Línea Celular Transformada , Sistema Nervioso Entérico/citología , Humanos , Proteínas de la Membrana/genética , Ratones , Ratones Endogámicos C57BL , Factores de Crecimiento Nervioso/metabolismo , Neuroglía/metabolismo , Neuronas/metabolismo , Proteínas Proto-Oncogénicas c-kit/metabolismo , ARN Mensajero/metabolismo , Subunidad beta de la Proteína de Unión al Calcio S100 , Proteínas S100/metabolismo , Transfección , Ubiquitina Tiolesterasa/metabolismoRESUMEN
BACKGROUND: Outcomes for patients with hepatocellular carcinoma (HCC) without cirrhosis and factors associated with disease progression remain unclear. The goals of this single-institution study were to define the outcomes for such patients, and to determine factors associated with survival and disease progression. METHODS: This was a retrospective review of consecutive patients with HCC without cirrhosis who underwent hepatic resection between 1985 and 2003. Survival was estimated by the Kaplan-Meier method and risk factors were identified by Cox proportional hazards models. RESULTS: A total of 143 patients were enrolled, of whom 29·4 per cent had identifiable risk factors for chronic liver disease. Major resection (at least three segments) was undertaken in 63·6 per cent of patients. The operative mortality rate was 3·5 per cent. Median disease-free survival was 2·4 years. Multivariable analysis revealed presence of multiple tumours as the only independent predictor of tumour recurrence. Median overall survival was 3·3 years. Factors independently associated with decreased overall survival were multiple tumours, high histological grade, perioperative transfusion, male sex and age at least 66 years. CONCLUSION: Patients with HCC but without cirrhosis have acceptable outcomes after resection. Specific risk factors for the development of HCC in these patients have yet to be defined.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Anciano , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/patología , Métodos Epidemiológicos , Femenino , Hepatectomía/mortalidad , Humanos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Metástasis Linfática , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/mortalidad , Reoperación , Carga TumoralRESUMEN
BACKGROUND: Aging produces inevitable changes in the function of most organs including the gastrointestinal tract. Together with enteric nerves and smooth muscle cells, interstitial cells of Cajal (ICC) play a key role in the control of gastrointestinal motility, yet little is known about the effect of aging on ICC. The aim of this study was to determine the effect of aging on ICC number and volume in the human stomach and colon. METHODS: Gastric and colonic tissues from patients aged 25-70 and 36-92 years old, respectively, and with no co-existent motility disorders were immunolabeled with an anti-Kit antibody and ICC were counted in the circular muscle and myenteric regions. Network volumes were measured using 3D reconstructions of confocal stacks. The effects of aging were determined by testing for linear trends using regression analysis. KEY RESULTS: In both stomach and colon, the number of ICC bodies and volume significantly decreased with age at a rate of 13% per decade. ICC size was only affected in the myenteric plexus in the colon. The changes associated with age were not differentially affected by sex or colonic region. CONCLUSIONS & INFERENCES: The number and volume of ICC networks in the normal human stomach and colon decline with age. This decrease in ICC likely reduces the functional capacity of the gastrointestinal motor apparatus, may contribute to changes in gastrointestinal motility with aging and may influence intestinal responses to insults such as disease, operative interventions and medications in older patients. Tissue specimens must be carefully age-matched when studying ICC in disease.
Asunto(s)
Envejecimiento/fisiología , Colon/citología , Células Intersticiales de Cajal/metabolismo , Estómago/citología , Adulto , Anciano , Anciano de 80 o más Años , Colon/fisiología , Femenino , Humanos , Células Intersticiales de Cajal/citología , Masculino , Persona de Mediana Edad , Proteínas Proto-Oncogénicas c-kit/metabolismo , Estómago/fisiologíaAsunto(s)
Cistoadenoma Mucinoso/diagnóstico , Quistes/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Bazo/anomalías , Enfermedades del Bazo/diagnóstico , Dolor Abdominal/diagnóstico , Dolor Abdominal/etiología , Adulto , Biopsia con Aguja Fina , Cistoadenoma Mucinoso/patología , Quistes/patología , Diagnóstico Diferencial , Endosonografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Pancreatectomía , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Medición de Riesgo , Bazo/patología , Esplenectomía , Enfermedades del Bazo/patología , Enfermedades del Bazo/cirugía , Resultado del TratamientoRESUMEN
The safety and efficacy of bariatric surgery in adolescents and especially in Medicare population have been challenged. Our aim was to determine short-term (30-day) and long-term outcomes of bariatric surgery in patients>or=60 years and Asunto(s)
Cirugía Bariátrica/estadística & datos numéricos
, Adolescente
, Anciano
, Apetito
, Índice de Masa Corporal
, Comorbilidad
, Defecación
, Femenino
, Humanos
, Tiempo de Internación
, Masculino
, Persona de Mediana Edad
, Obesidad Mórbida/epidemiología
, Obesidad Mórbida/cirugía
, Periodo Posoperatorio
, Resultado del Tratamiento
RESUMEN
Gastroesophageal reflux disease (GERD) is common in obese patients. The implications of obesity in the etiology, management and outcomes in treatment for GERD have become increasingly important due to an epidemic of obesity. The increasing prevalence of patients with both obesity and GERD merits evaluation of the appropriate surgical intervention for GERD and its symptoms. With the additional advantages of weight loss and resolution of weight-related morbidity (including GERD) bariatric procedures should be the procedure of choice in patients with medically complicated obesity. Patients in lower obesity classes with body mass indices (BMI) of 30-35 kg/m2 without other substantive weight-related comorbidity should prompt consideration of both fundoplication and bariatric procedures, tailoring the best approach based on the specific patient and future implications. Patients classified as overweight but not obese (BMI < 30) are likely best treated with fundoplication; however, no randomized trials comparing fundoplication with the current antireflux bariatric procedures exist.
Asunto(s)
Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/terapia , Obesidad/complicaciones , Obesidad/terapia , Cirugía Bariátrica , Susceptibilidad a Enfermedades , Fundoplicación , Derivación Gástrica , Reflujo Gastroesofágico/etiología , HumanosRESUMEN
BACKGROUND: Enteric neurotransmission is a complex process involving multiple neurotransmitters, including nitric oxide (NO). Our aim was to evaluate the role and mechanism(s) of action of NO in normal human jejunal longitudinal smooth muscle. METHODS: Transmural strips of normal human jejunum obtained from subjects undergoing gastric bypass were studied in organ chambers. Effects of exogenous NO (7 x 10(-6) mol/L to 7 x 10(-5) mol/L) and electrical field stimulation (nonspecific release of endogenous neurotransmitters) on spontaneous contractile activity and on precontracted muscle strips (substance P, 10(-5) mol/L) were evaluated in the presence and absence of the competitive NO synthase inhibitor N(G)-amino-L-arginine (L-NNA, 10(-3) mol/L) and the specific soluble guanylyl cyclase inhibitor 1H-[1,2,4]-oxadiazaolo-[4,3-a]-quinoxalin-1-one (ODQ, 10(-5) mol/L and 10(-4) mol/L). RESULTS: Exogenous NO dose-dependently inhibited spontaneous contractility and relaxed precontracted smooth muscle strips. The effects of NO were markedly attenuated or completely inhibited in the presence of ODQ. Electric field stimulation under nonadrenergic, noncholinergic conditions also inhibited spontaneous contractility and relaxed precontracted smooth muscle strips; both of these effects were attenuated, but not completely inhibited, in the presence of both ODQ and L-NNA. CONCLUSIONS: NO is an endogenous inhibitory neurotransmitter in human jejunal longitudinal smooth muscle, acting at least in part via a mechanism mediated by guanylyl cyclase. Other (non-nitrergic) nonadrenergic, noncholinergic inhibitory neurotransmitters are likely active in this portion of the human gut.
Asunto(s)
Sistema Nervioso Entérico/fisiología , Yeyuno/inervación , Músculo Liso/inervación , Inhibición Neural/fisiología , Óxido Nítrico/fisiología , Estimulación Eléctrica , Sistema Nervioso Entérico/efectos de los fármacos , Inhibidores Enzimáticos/farmacología , Motilidad Gastrointestinal/efectos de los fármacos , Motilidad Gastrointestinal/fisiología , Guanilato Ciclasa/antagonistas & inhibidores , Guanilato Ciclasa/fisiología , Humanos , Técnicas In Vitro , Inhibición Neural/efectos de los fármacos , Óxido Nítrico/farmacología , Oxadiazoles/farmacología , Quinoxalinas/farmacologíaRESUMEN
Clinical presentation and state-of-the-art imaging permit the differentiation of most cystic pancreatic neoplasms not only from other cystic pancreatic disorders but also from one another. The differentiation of serous cystic lesions from the mucinous neoplasms (cystadenoma or carcinoma and IPMT) is crucial because of the radically different biological characteristics of these two neoplasms. Although mucinous cystic neoplasms should be resected because of their premalignant or overtly malignant tendency, most patients with serous neoplasms require no operative intervention unless they are symptomatic. IPMT is best treated by a total pancreatectomy, although lesser subtotal resections should be strongly considered depending on patient age, medical comorbidity, and psychosocial situations.
Asunto(s)
Carcinoma Ductal Pancreático/patología , Cistoadenoma/patología , Quiste Pancreático/patología , Neoplasias Pancreáticas/patología , Adenocarcinoma Mucinoso/patología , Transformación Celular Neoplásica/patología , Cistoadenoma Mucinoso/patología , Cistoadenoma Papilar/patología , Cistadenoma Seroso/patología , Humanos , Quiste Pancreático/diagnóstico por imagen , Neoplasias Pancreáticas/diagnóstico por imagen , RadiografíaRESUMEN
To determine the role of vagal nerves in initiation and modulation of the gastric migrating motor complex (MMC), motor activity was recorded in four dogs before and after total abdominal vagotomy during fasting, after exogenous intravenous motilin and insulin, and after feeding. After vagotomy, a temporally coordinated cyclic gastric and small bowel MMC persisted with an unchanged period. During gastric phase III, vagotomy decreased number of contractions (42 +/- 4 vs. 16 +/- 2), number of groupings of contractions (14 +/- 1 vs. 7 +/- 1), and motility index (12 +/- 1 vs. 10 +/- 1) and increased the duration between groupings (1 +/- 1 vs. 3 +/- 1 min) (P < 0.05 in each). Before and after vagotomy, motilin and insulin induced a premature MMC with minor changes in contractile pattern. A 200-g liver meal but not a 50-g liver meal inhibited the gastric MMC after vagotomy. A cyclic MMC persisted after vagotomy, but the contractile pattern during gastric phase III was altered. After a short recovery period, vagal innervation to the stomach modulates the pattern but not the presence of gastric interdigestive motility during phase III.
Asunto(s)
Motilidad Gastrointestinal/fisiología , Intestino Delgado/inervación , Neuronas Motoras/fisiología , Estómago/inervación , Nervio Vago/fisiología , Animales , Perros , Ingestión de Alimentos/fisiología , Femenino , Motilidad Gastrointestinal/efectos de los fármacos , Hipoglucemiantes/farmacología , Insulina/farmacología , Intestino Delgado/fisiología , Motilina/sangre , Motilina/farmacología , Periodo Posprandial , Estómago/fisiología , Vagotomía , Nervio Vago/citología , Nervio Vago/cirugíaRESUMEN
HYPOTHESIS: Outcome of patients with adrenocortical carcinoma (ACC) has improved with the advent of more widely available and higher quality imaging. Operative management strategies and use of adjuvant therapy have not changed. DESIGN: Retrospective review of patient histories, imaging studies, operative data, adjuvant therapy, and outcomes at a single institution. Follow-up was complete for a mean of 53 months. Data was compared with prior institutional experience. SETTING: Tertiary care referral center. PATIENTS: All patients undergoing operative management for ACC during the period from 1980 to 1996. MAIN OUTCOME MEASURES: Determinants of recurrence, survival, and the effect of adjuvant therapy on overall outcome. RESULTS: Fifty-eight patients (30 men, 28 women) with a mean age of 53 years underwent primary operative management for ACC. Functional tumors were identified in 27 patients (47%). Mean tumor size was 12.5 cm. Stage according to the TNM staging system (AJCC Cancer Staging Manual) at presentation was I (n = 0), II (n = 30), III (n = 7), and IV (n = 21). Surgical management included curative resection in 41 (71%), noncurative resection in 14 (24%), and open biopsy in 3 (5%). Perioperative mortality was 5%. Recurrence occurred in 30 patients (73%) with a median time to recurrence of 17 months. Five-year survival by the Kaplan-Meier method was 37%. Prognostic factors (P<.05) included functional status, stage, and chemotherapy in stage III/IV patients. When compared with our prior institutional experience (1960-1980), current patients were more likely to present with stages I to II (52% vs. 34%), have curative resections (71% vs. 50%), and have improved 5-year survival (37% vs. 16%). CONCLUSIONS: (1) Surgical resection remains the principal treatment for stage I to III disease. (2) Adjuvant therapy may improve survival in patients with stage III or IV disease. (3) Current patients were more likely to present at an earlier stage, undergo curative resections, and have improved 5-year survival than institutional historical comparisons.
Asunto(s)
Neoplasias de la Corteza Suprarrenal/cirugía , Adolescente , Neoplasias de la Corteza Suprarrenal/mortalidad , Neoplasias de la Corteza Suprarrenal/patología , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Estudios RetrospectivosRESUMEN
Obscure gastrointestinal bleeding remains a significant diagnostic challenge. Our aims were (1) to determine the efficacy of intraoperative enteroscopy (IOE) in identifying lesions responsible for obscure gastrointestinal bleeding and (2) to determine the outcome of patients after treatment of these lesions. We retrospectively reviewed all patients who underwent IOE for obscure gastrointestinal bleeding from 1992 to 1998. Patients were divided into those with overt and those with occult gastrointestinal bleeding. Follow-up was complete in 67 patients (96%), with a median of 32 months (range 1 to 91 months). Seventy patients (52 overt and 18 occult) underwent IOE after extensive preoperative evaluation. Median duration of bleeding was 12 months, requiring a median of 14 blood transfusions. Risk factors for bleeding were identified in 46 patients (61%). A lesion was identified and treated in 52 patients (74%)-39 in the overt group and 13 in the occult group. Lesions identified were vascular (54%), ulcerations (31%), tumors (11%), and small bowel diverticula (4%). Overall, 35 patients (52%) were found to have one or more lesions at IOE that were treated surgically and had no further bleeding. IOE, through a mid-small bowel enterotomy, has low morbidity and is effective in that it identified a treatable lesion in 74% of patients, which led to cure of bleeding in 52%.
Asunto(s)
Endoscopía Gastrointestinal , Hemorragia Gastrointestinal/diagnóstico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
INTRODUCTION: Extrinsic innervation mediates a proabsorptive effect in small intestine. Our aim was to determine whether extrinsic neural input modulates similar effects in the proximal colon in vivo. METHODS: Ten adult dogs underwent enteric isolation of a 50-cm proximal colon loop; five each were randomized to undergo extrinsic denervation (Ext Den) of the isolated colonic segment or to serve as neurally innervated controls. After recovery, a 38 degrees C electrolyte solution (Na(+) 125 meq/L, K(+) 9 meq/L, Cl(-) 75 meq/L, HC03(-) 65 meq/L) was infused at 4 ml/min into the segment. Effluent was collected in 30-min intervals for 2 h after achieving steady state (determined by 14C nonabsorbable marker recovery); four studies were conducted at 1 and 12 weeks postoperatively. Net flux of H20, Na(+), K(+), and Cl(-) was determined. Colon morphometry was evaluated at 0 and 14 weeks. Data are presented as mean +/- SEM. Unpaired t test was applied for comparisons. RESULTS: Net absorptive flux of H20 (microL/min/cm) was decreased in Ext Den vs controls at 1 week (4.40 +/- 0.63 vs 7.92 +/- 0.92, P = 0.03) but was not different at 12 weeks (4.70 +/- 1.20 vs 5.97 +/- 0.69; P > 0.05). Na(+) and Cl(-) followed the trends in H20 absorption (P < or = 0.05). Crypt depth (microm) decreased in controls at 14 weeks vs 0 week (915 +/- 20 vs 740 +/- 07, P = 0.01) but remained unchanged in Ext Den. CONCLUSIONS: Loss of extrinsic neural input decreases colonic absorption. This observation suggests that extrinsic neural innervation provides net proabsorptive mechanisms for absorption of water and electrolytes in the proximal canine colon.
Asunto(s)
Colon/inervación , Colon/fisiopatología , Absorción Intestinal , Desequilibrio Hidroelectrolítico/fisiopatología , Animales , Colon/patología , Perros , Femenino , Intestino Delgado/trasplante , Trasplante de Tejidos/efectos adversos , Desequilibrio Hidroelectrolítico/etiología , Desequilibrio Hidroelectrolítico/patologíaRESUMEN
Reoperative surgery for hyperparathyroidism (HPT) is fraught with hazard. When preoperative imaging studies are inconclusive or patient comorbidities are extensive fine needle-aspiration (FNA) is helpful to confirm the presence of suspected parathyroid tissue in the neck. Some surgeons refrain from using FNA because of the concern of tissue implantation (parathyromatosis). A retrospective review (1984-1996) of all patients diagnosed with HPT undergoing FNA of suspected parathyroid tissue was performed to document whether a correlation exists between FNA of suspected parathyroid tissue and subsequent development of parathyromatosis. Parathyromatosis was considered to have occurred when proven by histology or suspected on the basis of clinical studies. Of 81 patients with HPT undergoing ultrasound-guided FNA to assess abnormalities in the neck 41 patients with confirmed parathyroid tissue were identified. The indications for FNA in these 41 patients were: prior failed cervical exploration (n = 33), prior neck surgery and/or radiation (n = 2), inconclusive noninvasive imaging studies (n = 15), and severe comorbidities (n = 8). Mean follow-up was 5.8 years. No case of FNA-induced parathyromatosis was identified. FNA is useful to confirm the presence of parathyroid tissue in very select patients with hyperparathyroidism. FNA often eliminates the need for other imaging studies, may prevent a needless or likely fruitless re-exploration, and does not cause parathyromatosis.
Asunto(s)
Biopsia con Aguja/efectos adversos , Coristoma/etiología , Hiperparatiroidismo/diagnóstico por imagen , Hiperparatiroidismo/patología , Cuello , Ultrasonografía Intervencional/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Biopsia con Aguja/métodos , Biopsia con Aguja/normas , Calcio/sangre , Femenino , Humanos , Hiperparatiroidismo/sangre , Hiperparatiroidismo/cirugía , Masculino , Persona de Mediana Edad , Selección de Paciente , Reoperación/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Ultrasonografía Intervencional/métodos , Ultrasonografía Intervencional/normasRESUMEN
Net absorption of water, electrolytes, and simple nutrients decreases early after jejunoileal autotransplantation (extrinsic denervation) in a canine model but recovers toward normal by 8 weeks. However, the ability of the extrinsically denervated ileum to adapt after total jejunectomy, which would be relevant as a model of segmental small bowel transplantation, remains unknown. Two groups of five dogs each were studied before and 2 weeks and 12 weeks after 50% proximal enterectomy. A control group remained neurally intact, whereas the other group underwent extrinsic denervation (Ext Den) of the remaining ileum. Using a perfusion technique, net absorption of water, electrolytes, and five simple nutrients (glucose, arginine, glutamine, and oleic and taurocholic acids) was measured at the three time points. Ileal morphometry was also evaluated. All dogs developed diarrhea, which resolved by 12 weeks in all but two of the Ext Den dogs. Weight in both groups was decreased at 2 weeks (P <0.05), returned to normal at 12 weeks in control dogs, but remained low in Ext Den dogs (P <0.05). Maximal weight loss was greater in the Ext Den group (P <0.05). No consistent or important differences in net absorptive fluxes of water, electrolytes, or simple nutrients were noted either within or between groups at any time point. Villous height, crypt depth, and longitudinal muscle width increased significantly at 12 weeks after jejunectomy in the Ext Den dogs, but not in the control dogs (P <0.05). Extrinsic denervation of the ileum results in persistent weight loss after proximal 50% enterectomy. Despite diarrhea, only minor changes in electrolyte absorption occur, and ileal net absorption of simple nutrients remains unaffected. The ileum of extrinsically denervated dogs undergoes a more prominent morphometric adaptation after jejunectomy. Extrinsic denervation necessitated by small bowel transplantation, independent of immune effects, does not appear to suppress the ileal adaptive response to maintain net absorption of water, electrolytes, and simple nutrients.
Asunto(s)
Adaptación Fisiológica/fisiología , Íleon/fisiología , Absorción Intestinal/fisiología , Yeyuno/cirugía , Animales , Desnervación , Perros , Femenino , Íleon/inervación , Intestino Delgado/trasplante , Yeyuno/inervación , Donadores Vivos , Síndrome del Intestino Corto/fisiopatología , Factores de TiempoRESUMEN
Duodenal carcinoid tumors are uncommon. It is not known whether they behave more like carcinoid tumors in the appendix (indolent course) or those in the ileum (often virulent)-crucial information for determining the need for radical resection. A retrospective review at our tertiary referral center (from 1976 to 1999) identified 27 patients with primary duodenal carcinoid lesions, excluding functional islet cell tumors. Endoscopic biopsy provided the diagnosis in 78% of patients. Treatment was by endoscopic excision (n = 11), transduodenal excision (n = 8), pancreaticoduodenectomy (n = 3), segmental distal duodenectomy (n = 2), or palliative operation (n = 2). One patient did not undergo operation because of comorbidity. Eighteen of 19 patients with tumors smaller than 2 cm remained disease free after local (endoscopic or transduodenal) excision. The exception was a patient with a small periampullary carcinoid lesion. In contrast, all four patients with carcinoid tumors 2 cm or larger who were resected for cure developed a recurrence (2 to 9 years postoperatively). We conclude that duodenal carcinoid tumors smaller than 2 cm may be excised locally; to ensure complete resection we recommend open transduodenal excision for tumors between 1 and 2 cm. Endoscopic follow-up is indicated. It is unclear whether patients with larger tumors benefit from more aggressive locoregional resection. Ampullary/periampullary carcinoid tumors should be considered separately, as their behavior is unpredictable.
Asunto(s)
Tumor Carcinoide/patología , Tumor Carcinoide/cirugía , Neoplasias Duodenales/patología , Neoplasias Duodenales/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Biopsia con Aguja , Tumor Carcinoide/mortalidad , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Neoplasias Duodenales/mortalidad , Endoscopía Gastrointestinal/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Síndrome Carcinoide Maligno/mortalidad , Síndrome Carcinoide Maligno/patología , Síndrome Carcinoide Maligno/cirugía , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
We analyzed a series of adrenocortical neoplasms to compare the clinicopathologic features and the expression of insulin-like growth factor-2 (IGF-2) in adrenocortical adenomas and carcinomas. IGF-2 is a growth factor commonly expressed in many tumors including adrenal cortical and medullary neoplasms. Formalin-fixed paraffin-embedded tissues from 64 adrenocortical adenomas and 67 adrenocortical carcinomas were analyzed. The carcinomas were histologically graded from 1 to 4 based on mitotic activity and necrosis. Tumor weight, size, and follow-up information were obtained by chart review. Expression of IGF-2 was detected by immunohistochemistry with the avidin-biotin-peroxidase complex method and a monoclonal antibody against IGF-2. Adrenocortical carcinomas were larger (mean: 13.1 cm, 787 g) than adenomas (mean: 4.2 cm, 52 g) (p < 0.001). Inpatients with adrenocortical carcinomas, high tumor grade (3 or 4) (p = 0.01) was associated with decreased survival. Expression of IGF-2 was higher in adrenocortical carcinomas than in adenomas (p < 0.001). These results show that tumor size and weight along with expression of IGF-2 protein are useful features to assist in distinguishing between adrenocortical adenomas and carcinomas, and that high tumor grade is a predictor of survival in adrenocortical carcinomas. However, single immunohistochemical markers such as IGF-2 or single histopathologic features cannot by themselves separate adrenocortical adenomas from carcinomas, and a combination of clinical, gross, and microscopic features are needed to establish the diagnosis in difficult cases.