Effects of smoking and different BMI cutoff points on surgical site infection after elective open ventral hernia repair.

PURPOSE: BMI > 40 kg/m2 and smoking have been identified as risk factors for surgical site infections (SSIs) after ventral hernia repair, however, the relationship with lower BMI values has not been described. The objective of this study was to analyze the relationship between different BMI thresholds, smoking, and SSI after open ventral hernia repair. METHODS: All patients who underwent an elective non-emergent open ventral hernia repair with mesh were extracted from the 2011 to 2016 NSQIP database. Bivariate, multivariate logistic regression, and Classification and Regression Tree (CART) analyses were used. RESULTS: Of 55,240 patients, 2,620 (4.7%) developed SSIs (superficial: 58.5%, deep:27%, organ-space: 16%). BMI (OR: 1.035; 95% CI:1.03-1.04; p < 0.001) and smoking (OR:1.51; 95% CI:1.37-1.67; p < 0.001) were identified in logistic regression analysis as the two most modifiable risk factors independently associated with SSIs. CART analysis demonstrated that the lowest SSI rate belonged to non-smokers with BMI < 24.2 kg/m2 (1.9%), and the highest SSI to smokers with BMI > 42.3 kg/m2 (12%). Between these values, there was a stepwise increase in SSI rate as BMI increased, while smoking added additional risk in each group. CONCLUSION: Following open hernia repair, the association between SSI and being overweight starts at a BMI of 24.2, a threshold lower than previously described. The risk of SSI increases in a stepwise fashion as BMI increases and is augmented by smoking. Future studies are needed to determine if SSI reduction can be achieved with a combination of smoking cessation and weight loss using these BMI thresholds.

Outcomes of concomitant mesh placement and intestinal procedures during open ventral hernia repair.

PURPOSE: The concept of mesh use during open ventral hernia repair with a concomitant intestinal procedure remains controversial and it remains unclear whether the SSI profile of contaminated fields in this setting more closely resembles clean-contaminated or dirty wounds. METHODS: Patients who underwent an open ventral hernia repair and intestinal procedures were extracted from the ACS-NSQIP database. Data analysis was performed for mesh versus no mesh groups in aggregate and matched cohorts. The 30-day outcomes including mortality, morbidity, surgical site infections (SSI), readmission, reoperation, and length of stay were compared between the groups. RESULTS: Of 5104 patients in the mesh group, 3297 patients were matched 1:1 with patients without mesh. Mesh placement was associated with higher overall morbidity (35.1% vs. 29.8%; p < 0.001), overall SSI (27.1% vs. 18%; p < 0.001), deep SSI (5.9% vs. 4.3%; p = 0.003), organ-space SSI (6.8% vs. 5.5%; p = 0.027), reoperation (9.9% vs. 8.2%; p = 0.016), readmission (16.7% vs. 12.7%; p < 0.001), and longer hospital stays (10.9 ± 15.2 vs. 9.7 ± 10.7; p < 0.001). When mesh was used, the SSI profile of contaminated fields was similar to dirty wounds (26.4% vs. 27.5%; p = 0.702), rather than clean-contaminated fields (26.4% vs. 19.2%; p < 0.001). CONCLUSION: Concomitant bowel procedure and mesh placement at the time of open ventral hernia repair was associated with worse outcomes. The SSI profile of the contaminated fields was more similar to dirty wounds. When deciding whether to place mesh during ventral hernia repairs with concomitant bowel procedures, strong consideration should be given to the increased risk of short-term complications versus the potential long-term benefits.

Circulation dynamics of Salmonella enterica subsp. enterica ser. Gallinarum biovar Gallinarum in a poultry farm infested by Dermanyssus gallinae.

Dermanyssus gallinae (Mesostigmata: Dermanyssidae, De Geer, 1778) is an ectoparasite of poultry, suspected to play a role as a vector of Salmonella enterica subsp. enterica ser. Gallinarum. Despite an association between them being reported, the actual dynamics in field remain unclear. Therefore, the present study aimed to confirm the interactions among mites, pathogen and chickens. The study was carried out in an industrial poultry farm infested by D. gallinae, during an outbreak of fowl typhoid. The presence of S. Gallinarum in mites was assessed and quantified by a semi-nested polymerase chain reaction (PCR) and real-time PCR, respectively, in mites collected during two subsequent productive cycles and the sanitary break. The anti-group D Salmonella antibodies were quantified by an enzyme-linked immunosorbent assay. During the outbreak and the sanitary break, S. Gallinarum was constantly present in mites. In the second cycle, scattered positivity was observed, although hens did not exhibit signs of fowl typhoid, as a result of the vaccination with BIO-VAC SGP695 (Fatro, Ozzano Emilia Bo, Italy). The data strongly suggest that D. gallinae acts as reservoir of S. Gallinarum, thus allowing the pathogen to persist in farms. Furthermore, the present study has highlighted the interactions among D. gallinae, S. Gallinarum and hens with respect to enhancing the mite-mediated circulation of S. Gallinarum in an infested poultry farm.

Cell growth control: little eukaryotes make big contributions.

The story of rapamycin is a pharmaceutical fairytale. Discovered as an antifungal activity in a soil sample collected on Easter Island, this macrocyclic lactone and its derivatives are now billion dollar drugs, used in, and being evaluated for, a number of clinical applications. Taking advantage of its antifungal property, the molecular Target Of Rapamycin, TOR, was first described in the budding yeast Saccharomyces cerevisiae. TORs encode large, Ser/Thr protein kinases that reside in two distinct, structurally and functionally conserved, multi-protein complexes. In yeast, these complexes coordinate many different aspects of cell growth. TOR complex 1, TORC1, promotes protein synthesis and other anabolic processes, while inhibiting macroautophagy and other catabolic and stress-response processes. TORC2 primarily regulates cell polarity, although additional readouts of this complex are beginning to be characterized. TORC1 appears to be activated by nutrient cues and inhibited by stresses and rapamycin; however, detailed mechanisms are not known. In contrast, TORC2 is insensitive to rapamycin and physiological regulators of this complex have yet to be defined. Given the unsurpassed resources available to yeast researchers, this simple eukaryote continues to contribute to our understanding of eukaryotic cell growth in general and TOR function in particular.

Saccharomyces cerevisiae Ccr4-not complex contributes to the control of Msn2p-dependent transcription by the Ras/cAMP pathway.

The Ccr4-Not complex is a global regulator of transcription that affects genes positively and negatively and is thought to modulate the activity of TFIID. In the present work, we provide evidence that the Ccr4-Not complex may contribute to transcriptional regulation by the Ras/cAMP pathway. Several observations support this model. First, Msn2/4p-dependent transcription, which is known to be under negative control of cAMP-dependent protein kinase (PKA), is derepressed in all ccr4-not mutants. This phenotype is paralleled by specific post-translational modification defects of Msn2p in ccr4-not mutants relative to wild-type cells. Secondly, mutations in various NOT genes result in a synthetic temperature-sensitive growth defect when combined with mutations that compromise cells for PKA activity and at least partially suppress the effects of both a dominant-active RAS2Val-19 allele and loss of Rim15p. Thirdly, Not3p and Not5p, which are modified and subsequently degraded by stress signals that also lead to increased Msn2/4p-dependent activity, show a specific two-hybrid interaction with Tpk2p. Together, our results suggest that the Ccr4-Not complex may function as an effector of the Ras/cAMP pathway that contributes to repress basal, stress- and starvation-induced transcription by Msn2/4p.

Preoperative cardiac risk assessment: an updated approach.

HYPOTHESIS: We provide an updated algorithm for approaching preoperative cardiac risk assessment in patients undergoing noncardiac surgery. DESIGN: A National Library of Medicine PubMed literature search was performed dating back to 1985 using the keywords "preoperative cardiac risk for noncardiac surgery." This search was restricted to English language articles involving human subjects. RESULTS: Patient-specific and operation-specific cardiac risk can be determined clinically. Patients with major cardiac risk factors have a high incidence of perioperative cardiac complications, whereas the risk is less than 3% for low-risk patients. For intermediate-risk patients, no prospective randomized studies demonstrate the efficacy of noninvasive stress testing (dipyridamole thallium or dobutamine echocardiography) or of subsequent coronary revascularization for preventing perioperative cardiac complications. Recent studies demonstrate that perioperative beta-blockade significantly reduces the adverse cardiac event rate in intermediate-risk patients. CONCLUSIONS: Most patients with high cardiac risk should proceed with coronary angiography. Patients with low cardiac risk can proceed to surgery without noninvasive testing. For intermediate-risk patients, consideration may be given to further stress testing prior to surgery; however, in most patients, proceeding to surgery with perioperative beta-blockade is an acceptable alternative.

Inhibition of intra-abdominal adhesions: a comparison of hemaseel APR and cryoprecipitate fibrin glue.

Our previous studies demonstrated fibrin glue (FG) prepared from cryoprecipitate (cryo) inhibits intra-abdominal adhesions in rats. A new FG, Hemaseel APR, is Food and Drug Administration (FDA) approved for hemostasis during cardiac surgery and splenic trauma. This study was undertaken to determine if Hemaseel FG prevents intra-abdominal adhesions, and to compare it to cryo FG. Forty-five rats underwent laparotomy. Bilateral peritoneal-muscular defects were created. Polypropylene mesh was sewn into each defect with a running silk suture. The bowel was abraded with gauze. The rats were then randomized to mesh covered with Hemaseel FG, cryo FG, or control. On postoperative day 7, the severity of adhesions were graded by percentage of mesh covered by adhesion (0-100%) and degree of adhesion (0-3). The mean percentage of mesh covered by adhesion was 9% for Hemaseel FG, 43% for cryo FG (p = .005), and 65% for the controls (p < .0001). The mean density adhesion score was 0.5 for Hemaseel FG, 1.2 for cryo FG (p = .04), and 2.1 for the controls (p < .0001). In the Hemaseel FG group, 77% of patches had no adhesions, compared with 37% in the cryo FG group (p = .004) and 13% in the controls (p < .0001). Thus, Hemaseel FG significantly decreases intra-abdominal adhesions, and is more effective than cryo FG.

Trends in cardiac morbidity and mortality after endoluminal abdominal aortic aneurysm repair; discussion 999-1000.

HYPOTHESIS: The adverse cardiac event rate following endoluminal abdominal aortic aneurysm (EAAA) repair has decreased as experience in performing the procedure has increased. Aneurysm complexity affects the rate of adverse cardiac events. DESIGN AND PATIENTS: Data from 173 consecutive patients undergoing EAAA repair from 2 successive periods were compared. There were 82 patients in the early group (group 1) and 91 patients in the later group (group 2). MAIN OUTCOME MEASURES: Myocardial infarction, congestive heart failure, unstable angina, major dysrhythmias, death. RESULTS: The cardiac event rate was 8.5% for group 1 vs 16.5% for group 2 (P =.16). Predictors of adverse cardiac events on multivariate analysis were the use of 4 or more graft extensions (P =.04), female sex (P =.01), and number of Eagle risk factors (P<.001). There were 2 postoperative deaths (2.4%) in group 1 and 4 (4.4%) in group 2 (P =.7). CONCLUSIONS: Following EAAA repair: (1) adverse cardiac events were found to correlate with use of 4 or more graft extensions, female sex, and the number of Eagle risk factors; (2) cardiac morbidity and mortality remain significant despite greater experience and improved technology; and (3) operative mortality remains acceptably low.

Bud8p and Bud9p, proteins that may mark the sites for bipolar budding in yeast.

The bipolar budding pattern of a/alpha Saccharomyces cerevisiae cells appears to depend on persistent spatial markers in the cell cortex at the two poles of the cell. Previous analysis of mutants with specific defects in bipolar budding identified BUD8 and BUD9 as potentially encoding components of the markers at the poles distal and proximal to the birth scar, respectively. Further genetic analysis reported here supports this hypothesis. Mutants deleted for BUD8 or BUD9 grow normally but bud exclusively from the proximal and distal poles, respectively, and the double-mutant phenotype suggests that the bipolar budding pathway has been totally disabled. Moreover, overexpression of these genes can cause either an increased bias for budding at the distal (BUD8) or proximal (BUD9) pole or a randomization of bud position, depending on the level of expression. The structures and localizations of Bud8p and Bud9p are also consistent with their postulated roles as cortical markers. Both proteins appear to be integral membrane proteins of the plasma membrane, and they have very similar overall structures, with long N-terminal domains that are both N- and O-glycosylated followed by a pair of putative transmembrane domains surrounding a short hydrophilic domain that is presumably cytoplasmic. The putative transmembrane and cytoplasmic domains of the two proteins are very similar in sequence. When Bud8p and Bud9p were localized by immunofluorescence and tagging with GFP, each protein was found predominantly in the expected location, with Bud8p at presumptive bud sites, bud tips, and the distal poles of daughter cells and Bud9p at the necks of large-budded cells and the proximal poles of daughter cells. Bud8p localized approximately normally in several mutants in which daughter cells are competent to form their first buds at the distal pole, but it was not detected in a bni1 mutant, in which such distal-pole budding is lost. Surprisingly, Bud8p localization to the presumptive bud site and bud tip also depends on actin but is independent of the septins.

An abnormal dipyridamole thallium/sestamibi fails to predict long-term cardiac events in vascular surgery patients.

Recent data demonstrate that dipyridamole-thallium (DTHAL) and sestamibi (DMIBI) are not predictive of adverse perioperative cardiac events in moderate-risk patients (one or more Eagle risk factors) undergoing major elective vascular surgery. Less data are available regarding the ability of DTHAL/DMIBI to predict adverse cardiac events on long term follow-up. We sought to determine whether an abnormal DTHAL/DMIBI is predictive of adverse cardiac events on long-term follow-up in moderate-risk patients undergoing major elective vascular surgery. Patients were enrolled prospectively between June 1997 and June 1999 at West Los Angeles VA and Harbor-UCLA Medical Centers. Adverse cardiac events were defined as congestive heart failure (CHF), myocardial infarction (MI), unstable angina (USA), and ventricular arrhythmias. Follow-up was obtained via clinic visits, telephone calls, and chart review. We studied 75 patients (76% male, 24% female) with a mean age of 65 years. Operative procedures were primarily femorodistal (83%) and aortic (16%). DTHAL/DMIBI results were normal in 35 patients (47%), demonstrated reversible ischemia in 26 (35%), and showed a fixed defect alone in 14 (18%). From the follow-up results of this study we conclude that there is no association between a reversible ischemia or an abnormal (fixed or reversible) DTHAL/DMIBI and adverse cardiac events or mortality on long-term follow-up in moderate-risk patients who have undergone major vascular surgery.

A simple model to help distinguish necrotizing fasciitis from nonnecrotizing soft tissue infection.

BACKGROUND: Necrotizing fasciitis (NF) has been associated with certain "hard" clinical signs (hypotension, crepitance, skin necrosis, bullae, and gas on x-ray), but these may not always be present. Using results of a previous study, we developed a simple model to serve as an adjunctive tool in diagnosing NF (admission WBC > 15.4 x 10(9)/L or serum sodium [Na] < 135 mmol/L) and determined its ability to distinguish between patients with NF and nonnecrotizing soft tissue infection (non-NF). STUDY DESIGN: A retrospective review was conducted of consecutive NF (n=31) and non-NF patients (n= 328) treated at a single institution during an 11-month period. Comparison of admission vital signs, physical examination findings, radiology results, and number of patients meeting model criteria was performed. RESULTS: Ninety percent of NF patients and 24% of non-NF patients met model criteria (p < 0.0001). The model had a sensitivity of 90%, a specificity of 76%, a positive predictive value of 26%, and a negative predictive value of 99% for diagnosing NF. Nineteen (61%) NF patients had no "hard" signs of NF; the model correctly classified 18 (95%) of these patients. CONCLUSIONS: Admission WBC greater than 15.4 x 10(9)/L and serum Na less than 135mmol/L are useful parameters that may help to distinguish NF from non-NF infection, particularly when classic "hard" signs of NF are absent.

Simplified admission criterion for predicting severe complications of gallstone pancreatitis.

HYPOTHESIS: Simple admission criteria (white blood cell count, > or =14. 5 x 10(9)/L; blood urea nitrogen level, > or =4.3 mmol/L [> or =12 mg/dL]; heart rate, > or =100 beats per minute; and serum glucose level, > or =8.3 mmol/L [> or =150 mg/dL]) are better predictors of severe complications of gallstone pancreatitis than an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 5 or greater, a modified Imrie (Glasgow) score of 3 or greater, and a biliary Ranson score of 3 or greater. DESIGN: A prospective consecutive case study. SETTING: A university-affiliated, urban, public hospital. PATIENTS: Ninety-two consecutive patients (77 women and 15 men, aged 18 to 76 years [mean age, 39 years]) with gallstone pancreatitis. Seventy-seven patients were Hispanic. MAIN OUTCOME MEASURES: Major local and systemic complications requiring intensive care unit care, and death. RESULTS: Fourteen patients (15%) had severe complications with a mortality of 2%. On univariate analysis, a white blood cell count of 14.5 x 10(9)/L or more (P =.03), a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) (P<.001), an APACHE II score of 5 or greater (P =.008), a modified Imrie score of 3 or greater (P<.001), and a biliary Ranson score of 3 or greater (P =.03) were statistically associated with the development of severe complications; whereas a blood urea nitrogen level of 4.3 mmol/L or more (> or =12 mg/dL) and a heart rate of 100 beats per minute or more were not. On multivariate analysis, only a serum glucose level of 8. 3 mmol/L or more (> or =150 mg/dL) was predictive of adverse events (P<. 001). CONCLUSIONS: Glucose level (> or =8.3 mmol/L [> or =150 mg/dL]) is the best single admission predictor of severe complications of gallstone pancreatitis and is superior to an APACHE II score of 5 or greater, a modified Imrie score of 3 or greater, and a biliary Ranson score of 3 or greater.

Infrarenal aortic rupture in association with a contiguous polymicrobial intraabdominal abscess including Eikenella corrodens.

Aortic rupture in association with a contiguous intraabdominal abscess is rare. We report an unusual case of aortic rupture in association with a polymicrobial abscess and review the related literature. Cultures grew Eikenella corrodens, a rare intraabdominal pathogen, as well as betahemolytic streptococcus and S. viridans. The patient was successfully managed by aortic ligation followed by an extraanatomic bypass.

Dipyridamole-thallium/sestamibi before vascular surgery: a prospective blinded study in moderate-risk patients.

PURPOSE: This study assessed in a prospective, blinded fashion whether a reversible defect on dipyridamole-thallium (DTHAL)/sestamibi (DMIBI) can predict adverse cardiac events after elective vascular surgery in patients with one or more clinical risk factors. METHODS: Consecutive patients with one or more clinical risk factors underwent a preoperative blinded DTHAL/DMIBI. Patients with recent congestive heart failure (CHF) or myocardial infarction (MI) or severe or unstable angina were excluded. RESULTS: Eighty patients (78% men; mean age, 65 years) completed the study. Diabetes mellitus was the most frequent clinical risk factor (73%), followed by age older than 70 years (41%), angina (29%), Q wave on electrocardiogram (26%), history of CHF (7%), and ventricular ectopy (3%). The results of DTHAL/DMIBI were normal in 36 patients (45%); a reversible plus or minus fixed defect was demonstrated in 28 patients (36%), and a fixed defect alone was demonstrated in 15 patients (19%). Nine adverse cardiac events (11%) occurred, including three cases of CHF, and one case each of unstable angina, Q wave MI, non-Q wave MI, and cardiac arrest (successfully resuscitated). Two cardiac deaths occurred (2% overall mortality), one after a Q wave MI and one after CHF and a non-Q wave MI. The cardiac event rate was 14% for reversible defect and 9.8% without reversible defect (P =.71). The cardiac event rate was 12.5% (one of eight cases) for two or more reversible defects, versus 11.1% (eight of 72 cases) for fewer than two reversible defects (P = 1.0). The sensitivity rate of two or more areas of redistribution was 11% (95% CI, 0.3%-48%), the specificity rate was 90%, and the positive and negative predictive values were 12.5% and 89%, respectively. CONCLUSION: Our study demonstrated no association between reversible defects on DTHAL/DMIBI and adverse cardiac events in moderate-risk patients undergoing elective vascular surgery.

The riboflavin/FAD cycle in rat liver mitochondria.

Here we provide evidence that mitochondria isolated from rat liver can synthesize FAD from riboflavin that has been taken up and from endogenous ATP. Riboflavin uptake takes place via a carrier-mediated process, as shown by the inverse relationship between fold accumulation and riboflavin concentration, the saturation kinetics [riboflavin Km and Vmax values were 4.4+/-1.3 microM and 35+/-5 pmol x min(-1) (mg protein)(-1), respectively] and the inhibition shown by the thiol reagent mersalyl, which cannot enter the mitochondria. FAD synthesis is due to the existence of FAD synthetase (EC 2.7.7.2), localized in the matrix, which has as a substrate pair mitochondrial ATP and FMN synthesized from taken up riboflavin via the putative mitochondrial riboflavin kinase. In the light of certain features, including the protein thermal stability and molecular mass, mitochondrial FAD synthetase differs from the cytosolic isoenzyme. Apparent Km and apparent Vmax values for FMN were 5.4+/-0.9 microM and 22.9+/-1.4 pmol x min(-1) x (mg matrix protein)(-1), respectively. Newly synthesized FAD inside the mitochondria can be exported from the mitochondria in a manner sensitive to atractyloside but insensitive to mersalyl. The occurrence of the riboflavin/FAD cycle is proposed to account for riboflavin uptake in mitochondria biogenesis and riboflavin recovery in mitochondrial flavoprotein degradation; both are prerequisites for the synthesis of mitochondrial flavin cofactors.

Saccharomyces cerevisiae Ras/cAMP pathway controls post-diauxic shift element-dependent transcription through the zinc finger protein Gis1.

The Saccharomyces cerevisiae protein kinase Rim15 was identified previously as a component of the Ras/cAMP pathway acting immediately downstream of cAMP-dependent protein kinase (cAPK) to control a broad range of adaptations in response to nutrient limitation. Here, we show that the zinc finger protein Gis1 acts as a dosage-dependent suppressor of the rim15Delta defect in nutrient limitation-induced transcriptional derepression of SSA3. Loss of Gis1 results in a defect in transcriptional derepression upon nutrient limitation of various genes that are negatively regulated by the Ras/cAMP pathway (e.g. SSA3, HSP12 and HSP26). Tests of epistasis as well as transcriptional analyses of Gis1-dependent expression indicate that Gis1 acts in this pathway downstream of Rim15 to mediate transcription from the previously identified post-diauxic shift (PDS) element. Accordingly, deletion of GIS1 partially suppresses, and overexpression of GIS1 exacerbates the growth defect of mutant cells that are compromised for cAPK activity. Moreover, PDS element-driven expression, which is negatively regulated by the Ras/cAMP pathway and which is induced upon nutrient limitation, is almost entirely dependent on the presence of Gis1.

Objective criteria may assist in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection.

BACKGROUND: Optimal treatment of necrotizing fasciitis (NF) requires rapid diagnosis. The purpose of the study was to identify objective admission measurements that help differentiate NF from nonnecrotizing (non-NF) infection and, among NF patients, to identify admission factors that predict mortality. METHODS: Twenty-one NF cases were paired with matched non-NF controls. Statistical comparison of admission vital signs, laboratory values, and radiographic studies was performed. RESULTS: On multivariate analysis, admission white blood cell count (WBC) >14 x 10(9)/L, serum sodium <135 mmol/L, and blood urea nitrogen (BUN) >15 mg/dL separated NF from non-NF patients. Mortality for NF patients was predicted by admission WBC >30 x 10(9)/L. Mortality was also significantly increased for patients transferred from an outside institution prior to definitive therapy. CONCLUSIONS: Objective admission criteria (elevated WBC and BUN and decreased serum sodium) can assist in distinguishing NF from non-NF infections. The best objective predictor of mortality in NF patients is marked elevation of admission WBC.

Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate gallstone pancreatitis: a prospective randomized trial.

OBJECTIVE: To determine whether endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) stone extraction should be performed routinely before surgery or'selectively after surgery in patients with mild to moderate gallstone pancreatitis. SUMMARY BACKGROUND DATA: The role and timing of ERCP in mild to moderate gallstone pancreatitis remains controversial. Routine preoperative ERCP identifies persisting CBD stones but carries risks of complications and may delay definitive care. Selective postoperative ERCP, performed only if a CBD stone is seen on intraoperative cholangiography (IOC), avoids unnecessary ERCP but risks unsuccessful stone extraction. METHODS: A prospective, randomized study of consecutive patients with gallstone pancreatitis was conducted. Using previously determined criteria, patients with acute cholangitis or necrotizing pancreatitis were excluded. Patients considered at high risk for persisting CBD stones (CBD size > or =8 mm on admission ultrasound, serum total bilirubin > or = 1.7 mg/dL, or serum amylase > or = 150 U/L on hospital day 4) were randomly assigned to routine preoperative ERCP followed by laparoscopic cholecystectomy, or laparoscopic cholecystectomy with selective postoperative ERCP and endoscopic sphincterotomy only if a CBD stone was present on IOC. Primary end points were costs, length of hospital stay, and the combined treatment failure rates (failure of diagnostic ERCP and IOC, complications of ERCP and endoscopic sphincterotomy, and complications of surgery). RESULTS: One hundred fifty-four consecutive patients with gallstone pancreatitis were evaluated prospectively for study eligibility. Sixty patients met the randomization criteria. Thirty patients were randomized to routine preoperative ERCP and 29 patients to selective postoperative ERCP (1 patient refused). Age, admission laboratory values, and APACHE II and Imrie scores were similar in both groups. By protocol, ERCP was performed in all patients in the preoperative ERCP group. In the postoperative ERCP group, ERCP was necessary in only 7 of 29 patients (24%). Mean hospital stay was significantly longer in the routine preoperative ERCP group (11.7 days) than in the selective postoperative ERCP group (9.0 days). Mean total cost was higher in the preoperative ERCP group ($9,426) than in the postoperative ERCP group ($7,798). The combined treatment failure rate was 10% in both groups. CONCLUSIONS: In patients with mild to moderate gallstone pancreatitis without cholangitis, selective postoperative ERCP and CBD stone extraction is associated with a shorter hospital stay, less cost, no increase in combined treatment failure rate, and significant reduction in ERCP use compared with routine preoperative ERCP.

Fibrin glue reduces intra-abdominal adhesions to synthetic mesh in a rat ventral hernia model.

Postoperative intra-abdominal adhesions are associated with significant morbidity and mortality. In this study, the effect of topical fibrin glue (FG) on adhesion formation in a rat model was investigated. Forty Sprague-Dawley male rats underwent midline laparotomy. Bilateral peritoneal-muscular abdominal wall defects were created and then replaced with premeasured soft tissue Goretex patches. Rats were randomized to FG sprayed over the patches or to a control group. Two observers blinded to the randomization assessed the severity of adhesions to the patch by scoring the density of adhesions (grades 0-3) and the percentage of the patch area covered by adhesions (0-100%). The mean percentage of the patch covered by adhesions was 32.8 +/- 6.1 per cent for the FG group versus 57.9 +/- 6.7 per cent for the control group (P < 0.01). The mean density of adhesions for the FG group was 0.95 (+/-0.17) versus 2.0 (+/-0.21) for the control group (P = 0.001). Topical FG reduces the severity and density of intra-abdominal adhesions in a rat model.

Correlation between admission laboratory values, early abdominal computed tomography, and severe complications of gallstone pancreatitis.

BACKGROUND: Our previous study demonstrated that Balthazar grade D or E pancreatitis on early abdominal computed tomography (CT) scan correlated with severe complications of gallstone pancreatitis (GP). OBJECTIVE: To compare the efficacy of individual admission laboratory criteria, multiple criteria scoring systems and CT scan for predicting severe complications of GP. METHODS: Consecutively admitted patients with GP underwent selective early CT scanning (<72 hours). All patients were prospectively monitored for severe complications. RESULTS: Of the 66 patients studied, 21 (32%) did not undergo for early CT scanning and underwent cholecystectomy with no complications. Forty-five patients (68%) had an early abdominal CT scan. Of the 12 patients with grade E pancreatitis, 6 (50%) developed severe complications versus only 2 of 33 (6%) with grade A to D pancreatitis (P = 0.002). A significant correlation was found between admission white blood cell count > or =14.5 x 10(9)/L and grade E pancreatitis on early CT scan (P = 0.002). However, admission glucose > or =150 mg/dL was the best predictor of complications (sensitivity 100%, negative predictive value 100%). CONCLUSION: Although Balthazar grade E on early CT scan correlates with severe complications of GP, admission glucose > or =150 mg/dL has a better sensitivity and negative predictive value, is quicker to use, and is more cost-effective as a prognostic indicator.