Neurologic complications of gastric partitioning.

Six patients who had gastric reduction for morbid obesity suffered severe complex neurologic disturbances that included confusion and inappropriate behavior. All were profoundly weak or paraplegic, and recovery was delayed and incomplete. Encephalopathy was documented by EEG and neurologic examination. The cause is uncertain. Acute catabolism of lipid may predispose to damage of the nervous system, but relative vitamin deficiency is a more obvious and treatable explanation.

Early surgical treatment of gastrinoma.

Medical treatment of the Zollinger-Ellison syndrome has been generally accepted because of the proven efficacy of the histamine (H2)-receptor antagonists in achieving symptomatic relief, and because of early reports indicating that few, if any, gastrinomas were resectable for cure. Gastrin radioimmunoassay (RIA) has made earlier and more certain diagnosis possible, and therefore reevaluation of the surgical management of gastrinomas is necessary. Experience with 60 gastrinoma patients is reported. Comparison between the pregastrin RIA years (before 1970) and post-gastrin RIA years was made to determine whether there was evidence to support the continuation of medical treatment without attempts to resect the gastrinoma. Twenty-five cases were diagnosed in the pre-RIA years. Age at diagnosis ranged from 17 to 68 years (median, 45 years). All patients were operated on. Metastases were found in 56 percent. No tumor was identified in 8 percent. Tumor was resected for "cure" (normal fasting gastrin levels for two years postoperatively) in one patient. Seventeen patients have died, and tumor was the cause of death in 70 percent. The five-year survival rate was 44 percent; the 10-year survival rate was 40 percent. Thirty-five cases were diagnosed after 1970. Age at diagnosis ranged from 39 to 61 years (median, 46 years). Thirty patients were operated on. Metastases were identified in 23 percent and no tumor was found in 17 percent. Tumor was resected for "cure" in 30 percent of patients. Seven patients have died and tumor caused death in 42 percent. The five-year survival rate was 82 percent; the 10-year rate was 64 percent. Advances in diagnosis and surgical technique since 1970 have made early operative treatment applicable in patients with gastrinoma. Because death in most cases is caused by progression of the tumor, an aggressive surgical approach to resect the tumor is advised soon after the diagnosis of Zollinger-Ellison syndrome is established.

Ontogeny of StAR and ACTH-R genes in ovine placenta.

It has been demonstrated that the ovine placenta secretes estrogen, progesterone and cortisol, and that plasma concentrations of estrogen and cortisol increase before birth. Among the elements important for steroid production is steroidogenic acute regulatory protein (StAR) which acutely delivers cholesterol from the outer to the inner mitochondrial membrane for rapid steroidogenesis. This study was designed to determine if StAR is present in ovine placenta, and if its expression changes during fetal development. In addition, because cortisol is secreted by the placenta, we also examined the expression of adrenocorticotropic hormone receptor (ACTH-R) to determine if it was present and if the pattern of expression changed as gestation proceeded. The mRNA levels for StAR and ACTH-R were assessed by RNase protection assay (RPA) and protein levels were measured by Western blot in placentas from pregnant ewes (100-105 days of gestation, n = 8; 120 days of gestation, n = 5; 135-142 days of gestation, n = 8). The data show that the ovine placenta expresses StAR and ACTH-R. There was a significant increase in the StAR mRNA and protein between 100 and 142 days of gestation, but there were no significant age-related changes in ACTH-R mRNA and protein levels. The data suggest that the increased steroid production by the placenta in late gestation may be related to the increased expression of StAR.

Use of the EEA stapling instrument for control of bleeding esophageal varices.

Transection of the esophagus with the EEA stapling device (United States Surgical Corp.) has been used to treat 20 patients with bleeding esophageal varices. Their ages ranged from 38 to 73 years (mean 56.7 years). Sixteen patients (80%) had Laënnec's cirrhosis. A previous occluded portosystemic shunt was present in five patients. Based on Child's classification, there were one class A patient, 18 class C patient, and one patient who was unclassified. Five patients underwent elective operation; four survived (80%). The cases of the remaining 15 patients were treated as emergencies or semiemergencies after intensive preoperative intervention including intravenous administration of vasopressin (Pitressin) (100%), balloon tamponade in 11 (73%), and sclerotherapy in three (20%) failed to control the hemorrhage adequately. None of the patients had rebleeding from varices during the postoperative period. However, 11 of the 15 patients (73%) died. All deaths were related to liver failure, except for two patients who died of irreversible acidosis secondary to shock. Technical difficulty was encountered six times with use of the stapling device, resulting in three perforations of the esophagus, which were recognized and repaired at the time. No deaths were attributed to this complication. Of the eight patients who survived the early postoperative period, three have since died--two of variceal hemorrhage and the other of hepatic failure. Two others have had recurrent variceal hemorrhage controlled by sclerotherapy. The duration of follow-up ranges from 10 to 60 months (mean 31 months). Transection of the esophagus with the EEA stapling device for acute variceal hemorrhage is associated with an excessively high mortality rate despite the fact that it controls variceal hemorrhage. It appears to be of value when used on an elective basis for selected patients who cannot benefit from other modes of treatment.

Morbidity of emergency operations in patients with metastatic cancer receiving chemotherapy.

During a 5-year period, 21 patients with metastatic cancer receiving chemotherapy for periods ranging from 2 months to 5 years have required emergency abdominal operations. Symptoms in 15 indicated perforated viscus, whereas six developed massive, unremitting hemorrhage. All were operated upon with the sole intent of correcting the life-threatening problem, and every attempt was made to maintain or normalize physiologic parameters postoperatively. Despite this, 51 major complications occurred in 19 patients, and 17 died in the immediate postoperative period, 11 following multiple systems failure. Two died within 1 month of transfer to another hospital nearer home. A single patient lived 5 months at a nursing facility. The only survivor is living in a complete state of remission 9 months after discharge. No distinguishing features that might preoperatively predict which patient might survive emergency operation were found. The monetary cost of returning the sole survivor to society was over $500,000, discounting the emotional expenditure required of patients, families, and hospital staff. The dilemma the surgeon faces in making therapeutic decisions regarding such patients requires careful weighing of realities and the willingness to assume responsibility for the best possible choice in order to free the patient and family from agonizing deliberations.

Recurrent hypersplenism caused by alcoholic cardiomyopathy after distal splenorenal shunt.

The hypersplenism associated with portal hypertension usually resolves with a successful shunting procedure. Recurrent hypersplenism has been associated with shunt thrombosis. We describe a patient with pancytopenia, jaundice, and diffuse edema after a distal splenorenal shunt. His shunt was angiographically proved patent. Extensive evaluation revealed severe alcoholic cardiomyopathy with passive splenic congestion. He died of cardiac failure. Alcohol is a systemic toxin that affects other organs, as well as the liver.

Gastrinoma: the predictive value of preoperative localization.

In the management of gastrinoma, a variety of preoperative tests for tumor localization are recommended. Their value in predicting surgical outcome is not well defined. We reviewed the preoperative investigation and operative outcome in 23 patients to assess the predictive value of localization before surgery. With results of laparotomy used as reference, the efficacy of computed tomography, angiography, ultrasonography, and magnetic resonance imaging, individually and combined for primary and metastatic disease, was determined. All investigative modalities were poor for the detection of primary gastrinomas, with individual sensitivities in the range of 20% to 29%. Their combined sensitivity was 53%, with a negative predictive value of only 38%. The detection of metastatic disease was better, with a combined accuracy of 83%. At laparotomy, tumor was identified in 19 of 23 (83%) patients. In 14 patients with negative preoperative workup, primary gastrinoma was found in 10 of 14 (71%) and resected for long-term cure in three of 14 (21%) patients. In all nine patients with positive preoperative test results, tumor was found and was resected for cure in four (44%) patients. In conclusion, preoperative localization of primary gastrinoma is unreliable, and a negative workup does not preclude cure. Therefore, despite the availability of effective palliative antiulcer therapy, all patients exclusive of those with multiple endocrine neoplasia, type I, or metastasis should undergo laparatomy with curative resection in mind.

Observations on fifty distal splenorenal shunts.

Fifty patients underwent conventional distal splenorenal shunts for bleeding esophageal varices. Five patient died within 30 days, giving an operative mortality of 10%. Three patients were lost of follow-up, but 47 patients were evaluated. Twelve patients died, 11 of liver failure, with more than half of the deaths occurring with 1 year, three fourths within 2 years, and all within 3 years after operation. Eleven patients rebled, and seven of these were among those who died. Sixteen patients had ascites prior to operation, but all responded to aggressive medical therapy. Twenty-two patients were available for study 2 or more years following operation. Eighteen (82%) are well with no encephalopathy, although the remaining four (18%) have had transient episodes of encephalopathy. Sixteen of the 18 patients judge their lifestyles to be productive. If the patient survived 24 months or longer, he had a four in five chance of living a normal life.

A critical comparison of the hematologic, cardiovascular, and pulmonary response to steroids and nonsteroidal anti-inflammatory drugs in a model of sepsis and adult respiratory distress syndrome.

Improved survival of patients receiving high-dose steroid therapy in sepsis and adult respiratory distress syndrome (ARDS) has been reported, but such therapy and its benefits remain controversial. Recently research has been directed toward manipulation of the arachidonic acid cascade. Improved survival and hemodynamics with administration of nonsteroidal anti-inflammatory drugs (NSAID) have been reported in animal models of sepsis and ARDS. The purpose of this study was to compare the effects of steroids (methylprednisolone) and NSAID (ibuprofen) in a porcine model of septic ARDS induced by a continuous infusion of live Pseudomonas aeruginosa. Cardiopulmonary parameters were monitored in animals intubated, paralyzed, and ventilated at a 250 ml tidal volume and 0.5 Fio2. Pigs were randomly assigned to one of five groups: groups I and II received respective doses of 12.5 mg/kg ibuprofen and 30 mg/kg methylprednisolone at 20 and 210 minutes after baseline; group III had P. aeruginosa only; groups IV and V received respective doses of ibuprofen and methylprednisolone at 20 and 210 minutes of sepsis. Significant pulmonary edema, increased intrapulmonary shunting, hypoxemia, hemoconcentration, and systemic hypotension occurred with P. aeruginosa infusion. In septic animals treated with ibuprofen normal systemic arterial pressure was maintained, hemoconcentration was decreased, and oxygenation was improved with a significant decrease in shunting and pulmonary edema. Administration of methylprednisolone improved hemoconcentration and cardiac index, but no significant effect on pulmonary edema, intrapulmonary shunting, or oxygenation was observed. The results of this study demonstrated a significant beneficial effect of ibuprofen and we would encourage controlled clinical trials of this drug in the management of sepsis and ARDS. On the other hand, methylprednisolone was found to be relatively ineffective in treatment of circulatory collapse and ARDS associated with sepsis.

Observations on the effect of a somatostatin analog in the Zollinger-Ellison syndrome: implications for the treatment of apudomas.

Somatostatin is known to inhibit hormone release and gastrointestinal secretion and hence may be useful in the treatment of amine precursor uptake, decarboxylase tumors. Clinical application has been limited by the short half-life, potency, and specificity of the natural hormone. Our study evaluated the effect of a synthetic analog of somatostatin, SMS 201-995 (Sandoz, Inc., E. Hanover, N.J.) on basal and stimulated gastrin release and gastric acid secretion in 10 patients with the Zollinger-Ellison syndrome. In experiment 1, H2-receptor antagonists were discontinued for 48 hours; SMS 201-995, 1 microgram/kg, was given subcutaneously; gastrin and SMS levels in plasma were determined by radioimmunoassay; and gastric secretion was measured and titrated at 0, 1, 2, 3, 4, 5, 6, 8, 10, 12, 14, 16, and 18 hours. The mean +/- SEM baseline gastrin level (1526 +/- 733 pg/ml) was significantly inhibited for 16 hours (p less than 0.05, paired t test). Gastric secretion was neutralized for as long as 18 hours (p 0.05). In experiment 2, three patients received either a secretin (2 U/kg) or a calcium stimulation test (2 mg/kg) with or without pretreatment with SMS 201-995, 1 microgram/kg, subcutaneously. The mean +/- SEM interpreted change in gastrin (ng X 60 min/ml) without SMS 201-995, 36.8 +/- 11 (secretin), and 129 +/- 30 (calcium) were reduced with SMS 201-995 to -1.1 +/- 0.76 (secretin) and -29 +/- 28 (calcium) (p less than 0.05). In the Zollinger-Ellison syndrome, SMS 201-995 caused significant and long-lasting inhibition of both tumor gastrin release and gastric acid secretion, probably by direct action on both the gastrinoma and the stomach. SMS 201-995 blocks acid secretion and secretin- and calcium-stimulated gastrin release, indicating that SMS 201-995 inhibits peptide secretion by postreceptor mechanisms. SMS 201-995 will be useful in the palliative treatment of apudomas.

Peritoneal fluid in human acute pancreatitis blocks hepatic mitochondrial respiration.

Peritoneal fluid may be the source of multi-system failure during the initial stages of acute pancreatitis. The toxicity of human pancreatic ascitic fluid (HPAF) collected under sterile conditions from 12 patients with acute pancreatitis was investigated with the use of an in vitro preparation of mitochondria. Hepatocyte mitochondria from Sprague-Dawley rats were prepared by standard techniques. Mitochondrial oxidative activity was determined in glutamate-malate medium, with micromodification of the YSI Model 53 (Yellow Springs, Ohio) oxygen electrode system. The oxygen uptake of 150 to 200 microliter samples of mitochondria suspension (20 to 25 mg/ml) was monitored for 3 minutes, after which 3 microliter of 0.1 M adenosine diphosphate (ADP) was added to the chamber to induce state 3 respiration. Two minutes after the oxygen trace returned to state 4 respirations, 20, 40, or 80 microliter of the HPAF sample was introduced into the reaction vessel and the oxygen measurement continued for an additional 3 minutes. After this, 3 microliter of 0.1 M ADP again was added to the reaction chamber and the oxygen measurement continued. Control runs were made with reconstituted pooled human serum used in place of the HPAF samples. A significant (p less than 0.05) increase in state 4 respiration occurred in all 12 samples of HPAF. Addition of ADP showed a significant decline (p less than 0.05) in respiratory control ratio in all specimens. A dose-response curve was observed in 8 of 12 HPAF samples tested.(ABSTRACT TRUNCATED AT 250 WORDS)

Idiopathic acute pancreatitis: the value of endoscopic retrograde cholangiopancreatography.

Acute pancreatitis is classified as idiopathic when an underlying cause cannot be identified through a careful history and appropriate noninvasive tests. Unless a cause can be identified, recurrent attacks cannot be effectively prevented. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 35 patients considered to have idiopathic recurrent acute pancreatitis, and an anatomic abnormality of either the pancreatic or biliary ductal system was demonstrated in 16. Ten underwent appropriate surgical procedures based on the results of ERCP, and 80% had no further episodes of acute pancreatitis. ERCP established the precise nature of potentially correctable anomalies and thereby facilitated precise preoperative planning. The wider use of ERCP in these patients may lessen the number of cases of acute pancreatitis considered to be idiopathic and lead to appropriate surgical therapy.

Determination of viability of ischemic intestine by Doppler ultrasound.

Doppler ultrasound was used to determine the viability of ischemic small intestine and to select the optimum point for resection of nonviable bowel. Twenty ischemic segments of small intestine were produced in dogs by ligating the vascular supply. The Doppler ultrasound probe then was used to determine the last point of arterial flow within the bowel wall. The dogs were reexplored after 24 hours. Histological examination of full-thickness biopsies showed the intestine to be normal in all 20 segments at the last audible Doppler signal, and in 19 of the 20 segments at 1 cm distal to the last signal. Progressive degrees of necrosis were observed at 2 and 3 cm distal to the last signal. Twenty-five segments of ischemic intestine were resected in baboons. All resections performed at the last Doppler signal or 1 cm distal to it were normal 1 month later. Of 15 resections performed at 2, 3, and 4 cm distal to the last signal, 10 showed evidence of stricture or anastomotic disruption. Doppler ultrasound is a reliable method for determining the viability of ischemic intestine and for selecting the optimum point for resection of nonviable bowel.

The vasoactive properties of ascitic fluid in acute pancreatitis in a porcine model.

The hemodynamic effect of pancreatic ascitic fluid was studied in a porcine model. Pancreatitis was induced by a low-pressure infusion of trypsin and taurocholate sodium into the pancreatic duct. The ascitic fluid that accumulated was then injected into the inferior vena cava of five pigs, with each pig receiving five infusions at 40-minute intervals. Mean arterial blood pressure and peripheral vascular resistance fell with each infusion, while pulmonary artery pressure increased. The magnitude of the drop in arterial blood pressure decreased with subsequent infusions, suggesting tachyphylaxis. The rise in pulmonary artery pressure increased with successive infusions. Anesthesia artifact and decay of the pancreatic ascitic fluid were ruled out as causes of the tachyphylaxis. Filtration separated the substances producing pulmonary effects and systemic blood pressure effects (0.2 to 11 microns vs 10,000 daltons to 0.2 micron). These data suggest that two mediators may produce the hemodynamic effects of pancreatic ascitic fluid.

The permanent gastrostomy. Use of the gastrointestinal anastomotic stapler.

A permanent feeding gastrostomy was quickly and simply constructed in 29 patients with low operative risk using the gastrointestinal anastomotic stapler. The technique consisted of a simple application of this stapler on a carefully selected section of the stomach to form a Janeway type of gastrostomy. Activation of the device placed two double rows of staples and cut between them. This left the mucosa in approximation both in the tube and in the body of the stomach. A few additional Lembert sutures was all that was necessary. There were no suture line leaks nor other complications peculiar to the method.

Changing indications for splenectomy. 30 years' experience.

During the last three decades, 2,4117 splenectomies have been performed at The Ohio State University Hospital. Indications for splenectomy include hypersplenism, incidental to other abdominal procedures, trauma, Hodgkin's staging, and other splenic disease. Hodgkin's staging has become the most frequent indication for splenectomy during the past five years, whereas splenectomy for hypersplenism has decreased. Thrombocytosis (platelet counts greater than 400,000/cu mm) was observed in 47% of all patients. Ninety-three percent of all thromboembolic complications occurred in this group. The overall morbidity of 39% has been decreased to 15% during the last five years. In-hospital mortality has decreased from 9.5% to 6%. Incidental splenectomy, even for benign disease, continues to be associated with complications and death.

Local cutaneous recurrence after conservative excision of malignant melanoma.

We examined the risk factors for the development of local recurrence in patients treated with a conservative wide local excision, which was defined as being less than the historical 5-cm margin. There were 118 patients with clinical stage I disease followed up for a minimum of 60 months or until death. The extent of wide local excision varied from 0.6 to 8.5 cm. The majority (76.3%) had a resection margin of 30 mm or less. Four patients (3.4%) had local recurrence within 5 cm of the primary closure scar or skin graft edge. The primary lesion in the patients with local recurrence had deeper invasion and larger diameters than the lesion in patients who did not have local recurrence. Other recognized risk factors, such as ulceration, satellitosis , and unrecognized subclinical stage II disease, at the time of initial diagnosis were noted in the patients eventually displaying local recurrence. Tumor aggressiveness was recognized. The patients who had local recurrence had excisions with wider margins (mean, 4.75 cm; range, 2.5 to 8.5 cm) than the patients without local recurrence (mean, 2.87 cm; range, 0.6 to 6.0 cm). A tumor-field effect did not contribute to local recurrence.

Endoscopic retrograde cholangiopancreatography. Its use in the evaluation of nonjaundiced patients with the postcholecystectomy syndrome.

Forty-two patients with the postcholecystectomy syndrome were studied by endoscopic retrograde cholangiopancreatography (ERCP). Both the biliary ductal system and pancreatic duct were well visualized in all patients. The ERCP was abnormal in 22 patients (52%). Abnormal findings included choledocholithiasis, papillary stenosis, pancreas divisum, pancreatic carcinoma, sclerosing cholangitis, incomplete cholecystectomy, and chronic pancreatitis. The results of one or more standard liver function tests and/or other noninvasive tests were abnormal in 36 patients; however, none reliably predicted the presence or specific anatomical type of pancreaticobiliary tract disease. Our data indicate that ERCP is essential in the diagnosis and management of the postcholecystectomy syndrome. The high yield of abnormal findings amenable to surgical correction in patients with recurrent biliary tract symptoms following cholecystectomy justifies the use of this procedure in all such patients.

Prevention of early failure of stapled gastric partitions in treatment of morbid obesity.

Clinical observations and data obtained in animal experiments indicate that the gastric partition is most susceptible to the stresses of solid food boluses between the second and sixth postoperative weeks, predisposing the operation to early failure. Tensiometer studies indicate that by the sixth to the eighth postoperative week, the staple line is as strong as uninjured stomach. Liquid diet restriction for eight weeks after gastric partitioning reduces the incidence of early operative failure. Until safe and effective methods of increasing staple line strength are established, all patients having gastric partitioning should be restricted to a liquid diet for eight weeks after operation.

Cytokine activation through sublethal hemorrhage is protective against early lethal endotoxic challenge.

OBJECTIVES: To determine the immunologic consequences of nonlethal hemorrhage on subsequent exposure to lipopolysaccharide (LPS) and to determine the role of interleukin 1 beta (IL-1) specifically in mediating the response to LPS with and without prior hemorrhage. DESIGN: Prospective, randomized, controlled experimental trial. PARTICIPANTS: Male BALB/c mice and transgenic mice deficient in IL-1 converting enzyme. INTERVENTIONS: Animals were subjected to hemorrhage (by cardiac puncture), LPS challenge by intraperitoneal injection, or hemorrhage followed 24 hours later by LPS challenge. Mortality was assessed every 4 hours for 96 hours following hemorrhage or LPS exposure. Serum IL-1 levels were determined 24 hours after exposure to hemorrhage and LPS. SETTING: University of South Florida Core General Surgery Research Facility, Tampa. MAIN OUTCOME MEASURES: Mortality and serum IL-1 levels. RESULTS: Hemorrhage alone resulted in complete survival, whereas LPS alone resulted in near-complete (95%) mortality. Hemorrhage, when given 24 hours before LPS challenge, afforded significant protection compared with LPS alone (67% survival vs 5% survival; P < .001). Serum IL-1 levels 24 hours after exposure to LPS were significantly lower in prehemorrhaged mice than in those receiving LPS alone. Transgenic mice incapable of producing biologically active IL-1 were further protected, demonstrating near-complete (95%) survival following hemorrhage and LPS challenge. CONCLUSIONS: Cytokine activation through nonlethal hemorrhage attenuates subsequent IL-1 response to early immunologic challenge. Such immune suppression appears to be protective early on and is supported by the near-complete immunity to LPS in animals incapable of producing biologically active IL-1.