Laparoscopic drainage of lymphoceles after kidney transplantation: indications and limitations.

BACKGROUND: Symptomatic lymphoceles are not uncommon after kidney transplantations. Surgical marsupialization with internal drainage is the treatment of choice. However, laparoscopic drainage is reportedly as effective, with only minimal trauma. METHODS: We attempted 14 laparoscopic lymphocele drainages during a 3-year period and studied the indications and limitations, using intraoperative ultrasonography in all cases. RESULTS: Laparoscopic drainage was successful in only 9 (64%) of 14 patients. A conversion to open laparotomy was necessary in five patients; their lymphoceles were lateral and either posterior or inferior to the kidney. Two patients with initially successful laparoscopic drainage required conversion to open laparotomy 21 and 83 days later; their lymphoceles were inferior to the kidney. Laparoscopic drainage shortened the median hospital stay by 4 days versus open surgical drainage and by 7 days versus conversion. Hospital costs for laparoscopic drainage averaged $7400 less versus open drainage and $10,300 less versus conversion. CONCLUSIONS: In patients with symptomatic lymphoceles medial and either superior or anterior to the kidney, laparoscopic drainage under intraoperative ultrasonographic guidance is easy, safe, and effective. It decreases hospitalization, convalescence, and costs. In patients with symptomatic lymphoceles lateral and either posterior or inferior to the kidney, laparoscopic drainage may fail because of anatomic inaccessibility and technical impracticability.

Gastritis after gastric bypass surgery.

To determine the preferable reconstruction of gastrointestinal continuity after gastric bypass, we studied by endoscopic, chemical, and histologic analyses 28 randomly selected patients with a loop gastroenterostomy, a loop gastroenterostomy plus enteroenterostomy between the afferent and efferent loops, and a Roux-en-Y anastomosis. Total bile acid levels for the three groups were: 5092 +/- 1673 mumol/L, 1638 +/- 581 mumol/L, and 404 +/- 384 mumol/L, respectively. The incidence of gastritis by endoscopy was 71% in the standard loop bypass, 45% in the enteroenterostomy group, and 13% in the Roux-en-Y group. Histologic abnormalities were present in 86% of the patients who underwent standard loop bypass, in 91% of those with an additional enteroenterostomy, and in 63% of the Roux-en-Y group. There was poor correlation of symptoms and objective findings. In our study Roux-en-Y reconstruction after gastric bypass, in comparison with loop gastroenterostomy or loop gastroenterostomy with an additional enteroenterostomy, is less likely to result in bile in the stomach, endoscopic changes, and histologic abnormalities.

Endoscopic dilation of a gastric anastomotic stricture.

A stricture developed in a patient two months after undergoind a Billroth I gastroduodenal anastomosis. His mechanical gastric obstruction was relieved by dilation up to 37 F caliber under direct vision using a fiberendoscope. The patient became, and has remained, symptom free. Visualization of the area two months after dilation showed an adequately patent anastomosis.

Ulcer perforation rate and pepsin. A study of the perfused cat esophagus.

The perforation rate of the cat esophagus varies as the log of the pepsin concentration when the esophagus is perfused in vivo with canine gastric juice at constant acidity, temperature, and pressure. The esophagus is extremely sensitive to gastric juice, frequently perforating before 60 minutes of perfusion. The maximal response is achieved with pepsin concentrations of 0.3 mg/mL, although the canine stomach is capable of concentrations as high as 1.3 mg/mL after vagal stimulation with 2 deoxy-D-glucose. These findings emphasize that peptic activity contributes significantly to initial acute esophageal ulceration induced by gastric secretions.

Role of pepsin in species differences in erosive gastritis.

This controlled study shows that the rabbit is more vulnerable to erosive gastritis after stress of operation, weight loss, and hypersecretion or acute ischemia than is the cat. Rabbit gastric juice also produces more erosions in the Shay rat preparation after four hours than does cat gastric juice (P less than .05). In vitro, rabbit pepsin has 1.5 times greater specific activity and possesses other kinetic differences. The deleterious effect of these qualitative differences on gastric mucosa may also be augmented by quantitative differences. Hypersecretion of pepsin has been reported once the mucosa is damaged. We conclude that demonstration of species-related differences in pepsin activity helps to explain an apparent discrepancy noted by others--namely, why the rabbit is so much more susceptible to stress-produced erosions than the cat or other experimental animals.

Inhibition of acetyl- and butyrylcholinesterase and amylase release from canine pancreas.

There are two tissue-fixed cholinesterases in dog pancreas: acetylcholinesterase and butyrylcholinesterase. In the present experiments, an organophosphate that only inhibits butyrylcholinesterase (isopropylpyrophosphoramide, or iso-OMPA) was compared with echothiophate and a nonorganophosphate compound, physostigmine. The latter two agents inhibit both cholinesterases. Fresh canine pancreas from anesthetized dogs was minced into fragments and suspended in Eagle's solution gassed with 100% O2. Amylase release was measured by the Phadebas method. In 2-h dose-response studies, there was a fivefold increase in sensitivity to acetylcholine when fragments were preincubated 1 h with iso-OMPA. There was a 1,000-fold increase in sensitivity when fragments were preincubated for 1 h in echothiophate. Basal amylase release in incubates with echothiophate were also increased. In dose-response studies with CCK-8, iso-OMPA was without effect, but echothiophate treatment resulted in a greater total response to CCK-8. There was a corresponding increase in basal output with echothiophate alone. Physostigmine also potentiates the response to CCK-8. Cumulative responses up to 3 h with half-maximal acetylcholine or half-maximal CCK-8 doses showed enhanced total output in fragments preincubated with echothiophate (p less than 0.05). The enhancement effect was atropine-sensitive to hexamethonium ganglionic blockade. In calcium-free medium, the enhancement with echothiophate was greatly reduced but still present. Inhibitors of both cholinesterases in the pancreas cause a greater total amylase release to sub-maximal doses of acetylcholine and CCK-8 than agents that only inhibit butyrylcholinesterase. Though our data do not provide direct proof, the results could be explained by a greater accumulation of endogenous acetylcholine when both cholinesterases are inhibited.

Ultrastructure of the guinea pig pancreas in acute hypercalcemia.

The effect of acute hypercalcemia on pancreatic ultrastructure and the ultrastructural localization of calcium during hypercalcemia were studied in the guinea pig pancreas. After 3 h of i.v. calcium infusion (0.6 mmol/kg/h), hypertrophy and distention of the Golgi apparatus and an increased number of condensing vacuoles were seen. At 6 h, vacuolar fusion and displacement of zymogen granules occurred. At 9 h, irregular distribution of zymogen granules, indentation of the nucleus with chromatin clumping, and inclusion of intact cell organelles were present. Disruption of the plasma membrane and release of cell organelles into the interstitial space were seen. Control animals receiving saline solution (0.9% NaCl) revealed normal pancreatic ultrastructure. The serum ionized calcium values were 0.65 +/- 0.36 mM in controls and 0.71 +/- 0.14, 0.79 +/- 0.21, and 1.22 +/- 0.50 mM at 3, 6, and 9 h of calcium infusion, respectively. The ultrastructural localization of calcium was performed with the pyroantimonate staining technique after 3 h of calcium and saline infusion. Large calcium deposits were found in calcium-treated animals along the plasma membrane and in the Golgi region. The findings indicate that calcium exerts a strong stimulatory effect that eventually leads to the degeneration of the pancreatic acinar cell.

Increased canine pancreatic acinar cell damage after organophosphate and acetylcholine or cholecystokinin.

Sublethal doses of organophosphate anticholinesterases cause acute pancreatitis in dogs within 2 h. In vitro studies using canine pancreatic fragments have also demonstrated that the peak of amylase release in response to acetylcholine is shifted far to the left after incubation with the organophosphates echothiophate (10(-4) M) or tetraisopropyl pyrophosphoramide (iso-OMPA) (10(-3) M), indicating an increased sensitivity of response. The present in vitro study examined whether there was also an increased susceptibility to acinar cell damage at the electron microscopic level after acetylcholine or cholecystokinin. Minced pieces of whole fresh canine pancreas 2-3 mm in size were placed in buffered Eagle's solution and gassed with 100% O2. After pretreatment 1 h with echothiophate or iso-OMPA, they were then incubated with acetylcholine (10(-5) M). Other tissues preincubated with echothiophate were stimulated with cholecystokinin (10(-9) M). These are submaximal doses for untreated canine pancreatic fragments. After acetylcholine and echothiophate or acetylcholine and iso-OMPA, there was extensive acinar damage with the appearance of large vacuoles and lakes, and interstitial edema. There was evidence of intense supramaximal stimulation and lateral exocytosis. Similar destructive changes were seen after echothiophate and cholecystokinin. In control sections from tissues stimulated with acetylcholine (10(-5) M) or cholecystokinin (10(-9) M, there were lumenal exocytotic patterns typical of submaximal stimulation. Other controls, organophosphate alone and unstimulated basal conditions, showed only minor changes. It is concluded that the increased sensitivity to acetylcholine after organophosphate incubation correlates with an increased susceptibility to acinar ultrastructural damage from acetylcholine and cholecystokinin.

Organophosphate sensitizes the human pancreas to acinar cell injury: an ultrastructural study.

Viable pancreas fragments from five human donors were incubated in oxygenated buffered Eagle Medium. The preparation and incubation conditions were based on the method of Scheele and Palade. In Group 1 there was 1-h preincubation with echothiophate (10(-4) M); then, acetylcholine (10(-5) M) was added. After 2 h tissues were prepared for electron microscopy. Acinar injury with vacuole formation was apparent. Many of these changes were observed in fragments incubated only with acetylcholine (10(-5) M) (Group 2) and in incubates with echothiophate only (10(-4) M) (Group 3); only minor changes were seen in controls with Eagle's Medium (Group 4). Large vacuoles were significantly more numerous in Group 1 than in Control Group 4 (p < 0.05). Zymogen granules were depleted in Groups 1, 2, and 3. This depletion was significant in Group 1 when compared with Group 4 (p < 0.02). These results extend previous in vitro results that showed increased amylase release after echothiophate treatment in human pancreas and a left shift in response to acetylcholine.

Organophosphate increases the sensitivity of human exocrine pancreas to acetylcholine.

Human pancreas contains two cholinesterase isoenzymes: acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE). In the present study, binding potency of two organophosphates for human cholinesterases were compared by the Ellman method. Echothiophate was found to have much greater potency than iso-OMPA for both cholinesterases. Using Karnovsky histochemical stains on human pancreatic tissue, the same results were confirmed. Dose-response studies with acetylcholine were done on viable pancreas fragments from nine human donors, without pancreatic disease (group I). Cold-preservation time was less than 30 h. Pancreas was minced into fragments, after the technique of Scheele and Palade, placed in Eagle's medium, and gassed with O2. Amylase release was measured by the Phadebas Method and corrected for basal release. There was a dose-dependent response to acetylcholine at 1 and 2 h, with a shift in peak amylase release to the left, when fragments were preincubated in 10(-4) M echothiophate. This indicated a 100-fold increase in sensitivity to acetylcholine. In three patients with chronic pancreatitis (Group II), there were variable patterns of response of amylase release to acetylcholine, and higher basal outputs. In Group III, prolonged storage conditions of over 40 h were tested for 4 pancreas donor tissues. There was no response to acetylcholine. These studies show that for up to 30 h cold storage, fragments of pancreas from human organ donors respond to acetylcholine in dose-dependent manner. An organophosphate, echothiophate (10(-4) M) which inhibits both cholinesterases, increases pancreatic sensitivity to acetylcholine, and these results are similar to findings from canine pancreas fragments, which also showed increased sensitivity.

Effect of the organophosphate iso-OMPA on amylase release by pancreatic lobules of dog, guinea pig, and cat.

Organophosphates (OPs) cause irreversible inhibition of cholinesterases (ChEs) and profound cholinergic stimulation. There are major differences in the response of the dog and cat pancreas to the in vivo administration of Diazinon (O,O-diethyl O-2-isopropyl-4-methyl-6-pyrimidyl phosphothioate), a butyrylcholinesterase (BuChE) inhibitor. Acute edematous pancreatitis is found in the dog but not in the cat. The present experiments were designed to see what effect OP had in vitro on pancreatic exocrine function of dog, cat, and guinea pig, and whether the effects were consistent with an anti-ChE activity. A water-soluble OP agent, tetraisopropyl pyrophosphoramide (iso-OMPA) at 10(-3) M, which like Diazinon inhibits BuChE, was used. Minced pieces of fresh whole pancreata 3 mm in size were taken from 3 dogs, 4 guinea pigs, and 2 cats. The tissues were placed in flasks containing Eagle's solution and gassed with 100% O2. Cumulative amylase release was measured by Phadebas method up to 3 h. At half-maximal acetylcholine (ACH) concentration (10(-5) M), the canine pancreas pretreated with iso-OMPA (10(-3) M) showed a 42-87% greater release of amylase than tissues receiving ACH alone (p less than 0.001). The same potentiated response to ACH was seen in guinea pig pancreas pretreated with iso-OMPA (p less than 0.001), but iso-OMPA pretreatment did not augment the ACH response in the cat. Atropine pretreatment effectively blocked all ACH responses, and there was no effect seen with iso-OMPA alone. In the dog, iso-OMPA in combination with half-maximal carbachol (10(-6) M), or in combination with half-maximal cholecystokinin (CCK-8) stimulation (10(-9) M), provided no potentiated amylase release.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperplasia of pancreatic duct epithelium produced by exposure to sodium deoxycholate.

Severe epithelial hyperplasia was produced in a canine model by the perfusion of the main pancreatic duct with 15 mM of deoxycholate at rates as low as 1.5 ml/day in 6 to 14 days. At higher rates (5 ml/day) deoxycholate caused complete epithelial cell lysis in the duct closest to the tip of the cannula with hyperplastic changes downstream from this section. Perfusion with a buffer solution alone and cannulation alone produced none of these changes in similar duct segments. No hyperplasia was seen in the upstream cannula obstructed duct, even in the presence of severe atrophy. Long-term (81 days) perfusion with 3 mM of deoxycholate at 3 ml/day resulted in more severe hyperplasia that still appeared benign. When glycine-conjugated deoxycholate was perfused through the duct, hyperplasia but no cell lysis was seen. In vitro, deoxycholate caused epithelial cell lysis in pancreatic duct fragments at concentrations of 0.5 mM and above. The results of this study suggest that secondary bile salts or other similar surface-active cytotoxic agents present in the biliary tree or duodenum may play a more important role in the pathogenesis of pancreatic ductal epithelial hyperplasia associated with pancreatic cancer than ductal obstruction.

Rapid long tube intubation of the jejunum by a new endoscopic device.

Despite the advantages of aseptic nonoperative intubation of the small intestine for decompression of obstructed loops, 48% of the attempts lead to failure to pass the tube through the pylorus. The difficulty and inconvenience of passage beyond the stomach have been overcome by the development of a special tube attachment adapted to a fiberoptic duodenoscope (Olympus Model GIF-K). Under direct endoscopic vision the tube can be carried into the second and third portion of the duodenum, released from the scope, and then further prodded into the jejunum. The entire procedure takes less than 15 minutes. Rapid intubation has now been easily carried out in five patients. Three patients had mechanical bowel obstruction. Rapid and effective decompression allowed adequate time for stabilization of concomitant serious problems such as (1) marked cardiopulmonary dysfunction secondary to a near fatal pulmonary embolus, (2) severe peritonitis post appendectomy, and (3) acidosis and dehydration. Surgical correction of the obstructing lesions was safely deferred for up to one week until the concomitant problems improved. The fourth patient, who was a renal transplant recipient, had chronic gastric ileus secondary to duodenal ulcer. Rapid passage of the long tube into the jejunum allowed restoration of nutrition and avoidance of gastrostomy. The fifth patient, with an ileus secondary to an infected abdominal aortic graft, underwent successful decompression but died of sepsis. He represents the only mortality. We propose that jejunal intubation using our technic is not only rapid but relatively easy and should encourage the wider acceptance of aseptic long tube intestinal decompression.

Hemodynamic, respiratory, and metabolic effects of laparoscopic cholecystectomy.

In 10 patients undergoing laparoscopic cholecystectomy, creation of pneumoperitoneum caused immediate venous hypertension and stasis in the lower extremities as measured by percutaneous catheter and duplex scanning. These changes disappeared after deflation. As measured by spirometry, significant reductions in forced vital capacity of 23% and forced expiratory volume in 1 second of 22% were present 24 hours after surgery, and plasma interleukin-6 levels rose to 18 pg/mL. The visual analogue scale of resting pain increased to a median value of 2.5 postoperatively. When compared with other studies of open cholecystectomy, our results showed fewer restrictions of ventilation, lower cytokine levels, and lower pain scores. The minimal soft tissue trauma and early ambulation after laparoscopic cholecystectomy may decrease the risk of thrombosis despite an acute episode of venous stasis.

Incidence and treatment of candida esophagitis in patients undergoing renal transplantation. Data from the Minnesota prospective randomized trial of cyclosporine versus antilymphocyte globulin-azathioprine.

Of 224 consecutive renal transplant patients in a prospective, randomized immunosuppressive trial, candida esophagitis developed in 5 despite nystatin prophylaxis. No differences were noted between cyclosporine and antilymphocyte globulin-azathioprine immunosuppressive treatment. All patients were diabetic, and four were recipients of cadaver kidneys. Candida esophagitis occurred within 6 months after transplantation, and only one patient had recurrence. All patients responded to treatment consisting of 2 to 6 days of intravenous amphotericin B (0.2 to 2 mg/kg total dose). The prevalence of candida esophagitis was not related to rejection episodes. Three of five patients eventually died, one 2 weeks after resolution of candida esophagitis from a hypoglycemic episode, one from acute exacerbation of pulmonary failure and relapsing pancreatitis in association with candida esophagitis and therapy-resistant candidemia, and one 17 months after candida esophagitis from pulmonary edema. Our findings show that candida esophagitis by itself is an easily managed complication, but is also a sign of potentially increased morbidity in these patients.

Hypercalcemia associated with pancreatitis and hyperamylasemia in renal transplant recipients. Data from the Minnesota randomized trial of cyclosporine versus antilymphoblast azathioprine.

The incidence and possible etiologic factors of acute pancreatitis and hyperamylasemia were statistically evaluated in renal transplant recipients. Two hundred twenty-four patients were randomized in a prospective trial of cyclosporine and antilymphoblast azathioprine immunosuppressive regimens. They had a median follow-up of 20 months. Pancreatitis developed in 8 patients and hyperamyl asemia developed in 20 patients. There were no statistical relationships between the incidences of pancreatitis and hyperamylasemia and the immunosuppressive drugs or viral infections. However, pancreatitis developed in 11 percent of the transplant patients with repeatedly elevated serum calcium levels (37 patients, p less than 0.01) and hyperamylasemia developed in 19 percent (p less than 0.025). Other etiologic factors, such as gallstones, alcoholism, and corticosteroids, played a minor role in this patient population. These results suggest that hypercalcemia is a major etiologic factor for pancreatitis in renal transplant recipients.

Effects of insecticide, diazinon, on pancreas of dog, cat and guinea pig.

The organophosphate insecticide Diazinon has been reported to cause acute pancreatitis in dogs. Based on histochemical examination of the acinar tissue, it was suggested that pancreatic tissue-fixed butyrylcholinesterase (BuChE) is the target enzyme of organophosphate toxicity. To further evaluate this theory, we exposed dogs, cats, and guinea pigs to a single sublethal dose of the organophosphate insecticide Diazinon (75 mg/kg). In cats, which lack pancreatic BuChE, no pathological changes occurred after two, three, and six hours, whereas in the guinea pigs as in dogs, both having abundant pancreatic BuChE, vacuolization of the acinar cells, interstitial edema and vasculitis indicate acute edematous pancreatitis as early as two hours. Atropine pretreatment (0.2 mg/kg) gave complete protection against pancreatitis. It was concluded that inhibition of pancreatic BuChe leads to cholinergic hyperstimulation of the acinar cell, which results in acute pancreatitis, and that pancreatic BuChE is essential for dogs and guinea pigs to downregulate cholinergic excitation. The insecticide pancreatitis model is considered a simple, non-invasive, reproducible, and cheap and useful method to evaluate early changes and methods of treatment in acute pancreatitis. Pancreatitis in humans has also been reported after accidental insecticide exposure.

Nonoperative management of small-bowel obstruction with endoscopic long intestinal tube placement.

Intestinal obstruction remains a major cause of morbidity and mortality in surgical patients. We reviewed the records of 77 patients with mechanical small-bowel obstruction who were treated with endoscopically and fluoroscopically placed Leonard long intestinal tube decompression. Most patients (59%) had failed a trial of nasogastric tube or Miller-Abbott tube decompression. Overall, 29 per cent of patients were able to resolve their obstruction with Leonard tube decompression alone. Subdivision of patients on the basis of the etiology of their obstruction demonstrated a much higher rate of success for tube decompression in adhesive obstruction (37%) versus malignant obstruction (12%) or inflammatory obstruction (no successes). Patients with radiographic and clinical evidence of complete intestinal obstruction were significantly less likely to respond to long intestinal tube treatment (13%). The long intestinal tube was easily passed in all patients. There were no complications of the intubation procedure in our series, and the incidence of tube-related complications was four per cent. We conclude that an initial period of long intestinal tube decompression allows a significant percentage of patients with mechanical small-bowel obstruction to be treated nonoperatively, particularly if a partial obstruction from postoperative adhesions is present. Patients who have failed a trial of nasogastric tube decompression and are poor operative risks should also be considered for long intestinal tube placement.