Recognition of streptococcal pharyngitis in adults.

In order to devise a strategy for the management of acute pharyngitis, the clinical features of 418 adults with sore throat were noted and throat cultures were obtained. Patients with cultures positive for group A beta-hemolytic streptococci had a significantly higher (P less than or equal to .01) frequency of recent exposure to streptococcal infection, pharyngeal exudate, enlarged or tender cervical nodes, and high fever (greater than or equal to 38.3 C [101 F]. Patients with negative cultures complained more frequently of cough. On the basis of these symptoms and signs, a clinical algorithm was developed and discriminant function scores were computed that identify patient populations with different probabilities of having streptococcal pharyngitis. The patients with moderate and high probabilities included 91% of patients with positive cultures but only 67% of the total patient population. These methods could be the basis for more efficient evaluation of adults with sore throat.

Pancreaticojejunostomy after Whipple's operation--in vivo evaluation of long-term patency: a preliminary report.

Evaluation of the patency of the pancreaticojejunostomy was conducted in four patients who had undergone Whipple's procedure. Three patients had a mucosa-to-mucosa anastomosis, and in one patient the pancreatic remnant had been invaginated into the jejunal loop. The longest interval between the operation and the present study was 9.7 years. After intravenous infusion of secretin (1 microgram/kg), the temporal changes in the pancreatic ductal caliber were measured by means of either ultrasonography (two patients) or computed tomography (two patients). The presence of adequate functional pancreatic tissue was assumed in all four patients on the basis of their clinical status and the normal ductal caliber before the secretin provocation. In two patients, the ductal system showed an initial dilatation following secretin administration and then gradually emptied. There were no changes of the Wirsung duct in the other two patients. These data suggest that the pancreaticojejunal anastomoses were patent in all four patients but had different degrees of stenosis. The present method allows a safe and noninvasive evaluation of the anastomosis in vivo. Since long-term patency of the pancreaticojejunostomy is feasible, it should be attempted whenever possible in patients undergoing Whipple's procedure.

Agenesis of the gallbladder without extrahepatic biliary atresia.

Agenesis of the gallbladder without extrahepatic biliary atresia is a rare disorder. At the UCLA-affiliated hospitals, 12 patients were classified in the following groups: (1) multiple fetal anomaly, (2) asymptomatic, and (3) symptomatic. All four patients in the multiple fetal anomaly group died of their other congenital defects. In the three patients in the asymptomatic group, the absent gallbladder was an incidental finding at autopsy. The five patients in the symptomatic group underwent operations for symptoms suggestive of biliary tract disease, with no gallbladder found; all were symptom free postoperatively. Operative strategy should include a complete exploration, operative cholangiography, and common bile duct exploration as necessary. Possible mechanisms responsible for symptoms include primary duct stones, biliary dyskinesia, or nonbiliary disorders. Computed tomography, biliary manometry, upper gastrointestinal tract endoscopy, and endoscopic cholangiography (with or without sphincterotomy) could be employed if symptoms continue.

Internationalization of general surgical journals: origin and content of articles published in North America and Great Britain from 1983 to 1998.

HYPOTHESIS: The origin and characteristics of articles published in the 6 highest rated (Institute for Scientific Information classification) English-language general surgical journals have changed significantly during the past 15 years. DESIGN: All articles published in 1983, 1988, 1993, and 1998 in 5 US surgical journals and 1 British surgical journal were reviewed and characterized. MAIN OUTCOME MEASURES: Absolute numbers and proportions of national and international articles published in each journal. RESULTS: Articles reviewed included 4868 in US journals and 1380 in the British journal. The total number of US journal articles decreased by 15.1%. The total number of British journal articles increased by 58.9%. The percentage of national articles decreased from 87.5% to 68.8% in US journals (P<.001) and constituted the minority of freely submitted articles in 1998 in 3 of 5 US journals. The percentage of national articles also decreased from 74.8% to 47.1% in the British journal (P<.001). Articles by European and Asian authors showed the most striking increases in all journals. The percentage of basic research articles declined in US journals from 23.3% to 17.9% (P =.001) owing to a 14.9% decline in national basic research articles. The percentage of clinical randomized studies increased from 2.2% to 4.1% (P<.008), but the increase was attributable to international articles. Government funding alone decreased from 13.6% to 11.2%, and government plus another source of funding decreased from 19.2% to 16.7% for national articles in US journals. CONCLUSIONS: Internationalization of the highly rated British and the 5 highest rated US general surgical journals has occurred. The decrease in the number of national articles in the US journals has been accompanied by significant decreases in government funding and basic research articles and a static output of clinical randomized studies from North America.

Canine gallbladder bile. Effects of proximal gastric vagotomy, truncal vagotomy, and truncal vagotomy with pyloroplasty on volume and composition.

Three groups of four dogs each underwent proximal gastric vagotomy, truncal vagotomy, or truncal vagotomy with pyloroplasty. Two dogs had sham operations. Gallbladder bile was aspirated and measured. Aliquots were cultured and assayed for cholesterol, phospholipid, and bile salts initially and at subsequent laparotomies. Both truncal vagotomy groups showed marked increases in aspirate volume at subsequent laparotomies. The sham and proximal gastric vagotomy groups showed a small initial decrease in mean aspirate volume without further significant changes. When the bile assay data were plotted on triangular coordinates, all point for all groups remained well within the area of cholesterol solubility. Nevertheless, two dogs in each truncal vagotomy group were found to have gallstones. No stones were found in the sham and proximal gastric vagotomy groups. Proximal gastric vagotomy appears to preserve fasting gallbladder bile volume and does not alter bile composition in the dog.

Benign hepatic tumors and their association with oral contraceptives.

The growing number of reports of benign hepatic tumors occurring in young women who have been receiving oral contraceptive steroids has led us to review the 33 patients reported in the literature and to cite two additional case reports. By presenting two reports, one describing focal nodular hyperplasia and the other multiple hepatic cell adenomas, we hope to emphasize the pathological differentiation between these two lesions in order to calrify further reporting. Twelve of the 35 patients had massive intraperitoneal bleeding; two other patients had less severe hemoperitoneum. Five deaths have been reported. Although the frequency of use of these agents has become such that a direct relationship between them and benign hepatic tumors is not proved, the clinician should bear the association in mind when presented with women taking oral contraceptives who have abdominal pain. The review is made in the hope of stimulation further case reporting and microscopical and ultrastructural analysis. We trust that three will clarify the possible role of contraceptive steroids as predisposing or etiologic agents.

Floating tumor debris. A cause of intermittent biliary obstruction.

Tumor debris, free-floating in the major biliary ductal system, is a cause of intermittent biliary obstruction that has previously not been recognized. Six patients had hepatic neoplasms with episodic jaundice and/or cholangitis due to floating tumor debris. Diagnosis included metastatic adenocarcinoma of the colon (n = 3), cholangiocarcinoma (n = 1), hepatocellular carcinoma (n = 1), and cavernous hemangioma (n = 1). All patients underwent biliary exploration, with hepatic resection and transhepatic intubation in two and T-tube placement in four. One patient died in the early postoperative period, and the major complication rate in the five survivors was 0%. Four of the five survivors had no further episodes suggestive of major bile duct obstruction. Our experience emphasizes the importance of distinguishing extrahepatic obstruction secondary to tumor debris from the more common causes of jaundice in patients with tumors and suggests that safe and effective palliation can be achieved in these patients.

Management of bile duct strictures. An evolving strategy.

In an effort to determine the role of interventional radiologic and endoscopic techniques in the management of benign biliary strictures, a retrospective analysis was carried out on 194 consecutive patients with bile duct strictures treated at UCLA between 1955 and 1990. Patients were classified as group 1 (1955 through 1979; n = 138) or group 2 (1980 through 1989; n = 56). Follow-up was for a minimum of 24 months and was in excess of 3 years in 179 patients (92%). Although the incidence of recurrent strictures was similar in the two groups (21% and 23%), the reoperation rate was significantly lower (P less than .02) in group 2 (6%) than in group 1 (21%). Percutaneous transhepatic biliary dilatation, used in 20 patients in group 2, was successful in 13 (93%) of 14 patients with anastomotic strictures and three (50%) of six patients with primary strictures (P less than .05). We conclude that surgical reconstruction remains the standard therapy for patients with primary bile duct strictures. Percutaneous transhepatic biliary dilatation has limited usefulness for these patients, but may be more appropriate for those with anastomotic strictures.

The spectrum of mucin-producing adenocarcinoma of the pancreas.

The clinical distinction between cystic and mucinous carcinomas of the pancreas has been poorly defined. Therefore we sought to stratify the entity known as pancreatic mucinous adenocarcinoma based on pathologic and clinical criteria. Clinical data and pathology specimens were reviewed for patients (n = 40) who had been diagnosed as having mucin-producing pancreatic adenocarcinoma and had undergone either resection or intraoperative biopsy of their pancreatic tumor during a 40-year period at the UCLA Medical Center. Based on histologic criteria, three distinct classes of pancreatic adenocarcinoma were identified: mucinous noncystic (colloid) adenocarcinoma (group I), mucinous cystadenocarcinoma (group II), and ductal adenocarcinoma (group III). Based on clinical behavior, groups I and III were indistinguishable. Compared to patients from groups I and III, those from group II were younger, more likely to be female, and had a better prognosis. Among mucin-producing adenocarcinomas of the pancreas, mucinous noncystic adenocarcinoma and ductal adenocarcinoma share similar clinical features, whereas true cystic lesions represent a distinct clinical entity.

Enhancement of biliary phospholipid radioactivity by intestinal administration of labeled precursors of hepatic lecithin synthesis.

An animal model is used to study the effects of different radioactive precursors of lecithin, administered intestinally, upon biliary lecithin synthesis. Choline caused greater biliary lecithin radioactivity than choline-labeled lecithin or palmitic acid. The clinical application of this finding is discussed with relation to patients with gallstones or potentially lithogenic bile. Oral administration of choline may increase biliary lecithin concentration and, thus, cholesterol-holding capacity in this patient group, thereby changing the character of the bile to a non-lithogenic state.

Bile acids inhibit pepsin activity against a refined substrate.

Studies using a refined substrate, n-acetyl-L-phenylalanyl-L-diiodotyrosine [n-APDT], demonstrate that bile salts inhibit pepsin activity in vitro by a noncompetitive effect on the enzyme.

Effects of long-term ingestion of soya phospholipids on serum lipids in humans.

The average reduction of 22 percent in serum cholesterol and 26 percent in triglycerides in the participants in this study was achieved by a diet low in fat and cholesterol supplemented with lecithin. The results are important because all of the participants were able to follow the diet protocol while continuing their normal activities and did so willingly and eagerly over the entire 26 month period. Although the statistical analyses of the data in this small group do not enable us to conclude that lecithin added to the low fat diet actually produced the reduced levels of cholesterol and triglycerides, the trend is encouraging. Because the lecithin and low fat diet was tolerated well with no significant side effects for 2 years, we suggest that a long-term prospective randomized study with a larger group of patients, including appropriate linoleic acid controls, be carried out to confirm or deny these preliminary findings.

Inhibition of pepsin activity by ursodeoxycholic acids and chenodeoxycholic acids.

The bile salts of ursodeoxycholic acid, glycoursodeoxycholic acid, tauroursodeoxycholic acid, chenodeoxycholic acid, glycochenodeoxycholic acid, and taurochenodeoxycholic acid were each found to inhibit pepsin proteolytic activity in vitro at various concentrations against the refined substrate n-APDT. The sodium salt of ursodeoxycholic acid was the most potent pepsin inhibitor among those tested.

Heterotopic pancreas. Review of a 26 year experience.

A retrospective review of 37 patients (22 men and 15 women) with histologically verified heterotopic pancreas treated at the department of surgery of the University of California at Los Angeles Medical Center from 1959 to 1985 was carried out. There were 31 adults (mean age 50 years) and 6 children (mean age 2.8 years). The majority of lesions were in the stomach, duodenum, and jejunum. One was found inside a duplicated stomach. Symptomatic lesions were confined to the gastroduodenal region and were larger, with frequent mucosal ulceration. Upper gastrointestinal contrast roentgenograms were sensitive tools for detection (87.5 percent of patients) and diagnosis (71.4 percent of patients) of these lesions. Endoscopy should be performed whenever epigastric pain is the presenting symptom. Resection of the tissue-bearing segment of small intestine is advisable when encountered incidentally at operation. In the absence of endoscopic biopsy confirmation, we recommend surgical exploration and frozen section histopathologic study for all symptomatic patients. Limited local excision has been shown to be a safe and adequate procedure for patients with these congenital anomalies.

Inhibition of pepsin activity by unconjugated bile acids. Inverse relation to number of hydroxyl groups.

The unconjugated bile acids cholic, deoxycholic, chenodeoxycholic, and lithocholic acid were each found to inhibit pepsin activity in vitro against the refined substrate n-adenosyl-L-phenylalanyl-L-3,5-diiodotyrosine (n-APDT). The degree of inhibition was inversely proportional to the number of hydroxyl substituents on the bile acid molecule. The implications of these findings in relation to the occurrence of peptic ulceration in patients undergoing Roux-Y biliary diversion is discussed.

Management of hepatic echinococcosis in Southern California.

In the United States, hydatid disease of the liver is being seen with increasing frequency in persons who have immigrated from endemic areas. At the University of California, Los Angeles Medical Center, 24 patients with 46 echinococcal cysts were managed over a 26 year period. Seven patients (29 percent) had cyst rupture: into the lungs in three patients, the biliary tree in two, and the peritoneum and duodenum in one patient each. In recent years, serologic tests, computerized axial tomography, and endoscopic retrograde cholangiopancreatography have greatly aided the diagnosis and management of these patients. Four patients were treated nonoperatively, and 20 patients (with a total of 41 cysts) underwent operation. Cyst management included partial cystectomy in 19 patients, complete cystectomy in 18 patients, left hepatic lobectomy in 2 patients, and marsupialization and removal of hepatic debris from the common duct in 1 patient each. Primary cyst closure, omental packing, external drainage, or cystojejunostomy was individualized on the basis of cyst size, location, secondary infection or rupture, and communication with the biliary tree. Morbidity, including two temporary external biliary fistulas, occurred in eight patients (40 percent) but could not be related to cyst management or preoperative rupture. No deaths occurred in this series.

Matched control study of distal splenorenal and portacaval shunts in the treatment of bleeding esophageal varices.

A matched control study was conducted to compare the effects of portacaval shunting with those of distal splenorenal shunting in patients with advanced hepatic cirrhosis and bleeding gastroesophageal varices. Patients in whom distal splenorenal shunts were performed had significantly less postoperative encephalopathy and hepatic failure and a significantly longer survival than did patients who underwent portacaval shunts.

Incidence of complications with operative choledochoscopy.

A 5 year retrospective study of the use of cholangioscopy in 153 difficult biliary cases including stones, strictures, tumors, and anomalies has been reported. In the 88 patients (58 percent) who underwent both operative cholangiography and cholangioscopy, the cholangioscope revealed 11 lesions (13 percent) missed by cholangiography. In this series, eight retained stones (5.2 percent) were detected on postoperative T-tube cholangiography; of this group, two patients had previous biliary surgery, two had an associated neoplasm, and four had incomplete cholangioscopy for various reasons. Postoperative complications included transient bile drainage (8 percent), pancreatitis (8 percent), persistent jaundice (7 percent), cholangitis (5 percent), and abscess (5 percent). Comparison of an operative cholangiography-only group with a cholangioscopy-only group revealed no significant difference in the incidence of postoperative complications. Cholangioscopy did not increase postoperative complications in this study. It frequently detected lesions missed by cholangiography and helped define the nature of the lesions. The incidence of retained stones may be reduced by use of the cholangioscope in difficult biliary cases. Its routine use in common bile duct exploration is recommended.

Operative endoscopy in the management of biliary tract neoplasms.

Operative endoscopy of the biliary system has been employed with ever increasing frequency at the UCLA Hospital during the last three years. In addition to its established value with respect to disclosing unsuspected stones in the bile ducts, choledochoscopy has been of great value in terms of more accurate diagnosis and staging of periampullary and bile duct neoplasms. It has been observed that many biliary tract carcinomas are multicentric in origin and that cholangiography is not adequate to identify small intrahepatic ductal lesions. More than one cell type of bile duct carcinoma may be present in the same patient. Choledochoscopy should be used in addition to the conventional criteria for resectability in all patients with ductal or periampullary carcinoma. Use of this technic will spare some patients needless radical procedures and should improve long-term cure rates by identifying those patients with truly localized disease for curative resections.

Caroli's Disease: a premalignant condition?

This study reports four new cases of Caroli's disease complicated by the development of cholangiocarcinoma. Caroli's disease appears to be a premalignant condition, but early diagnosis of malignancy in the cyst wall is difficult because signs of ductal stenosis develop slowly and treatment is often based on erroneous diagnosis of recurrent cholangitis. When carcinoma is present, operative intervention makes no difference in survival. In patients with Caroli's disease, adequate intraductal and hepatic biopsies should be obtained at the first operation. These patients should be followed carefully, and malignant growth should be suspected when cholangitis occurs despite patent anastomoses. Earlier diagnosis will obviate repeated operations in patients with malignant Caroli's disease.