Endogenous ethanol production and hepatic disease following jejunoileal bypass for morbid obesity.

In this study, we sought to determine whether or not elevated levels of ethanol were present in the systemic circulation, resulting from endogenous ethanol production, which might contribute to the hepatic damage following jejunoileal bypass for morbid obesity. Venous serum samples for assay of ethanol by gas-liquid chromatography were obtained in 8 normal subjects, 9 obese patients prior to surgery, 20 obese patients 2 weeks to 40 months after jejunoileal bypass, and in 2 dogs before and after jejunoileal bypass. Ethanol was detected after jejunoileal bypass in only 7 of the 20 patients and in the 2 dogs. Serum ethanol concentrations ranged from 0.15 to 4.12 mg/100 ml with a mean of 1.18 +/- 1.59 (SD)( mg/100 ml in the 7 patients and ranged from 0.20 to 2.23 mg/100 ml in the dogs. Incubation of the contents of the bypassed intestine of a dog with dextrose resulted in the production of significant amounts of ethanol. However, there was no correlation between the presence of ethanol in the serum and liver histology, when liver biopsy was obtained, postoperatively. Since ethanol was detected in the serum in only small concentrations and in only one-third of the patients, it is unlikely that ethanol production by bacteria in the intestine is of significance in the pathogenesis of liver disease following jejunoileal bypass.

Thoracic surgical content of an undergraduate surgical curriculum.

The surgical services have long been an excellent training ground for teaching clinical skills common to all physicians. The thoracic surgical service provides an additional opportunity to offer experience in trauma, resuscitation, and the management of many emergency situations common to all medical and surgical illness. With the use of a methodology previously reported by the Association for Surgical Education, a survey was developed and circulated among surgical department chairmen, directors of thoracic surgical training programs, and the medical school classes of 1978 who had completed 5 postgraduate years of training and/or practice. A modified Delphi technique was used to assess the information, and the rank order of mean scores for knowledge and skills was constructed for the various categories within the thoracic surgery curriculum. The Pearson product-moment correlation for the rank order of knowledge and skills demonstrated a high degree of correlation between directors and students (0.904 and 0.917, respectively), directors and chairmen (0.948 and 0.982, respectively), and between students and chairmen (0.900 and 0.952, respectively) for knowledge and skills. The most important knowledge categories were critical care and resuscitation (rank order 2.15), hemodynamic measurements and analysis (2.10), pulmonary embolus (2.06), and assessment of pulmonary function (1.92). The most important skills listed were thoracentesis (1.92), endotracheal intubation (1.86), and central vein cannulation (1.69). Analysis of data such as these permits construction of a surgery curriculum responsive to the goals and objectives of the faculty and implements the viewpoints of many individuals representing multiple backgrounds to formulate the most appropriate content for undergraduate surgical education.

Aorta-vena cava fistula.

In 1831 James Syme described the unusual occurrence of an aortocaval fistula in a 22-year-old man with luetic aortitis. This initial report was followed by illustration of this phenomenon in Rokitanski's Book of Pathologic Anatomy in 1841 and by Ryle's delineation of an aortocaval fistula on a pathologic specimen placed in Guy's Hospital Museum in 1892. The first series of aortocaval fistulas, cited by Rudolf Matas in 1909, consisted of a collection of 20 cases gathered by Boinet 10 years earlier. Several later reports, including those by Reid in 1925 and by Lehman in 1938, failed to add any additional cases. It was not until 1955 that Boffi presented an additional six patients who had this disorder, none of whom survived. Since that time, more than 100 cases of spontaneous aortocaval fistulas have been documented. This increasing experience has resulted in improved understanding and surgical treatment of these large-vessel arteriovenous communications. Nevertheless, lack of awareness and failure of recognition of this problem continue to impede its successful management. In this review we present two additional illustrative cases, summarize the clinical and pathophysiologic features of aortocaval fistulas, and outline present approaches to treatment.

Paraprosthetic-enteric fistula.

A case of paraprosthetic-enteric fistula is presented and the total reported literature of 21 cases is reviewed. Paraprosthetic-enteric fistula is a complication of aortic revascularization with synthetic prostheses. The entity is characterized by erosion of the gastrointestinal tract by an underlying prosthesis but absence of a true fistulous communication with the aortic lumen. It is both a distinct pathologic entity and a step in the formation of a true aortoenteric fistula with suture line involvement. The most frequent clinical manifestations are sepsis and gastrointestinal bleeding, but nonspecific abdominal pain is present occasionally as well. The distal duodenum is the portion of the gastrointestinal tract involved most commonly. Diagnostic evaluation should include endoscopy, aortography, and barium contrast studies. Venous and femoral arterial blood cultures also should be done in patients presenting with sepsis. Treatment should consist of either graft excision with extra-anatomic revascularization or graft excision alone when dealing with a previously thrombosed prosthesis.

The effect of estrogen on low-density lipoprotein binding kinetics in aortic endothelial cells.

The inhibition of atherosclerosis by estrogen has been shown clinically and experimentally, but the mechanism by which this occurs is unknown. Previous studies have shown that estrogen enhances the uptake of low-density lipoprotein (LDL) by bovine aortic endothelial cells (BAEC) while not altering membrane binding at saturating levels of LDL. In this study the effect of estrogen on LDL binding kinetics has been investigated. Computer-assisted Scatchard analysis of binding data suggests a single-site binding model. Estrogen-treated BAEC showed a lower binding affinity (Ka = 2.47 +/- 0.74 E7 M-1) than control cells (1.95 +/- 0.21 E7 M-1) (p = 0.0012). Estrogen-treated cells, however, had a greater binding capacity (Bmax = 1.26 +/- 0.07 E-10M) than control cells (Bmax = 8.49 +/- 0.44 E-11M) (p = 0.0004). The latter was due primarily to a difference in LDL binding at higher concentrations of LDL (greater than 40 micrograms/ml). These findings are consistent with an estrogen-stimulated increase in low-affinity binding of LDL to BAEC, which may not be directly receptor mediated and which appears to enhance the uptake of LDL at higher lipoprotein concentrations. Such alterations in LDL uptake by endothelial cells could influence the formation of atherosclerotic plaque.

Massive weight loss following jejunoileal bypass. I. Effects on pulmonary function.

Twelve morbidly obese patients had jejunoileal bypass surgery and serial detailed pulmonary function studies done over a one year period. Before operation they showed evidence of a decreased ventilation: perfusion ratio producing a "shuntlike effect" (Pao2 = 73, Paco2 = 37, pH = 7.44) while breathing room air (FIo2 = 0.209). They also had measurements consistent with pure restrictive lung disease. There was a highly significant improvement in the arterial oxygenation over the entire one year period and a significant loss of chest wall mass over the first 6 month period. The improved oxygenation most likely was due to a return of lung volumes toward normal and an improvement in the efficiency of the respiratory muscles.

The application and interviewing process for surgical house officership.

The application and interviewing procedure for surgical house officership is an important process to both the medical student and the clinical department. Up-to-date, informative, and honest appraisals of the training programs under evaluation must be obtained. A survey was undertaken to compare and contrast students' and surgical department members' perceptions of nationwide surgical residency application procedures. It is concluded from this sampling that the majority of medical students applying to university-sponsored surgical training programs and the training institutions themselves generally are satisfied with the present application and interviewing experience. Certain areas in need of reform were elucidated, and the following recommendations are offered to aid in the development of a more effective process: (1) if possible, the descriptive information brochure should be updated on a yearly basis and must be comprehensive in scope; (2) when "en masse" interviewing is conducted, it should be held on a number of dates during the year, not just one, and a limited time for "walk-in" interviews should be allowed; (3) an opportunity should be available for the spouse or fiance'(e) to accompany the applicant; (4) an interviewer should prepare for an interview by having read the applicant's file beforehand; and (5) the interviewing schedule should be arranged so that the applicant is able to meet either the department chairperson and/or program director.

The role of pre-resectional laser recanalization for obstructing carcinomas of the colon and rectum.

The Nd:YAG laser has proved its efficacy for recanalizing obstructing lesions throughout the gastrointestinal tract. In a preliminary report using the Nd:YAG laser as a pre-resectional treatment for functionally obstructing colorectal carcinoma we showed that this modality accomplished good decompression, allowing for formal bowel preparation, a definitive one-stage operation with no increased mortality or morbidity, and that the use of the Nd:YAG laser was significantly cost-effective. Our cumulative experience from 1985 to 1988 includes 11 patients; nine underwent pre-resection laser therapy followed by primary resection and anastomosis, and two underwent abdominoperineal resection. Tumors were located above the peritoneal reflection in nine patients and below in two patients. All patients had orthograde bowel preparation with Golytley the day after laser therapy and underwent definitive surgery. There were no wound or intra-abdominal infections or postoperative fatalities. These 11 laser-treated patients were compared with age-matched controls who had undergone earlier colonic diversion. No significant differences were noted for age, sex, tumor location or differentiation, stage, or overall survival. Comparisons between laser-treated patients and controls for the preoperative length of stay and total length of stay were significantly different (p = 0.002 and p = 0.001, respectively). When comparing laser-treated patients and controls, preoperative and total hospital costs were significantly different (p = 0.003 and p = 0.01). We have found that pre-resectional laser recanalization has allowed for primary resection and anastomosis in patients who have obstructing left colon and rectal carcinomas without compromising patient safety.

Interferon inhibition of IL-2-mediated lymphocyte proliferation.

Interleukin-2 (IL-2) combined with hybrid human alpha interferon (IFN-alpha A/D) mediates enhanced tumor regression compared with either agent alone. To elucidate the underlying mechanism of interaction of IL-2, with its known ability to induce expansion of T lymphocytes, and IFN-alpha A/D, with its antiproliferative activity, we studied splenocytes from normal and tumor-bearing C57BL/6 mice in 5-day cultures and measured proliferation by means of a standard 4-hour 3H-thymidine incorporation assay. Potent inhibition of IL-2-induced proliferation (usually greater than 90%) resulted from high concentrations of IFN (100 to 1000 U/ml). Splenocytes from both tumor-bearing and normal mice, cultured alone or with mitomycin-treated syngeneic tumor, MCA106, exhibited similar patterns of inhibition. Unexpectedly, allostimulation with DBA/2 (H-2d) stimulators and C57BL/6 (H-2b) responders showed enhanced proliferation, most pronounced at lower IFN concentrations. Time course of IFN action revealed minimal duration of exposure necessary for inhibition to be less than 24 hours. Microfluorometric cell analysis showed the striking increase in Thy-1+ cells (55% to 96%) induced by IL-2 with parallel increase in Lyt2+ cells but almost complete disappearance of L3T4+ cells. IFN reduced IL-2-induced increase in Lyt-2+ cells (61% to 31%). These results emphasize the complexity of IL-2 and IFN interaction and the potential for dose-related antagonistic effects. This may be important in the clinical use of this combination.

Dimethylsulfoxide-treated, cryopreserved venous allografts in the arterial and venous systems.

Autologous saphenous vein is the preferred conduit for most vascular reconstructive procedures; however, many authorities have emphasized the need for a reliable alternate. This study was designed to assess the short-term patency of dimethylsulfoxide-treated, cryopreserved saphenous vein allografts in both high- and low-flow states. An early patency rate of 58.3% was found for such allografts interposed in the arterial system. No instance of aneurysm formation was noted. Allografts interposed in the venous system uniformly occluded within 5 weeks. However, in animals treated with aspirin and dipyridamole there was an 83% early patency rate for cryopreserved allografts in the venous system. These studies suggest that dimethylsulfoxide cryopreservation is a viable technique for venous allograft preservation as demonstrated by satisfactory short-term patency of grafts implanted in the arterial system. The results also suggest that treatment with aspirin and dipyridamole has a beneficial effect on the early patency of such grafts placed in the venous system.

The efficacy of polyethylene glycol-electrolyte lavage solution versus traditional mechanical bowel preparation for elective colonic surgery: a randomized, prospective, blinded clinical trial.

This study documents the efficacy, safety and patient tolerance of GoLYTELY (Braintree Laboratories, Inc., Braintree, Mass.) an orally administered, nonexplosive, polyethylene glycol-electrolyte lavage solution, in elective colonic surgery. Fifty-three patients admitted for colonic surgery were randomized to either GoLYTELY or a traditional 3-day bowel preparation. Both groups received oral and perioperative antibiotics. Pre- and postpreparation weights, blood chemistries, and hematologic values were obtained. Postpreparation patient tolerance was assessed. During surgery the surgeon scored the bowel for the presence of retained air, fluid, or feces. Standardized semiquantitative aerobic and anaerobic bacterial counts were obtained from sigmoid aspirates. Postoperative infectious complications were recorded. Mechanical preparation with GoLYTELY resulted in a greater feeling of fullness, while the traditional preparation produced more hunger and abdominal cramping. The use of GoLYTELY resulted in better scores of overall quality and bowel appearance, reflecting a greater efficiency with which it removed air, fluid, and feces from the bowel. GoLYTELY also resulted in significantly fewer total aerobic and anaerobic organisms in sigmoid aspirates. This study suggests that GoLYTELY is a safe, well-tolerated, and effective orthograde lavage solution that has significant advantages over other mechanical preparations and should be considered the preparation of choice for elective colonic surgery.

Immunotherapy of pulmonary metastases using monoclonal antibody to T-cell suppressor factor and interleukin 2.

Tumor-induced immune suppression of the host may pose a barrier to successful immunotherapy. A monoclonal antibody (MAb 14-12) able to bind and inhibit murine soluble T-cell suppressor factor was tested for in vivo antitumor activity by treatment of mice bearing three-day established pulmonary metastases of a weakly immunogenic methylcholanthrene-induced fibrosarcoma (MCA 106). Administration intraperitoneally in combination with interleukin 2 (IL-2), a growth factor for activated T lymphocytes, resulted in a significant reduction (60% to 90%) of metastases. Neither IL-2 nor monoclonal antibody alone had significant antitumor effects. This study demonstrates in vivo potentiation of IL-2 antitumor activity with an anti-T-cell suppressor factor and points to possible strategies for clinical application.

Splenic complications of a pancreatic pseudocyst.

Six patients with pancreatic pseudocyst involving the spleen have been presented. The complications reported included massive hemorrhage into the pseudocyst, sepsis with splenic infarction, and splenic vein thrombosis. The diagnosis of intrasplenic pseudocyst based on clinical findings alone is difficult to arrive at but should be suggested by the presence of a mass in the left upper quadrant. Sonography and computerized axial tomography may be particularly helpful in confirming splenic involvement. Selective celiac arteriography should be performed whenever splenic involvement is suggested in order to confirm the diagnosis and to search for pseudoaneurysm formation. Urgent surgical intervention is usually warranted in view of the high incidence of serious complications and the propensity toward rapid clinical deterioration. Resection of the pseudocyst by splenectomy and distal pancreatectomy is the treatment of choice.

The utility of prophylactic laparoscopic cholecystectomy in transplant candidates.

BACKGROUND: This study addresses the impact of laparoscopic cholecystectomy prior to kidney or pancreas transplant. PATIENTS AND METHODS: Between January 1991 and July 1993, 551 patients were listed for transplant. Gallbladder ultrasound became part of the standard evaluation for all transplant candidates in October 1991. Pretransplant laparoscopic cholecystectomy was recommended for all patients found to have gallstones. To assess the benefit of this policy, patients transplanted prior to routine ultrasound (Group I; n = 88) were compared to those listed or transplanted after routine ultrasound (Group II; n = 406). RESULTS: In Group I, 18% developed gallstone complications requiring surgery. Surgical morbidity occurred in 14% and mortality in 7% of these operations. Graft loss occurred in 20% having biliary complications versus 7% among other recipients. In Group II, gallstones were detected in 10%, and 9% subsequently had laparoscopic cholecystectomy with no morbidity or mortality. CONCLUSIONS: Transplant recipients with unsuspected gallstones were found to have a high incidence of acute biliary complications. Urgent biliary surgery carried significant morbidity and mortality in these immunosuppressed patients and appeared to increase the risk of graft failure as well. A policy of screening gallbladder ultrasound and pretransplant laparoscopic cholecystectomy seems to reduce these concerns and is recommended for all transplant candidates.

Laparoscopic guided cholecystectomy.

Cholecystectomy remains the most effective form of therapy for patients with symptomatic cholelithiasis. An alternative method of gallbladder removal, laparoscopic guided cholecystectomy, was attempted in 100 patients. Five patients required conversion of the laparoscopic procedure to an open laparotomy for the following reasons: discovery of a pancreatic malignancy in one patient, extensive adhesions in one, presence of an aberrant accessory right hepatic duct in one, common hepatic duct injury in one, and avulsion of the cystic duct in one. Both ductal injuries occurred during the early phase of the clinical program. In those patients undergoing laparoscopic cholecystectomy, 93 were discharged within 24 hours of surgery and 94 returned to normal activity within 1 week. Laparoscopic guided cholecystectomy appears to offer a number of advantages in patient care as well as a significant reduction in health care expenses for gallbladder disease. Appropriate training in laparoscopic surgery is necessary in order to avoid operative complications.

Laparoscopic management of acute cholecystitis.

The role of laparoscopic surgery in patients presenting with acute cholecystitis remains controversial. From September 1989 through August 1992, a total of 720 patients underwent cholecystectomy. Ninety-six were unplanned admissions with a clinical diagnosis of acute cholecystitis. Laparoscopic surgery was attempted in 83 patients. Thirteen individuals were not offered laparoscopy because of the surgeon's inexperience. Twenty-two (27%) patients required the laparoscopic procedure converted to an open laparotomy. The mean postoperative hospital stay for patients undergoing laparoscopic cholecystectomy was 3.3 days versus 6.8 days for the laparotomy group. There was no mortality and no bile duct or major vascular injuries in either group. The overall operative morbidity rate was 16.9%. Laparoscopic cholecystectomy appears to be a safe and beneficial option in selected patients with acute cholecystitis. A low threshold for conversion to laparotomy appeared to be an important factor in maintaining a low incidence of operative complications. Several modifications to the technique of laparoscopic cholecystectomy have evolved over the 3-year study period and are described.

Establishment of a laparoscopic cholecystectomy training program.

A recently developed alternative to traditional laparotomy and cholecystectomy is laparoscopic-guided cholecystectomy. This procedure has the advantages of reduced hospital stay, early return to work, diminished abdominal wall scarring, and less patient discomfort. The complex nature of this procedure and the current lack of extensive clinical experience preclude the traditional "hands-on" training normally practiced in surgical residency programs. At the University of Maryland, we have developed a program to instruct both surgeons and surgical residents in the techniques of laparoscopic surgery. Technical competence is achieved under the close supervision and guidance of an experienced laparoscopic surgeon. Training of residents in this procedure, therefore, is not very different than that for other general surgical procedures. Surgeons already in clinical practice, however, gain experience under somewhat different circumstances. Initial training involves didactic instruction through laparoscopic surgical atlases and educational videotapes. Further training uses a simulation device which enables the trainee to practice techniques of laparoscopic suturing, knot-tying, and clip application. Actual operative experience is acquired primarily in experimental animal preparations. Laparoscopic-guided removal of the gallbladder is performed in young swine (20-25 kg) under conditions that mimic those in the operating room. Further clinical experience can be acquired by assisting on several laparoscopic operations, usually involving diagnostic or pelvic procedures. Actual operative experience with laparoscopic cholecystectomy, of course, comprises the final phase of the educational program. The introduction of clinical laparoscopic training into general surgery residency programs should influence the widespread adoption of this new procedure.